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Healthcare systems face difficulty implementing evidence-based practices, particularly multicomponent interventions. Additional challenges occur in settings serving vulnerable populations such as homeless Veterans, given the population's acuity, multiple service needs, and organizational barriers. Implementation Facilitation (IF) is a strategy to support the uptake of evidence-based practices. This study's aim was to simultaneously examine IF on the uptake of Maintaining Independence and Sobriety Through Systems Integration, Outreach and Networking-Veterans Edition (MISSION-Vet), an evidence-based multicomponent treatment engagement intervention for homeless Veterans with co-occurring mental health and substance abuse, and clinical outcomes among Veterans receiving MISSION-Vet. This multi-site hybrid III modified stepped-wedge trial involved seven programs at two Veterans Affairs Medical Centers comparing Implementation as Usual (IU; training and educational materials) to IF (IU + internal and external facilitation). A total of 110 facilitation events averaging 27 minutes were conducted, of which 85% were virtual. Staff (case managers and peer specialists; n = 108) were trained in MISSION-Vet and completed organizational readiness assessments (n = 77). Although both sites reported being willing to innovate and a desire to improve outcomes, implementation climate significantly differed. Following IU, no staff at either site conducted MISSION-Vet. Following IF, there was a significant MISSION-Vet implementation difference between sites (53% vs. 14%, p = .002). Among the 93 Veterans that received any MISSION-Vet services, they received an average of six sessions. Significant positive associations were found between number of MISSION-Vet sessions and outpatient treatment engagement measured by the number of outpatient visits attended. While staff were interested in improving patient outcomes, MISSION-Vet was not implemented with IU. IF supported MISSION-Vet uptake and increased outpatient service utilization, but MISSION-Vet still proved difficult to implement particularly in the larger healthcare system. Future studies might tailor implementation strategies to organizational readiness. ClinicalTrials.gov, NCT02942979.

Background Evidence-based treatment for co-occurring disorders is needed within programs that serve homeless Veterans to assist with increasing engagement in care and to prevent future housing loss. A specialized co-occurring disorders treatment engagement intervention called Maintaining Independence and Sobriety Through Systems Integration, Outreach and Networking - Veterans Edition (MISSION-Vet) was implemented within the Housing and Urban Development - Veterans Affairs Supportive Housing (HUD-VASH) Programs with and without an implementation strategy called Getting To Outcomes (GTO). While implementation was modest for the GTO group, no one adopted MISSION in the non-GTO group. This paper reports Veteran level outcome data on treatment engagement and select behavioral health outcomes for Veterans exposed to the MISSION-Vet model compared to Veterans without access to MISSION-Vet. Methods This hybrid Type III trial compared 81 Veterans in the GTO group to a similar group of 87 Veterans with mental health and substance use disorders from the caseload of staff in the non-GTO group. Comparisons were made on treatment engagement, negative housing exits, drug and alcohol abuse, inpatient hospitalizations, emergency department visits and income level over time, using mixed-effect or Cox regression models. Results Treatment engagement, 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). Supplemental exploratory analyses between Veterans who received “higher” and “lower” intensity MISSION-Vet services in the GTO group failed to show differences in alcohol and drug use, inpatient hospitalization and emergency department use. Conclusions Despite modest MISSION-Vet fidelity among staff treating Veterans in the GTO group, differences were found in treatment engagement. However, this study failed to show differences in alcohol use, drug use, mental health hospitalizations and negative housing exits over time among those Veterans receiving higher intensity MISSION-Vet services versus low intensity services. This project suggests that MISSION-Vet could be used in HUD-VASH to increase engagement among Veterans struggling with homelessness, a group often disconnected from care. Trial registration Clinicaltrials.gov, registration number: NCT01430741 , registered July 26, 2011.

