The Effect of Screening and Referral for Social Determinants of Health on Veterans' Outcomes
Phase: NA
Conditions: Cardiovascular Disease, Hypertension, Diabetes Mellitus, Hyperlipidemia
Sponsor: VA Office of Research and Development

Project ID: IIR 19-013, eRA# 101 HX003060-01
Funding Agency: VA HSR&D
Principal Investigator/Study Chair: Deborah Gurewich, PhD
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Abstract
Background: Despite medical advances, up to 70% of health outcomes are due 
to social determinants of health (SDoH) - the conditions in which people live and 
work that shape whether basic needs (e.g., housing, food) are met. These 
associations are especially well documented for cardiovascular disease (CVD). 
In response, health policy leaders recommend screening and referral (S&R) for 
unmet needs in clinical settings, and the American Heart Association recently 
concluded that the most significant opportunities for reducing CVD death and 
disability lie with addressing the social determinants of cardiovascular outcomes. 
A limited but promising evidence base supports these recommendations, but 
more rigorous research is needed to guide how best to intervene on unmet 
needs that affect health. 
Innovation: VA currently systematically screens for only two unmet needs 
(homelessness and food insecurity). Identification of other unmet needs (and 
referral to address them) occurs on an ad hoc basis, with varying approaches 
among clinics/ clinicians. We will implement comprehensive screening of nine 
unmet needs and systematic referral, developing tools and processes that, if 
efficacious, can be implemented within VA (and other) clinical systems. VA is 
currently funding several studies related to SDoH, but none test interventions that 
systematically identify a wide range of unmet social needs among Veterans and 
connect Veterans with identified needs to social service resources.
Specific Aims: 1) Describe the burden and distribution of nine unmet needs (i.e., 
housing; food insecurity; utility insecurity; transportation; legal guidance; 
employment; safety; and social isolation) among Veterans with or at-risk for CVD, 
and identify their associations with sociodemographic characteristics, and 
baseline health-related behaviors and clinical outcomes; 2) Compare the effects 
of three S&R study intervention conditions of varying intensity on Veterans’ 
connection to new SDoH resources (primary outcome), reduction of unmet 
needs, adherence, and clinical outcomes, and 3) Identify barriers and facilitators 
to Veterans’ connecting with social services and having needs met, and 
explanatory factors for observed RCT outcomes.
Methodology: We propose a three-year, two-phased mixed methods study. In 
Phase One (Aims 1 and 2), we will implement a three-armed randomized 
controlled trial at three VA sites to compare outcomes among Veterans 
randomized within each site to one of three study conditions: screening only; 
screening plus provision of tailored resource sheets; or screening plus resource 
sheets plus social work support. For each Veteran, we will examine associations 
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of unmet needs with baseline outcomes (Aim 1), and longitudinally examine the 
impact of each approach on connection to new SDoH resources and follow-up 
outcomes over a 12-month period (Aim 2).  In Phase Two (Aim 3), we will 
conduct interviews with Veterans and representatives of the VA- and community-
based programs to which Veterans are referred because of the trial to identify 
facilitators and barriers and potential explanatory factors related to the relative 
success of the interventions. 
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List of Abbreviations
ACO Accountable Care Organization
ACSC Ambulatory Care Sensitive Conditions
AHA American Heart Association
AHC Accountable Health Communities
AHRQ Agency for Healthcare Research and Quality
BMC Boston Medical Center
BP Blood Pressure
BS Bachelor of Science
CDC Centers for Disease Control and Prevention
CDW Corporate Data Warehouse
CHC Community Health Center
CHERP Center for Health Equity Research and Promotion
CHF Congestive Heart Failure
CHOIR Center for Healthcare Organization and Implementation Research
CMS Center for Medicare and Medicaid Services
CPT Current Procedure Terminology
CVD Cardiovascular Disease 
ED Emergency Department
EHR Electronic Health Record
HbA1c Hemoglobin A1c
HSR&D Health Services Research and Development
ICD10 International Classification of Disease 10th Revision 
IIR Investigator-Initiated Research
IOM Institutes of Medicine
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MLCHC Massachusetts League of Community Health Centers
MPH Master of Public Health
MPI Multiple Principal Investigators
MSW Master of Social Work
NACHC National Association of Community Health Centers
NAM National Academy of Medicine
NHLBI National Heart, Lung and Blood Institute
NIH National Institutes of Health
OPCC&CT Office of Patient Centered Care & Cultural Transformation 
PC Primary Care
PI Principal Investigator
PQI Preventative Quality Indicators
PRAPARE Protocol for Patients’ Assets, Risk, and Experiences
RA Research Associate
S&R Screening and Referring 
SDoH Social Determinants of Health
SEP Socioeconomic Position
VACS Veteran Aging Cohort Study
VERG Veterans Employee Resource Group
VINCI VA Informatics and Computing Infrastructure
VIReC VA Information Resource Center
VISTA Veterans Health Information Systems and Technology Architecture
VSSC VHA Support Service Center
WHO World Health Organization
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Contents
Protocol Title:  The Effects of Screening and Referral for Social Determinants of Health 
on Veterans’ Outcomes....................................................................................................8
1.0
Study Personnel....................................................................................................8
2.0
Introduction............................................................................................................8
3.0
Objectives............................................................................................................10
4.0
Resources and Personnel...................................................................................11
5.0
Study Procedures................................................................................................15
5.1 Study Design........................................................................................................15
5.2 Recruitment Methods............................................................................................21
5.3 Informed Consent Procedures..............................................................................24
5.4 Inclusion/Exclusion Criteria...................................................................................24
5.5 Study Evaluations.................................................................................................25
5.6 Data Analysis........................................................................................................26
5.7 Withdrawal of Subjects.........................................................................................31
6.0
Reporting.............................................................................................................31
7.0
Privacy and Confidentiality..................................................................................31
8.0
Communication Plan...........................................................................................32
9.0
References..........................................................................................................32
Appendix A:  Description of the Intervention and Randomization...............................34
Appendix B: Protocol for Warm Hand-Off to Veterans Crisis Line..............................37
Appendix C: Cover Letter Inviting Veteran Participation.............................................40
Appendix D: Study Fact Sheet....................................................................................41
Appendix E: Sample Resource Postcards..................................................................44
Appendix F: Opt-Out (Do-not-contact) Postcard.........................................................44
Appendix G: Veteran Recruitment Phone Script.........................................................46
Appendix H: Resource Representative Invitation Email..............................................54
Appendix I:  Index Unmet Needs Screening Tool.......................................................54
Appendix J: Eight-Week Follow-Up Survey................................................................59
Appendix K: Six-Month Follow-Up Survey..................................................................61
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Appendix L: Veteran Interview Guide (Not Connected)..............................................64
Appendix M: Veteran Interview Guide (Connected)....................................................67
Appendix N: Resource Representative Interview Guide.............................................70
Appendix O: Example Resource Sheets.....................................................................72
Appendix P: Mail and Email Text for Delivering Resource Sheets to Veterans……… 81
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Protocol Title:  The Effects of Screening and Referral for Social 
Determinants of Health on Veterans’ Outcomes
1.0
Study Personnel
Name
Project 
Role
Status
Email
Institution and Location
Gurewich, 
Deborah
PI
8/8ths 
VA
Deborah.Gurewich@va.gov
VA Boston Healthcare 
System, Boston, MA
Rosen, Amy
co-I
8/8ths 
VA
Amy.Rosen2@va.gov
VA Boston Healthcare 
System, Boston, MA
Niles, Barbara
co-I
8/8ths 
VA
Barbara.Niles@va.gov
VA Boston Healthcare 
System, Boston, MA
Linsky, Amy
co-I
8/8ths 
VA
Amy.Linsky@va.gov
VA Boston Healthcare 
System, Boston, MA
Friedman, 
Hannah
Co-I
8/8ths 
VA
Hannah.Friedman2@va.gov
VA Boston Healthcare 
System, Boston, MA
Bokhour, 
Barbara
co-I
8/8ths 
VA
Barbara.Bokhour@va.gov
Edith Nourse Rogers 
Memorial Veterans 
Hospital (Bedford VAMC), 
Bedford, MA
Fix, Gemmae
co-I
8/8ths 
VA
Gemmae.Fix@va.gov
Bedford VAMC, Bedford, 
MA
Li, Mingfei
co-I
IPA
Mingfei.Li@va.gov
Bedford VAMC, Bedford, 
MA
Hunt, Kelly
co-I
8/8ths 
VA
Kelly.Hunt@va.gov
Ralph H Johnson Medical 
Center, Charleston, MA
Dichter, Melissa
co-I
8/8ths 
VA
Melissa.Dichter@va.gov
Corporal MJ Crescenz VA 
Medical Center, 
Philadelphia, PA

Four sites will participate in this study, 3 of which are intervention sites 
(Boston, Charleston and Philadelphia) and 1 of which is a non-intervention 
site (Bedford). Team members at the non-intervention site will only be 
engaged in advising the study, qualitative data analysis, and 
dissemination activities. There is not a graduated start-up plan for any of 
the sites.
2.0
Introduction
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Credit for health outcomes is typically ascribed to biomedical advances, but up to 
70% of health outcomes result from social determinants of health (SDoH) -- the 
conditions in which individuals are born, live and work. SDoH shape whether 
basic needs (e.g., housing, utilities, food, transportation, employment, social 
connections, legal assistance, safety) are met.1, 2 As posited by Maslow’s 
hierarchy of needs model,3 individuals’ unmet needs can affect adherence to 
medical therapies and outpatient care appointments, preventable hospitalizations 
and urgent care use, and ultimately, health outcomes. These associations are 
well documented for cardiovascular disease (CVD), the leading cause of 
morbidity and mortality in the US. 4-6 Given the simultaneously high prevalence of 
CVD and its risk factors and unmet needs among Veterans, Veterans’ outcomes 
may be improved by comprehensively assessing and addressing unmet needs. 7
In fact, policymakers suggest routine, comprehensive screening for unmet needs 
in the clinical setting. 8 The American Heart Association recently concluded that 
the “most significant opportunities for reducing CVD death and disability lie with 
addressing the social determinants of CVD outcomes.” 9 These 
recommendations rest on limited, yet promising, evidence that implementing 
systematic screening and referral (S&R) for unmet needs leads to greater receipt 
of resources that address identified needs. 10, 11 Such a process can potentially 
improve both proximal outcomes, such as adherence to medications and care 
appointments, 12 as well as more distal outcomes, such as inpatient or urgent 
health care utilization and ideally, overall improved health. 13-15 
Currently, the VA has implemented nationwide, clinic-based S&R for two unmet 
needs (housing and food insecurity) and invests in social work (SW) to address a 
range of unmet needs. VA clinicians can refer patients to SW to address unmet 
needs; patients may also self-refer. Once connected to SW, Veterans are 
triaged, a bio-psychosocial assessment identifies unmet needs, and SWs 
facilitate referrals to resources to assist with identified needs. However, and of 
crucial importance, screening for a wider range of unmet needs (beyond 
housing and food) and referring to SW is ad hoc and highly variable across 
and within facilities. Thus, many Veterans who could benefit from VA SW are 
not systematically identified and referred. 
VAs’ lack of systematic and comprehensive S&R for unmet needs also means 
missed opportunities to better understand the scope and scale of unmet needs 
across the entire VA patient population, as no such data exists.14 This in turn 
limits VA’s understanding of how best to support and target SW services. It is 
also unknown whether a lower-intensity referral process (i.e., provision of tailored 
paper Resource Sheets to address unmet needs instead of a referral to SW) can 
help some Veterans to the same extent it helps patients in non-VA care settings. 
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10, 16 Thus, a critically important dimension of the study we propose is to test 
whether for some Veterans, a less intense intervention is adequate. If so, this 
has valuable implications for resource allocation decisions and future 
implementation.
To address these knowledge gaps, we propose a randomized controlled trial 
(RCT) to systematically screen Veterans with/at risk for CVD for nine unmet 
needs, characterize the prevalence of unmet needs and associations with 
outcomes, and compare the effect of two different intensity referral interventions. 
Our primary outcome is Veterans’ connections to new resources to address 
unmet needs. Additional outcomes include unmet need reduction, adherence 
(medications, ambulatory care appointments), utilization (preventable 
hospitalizations, urgent care), and clinical outcomes (blood pressure, glycemic 
control).
3.0
Objectives
We will compare outcomes among Veterans with or at risk for CVD at three VA 
sites randomized (at the site-level) to one of three arms: 1) unmet needs 
screening only, 2) screening + provision of tailored resource sheets to address 
identified unmet needs, or 3) screening + tailored resource sheet + social worker 
support. We will quantitatively examine associations of unmet needs with 
baseline and follow up outcomes, assessing the impact of varying intensity 
referral approaches. We will also qualitatively examine stakeholder perspectives 
about the barriers and facilitators to identifying and addressing unmet needs to 
provide insight into the relative success of each study arm. Specific aims are:
Aim 1:  Describe the prevalence and distribution of nine unmet needs (housing, 
food insecurity, utility insecurity, transportation, legal needs, employment, safety, 
social isolation, stress), and identify their associations with baseline 
sociodemographic characteristics, adherence, utilization and clinical outcomes. 
Aim 2: Compare the effectiveness of varying intensity referral strategies to 
address unmet needs on the primary outcome of connection to new resources to 
address unmet needs, and on secondary outcomes of post-intervention change 
in unmet needs, adherence, utilization, and clinical outcomes. H1. Based on 
Maslow’s model, we hypothesize that referrals (and more so for those enhanced 
by SW support) will increase the likelihood of patients connecting to new 
resources to address unmet needs (primary outcome), which may then have 
positive sequential effects, with reduced unmet needs, increased adherence, 
decreased urgent care/preventable utilization, and ultimately, improved clinical 
outcomes.
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Aim 3: Identify barriers and facilitators to Veterans’ connecting with resources to 
address unmet needs and getting needs met, and explore potential explanatory 
factors related to the relative success of each study arm.
This project addresses HSR&D priorities of health equity and population health, 
the Office of Social Work’s goal to link Veterans with resources and services in 
support of treatment goals, the Office of Patient Centered Care and Cultural 
Transformation’s priority to enhance the physical, emotional, and social well-
being of the whole person, the Office of Health Equity’s priority to address unmet 
needs to ensure health equity, and the Office of Primary Care’s aim to provide 
personalized, comprehensive and coordinated care. Findings from this study will 
provide crucial information to inform future efforts to identify and address 
Veterans’ unmet needs.
4.0
Resources and Personnel
PERSONNEL: VA BOSTON HEALTHCARE SYSTEM, BOSTON, MA
 
