Background Individuals who are homeless or vulnerably housed are at an increased risk for mental illness, other morbidities and premature death. Standard case management interventions as well as more intensive models with practitioner support, such as assertive community treatment, critical time interventions, and intensive case management, may improve healthcare navigation and outcomes. However, the definitions of these models as well as the fidelity and adaptations in real world interventions are highly variable. We conducted a systematic review to examine the effectiveness and cost-effectiveness of case management interventions on health and social outcomes for homeless populations. Methods and findings We searched Medline, Embase and 7 other electronic databases for trials on case management or care coordination, from the inception of these databases to July 2019. We sought outcomes on housing stability, mental health, quality of life, substance use, hospitalization, income and employment, and cost-effectiveness. We calculated pooled random effects estimates and assessed the certainty of the evidence using the GRADE approach. Our search identified 13,811 citations; and 56 primary studies met our full inclusion criteria. Standard case management had both limited and short-term effects on substance use and housing outcomes and showed potential to increase hostility and depression. Intensive case

BackgroundPersons experiencing homelessness and vulnerable housing or those with lived experience of homelessness have worse health outcomes than individuals who are stably housed. Structural violence can dramatically affect their acceptance of interventions. We carried out a systematic review to understand the factors that influence the acceptability of social and health interventions among persons with lived experience of homelessness.MethodsWe searched through eight bibliographic databases and selected grey literature sources for articles that were published between 1994 and 2019. We selected primary studies that reported on the experiences of homeless populations interacting with practitioners and service providers working in permanent supportive housing, case management, interventions for substance use, income assistance, and women- and youth-specific interventions. Each study was independently assessed for its methodological quality. We used a framework analysis to identify key findings and used the GRADE-CERQual approach to assess confidence in the key findings.FindingsOur search identified 11,017 citations of which 35 primary studies met our inclusion criteria. Our synthesis highlighted that individuals were marginalized, dehumanized and excluded by their lived homelessness experience. As a result, trust and personal safety were highly valued within human interactions. Lived experience of homelessness influenced attitudes toward health and social service professionals and sometimes led to reluctance to accept interventions. Physical and structural violence intersected with low self-esteem, depression and homeless-related stigma. Positive self-identity facilitated links to long-term and integrated services, peer support, and patient-centred engagement.ConclusionsIndividuals with lived experience of homelessness face considerable marginalization, dehumanization and structural violence. Practitioners and social service providers should consider anti-oppressive approaches and provide, refer to, or advocate for health and structural interventions using the principles of trauma-informed care. Accepting and respecting others as they are, without judgment, may help practitioners navigate barriers to inclusiveness, equitability, and effectiveness for primary care that targets this marginalized population.

Objectives: In Canada, alternate-level-of-care (ALC) beds in hospitals may be used when patients who do not require the intensity of services provided in an acute care setting are waiting to be discharged to a more appropriate care setting. However, when there is a lack of care options for patients waiting to be discharged, it contributes to prolonged hospital stays and bottlenecks in the health care system manifested as "hallway medicine." We examined the effectiveness of a function-focused transitional care program, the Sub-Acute care for Frail Elderly (SAFE) Unit, in reducing the length of stay (LOS) in hospital, as well as post-discharge acute care use and continuity of care. Design: Case-control study. Setting and Participants: A 450-bed nursing home located in Ontario, Canada, where the SAFE Unit is based. The study population included frail, older patients aged 60 years and older who received care in the SAFE Unit between March 1, 2018, and February 28, 2019 (n ¼ 153) to controls comprising of other hospitalized patients (n ¼ 1773). Methods: We linked facility-level to provincial health administrative databases on hospital admissions and emergency department (ED) visits, and the Ontario Health Insurance Plan claims database for physician billings to investigated the LOS during the index hospitalization, 30-day odds of post-discharge ED visits, hospital readmission, and follow-up with family physicians. Results: SAFE patients had a median hospital LOS of 13 days [interquartile range (IQR): 8e19 days], with 75% having fewer than 1 day in an ALC bed. In comparison, the median LOS in the control group was 15 days (IQR: 10e24 days), with one-third of those days spent in an ALC bed (median: 5 days, IQR: 3 e10 days). SAFE patients were more likely (64.1%) to be discharged home than control patients (46.3%). Both groups experienced similar 30-day odds of ED visits, hospital readmission and follow-up with a family physician. Conclusions and Implications: Frail older individuals in the SAFE Unit experienced shorter hospital stays, were less likely to be discharged to settings other than home and had similar 30-day acute care outcomes as control patients post-discharge.

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