# Surveillance of Modifiable Social Determinants of Health for Prioritizing Wraparound Supports

> **NIH VA I01** · EDITH NOURSE  ROGERS MEMORIAL VETERANS HOSPITAL · 2024 · —

## Abstract

Surveillance of Modifiable Social Determinants of Health for Prioritizing Wraparound
Supports
60% of Veterans in Veterans Treatment Courts (VTCs) have a co-occurring mental health and
opioid use disorder (OUD), thereafter called COD. Those Veterans are at risk for opioid
overdose (OOD) but have less engagement of medications for OUD (MOUD) and other OUD
treatments than other Veterans, resulting in unemployment and homelessness - predictors of
reoffending. Many Veterans in VTCs, particularly those with an OUD have multiple social
determinants of health (SDOH) issues that need to be addressed simultaneously. Adverse
SDOH have been identified as key barriers to MOUD engagement and increasing risk of OOD.
We have identified 8 modifiable SDOH (mSDOH)¾job insecurity, housing insecurity, financial
insecurity, food insecurity, legal problems, social/familial problems, transportation problems, and
violence¾that could be used to identify Veterans at highest risk of MOUD disengagement and
other suboptimal treatment engagement and OOD.
Maintaining Independence and Sobriety through Systems Integration, Outreach and
Networking-Criminal Justice (MISSION-CJ), is a cross disciplinary, team-based multicomponent
intervention that is being tested in a large implementation study by Dr. Smelson (MPI) in
collaboration with the Veteran Justice Outreach Program (VJP). However, MISSION-CJ goes
beyond traditional linkage support provided through VJP. It offers Veterans 6 months of
psychosocial treatment combined with assertive outreach, empowering clients to access and
engage in care and community services to address addiction, mental health and other mSDOH
needs while promoting recovery. Because of large caseload sizes among providers in VJP, it is
important that “Surveillance of mSDOH for MISSION” (SoS-MISSION) prioritizes Veterans in
VJP at high risk of MOUD suboptimal engagement and OOD (non-fatal and fatal) with mSDOH
to offer MISSION-CJ. This is critical as our implementation study demonstrated that VJP
providers have capacity to offer SoS-MISSION to fewer than 30% their clients.
In this application, we will develop and test SoS-MISSION, a dashboard which flags unmet
social needs of JIV at high risk of MOUD discontinuation and OOD. We will develop innovative
natural language processing (NLP) approaches, and then incorporate these mSDOH to improve
prediction of vulnerable Veterans in VJP with poor MOUD engagement and OOD. SoS-
MISSION addresses untreated addiction as listed as one focus in the National Drug Control
Strategy recently released by the White House. While efforts have identified single mSDOH
(e.g., homelessness) from EHR notes, little research examined concurrent mSDOH and their
attributes from structured and unstructured EHR and how they improve prediction of MOUD
engagement and OOD, and then integrated into MISSION-CJ.

## Key facts

- **NIH application ID:** 10747464
- **Project number:** 1I01HX003711-01A1
- **Recipient organization:** EDITH NOURSE  ROGERS MEMORIAL VETERANS HOSPITAL
- **Principal Investigator:** DAVID A SMELSON
- **Activity code:** I01 (R01, R21, SBIR, etc.)
- **Funding institute:** VA
- **Fiscal year:** 2024
- **Award amount:** —
- **Award type:** 1
- **Project period:** 2024-07-01 → 2028-06-30

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10747464

## Citation

> US National Institutes of Health, RePORTER application 10747464, Surveillance of Modifiable Social Determinants of Health for Prioritizing Wraparound Supports (1I01HX003711-01A1). Retrieved via AI Analytics 2026-05-25 from https://api.ai-analytics.org/grant/nih/10747464. Licensed CC0.

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