 
Deborah Gurewich, Ph.D., Principal Investigator, (8/8th VA).  Dr. 
Gurewich is an Investigator at the Center for Healthcare Organization and 
Implementation Research (CHOIR) based at the Boston VA Healthcare 
System (HCS).  Dr. Gurewich will have overall responsibility for leading 
and directing the study including coordinating all study personnel, leading 
weekly project meetings, and communicating with our operational 
partners. She will also oversee the research staff at each study site, which 
will include ensuring that staff are trained on the intervention and 
convening standing meetings with each site to track and monitor the trial 
implementation. She will have access to protected health information 
(PHI).
Amy Rosen, PhD co-Investigator (8/8th VA). Dr. Amy Rosen is a Senior 
VA HSR&D Research Career Scientist based at CHOIR Boston with over 
30 years of experience as a health services researcher. Dr. Rosen has 
extensive experience in collaborating with multiple VA sites, conducting 
and analyzing survey data, using large VA administrative databases 
(including data from the Corporate Data Warehouse), and in conducting 
advanced hierarchical regression models and other multivariate analyses. 
She will advise Dr. Gurewich on the quantitative methods. 
Barbara Niles, PhD co-Investigator (8/8th VA). Dr. Niles is a clinical 
psychologist in the Behavioral Science Division of the National Center for 
PTSD at VA Boston Healthcare System. She is an experienced clinical 
trialist with deep experience in the design and management of clinical 
trials, and in implementing such trials in VA clinical settings. Dr. Niles will 
advise Dr. Gurewich on the design, implementation and over-sight of the 
clinical trial.
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Amy Linsky, MD, MSc co-Investigator/Local Site Investigator (8/8th 
VA).  Dr. Linsky is an Investigator at Boston CHOIR and a board-certified 
internist in the section of General Internal Medicine at VA Boston 
Healthcare System. She has a dual role on the project. As co-I, she will 
provide clinical input on how SDoH affects the provision of care and health 
care utilization and outcomes, and advise on current practices within VA 
for identifying and addressing SDoH and interpreting study findings within 
this context. In her second role, se will serve as the Local Site Investigator 
for the Boston RCT site and in that capacity be responsible for ensuring 
recruitment and retention of study participants at VA Boston. She will have 
access to PHI.
Hannah Friedman, PhD., co-Investigator (8/8ths VA). Dr. Friedman is a 
post-doctoral fellow at Boston CHOIR. As part of her fellowship plan, she 
will assist the PI with data analysis in Aims 1, 2, and 3 and supporting 
dissemination efforts. She will have access to PHI.
Risette (Zoe) MacLaren, MSc, Project Manager (8/8ths VA). Ms. 
MacLaren is a senior project manager at Boston CHOIR. She will 
coordinate with project staff across the sites, maintain IRB approval and 
regulatory documents, ensure that database development and data 
analyses are on track, and oversee the maintenance of study data in a 
secure fashion. Ms. MacLaren will attend all project meetings and keep 
study records.
Daniel J Sturgeon, MS, Data Analyst (8/8ths VA).  Mr. Sturgeon is a 
program analyst at Boston CHOIR. He will be responsible for identifying 
eligible participants in Y1. Working closely with Dr. Li, he will be 
responsible for developing the analytic data sets, which will involve pulling 
data from VA’s Corporate Data Warehouse (CDW) and merging with 
primary data (the two rounds of unmet need screening data and the 8-
week follow-up survey). He will also be responsible for all programming 
related to executing the analytic models.  He will have access to PHI.
Alexa Silva, MSW (8/8ths VA). Ms. Silva is a master’s level social worker 
(MSW) on the study team at the Boston VAMC for Year 2 only. She will be 
based at the Boston study site and responsible for providing SW support 
services to Veterans randomized to the third study condition. She will have 
access to PHI.
Rory Ostrow, MPH, Research Assistant (8/8ths VA).  Mr. Ostrow is a 
Boston CHOIR Research Assistant. He will assist Ms. MacLaren in key 
aspects of the day-to-day management of the project, including the IRB 
and related DART applications, and subsequent amendments as needed.  
He will also assist with developing the resource sheets in Boston and 
oversee the resource sheet development in Charleston and Philadelphia.  
He will work closely with Dr. Gurewich in managing the qualitative data, as 
well as coding and analysis of the qualitative data. He may also conduct 
some of the qualitative interviews, as needed. He will have access to PHI. 
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Kathleen Codair, BS Research Assistant (8/8ths VA).  Ms. Codair is a 
Research Assistant at VA Boston CHOIR.  She will be based at the 
Boston clinical site and responsible for administering the unmet need 
screens, providing resource sheets to trial participants who identify unmet 
needs, and conducting the 8-week follow-up survey to determine if 
Veterans connected to services or not. She may also conduct qualitative 
interviews with select Veterans participating in the trial and 
representatives of VA programs and community organizations. She will 
only be involved in Boston site research activities. She will have access to 
PHI.
PERSONNEL: EDITH NOURSE ROGERS MEMORIAL VETERANS HOSPITAL, BEDFORD, 
 
 
MA 
 
 
Barbara Bokhour, Ph.D., co-Investigator (8/8ths VA). Dr. Bokhour is an 
investigator and Director at Bedford CHOIR. Dr. Bokhour has led studies 
that identified the importance of Veterans’ social context in managing their 
CVD, as well as developed a stories-based intervention whereby African-
American Veterans who had successfully managed their hypertension 
described strategies to reduce their CVD risk. She will advise on all 
elements of the study.
Gemmae Fix, PhD, Local Site Investigator (8/8ths VA). Dr. Fix is an 
Investigator at Bedford CHOIR. She is supported by a Career 
Development Award through HSR&D CDA 14-156, with Drs. Bokhour as 
mentor.  She is exploring the effects of SDoH in older Veterans with HIV 
and aging-related comorbidities like hypertension and CVD. She has 
expertise in qualitative methods. She will be a key member of the Aim 3 
qualitative team, contributing to finalizing the interview guides and 
assisting with data coding and analysis. She will also be involved in all 
study planning, and review and interpretation of findings. 
Mingfei Li, Ph.D., co- Investigator (IPA).  Dr. Li is a Statistical Scientist 
at Bedford CHOIR and a Professor of Mathematics at Bentley University in 
Waltham, MA. Dr. Li has experience with multilevel modeling, multiple 
regression, and structural equation modeling, as well as mixed-methods 
approach. She will be responsible for the statistical modeling for this 
project.  She will have access to PHI.
PERSONNEL: CORPORAL MJ CRESCENZ VA MEDICAL CENTER, 
 
 
PHILADELPHIA, PA
 
 
Melissa Dichter, PhD, MSW Local Site Investigator (8/8ths VA).  Dr. 
Dichter is the Associate Director and Core Investigator at the U.S. 
Department of Veterans Affairs Center for Health Equity Research and 
Promotion (CHERP) in Philadelphia, PA, and an Assistant Professor at the 
University of Pennsylvania Perelman School of Medicine, Department of 
Family Medicine and Community Health.  She has strong working 
relationships with members of the investigative team as well as operations 
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partners.  She will be responsible for hiring and supervising local staff, and 
ensuring recruitment and retention of study participants at the Philadelphia 
VA. She will also be responsible for obtaining necessary regulatory 
approvals for the site, participating in team meetings, helping to interpret 
findings and prepare reports for dissemination.  She will participate in calls 
with the rest of the leadership team and assist in analyses and 
dissemination of findings.  She will have access to PHI.
Catherine Westerduin, MSW, Social Worker (8/8ths VA). Ms. 
Westerduin will serve as master’s level social worker (MSW) at the 
Philadelphia VAMC for Year 2 only. She will be based at the Philadelphia 
study site and responsible for providing SW support services to Veterans 
randomized to the third study condition. Ms. Westerduin will have access 
to PHI.
Aneeza Agha, MA, Research Assistant (WOC, University of PA). Ms. 
Agha is based at the Philadelphia VAMC and will work with Ms. Morawej 
on administering the unmet need screens, providing resource sheets to 
trial participants who identify unmet needs, and conducting the 8-week 
follow-up survey to determine if Veterans connect to services or not. She 
may conduct qualitative interviews with select Veterans participating in the 
trial and representatives of VA programs and community organizations. 
She will assist with creating and maintaining resources sheets at this site. 
She will have access to PHI. 
Sabrina Morawej, MPH, Research Assistant (8/8ths VA). Ms. Morawej 
is based at the Philadelphia VAMC and will work with Ms. Agha on 
administering the unmet need screens, providing resource sheets to trial 
participants who identify unmet needs, and conducting the 8-week follow-
up survey to determine if Veterans connect to services or not. She may 
conduct qualitative interviews with select Veterans participating in the trial 
and representatives of VA programs and community organizations. She 
will assist with maintaining resource sheets at this site. She will have 
access to PHI. 
PERSONNEL: RALPH H JOHNSON MEDICAL CENTER, CHARLESTON, SC
 
 
Kelly Hunt, PhD, MSPH Local Site Investigator (8/8ths VA).  Dr. Hunt is 
an investigator at Charleston VA Health Equity and Rural Outreach 
Innovation Center (HEROIC), a Center of Innovation (COIN) and a 
Professor in the department of Public Health Science at the Medical 
University of South Carolina. She will be responsible for hiring and 
supervising local staff and to ensure recruitment and retention of study 
participants from the Ralph H Johnson VAMC. She will also be 
responsible for obtaining necessary regulatory approvals for the site, 
participating in team meetings, helping to interpret findings and prepare 
reports for dissemination. She will participate in calls with the rest of the 
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leadership team and assist in analyses and dissemination of findings. She 
will have access to PHI.
Tyler Singleton, MSW (8/8ths VA). Ms. Singleton is a master’s level 
social worker (MSW) at the Charleston VAMC for Year 2 only. She will be 
based at the Charleston study site and responsible for providing SW 
support services to Veterans randomized to the third study condition.  She 
will have access to PHI.
Lauren Fanning, MPH, Research Assistant (8/8ths VA). Ms. Fanning 
will be based at the Charleston VAMC and will administer the unmet need 
screen, provide resource sheets to trial participants who identify unmet 
needs, and conduct the 8-week follow-up surveys to determine if Veterans 
connect to services or not. She may also conduct qualitative interviews 
with select Veterans participating in the trial and representatives of VA 
programs and community organizations. She will assist with maintaining 
resource sheets at this site. She will have access to PHI.
SERVICES PERFORMED BY CONTRACTORS
 
 
We will use Alpha Transcription to transcribe the qualitative interviews.
5.0
Study Procedures
5.1 Study Design
To assess the efficacy of systematic S&R, we propose a two-phase, three-year 
mixed methods study (Phase One: quantitative, Phase Two: qualitative) to 
systematically screen Veterans with or at risk for CVD  for nine unmet needs, 
characterize the prevalence of unmet needs and association with outcomes, and 
compare the effects of two different referral interventions of varying intensity on 
multiple outcomes. 
In Phase One (Aim 1) we will survey Veterans about their unmet needs 
(N=1760) and conduct quantitative analyses of survey, administrative, and 
clinical data to characterize the prevalence of unmet needs and their association 
with baseline outcomes (adherence, utilization, and clinical). In Phase One (Aim 
2), we will implement a three-armed RCT at three VA sites to compare outcomes 
among Veterans with one or more unmet needs (N=880) randomized within each 
site to one of three intervention arms. Trial participants will participate in three 
surveys, all administered by phone: 1) an initial index unmet need survey; 2) an 
eight week follow-up survey to assess if participants connected to any new 
resources since the index screen and if so, to which one(s); and 3) six months 
after the initial index screen, the unmet need survey will be administered again.
We have the following study arms: 1) Unmet needs screening and provision of a 
post card with a generic list of VA resources (hereafter: “Screening” arm), 2) 
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Screening and provision of a post card with a generic list of VA resources plus 
provision of a tailored Resource Sheet listing available resources to address 
identified unmet needs (hereafter: “Awareness” arm), or 3) Screening and 
provision of generic list of VA resources plus provision of a tailored Resource 
Sheet plus research team SW-supported referral to assist with connection to 
resources for unmet needs (hereafter: “Assistance” arm). Quantitative analyses 
will longitudinally compare the effects of the two referral approaches of varying 
intensity and a generic intervention on the primary outcome of connections to 
new resources and secondary outcomes of reduction in unmet needs, 
adherence, utilization, and health outcomes. See Appendix A for a more 
detailed description of the intervention and approach to randomization. 
In Phase Two (Aim 3), we will conduct qualitative interviews with a purposeful 
sample of Veterans (N=60) and representatives of the VA- and community-based 
programs to which Veterans are referred (N=15). The interviews are designed to 
understand the conditions that facilitate and impede Veterans’ connection to 
resources and unmet need reduction, and to identify potential explanatory factors 
related to the relative success of the interventions. We will follow standard 
qualitative methods for data collection, coding, and analysis. 
Risk to Subjects
We are implementing a non-invasive behavioral intervention by screening and 
referring Veterans in some study arms to resources to address unmet needs, and 
in one arm, connecting Veterans with a social worker to support them in 
connecting to resources. Potential risks are minimal and would primarily involve 
loss of confidentiality, as follows.
Phase One

Quantitative Data (Administrative Databases):
 
  Given that we are using 
existing data sources, there will be no direct health risks to subjects as a 
result of the proposed research. The risks associated with the use of these 
existing data sources would be due to possible breaches of privacy and 
confidentiality. 

Quantitative Data (Surveys):
 
  Potential risks may include breaches of 
privacy and confidentiality. Veterans answering the survey items may also 
feel inconvenienced and/or uncomfortable answering questions about 
unmet needs and connection to resources to address unmet needs. 
Finally, Veterans randomized to the least referral-intense arm (screening-
only) could get frustrated with this assignment if they want more 
assistance with identified needs than this arm offers.
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Phase Two

Qualitative Data (Interviews):
 
  For the interviews with Veterans and 
representatives of organizations providing resources to help Veterans 
address unmet needs, potential risks may include breaches of privacy and 
confidentiality, inconvenience, as well as discomfort (in the case of 
Veterans) answering questions about unmet needs and accessing 
resources.
Adequacy of Protection from Risk
We have conducted a wide array of studies that require us to make careful use of 
confidential information. In addition, the VA Boston HCS and CHOIR have 
systems, oversight, experienced personnel, and organizational cultures that 
support the appropriate use of confidential information, thus helping to further 
minimize and protect study subject from potential risks. Collected data will be 
used only for research purposes and identifiers will be removed from all data 
files, which will only be identified with a study identifier (except for audio 
recordings which include voice as an identifier). Reported results will not contain 
any individual identifiers. Research records will be destroyed in accordance with 
the VHA Records Control Schedule (RCS). Paper files will be shredded. 
Research data maintained on electronic storage and memory devices such as 
computers, laptops, and CDs will be destroyed in a way it cannot be retrieved. 
Phase One
Quantitative Data (Administrative Databases): Only the Principal Investigator and 
study team members conducting data analyses will have access to the 
secondary data obtained from the national VA databases. We will store and 
analyze secondary data on two servers located at: 1) the VA Informatics and 
Computing Infrastructure (VINCI) and 2) VA Boston HCS. The secondary data 
obtained through the CDW will be stored and analyzed on VINCI, a VA 
proprietary data storage space that allows data analysis to occur in a virtual 
environment. This has the benefit of allowing data analysis to occur from VA-
encrypted desktops and laptops. The VINCI Workspace is a VA-secure, virtual 
computing environment. It is accessed through a single secure gateway for all 
users. The virtual environment is maintained from a central management server 
and provides a separate path for secure file transfer for controlling the security of 
the Workspace to prevent the removal of data. We will request permission for the 
data analyst to export datasets associated with this study to the VINCI server. 
Data will be uploaded to VINCI which allows both data storage space and data 
analysis to occur in a virtual secure environment providing even more protection 
from breach of confidentiality. 
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Secondary data may also be stored and analyzed on the VA Boston HCS server 
behind the firewall. Access to the computer systems is restricted and password 
protected. All research computers are located in locked offices and computers 
are password protected. Access to CHOIR offices is restricted. All space 
accessible to the public is separated from research offices. 
For all secondary data, we will take all necessary steps to protect privacy and 
confidentiality, in accordance with VA regulations and other applicable laws. All 
information on individuals will be kept confidential. Consistent with HIPAA 
regulations, we will use scrambled identifiers (when available) to allow linkages 
across files while protecting an individual’s identity or we will de-identify the 
datasets. Only project personnel will have access to the data.
Quantitative Data (Surveys): We will construct a secure, password protected 
database in VA REDCap (to which we already have access as a team) to input 
the survey data. Survey data will be stored in this secure database at VA Boston 
and all personnel who need access will be able to connect to the server.  Data 
will be cleaned and checked for accuracy by the project manager and data 
analyst. Mishandling of research data would compromise participant 
confidentiality. Thus, all possible measures will be taken to assure Veteran 
confidentiality. In addition, we will construct a secure, password protected 
database to create a record of study participants and those who have opted out 
of the study, using scrambled SSNs. This will be stored on a secure VA Boston 
server. 
To protect against risks associated with a Veteran getting upset during any of the 
survey processes, the RA will be trained to deal with difficult situations and 
remind participants that they may decline to answer any question or discontinue 
the survey at any time. Additionally, the research SW at each site will be on-call 
to assist as needed. In the rare instance that during the intervention either the RA 
or SW encounter unknown risks affecting participants health and welfare, they 
will advise the participant to contact their primary care team and with participant 
approval also notify the care team directly. If a participant indicates that he or she 
is having suicidal or homicidal thoughts, the RA and SW will be trained to offer 
the Veterans Crisis Line and a warm hand-off using established protocols (see 
Appendix B for warm hand-off protocol), and with participant approval also notify 
the care team directly. 
To protect against risks associated with Veterans who are unhappy about the 
condition to which they are randomized, we will take several steps to minimize 
this risk: 1) As part of the informed consent process, we will be explicit about the 
three study arms, that we cannot predict which arm a Veteran will be randomized 
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to; and 2) we will be clear that this a research study, which means that 
information we gather from Veterans will not be shared with their care team but 
that participants are welcome to follow-up with their care team at any time during 
their participation in the study. The RA will also be prepared to provide the care 
team phone number to the Veteran, if needed. 
Phase Two
Qualitative Data (Interviews): To protect against risks related to privacy and 
confidentiality, we will use VA computers to take notes and a VA Boston HCS 
IRB and Information Security Officer approved audio recorder and software 
(SpeechExec Pro Dictation and Transcription Software) when conducting the 
telephone interviews. Interviews will be digitally audio-recorded, with the 
permission of each Veteran. If a subject asks us to not record a portion of the 
interview, the recorder will be turned off immediately. The list of individuals who 
participate in interviews will be kept on the VA Boston server and will be recorded 
in a document that is password protected with restricted access to the members 
of the study team working on the qualitative data collection and analysis. Notes 
that are taken will be de-identified. Encrypted recordings will be emailed to the 
study team. The study team will store recordings on a secure VA server and will 
be password protected. All names and places mentioned will be deleted to 
protect confidentiality. De-identified audio-recordings will be transcribed by 
Veterans Command Transcription, a premier service provider for the VA. 
Transcribed interviews will be imported into a qualitative software program 
designed for maintaining and analyzing qualitative data. 
To protect against inconveniencing participants, we will restrict the length of the 
interviews to 45-60 minutes. To protect against risks associated with a Veteran 
getting upset during the interview, the RA will be trained to deal with difficult 
situations and remind participants that they may decline to answer any question 
or discontinue the interview at any time. 
Potential Benefits

Veterans will receive a post card that includes a list of VA crisis and 
homeless hotlines that can be immediately useful.

