Although abused women and homeless people leaving shelters represent different subgroups of vulnerable people in society, they share a crucial similarity: during the critical period of transition from shelter to community living they are both at a substantially increased risk for recurrence of the adverse events which brought them to the shelters in the first place [1, 2]. Institutional discharge has proved to be challenging for socially vulnerable people: they have to deal with a complex and fragmented system of care and are at a high risk of experiencing a loss of personal contacts during this transition period [3, 4].
Shelters for abused women and homeless people aim to prevent relapse of clients into their former situation and provide services to improve clients’ well-being and support their integration into the community . However, shelter organisations do not use standardised interventions which have been proved to be effective in supporting clients when they leave [6, 7]. The need for such interventions has increased in light of recent requirements by local authorities and health insurance companies to be accountable for care trajectories of clients and outcomes .
To date, studies into the effectiveness of interventions have been conducted mostly in the United States, and little is known about whether these evidence-based interventions would also be effective in European shelter systems (De Vet, Van Luijtelaar, Brilleslijper-Kater, Vanderplasschen, Beijersbergen & Wolf, unpublished data, May, 2013; Jonker, Sijbrandij, Van Luijtelaar, Cuijpers & Wolf, unpublished data, December, 2012) [6, 9]. The present studies examine whether a time-limited outreach intervention, critical time intervention (CTI) , is more effective than care-as-usual for abused women and homeless people who are making the transition from a shelter facility to supported or independent housing in The Netherlands.
CTI is being applied and tested in the United States, the United Kingdom and Brazil  and has been investigated among a range of populations, such as men and women after discharge from inpatient psychiatric treatment [11, 12] and people being released from prison [13, 14]. Research among homeless men with serious mental illness has shown CTI to reduce the number of days of homelessness, prevent new episodes of homelessness , diminish negative symptoms of schizophrenia , and reduce the risk of rehospitalisation . Previous research also suggests that CTI is cost-effective . To our knowledge, there is no research available on the effectiveness of CTI concerning abused women. However, CTI has proved to be effective for homeless mothers and children in reducing the time families were homeless and improving school and mental health outcomes among the children .
Victims of intimate partner violence
Intimate Partner Violence (IPV) is a major public health problem in many countries throughout the world . Victims often experience an accumulation of problems related to violence, poverty and social exclusion, which has numerous negative consequences for their health. Examples of frequently experienced adverse physical health consequences are severe injuries , chronic pain , gastro-intestinal problems  and gynaecological problems . Furthermore, IPV can result in several psychological problems, such as depression , post-traumatic stress disorder (PTSD)  and substance abuse . Frequently, IPV also leads to significant social isolation .
Estimates of the prevalence of women seeking refuge in shelters are rare. In one study it was estimated that 56,308 women and their children sought refuge in a shelter worldwide on any given day in 2011 . These women report more severe abuse, related injury  and PTSD symptoms  than the victims who do not seek refuge in shelters. Although victims consider shelters as the most supportive and helpful means to deal with past experiences of violence  and their stay in shelters has positive effects on their well-being [30–32], research shows that women leaving shelters encounter many problems. These problems complicate their transition from the shelter to community living (with or without their (ex-)partner). Women indicate they have needs concerning obtaining resources [33, 34], financial problems [3, 35], information on and access to community services  and specialised treatment for depression and symptoms of PTSD [3, 35]. Continuity of care is therefore essential and may help prevent re-victimisation and ensure improvements in the well-being of these women [3, 36].
