***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: The goal of this study was to evaluate the costs , under two different housing conditions , to the state mental health agency of caring for adults who are homeless and mentally ill . One hundred and twelve clients of the Massachusetts Department of Mental Health , living in psychiatric shelters , were r and omly assigned to one of two housing types : Evolving Consumer Households or Independent Living apartments . For the next 18 months each client was followed so that the cost of treatment , case management , and housing  could be collected and compared . The authors found that treatment and case management costs did not vary by housing type , but housing costs were significantly higher for those assigned to Evolving Consumer Households . Regardless of original housing assignment , treatment costs were lower for clients who remained where they were originally placed . The authors conclude that providing support for clients that increases housing stability reduces their need for treatment and that independent living arrangements may be a more costeffective policy choice This study examines community integration among homeless adults with mental illness 6 and 12 months after r and om assignment to Housing First ( independent apartments or congregate residence ) with support services or to treatment as usual ( TAU ) . Residence in independent apartments was associated with increased ‘ psychological integration ’ for participants with less severe needs ; however , no significant improvement in ‘ physical integration ’ was observed among any of the intervention groups . Analysis of individual items on the Psychological Integration subscale revealed that , compared to TAU , participants assigned to independent apartments were more likely to endorse statements related to the emotional components of community but not statements related to neighboring . Participants assigned to the congregate residence were more likely to endorse knowing their neighbors , but not interacting with neighbors or the emotional components of community . Findings are discussed in terms of housing program as well as broader context ual factors OBJECTIVE This study examined whether Housing First fidelity ratings correspond to program operation descriptions from administrative data and predict client outcomes . METHODS A multisite , r and omized controlled trial ( At Home/Chez Soi ) in five Canadian cities included two assessment s of 12 programs over two years . Outcomes for 1,158 clients were measured every six months . Associations between  fidelity ratings and administrative data ( Spearman correlations ) and participant outcomes ( mixed-effects modeling ) were examined . RESULTS Fidelity ratings were generally good ( mean ± SD=136.6 ± 10.3 out of a possible range of 38 - 152 ; 87 % of maximum value ) . Fidelity was significantly associated with three of four measures of program operation , with correlations between .55 and .60 . Greater program fidelity was associated with improvement in housing stability , community functioning , and quality of life . CONCLUSIONS Variation in program fidelity was associated with operations and outcomes , supporting scale validity and intervention effectiveness . These findings reinforced the value of using fidelity monitoring to conduct quality assurance and technical assistance activities Pragmatic trials are important for informing routine clinical practice , but current design s have shortcomings . Clare Relton and colleagues outline the new “ cohort multiple r and omised controlled trial ” design , which could help address the problems associated with existing Abstract Purpose Participant retention is an important challenge in longitudinal research on homeless people . High attrition can threaten validity , and may represent lost opportunities to deliver interventions . In this article , we report on attrition in the At Home/Chez Soi study , a multi-site r and omized controlled trial of a housing intervention for homeless people with mental illness . Methods We first calculate life tables , and then use clustered logistic regression to implement a discrete-time survival model . We use splines and indicator variables to capture non-linear and group-specific variation over time in the hazard function . As potential predictors , we consider study group , site , date of recruitment , age , sex , baseline substance dependence , baseline psychotic disorder , time homeless in life , community functioning , and education . Results The study recruited 2,148 homeless people with mental illness . Of these , 1,158 were r and omized to the housing first intervention ( HF ) , and 990 to treatment as usual ( TAU ) .  