Veterans will receive information about specific VA and community 
programs that can also be immediately useful. 

We will develop a screening tool to identify unmet needs and identify 
which approach to referral is better and under what conditions at helping 
Veterans connect to resources and at affecting outcomes. Our tools and 
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the findings can be used in the field to implement screening and referral 
processes to address unmet needs, and by other researchers studying 
this issue. 

Our study will identify the full burden of unmet needs among Veterans as 
well as which needs and clusters of needs are most impactful with respect 
to outcomes, information that can inform how and where VA targets 
resources to address unmet needs.    

If our study finds that systematic screening and referral for unmet needs is 
associated with improved outcomes, our study will establish the needed 
evidence base for more wide-spread adoption of this practice, which has 
the chance to benefit all VA-enrolled Veterans who experience unmet 
social needs. 
Safety and Data Monitoring Plan
Per FOA/RFA instructions, given that we are proposing a multisite intervention 
trial with human participants, HSR&D DSMB oversight is required. DSMB 
approval is accomplished by an independent review board chartered by HSR&D 
that meets at specified intervals and requires routine reporting from the PI. The 
PI will follow a specific Data and Safety Monitoring Plan and per HSR&D 
program guidelines, has submitted a Data Analysis Plan (DAP) as part of the 
Just-In-Time (JIT) compliance process. Studies are generally not allowed to 
begin until DSMB approval of the DAP has been provided. Currently, the DSMB 
meets on annual basis (generally in the early spring) but can request (or review) 
studies more frequently (if they determine that to be appropriate). The PI will 
receive a letter regarding the DSMB’s determination after the meeting, including 
any concerns and follow-up actions; the PI will then submit these letters to VA 
CIRB.
We anticipate minimal risk, as the proposed intervention is survey-based and 
providing resources but once the study is underway, study staff and investigators 
will monitor any adverse events and immediately report any adverse events to 
the DSMB. The Principal Investigator (PI) and project manager (PM) will routinely 
audit the data for accuracy and make any necessary corrections to ensure data 
reliability and accuracy. In addition, the PI and PM will review the plans for and 
implementation of subject recruitment and enrollment, to ensure adequate 
recruitment progress and that recruitment milestones are met. Recruitment 
problems will be identified and addressed and if necessary, sites without 
adequate enrollment will be replaced.
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Site monitoring progress reports will be submitted to the DSMB and other 
regulatory bodies (e.g., CIRB) as requested and/or required. As described in 
Section 5.1.b (Protection Against Risk), we will monitor every step of our 
recruitment procedures, survey data collection, and interviews to ensure that the 
confidentiality and privacy of our study populations are protected. Should we 
receive any negative feedback from research subjects or have any unexpected 
serious or adverse events, we will report this information to the DSMB, VA 
Central IRB, and local R&D offices immediately.   
In the unlikely event of a breach of confidentiality, the incident will be 
documented and reported to the DSMB, VA Central IRB and R&D immediately, 
as will any incident of protocol deviation. We will ensure the rights to privacy, 
confidentiality and safety are maintained. 
There is no safety condition that would trigger immediate suspension of the 
study.
Study Population
Phase One (Aim 1): The study population will be comprised of Veterans from 
the primary care (PC) clinics of three VA medical centers: 1) VA Boston 
Healthcare System; 2) Corporal Michael J. Crescenz VA Medical Center 
(Philadelphia); and 3) Ralph H. Johnson VA Medical Center (Charleston). 
Veterans with, or at risk for, cardiovascular disease (CVD) who had at least 1 PC 
visit in the prior year, will be eligible for the study, to ensure that included 
Veterans are at least minimally engaged in VA care. We define CVD patients as 
those with International Classification of Disease 10 (ICD10) diagnoses indicating 
coronary artery disease, cerebrovascular disease, or peripheral artery disease, 
and patients with CVD risk factors as having diagnoses of hypertension, diabetes 
mellitus (DM), or hyperlipidemia. We will exclude Veterans who have 1) impaired 
decision-making, and/or 2) are illiterate or have limited or no English proficiency.
Phase One (Aim 2): The study population will be comprised of the subset of 
subjects in Aim One who report having one or more unmet needs. 
Phase Two (Aim 3): The study population includes a purposeful sample of two 
stakeholder groups: 1) Veterans who participate in trial, and 2) representatives of 
the VA programs and community resources that Veterans are referred to as a 
result of the intervention. 

Veterans: We will seek three Veteran types: Veterans who did not connect 
to new resources; Veterans who connected to new resources but did not 
have their unmet needs met, and Veterans who connected to new 
resources and had their needs met. This sampling plan will allow us to 
understand the conditions that facilitate or impede a Veteran connecting to 
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resources, as well as the conditions under which resources do or do not 
address a Veteran’s needs. We will not exclude any subjects based on 
gender, race, or other classes (e.g., disabilities).

VA and Community Program Representatives: We will seek up to five of 
the most frequently used programs at each study site (15 total). By 
concentrating on the most highly used programs, this sampling plan will 
allow us to understand the experience of programs more likely to “feel” the 
effects of the intervention.
5.2 Recruitment Methods
Step 1 (determine potential eligibility based on existing administrative data): The 
study will begin with a 12-month retrospective baseline period in which Veteran 
clinical eligibility (i.e., diagnosis of CVD or CVD-risk) will be determined using 
data from CDW. We will not exclude any Veterans based on race, gender, or 
other classes (e.g., handicapped). We will exclude two classes of Veterans: 1) 
those with impaired decision-making and 2) those who are illiterate or have 
limited or no English proficiency. This initial step involves secondary data 
analysis only; we will not recruit Veterans as subjects for use of secondary data; 
we will request a HIPAA Waiver of Authorization for this step.
Step 2 (initial outreach by mail to potentially eligible participants): For the next 12 
months and on a weekly basis, the study Data Analyst will produce a primary 
care appointment list of eligible Veterans at each study site using data from 
CDW. In advance of an eligible Veteran’s appointment, the research team will 
mail the Veteran the following documents: 

A Cover Letter briefly describing the study and inviting participation (see 
Appendix C);

A Study Fact Sheet detailing the elements of informed consent and 
describing the study in more detail including that participants will complete 
a brief survey and based on the survey results, those deemed eligible for 
the RCT will be randomized to one of three study arms, while those 
deemed not eligible, will be done with the study after completing the initial 
survey (see Appendix D); 

A post card that includes phone numbers for the Veteran’s VA Medical 
Center, VA Veterans Crisis Line, and National Call Center for Homeless 
Veterans (see Appendix E);  

