Critical Time Intervention (CTI)
Critical Time Intervention (CTI) is a structured, nine-month intervention that provides support to people during and after a transition to community living from shelter, hospital, or other institutional setting, with the primary goal of preventing a return to homelessness and other adverse outcomes. When people move into housing, CTI provides focused, time-limited case management services that help people make lasting connections to other community resources that can provide ongoing supports. CTI is designed to prevent people from returning to homelessness by providing emotional and practical support during the critical transition period and facilitating and strengthening connections to a support network that may include treatment and other community services, family, friends, and other formal and informal supports. CTI has been used effectively to serve Veterans and other adults with serious mental illnesses and co-occurring substance use disorders experiencing homelessness. CTI has also been used to serve families that include a parent who has mental health and/or substance use problems.
Problem or Challenge:
The period when people who have experienced homelessness transition into housing can be difficult. It can be hard for a person with limited social skills who is also experiencing homelessness and mental health problems to negotiate fragmented service systems and make connections to community resources. Discharge plans and referrals to community-based programs are often not enough. People may struggle with substance use or other challenges that make it difficult to get connected to the support they need to achieve stability in housing, and arrangements for ongoing support sometimes don’t work out as planned. Many people with mental illnesses, substance use problems, or other risk factors who experience homelessness do not have a supportive social network. Even when concerned family members, friends, or neighbors want to offer support, they may lack knowledge about mental illness or substance use or have limited skills to solve problems when they arise. Connections can get broken with de-stabilizing consequences if a person misses appointments or gets into conflicts with family members or neighbors. The consequences too often lead to a return to homelessness.
CTI is a focused, structured, and time-limited intervention that provides case management services and emotional and practical support before, during, and immediately after a person makes the transition to a living situation in the community. CTI has three phases which last for a total of nine months. Each phase lasts about three months and each individual receives services that are provided by the same caseworker during all three phases. The caseworker may be a peer specialist who has both professional training and personal experience with similar issues, or a person with a bachelor or master’s degree. Peer specialists or caseworkers receive training in the CTI model and ongoing clinical supervision from a mental health professional. Each CTI worker typically works with 10-15 clients at a time. A goal is to establish a trusting relationship with the client. In addition to CTI workers who provide direct services to clients and a clinical supervisor, a CTI team may also include a field work coordinator who helps to coordinate linkages to housing and community supports that are mobilized to meet client needs.
Phase one is “transition to the community.” Services usually begin before the client leaves the shelter, hospital, or institution, providing an opportunity for the caseworker to establish a working relationship with the client and get to know his or her needs and goals. (Sometimes these are called “pre-CTI” services, and the three-month timeframe for the first phase of CTI begins at the time a client moves to housing.) During phase one a transition plan is developed, including plans to link the client to needed services and supports in the community. The CTI worker accompanies the client when he or she leaves the shelter, hospital, or other institutional setting to move into housing. During the first few weeks after the client moves in, the CTI worker makes frequent calls and home visits, providing support and advice, teaching independent living and crisis-resolution skills, and mediating any conflicts that arise. The CTI caseworker facilitates introductions and connections to community providers such as healthcare providers or mental health clinics and goes with clients to appointments. The CTI caseworker also meets with key people where the client is living and others who are part of the client’s social support network, including a property manager, a supportive family member, or an involved neighbor, and helps to connect these formal and informal supports together so that they can function as a network. The CTI caseworker offers to be available to the client and housing provider to respond to potential crises and help to resolve problems if they arise. She or he works with the client to develop a plan to address potential housing crises and identify ways to avoid or find solutions to problems that might lead to a return to homelessness. During this phase the caseworker, client, family members, and other service providers collaborate to make arrangements and agreements about medications, money management, and strategies to control substance use problems. This is a time to test the feasibility of support systems that the client will rely upon after the CTI worker will no longer be available.
