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2023 HSR&D/QUERI National Conference Abstract

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4054 — Enhancing the implementation of evidence-based practices for homeless Veterans with serious mental illness

Lead/Presenter: Sonya Gabrielian,  COIN - Los Angeles
All Authors: Gabrielian SE (VA HSR&D LA Center of Innovation), Koosis ER (National Center for PTSD) Chambers KN (Community Engagement and Reintegration Service, VA Greater Los Angeles) Hoffmann LC (VA HSR&D LA Center of Innovation) Carlson D (Department of Psychiatry, VA Greater Los Angeles) Gelberg L (VA HSR&D LA Center of Innovation) Hamilton A (VA HSR&D LA Center of Innovation) Young AS (VA HSR&D LA Center of Innovation)

Evidence-based practices (EBPs) improve housing and health for homeless-experienced Veterans with serious mental illness (HEV-SMI). Yet, it is immensely challenging to implement and sustain such EBPs with fidelity in real-world contexts that serve HEV-SMI. As social skills are an important determinant of housing outcomes for this population, but are uncommonly addressed in homeless services, we piloted a 12-session skills training intervention for HEV-SMI. This training was tailored from existing effective social skills training interventions for adults with SMI. We aimed to adapt the intervention’s implementation package (i.e., practice and training adaptations, as well as implementation supports).

We provided training, technical assistance, and case consultation to 9 frontline staff (social workers, mental health counselors, addiction therapists, and peer specialists) to deliver this once/week intervention to 6 groups of HEV-SMI (n = 35). During the early portion of the COVID-19 pandemic, we adapted the intervention to accommodate virtual care modalities or outdoor groups. Attendance was tracked at all groups. We observed a random sample of each interventionist’s groups to assess fidelity, using a checklist and metrics adapted from established social skills training interventions. We performed post-intervention semi-structured interviews with 14 HEV-SMI and all 9 interventionists to assess perceptions of the intervention and identify factors that support or impede its implementation; we used rapid qualitative analyses to synthesize these interview data.

Interventionists easily recruited HEV-SMI participants; Veterans were interested in the topic and receptive to the group-based format. All groups observed had acceptable fidelity. However, we experienced significant challenges retaining HEV-SMI; participants attended a mean of 4/12 sessions. Interviews suggested that HEV-SMI engagement would be enhanced with a drop in, open format; HEV-SMI often left the group because they left a transitional housing setting or were addressing competing needs (e.g., clothing or food). Some HEV-SMI and interventionists recommended that housing services be contingent on group engagement; the group taught skills that were deemed valuable for independent living and housing retention. Veterans valued training around finding apartments and managing finances; they liked structured role plays and found the material easy to understand. Interventionists deemed the groups useful and appreciated the training and implementation support provided. However, to implement this intervention in routine care, with adequate HEV-SMI engagement, robust buy-in from program-level leadership (interventionists’ direct supervisors, as opposed to higher-level support from facility or VISN leadership) was deemed critical to address competing responsibilities, staff shortages, and resource limitations.

HEV-SMI and frontline staff found a skills training intervention acceptable and appropriate across VA’s homeless programs; stakeholders deemed the intervention useful and endorsed its format. However, though participant recruitment and treatment fidelity were feasible, the intervention and supports for its implementation would benefit from additional tailoring and modifications.

To support successful implementation of an EBP for HEV-SMI in VA homeless programs, these data suggest the value of enhanced program-level leadership buy-in and a drop-in, open group format. Implementing this skills training intervention in accessible community-based settings or contexts where attendance can be mandated, e.g., residential rehabilitation programs, may increase engagement and retention of HEV-SMI.