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VetStar: Justice-Involved Veterans Successful Mental Health Diversion

Authors:

Kevin B. Gittner ,

Kennesaw State University, US
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Lisaann S. Gittner,

Texas Tech University Health Sciences Center, US
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Jeff A. Dennis,

Texas Tech University Health Sciences Center, US
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Lauren M. Matheny

University of Northern Colorado, US
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Abstract

Justice-involved veterans are a unique subpopulation with different mental health needs in pre-trial diversion than civilians. Veteran diversion can be challenging, creating evaluation issues at the program (i.e., development, implementation, outcomes), and individual (i.e., positive outcomes) levels. A case study of VetStar, a unified approach diversion for veterans spanning both the criminal justice and healthcare systems, is presented as a model for diversion of justice-involved veterans. The researchers obtained data from five publicly available sources: recorded radio interviews, VetStar published stakeholder reports, the VetStar Texas Veterans & Family Alliance 2018 grant submission, a photovoice project from the Lubbock Art Walk November 2019, and the Texas Veterans Commission Quarterly Reports and JMHCP Data Review. This case study found 10 major themes. VetStar is a non-profit organization using a modified version of assertive community treatment serving justice-involved veterans with mental health issues. We describe the progression of justice-involved veterans in the VetStar diversion program; 92% of the 571 veterans completing the VetStar program in five years did not re-offend for the same crime. VetStar’s approach could be performed in other subpopulations with distinct cultural identities. Modifications can be constructed and aligned within the construct of the subpopulation identity. Further research is needed to investigate VetStar’s FASTRR model, to help document a more detailed theory of the approach.

How to Cite: Gittner, K. B., Gittner, L. S., Dennis, J. A., & Matheny, L. M. (2022). VetStar: Justice-Involved Veterans Successful Mental Health Diversion. Journal of Veterans Studies, 8(1), 1–14. DOI: http://doi.org/10.21061/jvs.v8i1.246
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  Published on 17 Jan 2022
 Accepted on 02 Aug 2021            Submitted on 26 Feb 2021

Veterans are a sub-population with unique needs because of their military training, combat trauma, and the huge gulf between military and civilian lifestyles (Huddleston et al., 2008). While veterans returning from ongoing global conflicts face an abrupt and perhaps difficult integration back into civilian lifestyle, other factors such as mental health disorders, substance use disorder (SUD), and childhood trauma also contribute to increased risk for justice-involvement (Elbogen et al., 2012; Sreenivasan et al., 2013). Most veterans successfully perform the military to civilian transition (Cooper et al., 2018). However, some veterans stall in the transition, and those with less than honorable discharges have greater risk because fewer programs are available for assistance (Blodgett et al., 2013). The most common offenses among justice-involved veterans are: 29% public disorderly conduct offenses, 25% violent offenses, 24% driving under the influence, and 22% drug offenses (Blodgett et al., 2013). Fifty-five percent of the reported 181,500 veterans incarcerated in 2011–2012 reported having a mental health disorder with mental health diagnosis twice as high in veterans as in non-veterans (US Bureau of Justice Statistics, 2015). Veterans with post-traumatic stress disorder (PTSD) and traumatic brain injury report frequent symptoms of anger and irritability, and also had a 20% higher risk of justice-involvement (Elbogen et al., 2012). Almost a quarter were diagnosed with PTSD (US Bureau of Justice Statistics, 2015). Approximately 60% to 80% of justice-involved veterans had a SUD before arrest (Blodgett et al., 2013). Studies have also shown that substance use dramatically increases the overall risk (3–5 fold higher) of justice-involvement in veterans (Elbogen et al., 2012).

In recent decades, criminal justice diversion programs have been implemented across the US to reduce the number of persons with mental illness in jail. Recognition and funding for programs to divert individuals with mental illness before they get to jail have increased recently. Diverting from jail into specialized treatment programs to understand and resolve the underlying issues of why the individual was involved with law enforcement in the first place appears to have better long-term success in reducing recidivism and increasing treatment adherence (Pinals & Felthous, 2017). In some cases, these programs may target diversion for special sub-populations such as veterans to provide more focused outreach based on a set of shared characteristics. The overall goal of diversion programs is to address an individual’s issues through a continuum of care, including intensive supervision alongside treatment (Huddleston et al., 2008), after the onset of either an acute mental health episode or an encounter with the criminal justice system (Draine & Solomon, 1999). However, diversion from the criminal justice system to healthcare treatment, especially mental healthcare, is often fragmented. Diversion programs frequently focus on reducing incarceration and recidivism; therefore, tracking healthcare use and treatment among diverted individuals is normally not performed because it requires data from multiple systems outside the boundaries of the criminal justice agencies. Diversion in the criminal justice system typically focuses on the length of incarceration and recidivism and rarely accounts for treatments delivered by healthcare providers (Gittner & Dennis, 2021). Individual positive outcomes and effective reintegration into society can be overshadowed by the outcome of lowered recidivism (Huddleston et al., 2008; Slattery et al., 2013).

