Re-Engage: About a decade ago, VA researchers discovered that veterans with severe mental illnesses such as schizophrenia or bipolar disorder were at higher risk for homelessness and “unforeseen mortality” – deaths despite little or no time spent in inpatient care over the previous year. On the heels of these findings, the VA developed the Re-Engage program: Using an algorithm to identify at-risk veterans, caseworkers were given a list of veterans in the surrounding community and a toolkit of resources – an informational web portal, a brief training session via conference call, and the availability of a technical assistance hotline – that could be used to find them and bring them back into the VA health care system.

Changing the way one of the largest integrated health care systems in the world delivers services to the tens of thousands of veterans who struggle to find and maintain housing is a colossal undertaking.

After the program had been established, a team led by Amy Kilbourne, PhD, MPH, director of the VA’s Quality Enhancement Research Initiative (QUERI) examined outcomes among close to 5,000 veterans with severe mental illness who had been lost to care. The team’s findings were striking: 72 percent were successfully returned to care, and among those who returned, there was a sixfold decrease in unforeseen mortality. In other words, homeless veterans with severe mental illness who were returned to care through Re-Engage were six times more likely to survive.

With HSR&D funding, Kilbourne’s team then designed a study to test whether Re-Engage outcomes could be further improved by an enhanced implementation strategy, the facilitation model. In addition to the resources available to caseworkers in the original program, the facilitation model involved weekly collaboration with a trained facilitator, a mental health professional with knowledge of Re-Engage, and the VA organization. In the enhanced program, the facilitator and frontline provider worked closely together to overcome barriers to implementing Re-Engage, both on the patient side and the institutional side – making sure clients and colleagues alike were aware of the program’s benefits.

Kilbourne’s study compared the standard and enhanced strategies at randomized VA sites. “We found that more providers implement Re-Engage if they’re receiving facilitation,” Kilbourne said, “versus providers who only received the standard toolkit. So the additional support and training with facilitation got more providers to implement Re-Engage.”

Her team is still examining patient-level outcomes among the veterans who took part at the test sites, but the study has already had an effect, Kilbourne said: “We showed that this facilitation program works, and subsequent to that, the VA mental health operators, our clinical leadership in VA, have adopted the facilitation model and are using the facilitation model to continue to run the Re-Engage program.” The enhanced approach is now the approach to implementing Re-Engage, and is tracked as a national program in the VHA’s performance measures system, the Strategic Analytics for Improvement and Learning (SAIL) database.

Changing the way one of the largest integrated health care systems in the world delivers services to the tens of thousands of veterans who struggle to find and maintain housing is a colossal undertaking. Kertesz compares it to “turning around the Queen Mary.” But as VA researchers work to learn more about the problem of veteran homelessness and to extend the reach and capabilities of the professionals who work with homeless veterans, there’s plenty of reason to hope the number of homeless veterans will continue to decline – and that more of those veterans who do find themselves homeless, for whatever reason, will receive the care and services they need.

This article first appeared in Veterans Affairs & Military Medicine Outlook.