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Using a Service Sector Segmented Approach to Identify Community Stakeholders Who Can Improve Access to Suicide Prevention Services for Veterans Monica M. Matthieu, PiiD, LCSW*t; Giovanina Gardiner, MSW*; Bien Ziegemeier, MA*; Miranda Buxton, MSWf ABSTRACT Veterans in need of social services may access many different community agencies within the public and private sectors. Each of these settings has the potential to be a pipeline for attaining needed health, mental health, and benefits services; however, many service providers lack information on how to conceptualize where Veterans go for services within their local community. This article describes a conceptual framework for outreach that uses a service sector segmented approach. This framework was developed to aid recruitment of a provider-based sample of stakeholders {N = 70) for a study on improving access to the Department of Veterans Affairs and community-based suicide prevention services. Results indicate that although there are statistically significant differences in the percent of Veterans served by the different service sectors (F(9,55) = 2.71, p = 0.04), exposure to suicidal Veterans and providers' referral behavior is consistent across the sectors. Challenges to using this framework include isolating the appropriate sectors for targeted outreach efforts. The service sector segmented approach holds promise for identifying and refeiring at-risk Veterans in need of services.
INTRODUCTION The release of the 2012 suicide data report from the Department of Veterans Affairs (VA) highlights the vital role of outreach for ongoing suicide prevention efforts. ' As clinical and public health efforts continue to target Veteran suicide, the VA is striving for innovative and new ways to reach Veterans in their communities who are at increased risk for suicide. This article presents a framework for outreach to service providers in the public and private sectors who may have access to the Veteran population and who could potentially serve as a gateway to needed VA and community-based suicide prevention services. Background The research literature defines the public sector as any public agency, to include federal, state, or local government agencies, which provides benefits or services for the public use. This sector is differentiated from the private sector in that services are provided by nongovernmental and privately owned entities such as nonprofit community-based agencies and for-profit organizations.^'^ In addition, the term "health care sector" in the economic literature has been used to describe the delivery of health care services and products for *Department of Veterans Affairs, VA St. Louis Health Care System, Mental Health Service, 915 North Grand Blvd, Saint Louis. MO 63106. tSchool of Social Work, Saint Louis University, Tegeler Hall, Suite 300, 3550 Lindell Blvd, Saint Louis, MO 63103. :j:George Warren Brown School of Social Work and Public Health, Washington University in St. Louis, 700 Rosedale Avenue, Campus Box 1009, St. Louis, MO 63112. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs. doi: 10.7205/MILMED-D-13-00306
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humans. However, to our knowledge these various sectors have not been used as the foundation for recruiting providers within these types of organizations to participate in mental health services research focused on the particular population of former members of the U.S. Armed Forces. Implementation science suggests that one of the most efficient means of disseminating evidence-based interventions and quality improvement research findings involves identifying clusters or sectors that may first adopt the innovation or program.^"^ These "early adopters" are typically defined as key stakeholders with vast knowledge of issues facing the community, are considered hubs within communication channels, and may possess a vast professional and social network.*^ With respect to the Veteran population, a critical component of ascertaining a sample by sector is to first ask a variety of key stakeholders where Veterans typically seek services in their community. Yet in so doing, one must take into consideration the entire community, to include the federal and state health care and benefits systems for Veterans as well as all other social services available in the community. In addition to stakeholder perspectives, research has consistently indicated that traditional mental health settings are used as the primary information and referral gateway to a variety of community-based agencies and social services.^ Although these settings and clinical providers are one model that determines the need for mental health services based on individual characteristics of the client and their referrals to services, which are typically based on their existing professional networks,'° they may also fail to consider the full range of help-seeking behaviors Veterans exhibit within their community. Veterans may seek mental health services in traditional medical settings such as the VA health care system, community health centers or clinics.
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and yet they can also seek these same or allied services from local community-based organizations, such as employment agencies, faith-based organizations, schools, the justice system, and state and federal agencies that assist with a range of military and Veteran benefits. By first considering stakeholder opinions and then assessing the typical access points to mental health care for Veterans, identifying a range of community services organized by sectors can significantly broaden outreach efforts. The ability to look beyond the health care sector to identify where Veterans may present in their community for services offers great promise for VA's suicide prevention efforts.
Study Aims Evidence-based suicide prevenfion strategies to identify vulnerable and hard-to-reach Veteran populafions (e.g., nonenrolled Operation Enduring Ereedom/Operation Iraqi Ereedom and rural veterans) are underdeveloped." Research, federal reports, and the VA strategic plan all point to the importance of including stakeholders in design, implementation, and use of services locally."''^ With an eye to furthering these strategies, this study sought to elicit stakeholder perspectives on the organization- and provider-level barriers to Veterans accessing suicide prevention services in their local communities. Although other research in cancer communications uses a social ecological framework to aid recruitment efforts for diverse and hard-to-reach populations,'^ to our knowledge, there is a paucity of information on how sectors can be used to inform a recruitment strategy for mental health services research focusing on Veterans at risk for suicide. Therefore, for this article, there are two primary aims. Eirst, we will describe a conceptual framework that uses a service sector segmented approach to identify agency-based clinical and community providers who may come into contact with Veterans in need of suicide prevention services. Second, we will describe the methods used for ascertaining the sample, and in particular, the success of segmenting recruitment efforts by service sector to find agencies that serve Veterans. METHODS
Study Design This mixed-methods study consisted of a qualitative, semistructured interview and a quantitative, self-report survey that was administered to VA and community-based providers (N = 70) serving rural and urban communities in the Midwest. This design was selected to enable the use of both within-case and across-case analytic strategies. The primary objective was to attain in-depth information from diverse stakeholders affiliated with the VA and community agencies within 10 different service sectors. The total proposed sample size {N - 70) avoided groups with less than 5 individuals per service sector. Ethical approval was obtained before data
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collection from the local VA and the academic affiliate's institutional review boards and informed consent was obtained from each participant.
Ascertainment and Sampie Characteristics The ascertainment of the sample for this study used a service sector segmented approach. Considering the need to obtain data from providers serving rural-living Veterans, as well as to maintain representativeness of population dispersion, we chose both an urban and a rural segment of a Midwestern state as our sampling areas. We limited our sampling frame to agencies within the state given (1) our focus on returning Veterans, (2) the number of programs and services for Veteran and military service members offered by the public sector, and (3) the high density of private agencies in each region. Eor this study, the sample comprised 70 providers. The goal was to recruit at least 6 different VA and communitybased providers from the 10 different service sectors we identified (n - 60). In addition, the study oversampled providers (« = 10) from the aging sector to increase the focus on life transitions encountered as part of aging and on male Veterans over 50 years of age, because of their increased risk for suicide.' Characteristics of the sample included adults aged 18 and older who were employed in the public or private sector providing health, psychosocial, employment, benefits assistance, or other social services within organizations that may serve Veterans in one Midwestern state. The exclusion criteria, informed by our theoretical frameworks,'""''* included individuals who did not have sufficient experience with Veterans to provide a perspective on the topic of suicide prevention services.
Sampiing Strategy The providers were identified using a two-step, purposive, snowball sampling process. Eirst, the research team proposed 10 different Veteran-focused service sectors based on the principal investigator's nearly 15 years of experience as a VA social worker, her position as the community outreach codirector for a federally funded academic research center affiliated with a school of social work, and her professional networks within the Veteran community across the state. After defining each service sector, team members developed an initial contact list of agencies using the Internet to match the agency mission to each sector. Specific attention was paid to national agencies with local chapters such as the Americíin Red Cross, the Alliance on Mental Illness, state agencies such as the state Department of Mental Health, and local nonprofit agencies that focused on Veteran's issues such as Welcome Home. Erom this initial list of service sectors, descriptions, and matching agencies (Table I), the research team idenfified at least 3 providers within each of the 10 service sectors (« - 30).
