MIAMI Project:

MIRECC Initiative on Antipsychotic 

Management Improvement

Noosha Niv, Ph.D.

(310) 528-7554

noosha.niv@va.gov
MIAMI Journey

 1998-2000

 Increased recognition of the metabolic effects of secondgeneration antipsychotic medications

 2003

 VA/DOD Clinical Practice Guideline for the Management of 

Diabetes Mellitus in Primary Care

 2004

 Consensus guidelines for physical health monitoring of 

patients with schizophrenia (Am J Psych, 2004)

 ADA consensus conference on antipsychotic drugs and 

obesity and diabetes (Diabetes Care, 2004)

 Updated VA/DOD Clinical Practice Guidelines for 

Management of Psychosis
MIAMI Journey

 2003-2008

 Emerging evidence that despite the various guidelines, 

rates of metabolic monitoring were fairly low

 2007 - VA OIG Report: Healthcare Inspection: Atypical 

Antipsychotic Medications and Diabetes Screening and 

Management. Recommendations included:

 Implement and document weight reduction strategies

 Improve treatment and documentation of interventions for 

elevated fasting blood glucose levels

 Implement interventions to maintain blood pressures less 

than 140/90 for younger patients without diabetes who are 

prescribed atypical antipsychotic medications

 Achieve target blood glucose levels for younger patients 

with diabetes who are prescribed atypical antipsychotic 

medication
MIAMI Journey

2008 - VA Office of Mental Health Services: Report of the 

Workgroup on Atypical Antipsychotic Medications and 

Diabetes Screening and Management.

Assure access by primary care and mental health 

clinicians to guidance documents

Ensure mental health clinics are able to follow 

recommendations for monitoring of metabolic risk 

factors

Improve coordination of care between primary care 

and mental health for patients treated with 

antipsychotic medication

Improve referral of patients with identified metabolic 

risk factors to MOVE! or other wellness programs
MIAMI Journey

 2009 - MIAMI Project is funded: VA Office of Mental Health 

Services Initiative

 2-year national program designed to implement 

recommendations from the Atypical Antipsychotics Workgroup

 Administered by the VISN 22 and 16 MIRECCs in conjunction 

with Mental Health QUERI

 Project Goals: improve monitoring for and management of 

physical health problems among veterans taking atypical 

antipsychotic medications

 Improve adherence to guidelines around metabolic monitoring 

for antipsychotic medication 

 Decrease the number of veterans who are prescribed 

antipsychotic medications who are obese

 Increase the use of weight interventions among veterans who 

are prescribed antipsychotic medications and are obese
MIAMI Activities

Develop and disseminate effective tools for 

implementing antipsychotic monitoring programs

Educate champions who will go back to their 

facilities/VISNs and educate others

Assist with implementation of metabolic 

monitoring/management at VA clinics

Utilize VHS DSS and VA Corporate Data 

Warehouse to evaluate change in monitoring in 

VA
MIAMI Resources:

Practice Guidelines and 

Wellness Resources

 vaww.mirecc.va.gov/miamiproject/

Includes background information regarding MIAMI

 vaww.mirecc.va.gov/miamiproject/guidelines.asp

Clinical practice guidelines for obesity, diabetes, 

hypertension, dyslipidemia, and atypical antipsychotics

 vaww.mirecc.va.gov/miamiproject/resources.asp

EQUIP Wellness Manual

Food and Physical Activity Diary

BMI Chart
MIAMI Resources: 

Educational Tools

 vaww.mirecc.va.gov/miamiproject/education.asp

 Metabolic Monitoring and Management for Patients 

Taking Antipsychotic Medications: Guidance for VHA 

Primary Care Providers

A poster including essential information regarding 

metabolic monitoring and management

Educational slides to help promote awareness of the 

problem and educate other clinicians

Downloadable powerpoint presentations from 2010 

MIAMI Conference
MIAMI Resources:

Technical Assistance Center 

(TAC)

 vaww.mirecc.va.gov/miamiproject/technical_assist

ance_center.asp

 Goal of center is to support sites implementing 

routine monitoring

 Located in Little Rock at CeMHOR

 Monday thru Friday

8:00-4:30

Phone: 1-888-357-1978

Email: vhalitmiamiproject@va.gov
TAC Services

 Clinical consultations

 Metabolic Effects of Antipsychotic Medications

Current Monitoring and Management Guidelines

 Advice about implementation strategies

General – how to get started, who to involve

Specific – how to manage a particular challenge at a 

specific site

 Advice re: wellness resources for individuals with SMI

Accessing programs

How they fit with monitoring/management programs

How to engage veterans in these programs
TAC Services

Central repository for implementation tools

Sites can send tools to TAC to share with 

other sites

Distribution of “hardcopy” tools

“Connector” between sites and between sites 

and experts
Successful Strategies Shown to Help Implement 

Routine Monitoring for Metabolic Side Effects 

Richard R. Owen, MD

Mental Health Quality Enhancement Research Initiative (QUERI)

Center for Mental Healthcare & Outcomes Research

Central Arkansas Veterans Healthcare System
Overview

• Describe evidence for quality improvement (QI) 

strategies in general

• Describe evidence for strategies used to improve 

antipsychotic management 

• Implications for implementation of recommendations 

for metabolic monitoring and management
QI Strategies – Overview

• Change Strategies

• Team Approach

• Evidence-Based Quality Improvement

• Lessons from QUERI

– Formative Evaluation

– Facilitation

• Integrate QI Efforts with System Priorities and 

Resources
Lessons from Research –

Change Strategies

• Education

• Opinion Leaders 

• Clinical Champions

• Academic Detailing

• Audit and Feedback

• Incentives or Sanctions
Lessons from Research

Team-Based Quality Improvement

Evidence-Based Quality Improvement
Theoretical Support for 

Team-Based Approach

Theory Application in ASSIST project

Interpersonal / Sociopsychological 

Theories (eg, Diffusion of 

Innovation, Social Influence 

Theory, Social Cognitive Theory) 

Local opinion leaders use their influence 

to educate peers, encourage evidencebased care, and model targeted behaviors

Organizational Theories

Participation and support from 

organizational leadership is critical; 

resources offered to support team efforts 

Complexity / Systems Theories

Functional capacity and impact of team 

(as a whole) may be greater than sum of 

its parts; exploit ‘fuzzy boundaries’
Characteristics of Successful Clinical 

QI Teams*

Characteristics Implications

View team goals to be part of the 

organization’s key strategic goals

Ensure that team efforts align with 

broader org’l goals; provide regular 

updates on progress to senior leaders

View team leaders as competent, 

with clout to remove barriers to change

Ensure that team leaders have close 

connections to senior leaders and have 

a good understanding of clinical issues 

involved 

Know one another’s strengths / 

weaknesses, respect each other, 

may have worked together before 

Include team members who have 

worked together in the past and who 

have good interpersonal skills 

* Reference: Mills PD, Weeks WB. Joint Comm J on Qual Safety 

2004;30:152-162. „Successful‟ = achieved >20% sustained 

improvement on targeted clinical behavior.
Total Quality Management (TQM) & 

Continuous Quality Improvement (CQI)

• Structured organizational process for involving 

personnel in planning and executing a 

continuous flow of improvements to provide 

quality health care

• Implement evidence-based practices

• Data-based

• Typically conducted based on intuition and 

anecdotes regarding strategies for changing 

organization and provider behavior

Shojania KG, Grimshaw JM: Evidence-based quality improvement: 

The state of the science. Health Affairs. 2005; 24: 138-50.
Evidence-Based Quality Improvement (EBQI)

• Explicit use of the best available evidence to 

inform decisions about the care of individual 

patients.

• Implement in routine practice the processes 

and outcomes of care established by the best 

available evidence.

• Tension between centralized & locally driven
Lessons from QUERI

Formative Evaluation

Facilitation
Research Approach to Implementation 

Lessons from QUERI

• Design multi-component interventions based on theory (behavior 

change, organizational change) and/or results from formative 

evaluation

• Conduct formative or process evaluation

– identify determinants of care

– tailor intervention design and implementation to local context

– assess barriers to implementation

• Use external facilitation techniques

– Identify and test new approaches and methods for overcoming barriers

• Conduct summative or impact evaluation
PARIHS Model*

Successful implementation of evidence is 

a function of the relation between:

• nature of the evidence

• context or environment in which the proposed change 

is to be implemented and,

• way or method by which the change is facilitated

* Promoting Action on Research Implementation in Health Services 

[Kitson et al, 1998; 2002]
• Facilitators help QI teams understand what they need to 

change and how they need to change it in order to apply 

evidence to practice.

