BACKGROUND/RATIONALE:
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.
OBJECTIVE(S):
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.
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.
FINDINGS/RESULTS:
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.
IMPACT:
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.
PUBLICATIONS:
Journal Articles
- Niv N, Cohen AN, Sullivan G, Young AS. The MIRECC version of the Global Assessment of Functioning scale: reliability and validity. Psychiatric Services. 2007; 58(4): 529-35.
- Erhart SM, Young AS, Marder SR, Mintz J. Clinical utility of magnetic resonance imaging radiographs for suspected organic syndromes in adult psychiatry. Journal of Clinical Psychiatry. 2005; 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; 11(5): 358-67.
- Young AS, Mintz J, Cohen AN. Using information systems to improve care for persons with schizophrenia. Psychiatric Services. 2004; 55(3): 253-255.