An opt-out postcard (postage included) that will explain that the Veteran is 
eligible for the initial phase of the study and may be eligible for the 
subsequent phase, an RCT; indicate that if they are interested in 
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potentially participating that an RA will contact them by phone in advance 
of the Veterans upcoming PCP appointment, and; if they are not 
interested to return the opt-out card within 3 days of receiving it (see 
Appendix F).
Step 3 (phone follow-up to recruit, consent, and screen for eligibility): The 
research team will provide the final list of site-specific eligible Veterans who did 
not return an opt-out card to the RA situated at each study site. Guided by a 
phone script (see Appendix G), the RA will contact these Veterans by phone up 
to three weeks following the opt-out card mailing (making up to 5 attempts if they 
cannot reach the Veteran) to: 1) describe the study, 2) request participation, 
including potential randomization to one of three study arms if deemed eligible 
following the initial index screen, participation in subsequent surveys, and 
possible contact by phone to invite participation in a qualitative interview; and 3) 
obtain verbal consent. The RA will review the elements of informed consent and 
answer any questions the potential respondent might have. Among Veterans who 
verbally consent to participate, the RA will administer the index unmet need 
screen and, if Veteran is eligible for the RCT (i.e., 1 or more unmet needs) 
randomize them to one of the three trial arms using the sealed opaque envelope 
program (see Appendix A for details). 
Step 4 (recruitment for qualitative interviews; Veterans): Among study 
participants, we will purposefully sample 60 Veterans to participate in qualitative 
interviews. Sample selection and recruitment will be conducted on a rolling basis 
after the 6-month unmet needs re-screen is completed. The study RA will phone 
selected Veterans, ask for participation in an interview, and among those who 
accept, schedule an interview time. Note: As part of the RCT informed consent 
process, participants will be told that they may be contacted by phone to 
participate in a qualitative interview, which we believe eliminates the need to mail 
opt-out cards prior to contacting Veterans by phone for this phase of the study. 
During this initial call we will not re-consent participants but will review and 
remind potential participants of the purpose of the interviews and the elements of 
informed consent. 
Step 5 (recruitment for qualitative interviews; Agency representatives): We will 
also seek a purposeful sample of representatives of the VA and community 
programs that Veterans are referred to as a result of the intervention. Potential 
interviewees will first be contacted by email or phone (dependent on contact 
information available in VA Outlook and community agency websites) to assess 
their interest in being interviewed for the project. Each potential interviewee will 
be emailed a letter of invitation from the site PI (see Appendix H for Resource 
Representative Recruitment Email). The letter will contain all the elements of 
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consent: the risks and benefits of the study, confidentiality procedures, study 
personnel to contact regarding questions and concerns (including contact 
numbers for the VA Central Institutional Review Board), that participation is 
voluntary, and that participating or not participating in the interview will not affect 
their VA appointment (in the case of VA program representatives) or their 
organizational relationship with the VA (in the case of community program 
representatives). If a potential interviewee expresses interest in participating, we 
will use both email and phone to schedule an interview with the participant. A 
member of the study team will then review the letter before conducting an 
interview with any potential interviewee. Participation in the interview will be an 
indication of consent.
5.3 Informed Consent Procedures
Phase One (Aims 1 and 2): We will not recruit Veterans as subjects for use of 
secondary data given the minimal risks associated with the study. We will adhere 
to IRB requirements for informed consent and request a HIPAA waiver of 
authorization.
Phase One and Two (Aims 1, 2, and 3): The elements of informed consent will 
be provided in writing and orally, but we will seek a waiver of documentation of 
informed consent because the recruitment and informed consent process will be 
conducted entirely by phone, and we believe study poses no more than minimal 
risk.
To ensure consistent and thorough administration of the informed consent 
process for this study, the local RAs and investigators will be trained by the PI on 
the informed consent process and will conduct mock informed consent sessions 
with the PI prior to performing the informed consent process with patients. Site 
investigators and RAs will also be trained on the importance of allowing sufficient 
time for participants to consider the information provided and providing time and 
opportunity for the participants to ask questions and have those questions 
answered in order to inform their decision about whether to participate or not. We 
will conduct periodic internal audits of the informed consent process to ensure 
informed consent protocols are followed. These audits will take place weekly at 
the start of the outset of the study (i.e., first month of the trial) and then reduce in 
frequency as the study continues but will be at least two additional times over the 
remaining 11 months of the trial.                          
5.4 Inclusion/Exclusion Criteria
Our study population will be comprised of Veterans from the primary care (PC) 
clinics of three VA medical centers: 1) VA Boston Healthcare System; 2) 
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Corporal Michael J. Crescenz VA Medical Center (Philadelphia); and 3) Ralph H. 
Johnson VA Medical Center (Charleston). Note: There is a 4th site involved in this 
study (Bedford) but we are not identifying and recruiting Veterans from this site. 
Veterans with, or at risk for, cardiovascular disease (CVD) who had at least 1 PC 
visit in the prior year, will be eligible for the study, to ensure that included 
Veterans are at least minimally engaged in VA care. We define CVD patients as 
those with International Classification of Disease 10 (ICD10) diagnoses indicating 
coronary artery disease, cerebrovascular disease, or peripheral artery disease, 
and patients with CVD risk factors as having diagnoses of hypertension, diabetes 
mellitus (DM), or hyperlipidemia. We will not exclude any patients based on 
gender, race, or other classes (e.g., disabilities). We will exclude patients with 
impaired decision-making capacity and who are illiterate or have limited or no 
English proficiency.
Among study participants, we will also recruit a purposeful sample of Veterans 
who participated in the trial as well as representatives of the VA and community 
programs to which participants are referred as a result of the trial. For the 
Veteran interviews, we will seek three Veteran types: Veterans who did not 
connect to new resources; Veterans who connected to new resources but did not 
have their unmet needs met, and Veterans who connected to new resources and 
had their needs met. For the VA and community program representatives, we will 
seek up to five of the most frequently used programs at each study site. We will 
not exclude any potential respondents for the qualitative interviews based on 
gender, race, or other classes (e.g., handicapped).
5.5 Study Evaluations
RCT participants will be asked to complete three brief surveys over a 6-month 
period. A small sub-set of participants will additionally be invited to participate in 
qualitative interviews. 
Index Unmet Need Screen (survey #1): We will assess unmet needs among trial 
participants based on the index screen (administered prior to randomization). 
See Appendix I for the Index Unmet Need Survey.   
Eight-Week Follow-Up Survey (survey #2): Eight weeks after the index screen, 
the RA will conduct phone follow-up with each Veteran to assess if they 
connected to any new resources in the intervening time and if so, to which 
one(s). See Appendix J for the Eight-Week Follow-Up Survey and 
accompanying phone script.  
6-Month Unmet Need Re-Screen (survey #3): Six months after the index screen 
and by phone, the RA will re-administer the unmet need survey modified slightly 
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to exclude questions related to preferences for assistance (see Appendix K for 
the Six-Month Unmet Need Survey and accompanying phone script). We will 
define unmet need reduction in two ways: 1) one or more of baseline unmet 
needs no longer identified as an unmet need at the 6-month re-screen; and 2) 
percentage of baseline needs not reported as unmet needs at 6-month rescreen.
Qualitative Interviews with Veterans:  Among study participants, we will 
purposefully select and recruit 60 Veterans to participate in qualitative interviews. 
The interviews are designed to understand the conditions that facilitate or impede 
a Veteran connecting to resources, as well as the conditions under which 
resources do or do not address a Veteran’s needs. The RA at each study site will 
conduct the interviews. See Appendix L and M for the Veteran Interview Guides 
and accompanying phone scripts).
Qualitative Interviews with Representatives of VA and Community Resources: To 
understand how VA- and community-based programs experience the 
intervention, we will interview a purposeful sample of the VA- and community-
based programs that trial participants used as a result of the intervention. The RA 
at each study site will conduct the interviews. See Appendix N for the Resource 
Representative Interview Guide and accompanying phone script.
5.6 Data Analysis
Study Sample and Power Analysis
We aim for a total of 880 Veterans enrolled in the RCT (293/arm) based 
on power analyses provided below. Based on the study team’s prior 
primary care-based studies with a similar recruitment approach, we 
anticipate 80% of patients approached to complete the index screen will 
participate. Based on pilot data from the Bedford MA VA where 78% of 
Veterans reported one or more needs, we then conservatively estimate 
that 50% of Veterans screened will report at least one of the nine unmet 
needs for which we will screen. 
Thus, to yield a final sample of 880 Veterans with at least one unmet need 
enrolled in the study, we anticipate needing to approach 2200 eligible 
Veterans (733/site, or ~3 patients/day/site) i.e., of 2200, 80% (1760) will 
agree to participate in the study and of these, 50% (880) will have one or 
more unmet needs and be eligible for the RCT. If the participation rate or 
proportion of Veterans reporting at least one unmet need is lower than 
expected, we will increase the number of Veterans that we approach. We 
reviewed VA administrative data to determine the anticipated weekly count 
of Veterans eligible per site to participate in the study and there are more 
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than enough eligible Veterans to approach for additional screening if 
needed. We also anticipate drop-out rates at the 8-week follow-up survey 
to assess connection to resources and the 6-month unmet needs re-
screen, respectively. Though the study team’s prior study achieved a 65% 
follow up participation rate, here we conservatively anticipate a 50% 
participation rate for both the 8-week follow-up survey and the 6-month re-
screen, reducing the sample for the three arms first to 440 Veterans total 
and then to 220 Veterans total. 
Statistical Power for Aim 1: With a sample of N=1760 Veterans completing 
the index unmet needs screening, we will have 80% power to detect small 
effect sizes (f2=.01; OR=1.47) using 2-tailed significance tests at the 
α=.001 level if the intraclass correlation coefficient (ICC) (for the nesting of 
patients within sites) is negligible, or medium effect sizes (f2=.15; 
OR=4.07) even if the ICC is as high as .02 for testing associations 
between the presence of each unmet need and sociodemographic, 
adherence, utilization, and clinical (BP only) variables. HbA1c is 
anticipated to be a relevant clinical outcome for only 40% of the sample; 
for HbA1c, we will have 80% power to detect small effect sizes (f2=.03; 
OR=1.84) using 2-tailed significance tests at the α=.001 level if the ICC is 
negligible.
Statistical Power for Aim 2: The power analysis for Aim 2 focused on the 
primary outcome of connection to resources to address unmet needs. The 
sample size was determined based on previous research outside VA 
which found that individuals who completed a screening and referral 
intervention were 15% more likely (adjusted Odds Ratio (aOR)=2.1) to 
have enrolled in a new community resource to address unmet needs post-
referral compared to patients in the non-intervention arm. In the present 
study, we will have 80% power to detect an effect of this size (aOR=2.1) 
across the three arms using 2-tailed significance tests at the α=.05 level, 
even if we assume an attrition rate as high as 50% for the follow-up phone 
call at 8-weeks post-screen (retained N=440 across all sites and arms) 
and a conservative ICC value for patients nested within sites of .01. 
Previous empirical work found ICC values <.0001 when adjusting for a 
small number of covariates (e.g., race, marital status) to examine new 
connections to resources to address unmet needs; we intend to collect 
and use these covariates in the present study as well.  Assuming an ICC 
value of .0001, we will have 80% power to detect an effect as small as an 
aOR=1.7 if we assume a 50% attrition rate for the 8-week follow-up phone 
call, or as small as an aOR=2.0 if we assume a 70% attrition rate. We 
based our attrition rate upon the study team’s prior study where Veterans 
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had low incomes, high unemployment and low educational status, yet only 
35% were lost to a follow-up interview.
Quantitative Data Analysis
All data analysis will be conducted by study team members based in Boston. Dan 
Sturgeon is the study Data Analyst who will be responsible for developing the 
analytic data sets and all programming related to descriptive statistics and multi-
variate models. He will work closely with Mingfei Li, the statistician who will be 
responsible for developing the statistical models and overseeing the overall 
analytic approach. All analysis will be conducted on VINCI. 
Aim 1: Describe the prevalence and distribution of nine unmet needs (housing, 
food insecurity, utility insecurity, transportation, legal needs, employment, safety,  
social isolation, stress), and identify their associations with baseline 
sociodemographic characteristics, adherence, utilization and clinical outcomes. 
Our primary analysis for Aim 1 will be descriptive. We will use data obtained 
during the index screening (N=1760) to generate descriptive statistics (e.g., 
proportions, 95% confidence intervals (CIs) to characterize the prevalence and 
distribution of each of the nine unmet needs at baseline across all study sites. 
We will next conduct inferential analyses to examine associations between 
unmet needs and sociodemographic characteristics as well as baseline 
outcomes (i.e., adherence, utilization, and clinical outcomes drawn from CDW 
data in the 12-months before the index screening for each Veteran). Hierarchical 
Linear Modeling will be used to control for the nesting of patients within sites, and 
patient-level variables will be treated as random effects. Hierarchical Generalized 
Linear Modeling (HGLM) will be used as appropriate to handle binary variables. 
Variables found to have statistically significant associations with unmet needs will 
be entered into multivariable models to better understand the correlates of each 
need. Bonferroni-corrected significance levels will control for multiple 
comparisons.
Aim 2: Compare the effectiveness of varying intensity referral strategies to 
address unmet needs on the primary outcome of connection to new resources to 
address unmet needs, and on secondary outcomes of post-intervention change 
in unmet needs, adherence, utilization, and clinical outcomes
Our primary Aim 2 analysis will compare connection to new resources at 8-weeks 
post-index screen (our primary outcome of interest) across the study arms. 
HGLM will be used to control for the nesting of patients within sites. In all models, 
patient-level intercepts and slopes will be treated as random effects. We predict 
significantly greater connection to new resources in the ASSISTANCE arm 
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compared to the SCREENING arm, with the AWARENESS arm falling 
intermediate to these other two study arms.
Adherence, Utilization, and Clinical Outcomes. We will also conduct a series of 
secondary analyses to examine whether the study arms influence more distal 
outcomes, including adherence, utilization, and clinical outcomes. Specifically, to 
assess the impact of our intervention on more distal healthcare outcomes, we will 
use a difference-in-difference approach to examine whether changes from 
baseline at 6-months and 12-months post-referral differ across the three arms of 
our RCT (N=880).  A series of HLM/HGLM analyses with patients nested within 
sites will examine differences in change from baseline across arms for the 
adherence, utilization, and clinical outcomes. As with the other analyses, all 
models will treat patient-level intercepts and predictors as random effects. We 
will have 80% power to detect small-to-medium effects (f2=.05; OR=2.28) across 
the three arms using 2-tailed significance tests at the α=.05 level, even if we 
assume a conservative ICC value for patients nested within sites of .01. HbA1c is 
anticipated to be a relevant clinical outcome for only 40% of the sample and we 
anticipate missing HbA1c test data for 17% of these Veterans in the year 
following their index screen; thus, for HbA1c, we will have 80% power to detect 
small-to-medium effects (f2=.08; OR=2.71) across the three arms using 2-tailed 
significance tests at the α=.05 level, even if we assume a conservative ICC value 
for patients nested within sites of .01.
Unmet Need Reduction: Similar analyses will be used to examine differences 
across our three study arms in change from baseline in the proportion of unmet 
needs among the sub-sample of participants who complete the re-screening at 6-
months post-referral. Among this sub-sample (N=220, assuming attrition rates of 
50% at both the 8-week and 6-month follow-up phone surveys), we will have 
80% power to detect a small-to-medium effect (f2=.09; OR=2.94) across the 
three arms in terms of unmet need reduction using 2-tailed significance tests at 
the α=.05 level, even if we assume a conservative ICC value for patients nested 
within sites of .01.
Differences in Intervention Effectiveness. In addition to examining how the S&R 
influences connection to new resources, we will conduct additional analyses to 
examine whether there is differential impact between the two referral arms 
(Awareness and Assistance) on connection to new unmet needs resources; 
unmet need reduction; and adherence, utilization and clinical outcomes among 
Veterans with certain unmet needs or with fewer unmet needs. While we predict 
that providing SW support (Assistance arm) will generally have a larger impact 
on outcomes than providing a Resource Sheet alone (Awareness arm), it would 
be beneficial to know if the Resource Sheet alone (or even the screening and 
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provision of generic list of resources) is sufficient to produce comparable 
changes in outcomes among Veterans with certain unmet needs or among 
Veterans with fewer unmet needs. If true, future implementation research could 
create tailored interventions that funnel the resources for more time- and cost-
intensive referral strategies to only those Veterans who need it most.
Testing Conceptual Path. To the extent that we discover differences across 
intervention arms in any of our more distal outcomes, we will conduct exploratory 
analyses to test appropriate causal mediational paths as proposed in our 
conceptual model using a series of HLM/HGLM analyses (with patients nested 
within sites). That is, we will examine whether the impact of our intervention on 
more distal outcomes (e.g., BP) can be explained completely (or in part) by its 
impact on more proximal outcomes (e.g., connection to new resources, reduction 
in unmet needs). For example, if we find differences across study arms in 
reduction in unmet needs, we will test whether the effect of the intervention arm 
on reduction in unmet needs is mediated by the effect of the intervention arm on 
connection to new resources.
Examining marginal intervention effects over and above S&R occurring as part of 
usual care. Finally, given that Veterans may already be accessing resources for 
some unmet needs as part of usual care and related to existing screening for 
homelessness and food insecurity, we will conduct supplemental analyses to 
examine whether our intervention effects hold when controlling for use of VA SW 
services not attributable to the present intervention (e.g., services already being 
accessed separate from the study intervention). Although we will specifically be 
assessing connection to new resources following the S&R mechanisms in our 
three study arms, it is possible that individuals already connected to certain 
resources will be more likely to seek out additional support/resources (e.g., 
because they already have successful experiences using VA resources to meet 
certain unmet needs) or less likely to seek out additional support/resources (e.g., 
because they feel they already have the support they most need). Because VA 
screens for housing and food insecurity, Veterans may already be accessing 
resources for these. To examine whether the intervention has a significant impact 
on connection to new resources, unmet need reduction, and more distal health 
outcomes when controlling for use of VA SW services not attributable to the 
present study, we will conduct supplemental analyses that control for connection 
to resources associated with each of our nine unmet needs prior to enrollment in 
our intervention. Use of SW resources not attributable to our study will be 
measured via CPRS encounter forms, where SWs record encounters with 
patients, and from referral/consult documentation available in CPRS during the 
12 months prior to the start of our intervention.
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Qualitative Data Analysis
Aim 3: 
 
 Identify barriers and facilitators to Veterans’ connecting with resources to 
 
 
address unmet needs and getting needs met, and explore potential explanatory 
factors related to the relative success of each study arm.
Transcripts will be initially coded using a priori constructs consistent with our 
conceptual model (Anderson Behavioral Health Model). A directed content 
analysis approach, allowing for new themes to emerge will be used.17 As coding 
proceeds, new emergent themes will iteratively be identified, elaborated upon, 
and expanded based on team discussion. 18 New coding definitions may also be 
refined, and existing categories split and combined in the development of the 
coding matrix. This iterative process will eventually evolve to a point where all the 
existing categories will be sufficient to cover all new interview material that is 
obtained. The qualitative data analysis will be conducted by 3 study team 
members (Gurewich, Fix, Ostrow) and inter-rater reliability will be established 
using the “check-coding” process. 19 All coders will independently code the same 
interview transcripts, and initial reliability estimates between all pairs of coders 
will be computed. Coders will then meet to compare their coding, discuss areas 
of difficulty, and attempt to reach agreement. A new interview will then be 
independently coded by all, and the process will be repeated until a reliable level 
of agreement (>80%) is achieved across all coders. 19 After coding is complete, 
code output will be analyzed to identify themes within and across sample strata. 
All coding and analyses will be conducted using NVIVO qualitative analysis 
software.
5.7 Withdrawal of Subjects
There are not any anticipated circumstances under which subjects will be 
withdrawn from the research without their consent. Veteran participants may 
withdraw from the study at any time by telephone or email, which will be 
documented in the study files by the PI. Veteran participants can also stop any of 
the surveys – and for the relevant sub-sample, the interviews – at any time while 
they are happening. 
6.0
Reporting
Dr. Gurewich will lead regular study team meetings and will formally query the 
study team specifically for any serious adverse events, unanticipated 
occurrences related to subject safety, breaches of study protocol or 
confidentiality. Study team members will also be directed to bring any such 
problems to the attention of the PI as they occur. The PI will report relevant 
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occurrences both to the Central IRB and the site R&D Committee per VA 
procedures.
7.0
Privacy and Confidentiality
The study will not disclose protected heath information. All information on 
individual subjects will be kept confidential on restricted server files behind the 
VA firewall. Collected data will be used only for research purposes and identifiers 
will be removed from all data files, which will only be identified with a study 
identifier (except for audio recordings which include voice as an identifier). Only 
study team members will have access to the secure file containing study data on 
encrypted VA served, and access will be removed for personnel when they are 
no longer part of the study through IT request. Study staff will be well trained to 
protect the privacy of study participants and prevent breaches of confidentiality. 
All study team personnel with access to sensitive patient data will stay current on 
required VA information security and privacy policy trainings. Reported results 
will not contain any individual identifiers. Research records will be destroyed in 
accordance with the VHA Records Control Schedule (RCS). Paper files will be 
shredded. Research data maintained on electronic storage and memory devices 
such as computers, laptops, and CDs will be destroyed in a way they cannot be 
retrieved. 
8.0
Communication Plan
All site approvals will be obtained in compliance with Central IRB procedures. For 
each site participating in the study, we will notify the Director prior to conducting 
research at his/her facility. Also, we will process any changes in the protocol, 
informed consent, or cessation of engagement in research for any sites in 
concordance with Central IRB procedures.
The PI will meet regularly with the study team, with local site co-Investigators 
participating via VANTS conference lines and Skype videoconferencing systems. 
9.0
References
Bibliography of cited literature
1.
Frieden TR. A framework for public health action: the health impact pyramid. Am 
J Public Health. Apr 2010;100(4):590-5. doi:10.2105/ajph.2009.185652
2.
McGinnis JM, Williams-Russo P, Knickman JR. The case for more active policy 
attention to health promotion. Health Aff (Millwood). Mar-Apr 2002;21(2):78-93. 
doi:10.1377/hlthaff.21.2.78
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3.
Maslow AH. A theory of human motivation. Psychological Review 
1943;50(4):370-96. 
4.
Kuh D, Hardy R, Langenberg C, Richards M, Wadsworth ME. Mortality in adults 
aged 26-54 years related to socioeconomic conditions in childhood and adulthood: post 
war birth cohort study. BMJ. 11/9/2002 PMC131184 2002;325(7372):1076-1080. Not in 
File. 
5.
Lawlor DA, Ronalds G, Macintyre S, Clark H, Leon DA. Family socioeconomic 
position at birth and future cardiovascular disease risk: findings from the Aberdeen 
Children of the 1950s cohort study. AmJPublic Health. 7/2006 2006;96(7):1271-1277. 
Not in File. doi:AJPH.2005.066290 [pii];10.2105/AJPH.2005.066290 [doi]
6.
Lawlor DA, Smith GD, Ebrahim S. Association between childhood socioeconomic 
status and coronary heart disease risk among postmenopausal women: findings from 
the British Women's Heart and Health Study. AmJPublic Health. 8/2004 
2004;94(8):1386-1392. Not in File. doi:94/8/1386 [pii]
7.
Thurman WA, Harrison T. Social Context and Value-Based Care: A Capabilities 
Approach for Addressing Health Disparities. Policy, politics & nursing practice. Feb 
2017;18(1):26-35. doi:10.1177/1527154417698145
8.
Daniel H, Bornstein SS, Kane GC. Addressing Social Determinants to Improve 
Patient Care and Promote Health Equity: An American College of Physicians Position 
Paper. Ann Intern Med. Apr 17 2018;168(8):577-578. doi:10.7326/m17-2441
9.
Havranek EP, Mujahid MS, Barr DA, et al. Social Determinants of Risk and 
Outcomes for Cardiovascular Disease: A Scientific Statement From the American Heart 
Association. Circulation. Sep 1 2015;132(9):873-98. doi:10.1161/cir.0000000000000228
10.
Garg A, Toy S, Tripodis Y, Silverstein M, Freeman E. Addressing social 
determinants of health at well child care visits: a cluster RCT. Pediatrics. Feb 
2015;135(2):e296-304. doi:10.1542/peds.2014-2888
11.
Gordon JA, Emond JA, Camargo CA, Jr. The State Children's Health Insurance 
Program: a multicenter trial of outreach through the emergency department. Am J Public 
Health. Feb 2005;95(2):250-3. doi:10.2105/ajph.2003.037242
12.
Berkowitz SA, Hulberg A, Standish S, Reznor G, Atlas SJ. Addressing unmet 
basic resource needs as part of chronic cardiometabolic disease management. JAMA 
internal medicine. 2017;177(2):244-252. doi:10.1001/jamainternmed.2016.7691
13.
Garg A, Marino M, Vikani AR, Solomon BS. Addressing families' unmet social 
needs within pediatric primary care: the health leads model. Clinical pediatrics. Dec 
2012;51(12):1191-3. doi:10.1177/0009922812437930
14.
Taylor L, Tan A, Coyle C, et al. Leveraging Social Determinants of Health: What 
Works? PloS one. August 17, 2016 2106;11(8):20. doi:10.1371/journal.pone.0160217
15.
Shumway M, Boccellari A, O'Brien K, Okin RL. Cost-effectiveness of clinical case 
management for ED frequent users: results of a randomized trial. The American journal 
of emergency medicine. Feb 2008;26(2):155-64. doi:10.1016/j.ajem.2007.04.021
16.
Berkowitz SA, Hulberg AC, Standish S, Reznor G, Atlas SJ. Addressing Unmet 
Basic Resource Needs as Part of Chronic Cardiometabolic Disease Management. 
JAMA internal medicine. Feb 1 2017;177(2):244-252. 
doi:10.1001/jamainternmed.2016.7691
17.
Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual 
Health Res. Nov 2005;15(9):1277-88. doi:10.1177/1049732305276687
18.
Boyatzis R. Transforming Qualitative Information: Themaic Analysis and Code 
Development. Sage Publications; 1998.
19.
Miles M, Huberman A, Huberman M. Qualitative data analysis: An expanded 
sourcebook. . Sage Publications; 1994.
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20.
Miller WR, Rollnick S. Ten things that motivational interviewing is not. 
Behavioural and cognitive psychotherapy. 2009;37(2):129-140. 
21.
Miller WR, Rollnick S. Motivational interviewing: Preparing people for change, 
2nd ed. Motivational interviewing: Preparing people for change, 2nd ed. The Guilford 
Press; 2002:xx, 428-xx, 428.
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Appendix A:  Description of the Intervention and Randomization
Unmet Needs Screen: 
Veterans (anticipated N=1760) will be screened for unmet needs (index screen) 
and those identified as having at least one unmet need (target N=880) will be 
randomized to one of three study arms and screened again 6-months later. We 
will use the sealed opaque envelope program to generate randomization. For the 
index screen, a study Research Assistant (RA) will administer the screening 
instrument to Veterans by phone prior to the Veteran’s upcoming primary care 
(PC) clinic appointment to gather data on nine unmet needs (full screen in 
Appendix I). Six months after the index screen, the RA will re-screen each 
Veteran participant by phone. For each completed screen, we will provide 
Veterans $15 for their time. 
After the RA determines each participant is eligible (see Section 5.2. Recruitment 
Methods), randomization will occur by the RA opening sealed envelopes that 
reveal the treatment assignments (screening, awareness, or assistance). 
Envelopes will be opened for each participant in the order they are recruited. The 
RA will then inform the participant of their assignment. 
Resource Sheets: 
For Veterans in the Awareness and Assistance arms, the RA will provide (via U.S 
mail) Resource Sheets tailored to the unmet needs identified in the index screen. 
During the index screen (by phone), the RA will inform the Veteran that they will 
receive a Resource Sheet in the mail and mail the Resource Sheets to the 
Veteran within two days of the index screen. During the index screen, the RA will 
additionally ask the Veteran if they would also like to receive the Resource 
Sheets via email. For Veterans who respond affirmatively, the RA will send the 
Resource Sheets as an email attachment during the index screen phone call and 
offer to review its content with them. The email message will be sent via 
encrypted email and will not solicit reply. (Appendix G contains the phone script 
for this interaction, and Appendix P contains the Resource Sheet email text and 
the cover letter for mailing.)
For each of the nine unmet needs, following the approach used in the VISN 1 
pilot and at our academic affiliate hospital (Boston Medical Center), a Resource 
Sheet will include the names of available resources within VA and/or the local 
community that can help address the identified need(s) and contact information 
(e.g., address, phone, website, email) and hours of operation. (See Appendix O 
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for sample Resource Sheets currently used in VISN 1 unmet need screening and 
referral pilot). 
Prior to study initiation, we will contact all organizations listed on the Resource 
Sheets to determine if they have current capacity for referrals generated from our 
study. Organizations without such capacity will be replaced with other 
organizations with capacity. Then, following practices for regular updating of 
resource information used by our colleagues and by national organizations 
addressing unmet needs (e.g., Health Leads, NowPow), RAs at each site and in 
consultation with local SW services will contact the programs listed on the 
Resource Sheets monthly, to update status for accepting referrals and contact 
information. RAs will track and record time spent maintaining the Resource 
Sheets to identify the resource demands of this component of the intervention for 
replication purposes.
Social Work-Supported Referrals 
In the Assistance arm, we will hire and train social workers (one per site) to 
support Veterans to connect with resources following a standard operating 
procedure informed by current VA SW practices. Following the index screen and 
provision of tailored Resource Sheets, the RA will offer and encourage Veterans 
in this arm to receive assistance from a SW. Veterans may choose to opt out, but 
if they assent, the RA will provide the Veteran with the name and phone number 
of the SW who will contact the Veteran within two business days of the index 
screen (making up to five attempts to reach the Veteran by phone). During this 
initial call, the SW will use a standardized bio-psychosocial assessment tool used 
by VA SW and proven motivational interviewing methods20, 21 to uncover details of 
the Veteran’s unmet needs, identify barriers to resolving the unmet needs, and 
develop an action plan for the Veteran including how to overcome the identified 
barriers. In addition, following VA SW practice, the SW will call the resource(s) to 
which the Veteran has been referred to inform them the Veteran will be coming 
for services. The SW will conduct initial follow-up by phone one week after the 
interview/action plan development, with planned subsequent phone outreach 
every two weeks for up to seven weeks. At each call and as needed (i.e., if 
Veteran has not yet connected to services), the SW will again employ 
motivational interviewing methods with the goal of re-affirming the action plan or 
modifying it as needed. The SW will track and record all Veteran encounters in a 
research data base, including time spent, challenges and best practices 
identified.
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Appendix B: Protocol for Warm Hand-Off to Veterans Crisis Line
Taken from the Quantitative Workstream Handbook
For those with “Higher” or “Indeterminate Higher” Risk:

  Offer Veterans Crisis Line and warm hand-off (Refer to 
 
 VCL Warm Hand-
 
 
off Instructions
 
  Page (see last page)). Use the phone number: 585-393-
 
 
7938 and DO NOT provide this number to Veterans.
If the Veteran declines warm hand-off to VCL, attempt to keep 
 
 
the Veteran on the phone while also contacting the Veterans 
Crisis Line the VHA Suicide Prevention Office at 
VHASuicidePReventionOffice@va.gov
 
  .  
If the caller disconnects before the transfer can be made, send 
 
 
email to the VHA Suicide Prevention Office at the above email 
address.
VCL will continue outreach attempts until the Veteran is reached
 
  
or for one week, and will involve the Veteran’s local Suicide 
Prevention Coordinator (SPC) as appropriate.
Interviewer Reads: You mentioned earlier that you have had thoughts about 
harming yourself . [OR for those who refuse to answer question(s): You seem 
hesitant to answer questions about possible self-harm.]  I want to encourage you 
to talk with your doctor or mental health provider about these thoughts, and I will 
send a message to the Suicide Prevention Coordinator at your VA Medical 
Center mentioning that you have expressed these concerns. They may contact 
you to discuss these concerns further. In addition, I can transfer you to someone 
at the Veterans Crisis Line so that you can talk further right now with someone 
who is qualified to help you in this situation. 
In the rare occurrence that the interviewer is concerned about 
 
 
imminent risk (i.e., caller has already hurt self/others or has 
immediate plan to harm self/others and has access to means to 
inflict harm), contact Veterans Crisis Line  (VCL) for dispatch of 
emergency services by calling the VCL Warm Transfer number: 
585-393-7938 (DO NOT provide this number to Veterans).
Provide Veteran information for Veterans Crisis Line: name, current
 
  
location, phone number, date of birth
Interviewer Reads (for VCL warm hand-off): I am concerned for your safety 
and would like to reach out to the Veterans Crisis Line on your behalf. There will 
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be a brief silence, please hold on the line while I transfer you to someone who is 
qualified to help you.
Interviewer Reads (if Veteran refuses): I’d like to encourage you to contact 
your doctor or mental health provider and to call the Crisis Line whenever you 
need to. Their number is 1-800-273-TALK. Thank you for your time, and I wish 
you all the best with your continued treatment.
Abbreviated Script
Step 1: Once the Veteran has agreed to speak with someone at the VCL, let 
them know that there will be a brief silence as you get a VCL representative 
on the line.
Step 2: Press “Flash”, “Flashlink” or “Conference” button depending on 
the type of phone you are using.  
[Veteran will now be on hold]
Step 3: Dial the VCL direct line. (585-393-7938)
Step 4: Once the VCL representative is on the line, describe the situation 
and provide the Veteran’s contact information
Step 5: Press “Flash”, “Flashlink” or “Conference” to get the Veteran back 
on the line.
[At this point all three people will be present.]
Step 6: Let the Veteran know that you will be getting off the line and hang 
up.
Additional Notes

Call VCL ahead of time as it takes a while to connect

Connect to the direct line (1-800 #) only if a warm hand-off is wanted

Email is great way to connect with the VCL if there is a disconnection or if the 
Veteran declined a warm hand-off 

Provide background information of the Veteran to the VLC including birthday, 
location, phone #

Must send suicidality forms encrypted

Give the Veteran the 1-800 # if they want to use it later

If you hang up, the Veteran and the VCL are still connected (unless you have a 
cell phone)
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Appendix C: Cover Letter Inviting Veteran Participation
«letter_date»
«FName» «LName»
«Address 1», «Address 2»
«City», «State», «Zip»
Dear «Salutation»,
The Veterans Health Administration (VHA) understands that health begins with where 
Veterans live and work. For this reason, a team of VHA researchers are doing a research study 
to identify Veterans’ needs (things like not having enough food or difficulty paying utilities) 
and connect Veterans to resources that can address their needs. We are writing to invite you 
to participate in this study.
The study aims to understand how VHA can better meet the resource needs of Veterans. If 
you are interested in learning more, a researcher will contact you by telephone to explain the 
study and answer any questions you might have. 
Your participation is completely voluntary. We sincerely hope that you will be willing to 
assist us in this effort. We need as many Veterans as possible to participate so the results of 
this study will be meaningful. Please read the enclosed information sheet. It provides more 
details about the study.
If you do not want us to contact you about this study, please return the enclosed postcard so 
we will know not to call you. However, if you are interested in learning more, you do not have 
to do anything. If we do not receive your postcard within the next week, a member of the 
research team may contact you to discuss the study. 
If you have any questions, please contact the project manager at 857-364-2350. On behalf of 
the research team and those Veterans who may benefit from the results of the study, we thank 
you in advance for your help. 
Sincerely,
Deborah Gurewich, PhD
Study Lead 
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Appendix D: Study Fact Sheet
STUDY FACT SHEET
Study Title: The Effects of Screening and Referral for Social Determinants of Health on Veterans’ 
Outcomes                                                                     
Name of Study Lead (also called “Principal Investigator”): Deborah Gurewich, PhD
Name of Study Lead at your VA (also call “Local Site Investigator”): (insert relevant name)
1. What is the purpose of the study? To understand how the Veterans Health Administration 
(VHA) can best help Veterans who have resource needs. Resource needs are also called social 
determinants of health. These are things like having trouble paying for housing or a hard time 
paying important bills, like electric or gas bills. 
2.Who is invited to participate? You are eligible to participate if you 
a)
have heart disease or cardiovascular disease (CVD) or are at risk for heart disease (for 
example, because you have high blood pressure), and
b)
get primary care at the Boston, Charleston, or Philadelphia VA Healthcare Systems.
3. What does the study involve and how long will it last? The study has two parts. 
In Part One, someone from the research team will call you. They will want to talk for about 30 
minutes. They will go over the study and answer any questions you might have.  Next, they will 
conduct a brief questionnaire with you about your resource needs (for example, they will ask 
about your housing). Depending on your answers, you may be eligible for Part Two of the study. 
If you are not eligible for Part Two, that will be the end of your participation in the study. 
If you are eligible for Part Two of the study, you will be contacted by phone two more times – 
eight weeks and six months after the first telephone call. During these calls, a researcher will 
conduct brief questionnaires with you about your resource needs. These phone calls should take 
only 5-10 minutes. 
For Part Two of the study, you will be randomly assigned to one of three study groups:  A, B, or C 
(see Table 1). Being randomly assigned is like a flip of a coin for which group you would be 
placed in.

Group A
 
 : Participants in this group will receive a postcard listing local and national VHA 
help lines that may help with resource needs. 

Group B
 
 : Participants in this group will receive a postcard and also a written list of 
resources (i.e., agencies and programs) tailored to each participant’s specific resource 
needs. 

Group C:
 
  Participants in this group will receive a postcard, a written list of resources, and 
also be offered help from a social worker who is part of the research team. The social 
worker may contact you by phone to learn more about your resource needs and help 
you connect to agencies and programs. The social worker could contact the you by 
phone up to 5 more times.  
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If you are in Groups B or C, you might also be asked to participate in a phone interview. In 
contrast to the brief questionnaires described above, the phone interview will involve a longer 
list of questions and will take more time, we estimate 45-60 minutes. If you are selected for an 
interview, a member of the research team will contact you by phone between months 7 and 12. 
If you agree, the researcher will then schedule a time that is convenient for you to conduct the 
interview. Before the interview begins, we will ask your permission to audio record the 
interview. If you do not want the interview recorded, that is Ok and you can still participate in 
the interview. During the interview you will be asked about your experience participating in the 
study. Veterans who participate in Part Two of study will be in the study for 12 months.
Table 1. What Participants Will Receive by Study Group
Group A
Group B
Group C

Postcard listing local and 
national VHA help lines

Postcard listing local and 
national VHA help lines

Resource sheet listing 
agencies and programs to 
address specific resource 
needs 

Postcard listing local and 
national VHA help lines

Resource sheet listing 
agencies and programs to 
address specific resource 
needs

Assistance from a Social 
Worker to help connect to 
agencies and programs
4. What are the benefits of participating? People who participate in this study may have a 
better understanding of the resources that can help Veterans with resource needs. Your 
participation may also add much needed knowledge about resource needs among Veterans and 
how the VHA can better meet the needs of Veterans with resource needs.
5. What are the possible risks or discomforts of participating? Some people may feel 
uncomfortable or upset discussing resource needs during the telephone calls with research staff. 
You may choose to skip a question or stop the telephone call at any time. You can also withdraw 
from the study at any time. Some people may find the telephone calls inconvenient. We will 
make every effort to schedule phone calls when it is convenient for you and will try to keep 
them short. Finally, there is a general risk of loss of confidentiality, but we believe this risk is 
minimal. 
6. How will my private information be protected and who will have access to it? Information 
collected for this research study will be kept confidential as required by law and will not be 
shared with your care team. However, you are welcome to follow-up with your care team at any 
time during your participation this the study. The results of this study may be published for 
scientific purposes, but your record or identity will not be revealed unless required by law. We 
will store your information in ways we think are secure. We will store paper files in locked 
cabinets. We will store electronic files in computer systems with password protection and 
encryption. However, we cannot guarantee complete confidentiality. To help protect your 
personal information, we will assign you a study ID so that your identifiable information is not 
connected to you. 
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We will limit access to your personal information to members of the research team who need to 
review this information in order to conduct the study. In addition, a description of this study will 
be available at http://www.ClinicalTrials.gov as required by U.S law. This website will not include 
information that can identify you. 
Your research records will be destroyed in accordance with the VHA Record Control Schedule 
(www1.va.gov/VHAPUBLICATIONS/RCS10/rcs10-1/pdf). Records will be destroyed when allowed 
in the following manner: Paper records will be shredded; electronic records and audio 
recordings will be destroyed in a manner in which they cannot be retrieved.
Participating in this study will not affect your VHA healthcare including your healthcare 
providers’ ability to see your records as part of normal care and will not affect your right to have 
access to your records during and after the study is completed.
There are times when we might have to show your records to other people. For example, 
someone from the Office of Human Research Protections, the Government Accountability 
Office, the Office of the Inspector General, the VA Office of Research Oversight, the VA Central 
IRB, our local Research and Development Committee, and other study monitors may look at or 
copy portions of records that identify you.
7. What are the costs of participating in the study? You will not be charged for any activities or 
procedures that are part of this study. 
8. Do I have to take part in this study? No. Participating in the study is voluntary and if you 
refuse to take part in the study, there will be no penalty or loss of benefits to which you are 
otherwise entitled to from the VHA. There are also no consequences if you decide to withdraw 
from the study. In this instance, for data already collected prior to your withdrawal, the research 
team may continue to review the data already collected for the study but will not collect further 
information from you. 
9. Who do I contact about this study of I have questions? If you have any questions about the 
research study, concerns or complaints, you may contact the project manager at 857-364-2350. 
If you have questions about your rights as a study participant, or want to make sure the study is 
valid, you may contact the VHA Central Institutional Review Board toll free at 1-877-254-3130. 
This is the Board that is responsible for overseeing the safety of human participants in this 
study. You may call them at (insert contact information) if you have questions, complaints or 
concerns about the study or if you would like to obtain information or offer input.
10. Will I be compensated for being in this study? As a thank you for your participation, you will 
receive a $15 payment for each brief questionnaire you complete and a $25 payment if you 
participate in a telephone interview. The form of payment (for example, check/voucher, gift 
card, etc.) may vary depending on the VA in which you get your care.   
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Appendix E: Resource Postcards
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Appendix F: Opt-Out (Do-not-contact) Postcard
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Appendix G: Veteran Recruitment Phone Script
Phone Contact: 
Not Present: Hello, my name is__________, I’m calling from the [Name of VAMC].   I 
am trying to reach [Name of Veteran]. I’ll call back another time, thank you. Is there a 
good time to try calling back?
Voicemail: Hello, my name is [name of research team member] and I work at the 
[Name of VAMC]. I wanted to speak with [Name of Veteran] about a letter we sent a 
few weeks ago regarding a research study. If you are interested in learning more about 
this study, please contact me at 781-687-[extension]. If you get my voicemail please 
leave your name, the best number to reach you at, and the most convenient times to 
reach you. Thank you.  
Present: Hello, my name is [name of research team member] and I work at the [Name 
of VAMC]. I wanted to speak with you about a letter we sent you a few weeks ago about 
a research study.  
1. Do you have a minute?
If Yes: We are conducting a research study about Veterans’ resource needs. We 
sent you a letter a couple of weeks ago that included a Study Fact Sheet, 
describing the study.  Do you remember getting it? 
If Yes: (SKIP TO #2)
If No:  I apologize for that.  We can send you another letter if you would 
like. I can also tell you about the study now.  Is that okay?               
No:  Okay, great. I will make sure a letter is sent to you. I just want 
to confirm your mailing address [confirm].  Thank you for your 
time. If I don’t hear from you in 2 weeks I will call back and see if 
you are interested in participating. (END CALL)               
  
