BACKGROUND/RATIONALE:
Schizophrenia is a common, disabling serious mental illness. In fiscal year 2009, the VA provided care to over 230,000 people with serious mental illness and 24% of the VA's health care budget was spent on care for people with psychotic disorders. In VA and other systems, a large proportion of patients do not receive guideline-concordant care at specialty mental health clinics. Outcomes in routine practice are much worse than in state-of-the-art care. Previous efforts to improve care in specialty mental health have typically shown little or no success.

OBJECTIVE(S):
1) increase access to recovery-oriented services among veterans with schizophrenia; 2) implement information systems that accurately identify patients' preferences and needs for services; 3) implement a care model to support recovery-oriented care; 4) evaluate, in a controlled trial, the effect of this care model on treatment delivery and patient outcomes; and 5) identify facilitators and barriers to veteran participation in wellness programs.

METHODS:
This was a clinic-level controlled trial. Within four VISNs, eight specialty mental health programs were assigned to care as usual or implementation of the care model. In partnership with policy makers, it was decided to focus on two domains: Wellness and Supported Employment. Veterans with schizophrenia (n=801) and clinicians (n=171) were enrolled. At implementation sites, patients used kiosks that routinely assessed their needs and preferences. Implementation used evidence-based quality improvement methods, social marketing, opinion leaders, provider and patient education, and continual feedback to staff. Mixed methods were used to evaluate implementation and care model effectiveness. Patients and clinicians were surveyed and interviewed at baseline and 15 months. Intervention clinicians were also interviewed mid-study. A subset of patients and clinicians completed a qualitative interview regarding wellness services.

FINDINGS/RESULTS:
Readiness for organizational change varied by site and guided implementation. In terms of wellness, at baseline patients' mean Body Mass Index was 30 (obese), and 80% (n=637) were overweight. Overweight individuals at intervention sites were 2.3 times more likely to increase utilization of wellness services during the intervention period compared to control sites (95% CI: 1.5, 3.6; chi-sq = 14.4; p<.01). Controlling for pre-baseline and baseline weight, control sites patients' final weight was on average 13.4 7.6 lbs heavier than patients at intervention sites (F=4.8, p=.03). Post-implementation interviews with a subset of patients (n=44) indicate that provider encouragement of patients to engage and remain in these services is critical to utilization.

In terms of employment, at baseline 15% of patients were working (103/658) and 53% wanted to work (n=296/555). Individuals at intervention sites were 2.2 times more likely (95% CI: 1.1-4.3) to utilize Supported Employment services during the study as compared to control sites. There was no significant increase in competitive employment at intervention sites compared with control sites. When examining site level differences, one intervention site showed significant increases in employment (p=.004). This site had good Supported Employment model fidelity, much better than at other sites.

IMPACT:
The quality of specialty mental health care was improved through routine patient assessment, evidence-based quality improvement, and the application of implementation methods.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Pedersen ER, Huang W, Cohen AN, Young AS. Alcohol use and service utilization among veterans in treatment for schizophrenia. Psychological Services. 2018 Feb 1; 15(1):21-30. [view]
2. Brown AH, Cohen AN, Chinman MJ, Kessler C, Young AS. EQUIP: implementing chronic care principles and applying formative evaluation methods to improve care for schizophrenia: QUERI Series. Implementation science : IS. 2008 Feb 15; 3:9. [view]
3. Hamilton AB, Cohen AN, Glover DL, Whelan F, Chemerinski E, McNagny KP, Mullins D, Reist C, Schubert M, Young AS. Implementation of evidence-based employment services in specialty mental health. Health services research. 2013 Dec 1; 48(6 Pt 2):2224-44. [view]
4. Young AS, Cohen AN, Hamilton AB, Hellemann G, Reist C, Whelan F. Implementing Patient-Reported Outcomes to Improve the Quality of Care for Weight of Patients with Schizophrenia. The journal of behavioral health services & research. 2019 Jan 1; 46(1):129-139. [view]
5. Hamilton AB, Cohen AN, Young AS. Organizational readiness in specialty mental health care. Journal of general internal medicine. 2010 Jan 1; 25 Suppl 1:27-31. [view]
6. Goodsmith N, Cohen AN, Pedersen ER, Evans E, Young AS, Hamilton AB. Predictors of Functioning and Recovery Among Men and Women Veterans with Schizophrenia. Community mental health journal. 2023 Jan 1; 59(1):110-121. [view]
7. Cohen AN, Pedersen ER, Glynn SM, Hamilton AB, McNagny KP, Reist C, Chemerinski E, Young AS. Preferences for family involvement among veterans in treatment for schizophrenia. Psychiatric Rehabilitation Journal. 2019 Sep 1; 42(3):210-219. [view]
8. Young AS, Niv N, Chinman M, Dixon L, Eisen SV, Fischer EP, Smith J, Valenstein M, Marder SR, Owen RR. Routine outcomes monitoring to support improving care for schizophrenia: report from the VA Mental Health QUERI. Community mental health journal. 2011 Apr 1; 47(2):123-35. [view]
9. Young AS, Niv N, Cohen AN, Kessler C, McNagny K. The appropriateness of routine medication treatment for schizophrenia. Schizophrenia Bulletin. 2010 Jul 1; 36(4):732-9. [view]
10. Cohen AN, Chinman MJ, Hamilton AB, Whelan F, Young AS. Using patient-facing kiosks to support quality improvement at mental health clinics. Medical care. 2013 Mar 1; 51(3 Suppl 1):S13-20. [view]

