Policy makers and consumers are increasingly concerned about the quality and efficiency of care provided to individuals with severe, chronic illnesses such as schizophrenia. These illnesses are expensive to treat and present significant challenges to organizations that are responsible for providing effective care. Occurring in 1% of the United States population, schizophrenia accounts for 10% of permanently disabled people, and 2.5% of all healthcare expenditures. Clinical practice guidelines have been promulgated. Schizophrenia is treatable and outcomes can be substantially improved with the appropriate use of antipsychotic medication, caregiver education and counseling, vocational rehabilitation, and assertive treatment. However, in the VA and other mental health systems, many patients with schizophrenia receive substandard care. Methods are needed that improve the quality of usual care for this disorder while being feasible to implement at typical clinics.
To date, most efforts to improve care for schizophrenia have focused on educating clinicians or changing the financing of care, and have had limited success. We believe a more fundamental approach should be tried. While there are many potential strategies, experience in chronic medical illness and mental health support the efficacy of specific approaches. Collaborative care models are one such approach. They are a blueprint for reorganizing practice, and involve changes in division of labor and responsibility, adoption of new care protocols, and increased attention to patients' needs. Although collaborative care models have been successful in other chronic medical conditions, they have not yet been studied in the treatment of schizophrenia.
We have developed a collaborative care model for schizophrenia that builds on work in other disorders, and includes service delivery approaches that are known to be effective in schizophrenia. The model focuses on improving treatment through assertive care management, caregiver education and support, and standardized patient assessment with feedback of information to psychiatrists. This project, "EQUIP" (Enhancing Quality Utilization In Psychosis) is implementing collaborative care and evaluating its effectiveness in schizophrenia.
The objective of this project was to implement the care model at two large VA mental health centers, and evaluate its effect on clinicians, the organization of care, and treatment appropriateness, utilization and outcomes in veterans with schizophrenia. We hypothesized that this care model would increase provider adherence to treatment guidelines and improve the quality of care. We planned to describe implementation of the model, and barriers and facilitators to its implementation. We planned to evaluate the model by comparing treatment under the care model with usual care. Changes in the structure of care were evaluated using qualitative methods.
EQUIP was a controlled trial of the care model. At two VA medical centers, clinicians (n=66) and their patients (n=398) were randomized to an intervention or a 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. Data sources included patient interviews, clinician interviews, and data from VistA. The feasibility of more broadly implementing the collaborative care model was assessed utilizing qualitative and quantitative information about the model's strengths and weaknesses, factors that facilitated/impeded implementation, direct costs of implementation and maintenance, and effects on treatment service utilization.
The intervention was well received by patients, clinicians and managers. It identified a number of pervasive clinical problems at the sites. One site was found to be using little clozapine, even through many patients have severe, refractory psychosis. This led to the establishment of a centralized clozapine clinic. At both sites, it was found that a large proportion of patients were overweight, but few appropriate services were available for this problem. Both started wellness programs. The psychiatrists believe that the intervention improved medication prescribing and care by improving information and care management.
Challenges to implementation differed substantially by treatment domain. Challenges to improving family management included a need for care reorganization and intensive negotiation with clinicians, 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, attention to patient adherence, and psychiatrist resistance to changing treatment. Challenges to improving symptom management included limited clinician competency regarding clozapine and cumbersome pharmacy requirements. 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 strengthening the implementation.
Key challenges to improving care only 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 QUERI efforts, and are relevant to redesign and transformation of care delivery in specialty mental health.
- Niv N, Cohen AN, Sullivan G, Young AS. The MIRECC version of the Global Assessment of Functioning scale: reliability and validity. Psychiatric services (Washington, D.C.). 2007 Apr 1; 58(4):529-35.
- Niv N, Cohen AN, Mintz J, Ventura J, Young AS. The validity of using patient self-report to assess psychotic symptoms in schizophrenia. Schizophrenia Research. 2007 Feb 1; 90(1-3):245-250.
- Glynn SM, Cohen AN, Niv N. New challenges in family interventions for schizophrenia. Expert Review of Neurotherapeutics. 2007 Jan 1; 7(1):33-43.
- Erhart SM, Young AS, Marder SR, Mintz J. Clinical utility of magnetic resonance imaging radiographs for suspected organic syndromes in adult psychiatry. The Journal of clinical psychiatry. 2005 Aug 1; 66(8):968-73.
