2.7 Intensive Service Models for Families and Youth Speaker: Dr. Judith Samuels Some families and youth benefit from more intensive and long-lasting supportive services to help them successfully transition out of homelessness and achieve housing stability. This workshop will focus on evidence-based service models, including Critical Time Intervention (CTI) and “wrap around”, and how homeless service providers are adapting these service models to get better outcomes for homeless and at-risk families and young adults.

1. INTENSIVE SERVICE MODELS FOR
FAMILIES AND YOUTH
FAMILY CRITICAL TIME
INTERVENTION
(FCTI)
February 9, 2012
Los Angeles, California
Judith Samuels, PhD
Research Scientist, The Nathan S. Kline Institute for Psychiatric Research
Research Professor, New York University, Department of Child Psychiatry
Asst Professor, New York University, Wagner Graduate School of Public Service
Principal, SP3 Innovations

2. What I will cover:
 Original Critical Time Intervention model
 Family adaptation (FCTI): philosophy
 FCTI Research
 How the model works
 Core Components
 Other work with CTI

3. CTI Basics
 Time-limited
 Evidence base
 Increases continuity of care: from homeless
to housed
 Flexible to meet varying needs of
heterogeneous population
 Recovery oriented

4. Why CTI ???
 People in multiple systems, multiple
situations, often transitioning
 From homeless to housing
 From hospital to home
 From residential treatment program to home
 From prison to community
 From foster care to independence
What is the critical time?

5. The CTI Clinical Trial (1990-94)
Prevention of Homelessness Among
Individuals with Mental Illness
Elie Valencia, JD, MA
Ezra Susser, MD, DrPH
Alan Felix, MD
NY Presbyterian Hospital
Department of Psychiatry
5

7. Staying Housed
N=2,937
Lipton, F. R., Siegel, C., Hannigan, A., Samuels, J., & Baker, S. (2000).
Tenure in supportive housing for homeless persons with severe mental illness.
Psychiatric Services 51, 479-486.

8. Why don’t people “survive?”
 Multiple complex needs
 Need for supportive relationships
 Fragmented service systems
 Lack of continuity of care
RESULTS
 Recidivism to:
 Homelessness
 Prison
 Hospital
 Substance Abuse

9. Program/Intervention Process:
Critical Time Intervention
 Time-limited (9-month) case
management
 Titrated, 3 stages
 Focused team approach with aim of
reducing recurrent homelessness
 Continuity of care
 Starts before transition takes place

10. Program/Intervention Process:
Critical Time Intervention
Practices Employed
- motivational interviewing
- harm reduction
Clinical Interventions
 Mental Health Treatment Compliance
 Substance Abuse Services
 Money Management
 Prevention of Housing-Related Crises
 Family Psychoeducation
 Skills Training

11. Stages of CTI
Transition Months 1-3 Provide specialized
support. Implement
transition plan
Try Out Months 4-7 Facilitate and test
client’s problem-
solving skills
Transfer of Care Months 8-9 Terminate CTI
services with support
network safely in
place

12. Flexibility of CTI Model
 Designed to meet the individual’s needs. This
increases cost-effectiveness and maximizes
number of individuals served.
 Services may be direct and assertive AND/OR
maximize linkage to community resources.
 Services aim to increase autonomy, self-
care, and recovery.

13. Family CTI (FCTI)
Over-arching Philosophy of Approach
 comprehensive assessment of the homeless family, but does not assume
the complex psychosocial problems of the family are the cause of
homelessness
 emphasizes that lack of affordable housing is the most important factor
causing family homelessness
 in some cases, problems arise out of homelessness and poverty, in other
cases they merely co-exist
 for some families, psychiatric disorders, substance abuse, and an array of
psychosocial stressors may be contributing factors to the family’s
homelessness
 other economic factors contribute, such as the job market and accessibility
of entitlements
 once a family becomes homeless, any combination of the areas of need
may serve to hinder progress into stable community living
 intervention should target those problems and needs of the family
that are most closely linked to persistent homelessness.

14. Figure 5-2. Model Program: Critical Time Intervention with
Homeless Families
Program Family Critical Time Intervention model (FCTI). The program is
jointly funded by NIMH and the Center for Mental Health
Services/Center for Substance Abuse Treatment Homeless Families
Program.
Goal To apply effective, time-limited, and intensive intervention strategies
to provide mental health and substance abuse treatment, trauma
recovery, housing, support, and family preservation services to
homeless mothers with mental illnesses and substance use disorders
who are caring for their dependent children.
Features The Critical Time Intervention model (CTI) was developed in New
York City as a program to increase housing stability for persons with
severe mental illnesses and long-term histories of homelessness. Its
principle components are rapid placement in transitional
housing, fidelity to a Critical Time Intervention CTI model for families
(i.e., provision of an intensive, 9-month case management
intervention, with mental health and substance use treatments), a
focused team approach to service delivery, with the aim of reducing
homelessness, and brokering and monitoring the appropriate support
arrangements to ensure continuity of care.