Book Chapters

1. Chaney EF, Bonner LM, Vivell S, Cohen AN, Young AS, Rubenstein LV. How Behavioral Healthcare Informatics Systems Interface With Medical Informatics Systems: A Work in Progress. In: Dewan NA, Luo JS, Lorenzi NM, editors. Information Technology Essentials for Behavioral Health Clinicians. New York, NY: Springer; 2011. Part 4. 195-204 p. [view]

VA Cyberseminars

1. Cohen AN. Using Patient-Facing Kiosks to Support Quality Improvement at Mental Health Clinics. [Cyberseminar]. 2013 Sep 1. [view]

Conference Presentations

1. Chinman MJ, Shoai R, Cohen A, Young A, Hamilton AB. Addressing Implementation Challenges Deploying New Clinical Services. Presented at: VA HSR&D Field-Based Mental Health and Substance Use Disorders Meeting; 2010 Apr 29; Little Rock, AR. [view]
2. Young AS, Chinman MJ, Hamilton A, Smith J. Building Quality Improvement Teams to Address Gaps in Care: Tools, Methods, and Evaluation. Paper presented at: VA HSR&D Field-Based Mental Health and Substance Use Disorders Meeting; 2010 Apr 29; Little Rock, AR. [view]
3. Yano EM, Young AS, Cohen AN, Hamilton A, Rubenstein LV. Can Six Blind Men Find Apples & Oranges: Using Multiple Data Sources to Describe Variable Implementation of QI Interventions. Paper presented at: VA QUERI National Meeting; 2008 Dec 8; Phoenix, AZ. [view]
4. Young AS, Cohen AN, Hamilton A, Bowman A, Steele A, McNair K, Allan K, Tisi A. EQUIP: Evaluating Evidence-Based Quality Improvement in Specialty Mental Health. Poster session presented at: VA “One Team toward One Dream” National Quality, Patient Safety and Systems Redesign Conference; 2010 Jun 21; San Francisco, CA. [view]
5. Cohen AN, Young AS, Hamilton-Brown A, Chinman MJ, Henderson C, Thomesen C, Hamilton JD, Teague A, Robinson D, Hicks P, Widmark C, Reist C. Evaluating Challenges and Facilitators to Improving Care for Schizophrenia: EQUIP-2 Results at Eight VA Medical Centers. Paper presented at: VA MIRECC Annual Best Practices in Mental Health Conference; 2008 Jul 22; Arlington, VA. [view]
6. Young AS, Campinell A, Cuerdon T, Owen RR, Resnick SG, Rosenheck R. Evaluating Implementation and Spread of Evidence-Based Practices in VHA Specialty Mental Health Services. Paper presented at: VA QUERI National Meeting; 2008 Dec 8; Phoenix, AZ. [view]
7. 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. [view]
8. Smith J, Hagedorn H, VanDeusen Lukas C, Young AS. Evaluating Implementation Trials. Paper presented at: VA CIPRS Enhancing Implementation Science in the VA Training Conference; 2010 Jul 20; Denver, CO. [view]
9. Cohen AN, Young AS, Hamilton A, Chinman MJ. Evaluating Organizational context and readiness for change: EQUIP results at eight VA medical centers. Paper presented at: VA HSR&D National Meeting; 2009 Feb 11; Baltimore, MD. [view]
10. Cohen AN, Young AS, Hamilton A, Chinman MJ, Chemerinski E, Thomesen C, Teague A, Robinson D, Hicks P, Widmark C, Reist C. Evaluating Organizational Context and Readiness for Change: EQUIP Results at Eight VA Medical Centers. Poster session presented at: VA QUERI National Meeting; 2008 Dec 10; Phoenix, AZ. [view]
11. Young AS, Cohen AN, Whelan F, Hamilton AB. Implementation of evidence-based employment services for Veterans with serious mental illness. Paper presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 8; Philadelphia, PA. [view]
12. Young AS, Cohen AN, Hamilton A. Implementation of Evidence-Based Services for Weight at Specialty Mental Health Clinics. Paper presented at: National Institutes of Health Conference on the Science of Dissemination and Implementation: Research At The Crossroads; 2012 Mar 19; Bethesda, MD. [view]
