HUD/HHS/VA Collaborative Initiative to Help End Chronic Homelessness: Is System Integration Associated with Client Outcomes?. Measures


A brief summary of client and network measures are provided below. More detailed descriptions of these measures have been reported elsewhere (Mares & Rosenheck, 2007; Greenberg & Rosenheck, 2007).

Client measures

Individual characteristics

CICH intake and outreach staff completed a structured form on each person screened, which documented: 1) basic socio-demographic information (i.e., age, gender, and race/ethnicity); 2) eligibility characteristics (i.e., single individual vs. parent, and type of chronic homelessness experience  a current episode of homelessness lasting a year or longer vs. 4 or more episodes of homelessness during the past 3 years); 3) each of three disabling condition(s) (i.e., mental health, substance abuse or medical) identified at screening and during the baseline assessment interview; 4) outreach location and the agency initiating outreach; 5) outreach clinician observations of clinical problems; 6) response to early interactions with intake/outreach staff (i.e. interest in participating in the program); and, 7) date enrolled into the program (if applicable). Measures of time (days) from screening to enrollment (among those enrolled into the program), and time from enrollment to the baseline assessment interview (among CICH clients) were also documented.

Supplemental socio-demographic and clinical information (e.g., veteran status, disabling condition(s)) were collected during the baseline assessment interview, along with service use and client outcome data.

Service Use

Primary health care services

First, CICH clients were asked whether they had a "usual health care provider", and whether they had health insurance?

Then the number of routine, preventive healthcare procedures received during the past year was assessed from a list of 12 gender-neutral procedures (e.g., measurement of height, weight, blood pressure, cholesterol), plus either 4 male-specific procedures (e.g., prostate exam, PSA testing) or 2 female-specific procedures (i.e., PAP testing and breast exam) (Heslin, Andersen & Gelberg, 2003).

Clients reporting unhealthy behaviors were also asked the number of such behaviors that they had discussed with a healthcare professional during the previous year. These behaviors included drinking alcohol among drinkers, smoking among smokers, and diet/nutrition among those who were obese at baseline.

The total number of outpatient medical visits made during the past 3 months was also included as a primary health treatment measure.

Finally, the trust in physician scale (Anderson & Dedrick, 1990), an 11-item measure, was used to assess the level of trust felt by a patient with his/her primary doctor/physical healthcare provider.

Mental health services and substance abuse treatment

Clients were further asked whether they could identify a primary mental health or substance abuse treatment provider, as well as their total number of outpatient mental health visits and the total number of outpatient substance abuse treatment visits during the previous 3 months. A fourth measure addressed participation in self-help groups (i.e., Alcoholics Anonymous or Narcotics Anonymous)

A 7-item therapeutic alliance scale was used to measure the strength of the therapeutic relationship experienced by CICH clients with their primary mental health or substance abuse provider (Neale & Rosenheck, 1995).

Finally, clients' experience of personal choice in selecting mental health or substance abuse services was measured using a 5-item "consumer choice" scale (Monahan et. al., 2005).

Case management

Clients were also asked whether they could identify a primary case manager, and whether they were visited by a case manager in a community setting (i.e., either at home or at some other place in the community other than a service agency or healthcare facility setting) during the previous 3 months.

Clients were further asked whether they had a money manager ("a person or organization which helps you manage your money") and whether they had had any contact with their landlord, either in-person or by telephone, during the past 3 months? Money management has been identified as an important ingredient in the approach to helping homeless people developed by Tsemberis and colleagues (2000) - and landlord-tenant relationships have been found to be associated with housing outcomes among persons with mental health and/or substance abuse problems (Kloos et. al., 2002).

Services integration

Both objective and subjective measures were used to evaluate the integration and coordination of diverse CICH services. Services integration was defined as the extent to which the key components characterizing the CICH intervention (listed below) were provided to clients. An objective measure of overall services integration was based on calculation of the proportion of total component services received by clients using a series of six dichotomous service component measures including: 1) independent housing 2) case management, 3) general medical care, 4) substance abuse treatment, 5) mental health services, and 6) VA services. A higher score on this overall measure represented a more fully integrated service delivery.

