Enhanced Adoption of Measurement-Based Care in a Psychiatry Outpatient Clinic After High-Reliability Process Changes.

OBJECTIVE: This study examined the impact of high-reliability changes to how measurement-based care questionnaires were administered to patients on rates of questionnaire completion. METHODS: Medical record data were abstracted from 44,305 adult outpatient return visits to a psychiatry outpatient clinic within two 10-month periods (before and after process changes were implemented). Linear mixed models tested the change in questionnaire completion rates and the interaction effects between time and age, sex, and race. RESULTS: Patient completion of questionnaires increased by 79% after process changes. Women were more likely to complete questionnaires regardless of the process. After process changes, older patients and White patients were more likely to complete questionnaires. CONCLUSIONS: High-reliability process changes to measurement-based care questionnaire administration were associated with higher questionnaire completion rates. Racial, age, and sex disparities in questionnaire completion rates were notable and deserve attention in future measurement-based care implementation efforts.

The Patient Mania Questionnaire (PMQ-9): a Brief Scale for Assessing and Monitoring Manic Symptoms.

BACKGROUND: Measurement-based care is an effective clinical strategy underutilized for bipolar disorder partly due to lacking a widely adopted patient-reported manic symptom measure. OBJECTIVE: To report development and psychometric properties of a brief patient-reported manic symptom measure. DESIGN: Secondary analysis of data collected in a randomized effectiveness trial comparing two treatments for 1004 primary care patients screening positive for bipolar disorder and/or PTSD. PARTICIPANTS: Two analytic samples included 114 participants with varied diagnoses and test-retest data, and 179 participants with psychiatrist-diagnosed bipolar disorder who had two or more assessments with the nine-item Patient Mania Questionnaire-9 [PMQ-9]). MAIN MEASURES: Internal and test-retest reliability, concurrent validity, and sensitivity to change were assessed. Minimally important difference (MID) was estimated by standard error of measurement (SEM) and by standard deviation (SD) effect sizes. KEY RESULTS: The PMQ-9 had high internal reliability (Cronbach's alpha = 0.88) and test-retest reliability (0.85). Concurrent validity correlation with manic symptom measures was high for the Internal State Scale-Activation Subscale (0.70; p<0.0001), and lower for the Altman Mania Rating Scale (0.26; p=0.007). Longitudinally, PMQ-9 was completed at 1511 clinical encounters in 179 patients with bipolar disorder. Mean PMQ-9 score at first and last encounters was 14.5 (SD 6.5) and 10.1 (SD 7.0), a 27% decrease in mean score during treatment, suggesting sensitivity to change. A point estimate of the MID was approximately 3 points (range of 2-4). CONCLUSIONS: The PMQ-9 demonstrated excellent test-retest reliability, concurrent validity, internal consistency, and sensitivity to change and was widely used and acceptable to patients and clinicians in a pragmatic clinical trial. Combined with the Patient Health Questionnaire-9 (PHQ-9) measure of depressive symptoms this brief measure could inform measurement-based care for individuals with bipolar disorder in primary care and mental health care settings given its ease of administration and familiar self-report response format.

Comparison of Teleintegrated Care and Telereferral Care for Treating Complex Psychiatric Disorders in Primary Care: A Pragmatic Randomized Comparative Effectiveness Trial.

