Addressing Social Determinants of Health Among Rural Veterans

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Background: Rural Veterans represent over one third of all Veterans served by the Department of Veterans Affairs and rural America is strikingly different than urban areas with respect to the social and economic conditions that drive health. Based on research documenting the relationship between social adversity (e.g., homelessness, food insecurity) and health, policy makers suggest routine screening and referral (S&R) for unmet social and economic needs (hereafter: “unmet needs”) in the clinical setting. This call has catalyzed a small but promising evidence base, indicating that efficacy of S&R. However, the S&R evidence base focuses on unmet needs in urban settings. This means we lack the knowledge needed to adapt unmet need S&R for the unique needs of rural VA settings and the rural Veterans they serve. Significance: Our study addresses the HSR&D priorities to mitigate the unmet needs of Veterans and to integrate heath care solutions as much as possible into existing care, rather than depending on new personnel and resources. This study will advance these priorities by adapting the specifications of evidence-based S&R to align with existing unmet needs and unmet need resources in rural VA settings. This study will also establish a process for adapting S&R that can be replicated across VISNs and facilities. Innovation and Impact: This research is highly innovative as we know of no research that is implementing unmet need interventions for rural Veterans. We will provide novel knowledge about unmet needs among rural Veterans, the mechanism by which these needs manifest, and the social service infrastructure within the VA and community that serve rural Veterans. Our research is also innovative in our use of user-centered design (UCD) methods to adapt the specifications of an S&R intervention. Specifically, throughout the process of adapting S&R to the target local sites, we will engage and solicit feedback from the eventual end-users, including Veterans. Specific Aims: 1) Determine unmet needs among rural Veterans and their associations with health outcomes; 2) Assess existing systems for addressing unmet needs and adapt S&R to fit local conditions and stakeholder preferences; 3) Pilot test the adapted intervention and develop an Adaptation Playbook. Methodology: Guided by the Replicating Effective Programs (REP) framework, we propose a 3-year mixed- methods study. We will survey rural Veterans served by VISN 1 about their unmet needs and merge survey data with secondary VA data to assess the scope and scale of unmet needs and their associations with health care outcomes. We will conduct qualitative interviews with key stakeholders (Veterans, VA providers and staff, representatives of community agencies) to understand how unmet needs manifest among rural Veterans, the existing infrastructure for identifying unmet needs and referring for services, and opportunities and preferences for adapting S&R. We will use the information gathered from these interviews and UCD methods to adapt the specifications of S&R. Finally, we will pilot the adapted S&R intervention, refine as needed, and develop an Adaptation Playbook detailing how other facilities can adapt S&R to their local conditions. Next Steps/Implementation: Upon completion of the IIR, we will have moved through the first two of four REP phases (pre-conditions and pre-implementation). By doing so, we will understand the key components necessary for REP phases three and four, which will be the focus of future work (full-scale implementation of the adapted S&R intervention and evaluation) in on-going collaboration with our operational partners the New England Veterans Integrated Service Network, Office of Rural Health and Office of Social Work.