Impact of Combined Recovery Program and Home Telehealth Among Veterans with substance use disorders in the VA Inpatient Setting

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Justification: High inpatient readmissions among Veterans with SUDs constitutes a costly and persistent healthcare problem. VHA Handbook 1160.06 guides the development and implementation of recovery-oriented mental health (MH) services, although significant service gaps remain on VA inpatient settings. ‘Combined Recovery Program (CRP)’ is designed to address these gaps by enhancing stabilization of Veterans with SUDs beyond hospital discharge and consists of ‘Group Motivational Interviewing’, an adaptation of motivational interviewing; and ‘Life Skills for Housing Maintenance’, involving skills training for enhancing housing stability. To be added to CRP, Stable & Able (S&A) is a VA Home Telehealth (HT) nurse-monitored program providing assessment and self-management skills in the post-hospitalization phase. Gaps Addressed: This proposal addresses VA research priorities: access to care and MH, benefitting Veterans with SUDs. A significant proportion of these Veterans exhibit homelessness and suicidality. Study objectives address SAIL MH Composite measures ‘PDE1’ to increase Post-Discharge Treatment Engagement in MH care; and ‘HRF7’ to increase care processes for Veterans at high risk for suicide. During the COVID-19 pandemic, telehealth solutions offer safe treatment options as well as reduce isolation. Innovativeness: This proposal is consistent with 2018 MISSION Act in priority areas: mental illness, SUD, and housing instability via a technology-enabled format and through addressing gaps in the current inpatient recovery model involving limited availability of staff training in and availability of recovery-oriented services. CRP and S&A present innovative/novel interventions ready for deployment. Both CRP and S&A were designed specifically to assist high risk Veterans with SUDs to remain stably housed. S&A is conveniently provided via App using an iPad, cell phone, or the Medtronic Commander Flex and allows 3 mos. of daily monitoring by trained HT staff. Specific Aim I: Assess the relative effects of Treatment Engagement and Substance Use [and SUD-related problems] between CRP+S&A vs. CRP and CRP+S&A vs. TAU by 3-mos follow-up. Primary Hypothesis 1a: Treatment Engagement: Participants in CRP + S&A will attend more outpatient SUD treatment sessions and general MH treatment sessions compared to participants in CRP and to TAU. Primary Hypothesis 1b: Substance Use: Participants in CRP + S&A will lower quantity and frequency of substance use and SUD-related problems compared to participants in CRP and to TAU. Secondary Hypothesis 1c: Preventable Services: Participants in CRP + S&A will reduce Preventable Healthcare Services (hospital readmissions and ED visits) compared to participants in CRP and to TAU. Secondary Hypothesis 1d: Participants in CRP + S&A will report Greater QoL; # of Days Living in Stable Housing; and # of Days Engaging in Community Events and/or Activities compared to CRP and to TAU. Specific Aim II: Conduct Veteran participant thematic interviews and Staff ‘focus’ interviews to assess qualitative facilitators and barriers to implementation. Project Methods: 195 Veterans with SUDs in the Charleston VAMC inpatient setting will be recruited. Participants will be randomly assigned to: (1) CRP + S&A; (2) CRP; and (3) TAU. Participants will be followed- up at 1 and 3-months and data analyzed using mixed methods. Investigators of this project plan to evaluate implementation of the interventions proposed in other VA inpatient programs within the VISN through future implementation projects and will utilize study findings in partnership for improving SAIL performance measures. Description of Primary Outcomes: A. Treatment Engagement (measured in SUD and general MH treatment sessions attended); B. Substance Use (measured in quantity and frequency) and SUD-related problems. Secondary outcomes: C. Preventable Services (measured in hospital readmissions and ED visits) and D. Quality of Life, #Days Living in Stable Housing, and # Days Engaging in Community Events and/or Activities.