# Presentation: 139305

## Improving Care for Schizophrenia:Process Evaluation of Implementation in EQUIP

- Alexander S. Young, MD MSHSAlison H. Brown, PhD
- Matthew J. Chinman, PhD
- Amy N. Cohen, PhD
- Christopher Reist, MD
- VA Desert Pacific MIRECCGreater Los Angeles VA & Long Beach VAUCLA

## Improving Care for Schizophrenia:Process Evaluation of Implementation in EQUIP

- Alexander S. Young, MD MSHSAlison H. Brown, PhD
- Matthew J. Chinman, PhD
- Amy N. Cohen, PhD
- Christopher Reist, MD
- VA Desert Pacific MIRECCGreater Los Angeles VA & Long Beach VAUCLA

## EQUIP Team

- _West Los Angeles VA_
- Alison H. Brown, PhD
- Matthew Chinman, PhD
- Jim Mintz, PhD
- Noosha Niv, PhD
- Jennifer Pope, BS
- Qing Chen
- Kuo-Chung Shih
- Julia Yosef, MA

- _Long Beach VA_
- Michelle Briggs, RN
- Kirk McNagny, MD
- Christopher Reist, MD
- _Sepulveda VA_
- Daniel Auerbach, MD
- Christopher Kessler, MD
- Daniel Mezzacapo, RN

- Alexander S. Young, MD, MSHS (PI)
- Amy N. Cohen, PhD (co-PI)

- _Support_
- VA HSR&D QUERI: RCD 00-033 & CPI 99–383
- VA Desert Pacific MIRECC
- NIMH Center for Research on Quality in Managed Care (MH 068639)

## Care for Schizophrenia

- Lifetime prevalence = 1.3%
- VA
- > 100,000 patients per year
- 12% of health care costs
- Outcomes are good with
- assertive community treatment / MHICM
- appropriate medication
- caregiver involvement and support
- IPS / supported employment
- Use of these is low to moderate
- outcomes in routine care are often poor

## Improving Care for Schizophrenia

- VA Strategic Plan for Mental Health
- recovery-oriented & evidence-based care
- VA has improved care nationally
- not as much in mental health
- How to improve care for schizophrenia?
- little research has been done
- need methods that are feasible at all sites
- apply chronic illness model
- informatics, reorganization, proactive service delivery
- Challenges
- lack of routine, valid outcomes data in CPRS
- clinicians not using recovery-oriented treatments

## EQUIP

- Evaluate a Chronic Care Model in Schizophrenia
- “Enhancing QUality of Care In Psychosis” (EQUIP)
- improve treatment quality, recovery-orientation
- Randomized, controlled trial
- design
- 2 clinics, 65 psychiatrists, 398 patients
- randomize by MD
- intervention (2003-2004)
- train clinicians in clozapine, wellness groups, family services
- routine patient evaluation
- nurse assessment before each visit
- info sent to MDs (“PopUp”) & managers (quality reports)
- implement chronic care principles
- control: usual care

**Notes:**
In chronic illness, it is important to adopt care models that integrate 1) greater availability of clinical information, 2) reorganize the practice system and clinician roles, 3) foster care coordination, and 4) focus on
evidence-based protocols.  In mental health, the most successful efforts to improve care have involved implementation of collaborative care models. They are a blueprint for reorganizing practice, and involve
changing the division of labor and responsibility, adopting new care protocols, and becoming more responsive to patients’ needs. The day-to-day responsibility of illness management falls heavily on patients and their caregivers, and effective care must strengthen illness self-care while assuring that effective preventive and medical interventions occur. Follow-up needs to be active, sustained, and assertively monitored.
Clinical information has a central role in collaborative care, and improving this information can be a prerequisite to improving care.69 The VA has made progress with the national adoption of the Computerized
Patient Record System (CPRS), and associated reminder systems.70 Unfortunately, in mental health, the most critical clinical information is usually not documented in medical records.44 The sole mental health reminders are tardive dyskinesia (a side effect that is rarely caused by newer medications) and global functioning. In schizophrenia, effective care starts with accurate assessment, and includes attention to four domains
of evidence-based practices: 1) assertive care; 2) medication management; 3) caregiver services; and 4) rehabilitation.7, 16 Optimal treatment is team-based, involving collaboration between the patient, their
caregivers and a prepared, proactive practice team.10, 71 Problems with care are highly variable across VA clinics: 6 some sites use no clozapine, while others provide little care coordination. To improve care nationally,
information regarding the clinical needs of patients and treatment provision must be routinely and efficiently available, and intervention approaches developed must target each domain of evidence-based practice.

