A Pragmatic Randomized Controlled Trial of Financial Incentives in Case Management for Homeless Adults With Mental Illness
Abstract
Objective:
Financial incentives can facilitate behavior change and service engagement in health care settings, but research on their use with adults experiencing homelessness is limited. This study examined the effectiveness of financial incentives in improving service engagement and health outcomes among homeless adults with mental illness in Toronto.
Methods:
The authors of this randomized controlled trial recruited 176 participants receiving brief multidisciplinary case management services for homeless adults with mental illness after hospital discharge. In a 1:1 randomization design, 87 participants received a financial incentive of CAN$20 for every week they remained engaged with the service for up to 6 months. The remaining 89 participants received treatment as usual. The primary outcome was service contact rates for up to 6 months of follow-up. Secondary outcomes included self-reported health status, mental health symptoms, substance use, quality of life, housing stability, acute health service use, and working alliance. Negative binomial regression models, analyses of covariance, generalized estimating equations models, and Wilcoxon rank sum tests were used to examine differences between the financial incentive and treatment-as-usual groups across outcomes of interest.
Results:
No significant differences were found between the financial incentive and treatment-as-usual groups in service contact rates or any of the secondary outcomes examined over the 6-month period.
Conclusions:
In low-barrier, brief case management programs tailored to the needs of adults experiencing homelessness, financial incentives may not affect service engagement or health outcomes. Further research is needed to identify the effect of financial incentives on engagement in other services, including housing-based interventions.
HIGHLIGHTS
•
This randomized controlled trial examined the effects of financial incentives on service engagement among homeless adults with mental illness who received brief multidisciplinary case management services.
•
Financial incentives did not significantly affect service contact rates or any of the secondary outcomes over the 6-month study period.
•
Financial incentives may not improve service engagement or health outcomes when used in specialized case management programs for adults experiencing homelessness.
People experiencing homelessness have multiple unmet health and social needs, in addition to their need for shelter. High rates of acute and chronic health conditions, including mental illness, problematic substance use, cognitive impairment, and infectious diseases, contribute to high disease burden and premature death in this population (1–4). Despite their documented high morbidity and mortality rates, people experiencing homelessness encounter frequent barriers when accessing health and social services, such as competing needs, inaccessibility, concerns about safety and care quality, and lack of continuity of care (5–8). These barriers can cause people experiencing homelessness to prematurely disengage from services or to use more accessible but more costly acute care services that do not effectively meet their complex support needs (6, 9).
Financial incentive (FI) interventions have been used to facilitate health behavior change and service engagement in various populations and service delivery contexts. FIs involve the provision of monetary or material rewards, with monetary value contingent on the initiation or sustainment of target behaviors. FIs, including those used in voucher-based contingency management treatments, have been shown to effectively influence health decision making for both clinical and nonclinical populations (10, 11). Research on the use of FIs for people experiencing homelessness is limited, although evidence is promising for its reducing substance use, preventing and treating infectious diseases, and attaining health-related goals (12). Because of considerable heterogeneity in how FIs have been used and studied with people experiencing homelessness, it is unknown how these interventions can be most optimally used to improve service engagement and health outcomes. Further, FIs have been rarely examined as cointerventions to existing best practices, such as mental health case management, for people experiencing homelessness (13).
In this randomized controlled trial (RCT), we examined the effectiveness of FIs in improving engagement in brief multidisciplinary case management services and in enhancing health outcomes among adults experiencing homelessness and unmet mental health needs after hospital discharge. We hypothesized that participants receiving FIs as a cointervention to a brief multidisciplinary case management intervention would have higher levels of engagement with service providers; improved health, quality of life, and housing outcomes; and reduced acute health care use, compared with participants receiving the brief multidisciplinary case management intervention without an FI over a 6-month period.
Methods
Study Design and Intervention
Coordinated Access to Care for the Homeless–Financial Incentives (CATCH-FI) was a mixed-methods, pragmatic RCT that was conducted between November 2018 and May 2021. RCT participants were randomly assigned to one of two arms—FI intervention and treatment as usual—and assessed at baseline and 6 months postrandomization. Participants were recruited for the trial from the CATCH program, a multidisciplinary brief case management service in Toronto for people experiencing homelessness and mental health needs after hospital discharge. A sample size of 172 participants was sought to achieve 80% statistical power to detect a rate ratio of 1.25 with a two-sided test with p≤0.05, after accounting for an attrition rate of 22% (14).
