Start Submission Become a Reviewer

Reading: Applying Implementation Science Methods to Address Barriers to Employment Services Offered t...

Download

A- A+
Alt. Display

Research

Applying Implementation Science Methods to Address Barriers to Employment Services Offered through the United States Department of Veterans Affairs Health Care for Homeless Veterans Program

Authors:

Meagan Cusack ,

Center for Health Equity Research & Promotion, U.S. Department of Veterans Affairs; School of Social Policy & Practice, University of Pennsylvania, US
X close

Allyson Varley,

Birmingham VA Health Care System, U.S. Department of Veterans Affairs, US
X close

Ann Elizabeth Montgomery

Birmingham VA Health Care System, U.S. Department of Veterans Affairs; National Center on Homelessness among Veterans, U.S. Department of Veterans Affairs; School of Public Health, University of Alabama at Birmingham, US
X close

Abstract

Connecting veterans with employment services can address housing instability. This paper describes barriers to implementation of employment services within the US Department of Veterans Affairs (VA) Health Care for Homeless Veterans (HCHV) program and identifies strategies for improving implementation efforts. We conducted qualitative telephone interviews with HCHV Employment Specialists (N= 16) between December 2019 and March 2020 and analyzed transcripts using a template analysis approach and aligned identified barriers within the domains of the Consolidated Framework for Implementation Research (CFIR) with implementation strategies established through the Expert Recommendations for Implementing Change (ERIC) project using the CFIR-ERIC Implementation Strategy Matching Tool. Barriers within the intervention’s characteristics consist of its complexity and a lack of evidence-based practices. Inner setting barriers include insufficient resources to support service provision and a lack of knowledge, information, and feedback. Outer setting barriers include inadequate resources to respond to veterans’ needs, transportation limitations, and employer hiring practices. Within characteristics of providers, a lack of self-efficacy and satisfaction with organizational commitment serve as barriers. Finally, ineffective strategies to engage veterans and employers and insufficient feedback about the progress and quality of implementation act as process barriers. ERIC strategies to overcome these barriers fall into four categories: identify champions and build coalitions, formalize implementation efforts, improve education and training opportunities, and develop approaches to better implement services at new locations. Identified barriers and strategies can inform vocational development services provided through both HCHV Employment Specialists and other providers to support better employment, housing, and health outcomes among participants.

How to Cite: Cusack, M., Varley, A., & Montgomery, A. E. (2022). Applying Implementation Science Methods to Address Barriers to Employment Services Offered through the United States Department of Veterans Affairs Health Care for Homeless Veterans Program. Journal of Veterans Studies, 8(1), 255–265. DOI: http://doi.org/10.21061/jvs.v8i1.313
51
Views
15
Downloads
2
Twitter
  Published on 27 Jun 2022
 Accepted on 04 Apr 2022            Submitted on 19 Oct 2021

Veteran homelessness continues to be a concern in the United States. Following a 47% reduction in veteran homelessness between 2010 and 2016 (Henry et al., 2021), progress towards ending veteran homelessness stalled, leading the Secretaries of the US Departments of Housing and Urban Development (HUD) and Veterans Affairs (VA) to release a joint statement indicating their commitment to ending veteran homelessness, in part by ensuring veterans have access to quality supportive services (United States Department of Housing and Urban Development, 2021).

To identify veterans experiencing housing instability and connect them with needed services, VA administers the Homelessness Screening Clinical Reminder at least annually in Veterans Health Administration (VHA) outpatient facilities across the United States (Montgomery et al., 2013). Though a small proportion of veterans report housing instability (1.8%) and most resolve their housing issues prior to a subsequent screen (85.0%; Byrne et al., 2015; Fargo et al., 2017), additional support through employment services may assist veterans who face ongoing housing instability.

Veterans are more likely to report work limitations and dropping out of the labor pool and are less likely to have full-time employment compared with their civilian counterparts (Kramarow & Pastor, 2012; Tessler et al., 2005; US Department of Labor Bureau of Labor Statistics, 2021). Even among younger cohorts of veterans for whom employment is a key indicator of successful reintegration following military service, difficulties at work and job loss are significant barriers to employment (Kleykamp, 2013). Moreover, veterans with recent experiences of housing instability describe how financial difficulties (e.g., low or no income, debt, lack of funds to move into housing) lead to housing issues and identify affordability as a crucial component of housing stability (Cusack et al., 2020; Montgomery et al., 2020).

Increasing “meaningful and sustainable employment” is a key objective of Opening doors: The federal strategic plan to prevent and end homelessness (United States Interagency Council on Homelessness, 2015, pp. 40–41). In recognition of the important role employment plays in housing stability, the VHA Homeless Program Office offers vocational development opportunities through Homeless Veteran Community Employment Services (HVCES). HVCES offers a range of employment services from staff embedded in VHA Homeless Programs who act as a bridge to local employment opportunities and resources. Staff provide individualized support to help veterans overcome employment barriers and collaborate with existing VHA and community based service providers to improve veterans’ employment outcomes. Since the implementation of HVCES in 2014, rates of employment have increased among veterans participating in a variety of VHA Homeless Programs, including Grant and Per Diem (GPD), which provides transitional housing; Domiciliary Care for Homeless Veterans (DCHV), which provides residential treatment for veterans experiencing homelessness and comorbid behavioral health or medical issues; and the HUD–VA Supportive Housing (HUD-VASH) program, which provides permanent supportive housing (United States Department of Veterans Affairs, 2020).