– An appointed role

– Facilitator may be internal or external to the organization

– Role is about helping and enabling rather than telling 

or persuading

– Focus of facilitation can be narrow (eg, assistance with a specific 

task) or very broad in nature (eg, system redesign)

– Broad range of facilitator roles is possible, with corresponding skills 

and attributes needed to fill role effectively

PARIHS Model Conceptualization 

of Facilitation
Facilitation is a process of interactive problem-solving and 

support to meet specific implementation goals, which 

occurs in the context of a recognized need 

for improvement and a supportive interpersonal 

relationship.

– Content of facilitation and skills of facilitator may vary depending on 

project objectives

“Refined” Description of Facilitation 

Based on VA QUERI Experience*

* Stetler CB, et al. Implementation Science 2006; 

1:23.
Lessons from Research

Integrate QI efforts with existing 

plans/resources
Integration of QI effort with other 

efforts/resources

• Align with service-level, facility, VISN, national 

strategic plans

• Capitalize on existing resources

– Quality Management/Performance Improvement

– System Redesign

• Connect to other experts/initiatives, e.g.,

– Office of Quality & Performance – Clinical Practice 

Guidelines; Performance Measures

– National Center for Health Promotion/Disease Prevention

– Pharmacy Benefits Management Service

– Patient-Centered Medical Home
Systems Redesign – “VA-TAMMCS”

Vision

Analysis

Team

Map Aim

Measure

Change

Sustain 

Spread
Lessons from Research 

Studies of Strategies to Improve 

Metabolic Monitoring or Management:

ASSIST and EQUIP studies
A Study of Strategies to Improve 

Schizophrenia Treatment (ASSIST)

• Objective: Increase adherence to recommendations for metabolic 

monitoring and appropriate antipsychotic dosing

• Evidence-Based Quality Improvement (EBQI) approach with 

external facilitation

• Two influence strategies with facilitation were compared:

– Team QI (two sites)

– Opinion leader with administrative support (two sites)

– “Usual care” comparison – educational materials only (two sites)

• Richard Owen, PI, with Jeff Smith, Geoff Curran, and 

Teresa Hudson
ASSIST Tools

 Educational tools (for clinicians and patients)

 Clinical support tools

Pocket-sized booklet with dosing and side effect monitoring 

recommendations

CPRS clinical reminder for SE monitoring

 Performance monitoring tools (VISTA data)

Monthly site performance reports

Weekly provider-specific feedback on side effect 

monitoring
Barriers to Metabolic Monitoring 

(Formative Evaluation)

 System-level barriers:

 Lack of mechanisms, structural resources, staff to ensure that SE 

monitoring is done

 Perceived limitations of clinical reminder for metabolic monitoring

 Provider-level barriers:

 Lack of awareness of VA guidelines

 Low perceived need for quality improvement

 Inertia – resistance to change

 Patient-level barriers:

 Appointment attendance
ASSIST Study Results

• Team QI site

Increased weight monitoring from 70% to 93% at six 

months

Increased glucose monitoring from 53% to 80%

Increased lipid monitoring from 29% to 67%

• Opinion Leader site

Increased weight monitoring from 80% to 88%

Increased glucose monitoring from 48% to 63%

Increased lipid monitoring from 30% to 57%
External Facilitation in ASSIST

• Facilitator

– Guided formation of QI team

– Assisted team in development of local implementation plan

– Maintained regular contact with local QI team

• Email/telephone communication

• Participate in monthly ASSIST Team meetings

– Monitored implementation of project tools/strategies; 

performance on AP side effect monitoring and dosing

– Identified and problem-solved barriers to implementation

– Assisted in adapting tools/strategies as needed or 

suggested by local QI team to meet project goals
External Facilitation „Products‟ 

(Team QI Facility)