## Summative Results

- Improved
- prescribing for psychosis
- use of evidence-based weight intervention
- medication adherence
- No improvement
- use of clozapine
- use of family services
- patient quality of life
- patient satisfaction

**Notes:**
Medication treatment is probably inappropriate if:
(1) psychosis criterion: patient has
(A1) significant psychosis (BPRS hallucinations>=5 [moderately severe], suspiciousness>=5, unusual thought content [delusions] >=5, or disorganization>=5); and
(B) within the past 3 months: (i) no increase in dosage of an existing antipsychotic medication, and (ii) no start of a new antipsychotic medication (start can be an addition or a switch) and (iii) not on clozapine

## Process Evaluation: Domains

- Clinics
- structure and process of care
- Clinicians
- competencies, practices, burn-out
- Implementation activities
- Use of wellness, clozapine, and family services

**Notes:**
sub-sample

## Process Evaluation:Data from Clinicians

- Method: semi-structured interviews & questionnaires
- Pre-implementation (n=44)
- clinical practices
- expected barriers and facilitators
- Mid-implementation (n=18)
- usefulness and usability of PopUp and Quality Report
- Post-implementation (n=14)
- clinical practices
- attitudes, knowledge, skills: EBPs and recovery
- barriers and facilitators (especially family)

**Notes:**
sub-sample

## Results

- Challenges implementing evidence based practices differ by practice
- Family Services
- _pre & post survey_: most clinicians reported support for family services and involving families
- _utilization_: no patients who consented to family contact were referred to family intervention
- _post interview_: clinicians believed consumers lacked family contact (untrue) and that families could hurt patients
- _need_: reorganization & intensive negotiation between patients, families and clinicians

## Results

- Weight and wellness
- 1/3 to 1/2 of patients were obese
- evidence-based wellness intervention was implemented
- received by 73% of overweight patients
- psychiatrists did not change prescribing
- Clozapine and psychosis
- new clinic started but very few referrals
- pharmacy requirements cumbersome
- clinician competency low
- not trained or credentialed
- resistant: clozapine requires longer visits, more effort
- did not believe clozapine would helpful

## Informatics Results

- Quality reports
- little use by psychiatrists
- PopUp
- clinicians used
- data on side-effects and functioning
- messaging to collaborate
- did not use
- treatment guidelines
- symptom assessment
- Were critical for implementation

## Conclusions

- Implementation barriers vary by practice
- Common themes
- under-developed clinician competencies
- clinician burn-out
- low availability of psychosocial treatments
- organization of care not consistent with quality practice
- collaboration between services was very difficult (nutrition, pharmacy, primary care)
- needed more local input AND engagement of leadership (VISN)

## Lessons Learned

- Process evaluation critical
- lessons learned used midstream and in current work
- Challenges can only be fully understood during implementation
- In schizophrenia, implement
- routine outcome assessment
- resources for each treatment
- evidence-based quality improvement

## Slide 15

## References

- 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: QUERI Series. *Implementation Science *2008; 3: 9.
- Cradock J, Young AS, Sullivan G: The accuracy of medical record documentation in schizophrenia. *Journal of Behavioral Health Services & Research.* 2001; 28: 456-65
- Young AS, Sullivan G, Burnam MA, Brook RH: Measuring the quality of outpatient treatment for schizophrenia. *Archives of General Psychiatry.* 1998; 55: 611-7
- Young AS, Mintz J, Cohen AN: Clinical computing: using information systems to improve care for persons with schizophrenia. *Psychiatric Services* 2004; 55:253-5
- Young AS, Mintz J, Cohen AN, Chinman MJ: A network-based system to improve care for schizophrenia: the medical informatics network tool (MINT). *J Am Med Inform Assoc.* 2004; 11: 358-67.
- Young AS, Cohen AN, Mintz J: A vignette in the chapter on information systems. In: The Institute of Medicine. *Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series*. Washington DC: National Academies Press; 2005:241-242.