WEBVTT 00:00:02.533 --> 00:00:13.440 Ralf Schneider: Great, so we saw that someone couldn't hear, um we can just write a note for him 00:00:14.400 --> 00:00:21.040 that perhaps he needs to turn his speaker on his computer up since he is seeing everything. Um, 00:00:21.760 --> 00:00:31.440 but in the interests of time, I'd like to get started and welcome everyone. This is 00:00:31.440 --> 00:00:38.080 the Mental Health Recovery and Wellness Webinar Series. This series is made possible by the VA 00:00:38.080 --> 00:00:44.240 Office of Mental Health and Suicide Prevention, Psychosocial Rehabilitation and Recovery Section, 00:00:44.880 --> 00:00:51.120 and the VISN 5 Mental Illness Research Education and Clinical Center, or MIRECC 00:00:51.840 --> 00:00:55.520 in partnership with Employee Education System, 00:00:56.080 --> 00:01:03.440 planning committee members for this Webinar series include Dan Bradford, Valerie Fox, Spencer Glipa, 00:01:04.560 --> 00:01:12.960 Catherine Lewis, Marty Oexner, Kathryn Peacock-Dutt, Donna Russo, Tim Smith, and 00:01:15.360 --> 00:01:22.800 Samantha Hack. Today's Webinar is entitled Evaluation of Recovery-oriented Acute 00:01:22.800 --> 00:01:30.160 Inpatient Mental Healthcare. In other words, RAIN-MH. Our presenter for today's Webinar 00:01:30.160 --> 00:01:38.080 is Dr. Alan McGuire. Dr. Alan McGuire is a clinical research psychologist, who serves as a 00:01:38.080 --> 00:01:46.000 core investigator at the HSR&D Center for Health Information and Communication and an Associate 00:01:46.000 --> 00:01:55.360 Research Professor at Indiana University, Purdue University, Indianapolis. Dr. McGuire's research 00:01:56.080 --> 00:02:04.400 focuses on the dissemination and implementation of evidenced-based psychosocial interventions 00:02:04.400 --> 00:02:09.920 for people with chronic conditions such as severe mental illness, chronic pain, 00:02:09.920 --> 00:02:17.920 and substance use disorders. He has received funding from the National Institute of Health, VA 00:02:17.920 --> 00:02:26.560 Rehab Research and Development, VA Health Services Research and Development, and VA Query to support 00:02:26.560 --> 00:02:36.160 his work. So, at this time, we are happy to turn over the Webinar to our presenter, and we will be 00:02:36.160 --> 00:02:43.280 keeping track of comments that you make in chat and addressing those at the end of the session. 00:02:43.920 --> 00:02:49.280 Thank you Alan, why don't you take it away. Dr. Alan McGuire: Well thank you Ralf and thank 00:02:49.280 --> 00:02:54.000 you to the whole team that puts this series together. It's such a great resource and a lot 00:02:54.000 --> 00:03:00.800 of work that goes into it, so thank you guys very much for that. Um, I'm excited today to present on 00:03:00.800 --> 00:03:08.480 our ongoing research focused on recovery-oriented inpatient services, the RAIN-MH project. 00:03:09.760 --> 00:03:14.160 First of course, I want to just note that these views that I am talking about today 00:03:14.160 --> 00:03:19.840 are mine, and that the VA and everybody else will just completely deny they even know me 00:03:19.840 --> 00:03:24.800 if you say it's their views, and also I have no financial conflicts to disclose. 00:03:26.960 --> 00:03:34.880 I do want to take a moment to acknowledge the whole team here, including my co-investigators, 00:03:34.880 --> 00:03:39.440 our great operational partners from the Office of Mental Health and Suicide Prevention 00:03:39.440 --> 00:03:46.080 including Gayle Iwamasa and Marcia Hunt, as well as the funding that we receive from 00:03:46.800 --> 00:03:49.920 Health Services Research and Development through the form of an IAR. 00:03:52.320 --> 00:03:55.920 So we're going to take a moment here to have some polling questions. I've 00:03:56.880 --> 00:04:02.080 told you who I am and Spencer will bring up some questions that we will get at, who all you are. 00:04:06.080 --> 00:04:13.840 So Spencer if you can go ahead and bring up the first poll question. 00:04:17.600 --> 00:04:22.080 All right, so, the first question is I'd like you to tell me what is your 00:04:22.080 --> 00:04:26.720 involvement in acute inpatient services and we will check all that apply. So, 00:04:26.720 --> 00:04:32.080 have you regularly provided clinical or administrative services on the inpatient unit? 00:04:33.120 --> 00:04:38.160 Have you occasionally provided services on a unit? Have you conducted research involving inpatient? 00:04:39.280 --> 00:04:44.560 Have you been a patient or a family member yourself, or have you never formally been involved 00:04:44.560 --> 00:04:55.840 with inpatient services? I'm seeing results are trickling in here and, still getting a few 00:05:00.480 --> 00:05:04.720 All right, it looks like that we've gotten most people in so let's take a look at our... 00:05:06.080 --> 00:05:13.040 our results here. So it looks like that the vast majority of you, so 70% of you have 00:05:13.040 --> 00:05:16.320 regularly provided services, so that's great. A lot of people who are 00:05:17.280 --> 00:05:22.800 really down, down in the front line there, so that's great. Some other of you who are, 00:05:22.800 --> 00:05:29.120 like me, on the occasionally provided services, a solid quarter. A few fellow researchers out there, 00:05:29.120 --> 00:05:35.120 that's fantastic. And also a solid representation of patients and family members, that's great. 00:05:37.040 --> 00:05:42.080 And, then a few of you who have no involvement, so that's fine, welcome. 00:05:46.800 --> 00:05:51.840 All right, and I believe that we have a second poll question that we can bring up at this time. 00:05:57.200 --> 00:06:02.000 All right, and so, similar question, I'd like to know just kind of what is your primary role, 00:06:02.800 --> 00:06:07.520 check all that apply. Are you a mental health provider or some other 00:06:07.520 --> 00:06:14.960 type of provider? Are you primarily a researcher? Primarily administrator? Primarily a Veteran or 00:06:14.960 --> 00:06:20.480 family member obviously many of our VA employees are Veterans or family members themselves, 00:06:20.480 --> 00:06:33.840 and that's great. Or do you describe yourself as some other sort of, some other sort of animal? 00:06:35.040 --> 00:06:38.320 All right, it looks like those results have come in pretty quickly. 00:06:41.200 --> 00:06:48.320 All right. Great. So, again, we have a strong representation from providers here on this 00:06:48.320 --> 00:06:57.360 call that's great, as well as definitely a strong administrator representation, and just a few of us 00:06:57.360 --> 00:07:02.560 researchers, definitely solid Veteran presence. Okay, great. Thank you very much Spencer. 00:07:12.560 --> 00:07:19.840 Okay, so a little bit of background and rational for what we've done. So, there have been numerous 00:07:19.840 --> 00:07:25.840 efforts to define, measure, and support the implementation of recovery-oriented care 00:07:25.840 --> 00:07:31.200 in the outpatient setting, starting with seminal work by Bill Anthony and Pat Deagan that many, 00:07:31.200 --> 00:07:37.040 if not all of us, are familiar with, um as well as numerous people in recovery themselves. 