• Collaborative research-clinical partnership

• Placement of recommendations for antipsychotic side effect 

monitoring on medication order screens

• Enhanced monthly performance reports, tailored to clinician 

preferences and specifications

• Development of weekly reporting system identifying patients 

in need of metabolic side effect monitoring

– Provider name, patient identifier, AP fill date, medication name, 

info on monitoring parameters

– Now fully automated
Metabolic Monitoring at Team QI Facility

20

30

40

50

60

70

80

90

100

Apr '05 May Jun Jul Aug Sep Oct

Weight Glucose / HgA1C Lipids

Weekly reports implemented

%
Effective QI Components

• Computer routine to identify patients due for 

monitoring 

• Designating a provider or clinic to ensure that 

monitoring occurred

– Team site – designated team member to review weekly 

reports and contact providers

– Opinion Leader site – established clinic to perform baseline 

monitoring

• Leadership support

• VISN performance measures for SE monitoring
Limitations

• Case study results may not generalize to other 

VA sites

• One site randomized to Team QI had initial site 

visit but never began implementation phase of 

study
EQUIP

• EQUIP (Enhancing QUality of care In Psychosis)

– HSR&D QUERI implementation research

– Alexander Young, MD & Amy Cohen, PhD (Co-PIs)

• Evidence-Based Quality Improvement

– implement effective care in specialty mental health

• 8 medical centers assigned to intervention or 

control

– VISNs 3, 16, 17, 22

• Teams at intervention sites work to make

locally driven clinical changes
EQUIP: EBQI Design

EBQI

Provider and patient education

Quality manager

QI Informatics support

Performance feedback

Leadership support

“infrastructure”

“priority-setting”

Evidence 

base:

• TMAP

• EQUIP-1
EBQI Process

• Design choices by VISN leadership based on 

evidence

– pick sites, select 2 care targets, engage local 

medical center leadership

• Implementation by Medical Center leadership

– supported administratively and technically by 

researcher team acting as technical experts

– assemble local QI teams with facilitation and 

evaluation by researchers

– review progress & guide reorganization
Results

• 791 veterans with schizophrenia enrolled

– mean BMI=30 & 78% overweight

• Limited clinician knowledge regarding treatment 

options

• Intervention

– all clinicians informed of treatment options

– group leaders trained in 16-session intervention

– all patients screened & educated using kiosk

• Provision of evidence based care to patients

– intervention sites: increased from 15% to 32%

– control sites: no change
Take-Home Messages – Successful 

Implementation/QI efforts Involve:

– Leadership buy-in and active support

– Urgency for change

– Social influence strategies – e.g., opinion leaders

– Involvement of stakeholders

• Interdisciplinary team approach

• Local adaptation and implementation planning

– Integration with existing efforts

– Hard work

– Tools that make hard work more efficient

– Facilitation - internal or external
QUESTIONS?

Contact: 

Rick Owen, MD

Director, Mental Health QUERI

Director, Center for Mental Healthcare & Outcomes Research

Central Arkansas Veterans Healthcare System

Phone: (501) 257-1710

E-mail: Richard.Owen2@va.gov
Lynn Novorska, RD, LDN

MOVE! Dietitian Program Coordinator

National Center for Health Promotion 

and Disease Prevention (NCP),

VHA Office of Patient Care Services

VHA Weight Management 

in 

Review
2

Organization

Office of Patient Care Services –

– VHA National Center for Health Promotion 

and Disease Prevention (NCP), Durham, NC

• Linda Kinsinger, MD, MPH 

Chief Consultant for Preventive Medicine

• Products:

–Prevention Policy

–Clinical Prevention Tools

–Oversight
3

MOVE! Weight Management

– NCP MOVE! Weight Management Team:

– Ken Jones – Clinical Health Psychologist 

– Lynn Novorska – Registered Dietitian

– Sophia Hurley – Physical Therapist

– Tony Rogers – Web Master

– Susi Lewis – Registered Nurse

– Dr. Kinsinger – Medical Consultation/Oversight

• Our Products:

– Weight management policy

– Clinical tools for weight management

– Oversight of weight management care
4

Prevalence of Overweight/Obesity 

among Veterans in VHA
5

Prevalence of Overweight/Obesity 

among OEF/OIF Veterans

Source: 