This work focuses on services provided by Health Care for Homeless Veterans (HCHV) Employment Specialists stationed at more than 20 VA Medical Centers (VAMCs) across the country. Though HCHV Employment Specialists receive training and consultation from HVCES to respond to the employment needs of veterans facing homelessness and housing instability, evaluation of implementation and provision of services is limited. This paper describes barriers to implementation described by HCHV Employment Specialists and identifies strategies for improving future implementation efforts which, given the recent growth in unemployment attributed to the COVID-19 pandemic, may be of increasing value.

Methods

This project was approved as a quality improvement activity by the national directors of HVCES and HCHV. In addition, this project was deemed a quality improvement activity by the Birmingham VAMC Institutional Review Board.

The project team invited all HCHV Employment Specialists identified by VHA leadership to participate in one 60-minute qualitative telephone interview at a time convenient for them. During qualitative telephone interviews, HCHV Employment Specialists consented to participate in the interview and have the interview audio recorded. Deidentified recordings were professionally transcribed. HCHV Employment Specialists quoted here are identified using a participant identification number to maintain confidentiality.

Qualitative telephone interviews with HCHV Employment Specialists provided insight into the implementation of vocational development within HCHV. The Consolidated Framework for Implementation Research (CFIR)—a synthesis of over 100 implementation theories that offers an approach to understanding influences on implementation outcomes (Nilsen, 2015)—informed the development of the semi-structured interview guide and allowed the project team to identify implementation barriers across five broad domains:

  • intervention characteristics: attributes of the intervention;
  • inner setting: organizational context through which the implementation process proceeds;
  • outer setting: economic, political, and social contexts that influence the organization;
  • characteristics of individuals: attributes of the individuals involved in the implementation process; and
  • processes: process of implementing the intervention.

A template analysis approach guided the analysis of interview transcripts (Patton, 2015). The initial template—based on the interview guide as informed by the CFIR (n.d.)—focused on summarizing responses to open-ended questions and capturing verbatim exemplar quotes. Members of the project team reviewed three transcripts using the initial template and then discussed the process and made template revisions. During ongoing meetings, the team iteratively developed and refined the template until it reached consensus on a final version. Findings reflect implementation barriers identified across the five CFIR domains.

Next, the team matched barriers with implementation strategies—or the “techniques and strategies which constitute the ‘how to’ of implementation efforts” (Waltz et al., 2019, p. 2)—established through the Expert Recommendations for Implementing Change (ERIC) project, which ranks strategies to address CFIR barriers (Consolidated Framework for Implementation Research [CFIR], 2021). These strategies were developed by soliciting input from implementation science and practice communities through an online platform that allowed experts to select approaches most responsive to implementation barriers aligned with the CFIR; on average, experts endorsed six strategies for each barrier (Waltz et al., 2019). Based on these findings, Waltz et al. (2019) developed the CFIR-ERIC Implementation Strategy Matching Tool (CFIR, 2021) to enable users to select CFIR barriers and run a query to identify the most salient ERIC strategies to address them. Each ERIC strategy is given a cumulative percent that aligns with the strength of its endorsement to respond to identified barriers (i.e., if multiple barriers match a specific ERIC strategy, that implementation strategy will have a larger value). The findings presented here reflect the top implementation strategies for the barriers identified during interviews with HCHV Employment Specialists. All implementation strategies had a cumulative percent greater than 150% on the CFIR-ERIC Implementation Strategy Matching Tool.

Results

Between December 2019 and March 2020, all willing HCHV Employment Specialists (N = 16) participated in qualitative telephone interviews, reflecting variation in geography, facility complexity, and resource context. HCHV Employment Specialists described their role in supporting veterans’ employment and identified barriers to service provision within the five CFIR domains: intervention characteristics, inner setting, outer setting, characteristics of individuals, and processes. Identified barriers align with four strategic areas highlighted by the CFIR-ERIC Implementation Strategy Matching Tool: identify champions and build coalitions, formalize implementation efforts, improve education and training opportunities, and approaches to develop services at new locations.

HCHV Employment Services

HCHV Employment Specialists provide a variety of services to veterans experiencing homelessness and housing instability. Day-to-day tasks include conducting intake assessments; leading employment groups, workshops, and job fairs; providing personalized services to address veterans’ employment needs; and connecting veterans with community based services such as training assistance, resources to obtain clothing and equipment, and support for transportation. They often utilize a team-based approach in collaboration with Peer Support Specialists and Community Employment Coordinators (CECs)—VHA employees who identify available employment opportunities and serve as a liaison for employers—as well as other VHA Homeless Program staff. The breadth of the services provided was made apparent by one HCHV Employment Specialist who described themselves as “the conduit to anything employment”:

I assist veterans with their development toward getting employment, which means I help them build their resume, strengthen them on skills to know how to do it on their own. I help them with basic computer skills. I help them with obtaining community resources for clothing for interviews. If they need laptops for job searching, I connect them with organizations that assist with free laptops. I am the conduit to anything employment. I work with them and do mock interviews. I speak on their behalf to certain [Human Resource] reps if I have a relationship with them. I go out and look for positions that are available within certain parameters of the VA because of my population. A lot of them do not have transportation, so they need to use public transportation. So, I try to find positions within the vicinity of the VA, since they all seem to … be able to get here. [Participant #16]

