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

• 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 ]
  

• 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 ]
  

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.