CATCH provides coordinated and individualized general medical and mental health care, peer support, and intensive case management over a period of 3–6 months. Individuals access CATCH service providers (i.e., case managers and physicians) typically about 2.5 times per month, and care plans aim for 3 or 4 contacts per month during participants’ tenure in the program. Tailored to the needs of people experiencing homelessness and mental illness, the CATCH intervention has been extensively researched (8, 15–18). The study reported here was informed by a review of the literature and by consultation with CATCH service users and providers.
CATCH-FI trial enrollees who were randomly assigned to the intervention arm received CAN$20 as cash incentive for every week they remained engaged with CATCH service providers for up to 6 months of follow-up. These participants could earn up to $80 CAD per month by connecting with CATCH service providers, either in person, by telephone, by e-mail, or by text, as outlined in their care plan. Participants in the control arm received usual CATCH care without any financial or other incentive for program engagement. All participants received reminder phone calls before scheduled appointments.
The trial was approved by Unity Health Toronto (REB 18–196) and the Center for Addiction and Mental Health (REB 156/2018), and all participants provided informed consent. Additional trial details have been previously described (14).
Participants
CATCH-FI trial participants met criteria for the CATCH program: currently homeless (i.e., no place to stay for seven or more nights and unlikely to find housing in the upcoming month) or precariously housed (i.e., currently occupying a single room in a multitenant building or a house with shared common areas or a hotel or motel as a primary residence, with a history of one or more episodes of absolute homelessness in the past year); age ≥18 years; unmet mental health need, as determined by the service provider; and unmet support need, as determined by the service user. The definition of homelessness used in this trial was consistent with those used in past Canadian research (19, 20). The CATCH program excludes individuals who have shown recent aggressive behavior requiring a higher level of support and individuals whose illness severity necessitates residential care. Additional eligibility criteria for the CATCH-FI trial were as follows: new referral to the CATCH program, recent hospital admission or emergency department visit, and at least one contact with the CATCH team.
Randomization
The trial used 1:1 block randomization, which randomly assigns participants by using blocks of four and six, after the baseline assessment (21). This process enabled balanced group sizes throughout the recruitment process. It was not feasible for participants and study staff to be blind to group assignment because of the nature of the intervention.
Study Outcomes
Service engagement, as measured by the number of health-related contacts per month with CATCH service providers over the period of program enrollment, was the primary outcome and was extracted from program records. Engagements could occur in person, by telephone, by e-mail, or by text, depending on participants’ needs and preferences. Social or trivial contacts were not considered health-related contacts and were excluded from service engagement measurements. Given that the duration of participants’ involvement with the CATCH program for up to 6 months is individualized on the basis of each participant’s need, service engagement was measured in person-months.
Secondary outcomes were all self-reported and included health status, mental illness symptoms, substance use problems, quality of life, housing stability, acute health service use, and working alliance. Health status was assessed by using the 36-item Short Form Survey version-2.0 (SF-36v2) (22, 23). Mental illness symptoms were assessed with the Colorado Symptom Index (CSI) (24) and substance use problems with the Global Assessment of Individual Needs Short Screener–substance problem scale (GAIN-SS) (25). Quality of life was measured with the Quality of Life Index–20 (QoLI-20) (26) and the EQ-5D Visual Analog Scale (EQ-5D VAS) (27). Housing stability was assessed by using the Residential Time-Line Follow-Back (RTLFB) instrument (28). Three types of acute health service use in the past 6 months were also assessed (number of hospitalizations, number of days hospitalized, and number of emergency department visits). Working alliance was measured with the Working Alliance Inventory–Short Revised (WAI-SR) (29, 30). All measures have been previously validated and used with homeless adults experiencing mental illness (19); they are described in more detail in the published protocol (14).
