Development and Pilot Test of the Competency Assessment for Sexual Assault Prevention Practitioners.

Sexual assault is a preventable problem that is widespread and particularly prevalent for certain populations (e.g., female college students, Native American women). Despite the gravity of this public health priority, most individuals tasked with the primary prevention of sexual assault are not adequately trained for the job (e.g., professionals often trained solely in sexual assault response). To achieve optimal outcomes, professionals responsible for implementing sexual assault prevention must possess certain core competencies, or knowledge and skills essential for job performance, which include those needed for any primary prevention effort in addition to those specific to sexual assault prevention. The purpose of this study was to develop and assess the construct validity of a competency assessment tool for sexual assault prevention practitioners. An existing assessment tool, which was designed for injury and violence prevention practitioners, was tailored to reflect competencies needed by sexual assault prevention practitioners as informed by the literature. The newly tailored measure was pilot tested with 33 individuals with varying levels of expertise with sexual assault prevention. These individuals were categorized into three groups based on self-rated sexual assault prevention expertise (low, medium, or high) to assess group differences. As expected, the high expertise group rated higher knowledge in all the competencies than the medium and low expertise groups (except for the competency pertaining to developing and maintaining competency). Data collection and analyses were conducted in 2020. Implications for how the assessment tool can be used to identify gaps among individual practitioners and teams of practitioners are discussed.

Proactive, Recovery-Oriented Treatment Navigation to Engage Racially Diverse Veterans in Mental Healthcare (PARTNER-MH), a Peer-Led Patient Navigation Intervention for Racially and Ethnically Minoritized Veterans in Veterans Health Administration Mental Health Services: Protocol for a Mixed Methods Randomized Controlled Feasibility Study.

BACKGROUND: Mental health care disparities are persistent and have increased in recent years. Compared with their White counterparts, members of racially and ethnically minoritized groups have less access to mental health care. Minoritized groups also have lower engagement in mental health treatment and are more likely to experience ineffective patient-provider communication, which contribute to negative mental health care experiences and poor mental health outcomes. Interventions that embrace recovery-oriented practices to support patient engagement and empower patients to participate in their mental health care and treatment decisions may help reduce mental health care disparities. Designed to achieve this goal, the Proactive, Recovery-Oriented Treatment Navigation to Engage Racially Diverse Veterans in Mental Healthcare (PARTNER-MH) is a peer-led patient navigation intervention that aims to engage minoritized patients in mental health treatment, support them to play a greater role in their care, and facilitate their participation in shared treatment decision-making. OBJECTIVE: The primary aim of this study is to assess the feasibility and acceptability of PARTNER-MH delivered to patients over 6 months. The second aim is to evaluate the preliminary effects of PARTNER-MH on patient activation, patient engagement, and shared decision-making. The third aim is to examine patient-perceived barriers to and facilitators of engagement in PARTNER-MH as well as contextual factors that may inhibit or promote the integration, sustainability, and scalability of PARTNER-MH using the Consolidated Framework for Implementation Research. METHODS: This pilot study evaluates the feasibility and acceptability of PARTNER-MH in a Veterans Health Administration (VHA) mental health setting using a mixed methods, randomized controlled trial study design. PARTNER-MH is tested under real-world conditions using certified VHA peer specialists (peers) selected through usual VHA hiring practices and assigned to the mental health service line. Peers provide PARTNER-MH and usual peer support services. The study compares the impact of PARTNER-MH versus a wait-list control group on patient activation, patient engagement, and shared decision-making as well as other patient-level outcomes. PARTNER-MH also examines organizational factors that could impact its future implementation in VHA settings. RESULTS: Participants (N=50) were Veterans who were mostly male (n=31, 62%) and self-identified as non-Hispanic (n=44, 88%) and Black (n=35, 70%) with a median age of 45 to 54 years. Most had at least some college education, and 32% (16/50) had completed ≥4 years of college. Randomization produced comparable groups in terms of characteristics and outcome measures at baseline, except for sex. CONCLUSIONS: Rather than simply documenting health disparities among vulnerable populations, PARTNER-MH offers opportunities to evaluate a tailored, culturally sensitive, system-based intervention to improve patient engagement and patient-provider communication in mental health care for racially and ethnically minoritized individuals. TRIAL REGISTRATION: ClinicalTrials.gov NCT04515771; https://clinicaltrials.gov/ct2/show/NCT04515771. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/37712.

