Reduced mortality among Department of Veterans Affairs patients with schizophrenia or bipolar disorder lost to follow-up and engaged in active outreach to return for care.

OBJECTIVES: We determined whether contacting Department of Veterans Affairs (VA) patients with schizophrenia or bipolar disorders (serious mental illness [SMI]) who had dropped out of care for prolonged periods resulted in reengagement with VA services and decreased mortality. METHODS: We developed a list of patients with SMI who were last treated in fiscal years 2005 to 2006, and were lost to follow-up care for at least 1 year. VA medical centers used our list to contact patients and schedule appointments. Additional VA administrative data on patient utilization and mortality through May 2009 were analyzed. RESULTS: About 72% (2375 of 3306) of the patients who VA staff attempted to contact returned for VA care. The mortality rate of returning patients was significantly lower than that for patients not returning (0.5% vs 3.9%; adjusted odds ratio = 5.8; P < .001), after demographic and clinical factors were controlled. CONCLUSIONS: The mortality rate for returning patients with SMI was almost 6 times less than for those who did not return for medical care. Proactive outreach might result in patients returning to care and should be implemented to reengage this vulnerable group.

Enhancing Treatment Reengagement for Veterans With Serious Mental Illness: Evaluating the Effectiveness of SMI Re-Engage.

OBJECTIVE: This evaluation assessed the effectiveness of the Veterans Health Administration (VHA) program Reengaging Veterans With Serious Mental Illness in Treatment (SMI Re-Engage). The program serves veterans with serious mental illness who experience extended gaps in use of VHA care. METHODS: Propensity score-weighted survival analysis that adjusted for demographic, clinical, and utilization factors assessed whether being contacted via SMI Re-Engage predicted return to VHA care within 18 months of when clinicians received patient contact information and, among veterans contacted, whether return to VHA care was associated with mortality risk within the 18-month follow-up period. Among all veterans who returned to care, a post hoc propensity score-weighted logistic regression that adjusted for demographic, clinical, and utilization factors assessed whether being contacted via SMI Re-Engage was associated with returning to outpatient care versus inpatient or emergency care. RESULTS: Of veterans contacted (N=886), 42% returned to care, compared with 27% of veterans whom providers attempted to contact but could not reach (N=2,059). When analyses adjusted for covariates, veterans who were contacted had a higher risk of returning to care (hazard ratio (HR)=3.40, 95% confidence interval [CI]=2.70-4.28). Among veterans contacted, the association between return to VHA care and mortality risk was not significant. Post hoc analyses for veterans who returned to care (N=941) indicated that being contacted (versus not being contacted) was associated with higher odds of returning to outpatient care (versus inpatient or emergency care) (odds ratio=2.42, CI=1.68-3.47). CONCLUSIONS: SMI Re-Engage contact facilitated return to VHA care. SMI Re-Engage exemplifies how population health strategies can address health care discontinuities among people with serious mental illness.

Outreach to veterans with serious mental illness who are lost to care: Predictors of outreach contact.

This evaluation identified factors associated with outreach contact to veterans with serious mental illness (SMI) who were lost to Veterans Health Administration (VHA) care. From March 2012 through September 2013, the VHA SMI Re-Engage initiative identified 4,241 veterans for reengagement outreach; 31% of whom were successfully contacted. Higher odds of contact was associated with older age, married status, no history of homelessness, bipolar disorder diagnosis, having no recent inpatient stay, living closer to a VHA medical center, fewer years since last visit, and having a service-connected disability. Several factors are associated with recontact with veterans with SMI who are lost to VHA care. These may promote treatment engagement and retention. Study findings may inform outreach interventions to enhance access for these veterans. (PsycINFO Database Record

Effectiveness of Expanded Implementation of STAR-VA for Managing Dementia-Related Behaviors Among Veterans.

PURPOSE OF THE STUDY: Nonpharmacological, psychosocial approaches are first-line treatments for managing behavioral symptoms in dementia, but they can be challenging to implement in long-term care settings. The Veterans Health Administration implemented STAR-VA, an interdisciplinary behavioral approach for managing challenging dementia-related behaviors in its Community Living Center (CLCs, nursing home care) settings. This study describes how the program was implemented and provides an evaluation of Veteran clinical outcomes and staff feedback on the intervention. DESIGN AND METHODS: One mental health professional and registered nurse team from 17 CLCs completed STAR-VA training, which entailed an experiential workshop followed by 6 months of expert consultation as they worked with their teams to implement STAR-VA with Veterans identified to have challenging dementia-related behaviors. The frequency and severity of target behaviors and symptoms of depression, anxiety, and agitation were evaluated at baseline and at intervention completion. Staff provided feedback regarding STAR-VA feasibility and impact. RESULTS: Seventy-one Veterans completed the intervention. Behaviors clustered into 6 types: care refusal or resistance, agitation, aggression, vocalization, wandering, and other. Frequency and severity of target behaviors and symptoms of depression, anxiety, and agitation all significantly decreased, with overall effect sizes of 1 or greater. Staff rated both benefits for Veterans and program feasibility favorably. IMPLICATIONS: This evaluation supports the feasibility and effectiveness of STAR-VA, an interdisciplinary, behavioral intervention for managing challenging behaviors among residents with dementia in CLCs.

