The mission of the VISN 3 MIRECC Education unit is to develop programs that help change provider behavior and that improve the use of evidence based effective practices in psychopharmacologic, psychotherapeutic, and psychosocial programs. In addition, the Education unit collaborates closely with other parts of our MIRECC, the Mental Health Executive Board (MHEB), the Veteran’s Advisory Council of VISN 3, and other MIRECCs to bring these programs to the network. Our newest effort involves assisting VISN 3 in implementing recovery throughout its mental health programs.
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Suicide Risk Assessment
Grand Rounds Presentation 9-9-11 (Presentor: Bruce M. Levine, MD)
Table of Contents
Recently Completed Projects
MyHealtheVet Focus Groups
Project Coordinator: Bruce M. Levine, MD
In January 2004, the Under Secretary for Health endorsed the Action Agenda "Achieving the Promise: Transforming Mental Health Care in VA". One of the action steps it contains is to "develop MyHealtheVet to better serve the needs of veterans with mental illnesses". MyHealtheVet provides web based information on VA benefits, special programs, health information and services to veterans who have access to the Internet. It is now being piloted at nine facilities which has generated much positive feedback as well as recommendations for improvement. The ultimate version of My HealtheVet will contain a fully functional secure personal health record system including e-prescription refills, messaging, copies of the veterans health record and self-care tracking and management tools.
My HealtheVet is intended to promote greater participation of veterans in their own health choices and care. In order to fully develop a Mental Health portal for My HealtheVet, it was critical to involve veterans and families in the needs assessment/requirements phase. An effective needs assessment tool included conducting Focus Groups with veterans and their families so they could identify what they need to better understand their own behavioral health concerns and/or diagnoses and treatment.
Eight MIRECCs (including VISN3 MIRECC) held a total of 14 focus group discussions and distributed needs assessment questionnaires to determine the types of health information that veterans are interested in, how they stay aware of their health information and needs, and what their thoughts are about using an internet-based personal health record and informational website. Two of the focus groups assessed veterans with psychotic diagnoses, two assessed only women, two involved those with PTSD, two groups evaluated veterans with anxiety and depression, two were held for veterans with substance use disorders, one group involved OEF/OIF returnees, one was held for veterans from primary care, one examined the views of veterans who do not receive VA care, and one group assessed family members of veterans. The outcome of the Focus Groups will be used to refine and improve the My HealtheVet Mental Health portal.
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Suicide Risk Assessment and Prevention
Project Director: Bruce M. Levine, MD
The Suicide Risk Assessment and Prevention Initiative (SAP) was established in an effort to further enhance the lives of discharged SMI patients. The program achieves this goal by educating clinicians, increasing sensitivity to suicide risk, improving recognition of veterans with high risk of suicide, improving documentation of risk to enhance communication with non-mental health clinicians, and decreasing malpractice risk.
Since its first meeting in 2001, SAP’s suicide workgroup has produced the following:
- Members devised an evidence based suicide risk assessment that is currently being piloted. This instrument is being programmed as a dialogue box/clinical reminder for the Computerized Patient Record System (CPRS) and is tied to the alerts section as well. The goal is to implement this assessment throughout VISN 3. It is tied to a number of psychiatric diagnoses and all Mental Health Stop codes, and will come up in CPRS with variable frequency depending on the patients’ assessed level of risk. The instrument is designed so that explanatory material (definitions, how to score the assessment, background and evidence base for each item), as well as sample questions to ask a patient to evaluate the presence or absence of each item, are available to clinicians as they work through the assessment (this material is all available).
We will be looking at the rates of usage, quality of treatment plans generated by doing the assessment, satisfaction of users of the instrument, rates of suicidal ideation, as well as attempts and suicides in the Mental Health population in the VISN. We are also doing interrater reliability evaluations on the suicide assessment tool, and are looking at the sensitivity and specificity as it is implemented.
Because one concern of the staff is being able to intervene when suicide risk is determined to be present, future training will involve more about suicide intervention. In the early usage, clinicians have found the tool useful in generating higher quality treatment plans for the factors contributing to suicidality. There has been some concern about the perceived workload, as well as medical and legal ramifications of having a suicide assessment in the record. In the few pilots done thus far using a handwritten version of the instrument, the additional workload for interviewing the veteran and recording the results has varied from five to fourteen minutes.
- Recommendations for System Wide Application:
This is a risk assessment as opposed to a screening tool, and therefore has limited use for the entire system. First, it fits best within a Mental Health Setting. Second, while it has significant face validity, it has not yet been adequately tested to determine its true utility. We have never answered the question about whether improved assessment leads to improved prevention, and it will be a long time before we can answer that question. We expect that in the first year we will identify more suicides than in previous years, simply because assessing all mental health patients for suicide risk will increase our awareness about potential suicides, and may change how we categorize some deaths that occur.