Pre-implementation Evaluation of PARTNER-MH: A Mental Healthcare Disparity Intervention for Minority Veterans in the VHA.

To design PARTNER-MH, a peer-led, patient navigation program for implementation in Veterans Health Administration (VHA) mental health care settings, we conducted a pre-implementation evaluation during intervention development to assess stakeholders' views of the intervention and to explore implementation factors critical to its future adoption. This is a convergent mixed-methods study that involved qualitative semi-structured interviews and survey data. Data collection was guided by the Consolidated Framework for Implementation Research (CFIR). We interviewed and administered the surveys to 23 peers and 10 supervisors from 12 midwestern VHA facilities. We used deductive and inductive approaches to analyze the qualitative data. We also conducted descriptive analysis and Fisher Exact Test to compare peers and supervisors' survey responses. We triangulated findings to refine the intervention. Overall, participants viewed PARTNER-MH favorably. However, they saw the intervention's focus on minority Veterans and social determinants of health framework as potential barriers, believing this could negatively affect the packaging of the intervention, complicate its delivery process, and impact its adoption. They also viewed clinic structures, available resources, and learning climate as potential barriers. Peers and supervisors' selections and discussions of CFIR items were similar. Our findings informed PARTNER-MH development and helped identify factors that could impact its implementation. This project is responsive to the increasing recognition of the need to incorporate implementation science in healthcare disparities research. Understanding the resistance to the intervention's focus on minority Veterans and the potential barriers presented by contextual factors positions us to adjust the intervention prior to testing, in an effort to maximize implementation success.

Health service preferences among veterans in supported housing in relation to needs expressed and services used.

BACKGROUND: Understanding consumer service preferences is important for recovery-oriented care. AIMS: To test the influence of perceived service needs on importance attached to treatment for alcohol, drug, mental health, and physical health problems and identify the influence of service needs and preferences on service use. METHODS: Formerly homeless dually diagnosed Veterans in supported housing were surveyed in three waves for 1 year, with measures of treatment interests, health problems, social support, clinician-assessed risk of housing loss, and sociodemographics. Multiple regression analysis was used to identify independent influences on preferences in each wave. Different health services at the VA were distinguished in administrative records and baseline predictors for services used throughout the project were identified with multiple regression analysis. RESULTS: Self-assessed problem severity was associated with the importance of treatment for alcohol, drug, mental health, and physical health problems. Social support also had some association with treatment interest for alcohol abuse, as did baseline clinician risk rating at the project's end. Preferences, but not perceived problem severity, predicted the use of the corresponding health services. CONCLUSIONS: The health beliefs model of service interests was supported, but more integrated service delivery models may be needed to strengthen the association of health needs with service use.

Cost analysis of a randomized trial of Getting to Outcomes implementation support for a teen pregnancy prevention program offered in Boys and Girls Clubs in Alabama and Georgia.

Implementation support can improve outcomes of evidence-based programs (EBP) for adolescents, but with a cost. To assist in determining whether this cost is worthwhile, this study estimated the cost of adding Getting To Outcomes© (GTO) implementation support to a teen pregnancy and sexually transmitted infection prevention EBP called Making Proud Choices (MPC) in 32 Boys and Girls Clubs (BGCs) in Alabama and Georgia. Enhancing Quality Interventions Promoting Healthy Sexuality (EQUIPS) was a 2-year, cluster-randomized controlled trial comparing MPC with MPC + GTO. We used micro-costing to estimate costs and captured MPC and GTO time from activity logs completed by GTO staff. Key resource use and cost components were compared between the randomized groups, years, and states (to capture different community site circumstances) using 2-sample t tests. There were no significant differences between randomized groups in attendees per site, resource use, or costs for either year. However, there were significant differences between states. Adding GTO to MPC increased the societal costs per attendee from $67 to $144 (2015 US dollars) in Georgia and from $106 to $314 in Alabama. The higher Alabama cost was due to longer travel distances and to more BGC staff time spent on GTO in that state. GTO also improved adherence, classroom delivery, and condom-use intentions more in Alabama youth. Thus, Alabama's GTO-related BGC staff time costs may be better estimates of effective GTO. If teen childbearing costs taxpayers approximately $20,000 per teen birth, adding GTO to MPC would be worthwhile to society if it prevented one more teen birth per 140 attendees than MPC alone.Trial registration. ClinicalTrials.gov , NCT01818791. Registered March 26, 2013, https://clinicaltrials.gov/ct2/show/NCT01818791?term=NCT01818791&draw=2&rank=1.