00:07:38.320 --> 00:07:45.680 However, this focus on recovery-oriented inpatient care has received relatively less attention, 00:07:46.960 --> 00:07:53.120 but this, it's still important, because we know that inpatient care is an important part of the 00:07:53.120 --> 00:07:59.760 recovery journey for many people in recovery. Relapse is recognized as a part of recovery 00:07:59.760 --> 00:08:07.520 for many people and with relapse often times comes acute hospitalization. So it's really an important 00:08:07.520 --> 00:08:14.720 place to focus our attention. And consistent with that, the VA has made some very important strides. 00:08:15.680 --> 00:08:24.000 Back in 2013, just a little over seven years ago now, the VHA distributed it's inpatient mental 00:08:24.000 --> 00:08:30.240 health services handbook, that really was set out in detailed the services that should be provided 00:08:30.240 --> 00:08:36.400 in the inpatient setting, and in conjunction with that, they issued their recovery services toolkit, 00:08:36.400 --> 00:08:41.760 which was meant to be a guide for the field on how to implement recovery principals and 00:08:41.760 --> 00:08:47.680 practices within inpatient settings. One of the tools in that toolkit that has received a fair 00:08:47.680 --> 00:08:52.720 amount of attention is the Inpatient Recovery Checklist. This was developed as a guide for 00:08:52.720 --> 00:08:58.640 the systematic implementation of recovery-based services. It is a self-assessment that people 00:08:58.640 --> 00:09:04.080 in the field could use to see, where are we on this. Despite these great efforts though, 00:09:04.080 --> 00:09:09.440 there has not been a systemic assessment of recovery-oriented inpatient care within VA 00:09:09.440 --> 00:09:15.200 and really, at the time, there really hadn't been any large-scale systematic assessment. So, 00:09:16.320 --> 00:09:24.720 that is what we, the gap that we were trying to address. So, we proposed a study with 00:09:24.720 --> 00:09:30.320 three aims. The first aim, to assess the penetration of recovery-oriented inpatient 00:09:30.320 --> 00:09:36.720 care across VHA, and the second aim was to describe the implementation process and what 00:09:36.720 --> 00:09:42.640 challenges that people in the field faced in implementing recovery-oriented inpatient services, 00:09:42.640 --> 00:09:48.480 as well as what strategies they used to overcome these barriers. And finally, we wanted to look at 00:09:48.480 --> 00:09:53.440 the relationship between recovery-oriented inpatient care and Veteran outcomes. 00:09:56.160 --> 00:10:06.800 So, just briefly here is an overview. So, we have used a mixed qualitative and quantitative design. 00:10:06.800 --> 00:10:13.520 So this is a strategy in which both quantitative and qualitative data are collected and are 00:10:13.520 --> 00:10:21.200 integrated in a meaningful sort of way. And as we got involved in this work, we realized that there 00:10:21.200 --> 00:10:28.560 was kind of a preliminary step that was necessary, which is to really define and operationalize 00:10:28.560 --> 00:10:35.240 what does recovery-oriented inpatient care look like so that we can then measure it. [laughter] Um, 00:10:36.480 --> 00:10:42.400 and then after that step, we went to measure it at a selection of VA sites 00:10:43.280 --> 00:10:48.880 understand that implementation process, and then test the association with Veteran outcomes, 00:10:48.880 --> 00:10:56.240 and we are still in the data analysis phase, so my presentation today is going to focus primarily 00:10:56.240 --> 00:11:02.240 our efforts to define and operationalize recovery-oriented inpatient care, as well as 00:11:02.880 --> 00:11:08.800 our results from measuring it at our sample of sites. I'll go into just a little bit 00:11:08.800 --> 00:11:13.840 of understanding the implementation process, but those will be preliminary. 00:11:16.240 --> 00:11:20.480 So first the operationalization of recovery-oriented inpatient care, 00:11:20.480 --> 00:11:27.280 or the development of what we call the RAIN scale. So, the first question that we really 00:11:27.280 --> 00:11:32.240 faced is where to start. At the time, there were numerous definitions existed for 00:11:33.120 --> 00:11:38.240 recovery-oriented care broadly and how that might apply to inpatient care. We found that 00:11:38.240 --> 00:11:44.320 often times those were general or abstract that weren't operationalized in the way that we needed 00:11:44.320 --> 00:11:49.760 them to be for a research study, and we weren't quite sure how to choose the best. But, we 00:11:49.760 --> 00:11:56.720 did have the VA checklist that I mentioned before, it had certain advantages, including that it is 00:11:56.720 --> 00:12:03.840 meant for VA, it's tied directly to VA policy, and this was and is a VA study; however, the checklist 00:12:03.840 --> 00:12:12.000 was intended for self-assessment and quality assurance purposes, making it not an ideal fit for 00:12:12.000 --> 00:12:17.520 a research study. So we made some modifications. Some of the types of modifications that we made 00:12:18.400 --> 00:12:24.640 from the beginning were that one wording was sometimes not clear, to us, at least, as a research team. 00:12:25.200 --> 00:12:31.200 So, for instance, one of the items made reference to appear a reality check and we felt like, 00:12:31.200 --> 00:12:37.440 well we can't reliably know what that means, so, we kind of tried to work those into things that 00:12:37.440 --> 00:12:42.960 were a little more clear and straightforward. Um, multiple aspects of care were rated in a 00:12:42.960 --> 00:12:47.600 single item in research terms we call that a double-barreled item, so we just split those out 00:12:47.600 --> 00:12:55.840 into their own separate items. Um, the checklist includes 3-point anchors, not implemented all, 00:12:55.840 --> 00:13:01.120 progressing and fully implemented, or something along that line. We felt like we needed more 00:13:01.120 --> 00:13:07.680 precision for our purpose and, very importantly, we needed some objective criteria for how we would 00:13:07.680 --> 00:13:15.600 assess whether an element and how strongly an element was implemented. So, it's also 00:13:15.600 --> 00:13:22.720 important to note that after we developed this initial scale, based on the checklist, that 00:13:22.720 --> 00:13:27.760 we took the opportunity of this study that I'm going to describe, to make continuous 00:13:29.440 --> 00:13:35.840 improvements to the scale. Um, site scoring meetings occurred after each study visit, 00:13:35.840 --> 00:13:40.720 that I will describe a little bit more in detail later, but suffice to say that after each scoring 00:13:40.720 --> 00:13:46.320 meeting we collected notes, we really reflected on the process, not only how well did the site do, 00:13:46.320 --> 00:13:50.720 but also how well did our scale do. And then we would take these, we would also pair them with 00:13:50.720 --> 00:13:56.720 periodic reviews of the literature, and also check in with our operational partners, as well as our 00:13:56.720 --> 00:14:06.560 own practice partners at the local level. And so, what came out of this process is a 23-item scale 00:14:06.560 --> 00:14:13.360 with a 5-point ratings for each element, each of these 23 items represents one element 00:14:13.360 --> 00:14:22.480 of recovery-oriented inpatient care and they're rated from 0, .5, 1, 1.5 and 2 with 0 indicating 00:14:23.520 --> 00:14:28.800 pretty much a complete absence of that element. So here is the first item as goal setting, 00:14:28.800 --> 00:14:36.240 recovery-oriented goal setting, and so a 0 is really no process at all for collecting Veteran 00:14:36.240 --> 00:14:41.200 recovery goals, all the way up to a 2, which would be excellent quality and consistency. 