Enhancing Treatment Reengagement for Veterans With Serious Mental Illness: Evaluating the Effectiveness of SMI Re-Engage

OBJECTIVE

This evaluation assessed the effectiveness of the Veterans Health Administration (VHA) program Reengaging Veterans With Serious Mental Illness in Treatment (SMI Re-Engage). The program serves veterans with serious mental illness who experience extended gaps in use of VHA care.

METHODS

Propensity score-weighted survival analysis that adjusted for demographic, clinical, and utilization factors assessed whether being contacted via SMI Re-Engage predicted return to VHA care within 18 months of when clinicians received patient contact information and, among veterans contacted, whether return to VHA care was associated with mortality risk within the 18-month follow-up period. Among all veterans who returned to care, a post hoc propensity score-weighted logistic regression that adjusted for demographic, clinical, and utilization factors assessed whether being contacted via SMI Re-Engage was associated with returning to outpatient care versus inpatient or emergency care.

RESULTS

Of veterans contacted (N=886), 42% returned to care, compared with 27% of veterans whom providers attempted to contact but could not reach (N=2,059). When analyses adjusted for covariates, veterans who were contacted had a higher risk of returning to care (hazard ratio (HR)=3.40, 95% confidence interval [CI]=2.70-4.28). Among veterans contacted, the association between return to VHA care and mortality risk was not significant. Post hoc analyses for veterans who returned to care (N=941) indicated that being contacted (versus not being contacted) was associated with higher odds of returning to outpatient care (versus inpatient or emergency care) (odds ratio=2.42, CI=1.68-3.47).

CONCLUSIONS

SMI Re-Engage contact facilitated return to VHA care. SMI Re-Engage exemplifies how population health strategies can address health care discontinuities among people with serious mental illness.

Results from the multisite implementation of STAR-VA: a multicomponent psychosocial intervention for managing challenging dementia-related behaviors of veterans

Dementia is often associated with challenging behaviors that can significantly impact the quality of life of individuals with dementia and pose great difficulty for long-term care staff. Antipsychotic medications, historically the mainstay approach for managing such behaviors, have increasingly been associated with limited efficacy and increased death risk with older dementia patients. In an effort to promote and realize the promise of nonpharmacological management of challenging dementia-related behaviors, the U.S. Department of Veterans Affairs (VA) health care system has developed and implemented STAR-VA, an interdisciplinary behavioral intervention for managing challenging dementia-related behaviors of veterans, in 17 VA nursing homes, as part of a pilot implementation initiative. Sixty-four veterans with challenging behaviors associated with dementia participated in the STAR-VA intervention coordinated by Mental Health Providers completing specialized training. Challenging behaviors clustered into 6 behavior types: resistance to care, agitation, violence/aggression, vocalization, wandering, and other. Results indicate that STAR-VA led to significant reductions in the frequency and severity of challenging dementia-related behaviors, with overall effect sizes of approximately 1. In addition, the intervention led to significant reductions in depression and anxiety. Overall, the results support the feasibility and effectiveness of STAR-VA for managing challenging dementia-related behaviors in veterans in real-world, nursing home settings.

Health care utilization prior to loss to care among veterans with serious mental illness

OBJECTIVE

This study examined the association between utilization of Veterans Affairs (VA) health services and the probability of treatment dropout among veterans with serious mental illness.

METHODS

Utilization of VA health services in the fiscal year (FY) before treatment dropout among veterans with serious mental illness who were lost to care for at least 12 months beginning in FYs 2008 or 2009 (N=6,687) was compared with utilization in FYs 2007 or 2008 among veterans with serious mental illness who remained in care (N=6,687).

RESULTS

The veterans (mean age=54) were predominantly male (91%) and Caucasian (76%). After accounting for demographic and clinical variables, the analyses found that more primary care and mental health outpatient visits and fewer general medical and mental health hospitalizations were associated with lower odds of dropout.

CONCLUSIONS

Engagement in outpatient health care was associated with lower odds of loss to care among veterans with serious mental illness.

Assertive community treatment in veterans affairs settings: impact on adherence to antipsychotic medication