Phase two is “try out.” During this phase the caseworker monitors support linkages and adjusts the systems and plans that were put in place during the first phase. During this time the CTI caseworker meets with the client less frequently and provides fewer support services directly, and instead works to build and strengthen linkages with informal social supports and community service providers who have assumed primary responsibility for providing ongoing support to the client. The CTI caseworker stays in regular contact with the client to see how the plan is working and helps to intervene if a crisis occurs. The CTI worker is the primary resource to work with the client to make adjustments as needed to arrangements for ongoing support. This may include problem-solving with the client, helping to resolve conflicts, or renegotiating plans for treatment or other services.
Phase three is “transfer of care.” At this time the CTI caseworker has gradually reduced his or her role in delivering services and works as a consultant to the client and his or her support system, including involved family members and treatment providers. During this final phase the CTI worker may meet with the most significant members of the client’s support system to reaffirm their roles and to ensure that connections are in place for ongoing support in the community. The CTI worker may also work with the client to develop and put in motion plans for long-term goals related to work, education, family reunification, etc. The CTI worker reminds the client that he or she has a network of people to help when needed when time-limited CTI services end.
A CTI program needs to be connected to housing options or resources, and the model’s effectiveness depends upon having and leveraging connections to treatment services and other supports that will be available to people who have experienced homelessness. Members of the CTI team build and strengthen effective partnerships with a network of formal and informal supports that can be mobilized on behalf of clients. In addition to housing, supports may include mental health treatment, money management services, substance use treatment, self-help groups, health care, and employment services. Some of these supports may be available from other programs operated by the same agency that implements CTI but most of these supports are likely to be offered by other public or private organizations. Interagency agreements may be needed to facilitate access to services for program participants. Equally important supports may be available from family members, neighbors, faith communities, and civic groups. The CTI caseworker facilitates linkages to and connections among a network of services and supports that will be available to the client on an ongoing basis.
Caseworkers need to have training and appropriate clinical supervision and organizational support to implement the CTI model, which is highly focused and structured. CTI workers also need to be flexible and creative and comfortable doing most of their work in community settings. They need training in motivational interviewing and other evidence-based approaches to providing services. Agencies that implement CTI must have employment practices that allow workers to divide their time between the institution (shelter, hospital, etc.) and the community, and administrative policies that reflect an organizational commitment to delivering CTI as a time-limited service. This may include policies and procedures that facilitate helping clients make connections to ongoing services that may be available from other programs operated by the same agency.
Because CTI is a very focused, time-limited intervention used at the time of a significant transition from homelessness or an institutional setting, caseworkers must have a narrow focus on a few client-defined goals and problem areas that pose the greatest threat to successful community living and activate support to address those goals and risks. CTI caseworkers use motivational interviewing and an understanding of Stages of Change to provide support for clients to make gradual changes, helping people who have experienced homelessness use housing as a base to connect with available supports and take steps toward recovery and stability. CTI caseworkers need to focus on client needs and desires, using a shared decision-making approach to identify key needs and priority areas. CTI workers should listen non-judgmentally, be flexible in their approach but consistent in delivering on commitments, actively advocate on behalf of clients, and be available for crisis intervention.
Cultural sensitivity is important. CTI workers need to be able to establish trusting relationships with clients, family members, and other service providers and community members who may be part of the ongoing support system for the client. CTI peer specialists who have shared some of the life experiences facing their clients can offer practical support while also helping to inspire hope for recovery.
Rigorous evaluations of CTI have shown that the program model results in significant reductions in the likelihood of homelessness and the number of nights that participants spent homeless compared to usual care. For persons with serious mental illness, the costs of CTI are mostly offset by savings associated with reductions in the use of shelter, health care, and other public services.
CTI is listed in SAMHSA’s National Registry of Evidence-Based Practices and Programs (NREPP) and a summary of the research evidence is available on-line.
The nonprofit, nonpartisan Coalition for Evidence-Based Policy has recognized that Critical Time Intervention meets the “Top Tier Evidence Standard” and an evidence summary is available here.
Information about the Critical Time Intervention model including links to publications and training resources can be found at http://www.criticaltime.org/
Evidence-based practice: Motivational Interviewing