2019 HSR&D/QUERI National Conference
4002 — Improving patient activation in a cluster randomized trial evaluating implementation and outcomes of VA mental health Peer Specialists
Lead/Presenter: Matthew Chinman, COIN - Pittsburgh/Philadelphia
All Authors: Chinman M (VA Pittsburgh Healthcare System), Hamilton AB (VA Greater Los Angeles & UCLA), Oberman R (VA Greater Los Angeles) Cohen AN (VA Greater Los Angeles) Young AS(VA Greater Los Angeles & UCLA) Salyers MP (Indiana University Purdue University Indianapolis, Department of Psychology, IUPUI School of Science) Twamley EW (Neuropsychology Unit, Center of Excellence, VA San Diego Healthcare System, Department of Psychiatry, University of California, San Diego)
Access to care for Veterans with serious mental illness (SMI) remains suboptimal. Some previous research on Peer Specialists (PSs)â€”individuals in recovery from SMI, hired as clinical team membersâ€”suggests they can improve patient engagement and other outcomes, but often face significant implementation barriers. PSTs are trained to use their lived experiences to share â€˜been there' empathy, insights, be role models, inculcate hope, build skills, and engage patients to access treatment and community supports. To assess implementation and impacts on outcomes, this cluster randomized, controlled trial, the first within the VA, compared patients served by three intensive case management teams (Usual Care) to the patients of three similar teams that each deployed two PSs for one year using strategies drawn from implementation science.
PS sites received training on the PS role and ongoing coaching, and collaboratively planned the deployment. All PSs completed the 40 hour VA- sanctioned certification course. Patients' recovery, quality of life, activation (health self-management efficacy), interpersonal relations, and symptoms were assessed before and after the PSs worked. All patients (PS = 149, Usual Care = 133) had substantial psychiatric inpatient histories and primary Axis 1 psychiatric disorders. After the year, semi-structured interviews (n = 23; approx. 8 per site) were conducted with PSs, supervisors, clinical staff, patients, and research staff. Interviews were recorded and transcribed. Constant comparison was used to generate implementation challenges and successes.
Patients in the PS group improved significantly more (z = 2.00, df = 1, p = 0.05) than those receiving Usual Care on activation. There were no other significant differences. All participants described the PSs' addition as positive (especially their superior ability to bond with patients), but acknowledged certain "growing pains" related to establishing trust, boundaries, and role delineations. Most anticipated concerns about PS deployment were not realized.
Supporting VA's goal to improve access, PSs helped patients become more active in treatment. Implementation strategies (e.g., considerable pre-planning and coaching) prevented most anticipated concerns. All stakeholders valued the PS contributions.
PSs can increase care access through patient activation, which has traditionally been low among those with SMI. The implementation strategies used with PSs could be a model for deploying new interventions in many domains.