OBJECTIVES Assertive community treatment (ACT) programs may improve patients' outcomes, in part by increasing adherence to antipsychotic medication. This study assessed the association between ACT enrollment and subsequent antipsychotic adherence. METHODS The authors identified a national sample of 763 Veterans Affairs (VA) patients with schizophrenia who were newly enrolled in ACT in fiscal years 2001 to 2004 and had valid antipsychotic medication possession ratios (MPRs) for five sequential six-month periods, the first occurring before ACT enrollment. Propensity scores were used to match ACT patients 1:1 with eligible veterans who did not initiate ACT. Logistic regression analyses and generalized estimating equations (GEE) were used to assess the association between ACT enrollment and subsequent antipsychotic adherence. Antipsychotic adherence was compared among ACT enrollees with high, partial, or no participation in ACT services. RESULTS Before the index date, there was no significant difference in rates of good adherence (MPR ≥.8) among subsequent ACT enrollees (72%) and patients in the control group (70%). However, in each of the four periods after enrollment, ACT enrollees were more likely to have MPRs ≥.8. In GEE analyses, ACT enrollment was associated with 2.3 greater odds of MPRs ≥.8 (95% confidence interval=1.9-2.7). Among ACT enrollees, higher levels of participation were associated with MPRs ≥.8. CONCLUSIONS In this large, national study, ACT enrollment was associated with higher levels of antipsychotic adherence among VA patients with schizophrenia. This association persisted over time and was greatest among those with higher levels of ACT use.

Cost savings from assertive community treatment services in an era of declining psychiatric inpatient use

OBJECTIVE

To assess, during a period of decreasing psychiatric inpatient utilization, cost savings from Assertive Community Treatment (ACT) programs for individuals with severe mental illnesses.

DATA SOURCE

U.S. Department of Veterans Affairs' (VA) national administrative data for entrants into ACT programs.

STUDY DESIGN

An observational study of the effects of ACT enrollment on mental health inpatient utilization and costs in the first 12 months following enrollment. ACT enrollees (N = 2010) were propensity score matched to ACT-eligible non-enrollees (N = 4020). An instrumental variables generalized linear regression approach was used to estimate enrollment effects.

RESULTS

Instrumental variables estimates indicate that between FY2001 and FY2004, entry into ACT resulted in a net increase of $4529 in VA costs. Trends in inpatient use among ACT program entrants suggest this effect remained stable after FY2004. However, eligibility for ACT declined 37 percent, because fewer patients met an eligibility standard based on high prior psychiatric inpatient use.

CONCLUSIONS

Savings from ACT programs depend on new enrollees' intensity of psychiatric inpatient utilization prior to entering the ACT program. Although a program eligibility standard based on prior psychiatric inpatient use helped to sustain the savings from VA ACT programs, over time, it also resulted in an unintended narrowing of program eligibility.

Reduced mortality among Department of Veterans Affairs patients with schizophrenia or bipolar disorder lost to follow-up and engaged in active outreach to return for care

OBJECTIVES

We determined whether contacting Department of Veterans Affairs (VA) patients with schizophrenia or bipolar disorders (serious mental illness [SMI]) who had dropped out of care for prolonged periods resulted in reengagement with VA services and decreased mortality.

METHODS

We developed a list of patients with SMI who were last treated in fiscal years 2005 to 2006, and were lost to follow-up care for at least 1 year. VA medical centers used our list to contact patients and schedule appointments. Additional VA administrative data on patient utilization and mortality through May 2009 were analyzed.

RESULTS

About 72% (2375 of 3306) of the patients who VA staff attempted to contact returned for VA care. The mortality rate of returning patients was significantly lower than that for patients not returning (0.5% vs 3.9%; adjusted odds ratio = 5.8; P < .001), after demographic and clinical factors were controlled.

CONCLUSIONS

The mortality rate for returning patients with SMI was almost 6 times less than for those who did not return for medical care. Proactive outreach might result in patients returning to care and should be implemented to reengage this vulnerable group.

Initiation of assertive community treatment among veterans with serious mental illness: client and program factors

OBJECTIVES

Ensuring equitable access to mental health services is a national priority. The authors examined assertive community treatment (ACT) services initiation in the Veterans Affairs (VA) health system among program-eligible patients.

METHODS

The VA's National Psychosis Registry included 6,540 patients who met program eligibility criteria (mental illness diagnosis and prior hospitalization) in fiscal year (FY) 2003 (FY 2003) and had not received VA ACT services in FY 2001-FY 2003. Receipt of VA ACT services during FY 2004 was assessed with generalized estimating equations. Independent variables included age, gender, race and ethnicity, marital status, service-connected disability benefits, substance use disorder, psychiatric inpatient days in FY 2003, distance to the nearest facility with a VA ACT team, presence of an on-site team at the facility where the last VA psychiatric hospitalization occurred, and number of open slots with the nearest ACT team.

RESULTS

A total of 452 of the eligible patients (7%) received VA ACT services in FY 2004. In multivariate analyses, older age was associated with reduced odds of receiving ACT services (odds ratio [OR]=.92 per five years); being female (OR=1.86) and having schizophrenia (OR=1.64) were positively associated with ACT services initiation. Individuals living farther from ACT sites were less likely to receive ACT services (OR=.95 per ten miles). The marginal effects of distance were most substantial in the first 30 miles and beyond 100 miles.