Several studies have demonstrated the lack of evidence concerning the effectiveness of treatments and interventions for victims of IPV [6, 37]. In an extended international review Jonker, Sijbrandij, Van Luijtelaar, Cuijpers and Wolf (unpublished data, December, 2012) investigated the existing studies on the effectiveness of delivering shelter and post-shelter interventions to abused women. The results concerning post-shelter interventions, mainly consisting of advocacy services for women [34, 38], are encouraging: interventions can diminish recurrence of violence, help end relationships (if wanted) and assist in successfully obtaining the resources required . Furthermore, women experience a higher quality of life and are more satisfied with their social support due to post-shelter interventions [39, 40]. Family post-shelter interventions consisting of instrumental and emotional support and teaching mothers child management skills were also evaluated and show promising results [41, 42]. Nevertheless, as Jonker et al. (Jonker, Sijbrandij, Van Luijtelaar, Cuijpers, & Wolf, unpublished data, December, 2012) and Ramsay et al.  point out, the results of these studies must be interpreted with caution for a few reasons: the studies are few in number, some results are the outcome of only one study, and the quality of some of the studies is not clear. Also, there is an overall lack of standardised instruments in the studies. Evaluating the effectiveness of interventions for abused women after shelter exit therefore remains important, as underlined by several authors [6, 37].
Homelessness is often related to multiple and complex problems such as unemployment, financial problems and domestic conflicts [9, 43, 44]. In addition, physical complaints  and mental disorders  are more prevalent among homeless people than among the general population. Alcohol and drug dependence are the most common mental disorders, with 40% of the homeless population suffering from the former and 25% suffering from the latter. Furthermore, diagnoses of major depression (11%), personality disorders (23%), and psychotic illness (13%) have been frequently established among homeless persons .
Shelter services commonly require homeless people to transition through shelters and temporary housing situations before they become eligible for permanent independent housing in the community. These transitional housing facilities generally feature longer stays and offer a wide array of services for their residents (e.g. (mental) health, employment, legal and childcare services). After the transition to community housing, formerly homeless persons have to rely on conventional social welfare and health services again . People who have made the transition to independent housing often experience readmission to shelter services, probably due to insufficient income, inappropriate housing, inadequate skills and the absence of ongoing support in the community [48, 49]. To overcome the problems of long shelter stays and readmission to shelters, community-based programs have received more attention in recent years [7, 50]. Research indicates that evidence-based interventions which provide temporary assistance with transitioning out of an institutional living environment could enable most homeless people to improve their living conditions and stabilise their lives [4, 47].
Recently, De Vet et al. (De Vet, Van Luijtelaar, Brilleslijper-Kater, Vanderplasschen, Beijersbergen & Wolf, unpublished data, May, 2013) conducted a systematic review of the existing literature on the effectiveness of case management models which have been recommended for homeless clients and have been widely implemented. Results showed that both assertive community treatment (ACT) and CTI are cost-effective approaches. Because ACT is a model which advocates ongoing, comprehensive service provision by a multidisciplinary team which is accessible 24 hours a day, it is generally regarded as most appropriate for homeless persons with the greatest service needs (i.e. those with severe mental illness and/or substance abuse problems) . CTI, on the other hand, seems to be applicable in a variety of settings serving homeless populations with less severe problems, due to its practical and time-limited nature . In addition, this is the only model which was specifically designed for homeless persons who are at critical transitions in their lives . CTI has proved to be effective in decreasing time spent in shelters and increasing time spent in stable housing as well as in reducing psychiatric symptoms and substance use for severely mentally ill homeless men and for homeless veterans with a serious mental illness (De Vet, Van Luijtelaar, Brilleslijper-Kater, Vanderplasschen, Beijersbergen & Wolf, unpublished data, May, 2013). Whether CTI can be effective for other subgroups of homeless people, in settings outside the United States and for outcomes such as quality of life, physical health and received social support, remains to be seen.
CTI is expected to be an appropriate intervention for abused women and homeless people making the transition to community living after staying in a shelter facility. Therefore, the Academic Collaborative Centre for Shelters and Public Mental Health and the Netherlands Centre for Social Care Research decided to modify the intervention for the Dutch context and to investigate the effectiveness of CTI for abused women and homeless people leaving shelter facilities in two randomised controlled trials (RCTs).
The primary research questions of these two studies are:
Is CTI more effective than care-as-usual with regard to improving quality of life for clients leaving women’s shelter facilities to move into supported or independent housing?
Is CTI more effective than care-as-usual with regard to preventing recurrent loss of housing for clients leaving homeless shelter facilities to move into supported or independent housing?