CTI Model

Research Hidden

Critical Time Intervention for Men in Transition from a Shelter-Based Psychiatric Program PI: Ezra Susser, funded by the National Institute of Mental Health (NIMH), 1991-1996
This first randomized trial of the nine-month CTI model assessed its effectiveness in preventing homelessness among 96 men with serious mental disorder being placed into community housing from a large shelter in New York City. The men were followed up for 18 months.
FINDINGS

• Homelessness was reduced three-fold, and the effect persisted past the end of the active intervention. (Susser et al 1997)
• An economic analysis supported the cost-effectiveness of the intervention. (Jones et al 2003)
• Latent class growth analysis provided further evidence of the impact of CTI on reducing the risk of homelessness during the follow-up period. (Lennon et al 2005)
• Results from analysis of symptom data for 72 men showed that CTI was associated with a statistically significant decrease in negative symptoms. (Herman et al 2000)

PUBLICATIONS

• Susser, E., Valencia, E., Conover, S., Felix, A., Tsai, W., & Wyatt, R. (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.
• Conover, S., Berkman, A., Gheith, A., Jahiel, R., Stanley, D., Geller, P. A., et al. (1997). Methods for successful follow-up of elusive urban populations: an ethnographic approach with homeless men. Bulletin of the NY Academy of Medicine, 74(1), 90-108.
• Jones, K., Colson, P. W., Holter, M. C., Lin, S., Valencia, E., Susser, E., Wyatt, J.W. (2003). Cost-effectiveness of critical time intervention to reduce homelessness among persons with mental illness. Psychiatric Services, 54(6), 884-890.
• 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.
• Herman, D., Opler, L., A Felix, Valencia, E., R Wyatt, & Susser, E. (2000). Critical time intervention: Impact on psychiatric symptoms. Journal of Nervous and Mental Disease, 188(3), 135-140.
• Schutt, R.K., Hough, R.L., Goldfinger, S.M., Lehman, A.F., Shern, D.D., Valencia, E., Wood, P.A. (2009). Lessening homelessness among persons with mental illness: A comparison of five randomized treatment trials. Asian Journal of Psychiatry, 2(3), 100-105.

CTI Case Management of Homeless Veterans after Psychiatric Hospitalization PI: Wesley Kasprow, funded by the US Department of Veterans Affairs (VA), 2001-2004
The authors used a pre-post cohort design to compare two groups of homeless veterans with serious mental illness after discharge from eight VA medical centers across five states: 1) 278 veterans recruited before CTI was implemented; and 2) 206 veterans who were offered CTI.
FINDINGS:

• Veterans receiving CTI had on average 19% more days housed in each 90-day reporting period over the one-year follow-up. They also reported lower substance use and psychiatric problems.

PUBLICATIONS

• 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.

Brief Critical Time Intervention (B-CTI) PI: Lisa Dixon, funded by the Department of Veterans Affairs (VA), 2003
This randomized trial of 135 veterans with serious mental illness assessed the effectiveness of a brief CTI intervention (B-CTI) in attaining a limited outcome, namely to increase outpatient visits during the first three months after discharge from psychiatric hospital.

FINDINGS

• The B-CTI group had greater continuity of care (i.e., more two-month blocks of at least two outpatient visits) over six months than the control group.
• The B-CTI group had significantly fewer days between their hospital discharge and their first outpatient service than the control group.

PUBLICATIONS

• Dixon, L., Goldberg, R., Iannone, V., Lucksted, A., Brown, C., Kreyenbuhl, J., Fang, L., Potts, W. (2009) Use of a critical time intervention to promote continuity of care after psychiatric inpatient hospitalization. Psychiatric Services, 60(4), 451-458.

The Family Critical Time Intervention Study (F-CTI) PI: Judith Samuels, funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) and by the National Institute of Mental Health (NIMH), 2001-2005

This randomized trial evaluated a program that combined the Housing First model of rapid re-housing with Family CTI among 228 single-parent homeless families, where the mothers had a mental health and/or substance abuse problem. It tested the program’s effectiveness in improving the residential stability and mental health of the mothers and children. Families were followed over a 15-month period.

