Addiction Housing Case Management for Homeless Veterans

Addiction Housing Case Management for Homeless Veterans Enrolled in Addictions Treatment

Status

Completed

Phases

Study type

Interventional

Source

ClinicalTrials.gov

Registry ID

NCT01346514

Acronym

AHCM

Enrollment

181

Registered

2011-05-03

Start date

2011-10-31

Completion date

2016-05-31

Last updated

2017-02-28

For informational purposes only — not medical advice. Sourced from public registries and may not reflect the latest updates. Terms

Conditions

Homelessness, Mental Disorders, Substance Abuse Disorders

Keywords

Homeless Persons, Housing, Case Management, Veterans, Substance Related Disorders, Mental Disorders, Social Adjustment

Brief summary

The study examined intensive case management for homeless Veterans in addiction treatment by integrating addiction/housing case managers (AHCM), operating from a Life Skills Training perspective, into an addiction specialty program. The primary aim was to determine whether the AHCM intervention increases number of days housed during the year following treatment entry. Secondary aims were to compare costs and cost-effectiveness of AHCM vs. time and attention control, determine if AHCM improves addiction outcomes and functional status, and examine treatment process variables associated with improved outcomes.

Detailed description

Background: Homelessness, substance use, and co-occurring psychiatric disorders form a mutually perpetuating, downwardly spiraling triad that maintains a state of homelessness, increases morbidity and mortality and thereby escalates health care utilization and costs. Addiction treatment is one portal of health care entry accessed by many Veterans with this devastating triad, yet addiction treatment fails to address homelessness directly. Homeless Veterans entering addiction treatment have worse treatment outcomes and incur more costs than housed Veterans entering such treatment. Further, many homeless Veterans never obtain housing after treatment entry and substantial proportion of those who do may subsequently return to homelessness. Assertive community treatment / intensive case management shows promise in improving housing status, as well as substance use and mental health outcomes in this population. Life Skills Training, which has been shown to improve the likelihood of maintaining housing, may increase the effectiveness of this method of treatment. An approach to homelessness incorporating assertive community treatment / intensive case management and Life Skills Training has never previously been integrated into VA addiction specialty care. Objectives: The proposed study will examine intensive case management for homeless Veterans in addiction treatment by integrating addiction/housing case managers (AHCM), operating from a Life Skills Training perspective, into an addiction specialty program. The primary aim is to determine whether the AHCM intervention increases number of days housed during the year following treatment entry. Secondary aims are to compare costs and cost-effectiveness of AHCM vs. time and attention control, determine if AHCM improves addiction outcomes and functional status, and examine treatment process variables associated with improved outcomes. Methods: The proposed study is a, parallel design, intention to treat, randomized clinical trial comparing the AHCM intervention to a time and attention control (weekly housing group) among homeless Veterans (N=400) newly entering addiction treatment. Following baseline assessment, Veterans will be randomly assigned, stratified by gender and primary substance problem, to one of the two treatment conditions and followed for 12 months. All Veterans will receive addiction treatment as usual. Veterans assigned to the AHCM condition will have a case manager who is integrated with the interdisciplinary treatment team. The AHCM will meet with the Veteran weekly, assist the Veteran with potential housing options, support the Veteran in continuing addiction treatment and psychiatric care, visit the Veteran in the community when appropriate, and obtain point of care urine toxicology testing to assess abstinence with the goal of addressing substance use issues proactively. The AHCM will educate the Veteran on needed basic life skills using existing manuals. Veterans assigned to the control condition will attend a weekly housing group where housing options are discussed. Participants will complete research assessments every 3 months through one year and then every 6 months for up to 2 years post-randomization to assess housing status and other outcomes. The Northwest Regional Data Warehouse and Decision Support System data sources will be used to determine outpatient and inpatient VA health care services and costs for the 1 year before and 2 years after study enrollment. Impact: If the AHCM model interrupts the mutually perpetuating triad of homelessness, substance use, and co-occurring psychiatric disorders by increasing days stably housed, reducing costs and excessive health care utilization, and improving functional status, the model could be feasibly and rapidly replicated in VA addiction programs nationwide thereby decreasing homelessness among Veterans and preserving precious health care resources.

Interventions

BEHAVIORALIntensive Addiction/Housing Case Management

AHCM provided: 1) support in obtaining/maintaining housing through education about resources, coordination with VA and community housing program providers, assistance in establishing housing program eligibility, and problem-solving around threats to housing stability; 2) support for SUD and related issues that affect housing status through treatment engagement/re-engagement, referrals for needed services (e.g. psychiatric, medical, vocational), and addressing substance use issues proactively; 3) promotion of residential stability through Life Skills Training, which was designed to improve key skills (room and self-care, money management, and community participation).

BEHAVIORALHousing Support Group

The HSG focused on gaining support from fellow study participants and learning from those who successfully obtained housing. Group facilitators provided education about housing resources and assistance with housing-related issues.