Data Analysis
The primary outcome of health contacts per month was analyzed by using a negative binomial regression model (PROC GENMOD), with randomization group (FI intervention or treatment as usual) as the covariate and an offset equal to the log (number of months spent in the program). Analyses of covariance (ANCOVAs) were conducted for the secondary outcomes, that is, changes in the CSI, SF-36v2, QoLI-20, and EQ-5D VAS scores from baseline to the 6-month follow-up. ANCOVAs compared change scores from baseline to 6 months between the FI intervention and treatment-as-usual groups, with adjustment for baseline scores as a covariate.
Generalized estimating equation (GEE) models with negative binomial distribution were fitted for the count outcomes (i.e., GAIN-SS total score, number of days stably housed as assessed by the RTLFB, number of hospitalizations, number of days hospitalized, and number of emergency department visits), with main effects of randomization group, time, and the interaction of group and time. An offset was also included in the models of health service use outcomes to account for monthly differences in duration between baseline and 6 months. The GEE model for housing stability also included an offset represented by the natural log of days accounted for by the RTLFB during the past 6 months. Estimated rate ratios, with 95% CIs, were estimated for all GEE models. Given that the WAI-SR was completed only at the 6-month follow-up, its total scale score was compared between the randomization groups by using the Wilcoxon rank sum test.
Because the trial was ongoing at the beginning of the COVID-19 pandemic (as declared by the World Health Organization on March 11, 2020), exploratory analyses were necessary to determine the potential impacts of the pandemic on service engagement outcomes. A negative binomial model was fitted, with randomization group and trial involvement during the pandemic as covariates, and an offset for number of months of eligible CATCH program contacts. All statistical tests were two-sided and used a p≤0.05. SAS, version 9.4, was used for all analyses.
Results
Study Participants and Sample Characteristics
Of the 176 participants, 87 (49%) were randomly assigned to the FI intervention and 89 (51%) to treatment as usual (a CONSORT flow diagram is available in the online supplement to this article). Of the 176 participants, 138 completed the 6-month follow-up assessment (22% attrition rate). Attrition did not significantly differ between the FI intervention group (N=18, 21%) and the treatment-as-usual group (N=20, 23%). Of note, the baseline assessments of 28 participants (16%) and the 6-month assessments of 59 participants (34%) were completed during the COVID-19 pandemic. Sample characteristics by group are shown in Table 1.
| Characteristic | FI intervention (N=87) | Treatment as usual (N=89) | Total (N=176) | |||
|---|---|---|---|---|---|---|
| N | % | N | % | N | % | |
| Age (M±SD years) | 43.7±12.7 | 44.9±12.9 | 44.3±12.8 | |||
| Male or transgender male | 59 | 68 | 72 | 81 | 131 | 74 |
| Born in Canada | 64 | 74 | 62 | 70 | 126 | 72 |
| Ethnicitya | ||||||
| White | 46 | 54 | 53 | 60 | 99 | 56 |
| Black | 9 | 11 | 7 | 8 | 16 | 9 |
| Indigenous | 7 | 8 | 5 | 6 | 12 | 7 |
| Multiracial | 7 | 8 | 6 | 7 | 13 | 7 |
| Other | 16 | 20 | 18 | 19 | 34 | 19 |
| English as primary language | 75 | 86 | 75 | 84 | 150 | 85 |
| Education level | ||||||
| Less than high school | 31 | 36 | 33 | 37 | 64 | 36 |
| Completed high school | 18 | 21 | 14 | 16 | 32 | 18 |
| Attended postsecondary institution | 38 | 44 | 42 | 47 | 80 | 45 |
| Single or never married | 58 | 67 | 46 | 52 | 104 | 59 |
| Homelessness history | ||||||
| Longest episode (M±SD years) | 2.5±3.6 | 1.7±2.5 | 2.1±3.1 | |||
| Time since first episode (M±SD years) | 7.6±9.6 | 7.1±10.0 | 7.4±9.8 | |||
| Homelessness in past 6 months (M±SD days) | 93.7±65.0 | 92.8±68.2 | 93.3±66.5 | |||
| Source of incomeb | ||||||
| Paid employment | 5 | 6 | 5 | 6 | 10 | 6 |
| Income support | 30 | 34 | 30 | 34 | 60 | 34 |
| Disability income support | 40 | 47 | 36 | 40 | 76 | 43 |
| Other | 23 | 26 | 23 | 26 | 46 | 26 |
a
Data were missing for two participants.
b
Participants could have multiple income sources.
