2023 HSR&D/QUERI National Conference

4112 — Engaging stakeholders to inform national implementation of Critical Time Intervention (CTI) in a program serving homeless-experienced Veterans

Lead/Presenter: Sonya Gabrielian,  COIN - Los Angeles
All Authors: Gabrielian SE (VA LA HSR&D Center of Innovation), Cordasco KM (VA LA HSR&D Center of Innovation) Finley EP (VA LA HSR&D Center of Innovation) Hoffmann LC (VA LA HSR&D Center of Innovation) Harris T (VA LA HSR&D Center of Innovation) Calderon RA (VA LA HSR&D Center of Innovation) Barnard JM (VA LA HSR&D Center of Innovation) Ganz DA (VA LA HSR&D Center of Innovation) Olmos-Ochoa TT (VA LA HSR&D Center of Innovation)

The VA Grant and Per Diem Case Management “Aftercare” program provides six months of case management for homeless-experienced Veterans (HEVs) transitioning to permanent housing, with the aim of decreasing returns to homelessness. Services are provided by 128 community-based homeless service agencies across the nation who partner with VA to care for HEVs. Implementing Critical Time Intervention (CTI)—a structured, time-limited, and evidence-based case management practice—would standardize care across the agencies that provide Aftercare services. To prepare for national CTI implementation in Aftercare, we conducted a four-agency implementation pilot in which we adapted a CTI implementation package (training, technical assistance, and external facilitation); assessed stakeholder perspectives regarding CTI’s acceptability and appropriateness; and characterized contextual factors that supported or impeded CTI implementation.

We conducted 67 semi-structured interviews at pre-implementation, mid-implementation, and six months post-implementation, with a diverse group of HEVs (n = 37), case managers (n = 16), supervisors (n = 10), and VA leaders (n = 4) at the four pilot sites. Using rapid qualitative analyses, we assessed satisfaction with CTI and our implementation package, as well as contextual factors that affected CTI implementation.

HEVs expressed goals that aligned with CTI principles (e.g., engaging in behavioral health services). VA leaders thought CTI implementation would standardize and improve Aftercare practices. Aftercare case managers and supervisors had limited experience implementing evidence-based practices (EBPs) and desired CTI training with realistic case examples and longitudinal supports. Most had no prior knowledge of CTI, were highly satisfied with the training offered, and comfortable using this practice with HEVs. Staff at all agencies reported uncertainty about Aftercare’s performance metrics and CTI’s alignment with these metrics. Significant staff turnover at all sites negatively impacted CTI adoption and staff engagement. There was agency-level variation in other contextual factors impacting implementation, including pre-implementation case management supervision practices; leadership buy-in; competing case manager responsibilities; team dynamics; availability of local community (non-VA) resources for homeless persons; and clinical documentation requirements.

Aftercare stakeholders found CTI acceptable and appropriate; there was consensus that CTI was a compatible and useful practice for this setting. To support national CTI scale-up in Aftercare, these data suggest the value of robust and tangible CTI training—grounded in real-world Veteran cases—that highlights the congruence of this practice with relevant VA performance metrics. Variations in contextual factors are important considerations for tailoring our CTI implementation package for scale-up. At some Aftercare agencies, longitudinal implementation supports may be important to address key contextual factors that impede CTI implementation.

CTI was successfully implemented in four agencies that provide Aftercare services for HEVs. This pilot suggested that implementing CTI in diverse contexts requires balancing practice fidelity with adaptations that accommodate contextual differences across settings that serve HEVs. Variations in agency-level contextual factors may necessitate more intense and tailored supports (e.g., external facilitation, case consultation, learning collaboratives) to implement and sustain complex EBPs like CTI.