A Randomized Controlled Trial of MISSION-CJ for Justice-Involved Homeless Veterans with Co-Occurring Substance Use and Mental Health

背景：在每年从惩教机构释放的146，000名退伍军人中，约60% 精神健康和物质使用障碍（COD）并存。这些人经常访问 治疗不一致，导致反社会活动增加，加速失业， 无家可归是再次犯罪的有力预测因素VHA精神健康住院康复治疗 计划（MH RRT）通常为涉及司法的退伍军人（JIV）提供服务，估计每年有50%。JIV 接受他们的成瘾和行为健康需求的援助，但MH RRTP计划不直接 解决他们的反社会行为和认知。此外，MH RRTP放电是一个脆弱的过渡 没有一种国家过渡方法能促进退伍军人参与亲社会社区行为， 保持MH RRTP收益，并最终减少旋转门服务的使用。保持独立性和 通过系统集成、外展和网络实现清醒-刑事司法版本（MISSION-CJ）是一个 新的案例经理和同事为具有COD的JIV提供了基于团队的治疗。三个最近开放的试点， MISSION-CJ显示减少了犯罪累犯，改善了行为健康结果，并增加了获得 and engagement参与in care护理.随机对照试验（RCT）是传播前的关键步骤。 意义/影响：此应用程序是响应VHA使命法案，退伍军人护理优先事项， 获得护理，心理健康和健康公平。该项目的目的是：（a）增加获得和参与 VHA和基于社区的护理，（B）提供及时的以退伍军人为中心的护理，（c）改善健康和良好的- 在缩小差距的同时，它还包括支持VHA学习的实施目标。 创新：虽然MISSION-CJ部分源于对无家可归者的循证治疗 （使命），它包括一个新的概念框架和许多新的和差异化的功能，为CJ （1）侧重于监测进展的犯罪需求的治疗规划工具， 调整服务提供要素，（2）亲社会治疗课程，以及（3）解决以下问题的工具/资源 退伍军人的法律的问题。本研究试图通过MISSION-CJ改变实践范式， 通过超越目前将退伍军人与VA护理联系起来的模式， 健康结果，以混合治疗/联系的办法，解决犯罪的需要，支持 参与VA和非VA护理，并将累犯作为CJ研究的黄金标准。 具体目的：目的1：RCT将比较MISSION-CJ与EUC。我们预测那些在MISSION-CJ的人将 （1a）较低的刑事累犯率;（1b）较低的刑事累犯总体风险;（1c）较好的健康相关 结果（物质使用，心理健康，住房，就业）;和（1d）MISSION-CJ对1a的影响， 1b和1c，将介导（i）减少反社会态度，（ii）减少与反社会的联系， 同伴和增加与亲社会同伴的联系，（iii）更大的治疗参与（即，MH RRTP 完成;物质使用/心理健康持续护理; 12步小组出勤率），以及（iv）增加 重返社区。目标2：形成性评价将确定未来的障碍和促进因素 在全国其他MH RRT中实施MISSION-CJ。 方法：该项目将使用混合1型设计。首先，我们将测试使命的有效性- CJ在一个两个地点的RCT（贝德福德和帕洛阿尔托VA）与226名退伍军人与COD，承认一个MH RRTP， 在过去12个月内曾被逮捕、起诉和/或从监禁中获释的人。接下来我们就 使用覆盖范围、有效性、采用、实施和维护框架， 在每个站点与7名供应商和12名退伍军人进行评估，为未来的MISSION-CJ实施提供信息。 下一步/实施：根据本研究的结果，我们将与VACO运营部门合作， 合作伙伴和两个HSR&D创新中心进行大型多站点实施试验。

Background: Among the 146,000 Veterans released from correctional settings annually, approximately 60% have a co-occurring mental health and substance use disorder (COD). These individuals often access treatment inconsistently, resulting in increased antisocial activities and acceleration into unemployment and homelessness – strong predictors of reoffending. VHA Mental Health Residential Rehabilitation Treatment Programs (MH RRTPs) commonly serve justice-involved Veterans (JIVs) with an estimated 50% annually. JIVs receive assistance with their addiction and behavioral health needs, but MH RRTP programs do not directly address their antisocial behaviors and cognitions. Furthermore, MH RRTP discharge is a vulnerable transition and no national transitional approach facilitates Veteran engagement in prosocial community behaviors that maintain MH RRTP gains, and ultimately reducing revolving door service use. Maintaining Independence and Sobriety through Systems Integration, Outreach, and Networking-Criminal Justice version (MISSION-CJ) is a new case manager and peer delivered team-based treatment for JIVs with a COD. Three recent open pilots of MISSION-CJ showed reduced criminal recidivism, improved behavioral health outcomes and increased access and engagement in care. A randomized controlled trial (RCT) is a critical next step prior to dissemination. Significance/Impact: This application is responsive to the VHA MISSION Act, Veteran Care Priorities of Access to Care, Mental Health, and Health Equity. The project aims to (a) increase access and engagement in VHA and community-based care, (b) offer timely Veteran-centered care, and (c) improve the health and well- being of JIVs while reducing disparities. It also includes an implementation aim to support VHA learning. Innovation: While MISSION-CJ derives in part from an evidence-based treatment for homeless individuals (MISSION), it includes a new conceptual framework and numerous new and differentiating features for a CJ population including: (1) a treatment planning tool focused on criminogenic needs that monitors progress and tunes service delivery elements, (2) a prosocial treatment curriculum, and (3) tools/resources to address Veteran legal issues. With MISSION-CJ, this study attempts to change the practice paradigm and transform care for JIVs by moving beyond the current model of linking Veterans to VA care and tracking behavioral health outcomes, to a hybrid treatment/linkage approach that addresses criminogenic needs, supports engagement in VA and non-VA care, and targets recidivism as an outcome–the gold standard for CJ research. Specific Aims: Aim 1: An RCT will compare MISSION-CJ to EUC. We predict that those in MISSION-CJ will have (1a) lower criminal recidivism; (1b) lower overall risk for criminal recidivism; (1c) better health-related outcomes (substance use, mental health, housing, employment); and (1d) the effects of MISSION-CJ on 1a, 1b and 1c, will be mediated by (i) reductions antisocial attitudes, (ii) reductions in affiliations with antisocial peers and increases in affiliations with prosocial peers, (iii) greater treatment engagement (i.e., MH RRTP completion; substance use/mental health continuing care; 12-step group attendance), and (iv) increased community reintegration. Aim 2: A formative evaluation will identify barriers and facilitators to future implementation of MISSION-CJ in other MH RRTPs nationally. Methodology: This project will use a Hybrid Type 1 design. First, we will test the effectiveness of MISSION- CJ in a two-site RCT (Bedford and Palo Alto VAs) with 226 Veterans with a COD, admitted to an MH RRTP, and previously arrested and charged and/or released from incarceration in the past 12 months. Next, we will use the Reach, Effectiveness, Adoption, Implementation & Maintenance framework to conduct a formative evaluation with 7 providers and 12 Veterans at each site to inform future MISSION-CJ implementation. Next Steps/Implementation: Depending on the results of this study, we will work with our VACO operational partners and two HSR&D Centers of Innovation to conduct a large multisite implementation trial.