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Implementation of Evidence- Based Services for Weight at Specialty Mental Health Clinics

Authors:
Amy N Cohen at VA Greater Los Angeles Healthcare System
Amy N Cohen
Alexander S. Young at University of California, Los Angeles
Alexander S. Young
Alison Hamilton at VA Greater Los Angeles Healthcare System
Alison Hamilton
Kirk Mcnagny
Kirk Mcnagny
Kirk Mcnagny
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Implementation of Evidence-
Based Services for Weight at
Specialty Mental Health Clinics
Amy N. Cohen, PhD
Alexander S. Young, MD, MSHS
Alison B. Hamilton, PhD, MPH
Kirk McNagny, MD
Anna Teague, MD
Christopher Reist, MD
Schizophrenia
•Most common serious mental illness
•Chronic disorder of thought
•Cognitive deficits: attention, memory,
information processing, executive functioning
•Prevalence of 1%
•10% of all permanently disabled people
•Evidence-based practices (EBPs) exist
EQUIP:
Enhancing QUality In Psychosis
Funded by VA HSR&D QUERI
EQUIP Design
Long Beach
Los Angeles
Waco Temple Houston Shreveport
Bronx
Northport
3-year clinic-level controlled trial
4 Regions: 1 control, 1 intervention in each
201 providers, 801 patients
EQUIP Design continued
•Intervention: implement chronic illness
care model to increase use of EBPs for
individuals with schizophrenia
•Control: usual care
EQUIP Specific Aims
•Assist enrolled regions to implement and sustain evidence-
based care for schizophrenia
•Evaluate the effect (relative to usual care) of care model
implementation on provider competency, treatment
appropriateness, patient outcomes, and service utilization.
•Using mixed methods, evaluate processes of and variations
in care model implementation and effectiveness.
“Diagnostic” of the
existing context
(baseline
assessment)
organizational
readiness for
change
expectations of
project
existing services
and structure of
care
“Actuality” of implementation
•barriers to change
•adjustments to
interventions
Uses results of all
other FE stages
key stakeholder
experiences
could “rediagnose”
the context
Stages of Formative Evaluation
Post-Implementation
Pre-Implementation
Implementation
Monitoring impacts &
indicators of progress
toward goals
•dose & intensity of
intervention
• field notes
• documents
(minutes, etc.)
• ORC & Burnout
Inventory
• key stakeholder
interviews
• field notes
• Quality Coordinator logs
• documents
• key stakeholder
interviews
• QI tools
• field notes
• key stakeholder
interviews
• ORC & Burnout
Inventory
Data for Formative Evaluation
Post-Implementation
Pre-Implementation Implementation
Simpson Transfer Model
Exposure Step
Strategies/Tools
•Secure commitment
•Identify and prioritize local needs; values
•Choose care targets; history with targets
•Institutional & Personal Readiness
•Climate to Change
•Begin tailoring intervention
•“Packaging”
Institutional and Personal
Readiness for Change
TCU Organizational Readiness for Change (ORC) scale; Available at http://www.ibr.tcu.edu
Adoption Step
Strategies/Tools
•Regional Implementation Teams
•Opinion leaders
•Continue tailoring
•Continue to secure commitment, address needs and
values
Implementation Step
Strategies/Tools
•Routine assessment of patients (who is appropriate for
the service)
•Nurse care manager
–Shared cost; local site to assist in identification
•Care Management software
•Education
•Discuss and start using provider supports & incentives
Routine Assessment of Patient
Needs and Preferences
Audio, computer
assisted
self-interviewing
Kiosk in waiting
room for patients’
use at every visit
Patient Assessment System
Routine Assessment of Patient
Needs and Preferences
Patient Assessment System
Routine Education of Patients
Routine Monitoring
for Care Managers
Education of
Clinicians
By local experts and
opinion leaders
Care Reorganization
Developed new care flow diagram that included
•weighing of each patient at each visit (scale at kiosk)
•immediate information on weight/BMI for this session
and last 2 sessions (kiosk report, care management
tracking)
•routinized referral to in-clinic wellness program
•routinized feedback on progress towards goals
(appropriate referrals, attendance)
Care Reorganization continued
Trained staff to lead evidence-based wellness program
(16 sessions)
Freed up staff time to deliver program
Provided scales, tape measures
Identified room large enough for groups
Identified other weight and excercise programs that exist
at the medical center
Practice Step
Strategies/Tools
•Monthly Quality Meeting/Quality Reports
•Quarterly conference calls re: targets
•Continue Implementation Team Meetings
•Continue tailoring from formative evaluation data and
provider and leader input
•Finalize provider supports and incentives
Sustainability
Strategies/Tools
•Stakeholder feedback discussions
•Job descriptions
•Kiosk integrated into regular care
Patient Characteristics (n=801)
•Average age = 54
•92% male
•Duration of schizophrenia = 26 years
•Average BMI = 30.1
•30% have diabetes
Results: Process
•Clinician competencies
–variable, often low, regarding weight services
•Organization
–strong support
–collaboration between services was difficult (nutrition,
primary care wellness programs, specialty mental
health)
•Managers used data to reorganize care
–trained clinical staff to provide services
–set up weight groups to coincide with busy clinics
Results: Summative
Weight Service Utilization
Overweight individuals at implementation sites
were 2.3 times more likely to increase utilization
compared to individuals at control sites.