Tracking implementation strategies in the randomized rollout of a Veterans Affairs national opioid risk management initiative.

BACKGROUND: In 2018, the Department of Veterans Affairs (VA) issued Notice 2018-08 requiring facilities to complete "case reviews" for Veterans identified in the Stratification Tool for Opioid Risk Mitigation (STORM) dashboard as high risk for adverse outcomes among patients prescribed opioids. Half of the facilities were randomly assigned to a Notice version including additional oversight. We evaluated implementation strategies used, whether strategies differed by randomization arm, and which strategies were associated with case review completion rates. METHODS: Facility points of contact completed a survey assessing their facility's use of 68 implementation strategies based on the Expert Recommendations for Implementing Change taxonomy. We collected respondent demographic information, facility-level characteristics, and case review completion rates (percentage of high-risk patients who received a case review). We used Kruskal-Wallis tests and negative binomial regression to assess strategy use and factors associated with case reviews. RESULTS: Contacts at 89 of 140 facilities completed the survey (64%) and reported using a median of 23 (IQR 16-31) strategies. The median case review completion rate was 71% (IQR 48-95%). Neither the number or types of strategies nor completion rates differed by randomization arm. The most common strategies were using the STORM dashboard (97%), working with local opinion leaders (80%), and recruiting local partners (80%). Characteristics associated with case review completion rates included respondents being ≤ 35 years old (incidence rate ratio, IRR 1.35, 95% CI 1.09-1.67) and having < 5 years in their primary role (IRR 1.23; 95% CI 1.01-1.51), and facilities having more prior academic detailing around pain and opioid safety (IRR 1.40, 95% CI 1.12-1.75). Controlling for these characteristics, implementation strategies associated with higher completion rates included (1) monitoring and adjusting practices (adjusted IRR (AIRR) 1.40, 95% CI 1.11-1.77), (2) identifying adaptations while maintaining core components (AIRR 1.28, 95% CI 1.03-1.60), (3) conducting initial training (AIRR 1.16, 95% CI 1.02-1.50), and (4) regularly sharing lessons learned (AIRR 1.32, 95% CI 1.09-1.59). CONCLUSIONS: In this national evaluation of strategies used to implement case reviews of patients at high risk of opioid-related adverse events, point of contact age and tenure in the current role, prior pain-related academic detailing at the facility, and four specific implementation strategies were associated with case review completion rates, while randomization to additional centralized oversight was not. TRIAL REGISTRATION: This project is registered at the ISRCTN Registry with number ISRCTN16012111. The trial was first registered on May 3, 2017.

Cost Analysis of a Randomized Trial of Getting to Outcomes Implementation Support of CHOICE in Boys and Girls Clubs in Southern California.

Costs of supporting prevention program implementation are not well known. This study estimates the societal costs of implementing CHOICE, a voluntary after-school alcohol and other drug prevention program for adolescents, in Boys and Girls Clubs (BGCs) across Southern California with and without an implementation support system called Getting To Outcomes© (GTO). This article uses micro-costing methods to estimate the cost of the CHOICE program and GTO support. Labor and expense data were obtained from logs kept by the BGC staff and by the GTO technical assistance (TA) staff, and staff time was valued based on Bureau of Labor Statistics estimates. From the societal perspective, the cost of implementing CHOICE at BGCs over the 2-year study period was $27 per attendee when CHOICE was offered by itself (all costs incurred by the BGCs) and $177 per attendee when CHOICE was offered with GTO implementation support ($67 cost to the BGCs; $110 to the entity funding GTO). These results were most sensitive to assumptions as to the number of times CHOICE was offered per year. Adding GTO implementation support to CHOICE increased the cost per attendee by approximately $150. For this additional cost, there was evidence that the CHOICE program was offered with more fidelity and offered more often after the 2-year intervention ended. If the long-term benefits of this better and continued implementation are found to exceed these additional costs, GTO could be an attractive structure to support evidence-based substance misuse prevention programs. Trial Registration. This project is registered at ClinicalTrials.gov with number NCT02135991 (URL: https://clinicaltrials.gov/show/NCT02135991). The trial was registered May 12, 2014.

