Leon Sawh

A wraparound treatment engagement intervention for homeless veterans with co-occurring disorders.

This article reports the results of a low-intensity wraparound intervention, Maintaining Independence and Sobriety through Systems Integration, Outreach, and Networking (MISSION), to augment Treatment as Usual (TAU) and engage and retain homeless veterans with a co-occurring disorder (COD) in care. Using a quasi-experimental design, 333 homeless veterans were enrolled, 218 who received MISSION along with TAU and 115 who received TAU alone. Group assignment was based on MISSION treatment slot availability at time of enrollment. Compared with TAU alone, individuals receiving MISSION demonstrated greater outpatient session attendance within the 30 days before the 12-month follow up assessment and a larger decline from baseline in the number of psychiatric hospitalization nights. Individuals in the MISSION and TAU-only groups both showed statistically significant improvements in substance use and related problems at 12 months, with those in MISSION less likely to drink to intoxication and experience serious tension or anxiety. Although this study confirmed that compared with TAU alone, MISSION along with TAU is effective in augmenting usual care and engaging and retaining homeless veterans in treatment, some caution is warranted as this study did not involve random assignment. These results, however, are similar to a recent study involving a briefer version of the intervention which included random assignment. Based on these findings, MISSION is being further studied in the joint Department of Housing and Urban Development (HUD) - Department of Veterans Affairs (VA) Supportive Housing (HUD-VASH) program, which offers rapid housing placement and case management to aid in housing maintenance.

Integrating Permanent Supportive Housing and Co-Occurring Disorders Treatment for Individuals Who Are Homeless

ABSTRACT Objectives: While permanent housing, addictions, and mental health treatment are often critical needs to achieve housing stability and community reintegration, few studies have systematically integrated them into a single comprehensive approach for people experiencing chronic homelessness. This pilot study examined the feasibility and preliminary outcomes of systematically integrating permanent supportive housing and an evidence-based co-occurring disorders intervention called Maintaining Independence and Sobriety Through Systems Integration, Outreach, and Networking (MISSION). Methods: This single-group open pilot enrolled 107 people with co-occurring disorders experiencing chronic homelessness from two Massachusetts inner-city and rural areas. Enrolled subjects were interested in receiving permanent supportive housing along with 1 year of MISSION services. Data were collected through baseline and 6- and 12-month follow-up assessments. Results: Participants (Mage = 49.52 years, SD = 10.61) were mostly male (76.6%), Caucasian (52.3%), and unemployed (86.0%), with an average of 8.34 years (SD = 8.01) of homelessness. Self-reported lifetime problems with anxiety (75.7%) and depression (76.6%) were common, as was use of alcohol (30.8%), cannabis (31.8%), and cocaine (15.9%). Almost all participants (95.3%) were placed into permanent housing, which took on average 42.6 days from enrollment (SD = 50.09). Among those placed, nearly 80% of the clients were able to retain housing through the end of the study. Overall retention was high, with 86.0% remaining in MISSION treatment until the end of the study. While there were no significant changes in rehospitalization, service utilization, or substance use, there were modest significant mental health symptom improvements from baseline to program completion. Conclusions: This pilot study suggests that co-occurring disorder interventions like MISSION are feasible to integrate with permanent supportive housing despite the somewhat differing philosophies, and preliminary data suggested substantial improvements in housing and modest improvements in mental health symptoms. While caution is warranted given the lack of a comparison group, these findings are consistent with other rigorous studies using MISSION among homeless individuals who did not receive permanent supportive housing.