Excluding 79 people known to have died ,  attrition was 14 % . This proportion was higher in TAU than in HF ( 21 vs. 8 % , p < 0.01 ) . Attrition was significantly lower in one site than elsewhere , and was also lower among those with substance dependence ( 13 vs. 18 % , p < 0.01 ) and among those enrolled earlier in the study . The hazard varied over time in complex ways . Conclusions Results imply that study factors are more important than participant characteristics as determinants of retention , and that the immediate period after r and omization is a crucial one . The high overall retention demonstrates the effectiveness of existing techniques for retaining participants Purpose This study used an experimental design to examine longitudinal changes in subjective quality of life ( QoL ) among homeless adults with mental illness after assignment to different types of supported housing or to treatment as usual ( TAU , no housing or supports through the study ) . We hypothesized that subjective QoL would improve over time among participants assigned to supported housing as compared to TAU , regardless of the type of supported housing received or participants ’ level of need . Methods Participants ( n = 497 ) were stratified by level of need ( “ high ” or “ moderate ” ) and r and omly assigned to Housing First ( HF ) in scattered-site apartments , HF in a congregate setting ( high needs only ) , or TAU . Linear mixed-effects regression was used to model the association between study arm and self-reported QoL at baseline and at 6 and 12 months post-baseline by need level . Results Based on the adjusted overall score on the QoL measure , participants r and omized to HF reported significantly greater overall QoL as compared to TAU , regardless of need level or type of supported housing at both 6 and 12 months post-baseline . Scores on the safety and living situation subscales were significantly greater for both high and moderate need participants assigned to supported housing regardless of type at both 6 and 12 months post-baseline as compared to TAU . Conclusions Despite multiple health and social challenges faced by homeless individuals with mental illness , HF in both scattered-site and congregate models results in significantly greater perceived QoL as compared to individuals who do not receive HF even after a relatively short period of time OBJECTIVE Housing First with assertive community treatment ( ACT ) is a promising approach to assist people with serious mental illness to exit homelessness . The article presents two-year findings from a multisite trial on the effectiveness of Housing First with ACT . METHODS The study design was a r and omized controlled trial conducted in five Canadian cities . A sample of 950 participants with serious mental illness who were absolutely homeless or precariously housed were r and omly assigned to receive either Housing First with ACT ( N=469 ) or treatment as usual ( N=481 ) . RESULTS Housing First participants spent more time in stable housing than participants in treatment as usual ( 71 % versus 29 % , adjusted absolute difference [AAD]=42 % , p<.01 ) . Compared with treatment-as-usual participants , Housing First participants who entered housing did so more quickly ( 73 versus 220 days , AAD=146.4 , p<.001 ) , had longer housing tenures at the study end-point ( 281 versus 115 days , AAD=161.8 , p<.01 ) , and rated the quality of their housing more positively ( adjusted st and ardized mean difference [ASMD]=.17 , p<.01 ) . Housing First participants reported higher quality of life ( ASMD=.15 , p<.01 ) and were assessed as having better community functioning ( ASMD=.18 , p<.01 ) over the two-year period . Housing First participants showed significantly greater gains in community functioning and quality of life in the first year ; however , differences between the two groups were attenuated by the end of the second year . CONCLUSIONS Housing First with ACT is an effective approach in various context s for assisting individuals with serious mental illness to rapidly exit homelessness This study tests components of Wong and Solomon ’s ( 2002 , Mental Health Services Research , 4(2 ) , 13–28 ) model of community integration , identifying both the dimensions and predictors of integration . It evaluates community integration among adults with psychiatric disabilities assigned r and omly to receive either independent scatter-site apartments with the Housing First approach ( experimental ) or services as usual ( control ) . Factor analysis supported a definition of community integration that includes psychological , physical , and social domains , but also suggested the existence of another factor , independence/self-actualization . Regression analysis suggested that choice and independent scatter-site housing were predictors of psychological and social integration respectively . Psychiatric hospitalization , symptomatology and participation in substance use treatment were also found to influence aspects of integration . We discuss several issues that future studies should explore including the possibility that the same factor can differentially influence discrete aspects of integration , the role of person – environment fit , integration that is not based in the neighborhood , and , finally , conceptions of community integration from the perspective of consumers