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Evaluation The objective of the evaluation component of the MIRECC is to create an evaluation infrastructure to support the research, education and clinical programs within the VISN. This involves facilitating the evaluation of clinical and educational interventions to improve the treatment of veterans with Serious Mental Illness (SMI) as well as conducting health services research attuned to the VISN’s patient care mission. We work closely with the VISN 3 Mental Health Executive Board (MHEB) and provide assistance in examining and responding to mental health service delivery issues in the VISN. Projects center on two main themes: improving treatment for veterans with severe mental illness, and understanding and improving access to care. We also work closely with the Educational core (e.g. motivational interviewing and practice guidelines). Table of ContentsCurrent & Ongoing Projects
Completed Projects
PublicationsCurrent / Ongoing ProjectsTime Limited Case Management for Severe Mental Illness and Substance Abuse Disorders (TLC)David Smelson, PsyD; Miklos Losonczy, MD, PhDThe TLC model is a brief, intensive case management approach, providing a community linkage intervention that assists highly recidivist individuals with a persistent mental illness and co-occurring substance abuse (MICA) disorder with the transition from Acute Psychiatry to an outpatient MICA program in a Day Treatment Center. The treatment includes a modified form of Dual Recovery Therapy, which is a blending of tradi tional addiction treatment therapies (relapse prevention, motivational enhancement therapy, and 12-step Facilitation) with mental health approaches (cognitive-behavioral therapy and social skills training that varies according to the mental health problems) specifically designed to meet the unique needs of the dually diagnosed veteran. The program also incorporates elements of the Critical Time Intervention (CTI) Case Management Approach, which was originally developed to assist the homeless mentally ill in the engagement to the community. We specifically selected CTI as the case management approach because it incorporates effective discharge planning strategies, which are critical for the transition of our veterans from Acute Psychiatry to the Day Treatment Center. Both approaches have accompanying treatment manuals that we modified for an eight-week format, which will assist in the dissemination to other facilities. The outcomes to date have far surpassed our expectations, with dramatic individual improvements in a population that heretofore appeared to resist all efforts to help them. In addition, we believe that the TLC approach is both innovative and incorporates components of other best practices. The pilot study examined the integrated DRT and CTI approaches using a quasi-experimental design that included a group of mentally ill substance-abusing veterans who received the new TLC transitional service (N= 33), compared to a group of veterans who were offered the service, but refused it, and were subsequently discharged as usual (N= 29). Initial eight week post-treatment outcomes suggest that the individuals who received the service had significantly better attendance at the initial outpatient screening appointment (83% versus 55%, P= 0.02 ), were more likely to complete the second week of treatment (80% versus 38% P=0.001) , had better overall attendance in the Day Treatment Center (15.5 versus .72 days P=.001) and were less likely to be lost to follow-up at eight weeks (18% versus 76.9% P=.0001) compared to those who were discharged as usual without the service. Furthermore, the individuals who received the TLC service also seemed to have better medication compliance as indicated by the greater pharmacy prescription pick-ups ( 93% versus 79%, P=0.11). The six month post treatment outcomes showed a significant reduction in psychiatric rehospitalization days among the individuals who received the TLC service (13.1 versus 33 P=.05). This reduction in hospital days was particularly striking considering that the six-month pretreatment data indicated that those in the TLC group had more inpatient psychiatric treatment days ( 40.1 versus 30.5, P=.24 ).