Many communities offer diversion programs through specialty problem-solving courts serving specific subpopulations, yet veteran-specific courts are a relatively new specialization first introduced in 2008 (Huddleston et al., 2008; Russell, 2009). Problem-solving specialty courts are based on therapeutic jurisprudence. Key components of veteran diversion programs include integrating alcohol/drug treatment, mental health, and other rehabilitation services along with peer-support in the diversion program (Justice for Vets, 2012). Also, veteran recidivism rates are difficult to untangle because of the unavailability of data on different diversion program contents, eligibility requirements, and definitions used for recidivism (Hartley & Baldwin, 2019). Overall, veteran recidivism rates reported range from 0 to >40% (Hartley & Baldwin, 2019). Unfortunately, “[l]ittle is known about best practices that enhance outcomes … [or] follow best practices derived from drug courts, mental health courts, or traditional veteran treatment programs” (Huddleston et al., 2008). The literature points to the need for a unified approach of the criminal justice system and healthcare systems for diversion to be fully successful. The purpose of the reported case study is to examine and describe the FASTRR (Find, Assess, Stabilize, Treat, Reassess, Reintegrate) model used at VetStar, a program that uses a unified approach to diversion. The study will describe the FASTRR components, operational steps, and outcomes.

Materials and Methods

Data were collected from recorded radio interviews, VetStar published stakeholder reports, the VetStar Texas Veterans & Family Alliance 2018 grant submission/reports, and a photovoice project from the Lubbock First Friday Art Trail in November 2019. Demographics data used to describe the case study were collected from the Texas Veterans Commission Quarterly Reports and Justice and Mental Health Collaboration Program (JMHCP) Data Review. See Table 1 below.

Table 1

Data Sources.


DATA TYPE SOURCE

Recorded Interviews (13) AM580 KRFE

Grant Applications and Quarterly Reports (5) Texas Veterans Commission Awarded Grant

Stakeholder Reports (2) VetStar Annual Reports

Photography Project Materials (3) Art Walk

Demographics Texas Veterans Commission Quarterly Reports and JMHCP Data Review

Recorded radio interviews were publicly available from AM580 KRFE radio station (August 2018–January 2020). Radio interviews were conducted with VetStar employees, volunteers, veterans who have received assistance through VetStar, organizations that work with VetStar, and other military-related guests. A total of 19 recorded interviews were found, with 13 interviews directly relevant to the VetStar program (Stewart & Gittner, 2018, August 7a, 2018, August 7b, 2018, August 7c, 2018, August 28, 2018, December 18, 2018, January 8, 2018, November 13, 2018, November 20, 2018, October 9, 2018, October 16, 2018, October 23, 2018, October 30, 2018, September 4, 2018, September 11a, 2018, September 11b, 2018, September 25, 2020, January 24, 2020, November 18, 2020).

This study did not directly contact or interview any individuals and used only publicly available information for analysis. As such, the project did not require Institutional Review Board approval. Although interviews were publicly aired and recorded, names were not attached to quotes to preserve a certain level of anonymity. VetStar stakeholder reports are published on www.VetStar.org (VetStar, 2016, 2017). The VetStar Texas Veterans & Family Alliance grant is publicly available and has been widely shared in the community by VetStar. The grant was prepared for submission in 2017 for funding in 2018. In the November 2019 Art Walk, VetStar interns used the photo voice project to present general information and veterans’ viewpoints to the community. Texas Veterans Commission Quarterly Reports report summaries about veteran’s justice and mental health in Texas. JMHCP annually reports summary data about justice involvement in the region.

Data Analysis

A case study approach utilizing multiple sources of information was used to provide an in-depth analysis of the bounded VetStar program (Clark & Creswell, 2008; Creswell & Poth, 2018). A constructivist approach was used to develop and formulate themes and document a rich, detailed case description (Creswell & Poth, 2018). The raw data were used as the foundation for the thematic analysis; the codebook was developed during the analysis. With intent, the researchers who performed the analysis had a basic understanding of the VetStar program but were not familiar with specific details and the extent of how the program worked before starting the analysis process.