Consolidated Framework for Implementation Research (CFIR) Barriers

Intervention Characteristics

Overall, HCHV Employment Specialists reported positive perceptions of their role in assisting veterans with their employment needs. However, implementation barriers included both the complexity of their work and a lack of evidence supporting the specific vocational development services they offered, which varied greatly by VA facility. In addition, they often reported little guidance from leadership on effective approaches to this work, as one HCHV Employment Specialist expressed:

We didn’t know how to do a resume. We had no clue about the community services that were available. We didn’t know how to do job trainings and we didn’t have any type of tools … We had veterans that were … literally homeless, so they didn’t have any type of way to create a resume, to save it, to be able to maybe go to another computer, print it off. We had all these barriers, and we didn’t really have much support as far as tools … and even now we still don’t have those tools. [Participant #14]

HCHV Employment Specialists also reported complexity related to potential overlap with other VHA employment services and the need to connect veterans with the most appropriate option. This often included a high level of documentation and communication across VHA providers.

[Veterans] have to—whoever their primary care person is, they have to go to their primary care doctor or a mental health provider to put in a consultation for Compensated Work Therapy or CWT. Then once the consult is in, then my supervisor, she looks over all the consults that come in, and then she decides if it’s going to go—if they’ve got severe mental issues then it would go to supported employment, if they are able to work with no major physical limitations then they would come to me, or if they were recently incarcerated—I mean recently released from incarceration and they haven’t had a job in years and years or they were physically not able to work for years and years—then they would go to transitional work. [Participant #7]

The scope of services and intricacy in implementation, which were unique to each VA facility, suggest the potential to better formalize intervention characteristics. While many HCHV Employment Specialists learned on the job and/or followed the lead of supervisors, more established procedures could inform ongoing efforts to address veterans’ employment needs and direct them to the most appropriate services.

Inner Setting

Implementation barriers reflected in the inner setting included insufficient resources to support service provision and a lack of knowledge, information, and feedback, suggesting the need for an improved learning climate. Some HCHV Employment Specialists indicated they simply did not have enough time to carry out all of their job responsibilities. One HCHV Employment Specialist described this as their biggest barrier: “I don’t really have adequate time. That is the one thing that is lacking” [Participant #10].

In addition, HCHV Employment Specialists said it would be helpful if VHA could provide more resources to address veterans’ training and employment needs. Others reported that the ability to offer access to computers would go a long way to responding to technical barriers.

We need to have computer access for our veterans where we can do a computer class. I actually found a need for us to do a resume class … And when we do the resume class, that helps us out, but it’d be better if we could have a computer access room where we could sit down with the veterans and be able to spend those four hours walking around actually doing something. [Participant #12]

At the same time, they identified the need for more training and resources to enable them to perform their jobs better, especially for those who entered the role with very little training in vocational development. As one HCHV Employment Specialist said: “[the] majority of our training is that we basically have to go out and find it on our own and do everything” [Participant #8].

While HCHV Employment Specialists felt that their work did help veterans prepare for and secure employment, a lack of formal assessments and tracking systems to provide feedback was a common concern. Though data collected through the Homeless Operations Management and Evaluation System (HOMES)—which collects assessment and services use data for VHA Homeless Programs—are typically available, local processes sometimes limit which staff may enter data, making it less complete. Additionally, some HCHV Employment Specialists documented services and outcomes in veterans’ Computerized Patient Record System (CPRS) health records. However, in the absence of formal systems, many HCHV Employment Specialists devised their own data systems to assess and track veterans on their case load. Describing an inability to input data into HOMES, one HCHV Employment Specialist said:

It would be better if they allowed the Employment Specialist to enter if someone’s working into HOMES. I understand that they don’t want too many hands in that pot because it’s data that can be skewed and fiddled with. But allow us to go in to just—even if you can fix it so we can touch nothing else, just let us put in the employment data because it’s not being fully done the way it should be. [Participant #16]

Formal goals and evaluations of services by supervisors also varied. While some HCHV Employment Specialists described official metrics and review processes, other reported a lack of clear objectives. Taken together, these issues suggest the need for a learning climate that values the input of HCHV Employment Specialists and provides opportunities for reflective thinking and evaluation of processes to improve implementation.

Outer Setting

Given limitations to the assistance VA is able to offer veterans, HCHV Employment Specialists often rely on community resources to address veterans’ needs. Community based providers offer financial assistance for technical or vocational training, access to computer courses, and services to assist with resume development and skill building. They also assist with resources for employment needs, such as shoes, tools, clothing, and computers, as well as banking services and support for transportation. While community based organizations were essential to the work of HCHV Employment Specialists, some providers reported that they would benefit from improved networks with external organizations.

I have veterans that are strongly interested in pursuing [technical training]. They may even have a bit of a background from the military, but they’ve exhausted or do not have GI Bill benefits or Post-9/11 benefits … We have a population that wants to work, we have a population that is driven to see success, and we’re pushing that and sending [potential employers] employees, but yet we’re really kind of hemmed up a little bit, if you will, when it comes to training. [Participant #4]

Others highlighted how developing relationships with community providers and addressing veterans’ complex needs often takes a prohibitive amount of time.