Primary Outcome
During the study period, trial participants had 2,063 service contacts with the CATCH program (mean rate of contacts per person-month=2.64, 95% CI=2.33–3.00) (Table 2). The contact rates per person-month did not differ significantly between the FI intervention (mean rate of contacts per person-month=2.66, 95% CI=2.22–3.19) and treatment as usual (mean rate of contacts per person-month=2.63, 95% CI=2.19–3.14).
| Type of contact | FI intervention | Treatment as usual | Total | |||
|---|---|---|---|---|---|---|
| N | % | N | % | N | % | |
| Case management contact | ||||||
| In person | 411 | 41 | 424 | 40 | 835 | 40 |
| Othera | 504 | 51 | 507 | 47 | 1,011 | 49 |
| Physician contact | 78 | 8 | 139 | 13 | 217 | 11 |
| All contacts | 993 | 48 | 1,070 | 52 | 2,063 | 100 |
a
Phone call, text, and e-mail contacts.
Exploratory analyses to determine the effects of the COVID-19 pandemic on service engagement revealed no significant differences in contact rates between participants who completed the study assessments before the onset of the pandemic (2.45 contacts per person-month, 95% CI=2.09–2.87) and those who participated during the pandemic (3.00 such contacts, 95% CI=2.43–3.71). However, as expected, participants who were assessed during the pandemic had fewer in-person contacts with the CATCH program (184 in-person contacts of 813 total contacts, 23%), compared with those whose participation preceded the onset of the pandemic (651 in-person contacts of 1,250 total contacts, 52%). Study involvement during the pandemic did not significantly affect the overall rate of service contacts per person-month between the FI intervention and treatment-as-usual groups.
Secondary Outcomes
Table 3 presents data on the secondary outcomes for the FI intervention and treatment-as-usual groups. Changes from baseline to 6 months in health status, quality of life, use of acute care health services, and housing stability did not statistically significantly differ between the two groups. Ratings of the therapeutic working alliance also did not significantly differ between the two groups at 6 months.
| Outcome | FI intervention | Treatment as usual | pa | ||
|---|---|---|---|---|---|
| Baseline (M±SD) | 6 months (M±SD) | Baseline (M±SD) | 6 months (M±SD) | ||
| Mental illness symptom severity scoreb | 37.1±11.9 | 33.3±11.8 | 41.7±11.5 | 36.6±10.9 | .58 |
| Substance use problem scorec | 1.9±2.0 | 1.2±1.8 | 2.0±2.1 | 1.9±2.1 | .09 |
| Health status scored | |||||
| General medical | 45.8±13.0 | 46.1±11.2 | 47.1±11.4 | 48.2±9.7 | .35 |
| Mental | 34.3±14.7 | 39.2±12.1 | 31.4±13.6 | 35.5±13.7 | .33 |
| Health-related quality-of-life scoree | 61.0±23.4 | 61.5±22.7 | 59.4±23.7 | 62.1±22.5 | .67 |
| Quality-of-life scoref | |||||
| Total | 72.6±19.8 | 80.7±22.3 | 69.2±23.4 | 74.7±24.5 | .35 |
| Family | 14.5±6.8 | 14.8±7.3 | 14.4±6.6 | 14.8±7.3 | .83 |
| Finances | 4.8±3.0 | 6.0±3.6 | 4.5±2.8 | 5.3±3.0 | .19 |
| Leisure | 18.3±6.8 | 19.9±6.6 | 17.3±7.6 | 19.0±7.2 | .91 |
| Living | 2.8±1.8 | 3.6±2.2 | 2.5±1.7 | 3.0±1.9 | .19 |
| Safety | 17.2±6.2 | 20.0±6.6 | 15.5±6.3 | 17.3±7.7 | .10 |
| Social | 11.9±4.3 | 12.6±4.7 | 11.8±4.7 | 11.8±5.0 | .29 |
| Global | 3.5±1.8 | 4.0±1.8 | 3.2±1.7 | 3.4±1.8 | .06 |
| N of emergency department visitsg | 3.8±9.2 | 2.2±6.2 | 3.7±3.5 | 2.1±2.7 | .69 |
| N of hospital admissionsg | 1.9±4.5 | .5±.9 | 1.3±1.4 | .6±.9 | .14 |
| Days in hospitalg | 18.0±29.5 | 6.8±17.8 | 17.6±25.9 | 7.3±17.2 | .83 |
| Days in stable housingg,h | 28.9±35.8 | 30.5±39.7 | 30.0±34.7 | 28.1±41.1 | .73 |
| Working alliance scorei | NA | 46.8±12.0 | NA | 45.4±13.0 | .52 |
a
Statistical tests used to estimate p values included analyses of covariance (for Colorado Symptom Inventory [CSI], 36-item Short Form Survey version-2.0 [SF-36v2], EQ-5D Visual Analog Scale [EQ-5D VAS], Quality of Life Index–20 [QoLI-20], generalized estimating equation models with negative binomial distribution (Global Assessment of Individual Needs Short Screener–substance problem scale [GAIN-SS], Residential Time-Line Follow-Back [RTLFB], acute health service use), and Wilcoxon rank sum test (Working Alliance Inventory–Short Revised [WAI-SR])
b
Assessed with the CSI; possible scores range from 14 to 70, with higher scores reflecting more severe and frequent mental illness symptoms in the past month.
