Fully half of post-9/11 Veterans eventually receive service-connected disability for musculoskeletal disorder. These Veterans often go on to develop chronic pain and are at high risk for substance misuse. Early intervention, connecting Veterans to multimodal pain treatment, is important for Veterans transitioning from military to civilian healthcare to arrest worsening pain and the initiation or exacerbation of risky substance use. Screening, Brief Intervention and Referral to Treatment for Pain Management (SBIRT-PM) has been shown to be useful for this purpose; and case managers in the Post-9/11 Military2VA (M2VA) program are perfectly positioned to deliver it. M2VA Programs are at each VA medical center and are charged with coordinating VA health care for all service members separating from the military. 

The implementation of SBIRT-PM by M2VA likely requires facilitation because the social workers and nurses who provide case management are not otherwise directed to specific training in multimodal pain care or addiction services, and they are not routinely provided facility support for this effort that requires coordination across pain treatment modalities and systems. In collaboration with the national leadership of the M2VA program, we propose a 2-cohort, cluster randomized, type 2 hybrid trial to test the effectiveness, cost effectiveness and patient-level effects of an implementation facilitation strategy for SBIRT-PM. Informed by a 1-year planning phase, we will randomly assign 28 VA medical centers to one of two conditions. M2VA case managers in sites within the experimental condition will receive training in SBIRT-PM followed by implementation facilitation (case finding report, consultation groups, audit and feedback, and technical assistance and problem-solving support) delivered by an external facilitation team (with pain, addiction, case management, and implementation science expertise) and internal facilitators at each medical center. A Relational Coordination framework will guide facilitation efforts. Comparator sites will receive SBIRT-PM training-as-usual. A formative evaluation before, during, and after the trial will iteratively inform the adjustment of the implementation facilitation strategy to best fit this project. 

From the full cohort of Veterans who are seeking service-connection for musculoskeletal disorders, we will recruit and follow 1848 Veterans for more detailed phone assessments at baseline, 3 and 9 months after enrollment. We hypothesize that adding implementation facilitation to training-as-usual for SBIRT-PM will result in a higher proportion of Veterans who receive SBIRT-PM (Reach), higher proportion of case managers who attend training and use SBIRT-PM with at least three Veterans (Adoption), and better adherence to the SBIRT-PM protocol (Implementation). We further hypothesize that implementation facilitation of SBIRT-PM will improve Veterans clinical outcomes (pain, risky substance use) and increase the number of non-pharmacological pain treatments used. We will determine the cost-effectiveness and budget impact of implementation facilitation relative to training-as-usual to reach Veterans with SBIRT-PM and improve their clinical outcomes.