Serious mental illness (SMI) is the second most costly disorder treated in the VHA, yet clinical outcomes for these patients are often poor due to a combination of low quality care and severe cognitive and functional impairments. While these problems are multifaceted, studies outside the VHA have shown that using "consumer providers" (CPs) can improve and augment care. Similar to recovering addiction counselors, CPs are individuals with SMI who use their lived experiences to provide services to others with SMI. CPs can reach out to patients that are difficult to engage, assist patients with tasks of daily living, offer a variety of rehabilitation (vocational, social, residential) services, be role models and offer hope for recovery, and facilitate support groups. Randomized controlled and quasi-experimental trials outside the VHA have shown that CPs can provide services that yield at least equivalent patient outcomes with particular benefits noted on intensive case management teams. VHA has hired about 250 CPs to date, although their impact has not been documented. Yet its success outside the VHA and the recent emphasis on recovery-oriented care suggests the need to test this model in the VHA.
To conduct a randomized controlled trial testing the impact on patient level and team level outcomes of the implementation of CP services on six mental health intensive case management (MHICM) teams in VISN-22. The specific aims were to: 1) Evaluate the acceptability, facilitators of and barriers to the inclusion of two CPs to each intervention MHICM team. 2) Evaluate the effect of including CPs on the degree to which MHICM teams services are recovery-oriented. 3) Evaluate the effect of including CPs on veterans' clinical and recovery-focused outcomes. Our hypotheses were that CPs would be feasible and acceptable, that teams would become more recovery-oriented, and that the involvement of CPs would lead to greater gains in recovery, quality of life, empowerment with regard to illness, and to a lesser extent, symptoms compared to patients on teams without CPs.
This project was a "cluster randomized controlled trial" comparing 3 CP-MHICM teams (with CPs) to 3 control teams (i.e., without a CP), at MHICM sites within VISN-22. All patients on the 6 MHICM teams' caseload during each site's recruitment period were eligible. 285 MHICM patients were enrolled, 152 at the intervention sites and 133 at the control sites. Each intervention MHICM team used a strategic planning process to tailor the CP intervention to local priorities and structures, involving multiple meetings to discuss the CP's role, hiring, and incorporation of CPs into the team. The project hired the CPs, provided training, assisted in their implementation on the teams and provided ongoing supervision. The CPs worked for about 12 months.
Using a patient survey, the study assessed impacts of CPs on patient level outcomes including recovery-orientation of their team (Recovery Self-assessment scale), individual recovery (Mental Health Recovery Measure, Illness Self-Management Scale), quality of life (Quality of Life Interview), symptoms (BASIS-24), and patient activation (Patient Activation Measure). The patient level outcome assessments were conducted pre and post intervention. Final follow-up assessment rates ranged from 71- 95% at intervention sites and 80 - 88% at control sites.
We conducted site visits with all six MHICM teams using a validated, standardized protocol, rating each team's level of recovery orientation before and after the deployment of the CPs on the Recovery-Oriented Practices Index (ROPI). We conducted 23 focus groups and interviews with patients, providers and CPs at all intervention sites (about 8 per site) at the post time point to assess barriers and facilitators to CP implementation. All focus groups and interviews were recorded, transcribed, and coded using Atlas.ti.
The analyses of the patient survey data were comparisons of changes between baseline and followup scores with regression analyses of the change scores for all the outcomes mentioned above. The first analyses was whether the intervention group was significantly related to change considering only treatment group and statistically controlling for baseline score, and covariates (age, gender, race, living situation and education level). The second was the same as the first, adding site as a fixed covariate. The ROPI ratings were made on a very small number of units (6 teams), therefore the results were descriptive and involved a percent change from pre to post. The focus groups and interviews were each summarized and then summarized by site. The study team discussed the results. Using the constant comparison method, salient topics were compared within and across roles and sites.
Analyses of the change scores on the patient survey indicated that the intervention sites gained more on the PAM scale than the usual care sites (t=1.95 (df=192), p=0.05 for the model without site and t (df=185) =3.11, p=0.002 for the model adjusting for site. For the BASIS Interpersonal Relations Subscale, the site-unadjusted model did not show a between group difference in change scores however, the site-adjusted model indicated that the PEERs sites had a significant improvement (t=-2.70, p=0.0007). For all the other outcomes, the CP and Non-CP groups did not change significantly differently from each other over time. Intervention sites' ratings on the ROPI had a 20 percent change improvement from before and after the CP intervention, while the control sites had a 15 percent change improvement.