PUBLICATIONS

• Samuels, J., Shinn, M., Fischer, S., Thompkins, A., & Park, H. (2006). The impact of the family Critical Time Intervention on homeless children: Final report to the National Institute of Mental Health. Orangeburg, NY: Nathan Kline Institute of Psychiatric Research.
• Samuels J. Strengthening at risk and homeless young mothers and children. Needham, MA: National Center on Family Homelessness; 2010. Young family critical time intervention (CTI): Successful transitions from homelessness to stability.
• Shinn, M., Samuels, J., & Fisher, S. Effects of a family critical time intervention and passage of time on homeless children. (under review)
• Shinn, M.B., Samuels, J., Fischer, S. N., Thompkins, A., & Fowler, P. J. Family Critical Time Intervention: Longitudinal randomized controlled-trial testing effects on homeless children. (Manuscript in preparation).

Critical Time Intervention (CTI) in the Transition from Hospital to Community PI: Daniel Herman, funded by the National Institute of Mental Health (NIMH), 2001-2007
Following on the encouraging results of the first trial with men discharged from the shelter, this second randomized trial tested CTI with 150 previously homeless adults with serious mental illness following discharge from two psychiatric hospitals.

FINDINGS

• The prevalence of homelessness among participants receiving CTI was ~five times lower than among those receiving usual care. (Herman et al 2011)
• CTI was also associated with a significantly reduced risk of rehospitalization. (Tomita et al 2012)

PUBLICATIONS

• Herman, D.B., Conover, S., Gorroochurn, P., Hinterland, K., Hoepner, L., Susser, E. (2011) Randomized trial of Critical Time Intervention to prevent homelessness after hospital discharge. Psychiatric Services, 62: 713-719.
• Tomita, A., Herman, D. (2012) The impact of critical time intervention in reducing psychiatric rehospitalization after hospital discharge. Psychiatric Services, 63:935-937.
• Baumgartner, J., Herman, D. (2012) Community integration of formerly homeless men and women with severe mental illness after hospital discharge. Psychiatric Services, 63(5), 435-7.
• Manuel, J., Hinterland, K., Conover, S. and Herman, D. (2012) “I hope I can make it out there”: perceptions of women with server mental illness on the transition from hospital to community. Community Mental Health Journal, 48:302-308.
• Tomita, A., Lukens, E.P., Herman, D.B., (2013) Mediation analysis of critical time intervention for persons living with serious mental illnesses: Assessing the role of family relations in reducing psychiatric rehospitalization. Psychiatric Rehabilitation Journal. epub ahead of print.
• Chen, F.P. (2013) Developing community support for homeless people with mental illness in transition. Community Mental Health Journal, epub ahead of print.

Critical Time Intervention and Released Prisoners PI: Jenny Shaw, funded by the Medical Research Council, 2007
This pilot randomized trial tested the feasibility of two different models of implementing CTI with mentally ill men upon release from prisons in London and Manchester: 1) prison-based and 2) community-based with the CTI manager visiting the prison.

FINDINGS

• Participants receiving CTI were significantly more likely to engage with mental health services upon discharge (61%) than those receiving treatment as usual (10%).

PUBLICATIONS

• Jarrett, M., Thornicroft, G., Forrester, A., Harty, M., Senior, J., King, C., Huckle, S., Parrott, J., Dunn, G., and Shaw, J. (2012) Continuity of care for recently released prisoners with mental illness: a pilot randomised controlled trial testing the feasibility of a Critical Time Intervention. Epidemiology and Psychiatric Sciences, 21:187-193.

