Management of mental disorders in VA primary care practices.
ABSTRACT The association between facility-level organizational features and management of mental health services was assessed based on a survey of directors from 219 VA primary care facilities. Overall, 26.4% of VA primary care facilities referred patients with depression, while 72.6% and 46.1% referred patients with serious mental illness and substance use disorders, respectively Staffing mix (i.e., physician extenders such as nurse practitioners) was associated with a lesser likelihood of mental health referral. Managed care (preauthorization requirement) was associated with a greater likelihood of referral for depression. VA primary care programs, while tending to refer for more serious mental illnesses, may also be using mental health specialists and physician extenders to provide mental health care within general medical settings.
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ABSTRACT: Background Despite the availability of psychosocial evidence-based practices (EBPs), treatment and outcomes for persons with mental disorders remain suboptimal. Replicating Effective Programs (REP), an effective implementation strategy, still resulted in less than half of sites using an EBP. The primary aim of this cluster randomized trial is to determine, among sites not initially responding to REP, the effect of adaptive implementation strategies that begin with an External Facilitator (EF) or with an External Facilitator plus an Internal Facilitator (IF) on improved EBP use and patient outcomes in 12 months.Methods/DesignThis study employs a sequential multiple assignment randomized trial (SMART) design to build an adaptive implementation strategy. The EBP to be implemented is life goals (LG) for patients with mood disorders across 80 community-based outpatient clinics (N¿=¿1,600 patients) from different U.S. regions. Sites not initially responding to REP (defined as <50% patients receiving ¿3 EBP sessions) will be randomized to receive additional support from an EF or both EF/IF. Additionally, sites randomized to EF and still not responsive will be randomized to continue with EF alone or to receive EF/IF. The EF provides technical expertise in adapting LG in routine practice, whereas the on-site IF has direct reporting relationships to site leadership to support LG use in routine practice. The primary outcome is mental health-related quality of life; secondary outcomes include receipt of LG sessions, mood symptoms, implementation costs, and organizational change.DiscussionThis study design will determine whether an off-site EF alone versus the addition of an on-site IF improves EBP uptake and patient outcomes among sites that do not respond initially to REP. It will also examine the value of delaying the provision of EF/IF for sites that continue to not respond despite EF.Trial registrationClinicalTrials.gov identifier: NCT02151331.Implementation Science 09/2014; 9(1):132. · 3.47 Impact Factor
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ABSTRACT: The formal mission and strategic goals of the Center for the Study of Healthcare Provider Behavior (see bottom of this page) guide our activities in the do- mains of research, dissemination, technical assis- tance and training. Our mission and activities are also guided by the strategic priorities and mission of the Veterans Health Administration (VHA). VHA's current strategic emphasis is provided by the "Eight for Excellence" framework, comprising eight broad goals and associated strategies and initiatives. This overview article highlights selected Center activities supporting key goals and strategies in the Eight for Excellence initiative. Many of the Eight for Excellence goals emphasize continuous improvement in healthcare quality and safety. For example, Goal 1 broadly addresses continuous improvement in the quality and safety of health care for veterans, while Goal 5 calls for in- creased focus of VHA research and development activities on clinical and system improvements, including increased collaboration between VHA research and health care delivery and increased targeting of VHA health services research and the QUERI model to improve care delivery. These goals entail substantial overlap with our Cen- ter's core mission and activities: our portfolio of projects in research, technical assistance and train- ing are designed to strengthen VHA's ability to improve quality and safety through implementation of evidence-based practices. Center researchers are pursing improvement in tobacco use (Judith Katz-
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ABSTRACT: OBJECTIVE To ensure optimal care for patients with schizophrenia, antipsychotic medications must be appropriately prescribed and used. Therefore, the primary objectives of this study were to identify and describe pathways for antipsychotic prescribing, assess the consistency of observed pathways with treatment guidelines, and describe variability across facilities. METHODS Data from Veterans Affairs administrative data sets from fiscal year (FY) 2003 to FY 2007 were gathered for analysis in this retrospective cohort study of antipsychotic prescribing pathways among 13 facilities across two regional networks. Patients with a new episode of care for schizophrenia or schizoaffective disorder in FY 2005 were identified, and antipsychotic prescribing history was obtained for two years before and after the index diagnosis. Demographic characteristics and distribution of comorbidities were assessed. Median medical center rates of polypharmacy were calculated and compared with Fisher's exact test. RESULTS Of 1,923 patients with a new episode of schizophrenia care, 1,003 (52%) had complete data on prescribing pathways. A majority (74%) of patients were prescribed antipsychotic monotherapy, and 19% received antipsychotic polypharmacy. Of patients receiving antipsychotic polypharmacy, 65% began polypharmacy within 90 days of starting any antipsychotic treatment. There was a fourfold difference in polypharmacy across facilities. Antipsychotic polypharmacy was not associated with geographic location or medical center patient volume. Clozapine utilization was low (0%-2%). CONCLUSIONS Retrospective examination of longitudinal prescribing patterns identified multiple antipsychotic prescribing pathways. Although most patients received guideline-concordant care, antipsychotic polypharmacy was commonly used as initial treatment, and there was substantial variability among facilities. Study findings suggest the utility of secondary data to assess treatment adaptation or switching for practical clinical trials.Psychiatric services (Washington, D.C.) 03/2013; · 2.81 Impact Factor