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Improve Access to Suicide Prevention Services for Veterans TABLE I. Service Sector Mental Health
Substance Abuse
Aging
Homeless
Employment
Service Sectors, Descriptions, and Examples of Agencies Description
Agencies
Public (federal, state, and local) and private sector community agencies that provide general and specialty mental health services to include suicide prevention, health and Wellness, family psychoeducatlon. and military- and Veteranspecific information and referrals to mental health care Public (federal, state, and local) and private sector community agencies that provide specialty substance use services to include prevention of substance use, detoxification, ¡npatient or outpatient substance abuse treatment. and peer support/recovery services Public (federal, state, and local) and private sector community agencies that provide general and specialty services for older adults, defined as agencies that serve the primary populations of individuals 60 years and older, experiencing life transitions and in need of skilled nursing. caregiving, or other aging-related support services Public (federal, state, and local) and private sector community agencies that provide general and specialty services for the homeless, defined as agencies that serve the primary population of adults who are currently homeless or at risk of homelessness Public (federal, state, and local) and private sector community agencies that provide employment and career services to address issues of (un)employment. self-employment, entrepreneurship, and business development
VA mental health clinics in the state, local crisis and suicide prevention centers. Alliance on Mental Illness, the state Department of Mental Health, state and local university counseling and student health centers, counseling services for the National Guard and the Reserves, and providers in private practice, etc. VA's substance abuse clinics in the state, state Department of Mental Health substance abuse treatment facilities, substance abuse prevention agencies, detoxification facilities. Alcoholics Anonymous, and providers in private practice, etc. VA's Domiciliary, geriatric extended care, and community living centers, state Department of Health and Senior Services, state VA homes. assisted living and rehabilitation facilities. Alzheimer's Association, community hospice services, home health agencies, care giver and respite services. Area Agencies on Aging, etc. VA's Homeless Program including the grants and per diem programs, local Housing and Urban Development, community homeless programs. emergency shelters, food banks, homeless prevention programs, housing and financial literacy programs, etc. VA's Vocational Rehabilitation and Employment programs. Vet Success, Compensated Work Therapy, state Department of Economic Development and Career Centers, U.S. Small Business Administration, Veterans Business Resource Centers, etc. VA's Veterans Justice Outreach program, U.S. and state Department of Corrections, probation and parole offices, law enforcement agencies. Crisis Intervention Teams, Court systems including mental health treatment and Veterans courts, etc. VA representatives on college campuses, state and local universities, community colleges, universityaffiliated outreach and education programs. Area Health Education Centers, university-based Student Veteran Centers, etc. U.S. Departments of Defense and Veterans Affairs, state National Guard, state VA, The USO, American Red Cross, etc.
Justice System
Public (federal, state, and local) and private sector community agencies that provide general and specialty legal services for individuals. (particularly Veterans) who are engaged in some aspect of the criminal justice system
Education
Public (federal, state, and local) and private sector community agencies that provide education and training to include postsecondary education. community education, outreach, life skills and lifelong learning Public (federal, state, and local) and private sector community agencies that provide information. referral and morale, Wellness, and recreation services for current military service members on active duty, in the Reserves and National Guard Public (federal, state, and local) and private sector community agencies that provide information. referral, benefits assistance, and civic engagement services to former members of the U.S. Armed Forces Public (federal, state, and local) and private sector community agencies that that provide advocacy and policy related services for at-risk and vulnerable populations
Military
Benefits
Policy
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Veterans Service Organizations, state VA, The Mission Continues, etc.
Academic research centers, policy centers. House and Senate Committees on Veterans Affairs, Congressional offices. The White House's Joining Eorces program
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As a parallel process to developing the sampling strategy, this initial list included employees of a small group of agencies (n = 7) who were purposively selected to participate in the pilot phase of the study, because of their access to and knowledge of the target population, and who were considered key stakeholders in the Veteran community. These individuals, because of their participation in the pilot, were excluded from the formal study. This pilot phase included testing the interview guide and survey, recruitrnent and data management procedures, and finally, as a stimulus to initial recruitment, participant nominations. Every participant recruited for the study, including the pilot group, was asked to nominate 3 other practitioners within any of the 10 service sectors who they thought would be appropriate for the study. This nomination procedure sought to minimize potential bias in using the initial contact list developed by the research team. The second phase of sampling then focused on this resulting group of nominated providers (N = 149). The research team, using the Internet searches to confii'm agency mission, staffing profiles and duties, geographic service areas, organizations with satellite locations serving rural areas (e.g., community mental health centers, hospitals, homeless shelters) then classified each participant and their agency into 1 of the 10 service sectors. Weekly meetings to review agency information guided team decision-making on the assignment of sectors. Initial recruitment goals within each sector, which was also stratified by the geographic area of service delivery for the agency (i.e., agency primarily serves rural or urban areas) and participant job type (e.g., administrator or clinician), were used to monitor recruitment efforts.
Data Collection Procedures The research team was composed of a doctoral-level research social worker with experience in the design and conduct of mixed methods and suicide prevention research, a master's level cultural anthropologist, a rnaster's level quantitative analyst, and a graduate-level social work student project coordinator. An initial recruiting e-mail was sent to prospective participants with study information and informed consent materials attached. Follow-up telephone calls reviewed the materials, discussed the survey, and scheduled the interview. After attaining informed consent, all interviews were administered individually in person by the anthropologist, who has extensive experience conducting interviews on mental health topics and with adult social service providers. The interviewer trained all staff who participated as members of the coding team on qualitative data analysis procedures. Surveys were e-mailed to participants in advance of the interview, with additional copies brought to the session, completed by participants, and subsequently collected by the interviewer. The total survey response rate was 99% (« = 69).
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Theoretical Frameworks Guiding Measurement The semistructured interview guide and self-report surveys were developed by the research team based on constructs and items from the Behavioral Model of Health Services Use'"* and the Gateway Provider Model.'" The Anderson model is a framework that depicts service use as a function of "client needs, predisposing factors" that influence clients to want to use services, and "factors enabling" access to services. However, from the perspective of the provider, as in the Gateway Provider Model, the elements that influence use of services by the individual in need of care can also be elements that influence provider decision-making as to the need for services and referrals to attain those services. At the interface of the provider and the organization is the Gateway Provider Model. This model outlines the "enabling factors" for health care use, the view providers have of their "client's need for services," "predisposing factors," and the "provider's perceptions and knowledge of services to meet the client's need." Then the organizational context is applied to the model. This context, referred to as "structural characteristics," influences the provider and their decision-making process regarding making a referral to services to address a client's need. As such, these models have applicability to all Veterans at high risk for suicide who may be identified and referred to care by providers, some of whorn are VA staff, but also for community-based providers who tnay encounter Veterans within their own agencies in local communities.
