Young AS (Greater Los Angeles VA & UCLA), Hamilton A
(Greater Los Angeles VA & UCLA), Cohen AN
(Greater Los Angeles VA), Chinman MJ
(Greater Los Angeles VA & RAND), Kessler C
(Greater Los Angeles VA)
Schizophrenia is a common, chronic disorder that produces substantial disability when not appropriately treated. While treatments are effective, the quality of usual care is often poor. Improving care has been challenging. Prior projects have met with limited success, and have often lacked systematic process evaluations that characterized barriers and facilitators to improving care. The VA EQUIP project ("Enhancing QUality-of-care In Psychosis") developed methods to implement a chronic care model in schizophrenia, and evaluated implementation in a controlled trial. EQUIP focused on improving family management, and medication management of symptoms and side-effects. A major aim was to use mixed methods to evaluate processes of and variations in care model implementation, and thereby produce information to strengthen future implementation efforts.
At two VA medical centers, clinicians (n=66) and their patients (n=398) were randomized to an intervention or control condition. In the intervention group, a chronic care model was implemented for 15 months. Before, during, and after implementation, surveys and semi-structured interviews were conducted with clinicians and managers to assess their clinical practices, competencies, expectations, experiences, and observations concerning the implementation.
Challenges to implementation differed substantially by treatment domain. Challenges to improving family management included a need for care reorganization and intensive negotiation with families and patients to overcome resistance to this evidence-based treatment. Challenges to improving side-effect management included a need for routine patient assessment, establishment of therapeutic groups, and attention to patient adherence. Challenges to improving symptom management included limited clinician competency regarding clozapine. Across all treatments, there were high levels of burnout among clinicians and little support from services outside of specialty mental health. Routine patient assessment had a limited effect on clinicians, but was critical for implementation.
Key challenges to improving care became apparent during implementation. In schizophrenia, improving care will likely require resources to help providers easily implement practice changes. These should be combined with evidence-based quality improvement efforts that include routine assessment of relevant patient outcomes. Implementation will need to be tailored for each evidence-based treatment.
These results are being used to inform current VA quality improvement efforts, and may be relevant to other chronic illnesses.