Integrating Hospital and Community Care for Homeless People with Unmet Mental Health Needs: Program Rationale, Study Protocol and Sample Description of a Brief Multidisciplinary Case Management Intervention

  • Vicky StergiopoulosEmail author
  • Agnes Gozdzik
  • Rosane Nisenbaum
  • Denise Lamanna
  • Stephen W. Hwang
  • Joshua Tepper
  • Don Wasylenki
Original Article


The Coordinated Access to Care for Homeless People (CATCH) program is a brief multidisciplinary case management intervention for homeless adults discharged from hospital in Toronto, Canada. Here we describe the rationale for CATCH program development, details of the mixed methods evaluation underway, and the characteristics of 225 CATCH service users. Funded in 2010 by the local health authority, CATCH aimed to improve access, continuity of care, health and service use outcomes for homeless adults discharged from hospital. To assess the feasibility, acceptability and impact of the program, a mixed methods case study was undertaken in 2013. In total, 225 CATCH program users were enrolled in the study and completed quantitative survey measures at program entry to assess key health and social outcomes using a pre-post cohort study design. Follow-up assessments took place at 3- and 6-months. At study entry, most participants were male (79%), white (65%), Canadian-born (74%), single or never married (60%), and their average age was 39.9 ± 12.0 years. Nearly all participants (88%) had at least one emergency department visit in the past 6 months, more than half (53%) indicated at least three chronic health conditions, and 44% indicated at least three mental health diagnoses. In addition, qualitative data was collected to evaluate the experiences of continuity of care and challenges during care transitions for this population using in-depth interviews with a sample of CATCH service users (n = 22) and managers of partnered organizations (n = 7), as well as focus groups with CATCH staff (n = 8), other service providers (n = 7) and people with lived experience of homelessness (n = 8). Improving health and health service use outcomes among homeless adults with chronic health conditions are key priorities in many jurisdictions. Future findings can inform service delivery to homeless adults discharged from hospital, by exposing factors associated with positive program outcomes, as well as barriers and facilitators to continuity of care for this disadvantaged population.


Case management Homeless people Mental illness Health status Health service use Care transitions 



This study received funding support via a grant form Canadian Institutes for Health Research (CIHR). The authors gratefully acknowledge the contributions of the CATCH participants, service providers, and the research team.

Compliance with Ethical Standards

Informed Consent

All procedures followed will be in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000 (5). Informed consent was obtained from all participants for being included in the study.

Authors’ Contributions

VS conceived the study. RN, SWH, JT, and DW participated in the design of the study. DL coordinated study data collection. AG and VS drafted the manuscript. RN performed the statistical analyses. RN, DL, SWH, JT and DW participated in the preparation of the manuscript by providing critical revisions of drafts. All authors read and approved the final manuscript.

Conflict of Interest

VS, AG, RN, DL, SWH, JT and DW declare that they have no conflict of interest.

Supplementary material

11469_2017_9731_MOESM1_ESM.docx (16 kb)
Supplemental Table 1 (DOCX 15 kb)


