Enhancing Quality Utilization in Psychosis

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. 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 is 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 hypothesize that this care model will increase provider adherence to treatment guidelines and improve the quality of care. We will describe implementation of the model, and barriers and facilitators to its implementation. We will evaluate the model by comparing treatment under the care model with usual care. Changes in the structure of care are evaluated using qualitative methods.

METHODS: EQUIP is a controlled trial of the care model. Psychiatrists are randomly assigned to the new care model or to remain with usual care. Data sources include patient interviews, clinician interviews, and data from VistA. The feasibility of more broadly implementing the collaborative care model is 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 has been 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 are overweight, but few appropriate services were available for this problem. Both sites have started wellness programs. The psychiatrists believe that the intervention has improved medication prescribing and care by improving information and care management. Further results are pending.

STATUS: The care model was implemented for more than 15 months at two sites: Greater Los Angeles (GLA) and Long Beach VA Healthcare Centers. The Long Beach Mental Health Clinic had both intervention and usual care psychiatrists. At GLA, the Sepulveda Mental Health Clinic had both intervention and usual care psychiatrists, and the West Los Angeles Mental Health Clinic had usual care psychiatrists. All eligible psychiatrists except one were enrolled (n= 68). 375 patients enrolled, with approximately 149 in the intervention group. A computer system was developed to manage the research study and support the collaborative care model. Called the "Medical Informatics Network Tool" (MINT), it was implemented for all intervention clinicians, and is also used by research staff to manage enrollment and project data. Research assessments of patients and providers have been conducted at baseline, and the final research assessments and data analyses are underway.

IMPACT: This project will provide information regarding how to improve the quality and efficiency of care for schizophrenia.