Cluster Randomized Trial Comparing Standard vs Enhanced Implementation Strategies for Improving Outreach to Persons with SMI: 12-month Results

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Cluster Randomized Trial Comparing Standard vs Enhanced Implementation Strategies for Improving Outreach to Persons with SMI: 12-month Results David Goodrich Amy Kilbourne; Daniel Almirall; Zongshan

1 Cluster Randomized Trial Comparing Standard vs Enhanced Implementation Strategies for Improving Outreach to Persons with SMI: 12-month Results David Goodrich Amy Kilbourne; Daniel Almirall; Zongshan Lai; Kristen Abraham; Kristina Nord; Nicholas Bowersox VA Ann Arbor Center for Clinical Management Research Department of Psychiatry, University of Michigan Medical School Institute for Social Research, University of Michigan University of Detroit Mercy, Detroit, MI CCT Registration: ISRCTN

2 Background Persons with serious mental illness care discontinuity, poor outcomes Re-Engage program (brief care management) improved outcomes in national VA study * VA deployed a National Directive to further implement Re-Engage across the U.S. What is the most effective implementation strategy to enhance Re-Engage uptake? * Davis, et al. AJPH 2012

3 Objectives Determine, among VA sites not initially responding to a standard implementation strategy (REP*), the effect of adding Facilitation (Enhanced REP) immediately versus delayed on 12-month outcomes: Re-Engage uptake Utilization of care * REP = CDC s Replicating Effective Program s framework

4 Re-Engage Study Design

5 Setting and Participants All VA facilities (n=158) in the U.S., Puerto Rico with: 1. Local Recovery Coordinator (e.g., MSW, Psychologist) 2. >1 Veteran with SMI lost to care for 12 months as of 03/01/12 (N=5,047 Veterans)

6 Re-Engage Program 1. Local Recovery Coordinators received list of Veterans with SMI who dropped out of care with last known patient contact information 2. Attempt to contact Veteran to assess status 3. For successful contacts assess clinical needs and schedule VA appointment if Veteran desires to return to care 4. Document efforts in a web-based registry* * Non-response: sites with < 80% of patients with updated clinical status documented within 6 months of list receipt

7 Outcomes Primary Outcomes Uptake 1. Site-level updated documentation of patient clinical status using electronic registry 2. Attempted contact by phone or mail 3. Patient scheduled appointment Secondary Outcomes - Clinical 1. Any outpatient utilization 2. Any inpatient utilization

8 Implementation Strategies Standard REP Package (toolkit, guide) Training (calls, website) Brief technical assistance Uptake monitoring reports Enhanced REP* Package (toolkit, guide) Training (calls, website) Brief technical assistance Uptake monitoring reports Needs Assessment Garner local support Identify problems/barriers Problem-solve/action plan Feedback/link to resources * External facilitation by 3 doctoral-level mental health implementation consultants

9 Standard/Enhanced Replicating Effective Programs Pre- Implementation Identify need & program Identify settings Adapt & develop packagecommunity working group input REP Implementation Disseminate package Training Evaluation Monitor response Enhanced REP: Facilitation (external) Barriers assessment Provider coaching, problem-solvingmonthly calls Promote success Evaluation Outcomes Further diffusion, spread Process Evaluation Build business case: sustainability Kilbourne AM, Imp Sci 2013; Goodrich DE, Depress Res Treat 2012; Waxmonsky et al. Psych Serv 2013

10 Characteristics of Sites and Veterans Patient Level (N=5,047) 90% male, 18% Black, mean age of 55 years 40% had diagnosis of schizophrenia 13% had prior history of homelessness Site Level (n=158) # sites providing outpatient care only: 19 Mean total # Veterans treated/site in FY 2012: 40,858 (21,346) Mean (SD) patients with SMI lost to care: 33 (22)