Study design

Allocation

RANDOMIZED

Intervention model

PARALLEL

Primary purpose

HEALTH_SERVICES_RESEARCH

Masking

NONE

Eligibility

Sex/Gender

ALL

Age

18 Years to No maximum

Healthy volunteers

Inclusion criteria

* Veterans newly presenting or returning to specialty treatment for substance dependence at VA Puget Sound Seattle Division who, after an initial evaluation, are scheduled for a treatment appointment in the Addiction Treatment Center * Currently homeless (unsheltered, staying in temporary emergency shelter, or doubled up with friends/family)

Exclusion criteria

* Not planning to stay in the Puget Sound area during the next 12 months * Unable to provide informed consent

Design outcomes

Primary

Measure	Time frame	Description
Percent Days Housed in AHCM vs. HSG, Baseline to 12 Months.	12 months (18 to 24 month outcomes examined in secondary analyses)	The primary aim is to determine whether the Addiction/Housing Case Management intervention increases percent days in long-term housing (permanent or long-term transitional) during the year following treatment entry relative to a Housing Support Group.

Secondary

Measure	Time frame	Description
Change in Functional Status in AHCM vs. HSG From Baseline to 12 Months	Baseline to 12 months	Determine if Addiction/Housing Case Management compared to a Housing Support Group control significantly improved functional status outcomes among homeless Veterans entering addiction specialty care over the 12-month study course. Functional status was measured by Medical, Employment, Family/Social, and Legal Composite Scores (range 0 to 1 with higher scores indicating greater severity) on the Addiction Severity Index (ASI) and the Physical Component Summary (PCS, range 0 to 100 with lower scores indicating greater severity) on the SF-36. Negative change on the ASI measures indicates improvement. Positive change on the SF-36 PCS indicates improvement.
Change in Alcohol and Drug Outcomes in AHCM vs. HSG From Baseline to 12 Months	Baseline to 12 months	Determine if Addiction/Housing Case Management compared to a Housing Support Group control significantly improved alcohol and drug outcomes, as measured by Alcohol and Drug Composite Scores (range 0 to 1, with higher scores indicating greater severity) on the Addiction Severity Index (ASI), among homeless Veterans entering addiction specialty care over the 12-month study course. Negative change on the ASI measures indicates improvement.
Costs and Cost-effectiveness of AHCM vs. HSG, Baseline to 12 Months	Baseline to 12 months	Costs and cost-effectiveness of Addiction/Housing Case Management to the Housing Support Group condition.
Change in Mental Health Status in AHCM vs. HSG From Baseline to 12 Months	Baseline to 12 months	Determine if Addiction/Housing Case Management compared to a Housing Support Group control significantly improved mental health outcomes, as measured by the Psychiatric Composite Score (range 0 to 1, with higher scores indicating greater severity) on the Addiction Severity Index (ASI) and the Mental Component Summary (MCS, range 0 to 100 with lower scores indicating greater severity) of the SF-36, among homeless Veterans entering addiction specialty care over the 12-month study course. Negative change on the ASI Psychiatric Composite Score indicates improvement. Positive change on the SF-36 MCS indicates improvement.
Treatment Process Measures (Number of Treatment Sessions, Type of Housing Placement, and Change in Life Skills)	Baseline to 12 months	Analyses will explore whether treatment process variables mediate differences in outcomes between Addiction/Housing Case Management and time and attention conditions.
Change in Percent of Participants Abstinent From Baseline to 12 Month Follow-up	Baseline to 12 months	Determine if Addiction/Housing Case Management compared to a Housing Support Group control significantly increase the percent of participants abstinent from alcohol and drugs over the past 30 days among homeless Veterans entering addiction specialty care over the 12-month study course. Positive change indicates improvement.

Countries

United States

Participant flow

Recruitment details

Participants (n=181) were recruited from the VA Puget Sound, Seattle Division between October 2011 and November 2015.

Participants by arm

Arm	Count
Arm 1/Addiction Housing Case Management (AHCM) AHCM intervention/ AHCM involves intensive case management for housing, substance use, and related issues. Veterans assigned to the AHCM condition will have a case manager who is integrated with the interdisciplinary treatment team. The AHCM will meet with the Veteran weekly, assist the Veteran with potential housing options, support the Veteran in continuing addiction treatment and psychiatric care, visit the Veteran in the community when appropriate, and obtain point of care urine toxicology testing to assess abstinence with the goal of addressing substance use issues proactively. The AHCM will educate the Veteran on needed basic life skills using existing manuals	91
Arm 2/Housing Support Group (HSG) HSG/ The Housing Support Group is a time and attention control. Veterans assigned to HSG attend a weekly drop-in housing group where housing options are discussed and participants receive support from one another.	90
Total	181

Withdrawals & dropouts

Period	Reason	FG000	FG001
Overall Study	Death	3	4
Overall Study	Lost to Follow-up	19	30
Overall Study	Withdrawal by Subject	7	3