13. Young AS, Cohen AN, Hamilton A. Implementation of Evidence-Based Weight Practices in Specialty Mental Health. Paper presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 19; National Harbor, MD. [view]
14. Cohen AN, Glynn SM, Hamilton AH, Young AS, Dixon L. Implementation of family services in outpatient mental health. Poster session presented at: VA HSR&D National Meeting; 2008 Feb 12; Baltimore, MD. [view]
15. Young AS, Cohen AN, Hamilton A. Implementing Evidence-Based Quality Improvement and Patient Kiosks in Specialty Mental Health: Improving Employment Services and Outcomes. Paper presented at: National Institutes of Health Conference on the Science of Dissemination and Implementation: Research At The Crossroads; 2012 Mar 20; Bethesda, MD. [view]
16. Young AS, Cohen AN, Hamilton AB, Whelan F, Teague A, Chemerinski E, Schubert M, Reist C. Implementing Evidence-Based Quality Improvement and Patient Kiosks in Specialty Mental Health: Improving Employment Services and Outcomes. Paper presented at: American Medical Informatics Association Annual Symposium; 2013 Nov 5; Chicago, IL. [view]
17. Cohen AN, Young AS, Drapalski A. Implementing Family Services. Paper presented at: VA MIRECC Annual Best Practices in Mental Health Conference; 2008 Jul 22; Arlington, VA. [view]
18. 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. [view]
19. Brown A, Cohen AN, Chinman MJ, Young AS. Implementing recovery-oriented care in mental health: The importance of clinicians’ knowledge, attitudes, and beliefs. Poster session presented at: VA HSR&D National Meeting; 2009 Feb 12; Baltimore, MD. [view]
20. Young AS, Brown AH, Cohen AN, Chinman MJ, Reist C. Implementing Treatment Guidelines in Schizophrenia: Process Evaluation of Implementation in EQUIP. Poster session presented at: VA QUERI National Meeting; 2008 Dec 8; Phoenix, AZ. [view]
21. Young AS, Hamilton-Brown A, Chinman MJ, Cohen AN, Reist C. Improving Care for Schizophrenia: Process Evaluation of Implementation in EQUIP. Poster session presented at: VA MIRECC Annual Best Practices in Mental Health Conference; 2008 Jul 22; Arlington, VA. [view]
22. Young AS, Hamilton A, Cohen AN, Chinman MJ, Kessler C. Improving Care for Schizophrenia: Process Evaluation of Implementation in EQUIP. Presented at: VA HSR&D National Meeting; 2008 Feb 13; Baltimore, MD. [view]
23. Cohen AN, Hamilton AB, Ritchie MJ, Mittman BS, Kirchner JE, Wyatt GE, Fortney JC, Hellemann G, Liu H, Curran GM, Whelan F, Eccles AM, Parker LE, McNagny K, Hutchinson CS, Teague AB, Reist C, Young AS. Improving care quality through hybrid implementation/effectiveness studies: Best practices in design, methods, and measures. Paper presented at: National Institutes of Health / AcademyHealth Conference on the Science of Dissemination and Implementation; 2014 Dec 9; Bethesda, MD. [view]
24. Owen RR, Kilbourne A, Young A, Marder S. Improving General Medical Care for Veterans with Mental Illness. Paper presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 19; National Harbor, MD. [view]
25. Hynes DM, Perrin RA, Goldstein M, Achtmeyer C, Young A. Lessons from Evaluating the Implementation of New Informatics in an Integrated Healthcare Delivery System: The Veterans Health Administration. Paper presented at: American Medical Informatics Association Annual Symposium; 2011 Oct 22; Washington, DC. [view]
