Improving Linkage to Health and Other Services for Veterans Leaving Incarceration

Study Overview
=================
Brief Summary
-----------------
Veterans leaving incarceration and re-entering their communities (often described as reentry Veterans) face a number of challenges, including uncertainty about housing, vulnerability to substance use and relapse, on-going mental health concerns, and often multiple health conditions require timely continuity of care. The purpose of the project is to increase support for Veterans post-incarceration through the addition of trained peers with lived experience of being a Veteran and a history of incarceration. Emphasis will be on peers who will help link Veterans to Veterans Health Administration (VHA) services, including housing and healthcare. Peers will provide linkage with Health Care Reentry Veterans program specialists, transportation to appointments, and support in community reintegration. Peers will assist reentry veterans to make a successful transition and get and stay engaged in their care.

Detailed Description
-----------------
Veterans leaving incarceration (henceforth, reentry Veterans) are among the most underserved by the VA and thus are an increasingly high priority population. The Bureau of Justice Statistics estimates that 140,000 Veterans are incarcerated in the U.S. at a given time, approximately 80% of whom are eligible for VA benefits. Many of these Veterans had problems with substance use disorders (SUD)(including alcohol) and/or mental health (MH) issues prior to being incarcerated. The VA's national Health Care for Reentry Veterans (HCRV) program identifies 10,000-15,000 incarcerated Veterans annually preparing to transition back to the community. A HCRV outreach specialist works with incarcerated VHA-eligible Veterans to establish a post-release plan for linkage to VHA services. This program, with 1-2 outreach specialists per state, has improved the connection between reentry Veterans and the VHA. However, the investigators' analyses of homeless program data linked to VHA administrative data indicate that 43% of eligible HCRV Veterans do not have a VHA outpatient contact in the first 4 months post incarceration. Reducing this number is critical given the elevated rates of chronic health conditions, as well as MH or SUDs in this population. To address this gap, the investigators will work with the national HCRV office to implement an evidence-based peer support intervention to extend the reach and effectiveness of the HCRV program in linking Veterans to VHA. Peers with incarceration experience are likely to better understand and connect with Veterans on a personal level than the outreach specialist, and thus are more likely to maintain contact and link to VHA during the first months post-release. Peers are gaining popularity in forensic settings (called forensic peer specialists) with civilian populations and would likely be beneficial for a Veteran population . The aims of this project are: Conduct contextual analysis to identify VHA and community reentry resources, and to describe how reentry Veterans use them. Implement peer-support, in one state, to link reentry veterans to VHA primary, mental health, and SUD services. The investigators will use external and internal facilitation as the implementation strategy. Spread the peer-support intervention to another, geographically, and contextually different state.

Official Title
-----------------
Veterans Justice Reentry (Post-Incarceration) (QUE 15-284)

Conditions
-----------------
Linkage to Care, Homelessness, Substance Use Disorder, Mental Health

Intervention / Treatment
-----------------
* Behavioral: Peer-support plus usual care from the Health Care for Reentry Veterans program
* Behavioral: Usual care from the Health Care for Reentry Veterans program


Participation Criteria
=================
Eligibility Criteria
-----------------
Inclusion Criteria: Phase 1 Veteran released from a Massachusetts state prison or county jail. (for intervention subjects: interested in receiving reentry services) Phase 2 Veteran released from a Connecticut state prison or jail. (for intervention subjects: interested in receiving reentry services) Exclusion Criteria: - No history of dementia or other serious cognitive condition that would prevent them from being interviewed or completing a survey questionnaire.
Sexes Eligible for Study
-----------------
All

Accepts Healthy Volunteers
-----------------
No

Study Plan
=================
How is the study designed?
-----------------

Design Details

Primary Purpose: Supportive Care
Allocation: Non-Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Intervention Arm with Peer Support<br>Veterans in this arm will receive the peer-support intervention, in addition to the usual care from the Health Care for Reentry Veterans Program. | Behavioral: Peer-support plus usual care from the Health Care for Reentry Veterans program<br>* a peer mentor who is also a veteran will establish a relationship with each subject and provide instrumental and emotional support to the subject during the first 6 months of the subject's release from incarceration. This is in addition to the usual reentry support provided by the Health Care for Reentry Veterans program.<br>* Other names: peer mentoring; forensic peer support;|
| Other: Comparison Arm with Usual Care<br>Veterans in this arm will be receiving usual care from the Health Care for Reentry Veterans program (but they will not receive the peer-support intervention). They will be selected to be frequency-matched to veterans in the intervention arm by date of release from incarceration. | Behavioral: Usual care from the Health Care for Reentry Veterans program<br>* Health Care for Reentry Veterans program provides reentry planning while the veteran is incarcerated. An outreach worker visits the veteran in the incarceration facility to conduct a needs assessment and help create a reentry plan to cover issues such as where they will be housed, what health care appointments they will need in the first 30 days, whether they need legal assistance, etc.<br>* Other names: HCRV reentry support;|

What is the study measuring?
-----------------
Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Substance Use Care | Participant will have made and kept one or more substance use disorder care visits | 3 months after release from incarceration | 
| Mental Health | Participant will have made and kept one or more outpatient mental health care visits | 3 months after release from incarceration | 
| Primary Care | Participant will have made and kept one or more primary care visits | 3 months after release from incarceration | 

 Terms related to the study
=================
Keywords Provided by Centre Hospitalier Valida
-----------------
justice involvement, Homeless, Vulnerable Populations, Linkage to care, Veterans