The qualitative researchers on the team initially reviewed the interviews to screen for relevance to VetStar. During the process, emergent themes embedded in the data was identified as using a hermeneutic approach of reading, marking, annotating key phrases/words, and then comparing within and between sources for key phrases/words. One of the most common pitfalls of analyzing qualitative data is having an a priori opinion of the emergent codes/themes before beginning analysis (Sandelowski, 1995); to assure that this did not occur, the researchers who performed the analysis were independent of each other and naïve to the VetStar program. Upon confirmation of relevancy, the recordings were transcribed using Otter.ai and then confirmed for accuracy. All data, including transcripts, pictures, and publicly available data, were uploaded into NVIVO 12, and a spiral technique was utilized to organize findings (Creswell & Poth, 2018). Familiarization of data was completed by reading and re-reading transcripts, while the codes and themes were organized with concurrent critical evaluation of any new reoccurring themes. The processes of data collection, data preparation, codebook development, theme analysis, and interpretation overlap temporally and conceptually in qualitative work (Sandelowski, 1995). Qualitative research is an iterative and emergent process that is different than the static sequencing and linearity of quantitative research (Sandelowski, 1995). Any new themes identified then required all previously analyzed data to be confirmed. Consistency of data analysis was assured by the use of systematic coding procedures to produce dependability for the emergence of convergent and divergent themes; a master codebook was developed and then refined as subsequent data was analyzed. Coding consistency uses systematic coding procedures to produce confirmability, so others can use the same data, follow the same procedures, and the assignment of the same or similar themes to respondent answers will occur (Clochesy et al., 2015; Cope, 2014). Qualitative research uses trustworthiness and credibility as the components to assure responsible research (Lincoln & Guba, 1986). Thematic techniques do not provide statistical tests of significance, so themes were deemed emergent because the analysis used consensus from independent researchers for identification and confirmation of themes were validated with literature and member checking with the VetStar Director providing credibility (Floersch et al., 2010). Also, because thematic techniques do not provide statistical tests of significance, themes are significant by: (a) skillful identification of new themes and confirmation of themes identified in the extant literature, and (b) confidence in the systematic nature of the coding procedure (Clochesy et al., 2015).

Trustworthiness

To ensure the trustworthiness of the findings: (a) multiple reviews of the data were performed, (b) data and investigator triangulation was implemented, and (c) member checking was performed. Both method and investigator triangulation were used, bringing both confirmations of findings and different perspectives to the analysis (Carter et al., 2014). Method triangulation involves the use of multiple types of data about the same phenomenon including interviews, and written documents (Carter et al., 2014). Investigator triangulation involves the participation of two or more researchers in the same analysis to provide multiple observations and interpretations (Carter et al., 2014). A second researcher (again naïve to VetStar program) coded two recordings, and no new themes were identified (Carter et al., 2014). Member checking was utilized with the VetStar Director by discussing all emergent themes, asking if anything was missed, and reviewing the radio transcripts, Art Walk documents, quarterly reports, and stakeholder reports. In addition, they discussed the researchers understanding of the codes and themes (Carlson, 2010), and the Director then provided the Texas Veterans Commission Awarded Grant document and follow-up grant reporting summaries. Member checking confirmed the accuracy of the analysis with no additional emergent themes. Thick, rich descriptions were used to increase the confirmability and transferability of findings. An audit trail was created, beginning with the data collection process, and culminating in the reporting of findings. Combining credibility, transferability, and dependability with the short discussion of the data analysis technique and theoretical approach allows for the analysis’s confirmability and demonstrates rigor (Nowell et al., 2017).

Description of Case

Texas contains the second-largest veteran population in the US. In west Texas, over 105,000 veterans are spread across the mostly rural region of approximately 39,800 square miles (VA Veteran Population Projection Model, 2017). In Lubbock County, there are approximately 42 arrests daily, with ≥2 of those arrested are veterans; there are 15,000 bookings each year, rates of arrest for veterans (1.6/100) are about the same as rates of arrest for the general population (1.8/100). VetStar is a non-profit subsidiary of the local mental health authority for Lubbock County that operates in 32 west Texas counties (Nov 2018) with a budget of approximately $1.3 million in grant and donation funding (VetStar, 2018). VetStar’s primary mission is to fill the gap left by traditional programs by finding and supporting vulnerable veterans before or immediately after justice involvement to obtain treatment and then continue support indefinitely to assure reintegration within society (VetStar, 2017, 2018). “VetStar has spent the past 8-years building collaborations” (VetStar, 2017) in west Texas with active jail diversion to treatment with veterans beginning in 2015. Approximately 50% of veterans arrested in the region required some type of mental health or SUD intervention.

Find Assess Stabilize Treat Reassess Reintegrate (FASTRR) Model Description

VetStar uses the FASTRR (Find, Assess, Stabilize, Treat, Reassess, Reintegrate) model (VetStar, 2018) based on Assertive Community Treatment (ACT) model (Roberts, 2002) developed in the 1970s for individuals with serious mental illness (VetStar, 2017, 2018). VetStar’s FASTRR model is based upon the ACT model. The critical components of the ACT model are low caseloads so intensive interaction can occur between staff and patient; an integrated multidisciplinary team so wrap-around services can be provided; 24/7 availability; team autonomy for problem-solving; and part-time professional counselor/psychiatrist input (Udechuku et al., 2005). The ACT model has shown effectiveness in individuals with serious mental illness to reduce emergency room and hospital visits (Phillips et al., 2001), increase the quality of life during daily activities (Kim et al., 2015), and improve both social and occupational functioning (Udechuku et al., 2005). The ACT model is effective at engaging high-risk patients into community-based healthcare and social services (Phillips et al., 2001); but ACT requires intensive staffing, high staff to patient ratio, aggressive outreach, and 24/7 staff availability (Lamberti et al., 2001; Phillips et al., 2001). The ACT model has shown reductions in hospital and emergency room utilization. Most studies show little to no effects on arrests, recidivism, and length of jail stays (Lamberti et al., 2001). Although, the ACT model is associated with fewer convictions for new crimes and longer adherence to outpatient mental health treatment (Lamberti et al., 2017). Critics of the ACT model point to the high costs of the intensive initial treatment and support, but the cost is lower in the long-term (Clark et al., 1998). VetStar, when developing FASTRR, considered the high costs of the “stabilize and treatment” components while building in the relatively low-cost long-term 3–5 year “reassess and reintegration” support to each veteran utilizing peer support rather than clinical support.