00:14:42.720 --> 00:14:48.480 Inherent in this rating scale is that we are taking into account both the quality 00:14:48.480 --> 00:14:55.440 of the process that is in place, but also how consistently that process is implemented 00:14:55.440 --> 00:15:03.360 across Veterans who are admitted to that unit. And also we developed some scoring criteria, 00:15:03.920 --> 00:15:08.880 how it is that we would go about, and this was grounded in not only theoretically what 00:15:08.880 --> 00:15:14.720 we thought or seemed like would be very high versus very low, but also using our 00:15:17.200 --> 00:15:24.480 sites experience and when we saw it, we were sure to try to capture that in our scale. 00:15:25.520 --> 00:15:31.520 The scale is organized into four subscales. This is based on a series of confirmatory 00:15:31.520 --> 00:15:37.120 factor analyses that we conducted and that are still ongoing. It's a good start and it makes 00:15:37.120 --> 00:15:42.000 a lot of sense, but it's, um, the fit indices are not quite where we would like them to be, 00:15:42.000 --> 00:15:49.040 so we're still working on that. But, in general, the four subscales that we found were inpatient 00:15:49.040 --> 00:15:55.360 treatment planning, outpatient treatment planning, the group programming and the unit milieu. 00:15:58.800 --> 00:16:02.240 So let me walk through the elements falling under each of these 00:16:02.240 --> 00:16:09.280 subscales. So the inpatient treatment planning this is the process by which the 00:16:10.240 --> 00:16:16.400 plan starts with the Veteran's recovery goals, and seeking out and understanding what are the 00:16:16.400 --> 00:16:24.480 Veteran's goals for their own recovery. These are recorded in a written treatment plan and are used 00:16:24.480 --> 00:16:30.240 as the starting point for shared decision making for medication management and shared 00:16:30.240 --> 00:16:35.840 decision making for inpatient treatment. And by inpatient treatment, I'm talking about the 00:16:36.560 --> 00:16:43.600 care that happens while the Veteran is still on the unit. This takes place in the context of an 00:16:43.600 --> 00:16:50.400 interdisciplinary treatment team that the Veteran is considered at the center of, and also involves 00:16:51.200 --> 00:16:55.280 significant others and family members in this planning process. 00:16:57.520 --> 00:17:02.800 The outpatient treatment planning also starts with the Veteran's recovery goals and uses those 00:17:03.440 --> 00:17:08.960 to engage in a shared decision-making process to plan for outpatient treatment, or the care 00:17:08.960 --> 00:17:14.800 that the Veteran will receive after they are discharged from the unit. This outpatient care is 00:17:14.800 --> 00:17:21.120 coordinated between the inpatient and outpatient teams and that there is a philosophy towards the 00:17:21.120 --> 00:17:28.000 least restrictive discharge possible for each Veteran. So there isn't a assumption that all 00:17:28.000 --> 00:17:33.680 Veterans coming off of an inpatient unit will have to go to some sort of stepdown unit or residential 00:17:34.560 --> 00:17:42.560 or nursing home sort of setting, but that we want to get Veterans to the closest they can as living in 00:17:42.560 --> 00:17:48.640 the community with the appropriate supports. And finally, this is in reach, or the notion that 00:17:48.640 --> 00:17:54.400 outpatient treatment programs will provide services on the inpatient unit so that Veterans 00:17:54.400 --> 00:18:01.360 can experience firsthand the types of services that those outpatient programs provide, and can 00:18:01.360 --> 00:18:05.520 make a better and more informed decision regarding whether that is an appropriate fit for them. 00:18:08.400 --> 00:18:15.520 The group programming includes both if there is a sufficient volume of groups available on the unit, 00:18:15.520 --> 00:18:24.080 as well as a sufficient variety to meet the needs of the most diverse presenting concerns and needs 00:18:24.080 --> 00:18:29.440 of Veterans served by the unit, and that this programming is supported by the staff 00:18:29.440 --> 00:18:34.080 so that Veterans are encouraged to participate maximally in group programming 00:18:34.080 --> 00:18:42.720 with minimal disruptions or competing interests for that. So that groups are happening in a quiet 00:18:42.720 --> 00:18:48.640 space where Veterans can concentrate and there isn't a constant revolving door of nurses coming in, 00:18:48.640 --> 00:18:53.920 puling Veterans out for vitals and things like that. And then finally, that this 00:18:54.560 --> 00:18:59.280 programming is of high quality, so that it is of therapeutic value basically. 00:19:01.440 --> 00:19:11.082 And finally, the milieu. That the milieu is a warm and inviting home-like unit that is an autonomy 00:19:11.082 --> 00:19:17.280 promoting environment in which that to the most can be done while maintaining safety that Veterans 00:19:17.280 --> 00:19:23.360 are able to, you know, maintain their rights as humans and some sense of normality. That there is 00:19:23.360 --> 00:19:29.920 respectful and therapeutic interactions between staff and patients. Nurses and other staff are 00:19:31.200 --> 00:19:36.000 out and about in the milieu on a regular basis interacting in a respectful and supportive 00:19:36.000 --> 00:19:41.040 way with the Veterans, and that behavior is managed through the least restrictive means. 00:19:42.240 --> 00:19:48.480 So this is looking at minimizing the use of seclusion and restraint 00:19:48.480 --> 00:19:54.160 and things of that nature, even chemical restraint and using our verbal deescalation 00:19:55.200 --> 00:20:02.000 techniques and things of that nature, and ideally, preventing escalation before it even happens. 00:20:04.000 --> 00:20:06.960 There are a few other items that are included in the scale that didn't fall 00:20:07.760 --> 00:20:13.760 neatly into one of our other subscales, but are nonetheless, I think are important, one of which 00:20:13.760 --> 00:20:20.560 is there is integrated care for comorbid visible health needs. Also the availability and use of 00:20:20.560 --> 00:20:27.600 individual evidence-based psychotherapies. Suicide prevention, so the linkage with 00:20:27.600 --> 00:20:33.440 suicide prevention coordinators, as well as filling out and maintaining safety plans for 00:20:33.440 --> 00:20:39.440 Veterans for whom that's appropriate. Also, that this is a multidisciplinary treatment team with 00:20:39.440 --> 00:20:47.840 representation from all relevant disciplines. And finally, the inclusion of peer support services. 