Critical Time Intervention (CTI)

Society’s most vulnerable individuals during periods of transition including homeless individuals

Critical Time Intervention (CTI) is a time-limited practice that is designed to mobilize support for society’s most vulnerable individuals during periods of transition. It facilitates community integration and continuity of care by ensuring that a person has enduring ties to their community and support systems during these critical periods. CTI has been applied with veterans, people with mental illness, people who have been homeless or in prison, and many other groups.

Core Components:

• Addresses a period of transition
• Time-limited
• Phased approach
• Focused
• Decreasing intensity over time
• Community-based
• No early discharge
• Small caseloads
• Harm reduction approach
• Weekly team supervision
• Regular full caseload review

Phases of CTI:

• • Pre-CTI
    • Develop a trusting relationship with client.
  • Phase 1: Transition
    • Provide support & begin to connect client to people and agencies that will assume the primary role of support:
      • Make home visits
      • Engage in collaborative assessments
      • Meet with existing supports
      • Introduce client to new supports
      • Give support and advice to client and caregivers
  • Phase 2: Try-Out
    • Monitor and strengthen support network and client’s skills.
      • Observe operation of support network
      • Mediate conflicts between client and caregivers
      • Help modify network as necessary
      • Encourage client to take more responsibility
  • Phase 3: Transfer of Care
    • Terminate CTI services with support network safely in place.
      • Step back to ensure that supports can function independently
      • Develop and begin to set in motion plan for long-term goals
      • Hold meeting with client and supports to mark final transfer of care
      • Meet with client for last time to review progress made

Daniel Herman
Center for the Advancement of Critical Time Intervention (CACTI)

• https://www.criticaltime.org/
• Email: info@criticaltime.org

Homework

This program does not include a homework component.

Manual Information

There is a manual that describes how to deliver this program.

Program Manual(s)

Reach out to the program contact for more information.

Training Information

There is no training information available for this program.

Pre-Implementation Materials

There are no pre-implementation materials to measure organizational or provider readiness for Critical Time Intervention.

Formal Support for Implementation

There is no formal support available for implementation of Critical Time Intervention.

Fidelity Measures

There are no fidelity measures for Critical Time Intervention.

Established Psychometrics

There are no established psychometrics for Critical Time Intervention.

Fidelity Measures Required

No fidelity measures are required for Critical Time Intervention.

Implementation Guides or Manuals

There are no implementation guides or manuals for Critical Time Intervention.

Implementation Cost

There are no studies of the costs of Critical Time Intervention.

Research on How to Implement the Program

Research has not been conducted on how to implement Critical Time Intervention.

Child Welfare Outcome: Child/Family Well-Being

“What is included in the Relevant Published, Peer-Reviewed Research section?”

• 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. https://doi.org/10.1176/appi.ps.54.6.884

  Type of Study: Randomized controlled trial

  Number of participants: 96

  Population:

  • Age — CTI: 60%=35 years or older; TAU: 40%= Less than 35 years
  • Race/Ethnicity — 74% African American, 26% Other
  • Gender — 100% Male
  • Status —

    Participants were recruited from a psychiatric program in a men’s public shelter.

  Location/Institution: New York City

  Summary:

  The purpose of the study was to investigate the cost-effectiveness of the Critical Time Intervention (CTI) program, a time-limited adaptation of intensive case management, which has been shown to significantly reduce recurrent homelessness among men with severe mental illness. Participants were randomized to CTI or usual services. Measures utilized include administrative data from the New York City Department of Corrections and the New York State Office of Mental Health, interviews that collected housing, income, and service utilization, and employment information that collected information on the economic activity of participants. Results indicate that over the study period, the CTI group and the usual services group incurred mean costs of $52,374 and $51,649, respectively, for acute care services, outpatient services, housing and shelter services, criminal justice services, and transfer income. During the same period, the CTI group experienced significantly fewer homeless nights than the usual care group (32 nights versus 90 nights). For each willingness-to-pay value—the additional price society is willing to spend for an additional non-homeless night—greater than $152, the CTI group exhibited a significantly greater net housing stability benefit, indicating cost-effectiveness, compared with usual care. Limitations include reliance on self-reported data; the study was limited to one setting characterized by a rich array of services—New York City; and time had elapsed since the data were collected.