In terms of symptom severity, the individuals in the TLC group also showed a significant reduction in symptom severity on the BASIS 32 Relation to Self and Others (P=.006), Depression and Anxiety (P=.006), Daily Living/Role Functioning (.001) and Impulsive/Addictive (P=.02) subscale scores. Functional outcome assessments also indicated that the TLC group had greater improvement on the Clinical Global Improvement scale (3.9 versus 4.3 P= .07) and higher functioning on the Global Assessment in Functioning (56.2 versus 46.2 P=0001). These six-month outcomes are particularly exciting and suggest that the TLC intervention had robust treatment effects well beyond the eight weeks of treatment. It is also important to note that one individual in the TLC group also received Mental Health Intensive Case Management following the eight-week TLC intervention. The Mental Health Intensive Case Management was discontinued after six months because the individual was attending the Day Treatment Center regularly and no longer needed the intensive community outreach. No other individuals in either group received any other form of case management or additional outpatient treatment services besides the TLC and Day Treatment. Interestingly, as this intervention has become known throughout the veteran population, the percent of patients declining the intervention has also declined. PREVALENCE OF SUBSTANCE ABUSE IN SMI:
IMPACT OF SUBSTANCE ABUSE IN SMI:
TREATMENT NON-COMPLIANCE:
[Back to TOC] | [Back to Top] Peer Services to Support Engagement and Retention of Dually Diagnosed Veterans at the James J. Peters VA Medical Center, Bronx NYR. Claire Henderson, MD, PhDPeer support is a critical element of the Recovery Model being implemented nationally within VA Mental Health Services. A successful application was made for Mental Health Special Funding to support two peer specialists to join the staff of the Dual Diagnosis Program, who will help engage newly referred veterans and provide outreach to try to retain those whose attendance has fallen off. Impact for VA/veterans: MH Strategic Plan: [Back to TOC] | [Back to Top] Evaluation of the shift to a recovery orientation in VISN 3 mental health servicesR. Claire Henderson, MD, PhDOn the basis of a gap analysis, new services which are both evidence based and recovery oriented are being provided or applied for. The culture change required is being addressed through provider, management and veteran education. Evaluation will assess veterans’ and providers’ views on the recovery orientation of the services, and veterans’ views on their own recovery before and after the above initiatives. A smaller sample of veterans and providers will be interviewed at the two time points with respect to their treatment and rehabilitation priorities for the veteran subsample. Impact for VA/veterans: MH Strategic Plan: [Back to TOC] | [Back to Top] Implementing Effective, Collaborative Care for Schizophrenia (EQUIP-2)R. Claire Henderson, MD, PhDThe James J. Peters VA Medical Center is one of eight sites for this implementation study of effective care for schizophrenia and schizoaffective disorder, which, and one of four intervention sites for the study. Dr Henderson is site PI for this study, directed nationally by Alex Young, PI and Amy Cohen, Co-PI, in West Los Angeles. The intervention targets two care targets from the following: use of clozapine; wellness and weight management; family and caregiver services; vocational rehabilitation; or, peer support and recovery. Patients complete a self-assessment using computer at a kiosk each time they have a mental health clinic visit. This data is provided to clinicians during the patient’s visit, and to managers and staff on a regular basis. Care is targeted at unmet patient needs as identified by their self-report, using protocols developed for the project. The research studies the process of implementation, and the effect of the intervention on patient, provider, and organizational outcomes. Impact for VA/veterans: The study will provide information on the effectiveness of the implementation of improved informatics systems on the level of provision of a number of evidence based practices. MH Strategic Plan: [Back to TOC] | [Back to Top] Physiologic Monitoring for Antipsychotic MedicationsCarlos Jackson, PhDAccumulating evidence suggests that treatment with second generation antipsychotic medications (SGAs) may exacerbate weight-related health problems. Recently, the Food and Drug Administration issued a rule that newer antipsychotic medications must display a warning about the potential for weight gain and glucose dysregulation, and recommends monitoring weight and glucose for patients on these agents. However, most individuals with schizophrenia and related disorders are prescribed SGAs by psychiatrists whose traditional role may not have included diagnosing and treating primary “medical” illnesses. This study provides baseline data on the rate of medical monitoring for veterans prescribed antipsychotic medications for schizophrenia and related disorders, and for affective disorders with psychosis. In particular, we seek to determine the frequency of physiologic monitoring for weight, glucose level and lipid levels; to determine whether patients with co-morbid substance use disorders are more or less likely to receive medical monitoring; to determine whether patient-, provider-, or system-level characteristics make it more or less likely that patients receive particular elements of medical monitoring; and to compare monitoring rates for weight, glucose, and lipids to monitoring rates for established performance measures in the VA. [Back to TOC] | [Back to Top] Peer CounselingMIRECC solicited proposals via the MHEB for new peer supported case management projects after the previous MIRECC-supported initiative at TORCH was completed. We have funded one proposal at NY Harbor, “Mentorship for Substance Abuse and Trauma” by Kathlene Tracy, Ph.D., and are discussing the possibility of funding a second study. [Back to TOC] | [Back to Top] Mentorship for Substance Abuse and Trauma (MSAT)This project consists of a weekly mentorship group and a weekly individual mentorship pair contact. Ten veterans (five mentors and five mentees) will participate in MSAT for eight weeks, and twenty veterans will be randomized to either MSAT or TAU. [Back to TOC] | [Back to Top] Evaluating a Bio - terrorism Preparedness Campaign for VeteransMary Sano, PhDThis study focuses on developing and evaluating a bio-terrorism educational campaign aimed at increasing veterans’ knowledge about bio-terrorism, reducing veterans' current anxiety about a future bio-terrorism occurrence, and minimizing the psychological consequences if such a disaster was to occur. The study is based on an overarching conceptual framework derived from patient education literature demonstrating that improved knowledge and skills related to chronic illness serve to decrease anxiety and improve outcomes. We believe that this program will allow our veterans to feel empowered to take action in the event of a crisis, and will reduce the likelihood of victimization and panic. The campaign will be conducted in two concurrent phases, within two different settings, and will target two different populations of veterans (a hospital-based approach employing veterans utilizing VHA care, and a community-based approach employing veterans not utilizing VHA care). First year milestones include the establishment of an infrastructure; development, pilot-testing, and evaluation of a Veteran’s Survey on Bio-Terrorism (VSOB); completion of six focus group sessions with veterans across the country; and creation of Patient Education material. Initial focus group data attest to the necessity of this campaign. There appears to be no consistent knowledge about bio-terrorism in the veteran population, veterans conveyed confusion as to what constitutes a biological agent, and there was no consensus on which agents pose greater risk. In addition, veterans indicated a desire for specific bio-terrorism related information, and provision of information did not evoke any increase in levels of concern or anxiety. [Back to TOC] | [Back to Top] Can Family/Caregiver Involvement Improve TIDES Outcomes?The TIDES program which identifies and treats depression in the primary care sector has been highly effective in promoting recovery from depression, but there is still room for improvement in preventing relapse. This RRP project will evaluate whether components of Family Psychoeducation (FPE), an evidence-based treatment for reducing relapse in the mental health sector, can be incorporated into the TIDES program to promote better adherence and reduced relapse in the primary care sector as well. If effective, FPE-enhanced treatment for depression in the primary care sector could reduce promote recovery and reduce relapse in depression experienced by veterans, the majority of whom are treated in primary care. [Back to TOC] | [Back to Top] Suicide Assessment and Prevention Initiative(1)The VISN 3 evidence-based suicide risk assessment for CPRS has now been in use at each facility between 1 year and 3.5 years. We are now developing a multi-phased evaluation of its impact on clinician practice and patient outcome, looking at proximal outcome measures as well as distal measures. (2) In collaboration with VISN 3 MHCL and SPCs we are developing a new set of trainings for MH and PC staff in suicide prevention. (3) Continued collaboration with VISN 2 Center of Excellence in their Suicide prevention dissemination project and in the Consensus Meetings on Suicide prevention. [Back to TOC] | [Back to Top] COMPLETED PROJECTSWeight Management and Severe Mental Illness: Veterans' PerspectivesEllen Weissman, MD, MPH, Dawn Moot, MAIndividuals