Yes: (SKIP TO #3A)
If No: Ok, can I schedule another time to call you to describe the study and see if 
you might be interested in participating?
If Yes: (SCHEDULE A TIME)
If No: Thank you for your time. Good-bye.
2. Would you be interested in getting some more information about the study? 
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If not Interested: Thank you for your time. Good-bye. 
If interested: (GO TO #3)
3. Ok great. Let me describe the study to you and what it means to participate. The letter 
you received included a Study Fact Sheet. Do you have the Fact Sheet? 
If YES: Great, it would be helpful to have the Study Fact Sheet in front of you, so 
we can go through it together. I can wait while you get it. (WAIT AS NEEDED 
AND THEN GO TO #4)
If NO: No problem at all. (GO TO #3A) 
3a. I will read the information in the Fact Sheet to you, and you will have a 
chance to ask questions. Let me first tell you about the study aims:

(FOLLOW STUDY FACT SHEET #1 AND #2)

When done: Do you have any questions? (RESPOND TO 
ANY QUESTIONS ASKED)
3b. Now let me describe what it means to participate:

(FOLLOW STUDY FACT SHEET #3, FIRST TWO 
PARAGRAPHS)

When done with 2nd paragraph: Do you have any questions? 
(RESPOND TO ANY QUESTIONS ASKED)

Does this sound like something you would like to do?
If Yes: (GO TO #3C)
If No: Thank you for your time today. Goodbye.
3c. I am glad you are interested. There are a few more things we need to 
review before you agree to participate and enter the study:

(FOLLOW STUDY FACT SHEET #3, LAST TWO PARAGRAPHS)

When done: Do you have any questions? (RESPOND TO ANY 
QUESTIONS ASKED)

(FOLLOW STUDY FACT SHEET ITEM 4 THRU 9)

When done: Do you have any questions? (RESPOND TO ANY 
QUESTIONS ASKED)

(SKIP TO #5)
4. Since you have the Study Fact Sheet, I will review it with you in summary. Afterwards, 
you will have the opportunity to ask questions, and to confirm that you understand your 
role in the study. Does this sound OK? (ADDRESS ANY QUESTIONS AND PROCEED)

The purpose of the study is to identify the resource needs that Veterans have 
(things like not having enough food) and understand how VHA can best connect 
Veterans with services and programs that can address their needs. Your 
participation in the study would last for 12 months.
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
The study involves two parts. In Part One, someone from the research team will 
call you to conduct a brief questionnaire about your resource needs. Depending 
on your answers, you may be eligible for Part Two of the study. If you are eligible 
for Part Two, a member of the research team will contact you by phone two more 
times to administer brief questionnaires about your resource needs. These phone 
calls should take only 5-10 minutes.

For the second part of the study, you will be randomly assigned to one of three 
study groups (random is like a flip of a coin). Participants in different groups will 
receive varying levels of assistance in connecting to resources. This is detailed in 
Table 1 in the Fact Sheet.  

For the second part of the study, you may also be invited to participate in one 45-
60 minute phone interview.
4a. Do you have any questions so far about what the study involves and how long it 
would last? (RESPOND TO ANY QUESTIONS ASKED)
o
There are a few key additional points I want to highlight from the Study 
Fact Sheet. These include:

This study involves research.

Your participation is completely voluntary and if you choose to 
participate, you can withdraw at any time. 

If you do participate, the information we collect from you will be 
kept confidential and your identity will not be revealed in any of the 
results we report or publish.

The risks of participating are that you may get upset answering 
questions about resource needs or may find the phone calls 
inconvenient. We will do everything we can to minimize these 
risks. The benefit of participating is that you may have a better 
idea about available resources; you may also help VA in doing a 
better job serving Veterans.

There are no costs associated with participating in the study. As a 
thank you for participation, you will receive a $15 gift card to CVS* 
for each brief questionnaire you complete. And, if you’re selected 
(and agree) to participate in an interview, you will receive a $25 
gift card.
*(For CIRB: The nature of the participant payment varies by site. In 
Boston (prime site), participants will receive CVS gift cards; in 
Philadelphia, participants can receive a voucher/check or direct deposit; 
in Charleston, participants can receive payment via direct deposit or on a 
VA DirectExpress debit card. Each site has submitted a version of the 
Recruitment Phone Script that is tailored to their specific payment 
method. This version is for the prime site, Boston.)
4b. Do you have any questions? (RESPOND TO ANY QUESTIONS ASKED)
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5. Do you agree to participate in the study?  
If No:   Thank you very much for your time today.  Goodbye.
If Yes: Thank you for agreeing to participate in this study! We really appreciate it. 
(ENTHUSIASTIC RESPONSE) If you have time now, about 10 minutes, we can 
get started with Part One right now.
If don’t have time: When is a good time for you to answer some 
questions about your resource needs? (SCHEDULE A TIME AND 
CONFIRM BEST CONTACT NUMBER)         
If have time now: (GO TO #6)  
6. Complete unmet need survey. (For CIRB: See Appendix I)
7. Among participants who identified zero needs: Thank you for completing Part One 
of the study. It appears that you are not eligible for Part Two of this study, so today’s call 
will end the study team’s contact with you. We will be mailing you a $15 gift card* for 
your participation. *(CIRB Note: local site payment process differs across sites, as 
detailed in their respective CIRB amendments. This appendix is the Boston version.)
7a. Do you have any questions (RESPOND TO ANY QUESTIONS ASKED). 
Thank so much you for your time (END CALL).
8. Among Participants who identified one or more needs, randomize to one of 
three study arms.
9. Among participants randomized to Arm 1 (Screening): Thank you for completing 
Part One of the study. You are eligible for Part Two of the study and have been 
randomized to Group A. This means that in 8 weeks, I will recontact you to ask a few 
more questions about your needs. Do you have any questions? (RESPOND TO ANY 
QUESTIONS ASKED) (MENTION GIFT CARD AND VERIFY MAILING ADDRESS*.) 
Thank you for your time.
*(CIRB Note: local sites will explain their payment process, which differs from the prime 
site)
10. Among participants randomized to Arm 2 (Awareness): Thank you for 
completing Part One of the study. You are eligible for Part Two of the study and have 
been randomized to Group B. I would like to provide you with some written material 
about programs and agencies that might be able to help you with the needs you 
identified. I will mail you this material within the next two business days. If you like, I can 
also email the material to you right now and we can review it together over the phone. 
Would you like to do that?  
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If Yes to email: Great, I can email that to you right now. (CONFIRM/ASK FOR 
PARTICIPANT’S EMAIL ADDRESS AND SEND ENCRYPTED EMAIL.)
If No to email: No problem. You can look for a written list of resources in the mail 
in the next several days. The information will include my phone number in case 
you have any questions about the information once you receive it.
10a. I will also be mailing you a $15 gift card* to thank you for your time. And in 8 
weeks, I will recontact you to ask a few more questions about your needs. Do you 
have any questions? (RESPOND TO ANY QUESTIONS ASKED) (VERIFY MAILING 
ADDRESS FOR GIFT CARD)* Thank you for your time.
*(CIRB Note: local sites will explain their payment process, which differs from the 
prime site.)
11. Among participants randomized to Arm 3 (Assistance): Thank you for 
completing Part One of the study. You are eligible for Part Two of the study and have 
been randomized to Group C. I would like to provide you with some written material 
about programs and agencies that might be able to help you with the needs you 
identified. I will mail you this material within the next two business days. If you like, I can 
also email the material to you right now and we can review it together over the phone. 
Would you like to do that?
If Yes to email: Great, I can email that to you right now. (CONFIRM/ASK FOR 
PARTICIPANT’S EMAIL ADDRESS AND SEND ENCRYPTED EMAIL.)
If No: to email: No problem. You can look for a written list of resources in the 
mail in the next several days. The information will include my phone number in 
case you have any questions about the information once you receive it.
11a. I would also like offer you the assistance of a Social Worker (SW), who can 
assist you to connect to programs and agencies that might be able to help with the 
needs you identified.  Would you like to receive this assistance?
If No:  I encourage you to accept this assistance because it can be helpful. Are 
you sure you don’t want assistance from a SW who can assist you to connect to 
services? 
If does not want SW assistance: (GO TO #11b)
If wants SW assistance: (GO TO NEXT QUESTION)
If Yes: Terrific. The SW on the study team – his/her name is (insert name) -- will 
call you within two business days. Let me give you the name and number of the 
social worker so you have it. Do you have a pen and paper? (WAIT FOR PEN 
AND PAPER AND THEN PROVIDE NAME AND NUMBER)
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11b. In 8 weeks, I will recontact you to ask a few more questions about your needs. 
Do you have any questions? (RESPOND TO ANY QUESTIONS ASKED) (MENTION 
GIFT CARD AND VERIFY MAILING ADDRESS)* Thank you for your time.
*(CIRB Note: local sites will explain their payment process, which differs from the 
prime site.)
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Appendix H: Resource Representative Invitation Email
Dear [Resource Representative Name],
A team of Veterans Health Administration (VHA) researchers are doing a research study to 
identify Veterans’ needs (i.e., food insecurity, social isolation) and determine how the VHA 
can best connect Veterans to resources. We are writing to invite your participation in our 
study. If you are interested in learning more, please reply to this email. 
[Insert name of agency/VHA program] is among the resources that we have referred some of 
the Veterans participating in the study.  Part of our study includes phone interviews with 
resource providers such as yours to learn more about providing services to Veterans. We 
anticipate the call will take about 30 minutes. It will be scheduled at a time convenient for 
you. 
Your participation in this research study is completely voluntary. The interview data will 
be kept completely confidential. We will store the interview data in ways we think are 
secure – written materials will be stored in locked cabinets, and electronic material will 
be stored on secured, access-only servers. Your name nor the name of your Agency will 
not be shared in any presentations, reports, or papers summarizing our findings. 
If you have any questions about our study or this invitation, please contact me at [phone 
#] or [email]. 
We sincerely hope you will be willing to assist us in this effort. The perspective of 
community agencies/VHA departments is critical to ensuring that VHA can address 
Veterans’ resource needs.  
We look forward to hearing from you. If we don’t hear back from you in one week, we will 
follow-up again by email.
 Sincerely,
[Site LSI Name]
[VAMC Name, Location]
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Appendix I:  Index Unmet Needs Screening Tool 
DEMOGRAPHICS
1. Please indicate which of following types of people currently live with you in your 
household (check all that apply)

My spouse or partner

My child(ren) under age 18

My adult child(ren) age 18 or older

My parent(s)

Extended family

Roommate(s) not related to me

Other individuals
2. Overall, which one of the following best describes how well you are managing 
financially these days?

Living comfortably

Doing OK

Just getting by

Finding it difficult to get by
3. Are you of Hispanic or Latino origin or descent? 

Yes, Hispanic or Latino

No, not Hispanic or Latino
4. What is your race?  Please select all that apply.

White

Black or African-American

Asian

Native Hawaiian or other Pacific Islander

American Indian or Alaska Native

Other
5. What is your gender

Man

Woman

Transgender man

Transgender woman

Non-binary

Other
HOUSING AND UTILITIES
6. In the past 6 months, have you been living in stable housing that you own, rent, or 
stay in as part of a household? 

Yes

No
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7. Are you worried or concerned that in the next 2 months you may NOT have stable 
housing that you own, rent, or stay in as part of a household?

Yes

No
7a. (If Yes to Q6 or Q7): Are you already receiving assistance with your housing 
needs?
7b. (If Yes to 7a): Would you like additional assistance?
7c. (If No to 7a): Would you like assistance with your housing needs?
8. In the past 6 months has the electric, gas, oil or water company threatened to shut off 
service in your home? 

Yes

No

Already shut off

Not applicable
8a. (If Yes/Already shut off): Are you already receiving assistance with your gas, 
oil or water company needs?
8b. (If Yes to 8a): Would you like additional assistance?
8c. (If No to 8a): Would you like assistance with your gas, oil or water company 
needs?
EMPLOYMENT AND FOOD
9. Are you currently:

Employed for wages

Self-employed 

Out of work for 1 year or more 

Out of work for less than 1 year 

A Homemaker 

A Student 

Retired 

Unable to work 
9a. Do you want help finding or keeping work or a job (check all that apply)?

Yes, help finding a job

Yes, help keeping work

I do not want or need help

I am already receiving assistance with my employment needs
10. How often were the following statements true for you in the past 6 months?
i. Within the past 6 months, you worried that your food would run out before you 
got money to buy more. 

Often true

Sometimes true
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
Never true
ii. Within the past 6 months, the food you bought just didn't last and you didn't 
have money to get more. 

Often true

Sometimes true

Never true
 
10a. (If Often/Sometimes true to 10i or10ii): Are you already receiving assistance 
with your food needs?
10b. (If Yes to 10a): Would you like additional assistance?
10c. (If No to 10a): Would you like assistance with your food needs?
LEGAL AND TRANSPORTATION 
11. Are you currently dealing with any legal issues, for which you may need assistance? 

Yes

No
11a. (If Yes): Are you already receiving assistance with your legal needs?
11b. (If Yes to 11a): Would you like additional assistance?
11c. (If No to 11a): Would you like assistance with your legal needs?
12. In the past 6 months, has lack of transportation kept you from medical appointments, 
meetings, work, or getting things needed for daily living: Check all that apply

Yes, it has kept me from medical appointments or from getting my medications

Yes, it has kept me from non-medical meetings, appointments, or getting the 
things that I need

No
12a. (If Yes): Are you already receiving assistance with your transportation 
needs?
12b. (If Yes to 12a): Would you like additional assistance?
12c. (If No to 12a): Would you like assistance with your transportation needs?
SOCIAL AND EMOTIONAL STATUS 
13. In the last 6 months, how often did you feel lonely or isolated? 

Never

Rarely

Sometimes

Often 
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
Always
13a. (If Sometimes/Often/Always): Are you already receiving assistance with 
your feelings of loneliness or isolation?
13b. (If Yes to 13a): Would you like additional assistance?
13c. (If No to 13a): Would you like assistance with your feelings of loneliness or 
isolation?
14. Stress is when someone feels tense, nervous, anxious, or can’t sleep at night 
because their mind is troubled. In the last 6 months, how often did you feel stressed? 

Not at all

A little bit

Somewhat

Quite a bit

Very much
14a. (If Somewhat/Quite a bit/Very much): Are you already receiving assistance 
with your feelings of stress?
14b. (If Yes to 14a): Would you like additional assistance?
14c. (If No to 14a): Would you like assistance with your feelings of stress?
EXPOSURE TO VIOLENCE
15. Is anyone in your life hurting or threatening you?

