Briefs · Durham Strategic Framework

The CTI Model

Critical Time Intervention — the evidence behind Durham’s approach to housing stabilization.

City of Durham · Durham County · Durham Community Safety Department

What it is. Critical Time Intervention is a time-limited, phased case management model developed at Columbia University in the 1990s. Its premise is simple and well-proven: the months surrounding a major transition — out of homelessness, out of a hospital, into a home — are decisive. Support concentrated in that window changes long-term outcomes more than the same support spread thin over years. A CTI case manager works intensively at first, then deliberately steps back in phases, spending the arc connecting the household to supports that will outlast the case manager — family, community, income, mainstream services — rather than becoming a permanent fixture themselves. The model ends on purpose, and the ending is the point: by design, the household’s stability no longer depends on the program.

Why we use it for Housing Stabilization Case Management. Durham’s rental assistance is time-limited, so its case management must be built for time-limited work — a model whose entire architecture is aimed at what happens after it ends. CTI is that model. Its phased arc maps naturally onto a twelve-month subsidy; its endpoint discipline maps onto the Month 13 plan; and its evidence base is strong for high-acuity neighbors.

The evidence

The founding trials

In the first randomized trial, nine months of CTI significantly reduced homelessness among men with severe mental illness leaving shelter — an effect still evident at eighteen months.¹ A second randomized trial, with previously homeless adults with severe mental illness leaving psychiatric hospitals, found the reduced risk of homelessness persisted nine months after the intervention ended.² Across the two trials — 278 participants — CTI cut the likelihood of recurrent homelessness by more than sixty percent, earning the “Top Tier” evidence rating reserved for interventions proven in well-conducted randomized trials.³ An early cost-effectiveness analysis found the housing gains came at a favorable cost per night of stable housing gained.⁴

Breadth across populations and settings

The model has since been tested far beyond its original population: veterans across eight VA medical centers,⁵ reduced psychiatric rehospitalization in the founding cohort⁶ and again in a brief adaptation,⁷ a randomized trial of the family adaptation showing longitudinal benefits for children in families experiencing homelessness,⁸ a randomized trial with people leaving prison with severe mental illness,⁹ a feasibility trial with youth exiting homelessness,¹⁰ and a multicenter randomized trial in the Netherlands demonstrating the model travels across systems and countries.¹¹

What the reviews say

A 2020 systematic review of case management for homeless and vulnerably housed populations identified CTI among the intensive models with the strongest support.¹² A 2023 systematic review confirmed CTI’s effects across many kinds of institutional-to-community transitions.¹³ And a 2023 Campbell Collaboration meta-analysis found intensive case management’s protective effects strongest on rehospitalization and promising for housing stability — with the notable finding that people with greater support needs may gain the greatest benefit.¹⁴ Few models in homelessness services carry this much replicated, randomized evidence. That is why Durham built on it rather than inventing something new.

How Durham applies it

A thirteen-month arc. Durham’s Housing Stabilization Case Management runs CTI’s phases across the full span of assistance: Engagement & Assessment at enrollment; Transition (Months 1—3), the high-touch phase; Try-Out (Months 4—8), where the case manager deliberately steps back as the household takes the lead; Transfer (Months 9—12), where responsibility shifts to natural and community supports; and Durham’s added Month 13 Readiness phase — making the step off subsidy a planned move, not a cliff.

Three stabilization goals. Every arc drives at the three factors most predictive of whether housing holds: income generation, budget discipline, and the activation of natural supports.

A Housing Plan as the anchor. Each household’s work is organized around a written plan — monthly budget, housing history review, a time-bound income strategy, and a documented path to a finalized Month 13 plan by the end of Month 12.

Multiple providers, one model. Capacity is distributed across agencies for resilience and reach, but every provider operates from the same policies, the same documentation, and the same fidelity expectations.

Unified with Homeward Durham. CTI case management is mandatory for every household on Homeward Durham rental assistance — delivered by contracted housing stabilization case managers, with referring providers welcome to complete CTI training and continue as their client’s case manager inside the practice. And a housing stabilization case conferencing table supports every household in a unit toward its Month 13 plan.

An offer to the whole system

The City has already offered CTI training free to the entire homelessness system — and more than sixty people attended each of the trainings held so far. We will keep offering them, so the whole system can benefit from the model, not just the Housing Stabilization Case Management practice around Homeward Durham. This is an offer to the system, not a mandate: any case manager who wants CTI to inform their practice is welcome at the table.

Sources

1. Susser, Valencia, Conover, Felix, Tsai & Wyatt (1997), American Journal of Public Health 87(2).
2. Herman, Conover, Gorroochurn, Hinterland, Hoepner & Susser (2011), Psychiatric Services 62(7).
3. Social Programs That Work, Arnold Ventures evidence review — Top Tier rating.
4. Jones, Colson, Holter, Lin, Valencia, Susser & Wyatt (2003), Psychiatric Services 54(6).
5. Kasprow & Rosenheck (2007), Psychiatric Services 58(7).
6. Tomita & Herman (2012), Psychiatric Services 63(9).
7. Shaffer et al. (2015), Psychiatric Services 66(11).
8. Shinn, Samuels, Fischer, Thompkins & Fowler (2015), American Journal of Community Psychology 56(3–4).
9. Hopkin & Stevenson (2017), CrISP randomised controlled trial, Health Services and Delivery Research.
10. Kidd et al. (2020), American Journal of Orthopsychiatry 90(5).
11. de Vet et al. (2017), multicenter randomized trial, the Netherlands.
12. Ponka et al. (2020), PLOS ONE 15(4).
13. Manuel, Nizza, Herman, Conover, Esquivel, Yuan & Susser (2023), Administration and Policy in Mental Health 50(1).
14. Weightman et al. (2023), Campbell Systematic Reviews 19(2).