  1. Asada, Y., & Kephart, G. (2007). Equity in health services use and intensity of use in Canada. BMC Health Services Research, 7, 41. doi: 10.1186/1472-6963-7-41.CrossRefPubMedPubMedCentralGoogle Scholar
  2. Baker, G. R. (2011). Enhancing the continuum of care: Report of the avoidable hospitalization advisory panel. Toronto: Ministry of Health and Long-Term care. Retrieved from Scholar
  3. Barber, C. C., Fonagy, P., Fultz, J., Simulinas, M., & Yates, M. (2005). Homeless near a thousand homes: outcomes of homeless youth in a crisis shelter. American Journal of Orthopsychiatry, 75(3), 347–355. doi: 10.1037/0002-9432.75.3.347.CrossRefPubMedGoogle Scholar
  4. Bharel, M., Lin, W.-C., Zhang, J., O’Connell, E., Taube, R., & Clark, R. E. (2013). Health care utilization patterns of homeless individuals in Boston: preparing for Medicaid expansion under the Affordable Care Act. American Journal of Public Health, 103(S2), S311–S317. doi: 10.2105/AJPH.2013.301421.CrossRefPubMedPubMedCentralGoogle Scholar
  5. Boothroyd, R., & Chen, H. (2008). The psychometric properties of the Colorado Symptom Index. Administration and Policy in Mental Health, 35(5), 370–378.CrossRefPubMedGoogle Scholar
  6. Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101. doi: 10.1191/1478088706qp063oa.CrossRefGoogle Scholar
  7. Brazier, J., Roberts, J., & Deverill, M. (2002). The estimation of a preference-based measure of health from the SF-36. Journal of Health Economics, 21(2), 271–292. doi: 10.1016/S0167-6296(01)00130-8.CrossRefPubMedGoogle Scholar
  8. Busseri, M. A., & Tyler, J. D. (2003). Interchangeability of the Working Alliance Inventory and Working Alliance Inventory, short form. Psychological Assessment, 15(2), 193–197.CrossRefPubMedGoogle Scholar
  9. City of Toronto Shelter Support and Housing Administration (2013). 2013 Street Needs Assessment Results. Retrieved from Toronto, Canada.Google Scholar
  10. Dewa, C. S., Jacobson, N., Durbin, J., Lin, E., Zipursky, R. B., & Goering, P. (2010). Examining the effects of enhanced funding for Specialized Community Mental Health Programs on Continuity of care. Canadian Journal of Community Mental Health, 29(S5), 23–40. doi: 10.7870/cjcmh-2010-0032.CrossRefGoogle Scholar
  11. Fazel, S., Geddes, J. R., & Kushel, M. (2014). The health of homeless people in high-income countries: descriptive epidemiology, health consequences, and clinical and policy recommendations. The Lancet, 384(9953), 1529–1540.CrossRefGoogle Scholar
  12. Fontanella, C. A., Guada, J., Phillips, G., Ranbom, L., & Fortney, J. C. (2014). Individual and contextual-level factors associated with continuity of care for adults with schizophrenia. Administration and Policy in Mental Health, 41(5), 572–587. doi: 10.1007/s10488-013-0500-x.CrossRefPubMedPubMedCentralGoogle Scholar
  13. Fortney, J., Sullivan, G., Williams, K., Jackson, C., Morton, S. C., & Koegel, P. (2003). Measuring continuity of care for clients of public mental health systems. Health Services Research, 38(4), 1157–1175.CrossRefPubMedPubMedCentralGoogle Scholar
  14. Gaetz, S., Dej, E., Richter, T., & Redman, M. (2016). The state of homelessness in Canada 2016. Retrieved from Toronto.Google Scholar
  15. Goering, P., Streiner, D., Adair, C. E., Aubry, T., Barker, J., Distasio, J., … Zabkiewicz, D. (2011). The at Home/Chez Soi trial protocol: a pragmatic, multi-site, randomized controlled trial of Housing First in five Canadian cities. BMJ Open, 1(2), e000323.Google Scholar
  16. Greenberg, G. A., & Rosenheck, R. A. (2005). Continuity of care and clinical outcomes in a national health system. Psychiatric Services, 56(4), 427–433. doi: 10.1176/ Scholar
  17. Grinman, M. N., Chiu, S., Redelmeier, D. A., Levinson, W., Kiss, A., Tolomiczenko, G., … Hwang, S. W. (2010). Drug problems among homeless individuals in Toronto, Canada: prevalence, drugs of choice, and relation to health status. BMC Public Health, 10, 94. doi: 10.1186/1471-2458-10-94.
  18. Haggerty, J. L., Reid, R. J., Freeman, G. K., Starfield, B. H., Adair, C. E., & McKendry, R. (2003). Continuity of care: a multidisciplinary review. BMJ, 327(7425), 1219–1221. doi: 10.1136/bmj.327.7425.1219.CrossRefPubMedPubMedCentralGoogle Scholar