Recorded delirium in a national sample of elderly inpatients: potential implications for recognition.

This retrospective study examined delirium and related confusional diagnoses recorded in patients older than age 60 discharged from Veterans Affairs (VA) acute inpatient units nationally in 1996 (n = 267,947). Only 4% of patients had delirium or related confusional diagnoses recorded. Patients with recorded delirium had significantly higher mortality than did those without recorded delirium or those with other confusional diagnoses ("organic psychoses"); the most common delirium types were dementia with delirium and alcohol intoxication/withdrawal delirium. Organic psychoses patients had the longest lengths of stay and significantly more admissions to nonmedical/surgical units and discharges to nursing homes; almost 20% were African American. The recorded rate of delirium in the VA health system likely underestimates true prevalence and possibly reflects nonrecognition of delirium in many older veterans. Certain motoric and etiologic types of delirium may be more commonly diagnosed and recorded. Future research should prospectively examine recognition of motoric and etiologic delirium subtypes and racial differences in delirium diagnoses.

Results from the multisite implementation of STAR-VA: a multicomponent psychosocial intervention for managing challenging dementia-related behaviors of veterans.

Dementia is often associated with challenging behaviors that can significantly impact the quality of life of individuals with dementia and pose great difficulty for long-term care staff. Antipsychotic medications, historically the mainstay approach for managing such behaviors, have increasingly been associated with limited efficacy and increased death risk with older dementia patients. In an effort to promote and realize the promise of nonpharmacological management of challenging dementia-related behaviors, the U.S. Department of Veterans Affairs (VA) health care system has developed and implemented STAR-VA, an interdisciplinary behavioral intervention for managing challenging dementia-related behaviors of veterans, in 17 VA nursing homes, as part of a pilot implementation initiative. Sixty-four veterans with challenging behaviors associated with dementia participated in the STAR-VA intervention coordinated by Mental Health Providers completing specialized training. Challenging behaviors clustered into 6 behavior types: resistance to care, agitation, violence/aggression, vocalization, wandering, and other. Results indicate that STAR-VA led to significant reductions in the frequency and severity of challenging dementia-related behaviors, with overall effect sizes of approximately 1. In addition, the intervention led to significant reductions in depression and anxiety. Overall, the results support the feasibility and effectiveness of STAR-VA for managing challenging dementia-related behaviors in veterans in real-world, nursing home settings.

Cost savings from assertive community treatment services in an era of declining psychiatric inpatient use.

OBJECTIVE: To assess, during a period of decreasing psychiatric inpatient utilization, cost savings from Assertive Community Treatment (ACT) programs for individuals with severe mental illnesses. DATA SOURCE: U.S. Department of Veterans Affairs' (VA) national administrative data for entrants into ACT programs. STUDY DESIGN: An observational study of the effects of ACT enrollment on mental health inpatient utilization and costs in the first 12 months following enrollment. ACT enrollees (N = 2010) were propensity score matched to ACT-eligible non-enrollees (N = 4020). An instrumental variables generalized linear regression approach was used to estimate enrollment effects. RESULTS: Instrumental variables estimates indicate that between FY2001 and FY2004, entry into ACT resulted in a net increase of $4529 in VA costs. Trends in inpatient use among ACT program entrants suggest this effect remained stable after FY2004. However, eligibility for ACT declined 37 percent, because fewer patients met an eligibility standard based on high prior psychiatric inpatient use. CONCLUSIONS: Savings from ACT programs depend on new enrollees' intensity of psychiatric inpatient utilization prior to entering the ACT program. Although a program eligibility standard based on prior psychiatric inpatient use helped to sustain the savings from VA ACT programs, over time, it also resulted in an unintended narrowing of program eligibility.

Assertive community treatment in veterans affairs settings: impact on adherence to antipsychotic medication.

OBJECTIVES Assertive community treatment (ACT) programs may improve patients' outcomes, in part by increasing adherence to antipsychotic medication. This study assessed the association between ACT enrollment and subsequent antipsychotic adherence. METHODS The authors identified a national sample of 763 Veterans Affairs (VA) patients with schizophrenia who were newly enrolled in ACT in fiscal years 2001 to 2004 and had valid antipsychotic medication possession ratios (MPRs) for five sequential six-month periods, the first occurring before ACT enrollment. Propensity scores were used to match ACT patients 1:1 with eligible veterans who did not initiate ACT. Logistic regression analyses and generalized estimating equations (GEE) were used to assess the association between ACT enrollment and subsequent antipsychotic adherence. Antipsychotic adherence was compared among ACT enrollees with high, partial, or no participation in ACT services. RESULTS Before the index date, there was no significant difference in rates of good adherence (MPR ≥.8) among subsequent ACT enrollees (72%) and patients in the control group (70%). However, in each of the four periods after enrollment, ACT enrollees were more likely to have MPRs ≥.8. In GEE analyses, ACT enrollment was associated with 2.3 greater odds of MPRs ≥.8 (95% confidence interval=1.9-2.7). Among ACT enrollees, higher levels of participation were associated with MPRs ≥.8. CONCLUSIONS In this large, national study, ACT enrollment was associated with higher levels of antipsychotic adherence among VA patients with schizophrenia. This association persisted over time and was greatest among those with higher levels of ACT use.

