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IntroductionAnimal-assisted interventions (AAI) offer potential physical and psychological health benefits that may assist Veterans with post-traumatic stress disorder. However, more feasibility studies are needed regarding intervention details, adverse events, reasons for study withdrawal, and animal welfare.MethodsThis mixed methods feasibility trial involved a modified crossover study in which Veterans with PTSD/PTSD symptoms were provided a series of 8 nature and wildlife immersion experiences to evaluate feasibility and preliminary efficacy. The sample included 19 Veterans with PTSD/PTSD symptoms who were followed for a mean of 15.1 weeks. The intervention was comprised of a baseline forest walk, assisting with wildlife rehabilitation, observation in a wildlife sanctuary, and bird watching. Post study bird feeders were provided for sustainability. The theory of transcendent pluralism, which is grounded in mutual human and ecological dignity, guided the study. We viewed feasibility from the perspective of pattern integration with the natural world.ResultsThis AAI nature/wildlife immersion intervention was feasible, acceptable, and safe to administer to Veterans with PTSD/PTSD symptoms with appropriate support. Logistical and relational facilitators were identified that supported the wildlife immersion activities. Participants reported greatly enjoying the activities. Attention to animal welfare and care was an important ethical foundation that also contributed to feasibility.DiscussionAAI immersion experiences with wildlife are feasible and can safely be administered to Veterans with PTSD/PTSD symptoms. Logistical and relational facilitators are important to support nature and wildlife immersion activities.

Rates of alcohol use disorder (AUD) are increasing among civilian and veteran populations of women in the United States, and stress pathophysiology (i.e., abnormal acute and long-term change in physiological responses to stress) is central to the maintenance of alcohol misuse within this population. Heart rate variability (HRV) is one measure of stress regulation that may help to explain the association of stress with alcohol misuse among women. In the current analysis of pilot data, 20 women veterans attended an in-person laboratory session and completed 35 daily assessments of their alcohol use and craving. During the lab session, the effects of a stress induction procedure on self-reported alcohol craving and HRV were assessed. HRV was continuously measured and indexed in the time domain, using the root mean square of successive differences between normal heartbeats (RMSSD). Alcohol craving and use during the longitudinal 35-day study period were measured via self-report questionnaires sent to participants' phones. Results indicated that resting HRV in the lab was positively associated with odds of daily craving. Moreover, HRV during the stressor, as measured in lab, was positively associated with (1) overall alcohol craving in the lab (i.e., with resting and post-stress craving), and (2) number of daily drinks during the 35-day study period. This pilot study suggests the potential role of HRV in response to stressors in predicting alcohol craving and use among female veterans. It provides pilot data for research on stress-reactive HRV as a biomarker for alcohol misuse among women, and discusses directions for future research.

Background Healthcare systems face difficulty implementing evidence-based practices, particularly multicomponent interventions. Additional challenges occur in settings serving vulnerable populations such as homeless Veterans, given the population’s acuity, multiple service needs, and organizational barriers. Implementation Facilitation (IF) is a strategy to support the uptake of evidence-based practices. This study’s aim was to simultaneously examine IF on the uptake of Maintaining Independence and Sobriety Through Systems Integration, Outreach and Networking-Veterans Edition (MISSION-Vet), an evidence-based multicomponent treatment engagement intervention for homeless Veterans with co-occurring mental health and substance abuse, and clinical outcomes among Veterans receiving MISSION-Vet. Methods This multi-site hybrid III modified stepped-wedge trial involved seven programs at two Veterans Affairs Medical Centers comparing Implementation as Usual (IU; training and educational materials) to IF (IU + internal and external facilitation). Results A total of 110 facilitation events averaging 27 minutes were conducted, of which 85% were virtual. Staff (case managers and peer specialists; n = 108) were trained in MISSION-Vet and completed organizational readiness assessments (n = 77). Although both sites reported being willing to innovate and a desire to improve outcomes, implementation climate significantly differed. Following IU, no staff at either site conducted MISSION-Vet. Following IF, there was a significant MISSION-Vet implementation difference between sites (53% vs. 14%, p = .002). Among the 93 Veterans that received any MISSION-Vet services, they received an average of six sessions. Significant positive associations were found between number of MISSION-Vet sessions and outpatient treatment engagement measured by the number of outpatient visits attended. Conclusions While staff were interested in improving patient outcomes, MISSION-Vet was not implemented with IU. IF supported MISSION-Vet uptake and increased outpatient service utilization, but MISSION-Vet still proved difficult to implement particularly in the larger healthcare system. Future studies might tailor implementation strategies to organizational readiness. Trial registration ClinicalTrials.gov, NCT02942979.