themselves IMPORTANCE Scattered-site housing with Intensive Case Management ( ICM ) may be an appropriate and less-costly option for homeless adults with mental illness who do not require the treatment intensity of Assertive Community Treatment . OBJECTIVE To examine the effect of scattered-site housing with ICM services on housing stability and generic quality of life among homeless adults with mental illness and moderate support needs for mental health services . DESIGN , SETTING , AND PARTICIPANTS The At Home/Chez Soi project was an unblinded , r and omized trial . From October 2009 to July 2011 , participants ( N = 1198 ) were recruited in 4 Canadian cities ( Vancouver , Winnipeg , Toronto , and Montreal ) , r and omized to the intervention group ( n = 689 ) or usual care group ( n = 509 ) , and followed up for 24 months . INTERVENTIONS The intervention consisted of scattered-site housing ( using rent supplements ) and off-site ICM services . The usual care group had access to existing housing and support services in their communities . MAIN OUTCOMES AND MEASURES The primary outcome was the percentage of days stably housed during the 24-month period following r and omization . The secondary outcome was generic quality of life , assessed by a EuroQoL 5 Dimensions ( EQ-5D ) health question naire . RESULTS During the 24 months after r and omization , the adjusted percentage of days stably housed was higher among the intervention group than the usual care group , although adjusted mean differences varied across sites . [ table : see text ] The mean change in EQ-5D score from baseline to 24 months among the intervention group was not statistically different from the usual care group ( 60.5 [ 95%CI , 58.6 to 62.5 ] at baseline and 67.2 [ 95%CI , 65.2 to 69.1 ] at 24 months for the intervention group vs 62.1 [ 95 % CI , 59.9 to 64.4 ] at baseline and 68.6 [ 95%CI , 66.3 to 71.0 ] at 24 months for the usual care group , difference in mean changes , 0.10 [ 95%CI , −2.92 to 3.13 ] , P=.95 ) . CONCLUSIONS AND RELEVANCE Among homeless adults with mental illness in 4 Canadian cities , scattered site housing with ICM services compared with usual access to existing housing and community services result ed in increased housing stability over 24 months , but did not improve generic quality of life . TRIAL REGISTRATION is rct n.org Identifier : IS RCT N42520374 OBJECTIVES We examined the longitudinal effects of a Housing First program for homeless , mentally ill individuals ' on those individuals ' consumer choice , housing stability , substance use , treatment utilization , and psychiatric symptoms . METHODS Two hundred twenty-five participants were r and omly assigned to receive housing contingent on treatment and sobriety ( control ) or to receive immediate housing without treatment prerequisites ( experimental ) . Interviews were conducted every 6 months for 24 months . RESULTS The experimental group obtained housing earlier , remained stably housed , and reported higher perceived choice . Utilization of substance abuse treatment was significantly higher for the control group , but no differences were found in substance use or psychiatric symptoms . CONCLUSIONS Participants in the Housing First program  were able to obtain and maintain independent housing without compromising psychiatric or substance abuse symptoms Housing First ( HF ) is being widely disseminated in efforts to end homelessness among homeless adults with psychiatric disabilities . This study evaluates the effectiveness of HF with Intensive Case Management ( ICM ) among ethnically diverse homeless adults in an urban setting . 378 participants were r and omized to HF with ICM or treatment-as-usual ( TAU ) in Toronto ( Canada ) , and followed for 24 months . Measures of effectiveness included housing stability , physical ( EQ5D-VAS ) and mental ( CSI , GAIN-SS ) health , social functioning ( MCAS ) , quality of life ( QoLI20 ) , and health service use .  Two-thirds of the sample ( 63 % ) was from racialized groups and half ( 50 % ) were born outside Canada . Over the 24 months of follow-up , HF participants spent a significantly greater percentage of time in stable residences compared to TAU participants ( 75.1 % 95 % CI 70.5 to 79.7 vs. 39.3 % 95 % CI 34.3 to 44.2 , respectively ) . Similarly , community functioning ( MCAS ) improved significantly from baseline in HF compared to TAU participants ( change in mean difference = + 1.67 95 % CI 0.04 to 3.30 ) . There was a significant reduction in the number of days spent experiencing alcohol problems among the HF compared to TAU participants at 24 months ( ratio of rate ratios = 0.47 95 % CI 0.22 to 0.99 
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Risk of bias was much lower in studies with the homeless .
Overall , results from Independent Housing and Support- setting s are not inferior to results from institutionalised setting s. CONCLUSION The results indicate that Independent Housing and Support- setting s provide at least similar outcomes than residential care .