Up to 80% of Veterans who are homeless suffer from mental health and/or substance use disorders. The path into and out of homelessness is often complicated by untreated or under treated mental health and substance use disorders. The presence of these disorders can further isolate homeless individuals, resulting in greater utilization of emergency room visits and hospitalizations, which can be efficient in stabilizing medical crises, but ineffective in reducing housing loss. Thus, integrating mental health and substance use disorder treatment with community-based permanent housing and case management supports is important in sustaining housing placements for Veterans and for preventing relapses back into homelessness. While a number of treatments for co-occurring mental health and substance use disorders (COD) have proven to be effective, one approach called Maintaining Independence and Sobriety through Systems Integration, Outreach, and Networking-Veterans Edition, or MISSION-Vet, was developed specifically for Veterans who are homeless or formerly homeless with COD.
The MISSION-Vet approach, systematically incorporates several evidence-based practices into one comprehensive system of care to address COD among homeless Veterans. These practices have been found to work well when combined using a standardized protocol like MISSION-Vet and include assertive community treatment, peer support, dual disorders treatment, employment/education support and trauma informed care. The MISSION-Vet services are delivered by case manager/peer teams and share similar techniques and treatment philosophies as HUD-VASH, including Housing First and Harm Reduction, but have more structure and standardization in its sessions and tasks. MISSION-Vet includes treatment manuals and training to help providers deliver the services (available for download on the National Center on Homelessness Among Veterans Website at http://www.va.gov/homeless/nationalcenter_additional_information.asp). However, implementation science principles and our own experiences disseminating MISSION-Vet suggest that more active implementation strategies are needed to get a complex intervention like MISSION-Vet into routine practice by VA providers.
GTO facilitates the use of evidence-based practices
GTO is an implementation strategy designed to strengthen the knowledge, attitudes, and skills (collectively defined as "capacity") practitioners need to carry out evidence-based programs (http://www.rand.org/gto). GTO poses a series of steps practitioners should follow in order to obtain positive results and then provides the guidance necessary to complete those steps with quality (i.e., to perform each task as close to the ideal as possible). According to GTO, "carrying out" an evidence-based program involves much more than service delivery. It involves a series of steps within three areas: (1) planning - e.g., developing goals and performance targets, ensuring staff are trained in the evidence-based program; (2) implementation - e.g., monitoring program activities, maintaining adherence to an evidence-based program model, supervision; and (3) self-evaluation - e.g., tracking patient outcomes, using data to improve program operations. All of these steps are designed to be logically linked so that goals and performance targets correspond with program activities as well as process and outcome measures to assess if the targets are being met, which are linked to quality improvement activities that makes use of the process and outcome data. Several studies have shown that GTO helps practitioners conduct better programming.
This project has two Objectives: (1) to assess GTO's impact in facilitating adoption and use of MISSION-Vet (with fidelity) within HUD-VASH, and (2) to assess the effectiveness of MISSION-Vet in circumstances that more closely resemble regular practice.
This study is being carried out with HUD-VASH teams at the Central/Western Massachusetts, Washington DC, and Denver VA Medical Centers. At the time of the study start, the size of the three HUD-VASH teams were: Team 1 (450 HUD-VASH vouchers and 18 case managers), Team 2 (850 HUD-VASH vouchers and 27 case managers), and Team 3 (810 HUD-VASH vouchers and 24 case managers), for a total of 2110 HUD-VASH vouchers and 69 case managers. Within each site, existing sub-teams (including case managers/peers and Veterans they serve) were assigned to receive either MISSION-Vet Implementation as Usual (IU), which includes standard webinar training and access to the MISSION-Vet treatment manuals (on the National Center on Homelessness Among Veterans Website noted above) or IU along with GTO support (ongoing technical assistance to get MISSION-Vet into practice). Data were gathered on key components of MISSION-Vet-namely the DRT sessions, peer sessions, self-guided exercises, referrals made, and delivery of the workbook to each participating Veteran. This information was included in a note template for use by case managers in CPRS and later extracted. In addition to MISSION-Vet service delivery, we conducted semi-structured interviews with case managers from each Team in Northampton, Washington DC and Denver VAMC's (Team 1=5, Team 2=7, Team 3=10). We invited all case managers and peer specialists from the GTO group to participate. The response rates for Teams 1, 2, and 3 were 83%, 43%, 55%, respectively. We also used HOMES Registry data to examine outcomes with regard to treatment engagement, housing, hospitalization, mental health, substance abuse.
Within regard to Objective 1, no case managers/peers in the IU group adopted MISSION-Vet while 68% of the case managers/peers in the GTO group delivered MISSION-Vet services. Seven percent of Veterans with case managers/peers in the GTO group received at least one MISSION-Vet session (This represents a "lower bound" because the denominator was all HUD-VASH Veterans, many of whom do not need MISSION-Vet). Only 1.7% of Veterans with case managers in the GTO group received at least half of the available 24 structured DRT or Peer Support MISSION-Vet sessions. Most case managers appreciated the MISSION-Vet materials and felt the GTO planning meetings supported using MISSION-Vet. Case manager interviews also showed that MISSION-Vet could be confusing and wished that they had more involvement from leadership after their initial agreement to participate.