- Conferences: Evidence Based Practices for Suicidal Persons
- June 2006: Cosponsored with V4 and V19 MIRECC
- Partnered with AFSP, AAS
- Psychopharmacology, Current Research, NIMH Center Reports, OEF/OIF issues, Best Practice Research
- Breakouts: CBT, DBT, IPT, Family, Web Based, Community Based Interventions
- February 2007: Reprise in Denver
- New Topics to include Gender, Cross Cultural (e.g. Native American), OEF/OIF Panel
- Breakouts to focus on training and skill acquisition
- February 5, 2003, the workgroup held a 6-hour Suicide Assessment and Prevention Conference that was attended by 430 VISN 3 mental health staff, with the didactic portion being teleconferenced to V2. The first two hours of the program consisted of four half-hour talks: Maria Oquendo, MD presented “A Model for understanding Suicidal Behavior”, Gretchen Haas, PhD discussed “Suicide Risk Identification and Prevention”, James Stinnett, MD presented “Managing Risk Factors in Suicidal Patients”, and Bruce Levine, MD discussed “Psychological and Social Interventions for Suicidal Individuals”. The didactic session was followed by two workshops: the first on reviewing the assessment of suicidal patients, either from the attendees experience or from case vignettes culled form RCAs in V3; the second being a review of the proposed Suicide Risk Assessment with opportunities for feedback on the instrument. The V3 Suicide workgroup trained 40 facilitators throughout the VISN to lead these breakout sessions. Subsequently we have held a VTEL meeting with the facilitators, refined the risk assessment, are piloting it, and are moving towards implementation over the next few months, with further training scheduled for the rollout. With the cooperation of our HSRD group we will also be doing an evaluation of the effectiveness of this effort.
This project involved significant collaboration with the V4 MIRECC with Gretchen Haas (VISN 4 MIRECC co-director) serving on the V3 Workgroup and Katy Ruckdeschel making available the materials and strategies used in the suicide initiative in V4. This allowed for our efforts to be consistent with and complimentary to each other.
- Suicide Prevention: Next Steps
- Evaluate Instrument
- Treatment Plans with Assessment vs. TAU
- Mirror image study within VISN 3
- Prospective comparison with another VISN
- Over longer term evaluate case finding and impact on Suicide rates
- Use improved case finding to collaborate with Brain Bank
- Telephone Operator and Clerk/Secretary Guideline
- Physical Plant
- Road Shows
- Primary Care Education facility by facility
- Develop screening program for PC
- Suicide Education for MH and SAS, another round
- Expand assessment to all outpatients
- Develop Local Computer Module for Suicide Risk Assessment
- Web Based Interactive Training (national)
- Assessment, treatment, service Coordination
- Collaboration with EES, VISN 4, 19 and others
- Modular training, Case Based
- Continued Collaboration with VISN 1
- Hand Template
- Template Explanations
- Sample Questions
- CPRS Suicide Template demonstration
- Presentation on Suicide Prevention Day
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Clozapine Education and Consultation Program
Project Director: Bruce M. Levine, MD
Despite remaining the gold standard for the treatment of treatment refractory schizophrenia, Clozapine has remained underutilized, and is the slowest step to be adopted in the various psychopharmacology algorithms. The VA has had an historically low use of Clozapine for seriously mentally ill veterans, and VISN 3 has had a low usage for the VA. In order to increase usage in VISN 3, the MIRECC developed a Clozapine education and consultation program. To date, the program has resulted in a 80 percent increase in Clozapine utilization, and in 37 additional Clozapine trials at the Montrose VA. Of particular import is that a 35 percent response rate, vigorous enough to lead to discharge, was achieved with severe nonresponders (VIDI patients).
- Education: The educational piece of this program consists of a series of Video teleconferences outlining the use of psychopharmacology guidelines, the evidence base for 2nd generation antipsychotics, the evidence base for Clozapine, and day-to-day use of Clozapine. We also collected a series of “Essential Papers on Clozapine” and have made them available to VISN 3 practitioners. The MIRECC Education Director and Coordinator of this program visited each VISN 3 facility to discuss clinicians’ experiences with Clozapine and usage issues at each facility.
- Consultation: Because of Clozapine’s unique side effect profile, a consultation program was devised for physician use. This program enables psychiatrists considering a switch to Clozapine, and those managing patients on Clozapine, to call the MIRECC and receive a real-time consultation from a clinician experienced in the use of the medication. We have also made a number of visits to facilities within the VISN to offer live consultation of difficult clinical situations.