Longitudinal assessment of the association between implementation strategy use and the uptake of hepatitis C treatment: Year 2.

BACKGROUND: To increase the uptake of evidence-based treatments for hepatitis C (HCV), the Department of Veterans Affairs (VA) established the Hepatitis Innovation Team (HIT) Collaborative. Teams of providers were tasked with choosing implementation strategies to improve HCV care. The aim of the current evaluation was to assess how site-level implementation strategies were associated with HCV treatment initiation and how the use of implementation strategies and their association with HCV treatment changed over time. METHODS: A key HCV provider at each VA site (N = 130) was asked in two consecutive fiscal years (FYs) to complete an online survey examining the use of 73 implementation strategies organized into nine clusters as described by the Expert Recommendations for Implementing Change (ERIC) study. The number of Veterans initiating treatment for HCV, or "treatment starts," at each site was captured using national data. Providers reported whether the use of each implementation strategy was due to the HIT Collaborative. RESULTS: Of 130 sites, 80 (62%) responded in Year 1 (FY15) and 105 (81%) responded in Year 2 (FY16). Respondents endorsed a median of 27 (IQR19-38) strategies in Year 2. The strategies significantly more likely to be chosen in Year 2 included tailoring strategies to deliver HCV care, promoting adaptability, sharing knowledge between sites, and using mass media. The total number of treatment starts was significantly positively correlated with total number of strategies endorsed in both years. In Years 1 and 2, respectively, 28 and 26 strategies were significantly associated with treatment starts; 12 strategies overlapped both years, 16 were unique to Year 1, and 14 were unique to Year 2. Strategies significantly associated with treatment starts shifted between Years 1 and 2. Pre-implementation strategies in the "training/educating," "interactive assistance," and "building stakeholder interrelationships" clusters were more likely to be significantly associated with treatment starts in Year 1, while strategies in the "evaluative and iterative" and "adapting and tailoring" clusters were more likely to be associated with treatment starts in Year 2. Approximately half of all strategies were attributed to the HIT Collaborative. CONCLUSIONS: These results suggest that measuring implementation strategies over time is a useful way to catalog implementation of an evidence-based practice over time and across settings.

Protocol for evaluating the nationwide implementation of the VA Stratification Tool for Opioid Risk Management (STORM).

BACKGROUND: Mitigating the risks of adverse outcomes from opioids is critical. Thus, the Veterans Affairs (VA) Healthcare System developed the Stratification Tool for Opioid Risk Management (STORM), a dashboard to assist clinicians with opioid risk evaluation and mitigation. Updated daily, STORM calculates a "risk score" of adverse outcomes (e.g., suicide-related events, overdoses, overdose death) from variables in the VA medical record for all patients with an opioid prescription and displays this information along with documentation of recommended risk mitigation strategies and non-opioid pain treatments. In March 2018, the VA issued a policy notice requiring VA Medical Centers (VAMCs) to complete case reviews for patients whom STORM identifies as very high-risk (i.e., top 1% of STORM risk scores). Half of VAMCs were randomly assigned notices that also stated that additional support and oversight would be required for VAMCs that failed to meet an established percentage of case reviews. Using a stepped-wedge cluster randomized design, VAMCs will be further randomized to conduct case reviews for an expanded pool of patients (top 5% of STORM risk scores vs. 1%) starting either 9 or 15 months after the notice was released, creating four natural arms. VA commissioned an evaluation to understand the implementation strategies and factors associated with case review completion rates, whose protocol is described in this report. METHODS: This mixed-method study will include an online survey of all VAMCs to identify implementation strategies and interviews at a subset of facilities to identify implementation barriers and facilitators. The survey is based on the Expert Recommendations for Implementing Change (ERIC) project, which engaged experts to create consensus on 73 implementation strategies. We will use regression models to compare the number and types of implementation strategies across arms and their association with case review completion rates. Using questions from the Consolidated Framework for Implementation Research, we will interview stakeholders at 40 VAMCs with the highest and lowest adherence to opioid therapy guidelines. DISCUSSION: By identifying which implementation strategies, barriers, and facilitators influence case reviews to reduce opioid-related adverse outcomes, this unique implementation evaluation will enable the VA to improve the design of future opioid safety initiatives. TRIAL REGISTRATION: This project is registered at the ISRCTN Registry with number ISRCTN16012111 . The trial was first registered on 5/3/2017.