Yes

No
15a. (If Sometimes/Often/Always): Are you already receiving assistance with your 
being hurt or threatened? 
15b. (If Yes to 15a): Would you like additional assistance?
15c. (If No to 15a): Would you like assistance with your being hurt or threatened? 
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Appendix J: Eight-Week Follow-Up Survey
Phone Contact:
Hello, my name is__________, I’m calling from the (Name of VAMC).  I am trying to 
reach [Name of Veteran].
Not Present:    I’ll call back another time, thank you. Is there a good time to try calling 
back?
Voicemail: Hello, my name is [name of research team member], I am calling from the 
(Name of VAMC). I wanted to speak with [Name of Veteran] about the Resource 
Needs Study. It’s time to complete one of the brief questionnaires that are part of this 
study, it will only take about 5 minutes to complete. Please contact me at 781-687-
[extension]. If you get my voicemail please leave your name, the best number to reach 
you at, and the most convenient times to reach you. Thank you.  
Present: Hello, my names is [name of research team member] and I work at the 
(Name of VAMC). I wanted to speak with you about the Resource Needs Study you are 
participating in.  It’s time to complete one of the brief questionnaires that are part of this 
study, it will only take about 5 minutes to complete. Do you have a few minutes now?
If No: When is a good time for you to answer some questions about your social 
circumstances? (SCHEDULE A TIME AND CONFIRM BEST CONTACT 
NUMBER)
If Yes: Great, let’s get started.
Screening Survey
1. Since we last talked on [insert index screening date], were you able to connect with 
any new programs or services for help with [insert needs identified from index screen)?
Yes
No (skip to Q5)
2. Which programs or services did you connect with?
3. Were you able to get the help you wanted from this (these) program(s)? 
Yes
No
4. How did you connect with this (these) program(s)?  
Probes
phone call
walk in
web-based
e-mail 
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5. Why were you unable to connect with the [insert specific resources that were provided 
to respondent at index screen, e.g., food, employment] programs(s)?
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Appendix K: Six-Month Follow-Up Survey 
Phone Contact
 
 : 
Hello, my name is__________, I’m calling from the (Name of VAMC).  I am trying to 
reach [Name of Veteran].
Not Present:    I’ll call back another time, thank you. Is there a good time to try calling 
back?
Voicemail: Hello, my name is [name of research team member], I am calling from the 
(Name of VAMC). I wanted to speak with [Name of Veteran] about the Resource 
Needs Study. It’s time to complete one of the brief questionnaires that are part of this 
study, it will only take about 10 minutes to complete. Please contact me at 781-687-
[extension]. If you get my voicemail please leave your name, the best number to reach 
you at, and the most convenient times to reach you. Thank you.  
Present: Hello, my names is [name of research team member] and I work at the 
(Name of VAMC). I wanted to speak with you about the Resource Needs Study you are 
participating in.  It’s time to complete one of the brief questionnaires that are part of this 
study, it will only take about 10 minutes to complete. Do you have a few minutes now?
If No: When is a good time for you to answer some questions about your social 
circumstances? (SCHEDULE A TIME AND CONFIRM BEST CONTACT 
NUMBER)
If Yes: Great, let’s get started.
Screening Survey
HOUSING AND UTILITIES
1. In the past 6 months, have you been living in stable housing that you own, rent, or 
stay in as part of a household? 

Yes

No
2. Are you worried or concerned that in the next 2 months you may NOT have stable 
housing that you own, rent, or stay in as part of a household?

Yes

No
3. In the past 6 months has the electric, gas, oil or water company threatened to shut off 
service in your home? 

Yes

No

Already shut off

Not applicable
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EMPLOYMENT AND FOOD
4. Are you currently:

Employed for wages

Self-employed 

Out of work for 1 year or more 

Out of work for less than 1 year 

A Homemaker 

A Student 

Retired 

Unable to work 
5. How often were the following statements true for you in the past 6 months?
i. Within the past 6 months, you worried that your food would run out before you 
got money to buy more. 

Often true

Sometimes true

Never true
ii. Within the past 6 months, the food you bought just didn't last and you didn't 
have money to get more. 

Often true

Sometimes true

Never true
LEGAL AND TRANSPORTATION 
6. Are you currently dealing with any legal issues, for which you may need assistance? 

Yes

No
7. In the past 6 months, has lack of transportation kept you from medical appointments, 
meetings, work, or getting things needed for daily living: Check all that apply

Yes, it has kept me from medical appointments or from getting my medications

Yes, it has kept me from non-medical meetings, appointments, or getting the 
things that I need

No
SOCIAL AND EMOTIONAL STATUS 
8. In the last 6 months, how often did you feel lonely or isolated? 

Never

Rarely

Sometimes

Often 

Always
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9. Stress is when someone feels tense, nervous, anxious, or can’t sleep at night 
because their mind is troubled. In the last 6 months, how often did you feel stressed? 

Not at all

A little bit

Somewhat

Quite a bit

Very much
EXPOSURE TO VIOLENCE
10. Is anyone in your life hurting or threatening you?

Yes

No
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Appendix L: Veteran Interview Guide (Not Connected) 
Phone Script
Hello, my name is [RA’s name] from [name of VAMC]. I’m calling to talk to you about 
the Resource Needs Study you are participating in. 
As a participant in our study, you recently completed a questionnaire and indicated that 
you had the following needs [insert domain(s)]. 
I’d like to ask you a few questions about this/these need(s), as well as your experience 
participating in our study. This should take about [30-45 minutes depending on how 
much you have to say]. 
Do you have time to talk now, or would you like to schedule another time?
If scheduling for later:
OK, sure, when is a good time for us to call you for this interview? (CONFIRM 
DATE/TIME)
Is this the best number to reach you at that time? (CONFIRM PHONE NUMBER)
Thank you for you participating, I look forward to talking with you at (agreed 
date/time). 
If interviewing now: 
Great, thank you! 
(Informed Consent Reminder) Before we begin, I want to remind you that you are 
participating in research; your participation is voluntary; and you may decline to 
answer any of my questions or stop this interview at any time. I would like to use 
an audio-recorder so I can do a good job of listening to you. Is that alright with 
you?
Remember that we will not use your name or identify you in any way in 
presentations
Do you have any questions before we begin? (RESPOND TO ANY 
QUESTIONS)
Do you have any questions before I turn on the audio recorder? (RESPOND TO 
ANY QUESTIONS)
OK, let’s get started. (TURN ON AUDIO RECORDER, IF RESPONDENT 
AGREED)
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Interview Guide 
Note: This is a semi-structured, qualitative interview guide meant to be used flexibly. 
The interviewer may follow-up with further open-ended questions and requests for 
clarification.  The interviewer may also follow-up on issues raised by the participant. 
Questions may be asked in a different order, depending on the flow of conversation.  
Not all questions will be asked of each interviewee, as some questions may not be 
relevant to all subjects. [sub-questions are prompts]
1.
To begin, it would be helpful for me to know a little about. Can you briefly tell me 
a little about yourself, like where you work, live or, who you live with?
2.
Now let’s talk about your experience participating in our study. As part of the 
study, you completed a questionnaire over the phone about your unmet needs 
(like whether you had reliable transportation) and whether you wanted assistance 
with the needs you have. 
a.
How did you experience that? 
b.
What did you like and not like? 
c.
What suggestions to you have about how VA could best learn about the 
resource needs that Veterans have?
3.
In the questionnaire you indicated that you had the following needs [insert 
domains(s)]. I’d like to ask you a few questions about this/these need(s). And at 
any point, It would be helpful if you could make any important distinctions across 
before the pandemic, during the pandemic and now.
a.
Tell me about your experience with [insert unmet need domain(s)], how 
long you have had this/these needs, how much you worry about 
this/these needs.
4.
How did you feel about receiving a list of services and contact information that 
could help you to address your need(s) for [insert domain(s)]? 
a.
What worked for you about the experience? 
b.
What didn’t work for you?
c.
Are there ways these handouts could have been made more useful for 
you?
5.
SW ARM ONLY How did you feel about a social worker assisting you to connect 
to services that might help you with your need for [insert domain(s)]? 
a.
What worked for you about the experience? 
b.
What didn’t work for you?
c.
Are there things the social worker could have done to be more helpful for 
you?
6.
Among all the things that you need to manage in your life, how does [insert 
domain] need fit in? 
7.
(For respondents who tried but were unable to connect to new services) Through 
your participation in the study, we understand that you tried to connect with new 
services from (insert name(s) of program(s)/organization(s) but were unable to. 
Can you tell us about this experience? 
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8.
(For respondents who did not try to connect to new services) Through your 
participation in the study, we understand that you did not try to connect with new 
services from (insert name(s) of program(s)/organization(s) Thinking back to 
when you were provided a list of services that might be able to help you with your 
needs – and (if applicable) contacted by social worker to assist you in accessing 
services – what were some of the reasons you didn’t try to use these services?
9.
What would have made it easier to connect with these services? 
a.
Probe:
b.
Location
c.
Access to phone and/or internet
d.
Perceived ability to navigate social service delivery system
e.
Assistance from others
10. In the thinking about your need(s) for [insert domain(s)], were you confident that 
available services within the VA or the community in which you live could help 
you with this/these need(s)? Why or why not?
11. Is there anything else you’d like to tell us about your experience participating in 
the study?
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Appendix M: Veteran Interview Guide (Connected)
Phone Script
Hello, my name is [RA’s name] from [name of VAMC]. I’m calling to talk to you about 
the Resource Needs Study you are participating in. 
As a participant in our study, you recently completed a questionnaire and indicated that 
you had the following needs [insert domain(s)]. 
I’d like to ask you a few questions about this/these need(s), as well as your experience 
participating in our study. This should take about 30-45 minutes depending on how much 
you have to say. 
Do you have time to talk now, or would you like to schedule another time?
If scheduling for later:
OK, sure, when is a good time for us to call you for this interview? (CONFIRM 
DATE/TIME)
Is this the best number to reach you at that time? (CONFIRM PHONE NUMBER)
Thank you for you participating, I look forward to talking with you at (agreed 
date/time). 
If interviewing now: 
Great, thank you! 
(Informed Consent Reminder) Before we begin, I want to remind you that you are 
participating in research; your participation is voluntary; and you may decline to 
answer any of my questions or stop this interview at any time. 
Remember that we will not use your name or identify you in any way in 
presentations of our study results. I would like to use an audio-recorder so I can 
do a good job of listening to you. Are you Ok with that?
Do you have any questions before we begin? (RESPOND TO ANY 
QUESTIONS)
OK, let’s get started. (TURN ON AUDIO RECORDER, IF RESPONDENT 
AGREED)
Interview Guide 
Note: This is a semi-structured, qualitative interview guide meant to be used flexibly. 
The interviewer may follow-up with further open-ended questions and requests for 
clarification.  The interviewer may also follow-up on issues raised by the participant. 
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Questions may be asked in a different order, depending on the flow of conversation.  
Not all questions will be asked of each interviewee, as some questions may not be 
relevant to all subjects. [sub-questions are prompts]
1.
To begin, it would be helpful for me to know a little about. Can you briefly tell me 
a little about yourself, like where you work, live or, who you live with.
2.
Now let’s talk about your experience participating in our study. As part of the 
study, you completed a questionnaire over the phone about your unmet needs 
(like whether you had reliable transportation) and whether you wanted assistance 
with the needs you have. How did you experience that? What did you like and 
not like about the experience? What suggestions do you have about how the VA 
could best learn about the resource needs Veterans have? 
3.
In the questionnaire you indicated that you had the following needs [insert 
domains(s)]. I’d like to ask you a few questions about this/these need(s). And at 
any point, It would be helpful if you could make any important distinctions across 
before the pandemic, during the pandemic and now.
a.
Tell me about your experience with [insert unmet need domain(s)], how 
long you have had this/these needs, how much you worry about 
this/these needs.
4.
How did you feel about receiving a list of services and contact information that 
could help you to address your need(s) for [insert domain(s)]? 
a.
What worked for you about the experience? 
b.
What didn’t work for you?
c.
Are there ways these handouts could have been made more useful for 
you?
5.
SW ARM ONLY How did you feel about a social worker assisting you to connect 
to services that might help you with your need for [insert domain(s)]? 
a.
What worked for you about the experience? 
b.
What didn’t work for you?
c.
Are there things the social worker could have done to be more helpful for 
you?
6.
Through your participation in the study, we understand that you received new 
services from [insert name(s) of program(s)/organization(s)]. 
a.
Can you tell us a little about that? 
b.
Can you walk us through the steps you took to get these services? Was it 
easy to connect to these services? Why or why not? Probes:
i.
Location
ii.
Access to phone and/or internet
iii.
Perceived ability to navigate social service delivery system
iv.
Assistance from others
c.
What did you think about the organization[s] you were told about? 
7.
How was your experience receiving services? 
a.
How helpful was/were the service(s) in addressing your need(s)?
b.
Are there things that worked well or did not? 
c.
How could the service(s) better meet your needs?
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d.
What else should I know about the services you received? 
e.
How could the VA better address your unmet needs? (probe for what 
would be most helpful for the respondent). 
8.
What did you think about the organization[s] you were told about? 
9.
Among all the things that you need to manage in your life, how does [insert 
domain] need fit in? 
10. Is there anything else you’d like to tell us about you? Your experience 
participating in the study?
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Appendix N: Resource Representative Interview Guide 
Phone Script 
Hello, my name is [RA Name] from [VAMC Name]. 
I’m calling to conduct an interview with you about your experience as a resource 
provider for the Veterans in our study identifying unmet resource needs. 
Is this still a good time to talk? 
If No: No problem, when will be a good time for us to talk? (ANSWER ANY 
QUESTIONS AND RESCHEDULE THE CALL.)
Great. I look forward to talking to you then.
If Yes: Great! This call should take about 30 minutes.
I want to remind you of a few things before we begin: your participation is completely 
voluntary; you can stop the interview at any time, and you may choose not to answer 
any question you are uncomfortable answering. Your answers will be kept 
completely confidential and we will not use your name to identify you in any results. I 
would like to use an audio-recorder so I can do a good job of listening to you. Are 
you Ok with that? 
Do you have any questions before we begin? (ANSWER ANY QUESTIONS) 
OK, let’s get started. (TURN ON AUDIO RECORDER, IF RESPONDENT AGREED)
Interview Guide
Note: This is a semi-structured, qualitative interview guide meant to be used flexibly. 
The interviewer may follow-up with further open-ended questions and requests for 
clarification.  The interviewer may also follow-up on issues raised by the participant. 
Questions may be asked in a different order, depending on the flow of conversation.  
Not all questions will be asked of each interviewee, as some questions may not be 
relevant to all subjects. [sub-questions are prompts]
1.
Tell me a little about your work in general.
a.
What specifically is your role? 
2.
Can you tell me about your program? 
a.
What kind of services does your program provide? 
b.
(For community-based programs): Can you tell me a little about your 
organization’s relationship with the VA?
3.
How do clients/patients typically find you? 
a.
Who is eligible for your program (inclusion and exclusion criteria)?
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b.
 (For VA programs): What types of VA providers/departments refer to 
you? 
c.
(For community-based programs): What types of organizations, if any, 
refer to you?
d.
(For community-based programs only) Do you have a way of knowing if 
clients are Veterans?
e.
How could the referral process for your services be improved? 
4.
Can you tell me about the ebbs & flows in your work?  
a.
In particular, what about volume in utilization of your services?  
b.
During the past year, did you notice increased Veteran referrals to your 
programs and if so, how did you manage the uptick in referrals? 
c.
It would be helpful if you could make any important distinctions across 
before the pandemic, during the pandemic and now.
5.
How does the potential for increased Veteran referrals for your services sit with 
you? What might you need to address an increase? What should VA know?
6.
(For community-based programs only) Is there anything particular to Veterans 
when thinking about the services you provide and if so, please tell us about it.
7.
(For community-based programs only) What does the VA need to know about 
working with your organization?
8.
There is increasing incentivization for health care organizations like the VA to 
screen for unmet social needs and refer patients with identified needs to 
programs/organizations such as yours. What are your thoughts on this?
9.
Is there anything else you’d like to share about how the VA can best address the 
unmet social needs of the Veterans they serve?
10. Given everything we’ve talked about today, is there anything else I should know? 
Something you thought I’d asked but didn’t?
Thank you for your time.
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Appendix O: Example Resource Sheets
(See pages following)
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Social Risk Factors Resource Guide: TRANSPORTATION RESOURCES
If you have any questions about the information provided below or want additional 
assistance contacting the programs, please contact Timothy Driscoll, 781-687-
2374, Health Care for Homeless Veterans Program at Bedford VA. 
The Bedford Shuttle Services:  Shuttle service to Boston VA facilities and Bedford 
CBOC locations. You must be scheduled to utilize so please call (781) 687-2505 with 
questions. Seating is limited to scheduled Veterans. Full Listing of shuttle services and 
times and location of departure available [website will be provided here]. 
MBTA Cards, Social Work Service 781-687-2375
MBTA cards for Veteran’s who are without funds and in need of transportation within the 
Mass Transit system.
The Ride is the T's Paratransit program, provides door-to door transportation to eligible 
people who cannot use general public transportation all or some of the time, because of 
a physical, cognitive or mental disability In order to use THE RIDE you must complete 
and submit an application. Per ADA regulations, 21 days is allowed to process 
applications upon receipt. Only completed signed original applications, mailed to the 
address below, will be considered for review. You will receive written notification of 
eligibility via U.S. mail.
[website for MBTA will be provided here]. 
MBTA Office for Transportation Access
10 Park Plaza - Room 5750
Boston, MA 02116
(800) 533-6282 in-state toll free
(617) 222-5123
TTY (617) 222-5415
Regional Transit Authority Contact Information
You can learn more about regional or local transportation service options below: 
CATA - Cape Ann Transportation Authority [website will be provided here]
Gloucester (978) 283-7916
 
