Homelessness disproportionately affects Veterans with serious mental illness (SMI, e.g., schizophrenia, bipolar disorder). Many Veterans with SMI are at risk of homelessness because of substance use, unstable employment, and incarceration, and are disproportionately represented among Veterans who are chronically homeless. Moreover, Veterans with SMI who drop out of VA care are more likely to die than those engaged in VA care. In a landmark quality improvement study, the VA Office of the Medical Inspector (OMI) and Mental Health Services (MHS) implemented the Re-Engage program to facilitate access to services among Veterans with SMI who had dropped out of VA care. The program led to the majority of Veterans with SMI returning to care and was associated with a subsequent 12-fold decreased risk of mortality (0.5% versus 6%) compared to Veterans who were not brought back into care.
Taking advantage of the national roll-out of Re-Engage per VHA Directive 2012-002, the primary aim of this study is to determine whether an Enhanced versus standard implementation strategy (Replicating Effective programs-REP) led to improved uptake of Re-Engage among local providers and ultimately, improved access to VA health and social services among Veterans with SMI who were at risk of homelessness and who were lost to care. Secondary aims included determining the natural history of utilization and pathways to health care, housing, and other social services used by Veterans with SMI, determine the organizational factors associated with use of social services and time to receipt of services, and describe how implementation of the re-engagement program is affected by organizational variation in provision of services to Veterans.
Using VA national administrative databases, Veterans with a history of homelessness and prior VA utilization history who had not been seen in VA care for at least one year were initially identified and stratified by the site where they were last seen. One mental health provider from each VA site in the U.S. (N=158) with at least one Veteran who was lost to care was initially given a REP-based package and training program in Re-Engage. The Re-Engage program involved giving each site provider a list of patients with SMI who had not been seen at their facility for at least a year, requesting that providers contact these patients, assessing patient clinical status, and where appropriate, facilitating appointments to VA health services. At month 6, sites considered non-responsive (N=89, total of 3,075 patients), defined as providers updating documentation for less than <80% of patients on their list, were randomized to two adaptive implementation interventions: Enhanced REP (provider coaching; N=40 sites) for 6 months followed by standard REP for 6 months; versus continued standard REP (N=49 sites) for 6 months followed by 6 months of Enhanced REP for sites still not responding. Principal outcomes included outpatient treatment engagement (number of medical or mental health visits based on VA administrative and electronic medical record data), employment, housing, hospitalizations, and mortality using national VA databases.
VA sites randomized to receive Enhanced compared to standard REP in the first 6 months reported improved Re-Engage program uptake: including greater percentage of patients with an attempted contact (41% vs. 31% ; p=.01). Multilevel analyses examining 12-month effects of immediate versus delayed use of Enhanced REP indicated that patients from sites that were randomized to receive Enhanced REP immediately compared to standard REP were over twice as likely to have a completed contact (adjusted OR=2.13; 95% CI: 1.09-4.19, P=.02) after adjusting for patient and site-level characteristics. There were no differences in patient-level utilization between Enhanced and standard REP sites.
Implementation of effective outreach programs designed to help prevent homelessness among Veterans require a better understanding of the optimal strategies that can be used beyond the dissemination of a toolkit and training program. An ongoing national initiative, Re-Engage is a population management program designed to improve access to care for vulnerable Veteran populations.
Knowing when to use augmented strategies like Enhanced REP has financial implications by helping VA decision makers give additional resources to under-resourced or "late-adopter" sites. Effective implementation of the Re-Engage outreach program may improve VA providers' chances of reducing adverse consequences (e.g., homelessness) for Veterans with serious mental illnesses who had lost contact with VHA health care.
- Kilbourne AM, Goodrich DE, Lai Z, Almirall D, Nord KM, Bowersox NW, Abraham KM. Reengaging veterans with serious mental illness into care: preliminary results from a national randomized trial. Psychiatric services (Washington, D.C.). 2015 Jan 1; 66(1):90-3.