Harnessing Implementation Science to Increase the Impact of Health Equity Research.

BACKGROUND: Health disparities are differences in health or health care between groups based on social, economic, and/or environmental disadvantage. Disparity research often follows 3 steps: detecting (phase 1), understanding (phase 2), and reducing (phase 3), disparities. Although disparities have narrowed over time, many remain. OBJECTIVES: We argue that implementation science could enhance disparities research by broadening the scope of phase 2 studies and offering rigorous methods to test disparity-reducing implementation strategies in phase 3 studies. METHODS: We briefly review the focus of phase 2 and phase 3 disparities research. We then provide a decision tree and case examples to illustrate how implementation science frameworks and research designs could further enhance disparity research. RESULTS: Most health disparities research emphasizes patient and provider factors as predominant mechanisms underlying disparities. Applying implementation science frameworks like the Consolidated Framework for Implementation Research could help disparities research widen its scope in phase 2 studies and, in turn, develop broader disparities-reducing implementation strategies in phase 3 studies. Many phase 3 studies of disparity-reducing implementation strategies are similar to case studies, whose designs are not able to fully test causality. Implementation science research designs offer rigorous methods that could accelerate the pace at which equity is achieved in real-world practice. CONCLUSIONS: Disparities can be considered a "special case" of implementation challenges-when evidence-based clinical interventions are delivered to, and received by, vulnerable populations at lower rates. Bringing together health disparities research and implementation science could advance equity more than either could achieve on their own.

Evaluating the impact of getting to outcomes-underage drinking on prevention capacity and alcohol merchant attitudes and selling behaviors.

Underage drinking is a significant problem facing US communities. Several environmental alcohol prevention (EAP) strategies (laws, regulations, responsible beverage service training and practices) successfully address underage drinking. Communities, however, face challenges carrying out these EAP strategies effectively. This small-scale, 3-year, randomized controlled trial assessed whether providing prevention coalitions with Getting To Outcomes-Underage Drinking (GTO-UD), a tool kit and implementation support intervention, helped improve implementation of two common EAP strategies, responsible beverage service training (RBS) and compliance checks. Three coalitions in South Carolina and their RBS and compliance check programs received the 16-month GTO-UD intervention, including the GTO-UD manual, training, and onsite technical assistance, while another three in South Carolina maintained routine operations. The measures, collected at baseline and after the intervention, were a structured interview assessing how well coalitions carried out their work and a survey of merchant attitudes and practices in the six counties served by the participating coalitions. Over time, the quality of some RBS and compliance check activities improved more in GTO-UD coalitions than in the control sites. No changes in merchant practices or attitudes significantly differed between the GTO-UD and control groups, although merchants in the GTO-UD counties did significantly improve on refusing sales to minors while control merchants did not.

Lessons learned from a quality improvement intervention with homeless veteran services.

Homeless veterans are a vulnerable population, with high mortality and morbidity rates. Evidence-based practices for homelessness have been challenging to implement. This study engaged staff members from three VA homeless programs to improve their quality using Getting-To-Outcomes (GTO), a model and intervention of trainings and technical assistance that builds practitioner capacity to plan, implement, and self-evaluate evidence-based practices. Primarily used in community-based, non-VA settings, this study piloted GTO in VA by creating a GTO project within each homeless program and one across all three. The feasibility and acceptability of GTO in VA is examined using the results of the projects, time spent on GTO, and data from focus groups and interviews. With staff members averaging 33 minutes per week on GTO, each team made significant programmatic changes. Homeless staff stated GTO was helpful, and that high levels of communication, staff member commitment to the program, and technical assistance were critical.

Establishing and evaluating the key functions of an interactive systems framework using an assets-getting to outcomes intervention.