- Results: These initiatives have led to an average increase of 80% in the usage of Clozapine across the VISN, but without further increase in 2 years. In addition, they have been exported to MH QUERI and adapted for trials in other Networks, have contributed to White Paper on change in VHA Clozapine Policy, and we have re-surveyed VISN 3 providers on Clozapine prescribing.
- New Initiatives: The following list outlines current and upcoming additions to this project:
- Case Finder
- Pilot in Bronx with Chart Reviews
- Automate follow-up and outcome of identified cases
- Education Program for Veterans with SMI
- VISN 3 Clozapine Responders
- Participate in above program
- Characterize subgroup that develops weight loss and improved metabolic profile after stabilization on CLZ
- Academic detailing using findings of CATIE re Clozapine
- Continue work nationally to improve Clozapine access and use in VHA
Experimental Education and Recovery Implementation
Project Director: Bruce M. Levine, MD
After a VISN wide conference: “Recovery in Action” which introduced VISN 3’s recovery implementation initiative, the MIRECC organized veteran and staff focus groups about the barriers to recovery and needs of staff and veterans for implementation. The experience was so powerful that the recommendation was to do this at each facility for all staff and as many veterans as possible. We have trained 65 leaders across all facilities in the network, half staff and half veterans. The “Recovery Discussions” have begun at 1 facilitiy, is awaiting IRB approval at the other facilities within the VISN and the rollout will be administered by the VISN 3 LRCs. We plan to evaluate the efficacy of this modality for implementation of recovery transformation in the VA.
Clinical Consultations/MIRECC VTELS
- MIRECC Consultation Service
- The MIRECC provides expert second opinion conferences both live and via video teleconference on a regular basis (twice monthly at Hudson Valley, monthly at Northport, eight per year at NY Harbor, monthly inpatient and bimonthly outpatient at JJP, one-to-two times per year at NJ) for veterans who are not succeeding with their current treatment regiments. These conferences reach staff as well as trainees in all disciplines and help disseminate rigorous psychopharmacologic practices, evidence based psychotherapeutic, rehabilitative and psychosocial treatments, and recovery oriented practice.
- Bibliotherapy Resource List
- MIRECCs from VISN 1, 3, 16, 19, and 21 have created a list of educational resources pertaining to PTSD, schizophrenia, substance abuse, depression, bipolar disorder, generalized anxiety, health/wellness, sexual trauma, and traumatic brain injury that can serve as self-help guides or supplements to treatment. Resources will include books, pamphlets, and websites with information on the title, author, publisher/source, date, and approximate cost. Relevant empirical findings and article citations will also be included. This resource will be disseminated through the OMHS Office of Psychotherapy Programs and the national MIRECC website.
- This list can assist clinicians, peer technicians, and veterans to incorporate psychoeducational materials into their current practice/treatment. Providing information about self-help resources is consistent with the VA’s recovery philosophy.
- Bibliotherapy Resource Guide
- Implementation Science Group
- In 2007, the MIRECC & COE Education Group formed an Implementation Science interest group to teach ourselves more about implementation strategies and how to apply these techniques to different educational initiatives. The group meets monthly to review articles and discuss implementation issues and research. Experts are invited to present to the group. These ongoing discussions will enhance education efforts by promoting effective strategies for putting innovative knowledge and skills into routine practice.
- MIRECC Recovery Interest Group
- Since July, 2006, a MIRECC Recovery Interest Group has met monthly to share information about how each Center is attempting to implement recovery. The group discusses common problems and look for ways to collaborate. Recent topics have included educating local recovery coordinators, teaching about leadership, disability and recovery, using recovery toolkits, training peer technicians, and examples of effective Consumer Councils. This group will further disseminate information about recovery implementation across MIRECCs and COEs.
- Suicide Pocket Card, Revised Version and Resource Guide
- With increased emphasis on suicide prevention, a new pocket guide accompanied by a brief manual containing expanded explanations and descriptions was needed to offer guidance to the field. This need was accelerated following the release of the JCAHO safety goals. Evaluating potentially suicidal veterans in non-Mental Health settings was emphasized in the new pocket card, although issues of risk assessment were addressed in the resource guide. The guide is consistent with the evidence-based efforts toward suicide screening and assessment taking place at the VA. The card and guide is expected to facilitate rapid dissemination of knowledge to the field about effective suicide screening, risk assessment and offer guidance on acute management. It will provide a basis from which to develop more complete prevention efforts.