00:20:50.320 --> 00:20:54.800 So, how did we go about assessing recovery-oriented care within the VA? 00:20:57.280 --> 00:21:05.360 Well, we sought out to recruit a sample of 34 acute inpatient units across the VA. I 00:21:05.360 --> 00:21:11.360 have to tell you that this was driven by what a statistician told us we needed to have power 00:21:11.360 --> 00:21:15.920 to reach our aims I put it down in the proposal thinking there is no way I'm actually going to be 00:21:15.920 --> 00:21:21.360 able to recruit all these, but we will do the best we can. And low and behold, the field responded 00:21:21.360 --> 00:21:25.920 with great generosity in offering up their time to participate in our research and we actually 00:21:25.920 --> 00:21:32.560 made our goal and I'm very excited that we have a diverse sample. These units represent every 00:21:32.560 --> 00:21:38.240 major region of the country, so 16 different VISNs are represented in this sample. And although it 00:21:39.040 --> 00:21:45.200 says only three of these sites were rural, I will say that that is just based on VA Medical Center 00:21:45.200 --> 00:21:51.200 classification many of these sites are serving a very large proportion of Veterans that are coming 00:21:51.200 --> 00:21:58.080 from rural areas. Some Veterans of course coming hundreds of miles to the closest inpatient unit. 00:22:00.560 --> 00:22:05.600 So lets talk a little bit about the data sources that we used to assess recovery-oriented care. We 00:22:05.600 --> 00:22:12.080 used several. So first, there were observations, well not first, but um, there are observations 00:22:12.080 --> 00:22:17.520 from two-day site visits conducted by the team. Additionally, we conducted key informant 00:22:17.520 --> 00:22:23.760 interviews with staff, Veteran interviews with Veterans who had been recently discharged from 00:22:23.760 --> 00:22:28.880 that unit, administrative data that was collected from the corporate data warehouse 00:22:28.880 --> 00:22:37.280 that included things like the number of individual psychotherapy encounters for Veterans during the 00:22:37.280 --> 00:22:42.000 past six months, the number of group psychotherapy encounters, or group therapy encounters and things 00:22:42.000 --> 00:22:47.680 of that nature. And then, finally, we conducted at least five chart reviews for each site. 00:22:50.640 --> 00:22:59.600 The key informant interviews, so we targeted, for each unit, interviews with the Unit Nurse Manager, 00:22:59.600 --> 00:23:06.480 the Medical Director or lead Psychiatrist, the Inpatient Program Coordinator, a Social Worker 00:23:06.480 --> 00:23:12.800 and the Local Recovery Coordinator, and we were able to get an average of a little over four interviews 00:23:12.800 --> 00:23:19.840 per site, ranged from 3 to 7. These were one-hour telephone interviews. They were semi-structured 00:23:21.280 --> 00:23:28.160 and they focused primarily on the implementation of these inpatient elements, but also tried to 00:23:28.160 --> 00:23:33.360 get at the implementation process, or as I call it, the implementation story. How is it 00:23:33.360 --> 00:23:38.480 that things came, the elements that you have in place came to be in place at your site, 00:23:39.360 --> 00:23:44.640 and what barriers did you face and why the things that you don't have, do you not have? 00:23:47.760 --> 00:23:53.680 For our Veteran interviews, we were able to recruit an average of almost six Veterans per 00:23:53.680 --> 00:23:59.360 site, and as you will see here, the demographics, despite the fact that we did over-sample for 00:24:00.320 --> 00:24:05.920 non-white Veterans, and for Hispanic Veterans, as well as for women Veterans, the 00:24:07.360 --> 00:24:19.520 breakdown roughly does represent the VA Veteran sample. So let me talk a little bit about how it 00:24:19.520 --> 00:24:27.360 is that we went about scoring sights. So, first of all, there was a group of raters that are members 00:24:27.360 --> 00:24:34.480 of the study team. I myself was one of them as well as four or five of my colleagues. I will 00:24:34.480 --> 00:24:42.000 say that we were very fortunate our team included decades of experience, as mental health providers, 00:24:42.000 --> 00:24:49.520 consultants, researchers, and family members. So, these, for each site, 00:24:49.520 --> 00:24:55.280 there would be a primary rater assigned, as well as secondary and tertiary raters were assigned as 00:24:55.280 --> 00:25:01.600 necessary based on the size and the complexity of the unit. The primary rater coordinated data 00:25:01.600 --> 00:25:09.360 collection for that site. They would lead the site visit and after all data collection was done, 00:25:09.360 --> 00:25:15.760 they would draft a preliminary site summary. We would convene a site scoring meeting, in which at 00:25:15.760 --> 00:25:22.400 least four members of the rater team, including the primary and any secondary or tertiary raters were 00:25:22.400 --> 00:25:27.440 present. They would present all the data that we had collected, and we would attempt to come 00:25:27.440 --> 00:25:35.920 to consensus, 0.5, 1.5 what have you, for a rating for each of these elements. In the case in which 00:25:35.920 --> 00:25:40.640 we really just could not come to consensus, it felt like we didn't have enough information, then 00:25:40.640 --> 00:25:47.120 we would go back to the sites with any clarifying questions that we would have. I would also say 00:25:47.120 --> 00:25:51.920 that data triangulation was very important to us throughout this process. So for each of the sites 00:25:51.920 --> 00:25:57.680 we would offer a wrap up meeting at the end of the site visit, in which we would say to our primary 00:25:57.680 --> 00:26:02.320 point of contact, you know, whoever, or whomever would like to come, whoever would like to come, 00:26:02.320 --> 00:26:07.360 let's come, we can share our initial thoughts, what we've seen, what are your relative strengths and 00:26:07.360 --> 00:26:13.680 weaknesses. But as part of that process, we really want to say that if we say this is what we saw and 00:26:13.680 --> 00:26:18.000 you like, oh, no, no, no, you missed this, please tell us so that we can kind of verify 00:26:18.000 --> 00:26:27.360 with you that we are actually capturing a fair representation of your unit. So, what did we find? 00:26:31.280 --> 00:26:38.000 So here, in this box, we see, I have broken down the elements based on whether they were very 00:26:38.000 --> 00:26:46.160 commonly implemented, uncommon to see them, or very uncommon. And in order to categorize them 00:26:46.160 --> 00:26:49.120 with that I used a kind of top box approach but 00:26:49.680 --> 00:26:58.000 sort of, of how many sites scored a 1.5 or 2. So that would land you in the range of 00:26:58.000 --> 00:27:03.680 that it was both a high quality and high consistency for that particular element. 00:27:04.320 --> 00:27:12.480 And to be rated as very common, those are elements in which 75% of those 34 units that we visited 00:27:12.480 --> 00:27:20.720 had a 1.5 or a 2 on that particular element. The very uncommon would be 25% or less 00:27:20.720 --> 00:27:29.360 of sites. And then the common versus uncommon is at the 50% breakpoint. So, I'll give you a 00:27:29.360 --> 00:27:36.240 moment to kind of scan through that, but I'll be walking through some more specific examples next. 00:27:41.520 --> 00:27:47.760 So, here is a table, it's a little bit busy, but this is for the inpatient treatment 00:27:47.760 --> 00:27:54.880 planning elements. And, what you will see here is a lot of red. So, far and away, 00:27:54.880 --> 00:28:00.240 the inpatient treatment planning elements were the least frequently implemented elements 00:28:01.120 --> 00:28:10.000 as a whole. Some of the lowest scoring elements in general were located here. As you can see, goal 00:28:10.000 --> 00:28:14.720 setting, written treatment plan, shared decision making for medication management, decision 00:28:14.720 --> 00:28:23.360 making for inpatient treatment are all in that red column with very, very few sites scoring 1.5 or 2. 00:28:26.720 --> 00:28:32.800 In contrast, outpatient treatment planning items are all in the yellow where we see kind 00:28:32.800 --> 00:28:37.120 of a range, where there are some sites that are doing it fairly well and there are also 00:28:37.120 --> 00:28:43.840 plenty of sites that aren't doing particularly well with some kind of clustering in the middle. 