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

背景：在每年从惩教场所释放的146,000名退伍军人中，约有60% 同时患有精神健康和物质使用障碍(COD)。这些个人经常访问 治疗不一致，导致反社会活动增加，加速失业和 无家可归--再次犯罪的强烈预测因素。VHA精神卫生康复治疗 方案(MH RRTP)通常为涉及正义的退伍军人(JIV)提供服务，估计每年有50%。合资企业 在成瘾和行为健康需求方面获得帮助，但MH RRTP计划不直接提供帮助 解决他们的反社会行为和认知问题。此外，MH RRTP排放是一种脆弱的过渡 而且没有一种国家过渡方法会促进退伍军人参与亲社会的社区行为， 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、推广和网络实现清醒--刑事司法版本(任务-CJ)是 新的病例经理和同行为具有死亡原因的JIV提供了基于团队的治疗。最近的三个公开试点 任务-CJ显示减少了犯罪累犯率，改善了行为健康结果，并增加了获得机会 以及对护理的投入。随机对照试验(RCT)是传播前的关键下一步。 意义/影响：此应用程序响应VHA使命法，退伍军人护理优先事项 获得护理、心理健康和健康公平。该项目的目标是：(A)增加进入和参与的机会 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，以及(C)改善健康和福利 在缩小差距的同时成为合资企业的一部分。它还包括支持VHA学习的实施目标。 创新：虽然使命-CJ部分源于对无家可归者的循证治疗 (任务)，它包括一个新的概念框架和许多新的和与众不同的CJ特征 人口包括：(1)侧重于引起犯罪的需要的治疗规划工具，监测进展和 调整服务交付要素，(2)亲社会治疗课程，以及(3)要解决的工具/资源 老牌法律问题。本研究以使命-CJ为研究对象，试图改变实践范式，进行转型 通过超越当前将退伍军人与退伍军人护理联系起来的模式并跟踪行为来关怀合资企业 从健康结果到解决引发犯罪的需求的混合治疗/联系办法，支持 致力于退伍军人管理局和非退伍军人管理局的护理，并将累犯率作为结果-CJ研究的黄金标准。 具体目标：目标1：RCT将任务-CJ与EUC进行比较。我们预测那些在使命-CJ中的人将 有(1a)较低的犯罪累犯率；(1b)较低的刑事累犯总体风险；(1c)较好的健康相关 结果(药物使用、精神健康、住房、就业)；和(1d)使命--社区正义对1a的影响， 1b和1c，将通过(一)减少反社会态度，(二)减少与反社会的联系 (3)更大的治疗参与度(即，MH RRTP 完成；物质使用/心理健康持续护理；12步小组出勤)，以及(4)增加 重新融入社区。目标2：形成性评估将确定未来的障碍和促进者 在全国其他MH RRTP中执行使命-CJ。 方法：本项目将使用混合类型1设计。首先，我们将检验任务的有效性-- CJ接受了两个部位的RCT(贝德福德和帕洛阿尔托VAS)，其中226名退伍军人有COD，进入了MH RRTP， 并在过去12个月中被逮捕、起诉和/或获释。接下来，我们将 使用REACH、有效性、采用、实施和维护框架进行形成性 在每个地点与7个提供者和12名退伍军人进行评估，以告知未来任务-CJ的执行情况。 下一步/实施：根据本次研究的结果，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.