1. Testing the Getting To Outcomes implementation support strategy to facilitate the use of an evidence based practice in VA homeless programs
Matthew Chinman, Ph.D.; Sharon McCarthy, Ph.D.; Gordon Hannah, Ph.D.
VISN 4 MIRECC, VA Pittsburgh
Thomas Byrne, Ph.D.; David Smelson, Psy.D.
VA National Center on Homelessness Among Veterans; VA Center for Healthcare Organization and Implementation Research
September – 4th Biennial Society for Implementation Research
Collaboration Conference

2. Homeless Veterans
VA efforts to combat homelessness among Veterans has drastically reduced the number of homeless Veterans
About 80% of the remaining 48,000 Veterans who are homeless have co-occurring substance and mental health disorders: integrated care is most effective

3. Compare GTO to Implementation as Usual in real world of HUD-VASH
MISSION-Vet + GTO
(DC, Northampton, Denver)
N=37
MISSION-Vet
(DC, Northampton, Denver)
N=22
VS.
AIM One: MISSION fidelity – Track MISSION services delivered AIM Two: Housing outcomes - HOMES (CM report) AIM Three: Mental health, substance use and functional outcomes - HOMES (CM report) AIM Four: Track factors key to the successful deployment of MISSION-Vet – CFIR based interviews and ratings
Department of Veterans Affairs (Mental Health QUERI): MISSION-Vet HUD-VASH Implementation Study (SDP ). Smelson, PI, Chinman, Co-PI; 1/31/12-6/30/16.

4. An integrated treatment for Veterans with SA
MISSION Vet: Maintaining Independence and Sobriety through Systems Integration, Outreach and Networking: Veterans Edition
An integrated treatment for Veterans with SA
Case managers and Peer Specialists work with Veteran about 2.5 hours/week for 1 year
Comprehensive, manualized patient and clinician tools
Free web based materials and trainings 1

5. HUD VASH: Housing and Urban Development – VA Supportive Housing
Provides subsidized housing from HUD
Case management provided by the VA
The goal to end Veteran homelessness and Housing First approach has strained resources, especially staff
Primary goal to provide and sustain housing
During study, caseloads increased in size and acuity

6. GTO model supports high quality program implementation
Find existing
programs and
best practices
worth copying. 3
Modify the program
or best practices
to fit your needs. 4
Identify goals,
target population,
and desired
outcomes. 2
Assess capacity
(staff, financing,
etc.) to implement
the program. 5
Steps 1-6
PLANNING
DELIVERING PROGRAMS
Choose which
problem(s) to
focus on. 1
Make a plan
for getting started:
who, what, when,
where, and how. 6
This is the process that we help communities to walk through/
As you can see it’s a very generic framework..although we started in substance abuse it can be applied any domain. We will show you later all the areas we are working in
We often joke that it is so generic, you could use this model to run your life. We have a training exercise that asks the audience to use this model to plan a vacation or the buying of a car.
One can also jump in at any point in the flow and get a benefit. For example, one can always do evaluation better, even if there wasn’t the best planning early on.
Steps 7-10
EVALUATING AND IMPROVING
Consider how to
keep the program
going if it is
successful. 10
Evaluate
planning and
implementation.
How did it go? 7
Make a plan for
Continuous
Quality
Improvement. 9
Evaluate
program’s success
in achieving
desired results. 8

7. GTO uses multiple implementation strategies to build capacity
Choose which
problem(s) to
focus on. 1
target population,
Identify goals,
and desired
outcomes. 2
worth copying.
best practices
programs and
Find existing 3
Modify the program
to fit your needs.
or best practices 4
etc.) to implement
(staff, financing,
the program.
Assess capacity 5
where, and how.
who, what, when,
for getting started:
Make a plan 6
PLANNING
Steps 1-6
DELIVERING PROGRAMS
How did it go?
implementation.
planning and
Evaluate 7
program’s success
desired results.
in achieving 8
Improvement.
Continuous
Make a plan for
Quality 9
keep the program
Consider how to
successful.
going if it is 10
EVALUATING AND IMPROVING
Steps 7-10

8. Adapted GTO to fit HUD-VASH reality
Bi-weekly meetings for months
What is your goal?
(e.g., house Vets)
What will you do ?
(e.g., MISSION-Vet)
How will you fit it into HV?
What is your plan?
(e.g., How many will you serve with MISSION?)
How was implementation?
Did you reach your goal?
What should
change to
reach goal?
Quality Improvement
Full day on GTO

9. Case Managers in GTO group tried MISSION; IU group did no MISSION

10. Case Managers in GTO group delivered MISSION with few Veterans

11. Case Managers in GTO group delivered MISSION with low fidelity

12. Veteran level outcomes show slight signal for MISSION
Compared 87 Vets from GTO group with ‘comparison’ group from IU group on housing status, employment status, service intensity, drug/alcohol dependence, inpatient hospitalizations, emergency department visits
Vets receiving MISSION got about 2 more contacts per month than comparison Vets
No other outcomes were significant
A subgroup of higher intensity MISSION trended positively (favoring GTO/MISSION) on alcohol use, drug use, mental health hospitalization, and probability of medical hospitalization and medical ER use 1

13. Case Managers in GTO group faced many challenges
CFIR Constructs
Team 1
Team 2
Team 3
Intervention Characteristics
Intervention source -1
Evidence strength
Relative advantage +1
Adaptability +2
Complexity
Design quality
Inner Setting
Networks and communications -2
Compatibility
Relative priority
Org. incentives and rewards
Goals and feedback
Leadership engagement
Available resources
Access to knowledge and info
Outer Setting
Patient needs and resources
Cosmopolitan
Process
Planning
Engaging key stakeholders
Engaging Veterans

14. GTO was able to facilitate some MISSION, but challenges were great
Sites valued MISSION and used it for certain cases that were high need; GTO planning and TA support was key
Control group showed what happens with no support
Using MISSION across whole caseload unrealistic
New housing initiative (more Vets with more problems) made new initiatives difficult
Organizational barriers and a lack of leadership support hurt implementation

15. Translating Research into Practice
Practice/Policy implications for my setting/stakeholders (context-specific)
MISSION could be a good fit for care structures that can devote more time per Veteran
MISSION guidance valued
Facilitated care that taps into why case managers first decided to serve
Demonstrates need for readiness at site
Among leaders to support innovation
Among clinical providers to try something new
Practice/Policy implications beyond my setting/stakeholders (Generalizable)
Demonstrates that policy memos or other edicts from a central authority (VA central office), by themselves, have little impact
Demonstrates that one time trainings attended by clinical providers have no impact; continued follow up from facilitation is needed

16. Questions? Matthew Chinman, PhD VA Pittsburgh Healthcare System
Research Office Building (151R)
University Drive C
Pittsburgh, PA