Partnered Implementation Evaluation of a National Sponsorship Program for Transitioning Service Members

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Problem in VA Proposal is Addressing. The United States is currently experiencing a national epidemic of suicide for its youngest Service Members (SMs) still serving in the Department of Defense (DOD, 2019) and those that have already transitioned out of the military. For example, the rate of suicide for Veterans aged 18- 34 years old having more than doubled from approximately 22 suicide deaths per 100,000 in 2006 to 45 per 100,000 in 2016 (VA, 2018; VA 2019). It appears that a period of significant risk for these young Veterans is during their first year after separating from the military with recent estimates suggesting an increase of nearly 50% during this period (Kang et al., 2015; Shen, Cunha, & Williams, 2016). As a result of the troubling trends, two executive orders have been issued within the last two years calling for federal organizations to work closer with local, nonprofit and academia organizations to implement a public health approach to suicide prevention. Preventing suicide remains a top priority for the VA with similar sentiments of a public health perspective to suicide prevention being recently published National Strategy for Preventing Suicide (VA, 2018). In this strategy, the VA acknowledged that it must reach out to Servicemembers (SMs) and Veterans in the community before they experience an acute crisis (VA, 2018). Similarly, VISN 17 made a significant commitment to the Expiration Term of Service (ETS) Sponsorship program in order to engage SMs prior to them exiting the military. Preliminary analysis was conducted for a recent randomized control trial with post- 9/11 Veterans in New York City that received the support from ETS Sponsors with the results showing a moderate treatment effect for both reduced transition stressors and improved social support (Geraci, 2018). Aims. We propose a Hybrid Type 2 effectiveness-implementation trial to evaluate the expansion of ETS Sponsorship across six cities from FY 2020 to 2023 in Texas. Aim #1 will determine the effectiveness of the ETS sponsorship program, as evidenced by measures of transition stressors, social support, psychological distress, suicidal ideation and behaviors, and VA/non-VA service utilization. Aim #2 will determine the feasibility and potential utility of implementing the ETS Sponsorship program to six cities in Texas. SMs that transition to cities without an established ETS Sponsorship program will experience their transition from military to civilian life as usual (i.e., services available from the U.S. Army Soldier for Life-Transition Assistance Program). After cities have implemented the ETS Sponsorship program, transitioning SMs will have access to an ETS Sponsor in their city and warm handoffs to community services. Methods. We will use a stepped wedge design while using other cities as controls until they begin implementation. This design will allow us to extend implementation support to the maximal number of cities and enhance the formative evaluation (periodic reflections with key partners and SM interviews). The stepped wedge design also enables us to make efficient use of all data available for within-site and between-site comparisons. For the within-site comparison, cities will act as their own controls in a program evaluation that compares cities pre- versus post- implementation. The comparison examines cities as they cross-over from control to intervention states. The between-site comparison evaluates the intervention period for a city vs. all other intervention and control periods for all cities. Outcomes of interest are measured for all transitioning SMs at each city within the given intervention time period. We randomized at the city level and will use individual SMs as the unit of observation for primary quantitative outcome measures. Six cities will participate in the program evaluation, with two cities allocated to each of the three start dates or steps. Hierarchical models will be run in which SMs are nested within city analyzing the results of the pre-implementation and post- implementation assessments. Hierarchical random effects models examine within- and between-group change across time and by condition.