2019 HSR&D/QUERI National Conference
1093 — Expanding VA Mental Health Services to Treat Risk for Criminal Recidivism: Findings from an Effectiveness-Implementation Trial
Lead/Presenter: Daniel Blonigen, COIN - Palo Alto
All Authors: Blonigen DM (Center for Innovation to Implementation, VA Palo Alto HCS; Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine), Cucciare MA (Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Affairs HCS; Department of Psychiatry, University of Arkansas for Medical Sciences), Timko C (Center for Innovation to Implementation, VA Palo Alto HCS; Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine) Smith JS (Center for Innovation to Implementation, VA Palo Alto HCS) Javier S (Center for Innovation to Implementation, VA Palo Alto HCS; Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine) Morson R (Palo Alto University) Smelson D (Center for Health Care Organization and Implementation Research, Bedford VAMC, University of Massachusetts Medical School, Worcester)
VA mental health services are increasingly called upon to treat justice-involved Veterans to reduce their risk for criminal recidivism. Moral Reconation Therapy (MRT) is a cognitive-behavioral intervention with empirical support for reducing recidivism among justice-involved adults in correctional settings. However, the barriers and facilitators to implementation in non-correctional settings are unknown. We examined this issue using a process evaluation from a three-site effectiveness-implementation trial of MRT for justice-involved Veterans in VA Mental Health Residential Rehabilitation Treatment Programs (RRTPs).
Across sites, semi-structured qualitative interviews were conducted with 36 Veterans who were randomized to MRT and had varied levels of engagement in the intervention, and 10 RRTP staff who were involved in the implementation of MRT during the trial. Interviews were guided by select domains from the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, and a focus on patient engagement. Audio-files were transcribed and analyzed using Rapid Qualitative Analysis to identify barriers and facilitators to implementing MRT in RRTPs across VA.
Barriers to Reach included competing demands in the RRTP and other patient obligations-e.g., work, family. To enhance Reach, interviewees suggested using court-related incentives and sanctions as part of treatment, expanding eligibility for MRT to include non-justice involved Veterans, and promoting the benefits of MRT with patients early in treatment-e.g., testimonials from MRT graduates. Internal motivation was viewed as a key facilitator to patient engagement. Regarding Adoption and Maintenance, MRT was viewed as complementary with RRTP care; however, participants also reported a need to better integrate MRT into the RRTP schedule and curriculum, educate RRTP staff on the purpose of MRT to generate buy-in, and develop a community-of-practice network, VA-wide.
Although MRT was viewed as complementary with RRTP care, modifications are likely needed to facilitate Reach and engagement with patients and Adoption and Maintenance among RRTP staff, including better coordination with treatment courts and adding motivational tools to the MRT curriculum.
Our findings provide guidance to practitioners and policymakers on best practices for implementing MRT in VA RRTPs, which in turn will increase access to this evidence-based intervention for a vulnerable population of Veterans.