With regard to Objective 2, service intensity, as measured by the overall number of case manager contacts with Veterans and others (e.g. family members, health providers), was significantly higher among Veterans in the GTO group (B = 2.30, p = .04) and declined less steeply over time relative to the non-GTO group (B = -0.19, p = .01). Supplemental analyses found that Veterans who received "medium" intensity MISSION-Vet services (compared to "low intensity)" had improved alcohol and drug use, inpatient hospitalization and emergency department use that approached statistical significance.
This study has yielded several important implications and lessons regarding implementation of a new best practice into an existing program or facility. Implementing new evidence-based practices is always challenging, especially given the current housing and clinical demands faced by HUD-VASH teams and the comprehensive nature of an integrated service model like MISSION-Vet. However, our data suggest that GTO implementation support can help HUD-VASH teams adopt MISSION-Vet to fit within their local environment. Veterans served in MISSION-Vet (supported by GTO) received double the amount of services delivered by standard HUD-VASH practices. However, despite the implementation support, none of the providers delivered MISSION-Vet with high fidelity. In fact, many of the providers only had modest fidelity. Despite the fidelity issues, higher intensity MISSION-Vet services were associated with less alcohol use, drug use, mental health hospitalizations and negative housing exits over time. This is critical as increased care intensity is associated with better rates of care access and engagement, which are VA national performance measures.
Further, discussions with MISSION-Vet case managers and peer specialists as well as with program administrators suggest that while time demands prevented larger-scale implementation across most HUD-VASH clients to date, MISSION-Vet is being targeted to those Veterans on caseloads who are in the most critical need of intensive services. Many HUD-VASH case managers were intrinsically motivated because they viewed MISSION-Vet as an opportunity to deliver more intensive services that some of the Veterans they serve need, as evidenced by the above quotes and by the adoption of MISSION-Vet into a new case management team for high risk clients at one of the sites. That site also asked for additional MISSION-Vet training and GTO consultation.
Despite the preliminary success, we also wish to acknowledge certain challenges associated with initiating MISSION-Vet that could apply to the process of implanting any new evidence-based practice within the VA Healthcare System. First, peer support specialists had to be hired and incorporated into the teams at the same time the case managers were learning the new approach. Several studies have noted that time and attention is needed to lay the groundwork with existing staff and leadership before hiring peer specialists to improve the likelihood of their successful integration into existing clinical teams. Second, the start of MISSION-Vet was occurring while teams nationwide were receiving new housing vouchers (each voucher represents a Veteran who is homeless and scheduled to receive housing assistance). Therefore, participating HUD-VASH teams needed assistance in balancing the immediate demands of providing housing against the planning and integration of MISSION-Vet services for Veterans who were already housed. GTO was helpful in this regard as GTO teams, along with the GTO provider, tailored implementation of MISSION-Vet to fit the structures and schedules of each team.
External Links for this Project
- Smelson DA, Chinman M, McCarthy S, Hannah G, Sawh L, Glickman M. A cluster randomized Hybrid Type III trial testing an implementation support strategy to facilitate the use of an evidence-based practice in VA homeless programs. Implementation science : IS. 2015 May 28; 10(1):79. [view]
- Smelson DA, Kline A, Kuhn J, Rodrigues S, O'Connor K, Fisher W, Sawh L, Kane V. A wraparound treatment engagement intervention for homeless veterans with co-occurring disorders. Psychological Services. 2013 May 1; 10(2):161-7. [view]
- Smelson DA, Chinman M, Hannah G, Byrne T, McCarthy S. An evidence-based co-occurring disorder intervention in VA homeless programs: outcomes from a hybrid III trial. BMC health services research. 2018 May 5; 18(1):332. [view]
- Blonigen DM, Cucciare MA, Timko C, Smith JS, Harnish A, Kemp L, Rosenthal J, Smelson D. Study protocol: a hybrid effectiveness-implementation trial of Moral Reconation Therapy in the US Veterans Health Administration. BMC health services research. 2018 Mar 7; 18(1):164. [view]
- McInnes DK, Sawh L, Petrakis BA, Rao S, Shimada SL, Eyrich-Garg KM, Gifford AL, Anaya HD, Smelson DA. The potential for health-related uses of mobile phones and internet with homeless veterans: results from a multisite survey. Telemedicine journal and e-health : the official journal of the American Telemedicine Association. 2014 Sep 1; 20(9):801-9. [view]
- O'Connor K, Kline A, Sawh L, Fisher W, Rodrigues S, Kane V, Kuhn J, Ellison ML, Smelson DA. Unemployment and Co-occurring Disorders Among Homeless Veterans. Journal of Dual Diagnosis. 2013 Mar 27; 9(2):134-138. [view]
- Chinman M, McCarthy S, Hannah G, Byrne TH, Smelson DA. Using Getting To Outcomes to facilitate the use of an evidence-based practice in VA homeless programs: a cluster-randomized trial of an implementation support strategy. Implementation science : IS. 2017 Mar 9; 12(1):34. [view]
- Smelson D, Chinman MJ, McCarthy S, Siegfriedt J, Sawh L, Kane V, Weaver D, Strong S, Issa F. Implementing evidence-based co-occurring disorder treatment in VA-HUD VASH: the MISSION-GTO study. Paper presented at: VA MIRECC Homeless Veterans with SMI: From Street to Independence Conference; 2013 May 14; Baltimore, MD. [view]
- McCarthy SA, Chinman MJ, Smelson D, Hannah G. Incorporating evidence-based dual-diagnosis treatments into VA homelessness services. Poster session presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 9; Philadelphia, PA. [view]
Mental, Cognitive and Behavioral Disorders, Substance Use Disorders