with schizophrenia and related disorders are at increased risk for obesity and related disorders compared to the general population. Evidence suggests that treatment with second-generation antipsychotic medications elevates the risk for weight gain, hyperglycemia and hyperlipidemia and that the risk varies across particular agents. Weight gain may lead to non-adherence with prescribed antipsychotic medications, which is particularly dangerous because non-adherence is associated with relapse and rehospitalization. This study used focus group methodology to: 1) examine the knowledge, attitudes, and beliefs of veterans with SMI about their physical health, particularly concerning being overweight or obese; 2) assess attitudes concerning interventions aimed at reducing weight through diet and exercise; 3) examine perceived self-efficacy to make changes; and 4) gauge veterans’ personal interest in participating in these interventions. The results of the study have been published and will be used to guide the development of health promotion interventions for people with severe mental illness. [Back to TOC] | [Back to Top] Impact of Risperidone Tablet-Splitting on Medication Adherence and Service UtilizationEllen Weissman, MD, MPH; Cornelia Dellenbaugh, MPHTablet-splitting is used to reduce the cost of medications for patients and health systems. If a physician prescribes a higher dose formulation and instructs the patient to split the tablet, the cost of the medication can be cut by as much as half. However, the impact of tablet splitting on clinical outcomes is not well studied. In order to determine the clinical impact of tablet splitting, we are currently analyzing administrative data from 6,350 Schizophrenic patients VISN-wide who were prescribed Risperidone, some of whom were instructed to split tablets. Outcome measures include an adherence index (medication possession ratio [MPR]) and service utilization records such as kept appointment rate, ratio of unscheduled to kept scheduled appointments, and admissions tallies. Pilot data from one VISN site: Following the initiation of tablet-splitting, pilot data show an increase in MPR, indicating that more pills were dispensed than were required to cover the number of days the patient was seen. In addition, there was an increase in unscheduled appointments and a higher ratio of unscheduled to kept appointments (p<. 0001). Kept appointment rates remained unchanged. Investigators believe that these findings occurred as a result of patients’ confusion about splitting instructions, or due to pills crumbling during splitting. Next steps: Ongoing analyses examine whether the increase in unscheduled appointments and MPR are limited to the first month or two after initiating splitting. Data from additional sites in the VISN are also being analyzed. [Back to TOC] | [Back to Top] Examination of VISN-Wide Antipsychotic Prescribing PatternsEllen Weissman, MD, MPH; Susan Essock, PhDThis study used administrative prescribing data to track secular trends in antipsychotic prescribing patterns, to identify variations in practice among sites, and to identify potential quality of care issues. We have identified low rates of Clozapine utilization in VISN 3, a finding that has led the MIRECC Education Core to develop a Clozapine education program intended to increase access to Clozapine for veterans with SMI who have not responded well to adequate trials of other antipsychotic medications. [Back to TOC] | [Back to Top] Implementing Peer-Assisted Case Management to Help Homeless Veterans with Mental Illness Transition to Independent HousingEllen M. Weissman, Nancy H. Covell, Mara Kushner, Julie Irwin, Susan M. EssockFormerly homeless mentally ill veterans are at an important crossroads when they move from living in an institutional setting such as a shelter or supportive residential facility to independent living. We hypothesized that peer advisors, veterans with severe mental illness who had been homeless previously, who graduated from a Healthcare for Homeless Veterans program, and subsequently maintained independent, stable housing could assist other veterans make a successful transition to independent living. Program leadership at Project TORCH (The Outreach and Rehabilitation Center for Homeless Veterans), part of the VA New York Harbor Health Care System, and the MIRECC developed a pilot peer-assisted case management program. Pilot data suggest that participants who received peer advisors were more likely to follow up with assessments than were controls. In addition, the program was well received by the participants, peer advisors and staff; and peer advisors exhibited increased self-confidence and self-esteem and developed personal styles for service delivery. [Back to TOC] | [Back to Top] Adherence to Antipsychotic MedicationsEllen Weissman, MD, MPHNon-adherence to prescribed antipsychotic