An evidence-based co-occurring disorder intervention in VA homeless programs: outcomes from a hybrid III trial.

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.

Relationship between race and community water and sewer service in North Carolina, USA.

Previous evidence has identified potential racial disparities in access to community water and sewer service in peri-urban areas adjacent to North Carolina municipalities. We performed the first quantitative, multi-county analysis of these disparities. Using publicly available data, we identified areas bordering municipalities and lacking community water and/or sewer service in 75 North Carolina counties. Logistic regression was performed to evaluate the relationship between race and access to service in peri-urban areas, controlling for population density, median home value, urban status, and percent white in the adjacent municipality. In the peri-urban areas analyzed, 67% of the population lacked community sewer service, and 33% lacked community water service. In areas other than those with no black residents, odds of having community water service (p<0.01) or at least one of the two services (p<0.05) were highest for census blocks with a small proportion of black residents and lowest in 100% black census blocks, though this trend did not hold for access to community sewer service alone. For example, odds of community water service were 85% higher in areas that were greater than 0% but less than 22% black than in 100% black areas (p<0.001). Peri-urban census blocks without black populations had the lowest odds of community water service, community sewer service, and at least one of the two services, but this difference was only statistically significant for sewer. Peri-urban areas lacking service with no black residents were wealthier than 100% black areas and areas with any percent black greater than 0%. Findings suggest two unserved groups of differing racial and socioeconomic status: (1) lower-income black populations potentially excluded from municipal services during the era of legal racial segregation and (2) higher-income non-black populations. Findings also suggest greater racial disparities in community water than community sewer services statewide.

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.

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.

Employment and mental health service utilization in Washington State.

This study examined employment among individuals utilizing publicly funded mental health services in Washington State during a 2-year period through the analysis of archival administrative data. The mean income found in this study was higher than that reported in the supported employment literature. This difference likely reflects the inclusion of individuals with less severe mental illness and ongoing employment who are typically excluded from studies of supported employment. Individuals in this study were employed in all industrial sectors in a distribution similar to the general population, although somewhat over-represented in service industries. Employment rates varied from 15% to 21% over a 3-year period and did not appear to increase after treatment. Employment rates tended to decline after the receipt of public support. Among individuals who lost employment, service utilization was found to increase prior to the loss of employment. Policy implications are discussed.

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.

BACKGROUND: The Housing and Urban Development-Veterans Affairs Supportive Housing (HUD-VASH) program is one of the largest initiatives to end Veteran homelessness. However, mental health and substance use disorders continue to reduce client stability and impede program success. HUD-VASH programs do not consistently employ evidence-based practices that address co-occurring mental health and substance use disorders. This paper presents a study protocol to evaluate the implementation of an evidence-based, co-occurring disorder treatment called Maintaining Independence and Sobriety Through Systems Integration, Outreach, and Networking-Veterans Edition (MISSION-Vet) in HUD-VASH using an implementation strategy called Getting To Outcomes (GTO). METHODS/DESIGN: In three large VA Medical Centers, this Hybrid Type III trial will randomize case managers and their clients by HUD-VASH sub-teams to receive either MISSION-Vet Implementation as Usual (IU-standard training and access to the MISSION-Vet treatment manuals) or MISSION-Vet implementation augmented by GTO. In addition to testing GTO, effectiveness of the treatment (MISSION-Vet) will be assessed using existing Veteran-level data from the HUD-VASH data monitoring system. This project will compare GTO and IU case managers and their clients on the following variables: (1) fidelity to the MISSION-Vet intervention; (2) proportion of time the Veteran is housed; (3) mental health, substance use, and functional outcomes among Veterans; and (4) factors key to the successful deployment of a new treatment as specified by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) model. DISCUSSION: This project is an important step for developing an implementation strategy to increase adoption of evidence-based practice use in VA homeless programs, and to further examine efficacy of MISSION-Vet in HUD-VASH. This project has important implications for program managers, policy makers, and researchers within the homelessness field. VA Central IRB approval for this study was granted in October 2011. The three sites were trained on MISSION-Vet and GTO in the first half of 2013. The first GTO planning meetings began after training occurred, between January 2013 and November 2013, across the three sites. The data collection-via a fidelity measure embedded into the VA Computerized Patient Record System-began as each site initiated MISSION-Vet, between April 2013 and January 2014. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01430741.

Associative memory in chronic schizophrenia: a computational model.

We developed a computer model to simulate associative memory recall of patients with chronic schizophrenia. Model inputs consisted of words derived from normative data that differed in terms of connectivity and network size, with the former quantitatively represented by parametric weights and the latter by the specific number of word associates that formed a particular network. Previous behavioral studies of normal subjects indicated better recall for words of high connectivity-small network (HCSN), followed by low connectivity-small network (LCSN), high connectivity-large network (HCLN), and low connectivity-large network (LCLN). This pattern of recall differed from that observed in behavioral studies of schizophrenic patients, which showed better recall for high connectivity words, regardless of network size. Holding constant network size while manipulating connection weights effectively simulated this schizophrenic pattern of recall. That is, manipulation of parametric weights coupled with a slight increase in noise significantly and reliably elicited the response pattern of abnormal connectivity demonstrated in the prior behavioral study of patients with chronic schizophrenia. An increase in noise was a necessary, but insufficient step in modeling the response pattern of abnormal connectivity. These findings provide support for the use of computational models to investigate dynamics of associative word recall in patients with chronic schizophrenia.

Lessons learned from a quality improvement intervention with homeless veteran services.

Homeless veterans are a vulnerable population, with high mortality and morbidity rates. Evidence-based practices for homelessness have been challenging to implement. This study engaged staff members from three VA homeless programs to improve their quality using Getting-To-Outcomes (GTO), a model and intervention of trainings and technical assistance that builds practitioner capacity to plan, implement, and self-evaluate evidence-based practices. Primarily used in community-based, non-VA settings, this study piloted GTO in VA by creating a GTO project within each homeless program and one across all three. The feasibility and acceptability of GTO in VA is examined using the results of the projects, time spent on GTO, and data from focus groups and interviews. With staff members averaging 33 minutes per week on GTO, each team made significant programmatic changes. Homeless staff stated GTO was helpful, and that high levels of communication, staff member commitment to the program, and technical assistance were critical.

Maintaining product-process balance in community antipoverty initiatives.

Antipoverty initiatives strive to improve distressed communities by producing outputs, such as housing, new businesses, and enhanced social services, and by building the capacity of communities to address their own problems. Although crucial for addressing the social and cultural factors contributing to community problems and for the sustainability of initiatives, capacity building is frequently set aside once implementation of initiatives begins. This article explores the funding realities, implementation demands, and power dynamics between stakeholders that result in output production being favored over capacity building. Examples from past and ongoing initiatives illustrate points and drive recommendations to help future initiatives maintain a balance between producing outputs and building capacity.

Developing a community science research agenda for building community capacity for effective preventive interventions.

Research has shown that prevention programming can improve community health when implemented well. There are examples of successful prevention in local communities, however many continue to face significant challenges, demonstrating a gap between science and practice. Common strategies within the United States to address this gap are available (e.g., trainings), but lack outcomes. Building community capacity to implement high quality prevention can help communities achieve positive health outcomes, thereby narrowing the gap. While there is ample research on the efficacy of evidence-based programs, there is little on how to improve community capacity to improve prevention quality. In order to narrow the gap, a new model of research-one based in Community Science-is suggested that improves the latest theoretical understanding of community capacity and evaluates technologies designed to enhance it. In this article, we describe this model and suggest a research agenda that can lead to improved outcomes at the local level.