  19. Hanson, W. E., Curry, K. T., & Bandalos, D. L. (2002). Reliability generalization of Working Alliance Inventory Scale Scores. Educational and Psychological Measurement, 62(4), 659–673. doi: 10.1177/0013164402062004008.CrossRefGoogle Scholar
  20. Harris, P. A., Taylor, R., Thielke, R., Payne, J., Gonzalez, N., & Conde, J. G. (2009). Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. Journal of Biomedical Informatics, 42(2), 377–381. doi: 10.1016/j.jbi.2008.08.010.CrossRefPubMedGoogle Scholar
  21. Herman, D. B., Opler, L., Felix, A., Valencia, E., Wyatt, R. J., & Susser, E. (2000). A critical time intervention with mentally ill homeless men: impact on psychiatric symptoms. Journal of Nervous and Mental Disease, 188(3), 135–140.CrossRefPubMedGoogle Scholar
  22. Herman, D. B., Conover, S., Felix, A., Nakagawa, A., & Mills, D. (2007). Critical time intervention: an empirically supported model for preventing homelessness in high risk groups. Journal of Primary Prevention, 28(3–4), 295–312. doi: 10.1007/s10935-007-0099-3.CrossRefPubMedGoogle Scholar
  23. Herman, D. B., Conover, S., Gorroochurn, P., Hinterland, K., Hoepner, L., & Susser, E. S. (2011). Randomized trial of critical time intervention to prevent homelessness after hospital discharge. Psychiatric Services, 62(7), 713–719. doi: 10.1176/ Scholar
  24. Horvath, A. O., & Greenberg, L. S. (1989). Development and validation of the Working Alliance Inventory. Journal of Counseling Psychology, 36(2), 223–233.CrossRefGoogle Scholar
  25. Hwang, S. W. (2001). Homelessness and health. CMAJ: Canadian Medical Association Journal, 164(2), 229–233.PubMedPubMedCentralGoogle Scholar
  26. Hwang, S. W., Tolomiczenko, G., Kouyoumdjian, F. G., & Garner, R. E. (2005). Interventions to improve the health of the homeless: a systematic review. American Journal of Preventive Medicine, 29(4), 311–319. doi: 10.1016/j.amepre.2005.06.017.CrossRefPubMedGoogle Scholar
  27. Hwang, S. W., Weaver, J., Aubry, T., & Hoch, J. S. (2011). Hospital costs and length of stay among homeless patients admitted to medical, surgical, and psychiatric services. Medical Care, 49(4), 350–354. doi: 10.1097/MLR.0b013e318206c50d.CrossRefPubMedGoogle Scholar
  28. Jones, K., Colson, P. W., Holter, M. C., Lin, S., Valencia, E., Susser, E., & Wyatt, R. J. (2003). Cost-effectiveness of critical time intervention to reduce homelessness among persons with mental illness. Psychiatric Services, 54(6), 884–890.CrossRefPubMedGoogle Scholar
  29. Joyner, L. M., Wright, J. D., & Devine, J. A. (1996). Reliability and validity of the addiction severity index among homeless substance misusers. Substance Use and Misuse, 31(6), 729–751.CrossRefPubMedGoogle Scholar
  30. Kashner, T., Rosenheck, R., Campinell, A., et al. (2002). Impact of work therapy on health status among homeless, substance-dependent veterans: a randomized controlled trial. Archives of General Psychiatry, 59(10), 938–944. doi: 10.1001/archpsyc.59.10.938.CrossRefPubMedGoogle Scholar
  31. Kasprow, W. J., & Rosenheck, R. A. (2007). Outcomes of critical time intervention case management of homeless veterans after psychiatric hospitalization. Psychiatric Services, 58(7), 929–935. doi: 10.1176/ Scholar
  32. Kertesz, S. G., Larson, M. J., Horton, N. J., Winter, M., Saitz, R., & Samet, J. H. (2005). Homeless chronicity and health-related quality of life trajectories among adults with addictions. Medical Care, 43(6), 574–585.CrossRefPubMedGoogle Scholar
  33. Lehman, A. F., Dixon, L. B., Kernan, E., DeForge, B. R., & Postrado, L. T. (1997). A randomized trial of assertive community treatment for homeless persons with severe mental illness. Archives of General Psychiatry, 54(11), 1038–1043.CrossRefPubMedGoogle Scholar
  34. Lennon, M. C., McAllister, W., Kuang, L., & Herman, D. B. (2005). Capturing intervention effects over time: reanalysis of a critical time intervention for homeless mentally ill men. American Journal of Public Health, 95(10), 1760–1766. doi: 10.2105/AJPH.2005.064402.CrossRefPubMedPubMedCentralGoogle Scholar
  35. Lewis, S. (2015). A system in name only—Access, variation, and reform in Canada’s Provinces. New England Journal of Medicine, 372(6), 497–500. doi: 10.1056/NEJMp1414409.CrossRefPubMedGoogle Scholar
  36. McLellan, A. T., Luborsky, L., Woody, G. E., & O’Brien, C. P. (1980). An improved diagnostic evaluation instrument for substance abuse patients. The Addiction Severity Index. Journal of Nervous and Mental Disease, 168(1), 26–33.CrossRefPubMedGoogle Scholar