11 12 Month Uptake Results Phase II Phase I R

12 12 Month Uptake Results Phase I Phase II R

13 12 Month Uptake Results Phase I Phase II R

14 Clinical Outcomes Received 6 Months of Enhanced REP (Immediate) N=1,543 Received 6 months of Standard REP (Delayed) N=1,532 Cumulative Outcomes Assessed over the 12-Month Period (August 31, 2012-August 31, 2013) Any outpatient use 23.2% 24.9% Any inpatient use 3.6% 3.8% Outcomes in First 6 Months of Implementation Intervention Any outpatient use 15.2% 16.7% Any inpatient use 2.6% 2.8% Outcomes in Second 6 Months of Implementation Intervention Any outpatient use 17.9% 18.9% Any inpatient use 1.8% 2.0%

15 Summary Sites received E-REP (immediate or delayed) had greater uptake of Re-Engage vs. sites receiving REP Attempted contact rate ~50% overall No significant impact on 12-month patient utilization Estimated cost of added Facilitation = 7.3 hours per site for a 6 month dose

16 Conclusions External Facilitation delivered nationally improved uptake of an outreach program Additional implementation support might be needed for less responsive sites Operational partnerships enabled randomization of implementation strategies to enhance uptake of national policy

17 Acknowledgements Ann Arbor CCMR: Amy Kilbourne, PhD, MPH (PI) Kristina Nord, MSW Zongshan Lai, MPH VA Mental Health Services: Jeffrey Burk, PhD David Carroll, PhD David Goodrich, EdD Kirstin Taki, BA Peggy Henderson, PsyD VA Local Recovery Coordinators VA Serious Mental Illness Treatment Resource & Evaluation Center: Kristen Abraham, PhD Stephanie Visnic, BA University of Michigan: Daniel Almirall, PhD Nicholas Bowersox, PhD Joanna Bratton, BSW Funding: VA Health Services Research & Development SDR11-232

18 Characteristics of Sites Characteristic All Sites N=158 Initially Responsive n=69 Overall n=89 Initially Non-Responsive sites n=89 E-REP n=40 Standard REP n=49 Region N (%) N (%) N (%) N (%) N (%) Site delivers outpatient care only Northeast 41 (25.9) 19 (27.5) 22 (24.7) 12 (30.0) 10 (20.4) Midwest 38 (24.1) 15 (21.7) 23 (25.8) 13 (32.5) 10 (20.4) South 45 (28.5) 23 (33.3) 22 (24.7) 8 (20.0) 14 (28.6) West 34 (21.5) 12 (17.4) 22 (24.7) 7 (17.5) 15 (30.6) 19 (12.0) 9 (13.0) 10 (11.2) 4 (10.0) 6 (12.2) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Total Veterans per site FY 12 Veterans with SMI lost to care/site 40,858 (21,346) 41,943 (22,867) 40,016 (20,179) 41,427 (18,216) 38,865 (21,770) 17(6) 17(6) 17(7) 17(6) 17(7)

19 Patient Characteristics Characteristic All Sites N=158 N=5,047 Veterans Initially Responsive n=69 n=1,972 Veterans Overall n=89 n=3,075 Veterans Initially Non-Responsive sites n=89 E-REP n=40 n=1,543 Veterans Standard REP n=49 n=1,532 Veterans N (%) N (%) N (%) N (%) N (%) Male 4550 (90.2) 1768 (89.7) 2782 (90.5) 1405 (91.1) 1377(89.9) Black 886 (17.6) 322 (16.3) 564 (18.3) 329 (21.3) 235 (15.3)* Married 1363 (27.0) 548 (27.8) 815 (26.5) 405 (26.3) 410 (26.8) Service Connected 1422 (28.2) 561 (28.5) 861 (28.0) 424 (27.5) 437 (28.5) Homeless history 650 (12.9) 227 (11.5) 423 (13.8) 229 (14.8) 194 (12.7) Schizophrenia 2017 (39.9) 739 (37.5) 1278 (41.6)* 683 (44.3) 595 (38.8)* Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Age, yrs (14.3) 54.4 (14.3) 55.5 (14.4)* 55.5 (14.1) 55.6 (14.6) No. Comorbidities 1.4 (1.7) 1.5 (1.7) 1.4 (1.6) 1.4 (1.6) 1.5 (1.7) *p-value<0.05 based on Rao-Scott Chi-Square test for categorical variables, and two-tailed t-test for continuous variables.

