Housing Transitions QUERI

Study Overview
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Brief Summary
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The VA Grant and Per Diem (GPD) case management aftercare program provides six months of case management for homeless-experienced Veterans undergoing housing transitions. This Partnered Implementation Initiative (PII) proposes to implement and evaluate Critical Time Intervention (CTI)-an evidence-based, structured, and time-limited case management practice-in 32 GPD case management aftercare sites across the nation.

Detailed Description
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The VA Grant and Per Diem case management (GPD-CM) program provides six months of case management for homeless-experienced Veterans (HEVs) undergoing housing transitions. At present, no specific case management paradigm is required in the GPD-CM program, resulting in practice variation across sites. This Partnered Implementation Initiative (PII) implements Critical Time Intervention (CTI)-an evidence-based, structured, and time-limited case management practice-at 32 VA GPD-CM sites. The investigators will use the Replicating Effective Programs (REP) implementation bundle to support CTI implementation at all 32 sites. Half of these sites will also receive 9 months of external facilitation (enhanced REP) as additional support for CTI implementation. In a type 3 hybrid trial, the investigators will use mixed methods to examine the impacts of REP versus enhanced REP. Using trial data, the investigators will develop a business case analysis and implementation playbook for the investigators' program partners to support continued CTI spread and sustainment in the GPD-CM program.

Official Title
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Implementing and Sustaining Critical Time Intervention (CTI) in Case Management Programs for Homeless-experienced Veterans (PII 21-285)

Conditions
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Homelessness

Intervention / Treatment
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* Behavioral: Critical Time Intervention
* Other: External Facilitation
* Other: Replicating Effective Programs


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Grant and Per Diem (GPD) case management aftercare grantees in 7 Veterans Integrated Service Networks (VISN), all of whom provide 6-months of case management to Veterans who have experienced homelessness. Exclusion Criteria: None
Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Other
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: The investigators are implementing Critical Time Intervention (CTI), an evidence-based, time limited case management practice for individuals experiencing homelessness. The investigators will be randomizing sites receiving CTI into one of two levels of implementation support (low vs. high intensity support).
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Replicating Effective Programs (REP)<br>A stakeholder-informed training and technical assistance implementation strategy | Behavioral: Critical Time Intervention<br>* An evidence-based, structured, and time-limited case management practice<br>* Other names: CTI;Other: Replicating Effective Programs<br>* A stakeholder-informed training and technical assistance implementation strategy<br>* Other names: REP;|
| Active Comparator: REP + External Facilitation (Enhanced REP)<br>REP plus site specific weekly facilitation to support CTI implementation. | Behavioral: Critical Time Intervention<br>* An evidence-based, structured, and time-limited case management practice<br>* Other names: CTI;Other: External Facilitation<br>* Site-specific support to help sites develop tailored plans to implement CTI.<br>* Other names: Coaching;Other: Replicating Effective Programs<br>* A stakeholder-informed training and technical assistance implementation strategy<br>* Other names: REP;|
| No Intervention: Control Group<br>No CTI implementation | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Fidelity to CTI | % of Sites with adequate fidelity to CTI at 12 months, as measured by the CTI fidelity scale | 12 months after implementation start | 
| Sustainment of CTI | % of Sites with adequate fidelity to CTI at 18 months, as measured by the CTI fidelity scale | 18 months after implementation start | 
| Dollars spent delivering CTI at each site | Case manager salary and benefits | Between 6 and 18 months after implementation start | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Housing stability | Days between entry into the GPD case management program and indicator of housing instability | Between 6 and 18 months after implementation start | 
| Cost of CTI as Implemented | Mean monthly cost of CTI case management per GPD case management Veteran served, compared to the mean monthly cost in the non-CTI GPD case management programs. | Between 6 and 18 months after implementation start | 
| Hospitalization rates | Number of days between entry into the GPD case management program and hospitalization, number of hospitalizations, number of bed days | Between 6 and 18 months after implementation start | 
| Cost of Implementation Strategies | Dollars spent on REP versus enhanced REP | Through study completion, 4 years | 
| Return on Investment (ROI) of CTI | Dollars saved via improved housing stability and decreased hospitalizations among patients engaged in CTI versus control participants | 6-, 12-, and 18-months after GPD case management program enrollment | 
| Outpatient service use | Number of outpatient appointments | Between 6 and 18 months after implementation start | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Care Management, Homeless, Implementation, Mental Health Care, Quality Assurance, Improvement