Measures Data collected for the interview focused on three main topics from the providers' perspective: (1) Veterans' overall need for mental health and suicide prevention services, (2) the referral process to attain these services, and (3) the barriers encountered in accessing mental health services, particularly when Veterans are at heightened risk for suicide. The interview guide divided these topics into five sections (predisposing and enabling factors, provider perspective on client service needs, provider knowledge of services to meet client needs, multilevel barriers to care, and the structural characteristics of the employing organization), with additional questions pertaining to older Veterans asked of providers in the aging sector. Several close-ended questions were also included in the interview guide, particularly when asking for clarification on survey answers (i.e., military service is assessed on intake, percent of current client population with a history of military service) and in regard to Veteran mental health care needs (perceived need for suicide prevention services for Veterans). Four of the five sections of the self-report survey instrument have been used previously.''''"'* The sections were (1) organizational assessment (developed for use in this study), (2) provider demographics, (3) individual-level factors, (4) exposure to suicide, and (5) awareness of suicide prevention resources. The organizational assessment collected
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data with regard to the type of organization, annual budget, number of clinical/medical and all employees, annual number of clients served, age range of clientele, type of services provided, and if sei"vices were military- or Veteran-focused. Demographics data on the provider's age, gender, race, ethnicity, education, job role, and years of clinical experience were collected. The individual-level factors data included an assessment of the participant's lifetime history of general and clinical interviewing experience and trainings attended related to suicide and crisis. The provider exposure to suicide included a series of questions related to lifetime exposure to suicide, such as previous contact with potentially suicidal individuals, suicide attempters, and suicide decedents. Also included were a series of questions about provider referral behavior, including the lifetime number of referrals offered for suicidal individuals and the relationship to the person referred. For this study, the number of referrals was recoded into a dichotomous variable using a range previously used in literature,'"^ where 1 = referred greater than 11 individuals and 0 = referred 11 or fewer individuals, as nearly everyone in our study had referred someone for suicide prevention services over their lifetime. Finally, awareness of suicide resources was assessed using four items with dichotomous (e.g., scored "yes" or "no") response options. These items asked participants whether they had any awareness of efforts regarding suicide prevention specific to their (1) workplace, (2) local community, (3) state, and (4) nation.
Data Analysis For this study, we only report on a subset of survey data. Data on service sector assignment were obtained from the research team's recruitment tracking database and combined with the participants' survey data. All data were entered by the research team into Microsoft Access then transferred to SPSS 19.0 (IBM Corporation, Armonk, New York) for univariate and bivariate analysis. Missing data on some survey items led to differences in sample sizes for some items. To assess the aims of this study related to success of segmenting recruitment efforts by service sector to identify agencies that serve Veterans, rates of success in scheduling and completing interviews were calculated by service sector using a x^ analysis. Rates of success in terms of finding agencies that served Veteran populations were also calculated and compared across service sector using a one-way analysis of variance to detect differences between rates of Veterans served by service sector. Referral behavior and contact with suicidal individuals were compared across service sector using a j ^ analysis. RESULTS
Recruiting by Service Sectors Table I outlines 10 different service sectors, descriptions, and typical examples of agencies who's clinical and community
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providers may come into contact with Veterans in need of suicide prevention services. First, the "mental health service sector" was defined by VA and non-VA mental health clinics, inpatient and outpatient psychiatric treatment facilities, and TABLE II.
Demographics and Organizational Characteristics Provider Variables
N
%
Mean Age = 46.4 (SD = 9.5) Gender Male Female Race Caucasian African American Native American Ethnicity Hispanic/Latino Education Master's or Above Bachelor's or Below Degree Social Worker Counselor—General Psychologist Chemical Dependency Counselor Nurse Veteran Status Yes, History of Service in U.S. Armed Forces Job Role Administrator Clinician VA Provider Yes, VA Employee
65 69 37 32 68 60
53.6 46.4
6
1 67 7 69 51 18 49 30 8 3 2
t 70 21 63 39 24 70 17
Organization Variables
N
Type of Organization Not-for-Profit Agency For-Profit Agency Governmental Agency College/University Public/Private Hospital Other Budget Under $1 Million Over$l Million Total Number of Employees Less Than 100 100 or More Total Number of Clinical/Medical Staff Less Than 25 25 or More Number of Clients Less Than 1,000 1,000 or More Age Range of Clients Birth to 17 Years 18-24 Years 25-64 Years 65 Years and Older Provides Veteran-Focused Services Yes Provides Services to Rural Areas Yes
69 25 3 32 6 2 1 56 28 28 67 38 29 65 41 24 65 22 43 69 22 58 64 54 67 50 30
87.0 10.1 L4 10.4 73.9 26.1 61.2 16.3 6.1 4.1 2.0 30.0 61.9 38.1 24.3 % 36.2 4.3 46.4 8.7 2.9 1.4 50.0 50.0 56.7 43.3 63.1 36.9 33.8 66.2 31.4 89.2 91.4 77.7 74.6 42.9
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community mental health centers, such as those run by the state department of mental health and by private providers. The "substance abuse sector" consisted of inpatient and outpatient substance abuse prevention and treatment settings. The "aging sector" comprised agencies whose primary populations include those over 60 years of age with services focusitig on older adults. The "homeless sector" included agencies whose primary population included those who were homeless or at risk of homelessness. The "employment sector" consisted of those organizations whose primary concern is assisting with (un)employment, self-employment, and/or business development. The "justice system sector" comprised law enforcement, courts, and other legal agencies whose primary population includes those involved in the criminal justice system. The "education sector" consisted of organizations whose primary mission is adult postsecondary education. The "military sector" consisted of agencies whose primary population includes current military service members. The "benefits sector" consists of agencies that provide information, referral, benefits assistance, and/or civic engagement opportunities for Veterans. Finally, the "policy sector" included agencies whose primary mission is advocacy and/ or specific policy, research, or allied services targeting service delivery for vulnerable and at-risk populations.
Success Rates Using the Service Sector Segmented Approach A total of 149 potential participants were contacted with 70 participating in the study, for a response rate of 47%. Overall, the sample was composed of middle-aged, Caucasian, Master's level-educated social workers. As shown in Table II, the sample was almost half women and half men, nearly two-thirds were administrators, and about 30% had previously served in the military. Organizationally, the majority of providers
worked in medium to large governmental settings, with 75% of the sample reporting to provide Veteran-focused services. In terms of success rates, there were no statistically significant differences between recruitment by service sector iX^ = 13.35, p = 0.20); all had rates around 50% per sector. Results (Fig. 1) indicate statistically significant differences in the mean percentage of Veterans served by the agency in each service sector, meaning that not all agencies in our study served a similar percentage of Veterans (F(9,55) = 2.71, p = 0.04). Agencies that provided Veteran-specific services, such as those in the benefits sector, had the highest percentage of Veteran clients, as may be expected. Seven of the ten sectors indicated more than 50% of their population served includes Veterans. Finally, there were no statistically significant differences by service sector in terms of contact with suicidal individuals (X^ = 11.62, p = 0.24), nor were there differences by referral rate (/" = 9.19, p = 0.42). Similar results were found when comparing referral of a Veteran across service sectors (x^ 8.21, p = 0.51). See Table III for more detail. DISCUSSION This article describes a conceptual framework for identifying community and clinical providers employed in organizations that rnay come into contact with Veterans, some of whom may be in need of mental health, suicide prevention, or other service needs. Although the service sector segmented approach was used in this study with some success in guiding recruitment efforts, the framework may also be useful to inform outreach strategies to engage the public and private sectors in identifying and referring Veterans to needed and appropriate services. As reiterated by the VA's recent release of 2012 suicide data,' the issue of Veteran suicide is of great concern in all
I Percent Veterans served
0 FIGURE 1.
20
40
100
Percent of Veterans served by service sector.
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Improve Access to Suicide Prevention Services for Veterans TABLE in.