There has only been one study conducted on ACT within a veteran population with mental illness (Rosenheck & Neale, 1998). The ACT program at the Veterans Administration (VA) showed participants had greater use of outpatient services and fewer hospitalization at most sites, but the results are inconclusive compared to veterans receiving standard mental healthcare (Rosenheck & Neale, 1998). There was a significant limitation in the VA ACT program because fidelity to ACT core components was not standardized. Thus, there was no way to separate the impact of program design from the influence of implementation conditions at each site (Rosenheck & Neale, 1998). Published reviews of implemented ACT models revealed significant variability in program structure, daily operations, and treatment populations served. Thus, outcomes for these programs have been mixed (Lamberti et al., 2017).

This is the first time the FASTRR model has been used in practice for any population, including veterans. Standard therapy was not slowing down the jail recidivism rate for justice-involved veterans, so VetStar developed the FASTRR model (Figure 1) as a novel intervention for implementation. FASTRR builds upon ACT programming by actively finding veterans during initial detention to identify unaddressed veteran mental health issues. The ACT model requires intensive, long-term service for individuals reluctant to engage in traditional mental health treatment and has substantial outreach and engagement activities to remain engaged in treatment (Hayes et al., 2006; Roberts, 2002). FASTRR is a unified approach diversion beginning in jail and the community long after jail release and healthcare treatment discharge. VetStar’s FASTRR model is a 6-component intervention: Find, Assess, Stabilize, Treat, Reassess, and Reintegrate; it is not always sequential and varies depending on context and situation.

FASTRR Application in the Community
Figure 1 

FASTRR Application in the Community.

  1. Find: General community outreach is a major offering VetStar provides to increase knowledge about support programs. Community outreach helps VetStar adjust to changing veteran needs, while anchoring VetStar in West Texas as a resource for all veterans. Referrals are actively solicited from the community, law enforcement, and healthcare providers.
  2. Assess: VetStar responds 24/7 to veterans in crisis. VetStar responds to crises, both escorted and unescorted, by first responders. VetStar helps justice-involved veterans navigate the criminal justice system using mediation and advocacy by identifying justice involved-veterans, networking with prosecutors and judges, designing treatment for trauma, mental health, and SUD, and implementing crisis interventions. Initially, a complete needs assessment is performed (physical, mental, social) to facilitate the linkage between the assessment process and individual service plan. Depending upon the immediacy, level of support needed, and location of the veteran (e.g., jail, homeless, hospital, private residence), care is provided by VetStar, or a partner agency trained by them in veteran cultural competency. Depending upon the veteran’s needs, arrest charges, and military discharge status, a plan is developed to restore bio-psycho-social functioning in the community.
  3. Stabilize: VetStar transports the veteran to the next level of care. Some veterans may already have stable, safe housing. Still, if a veteran does not have housing or is at risk of losing current housing, shelter is immediately provided using the housing first approach (Montgomery et al., 2013; VetStar, 2017). After housing, stabilization continues meeting emergent needs (e.g., clothing, food, childcare, utility assistance, government paperwork assistance, financial assistance, and transportation).
  4. Treat: Evidence-based treatment for mental health and SUD is offered through both in- and outpatient options. The VetStar treatment coordinator streamlines referral to inpatient care. Outpatient care is offered either at VetStar or through partner agencies trained in veteran cultural competency. In addition, the veteran’s family is also integrated into treatment.
  5. Reassess: At treatment completion, the veteran is reassessed to determine appropriate case management through a wrap-around service plan. The plan is designed to catch the veteran before destabilization. The plan can include one or all of the following components: ongoing mental health support, facilitating access to healthcare, employment, vocational training, college support, food security, service dogs, financial counseling, legal aid, peer social support.
  6. Reintegrate: Once veterans receive any service, they are asked to join a peer support task force to “give back” to other veterans. The task force is managed by VetStar mental health case managers skilled in facilitating peer support groups, fostering mentoring relationships, and providing constant community situational awareness of each veteran’s status. Veterans in treatment report better relationships with other veterans and view peer relationships as critical to remaining stable (Greden et al., 2010; Laffaye et al., 2008). Reintegration is critical in reducing recidivism risk by lowering risk factors such as negative family circumstances, lack of positive work and social activities, and involvement with anti-social associates (Blodgett et al., 2013).

FASTRR model spans the criminal justice system, healthcare system, and the community. When a veteran is found, either already justice-involved or at risk for justice-involvement, the veteran is cycled through assessment, stabilization, and treatment. Transitions occur during the treatment/stabilization period between the justice system and the community. Continual reassessment continues in the community even after reintegration and can lead back into stabilization and treatment.