20 Adjusted Results Compared Immediate vs. Delayed Facilitation #1 Received 6 Months of Enhanced REP (Immediate) N=1543 #2 Received 6 months of Standard REP (Delayed) N=1532 Unadjusted OR (95% CI) Adjusted OR# (95% CI) Cumulative Outcomes Assessed over the Twelve-Month Period (August 31, 2012-August 31, 2013) Any outpatient use 358 (23.2%) 382 (24.9%) 0.90 (0.70, 1.16) 0.94 (0.72, 1.22) Any inpatient use 56 (3.6%) 58 (3.8%) 0.97 (0.62, 1.54) 1.00 (0.66, 1.51) Any in- or outpatient use 361 (23.4%) 383 (25.0%) 0.91 (0.71, 1.17) 0.94 (0.72, 1.23) Outcomes in First 6 Months of Implementation Intervention (August 31, 2012-February 28, 2013) Any outpatient use 234 (15.2%) 256 (16.7%) 0.89 (0.69, 1.16) 0.95 (0.73, 1.24) Any inpatient use 40 (2.6%) 43 (2.8) 0.89 (0.54, 1.46) 0.89 (0.53, 1.49) Any in- or outpatient use 237 (15.4%) 257 (16.8%) 0.91 (0.70, 1.17) 0.96 (0.74, 1.25) Outcomes in Second 6 Months of Implementation Intervention (March 1, 2013-August 31, 2013) Any outpatient use 276 (17.9%) 290 (18.9%) 0.96 (0.72, 1.28) 0.99 (0.74, 1.34) Any inpatient use 28 (1.8%) 30 (2.0%) 0.92 (0.51, 1.65) 0.99 (0.56, 1.72) Any in- or outpatient use 278 (18.0%) 291 (19.0%) 0.96 (0.72, 1.28) 0.99 (0.74, 1.33) These models considered patients clustered within sites, and sites are nested within VISNs. *p-value<0.05

21 Adjusted Results Compared Immediate vs. Delayed Facilitation #1 Received 6 Months of Enhanced REP (Immediate) N=1543 #2 Received 6 months of Standard REP (Delayed) N=1532 Unadjusted OR (95% CI) Cumulative Outcomes Assessed over the Twelve-Month Period (August 31, 2012-August 31, 2013) Adjusted OR# (95% CI) Updated status 848 (54.96%) 613 (40.01%) 1.18 (0.43, 3.28) 1.29 (0.43, 3.90) Attempted contact 694 (44.98%) 491 (32.05%) 1.06 (0.44, 2.59) 1.13 (0.44, 2.93) Completed contact 198 (12.83%) 142 (9.27%) 1.26 (0.72, 2.18) 1.31 (0.70, 2.43) Outcomes in First 6 Months of Implementation Intervention (August 31, 2012-February 28, 2013) Updated status 605 (39.21%) 262 (17.10%) 2.85(0.99, 8.25) 2.81 (0.93, 8.54) Attempted contact 479 (31.04%) 207 (13.51%) 2.15(0.81, 5.71) 2.21 (0.80, 6.05) Completed contact 121 (7.84%) 57 (3.72%) 1.94(1.01, 3.74)* 2.13 (1.09, 4.19)* Outcomes in Second 6 Months of Implementation Intervention (March 1, 2013-August 31, 2013) Updated status 243 (15.75%) 351 (22.91%) 0.30 (0.11, 0.84)* 0.33 (0.12, 0.91)* Attempted contact 215 (13.93%) 284 (18.54%) 0.39 (0.15, 1.08) 0.43 (0.16, 1.19) Completed contact 77 (4.99%) 85 (5.55%) 0.58 (0.26, 1.30) 0.61 (0.25, 1.49) These models considered patients clustered within sites, and sites are nested within VISNs. *p-value<0.05

22 12 Month Uptake Results Phase II Phase I R

PSYCHOSOCIAL REHABILITATION AND RECOVERY SERVICES SECTION

Jeffrey Burk, Ph.D., Associate Chief Consultant PSYCHOSOCIAL REHABILITATION AND RECOVERY SERVICES SECTION UNIFORM MENTAL HEALTH SERVICES HANDBOOK 5. b. (2) Mental health services must be recovery-oriented.