If I have a veteran that is locked and loaded to get a job somewhere and then that employer says, hey, you need the following and you can start tomorrow. Say, steel-toed boots or something so simple. I have to go beg and plead … maybe find a secondhand store to get this individual a pair of steel-toed boots. [Participant #5]

Additionally, external issues could undermine implementation efforts. Transportation, or lack thereof, was mentioned as a barrier by every interviewed HCHV Employment Specialist. This was due both to a lack of financial assistance to help veterans afford transportation and a lack of public transportation options serving the areas where veterans live and work, including options that run 24 hours a day.

The biggest problem is getting them back and forth to work because there’s—on Saturday, the bus stops running at noon. On Sunday, there’s no bus at all. And so, the employer is going, “Well, I can’t have you not coming in on the weekends because you don’t have a ride.” Or sometimes you can get there, but then you can’t get home. [Participant #2]

Hiring practices could also make it difficult for veterans to meet employment criteria. HCHV Employment Specialists reported that drug testing, rather than problematic substance use, more often presented a challenge in identifying employment opportunities.

We’re not allowed to introduce them to job leads from cannabis-friendly companies. The federal government still recognizes cannabis as a drug. So, it’s a schedule-one drug, so we’re not allowed to do anything with that. So we can’t work with [those employers]. [Participant #12]

Moreover, they indicated that identifying employment options for veterans with a history of justice involvement could be almost impossible.

I just think one of our major obstacles is finding quality employment for people that have had these really bad felonies. I mean because they still want to work, and they’ve done their time. They’ve done what they’re supposed to do, so how do they get to the next level if you don’t give them a chance? [Participant #7]

HCHV Employment Specialists recognized the importance of the outer setting and highlighted the value of building strong relationships with community providers and employers. However, their work was often stymied by systems outside of their control, including external processes, transportation limitations, and hiring practices, suggesting opportunities for greater collaboration and networking that may be responsive to these issues.

Characteristics of Individuals

Implementation barriers attributed to HCHV Employment Specialists included a lack of self-efficacy and satisfaction with organizational commitment. Some described a breakdown in communication at local VA facilities and a lack of support that restricted service provision.

The problem I have is a lot of social workers believe that, “Oh, I have a social work degree so I should know how to do your job.” You don’t … And then we don’t get a lot of support. They don’t tell our veterans about stuff. They delete our emails a lot without reading them. They don’t know what we’re talking about … It’s just we don’t have the support like we should. [Participant #12]

Several HCHV Employment Specialists reported a lack of communication with providers whose primary aim was not employment and limitations of VHA employment services that could undermine their work. They reported that the time-limited nature of some services can fail to ensure long-term, full-time employment of veterans and noted difficult hiring veterans at VA. While HCHV Employment Specialists still tried to assist these veterans through referrals to community resources, they understood their constraints in helping all veterans.

We have people that have been in [transitional work] programs all over the United States and just go from one VA to another. [My supervisor] has to decide, well, you’ve had all the services you can have. So in that case we’d send them—we have career centers in our area … We have career centers that we refer them to. So we don’t just say, well, we’re not going to help you at all, we just—we help them transition out to something else if we just can’t do anything for them. [Participant #7]

HCHV Employment Specialists described going above and beyond to serve veterans. Yet, they sometimes felt restricted in what they could do and described needing greater support from their VHA colleagues to achieve more positive employment outcomes for veterans.

Processes

The final CFIR domain relates to the process of implementing vocational development within HCHV. One process barrier described by HCHV Employment Specialists was ineffective strategies to engage veterans in these optional services. HCHV Employment Specialists recognized that veterans experiencing housing instability have to deal with complex issues, but they also saw employment as an important component to holistic care. One suggested that meeting with an HCHV Employment Specialist should be mandatory for veterans in VHA Homeless Programs, whether veterans ultimately decide to pursue employment or not:

Any veteran in the Homeless Program, I think they should find a way of making it at least mandatory for them to at least visit the office once and speak to an employment assistance rep to at least discuss employment. I’ll be happy to sit down with and listen to somebody who may spew total disdain for employment. But I’d like to hear it. And then I’d like to try to challenge them … to some degree if I can. If it works, it works. If it doesn’t, it doesn’t. Or maybe I plant a seed of, maybe I ought to consider that. And once they understand that work is not just work. Work is not just the money. Work is part being part of the community, networking. It’s good for the psyche. It gets you out of the house. We have too many veterans that stay in their home all day long. So, I wish it was mandatory. [Participant #5]

HCHV Employment Specialists also agreed that greater awareness of their services—both for veterans and employers in the community—could promote better outcomes for veterans. One suggested that national marketing could increase awareness of employment assistance for veterans struggling to find employment: “I just think we should spread the net a little bit more and get out and talk to more people so veterans know that these programs exist” [Participant #7]. Another reported the need to bring awareness to employers who might take a chance on veterans receiving services through VHA who they might otherwise pass over for a job:

We do find a lot of businesses or companies that are lost on—well, heck, we didn’t know about you guys, how do we find a way to get veterans to consider working for us, how would we—it’s a lot of those questions that we have from employers that’s kind of to me a little shocking. Is there a way for a salesman type job—a marketing of the veterans that we can provide to them? The fact that we could have continuous job coaching, conflict resolution, case management from a social worker or [Registered Nurse]. That veteran sure is being taken care of in several regards, and so overall, a lot of them turn out to be an incredible employee. They find a new sense of self-worth and determination and drive. [Participant #4]

Another process barrier was the lack of feedback on progress and the quality of services. As described above, HCHV Employment Specialists often use their own discretion as to what information to collect and assess and rely on other VHA service providers to obtain follow-up information or data on veterans. Follow-up is sometimes team-based, particularly in collaboration with HUD-VASH. However, VA facilities seemed to offer little or no quantitative or qualitative feedback about the progress and quality of implementation of employment services nor regular personal and team debriefing about progress and experiences. One HCHV Employment Specialist described relying on data collected on employment outcomes for HUD-VASH participants as an indicator of veterans’ overall job attainment, which they felt was insufficient:

What ends up happening is we end up with a measurement for HUD-VASH [employment outcomes] and we sort of say well, that’s for everything. And it’s not—we are—it’s really skating by. It’s not being scrutinized. [Participant #2]

These barriers put forward a need to better educate and engage both veterans and employers so that they are aware of the assistance offered by HCHV Employment Specialists and wider VHA programs as well as better collaboration within VA, especially related to tracking and assessment of service provision and outcomes.

Expert Recommendations for Implementing Change (ERIC) Strategies to Address Barriers

Based on these reported barriers, the CFIR-ERIC Implementation Strategy Matching Tool identified strategies for improving implementation efforts and promoting the work of HCHV Employment Specialists that fell within four broad areas: identify champions and build coalitions, formalize implementation efforts, improve education and training opportunities, and develop approaches to better implement services at new locations. Table 1 includes the ERIC Strategies highlighted by the CFIR-ERIC Implementation Strategy Matching Tool to address barriers detailed by HCHV Employment Specialists alongside the cumulative percent of endorsement as an implementation strategy across the identified barriers.

Table 1

Expert Recommendations for Implementing Change (ERIC) Strategies.


Identify Champions and Build Coalitions

∘ Identify and prepare intervention champions (280%)
∘ Conduct local consensus discussions (234%)
∘ Build a coalition (233%)
∘ Use advisory boards and workgroups (169%)

Improve Education and Training Opportunities

∘ Conduct educational meetings (252%)
∘ Capture and share local knowledge (248%)
∘ Create a learning collaborative (232%)
∘ Develop educational materials (184%)
∘ Facilitate interactive problem solving and support (179%)
∘ Conduct ongoing training (170%)

Formalize Implementation Efforts

∘ Involve veterans (190%)
∘ Audit services and provide feedback (185%)
∘ Obtain and use veteran feedback (175%)
∘ Develop a formal implementation blueprint (170%)
∘ Organize implementation team meetings (169%)

Developing Services at New Locations

∘ Assess for readiness and identify barriers and facilitators (209%)
∘ Inform local opinion leaders (163%)
∘ Conduct local needs assessments (155%)
∘ Conduct educational outreach visits (151%)

Note: The number in parentheses reports the cumulative percent of endorsement.

The first key area suggests the importance of identifying and preparing intervention champions, conducting local consensus discussions, building coalitions, and using advisory boards and workgroups to promote the work of HCHV Employment Specialists. The CFIR-ERIC Implementation Strategy Matching Tool (CFIR, 2021) recommends these strategies to overcome barriers related to engaging internal and external stakeholders. They can address challenges related to the complexity and quality of evidence supporting the intervention as well as encourage a learning climate that values leader and stakeholder engagement and demonstrates a commitment to vocational development services within HCHV. Leveraging appropriate champions with VHA can facilitate stakeholder engagement (Bonawitz et al., 2020) while building stakeholder coalitions and advisory groups ensures that community organizations and employers are systematically engaged in HCHV employment practices.

The second key area highlights the need for improvements in education and training opportunities by conducting educational meetings, capturing and sharing best practices, creating learning collaboratives, developing educational materials, facilitating interactive problem solving, and conducting ongoing training. The CFIR-ERIC Implementation Strategy Matching Tool (CFIR, 2021) recommends these strategies to overcome barriers related to the challenges HCHV Employment Specialists faced accessing appropriate knowledge and information to implement services. Developing education and training can also reduce obstacles related to complexity and increase the self-efficacy of HCHV Employment Specialists. In addition, building a system where educational materials and best practices are continuously developed and disseminated can promote a learning climate where stakeholders feel valued and knowledgeable.

The third key area describes how implementation efforts can be better formalized by involving veterans, auditing services to provide feedback mechanisms, obtaining and using veteran feedback, developing a formal implementation blueprint, and organizing implementation team meetings. The CFIR-ERIC Implementation Strategy Matching Tool (CFIR, 2021) recommends these strategies to overcome barriers related to the unique employment needs of veterans and difficulties engaging veterans in employment services, lack of formal tracking systems, and the absence of clearly communicated goals. Obtaining and incorporating veteran feedback in implementation processes ensures that veteran needs and perspectives are incorporated while improving quantitative and/or qualitative feedback about implementation progress can stimulate reflection and evaluation to encourage process improvements. Additionally, a formal implementation plan and regular team meetings can promote communication across diverse stakeholders to ensure that larger implementation goals and processes are aligned (Lundmark et al., 2021).