Results

Descriptive Data

Since 2014, 92% of the veterans who have completed treatment at VetStar for mental health or substance use, have not re-offended for the same crimes (VetStar, 2017, 2018). Unfortunately, VetStar did not collect on whether the veteran subsequently was arrested for other types of crimes after completing the program. The program enrolled and diverted 292 veterans from 452 veteran bookings in 2018 and 279 veterans from 356 veteran bookings in 2019 veterans (Note: approximately 25% of veterans (202) were released from jail less than 24 hours from booking; VetStar was unable to contact many of them once they were released). Out of 292 veterans in 2018, 30 went to residential treatment centers, six were treated for more than one co-morbid condition in inpatient settings, and local outpatient interventions served the rest within the community.

From June 2018 to March 2019, different veterans attended the following therapies: 42 equine therapy, 178 bi-monthly check-ins, 76 Seeking Safety programs, and 26 attended clinical mental health family counseling (1SG Gregory F. Gittner, personal communication, October 30, 2020). Twenty-nine spouses and three children attended outreach mental health services. The housing initiative averages 11.25 days from homelessness to stable housing (VetStar, 2017, 2018). In 2019, 70 veterans and families were placed in stable housing (i.e., 280 months of rent paid at the cost of $141,670). None of the veterans (42) using equine therapy have remained homeless (1SG Gregory F. Gittner, personal communication, October 30, 2020). VetStar assistance was offered to 808 veterans who were booked into the Lubbock County Detention Center during the time; 202 were unable to be contacted because they were released less than 24 hours after arrest. We report descriptive data on the 571 veterans and families participating in the program; the data was obtained from reports for the Texas Veterans Commission Awarded Grant (1SG Gregory F. Gittner, personal communication, October 30, 2020). The participation rate was 95.7% in the program. See Table 2 below.

Table 2

Demographics of the VetStar’s Clients.


DEMOGRAPHICS 2017 2018

White 146 (46%) 152 (49%)

Black 70 (22%) 69 (22%)

Hispanic 92 (29%) 89 (29%)

Male 304 (96%) 292 (94%)

Female 14 (4%) 19 (6%)

Note: There is missing data and totals are not equal across categories (TV&FA 2017 grant application); 2019 data is currently unavailable.

Qualitative Themes

Major themes generated from the analysis of the oral radio interviews are presented; the themes deepen our understanding of extant knowledge about the object of inquiry (Clochesy et al., 2015). Qualitative research methods are deployed to understand and describe new contextual issues and topics, requiring data from the bottom-up perceptions, understandings, and participants voices.

“So, I Served”

“While I was in the Airforce back in <location>.” Rank, number and length of tours, tour locations, branch of service, and how they processed into and out of the military were consistently discussed. Interviewees who were not service members themselves discussed service of the spouses, parents, or grandparents. The continuous discussion about service was a segue for both the interviewer to develop rapport with the interviewee while at the same time developing rapport with VetStar staff. “[He-VetStar Staff Member] just started talking to me, military to military, gained a little bit of rapport.” By establishing connections to the military service, VetStar could better connect similar veterans into peer groups for ongoing peer support. Reintegration is one of the tenets of FASTRR, ongoing peer support is created between veterans in the program, VetStar staff, and others who have successfully transitioned to civilian life because of a similar service branch, duty station, or tour posting. The theme demonstrates how looking for common ground can lead to connections that quickly build rapport.

“Unfortunate Circumstances Strike”

Life-changing events may have initiated contact with the criminal justice system, the healthcare system, or the local authorities, yet the events ranged in scope. One veteran said, “I lost my job and ended up on the street,” whereas another said, “I just snapped. I attacked my wife. And then, when she ran out of the house, I grabbed my pistol. And I was done […] I ended up in jail.”

Some of these events were the culmination of a life spiraling out of control. A family member said, “He sold his truck and attempted to rob a convenience store in an effort to support his drug habit.” Other stories entailed complications from military service, a veteran talked about another veteran, Those injuries, and subsequent attempts to treat those injuries left him in a wheelchair.”

Some events sent veterans on a trajectory requiring support, while other events may seem mundane, such as their bike being vandalized, highlighting the fact that all events span a wide range of issues. A VetStar staff member said, sometimes “A Vietnam or Korean veteran […] needs a yard mowed, or just needs someone to talk to,” before the zoning office issued a citation or the family decided to remove the veteran from their home. The find component of FASTRR was captured within this theme. Finds varied; it could be a visitation from VetStar staff with a veteran inmate in the detention center, a phone call from a police officer asking for a VetStar staffer to meet them and a veteran on the street, it could be a request from SWAT to come to an incident, a call from the zoning officer before a zoning violation case is referred for prosecution, a call from a public defender to meet their client and/or a call from a concerned citizen about a veteran they know. Each case is different, varying in degree from mundane to life-threatening but all included some type of event that could change the veteran’s life trajectory.

