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

理由：SUD退伍军人中的高住院再入院率构成了一种昂贵且持久的 医疗保健问题。VHA手册1160.06指导面向恢复的 心理健康（MH）服务，虽然显着的服务差距仍然存在VA住院设置。的合并 康复计划（CRP）旨在通过加强患有SUD的退伍军人的稳定来解决这些差距 除了出院，包括“小组动机访谈”，一个改编的动机 “住房维护生活技能”，包括提高住房稳定性的技能培训。 要添加到CRP，稳定和能力（S&A）是一个VA家庭远程医疗（HT）护士监测计划，提供 住院后阶段的评估和自我管理技能。 解决的差距：该提案解决了VA研究的优先事项：获得护理和MH，使退伍军人受益 关于SUD这些退伍军人中有很大一部分表现出无家可归和自杀倾向。研究目的 解决SAIL MH综合措施“PDE 1”，以增加MH护理中的出院后治疗参与; 和“HRF 7”，以增加对自杀高危退伍军人的护理程序。在COVID-19大流行期间， 远程保健解决方案提供了安全的治疗选择，并减少了隔离。 创新性：该提案在优先领域与2018年使命法案一致：精神疾病，SUD， 通过技术支持的形式和通过解决当前住院患者恢复方面的差距， 这种模式涉及有限的工作人员培训和面向恢复的服务。CRP和S&A 提出可供部署的创新/新颖干预措施。CRP和S&A都是专门为 协助患有SUD的高风险退伍军人保持稳定的住房。S&A通过应用程序使用 iPad、手机或Medtronic Commander Flex，允许3个月。由训练有素的HT工作人员进行日常监测。 具体目标I：评估治疗参与和物质使用[以及SUD相关]的相对影响 3个月随访时CRP+S&A与CRP和CRP+S&A与TAU之间的问题]。 主要假设1a：治疗参与：CRP + S&A的参与者将参加更多的门诊SUD 治疗疗程和一般MH治疗疗程与CRP和TAU受试者相比。 主要假设1b：物质用途：CRP + S&A的参与者将降低 与CRP和TAU参与者相比，物质使用和SUD相关问题。 次要假设1c：可报销服务：CRP + S&A的参与者将减少可报销服务 与CRP和TAU受试者相比，医疗服务（再入院和艾德访视）。 次要假设1d：CRP + S&A的参与者将报告更高的QoL;稳定生活天数 住房;与CRP和TAU相比，参与社区活动和/或活动的天数。 具体目标二：进行资深参与者专题访谈和工作人员“焦点”访谈， 促进者和执行障碍。 项目方法：将招募195名在查尔斯顿VAMC住院环境中患有SUD的退伍军人。 参与者将被随机分配到：（1）CRP + S&A;（2）CRP;和（3）TAU。参与者将被跟踪- 在1个月和3个月时，使用混合方法分析数据。本项目的研究者计划评估 在VISN内的其他VA住院计划中实施建议的干预措施， 执行项目，并将利用研究结果的伙伴关系，以改善SAIL业绩措施。 主要结局描述：A。治疗参与度（在SUD和一般MH治疗中测量 出席的会议）; B.物质使用（以数量和频率衡量）和SUD相关问题。 次要结局：C。可负担的服务（以再入院和艾德就诊为衡量标准）和D.质量 生活，#天生活在稳定的住房，#天参与社区活动和/或活动。

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.