Health care utilization prior to loss to care among veterans with serious mental illness.

OBJECTIVE: This study examined the association between utilization of Veterans Affairs (VA) health services and the probability of treatment dropout among veterans with serious mental illness. METHODS: Utilization of VA health services in the fiscal year (FY) before treatment dropout among veterans with serious mental illness who were lost to care for at least 12 months beginning in FYs 2008 or 2009 (N=6,687) was compared with utilization in FYs 2007 or 2008 among veterans with serious mental illness who remained in care (N=6,687). RESULTS: The veterans (mean age=54) were predominantly male (91%) and Caucasian (76%). After accounting for demographic and clinical variables, the analyses found that more primary care and mental health outpatient visits and fewer general medical and mental health hospitalizations were associated with lower odds of dropout. CONCLUSIONS: Engagement in outpatient health care was associated with lower odds of loss to care among veterans with serious mental illness.

Leading from the middle: replication of a re-engagement program for veterans with mental disorders lost to follow-up care.

Objectives. Persons with mental disorders experience functional impairments and premature mortality. Limited continuity of care may contribute to disparities in this group. We describe the replication of an evidence-based outreach program (Re-Engage) to reconnect Veterans with mental disorders into care who have dropped out of services. Methods. Using the Enhanced Replicating Effective Programs framework, population-based registries were used to identify Veterans lost-to-care, and providers used this information to determine Veteran disposition and need for care. Providers recorded Veteran preferences, health status, and care utilization, and formative process data was collected to document implementation efforts. Results. Among Veterans who dropped out of care (n = 126), the mean age was 49 years, 10% were women, and 29% were African-American. Providers determined that 39% of Veterans identified for re-engagement were deceased, hospitalized, or ineligible for care. Of the remaining 68 Veterans, outreach efforts resulted in contact with 20, with 7 returning to care. Providers averaged 14.2 hours over 4 months conducting re-engagement services and reported that gaining facility leadership support and having service agreements for referrals were essential for program implementation. Conclusions. Population-level, panel management strategies to re-engage Veterans with mental disorders are potentially feasible if practices are identified to facilitate national rollout.

Initiation of assertive community treatment among veterans with serious mental illness: client and program factors.

OBJECTIVES: Ensuring equitable access to mental health services is a national priority. The authors examined assertive community treatment (ACT) services initiation in the Veterans Affairs (VA) health system among program-eligible patients. METHODS: The VA's National Psychosis Registry included 6,540 patients who met program eligibility criteria (mental illness diagnosis and prior hospitalization) in fiscal year (FY) 2003 (FY 2003) and had not received VA ACT services in FY 2001-FY 2003. Receipt of VA ACT services during FY 2004 was assessed with generalized estimating equations. Independent variables included age, gender, race and ethnicity, marital status, service-connected disability benefits, substance use disorder, psychiatric inpatient days in FY 2003, distance to the nearest facility with a VA ACT team, presence of an on-site team at the facility where the last VA psychiatric hospitalization occurred, and number of open slots with the nearest ACT team. RESULTS: A total of 452 of the eligible patients (7%) received VA ACT services in FY 2004. In multivariate analyses, older age was associated with reduced odds of receiving ACT services (odds ratio [OR]=.92 per five years); being female (OR=1.86) and having schizophrenia (OR=1.64) were positively associated with ACT services initiation. Individuals living farther from ACT sites were less likely to receive ACT services (OR=.95 per ten miles). The marginal effects of distance were most substantial in the first 30 miles and beyond 100 miles. CONCLUSIONS: Most patients who were eligible for yet not already receiving VA ACT services went without these services in FY 2004. Geographic distance limited services initiation. Focused efforts are needed to enhance ACT services initiation and delivery, particularly for individuals in remote locations.

Use of Alcohol Screening and Brief Interventionsin Primary Care Settings:Implementation and Barriers.

Although evidence indicates that brief alcohol screening and interventions are effective across primary care settings, implementation of these techniques has been problematic. The primary objective of this study was to determine current practices and barriers for screening and interventions with primary care patients across randomly selected clinics in a large health care system, the Veterans Health Administration. Focus groups and mailed structured surveys were used. Results from providers indicated that 85% of patients treated in primary care received some screening for alcohol use disorders. The CAGE was the predominant screening tool. The primary clinical focus was on treatment referrals for patients who met abuse/dependence criteria. Lack of time was the most important perceived barrier to implementing screening and brief alcohol interventions for at-risk and problem drinkers. Implications for implementation of screening and intervention programs for a range of drinkers (at-risk use, problem use, abuse, dependence) are discussed.