VetStar Introductions

Community connectedness is part of the FASTRR model. A law enforcement officer and VetStar staff discussed as the program visibility increases, the community is more likely to identify and refer veterans in need of support services. Introductions to VetStar varied, whether the veteran got a visitor in jail, or the spouse of a combat veteran needed an internship and “found that military family that I had been missing.” VetStar is networked within the community through a radio outreach program, law enforcement, and other veterans looking out for their fellow military families. A veteran said, “I think he gave [VetStar] my information and said hey, you might want to go check on this vet.” Interviewees discussed VetStar’s integration within the entire community. Many times, someone who either was previously served by or worked with VetStar would make a referral to check on struggling veterans. Interviewees many times were not quite sure how VetStar found them. Find and reintegrate go together because taskforce members are not only receiving and providing peer-support, but they are also involved in finding other veterans in need.

“Let’s Put a Game Plan Together”

Once veterans are found, VetStar mobilizes them to use all available resources using their FASTRR model. Each case is assessed individually, and a plan is developed. Components of the plan include immediate basic need stabilization (i.e., food, shelter, and medication); VetStar staff discussed, “Using the ‘housing first strategy, he was put in a hotel for the night [and] given food.” Then, the veteran undergoes a screening process which includes their physical and mental health status assessments, financial status, legal status, and eligibility for different services. “VetStar [is] able to begin the stabilization process to assist […] in various areas.” VetStar uses a network of organizations and services to then enact the game plan to transition the veteran from dependency on VetStar to utilization of community services and eventually to become as self-reliant as they can. A vast array of community connections is mobilized for each veteran. A staff member at community organization said, “[VetStar] work(s) between all the many different agencies” to help resolve issues. The FASTRR components to stabilize, assess, and treat are used as a plan that includes treatment, legal, financial, housing relationship, and employment issues.

VetStar Network

Many of the AM 580 KRFE radio interviews discussed the VetStar network, “…been working really closely over the past few years building relationships.” Through these relationships, VetStar has developed a vast network of organizations to partner with, including 74 different external agencies. Organizations included the west Texas justice system and law enforcement agencies, Veterans Health Administration, local and statewide support programs, local businesses and news/marketing organizations, and a local University. The vast network of contacts and organizations means “there’s a lot of options and referrals that [VetStar] can provide.” The components of FASTRR, find, treat, and reintegrate are demonstrated by VetStar’s use of this network of agencies to assure each veteran receives what they need.

Transition Roadmap

Many veterans have discussed the difficulties of coming back to the civilian world. A veteran said, “I’m kind of off now to, you know, we all end up having these transitional issues […] and I’m asked to become civilized again.” A consistent theme is that all veterans have issues transitioning back; however, what differentiates each story is the level of difficulty. The Veterans Health Administration (VA) serves millions of veterans annually. However, the VA system has many barriers creating access gaps, especially in rural counties (Elnitsky et al., 2013; US Department of Veteran Affairs, 2017). A VetStar staff member said, “Most of our veterans do not have time to wait for state and federal gaps in services to be filled. This is VetStar’s location in the battlespace. We are the gap-fillers. We move quickly.”

“I Want to Thank [VetStar] for Their Help”

Through 2017, 522 successful jail interceptions were logged (VetStar, 2018), and while it was not a 100% success rate, “Even if they didn’t complete the program, that they can come back, and we will start again.” One veteran summed up his success through VetStar, which was repeated by others.

I couldn’t have done anything, any of this without VetStar. If it wasn’t for the donations, if it wasn’t for the people that volunteer with VetStar, if it wasn’t for the people working there, I honestly don’t think I would be here. I didn’t know the roadmap to get out, but VetStar, because they were in the right state of mind, and they’ve got enough resources to pull from. They were able to help me develop that roadmap, but honestly it couldn’t be done without them.

Once veterans are given a “hand up” during their transition, veterans “essentially just pick up where [VetStar] leave[s] off and can be self-sustaining.” While the program success was echoed by many other veterans, volunteers, and staff, it would not be fair to overlook program failures. In all successes, there are always challenges. While the goal is to help every veteran, not every veteran wants or can accept help. The only failure that had a profound effect on a long-time staff member disclosed in over 6-years of applying the FASTRR program,

After three months, he just came in one day into my office, threw the keys on the desk and say that’s it, I can’t handle the pressure and responsibility of having to hold a job knowing I have this monthly bill over my head. I just emotionally cannot deal with it and that’s the only [veteran] in <xxx> I’ve ever had like that.

“I Found My Mission”

A veteran said, “Once a veteran receives any VetStar services, they are asked to join [Taskforce Lubbock] TF-LBB to ‘give back’ to other veterans.” The most important piece to FASTRR is the networking of veterans and veterans’ families with civilians, the local community, and businesses that form the backbone of the find, assess, stabilize, reassess, and reintegrate components. The development of a peer network supports veterans who are struggling, but “We found that’s kind of therapy in itself, a working therapy.” Veteran peers can find a “new mission” leading to a sense of belonging. The veterans are encouraged to form mentoring relationships with successful veterans in the community; the relationships foster reintegration and provide periodic reassessment. A veteran peer mentor said,

[VetStar] finally gave me a chance to help one vet move and after that, it was all she wrote. I was showing up every chance they needed somebody … it was probably an insignificant moment in [my mentor’s] time, but it was a huge moment for me. Time and time again, veterans stated that volunteering was the “new mission” they sought, one said, “they started giving me a place where I could volunteer; to get that fulfillment of being around other veterans, of helping other veterans that are struggling, and they allowed me to use my story and where I’ve been to assist other veterans. It’s therapeutic.”