00:28:44.800 --> 00:28:48.320 The same is true for group programming. Some are doing it well, 00:28:48.320 --> 00:28:51.600 some are not doing it so well, a lot of them clustered in the middle. 00:28:54.320 --> 00:29:01.680 And finally, milieu, a similar sort of, similar sort of process there. The one exception being 00:29:01.680 --> 00:29:05.520 behavior managed through least restrictive means, which I will talk a little bit more about later, 00:29:05.520 --> 00:29:13.120 but it was in the green with a lot of sites doing a very nice job on this. Then these non-item 00:29:13.120 --> 00:29:20.720 factors are as, one would guess, a hodgepodge.[laughter] So, with two of the highest scoring items, 00:29:21.280 --> 00:29:26.960 located here, integrated care for comorbid physical needs and suicide prevention, but then 00:29:26.960 --> 00:29:32.480 also one of the lowest scoring with individual evidence-based psychotherapy showing up here. 00:29:35.760 --> 00:29:39.280 So, let's unpack this just a little bit. So, 00:29:39.280 --> 00:29:46.480 first of all, I want to pause and just note that I feel as though that the development of this scale 00:29:46.480 --> 00:29:52.320 is a big step forward in terms of conceptualizing and operationalizing recovery-oriented care 00:29:52.320 --> 00:29:56.320 in the context of acute mental health care kind of that last frontier 00:29:56.320 --> 00:30:03.600 in mental health recovery. I feel as though that we a case for some pretty strong content validity 00:30:04.160 --> 00:30:10.480 in that the elements that we included in this that arose from our process are very consistent with 00:30:10.480 --> 00:30:15.360 numerous perspectives, including literature on the patient perspective of what they, 00:30:16.000 --> 00:30:22.320 what patients want out of inpatient care, and view as high quality and recovery-oriented. 00:30:22.320 --> 00:30:27.760 Same for staff and provider perspectives, and also consistent with other efforts 00:30:27.760 --> 00:30:32.640 in which people have attempted to implement recovery-oriented care in their own settings. 00:30:33.200 --> 00:30:37.760 So in other words, nothing really popped out up here that was strange or foreign. 00:30:39.760 --> 00:30:44.080 But we're definitely not done yet, so, the psychometrics for this scale 00:30:44.880 --> 00:30:49.200 definitely have some issues. There are some item level issues that need some tweaking 00:30:49.760 --> 00:30:54.480 and, as I mentioned before the factor analysis, the fit is still not strong. And so definitely 00:30:54.480 --> 00:31:01.600 we have a some more scale development to do. We also really need feedback from the field that 00:31:01.600 --> 00:31:05.680 starts today. These are the first time that have presented these results and I'm really excited 00:31:05.680 --> 00:31:10.720 to hear what feedback I get from you all, and of course the peer review process as we submit this 00:31:10.720 --> 00:31:16.000 to journal publication and then whatnot. And then of course we really want those outcomes, 00:31:16.800 --> 00:31:21.840 the association with Veteran outcomes. I was hoping to have those to share with you today, but 00:31:21.840 --> 00:31:29.920 alas, it just wasn't, wasn't ready yet. Let's talk about some VA successes. So, 00:31:29.920 --> 00:31:35.200 of those elements that were very commonly implemented two of them, suicide prevention 00:31:35.200 --> 00:31:41.200 and behavior management really shouldn't come as a surprise. So suicide prevention is, of course, 00:31:42.000 --> 00:31:48.560 the number one priority for VA mental health and I think that that has definitely shown some 00:31:49.200 --> 00:31:56.000 um, shown some uh, some, borne some fruit here. Similarly, there are 00:31:56.000 --> 00:32:04.640 definitely metrics that look at how often units are using these more restrictive and aggressive 00:32:04.640 --> 00:32:09.600 behavior management techniques, such as seclusion restraint, and we found that by and large that 00:32:09.600 --> 00:32:15.040 there really was an emphasis on attempting to manage behavior through these less restrictive means. 00:32:15.920 --> 00:32:20.880 Some other feathers in our cap, if you will, so, the integration of physical health, I think that 00:32:20.880 --> 00:32:28.560 the VA is really capitalizing on itself as a full service integrated healthcare system. So, 00:32:29.200 --> 00:32:36.880 in contrast to a standalone mental health unit, the units in our sample were making use of the 00:32:36.880 --> 00:32:43.440 availability of physical health. And this is, they should be commended for this. I should note that 00:32:44.160 --> 00:32:50.640 many of the people I talk to across VA say that many of the Veterans that they serve, 00:32:50.640 --> 00:32:56.000 they're coming in after being largely absent from the healthcare setting for a large period of 00:32:56.000 --> 00:32:59.920 time. So there is a lot of what we call deferred maintenance - Veterans coming in that haven't been 00:32:59.920 --> 00:33:04.800 receiving dental care, that haven't been receiving adequate primary care coverage and things like 00:33:04.800 --> 00:33:09.840 that. And so, at the same time that they're trying to do all of this important work regarding 00:33:10.400 --> 00:33:14.880 getting their mental healthcare up and running, they're also trying to get them caught up on all 00:33:14.880 --> 00:33:20.320 of these things and that's a lot of work, and it's really important. And finally, the quality of 00:33:20.320 --> 00:33:27.200 the programming is a pretty high quality of group programming out there that is going on currently. 00:33:30.160 --> 00:33:35.680 Now, on the other side of things, urgent attention needed. So, this 00:33:36.800 --> 00:33:41.200 inpatient treatment planning cascade, as I'm kind of calling it right now, 00:33:41.200 --> 00:33:47.760 was where a lot, a lot of work still needs to be done. This notion of starting with the 00:33:47.760 --> 00:33:53.280 goals, Veterans' own goals, recording those in a written treatment plan and have that drive 00:33:53.280 --> 00:33:58.080 shared decision making regarding medication and inpatient treatment, and supporting individual 00:33:58.080 --> 00:34:05.600 therapy. That just, it seems like that is really a struggle in the field at this point in time. So 00:34:05.600 --> 00:34:10.400 that, I think, jumped out at me as the kind of the number one need for where we need more support. 00:34:13.760 --> 00:34:18.000 So, let me talk a little bit about the implementation data and some preliminary thoughts. 