  37. Miles, M. B., Huberman, A. M., Saldana, J., & Arizona State University. (2014). Qualitative data analysis a methods sourcebook (3rd ed.). Thousand Oaks: SAGE Publications Inc.Google Scholar
  38. Ministry of Health and Long-Term Care (2012a). About health links. Retrieved from
  39. Ministry of Health and Long-Term Care (2012b). Improving care for high-needs patients: McGuinty Government Linking Health Providers, Offering Patients More Co-ordinated Care. Retrieved from
  40. New Hampshire Dartmouth Rehabilitation Centre (1995). Residential follow-back calendar. Retrieved from Lebanon, NH.Google Scholar
  41. Rothbauer, P. (2008). Triangulation. In L. M. Given (Ed.), The SAGE encyclopedia of qualitative research methods. Thousand Oaks: SAGE Publications Ltd.Google Scholar
  42. Salize, H. J., Werner, A., & Jacke, C. O. (2013). Service provision for mentally disordered homeless people. Current Opinion in Psychiatry, 26(4), 355–361. doi: 10.1097/YCO.0b013e328361e596.CrossRefPubMedGoogle Scholar
  43. Seidman, L. J., Schutt, R. K., Caplan, B., Tolomiczenko, G. S., Turner, W. M., & Goldfinger, S. M. (2003). The effect of housing interventions on neuropsychological functioning among homeless persons with mental illness. Psychiatric Services, 54(6), 905–908.CrossRefPubMedGoogle Scholar
  44. Singer, J. D., & Willett, J. B. (2003). Applied longitudinal data analysis: Modeling change and event occurrence. New York Oxford University Press.Google Scholar
  45. Stake, R. (2005). Qualitative case studies. In N. K. Denzin & Y. S. Lincoln (Eds.), The Sage handbook of qualitative research (3rd ed., pp. 433–466). Thousand Oaks: Sage.Google Scholar
  46. Stergiopoulos, V., Cusi, A., Bekele, T., Skosireva, A., Latimer, E., Schutz, C., … Rourke, S. B. (2015). Neurocognitive impairment in a large sample of homeless adults with mental illness. Acta Psychiatrica Scandinavica, 131(4), 256–268. doi: 10.1111/acps.12391.
  47. Susser, E., Valencia, E., Conover, S., Felix, A., Tsai, W. Y., & Wyatt, R. J. (1997). Preventing recurrent homelessness among mentally ill men: a “critical time” intervention after discharge from a shelter. American Journal of Public Health, 87(2), 256–262.CrossRefPubMedPubMedCentralGoogle Scholar
  48. Tomita, A., & Herman, D. B. (2012). The impact of critical time intervention in reducing psychiatric rehospitalization after hospital discharge. Psychiatric Services, 63(9), 935–937. doi: 10.1176/ Scholar
  49. Tomita, A., & Herman, D. B. (2015). The role of a critical time intervention on the experience of continuity of care among persons with severe mental illness after hospital discharge. Journal of Nervous and Mental Disease, 203(1), 65–70. doi: 10.1097/NMD.0000000000000224.CrossRefPubMedPubMedCentralGoogle Scholar
  50. Tsemberis, S., McHugo, G., Williams, V., Hanrahan, P., & Stefancic, A. (2007). Measuring homelessness and residential stability: the residential time-line follow-back inventory. Journal of Community Psychology, 35(1), 29–42.CrossRefGoogle Scholar
  51. Ware, J. E., Jr., & Sherbourne, C. D. (1992). The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Medical Care, 30(6), 473–483.CrossRefPubMedGoogle Scholar
  52. Ware, J. E., Jr., Snow, K., Kosinski, M., & Gandek, B. (1993). SF-36 Health Survey Manual and Interpretation Guide Boston. MA: New England Medical Centre, The Health Institute.Google Scholar

Copyright information

© Springer Science+Business Media New York 2017

Authors and Affiliations

  • Vicky Stergiopoulos
    • 1
    • 2
    • 3
    Email author
  • Agnes Gozdzik
    • 2
  • Rosane Nisenbaum
    • 2
    • 4
  • Denise Lamanna
    • 2
  • Stephen W. Hwang
    • 2
    • 5
  • Joshua Tepper
    • 6
  • Don Wasylenki
    • 3
  1. 1.Centre for Addiction and Mental HealthTorontoCanada
  2. 2.Centre for Urban Health Solutions, Li Ka Shing Knowledge InstituteSt. Michael’s HospitalTorontoCanada
  3. 3.Department of PsychiatryUniversity of TorontoTorontoCanada
  4. 4.Dalla Lana School of Public HealthUniversity of TorontoTorontoCanada
  5. 5.Division of General Internal Medicine, Department of MedicineUniversity of TorontoTorontoCanada
  6. 6.Health Quality OntarioTorontoCanada

Personalised recommendations