Results: Summative
Weight Service Utilization
Average number of weight appointments
Pre-study
During study
Implementation Sites
2
11
Control Sites
2
2
Results: Summative
Weight changes
Implementation group was on average 13.4 +/- 7.6
lbs lighter than the control group at the end of
the intervention (F=4.83, p=.03).
The model explained 86% of the variation in
weight at the end of the study.
Provider Comments
•“The availablity of the computer has made it
easy for [patients] to monitor how they’re
doing with [their weight].”
•“We weren’t doing a bad job before, but now
we are doing an enhanced job.”
•There was concern about sustainability.
•Another commented that giving data to
clinicians was essential.
Conclusions
•Explanatory theory (STM) helped guide study and
reports
•Successful research-operations partnership allowed
for implementation to match VA operational goals and
be tailored to local context
•Care reorganization and implementation strategies and
tools increased availability of appropriate wellness
services and improved patient outcomes
EQUIP Team
VISN 16
Anna Teague, MD (PI: Houston)
Dean Robinson, MD (PI: Shreveport)
Deborah Mullins, PhD
Ann Feder, CSW
Kathy Henderson, MD
Avila Steele, PhD
Christy Gamez-Galka, PhD
VISN 3
Eran Chemerinski, MD (PI: Bronx)
Charlene Thomesen, MD (PI: Northport)
Claire Henderson, MD
Deborah Kayman, PhD
Helen Rasmussen, PhD
VISN 22
Christopher Reist, MD (PI: Long Beach)
Kirk McNagny, MD
Larry Albers, MD
David Franklin, PsyD, MPH
Stacey Maruska, LCSW
VISN 17
Max Shubert, MD (PI: Central Texas)
Paul Hicks, MD
Wendell Jones, MD
Staley Justice, MSW
Sherry Fairchild, PhD
Alexander S. Young, MD, MSHS (PI)
Jennifer Pope, BS
Patricia Parkerton, PhD
Youlim Choi
Amy N. Cohen, PhD (co-PI)
Alison Hamilton, PhD, MPH
Stone Shih
Paul Jung
Los Angeles MIRECC (Coordinating Site)
•Acknowledgements
– VA HSR&D and QUERI (RCD 00-033, CPI 99-383, MHS 03-
218)
– VA Desert Pacific Mental Illness Research, Education and
Clinical Program (MIRECC)
–NIMH UCLA-RAND Center for Research on Quality in
Managed Care
•For further information
–Amy Cohen
–Amy.cohen@va.gov
–MIRECC, West Los Angeles VA Healthcare Center,
11301 Wilshire Blvd. (210A), Los Angeles CA 90073
References
•Young AS, Forquer SL, Tran A, Starzynski M, Shatkin J: Identifying clinical
competencies that support rehabilitation and empowerment in individuals with
severe mental illness. Journal of Behavioral Health Services & Research. 2000; 27:
321-333.
•Chinman M, Young AS, Schell T, Hassell J, Mintz J: Computer-assisted self-
assessment in persons with severe mental illness. Journal of Clinical Psychiatry.
2004; 65: 1343-1351.
•Chinman M, Hassell J, Magnabosco J, Nowlin-Finch N, Marusak S, Young AS: The
feasibility of computerized patient self-assessment at mental health clinics.
Administration and Policy in Mental Health. 2007; 34: 401-9.
•Brown AH, Cohen AN, Chinman MJ, Kessler C, Young AS: EQUIP: Implementing
Chronic Care Principles and Applying Formative Evaluation Methods to Improve
Care for Schizophrenia. Implementation Science. 2008; 3: 9.
•Young AS, Niv N, Cohen AN, Kessler C, McNagny K: The appropriateness of
routine medication treatment for schizophrenia. Schizophrenia Bulletin. 2008;
advance access.
•Hamilton AB, Cohen AN, Young AS. Organizational Readiness in Specialty Mental
Health Care. Journal of General Internal Medicine. 2010; 25: 27-31.
•Cohen, AN, Glynn, SM, Hamilton, AB, Young, AS. Implementation of a Family
Intervention for Individuals with Schizophrenia. Journal of General Internal
Medicine. 2010; 25: 32-37.
ResearchGate has not been able to resolve any citations for this publication.
Implementation of a Family Intervention for Individuals with Schizophrenia
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