Integrating Interprofessional Trainees into a Complex Care Program for Veterans Experiencing Homelessness: Effects on Health Services Utilization.

PURPOSE: High-quality, comprehensive care of vulnerable populations requires interprofessional ambulatory care teams skilled in addressing complex social, medical, and psychological needs. Training health professionals in interprofessional settings is crucial for building a competent future workforce. The impacts on care utilization of adding continuity trainees to ambulatory teams serving vulnerable populations have not been described. We aim to understand how the addition of interprofessional trainees to an ambulatory clinic caring for Veterans experiencing homelessness impacts medical and mental health services utilization. METHODS: Trainees from five professions were incorporated into an interprofessional ambulatory clinic for Veterans experiencing homelessness starting in July 2016. We performed clinic-level interrupted time series (ITS) analyses of pre- and post-intervention utilization measures among patients enrolled in this training continuity clinic, compared to three similar VA homeless clinics without training programs from October 2015 to September 2018. RESULTS: Our sample consisted of 37,671 patient- months. There was no significant difference between the intervention and comparison groups' post-intervention slopes for numbers of primary care visits (difference in slopes =-0.16 visits/100 patients/month; 95% CI -0.40, 0.08; p=0.19), emergency department visits (difference in slopes = 0.08 visits/100 patients/month; 95% CI -0.16, 0.32; p=0.50), mental health visits (difference in slopes = -1.37 visits/month; 95% CI -2.95, 0.20; p= 0.09), and psychiatric hospitalizations (-0.005 admissions/100 patients/month; 95% CI -0.02, 0.01; p= 0.62). We found a clinically insignificant change in medical hospitalizations. CONCLUSIONS: Adding continuity trainees from five health professions to an interprofessional ambulatory clinic caring for Veterans experiencing homelessness did not adversely impact inpatient and outpatient care utilization. An organized team-based care approach is beneficial for vulnerable patients and provides a meaningful educational experience for interprofessional trainees by building health professionals' capabilities to care for vulnerable populations.

Autism as the Low-Fitness Extreme of a Parentally Selected Fitness Indicator.

Siblings compete for parental care and feeding, while parents must allocate scarce resources to those offspring most likely to survive and reproduce. This could cause offspring to evolve traits that advertise health, and thereby attract parental resources. For example, experimental evidence suggests that bright orange filaments covering the heads of North American coot chicks may have evolved for this fitness-advertising purpose. Could any human mental disorders be the equivalent of dull filaments in coot chicks-low-fitness extremes of mental abilities that evolved as fitness indicators? One possibility is autism. Suppose that the ability of very young children to charm their parents evolved as a parentally selected fitness indicator. Young children would vary greatly in their ability to charm parents, that variation would correlate with underlying fitness, and autism could be the low-fitness extreme of this variation. This view explains many seemingly disparate facts about autism and leads to some surprising and testable predictions.

Evidence of a latitudinal gradient in the age at onset of schizophrenia.

Variation in the age at onset of a multifactorial disease often reflects variation in cause. Here we show a linear latitudinal gradient in the mean age at onset of schizophrenia in 13 northern hemisphere cities, ranging from 25 years old in Cali, Columbia (at 4 degrees north) to 35 years old in Moscow, Russia (at 56 degrees north). To our knowledge, this striking association has not been previously reported. We consider several explanations, including the effects of pathogen stress, natural selection, sexual selection, migration, life-history profiles, or some combination of these factors, and we propose a test of competing causal hypotheses.

Schizophrenia as one extreme of a sexually selected fitness indicator.

Schizophrenia remains an evolutionary paradox. Its delusions, hallucinations and other symptoms begin in adolescence or early adulthood and so devastate sexual relationships and reproductive success that selection should have eliminated the disorder long ago. Yet it persists as a moderately heritable disorder at a global 1% prevalence--too high for new mutations at a few genetic loci. We suggest that schizophrenia persists and involves many loci because it is the unattractive, low-fitness extreme of a highly variable mental trait that evolved as a fitness ("good genes") indicator through mutual mate choice. Here we show that this hypothesis explains many key features of schizophrenia and predicts that some families carry modifier alleles that increase the indicator's neurodevelopmental sensitivity to heritable fitness and condition. Such alleles increase the extent to which high-fitness family members develop impressive courtship abilities and achieve high reproductive success, but also increase the extent to which low-fitness family members develop schizophrenia. Here we introduce this fitness indicator model of schizophrenia, discuss its explanatory power, explain how it resolves the evolutionary paradox, discuss its implications for gene hunting, and identify some empirically testable predictions as directions for further research.

