Many Veterans (30.4%) with cardiovascular diseases (CVDs) continue to engage in behaviors that increase risk of cardiovascular events and early mortality, such as smoking or hazardous drinking. While the VA has several programs designed to help Veterans quit smoking or quit/reduce drinking, there is a gap in service for Veterans who are not ready for change-based treatments but continue to smoke or drink hazardously. VA Patient Aligned Care Teams (PACTs) screen all patients annually for alcohol and tobacco use, and thus the PACT platform is an ideal way to reach Veterans with CVDs who smoke and/or drink hazardously. Through the Primary Care Mental Health Integration (PCMHI) initiative, mental and behavioral health providers are embedded to provide effective, evidence-based, Veteran-centered, behavioral health interventions for a variety of co-occurring behavioral health concerns and medical problems. Educational and self-monitoring interventions are evidence-based and increase substance users' intentions to make a behavior change, and additionally improve patient factors including engagement, willingness to accept behavioral health referrals, and self-management strategies. This research proposal focuses on adapting elements of these evidence- based interventions specifically for a PACT-based VA setting to appeal to Veterans not yet ready to change smoking and/or drinking. This intervention aims to increase intention to change and may improve rates of cessation and engagement with change-based programs. The intervention will fill a gap in care and potentially improve the health and longevity of Veterans seen in PACT. Dr. Julie Gass is a clinical psychologist and postdoctoral fellow at the Center for Integrated Healthcare (CIH), a VA Mental Health Center of Excellence charged with improving Veteran healthcare through PCMHI. The purpose of this Career Development Award-2 (CDA-2) is to facilitate Dr. Gass's transition into an independent HSR&D investigator with a long-term objective of improving Veterans' health by studying the effectiveness of evidence-based, Veteran-centered interventions for commonly co-occurring behavioral and medical concerns within PACT patients. The short-term objective of this CDA-2 is to obtain formal training, expert mentorship, and research experience to facilitate a VA HSR&D career focused on improving interventions and PACT processes for Veterans who smoke and/or drink hazardously while diagnosed with CVDs. The CDA-2 will provide Dr. Gass (who has experience in tobacco treatment/research) with needed training in (1) RCT design, implementation, and data analysis; (2) team-based care in PC; (3) brief alcohol treatments; (4) qualitative analysis for intervention development; and (5) grantsmanship, which will allow her to conduct the three projects comprising the CDA-2 research plan. As it is important that any new intervention be accessible and feasible for the PACT and the patient, this research will use the extant literature, stakeholder feedback, and careful piloting to develop the most feasible and patient-centered intervention. The intervention will be piloted in this project in two modes: PACT team- delivered and PCMHI-delivered.
Specific Aims of this CDA-2 are as follows.
Aim 1, informed by pilot data and systematic literature review, is a qualitative study both of local and national stakeholders and experts to understand the preferences, barriers, and facilitators to engaging in conjoint appointments, and to refine the intervention;
Aim 2 is designed to test this intervention in a small sample and make any necessary modifications;
and Aim 3 is a pilot test of the manual in PACT to obtain feedback on the acceptability and feasibility of using evidence-based substance use intervention techniques in real-world clinical practice. Results of the CDA-2 will inform submission of an HSR&D merit proposal for a larger RCT to be submitted by the end of Year 3.

Public Health Relevance

Many Veterans who have cardiovascular diseases (CVDs) still smoke cigarettes or drink too much alcohol, which worsens these diseases. The VA has many programs and treatments available for Veterans who are ready and willing to change these behaviors, but there are many patients who are not yet ready. Patient- aligned care teams (PACTs), which include primary care mental health integration (PCMHI) providers, are the ideal setting to reach Veterans who are not ready to change smoking or hazardous drinking and discuss ways to increase readiness. Helping Veterans understand the risks of these behaviors, the possible benefits of changing, and how and why they engage in these behaviors is key to increasing readiness and intention to change; this intervention can occur during a Veteran's already-scheduled PACT appointment for optimal convenience. Incorporating Veterans' and providers' treatment preferences will enhance the intervention is acceptable, Veteran-centered, and able to be successfully implemented into real-world PACT clinical practice.

National Institute of Health (NIH)
Veterans Affairs (VA)
Veterans Administration (IK2)
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VA Western New York Healthcare System
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