26. Armstrong N, Cohen AN, Niv N, Hamilton A, Young AS. Measuring Veteran Recovery at Mental Health Clinics: The Mental Health Recovery Measure (MHRM). Paper presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 19; National Harbor, MD. [view]
27. Cohen AN, Hamilton A, Armstrong N, Young AS. Mental Health Consumer and Provider Perspectives on a Weight Management Program: Improving Implementation of Needed Services. Paper presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 19; National Harbor, MD. [view]
28. Young AS, Hamilton AB, Cohen AN. Mental Health QUERI: Patient-Facing Kiosks to Improve Care. Paper presented at: American Medical Informatics Association Annual Symposium; 2013 Nov 17; Washington, DC. [view]
29. Hamilton A, Cohen AN, Young AS. Organizational Readiness at Mental Health Clinics. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2010 Apr 28; Minneapolis, MN. [view]
30. Cohen AN, Hamilton A, Young AS. Organizational Readiness in Specialty Mental Health Care. Paper presented at: National Institutes of Health Conference on the Science of Dissemination and Implementation: Methods and Measurement; 2010 Mar 15; Bethesda, MD. [view]
31. Cohen AN, Chinman MJ, Hamilton AB, Whelan F, Young AS. Patient-facing kiosks for Veterans with schizophrenia: reducing risk by dynamically identifying service needs. Paper presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 9; Philadelphia, PA. [view]
32. Cohen AN, Hamilton A, Teague A, Nathan A, McNagny K, Schubert M, Young AS. System-level barriers to improving care: Organizational readiness for change. Poster session presented at: VA “One Team toward One Dream” National Quality, Patient Safety and Systems Redesign Conference; 2010 Jun 21; San Francisco, CA. [view]
33. Young AS, Niv N, Cohen AN, Kessler C, McNagny K. The Quality of Medication Management for Schizophrenia: An Update. Presented at: VA HSR&D National Meeting; 2008 Feb 14; Baltimore, MD. [view]
34. Young AS, Niv N, Cohen AN, Mintz J, Ventura J. The validity of using patient self-report to assess psychotic symptoms in schizophrenia. Poster session presented at: VA HSR&D National Meeting; 2008 Feb 12; Baltimore, MD. [view]
35. Mittman BS, Stetler CB, Atkins D, Smith J, Asch SM, Young AS. US Department of Veterans Affairs Quality Enhancement Research Initiative (QUERI): Bridging Research and Practice in A Large Healthcare Delivery System. Paper presented at: Knowledge Translation Forum for the Future Annual Conference; 2008 Jun 9; Banff, Canada. [view]
36. Hamilton A, Cohen AN, Young AS. Using organizational readiness data to tailor implementation strategies to local contexts. Paper presented at: National Institutes of Health Conference on the Science of Dissemination and Implementation: Research At The Crossroads; 2012 Mar 19; Bethesda, MD. [view]
37. Cohen A, Chinman MJ, Hamilton AB, Whelan F, Young AS. Using patient-facing kiosks to support quality improvement at mental health clinics. Poster session presented at: AcademyHealth Annual Research Meeting; 2013 Jun 25; Baltimore, MD. [view]
38. Chinman MJ, Lucksted A, Gresen R, Davis M, Losonczy M, Sussner B, Martone L, Young AS. Using Stakeholder Assessments to Improve Implementation of the VA Uniform Service Package. Paper presented at: VA HSR&D National Meeting; 2009 Feb 12; Baltimore, MD. [view]
39. Hamilton A, Cohen AN, Young AS. Women with Schizophrenia Who Use Outpatient VA Clinics. Poster session presented at: VA HSR&D Field-Based Women's Health Meeting; 2010 Jul 14; Arlington, VA. [view]

DRA: Mental, Cognitive and Behavioral Disorders, Health Systems
DRE: none
Keywords: Schizophrenia, Translation
MeSH Terms: none