Substance use disorder (SUD) in people with severe mental illness (SMI) has been associated with psychiatric relapse, hospitalizations, homelessness, serious infectious disease, unemployment, violence, and incarceration. Integrated dual disorders treatment (IDDT) is an evidence-based practice for people with SMI and co-occurring SUD that can help reduce these negative outcomes. IDDT combines mental health and substance abuse services on a single treatment team, with strong emphases on stagewise treatment, comprehensive services that address a range of important needs, outreach, and motivational approaches. Unfortunately, IDDT is not routinely implemented in VA facilities.
This project sought to inform future implementation efforts for IDDT in the VA by addressing two specific aims: 1) identify barriers and facilitators to VA implementation via a qualitative evaluation in four pilot sites, varying on both implementation duration and program type, 2) document costs associated with IDDT implementation to inform future efforts. The project used the Consolidated Framework for Implementation Research (CFIR) model as conceptual framework for the evaluation.
Two sites, a Psychiatric Rehabilitation and Recovery Center (PRRC) team and Mental Health Intensive Case Management (MHICM) team had been receiving technical assistance and training on IDDT for two years. Two other sites, a HUD VA Supported Housing (HUDVASH) team and MHICM team, started implementation with this project. External facilitation included a baseline and 12-month fidelity assessment with report and recommendations, intensive onsite clinical training for staff, and ongoing monthly consultation.
Members of the research team observed implementation efforts in the two new teams and conducted individual interviews with key stakeholders (team and service line leaders, clinicians, the external facilitator, and Veterans) at all four programs. Key stakeholders included IDDT The study team held intensive coding sessions early in the project code interviews and observations and refine the CFIR codebook. Coders then synthesized barrier and facilitator themes by CFIR element for each site to form preliminary site profiles. Midway through the project, study investigators convened an expert panel of both local and VA Central Office leaders to reflect on preliminary site profiles. Follow-up interviews and event observations were collected and coded, with updated site profiles and overall synthesis of the data by CFIR element.
For costs, we aggregated staff hours spent in fidelity assessment, training, coaching, planning, and shadowing efforts and multiplied by individuals' published salary, plus 30% fringe. We used annualized data for ease of interpretation.
For outer context, all team leaders expressed a strong sense that IDDT was a good approach that fit the clinical population. Other outer context themes serving as facilitators included: addressing gaps in VA services for coordinated care, hearing about the success of other IDDT programs, proximity to national experts in IDDT, and support from service line and facility leaders. The PRRC program also cited improvements to unique encounters performance metric, as the program began successfully engaging some consumers. Outer context barriers included: lack of support from facility and service, detailing, and existing staffing or procedures inconsistent with the model.
For inner context, team cultures more strongly aligned with recovery-oriented care seemed to serve as ideal starting ground for implementing IDDT. Leadership and communication about IDDT implementation efforts and timelines were also important. Staff turnover was a noted barrier.
In general, experience with motivational interviewing, stage of change, and/or IDDT itself were considered strong facilitators as individual characteristics. In addition, even without this experience, team members with a willingness to learn new approaches and tendency to embrace Veteran-centered care were considered more "ready" to implement IDDT. Team members with a stronger background in 12-step models or those less familiar with the recovery model were noted as resisting the change to IDDT
All four teams specifically noted that the implementation process for IDDT is long and requires ongoing focused attention, leadership and coaching, with initial start-up probably taking more than one year. The larger HUDVASH team decided to implement with a small "teamlet" midway through the year. The two new programs eventually decided to pursue a service agreement to coordinate to complement the strengths and weaknesses of each. The older PRRC and MHICM teams attempted to coordinate similarly, but struggled to do so effectively when experiencing philosophical or staging disagreements. Facilitation for both programs could have also been improved with more knowledge about the VA service system (a possible disadvantage for external facilitation), better engagement of service leadership at the facility, and faster movement from abstract model concepts to coaching and shadowing in actual IDDT casework. These sentiments were echoed, albeit less strongly, in the themes of barriers and facilitators with the two more mature teams. A strong facilitator endorsed by both new and older teams in the implementation process was shadowing a more mature team in a VA setting to see how the model really looks after it "goes live."
IDDT intervention characteristics found to be advantageous included using MI, staging, and harm reduction with this population. Older team leaders liked the fact that the model is packaged with its own fidelity scale and that facilitators used well-developed materials to help staff learn the model. The flexibility of the model was endorsed as a positive by some. Conversely, a common refrain on all teams was a desire for more concrete, clarifications about what IDDT dictated clinically with a particular Veteran. Staff were inconsistent in their depiction of IDDT's complexity.
HUDVASH spent 377 staff hours ($14,634) in implementation efforts. MHICM spent 191 hours ($8,739) in implementation efforts. External facilitation annualized hours were fairly constant for HUDVASH and MHICM: 69 hours ($2,424) and 63 hours ($2,222).
The project will inform future efforts to implement IDDT in the VA and improve services for veterans struggling with severe mental illness and substance use disorders. IDDT addresses a critical gap in services provided to veterans with both mental health and substance use disorders, but remains difficult to implement for even mature teams. In some ways, coordinating across team lines is a common strategy in VA efforts but is antithetical to the IDDT model ideal: a single, cohesive team to provide comprehensive services to Veterans with dual disorders.
- Watson DP, Rollins AL. The Meaning of Recovery from Co-Occurring Disorder: Views from Consumers and Staff Members Living and Working in Housing First Programming. International journal of mental health and addiction. 2015 Oct 1; 13(5):635-649.