Improving Community Integration in Homeless Veterans with Serious Mental Illness: A Pilot Study of MI-CBT Enhanced with Mobile Technology

For Veterans with serious mental illness (SMI) experiencing homelessness, obtaining permanent housing is only the first step in achieving stability and improved quality of life. Many recently housed Veterans continue to struggle with many aspects of functioning and day to day living. Difficulties with

community integration, which includes engagement in vocational, recreational, social, and independent living activities, are common. For providers, maintaining connection with these individuals and engaging them in sustained treatment to improve functional outcomes once they obtain permanent housing pose significant challenges. During this critical transition, as Veterans

move from temporary to permanent housing, they are particularly susceptible to falling out of mental healthcare and other VA services. However, few, if any, evidence-based psychosocial treatments designed to increase functional recovery, including community integration, have been systematically applied during this transitional period. Whether such treatments could prove effective in improving

engagement and increasing continuity of care for these Veterans is not known. The current pilot study aims to test the feasibility and acceptability of an 8-week individualized intervention that combines motivational interviewing (MI) and cognitive behavioral therapy (CBT) in a hybrid in-person/remote

format (MI-CBTech) to improve community integration in Veterans with SMI experiencing homelessness. This study has the potential to fill key gaps in treatment options for this high priority population. The long-term goal of the intervention is to return these individuals to functional independence so they may participate more fully in their lives and communities.

For the proposed study, 50 Veterans with SMI experiencing homelessness will be recruited from the VA Greater Los Angeles Healthcare System (GLA) Domiciliary, a residential treatment program. Participants will be randomly assigned to either the MI-CBTech experimental arm or control arm (mindfulness). All participants will be administered interviews (symptom ratings and community

functioning), and assessments of cognitive ability during an in-person baseline visit. Both treatment arms will consist of 8 weeks of active intervention, including three in-person visits (3 MI sessions for MI-CBTech and 3 supportive therapy sessions for the control arm) followed by 6 weeks of mobile

phone application use. During the period of remote application use, both arms will have phone check- ins during weeks 2, 4, and 6 to obtain information on application use and troubleshoot any potential problems with compliance or completion. Participants will complete two repeat assessments of community functioning, one at end of treatment and one at 16-week follow-up.

For feasibility, the primary outcome measures will be participant recruitment (successful target enrollment rate and completion of baseline in-person assessment and sessions) and retention (completion of post-treatment and follow-up assessments). For acceptability, the primary measures will be adherence (application use and completion of homework assignments) and subjective

satisfaction (as measured by a composite satisfaction index). These results will lay the groundwork for a future Merit Review Award application that will support a controlled efficacy study.