  Length of controlled postintervention follow-up: None.

• Clark, C., Guenther, C. C., & Mitchell, J. N. (2016). Case management models in permanent supported housing programs for people with complex behavioral issues who are homeless. Journal of Dual Diagnosis, 12(2), 185–192. https://doi.org/10.1080/15504263.2016.1176852

  Type of Study: Other quasi-experimental

  Number of participants: 234

  Population:

  • Age — CTI: Mean=46.42 years; ACT: Mean=40.88 years
  • Race/Ethnicity — CTI: 81 Caucasian, 55 African American, 20 Hispanic/Latino, 5 Multiracial, 2 American Indian, and 1 Other/Refused; ACT: 48 Caucasian, 30 African American, 12 Hispanic/Latino, 8 Multiracial, 2 Other/Refused, 1 American Indian, and 1 Asian
  • Gender — CTI: 88% Male and 13% Female; ACT: 69% Male and 31% Female
  • Status —

    Participants were individuals with co-occurring disorders and histories of chronic homelessness.

  Location/Institution: Not specified

  Summary:

  The purpose of the study was to examine two evidence-based models of case management for people with co-occurring disorders and histories of chronic homelessness and to better understand their roles in permanent supported housing. Participants were assigned to Critical Time Intervention (CTI) or Assertive Community Treatment (ACT). Measures utilized include the Government Performance and Results Act (GPRA) Client Outcome Measure for Discretionary Programs, the Dartmouth Assertive Community Treatment Scale (DACTS), the CTI Fidelity Scale Manual, and the Brief Symptom Inventory (BSI). Results indicate that both programs operated at high levels of fidelity. Despite similar criteria for participation, there were significant differences between groups. CTI participants were older, were more likely to be male, were more likely to be homeless, and reported greater psychiatric symptoms and higher levels of substance use. Separate outcome analyses suggested that each program was successful in supporting people to transition from homelessness to stable housing; 88.6% of Assertive Community Treatment participants were homeless at baseline, while at 6 months 30% were homeless, and 91.3% of those in CTI were homeless at baseline, while 44.3% were homeless at 6 months. Participants in the Critical Time Intervention program also showed significant decreases in alcohol use, drug use, and psychiatric symptoms. Limitations include that no conclusions can be reached from pre- and post- comparisons without a control or comparison group and that the CTI Fidelity Scale Manual has not been published or subject to peer scrutiny.

  Length of controlled postintervention follow-up: None

• de Vet, R., Beijersbergen, M. D., Jonker, I. E., Lako, D. A. M., van Hemert, A. M., Herman, D. B., & Wolf, J. R. L. M. (2017). Critical Time Intervention for homeless people making the transition to community living: A randomized controlled trial. American Journal of Community Psychology, 60(1-2), 175–186. https://doi.org/10.1002/ajcp.12150

  Type of Study: Randomized controlled trial

  Number of participants: 183

  Population:

  • Age — CTI: Mean=41.42 years; Control: Mean=39.72 years
  • Race/Ethnicity — Not specified
  • Gender — CTI: 51 Female; Control: 34 Female
  • Status —

    Participants were eighteen shelters of nine shelter organizations that participated in the Academic Collaborative Center for Shelter and Recovery in 2009.

  Location/Institution: Netherlands

  Summary:

  The purpose of the study was to test whether Critical Time Intervention (CTI), a time-limited intervention developed to support vulnerable people during times of transition, is effective outside the United States. Participants were randomized to CTI or care-as-usual. Measures utilized include the Residential Follow-Back Calendar to assess participants’ residential histories, family and social support were measured using the average score on a 5-point scale of five items from the RAND Course of Homelessness Study, the Lehman’s Brief Quality of Life Interview, the Global Severity Index, the 53-item Brief Symptom Inventory, the 10-item Rosenberg Self-Esteem Scale, and the European Addiction Severity Index. Results indicate that the primary outcome of number of days rehoused did not differ between groups. CTI had a significant effect on family support and, for people experiencing less social support, psychological distress. Groups did not differ significantly on social support, fulfillment of care needs, quality of life, self-esteem, excessive alcohol use, or cannabis use. Limitations include that some of the data collectors had occasionally become aware of condition assignment and the lack of follow-up.