Importance: Only one-third of patients with complex psychiatric disorders engage in specialty mental health care, and only one-tenth receive adequate treatment in primary care. Scalable approaches are critically needed to improve access to effective mental health treatments in underserved primary care settings. Objective: To compare 2 clinic-to-clinic interactive video approaches to delivering evidence-based mental health treatments to patients in primary care clinics. Design, Setting, and Participants: This pragmatic comparative effectiveness trial used a sequential, multiple-assignment, randomized trial (SMART) design with patient-level randomization. Adult patients treated at 24 primary care clinics without on-site psychiatrists or psychologists from 12 federally qualified health centers in 3 states who screened positive for posttraumatic stress disorder and/or bipolar disorder and who were not already receiving pharmacotherapy from a mental health specialist were recruited from November 16, 2016, to June 30, 2019, and observed for 12 months. Interventions: Two approaches were compared: (1) telepsychiatry/telepsychology-enhanced referral (TER), where telepsychiatrists and telepsychologists assumed responsibility for treatment, and (2) telepsychiatry collaborative care (TCC), where telepsychiatrists provided consultation to the primary care team. TER included an adaptive intervention (phone-enhanced referral [PER]) for patients not engaging in treatment, which involved telephone outreach and motivational interviewing. Main Outcomes and Measures: Survey questions assessed patient-reported outcomes. The Veterans RAND 12-item Health Survey Mental Component Summary (MCS) score was the primary outcome (range, 0-100). Secondary outcomes included posttraumatic stress disorder symptoms, manic symptoms, depressive symptoms, anxiety symptoms, recovery, and adverse effects. Results: Of 1004 included participants, 701 of 1000 (70.1%) were female, 660 of 994 (66.4%) were White, and the mean (SD) age was 39.4 (12.9) years. Baseline MCS scores were 2 SDs below the US mean; the mean (SD) MCS scores were 39.7 (14.1) and 41.2 (14.2) in the TCC and TER groups, respectively. There was no significant difference in 12-month MCS score between those receiving TCC and TER (ß = 1.0; 95% CI, -0.8 to 2.8; P = .28). Patients in both groups experienced large and clinically meaningful improvements from baseline to 12 months (TCC: Cohen d = 0.81; 95% CI, 0.67 to 0.95; TER: Cohen d = 0.90; 95% CI, 0.76 to 1.04). For patients not engaging in TER at 6 months, there was no significant difference in 12-month MCS score between those receiving PER and TER (ß = 2.0; 95% CI, -1.7 to 5.7; P = .29). Conclusions and Relevance: In this comparative effectiveness trial of patients with complex psychiatric disorders randomized to receive TCC or TER, significantly and substantially improved outcomes were observed in both groups. From a health care system perspective, clinical leadership should implement whichever approach is most sustainable. Trial Registration: ClinicalTrials.gov Identifier: NCT02738944.

A Roadmap to Inform the Implementation of Evidence-Based Collaborative Care Interventions in Communities: Insights From the Michigan Mental Health Integration Partnership.

Background: Despite increasing calls for further spread of evidence-based collaborative care interventions (EBIs) in community-based settings, practitioner-driven efforts are often stymied by a lack of experience in addressing barriers to community-based implementation, especially for those not familiar with implementation science. The Michigan Mental Health Integration Partnership (MIP) is a statewide initiative that funds projects that support implementation and uptake of EBIs in community-based settings. MIP also provides an in situ implementation laboratory for understanding barriers to the uptake of EBIs across a variety of settings. We report findings from a statewide qualitative study of practitioners involved in MIP projects to garner their perspectives of best practices in the implementation of EBIs. Methods: Twenty-eight semi-structured interviews of practitioners and researchers from six MIP Projects were conducted with individuals implementing various MIP EBI projects across Michigan, including stakeholders from project teams, implementation sites, and the State of Michigan, to identify common barriers, challenges, and implementation strategies deployed by the project teams, with the purpose of informing a set of implementation steps and milestones. Results: Stakeholders identified a number of barriers to and strategies for success, including the need for tailoring program deployment and implementation to specific site needs, development of web-based tools for facilitating program implementation, and the importance of upper-level administration buy-in. Findings informed our resultant community-based Implementation Roadmap, which identifies critical steps across three implementation phases-pre-implementation, implementation, and sustainability-for implementation practitioners to use in their EBI implementation efforts. Conclusion: Implementation practitioners interested in community-based EBI implementation often lack access to operationalized implementation "steps" or "best practices" that can facilitate successful uptake and evaluation. Our community-informed MIP Implementation Roadmap, offering generalized steps for reaching successful implementation, uses experiences from a diverse set of MIP teams to guide practitioners through the practices necessary for scaling up EBIs in community-based settings over pre-implementation, implementation and sustainability phases.

Going Virtual During a Pandemic: An Academic Psychiatry Department's Experience with Telepsychiatry.