CTI Training & Technical Assistance Evaluation PI: Peggy Shorr, funded by Mizuho Foundation, 2007-2008
The Center for Urban Community Services (CUCS) partnered with CTI researchers at the Columbia University Center for Homelessness Prevention Studies to design and implement an in-person training curriculum, consisting of two 4-hour training sessions followed by on-site consultation with each team. This study tested the effectiveness of the training in helping three agencies – The Bridge, Puerto Rican Family Institute (PRFI) and Common Ground Community – to understand and successfully implement the CTI model. This project was part of a larger effort to expand dissemination efforts on a national scale.

FINDINGS

• Overall ratings of the two training sessions by the Bridge and PRFI teams were ‘very good’ to ‘excellent’ with trainees reporting that both offered a good balance of issues covered. (Common Ground Community started their program later)
• The overall fidelity score across the three sites was 4, well implemented (89%).

PUBLICATIONS

• Center for Urban Community Services. CTI Training & Technical Assistance Evaluation: Final Report, February 13, 2008.

Project Aspire PI: Elizabeth Cleek, funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), 2005-2010
This award-winning project used three evidence-based practices (CTI, Seeking Safety, and Wellness-Self Management) with the aim of positively impacting sustainable housing placements for 143 homeless women with mental illness and chemical abuse histories after discharge from a shelter in Brooklyn, NY.

FINDINGS

• Within one year of placement, the 106 housed women had significantly low levels (6.6%) of recidivism to the shelter compared to the average recidivism level (14.9%) to the NYC adult shelter system within a year.

Project Connect PI: Ilana Nossell, funded by New York State Health Foundation, 2009-2010
This quasiexperimental study evaluated the effectiveness of Project Connect, a pilot program with 97 homeless men, who were frequent users of a psychiatric emergency room (CPEP) in New York City. The goal was to engage the men with outpatient treatment and other community supports in order to promote recovery and decrease subsequent use of the CPEP. This was the first CTI program to use peer specialists to deliver the intervention.

FINDINGS

• Outpatient service use increased significantly among Project Connect participants both during and after the intervention, while it declined in the comparison group.
• There was no difference between the two groups in their reduction of use of emergency or inpatient services.

CTI for Men with Mental Illness Leaving Prison PI: Jeffrey Draine funded by the National Institute of Mental Health (NIMH), 2006 – 2011
This is the first randomized trial to test CTI following incarceration. It tested the effectiveness of CTI in preventing re-offending and improving community integration for 215 men with serious mental illness, who had been released to Camden County from seven New Jersey prisons.

Mental Illness and Community Reentry in a Multi-Ethnic Population of Female Inmates PI: Cathleen E. Willging, funded by the National Institute of Mental Health (NIMH), 2008-2011

This project utilized a combination of research methods with 99 prisoners and members of their social support networks to adapt CTI for female inmates in the predominantly rural state of New Mexico. This was in preparation for a larger study of the effectiveness of the adapted CTI in enhancing mental health and criminal justice outcomes.

Evidence-Based Practice in Community-Based Social Work: A Multi-Media Strategy – Phases I-II PI: Jeffrey Olivet, funded by the National Institute of Mental Health (NIMH), 2008-2013
The Center for Social Innovation (C4SI) partnered with CTI researchers at the Columbia University Mailman School of Public Health to design and implement an eight-week online instructor-led CTI training curriculum.

For Phase I: 27 participants representing 21 agencies in 12 states were recruited for a pilot study. Evaluation involved pre- and post-course written evaluations and telephone interviews.

For Phase II: a randomized trial compared the online course that combined live and multimedia self-paced elements to the in-person training (see Mizuho grant above) provided by the Center for Urban Community Services (CUCS) to train 179 providers from 19 agencies across the US and Canada. Both had a comparable curriculum and involved 24 hours of instruction. The in-person curriculum included telephone consultation to assist programs to implement CTI.

