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- Anttila, Sten, et al.
(författare)
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Housing programs and case management for reducing homelessness and increasing residential stability for homeless people
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Annan publikation (övrigt vetenskapligt/konstnärligt)abstract
- The Universal Declaration of Human Rights (Article 25) states that everyone has a right to housing. Yet according to the UNHCR there are approximately 100 million homeless people worldwide. Homelessness has many negative detrimental consequences on an individual as well as on a societal level. The condition of homeless seriously affects well-being and health in general and may contribute to mental illness in particular. Once homeless, people tend to be deprived of economic, social and psychological resources that are necessary in order to get a new accommodation. If this happens the resources of some clients may be too poor and few to prevent future evictions.Case management is a collaborative process, including assessment, planning, facilitation and advocacy for options and services, intended to make sure that the client’s needs are met. Intensive case management, including assertive community treatment, is intended to ensure that the client receives sufficient services, support and treatment when and where it is needed. In this way intensive case management (case load <1:15, 24-7 availability, and the combined competence of a multidisciplinary team), may help homeless people to obtain accommodation, and once housed avoid eviction.Housing programs are more or less based on housing philosophies. According to one philosophy stable and independent housing is needed for the client to become treatment ready. Housing should neither be contingent on sobriety nor on treatment compliance, but only on rules that apply for ordinary tenants. In other words housing is parallel to and not integrated with treatment, or with other services. An alternative philosophy is based on the assumption that some clients (possibly those with a bio-chemical dependence on drugs) may need a transitional period of sobriety and treatment compliance, before they can live independently in their own apartments. Without this transitional phase the assumption is that they will soon face eviction, and return to homelessness. According to this philosophy housing is integrated with treatment. By combining housing and case management within the framework of a comprehensive program, the work to find accommodation and to prevent eviction is assumed to be facilitated.The objective was to assess the effectiveness of 9 possible combinations of housing programs and case management as means to increase residential stability and reduce homelessness. The possible combinations were based on three housing alternatives and three case management alternatives which entails 36 possible comparisons:Housing parallel to treatment, housing integrated with treatment, and no housingIntensive of case management (ICM and ACT), ordinary case management, and no case management.Electronic databases were searched by means of terms referring to population, intervention, and design (Campbell Library, Cochrane Library (including CENTRAL), PubMed, PsycINFO, Sociological Abstracts, Social Services Abstracts, ASSIA, CINAHL, ERIC, and Dissertation Abstracts International). Reference lists were hand searched, and international experts were contacted. For a study to be included the following criteria had to be met:Population: homeless or at risk of becoming homelessIntervention: housing programs with case management, housing programs without case management, or case management without a housing programComparison: any of the alternative interventions above, plus usual care, waiting lists, or no interventionOutcome: residential stability or homelessnessDesign: randomized controlled trials or observational studies (with comparison groups matched at baseline or on propensity scores)Pairs of reviewers independently screened abstracts, and read full text documents. Data was extracted and coded by two reviewers. Two reviewers also assessed risks of bias for each study and their outcomes. In several cases data had to be recalculated in order to fit the format necessary for meta-analysis based on Review Manager.After screening 1, 764 abstracts and assessing 276 documents in full text, 32 unique studies were included (26 randomized controlled trials and 6 observational studies) in this review. All studies were from the USA except three, which were undertaken in the UK (two randomized controlled trials and one observational study). The number of included studies is thus relatively high, but the body of evidence is poor, as most studies are characterized by high risk of aggregated bias (11 studies) or moderate risk of aggregated bias (15 studies and 19 comparisons). Only 6 studies were classified as having low aggregated risk of bias. In addition, most studies are rather old. The median publication year is 1998. There are 16 studies published between 2000 and 2010 (11 randomized trials and five observational studies). Since 2005 only five included studies were published (three randomized trials and two observational studies). The results can be summarized in seven points:a) Housing parallel to treatment is not superior to housing integrated with treatment or vice versa.b) Empirical results indicate that parallel housing as such is superior to no housing.c) There is not sufficient evidence to conclude that integrated housing as such is superior to no housing.d) Empirical results indicate that intensive case management as such (ACT and ICM) is superior to usual care (such as drop in centers, outpatient treatment, ordinary after care, etc.).e) Empirical results indicate that parallel housing in combination with intensive case management (ACT and ICM) is superior to usual care (such as drop in centers, outpatient treatment, ordinary after care, etc.).f)There is not sufficient evidence to conclude that integrated housing in combination with intensive case management (ACT and ICM) is superior to usual care (such as drop in centers, outpatient treatment, ordinary after care, etc.) Conclusion: Parallel housing, in combination with intensive case management (ICM and ACT), improves housing outcomes in comparison to usual care (outpatient treatment, drop in centers, ordinary after care, brokered case management, etc.). Intensive case management as well as housing contributes to this effect. However, evidence is not decisive when parallel housing is compared to integrated housing. Empirical results are highly contradictory. Studies focusing on specific subgroups such as women and persons with severe substance abuse problems are required.
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