00:34:18.000 --> 00:34:23.280 As I said before, data analysis is ongoing, so what I'm sharing here is really more 00:34:23.280 --> 00:34:28.480 kind of what is starting to emerge and kind of my thoughts rather than being the product 00:34:28.480 --> 00:34:34.800 of rigorous qualitative analysis, so, I reserve the right to change my mind later. I would say 00:34:34.800 --> 00:34:44.480 that the biggest headline from these data, was how sparse they were. So, really, it felt like it was 00:34:44.480 --> 00:34:51.120 hard to get much information about how did things get to be the way that they are now. 00:34:52.080 --> 00:34:59.920 Why is that? Well, one thing that is of note, is that it was hard to get to a common understanding 00:34:59.920 --> 00:35:08.400 of the comments, of the elements that we were talking about. So, we would say, "well, you know, shared decision making," 00:35:08.400 --> 00:35:14.880 and then they would say, "oh yes, we do shared decision making for all of our Veterans, for all 00:35:14.880 --> 00:35:20.960 of their medications." And then we would dig into that a little bit more and say, "well what do you 00:35:20.960 --> 00:35:27.360 mean by that," and like, "well, you know, the doctor will provide them with his recommendation and, 00:35:27.360 --> 00:35:32.880 you know, they can say no if they want to and we'll take that into consideration." Say, "well, 00:35:32.880 --> 00:35:38.560 you know, that's not quite what we meant by shared decision making." So, we spent so much time really 00:35:38.560 --> 00:35:44.800 kind of digging in to what is actually going on at this site because there wasn't this lingua franca 00:35:44.800 --> 00:35:48.640 that often times we didn't get to those implementation questions, or didn't have, 00:35:48.640 --> 00:35:54.240 we had limited bandwidth for it I would say. Also, there was an institutional amnesia. Many 00:35:54.240 --> 00:35:59.120 of these sites have experienced lots and lots of staff turnover, and so you would ask, "Hey how did 00:35:59.120 --> 00:36:04.000 this get to be the way it is now?" and the staff would say, "Well, you know, I've been here for two 00:36:04.000 --> 00:36:10.240 years and it's always been that way." And finally, there was no singular launch of recovery-oriented 00:36:10.240 --> 00:36:17.680 inpatient care. Yes, there was this 2013 toolkit launch, but most of the sites that 00:36:17.680 --> 00:36:22.480 we saw had already been doing some of these things, or at least attempting to do some of 00:36:22.480 --> 00:36:28.240 these things before the launch of that toolkit and then even afterwards it varied in terms of 00:36:28.240 --> 00:36:32.320 what pieces of the toolkit they were using. So it wasn't like many places where you say, 00:36:32.320 --> 00:36:38.080 Hey, this is when VA launched its training in consultation for cognitive behavioral therapy 00:36:38.080 --> 00:36:42.720 for chronic pain, and it was a singular thing. So it just made it harder to talk about in that way. 00:36:44.160 --> 00:36:48.000 Model specificity I would say is a barrier and a facilitator. 00:36:48.640 --> 00:36:52.800 Everybody can talk to me about their 40 hours of programming, because there's a number to it, 00:36:52.800 --> 00:36:57.200 you just count up the number of groups that you have, and you either have 40 or you don't. 00:36:57.920 --> 00:37:02.640 Versus, as I said before, shared decision making or even goal setting, where they may say, "Oh yes, 00:37:02.640 --> 00:37:06.640 we asked the Veteran about their goals," but then we ask them more about that and they say, 00:37:06.640 --> 00:37:10.160 "Well yeah, you know, when the nurse does the intake she says, you know, what's your goal and 00:37:10.160 --> 00:37:14.480 they say uh, well, you know, I wanna get into the DOM and that's where they leave it." 00:37:15.280 --> 00:37:22.160 Well, that's kind of not what we were talking about, and so that uh, the more kind of, um, easy 00:37:22.160 --> 00:37:28.080 to count it is, the easier it is to talk about it, and the easier it is to implement. Also, 00:37:28.080 --> 00:37:33.200 it will come as no surprise to many of you, that there is a big focus on safety and acute 00:37:33.200 --> 00:37:39.200 stabilization within inpatient units. There has to be, because keeping our Veterans safe has to be 00:37:39.200 --> 00:37:45.440 number one priority and keeping our staff safe as well. And then also there are, of course, are many 00:37:46.000 --> 00:37:53.040 people who are still rooted in the medical model and I point at prescribers here, not because I 00:37:53.040 --> 00:38:01.200 am suggesting that prescribers are further behind non-prescribers, but yet their role is so central, 00:38:01.200 --> 00:38:07.200 particularly on an acute inpatient unit that there is some sense that if the prescriber is 00:38:07.760 --> 00:38:12.720 actively against this notion of recovery-oriented care, there's, that's kind of the end of the game. 00:38:13.280 --> 00:38:18.160 Versus other, other disciplines you might be able to work around for some elements. 00:38:18.960 --> 00:38:24.000 So I just included a sample quote here that really demonstrated this. This is from a psychologist, 00:38:24.000 --> 00:38:28.400 a Treatment Coordinator at one of our sites, and he said, Yeah, it's basically I find that 00:38:28.400 --> 00:38:33.360 the treatment team meetings are, I guess, like 90% about discussions about medications, 00:38:33.360 --> 00:38:38.240 and there is very little room for any psychosocial type issues. I believe that our psychiatrist is 00:38:38.240 --> 00:38:42.720 totally grounded in the biological processes and totally believes in those, and therefore, 00:38:42.720 --> 00:38:47.120 theirs psychosocial issues are either discounted or they're farmed out to the social workers. 00:38:48.240 --> 00:38:51.600 So, I thought that this was really emblematic of a place were there were people who were 00:38:51.600 --> 00:38:55.760 trying to do this. They had set up this interdisciplinary treatment team meeting, 00:38:57.280 --> 00:39:03.280 um, where the Veteran was hypothetically brought in to be part of this discussion, but 00:39:03.840 --> 00:39:08.720 you had one, this psychiatrist, who was just saying like, Yeah, 00:39:08.720 --> 00:39:12.880 no, we're just gonna talk about which medication and we've already made these decisions. And so, 00:39:12.880 --> 00:39:16.720 kind of nothing else could happen with that in any sort of a reasonable sense. 00:39:18.960 --> 00:39:23.280 Um, I will just say briefly, regarding facilitators, that there was no one thing 00:39:23.280 --> 00:39:31.600 that if sites did this thing, or had this thing, then they were good. Um, staffing is really 00:39:31.600 --> 00:39:36.960 helpful. If you don't have the overall staffing it makes it harder, but there were sites that 00:39:36.960 --> 00:39:41.280 were really well staffed that didn't implement very well, and there were sites that were really 00:39:41.280 --> 00:39:45.320 struggling with staffing, but yet still pulled it off. There's some examples; like, if you don't 00:39:45.320 --> 00:39:50.800 have a psychologist or a therapist, then you're probably not gonna have individual therapy. 