The focus groups and interviews showed that the MHICM teams generally viewed the CPs as positive. All agreed that CPs connected well with patients and patients reported feeling supported by CPs during everyday tasks. Many staff and CPs talked about "growing pains" related to establishing trust, boundaries, and role delineations. Anticipated concerns about CP-patient boundary violations were not realized, in part because of considerable pre-planning of the CP's role. Sites did struggle with how to best use some of the CPs and how much structure to place on them, at times leading to under- or misutilization of the CPs.
Deploying CPs on MHICM teams helped improve patient activation and patients' interpersonal relationships. Becoming more active in one's own care and having more of a social network are key areas of recovery from serious mental illness. Hiring more CPs to work in MHICM or other areas of the VHA mental health system could be beneficial to veterans with serious mental illness.
External Links for this Project
- Chinman M, Oberman RS, Hanusa BH, Cohen AN, Salyers MP, Twamley EW, Young AS. A cluster randomized trial of adding peer specialists to intensive case management teams in the Veterans Health Administration. The journal of behavioral health services & research. 2015 Jan 1; 42(1):109-21. [view]
- Hamilton AB, Chinman M, Cohen AN, Oberman RS, Young AS. Implementation of consumer providers into mental health intensive case management teams. The journal of behavioral health services & research. 2015 Jan 1; 42(1):100-8. [view]
- Chinman M, Salzer M, O D. National survey on implementation of peer specialists in the VA: implications for training and facilitation. Psychiatric Rehabilitation Journal. 2012 Dec 1; 35(6):470-3. [view]
- Chinman M, George P, Dougherty RH, Daniels AS, Ghose SS, Swift A, Delphin-Rittmon ME. Peer support services for individuals with serious mental illnesses: assessing the evidence. Psychiatric services (Washington, D.C.). 2014 Apr 1; 65(4):429-41. [view]
- Chinman M, Shoai R, Cohen A. Using organizational change strategies to guide peer support technician implementation in the Veterans Administration. Psychiatric Rehabilitation Journal. 2010 Jan 1; 33(4):269-77. [view]
- Chinman M, Oberman RS, Hanusa BH, Cohen AN, Salyers MP, Twamley EW, Young AS. Erratum to: A Cluster Randomized Trial of Adding Peer Specialists to Intensive Case Management Teams in the Veterans Health Administration. The journal of behavioral health services & research. 2015 Jan 1; 42(1):122. [view]
- McGuire AB, Gearhart TD. Motivational Interviewing. In: Best Practices in Community Mental Health: A Pocket Guide. Chicago, IL: Lyceum Books, Inc; 2013. Chapter 13. 199-210 p. [view]
- Rodrigues S, Chinman MJ, Hills S, Ellison ML, McKay C. Peer support. In: Smelson D, Sawh L, Ziedonis D, editors. Maintaining Independence and Sobriety through Systems Integration, Outreach, and Networking [Treatment Manual]. Washington, DC: United States Department of Veterans Affairs, Office of Research and Development, Health Services Research and Development and The National Center on Homelessness Among Veterans; 2011. Chapter 5. 56-68 p. [view]
- Chinman MJ. Building the case for peer support services (MIRECC/CoE Mental Health Innovations Newsletter). [Newsletter]. 2014 May 1. [view]
- Chinman MJ, Henze K, Sweeney P. Peer specialist toolkit: implementing peer support services in VHA. [Website]. 2013 Mar 1. [view]
- 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]
- 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]
- Chinman MJ, Henze K, Russo A, Sweeny P. Case examples of using organizational change strategies to support the Uniform Services Handbook requirements for peer support. Presented at: VA Mental Health Annual Conference; 2011 Aug 22; Baltimore, MD. [view]
- Chinman MJ. Consumer Providers. Gli UFE in Versione USA. Paper presented at: Utenti Familiari Esperti Conference; 2010 Jun 11; Trento, Italy. [view]
- Chinman MJ. Current research in peer support: implications for practice. Presented at: VA VISN 4 Peer Support in Recovery: Learning About and Celebrating Peers Training Conference; 2011 Mar 4; Pittsburgh, PA. [view]
