Implementing and sustaining Critical Time Intervention (CTI) in case management programs for homeless-experienced Veterans

背景：VA补助金和每日津贴病例管理（GPD-CM）计划提供6个月的病例 管理无家可归的退伍军人（HEV）经历住房过渡。目前没有 在GPD-CM计划中需要特定的案例管理范例，导致实践中的差异 网站.关键时间干预（CTI）的国家实施-一个基于证据的，结构化的，和时间- 有限的情况下，管理计划的混合动力汽车经历住房过渡，将标准化， 改善GPD-CM计划中的病例管理。在常规护理环境中实施CTI需要 平衡CTI保真度的需求与适应为这一人群服务的各种计划的适应性。 此外，某些组织环境可能需要更密集和量身定制的支持来实施CTI。 目的：我们建议在32个政府发展局辖下的中医药中心推行计算机技术创新计划。在这些领域实施和维持CTI 我们将使用复制有效计划（REP）实施包，使各站点能够实现 忠实于CTI的核心组件，同时适应适应GPD-CM设置的多样性 和上下文。我们将随机分组一半的网站也接受9个月的外部促进 （“增强型REP”），这是一个既定的流程，为供应商和行业领导者提供量身定制的支持， 努力采用循证护理方案并将其纳入日常护理过程。我们的具体目标是：1）使用REP 和增强的REP，以支持在32个GPD-CM站点实施和维持CTI; 2）比较， 第3类混合实施效果试验，REP与增强REP对CTI保真度的影响， 可持续性、质量指标（侧重于住房稳定性和住院率）以及成本和回报率， 投资;以及3）为计划合作伙伴生成两个关键产品-业务案例分析和 实施行动手册-支持GPD-CM计划中CTI的持续推广和维护。 方法：我们将使用在我们的QUERI中开发和完善的CTI培训和技术援助包- VISN合作实施计划（PII）启动，在32个GPD-CM站点实施CTI。我们将使用 REP将支持CTI在所有32个站点的实施。其中一半的网站还将获得9个月的外部 促进（EF，作为增强REP的一部分），建立在我们的EF经验和PII中开发的材料基础上 启动为了比较REP与增强REP的影响，我们将进行一项群集随机化类型3 杂交试验我们将使用一种在两个级别上进行随机化的展示设计： 开始（三个队列）和实施战略（REP与增强REP）。我们将使用置换块 随机化，以平衡队列中接受每种策略的研究中心的关键研究中心特征。 我们将使用混合方法来评估REP与增强REP的影响。 有效性、对CTI的忠诚度是我们的主要成果，其次是可持续性、质量指标和成本。我们 假设增强的REP将比单独的REP具有更高的成本，但是将导致更强的CTI保真度， 可持续性和质量指标，从而为增强REP提供明确的业务案例。这项工作将导致 这些产品将支持我们的计划合作伙伴在GPD-CM计划中传播和维持CTI。 意义：目前，在GPD-CM计划中不需要特定的病例管理范例， 从而导致各地点之间的显著实践差异。在这个项目中实施CTI是一个独特的 有机会减少各研究中心的临床差异，提高住房稳定性并减少住院治疗 在混合动力汽车，进一步VA网络主任的优先事项，以提高战略的吸收，以解决 健康差距和健康的退伍军人社会决定因素。

Background: The VA Grant and Per Diem case management (GPD-CM) program provides six months of case management for homeless-experienced Veterans (HEVs) undergoing housing transitions. At present, no specific case management paradigm is required in the GPD-CM program, resulting in practice variation across sites. National implementation of Critical Time Intervention (CTI)—an evidence-based, structured, and time- limited case management program for HEVs experiencing housing transitions—would standardize and improve case management in the GPD-CM program. Implementing CTI in routine care settings requires balancing the need for CTI fidelity with adaptations to fit the diverse programs serving this population. Moreover, some organizational contexts may require more intense and tailored supports to implement CTI. Objectives: We propose to implement CTI at 32 GPD-CM sites. To implement and sustain CTI across these sites, we will use the Replicating Effective Programs (REP) implementation bundle to enable sites to achieve fidelity to CTI’s core components, while accommodating adaptations to fit the diversity of GPD-CM settings and contexts. We will cluster randomize half the sites to also receive 9 months of external facilitation (“enhanced REP”), an established process of providing tailored support for providers and leaders in the ir efforts to adopt and incorporate EBPs into their routine care processes. Our Specific Aims are to: 1) Use REP and enhanced REP to support the implementation and sustainment of CTI in 32 GPD -CM sites; 2) Compare, in a type 3 hybrid implementation-effectiveness trial, the impacts of REP vs. enhanced REP on CTI fidelity and sustainment, quality metrics (focused on housing stability and hospitalization rates), and costs and return-on- investment; and 3) Generate two key products for program partners—a business case analysis and an implementation playbook —to support continued spread and sustainment of CTI in the GPD -CM program. Methods: We will use a CTI training and technical assistance package developed and refined in our QUERI- VISN Partnered Implementation Initiative (PII) Start-up to implement CTI in 32 GPD-CM sites. We will use REP to support CTI implementation at all 32 sites. Half of these sites will also receive 9 months of external facilitation (EF, as part of enhanced REP), building on our EF experiences and materials developed in the PII Start-up. To compare the impacts of REP vs. enhanced REP, we will conduct a cluster randomized type 3 hybrid trial. We will use a rollout design in which randomization occurs at two levels: when impleme ntation begins (three cohorts) and the implementation strategy (REP vs. enhanced REP). We will use permuted block randomization to balance key site characteristics among sites receiving each of these strategies across cohorts. We will use mixed methods to assess the impacts of REP vs. enhanced REP. As fidelity to CTI influences its effectiveness, fidelity to CTI is our primary outcome, followed by sustainment, quality metrics, and costs. We hypothesize that enhanced REP will have higher costs than REP alone, but will result in stronger CTI fidelity, sustainment, and quality metrics, leading to a clear business case for enhanced REP. This work will lead to products that will support our program partners in spreading and sustaining CTI in the GPD-CM program. Significance: At present, no specific case management paradigms are required in the GPD-CM program, resulting in significant practice variation across sites. Implementing CTI in this program is a unique opportunity to reduce clinical variation across sites, improve housing stability and decrease hospitalizations among HEVs, and further VA Network Directors’ priorities to improve the uptake of strategies to address health disparities and Veteran social determinants of health.