Background: The novel coronavirus pandemic (COVID-19) led healthcare providers, including mental health providers, across the U.S. to swiftly shift to telemedicine. Objectives: This shift gave our Department of Psychiatry a chance to better understand key challenges and opportunities vis-à-vis virtual mental healthcare. We aimed to obtain provider feedback on the use of telepsychiatry and to learn from the provider perspective about patient experiences with video visits. This information will be used to inform the telemedicine strategy at a systems level within our psychiatry department, our academic health system, as well as the field of telemedicine as a whole. Design and Sample: A 22-item online questionnaire comprising 16 quantitative and six qualitative items was distributed to providers currently using video visits to provide care. Results: A total of 89 mental health providers completed the questionnaire. Outcomes demonstrated that while providers perceive challenges associated with virtual care (e.g., fatigue, technology-related issues, and age-related concerns), they also recognize a number of benefits to themselves and their patients (e.g., convenience and increased access). Overall, provider satisfaction, comfort, and willingness to use telepsychiatry was high. Conclusions: The vast majority of providers adapted quickly to the use of virtual platforms; many endorse advantages that suggest virtual care will continue to be a modality they provide in the future, post-COVID-19. It will be important to continue to evaluate aspects of virtual care that may limit clinical assessments and to optimize use to improve access, convenience, and cost-efficiency of mental healthcare delivery.

The effect of a computerized best practice alert system in an outpatient setting on metabolic monitoring in patients on second-generation antipsychotics.

WHAT IS KNOWN AND OBJECTIVE: Metabolic syndrome is a well-documented adverse effect of second-generation antipsychotics (SGAs). Patients with metabolic syndrome are at an increased risk of potentially fatal cardiovascular events, including myocardial infarction and stroke. This elevated risk prompted the creation of a national guideline on metabolic monitoring for patients on SGAs in 2004. However, monitoring practices remained low at our clinic. To address this concern, a clinical decision support system was developed to alert providers of monitoring requirements. The purpose of this study is to determine the effect of the best practice alert (BPA), and to assess the impact of provider and patient characteristics on metabolic laboratory (lab) order rates. METHODS: A retrospective chart review was conducted at a large outpatient psychiatric clinic. Data were collected from all adult patients who were prescribed an SGA and triggered the BPA (indicating lab monitoring is needed for the patient). Data collection included a variety of patient, provider and alert variables. The primary outcome was a composite of fasting blood glucose (FBG), haemoglobin A1c (HbA1c) and/or fasting lipid panel order rates. Secondary outcomes included the rate of valid response, which considered appropriate reasons for not ordering labs (ie monitoring already completed during recent primary care visit), as well as order rates of individual labs. RESULTS AND DISCUSSION: Data from 1112 patients were collected and analysed. Patients with a thought disorder diagnosis had significantly more labs ordered than those without. No other patient factors affected order rates. Resident psychiatrists and nurse practitioners ordered significantly more labs and had significantly more valid responses than attending psychiatrists. An active alert, which fired during medication order entry, was associated with a higher rate of lab ordering and valid response compared to a passive alert, which fired whenever a prescribing healthcare provider opened the chart. WHAT IS NEW AND CONCLUSION: Prescribers may associate metabolic syndrome with schizophrenia or with use of SGAs specifically in thought disorders, even though these medications pose a risk for all indications. Higher rates of monitoring by resident physicians may have been due to spending more time with patients during the encounter and in documentation. Lastly, the active BPA was an effective tool to increase metabolic monitoring in patients taking SGAs. Continued education on the importance of regular metabolic monitoring should be implemented for all providers.

Developing Telemental Health Partnerships Between State Medical Schools and Federally Qualified Health Centers: Navigating the Regulatory Landscape and Policy Recommendations.

BACKGROUND: Federally Qualified Health Centers (FQHCs) deliver care to 26 million Americans living in underserved areas, but few offer telemental health (TMH) services. The social missions of FQHCs and publicly funded state medical schools create a compelling argument for the development of TMH partnerships. In this paper, we share our experience and recommendations from launching TMH partnerships between 12 rural FQHCs and 3 state medical schools. EXPERIENCE: There was consensus that medical school TMH providers should practice as part of the FQHC team to promote integration, enhance quality and safety, and ensure financial sustainability. For TMH providers to practice and bill as FQHC providers, the following issues must be addressed: (1) credentialing and privileging the TMH providers at the FQHC, (2) expanding FQHC Scope of Project to include telepsychiatry, (3) remote access to medical records, (4) insurance credentialing/paneling, billing, and supplemental payments, (5) contracting with the medical school, and (6) indemnity coverage for TMH. RECOMMENDATIONS: We make recommendations to both state medical schools and FQHCs about how to overcome existing barriers to TMH partnerships. We also make recommendations about changes to policy that would mitigate the impact of these barriers. Specifically, we make recommendations to the Centers for Medicare and Medicaid about insurance credentialing, facility fees, eligibility of TMH encounters for supplemental payments, and Medicare eligibility rules for TMH billing by FQHCs. We also make recommendations to the Health Resources and Services Administration about restrictions on adding telepsychiatry to the FQHCs' Scope of Project and the eligibility of TMH providers for indemnity coverage under the Federal Tort Claims Act.

