Centralizing Telehealth Test-to-Treat Through a Regional Clinical Contact Center: A Veterans Health Administration Pilot.

Background: This project describes a Veterans Health Administration telehealth pilot to facilitate COVID-19 oral antiviral treatment as part of the national test-to-treat (T2T) strategy. The pilot was operationalized for two pilot VA medical centers by the regional clinical contact center (CCC) for a Veteran Integrated Service Network, which offers multiple services through several virtual modalities. Methods: Nurse triage and medical provider evaluation templates were developed for the CCC to standardize clinical interventions with veteran callers reporting positive home COVID-19 test results. When veterans were determined eligible and consented to treatment with an emergency use authorization (EUA) antiviral medication, CCC providers used secure direct messaging for synchronous communication with local pharmacy services to facilitate adjudication and dispensing. Templates for pharmacy documentation and primary care follow-up monitoring were also developed and disseminated. Results: In total, 198 veterans (mean age 65 years, 89% male, 88% non-Hispanic White) were evaluated through telehealth by regional CCC providers using the T2T process and 96% were prescribed an antiviral medication. Primary care follow-up occurred in 86% of cases, a median of 3 days after the telehealth evaluation. The 30-day all-cause hospitalization rate was 1.5% and there were no deaths within 30 days of treatment initiation. Conclusions: Veterans Integrated Service Network's CCC telehealth triage and evaluation processes enabled safe EUA-compliant care delivery, improved evaluator experience and efficiency, and augmented existing EUA processes in place by front-line pharmacy and primary care teams.

Staff perceptions implementing interprofessional team-based behavioural healthcare.

The US Veterans Health Administration (VHA) in 2013 mandated a nationwide implementation of interprofessional team-based care in the general mental health setting and officially endorsed the collaborative care model in 2015 to guide the coordinated and anticipatory care to be delivered by these teams. Front-line clinic staff are major stakeholders whose practices are most directly affected by this implementation and may or may not view teams as useful or feasible for their practice. Our objective was to examine their perspectives on delivering team-to-patient care in order to understand what system-level efforts can best support the transition to such care from the more conventional provider-to-patient care. We conducted 14 semi-structured interviews with staff from general mental health clinics across three different VHA medical facilities. The interview questions focused on asking how care is organised and delivered at their clinic, their experiences in collaborating with other staff, and how the clinic handles changes. Four recurrent themes were identified: navigating workplace supervision, organisation, and role structures; continuing professional growth and relationships; delivering patient-focused care through education and connection to resources; and utilising information technology for communication and panel-based management. Quality improvement efforts were rarely discussed during the interviews. Our results indicate that staff's endorsement of the implementation of interprofessional care teams in general mental health settings may be strengthened through associated efforts targeted at enhancing their experiences aligned to these emergent themes.

Using Mixed Methods to Examine the Role of Veterans' Illness Perceptions on Depression Treatment Utilization and HEDIS Concordance.

BACKGROUND: Although depression screening occurs annually in the Department of Veterans Affairs (VA) primary care, many veterans may not be receiving guideline-concordant depression treatment. OBJECTIVES: To determine whether veterans' illness perceptions of depression may be serving as barriers to guideline-concordant treatment. RESEARCH DESIGN: We used a prospective, observational design involving a mailed questionnaire and chart review data collection to assess depression treatment utilization and concordance with Healthcare Effectiveness Data and Information Set guidelines adopted by the VA. The Self-Regulation Model of Illness Behavior guided the study. SUBJECTS: Veterans who screened positive for a new episode of depression at 3 VA primary care clinics in the US northeast. MEASURES: The Illness Perceptions Questionnaire-Revised, measuring patients' perceptions of their symptoms, cause, timeline, consequences, cure or controllability, and coherence of depression and its symptoms, was our primary measure to calculate veterans' illness perceptions. Treatment utilization was assessed 3 months after the positive depression screen through chart review. Healthcare Effectiveness Data and Information Set (HEDIS) guideline-concordant treatment was determined according to a checklist created for the study. RESULTS: A total of 839 veterans screened positive for a new episode of depression from May 2009-June 2011; 275 (32.8%) completed the survey. Ninety-two (33.9%) received HEDIS guideline-concordant depression treatment. Veterans' illness perceptions of their symptoms, cause, timeline, and controllability of depression predicted receiving guideline-concordant treatment. CONCLUSIONS: Many veterans are not receiving guideline-concordant treatment for depression. HEDIS guideline measures may not be assessing all aspects of quality depression care. Conversations about veterans' illness perceptions and their specific needs are encouraged to ensure that appropriate treatment is achieved.

