Implementing Effective, Collaborative Care for Schizophrenia (EQUIP-2)

This study has been completed.
Sponsor:
Collaborator:
University of California, Los Angeles
Information provided by (Responsible Party):
Department of Veterans Affairs
ClinicalTrials.gov Identifier:
NCT00137280
First received: August 25, 2005
Last updated: April 25, 2014
Last verified: April 2014

August 25, 2005
April 25, 2014
June 2007
March 2010   (final data collection date for primary outcome measure)
Evaluate the effect of care model implementation on provider competencies, treatment appropriateness, patient outcomes and service utilization [ Time Frame: 12 months ] [ Designated as safety issue: No ]
At 9 months, evaluate the effect of care model implementation on provider competencies, treatment appropriateness, patient outcomes and service utilization
Complete list of historical versions of study NCT00137280 on ClinicalTrials.gov Archive Site
  • Evaluate processes of and variations in care model implementation and effectiveness to strengthen the intervention and to assess acceptability, how strategies affect implementation and the impact of individual components on treatment appropriateness [ Time Frame: 12 months ] [ Designated as safety issue: No ]
  • Identify facilitators and barriers to wellness program participation in an effort to strengthen the weight management services available to patients with schizophrenia [ Time Frame: 9 months ] [ Designated as safety issue: No ]
Evaluate processes of and variations in care model implementation and effectiveness to strengthen the intervention and to assess acceptability, how strategies affect implementation and the impact of individual components on treatment appropriateness
Not Provided
Not Provided
 
Implementing Effective, Collaborative Care for Schizophrenia (EQUIP-2)
Implementing Effective, Collaborative Care for Schizophrenia

This project evaluates the the implementation and effectiveness of a care model to improve treatment for schizophrenia within the context of diverse VA practices and priorities. The project provides more information to VA clinicians and managers about veterans with schizophrenia or schizoaffective disorder who are overweight and/or who would like to return to competitive work. The project facilitates reorganization of care practices in order to get veterans needed and desired services around wellness and work. The project creates a platform that other clinical and research interventions can build upon to improve care, and is designed to inform a national strategy for implementing evidence-based care in schizophrenia.

Objectives:

EQUIP-2 is a clinic-level controlled trial. From the four participating VISNs, eight specialty mental health programs were enrolled and assigned to care as usual or to receive an intervention supporting evidence-based quality improvement and use of a chronic illness care model. Participants are VISN 3 (James J. Peters VA; Northport VA); VISN 16 (Houston VA; Shreveport VA); VISN 17 (Waco VA; Temple VA); and VISN 22 (Long Beach VA; Greater Los Angeles VA). The objectives of this QUERI Service Directed Project are 1) assist in identifying and making available recovery-oriented services to veterans with schizophrenia; 2) implement information systems that efficiently and accurately identify patient status and who would be appropriate for these services; 3) implement a care model to support recovery-oriented care delivery; 4) evaluate, in a controlled trial, the effect of implementation on treatment delivery and patient outcomes; and 5) identify facilitators and barriers to wellness program participation in an effort to strengthen the weight management services available to patients with schizophrenia. The project studies intervention feasibility, acceptability, and impact on outcomes; performs qualitative analyses examining processes and variation in care model implementation and impact. Research includes a controlled trial of the impact of implementation, relative to usual care, on treatment quality. Participants include clinic staff and patients with schizophrenia. Data sources include interviews with participants, focus groups with a sub-set of patients, implementation documentation, the project informatics system, and VistA.

Methods:

The care model targets two clinical domains selected by the VISNs from the following: Supported Employment (SE), caregiver support, wellness programs, clozapine, and peer support. All 4 VISNs chose the same two targets, SE and wellness. The support for the care model includes: 1) at each visit, routine collection of patient outcomes data and provision of decision support using a self-assessment kiosk; 2) provision of "psychiatric vital signs" to patients and clinicians at the time of the clinical encounter via report that prints from the kiosk; 3) education and activation of both clinicians and patients around the clinical targets; 4) regular reports identifying patients appropriate for services associated with these targets; and 5) facilitation of problem-solving and quality improvement addressing any barriers to utilization of these services.

