The overall goal of the Bridging the Care Continuum for Vulnerable Veterans across VA and Community Care (BridgeCC) QUERI program is to improve health outcomes associated with mental health (MH) and substance use disorders (SUD), expanding access to and engagement in prevention, treatment and supportive services for Veterans most impacted by social determinants of health. While VA has begun to venture beyond the walls of its 170 VA medical centers and 1200 CBOCs, it offers a limited community-based system of care for those with MH and SUD. The Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act recognizes that achieving better Veteran health requires greater partnership with community providers and organizations who may be the first to see a Veteran in crisis. It acknowledges that coordination across systems is required, with each system (VA and community providers) delivering the services in its area of strengths, resulting in integrated, accessible highest quality care for the whole Veteran. This is particularly important for individuals with MH and SUD whom are also homeless and/or criminally justice involved as they often cycle in and out of VA and non-VA care and offer lessons learned for other less vulnerable groups. Therefore, BridgeCC will study low intensity implementation strategies (educational outreach and/or academic detailing) and a high intensity implementation strategy (implementation facilitation) for deploying three evidence based practices (EBPs) addressing opiate overdose prevention, Veterans treatment court participants, and those being released from incarceration. Our implementation of EBPs consists of pre- implementation, implementation and sustainment phases, aligned with the QUERI Implementation Roadmap, and guided by the Dynamic Sustainability Framework (DSF). Our Specific Aims are as follows: Aim 1: Identify pre-implementation barriers to adopting EBPs and implementation strategies across sites. We will conduct formative evaluations with key stakeholders at each of the 18 sites. Process maps will be created to increase our understanding of practice setting variations. Data will be used to develop fidelity-consistent modifications to the EBPs and to our selected implementation strategies. Aim 2: Evaluate the implementation of our EBPs and our selected implementation strategies. Using hybrid type III, stepped wedge designs, we will implement our three EBPs at 18 sites through tailored strategies of implementation facilitation, and academic detailing. Outcomes include linkage to care, incarceration and overdose rates (effectiveness); acceptability, costs, feasibility, and fidelity (implementation). Aim 3: Ensure sustainment of our EBPs through ongoing program planning and stakeholder engagement. Our Technical Expert Panel, VA program partners and each site's key stakeholders will participate in semi-annual EBP sustainability assessments throughout BridgeCC funding. Each assessment will lead to a site-specific tailored action plan, addressing components of the DSF. The Implementation Core will guide each EBP project team through formative evaluations, process mapping and planning for sustainability (pre-implementation phase), fidelity- consistent adaptations, trainings, and assessment of implementation and effectiveness outcomes, including business case analyses (implementation phase) and continuous quality improvement to prevent voltage drop and program drift (sustainment phase). As indicated by the DSF, we will continuously assess fit between our EBPs, our 18 implementation sites and VA stakeholder, program office and VISN priorities. Our Mentoring Core will train a new generation of implementation scientists through experiential, hands-on training including substantive involvement in two EBP implementations, and participation in our existing 12-session Implementation Science Seminar Series, developed by our Implementation Core PI. Our BridgeCC QUERI program will be assessed through National and VISN priority metrics, including those related to access to care.

The overall goal of the Bridging the Care Continuum for Vulnerable Veterans across VA and Community Care (BridgeCC) QUERI program is to improve health outcomes associated with mental health and substance use disorders, expanding access to and engagement in prevention, treatment and supportive services for Veterans most impacted by social determinants of health. We will implement 3 evidence-based practices (EBPs), addressing, respectively, distribution of naloxone to reduce overdoses, treatment of co-occurring mental health and substance use disorders, and social support for formerly incarcerated Veterans. We will use hybrid type III effectiveness-implementation, stepped wedge, cluster randomized trials at 18 VA sites to examine outcomes associated with low intensity implementation strategies (educational outreach and/or academic detailing) followed by a high intensity implementation strategy (implementation facilitation). Our implementation projects are guided by the QUERI Implementation Roadmap and the Dynamic Sustainability Framework.