Suicide Exposure by Service Sector Contact With Someone Suicidal
Service Sector Mental Health (n = 12) Substance Abuse (« = 3) Aging (n = 9) Homelessness (n = 10) Employment (H = 6) Justice System (n = 10) Benefits (n = 5) Military (n = 5) Education (n = 3) Policy (n = 6) Total (n = 69)
N 12 2 9 10 5 10 4 5 3 5 65
% 100 66.7
100 100 83.3 100 80.0 100 100 83.3 94.2
Referred >11 People Service Sector Mental Health (n = 12) Substance Abuse (n = 2) Aging (n = 9) Homelessness (n = 10) Employment (n = 5) Justice System (n = 10) Benefits (n = 4) Military (n = 5) Education (;; = 3) Policy (n = 5) Total (« = 65)
N 9 1 2 5 3 5 1 2 2 1 31
% 75.0 50.0 22.2 50.0 60.0 50.0 25.0 40.0 66.7 20.0 47.7
Referred a Veteran for Suicide Prevention Services Service Sector Mental Health (« = 12) Substance Abuse (« = 2) Aging (77 = 9) Homelessness (« = 10) Employment (n = 5) Justice System (ii = 10) Benefits (;i = 4) Military (n = 3) Education (« = 3) Policy (« = 5) Total (« = 65)
N 8 1 3 5 4 5 4 2 2 2 36
P 0.24
% 66.7 50.0 33.3 50.0 80.0 50.0 100 40.0 66.7 40.0 55.4
P 0.24
P 0.24
of our communities. Thus, one specific goal of this study was to develop a framework to improve methods of locating Veterans within their community. As one example, this approach can specifically aid clinical and community providers in proactive decision-making and thoughtful allocation of scarce resources when competing demands on their time necessitate a more focused outreach plan. By considering different sectors, clinical and community providers can potentially expand their professional networks to identify and refer Veterans in crisis when in need of care. Eor private sector program planners, this framework can also be used to align the program objectives with targeted outreach activities in specific community locations with a greater density of high-risk individuals or to specifically address a
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service sector with high-priority clinical need. And finally, the framework can inform strategic planning and policy making when drafting calls to action and national agenda setting to address long-term, public health, and complex prevention issues. The second aim of this article was to highlight the specific benefit of this approach in terms of outreach to Veterans within their community. Our findings indicate that all of the providers in each service sector have had experience with suicidal individuals with the highest percentages found in the mental health, military, homeless, justice, education, and aging sectors. Results also indicate that there are some service sectors, such as the employment sector, that may not seem specifically targeted toward Veterans, yet actually have a significant amount of Veteran clients. In addition, there are service sectors that are known to provide benefits services specifically for Veterans, but that are not focused on providing mental health services. These agencies are encountering Veterans with mental health issues and are referring Veterans for services, including suicide prevention services. Interestingly, nearly the entire sample (96.4%, n = 65) had referred someone to mental health services. Although mental health providers may have referred more individuals for services, they are by no means the only ones encountering Veterans at risk for suicide. Contact with suicidal individuals was prevalent not only in the mental health sector, but also within the employment and justice system sectors. Nearly the entire sample had contact with someone who was suicidal at some point in their life. Contact with a suicidal Veteran was similarly not limited solely to those who typically work with Veterans—there were no statistically significant differences within our sample among those who had contact with and even referred a Veteran for suicide prevention services. However, this highlights a need to expand outreach efforts beyond the traditional locations and for providers to think more broadly about how and where to locate Veterans within the community. This service sector segmented approach offers a novel way of approaching this outreach issue.
Study Limitations Although using the conceptual framework divided by service sectors was beneficial to aid recruitment, there were limitations to its use that should be considered when applying the framework. Eirst, segmenting sample ascertainment by service sectors can be somewhat of a moving target— i.e., there are many ways to describe various sectors (e.g., type of services, primary client population) and those definitions are inherently unstable in a constantly changing public-private sector service delivery environment. Providers may also define their membership in a particular sector differently than researchers or define the services they provide in more than one sector or crossing sectors (e.g., the education sector provides health services for em-olled
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students Veterans, faith-based organizations provide many homeless sector services). Second, the response rate (47%) to our study was moderate, which may have been partially or fully driven by our exclusion criteria and nominating procedure that asked providers to recommend others with sufficient experience with Veterans. Given this variability and the potential omission of other relevant sectors and providers, the framework is presented here as merely an additional tool to augment other established strategic planning and outreach efforts.
Implications for Future Research, Clinical Practice, or Policy Clinical and community providers in the public and private sectors may use this approach as a means of identifying new portals to better align and target their outreach efforts. With regard to suicide prevention, it remains critically important to consider all sectors, not just the mental health sector, in communities where Veterans may seek services. However, future research is needed to determine the use and feasibility of using this approach to improve access to care for Veterans at risk of suicide. Finally, although this study focused on the providers' perspective of Veterans' need for services. Veterans themselves may have an entirely different outlook on desired services in their community that would add to the relevance and importance of this framework. Future studies to examine the Veteran perspective on seeking services are needed, CONCLUSIONS Farly identification of Veterans at risk for suicide can be lifesaving. This study offers a framework to identify providers within the public and private sector who may come into contact with Veterans in hopes of expanding the network of people who can help to prevent suicide. Although some results confirm what was expected (i.e., mental health care providers refer more suicidal individuals, more Veterans are served by the benefits service sector), these results also indicate that consideration of nontraditional service sectors, such as education, justice, and employment services, is a useful means of locating potentially suicidal Veterans. Segmenting outreach efforts by service sector allows providers to conceptualize the various ways in which Veterans interact with the community to increase their success at locating at-risk Veterans and providing them with potentially lifesaving assistance. ACKNOWLEDGMENTS The authors thank Lu Han, Tara Sabharwal, and Rachel Perkins, the Center for Violence and Injury Prevention, and all our community stakeholders
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for their assistance and support of this project. This project is funded by the Department of Veterans Affairs (VA), Health Services Research and Development (HSRD), Quality Enrichment Research Initiative (QUERI RRP 11-002), and the Center for Violence and Injury Prevention (grant number 1620-94692). This study was also supported with resources and the use of facilities at the VA St. Louis Health Care System.
REFERENCES 1. Kemp J, Bossarte R: Suicide Data Report. Washington, DC, United States Department of Veterans Affairs, Mental Health Services, Suicide Prevention Program, 2012. Available at http://www.va.gov/opa/docs/ Suicide-Data-Report-2012-final.pdf; accessed May 1,2013. 2. Aarons GA, Hurlburt M, Horwitz SM: Advancing a conceptual model of evidence-based practice implementation in public service sectors. Adm Policy Ment Health 2011; 38: 4-23. 3. Soteri-Proctor A: Making use of qualitative tools: towards a fuller understanding of the voluntary sector's engagement with public service delivery. Int J Soc Res Meth 2010; 13(5): 411-24. 4. International Standard Industrial Classification: International Standard Industrial Classification of All Economic Activities, Rev. 4. New York, NY, United Nations, United Nations Statistics Division, 2013. Available at http://unstats.un.org/unsd/pubIication/seriesM/seriesm_4rev4e.pdf; accessed May 1,2013. 5. Berwick DM: Disseminating interventions in health care. JAMA 2003; 289(15): 1969-75. 6. Proctor E, Silmere H, Raghavan R, et al: Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Adm Policy Ment Health 2011; 38: 65-76. 7. Proctor EK, Rosen A: Erom knowledge production to implementation: research challenges and imperatives. Res Soc Work Pract 2008; 18: 285-91. 8. Rogers EM: Diffusion of Innovations. Glencoe, IL, Free Press, 1962. 9. Carey K, Montez-Rath ME. Rosen AK, Christiansen CL, Loveland S, Ettner SL: Use of VA and Medicare services by dually eligible Veterans with psychiatric problems. Health Serv Res 2008; 43(4): 1164-83. 10. Stiffman AR, Pescosolido B, Cabassa LJ: Building a model to understand youth service access: the gateway provider model. Ment Health Serv Res 2004; 6(4): 189-98. 11. U.S. Department of Veteran Affairs (DVA): Report of the blue ribbon work group on suicide prevention in the veteran population. Washington, DC, U.S. Department of Veteran Affairs, 2008. Available at http://www .mentalhealth.va.gov/suicide_prevention/Blue_Ribbon_Report-EINAL_ June-30-08.pdf; accessed May 1, 2013. 12. Goldsmith S, Pellmar T, Klienman A, Bunney W: Reducing Suicide: A National Imperative. Washington, DC, The National Academies Press, 2002. 13. Wells AA, Zebrack BJ: Psychosocial barriers contributing to the underrepresentation of racial/ethnic minorities in cancer clinical trials. Soc Work Health Care 2008; 46(2): 1-14. 14. Anderson RM: Revisiting the behavioral model and access to medical care: does it matter? J Health Soc Behav 1995; 36(1): 1-10. 15. Matthieu MM, Chen Y, Schohn M, Lantinga LJ, Knox KL: Education preferences and outcomes from suicide prevention training in the Veterans Health Administration: one-year follow-up with healthcare employees in upstate New York. Mil Med 2009; 174: 1123-31. 16. Matthieu MM, Cross W, Batres AR, Flora CM, Knox KL: Evaluation of gatekeeper training for suicide prevention in Veterans. Arch Suicide Res 2008; 12: 148-54.