CONCLUSIONS

Most patients who were eligible for yet not already receiving VA ACT services went without these services in FY 2004. Geographic distance limited services initiation. Focused efforts are needed to enhance ACT services initiation and delivery, particularly for individuals in remote locations.

Use of Alcohol Screening and Brief Interventions<br />in Primary Care Settings:Implementation and Barriers

Although evidence indicates that brief alcohol screening and interventions are effective across primary care settings, implementation of these techniques has been problematic. The primary objective of this study was to determine current practices and barriers for screening and interventions with primary care patients across randomly selected clinics in a large health care system, the Veterans Health Administration. Focus groups and mailed structured surveys were used. Results from providers indicated that 85% of patients treated in primary care received some screening for alcohol use disorders. The CAGE was the predominant screening tool. The primary clinical focus was on treatment referrals for patients who met abuse/dependence criteria. Lack of time was the most important perceived barrier to implementing screening and brief alcohol interventions for at-risk and problem drinkers. Implications for implementation of screening and intervention programs for a range of drinkers (at-risk use, problem use, abuse, dependence) are discussed.

Delays in adopting evidence-based dosages of conventional antipsychotics

By the 1980s, strong research evidence had emerged supporting the use of moderate doses of conventional antipsychotics-between 300 and 1,000 mg of chlorpromazine equivalent daily. We conducted a cross-sectional study of dosages of antipsychotics prescribed for 936 veterans with schizophrenia in 14 facilities between 1991 and 1995. Only 52 percent of these patients received prescriptions for recommended dosages; dosages were below the recommended range for 20 percent and above the range for 28 percent. African Americans were more likely than others to have received high dosages. These data suggest that there was considerable delay in the adoption of evidence-based dosing of conventional antipsychotics. Efforts must be made to transfer research findings more rapidly into practice.

Adherence assessments and the use of depot antipsychotics in patients with schizophrenia

BACKGROUND

Antipsychotic medications significantly ameliorate the symptoms of schizophrenia, but patients are often noncompliant with these medications. Research evidence supports the use of depot antipsychotics in noncompliant patients.

METHOD

Between January 9, 1991, and December 19, 1995, 1307 veterans with schizophrenia or schizoaffective disorder (ICD-9) were enrolled in a study of enhanced psychosocial programming at 14 Veterans Administration Medical Centers. All had a history of high inpatient use. At enrollment, clinicians listed patient medications, rated patient compliance, and completed a Brief Psychiatric Rating Scale (BPRS) and Global Assessment of Functioning (GAF). Patients reported medication side effects. We describe depot antipsychotic use among these patients and examine the relationship between depot use, assessed compliance, and patient characteristics.

RESULTS

At enrollment, 18% of patients in this cohort were receiving depot antipsychotics; however, clinicians reported that 49% had been noncompliant with medication in the past year. Depot use varied significantly with treatment site; African Americans were more likely to receive depot antipsychotics and less likely to receive atypical antipsychotics than white patients. Patients on depot and oral agents had similar levels of psychiatric symptoms, but patients on depot antipsychotics were more likely to receive high doses and complain of side effects.

CONCLUSION

Clinicians prescribed depot antipsychotics relatively infrequently, despite high rates of noncompliance and high levels of inpatient use. Variation in use with treatment site and ethnic group suggests barriers to implementing research-based recommendations for depot use in noncompliant patients. Quality improvement programs should consider facilitating the appropriate use of depots.

Longitudinal assessment of inpatient use and functioning of seriously mentally ill veterans with and without co-occurring substance use disorders

The purpose of this study was to delineate differences in inpatient service utilization and functional and subjective outcomes between veterans with a serious mental illness (SMI) and those with co-occurring serious mental illnesses and substance abuse (SA) disorders. This study assessed 2-year inpatient utilization and outcomes for 682 SMI veterans enrolled in specialized psychosocial treatment programs which did not have a substance abuse focus. Outcomes included psychiatric symptomatology, impairment in activities of daily living, global life satisfaction, days of hospitalization per year, and number of hospital admissions per year. Of the 682 patients, 198 (29%) had secondary diagnoses of substance abuse/dependence. Patients with co-occurring serious mental illness and substance use disorders had significantly more inpatient admissions per year than other SMI patients but did not differ in cumulative inpatient stays. The SMI/SA patients improved more than the other patients in terms of clinician rating of Global Assessment of Functioning. Patients with SMI/SA had significantly fewer psychiatric symptoms on the Brief Psychiatric Rating Scale, and all patients showed improvement on the BPRS, instrumental activities of daily living, and general life satisfaction rating. Seriously mentally ill patients with co-occurring substance use disorders fared as well as other SMI patients when enrolled in intensive, specialized state-of-the-art treatment programs.