00:39:50.800 --> 00:39:55.520 Some sites try to have outpatient providers come on the unit and provide it, but it just really, 00:39:55.520 --> 00:40:01.440 it was very sparse. Also, having a champion for recovery-oriented care can really help, 00:40:02.240 --> 00:40:07.440 but it also depends on who that person is, how much clout they have, can they get trumped, 00:40:07.440 --> 00:40:13.360 do they have buy in, things like that. So, future directions for our team we're gonna 00:40:13.360 --> 00:40:18.560 continue our work analyzing relationships to outcomes, and analyzing our implementation 00:40:19.680 --> 00:40:25.440 data. I will say, that there are some real needs. For instance, I mentioned inpatient programming 00:40:25.440 --> 00:40:31.040 and the types of group and individual therapy. There is not really a research base for this. We 00:40:31.040 --> 00:40:36.320 talk a lot about providing evidenced-based psychotherapy. So for instance, CBT-D, 00:40:37.120 --> 00:40:44.560 in the settings, but those models were designed for outpatient settings. Nobody has 12 weeks, 00:40:44.560 --> 00:40:48.960 well, I won't say that, but it's very, very rare that a Veteran has 12 weeks on inpatient, 00:40:48.960 --> 00:40:54.320 and we hope that they don't. So what does it look like? What are the effective practices and what 00:40:54.320 --> 00:41:00.640 should be the target of those practices? I would say two other things, so specific models for goal 00:41:00.640 --> 00:41:05.840 setting and for shared decision making, I know there are some, um, but really understanding how 00:41:05.840 --> 00:41:11.120 those could be used to support those processes on the inpatient unit I think is definitely a very 00:41:11.120 --> 00:41:16.640 important question for the field. So, I'm gonna stop there with my thoughts, I'm really interested 00:41:16.640 --> 00:41:23.120 in your questions and I just want to thank you for tuning in today and so I'll turn it over now to 00:41:23.120 --> 00:41:28.480 the moderators to see what questions we have. Ralf Schneider: Sure, uh, so, uh, this is Ralf, we 00:41:28.480 --> 00:41:36.240 have Alyssa Rippy who got in the first question, and she started out by asking, "Were the treatment 00:41:36.240 --> 00:41:43.520 plans being completed in MHS" and, you know, what was behind that, was her thought, "if you had a 00:41:43.520 --> 00:41:54.000 sense of "why the inpatient treatment planning was so low? Did it have to do with um, the 00:41:54.000 --> 00:42:02.160 templates not being in, um, and then providing recovery-oriented planning that wasn't documented?" 00:42:02.160 --> 00:42:07.520 I think that was the gist of it. 00:42:07.520 --> 00:42:13.520 Dr. Alan McGuire: Uh huh. Yeah, so that's a, that's a great question. Thank you very much. So, almost all, with the exception 00:42:13.520 --> 00:42:19.440 of maybe one unit, and I will point out that that unit was one of the highest scorers, used Mental 00:42:19.440 --> 00:42:24.240 Health Suite, um, I have done some previous work regarding mental health treatment planning and I 00:42:24.240 --> 00:42:29.120 will say it is very, very hard, and we are talking about, when we talk about it in these items, 00:42:29.120 --> 00:42:37.680 we're not talking about is there a treatment plan with the required elements in, in CPRS. 00:42:37.680 --> 00:42:45.360 So, Mental Health Suite gets you there but what it doesn't get you is the more soft skill stuff. 00:42:45.360 --> 00:42:53.760 Are you gathering a real goal from the Veteran and documenting that, and is that real goal and 00:42:53.760 --> 00:43:01.600 plan being used to drive the care that is actually taking place on the unit? In some cases, 00:43:01.600 --> 00:43:06.880 there is that really seductive drop down menu that provides you those pre-populated goals 00:43:07.840 --> 00:43:14.320 and we would sniff those out and recognize that they were being used, in some cases 00:43:14.320 --> 00:43:20.560 for convenience sake and not really matching what the Veteran said. My personal pet peeve 00:43:20.560 --> 00:43:24.560 is when a goal is put in with quotation marks around it that it clearly comes from a 00:43:24.560 --> 00:43:29.360 pre-populated goal and isn't actually a quote from the Veteran. That's not what we're looking for. 00:43:31.040 --> 00:43:38.320 But, Mental Heath Suite aside, there is, regarding the inpatient treatment with some units, because 00:43:38.320 --> 00:43:45.520 their focus was very much we are about acute stabilization, we are about adjusting their 00:43:45.520 --> 00:43:52.320 medications and then getting them out as fast as they can that the kind of esprit de corps was 00:43:53.440 --> 00:43:59.040 we don't really provide treatment on the unit, so there is not a reason to spend a whole lot of time 00:43:59.040 --> 00:44:05.120 thinking about which groups that they might go to, or what they might need from therapy, or how the 00:44:05.120 --> 00:44:11.520 medications that we might, medication adjustments that we might make on the unit might tie into 00:44:11.520 --> 00:44:15.280 their life outside of the unit, because that's just not what they were focused on. So, there's 00:44:15.280 --> 00:44:20.240 a whole lot of issues there that go into that. Ralf Schneider: Thank you. Um, Alicia 00:44:20.240 --> 00:44:25.520 Lucksted had a question, "How do your psychometric concerns that you mention 00:44:26.080 --> 00:44:32.320 impact your interpretation of the results?" Dr. Alan McGuire: Yeah, that's a fantastic 00:44:32.320 --> 00:44:39.440 question, thank you Alicia. Um, so, in a number of ways. So, some of the issues 00:44:39.440 --> 00:44:45.760 where we were able to address kind of uh, so we made some scoring rules. For instance, regarding 00:44:46.400 --> 00:44:53.600 the group variety item that we have reversed based on the distributions that we were seeing and, 00:44:54.880 --> 00:45:01.440 so there were a whole lot of clustering in the initial item at .5 because we said that there were 00:45:01.440 --> 00:45:05.680 these four types of groups that were critical for inpatient programming, and if they didn t have it 00:45:05.680 --> 00:45:10.800 then we automatically drop them down to a .5. We relaxed that because we felt like we didn't have 00:45:12.160 --> 00:45:17.200 sufficient justification to really make that call. So some of those we were able to adjust 00:45:17.200 --> 00:45:23.120 them that way. Then there were others that are just going to have to be focus of future work. 00:45:24.000 --> 00:45:30.560 We might have to drop certain items from our outcome analysis to adjust for those issues. 00:45:31.680 --> 00:45:36.960 So that's the , unfortunately when you're talking about site level assessment it's not like, 00:45:36.960 --> 00:45:40.400 you know, my statistician is like, hey, you know, could you maybe get 10 more sites, I think that 00:45:40.400 --> 00:45:45.600 would help with the and like, no we can t just go to 10 more sites, especially during COVID. 00:45:45.600 --> 00:45:53.840 So, um, that's the long and the short of that. Ralf Schneider: Thank you. Um, next 00:45:55.040 --> 00:46:01.280 question was from Richard Keeney. "Would you weigh any of the areas you were measuring 00:46:01.280 --> 00:46:07.280 as more important than others in regard to implementing a recovery model?" And I think you 00:46:07.280 --> 00:46:13.840 said something about what you thought was central, but maybe you could speak more to that one. 00:46:13.840 --> 00:46:17.200 Dr. Alan McGuire: Yeah, absolutely. So I personally 00:46:18.560 --> 00:46:26.000 have a hard time wrapping my mind around how you do true recovery-oriented programming if it's not 00:46:26.000 --> 00:46:35.920 being driven by a nuanced understanding of the Veteran's recovery goals. That to me is just the starting 00:46:35.920 --> 00:46:42.320 point of recovery-oriented care is understanding what does this Veteran want for his or her 00:46:42.320 --> 00:46:48.080 recovery, and starting there. So, I feel like that this inpatient treatment planning cascade, 00:46:48.080 --> 00:46:55.040 starting with a goal plan, the goal setting is, is really, I would put it as the most important 00:46:55.600 --> 00:47:00.560 piece. But that's, of course, just my opinion. Ralf Schneider: All right. Fair enough. 