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2011 HSR&D National Meeting Abstract

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2011 National Meeting

1016 — Returning Veterans with Schizophrenia to Paid, Competitive Employment

Cohen AN (Greater Los Angeles VA + UCLA), Young AS (Greater Los Angeles VA + UCLA), Hamilton AB (Greater Los Angeles VA + UCLA), Teague A (VISN 6 MH Care Line; Durham VA), Mullins D (Michael E. DeBakey VA Medical Center), Chemerinski E (James J. Peters VA Medical Center), Schubert M (Central Texas VA Medical Center), Steele A (Michael E. DeBakey VA Medical Center), McNagny K (Long Beach VA Medical Center), Reist C (Long Beach VA Medical Center)

Objectives:
Chronic unemployment affects 90% of individuals with schizophrenia. Employment can improve symptoms, provide opportunities to improve social skills, increase self-efficacy, and reduce the economic costs of the illness. An evidence-based treatment, Supported Employment (SE), exists, but is underutilized by this population. The VA HSR&D QUERI project, Enhancing QUality of care In Psychosis (EQUIP), aimed to increase utilization of SE and employment rates using evidence-based quality improvement methods.

Methods:
This was a clinic-level controlled trial involving 8 mental health clinics across 4 VISNs. One clinic in each VISN was assigned to intervention; one to care as usual. Prior to implementation, 39 key stakeholders were interviewed to assess readiness for change. 808 veterans with schizophrenia enrolled. At baseline and one year follow-up, veterans reported interest in returning to paid, competitive employment and work status. Kiosks were installed in waiting rooms for veterans to self-report work interest and status at each clinic visit. These self-report data were provided to the clinician and veteran via a kiosk printout.

Results:
Stakeholder interviews were evaluated using Atlas.ti and indicated shortcomings with knowledge and attitudes toward SE. At baseline, 15% (121/808) of enrolled veterans were working, and 60% (413/686) responded they wanted to work. Over the one year at the intervention sites, SE utilization almost doubled from 5.7% (22/383) to 10.7% (41/383); veterans with paid employment also increased from 11.8% (46/389) to 14.9% (45/303). Over the same period at control sites, those using SE services remained virtually the same: 5.9% (24/406) to 6.9% (28/406); there was a slight decrease in employment rates from 17.7% (74/418) to 16.2% (57/352). At one intervention site, managers used kiosk data on veterans’ desire to return to work to gain one more SE FTE. At another intervention site, managers used kiosk data to justify reorganizing care so that psych interns could provide SE services.

Implications:
Consistent with the literature, only 15% of veterans with schizophrenia in this large sample were working. Unknown until this study, 60% want to work. This large gap in evidence-based, recovery-oriented care was addressed and increased service utilization, capacity of the service, and number of veterans working.

Impacts:
As with other implementation efforts, successful uptake may require an assessment of the clinic readiness for change and utilization of QI techniques to address shortcomings in knowledge, attitudes, and capacity.


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