Quality of Mental Health Services for Homeless Veterans in Primary Care Settings

背景：我的长期目标是成为一名独立的退伍军人健康服务研究员，专注于 设计和测试综合护理解决方案，以改善精神健康和药物滥用(MHSA)服务 弱势退伍军人的机会、质量和结果。这架CDA-2将为我提供 评估、修改和实施组织变革所需的指导、技能和经验 改善初级保健环境中易受伤害退伍军人的MHSA结果。 意义/影响：无家可归的退伍军人抑郁症和阿片类药物使用率很高 获得传统初级保健服务的无序和障碍。确定有效的模型很重要 在退伍军人在退伍军人管理局和社区有更多护理选择的时候，MHSA服务集成 设置。退伍军人管理局的无家可归患者联合护理小组(H-PACT)计划，在60多家退伍军人管理局机构实施， 提供一个天然的实验室来确定MHSA服务集成的最佳方法，以提升退伍军人 健康。我的研究将通过确定H-PACT的有效性来影响退伍军人健康 在有无家可归经历的退伍军人中提供高质量的MHSA护理和减轻MHSA的不利后果； 确定H-PACT和其他患者看护团队的独特和可能可修改的方面 (PACTS)，可以扩大规模，为无家可归的有经验的退伍军人实现卓越的MHSA结果 专门化和非专门化的协定设置。这项研究与退伍军人事务部的研究重点非常一致 精神健康和初级保健，以及与成瘾康复和社区护理有关的立法优先事项。 创新：虽然先前的研究表明H-PACT改善了初级保健的利用率和退伍军人的体验 在谨慎的情况下，更少的研究集中在确定H-PACT的哪些功能是成功的。我们缺乏数据 关于H-PACTS中的退伍军人的临床过程措施和结果，关于以下方面的信息 MHSA服务整合存在于H-PACTS和传统的照顾无家可归者的协议中-经验丰富 退伍军人，以及为无家可归的有经验的退伍军人提供MHSA质量的障碍和促进者。 具体目标：My CDA-2有三个主要目标：1)比较MHSA服务的护理质量(例如，临床 抑郁症、阿片类药物使用障碍的绩效衡量)和结果(例如，精神病院住院， 阿片类药物相关过量，自杀)无家可归的退伍军人在H-PAPS中与其他 相同设施中的协定；2)衡量MHSA服务集成的水平和特征(例如，协调 通过社区服务、供应商代管、完全融合)，为H- 协定和其他协定；以及3)评估MHSA服务做法和障碍，4个设施排名较低，4个 在MHSA为无家可归的有经验的退伍军人提供的服务质量指标上排名靠前。我会用我的 导师培养专业知识，研究初级保健环境中的MHSA服务质量，并增强我的 基础培训，掌握调查设计、定性方法和实施科学方面的新技能。 方法：我的目标是1)使用退伍军人管理局的管理数据来实施基于护理质量的MHSA服务 关于退伍军人事务部的绩效衡量和既定定义；2)采用H-PACT的组织调查 从H-PACTS和PACTS调查提供商关于如何实现MHSA服务集成的结构 无家可归-有经验的退伍军人；以及；3)在低绩效和高绩效设施中进行利益相关者访谈，以 确定为无家可归的有经验的退伍军人提供高质量MHSA服务的障碍。 后续步骤/实施：调查结果将向退伍军人管理局提供商、运营合作伙伴和 领导层对H-PACT倡议的有效性，以及支持Low的干预目标 执行H-PACTS。我的实施前研究结果和培训经验将为我的未来提供信息 工作重点是MHSA在专门协定环境下的成果，包括HSR&D有效性- 实施研究(IIR)应用，以提高PACTS中无家可归退伍军人的MHSA服务质量。

Background: My long-term goal is to become an independent VA health services researcher focused on designing and testing integrated care solutions to improve mental health and substance abuse (MHSA) services access, quality, and outcomes for vulnerable Veteran populations. This CDA-2 will provide me with the necessary mentorship, skills, and experiences to evaluate, modify and implement organizational changes that improve MHSA outcomes for vulnerable Veterans in primary care settings. Significance/Impact: Veterans who have been homeless have high rates of depression and opioid use disorder and barriers to accessing traditional primary care services. It is important to determine effective models of MHSA services integration at this time when Veterans have more options for care in VA and community settings. VA’s homeless patient aligned care team (H-PACT) program, implemented in over 60 VA facilities, offers a natural laboratory to determine optimal approaches of MHSA services integration to advance Veteran health. My research will impact Veteran health by determining the effectiveness of H-PACT for providing high quality MHSA care and mitigating adverse MHSA outcomes among homeless-experienced Veterans; and by determining the unique and potentially modifiable aspects of H-PACT and other patient aligned care teams (PACTs) that could be scaled to achieve superior MHSA outcomes for homeless-experienced Veterans in specialized and non-specialized PACT settings. This research strongly aligns with VA research priorities of mental health and primary care, and legislative priorities related to addiction recovery and community care. Innovation: While prior studies suggest H-PACT improves primary care utilization and Veteran experiences with care, there is less research focused on determining what features of H-PACT are successful. We lack data on clinical process measures and outcomes for Veterans empaneled in H-PACTs, information on aspects of MHSA services integration that exists within H-PACTs and traditional PACTs caring for homeless-experienced Veterans, and the barriers and facilitators that contribute to MHSA quality for homeless-experienced Veterans. Specific Aims: My CDA-2 has three primary aims: 1) Compare MHSA services quality of care (e.g., clinical performance measures for depression, opioid use disorder) and outcomes (e.g., psychiatric hospitalization, opioid-related overdose, suicide) for homeless-experienced Veterans empaneled in H-PACTs versus other PACTs in the same facilities; 2) Measure levels and features of MHSA services integration (e.g., coordination with community services, co-location of providers, full integration) for homeless-experienced Veterans in H- PACTs and other PACTs; and 3) Evaluate MHSA service practices and barriers in 4 facilities ranked low and 4 ranked high on measures of MHSA services quality for homeless-experienced Veterans. I will work with my mentors to develop the expertise to study MHSA services quality in primary care settings, and to augment my foundational training with new skills in survey design, qualitative methods and implementation science. Methodology: I aim to 1) use VA administrative data to operationalize MHSA services quality of care based on VA performance measures and established definitions; 2) adapt an organizational survey of H-PACT structures to survey providers from H-PACTs and PACTs about how MHSA services integration is achieved for homeless-experienced Veterans, and; 3) conduct stakeholder interviews in low and high performing facilities to identify barriers to delivering high quality MHSA services for homeless-experienced Veterans. Next Steps/Implementation: Findings will provide information to VA providers, operational partners, and leadership about the effectiveness of the H-PACT initiative, and targets for intervention to bolster lower performing H-PACTs. My pre-implementation research findings and training experiences will inform my future work focused on MHSA outcomes in specialized PACT settings, including an HSR&D effectiveness- implementation study (IIR) application to improve MHSA services quality for homeless Veterans in PACTs.