  Length of controlled postintervention follow-up: None.

• Lako, D. A. M., Beijersbergen, M. D., Jonker, I. E., Vet, R., Herman, D. B., Hemert, A. M., & Wolf, J. R. L. M. (2018). The effectiveness of Critical Time Intervention for abused women leaving women’s shelters: A randomized controlled trial. International Journal of Public Health, 63(4), 513–523. https://doi.org/10.1007/s00038-017-1067-1

  Type of Study: Randomized controlled trial

  Number of participants: 136

  Population:

  • Age — CTI: Mean=34.24 years; CAU: Mean=33.58 years
  • Race/Ethnicity — Not specified
  • Gender — 100% Female
  • Status —

    Participants were abused women transitioning from women’s shelters to community living.

  Location/Institution: Nine women’s shelters across the Netherlands

  Summary:

  The purpose of the study was to examine the effectiveness of Critical Time Intervention (CTI)—an evidence-based intervention—for abused women transitioning from women’s shelters to community living. Participants were randomized to CTI or care-as-usual. Measures utilized include the Lehman’s Brief Quality of Life Interview, the 20-item Center for Epidemiological Studies Depression Scale, the 5-item Impact of Event Scale, the Global Severity Index, the 53-item Brief Symptom Inventory, and the 10-item Rosenberg Self-Esteem Scale. Results indicate that women in the CTI group had significantly fewer symptoms of post-traumatic stress and a significant fourfold reduction in unmet care needs compared to women in the care-as-usual group. No differences were found for quality of life, re-abuse, symptoms of depression, psychological distress, self-esteem, family support, and social support. Limitations include that further inspection of the scores of Dutch-speaking and non-Dutch-speaking women separately on the significant outcomes of CTI in this study revealed a different effect of CTI on these groups, and more research with a larger number of non-Dutch-speaking women needs to be done to confirm this finding.

  Length of controlled postintervention follow-up: None.

• de Vet, R., Beijersbergen, M. D., Lako, D. A. M., van Hemert, A. M., Herman, D. B., & Wolf, J. R. L. M. (2019). Differences between homeless women and men before and after the transition from shelter to community living: A longitudinal analysis. Health & Social Care in the Community, 27(5), 1193–1203. https://doi.org/10.1111/hsc.12752

  Type of Study: Randomized controlled trial

  Number of participants: 183

  Population:

  • Age — Female: Mean=37.90 years and Male: Mean= 42.93 years
  • Race/Ethnicity — Not specified
  • Gender — 98 Male and 85 Female
  • Status —

    Participants were 18 shelters of nine shelter organizations that participated in the Academic Collaborative Center for Shelter and Recovery in 2009.

  Location/Institution: Netherlands

  Summary:

  The study used the same sample as de Vet et al. (2017). The purpose of the study was to assess whether women participating in the Critical Time Intervention (CTI) in homeless shelters differed from men on social quality factors that constitute the quality of their daily life, and whether factor scores changed at a different rate for women and men after shelter exit. Participants were randomized to CTI or care-as-usual. Measures utilized include family and social support were measured using the average score on a 5-point scale of five items from the RAND Course of Homelessness Study, the Lehman’s Brief Quality of Life Interview, the Short‐Form Quality of Life and Care Questionnaire, the 10-item Rosenberg Self-Esteem Scale, the 53‐item Brief Symptom Inventory (BSI), and the European Addiction Severity Index. Results indicate that at baseline, women were significantly younger than men. They were more likely to have children, to have minor children staying with them, to be lower educated, to be unemployed, and to have been victimized than men. Women had used more services and reported lower self‐esteem, less satisfaction with health and empowerment and higher psychological distress. They were less likely than men to have used alcohol excessively or cannabis. There were no significant differences between women and men in changes over time on the social quality factors. As women were disadvantaged at baseline compared to men regarding many factors, women in homeless shelters are a particularly vulnerable group. Moreover, an opportunity remains for shelter services to improve women’s social quality during and after their shelter stay. Limitations include the reliance on self-reported data, that findings cannot be extrapolated to those who did not fit the selection criteria, and the small proportion of eligible clients who participated (36%).

  Length of controlled postintervention follow-up: None.