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SDR 11-232
Population-based Outreach Services to Reduce Homelessness among Veterans with SMI
Amy M. Kilbourne, PhD MPH VA Ann Arbor Healthcare System, Ann Arbor, MI Ann Arbor, MI Funding Period: September 2011 - August 2015 Portfolio Assignment: Mental and Behavioral Health |
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BACKGROUND/RATIONALE:
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. OBJECTIVE(S): 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. METHODS: 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. FINDINGS/RESULTS: 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. IMPACT: 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. External Links for this ProjectNIH ReporterGrant Number: I01HX000617-01Link: https://reporter.nih.gov/project-details/8183355 Dimensions for VA Dimensions for VA is a web-based tool available to VA staff that enables detailed searches of published research and research projects. Learn more about Dimensions for VA. VA staff not currently on the VA network can access Dimensions by registering for an account using their VA email address. Search Dimensions for this project PUBLICATIONS:Journal Articles
DRA:
Mental, Cognitive and Behavioral Disorders
DRE: Treatment - Observational Keywords: none MeSH Terms: none |