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Using a Service Sector Segmented Approach to Identify Community Stakeholders Who Can Improve Access to Suicide Prevention Services for Veterans Monica M. Matthieu, PiiD, LCSW*t; Giovanina Gardiner, MSW*; Bien Ziegemeier, MA*; Miranda Buxton, MSWf ABSTRACT Veterans in need of social services may access many different community agencies within the public and private sectors. Each of these settings has the potential to be a pipeline for attaining needed health, mental health, and benefits services; however, many service providers lack information on how to conceptualize where Veterans go for services within their local community. This article describes a conceptual framework for outreach that uses a service sector segmented approach. This framework was developed to aid recruitment of a provider-based sample of stakeholders {N = 70) for a study on improving access to the Department of Veterans Affairs and community-based suicide prevention services. Results indicate that although there are statistically significant differences in the percent of Veterans served by the different service sectors (F(9,55) = 2.71, p = 0.04), exposure to suicidal Veterans and providers' referral behavior is consistent across the sectors. Challenges to using this framework include isolating the appropriate sectors for targeted outreach efforts. The service sector segmented approach holds promise for identifying and refeiring at-risk Veterans in need of services.
INTRODUCTION The release of the 2012 suicide data report from the Department of Veterans Affairs (VA) highlights the vital role of outreach for ongoing suicide prevention efforts. ' As clinical and public health efforts continue to target Veteran suicide, the VA is striving for innovative and new ways to reach Veterans in their communities who are at increased risk for suicide. This article presents a framework for outreach to service providers in the public and private sectors who may have access to the Veteran population and who could potentially serve as a gateway to needed VA and community-based suicide prevention services. Background The research literature defines the public sector as any public agency, to include federal, state, or local government agencies, which provides benefits or services for the public use. This sector is differentiated from the private sector in that services are provided by nongovernmental and privately owned entities such as nonprofit community-based agencies and for-profit organizations.^'^ In addition, the term "health care sector" in the economic literature has been used to describe the delivery of health care services and products for *Department of Veterans Affairs, VA St. Louis Health Care System, Mental Health Service, 915 North Grand Blvd, Saint Louis. MO 63106. tSchool of Social Work, Saint Louis University, Tegeler Hall, Suite 300, 3550 Lindell Blvd, Saint Louis, MO 63103. :j:George Warren Brown School of Social Work and Public Health, Washington University in St. Louis, 700 Rosedale Avenue, Campus Box 1009, St. Louis, MO 63112. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs. doi: 10.7205/MILMED-D-13-00306
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humans. However, to our knowledge these various sectors have not been used as the foundation for recruiting providers within these types of organizations to participate in mental health services research focused on the particular population of former members of the U.S. Armed Forces. Implementation science suggests that one of the most efficient means of disseminating evidence-based interventions and quality improvement research findings involves identifying clusters or sectors that may first adopt the innovation or program.^"^ These "early adopters" are typically defined as key stakeholders with vast knowledge of issues facing the community, are considered hubs within communication channels, and may possess a vast professional and social network.*^ With respect to the Veteran population, a critical component of ascertaining a sample by sector is to first ask a variety of key stakeholders where Veterans typically seek services in their community. Yet in so doing, one must take into consideration the entire community, to include the federal and state health care and benefits systems for Veterans as well as all other social services available in the community. In addition to stakeholder perspectives, research has consistently indicated that traditional mental health settings are used as the primary information and referral gateway to a variety of community-based agencies and social services.^ Although these settings and clinical providers are one model that determines the need for mental health services based on individual characteristics of the client and their referrals to services, which are typically based on their existing professional networks,'° they may also fail to consider the full range of help-seeking behaviors Veterans exhibit within their community. Veterans may seek mental health services in traditional medical settings such as the VA health care system, community health centers or clinics.
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and yet they can also seek these same or allied services from local community-based organizations, such as employment agencies, faith-based organizations, schools, the justice system, and state and federal agencies that assist with a range of military and Veteran benefits. By first considering stakeholder opinions and then assessing the typical access points to mental health care for Veterans, identifying a range of community services organized by sectors can significantly broaden outreach efforts. The ability to look beyond the health care sector to identify where Veterans may present in their community for services offers great promise for VA's suicide prevention efforts.
Study Aims Evidence-based suicide prevenfion strategies to identify vulnerable and hard-to-reach Veteran populafions (e.g., nonenrolled Operation Enduring Ereedom/Operation Iraqi Ereedom and rural veterans) are underdeveloped." Research, federal reports, and the VA strategic plan all point to the importance of including stakeholders in design, implementation, and use of services locally."''^ With an eye to furthering these strategies, this study sought to elicit stakeholder perspectives on the organization- and provider-level barriers to Veterans accessing suicide prevention services in their local communities. Although other research in cancer communications uses a social ecological framework to aid recruitment efforts for diverse and hard-to-reach populations,'^ to our knowledge, there is a paucity of information on how sectors can be used to inform a recruitment strategy for mental health services research focusing on Veterans at risk for suicide. Therefore, for this article, there are two primary aims. Eirst, we will describe a conceptual framework that uses a service sector segmented approach to identify agency-based clinical and community providers who may come into contact with Veterans in need of suicide prevention services. Second, we will describe the methods used for ascertaining the sample, and in particular, the success of segmenting recruitment efforts by service sector to find agencies that serve Veterans. METHODS
Study Design This mixed-methods study consisted of a qualitative, semistructured interview and a quantitative, self-report survey that was administered to VA and community-based providers (N = 70) serving rural and urban communities in the Midwest. This design was selected to enable the use of both within-case and across-case analytic strategies. The primary objective was to attain in-depth information from diverse stakeholders affiliated with the VA and community agencies within 10 different service sectors. The total proposed sample size {N - 70) avoided groups with less than 5 individuals per service sector. Ethical approval was obtained before data
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collection from the local VA and the academic affiliate's institutional review boards and informed consent was obtained from each participant.