15. Research:
Westchester Families First
 Randomized trial
 Family Critical Time Intervention (FCTI) with rapid
re-housing
 Vs. services/system as usual
 Baseline interview, 3, 9,15,24 month follow-up
 Targets homeless families, singles moms
w/mental illness and/or substance abuse
 Challenges “housing readiness” criteria
 RAPID RE-HOUSING
 Housing is SCATTER SITE

16. Research:
CTI for Homeless Families
 Target Population
 Single Female Headed Households
 Children Under 18
 Literally Homeless
 Mental Health and/or Substance Abuse Problem
 High prevalence of:
 Trauma history (abuse, separation)
 Low education
 Poor work history
 Health problems
 Unstable housing history

17. Research:
CTI for Homeless Families
 SAMHSA funding for “parent” study
 NIMH funding for children study
 Intervention program funded by State of NY
 Housing funded by HUD and Westchester County
 Random assignment:
 100 families CTI,
 123 families in control group
 No differences between groups at baseline
 Outcomes:
 CTI families have less time homeless
 Children have better school and mental health outcomes

18. Family CTI Features
 Strengthens ties to services, family, friends
 Provides emotional and practical support
 Time-limited
 Limited goals
 Simple and adaptable
 Provide STRUCTURE to case management

19. Stages of Family CTI
 0-3 Months: Transition to the
Community
 4-6 Months: Practicing Phase
 7-9 Months: Transfer of Care

20. Stage 1: Transition to the
Community
 Much of this work was done in shelter
 This stage may be longer while securing housing
 Intensive, assertive outreach-- Develop linkages to
community resources, evaluate and build living skills
 This stage is more complex for families as children’s
needs are also addressed
 Provide direct services when needed
 Psychiatist/psychologist meets weekly with CTI
workers and consumers
 Visit at least weekly
 More intensive while in shelter

21. Stage 2:
Practicing Phase
 Solidify linkages to community resources
 This includes schools, TANF workers, food
pantries, religious/spiritual resources
 Promote independent living skills
 Includes family resources assessment and plans
 Observe and test current plan
 Develop long-term plan
 Less frequent visits, more phone follow-up

22. Stage 3:
Transfer of Care
 Fine tuning of linkages
 Higher level skills training (employment,
education, social skills)
 Termination with the client

23. Diagram of FCTI Model
Guidelines for Effective Communication
Active & Focused, Supporting & Empathetic, Flexible but Consistent,
Fostering autonomy while remaining available
PRE-FCTI PHASE 1
PHASE 2
PHASE 3
3 months 3 months 3 months

24. What Makes FCTI Different?
 Highly Structured Model
 Continuity of assistance
 From shelter to housing
 Focus on Cause of Housing Instability
 Time limited
 Although a safety net is recommended
 High Level Clinical Support
 Motivational Interviewing
 Titrated model – intensity lowered over time
 CTI is an EBP

25. MODEL COMPONENT:
Continuity of Assistance
 From shelter to new home
 FCTI work begins shelter entry
 Intake/assessment
 Building relationship through Motivational
Interviewing
 Service plan based on mom’s goals
 Connections to community providers
 Support during move back to community

26. MODEL COMPONENT:
Intensive Clinical Support
 Does not replace case work supervisor
 Can be part time
 Supports team
 Provides indirect and direct care
 Opportunity for staff to increase knowledge
 Can help ensure model fidelity

27. MODEL COMPONENT:
Intensive Time Limited – 9 months
 Many case work models are much longer
 Untilfamily is “ready”
 Can foster dependence
 Many families have more strengths than we
think
 “survival” rate is very high
 Allows for more families to be service
 We stress the time limit from day so everyone
is productive

28. MODEL COMPONENT:
Titrated Model – 3 stages
 Allows for uneven case load
 12 cases: 4 stage 1, 4 stage 2, 4 stage 3
 Forces case worker to move family toward
discharge
 Forces family to move toward discharge
 Reinforces strengths
 Reinforces “housing first” goal

29. Additional adaptations:
 Young Families Model
 Emphasis on child development, baby care
 Evaluated in pilot study
 Youth Aging Out of Foster Care
 Longer
model
 Emphasis on life skills
 Families leaving residential treatment

30. And more…
 Current dissemination work:
 US Veterans Administration: homeless veteran
families (SSVF program)
 NY City: Home to Stay
 City of Ottawa, Canada
 UMOM, Arizona
 Training Guide: Ready in Summer 2012
 Training methods: on-site, distance led

31. Judith Samuels, PhD
 For more information contact me:
jasamuels28@gmail.com
Visit the CTI website:
www.criticaltime.org