Genetic Variation of the Mu Opioid Receptor (OPRM1) and Dopamine D2 Receptor (DRD2) is Related to Smoking Differences in Patients with Schizophrenia but not Bipolar Disorder.

It is not known why mentally ill persons smoke excessively. Inasmuch as endogenous opioid and dopaminergic systems are involved in smoking reinforcement, it is important to study mu opioid receptor (OPRM1) A118G (rs1799971), dopamine D2 receptor (DRD2) Taq1A (rs1800497) genotypes, and sex differences among patients with schizophrenia or bipolar disorder. Smokers and nonsmokers with schizophrenia (n=177) and bipolar disorder (n=113) were recruited and genotyped. They were classified into three groups: current smoker, former smoker, and never smoker by tobacco smoking status self-report. The number of cigarettes smoked per day was used as the major tobacco smoking parameter. In patients with schizophrenia, tobacco smoking prevalence was greater in males than in females as expected, but women had greater daily cigarette consumption (p<0.01). Subjects with schizophrenia who had the OPRM1 *G genotype smoked more cigarettes per day than the AA allele carriers with schizophrenia (p<0.05). DRD2 Taq1A genotype differences had no effect on the number of cigarettes smoked per day. However, female smokers with schizophrenia who were GG homozygous of the DRD2 receptor smoked more than the *A male smokers with schizophrenia (p<0.05). In bipolar patients, there were no OPRM1 and DRD2 Taq1A genotype differences in smoking status. There also were no sex differences for smoking behavior among the bipolar patients. The results of this study indicate that single nucleotide polymorphism (SNP) of the less functional mu opioid receptor increases tobacco smoking in patients with schizophrenia. Alteration of DRD2 receptor function also increased smoking behavior in females with schizophrenia.

Effectively implementing FDA medication alerts utilizing patient centered medical home clinical pharmacists.

FDA medication alerts can be successfully implemented within patient centered medical home (PCMH) clinics utilizing clinical pharmacists. Targeted selection of high-risk patients from an electronic database allows PCMH pharmacists to prioritize assessments. Trusting relationships between PCMH clinical pharmacists and primary care providers facilitates high response rates to pharmacist recommendations. This health system approach led by PCMH pharmacists provides a framework for proactive responses to FDA safety alerts and medication related quality measure improvement.

Implementing the Collaborative Care Model as Part of a Countywide Initiative.

This column describes the planning and implementation of an integrated behavioral health project which was facilitated and endorsed by a developing accountable health community, the Washtenaw Health Initiative (WHI). The WHI is a voluntary countywide coalition of academic, community, health system, and county government agencies dedicated to improving access to high-quality health care for low-income, uninsured, and Medicaid populations. When lack of access to mental health services was identified as a pressing concern, the WHI endorsed pilot testing of collaborative care, an evidence-based treatment model, in county safety-net clinics. Challenges, outcomes, and relevance of this initiative to other counties or regional entities are discussed.

Determinants of National Guard Mental Health Service Utilization in VA versus Non-VA Settings.