- Kilbourne AM, Almirall D, Goodrich DE, Lai Z, Abraham KM, Nord KM, Bowersox NW. Enhancing outreach for persons with serious mental illness: 12-month results from a cluster randomized trial of an adaptive implementation strategy. Implementation science : IS. 2014 Dec 28; 9:163.
- Kilbourne AM, Abraham KM, Goodrich DE, Bowersox NW, Almirall D, Lai Z, Nord KM. Cluster randomized adaptive implementation trial comparing a standard versus enhanced implementation intervention to improve uptake of an effective re-engagement program for patients with serious mental illness. Implementation science : IS. 2013 Nov 20; 8(1):136.
- Abraham KM, Lai Z, Bowersox NW, Goodrich DE, Visnic S, Burk JP, Kilbourne AM. Health care utilization prior to loss to care among veterans with serious mental illness. Psychiatric services (Washington, D.C.). 2013 Jun 1; 64(6):594-6.
- Goodrich DE, Bowersox NW, Abraham KM, Burk JP, Visnic S, Lai Z, Kilbourne AM. Leading from the middle: replication of a re-engagement program for veterans with mental disorders lost to follow-up care. Depression research and treatment. 2012 Sep 25; 2012(2012):325249.
- Birgenheir DG, Lai Z, Kilbourne AM. Datapoints: trends in mortality among homeless VA patients with severe mental illness. Psychiatric services (Washington, D.C.). 2013 Jul 1; 64(7):608.
- Goodrich DE, Almirall D, Abraham KM, Nord KM, Bowersox NW, Kilbourne AM. Cluster randomized trial comparing standard versus enhanced implementation strategies for improving outreach to persons with SMI: 12-month results. Poster session presented at: National Institutes of Health / AcademyHealth Conference on the Science of Dissemination and Implementation; 2015 Dec 14; Washington, DC.
- Goodrich DE, Almirall D, Abraham K, Nord K, Zai L, Bowersox NW, Kilbourne AM. Cluster Randomized Trial Comparing Standard versus Enhanced Implementation Strategies for Improving Outreach to Persons with SMI: 12-Month Results. Paper presented at: National Institutes of Health / AcademyHealth Conference on the Science of Dissemination and Implementation; 2014 Dec 8; Bethesda, MD.
- Kilbourne AM, Almirall D. Sequential Multiple Assignment Randomized Trials (SMART) and Adaptive Designs for Implementation Studies. Paper presented at: National Institutes of Health / AcademyHealth Conference on the Science of Dissemination and Implementation; 2014 Dec 8; Bethesda, MD.
- Kilbourne AM. SMI Health Implementation & Partnership Strategies: Implementation of A Re-Engagement Program for Veterans with SMI Lost to Follow-up. Paper presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 19; National Harbor, MD.
- Kilbourne AM, O'Toole T, Saxon A, Kertesz S. Building the Plane While Flying It: Lessons from the VA Homelessness Health Services Research-National Center on Homelessness Initiative. Paper presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 18; National Harbor, MD.
- O'Toole T, Kilbourne AM, Saxon A, Kertesz A. Finding and Following: Methodological Challenges in Homeless Veterans Research. Paper presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 16; National Harbor, MD.
- Kilbourne AM. Engage Veterans In Care. Paper presented at: Trauma Spectrum Disorders Annual Conference; 2011 Dec 5; Bethesda, MD.
- Kilbourne AM. Outreach to Veterans with SMI. Call to Action Panel Session on Incorporating Homeless Populations into Preparedness Planning and Response. Paper presented at: VA Comprehensive Emergency Management Program Evaluation and Research Conference; 2011 May 10; Washington, DC.
- Kilbourne AM. Homelessness among Veterans. Presented at: VA National Center on Homelessness Among Veterans Research Summit; 2011 Apr 8; Tampa, FL.
Mental, Cognitive and Behavioral Disorders
Treatment - Observational