Effectiveness of a housing support team intervention with a recovery-oriented approach on hospital and emergency department use by homeless people with severe mental illness: a randomised controlled trial

Abstract

Aims Many people who are homeless with severe mental illnesses are high users of healthcare services and social services, without reducing widen health inequalities in this vulnerable population. This study aimed to determine whether independent housing with mental health support teams with a recovery-oriented approach (Housing First (HF) program) for people who are homeless with severe mental disorders improves hospital and emergency department use. Methods We did a randomised controlled trial in four French cities: Lille, Marseille, Paris and Toulouse. Participants were eligible if they were 18 years or older, being absolutely homeless or precariously housed, with a diagnosis of schizophrenia (SCZ) or bipolar disorder (BD) and were required to have a high level of needs (moderate-to-severe disability and past hospitalisations over the last 5 years or comorbid alcohol or substance use disorder). Participants were randomly assigned (1:1) to immediate access to independent housing and support from the Assertive Community Treatment team (social worker, nurse, doctor, psychiatrist and peer worker) (HF group) or treatment as usual (TAU group) namely pre-existing dedicated homeless-targeted programs and services. Participants and interviewers were unmasked to assignment. The primary outcomes were the number of emergency department (ED) visits, hospitalisation admissions and inpatient days at 24 months. Secondary outcomes were recovery (Recovery Assessment Scale), quality of life (SQOL and SF36), mental health symptoms, addiction issues, stably housed days and cost savings from a societal perspective. Intention-to-treat analysis was performed. Results Eligible patients were randomly assigned to the HF group (n = 353) or TAU group (n = 350). No differences were found in the number of hospital admissions (relative risk (95% CI), 0.96 (0.76–1.21)) or ED visits (0.89 (0.66–1.21)). Significantly less inpatient days were found for HF v. TAU (0.62 (0.48–0.80)). The HF group exhibited higher housing stability (difference in slope, 116 (103–128)) and higher scores for sub-dimensions of S-QOL scale (psychological well-being and autonomy). No differences were found for physical composite score SF36, mental health symptoms and rates of alcohol or substance dependence. Mean difference in costs was €-217 per patient over 24 months in favour of the HF group. HF was associated with cost savings in healthcare costs (RR 0.62(0.48–0.78)) and residential costs (0.07 (0.05–0.11)). Conclusion An immediate access to independent housing and support from a mental health team resulted in decreased inpatient days, higher housing stability and cost savings in homeless persons with SCZ or BP disorders.

The Effect of a Housing First Intervention on Acute Health Care Utilization among Homeless Adults with Mental Illness: Long-term Outcomes of the At Home/Chez-Soi Randomized Pragmatic Trial

“…For participants with high needs at baseline, receiving HF with ACT support, there were no significant effects on all-cause and mental health hospitalizations, but a significant reduction in the number of days in hospital as well as the number of ED visits. A study of an HF intervention in four French cities among high-need participants similarly found no significant effects on hospitalization or ED visits, but reduced inpatient days [ 26 ]. Another randomized study of the effects of permanent supportive housing for chronically homeless high users of multiple systems in Santa Clara County, California (USA) found no effects on ED or inpatient care use [ 27 ].…”

Residential Mobility of a Cohort of Homeless People in Times of Crisis: COVID-19 Pandemic in an European Metropolis

“…In an ideal world, the 'step-by-step' model aims to facilitate the progressive movement of homeless people from the streets to emergency shelters (ETHOS 2), and then onwards to stabilization shelters (ETHOS 3) in order to help prepare them for private housing. This model remains dominant at the policy level, despite the existence of other models like Housing First, which promote direct and unconditional access to housing and have proven more effective at producing housing stability [29,30]. Our study shows (Figure 4) that there were very few instances of people moving from homeless directly to private housing, and lots of people in the step-by-step model, experiencing long stays in emergency shelters and little access to stabilization shelters at a later stage.…”

Mortality among inpatients with bipolar disorders and COVID-19: a propensity score matching analysis in a national French cohort study

“…The overrepresentation of socially favored patients with BD may also suggest lower access to hospital care in deprived patients with BD than in controls. Previous studies have suggested that, among deprived individuals, patients with severe mental illnesses, such as BD, are some of the most underserved and undertreated populations (Nielsen et al, 2019 ; Tinland et al, 2020 ). In a recent study on homeless individuals, the main negative predictors for hospital use were a lower social functioning score and BDs (Loubière et al, 2020 ).…”