Ascertainment and Sampie Characteristics The ascertainment of the sample for this study used a service sector segmented approach. Considering the need to obtain data from providers serving rural-living Veterans, as well as to maintain representativeness of population dispersion, we chose both an urban and a rural segment of a Midwestern state as our sampling areas. We limited our sampling frame to agencies within the state given (1) our focus on returning Veterans, (2) the number of programs and services for Veteran and military service members offered by the public sector, and (3) the high density of private agencies in each region. Eor this study, the sample comprised 70 providers. The goal was to recruit at least 6 different VA and communitybased providers from the 10 different service sectors we identified (n - 60). In addition, the study oversampled providers (« = 10) from the aging sector to increase the focus on life transitions encountered as part of aging and on male Veterans over 50 years of age, because of their increased risk for suicide.' Characteristics of the sample included adults aged 18 and older who were employed in the public or private sector providing health, psychosocial, employment, benefits assistance, or other social services within organizations that may serve Veterans in one Midwestern state. The exclusion criteria, informed by our theoretical frameworks,'""''* included individuals who did not have sufficient experience with Veterans to provide a perspective on the topic of suicide prevention services.
Sampiing Strategy The providers were identified using a two-step, purposive, snowball sampling process. Eirst, the research team proposed 10 different Veteran-focused service sectors based on the principal investigator's nearly 15 years of experience as a VA social worker, her position as the community outreach codirector for a federally funded academic research center affiliated with a school of social work, and her professional networks within the Veteran community across the state. After defining each service sector, team members developed an initial contact list of agencies using the Internet to match the agency mission to each sector. Specific attention was paid to national agencies with local chapters such as the Americíin Red Cross, the Alliance on Mental Illness, state agencies such as the state Department of Mental Health, and local nonprofit agencies that focused on Veteran's issues such as Welcome Home. Erom this initial list of service sectors, descriptions, and matching agencies (Table I), the research team idenfified at least 3 providers within each of the 10 service sectors (« - 30).
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Improve Access to Suicide Prevention Services for Veterans TABLE I. Service Sector Mental Health
Substance Abuse
Aging
Homeless
Employment
Service Sectors, Descriptions, and Examples of Agencies Description
Agencies
Public (federal, state, and local) and private sector community agencies that provide general and specialty mental health services to include suicide prevention, health and Wellness, family psychoeducatlon. and military- and Veteranspecific information and referrals to mental health care Public (federal, state, and local) and private sector community agencies that provide specialty substance use services to include prevention of substance use, detoxification, ¡npatient or outpatient substance abuse treatment. and peer support/recovery services Public (federal, state, and local) and private sector community agencies that provide general and specialty services for older adults, defined as agencies that serve the primary populations of individuals 60 years and older, experiencing life transitions and in need of skilled nursing. caregiving, or other aging-related support services Public (federal, state, and local) and private sector community agencies that provide general and specialty services for the homeless, defined as agencies that serve the primary population of adults who are currently homeless or at risk of homelessness Public (federal, state, and local) and private sector community agencies that provide employment and career services to address issues of (un)employment. self-employment, entrepreneurship, and business development
VA mental health clinics in the state, local crisis and suicide prevention centers. Alliance on Mental Illness, the state Department of Mental Health, state and local university counseling and student health centers, counseling services for the National Guard and the Reserves, and providers in private practice, etc. VA's substance abuse clinics in the state, state Department of Mental Health substance abuse treatment facilities, substance abuse prevention agencies, detoxification facilities. Alcoholics Anonymous, and providers in private practice, etc. VA's Domiciliary, geriatric extended care, and community living centers, state Department of Health and Senior Services, state VA homes. assisted living and rehabilitation facilities. Alzheimer's Association, community hospice services, home health agencies, care giver and respite services. Area Agencies on Aging, etc. VA's Homeless Program including the grants and per diem programs, local Housing and Urban Development, community homeless programs. emergency shelters, food banks, homeless prevention programs, housing and financial literacy programs, etc. VA's Vocational Rehabilitation and Employment programs. Vet Success, Compensated Work Therapy, state Department of Economic Development and Career Centers, U.S. Small Business Administration, Veterans Business Resource Centers, etc. VA's Veterans Justice Outreach program, U.S. and state Department of Corrections, probation and parole offices, law enforcement agencies. Crisis Intervention Teams, Court systems including mental health treatment and Veterans courts, etc. VA representatives on college campuses, state and local universities, community colleges, universityaffiliated outreach and education programs. Area Health Education Centers, university-based Student Veteran Centers, etc. U.S. Departments of Defense and Veterans Affairs, state National Guard, state VA, The USO, American Red Cross, etc.
Justice System
Public (federal, state, and local) and private sector community agencies that provide general and specialty legal services for individuals. (particularly Veterans) who are engaged in some aspect of the criminal justice system
Education
Public (federal, state, and local) and private sector community agencies that provide education and training to include postsecondary education. community education, outreach, life skills and lifelong learning Public (federal, state, and local) and private sector community agencies that provide information. referral and morale, Wellness, and recreation services for current military service members on active duty, in the Reserves and National Guard Public (federal, state, and local) and private sector community agencies that provide information. referral, benefits assistance, and civic engagement services to former members of the U.S. Armed Forces Public (federal, state, and local) and private sector community agencies that that provide advocacy and policy related services for at-risk and vulnerable populations
Military
Benefits
Policy
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Veterans Service Organizations, state VA, The Mission Continues, etc.
Academic research centers, policy centers. House and Senate Committees on Veterans Affairs, Congressional offices. The White House's Joining Eorces program
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As a parallel process to developing the sampling strategy, this initial list included employees of a small group of agencies (n = 7) who were purposively selected to participate in the pilot phase of the study, because of their access to and knowledge of the target population, and who were considered key stakeholders in the Veteran community. These individuals, because of their participation in the pilot, were excluded from the formal study. This pilot phase included testing the interview guide and survey, recruitrnent and data management procedures, and finally, as a stimulus to initial recruitment, participant nominations. Every participant recruited for the study, including the pilot group, was asked to nominate 3 other practitioners within any of the 10 service sectors who they thought would be appropriate for the study. This nomination procedure sought to minimize potential bias in using the initial contact list developed by the research team. The second phase of sampling then focused on this resulting group of nominated providers (N = 149). The research team, using the Internet searches to confii'm agency mission, staffing profiles and duties, geographic service areas, organizations with satellite locations serving rural areas (e.g., community mental health centers, hospitals, homeless shelters) then classified each participant and their agency into 1 of the 10 service sectors. Weekly meetings to review agency information guided team decision-making on the assignment of sectors. Initial recruitment goals within each sector, which was also stratified by the geographic area of service delivery for the agency (i.e., agency primarily serves rural or urban areas) and participant job type (e.g., administrator or clinician), were used to monitor recruitment efforts.
Data Collection Procedures The research team was composed of a doctoral-level research social worker with experience in the design and conduct of mixed methods and suicide prevention research, a master's level cultural anthropologist, a rnaster's level quantitative analyst, and a graduate-level social work student project coordinator. An initial recruiting e-mail was sent to prospective participants with study information and informed consent materials attached. Follow-up telephone calls reviewed the materials, discussed the survey, and scheduled the interview. After attaining informed consent, all interviews were administered individually in person by the anthropologist, who has extensive experience conducting interviews on mental health topics and with adult social service providers. The interviewer trained all staff who participated as members of the coding team on qualitative data analysis procedures. Surveys were e-mailed to participants in advance of the interview, with additional copies brought to the session, completed by participants, and subsequently collected by the interviewer. The total survey response rate was 99% (« = 69).