Substance abuse and the need for money management assistance among psychiatric inpatients.

Patients who mismanage their funds may benefit from financial advice, case management or the involuntary assignment of a payee who restricts direct access to funds. Data from a survey of psychiatric inpatients at four VA hospitals (N = 236) was used to evaluate the relationship between substance abuse and clinician-rated need for money management assistance. Multivariate analytic techniques were used to control for sociodemographic factors and psychopathology. Alcohol and drug use severity both were modestly associated with need for assistance. The effect of substance use severity was greater in patients who were also diagnosed with a major mental illness. Clinicians indicated that 27 patients (11% of the sample) required an involuntary payee and 21 of the 27 (78%) had a Substance Abuse diagnosis. Only drug use severity was significantly associated with need for a payee. These data describe a substantial unmet need for money management assistance in psychiatric inpatients, particularly among those with substance abuse disorders. There is a need to examine the process by which the Social Security and Veterans Benefits Administrations assign payees to determine whether patients with co-morbid substance abuse are not being assigned a payee in spite of their discernible need for one.

Feasibility of a skills training approach to reduce substance dependence among individuals with schizophrenia.

A novel treatment for persons who have both schizophrenia and substance abuse was evaluated by incorporating cognitive-behavioral drug relapse prevention strategies into a skills training method originally developed to teach social and independent living skills to patients with schizophrenia. Thirty-four of 56 patients completed treatment and a three-month follow-up assessment. Participants learned substance abuse management skills and reported that they found the treatment relevant, useful, and satisfying, and their drug use decreased. Improvements were noted in medication adherence, psychiatric symptoms, and quality of life. This manual-driven therapy may play an important role in the treatment of substance abuse among patients with schizophrenia.

Veterans who may need a payee to prevent misuse of funds for drugs.

OBJECTIVE: This study sought to determine the possible need for a payee among Department of Veterans Affairs (VA) inpatients with substance use disorders who receive public support payments. METHODS: A total of 290 veterans hospitalized in VA psychiatric units completed a survey designed to identify patients who may be in need of a payee because of excessive expenditures for substances of abuse. Level 1 screening identified patients with a general likelihood of needing a payee because they received public support payments, did not have a payee, and had a substance abuse diagnosis. Level 2 screening identified level 1 patients for whom there was further evidence of need for a payee because, in addition to spending substantial amounts of money on substances of abuse, they reported either difficulty meeting basic material needs or substantial harm from substance use. RESULTS: Of 290 patients surveyed, 78 (27 percent) met level 1 criteria. Altogether, 35 patients (45 percent of level 1 patients and 13 percent of all surveyed patients) met the more specific level 2 criteria, indicating that they were likely to be in need of a payee. As expected, veterans who met the level 2 criteria were more likely than those meeting only the level 1 criteria to have both self-rated and clinician-rated difficulties managing money. However, clinicians did not rate these veterans as more likely to benefit from a payee. CONCLUSIONS: A substantial proportion of veterans who have not been assigned a payee may need one. More effective approaches to money management in this population are needed.

Payee relationships: institutional payees versus personal acquaintances.

Most patients' payees are friends or family members, but quantitative evaluations of patients' experience of payeeship published thus far have involved patients whose payees were mental health staff. We compared ratings of different aspects of payeeship among veterans whose payees were family or friends (n = 27) and among those with institutional payees (lawyers, accountants, or clinic-affiliates, n = 22). After adjusting for differences in sociodemographic characteristics, the two groups had small and statistically non-significant differences on measures of their interaction with their payees. Overall satisfaction with payees and trust in them was high.

Do patients who mismanage their funds use more health services?

One rationale for establishing programs that help patients manage their funds is that such patients make extensive use of expensive inpatient services. We surveyed the money management habits of 406 inpatients and determined their use of Veterans Administration (VA) services and related costs over the subsequent year. In multivariate analyses, there was no statistically significant relationship between need for money management and service use or cost. The misspending of funds for drugs may precipitate hospitalization for some outpatients. However, in a sample of hospitalized patients, mismanagement of funds was not associated with longer length of stay or increased service use following discharge.