FINDINGS

• The pilot study showed promising results in the areas of knowledge gain and retention for the 93% of participants who completed the course. (Olivet et al 2009)
• Within 30 days of completing the course, 80% actively began to implement CTI in their agencies. (Olivet et al 2009)
• Knowledge gains were significant pre vs. post training across both groups; both had comparable means. (Olivet 2013)
• Implementation rates were strong for both groups and higher for the in-person group (100%) than for the online group (78%). (Olivet 2013)
• Fidelity to the model, using the CTI Fidelity ScaleTM, was comparable across the two groups. (Olivet 2013)

PUBLICATIONS

• Olivet, J., Johnston, S.C., Zerger, S. Small Business Innovation Research Phase I Evidence-Based Practice in Community-Based Social Work: A Multi-Media Strategy Final Report, October 7, 2013. Newton, Massachusetts: Center for Social Innovation.
• Olivet, J. Small Business Innovation Research Phase II Evidence-Based Practice in Community-Based Social Work: A Multi-Media Strategy Final Report, February 28, 2013. Needham, MA: Center for Social Innovation.

Critical Time Intervention-Brazil (CTI-Br) PI: Maria Tavares Cavalcanti, funded by the Brazilian federal government, 2010
This pilot study recruited 19 people with schizophrenia spectrum disorders served by the Psychosocial Service Centers (CAPS) in Rio de Janeiro to test the feasibility of implementing an adapted CTI for the Brazilian context. The problems of violence, drug use and unemployment in Rio’s favelas are concrete obstacles to continuity of mental health care.

PUBLICATIONS

• Tavares Cavalcanti, M., Carvalho, M., Valencia, E., Magalhães Dahl, C., Mitkiewicz de Souza, F. (2011) Adaptation of Critical Time Intervention for use in Brazil and its implementation among users of psychosocial service centers (CAPS) in the municipality of Rio de Janeiro. Ciência & Saúde Coletiva, 16(12):4635-4642.
• Mitkiewicz de Souza, F., Carvalho, M.C., Valencia, E., Carpinteiro da Silva, T.F., Magalhães Dahl, C., Tavares Cavalcanti, M. (2012) Monitoring of patients within the schizophrenia spectrum: adaptation of intervention for transition periods (“Critical Time Intervention”) for the Brazilian context in psychosocial care centers in the city of Rio de Janeiro. Cadernos Saúde Coletivo, 20(4): 427-435.

CTI for Severely Mentally Ill Released Prisoners: A Randomized Control Trial (CrISP) PI: Jenny Shaw, funded by the British National Institute for Health Research, 2012
After the encouraging results of the pilot, the investigators conducted a full-scale randomized trial at three prisons in Manchester, Leeds and Brixton to test the effectiveness of CTI in improving engagement with services and reducing re-offending.

CTI Netherlands Shelter Study (EffeCTIef) PI: Judith Wolf, funded by the Netherlands government (ZonMw), 2010-2013
Two randomized trials were funded by the same grant:

• The Homeless Sector Trial assessed the effectiveness of CTI in improving housing and other outcomes in people from nine adult homeless shelters.
• The Women’s Shelter Sector Trial assessed the effectiveness of CTI in improving quality of life in women from eight domestic violence shelters.

PUBLICATIONS

• Lako, D.A.M., de Vet, R., Beijersbergen, M.D., Herman, D.B.. van Hemert, A.M.. and Wolf, J.R.L.M. (2014) The effectiveness of critical time intervention for abused women and homeless people leaving Dutch shelters: study protocol of two randomised controlled trials. BMC Public Health, 13, 555.

Critical Time Intervention-Intensive Housing Support Program (CTI-IHSP) Sheryl Carmody, funded by Australian & Western Australian governments under National Partnership Agreement on Homelessness, 2010-2013
The Ruah CTI-IHSP program enrolled 121 people with severe mental illness and at risk for homelessness when they were discharged from mental health inpatient units in Perth. This was the first time that an agency’s electronic medical records were used for generating fidelity ratings.