Community practitioners can face difficulty in achieving outcomes demonstrated by prevention science. Building a community practitioner's prevention capacity-the knowledge and skills needed to conduct critical prevention practices-could improve the quality of prevention and its outcomes. The purpose of this article is to: (1) describe how an intervention called Assets-Getting To Outcomes (AGTO) was used to establish the key functions of the ISF and present early lessons learned from that intervention's first 6 months and (2) examine whether there is an empirical relationship between practitioner capacity at the individual level and the performance of prevention at the program level-a relationship predicted by the ISF but untested. The article describes an operationalization of the ISF in the context of a five-year randomized controlled efficacy trial that combines two complementary models designed to build capacity: Getting To Outcomes (GTO) and Developmental Assets. The trial compares programs and individual practitioners from six community-based coalitions using AGTO with programs and practitioners from six similar coalitions that are not. In this article, we primarily focus on what the ISF calls innovation specific capacity and discuss how the combined AGTO innovation structures and uses feedback about its capacity-building activities, which can serve as a model for implementing the ISF. Focus group discussions used to gather lessons learned from the first 6 months of the AGTO intervention suggest that while the ISF may have been conceptualized as three distinct systems, in practice they are less distinct. Findings from the baseline wave of data collection of individual capacity and program performance suggest that practitioner capacity predicts, in part, performance of prevention programs. Empirically linking practitioner capacity and performance of prevention provides empirical support for both the ISF and AGTO.

National survey on implementation of peer specialists in the VA: implications for training and facilitation.

OBJECTIVES: Peer support is fundamental to the promotion of recovery as indicated in the President's New Freedom Commission Report. Five years into the Department of Veterans Affairs' (VA) initiative to hire Peer Specialists (PSs)-individuals with serious mental illnesses assigned to clinical teams to support others with serious mental illnesses-this study explored challenges, facilitators, and progress of PS implementation from a stakeholder group involved in their management. METHODS: Ninety-two VA Local Recovery Coordinators (LRCs) from across the nationwide VA mental health system were surveyed about their perceptions about PS hiring, status of implementation, impact, barriers and facilitators to successful employment of PSs, and willingness to support implementation. RESULTS: The data suggest that PS implementation is going well overall, but challenges remain such as hiring delays, lack of understanding about the PS role, and lack of funding. CONCLUSIONS AND IMPLICATIONS: Implementation challenges can undermine the employment of PSs. The VA and other organizations using PSs could improve implementation by monitoring the challenges and proactively facilitating the process on an ongoing basis.

Routine outcomes monitoring to support improving care for schizophrenia: report from the VA Mental Health QUERI.

In schizophrenia, treatments that improve outcomes have not been reliably disseminated. A major barrier to improving care has been a lack of routinely collected outcomes data that identify patients who are failing to improve or not receiving effective treatments. To support high quality care, the VA Mental Health QUERI used literature review, expert interviews, and a national panel process to increase consensus regarding outcomes monitoring instruments and strategies that support quality improvement. There was very good consensus in the domains of psychotic symptoms, side-effects, drugs and alcohol, depression, caregivers, vocational functioning, and community tenure. There are validated instruments and assessment strategies that are feasible for quality improvement in routine practice.

Reducing inequities among children with asthma in the island of Puerto Rico: experiences of a community-based, trans-sectoral effort.

Children living in the Commonwealth of Puerto Rico have the highest poverty and asthma prevalence rates of all U.S. children. Since 2000, a group of community, health care, education, housing, and academic representatives have been collaborating in a project to improve quality of life and reduce disparities among children with asthma in very poor communities in Puerto Rico. To date the project has implemented a successful intervention in the Luis Lloréns Torres Housing Project, aimed at adapting evidence-based interventions to improve the social and physical environment of children with asthma. The program has recently been extended to another San Juan housing area, the Manuel A. Pérez Housing Project. Using implementation theory, the authors report and reflect on the project's experience to date, provide recommendations, and discuss implications of lessons learned to address inequities in asthma care throughout other underserved areas in the U.S., Latin America, and the Caribbean.

The feasibility of computerized patient self-assessment at mental health clinics.