2008 VSSC 

data
6

Common Diseases by BMI

0%

10%

20%

30%

40%

50%

60%

70%

80%

BMI <25 BMI 25-29.9 BMI 30-34.9 BMI 35-39.9 BMI >=40

Osteoarthritis

Diabetes

Hypertension

Source: 

2008 VSSC 

data
7

A Bit of MOVE! History

• 2001 Primary Care Meeting/Survey

• 2002 Initial staffing, development of tools

• 2003 Pilot began

• 2004 National Program Manager & team formed

• 2005 Early implementation

• VISNs 2, 8, 23 and individual medical centers

• 2006 National Implementation

• HealthierUS Veterans Initiative

• CPG

• Resources

• 2008

• Copayment eliminated by modification of CFR

• Developed and initiated FY-2009 – Weight Screening Performance Measure

• 2009 

• First two national meetings with MOVE! Coordinators

• 2010

• TeleMOVE! Launched

• Training update – conversion to LMS

• HealthierUS Veterans Initiative transformed 
8

Resources 

• 2006

– Websites

• www.move.va.gov - Patients

• vaww.move.med.va.gov – VA Staff

– MOVE! Handbook 1101.1 signed by USH in March 2006

– On-line training – 1

st release

– Toolkits and supplements

– Starter Packs, Clinical Reference Guide & Quick Start Manuals

– Pedometers available in Prosthetics 

– VSSC Utilization Data Cube 

– VA/DoD CPG

• 2008 

– Co-payment Exempt, June 2008

– Performance Measure for Screening (FY ‟09)

• 2009

– MOVE! Intensive Guidance

• 2010

– TeleMOVE! – Launch of CCHT Weight Management DMP

– MOVE! Online Training

– Revised References
9

Goals of MOVE!

• Address obesity using best available medical evidence 

• Screen every Veteran and assess risk of excess weight

• For those at risk, offer a weight loss program that can 

achieve a 5-10% weight reduction 

• Base of program is supported self management

• Integrate treatment with Primary Care 

• Maintain a program that will evolve through evaluation, 

identification of best practices, and new evidence
10

MOVE! Screening and Treatment

• Screening/Assessment 

– Annual PC Screening - offering MOVE! to “at risk 

patients” – patient wanting to work on weight 

complete MOVE!23 Patient Questionnaire 

• Supporting Self Management 

– Individual (telephone) – Initially called Level 1

– Group Sessions – Initially called Level 2

– Specialty Consultation – Initially called Level 2

More Intensive Weight Management Care 

(not required to be available at every facility)

• Weight Loss Medications (Level 3) - Available

• MOVE! Intensive (Level 4) – Some Facilities

• Bariatric Surgery (Level 5) – Some Facilities
11

MOV5 Weight Screening: Supporting Indicator (FY „08) 

Performance Measure (FY ‟09 & 10) 

FY „08 FY 2009 FY 2010 

(thru 2nd Qtr.)

National 65%

No Goal

90%

Target = 

65%

94%

Target = 

90%

http://vaww.pdw.med.va.gov/MeasureMaster/MMIndex.asp?qtr=20102
12

MOVE! Patients to Date Nationally (at least one visit)

•Total = 250,048 Patients

•Averaging about 6,300 new patients per month
13

MOVE! National Data Treatment Encounters

Total Visits = 1,363,297

1,363,297/250,048 = 5.5 contacts per patient
14

What‟s next?

MOVE!

Technology

Linked 

Care

TeleMOVE! 

CCHT Weight 

Management 

DMP

Telephone 

Lifestyle 

Coaching 

Telephone eMOVE! 

Support

Hotline

V-Tel
15

Questions?
16

National Center for Health Promotion and Disease Prevention

VHA Office of Patient Care Services

Linda Kinsinger, MD, MPH, Chief Consultant for Preventive Medicine

3022 Croasdaile Drive, Suite 200

Durham, NC 27705

(919) 383-7874 (ext. 228)

www.prevention.va.gov

Lynn Novorska, RD, LDN

MOVE! Dietitian Program Coordinator

(919) 383-7874 (ext. 245)

Susi Lewis, MA, RN, CPHQ

MOVE! Special Projects Coordinator - Clinical Resources 

(919) 383-7874 (ext. 234)

www.move.va.gov