- White DA, McGuire AB, Salyers MP. Facilitators and Barriers to Illness Management and Recovery Implementation. Poster session presented at: Midwestern Psychological Association Annual Meeting; 2013 May 2; Chicago, IL. [view]
- Chinman MJ. Helping staff comply with the Uniform Services Handbook requirements of peer support. Paper presented at: VA Mental Health Annual Conference; 2009 Jul 22; Baltimore, MD. [view]
- Chinman MJ, McCarthy S, Hannah G. Homeless outcomes: a model for evaluation and success (HOMES). Poster session presented at: VA National Summit on Ending Homelessness Among Veterans; 2009 Nov 3; Washington, DC. [view]
- Cohen AN, Hamilton A, Chinman M, Ebener P, Oberman R, Young AS. Implementation of consumer providers in mental health settings. Poster session presented at: AcademyHealth Annual Research Meeting; 2013 Jun 23; Baltimore, MD. [view]
- Chinman MJ, Lucksted A, Gresen RC, Davis M, Losonczy M, Sussner B, Martone L. Implementation of mental health peer support technicians in the VA. Poster session presented at: VA Mental Health Annual Conference; 2008 Jul 22; Arlington, VA. [view]
- Chinman MJ, Shoai R, Cohen AN, Young AS, Hamilton A. Implementation of new clinical services: paradigm shifts and practical adjustments. 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]
- Chinman MJ. Implementing and sustaining peer positions. Presented at: VA VISN 4 Peer Support in Recovery: Learning About and Celebrating Peers Training Conference; 2011 Mar 4; Pittsburgh, PA. [view]
- Chinman MJ. Implementing peer support. Presented at: VA VISN 1 Partnering with Peers: Exploring the Next Frontier in VA Mental Health Services Clinical Conference; 2009 Sep 25; Bedford, MA. [view]
- Chinman MJ. Implementing peer support: barriers and breakthroughs. Presented at: VA Employee Education System / Office of Mental Health Services Peer Support: Lighting the Path to Recovery Conference; 2009 Jun 18; Salt Lake City, UT. [view]
- Chinman MJ. LRC Survey Data and Impact on Implementation of Peer Support Efforts in VA. Paper presented at: VA Employee Education System / Office of Mental Health Services Peer Support: Combating Stigma Conference; 2010 Aug 10; Chicago, IL. [view]
- Bonfils KA, McGuire AB, Kukla ME, Myers L, Salyers MP. Participation in Illness Management and Recovery. Poster session presented at: Midwestern Psychological Association Annual Meeting; 2013 May 2; Chicago, IL. [view]
- Chinman MJ. Peer Specialists: Implementation, evidence, and effective supervision. Paper presented at: Pillars of Peer Support Services Annual Summit; 2014 Oct 8; Atlanta, GA. [view]
- Chinman MJ, O’Brien-Mazza D. Peer support implementation in DVA mental health programs: maximizing the effectiveness of mental health services in the prevention of suicide. Paper presented at: VA / Department of Defense Suicide Prevention Annual Conference; 2011 Mar 23; Boston, MA. [view]
- Oles S, McGuire AB. Relationship between personal and treatment plan goals in consumers with severe mental illness. Poster session presented at: Midwestern Psychological Association Annual Meeting; 2013 May 2; Chicago, IL. [view]
- Chinman MJ. Toward the Implementation of Peer Workers in Clinical Settings. Paper presented at: Peer Staff Behavioral Health "We're in this Together" Conference; 2010 Jun 22; New Haven, CT. [view]
- 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]
- 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]
- Chinman MJ, McCarthy S, Hannah G. VA HOMES: Building capacity of VA homeless staff to adopt and self-evaluate evidence-based treatments through the getting to outcomes framework. Presented at: VA Implementing a Public Health Model for Meeting the Mental Health Needs of Veterans Annual Mental Health Conference; 2010 Jul 27; Baltimore, MD. [view]
- Cohen AN, Armstrong N, Hellemann G, Young AS. Validating a Brief Measure of Mental Health Recovery. Poster session presented at: AcademyHealth Annual Research Meeting; 2013 Jun 24; Baltimore, MD. [view]
Mental, Cognitive and Behavioral Disorders, Health Systems
Prognosis, Treatment - Observational
Caregivers – not professionals, Mental Health Care, Mental health care delivery, Mental health care service, Organizational issues, Severe mental illness
Mental Health Services