Boosting employment to improve health and recovery among Veterans in substancetreatment: National evaluation of Supported Employment implementation andmodifications in a novel population (BEST-SE)

About This Grant

Background: Employment is a major social determinant of health. In Veterans with substance use disorders (SUDs), employment is associated positive health and wellbeing. However, many Veterans with SUDs are unemployed and the majority do not have access to quality employment supports. In response, national VA policy by the Office of Mental Health and Suicide Prevention (OMHSP) mandated the implementation of empirically based supported employment (SE) services into SUD specialty treatment settings (SE-SUD) at 156 VA sites. SE was originally developed, tested, and used to help people with serious mental illness attain community work, hence, this SE-SUD initiate is a new application of this recovery service. To date, SE-SUD implementation has been slow, and the nature and effects of the rollout on Veteran outcomes are unknown. Significance: This project advances the President’s National Drug Control Strategy that emphasizes the employment needs of Americans with SUDs. The study will also further the goals of the 2016 Comprehensive Addiction and Recovery Act promoting the study and utilization of patient centered, behavioral approaches in opioid use disorders (OUD). SE-SUD represents a novel approach to enhance wellness in this population. In addition, this study tackles a chief social determinant of health, employment, in a marginalized population that has been historically underserved regarding their employment needs. Innovation & impact: Leveraging multiple sources of system-wide VA and non-VA community data and incorporating an array of stakeholder input and data, this project will used the expanded RE-AIM framework to study SE-SUD implementation outcomes, in addition to key contextual factors that impact these outcomes. Additionally, guided by the FRAME model, this is one of the first studies to examine the extent and nature of practice modifications as they are applied in the real world as related to patient outcomes involved in a complex integrative service in SE. Innovative methods, including configurational analyses, will identify causal relationships between modifications and employment outcomes. These findings will inform novel directions for other health services interventions that seek to address social determinants of health by optimizing practice through a balance of maintaining quality guidelines with empirically driven, planned adaptation s. Specific Aims: Aim 1 will assess the RE-AIM domains of SE-SUD adoption, factors driving adoption, and reach. The results will produce a range of high and low reach sites that will be the focus of intensive data collection in Aim 2, in which implementation process will be described and SE-SUD fidelity and modifications used by providers will be examined. Aim 3 will prospectively examine the effects of SE-SUD on Veteran outcomes. Lastly, the relationship between modifications, fidelity, and Veteran outcomes will be assessed. Methods: This study will use convergent parallel mixed methods design. Aim 1 will integrate national survey and administrative data to determine SE-SUD adoption, factors driving adoption, and reach. Using a case summary matrix approach, Aim 2 will combine data from site visits, chart reviews, and interviews at 24 sites to assess SE-SUD implementation process, fidelity, and modifications. Using an interrupted time series design, Aim 3 will examine effects of SE-SUD on Veteran outcomes across 9 months (primary endpoint) in a national sample of 180 unemployed Veterans receiving SE-SUD. Outcomes include employment, health, recovery, and suicidality. Configurational analysis will identify SE modifications associated with favorable Veteran outcomes. Next steps/Implementation: In close collaboration with OMHSP partners, BEST-SE findings will inform future policy changes regarding the integration of SE services into multi-tiered SUD treatment settings and practice guidelines that promote Veteran outcomes accompanied by empirically defined modifications that fit local context. The study will also provide information and tools to improve national uptake and maintenance of SE- SUD and will inform the ability of SE-SUD to improve employment in a vulnerable Veteran population.