medications is common in the treatment of schizophrenia and schizoaffective disorder. Medication non-adherence is associated with increased rates of relapse and rehospitalization. Two pilot studies examined factors affecting adherence with antipsychotic medications. One study enrolled veterans who were prescribed oral antipsychotic medications, and in an interview format, explored reasons why they chose to take or not take their medications as prescribed. The second study enrolled patients who had a history of repeat hospitalizations and used information from structured interviews, pharmacy data, and physiologic measures to examine factors related to medication adherence/non-adherence. From these studies we hope to gain a better understanding of adherence and to use this information to develop interventions aimed at improving adherence to antipsychotic medication. [Back to TOC] | [Back to Top] Effects of debriefing VA staff post 9-11Ellen Weissman, MD, MPH; Mara Kushner, CSWIn response to the terrorist attacks on September 11, 2001, external debriefers from Readjustment Counseling Services were brought in to the VA NJHCS and conducted debriefings attended by over 700 staff over a two-week period in November 2001. A psychoeducational format was used. Along with the Mental Health Executive Board, we conducted a survey to evaluate the debriefing sessions. Based on a response rate of 11% of attendees (low, but typical for surveys of this type), we found that more than three quarters of those attending did so because they wanted to; that self-reported distress levels among staff immediately after 9/11 were high, and had decreased substantially by the time the survey was conducted; most people felt better after attending the debriefing sessions; and the most commonly endorsed ways the debriefing sessions helped were “learning I was not alone in how events impacted me,” “sharing experiences with others,” and “better understanding of how events impacted me.” Ninety-one percent of respondents would attend debriefings in the future if similar circumstances arose. Respondents were split on whether having local or outside staff was preferable. [Back to TOC] | [Back to Top] Service Utilization for PTSD Following the September 11 Terrorist AttacksEllen Weissman, MD, MPH; Mara Kushner, CSW; Sue MarcusAlong with the VISN 3 Mental Health Executive Board (MHEB), the evaluation core has analyzed service utilization data from VISN 3 to determine the impact of the September 11, 2001 terrorist attacks on service utilization. We are particularly interested in its impact on the number of veterans treated for post-traumatic stress disorder (PTSD) and the potential emergence of new cases of PTSD among the veteran population following the attacks. This information is relevant for clinicians and administrators involved in planning for and responding to potential future disasters, in order to ensure adequate access to needed services in the wake of traumatic events. [Back to TOC] | [Back to Top] Consensus Conferences on Antipsychotic Treatment IssuesSusan Essock, PhD; Steve Marder; Alec Miller; Ellen Weissman, MD, MPHAlong with VISN 22 and others, we have convened two annual expert consensus conferences at the Mt. Sinai School of Medicine. The first conference in Fall 2001 resulted in published expert recommendations addressing controversial issues in antipsychotic prescribing in everyday practice for which the evidence base is insufficient to provide definitive guidance. The second conference in Fall 2002 addressed medical monitoring for patients prescribed antipsychotic medications. This unique conference brought together psychiatric experts and medical experts from a variety of specialty areas to make recommendations for medical monitoring that could be used by practitioners who prescribe antipsychotic medication in everyday clinical practice. [Back to TOC] | [Back to Top] PublicationsWeissman EM, Rosenheck RA, Essock SM. Impact of modifying risk adjustment models on rankings of access to care in the VA mental health report card. Psychiatric Services 53(9):1153-8, 2002. Weissman EM. Antipsychotic prescribing practices in the V.A.- New York metropolitan region. Schizophrenia Bulletin, 28(1):31-42, 2002. Marder SR, Essock SM, Miller AL, Buchanan RW, Davis JM, Kane JM. The Mount Sinai conference on the pharmacotherapy of schizophrenia. Schizophrenia Bulletin 28(1): 5-16, 2002. Weissman, EM, Essock SM. The pharmacoeconomics of antipsychotic medications. Expert Review of Pharmacoeconomics & Outcomes Research, 2(1):13-21, 2002. Mellman TA, Miller AL, Weissman EM, Crismon ML, Essock SM, Marder SM. Evidence-based pharmacologic treatment for people with severe mental illness: a focus on guidelines and algorithms. Psychiatric Services, 52(5):619-25, 2001. [Back to TOC] | [Back to Top] Page Content Provider: Bikki Smith |
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