Clinical trial NCT01346514: Addiction Housing Case Management for Homeless Veterans
Official title: Addiction Housing Case Management for Homeless Veterans Enrolled in Addictions Treatment
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: NA
Conditions: Homelessness
Substance Abuse Disorders
Mental Disorders
Keywords: Homeless Persons
Housing
Case Management
Veterans
Substance Related Disorders
Mental Disorders
Social Adjustment
Lead sponsor: VA Office of Research and Development
Sponsor class: FED
First posted: 2011-05-03
Enrollment: 181
Sex: ALL
Minimum age (years): 18
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: PARALLEL
Primary purpose: HEALTH_SERVICES_RESEARCH

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.

Eligibility criteria: 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

Primary outcomes:
measure: Percent Days Housed in AHCM vs. HSG, Baseline to 12 Months.
timeFrame: 12 months (18 to 24 month outcomes examined in secondary analyses)
Secondary outcomes:
measure: Costs and Cost-effectiveness of AHCM vs. HSG, Baseline to 12 Months
timeFrame: Baseline to 12 months
measure: Change in Functional Status in AHCM vs. HSG From Baseline to 12 Months
timeFrame: Baseline to 12 months
measure: Change in Alcohol and Drug Outcomes in AHCM vs. HSG From Baseline to 12 Months
timeFrame: Baseline to 12 months
measure: Change in Percent of Participants Abstinent From Baseline to 12 Month Follow-up
timeFrame: Baseline to 12 months
measure: Change in Mental Health Status in AHCM vs. HSG From Baseline to 12 Months
timeFrame: Baseline to 12 months
measure: Treatment Process Measures (Number of Treatment Sessions, Type of Housing Placement, and Change in Life Skills)
timeFrame: Baseline to 12 months
Other outcomes:
Locations:
city: Seattle
country: United States
facility: VA Puget Sound Health Care System Seattle Division, Seattle, WA
state: Washington
Study officials:
affiliation: VA Puget Sound Health Care System Seattle Division, Seattle, WA
name: Andrew J. Saxon, MD
role: PRINCIPAL_INVESTIGATOR
References:
citation: Malte CA, Cox K, Saxon AJ. Providing intensive addiction/housing case management to homeless veterans enrolled in addictions treatment: A randomized controlled trial. Psychol Addict Behav. 2017 May;31(3):231-241. doi: 10.1037/adb0000273.
citation: Cox KB, Malte CA, Saxon AJ. Characteristics and service utilization of homeless veterans entering VA substance use treatment. Psychol Serv. 2017 May;14(2):208-213. doi: 10.1037/ser0000133.