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Theoretical Frameworks Guiding Measurement The semistructured interview guide and self-report surveys were developed by the research team based on constructs and items from the Behavioral Model of Health Services Use'"* and the Gateway Provider Model.'" The Anderson model is a framework that depicts service use as a function of "client needs, predisposing factors" that influence clients to want to use services, and "factors enabling" access to services. However, from the perspective of the provider, as in the Gateway Provider Model, the elements that influence use of services by the individual in need of care can also be elements that influence provider decision-making as to the need for services and referrals to attain those services. At the interface of the provider and the organization is the Gateway Provider Model. This model outlines the "enabling factors" for health care use, the view providers have of their "client's need for services," "predisposing factors," and the "provider's perceptions and knowledge of services to meet the client's need." Then the organizational context is applied to the model. This context, referred to as "structural characteristics," influences the provider and their decision-making process regarding making a referral to services to address a client's need. As such, these models have applicability to all Veterans at high risk for suicide who may be identified and referred to care by providers, some of whorn are VA staff, but also for community-based providers who tnay encounter Veterans within their own agencies in local communities.
Measures Data collected for the interview focused on three main topics from the providers' perspective: (1) Veterans' overall need for mental health and suicide prevention services, (2) the referral process to attain these services, and (3) the barriers encountered in accessing mental health services, particularly when Veterans are at heightened risk for suicide. The interview guide divided these topics into five sections (predisposing and enabling factors, provider perspective on client service needs, provider knowledge of services to meet client needs, multilevel barriers to care, and the structural characteristics of the employing organization), with additional questions pertaining to older Veterans asked of providers in the aging sector. Several close-ended questions were also included in the interview guide, particularly when asking for clarification on survey answers (i.e., military service is assessed on intake, percent of current client population with a history of military service) and in regard to Veteran mental health care needs (perceived need for suicide prevention services for Veterans). Four of the five sections of the self-report survey instrument have been used previously.''''"'* The sections were (1) organizational assessment (developed for use in this study), (2) provider demographics, (3) individual-level factors, (4) exposure to suicide, and (5) awareness of suicide prevention resources. The organizational assessment collected
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data with regard to the type of organization, annual budget, number of clinical/medical and all employees, annual number of clients served, age range of clientele, type of services provided, and if sei"vices were military- or Veteran-focused. Demographics data on the provider's age, gender, race, ethnicity, education, job role, and years of clinical experience were collected. The individual-level factors data included an assessment of the participant's lifetime history of general and clinical interviewing experience and trainings attended related to suicide and crisis. The provider exposure to suicide included a series of questions related to lifetime exposure to suicide, such as previous contact with potentially suicidal individuals, suicide attempters, and suicide decedents. Also included were a series of questions about provider referral behavior, including the lifetime number of referrals offered for suicidal individuals and the relationship to the person referred. For this study, the number of referrals was recoded into a dichotomous variable using a range previously used in literature,'"^ where 1 = referred greater than 11 individuals and 0 = referred 11 or fewer individuals, as nearly everyone in our study had referred someone for suicide prevention services over their lifetime. Finally, awareness of suicide resources was assessed using four items with dichotomous (e.g., scored "yes" or "no") response options. These items asked participants whether they had any awareness of efforts regarding suicide prevention specific to their (1) workplace, (2) local community, (3) state, and (4) nation.
Data Analysis For this study, we only report on a subset of survey data. Data on service sector assignment were obtained from the research team's recruitment tracking database and combined with the participants' survey data. All data were entered by the research team into Microsoft Access then transferred to SPSS 19.0 (IBM Corporation, Armonk, New York) for univariate and bivariate analysis. Missing data on some survey items led to differences in sample sizes for some items. To assess the aims of this study related to success of segmenting recruitment efforts by service sector to identify agencies that serve Veterans, rates of success in scheduling and completing interviews were calculated by service sector using a x^ analysis. Rates of success in terms of finding agencies that served Veteran populations were also calculated and compared across service sector using a one-way analysis of variance to detect differences between rates of Veterans served by service sector. Referral behavior and contact with suicidal individuals were compared across service sector using a j ^ analysis. RESULTS
Recruiting by Service Sectors Table I outlines 10 different service sectors, descriptions, and typical examples of agencies who's clinical and community
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providers may come into contact with Veterans in need of suicide prevention services. First, the "mental health service sector" was defined by VA and non-VA mental health clinics, inpatient and outpatient psychiatric treatment facilities, and TABLE II.
Demographics and Organizational Characteristics Provider Variables
N
%
Mean Age = 46.4 (SD = 9.5) Gender Male Female Race Caucasian African American Native American Ethnicity Hispanic/Latino Education Master's or Above Bachelor's or Below Degree Social Worker Counselor—General Psychologist Chemical Dependency Counselor Nurse Veteran Status Yes, History of Service in U.S. Armed Forces Job Role Administrator Clinician VA Provider Yes, VA Employee
65 69 37 32 68 60
53.6 46.4
6
1 67 7 69 51 18 49 30 8 3 2
t 70 21 63 39 24 70 17
Organization Variables
N
Type of Organization Not-for-Profit Agency For-Profit Agency Governmental Agency College/University Public/Private Hospital Other Budget Under $1 Million Over$l Million Total Number of Employees Less Than 100 100 or More Total Number of Clinical/Medical Staff Less Than 25 25 or More Number of Clients Less Than 1,000 1,000 or More Age Range of Clients Birth to 17 Years 18-24 Years 25-64 Years 65 Years and Older Provides Veteran-Focused Services Yes Provides Services to Rural Areas Yes
69 25 3 32 6 2 1 56 28 28 67 38 29 65 41 24 65 22 43 69 22 58 64 54 67 50 30
87.0 10.1 L4 10.4 73.9 26.1 61.2 16.3 6.1 4.1 2.0 30.0 61.9 38.1 24.3 % 36.2 4.3 46.4 8.7 2.9 1.4 50.0 50.0 56.7 43.3 63.1 36.9 33.8 66.2 31.4 89.2 91.4 77.7 74.6 42.9
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community mental health centers, such as those run by the state department of mental health and by private providers. The "substance abuse sector" consisted of inpatient and outpatient substance abuse prevention and treatment settings. The "aging sector" comprised agencies whose primary populations include those over 60 years of age with services focusitig on older adults. The "homeless sector" included agencies whose primary population included those who were homeless or at risk of homelessness. The "employment sector" consisted of those organizations whose primary concern is assisting with (un)employment, self-employment, and/or business development. The "justice system sector" comprised law enforcement, courts, and other legal agencies whose primary population includes those involved in the criminal justice system. The "education sector" consisted of organizations whose primary mission is adult postsecondary education. The "military sector" consisted of agencies whose primary population includes current military service members. The "benefits sector" consists of agencies that provide information, referral, benefits assistance, and/or civic engagement opportunities for Veterans. Finally, the "policy sector" included agencies whose primary mission is advocacy and/ or specific policy, research, or allied services targeting service delivery for vulnerable and at-risk populations.