Animal-assisted interventions (AAI) offer potential physical and psychological health benefits that may assist Veterans with post-traumatic stress disorder. However, more feasibility studies are needed regarding intervention details, adverse events, reasons for study withdrawal, and animal welfare. This mixed methods feasibility trial involved a modified crossover study in which Veterans with PTSD/PTSD symptoms were provided a series of 8 nature and wildlife immersion experiences to evaluate feasibility and preliminary efficacy. The sample included 19 Veterans with PTSD/PTSD symptoms who were followed for a mean of 15.1 weeks. The intervention was comprised of a baseline forest walk, assisting with wildlife rehabilitation, observation in a wildlife sanctuary, and bird watching. Post study bird feeders were provided for sustainability. This AAI nature/wildlife immersion intervention was feasible, acceptable, and safe to administer to Veterans with PTSD/PTSD symptoms with appropriate support. Logistical and relational facilitators were identified that supported the wildlife immersion activities. Participants reported greatly enjoying the activities. Attention to animal welfare and care was an important ethical foundation that also contributed to feasibility. AAI immersion experiences with wildlife are feasible and can safely be administered to Veterans with PTSD/PTSD symptoms. Logistical and relational facilitators are important to support nature and wildlife immersion activities.

Background Veterans involved in the criminal legal system (CLS) exhibit disproportionately high rates of comorbid mental health and substance use disorders (COD) and homelessness—conditions that increase both the risk of recidivism and suicide. Despite elevated risk, limited research has examined the relationship between criminogenic risk factors and suicidality in this population. Objectives This study examined differences in criminogenic risk, psychiatric burden, and social determinants of health (SDOH) among CLS-involved veterans with COD, comparing those with suicidality risk to those without. Methods Baseline data were analyzed from 127 veterans admitted to three Department of Veterans Affairs (VA) Mental Health Residential Rehabilitation Treatment Programs who were enrolled in a randomized controlled trial of the MISSION-CJ intervention (ClinicalTrials.gov Identifier: NCT04523337). Eligible veterans had recent CLS involvement and documented COD diagnoses. Assessments included the Level of Service Inventory–Revised (LSI-R), the Measures of Criminal Attitudes and Associates (MCAA), structured psychiatric interviews, standardized symptom inventories, and measures of social determinants of health. Suicidality risk was defined as experiencing recent thoughts of suicide and/or attempted suicide in their lifetime. Results Most veterans (80%) were classified as having moderate-high to high criminogenic risk based on total LSI-R scores. Compared to those without suicidality risk, veterans with suicidality risk demonstrated significantly higher criminogenic risk as evidenced by total LSI-R scores ( p  = .01), more antisocial attitudes ( p  = .04), particularly entitlement and violence beliefs ( p  = .02, p  = .01, respectively), greater emotional and functional impairment ( p  < .001), and a higher prevalence of probable posttraumatic stress disorder (PTSD; 64% vs. 41%, p  = .009). SDOH, including unstable housing and limited community integration, were highly prevalent but did not significantly differ between those with and without risk of suicide. Conclusions Among CLS-involved homeless veterans with COD, suicidality was associated with elevated criminogenic risk and greater psychiatric burden, particularly PTSD. These findings underscore the need for integrated interventions that address both criminogenic and behavioral health factors to support recovery, reduce suicide risk and mental health symptoms, and mitigate CLS recidivism. Trial registration This study was preregistered at https://ClinicalTrials.gov with registration number NCT04523337.