- Young AS, Mintz J, Cohen AN, Chinman MJ. A network-based system to improve care for schizophrenia: the Medical Informatics Network Tool (MINT). Journal of the American Medical Informatics Association : JAMIA. 2004 Sep 1; 11(5):358-67.
- Young AS, Mintz J, Cohen AN. Using information systems to improve care for persons with schizophrenia. Psychiatric services (Washington, D.C.). 2004 Mar 1; 55(3):253-255.
- Young AS, Cohen AN, Mintz J. Committee on crossing the quality chasm: Adaptation to mental health and addictive disorders. 2005 Nov 1.
- Cohen AN, Glynn SM, Drapalski A, Dixon L. Engaging Families in the Care of Veterans with SMI. Paper presented at: VA HSR&D Field-Based Mental Health and Substance Use Disorders Meeting; 2010 Apr 28; Little Rock, AR.
- Cohen AN, Glynn SM, Hamilton A, Young AS. Implementing Family Services at Mental Health Clinics. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2010 Apr 28; Minneapolis, MN.
- Cohen AN, Young AS, Niv N, Reist C, Hamilton A. Implementation of a Psychosocial Weight Management Program at Mental Health Clinics. Paper presented at: Society of General Internal Medicine Annual Meeting; 2010 Apr 28; Minneapolis, MN.
- Young AS, Niv N, Cohen AN, Hamilton A, Reist C. Implementation of a Psychosocial Weight Management Program at Mental Health Clinics. Poster session presented at: VA HSR&D Field-Based Mental Health and Substance Use Disorders Meeting; 2010 Apr 27; Little Rock, AR.
- Young AS, Niv N, Cohen AN, Hamilton A, Reist C. Implementation of a Psychosocial Weight Management Program at Mental Health Clinics. Paper presented at: Quality of Behavioral Healthcare: A Drive for Change Through Research Conference; 2010 Apr 13; Clearwater Beach, FL.
- Young AS, Hamilton A, Cohen AN. Evaluating Implementation of Evidence-Based Care for Schizophrenia. Paper presented at: National Institutes of Health Conference on the Science of Dissemination and Implementation: Methods and Measurement; 2010 Mar 15; Bethesda, MD.
- Cohen AN, Young AS, Hamilton A, Glynn SM, Dixon LB. Implementing Family Services at Two VA Specialty Mental Health Clinics. Poster session presented at: VA QUERI National Meeting; 2008 Dec 10; Phoenix, AZ.
- Young AS. Implementing Recovery-Oriented, Evidence-Based Practices in Schizophrenia. Paper presented at: VA MIRECC Annual Best Practices in Mental Health Conference; 2007 Jul 19; Alexandria, VA.
- Cohen AN, Kessler C, McNagny K, Reist C, Mintz J, Young AS. EQUIP: Improving care for schizophrenia. Paper presented at: VA Best Practices Annual Symposium; 2006 Sep 1; Portland, OR.
- Young AS, Cohen AN, Kessler C, McNagny K, Reist C, Mintz J. Implementing best practices to improve care for schizophrenia (EQUIP). Paper presented at: VA MIRECC Annual Best Practices in Mental Health Conference; 2006 Sep 1; Portland, OR.
- Cohen AN, Glynn S, Brown AH, Young AS. Involving families in the care of patients with schizophrenia: Patient and provider barriers. Paper presented at: AcademyHealth Annual Research Meeting; 2006 Jun 1; Seattle, WA.
- Cohen AN, Young AS. EQUIP: Evaluating a chronic illness care model for schizophrenia. Paper presented at: AcademyHealth Annual Research Meeting; 2006 Jun 1; Seattle, WA.
- Young AS, Cohen AN, Mintz J. Evaluating a chronic care model designed to improve treatment for schizophrenia (EQUIP). Paper presented at: VA HSR&D National Meeting; 2006 Feb 1; Arlington, VA.
- Young AS, Cohen AN, Chinman MJ, Mintz J. Informatics to Improve Care for Schizophrenia. Paper presented at: VA Information Technology Annual Conference; 2004 Aug 1; Austin, TX.
- Glynn S, Cohen AN, Randolph G, Young AS. Treatment Planning for Veterans with Serious Psychiatric Illnesses and Caregivers. Paper presented at: VA HSR&D National Meeting; 2004 Mar 1; Washington, DC.
Mental, Cognitive and Behavioral Disorders, Health Systems
Epidemiology, Treatment - Observational, Technology Development and Assessment
Clinical practice guidelines, Functional status, Organizational issues
Quality Assurance, Health Care, Schizophrenia, Patient Care