Finally, the fourth key area provides approaches to developing services at new locations by assessing for readiness and identifying barriers and facilitators, informing local opinion leaders, and conducting local needs assessments and educational outreach visits. The CFIR-ERIC Implementation Strategy Matching Tool (CFIR, 2021) recommends these strategies to overcome barriers related to planning, executing, and evaluating the implementation of new vocational development services within HCHV. Conducting needs assessments guarantees that implementation plans are tailored to the local needs of veterans. These efforts can also reduce complexity and improve perceptions of the intervention among internal and external stakeholders.

Discussion

Returning to work is associated with improvements in a variety of factors, including financial security, physical and psychological health, quality of life, and self-esteem (Bond, 1998; Caplan et al., 1989; Cook et al., 2016; Kashner et al., 2002; Payne & Graham Jones, 1987; Vinokur et al., 1991). The work of HCHV Employment Specialists addresses veterans’ employment needs and, in turn, can support better housing and health outcomes. Strategies to overcome implementation barriers can inform future vocational development services provided through both HCHV Employment Specialists and other service providers.

The labor market itself can contribute to the employment outcomes of people experiencing homelessness and risk. Characteristics of the labor market (e.g., insufficient work, inconsistent pay, and relationships with employers), available economic opportunities (e.g., temporary and/or undesirable employment), and homelessness services and labor market attachment difficulties (e.g., restricted shelter hours versus alternative sleeping hours for people working evening shifts) intersect to either facilitate or impede employment access and financial—and subsequently, housing—stability (Shier et al., 2012). HCHV Employment Specialists are uniquely positioned to respond to these labor market issues by working alongside veterans and employers to identify appropriate employment opportunities and advocate on behalf of veterans. Moreover, they can utilize targeted engagement strategies to engage veterans of different backgrounds and circumstances (Aronson et al., 2019).

However, HCHV Employment Specialists identified implementation barriers that limit their ability to respond to labor market conditions, such as the complexity of the services they provide, a lack of resources to support veterans’ needs (e.g., training and employment needs, computer access, transportation), and employer policies (e.g., drug testing, background checks). Their work could be better supported through developing more formal implementation processes, which should involve and incorporate feedback from both veterans and employers. Advisory boards or collaboratives that include representatives from community organizations that work in tandem to provide necessary supports to meet veterans’ employment needs would also be helpful. These strategies could streamline service provision and identify and respond to the gaps described by HCHV Employment Specialists.

Mental health, health, and disability may also contribute to employment difficulties among people with experiences of housing instability (Zuvekas & Hill, 2001). HCHV Employment Specialists operate within a large healthcare system and suggested that employment should be considered a part of holistic care. In particular, they saw the potential of employment to support other health-related outcomes among the veterans they served.

Yet, HCHV Employment Specialists described a lack of self-efficacy and satisfaction with organizational commitment to providing employment services through HCHV. Moreover, despite being part of a larger organizational structure, HCHV Employment Specialists reported a lack of formal data tracking and performance metrics that could inform both their own work and that of other providers. Identifying local champions and conducting consensus discussions and/or implementation team meetings could help overcome these barriers by providing a supportive infrastructure where providers can share local knowledge and support one another. Auditing services and developing feedback mechanisms will strengthen these efforts.

A study examining implementation of supported employment for veterans with psychiatric or addiction disorders who were experiencing homelessness argued that more intensive, on-site training and performance monitoring may be needed to optimize implementation and model fidelity (Rosenheck & Mares, 2007). Similarly, the ERIC recommendations offered here suggest the need for more educational and training opportunities of HCHV Employment Specialists, which may assist them in identifying additional resources to support veterans’ employment needs while also allowing them to learn helpful strategies from one another. Further, as noted above, auditing services and developing feedback mechanisms can reinforce learnings.

Finally, for VAMCs and other organizations that would like to develop new vocational development services at their facilities, assessing for readiness and determining barriers and facilitators to providing services can guide implementation. Conducting needs assessments to identify how best to implement the intervention can inform ongoing processes. Following assessment and implementation, evaluating accomplishments can help achieve and sustain effective change (Smith, 2005). Offering educational outreach can help organizations at the early stages of development, and continued training opportunities can provide learning opportunities that promote best practices and details on emerging innovations in the field.

Strengths and Limitations

The CFIR-ERIC Implementation Strategy Matching Tool (CFIR, 2021) offers a structured approach to identifying strategies to implementation barriers and has been recently used in a variety of settings to conceptualize provider views and refine implementation processes (Godbee et al., 2019; Juckett et al., 2020; Li et al., 2021; Waltz et al., 2019). Given that HCHV Employment Specialists overlap with homeless and employment providers both within VHA and the broader community, the CFIR offered an appropriate tool to understand these separate spheres and their impact on implementation efforts. Matching identified barriers with ERIC strategies uncovered four strategic areas to greater support their work. However, given the diversity and complexity of the VA facilities and communities examined here, this work cannot speak to fidelity to any one approach or model, but rather the general setting within which HCHV Employment Specialists work and strategies to promote better outcomes.