OBJECTIVE: To determine associations between need, enabling, and predisposing factors with mental health service use among National Guard soldiers in the first year following a combat deployment to Iraq or Afghanistan. DATA SOURCES/STUDY SETTING: Primary data were collected between 2011 and 2013 from 1,426 Guard soldiers representing 36 units. STUDY DESIGN: Associations between Guard soldier factors and any mental health service use were assessed using multivariable logistic regression models in a cross-sectional study. Further analysis among service users (N = 405) assessed VA treatment versus treatment in other settings. PRINCIPAL FINDINGS: Fifty-six percent of Guard soldiers meeting cutoffs on symptom scales received mental health services with 81 percent of those reporting care from the VA. Mental health service use was associated with need (mental health screens and physical health) and residing in micropolitan communities. Among service users, predisposing factors (middle age range and female gender) and enabling factors (employment, income above $50,000, and private insurance) were associated with greater non-VA services use. CONCLUSION: Overall service use was strongly associated with need, whereas sector of use (non-VA vs. VA) was insignificantly associated with need but strongly associated with enabling factors. These findings have implications for the recent extension of veteran health coverage to non-VA providers.

Effectiveness of the tobacco tactics program for psychiatric inpatient veterans: an implementation study.

BACKGROUND: The objective of this study was to evaluate the effectiveness of the inpatient, nurse-administered Tobacco Tactics program for patients admitted for psychiatric conditions in two Veterans Affairs (VA) hospitals compared to a control hospital. METHODS: This is a subgroup analysis of data from the inpatient tobacco tactics effectiveness trial, which was a longitudinal, pre- post-nonrandomized comparison design with 6-month follow-up in the three large Veterans Integrated Service Networks (VISN) 11 hospitals. RESULTS: Six-month self-reported quit rates for patients admitted for psychiatric conditions increased from 3.5% pre-intervention to 10.2% post-intervention compared to a decrease in self-reported quit rates in the control hospital (12% pre-intervention to 1.6% post-intervention). There was significant improvement in self-reported quit rates for the pre- versus post-intervention time periods in the Detroit and Ann Arbor intervention sites compared to the Indianapolis control site (P=0.01) and cotinine results were in the same direction. CONCLUSION: The implementation of the Tobacco Tactics intervention has the potential to significantly decrease smoking and smoking-related morbidity and mortality among smokers admitted to VA hospitals for psychiatric disorders.

Reported barriers to mental health care in three samples of U.S. Army National Guard soldiers at three time points.

The military community and its partners have made vigorous efforts to address treatment barriers and increase appropriate mental health services use among returning National Guard soldiers. We assessed whether there were differences in reports of treatment barriers in 3 categories (stigma, logistics, or negative beliefs about treatment) in sequential cross-sectional samples of U.S. soldiers from a Midwestern Army National Guard Organization who were returning from overseas deployments. Data were collected during 3 time periods: September 2007-August 2008 (n = 333), March 2009-March 2010 (n = 884), and August 2011-August 2012 (n = 737). In analyses using discretized time periods and in trend analyses, the percentages of soldiers endorsing negative beliefs about treatment declined significantly across the 3 sequential samples (19.1%, 13.9%, and 11.1%). The percentages endorsing stigma barriers (37.8%, 35.2%, 31.8%) decreased significantly only in trend analyses. Within the stigma category, endorsement of individual barriers regarding negative reactions to a soldier seeking treatment declined, but barriers related to concerns about career advancement did not. Negative treatment beliefs were associated with reduced services use (OR = 0.57; 95% CI [0.33, 0.97]).

Effectiveness of the tobacco tactics program in the Department of Veterans Affairs.

PURPOSE: The purpose was to determine the effectiveness of the Tobacco Tactics program in three Veterans Affairs hospitals. METHODS: In this effectiveness trial, inpatient nurses were educated to provide the Tobacco Tactics intervention in Ann Arbor and Detroit, while Indianapolis was the control site (N = 1,070). Smokers were surveyed and given cotinine tests. The components of the intervention included nurse counseling, brochure, DVD, manual, pharmaceuticals, 1-800-QUIT-NOW card, and post-discharge telephone calls. RESULTS: There were significant improvements in 6-month quit rates in the pre- to post-intervention time periods in Ann Arbor (p = 0.004) and Detroit (p < 0.001) compared to Indianapolis. Pre- versus post-intervention quit rates were 4 % compared to 13 % in Detroit, were similar (6 %) pre- and post-intervention in Ann Arbor, and dropped from 26 % to 12 % in Indianapolis. CONCLUSION: The Tobacco Tactics program, which meets the Joint Commission standards that apply to all inpatient smokers, has the potential to significantly decrease smoking among Veterans.