00:47:01.680 --> 00:47:08.800 Anne Canastra asked, "Could sites request a coach to review some of your scores and 00:47:08.800 --> 00:47:14.240 implement action plans to address gaps in some of their areas. In other words, 00:47:15.760 --> 00:47:23.840 were you aware of follow-up that they could implement based on you coming back to them?" 00:47:23.840 --> 00:47:33.360 Dr. Alan McGuire: Yeah. So um, that's a great question, and so, we have had a couple of sites 00:47:33.360 --> 00:47:40.720 that have reached back out to us and um, have asked for, you know we want to use this to grow, 00:47:40.720 --> 00:47:44.960 what can we do, are there people who are farther along than us that we can talk to 00:47:44.960 --> 00:47:52.560 and there has. So far, we've gotten a site that scored very well who was graciously 00:47:53.440 --> 00:47:58.800 agreed to speak with those sites, so we've been able to do some matchmaking there. 00:47:59.600 --> 00:48:05.200 Um, and, you know, I wish that, I wish that the Office of Mental Health and Suicide Prevention 00:48:05.200 --> 00:48:11.520 had a team of external facilitators who could, you know, [laugher] who could parachute in and 00:48:11.520 --> 00:48:17.040 provide support. I've talked with Gayle Iwamasa just the other day and we were in 00:48:17.040 --> 00:48:22.080 initial conversations about what we could do, what sort of resources that we could develop 00:48:23.520 --> 00:48:32.880 for the field, um, and uh, and that's still in development. You know, we, our team is 00:48:32.880 --> 00:48:38.240 research funded and so it's, it's not like we have somebody supporting us to be able to provide that. 00:48:39.200 --> 00:48:44.000 But, I'm, the, I guess the short answer is that I'm more than happy to try to 00:48:44.000 --> 00:48:50.240 facilitate a Community of Practice for sites that want to continue and improve on this, and talk 00:48:50.240 --> 00:48:56.480 about, do follow-up conversations with scores, and learn more about the scale and our process 00:48:57.280 --> 00:49:00.160 through those conversations. Ralf Schneider: Great, thanks. 00:49:00.160 --> 00:49:08.720 And then, Rob Ansen, um, prefaced it by saying, "Not sure if this is a fair question, but 00:49:09.680 --> 00:49:15.840 you may have noticed, or did you see in inpatient settings that might have been shifting toward a more 00:49:15.840 --> 00:49:22.880 a PSR-oriented care, was there a shift in the dynamics of how the units functioned? 00:49:23.600 --> 00:49:29.040 For instance, with Peer Support staff given a larger role or included in treatment 00:49:29.040 --> 00:49:34.720 team decisions?" 00:49:34.720 --> 00:49:41.680 Dr. Alan McGuire:Okay, so Rob I'll try to unpack your question here. Um, so see inpatient settings shift 00:49:41.680 --> 00:49:47.520 toward a more psychosocial rehab orientation. Was there is a shift in the dynamics of how 00:49:47.520 --> 00:49:58.160 the unit functioned? Wow. What a sophisticated question. I think if I was answering it, I would 00:49:58.160 --> 00:50:05.920 kind of be speculating because I haven't looked at it from that lens. So I'm gonna hesitate to 00:50:05.920 --> 00:50:10.240 answer that question. Sorry Rob, I don't mean to cop out because it's really sophisticated, but I 00:50:10.240 --> 00:50:18.560 don't want to just make things up on the spot. [laughter] Ralf Schneider: All right. I think that's about 00:50:18.560 --> 00:50:27.280 all the questions we had, although we have someone typing in. Let's just see oh, you have a comment 00:50:27.280 --> 00:50:32.880 from Christina that you can see. Dr. Alan McGuire: Uh huh. 00:50:32.880 --> 00:50:41.760 Yeah so, she has mentioned that "some goals are at odds with a lengthy stay of four days and 00:50:41.760 --> 00:50:46.480 inpatient by utilization management." Yeah. "...may be helpful for RAIN-MH programming to meet with 00:50:47.360 --> 00:50:54.240 UM teams." Oh yeah, yeah. Um, so, thank you very much for that thought. 00:50:54.240 --> 00:51:00.800 Utilization management is an interesting player in this. I do just anecdotally have 00:51:01.440 --> 00:51:09.680 memory of a site that I went to where utilization management sat on the treatment team and 00:51:09.680 --> 00:51:14.320 I will say that I could see that being a nightmare scenario for some places. 00:51:16.400 --> 00:51:22.960 For this particular unit, I thought that the utilization management people asked very good 00:51:22.960 --> 00:51:30.400 questions regarding why does this Veteran need to continue to be on the acute unit, 00:51:31.280 --> 00:51:37.440 and was willing to have a conversation with the rest of the treatment team regarding that. Um, 00:51:38.400 --> 00:51:48.080 I think what Dr. Hines points towards here too is this interplay between what are we 00:51:48.080 --> 00:51:54.480 going to get done, what's reasonable to get done while the Veteran is on the acute unit, 00:51:55.280 --> 00:52:04.960 versus what needs to be held off until they get established in outpatient, and I would 00:52:04.960 --> 00:52:11.760 encourage us as a field to think very carefully regarding how do we make that transition to be 00:52:12.320 --> 00:52:18.960 as seamless as possible? The Veteran is still the Veteran before they're admitted, 00:52:18.960 --> 00:52:23.040 while they're admitted and after they're admitted, but yet it seems as though 00:52:23.040 --> 00:52:29.680 in many places there is a completely different view of the Veteran, a completely different set of 00:52:29.680 --> 00:52:35.120 goals and objectives for that Veteran, and the more that we can make that a seamless transition I 00:52:35.120 --> 00:52:39.920 think the better that we will serve our Veterans. Ralf Schneider: Thank you so much. This is our 00:52:39.920 --> 00:52:43.680 last question that if you just have a quick thought on this, 00:52:44.320 --> 00:52:50.960 um, and then we'll wrap up. "What's your thoughts on the importance, or lack of importance of Peer 00:52:50.960 --> 00:52:59.200 Support Specialists on inpatient units?" Dr. Alan McGuire: Uh huh. Yeah, um, I think, 00:52:59.200 --> 00:53:04.640 I'm a big proponent of Peer Support Specialists in all aspects of care. We saw, 00:53:05.680 --> 00:53:09.760 so I would say that it's not just about having the Peer Support Specialist on the unit, 00:53:09.760 --> 00:53:15.440 but what did they do, how did they fit within the interdisciplinary team? One unit that really 00:53:15.440 --> 00:53:21.360 struggled with recovery range of care, it was the recovery Peer Support Specialist who said, "No, we 00:53:21.360 --> 00:53:27.493 don't do recovery here, we're acute stabilization." That was a quote. So, it's very easy for, it's 00:53:27.493 --> 00:53:33.920 definitely possible to include them and still minimize their role, not use them appropriately, 00:53:33.920 --> 00:53:38.880 or have them be overwhelmed by the culture. However, if you have a good culture or have a good 00:53:38.880 --> 00:53:44.480 role for them, they can be a tremendous asset. Ralf Schneider: Thank you. So to wrap things up, 00:53:44.480 --> 00:53:52.080 just to remind everyone to please go to TMS and complete the 10-item test and the Webinar 00:53:52.080 --> 00:53:59.920 evaluation within the next 30 days so you can receive your CE credit. And as most of you know, 00:53:59.920 --> 00:54:06.240 this is a monthly presentation that we provide. Our next presentation will be on Tuesday, 00:54:06.240 --> 00:54:14.160 December 8th at noon eastern. Drs. Lauren Lovato Jackson and Meredith Sears will be presenting 00:54:14.160 --> 00:54:19.600 on Targeting Firearms in Dialectical Behavior Therapy. We will see you then, 00:54:19.600 --> 00:54:27.360 and Dr. McGuire thank you again for a very interesting presentation. Great work.