U.S. Department of Veterans Affairs Veterans Justice Outreach Program Connecting Justice-Involved Veterans With Mental Health and Substance Use Disorder Treatment

The Veterans Justice Outreach (VJO) program of the U.S. Veterans Health Administration has a primary mission of linking military veterans in jails, courts, or in contact with law enforcement to mental health and substance use disorder treatment. National data of veterans with VJO contact were used to describe demographic characteristics, and mental health and substance use disorder diagnoses and treatment use and test correlates of treatment entry and engagement using multi-level logistic regression models. Of the 37,542 VJO veterans, treatment entry was associated with being homeless and having a mental health disorder or both a mental health and a substance use disorder versus a substance use disorder only. Being American Indian/Alaskan Native was associated with lower odds of treatment entry. Engagement was associated with female gender, older age, Asian race, urban residence, and homeless status. Increased utilization of substance use disorder treatment, especially pharmacotherapy, is an important quality improvement target.

Preliminary needs assessment of mobile technology use for healthcare among homeless veterans

Background. Homeless veterans have complex healthcare needs, but experience many barriers to treatment engagement. While information technologies (IT), especially mobile phones, are used to engage patients in care, little is known about homeless veterans’ IT use. This study examines homeless veterans’ access to and use of IT, attitudes toward health-related IT use, and barriers to IT in the context of homelessness. Methods. Qualitative interviews were conducted with 30 homeless veterans in different housing programs in Boston, MA, ranging from emergency shelters to supportive transitional housing that allow stays of up to 2 years. Interviews were conducted in person, audio recorded and then transcribed. Three researchers coded transcripts. Inductive thematic analysis was used. Results. Most participants (90%) had a mobile phone and were receptive to IT use for health-related communications. A common difficulty communicating with providers was the lack of a stable mailing address. Some participants were using mobile phones to stay in touch with providers. Participants felt mobile-phone calls or text messages could be used to remind patients of appointments, prescription refills, medication taking, and returning for laboratory results. Mobile phone text messaging was seen as convenient, and helped participants stay organized because necessary information was saved in text messages. Some reported concerns about the costs associated with mobile phone use (calls and texting), the potential to be annoyed by too many text messages, and not knowing how to use text messaging. Conclusion. Homeless veterans use IT and welcome its use for health-related purposes. Technology-assisted outreach among this population may lead to improved engagement in care.

Sex differences in mental health and substance use disorders and treatment entry among justice-involved Veterans in the Veterans Health Administration

Background:Over half of veterans in the criminal justice system have mental health or substance use disorders. However, there is a critical lack of information about female veterans in the criminal justice system and how diagnosis prevalence and treatment entry differ by sex. Objectives:To document prevalence of mental health and substance use disorder diagnoses and treatment entry rates among female veterans compared with male veterans in the justice system. Research Design:Retrospective cohort study using national Veterans Health Administration clinical/administrative data from veterans seen by Veterans Justice Outreach Specialists in fiscal years 2010–2012. Subjects:A total of 1535 females and 30,478 male veterans were included. Measures:Demographic characteristics (eg, sex, age, residence, homeless status), mental health disorders (eg, depression, post-traumatic stress disorder), substance use disorders (eg, alcohol and opioid use disorders), and treatment entry (eg, outpatient, residential, pharmacotherapy). Results:Among female veterans, prevalence of mental health and substance use disorders was 88% and 58%, respectively, compared with 76% and 72% among male veterans. Women had higher odds of being diagnosed with a mental health disorder [adjusted odds ratio (AOR)=1.98; 95% confidence interval (CI), 1.68–2.34] and lower odds of being diagnosed with a substance use disorder (AOR=0.50; 95% CI, 0.45–0.56) compared with men. Women had lower odds of entering mental health residential treatment (AOR=0.69; 95% CI, 0.57–0.83). Conclusions:Female veterans involved in the justice system have a high burden of mental health disorders (88%) and more than half have substance use disorders (58%). Entry to mental health residential treatment for women is an important quality improvement target.

