Co-designing Implementation Strategies to Increase Uptake of Whole Health for Older Veterans Experiencing Homelessness

Summary

The number of older Veterans (aged 55+ years) experiencing homelessness (VEH) has skyrocketed in the past 13 years, with an 150% increase from 2010 to 2023.¹ Older VEH are at high risk for multiple chronic health conditions, including mental health and substance use disorders. In addition, they frequently struggle with management of these conditions.^2-5 Poor management of mental health and substance use disorders may interfere with their ability to stay in housing, harm their quality of life, and increase suicide risk.^{6, 7} In addition to challenges managing chronic conditions, older VEH often struggle with isolation, loneliness, and lack of purpose. These conditions can all exacerbate and be exacerbated by mental health and substance use disorders.^8-11

Over the last decade, the Veterans Health Administration (VHA) has been implementing a Whole Health System of Care that aims to build Veterans’ skills to take control of their health and wellbeing.¹² One component of Whole Health is Whole Health well-being programs which encompass a number of evidence-based interventions for improving Veterans’ ability to manage challenges associated with chronic illness (e.g., pain, perceived stress), engagement in care, and overall well-being and purpose.^13-15 While significant resources have been dedicated to implementing Whole Health in VHA in general care, little focus has been placed on connecting VEH with Whole Health well-being programs. This proposal aims to address this gap by developing a multifaceted implementation strategy to increase uptake of Whole Health well-being programs among older Veterans with mental health and/or substance use disorders in HUD-VASH (VA’s supportive housing program). We will conduct interviews with Veterans and providers to identify and prioritize barriers and facilitators to increase uptake of Whole Health well-being programs among older VEH. From these barriers, we will co-design with implementation collaborators strategies to overcome them.

Significance

As older VEH with mental health/substance use disorders transition out of HUD-VASH and into permanent housing, they gain more stability in their lives. Older VEH’s transition into permanent housing is an ideal time to identify those who are struggling and get them connected to Whole Health well-being programs that will help them build skills to move from “surviving” to “thriving.” These programs can help them develop skills to set long-term health and well-being goals and better manage their mental health/substance use conditions and symptoms, which is a priority as these conditions could otherwise prevent them from staying in long-term housing.^16-18

Through these implementation strategies, we will ultimately aim to improve mental health/substance use disorder outcomes and well-being for VEH, which are a marginalized population within the Veteran community. This work is in strong alignment with the VHA Secretary’s priorities of 1) putting Well-Being of the Veterans at the Center of the Enterprise and 2) doing a better job reaching Veterans at risk of homelessness or suicide.

Benefits

Demonstrated benefits are those that have been observed and are verifiable.

Potential benefits are those logically expected with moderate to high confidence.

Clinical & medical benefits

Engaged patients and providers in identification of barriers and co-design of implementation strategies. potential.

Patient-guided research

Primary beneficiary:

Patients

Community & public health benefits

Increased uptake of Whole Health well-being programs among VEH. potential.

Health care accessibility

Primary beneficiary:

Patients

Increased integration of Whole Health into HUD-VASH providers’ service delivery. potential.

Health care delivery

Primary beneficiary:

Patients

Reduced Veteran loneliness, increased sense of purpose/meaning, improved engagement in healthcare services. potential.

Disease prevention & reduction

Primary beneficiary:

Patients

This research has clinical and community implications. The framework for these implications was derived from the Translational Science Benefits Model created by the Institute of Clinical & Translational Sciences at Washington University in St. Louis.¹⁹

Clinical

Our hope is that our co-designed strategies will lead to increased uptake of Whole Health wellbeing programs among Veterans and increased integration of Whole Health within HUD-VASH providers’ service delivery. Our ultimate goal is that increased integration of Whole Health into services for VEH will lead to 1) reduced Veteran loneliness and isolation 2) increased goal-setting and perceptions of meaning and purpose in their lives and 3) improved management of their mental health/substance use conditions and symptoms.

Community

Engaging providers and Veterans from the beginning in co-designing our implementation strategies will help ensure that they are feasible to implement and valued by both HUD-VASH providers and patients.

Lessons Learned

Different VAs may have very different Whole Health services that are available, as well as different relationships between their Whole Health and HUD-VASH programs. Thus, different types of strategies or tailoring of strategies may be needed depending on these factors.