c
Assessed with the GAIN-SS; possible scores range from 0 to 5, with higher scores reflecting more substance use problems in the past month.
d
Assessed with the SF-36v2; possible scores range from 0 to 100, with higher scores reflecting better health status.
e
Assessed with the EQ-5D VAS; possible scores range from 0 to 100, with higher scores reflecting better perceived health state.
f
Assessed with the QoLI-20. Total score, possible scores range from 20 to 140; family and safety, possible scores range from 4 to 28; finances, possible scores range from 2 to 14; leisure, possible scores range from 5 to 35; living and global, possible scores range from 1 to 7; social, possible scores range from 3 to 21. Higher scores on all domains reflect greater quality of life.
g
In past 6 months.
h
Assessed with the RTLFB.
i
Assessed with the WAI-SR; possible scores range from 12 to 60, with higher scores reflecting a stronger therapeutic working alliance.
Discussion
This study examined the effectiveness of FIs as a cointervention to a multidisciplinary brief case management service for homeless people with mental illness after hospital discharge. Contrary to our hypotheses, no significant differences in service engagement or other health outcomes of interest were found between the FI intervention and treatment-as-usual groups. Regarding the service engagement findings, care plans developed in the multidisciplinary case management program typically aim for 3 or 4 service contacts per month. The contact rates for both the FI intervention and treatment-as-usual groups were near this range. Therefore, FIs may not have yielded additional service contacts, because participants were already connecting with the program regularly. The finding of minimal effects of the intervention on service contacts is consistent with findings from some previous studies examining FIs and case management. In two studies (31, 32), FIs were not associated with changes in engagement in case management services, although other benefits were noted. However, our findings differ from results of research on FIs in other service models for people experiencing homelessness, which indicated that these interventions can yield important behavioral health changes, including promotion of abstinence from substance use, engagement with infectious disease treatment, and retention in health services (12).
Qualitative research conducted in parallel with the present RCT provided further contextualization of our findings (33). Notably, perspectives on FIs differed between service users and providers; the latter group perceived that FIs had yielded or would yield greater service engagement, as we had hypothesized. In contrast, most service users receiving FIs did not perceive that FIs had affected or would affect their health-related decision making. These participants viewed intrinsic motivation and quality of care to be more meaningful facilitators of service engagement (33). All trial participants, whether they received the FI intervention or treatment as usual, had access to the same multidisciplinary case management service for people experiencing homelessness, which may have contributed to the lack of significant differences between the two groups. This possible reason for the observed lack of differences is supported by earlier research on the program, which found that service users valued the intervention’s low-barrier accessibility; individualized, knowledgeable, and responsive service provision; and help navigating services in a timely and coordinated way (8). Similar results have been found in primary care, with specialized services for people experiencing homelessness being perceived more positively than mainstream primary care (34, 35). Taken together, such results may indicate that FIs have fewer effects on service engagement within settings that are already tailored to the needs of people experiencing homelessness, whereas FIs may have greater impact in mainstream health care settings.
