The Impact of Financial Incentives on Service Engagement Among Adults Experiencing Homelessness and Mental Illness: A Pragmatic Trial Protocol

Background: People experiencing homelessness and mental illness have poorer service engagement and health-related outcomes compared to the general population. Financial incentives have been associated with increased service engagement, but evidence of effectiveness is limited. This protocol evaluates the acceptability and impact of financial incentives on service engagement among adults experiencing homelessness and mental illness in Toronto, Canada. Methods: This study protocol uses a pragmatic field trial design and mixed methods (ClinicalTrials.gov Identifier: NCT03770221). Study participants were recruited from a brief multidisciplinary case management program for adults experiencing homelessness and mental illness following hospital discharge, and were randomly assigned to usual care or a financial incentives arm offering $20 for each week they attended meetings with a program provider. The primary outcome of effectiveness is service engagement, measured by the count of participant-provider health-care contacts over the 6-month period post-randomization. Secondary health, health service use, quality of life, and housing outcomes were measured at baseline and at 6-month follow-up. Quantitative data will be analyzed using descriptive statistics and inferential modeling including Poisson regression and generalized estimating equations. A subset of study participants and other key informants participated in interviews, and program staff in focus groups, to explore experiences with and perspectives regarding financial incentives. Qualitative data will be rigorously coded and thematically analyzed. Conclusions: Findings from this study will contribute high quality evidence to an underdeveloped literature base on the effectiveness and acceptability of financial incentives to improve service engagement and health-related outcomes among adults experiencing homelessness and mental illness.