FINDINGS

• Of the 45 clients with Department of Housing data, 73% remained in stable housing for at least 12 months after discharge. Given that many clients had been struggling for years with unstable housing, this was an extremely successful result. (Lette 2012)
• The fidelity score from an audit of the practices of the IHSP team during the last half of 2011 was 4.6=ideally implemented. (Lette 2012)

PUBLICATIONS

• Lette, H. (2012) Fidelity Audit of Intensive Housing Support Program.
• Lette, H. (2014) The Ruah Intensive Housing Support Program: Adapting evidence based practice. Parity, 37-39.

CTI-Hoarding Disorder (CTI-HD) PI: Carolyn Rodriguez, funded by ECRIP, 2013
The aim of this study is to test whether the adapted CTI-HD reduces the risk of homelessness for people with hoarding disorder who have been threatened with eviction.

Critical Time Intervention–Task Shifting (CTI-TS) Co-PIs: Sandro Galea and Ezra Susser, funded by the National Institute of Mental Health (NIMH), 2012-2016
This multi-country pilot of an adapted CTI (CTI-TS) in Rio de Janeiro in Brazil, Santiago in Chile, and Buenos Aires in Argentina is the first RCT of the CTI model in Latin America. CTI-TS includes peer support workers in addition to community mental health workers, which have been used in previously tested versions of CTI. The primary outcomes of this pilot RCT are to improve quality of life and reduce unmet needs. Among the secondary outcomes is to improve the social integration of the participants.

PUBLICATIONS

• Baumgartner, J.N., Carpinteiro da Silva, T.F., Valencia, E., Susser, E. (2012) Measuring social integration in a pilot randomized controlled trial of Critical Time Intervention-Task Shifting in Latin America. Cadernos Saúde Coletivo, 20(4): 436-439.
• Carpinteiro da Silva, T.F., Lovisi, G.M., Conover, S. (2014) Developing an instrument for assessing fidelity to the intervention in Critical Time Intervention – Task Shifting (CTI-TS) – preliminary report. Archives of Psychiatry and Psychotherapy, 1: 55–62.
• Carpinteiro da Silva, T.F., Lovisi, G., Tavares Cavalcanti, M., Dahl, C., Conover, S., Valencia, E., Susser, E. (2014) Critical time intervention – Task shifting: a new psychosocial intervention for people with severe mental illness in Latin America. Revista Psiquiatria Clínica, 40(6):243.

OTHER CTI PUBLICATIONS

• Thornicroft, G., Susser, E. (2001) Editorial: Evidence-based psychotherapeutic interventions in the community care of schizophrenia. The British Journal of Psychiatry, 178:2-4.
• Herman, D., 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.
• Draine, J., & Herman, D.B. (2007). Critical time intervention for reentry from prison for persons with mental illness. Psychiatric Services, 58(12), 1577-1581.
• Van der Plas, A.G., Abdoelbasier, S., van Hemert, A.M. (2010). Engaging patients with serious mental illness in care services by Critical Time Intervention. Ned Tijddschr Geneeskd, 154, A1791.
• Herman, D., Mandiberg, J. (2010). Critical Time Intervention: model description and implications for the significance of timing social work interventions. Research on Social Work Practice, 20(5), 502-508.
• Herman D., Conover S., Draine J., Critical time intervention, in Psychosocial treatment of schizophrenia: clinician’s guide to evidence-based practice. Edited by Rubin A, Springer DW, Trawver K. Hoboken, N.J., John Wiley & Sons, 2010.
• Chen, F.P. (2012). Exploring how service setting factors influence practice of Critical Time Intervention. Journal of Society for Social Work and Research. 3, 51-64.
• Chen, FP, Ogden, L. (2012) A working relationship model that reduces homelessness among people with mental illness. Qualitative Health Research, 22(3): 373-383.
• Prince, J.D. (2013). Commentary: Critical time intervention reduces psychiatric rehospitalisation among formerly homeless individuals with psychotic diagnoses. Evidence Based Mental Health, 16(2), 38.
• Herman, D. (2013). Transitional support for adults with severe mental illness: Critical time intervention and its roots in assertive community treatment. Research on Social Work Practice, epub ahead of print.