Effects of the 2011 duty hour reforms on interns and their patients: a prospective longitudinal cohort study.

IMPORTANCE: In 2003, the first phase of duty hour requirements for US residency programs recommended by the Accreditation Council for Graduate Medical Education (ACGME) was implemented. Evidence suggests that this first phase of duty hour requirements resulted in a modest improvement in resident well-being and patient safety. To build on these initial changes, the ACGME recommended a new set of duty hour requirements that took effect in July 2011. OBJECTIVE: To determine the effects of the 2011 duty hour reforms on first-year residents (interns) and their patients. DESIGN: As part of the Intern Health Study, we conducted a longitudinal cohort study comparing interns serving before (2009 and 2010) and interns serving after (2011) the implementation of the new duty hour requirements. SETTING: Fifty-one residency programs at 14 university and community-based GME institutions. PARTICIPANTS: A total of 2323 medical interns. MAIN OUTCOME MEASURES: Self-reported duty hours, hours of sleep, depressive symptoms, well-being, and medical errors at 3, 6, 9, and 12 months of the internship year. RESULTS: Fifty-eight percent of invited interns chose to participate in the study. Reported duty hours decreased from an average of 67.0 hours per week before the new rules to 64.3 hours per week after the new rules were instituted (P < .001). Despite the decrease in duty hours, there were no significant changes in hours slept (6.8 → 7.0; P = .17), depressive symptoms (5.8 → 5.7; P = .55) or well-being score (48.5 → 48.4; P = .86) reported by interns. With the new duty hour rules, the percentage of interns who reported concern about making a serious medical error increased from 19.9% to 23.3% (P = .007). CONCLUSIONS AND RELEVANCE: Although interns report working fewer hours under the new duty hour restrictions, this decrease has not been accompanied by an increase in hours of sleep or an improvement in depressive symptoms or well-being but has been accompanied by an unanticipated increase in self-reported medical errors.

Exploring the impact of suicide on clinicians: a multidisciplinary retreat model.

OBJECTIVE: We developed an every other year, scheduled retreat model for clinicians and trainees to explore emotional and professional reactions that they may face after a patient's suicide. METHODS: Psychiatry ambulatory clinical staff, residents, and faculty participated in a halfday retreat, which consisted of an opening panel discussion, in which panel members related their experiences of patient suicide, break out groups, and a final panel discussion. Unlinked preand post-retreat surveys were electronically sent to all potential participants. RESULTS: The pre-retreat survey was completed by 103 clinicians; 20% of the respondents were trainees or fellows, and 47% reported that they had experienced a patient suicide. Text responses to the pre-retreat survey reflected the wish to obtain a better understanding of the impact of patient suicide on caregivers, to cope with the event from a personal and professional standpoint, and to get a clearer understanding of what supports are available within the department. The post-retreat survey was completed by 45 clinicians. Comments after the retreat reflected an increased awareness of both shortand long-term effects on clinicians after a patient suicide and the extensive impact that a patient suicide can have on providers within their ambulatory care department. CONCLUSION: An alldepartment ambulatory retreat model has value in providing clinicians with support and information in a structured, educational setting to help reduce the sense of stigma and provide an increased awareness of the magnitude of the impact on clinicians who experience the death of a patient by suicide.

Clinical skills verification, formative feedback, and psychiatry residency trainees.

OBJECTIVE: The authors describe the implementation of Clinical Skills Verification (CSV) in their program as an in-training assessment intended primarily to provide formative feedback to trainees, strengthen the supervisory experience, identify the need for remediation of interviewing skills, and secondarily to demonstrating resident competence for American Board of Psychiatry and Neurology (ABPN) certification in Psychiatry. METHODS: The authors review the background and context of the implementation of CSV, and describe how the experience is structured within their residency program. RESULTS: The authors have embedded CSV experiences into clinical rotations across all years of residency training, aiming to complete 6-12 evaluations for each resident in each year. The authors provide training to faculty regarding supervision and formative feedback, including interrater reliability sessions for the CSV assessment. CONCLUSION: Effective incorporation of the CSV assessment into regular clinical settings can improve clinical supervision, residents' training experience, and the field's ability to consistently produce qualified, competent psychiatrists.