title: A Hybrid III stepped wedge cluster randomized trial testing an implementation strategy to facilitate the use of an evidence-based practice in VA Homeless Primary Care Treatment Programs.
abstract: Homeless veterans often have multiple health care and psychosocial needs, including assistance with access to housing and health care, as well as support for ongoing treatment engagement. The Department of Veterans Affairs (VA) developed specialized Homeless Patient Alignment Care Teams (HPACT) with the goal of offering an integrated, "one-stop program" to address housing and health care needs of homeless veterans. However, while 70% of HPACT's veteran enrollees have co-occurring mental health and substance use disorders, HPACT does not have a uniform, embedded treatment protocol for this subpopulation. One wraparound intervention designed to address the needs of homeless veterans with co-occurring mental health and substance use disorders which is suitable to be integrated into HPACT clinic sites is the evidence-based practice called Maintaining Independence and Sobriety through Systems Integration, Outreach, and Networking-Veterans Edition, or MISSION-Vet. Despite the promise of MISSION-Vet within HPACT clinics, implementation of an evidence-based intervention within a busy program like HPACT can be difficult. The current study is being undertaken to identify an appropriate implementation strategy for MISSION-Vet within HPACT. The study will test the implementation platform called Facilitation and compared to implementation as usual (IU). The aims of this study are as follows: (1) Compare the extent to which IU or Facilitation strategies achieve fidelity to the MISSION-Vet intervention as delivered by HPACT homeless provider staff. (2) Compare the effects of Facilitation and IU strategies on the National HPACT Performance Measures. (3) Compare the effects of IU and Facilitation on the permanent housing status. (4) Identify and describe key stakeholders' (patients, providers, staff) experiences with, and perspectives on, the barriers to, and facilitators of implementing MISSION.
  
  
  
  Type III Hybrid modified stepped wedge implementation comparing IU to Facilitation across seven HPACT teams in three sites in the greater Los Angeles VA system. This is a cluster randomized trial.
  
  
  
  Integrating MISSION-Vet within HPACT has the potential to improve the health of thousands of veterans, but it is crucial to implement the intervention appropriately in order for it to succeed. The lessons learned in this protocol could assist with a larger roll-out of MISSION within HPACT. This protocol is registered with clinicaltrials.gov and was assigned the number NCT 02942979.
authors.affiliation: VA National Center on Homelessness among Veterans, Washington, DC, USA. msimmons@post.harvard.edu.|VA Center for Health Organization and Implementation Research, Bedford, MA, USA. msimmons@post.harvard.edu.|Boston University School of Public Health, Boston, MA, USA. msimmons@post.harvard.edu.
authors.forename: Molly M
authors.identifier: 0000-0002-8912-7379
authors.initials: MM
authors.lastname: Simmons
authors.affiliation: VA Greater Los Angeles Health Care System, Los Angeles, CA, USA.|UCLA David Geffen School of Medicine, Los Angeles, CA, USA.
authors.forename: Sonya
authors.initials: S
authors.lastname: Gabrielian
authors.affiliation: VA National Center on Homelessness among Veterans, Washington, DC, USA.|Boston University School of Social Work, Boston, MA, USA.
authors.forename: Thomas
authors.initials: T
authors.lastname: Byrne
authors.affiliation: VA Center for Health Organization and Implementation Research, Bedford, MA, USA.|Boston University School of Public Health, Boston, MA, USA.
authors.forename: Megan B
authors.initials: MB
authors.lastname: McCullough
authors.affiliation: VA Greater Los Angeles Health Care System, Los Angeles, CA, USA.|College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA.|VA Quality Enhancement Research Initiative for Team-Based Behavioral Health, Palo Alto, CA, USA.
authors.forename: Jeffery L
authors.initials: JL
authors.lastname: Smith
authors.affiliation: VA Palo Alto Health Care System, Palo Alto, CA, USA.|VA Quality Enhancement Research Initiative for Team-Based Behavioral Health, Palo Alto, CA, USA.
authors.forename: Thom J
authors.initials: TJ
authors.lastname: Taylor
authors.affiliation: VA National Center on Homelessness among Veterans, Washington, DC, USA.|Alpert Medical School at Brown University, Providence, RI, USA.
authors.forename: Tom P
authors.initials: TP
authors.lastname: O'Toole
authors.affiliation: VA Medical Center Wilmington, Wilmington, DE, USA.
authors.forename: Vincent
authors.initials: V
authors.lastname: Kane
authors.affiliation: VA Center for Health Organization and Implementation Research, Bedford, MA, USA.|Boston University School of Public Health, Boston, MA, USA.
authors.forename: Vera
authors.initials: V
authors.lastname: Yakovchenko
authors.affiliation: VA Center for Health Organization and Implementation Research, Bedford, MA, USA.|Boston University School of Public Health, Boston, MA, USA.|VA Bridging the Care Continuum-Quality Enhancement Research Initiative, Bedford, MA, USA.
authors.forename: D Keith
authors.initials: DK
authors.lastname: McInnes
authors.affiliation: VA National Center on Homelessness among Veterans, Washington, DC, USA.|VA Center for Health Organization and Implementation Research, Bedford, MA, USA.|VA Bridging the Care Continuum-Quality Enhancement Research Initiative, Bedford, MA, USA.|University of Massachusetts Medical School, Worcester, MA, USA.
authors.forename: David A
authors.initials: DA
authors.lastname: Smelson
mesh_terms: D016000:Cluster Analysis; D055317:Evidence-Based Practice / Q000379:methods*; D006703:Ill-Housed Persons / Q000523:psychology*; D006801:Humans; D015141:Los Angeles; D001523:Mental Disorders / Q000150:complications / Q000523:psychology / Q000628:therapy*; D011320:Primary Health Care / Q000379:methods*; D015397:Program Evaluation; D019966:Substance-Related Disorders / Q000150:complications / Q000523:psychology / Q000628:therapy*; D014481:United States; D014493:United States Department of Veterans Affairs; D014728:Veterans / Q000523:psychology*
keywords: Co-occurring disorders; Facilitation; Step wedge design; Vulnerable populations