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

• 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 ]

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.

• Schizophrenia
• Chronic Illness
• Unemployment
• Weight Gain
• Psychotic Disorder

• Experimental: Arm 1
  Collaborative Care Model (described below)
  Intervention: Procedure: Collaborative Chronic Illness Care Model
• No Intervention: Arm 2
  Usual Care

• Young AS, Niv N, Chinman M, Dixon L, Eisen SV, Fischer EP, Smith J, Valenstein M, Marder SR, Owen RR. Routine outcomes monitoring to support improving care for schizophrenia: report from the VA Mental Health QUERI. Community Ment Health J. 2011 Apr;47(2):123-35. Epub 2010 Jul 25.
• Cohen AN, Glynn SM, Hamilton AB, Young AS. Implementation of a family intervention for individuals with schizophrenia. J Gen Intern Med. 2010 Jan;25 Suppl 1:32-7.
• Hamilton AB, Cohen AN, Young AS. Organizational readiness in specialty mental health care. J Gen Intern Med. 2010 Jan;25 Suppl 1:27-31.
• Brown AH, Cohen AN, Chinman MJ, Kessler C, Young AS. EQUIP: Implementing chronic care principles and applying formative evaluation methods to improve care for schizophrenia: QUERI Series. Implement Sci. 2008 Feb 15;3:9.
• Niv N, Shatkin JP, Hamilton AB, Unützer J, Klap R, Young AS. The Use of Herbal Medications and Dietary Supplements by People with Mental Illness. Community Ment Health J. 2009 Aug 18; [Epub ahead of print]
• Young AS, Niv N, Cohen AN, Kessler C, McNagny K. The Appropriateness of Routine Medication Treatment for Schizophrenia. Schizophr Bull. 2008 Nov 7; [Epub ahead of print]
• Young AS, Klap R, Shoai R, Wells KB. Persistent depression and anxiety in the United States: prevalence and quality of care. Psychiatr Serv. 2008 Dec;59(12):1391-8.
• Cohen AN, Glynn SM, Murray-Swank AB, Barrio C, Fischer EP, McCutcheon SJ, Perlick DA, Rotondi AJ, Sayers SL, Sherman MD, Dixon LB. The family forum: directions for the implementation of family psychoeducation for severe mental illness. Psychiatr Serv. 2008 Jan;59(1):40-8.

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