To inform future wellness implementation, in-depth, semi-structured interviews have been conducted with patients who participated in wellness groups ("participants"), and with patients who were referred (because they were overweight or obese) but did not participate ("non-participants"). Participants consist of all enrolled patients who attended the wellness program (n=106) with special attention to those patients who completed at least half of the wellness program (n=53). Non-participants consist of patients who were referred to the wellness program but did not attend (n=57). Clinicians were interviewed specifically regarding wellness implementation.

Findings / Results:

The research enrolled 801 veterans with schizophrenia and 171 mental health clinicians and administrators across 8 sites in 4 VISNs. EQUIP significantly improved use of evidence-based services and outcomes for Veterans. Regarding Supported Employment (SE), individuals at intervention sites were 2.2 times more likely to utilize SE services during the study as compared to individuals at control sites. Formative evaluation indicated an overall increase in SE capacity at intervention sites, via reorganization of resources. One site with high fidelity to the SE model increased the number of Veterans who returned to competitive employment. Regarding weight management, overweight individuals at implementation sites were 2.3 times more likely to use weight services during the study compared to control sites. Controlling for pre-baseline and baseline weight, at control sites patients' final weight was 13.4 pounds heavier than at intervention sites. Sites had varying levels of attendance at the groups, although any attendance is a considerable improvement in care for wellness at these sites. Identifying barriers and facilitators (objective 5) is ongoing.

Status:

The intervention and data collection are complete. Staff worked with sites to sustain gains. Dr. Young is working with VA OI&T to develop and implement routine kiosk self-assessment as part of the VA electronic health record. Data are being analyzed, and methods and results disseminated.

Impact:

Schizophrenia is a common, disabling illness that has a very high cost to society. In fiscal year 2000, the VA provided care to over 102,000 people with schizophrenia, and 16% of the VA's health care budget was spent on care for people with psychotic disorders. This project evaluates implementation of a care model to improve treatment for schizophrenia within the context of diverse VA practices and priorities. It is possible to use technology to elicit information regarding patient preferences and needs, and to establish evidence-based quality improvement that uses this information to implement recovery-oriented care. The project created a platform that clinical and research interventions can build upon to improve care, and informs a national strategy for implementing evidence-based care in specialty mental health settings, including practices for weight management and return to competitive employment.

Interventional
Not Provided
Allocation: Non-Randomized
Endpoint Classification: Safety/Efficacy Study
Intervention Model: Factorial Assignment
Masking: Open Label
Primary Purpose: Health Services Research
  • Schizophrenia
  • Chronic Illness
  • Unemployment
  • Weight Gain
  • Psychotic Disorder
Procedure: Collaborative Chronic Illness Care Model
A care model that integrates greater availability of clinical information, reorganizes the practice system and provider roles, fosters care coordination, and focuses on evidence-based protocols--specifically supported employment and wellness services for individuals with schizophrenia.
  • Experimental: Arm 1
    Collaborative Care Model (described below)
    Intervention: Procedure: Collaborative Chronic Illness Care Model
  • No Intervention: Arm 2
    Usual Care

*   Includes publications given by the data provider as well as publications identified by ClinicalTrials.gov Identifier (NCT Number) in Medline.
 
Completed
1067
May 2011
March 2010   (final data collection date for primary outcome measure)

Inclusion Criteria:

  • Providers(Psychiatrists, Case Managers, Nurses, Supported Employment workers Nutritionists, Local Recovery Coordinators, Quality Improvement experts) working at one of the participating VA Medical Centers

Patients:

  • At least 18 years old
  • Diagnosis of Schizophrenia, Schizoaffective, or schizophreniform disorder
  • At least 1 treatment visit with a clinician at the clinic during the 6 months prior to enrollment and then at least 1 treatment visit with a clinician at the clinic during the 5 months of enrollment.

Exclusion Criteria:

None

Both
18 Years and older
No
Contact information is only displayed when the study is recruiting subjects
United States
 
NCT00137280
MNT 03-213, P30MH082760
No
Department of Veterans Affairs
Department of Veterans Affairs
University of California, Los Angeles
Principal Investigator: Alexander S. Young, MD MSHS VA Greater Los Angeles Health Care System
Department of Veterans Affairs
April 2014

ICMJE     Data element required by the International Committee of Medical Journal Editors and the World Health Organization ICTRP