OBJECTIVES: Improving the quality of care for severe mental illness (SMI) has been difficult because patients' clinical information is not readily available. Audio computer-assisted self-interviewing (ACASI) supports data collection by asking patients waiting for appointments clinical questions visually and aurally. It has improved outcomes for many disorders. While reliable and accurate for SMI in research settings, this study assesses questions about ACASI's feasibility in usual care. DESIGN: Patient and provider surveys and provider focus groups after 12 months of ACASI implementation. SETTING: Two outpatient mental health clinics in Los Angeles, one run by the Department of Veterans Affairs and the other by Los Angeles County Department of Mental Health. PARTICIPANTS: 266 patients with SMI and 14 psychiatrists. INTERVENTION: Patients completed an ACASI survey on symptoms, drug use, medication adherence and side-effects by internet using a touch-screen monitor. A 1-page report summarizing each patient's results was printed and given to providers by patients during appointments. MAIN OUTCOME MEASURE: Feedback surveys (patients and psychiatrists) and focus groups and interviews (psychiatrists) assessed usability, usefulness, effects on treatment, and barriers to sustaining ACASI. RESULTS: Patients believed the PAS was enjoyable, easy to learn and use, and that it improved communication with their psychiatrists. Providers believed the PAS was easy to use, had a small impact on care, could be improved by being more detailed and comprehensive, and requires outside support to continue its use. CONCLUSIONS: ACASI was easy to use and enhanced communication. Systems like this can be a valuable part of quality improvement projects.

Characteristics of individuals with severe mental illness who use emergency services.

Emergency services are both a safety net and a locus for acute treatment. While the population with severe, persistent mental illness uses emergency services at a high rate, few studies have systematically examined the causes of this service use. This study examines a random sample of 179 people who were high uti- lizers of services from the Los Angeles County Department of Mental Health. Interviews were conducted and 5 years of service use data were studied. Greater use of emergency services was associated with male gender, minority race, severe illness, homelessness, and less family support. Efforts to reduce emergency services need to improve access to appropriate community services, particularly for people who are homeless or lack family support.

Computer-assisted self-assessment in persons with severe mental illness.

BACKGROUND: It has been difficult to improve care for severe mental illness (SMI) in usual care settings because clinical information is not reliably and efficiently managed. Methods are needed for efficiently collecting this information to evaluate and improve health care quality. Audio computer-assisted self-interviewing (ACASI) can facilitate this data collection and has improved outcomes for a number of disorders, suggesting the need to test its accuracy and reliability in people with SMI. METHOD: Ninety patients with DSM-IV schizophrenia or schizoaffective disorder (N = 45) or bipolar disorder (N = 45) recruited between Oct. 15, 2002, and July 1, 2003, were randomly assigned to 1 of 2 study groups and completed 2 standardized symptom surveys (Revised Behavior and Symptom Identification Scale and the symptom severity scale of the Schizophrenia Outcomes Module 2) 20 minutes apart in a crossover study design. Half of the patients first completed the scales via an in-person interview, and the other half first completed the scales via an ACASI survey self-administered through an Internet browser using a touchscreen developed to meet the cognitive needs of people with SMI. We evaluated attitudes toward ACASI, understanding of the ACASI survey, internal consistency, correlations between the ACASI and interview modes, concurrent validity, and a possible administration mode bias. RESULTS: All ACASI and in-person interview scales had similar internal reliability, high correlations (r = 0.78-1.00), and mean scores similar enough as not to be different at p < .05. A large majority rated the ACASI survey as easier, more enjoyable, more preferable if monthly completion of a survey were required, and more private, and 97% to 99% perfectly answered questions about how to use it. CONCLUSION: ACASI data collection is reliable among people with bipolar disorder and schizophrenia and could be a valuable tool to improve their care.

An instrument to assess competencies of providers treating severe mental illness.

One approach to improving the quality of care for severe mental illnesses (SMI) such as schizophrenia is through the improvement of provider competencies; the attitudes, knowledge, and skills needed to deliver high-quality care. This paper describes a new instrument designed to measure such a set of competencies. A total of 341 providers of services to clients with SMI at 38 clinics within 5 publicly financed treatment organizations in 2 western states were asked to complete a paper-and-pencil survey including the new Competency Assessment Instrument (CAI: 15 scales, each assessing a particular provider competency), and additional measures used to establish validity (Recovery Attitude Questionnaire--7, Client Optimism Scale). Seventy-nine percent (N = 269) responded at baseline, 83% (N = 282) responded at 2 weeks. Ninety-seven percent of baseline respondents completed the survey at 2 weeks. Most CAI scales have good internal consistency (Cronbach's alphas = .52-.93), test-retest reliability (scales ranged from .42 to .78), and validity, and should be useful in efforts to improve care.