VA Homeless Programs
Application of Implementation Science for New Homeless Intervention Models
Application of Implementation Science for New Homeless Intervention Models
Implementation research is the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice designed to improve the quality and effectiveness of health services and care. VA and the National Center on Homelessness among Veterans (the Center) uses a scientific implementation framework for the evaluation and dissemination of new homeless intervention models To facilitate dissemination and implementation of new VA Homeless Program intervention models, the Center constructed a process and adapted a model implementation framework, based on the public health implementation science literature. This section provides an overview of this implementation framework which VA has utilized to implement new homeless intervention models.
The VA National Center on Homelessness among Veterans Implementation Science Flow Chart
Implementation Science: What Is It and Why Should We Care? (November 2017)
VA National Center on Homelessness among Veterans podcast on Implementation Science:
Strategies for implementing implementation science: a methodological overview.
Handley MA, Gorukanti A, Cattamanchi A. Emerg Med J. 2016 Sep;33(9):660-4. doi: 10.1136/emermed-2015-205461. Epub 2016 Feb 18. Review
An introduction to implementation science for the non-specialist. Bauer MS, Damschroder L, Hagedorn H, Smith J, Kilbourne AM. BMC Psychol. 2015 Sep 16;3:32. doi: 10.1186/s40359-015-0089-9.
Implementation science in healthcare: Introduction and perspective. Wensing M.
Z Evid Fortbild Qual Gesundhwes. 2015;109(2):97-102. doi: 10.1016/j.zefq.2015.02.014. Epub 2015 Apr 15. Review.
Casey R, Clark C, Smits P, Peters R. Application of Implementation Science for Homeless Interventions. Am J Public Health. 2013 December; 103(Suppl 2): S183–S184.
Wandersman A, Duffy J, Flaspohler P. et al. Bridging the gap between prevention research and practice: the interactive systems framework for dissemination and implementation. Am J Community Psychol. 2008; 41:171–181. [PubMed]
Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4:50. [PMC free article] [PubMed]
Chinman M,McCarthy S, Hannah G, Byrne T, Smelson D, Using Getting To Outcomes to facilitate the use of an evidence-based practice in VA homeless programs: a cluster-randomized trial of an implementation support strategy, Implementation Science, volume 12, Article number: 34 (2017)
Abraham Wandersman and colleagues (2008) proposed a framework that was originally designed to operate in the prevention field but works in varied systems and incorporates the perspectives of diverse stakeholders. The adapted framework involves four interrelated systems: (1) Synthesis, to distill knowledge about practice interventions, (2) Translation for Model Sites, to convert this knowledge into user-friendly formats for applications in specific program contexts by identifying potential barriers and programmatic adjustments that are needed, (3) Delivery of the Intervention Model, through analysis of suitable sites and obtaining stakeholder buy-in, and (4) Support and Technical Assistance to ensure that model sites have adequate resources to implement the homeless interventions and to provide data to examine the fidelity and outcomes of implementation. The Center has augmented this framework to include processes specific to homeless Veteran interventions and to the VA system.
The VA National Center on Homelessness among Veterans uses this framework to implement new model development initiatives. A brief discussion of the Implementation Science steps for development of the Safe Haven Model is posted below:
The first step of the Implementation Science framework, Synthesis, is the process of compiling and summarizing information about the program design. Additionally, an administrative review of public law, VA regulation, and federal authorities was also necessary to determine modifications needed to implement a Safe Haven model within federal statute.
The next step, Translation, is the process of converting scientific, programmatic, and existing knowledge (and perceptions) into a practitioner-based service delivery model. Based on reviews, the following key program operational principles and components were identified: serve the hard-to-reach homeless persons with severe mental illness; target those on the streets that have been unable or unwilling participate in supportive services; provide 24-hour residence in private or semi-private accommodations; and, offer full supportive services while not requiring participants to participate in those services as a condition of program residence. During this phase, a deliberate consideration of the theoretical model versus the practical application was processed. The Center modified the design of the VA Safe Haven to implement the program as a bridge program rather than permanent housing based on a review of length of stay in existing programs and to accommodate VA regulatory requirements governing program funding. Training requirements and the educational curriculum for program staff are also considered during this step along with assessment of funding, staffing, and operational requirements.
The third step, Model Delivery, outlines the specific actions of launching the program. Sites were identified as those with high populations of chronically homeless, particularly those sites that identified a need for Safe Haven services in their five-year plan to end homelessness among veterans. Local VA and community infrastructure were also examined which included a review of capacity, evidence of commitment and collaboration between the local VA and continuums of care, and knowledge of program design. As Safe Haven services were, in part, contracted by VA with community-based entities, sites were also identified as those that had providers familiar with Safe Haven principles.
At identified sites, abilities of the staff of both VA and the community entities were assessed and an educational curriculum was based on staff knowledge and capacity. Initial trainings were developed and delivered through on-site support teams. The trainings included both clinical and administrative issues in Safe Haven development and management. Clinical topics included: creating and sustaining low demand program designs, assessing participant treatment needs, developing plans for care that recognize Veteran choice, and working with and leveraging community partnerships for outreach and to fill protentional gaps in services. Management topics included: data collection and reporting, staffing, medication management, and veteran safety.
The final step, Support/Technical Assistance,details the activities necessary to sustain the model through the process of implementation, refinement, and evaluation. The model was dynamic and interactive, as consistent feedback was available from providers and managers through various mediums including site visits, web-based applications, and tele-conference forums. Ongoing support was adjusted to various levels of need and expertise of staff providing services such as administrative personnel, discipline specific providers, and paraprofessionals. Processes were developed to evaluate the technical assistance that was provided through assessment of knowledge gained and the impact on program process and outcome measures. To ensure consistency in performance metrics, data collection processes were developed at each site to measure the extent to which the programs met the following objectives related to key program design principles:
- Target the chronically homeless population diagnosed with co-occurring disorders;
- Increase participants' housing stability;
- Improve participant outcomes related to alcohol, drug, mental health, medical, social-vocational, and family problems; and
- Increase participants' income and benefits.
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Implementation Science Frameworks for Specific Programs
Community Resource and Referral Centers
Domiciliary Low Demand Model
Safe Haven Model
Telephone Continuing Care and Recovery Support Model
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