Comparing two strategies to support the implementation of evidence-based practices for substance use disorders in...

Homeless-experienced Veterans (HEVs) have higher rates of substance use disorders (SUDs) than housed Veterans, which impairs their ability to retain housing. The Department of Housing and Urban Development-VA Supportive Housing (HUD-VASH) initiative, which provides subsidized permanent housing and supportive services, contributed to the 50% reduction in Veteran homelessness over the past decade. However, ~ 40% of Veterans exit HUD-VASH within two years, often due to untreated SUDs. We will use two strategies to support the implementation of Medications for Addiction Treatment (MAT) and Cognitive Behavioral Therapy for Substance Use Disorders (CBT-SUD) in 12 HUD-VASH sites; conduct an evaluation of this implementation effort; and generate an implementation playbook to support continued spread of MAT and CBT-SUD in HUD-VASH.

We will use Replicating Effective Programs (REP) to implement MAT and CBT-SUD at 12 sites over 18 months. After 9 months of REP alone, half (n = 6) of these sites will also receive Consumer Engagement (CE) for 9 months, activating HEVs to adopt these practices via peer coaching. We will conduct a type 3 hybrid cluster-randomized trial to compare the impacts of REP versus REP + CE. Randomization will occur at two levels: implementation start date (3 cohorts) and the implementation strategy (REP versus REP + CE). We will use stratified block randomization to balance site size among sites receiving each strategy across cohorts. We will use mixed methods to assess the impacts of REP versus REP + CE on implementation outcomes (reach [primary outcome], adoption, and sustainment); Veteran outcomes (primarily housing); provider and Veteran experiences; and costs and budget impacts. We hypothesize that REP + CE will have higher implementation costs than REP but result in improved MAT and CBT-SUD implementation and Veteran outcomes, leading to a business case for REP + CE.

Implementing MAT and CBT-SUD within HUD-VASH can improve HEVs' housing and health. By identifying effective strategies to support the implementation of these practices, we aim to inform other implementation efforts of behavioral health practices in homeless service settings.

This project was registered with ClincialTrials.gov as "Coordinated Access for Addiction Recovery and Equity in VA Supportive Housing." Trial registration NCT07141394, registered 8/26/2025 ( https://clinicaltrials.gov/study/NCT07141394?term=CARE-VASH&rank=1 ).