The finding of nonsignificant differences in health outcomes between the FI intervention and treatment-as-usual groups is not surprising, given the similar rates of service engagement and the complex needs of people served by the brief multidisciplinary case management intervention. Because most participants had few to no days in stable housing, they likely had multiple unmet needs, such as for shelter, food, clothing, health care, social support, and bathroom facilities, which competed with the support offerings of the program (5). FIs may have been insufficient for overcoming this barrier. Moreover, the case management program serves people with moderate-to-high needs after hospital discharge, and many participants reported repeated visits to acute care services and inpatient stays during the 6-month follow-up period. The postdischarge period represents a time of ongoing acute needs for participants without the security of stable housing. Therefore, FIs may be more effective in changing health behaviors among individuals with less pressing health needs or after they have exited homelessness (12).
Taken together, these results indicate that future research is warranted on whether FIs can enhance service engagement of homeless adults and improve health outcomes as a cointervention to health and social services, including primary care and permanent supportive housing. It will also be important to further explore the types of FIs that are optimally effective in terms of form, magnitude, direction, frequency, and other characteristics (12, 36).
Of note, study participants perceived FIs to be an acceptable and helpful cointervention, enhancing their quality of life (33). Nonetheless, despite growing evidence of the general effectiveness of FIs and their acceptability by service users, FIs have not been without their critics (37). One set of concerns is related to fears that FIs will be misused by recipients (e.g., spending funds on alcohol and drugs) (38, 39). However, it is important to acknowledge that the FI intervention in our trial did not produce additional harms associated with greater financial resources. As in past research (40), FIs did not lead to further substance use problems in the intervention group. In fact, compared with the treatment-as-usual group, FI intervention participants reported a greater decline over the study period in substance use problems, although this difference was not significant. Thus, our study adds further evidence that FIs do not enable substance use harms among homeless people with mental illness, even during periods of high vulnerability, such as posthospitalization.
This study had several limitations. First, almost half of the participants were involved in the trial after the onset of the COVID-19 pandemic. Exploratory analyses were used to examine any between-group differences related to participation during the pandemic; however, the impacts of such a global health crisis on trial outcomes cannot be fully known. In particular, participants had more service contacts during the pandemic that were not in-person contacts, and it is unknown how the pandemic affected service accessibility for a population that has variable access to technological devices and privacy (41). Further, time-limited income supports of CAN$2,000 per month became available during the trial period for people who experienced employment-related income losses due to the pandemic. Although very few people experiencing homelessness would have been eligible for this benefit—and recent research suggests that few individuals with histories of homelessness received it (42)—the publicity and availability of this new benefit may have affected attitudes toward the value of FIs among some participants. Finally, data on service contact duration and reason were not collected. Such data were not collected because participants had multiple unmet needs and service contacts rarely addressed a single issue. A service contact could also occur by e-mail and text, for which duration would not be applicable. Nevertheless, given that the case management program provides health, peer, housing, and system navigation supports and that it was unknown whether FIs affected these specific domains of service engagement, this research gap should be the focus of future research.
Conclusions
The provision of cash FIs as a cointervention to a brief multidisciplinary case management service did not yield significantly greater service engagement or improved health outcomes, compared with usual care, for homeless people with mental illness after hospital discharge. Our findings suggest that FIs may not affect service engagement in programs already providing low-barrier access, service coordination, and individualized service provision—key drivers of service engagement for this population after hospital discharge. Further research is needed to identify how FIs may improve service engagement in other health and housing interventions.
Acknowledgments
The authors thank the CATCH program staff and service users for their time and participation in this study and the Survey Research Unit research staff at the MAP Centre for Urban Health Solutions, St. Michael’s Hospital, Unity Health Toronto.
Supplementary Material
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Information & Authors
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History
Received: 28 July 2022
Revision received: 11 November 2022
Revision received: 28 December 2022
Accepted: 30 December 2022
Published online: 23 February 2023
Published in print: August 01, 2023
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Competing Interests
The authors report no financial relationships with commercial interests.
Funding Information
This study was supported by the Ontario Ministry of Health’s Health System Research Fund (grant number 259) and the Canadian Institutes of Health Research (CIHR Foundation Grant number 143259).
Registered at ClinicalTrials.gov: NCT03770221.
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