Integrated Dual Disorders Treatment: Implementation During Early Adoption

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This project involves prospective observation of the early implementation of integrated dual disorders treatment (IDDT) at two VA facilities in the Midwest, plus interviews and fidelity assessments at two additional VA sites. IDDT is an evidence-based practice for people with serious mental illnesses and co-occurring substance use disorders. This model combines mental health and substance abuse services on a single treatment team, with strong emphases on stagewise assessment and interventions, comprehensive services, and use of motivational approaches to achieve improvements in mental health and substance use. Though the IDDT is being implemented more widely outside the VA, the model is not routinely implemented in VA facilities. This RRP proposal seeks to answer basic questions that will inform future implementation efforts for IDDT in the VA: What barriers are encountered in implementation of IDDT? Are there additional barriers noted in the second and third years of early implementation? What strategies do early adopters employ to overcome barriers? Which of these strategies seem to work? What are the promising VA service contexts for implementing IDDT? How much do early implementation efforts cost? Each participating VA facility has expressed interest in IDDT implementation to staff of the Ohio Center for Evidence-Based Practice (CEBP) at Case Western Reserve University, a national leader in IDDT implementation. One site obtained funding to receive technical assistance and training on IDDT from the CEBP and had their baseline fidelity assessment in January 2012. Another site began implementing the practice in Fall 2012. Two sites would start implementation with this project, using RRP funds. External facilitation includes a baseline fidelity assessment with report and recommendations for beginning the implementation, intensive onsite clinical training for staff, ongoing phone and onsite consultation (at least monthly contact), and a 12-month follow-up fidelity assessment to gauge adherence to the model and plan for further improvements. The project would also fund a 24- month fidelity assessment to track the progress of the two sites who began implementation in 2012. Members of the research team will observe implementation efforts and conduct individual interviews with key stakeholders at the two facilities beginning implementation with this RRP -- after baseline fidelity feedback is received and again after the 12-month fidelity feedback is received. Individual interviews with key stakeholders will also be conducted either in person or via phone for the two sites who began implementation in 2012. Key stakeholders could include the designated IDDT "team leader," mental health, psychiatry and/or social work service chiefs, substance abuse service chief, a portion of implementing clinicians, and the external facilitator from the Ohio CEBP. The veteran perspective is also a valuable one and will be sought in interviews that take place during fidelity assessments. Observations will be summarized by research staff in written form for analysis. Interviews will be audiotaped and transcribed for analysis. To facilitate completion of qualitative data coding and analysis in a limited timeframe, the study team will hold intensive coding sessions early in the project and use an iterative process to further refine interview questions, codes, and determine themes throughout the remainder of the project period. In month 6, the study investigators will convene an expert panel of both local site and VA Central Office leaders relevant to IDDT implementation to provide formative feedback on the implementation approach to improve efforts in the remaining 12 months of the project. The panel will meet again in Month 16 to formulate the final set of important themes obtained and plan the service-directed project proposal.