A second objective measure of overall service delivery represented the total number of outpatient health visits of all kinds  including medical, mental health, and substance abuse treatment visits  received during the previous 3 months. Clients were further asked to estimate the total number of different individual service providers assisting them during the past 3 months.

To supplement these objective measures, a 5-item subjective scale was developed to measure the extent to which the delivery of these services was perceived to be well coordinated or fragmented. Higher scores on this measure reflected a higher degree of coordination of services and less fragmentation.

Client outcomes


Clients were asked at each interview the number of days during the past 3 months that they were housed in each of nine settings, as well as where they were residing at the time of each assessment. The number of days "housed" was defined as living in their own place, someone else's place, or in an SRO hotel or boarding home. SRO hotels were considered residences because some sites used such housing as the primary housing resource for CICH clients at some sites (i.e., Los Angeles, San Francisco). Nights spent in shelters, outdoors, in vehicles, or in abandoned buildings were classified as representing "homeless" housing status.

Clients who were living in their own places were also asked to report their level of satisfaction with their housing using a 20-item housing satisfaction scale developed by Tsemberis and colleagues (2003), as part of the SAMHSA Supported Housing Initiative (CMHS, 2001).

Community adjustment

To evaluate how well CICH clients were integrated into and engaged in community life, they were asked whether they had participated in each of 16 common activities (e.g., visiting with others, going to a grocery store, reading a newspaper) during the previous 2 weeks (Katz, 1963). Responses to these items were then summed to create a "community involvement" scale measure, where a higher score represented greater participation in community activities.

Social support networks were assessed by questions asking the number of types of persons who would be available to help them about three different types of assistance: a short-term loan of $100, a ride to an appointment, or someone to talk with if they felt suicidal (Vaux et. al., 1987).

Additional single-item measures addressed a) whether clients knew any of their neighbors well, b) the number of days spent in jail during the past 3 months, and c) satisfaction with life overall (subjective quality of life), scored on a 7-point terrible=1 to delighted=7 scale, with a higher score indicating greater satisfaction with life. (Lehman, 1988).


CICH client income was expected to rise as a result of participating in the program, both through increased access to public support benefit payments and through employment. Clients were asked whether they had received any of several types of public support income during the past month, and if so, the amount of such income. Information on days of employment and employment income were also obtained, along with informal types of income. Responses to these items were summed to create a measure of total income.

Mental health and physical health status

The Medical Outcomes Study Short Form (SF)-12 mental health subscale (Ware et. al., 1998), three subscales from the Brief Symptom Inventory (BSI) (Derogatis & Spencer, 1982), and an observed psychotic behavior rating scale (Dohrenwend, 1982) were used to evaluate mental health status.

Substance abuse

Items from the Addiction Severity Index (ASI) documented the number of days each client drank to intoxication and whether they had used any illicit drugs during the previous month. Alcohol and drug sub-scales (McLellan et. al., 1980) measured alcohol and drug use problems. A higher score on an these ASI sub-scales reflect a greater, more serious substance use problem.

Service costs

Service costs were estimated for four aggregated types of care: medical/dental treatment, mental health services, substance abuse services, and the total for all three types of services. Costs were estimated on the basis of average unit cost data compiled for a recent NIMH funded cost effectiveness study of treatment of schizophrenia (Rosenheck et. al., 2006).

Total health costs were also sub-grouped across types of service into inpatient and outpatient costs.

Network measures

Best practices

An evidence-based practices scale was used to measure the degree to which each of the 11 CICH networks was viewed by its core agencies as having implemented evidence-based practices, which included 18 practices identified in 2003 by the Substance Abuse and Mental Health Services Administration (SAMHSA) (SAMHSA, 2003). A higher score on this scale represented a greater use of evidence-based practices.

Services planning

A services planning scale was developed to represent inter-agency joint planning and coordination, which included cooperation in serving clients, goal congruence, client referral, cooperative planning, co-location of staff and services, information sharing and communication.

Trust and respect

A third scale assessed the degree to which trust and respect existed between agency dyads. A higher score on this scale represented a higher level of trust and respect.

Exchange of resources

An exchange of resources scale was constructed to measure whether an active fiscal relationship existed between each pair of agencies at each site. For every pair of agencies this scale indicated whether there existed any transfer of resources.

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