Observational studyBMC health services research2026
Evaluating the impacts of critical time intervention implementation on health service utilization among homeless-experienced veterans: a retrospective observational study.
Observational study in BMC health services research, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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10 authors.
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Abstract
backgroundCritical Time Intervention (CTI) is an evidence-based, time-limited case management practice that improves housing outcomes among homeless-experienced adults. While CTI's effect on housing outcomes has been well-studied, its impacts on health services utilization are less clear. In the context of a U.S Department of Veterans Affairs (VA) CTI implementation effort, we assessed relationships between CTI implementation, including fidelity, and Veterans' VA health services utilization.
methodsWe conducted a retrospective observational study of 9,051 Veterans who received services, 10/1/2019 to 5/1/2025, from one of 156 case management sites that worked with VA; 32 of these sites implemented CTI. Within the 18 implementing CTI sites that completed fidelity ratings, we compared health services utilization for Veterans (n = 2,022) at sites with adequate (n = 12 sites) vs. inadequate (n = 6 sites) fidelity. We performed multivariate regression using generalized estimating equations with clustering by site, adjusting for Veterans' demographics and diagnoses, and VA facility complexity. Regression models identified the impacts of CTI (versus non-CTI), and fidelity (adequate versus inadequate), on health service utilization; we used negative binomial regression for count outcomes (number of primary care, emergency department [ED], behavioral health, homeless services, outpatient medical-surgical visits) and logistic regression for binary outcomes (presence of inpatient mental health, or medical-surgical hospitalizations).
resultsCTI Veterans had lower rates of utilization across all service types compared to non-CTI, including primary care (IRR = 0.98, 95% CI: 0.97-0.98), ED (IRR = 0.93, 95% CI: 0.90-0.95), homeless services (IRR = 0.91, 95%CI: 0.89-0.93) and hospitalizations (AOR = 0.79, 95%CI: 0.68-0.91). Among CTI Veterans, Veterans at sites with adequate fidelity had more primary care use (IRR = 1.04, 95% CI: 1.02-1.07), less ED use (IRR = 0.84, 95% CI: 0.80-0.90) and more homeless service use (IRR = 1.10, 95% CI: 1.05-1.15).
conclusionsCTI Veterans had lower service utilization rates compared to non-CTI Veterans. However, adequate CTI fidelity is associated with increased primary care use and decreased ED use; this finding may be due to high-quality CTI implementation and/or site-level characteristics that enabled better CTI fidelity. Ensuring fidelity to CTI implementation may hold value in promoting optimal care linkages for homeless-experienced Veterans and other clients with high needs.
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