A Dialectical Behavior Therapy (DBT) Clinic is being piloted at the Bronx VA to treat Self-Destructive Personality Disordered veterans. This project, led by Dr. Marianne Goodman, uses a manualized cognitive behavioral treatment approach that was developed to treat chronically suicidal individuals, many of whom met criteria for Borderline Personality Disorder (BPD). The approach combines behavioral interventions including skills training, exposure, problem solving with cognitive techniques of mindfulness, and stresses the importance of client-therapist connection. The DBT approach has also been successfully adapted to inpatient settings, criminal justice settings, outpatient populations of BPD substance abusers, depressed and suicidal adolescents with BPD or BPD traits, and binge-eating disordered individuals.
Despite the pronounced difficulties in interpersonal relationships inherent in BPD, minimal attention has been paid to couples and family treatment in the literature. We are currently treating subjects with Borderline Personality Disorder and their family memberswith a seven-session course of familyDialectical Behavioral Therapy to examine the impact of family DBTon measures of mood and emotion, aggression, family function, intrafamily conflict tactics and violence, relationship quality and adjustment, and communication patterns. Preliminary data will be available after January 2005.
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Family Interventions for Serious Psychiatric Disorders in VA: Implementing a Continuum of Services
This September, 2009, conference will provide VISN 3 Mental Health staff with increased knowledge and skills to deal with family psychoeducation, which includes Behavioral Family Therapy and Family Focused Therapy and family consultation. It is the VISN 3 expectation that all attendees will identify three (3) families, apply one of the interventions learned in the conference and participate in the post-conference bi-monthly 60 minute family intervention consultation sessions for approximately 6-9 months following the training. These will occur either in person or via telephone and might run for up to 75 minutes, depending on the number of participants.
VISN 3 Peer Technician Retreat
MIRECC, MHCL, and LRCs collaborated on this one day conference for Peer Technicians hired in recent enhancements. This conference focused on professional identity and development. Dan O’Brien-Mazza was the keynote speaker. The curriculum included roles within the VISN with an outline of the mental health care system structure in VISN 3 and the VA, as a whole, followed by talks on ethics, professional development, and breakout sessions, which featured role plays and discussions of a variety of clinical/professional situations that Peer Technicians would encounter.
As a result of growing interest among the MIRECC & COE Education Group in implementation science, we have collaborated with EES, the GRECCs, and Ken Shay, Director of VA Geriatric Programs, to develop a workshop focused on implementation science theory and its application. The multi-day meeting during the fall of 2008 was a small skill-based workshop to meet the needs of our two groups. QUERI, HSR&D staff, and other implementation experts with successful projects served as faculty.
Planning Committees for Continuing the Transformation of VA Mental Health Services: Bridging the Gaps
This, 740 person, conference combined the national MIRECC conference and the Best Practices conference into one comprehensive meeting. Additional partners included NEPEC, SMITRC, PERC, Mental Health (MH) and Substance Abuse Disorder (SUD), QUERIs, NCPTSD, CESATE, VISN 2 Center for Integrated Healthcare, and Vet Centers. The conference focused on progress toward implementing the VA MH Strategic plan and its goals. MIRECC directors agreed to support needed training initiatives for local recovery coordinators.
VHA Local Recovery Coordinator Training
The MIRECCs spearheaded efforts to develop the first national training for the Local Recovery Coordinators (LRCs). The LRCs are given the task of facilitating the implementation of recovery-oriented mental health programs at their respective sites. This training served to communicate a common philosophy and policy to LRCs and assisted them in assessing their needs for program development. By the close of training, the LRCs had set two short-term and one long-term goal for program change and drafted an Action Plan for meeting their goals.
National Suicide Prevention Coordinators Training
The VA hired Suicide Prevention Coordinators at each Medical Center facility during the spring and summer of 2007. An initial face-to-face training for coordinators was held in Atlanta, in August, 2007. This meeting, attended by 175 Suicide Prevention Coordinators and other key mental health officials, was designed to alert everyone to best practices in suicide prevention strategies, as well as help newly hired coordinators understand their role and the expectations of their position. Monthly and as-needed audio-conferences are held to continue providing on-going education and direction. Continual support is provided by the CoE, the VISN 3 & 19 MIRECCs, the Office of Mental Health, and the National Center for Patient Safety. Attendance at the conference exceeded expectations and attendee evaluations of the conference were excellent. Suicide Prevention Coordinators have already begun to implement selected strategies in the area of suicide prevention.
Evidence-Based Interventions for Suicidal Persons
This was a regional conference in collaboration with VISN 4 MIRECC and VISN 19 MIRECC, which was held in Atlantic City, NJ from June 13th to June 14th of 2006, and repeated, with some modifications, in February, 2007, in Denver, CO. The conference focused on educating providers on the state-of-the-art evidence-based interventions for persons at risk for suicide. These included psychopharmacological as well as psychosocial interventions such as CBT, DBT, IPT, family and web-based treatments. There were also programs focused on research and evaluation issues, and the implementation of these interventions within the VA.