To our knowledge, this is the first examination of the services provided by HCHV Employment Specialists. However, this work was confined to information from providers affiliated with VHA and specific VA facilities and may not be generalizable to other employment services or contexts. Future research should examine additional employment services and resources offered to veterans, both within and outside VA.

Conclusion

HCHV Employment Specialists offer a variety of employment services to veterans experiencing homelessness and housing instability. Yet, a lack of resources to support both HCHV Employment Specialists’ work and veterans’ needs as well as external policies of employers that create employment barriers and insufficient outreach and information about the availability of services among both veterans and employers present barriers to implementing these services. In addition, a lack of formal data collection hinders feedback on service provision and veteran outcomes. Engaging more diverse stakeholders to build coalitions, formalizing implementation efforts, and improving training can help bridge these gaps. Once adapted to meet local conditions and needs, these recommendations offer a framework to limiting and responding to implementation barriers and better preparing new facilities to provide these services.

Acknowledgements

We would like to acknowledge the following individuals from the Veterans Health Administration Homeless Programs Office who made this project possible: Carma Heitzmann, the Director of Homeless Veterans Community Employment Services, and Eileen Devine, the Director of Health Care for Homeless Veterans.

Funding Information

This work was supported by the United States Department of Veterans Affairs (VA) Health Services Research & Development [IIR 13-334] and through intramural funding provided by the VA National Center on Homelessness among Veterans.

Competing Interests

The authors have no competing interests to declare.

References

  1. Aronson, K. R., Perkins, D. F., Morgan, N. R., Bleser, J. A., Vogt, D., Copeland, L., Finley, E., & Gilman, C. (2019). Post-9/11 Veteran transitions to civilian life: Predictors of the use of employment programs. Journal of Veterans Studies, 5(1), 14–22. DOI: https://doi.org/10.21061/jvs.v5i1.127 

  2. Bonawitz, K., Wetmore, M., Heisler, M., Dalton, V. K., Damschroder, L. J., Forman, J., Allan, K. R., & Moniz, M. H. (2020). Champions in context: Which attributes matter for change efforts in healthcare? Implementation Science, 15(1), 1–10. DOI: https://doi.org/10.1186/s13012-020-01024-9 

  3. Bond, G. R. (1998). Principles of the individual placement and support model: Empirical support. Psychiatric Rehabilitation Journal, 22(1), 11. DOI: https://doi.org/10.1037/h0095271 

  4. Byrne, T., Fargo, J. D., Montgomery, A. E., Roberts, C. B., Culhane, D. P., & Kane, V. (2015). Screening for homelessness in the Veterans Health Administration: Monitoring housing stability through repeat screening. Public Health Reports, 130(6), 684–692. DOI: https://doi.org/10.1177/003335491513000618 

  5. Caplan, R. D., Vinokur, A. D., Price, R. H., & Van Ryn, M. (1989). Job seeking, reemployment, and mental health: A randomized field experiment in coping with job loss. Journal of Applied Psychology, 74(5), 759. DOI: https://doi.org/10.1037/0021-9010.74.5.759 

  6. Consolidated Framework for Implementation Research. (n.d.). CFIR guide. https://cfirguide.org/guide/app/#/ 

  7. Consolidated Framework for Implementation Research. (2021). Strategy design. https://cfirguide.org/choosing-strategies/ 

  8. Cook, J. A., Burke-Miller, J. K., & Roessel, E. (2016). Long-term effects of evidence-based supported employment on earnings and on SSI and SSDI participation among individuals with psychiatric disabilities. American Journal of Psychiatry, 173(10), 1007–1014. DOI: https://doi.org/10.1176/appi.ajp.2016.15101359 

  9. Cusack, M., Montgomery, A. E., Sorrentino, A. E., Dichter, M. E., Chhabra, M., & True, G. (2020). Journey to home: development of a conceptual model to describe veterans’ experiences with resolving housing instability. Housing Studies, 35(2), 310–332. DOI: https://doi.org/10.1080/02673037.2019.1598551 

  10. Fargo, J., Montgomery, A. E., Byrne, T., Brignone, E., Cusack, M., & Gundlapalli, A. V. (2017). Needles in a haystack: Screening and healthcare system evidence for homelessness. Studies in Health Technology and Informatics, 235, 574–578. 

  11. Godbee, K., Gunn, J., Lautenschlager, N. T., Curran, E., & Palmer, V. J. (2019). Implementing dementia risk reduction in primary care: A preliminary conceptual model based on a scoping review of practitioners’ views. Primary Health Care Research & Development, 20. DOI: https://doi.org/10.1017/S1463423619000744 

  12. Henry, M., deSours, T., Roddey, C., Gayen, S., & Bednar, T. J. (2021, January). The 2020 annual homeless assessment report (AHAR) to Congress. Abt Associates. https://www.huduser.gov/portal/sites/default/files/pdf/2020-AHAR-Part-1.pdf 

  13. Juckett, L. A., Bunger, A. C., Jarrott, S. E., Dabelko-Schoeny, H. I., Krok-Schoen, J., Poling, R. M., Mion, L. C., & Tucker, S. (2020). Determinants of fall prevention guideline implementation in the home-and community-based service setting. The Gerontologist. DOI: https://doi.org/10.1093/geront/gnaa133 