Background Only 7% of individuals with co-occurring mental health and substance use disorder (COD) receive services for both conditions. We implemented and evaluated maintaining independence and sobriety through systems integration, outreach and networking-Veteran's edition (MISSION-Vet), an evidence-based manualized psychosocial intervention for Veterans with CODs. This paper identifies the generative mechanisms that explain “how, for whom, and under what conditions” MISSION-Vet adoption, implementation, and fidelity work when applied in a complex adaptive system with facilitation support. Methods Within two VA healthcare systems (Sites A and B), a hybrid III trial tested facilitation to implement MISSION-Vet. We conducted a two-site case study based on 42 semi-structured consolidated framework for implementation research (CFIR) guided interviews with site leadership, implementers (social workers, peer specialists), and team members (facilitators, site leads). Interviews were coded and CFIR constructs used to generate “Context + Mechanism = Outcome” configurations to understand the conditions of MISSION-Vet adoption, implementation, and fidelity. Results Site A was low, and Site B was high in adoption, implementation, and fidelity. Adoption hesitancy/eagerness (outcome) resulted from the interaction of “external policy” (context) dampening/encouraging a “tension for change” (mechanism). Implementation intensity (outcome) was based on how “peer pressure” or practice culture (context) activated staff “self-efficacy” (mechanism) to engage with MISSION-Vet and appraise its “relative advantage” over current practices (mechanism). Fidelity relied on how “staffing structure and availability” (context) activated/muted “facilitation” (mechanism) to result in strategy and intervention adaptation (outcome). Conclusions We delineated how specific contexts activated certain mechanisms to drive the different stages of implementation of a multi-faceted COD treatment intervention. Trial registration ClinicalTrials.gov, NCT02942979. Plain language abstract Implementation is inherently dynamic and influenced by interdependent factors operating at the individual, organizational, and system levels. This is especially true for complex interventions addressing co-occurring mental health and substance use disorders because such interventions involve multiple treatment modalities delivered simultaneously, in busy practice settings, with challenging populations. This paper pairs consolidated framework for implementation research (CFIR) constructs with a realist evaluation approached to generate configurations important to the adoption, implementation, and adaptation stages of a highly complex intervention addressing the behavioural health and housing needs of a vulnerable population. Each configuration describes how contextual factors trigger mechanisms to generate implementation outcomes and answers “what works for whom, in what circumstances and in what respects, and how?” These findings further our understanding of possible mechanisms of change and push us to be more precise about identifying causal relationships among constructs that contribute to the success of implementing complex interventions. This work also moves us to think theoretically and methodologically in a more dynamic fashion, thereby leading to more responsive implementation practice.