Unemployment and Co-occurring Disorders Among Homeless Veterans

Objective: To examine employment patterns from 2005 to 2008 among homeless veterans with co-occurring mental health and substance use disorders relative to national trends in veteran and non-veteran populations. Methods: Unemployment rates for homeless veterans (N = 328) with co-occurring disorders were compared to national veteran and non-veteran unemployment rates using Current Population Survey data. Results: From 2005 to 2008, unemployment among the homeless veteran sample with co-occurring disorders increased from 47% to 66%. While unemployment decreased for Current Population Survey comparison groups from 2006 to 2007, homeless veterans with co-occurring disorders experienced a 35.62% increase in unemployment. Conclusions: Homeless veterans with co-occurring disorders were disproportionately affected by the 2007 recession. This increase in unemployment, relative to comparison group data, indicates the need for more comprehensive and integrated vocational supports aimed at obtaining competitive employment upon program discharge. Future research should monitor the impact of economic fluctuations on placement and employment sustainability for homeless veterans with co-occurring disorders.

A cluster randomized Hybrid Type III trial testing an implementation support strategy to facilitate the use of an evidence-based practice in VA homeless programs.

BackgroundThe Housing and Urban Development-Veterans Affairs Supportive Housing (HUD-VASH) program is one of the largest initiatives to end Veteran homelessness. However, mental health and substance use disorders continue to reduce client stability and impede program success. HUD-VASH programs do not consistently employ evidence-based practices that address co-occurring mental health and substance use disorders. This paper presents a study protocol to evaluate the implementation of an evidence-based, co-occurring disorder treatment called Maintaining Independence and Sobriety Through Systems Integration, Outreach, and Networking—Veterans Edition (MISSION-Vet) in HUD-VASH using an implementation strategy called Getting To Outcomes (GTO).Methods/designIn three large VA Medical Centers, this Hybrid Type III trial will randomize case managers and their clients by HUD-VASH sub-teams to receive either MISSION-Vet Implementation as Usual (IU—standard training and access to the MISSION-Vet treatment manuals) or MISSION-Vet implementation augmented by GTO. In addition to testing GTO, effectiveness of the treatment (MISSION-Vet) will be assessed using existing Veteran-level data from the HUD-VASH data monitoring system. This project will compare GTO and IU case managers and their clients on the following variables: (1) fidelity to the MISSION-Vet intervention; (2) proportion of time the Veteran is housed; (3) mental health, substance use, and functional outcomes among Veterans; and (4) factors key to the successful deployment of a new treatment as specified by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) model.DiscussionThis project is an important step for developing an implementation strategy to increase adoption of evidence-based practice use in VA homeless programs, and to further examine efficacy of MISSION-Vet in HUD-VASH. This project has important implications for program managers, policy makers, and researchers within the homelessness field. VA Central IRB approval for this study was granted in October 2011. The three sites were trained on MISSION-Vet and GTO in the first half of 2013. The first GTO planning meetings began after training occurred, between January 2013 and November 2013, across the three sites. The data collection—via a fidelity measure embedded into the VA Computerized Patient Record System—began as each site initiated MISSION-Vet, between April 2013 and January 2014.Trial registrationClinicalTrials.gov: NCT01430741

Integrating a Co-occurring Disorders Intervention in Drug Courts: An Open Pilot Trial

Little research has focused on systematically integrating clinical treatment within existing drug court procedures. This could be particularly useful for clients with substance use disorders, who comprise those on court dockets and often have co-existing mental health issues. This article reports on the preliminary outcomes of integrating MISSION-Criminal Justice (MISSION-CJ), a co-occurring mental health and substance use wraparound intervention, within two Massachusetts drug courts. In this open pilot, clients completed intake and 6-month follow-up assessments. The participants were primarily Caucasian (86%), male (82%), had at least 2 prior arrests, and received outpatient treatment for mental health (54%), alcohol use (51%), or drug use (88%) prior to enrolling in MISSION-CJ. Six-month follow-up data suggested that participants showed statistically significant reductions in average number of nights spent in jail, alcohol use, and drug use, as well as an increase in full time employment.