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Recently Completed Projects
Veterans with Intractable Discharge Issues (VIDI)
This project involved review of every longstay patient remaining in VISN 3. A team of clinicians co-chaired by the MIRECC Education Director and MHEB Business Manager reviewed and discussed each patient in terms of diagnostic assessment, psychopharmacologic treatment, psychosocial and rehabilitation interventions, as well as behavioral, family, community and financial discharge impediments. Some of these patients have made progress through recommended interventions, and a white paper is being prepared which characterizes the population and makes recommendations for enhancing recovery.
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Juan Mezzich, MD, PhD
The goal of cultural competency training at the Bronx VA was to enhance clinical and cultural competence through the DSM-IV cultural formulation. This involved a specially prepared guidebook to the culturally competent assessment and a reader of important papers on cross-cultural psychiatry. The course was delivered to one team at the Bronx VA through 10 weekly sessions. Data was collected on the impact of the course upon the trained mental health professionals, and subsequent steps include evaluation of impact on patient care and outcomes, as well as offering the course to other facilities in the network.
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MIRECC Clinical Practice Guidelines/NJ Algorithm
David Smelson, PsyD, Miklos Losonczy, MD, PhD, Bruce Levine, MD
This implementation pilot study examined the effect of clinical monitoring and feedback on physicians’ level of clinical practice guideline adherence. In addition, researchers investigated the effect of guideline adherence on clinical outcomes, such as community tenure and hospitalization frequency. Results revealed that monitoring had weak effects on guideline adherence, and no effect was found on mental health service utilization. Thus, researchers concluded that labor-intensive use of clinical monitors might not be justified.
The project involved formation of Internal and External Advisory Boards that assisted with rolling out of staff training on the algorithm and instruments, development of a side effect and co-existing symptom algorithm, development of a fidelity measure, and development of a consumer satisfaction measure. Two groups of physicians were analyzed from VA facilities in East Orange and Lyons, NJ, and 51 patients were followed for one year after being placed into the treatment algorithms. Below is a brief explanation of the algorithm’s development, instruments used, assessment measures, and possible future directions.
A review of existing algorithms, including VA National Guidelines, APA, the Texas Medication Algorithm Project (TMAP), and PORT was conducted. After careful consideration, a modified version of TMAP was selected, and named the New Jersey Algorithm.
The sequence includes two trials of atypical antipsychotics followed by a Clozaril trial. If no favorable response is observed, a third atypical neuroleptic is tried, followed by a typical neuroleptic, followed by a combination of antipsychotic medications. The consensus of the internal advisory committee was to provide a flexible algorithm that will allow for minor modifications as new research is disseminated. Though a positive outcome has not been observed with the NJ Algorithm to date, researchers suspect that a larger sample size might generate significant findings in the future.
A modified set of TMAP assessment measures was used to evaluate patient progress and algorithm effectiveness, a fidelity measure was developed to ensure physician compliance with prescription guidelines, and a survey was administered to assess patient concerns.
A pre-study survey was distributed to evaluate physician background knowledge and needs. Results indicated that physicians were familiar with clinical practice guidelines, believed guidelines would be beneficial based on expert consensus, and expressed eagerness to learn more about the use of algorithms.
Training experiences from the project led investigators to begin developing a clinical practice guidelines exportable educational curriculum. This curriculum could be used for implementing clinical practice guidelines at both VA and non-VA sites. The internal advisory committee agreed on the ten topics listed below, and plans to partner with the NY State Office of Mental Health in developing this curriculum. This curriculum program will be recorded on audiotapes, and will have accompanying continuing education credit to facilitate participation.
Core Curriculum Topics:
- Psychopharmacology Review
- Increasing Medication Compliance
- The Use of Adjunctive Psychopharmacological Agents in Psychosis
- Management of Impulsivity and Aggression
- Psychopharmacology in Acute Psychiatry
- Psychopharmacology in Symptomatically Persistent Patients
- Management of Patients with Psychosis and Concurrent Substance Dependence
- Special Considerations in Geropsychiatric Patients
- Effective Non-pharmacological Treatment Modalities for Schizophrenia
Members also recognized the need to develop a dual-diagnosis clinical practice guideline, and put together a workgroup comprised of local and national experts in this area. Depending on the study results, we also want to explore the use of computerized clinical reminders as a more cost effective method for doing monitoring and guideline adherence.
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