Success Rates Using the Service Sector Segmented Approach A total of 149 potential participants were contacted with 70 participating in the study, for a response rate of 47%. Overall, the sample was composed of middle-aged, Caucasian, Master's level-educated social workers. As shown in Table II, the sample was almost half women and half men, nearly two-thirds were administrators, and about 30% had previously served in the military. Organizationally, the majority of providers
worked in medium to large governmental settings, with 75% of the sample reporting to provide Veteran-focused services. In terms of success rates, there were no statistically significant differences between recruitment by service sector iX^ = 13.35, p = 0.20); all had rates around 50% per sector. Results (Fig. 1) indicate statistically significant differences in the mean percentage of Veterans served by the agency in each service sector, meaning that not all agencies in our study served a similar percentage of Veterans (F(9,55) = 2.71, p = 0.04). Agencies that provided Veteran-specific services, such as those in the benefits sector, had the highest percentage of Veteran clients, as may be expected. Seven of the ten sectors indicated more than 50% of their population served includes Veterans. Finally, there were no statistically significant differences by service sector in terms of contact with suicidal individuals (X^ = 11.62, p = 0.24), nor were there differences by referral rate (/" = 9.19, p = 0.42). Similar results were found when comparing referral of a Veteran across service sectors (x^ 8.21, p = 0.51). See Table III for more detail. DISCUSSION This article describes a conceptual framework for identifying community and clinical providers employed in organizations that rnay come into contact with Veterans, some of whom may be in need of mental health, suicide prevention, or other service needs. Although the service sector segmented approach was used in this study with some success in guiding recruitment efforts, the framework may also be useful to inform outreach strategies to engage the public and private sectors in identifying and referring Veterans to needed and appropriate services. As reiterated by the VA's recent release of 2012 suicide data,' the issue of Veteran suicide is of great concern in all
I Percent Veterans served
0 FIGURE 1.
20
40
100
Percent of Veterans served by service sector.
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Improve Access to Suicide Prevention Services for Veterans TABLE in.
Suicide Exposure by Service Sector Contact With Someone Suicidal
Service Sector Mental Health (n = 12) Substance Abuse (« = 3) Aging (n = 9) Homelessness (n = 10) Employment (H = 6) Justice System (n = 10) Benefits (n = 5) Military (n = 5) Education (n = 3) Policy (n = 6) Total (n = 69)
N 12 2 9 10 5 10 4 5 3 5 65
% 100 66.7
100 100 83.3 100 80.0 100 100 83.3 94.2
Referred >11 People Service Sector Mental Health (n = 12) Substance Abuse (n = 2) Aging (n = 9) Homelessness (n = 10) Employment (n = 5) Justice System (n = 10) Benefits (n = 4) Military (n = 5) Education (;; = 3) Policy (n = 5) Total (« = 65)
N 9 1 2 5 3 5 1 2 2 1 31
% 75.0 50.0 22.2 50.0 60.0 50.0 25.0 40.0 66.7 20.0 47.7
Referred a Veteran for Suicide Prevention Services Service Sector Mental Health (« = 12) Substance Abuse (« = 2) Aging (77 = 9) Homelessness (« = 10) Employment (n = 5) Justice System (ii = 10) Benefits (;i = 4) Military (n = 3) Education (« = 3) Policy (« = 5) Total (« = 65)
N 8 1 3 5 4 5 4 2 2 2 36
P 0.24
% 66.7 50.0 33.3 50.0 80.0 50.0 100 40.0 66.7 40.0 55.4
P 0.24
P 0.24
of our communities. Thus, one specific goal of this study was to develop a framework to improve methods of locating Veterans within their community. As one example, this approach can specifically aid clinical and community providers in proactive decision-making and thoughtful allocation of scarce resources when competing demands on their time necessitate a more focused outreach plan. By considering different sectors, clinical and community providers can potentially expand their professional networks to identify and refer Veterans in crisis when in need of care. Eor private sector program planners, this framework can also be used to align the program objectives with targeted outreach activities in specific community locations with a greater density of high-risk individuals or to specifically address a
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service sector with high-priority clinical need. And finally, the framework can inform strategic planning and policy making when drafting calls to action and national agenda setting to address long-term, public health, and complex prevention issues. The second aim of this article was to highlight the specific benefit of this approach in terms of outreach to Veterans within their community. Our findings indicate that all of the providers in each service sector have had experience with suicidal individuals with the highest percentages found in the mental health, military, homeless, justice, education, and aging sectors. Results also indicate that there are some service sectors, such as the employment sector, that may not seem specifically targeted toward Veterans, yet actually have a significant amount of Veteran clients. In addition, there are service sectors that are known to provide benefits services specifically for Veterans, but that are not focused on providing mental health services. These agencies are encountering Veterans with mental health issues and are referring Veterans for services, including suicide prevention services. Interestingly, nearly the entire sample (96.4%, n = 65) had referred someone to mental health services. Although mental health providers may have referred more individuals for services, they are by no means the only ones encountering Veterans at risk for suicide. Contact with suicidal individuals was prevalent not only in the mental health sector, but also within the employment and justice system sectors. Nearly the entire sample had contact with someone who was suicidal at some point in their life. Contact with a suicidal Veteran was similarly not limited solely to those who typically work with Veterans—there were no statistically significant differences within our sample among those who had contact with and even referred a Veteran for suicide prevention services. However, this highlights a need to expand outreach efforts beyond the traditional locations and for providers to think more broadly about how and where to locate Veterans within the community. This service sector segmented approach offers a novel way of approaching this outreach issue.
Study Limitations Although using the conceptual framework divided by service sectors was beneficial to aid recruitment, there were limitations to its use that should be considered when applying the framework. Eirst, segmenting sample ascertainment by service sectors can be somewhat of a moving target— i.e., there are many ways to describe various sectors (e.g., type of services, primary client population) and those definitions are inherently unstable in a constantly changing public-private sector service delivery environment. Providers may also define their membership in a particular sector differently than researchers or define the services they provide in more than one sector or crossing sectors (e.g., the education sector provides health services for em-olled
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Improve Access to Suicide Prevention Services for Veterans
students Veterans, faith-based organizations provide many homeless sector services). Second, the response rate (47%) to our study was moderate, which may have been partially or fully driven by our exclusion criteria and nominating procedure that asked providers to recommend others with sufficient experience with Veterans. Given this variability and the potential omission of other relevant sectors and providers, the framework is presented here as merely an additional tool to augment other established strategic planning and outreach efforts.
Implications for Future Research, Clinical Practice, or Policy Clinical and community providers in the public and private sectors may use this approach as a means of identifying new portals to better align and target their outreach efforts. With regard to suicide prevention, it remains critically important to consider all sectors, not just the mental health sector, in communities where Veterans may seek services. However, future research is needed to determine the use and feasibility of using this approach to improve access to care for Veterans at risk of suicide. Finally, although this study focused on the providers' perspective of Veterans' need for services. Veterans themselves may have an entirely different outlook on desired services in their community that would add to the relevance and importance of this framework. Future studies to examine the Veteran perspective on seeking services are needed, CONCLUSIONS Farly identification of Veterans at risk for suicide can be lifesaving. This study offers a framework to identify providers within the public and private sector who may come into contact with Veterans in hopes of expanding the network of people who can help to prevent suicide. Although some results confirm what was expected (i.e., mental health care providers refer more suicidal individuals, more Veterans are served by the benefits service sector), these results also indicate that consideration of nontraditional service sectors, such as education, justice, and employment services, is a useful means of locating potentially suicidal Veterans. Segmenting outreach efforts by service sector allows providers to conceptualize the various ways in which Veterans interact with the community to increase their success at locating at-risk Veterans and providing them with potentially lifesaving assistance. ACKNOWLEDGMENTS The authors thank Lu Han, Tara Sabharwal, and Rachel Perkins, the Center for Violence and Injury Prevention, and all our community stakeholders
MILITARY MEDICINE, Vol. 179, April 2014
for their assistance and support of this project. This project is funded by the Department of Veterans Affairs (VA), Health Services Research and Development (HSRD), Quality Enrichment Research Initiative (QUERI RRP 11-002), and the Center for Violence and Injury Prevention (grant number 1620-94692). This study was also supported with resources and the use of facilities at the VA St. Louis Health Care System.
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