LRTA - Lowell Regional Transit Authority [website will be provided here]
Lowell (978) 459-0164 TTY (800) 439-2370
 
MWRTA - MetroWest Regional Transit Authority [website will be provided here]
Framingham (508) 935-2222 1-888-996-9782
 
MVRTA - Merrimack Valley Regional Transit Authority [website will be provided here]
Haverhill (978) 469-1254 (V/TTY)
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Social Risk Factors Resource Guide: FOOD SECURITY RESOURCES
If you have any questions about the information provided below or want additional 
assistance contacting the programs, please contact Timothy Driscoll, 781-687-
2374, Health Care for Homeless Veterans Program at Bedford VA. 
SNAP: Supplemental Nutrition Assistance Program – formerly known as SNAP. 
[website for SNAP will be provided here]
SNAP benefits are provided by the federal government and administered by DTA.  
Residents of the Commonwealth who participate in SNAP are families with children, 
elders and disabled.  To apply for SNAP benefits, you may fill out the SNAP application 
to see if you are eligible to receive benefits. To find the Transitional Assistance office 
that covers your city/town, visit the above link and click on the “Transitional Assistance 
Office” link.  If you are not sure which office to contact or you have questions about how 
to apply for DTA programs, please contact the DTA Application Information Hotline at 1-
800-249-2007, Monday through Friday from 8:45 AM – 5:00 PM.
Some Local offices include:
Lawrence                                                 
15 Union Street
Lawrence, MA 01840
Phone: (978) 725-7100
Fax: (978) 681-6216 Mon - Fri
7:00am to 5:00pm
Lowell 
131 Davidson Street
Lowell, MA 01852
Phone: (978) 446-2400
Fax: (978) 458-7563 Mon - Fri
7:00am to 5:00pm
Malden 
200 Pleasant Street
Malden, MA 02148
Phone: (781) 388-7300
Fax: (617) 727-7493 Mon - Fri
7:45am to 5:00pm
Revere
300 Ocean Avenue
Revere, MA 02151
Phone: (781) 286-7800 (800) 650-2560
Fax: (617) 727-4567 Mon - Fri
7:00am to 5:00pm
To find a food pantry or free meal program near you, call:
The FoodSource Hotline
Merrimack Valley Food Bank (Lowell)
Telephone: 1-800-645-8333
Telephone: 978-454-7272
TTY: 1-800-377-1292
Web site: Merrimack Valley Food Bank
Web site: The FoodSource Hotline
Greater Boston Food Bank (Eastern Massachusetts)
Telephone: 617-427-5200  
Web site: The Greater Boston Food Bank - Get Help
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Social Risk Factors Resource Guide: UTILITY ASSISTANCE RESOURCES
If you have any questions about the information provided below or want additional 
assistance contacting the programs, please contact Timothy Driscoll, 781-687-2374, 
Health Care for Homeless Veterans Program at Bedford VA. 
Fuel Assistance:  even if heat is included in your rent you may still be eligible for fuel assistance 
benefits as long as you are paying at least 30% of your gross income towards your rental 
portion.  Fuel Assistance is open from November 1st to April 30th.   Documentation needed 
includes:  A.) Four most recent consecutive pay stubs from date of application or a letter from 
your employer indicating gross wages for the same time period. B.) Social Security numbers of 
everyone living in the household.  C.) Proof of residency such as a rent receipt or real estate tax 
bill. D.) Utility bills including gas, electric, oil, wood, coal, propane or other.  E.) There may be 
additional required documentation depending on family circumstances, living arrangements, or 
heating source. 
Lawrence: 978.681.4900
Lowell:  978.459.6161
Haverhill: 978.373.1971
Bedford: 978.459.6161
Arlington: 781.643.2358
Individuals and families eligible for Fuel Assistance are automatically submitted to utility 
companies for enrollment in special discount programs. 
Low Income Gas Rate, sponsored by Bay State Gas, provides a discount of 
approximately 20% off their gas bill.
Assurance phone for free phone to qualifying households
Lifeline Telephone Assistance, sponsored by NYNEX, provides for a discount of $9.50 
on their telephone bill. Only one telephone line per household is eligible.
 Low income electric rate, R-2 rate, for Mass. Electric. This is a discounted rate of 33% 
off electric bills.  
Bay State Gas discounted Low Income Gas Rate [website will be provided here]
Lifeline Telephone Assistance [website will be provided here] SafeLink Wireless Phone 
[website will be provided here]
National Grid Discount Rate (R2 Rate) 1.800. 322-3223 and [website will be provided 
here]
NSTAR (R2 Rate) 800-566-2080 or apply on line 
 
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Social Risk Factors Resource Guide: HOUSING STABILITY RESOURCES
If you have any questions about the information provided below or want additional 
assistance contacting the programs, please contact Timothy Driscoll, 781-687-2374, 
Health Care for Homeless Veterans Program at Bedford VA. 
HUD/VASH Program, Ed Fleming, Program Manager, 781-687-3521 
Provide permanent housing options to homeless Veterans or Veterans at risk of homelessness 
as well as clinic case management support. 
Healthcare for Homeless Veterans, Tim Driscoll, Program Manager 781-687-2374 
Daily Walk-In Clinics to assist homeless Veterans. Provide clinical support to homeless Veterans 
around medical, mental health and substance use issues.
FURNITURE RESOURCES
Household 
Goods 
Recycling of 
Massachusetts
(978) 635-1710
530 Main 
St. 
Acton 
MA 01720 
Project Home 
Again
(978) 470-1356
 
Andover
MA
01810
My Brother’s 
Keeper
(508) 238-7512 
P.O. Box 
338 
Easton 
MA 02356 
Massachusetts 
Coalition for the 
Homeless
(781) 595-7570
15 Bubier 
St. 
Lynn
(Boston) 
MA 01901 
Mission of 
Deeds
(781) 944-9797
6 Chapin 
Ave
Reading 
(Boston)
MA 01867
Central MA 
Housing 
Alliance 
Furniture 
Exchange
(508) 791-7265
7-11 
Bellevue
Worcester MA 01609
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Supportive Services for Veterans and their Families: VA aims to improve very low-income 
Veteran families’ housing stability through the SSVF Program with outreach, case management, 
and assistance in obtaining benefits. Here is a list of SSVF Partners:
Lynn Housing Authority, Essex County & Middlesex County: 781-581-8640
Soldier On, Inc. /Berkshire, Hampshire, Franklin: 866-406-8449
Veterans Northeast Outreach Center Essex and Middlesex Counties, MA 978-372-3626
Veterans, Inc. /Worcester County: 800-482-2565
Vietnam Veterans Workshop, Inc. 617-371-1850
Vietnam Veterans Workshop, Inc./City of Boston (Suffolk County, only city)
617-371-1850
Volunteers of America of Massachusetts, Inc./Suffolk, Middlesex, Plymouth, Norfolk, 
Balance of State:  617-447-4287
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Social Risk Factors Resource Guide: LEGAL SUPPORT RESOURCES
If you have any questions about the information provided below or want additional 
assistance contacting the programs, please contact Timothy Driscoll, 781-687-2374, 
Health Care for Homeless Veterans Program at Bedford VA. 
Veteran Justice Outreach Program (VJO) 781-687-2377 
VA Program providing support to VA eligible Veterans involved in the justice system. VJO 
Specialists provide direct outreach, assessment, case management, and pre-trial diversion 
through access to VA healthcare services.  
Center for Public Representation (413) 587-6265 [website will be provided here]
Non-profit organization that provides legal assistance to consumers 
Committee for Public Counsel Services (CPCS) (800) 882-2095
Provides free legal representation for consumers facing commitment hearings
Disability Law Center (800) 872-9992 [website will be provided here]
Non-profit organization that provides legal assistance for any person with a disability including 
consumers.  
Mass. Correctional Legal Services (617) 482-2773
Non-profit advocacy organization for inmates
Mass. Law Reform Institute (617) 357-0700 [website will be provided here]
Non-profit agency that provides legal assistance, information and advocacy particularly for the 
poor and disenfranchised
Mass. Commission Against Discrimination (MCAD) (617) 727-3990
Assists in any discrimination case including workplace.
Mental Health Legal Advisors Committee (800) 342-9092 [website will be provided here]
Agency that provides legal assistance to consumers
 
Volunteer Lawyers Project (617) 423-0648                                                                                   
Network of attorneys that provide legal representation at reduced fees
Find Legal Help website [website will be provided here]
Features a state-by-state listing of legal help with links to basic legal information, lawyer 
referrals and free legal help. To find a pro bono program click on the “Free Legal Help” or “Pro 
bono”.
Law Help website [website will be provided here]
Helps low- and moderate-income people find free legal aid programs in their communities as 
well as answers to questions about their legal rights. 
Pro Bono website [website will be provided here]
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A national, online resource for legal aid and pro bono attorneys, law professors and students, 
and related social services advocates.
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Social Risk Factors Resource Guide: EXPOSURE TO VIOLENCE AND/OR ABUSE 
RESOURCES
If you have any questions about the information provided below or want additional 
assistance contacting the programs, please contact Timothy Driscoll, 781-687-2374, 
Health Care for Homeless Veterans Program at Bedford VA. 
Resources for Crisis/Emergency Response
For immediate need, dial 911 or report to local emergency room/urgent care.
Edith Nourse Rogers Memorial Veterans Hospital - VA Police
Description: VA Campus Police at Edith Nourse Rogers Memorial Veterans Hospital (Bedford, 
MA)
Contact: Emergency line: 781-687-2555.  NON-Emergency line: 781-687-2404
Eligibility requirements: none
Cost: none 
Massachusetts Department of Children & Families
Description: Massachusetts child abuse and neglect protection services
Contact: Main line: 617-748-2000.  Hotline to file report: 1-800-792-5200.  
[website will be provided here]
Eligibility requirements: Legal minors under 18 and adults 18-22 transitioning out of DCF 
care.
Cost: None
Massachusetts Department of Elder Services (person is over age 60)
Description: If a person over the age of 60 and living in the community experiences physical, 
sexual, or emotional abuse, caretaker neglect, financial exploitation, or self-neglect.
Contact: 1-800-922-2275.  (If abuse by nursing home or hospital, contact Department of Public 
Health at 1-800-462-5540). [website will be provided here]
Eligibility requirements: People over the age of 60 and living in the community.
Cost: None
Massachusetts Disabled Persons Protection Commission
Description: Protection of adults with disabilities from serious physical and/or emotional injury 
from acts and/or omissions from their caregivers. 
[website will be provided here]
Contact: 1-800-426-9009
Eligibility requirements: Adults with disabilities.
Cost: None
Resources for Treatment/Clinical Care
Mental Health Clinic Recovery Services
Description: Outpatient mental health treatment with comprehensive behavioral health teams 
(i.e., psychiatry, nursing, psychology, social work staff).
Contact: 781-687-2347
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Eligibility requirements: Eligible for VA care.
Cost: Visit copay if applicable
Safing Center
Description: Outpatient therapy focused on treatment and prevention of intimate partner 
violence. [website will be provided here]
Contact: 781-687-3998
Eligibility requirements: Veteran eligible for VA care.  Non-veteran collaterals (e.g., partners) 
can receive couples therapy with the veteran or up to 4 individual therapy sessions.
Cost: Visit copay, if applicable.
Military Sexual Trauma (MST) Coordinator
Description: Resource for eligibility and treatment coordination related to sexual assault.
Contact: 781-687-3226
Eligibility requirements: Eligible for VA care.
Cost: Visit copay if applicable.
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Social Risk Factors Resource Guide: EMPLOYMENT RESOURCES
If you have any questions about the information provided below or want additional 
assistance contacting the programs, please contact Timothy Driscoll, 781-687-2374, 
Health Care for Homeless Veterans Program at Bedford VA or John Bowers, 781-687-
2575, Vocational Rehab Specialists at Bedford VA. 
Veterans Employment Resources / Vocational Support
Description:  A variety of services to help veterans re-entering the workforce including 
transitional work, supported employment and job search assistance
Contact:  John Bowers / Paul Cheney 781-687-2575
Eligibility requirements:  Eligible for VA Care; Determined by VA admissions
Cost: None
Massachusetts Rehabilitation Commission (“Mass Rehab”)
Description:  The Vocational Rehabilitation Program helps people with disabilities get and keep 
a job. 
Contact:  Main number: 617- 204-3600
Eligibility requirements: Have a disability. Want to work and need Vocational Rehabilitation 
services to train, find, or keep a job.
Cost: None
Vocational Rehabilitation and Employment (VR&E)/Veterans Benefits Administration
Description:  Vocational Rehabilitation and Employment (VR&E) services to help with job 
training, employment accommodations, resume development, and job seeking skills coaching
Contact: [website will be provided here]
Eligibility requirements: Have a service connected disability of at least 10%. Have a discharge 
other than dishonorable.
Cost: None
**Please note: Veterans Employment Resources also offers connection to pro bono legal 
services and child support assistance. Please contact Paul Cheney at 781-687-2575 for 
information on the legal clinic and Debra Locke at 781-687-2427 for information on the child 
support clinic.
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Social Risk Factors Resource Guide: SOCIAL SUPPORT
If you have any questions about the information provided below or want additional 
assistance contacting the programs, please contact Anthony Russo, 781-687-3322 or 
[email available], Health Technician at Bedford VA.        
VA Community Recovery Connections Program
Description:  Information about Veteran peer support groups, community-based self-help 
groups, and other group-based opportunities to connect with other Veterans and civilians.  
Contact:  Tony Russo 781-687-3322
Eligibility requirements:  Eligible for VA Care; Determined by VA admissions
Cost: None
VA Social Skills Educational Opportunities
Description: Education and training for Veterans interested in increasing their social skills and 
broaden their connections to Veterans and civilians around them.  Services include individual 
and group trainings and coaching to build social support.  
Contact:  Michelle Esterberg 781-687-3935
Eligibility requirements:  Eligible for VA Care; Determined by VA admissions
Cost: None
Name of program / resource: Veteran Coffee Socials
Description:  Open weekly community-based meetings of Veterans in 22 communities in the 
local area.  The only agenda is for Vets to get together to connect with other Vets, share 
information and support, and watch out for other Veterans in that community.  These are free-
standing independent groups.  
Contact:  Steven Hines (781-687-3173) can provide a listing of Veteran Coffee Socials time 
and location.
Eligibility requirements: None – open to all.
Cost: None
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Appendix P. Mail and Email Text for Delivering Resource Sheets to 
Veterans
1.
Cover Letter to Veterans 
 
 mailed
 
  with Resource Sheets:
 
 
Veterans’ Resource Needs Study
(Address of Site location)
(Phone number for Site RA)
(Date)
Hello, and thank you for participating in our study!
When we spoke on the phone several days ago, I promised to mail you some written 
material on agencies and programs that may be able to help you with the needs that you 
identified. 
Please read through the enclosed material, and contact any of the listed programs or 
services directly at any time. 
If you have questions about enclosed material, please call me at the number above.
Thank you.
2.
Email message to Veterans who choose to have Resource Sheet 
 
 emailed
 
 : 
Hello, and thank you for participating in our study!
The written material about Veterans’ resources that I mentioned on the phone today is 
attached to this message for you to download and open. You will also receive a printed 
copy in the mail in a few days.
Thank you.
*This email and attachment were sent with privacy encryption.
PLEASE DO NOT REPLY TO THIS MESSAGE. This is not a regularly maintained 
account and a response cannot be guaranteed. Should you need to connect with us, 
please call (insert site RA phone number).
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