Background Few studies have examined the effectiveness of telephone smoking cessation interventions by severity of behavioral health symptoms. Using data from a telephone counseling study, we examined whether abstinence rates varied by level of behavioral health symptoms. Methods The parent study recruited adults who smoke cigarettes ( N  = 577) referred by mental health providers at six Veterans Health Administration facilities. Participants were randomized to specialized telephone counseling (intervention) or state Quitline referral (control). Participants completed assessments at baseline and 6 months, including the BASIS-24, a self-report measure of behavioral health symptoms and functioning. We used the BASIS-24 median to dichotomize participants as having high or low scores. The primary outcome was 30-day self-reported abstinence at 6 months. We compared groups on outcomes by logistic regression and performed an interaction effect analysis between treatment assignment and groups. Results At baseline, those with high behavioral health symptoms scores reported heavier nicotine dependence and more sedative and/or antidepressant use, compared to participants with low behavioral health symptoms. At 6 months, participants with low behavioral health symptoms scores in the intervention reported higher rates of 30-day abstinence compared to those in the control arm (26% vs 13%, OR = 2.3, 95% CI = 1.8, 2.9). People with high behavioral health symptoms scores reported no difference in 30-day abstinence between the treatment assignments at 6 months (12% vs. 13%, OR = 1.1, 95% CI = 0.6, 2.0). Conclusions Only participants with low behavioral health symptoms scores reported higher abstinence rates in the intervention compared to the state Quitline. Future research can examine alternative approaches for people with worse mental well-being and functioning. Trial registration The parent study is registered at www.clinicaltrials.gov NCT00724308.

Homelessness is poorly captured in most administrative data sets making it difficult to understand how, when, and where this population can be better served. This study sought to develop and validate a classification model of homelessness. Our sample included 5,050,639 individuals aged 11 years and older who were included in a linked dataset of administrative records from multiple state-maintained databases in Massachusetts for the period from 2011-2015. We used logistic regression to develop a classification model with 94 predictors and subsequently tested its performance. The model had high specificity (95.4%), moderate sensitivity (77.8%) for predicting known cases of homelessness, and excellent classification properties (area under the receiver operating curve 0.94; balanced accuracy 86.4%). To demonstrate the potential opportunity that exists for using such a modeling approach to target interventions to mitigate the risk of an adverse health outcome, we also estimated the association between model predicted homeless status and fatal opioid overdoses, finding that model predicted homeless status was associated with a nearly 23-fold increase in the risk of fatal opioid overdose. This study provides a novel approach for identifying homelessness using integrated administrative data. The strong performance of our model underscores the potential value of linking data from multiple service systems to improve the identification of housing instability and to assist government in developing programs that seek to improve health and other outcomes for homeless individuals.

Background Recovery Colleges are a relatively recent initiative within mental health services. The first opened in 2009 in London and since then numbers have grown. They are based on principles of personal recovery in mental health, co-production between people with lived experience of mental health problems and professionals, and adult learning. Student eligibility criteria vary, but all serve people who use mental health services, with empirical evidence of benefit. Previously we developed a Recovery College fidelity measure and a preliminary change model identifying the mechanisms of action and outcomes for this group, which we refer to as service user students. The Recovery Colleges Characterisation and Testing (RECOLLECT) study is a five-year (2020–2025) programme of research in England. The aim of RECOLLECT is to determine Recovery Colleges’ effectiveness and cost-effectiveness, and identify organisational influences on fidelity and improvements in mental health outcomes.  Methods RECOLLECT comprises i) a national survey of Recovery Colleges, ii) a prospective cohort study to establish the relationship between fidelity, mechanisms of action and psychosocial outcomes, iii) a prospective cohort study to investigate effectiveness and cost-effectiveness, iv) a retrospective cohort study to determine the relationship between Recovery College use and outcomes and mental health service use, and v) organisational case studies to establish the contextual and organisational factors influencing fidelity and outcomes. The programme has been developed with input from individuals who have lived experience of mental health problems. A Lived Experience Advisory Panel will provide input into all stages of the research. Discussion RECOLLECT will provide the first rigorous evidence on the effectiveness and cost effectiveness of Recovery Colleges in England, to inform their prioritising, commissioning, and running. The validated RECOLLECT multilevel change model will confirm the active components of Recovery Colleges. The fidelity measure and evidence about the fidelity-outcome relationship will provide an empirically-based approach to develop Recovery Colleges, to maximise benefits for students. Findings will be disseminated through the study website (researchintorecovery.com/recollect) and via national and international Recovery College networks to maximise impact, and will shape policy on how Recovery Colleges can help those with mental health problems lead empowered, meaningful and fulfilling lives.