  14. Kashner, T. M., Rosenheck, R., Campinell, A. B., Suris, A., Crandall, R., Garfield, N. J., Lapuc, P., Pyrcz, K., Soyka, T., Wicker, A., & CWT Study Team. (2002). Impact of work therapy on health status among homeless, substance-dependent veterans: A randomized controlled trial. Archives of General Psychiatry, 59(10), 938–944. DOI: https://doi.org/10.1001/archpsyc.59.10.938 

  15. Kleykamp, M. (2013). Unemployment, earnings and enrollment among post 9/11 veterans. Social Science Research, 42(3), 836–851. DOI: https://doi.org/10.1016/j.ssresearch.2012.12.017 

  16. Kramarow, E. A., & Pastor, P. N. (2012, August). The health of male veterans and nonveterans aged 25-64, United States, 2007–2010 (No. 101). US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. https://www.cdc.gov/nchs/data/databriefs/db101.pdf 

  17. Li, J., Smyth, S. S., Clouser, J. M., McMullen, C. A., Gupta, V., & Williams, M. V. (2021). Planning implementation success of syncope clinical practice guidelines in the emergency department using CFIR framework. Medicina, 57(6), 570. DOI: https://doi.org/10.3390/medicina57060570 

  18. Lundmark, R., Hasson, H., Richter, A., Khachatryan, E., Åkesson, A., & Eriksson, L. (2021). Alignment in implementation of evidence-based interventions: A scoping review. Implementation Science, 16(1), 1–14. DOI: https://doi.org/10.1186/s13012-021-01160-w 

  19. Montgomery, A. E., Byrne, T. H., Cusack, M. C., Chhabra, M., Sorrentino, A. E., Dichter, M. E., & True, G. (2020). Patients’ perspectives on elements of stable housing and threats to housing stability. Journal of the Society for Social Work and Research, 11(4), 545–567. DOI: https://doi.org/10.1086/712238 

  20. Montgomery, A. E., Fargo, J. D., Byrne, T. H., Kane, V. R., & Culhane, D. P. (2013). Universal screening for homelessness and risk for homelessness in the Veterans Health Administration. American Journal of Public Health, 103(S2), S210–S211. DOI: https://doi.org/10.2105/AJPH.2013.301398 

  21. Nilsen, P. (2015). Making sense of implementation theories, models, and frameworks. Implementation Science, 10(53), 1–13. DOI: https://doi.org/10.1186/s13012-015-0242-0 

  22. Patton, M. Q. (2015). Qualitative research and evaluation methods: Integrating theory and practice. SAGE. 

  23. Payne, R. L., & Graham Jones, J. (1987). The effects of long-term unemployment on attitudes to employment. Journal of Organizational Behavior, 8(4), 351–358. DOI: https://doi.org/10.1002/job.4030080407 

  24. Rosenheck, R. A., & Mares, A. S. (2007). Implementation of supported employment for homeless veterans with psychiatric or addiction disorders: Two-year outcomes. Psychiatric Services, 58(3), 325–333. DOI: https://doi.org/10.1176/ps.2007.58.3.325 

  25. Shier, M. L., Jones, M. E., & Graham, J. R. (2012). Employment difficulties experienced by employed homeless people: Labor market factors that contribute to and maintain homelessness. Journal of Poverty, 16(1), 27–47. DOI: https://doi.org/10.1080/10875549.2012.640522 

  26. Smith, I. (2005). Achieving readiness for organisational change. Library Management, 26(6/7), 408–412. DOI: https://doi.org/10.1108/01435120510623764 

  27. Tessler, R., Rosenheck, R., & Gamache, G. (2005). Declining access to alcohol and drug abuse services among veterans in the general population. Military Medicine, 170(3), 234–238. DOI: https://doi.org/10.7205/MILMED.170.3.234 

  28. United States Department of Housing and Urban Development. (2021, April). Secretaries of HUD, VA joint statement on ending veteran homelessness [Press release]. https://www.hud.gov/press/press_releases_media_advisories/HUD_No_21_059 

  29. United States Department of Labor Bureau of Labor Statistics. (2021, March). Table 2a. Employment status of persons 18 years and over by veteran status, age, and period of service, 2020 annual averages. Economic News Release. https://www.bls.gov/news.release/Vet.t02A.htm 

  30. United States Department of Veterans Affairs. (2020, October). Homeless Veteran Community Employment Services (HVCES). https://www.va.gov/HOMELESS/docs/HVCES-Fact-Sheet-October-2020.pdf 

  31. United States Interagency Council on Homelessness. (2015, June). Opening doors: Federal strategic plan to prevent and end homelessness. https://www.usich.gov/resources/uploads/asset_library/USICH_OpeningDoors_Amendment2015_FINAL.pdf 

  32. Vinokur, A. D., Van Ryn, M., Gramlich, E. M., & Price, R. H. (1991). Long-term follow-up and benefit-cost analysis of the Jobs Program: A preventive intervention for the unemployed. Journal of Applied Psychology, 76(2), 213. DOI: https://doi.org/10.1037/0021-9010.76.2.213 

  33. Waltz, T. J., Powell, B. J., Fernández, M. E., Abadie, B., & Damschroder, L. J. (2019). Choosing implementation strategies to address contextual barriers: Diversity in recommendations and future directions. Implementation Science, 14(1), 1–15. DOI: https://doi.org/10.1186/s13012-019-0892-4 

comments powered by Disqus