Baseline characteristics

Characteristic	Arm 1/Addiction Housing Case Management (AHCM)	Arm 2/Housing Support Group (HSG)	Total
Age, Continuous	50.8 years STANDARD_DEVIATION 9.5	50.9 years STANDARD_DEVIATION 9.6	50.9 years STANDARD_DEVIATION 9.5
Episodes of Homelessness 1 episode	51 participants	55 participants	106 participants
Episodes of Homelessness 2 episodes	24 participants	17 participants	41 participants
Episodes of Homelessness 3 episodes	4 participants	10 participants	14 participants
Episodes of Homelessness 4 episodes	4 participants	4 participants	8 participants
Episodes of Homelessness 5 or more episodes	8 participants	3 participants	11 participants
Episodes of Homelessness Unknown	0 participants	1 participants	1 participants
Gender Female	2 Participants	2 Participants	4 Participants
Gender Male	89 Participants	88 Participants	177 Participants
Primary Substance of Use Alcohol	57 participants	59 participants	116 participants
Primary Substance of Use Cocaine	15 participants	15 participants	30 participants
Primary Substance of Use Opioids	9 participants	8 participants	17 participants
Primary Substance of Use Other	10 participants	8 participants	18 participants
Race/Ethnicity, Customized Asian/Pacific Islander	2 participants	0 participants	2 participants
Race/Ethnicity, Customized Black	32 participants	28 participants	60 participants
Race/Ethnicity, Customized Hispanic	2 participants	3 participants	5 participants
Race/Ethnicity, Customized Native American	0 participants	6 participants	6 participants
Race/Ethnicity, Customized White	55 participants	53 participants	108 participants
Time Homeless, Current Episode 1-2 years	9 participants	10 participants	19 participants
Time Homeless, Current Episode 1-6 months	31 participants	27 participants	58 participants
Time Homeless, Current Episode 2 or more years	15 participants	27 participants	42 participants
Time Homeless, Current Episode 6-12 months	21 participants	15 participants	36 participants
Time Homeless, Current Episode Less than 1 month	15 participants	10 participants	25 participants
Time Homeless, Current Episode Unknown	0 participants	1 participants	1 participants

Adverse events

Event type	EG000 affected / at risk	EG001 affected / at risk
deaths Total, all-cause mortality	— / —	— / —
other Total, other adverse events	18 / 91	13 / 90
serious Total, serious adverse events	39 / 91	31 / 90

Outcome results

Primary

Percent Days Housed in AHCM vs. HSG, Baseline to 12 Months.

The primary aim is to determine whether the Addiction/Housing Case Management intervention increases percent days in long-term housing (permanent or long-term transitional) during the year following treatment entry relative to a Housing Support Group.

Time frame: 12 months (18 to 24 month outcomes examined in secondary analyses)

Population: The percent of days in long-term transitional housing and/or own home was calculated for all patients using self-report and VA Homeless Operations Management and Evaluation System (HOMES) data. Individuals with no self-report or HOMES data were coded as not housed.

Arm	Measure	Group	Value (MEAN)
Arm 1/Addiction Housing Case Management (AHCM)	Percent Days Housed in AHCM vs. HSG, Baseline to 12 Months.	Percent Days Housed, 3 Month	25.0 percent days housed
Arm 1/Addiction Housing Case Management (AHCM)	Percent Days Housed in AHCM vs. HSG, Baseline to 12 Months.	Percent Days Housed, 9 Month	53.9 percent days housed
Arm 1/Addiction Housing Case Management (AHCM)	Percent Days Housed in AHCM vs. HSG, Baseline to 12 Months.	Percent Days Housed, 6 Month	48.9 percent days housed
Arm 1/Addiction Housing Case Management (AHCM)	Percent Days Housed in AHCM vs. HSG, Baseline to 12 Months.	Percent Days Housed, 12 Month	53.1 percent days housed
Arm 1/Addiction Housing Case Management (AHCM)	Percent Days Housed in AHCM vs. HSG, Baseline to 12 Months.	Percent Days Housed, Baseline	14.7 percent days housed
Arm 2/Housing Support Group (HSG)	Percent Days Housed in AHCM vs. HSG, Baseline to 12 Months.	Percent Days Housed, 12 Month	51.4 percent days housed
Arm 2/Housing Support Group (HSG)	Percent Days Housed in AHCM vs. HSG, Baseline to 12 Months.	Percent Days Housed, Baseline	12.0 percent days housed
Arm 2/Housing Support Group (HSG)	Percent Days Housed in AHCM vs. HSG, Baseline to 12 Months.	Percent Days Housed, 3 Month	14.1 percent days housed
Arm 2/Housing Support Group (HSG)	Percent Days Housed in AHCM vs. HSG, Baseline to 12 Months.	Percent Days Housed, 6 Month	44.4 percent days housed
Arm 2/Housing Support Group (HSG)	Percent Days Housed in AHCM vs. HSG, Baseline to 12 Months.	Percent Days Housed, 9 Month	48.5 percent days housed

Secondary

Change in Alcohol and Drug Outcomes in AHCM vs. HSG From Baseline to 12 Months

Determine if Addiction/Housing Case Management compared to a Housing Support Group control significantly improved alcohol and drug outcomes, as measured by Alcohol and Drug Composite Scores (range 0 to 1, with higher scores indicating greater severity) on the Addiction Severity Index (ASI), among homeless Veterans entering addiction specialty care over the 12-month study course. Negative change on the ASI measures indicates improvement.