Background Incorporating evidence-based integrated treatment for dual disorders into typical care settings has been challenging, especially among those serving Veterans who are homeless. This paper presents an evaluation of an effort to incorporate an evidence-based, dual disorder treatment called Maintaining Independence and Sobriety Through Systems Integration, Outreach, and Networking—Veterans Edition (MISSION-Vet) into case management teams serving Veterans who are homeless, using an implementation strategy called Getting To Outcomes (GTO). Methods This Hybrid Type III, cluster-randomized controlled trial assessed the impact of GTO over and above MISSION-Vet Implementation as Usual (IU). Both conditions received standard MISSION-Vet training and manuals. The GTO group received an implementation manual, training, technical assistance, and data feedback. The study occurred in teams at three large VA Medical Centers over 2 years. Within each team, existing sub-teams (case managers and Veterans they serve) were the clusters randomly assigned. The trial assessed MISSION-Vet services delivered and collected via administrative data and implementation barriers and facilitators, via semi-structured interview. Results No case managers in the IU group initiated MISSION-Vet while 68% in the GTO group did. Seven percent of Veterans with case managers in the GTO group received at least one MISSION-Vet session. 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; there was little involvement from leadership after their initial agreement to participate; the data feedback system had a number of difficulties; and case managers did not have the resources to implement all aspects of MISSION-Vet. Conclusions This project shows that GTO-like support can help launch new practices but that multiple implementation facilitators are needed for successful execution of a complex evidence-based program like MISSION-Vet. Trial registration ClinicalTrials.gov NCT01430741

Healthcare must rapidly and systematically learn from earlier COVID-19 responses to prepare for future crises. This is critical for VA’s Mental Health Residential Rehabilitation and Treatment Programs (RRTPs), offering 24/7 care to Veterans for behavioral health and/or homelessness. We adapted the World Health Organization’s After Action Review (AAR) to conduct semi-structured small-group discussions with staff from two RRTPs and Veterans who received RRTP care during COVID-19, to examine COVID-19’s impact on these programs. Six thematic categories emerged through qualitative analysis (participant-checked and contextualized with additional input from program leadership), representing participants’ recommendations including: Keep RRTPs open (especially when alternative programs are inaccessible), convey reasons for COVID-19 precautions and programming changes to Veterans, separate recovery-oriented programming from COVID-19-related information-sharing, ensure Wi-Fi availability for telehealth and communication, provide technology training during orientation, and establish safe procedures for off-site appointments. AAR is easily applicable for organizations to debrief and learn from past experiences.

BACKGROUND:Over half of veterans in the criminal justice system have mental health or substance use disorders. However, there is a critical lack of information about female veterans in the criminal justice system and how diagnosis prevalence and treatment entry differ by sex. OBJECTIVES:To document prevalence of mental health and substance use disorder diagnoses and treatment entry rates among female veterans compared with male veterans in the justice system. RESEARCH DESIGN:Retrospective cohort study using national Veterans Health Administration clinical/administrative data from veterans seen by Veterans Justice Outreach Specialists in fiscal years 2010–2012. SUBJECTS:A total of 1535 females and 30,478 male veterans were included. MEASURES:Demographic characteristics (eg, sex, age, residence, homeless status), mental health disorders (eg, depression, post-traumatic stress disorder), substance use disorders (eg, alcohol and opioid use disorders), and treatment entry (eg, outpatient, residential, pharmacotherapy). RESULTS:Among female veterans, prevalence of mental health and substance use disorders was 88% and 58%, respectively, compared with 76% and 72% among male veterans. Women had higher odds of being diagnosed with a mental health disorder [adjusted odds ratio (AOR)=1.98; 95% confidence interval (CI), 1.68–2.34] and lower odds of being diagnosed with a substance use disorder (AOR=0.50; 95% CI, 0.45–0.56) compared with men. Women had lower odds of entering mental health residential treatment (AOR=0.69; 95% CI, 0.57–0.83). CONCLUSIONS:Female veterans involved in the justice system have a high burden of mental health disorders (88%) and more than half have substance use disorders (58%). Entry to mental health residential treatment for women is an important quality improvement target.