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Implementing MISSION-VET for Homeless Veterans with Comorbid Mental Illness and Substance Abuse Disorder

VA continues to strive toward ending chronic homelessness among Veterans. Co-occurring mental health and substance use disorders (COD) are one of the most common clinical problems among homeless Veterans – andthreatenlong-term housing stability and general substance use and mental health recovery. Maintaining Independence and Sobriety through Systems Integration, outreach and Networking-Veterans Edition (MISSION-Vet) is an evidence-based intervention developed within VA, with partial funding by HSR&D, and is included in the Substance Abuse and Mental Health Service Administration (SAMHSA) National Registry of Evidence-based Programs and Practices (NREPP) to address COD among homeless individuals.

MISSION-VET services can be initiated in inpatient, residential or outpatient settings. These services are provided by treatment teams that include a case manager and a peer support specialist, who support Veterans during critical care transition points. Treatment teams deliver COD services directly and provide essential service links to both VA and community-based programs to help homeless and formerly homeless Veterans:

• Engage in mental health, substance abuse, and medical treatment;
• Locate and participate in recovery support groups (i.e., Alcoholics Anonymous and Narcotics Anonymous);
• Obtain and maintain employment; and
• Enroll in educational programs.

As is true for many complex interventions such as MISSION-VET, implementation support is often needed to get the intervention into routine clinical practice and with good fidelity. Therefore, this QUERI study* was undertaken to test whether the implementation strategy called Getting To Outcomes® (GTO)—streamlined and tailored to the VA context—could assist VA staff within the VA HUD-VASH Program in delivering MISSION-VET services above and beyond standard MISSION-VET training (Implementation as Usual or IU). [HUD-VASH is a collaborative program between the Department of Housing and Urban Development (HUD) and VA that combines HUD housing vouchers with VA supportive services to help homeless Veterans find and sustain permanent housing.] This project also examined whether Veterans receiving MISSION-VET from staff whom had training and GTO support would show greater improvements compared to those whom received services from staff in the IU group.

This study was an implementation and effectiveness trial that included case managers and peer specialists from HUD-VASH teams in the VA Central Western Massachusetts Healthcare System, Washington DC VA Medical Center, and VA Eastern Colorado Health Care System. All participating staff (n=57) were trained to deliver MISSION-VET through a standard training webinar. Getting To Outcomes® was offered as an implementation support tool to 35 VA HUD-VASH team members across all three teams, whereas the other 22 only received Implementation as Usual. The trial assessed MISSION-VET service delivery, collected via administrative data, as well as feedback from participants on implementation barriers and facilitators, which was collected via interviews.

Findings

QUERI investigators found that 68% of the group who received implementation support via Getting to Outcomes® delivered some MISSION-VET, whereas none delivered MISSION-VET in the Implementation as Usual group. With regard to Veteran-level outcomes, service engagement, as measured by the overall number of case manager contacts with Veterans and others (i.e., family members, health providers), was significantly higher among Veterans in the GTO group and declined less steeply over time relative to the comparison group. Most case managers appreciated the MISSION-VET materials and felt the GTO planning meetings supported using MISSION-Vet. Several barriers undermined more MISSION-Vet implementation, including MISSION-VET’s complexity, as well as HUD-VASH’s prioritization of housing placement in front of addressing comorbid mental health and substance abuse symptoms by program design.

Impact

There is a substantial need for uniform implementation to assist homeless Veterans with a COD in accessing and engaging in care and reducing housing loss. This study found that GTO significantly improved the amount of MISSION-Vet being offered to Veterans and that MISSION-VET was helpful in increasing access to care. Bridging the Care Continuum QUERI is conducting a multisite study of MISSION-VET and is utilizing facilitation as the implementation approach.

For more information about this study, please contact David Smelson, PsyD, at David.Smelson@umassmed.edu .

*The QUERI GTO study included collaborators from: National Center on Homelessness among Veterans, VA Office of Mental Health, VA Homeless Program Office, VISN 4 Mental Illness Research Education Clinical Center, and HSR&D’s Center for Healthcare Organization and Implementation Research

References:

Chinman M, McCarthy S, Hannah G, Byrne T, and Smelson D. 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. 2017;12:34.

Smelson D, Chinman M, McCarthy S, et al. (2015). A cluster-randomized hybrid III trial testing an implementation support strategy to facilitate the use of an evidence-based practice in VA homeless programs. Implementation Science. 2015;10:79.