Program Description

The extensive list of services and opportunities discussed were: (a) housing needs, (b) beyond housing needs, (c) support and therapy, (d) justice-involved, (e) transitional roadmap, and (f) community outreach. A member of the VetStar staff said,

We are a one start shop, so we want to be able to either connect you to who you need to be connected to. We want to see […] where you do qualify. We want to get you plugged in with other veterans that can help you.

VetStar is the place to start when veterans are in need, as emphasized in the commonly referred to “one start shop” comments from the interviews. Veterans can utilize any or all the unique supports discussed through the interviews. The services are not mutually exclusive, with many resources overlapping with others and are all used as part of FASTRR stabilize and treat steps.

Housing Needs. During the AM 580 KRFE radio interviews, one of the VetStar staff explained, “The Housing First approach assumes that people should start with stable permanent housing.” VetStar has adopted housing as the first objective upon any introduction to a veteran. Some veterans may already have stable, safe housing options. Still the goal is to ensure if a veteran does not have housing or is at risk of losing their current housing, the housing need is immediately fulfilled. Additional needs come along with housing, including home furnishings, home repairs, and home modifications, all of which VetStar can provide. Once housing is stabilized, more extensive services are provided. In the FASTRR model, stabilization of housing is the basic foundation for all other supports.

Beyond Housing. Many other services may be necessary to help veterans get back on their feet and remain on a trajectory for success. These services are part of FASTRR reassess and include career counseling and job networking to ensure financial stability. Other needs may include access to food, childcare, utility assistance, paperwork assistance, financial planning, and transportation.

Support and Therapy. Again, during the AM580 KRFE radio interviews, one of the VetStar staff explained, “Positive coping skills for the veterans [are] tools that they can use.” The trauma some veterans carry requires a strong support system as well as mental health counseling. Staff said, “There is some adolescent and child therapy available […] we do family group therapy.” In addition to therapy with trained counselors, therapy options include family therapy, couples therapy, equine therapy (experiential mental health treatment that involves interacting with horses and the counselor), peer veteran support groups, and horticultural (i.e., gardening) therapy. VetStar integrates support from peers who may have had similar experiences into the therapy process. It is the combination of shared experiences and peer support integral to VetStar’s tenets of FASTRR reassess and reintegrate.

Justice-Involved. A veteran said, “VetStar spends an enormous amount of time in mediation and veteran advocacy.” The VetStar justice outreach program has many components such as: finding veterans that have entered the system, speaking with prosecutors and judges, setting up treatment for trauma and substance abuse, and developing and implementing a crisis intervention strategy. Staff from a community organization said, “Navigating this process, by linking [veterans] to resources that can help them out of that situation” is the VetStar objective for justice-involved veterans. Part of the FASTRR find, assess, and reintegrate steps include providing services for incarcerated veterans, there is a plan for their release. Depending upon the individual, VetStar may directly transport to treatment, provide six months of stable, supportive housing, assist with employment/retraining. When veterans are incarcerated, the ability to organize these resources is limited. VetStar has served 522 veterans directly in jail and after their release (VetStar, 2017, 2018).

Community Outreach. Staff at other community organizations talked about VetStar offering courses/training and continuing education related to veterans to local law enforcement, veteran’s organizations, and the local university. VetStar has an ever-increasing volunteer network comprised of veterans, civilian volunteers, and community businesses. Additionally, they work with other veteran organizations to host events and fundraisers for veterans. Community outreach helps VetStar grow and develop while anchoring VetStar in the local community as a resource for all veterans.

Limitations

The case study of a successful diversion program for justice-involved veterans potentially has limited generalizability. Case study design can be used to inform practice; however, the context needs to be considered when replicating the program. This study was conducted using secondary data.

Discussion

This case study describes the components of a unified approach to diversion, FASTRR model, for veterans. The components of FASTRR are foundational to VetStar’s outcomes, and subsequently, the veterans’ reintegration. Veterans have expressed their gratitude for VetStar and their inclusive approach in providing essential support services. Many stated that had it not been for VetStar bridging the gap in the continuum of care, they most likely would have been limited to accepting disjointed criminal justice and healthcare system services without a clear pathway for healing and reintegration.