Implementation of evidence-based psychotherapies for posttraumatic stress disorder in VA specialty clinics.

OBJECTIVE: The U.S. Department of Veterans Affairs (VA) has engaged in substantial efforts to promote the use of evidence-based psychotherapies for posttraumatic stress disorder (PTSD). The authors evaluated the effectiveness of these efforts. METHODS: This study used a cross-sectional, mixed-methods evaluation of treatment provided by the VA at specialty PTSD clinics in New England during the first six months of fiscal year 2010. Natural language processing algorithms were applied to clinical notes to determine utilization of evidence-based psychotherapy (prolonged exposure therapy and cognitive-processing therapy) among patients who were newly diagnosed as having PTSD. Data regarding efforts to implement evidence-based psychotherapy and other clinic characteristics were obtained through qualitative interviews with clinical and administrative staff (N=30), and the Promoting Action on Research Implementation in Health Services framework was used to identify clinic factors associated with use of evidence-based psychotherapy. RESULTS: Six percent of patients (N=1,924) received any sessions of an evidence-based psychotherapy for PTSD (median=five sessions). Several clinic factors were associated with an increased rate of implementation, including prior experience with use of the treatments, customization of training, and prolonged contact with the implementation and training team. Facilitation with broad training goals and clinics with highly organized systems of care were negatively associated with implementation. CONCLUSIONS: Few patients with PTSD received evidence-based psychotherapy for PTSD during their first six months of treatment at a VA specialty PTSD clinic. The implementation framework poorly predicted factors associated with uptake of evidence-based psychotherapy. These results suggest that additional research is needed to understand implementation of evidence-based therapy in mental health settings.

Caring with comfort rooms. Reducing seclusion and restraint use in psychiatric facilities.

The reduction of seclusion and restraint is a national patient safety focus in psychiatric settings. Studies have demonstrated that multisensory or comfort rooms contribute to higher consumer satisfaction and lower rates of seclusion and restraint in general hospitals. As an alternative to the traditionally uncomfortable time-out room, a comfort room was constructed on an acute adult inpatient unit. This space was designed with comfortable furniture, soothing colors, soft lighting, quiet music, and other sensory aids to help reduce unsettled patients' level of stress. The frequency and duration of seclusion and restraint use on the pilot unit was studied before and after implementation of the comfort room. The use of seclusion and restraint was also compared with a similar admission unit without a comfort room. Results supported the hypothesis that the presence of a comfort room significantly reduced seclusion and restraint, and that the use of the comfort room helped reduce patients' stress.

The effectiveness of assertive community treatment for homeless populations with severe mental illness: a meta-analysis.

OBJECTIVE: The purpose of this study was to assess the effectiveness of assertive community treatment in the rehabilitation of homeless persons with severe mental illness using a meta-analysis. METHOD: A structured literature search identified studies for review. Inclusion criteria were the use of an assertive community treatment-based rehabilitation treatment in an experimental or quasi-experimental model, exclusive treatment of homeless subjects, and follow-up of housing and psychiatric outcomes. Two reviewers independently abstracted data on methodology and outcomes from included studies. The authors calculated effect differences, summary effects and confidence intervals (CIs) for housing, and hospitalization and symptom severity outcomes. RESULTS: Of the 52 abstracts identified, 10 (19%) met inclusion criteria. Of these, six were randomized controlled trials, and four were observational studies, totaling 5,775 subjects. In randomized trials, assertive community treatment subjects demonstrated a 37% (95% CI=18%-55%) greater reduction in homelessness and a 26% (95% CI=7%-44%) greater improvement in psychiatric symptom severity compared with standard case management treatments. Hospitalization outcomes were not significantly different between the two groups. In observational studies, assertive community treatment subjects experienced a 104% (95% CI=67%-141%) further reduction in homelessness and a 62% (95% CI=0%-124%) further reduction in symptom severity compared with pretreatment comparison subjects. CONCLUSIONS: Assertive community treatment offers significant advantages over standard case management models in reducing homelessness and symptom severity in homeless persons with severe mental illness.