# Bridging the Care Continuum for Vulnerable Veterans across VA and Community Services

> **NIH VA I50** · EDITH NOURSE  ROGERS MEMORIAL VETERANS HOSPITAL · 2021 · —

## Abstract

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

## Key facts

- **NIH application ID:** 10072804
- **Project number:** 1I50HX003292-01
- **Recipient organization:** EDITH NOURSE  ROGERS MEMORIAL VETERANS HOSPITAL
- **Principal Investigator:** Anashua RANI Elwy
- **Activity code:** I50 (R01, R21, SBIR, etc.)
- **Funding institute:** VA
- **Fiscal year:** 2021
- **Award amount:** —
- **Award type:** 1
- **Project period:** 2020-06-01 → 2025-09-30

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10072804

## Citation

> US National Institutes of Health, RePORTER application 10072804, Bridging the Care Continuum for Vulnerable Veterans across VA and Community Services (1I50HX003292-01). Retrieved via AI Analytics 2026-05-24 from https://api.ai-analytics.org/grant/nih/10072804. Licensed CC0.

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