Evidence is limited regarding the effectiveness of criminal justice diversion programs (Gittner & Dennis, 2021). VetStar utilizing FASTRR provides a model of diversion navigating the complex interplay between the criminal justice and the healthcare systems, and benefits from a collaborative network of law enforcement and mental health organizations in its service region (Croft et al., 2016; Dennis et al., 2019). Without such community collaboration, the outcomes of VetStar would likely be attenuated; for veterans, who experience disconnection from the community and traditional mental health treatment, substantial outreach and engagement activities are necessary to keep them engaged (Hayes et al., 2006; Roberts, 2002). Our results of ≥90% of justice-involved veterans engaging and complying with mental health treatment is similar to the Veterans Health Administration (VHA) Veterans Justice Outreach (VJO) program for homeless veterans (Finlay et al., 2016). In the VJO program, veterans who lived in urban areas (compared to rural areas) or who were homeless (compared to housed) also had higher odds of engaging in treatment (Finlay et al., 2016). Our results differ from the VJO program because we found no difference in treatment engagement between housed and homeless veterans; in addition, our population was rural. The FASTRR model fosters reintegration because the community is involved right from the start of treatment, demonstrating the connectedness of the community with and for the veteran, and integrating the veteran into the community as part of the solution for the next veteran.

It appears that better outcomes are achieved by using holistic case management within one organization, no matter what system (criminal justice or healthcare) initially had jurisdiction. The VetStar program at initial contact with veterans has a similar approach as the VJO program; however, VetStar provides much more support during and after treatment. The VJO program is not per se a jail diversion program, however, the program coordinates with the justice system to connect eligible veterans with health care and benefits. Almost all veterans (97%) who entered VHA care after contact with the VJO program suggest these veterans are much better at connecting to care than the general VHA patient population (Finlay et al., 2016). The VJO program utilizes holistic case management across the sectors to assure appropriate care (Finlay et al., 2016), which is similar to the initial FASTRR components (Find, Assess, Stabilize, Treat) of the VetStar approach. A unified approach across the criminal justice, legal, and healthcare systems embedded in the community address the totality of needs for veterans, as exemplified by VetStar applying FASTRR. Through our case study themes, we see the progression of justice involved veterans, from the “unfortunate circumstance” to the new mission’s uplifting direction giving them purpose and active involvement in VetStar.

The veteran subpopulation is unique because basic training creates a shared military identity during their military career and into their life as a veteran (Demers, 2011); the shared military identity could be a key component difficult to replicate in other subpopulations. However, in subpopulations with distinct cultural identities, modifications may plausibly be constructed and aligned within the construct of the subpopulation identity. A consistent theme in this study was cultural identity and belonging. Although VetStar includes a mentorship component, the shared military experiences foster a true sense of belonging and relatability between the peer mentee and mentors. A previous study of veterans’ courts in Massachusetts provided evidence that the method of veteran engagement and diversion program recruitment could be construed as coercive by veterans (Trojano et al., 2017). Combat veterans may perceive an obligation to enroll due to their acculturation to compliance during their service (Trojano et al., 2017); in the VetStar program, the theme of shared experiences and peer support was continually reinforced to counteract any pressure the veteran might perceive to join the program. Through a trusted relationship, veterans can develop confidence that their VetStar mentors will be there when needed, which aids in accepting support, and eventually the final stage of reintegration. The need to belong is critical for successful reintegration (Demers, 2011), surpassing any other factor for veterans trying to bridge the civilian/military cultural gap (Albertson, 2019; Demers, 2011). Maintaining Independence and Sobriety through Systems Integration, Outreach, and Networking-Criminal Justice (MISSION-CJ) is another veteran jail diversion program that is currently being developed. The program has four components, critical time intervention, dual recovery therapy, peer-support, and vocational skill building (Smelson et al., 2015). Each stage of MISSION-CJ program has formalized sessions and outcomes have been mixed with a 4.8% recidivism rate and small but not significant increases in treatment access and compliance (Smelson et al., 2015). The peer support component of MISSION-CJ utilizes a formal 11 session program (Smelson et al., 2015) versus VetStar’s FASTRR ongoing mentoring peer support through monthly shared group projects. Thus, when a veteran participant in the VetStar program says, “they found their mission,” and subsequently, they also reintegrated and found belonging within the community. VetStar has created a veteran peer group that functions within the civilian community but also is separate from the civilian community. The VetStar peer-group has a military-orientation fostering a sense of belonging which has been shown as critical to the success of peer support programming and successful military-to-civilian transition (Albertson, 2019; Demers, 2011; Smelson et al., 2015).

Conclusion

The described outcomes are based on holistic case management by one organization, VetStar, no matter what system (criminal justice or healthcare) initially had jurisdiction. FASTRR, as implemented by VetStar is a unified approach to diversion embedded within the community, offering veterans a concerted effort of support services, especially following justice involvement. The FASTRR components are consistently applied in the daily operations of the VetStar program. Discussions with volunteers, staff, and outside organizations reinforced the idea that a unified approach to diversion in the veteran population can successfully reintegrating veterans into civilian life. The FASTRR program has the potential to apply across subpopulations with appropriate cultural/contextual modifications and could be administered uniformly through the expansion of specialty problem-solving courts. Further research is needed to investigate VetStar’s FASTRR model to help document a more detailed theory of the approach by grounding it in evidence. The next steps could be the implementation and testing of the FASTRR program in either a different subpopulation or in a different veteran context.

Competing Interests

The authors have no competing interests to declare.

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