Abstract Background Evidence-based treatment for co-occurring disorders is needed within programs that serve homeless Veterans to assist with increasing engagement in care and to prevent future housing loss. A specialized co-occurring disorders treatment engagement intervention called Maintaining Independence and Sobriety Through Systems Integration, Outreach and Networking - Veterans Edition (MISSION-Vet) was implemented within the Housing and Urban Development - Veterans Affairs Supportive Housing (HUD-VASH) Programs with and without an implementation strategy called Getting To Outcomes (GTO). While implementation was modest for the GTO group, no one adopted MISSION in the non-GTO group. This paper reports Veteran level outcome data on treatment engagement and select behavioral health outcomes for Veterans exposed to the MISSION-Vet model compared to Veterans without access to MISSION-Vet. Methods This hybrid Type III trial compared 81 Veterans in the GTO group to a similar group of 87 Veterans with mental health and substance use disorders from the caseload of staff in the non-GTO group. Comparisons were made on treatment engagement, negative housing exits, drug and alcohol abuse, inpatient hospitalizations, emergency department visits and income level over time, using mixed-effect or Cox regression models. Results Treatment engagement, as measured by the overall number of case manager contacts with Veterans and others (e.g. family members, health providers), was significantly higher among Veterans in the GTO group (B = 2.30, p = .04). Supplemental exploratory analyses between Veterans who received “higher” and “lower” intensity MISSION-Vet services in the GTO group failed to show differences in alcohol and drug use, inpatient hospitalization and emergency department use. Conclusions Despite modest MISSION-Vet fidelity among staff treating Veterans in the GTO group, differences were found in treatment engagement. However, this study failed to show differences in alcohol use, drug use, mental health hospitalizations and negative housing exits over time among those Veterans receiving higher intensity MISSION-Vet services versus low intensity services. This project suggests that MISSION-Vet could be used in HUD-VASH to increase engagement among Veterans struggling with homelessness, a group often disconnected from care. Trial registration Clinicaltrials.gov, registration number: NCT01430741, registered July 26, 2011.

Abstract Background 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. Design 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. Discussion 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.

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.

BackgroundOpioid overdose (OD) and related deaths have significantly increased in the United States over the last 2 decades. Existing studies have mostly focused on demographic and clinical risk factors in noncritical care settings. Social and behavioral determinants of health (SBDH) are infrequently coded in the electronic health record (EHR) and usually buried in unstructured EHR notes, reflecting possible gaps in clinical care and observational research. Therefore, SBDH often receive less attention despite being important risk factors for OD. Natural language processing (NLP) can alleviate this problem. ObjectiveThe objectives of this study were two-fold: First, we examined the usefulness of NLP for SBDH extraction from unstructured EHR text, and second, for intensive care unit (ICU) admissions, we investigated risk factors including SBDH for nonfatal OD. MethodsWe performed a cross-sectional analysis of admission data from the EHR of patients in the ICU of Beth Israel Deaconess Medical Center between 2001 and 2012. We used patient admission data and International Classification of Diseases, Ninth Revision (ICD-9) diagnoses to extract demographics, nonfatal OD, SBDH, and other clinical variables. In addition to obtaining SBDH information from the ICD codes, an NLP model was developed to extract 6 SBDH variables from EHR notes, namely, housing insecurity, unemployment, social isolation, alcohol use, smoking, and illicit drug use. We adopted a sequential forward selection process to select relevant clinical variables. Multivariable logistic regression analysis was used to evaluate the associations with nonfatal OD, and relative risks were quantified as covariate-adjusted odds ratios (aOR). ResultsThe strongest association with nonfatal OD was found to be drug use disorder (aOR 8.17, 95% CI 5.44-12.27), followed by bipolar disorder (aOR 2.69, 95% CI 1.68-4.29). Among others, major depressive disorder (aOR 2.57, 95% CI 1.12-5.88), being on a Medicaid health insurance program (aOR 2.26, 95% CI 1.43-3.58), history of illicit drug use (aOR 2.09, 95% CI 1.15-3.79), and current use of illicit drugs (aOR 2.06, 95% CI 1.20-3.55) were strongly associated with increased risk of nonfatal OD. Conversely, Blacks (aOR 0.51, 95% CI 0.28-0.94), older age groups (40-64 years: aOR 0.65, 95% CI 0.44-0.96; >64 years: aOR 0.16, 95% CI 0.08-0.34) and those with tobacco use disorder (aOR 0.53, 95% CI 0.32-0.89) or alcohol use disorder (aOR 0.64, 95% CI 0.42-1.00) had decreased risk of nonfatal OD. Moreover, 99.82% of all SBDH information was identified by the NLP model, in contrast to only 0.18% identified by the ICD codes. ConclusionsThis is the first study to analyze the risk factors for nonfatal OD in an ICU setting using NLP-extracted SBDH from EHR notes. We found several risk factors associated with nonfatal OD including SBDH. SBDH are richly described in EHR notes, supporting the importance of integrating NLP-derived SBDH into OD risk assessment. More studies in ICU settings can help health care systems better understand and respond to the opioid epidemic.