Organizational Characteristics of High- and Low-Clozapine-Utilization Clinics in the Veterans Health Administration

Objective: Treatment-resistance schizophrenia occurs in 20-30% of patients. Clozapine is the only medication proven effective for treatment-resistant schizophrenia. However, less than 25% of treatment-resistant schizophrenia patients receive clozapine in most settings. Therefore, this study was conducted to identify facilitators and barriers to clozapine use, to inform development of interventions to maximize appropriate clozapine-utilization. Methods: Seventy semi-structured phone interviews were conducted with five high- and five low-utilization VA Medical Centers, from different US regions including urban and rural areas. Interviewees were key informants of clozapine processes, including mental health leadership, psychiatrists, clinical pharmacists and advanced practice nurses. Interviews were analyzed using an emergent thematic strategy to identify barriers and facilitators to clozapine prescribing. Results: Key elements associated with high-utilization included integration of non-physician psychiatric providers and clear organizational processes and infrastructure for treatment of severe mental illness (e.g. clozapine clinics, larger mental health intensive case management services). Low-utilization was associated with lack of champions to support clozapine processes and limited-capacity care systems. Obstacles identified at both high- and low-utilization sites included complex time-consuming paperwork, reliance on few individuals to facilitate processes, and issues related to transportation for patients living far from care facilities. Conclusions: Implementation efforts to organize, streamline and simplify clozapine processes, development of a multidisciplinary clozapine clinic, increasing the size and capacity of existing clinics, and provision of transportation are reasonable targets to increase clozapine utilization

Organizational Characteristics of Veterans Affairs Clinics With High and Low Utilization of Clozapine

OBJECTIVE: Twenty to thirty percent of patients with schizophrenia experience treatment resistance. Clozapine is the only medication proven effective for treatment-resistant schizophrenia. However, in most settings less than 25% of patients with treatment-resistant schizophrenia receive clozapine. This study was conducted to identify facilitators of and barriers to clozapine use to inform development of interventions to maximize appropriate clozapine utilization. METHODS: Seventy semistructured phone interviews were conducted with key informants of clozapine processes at U.S. Department of Veterans Affairs medical centers in various U.S. regions, including urban and rural areas, with high (N=5) and low (N=5) rates of clozapine utilization. Interviewees included members of mental health leadership, psychiatrists, clinical pharmacists, and advanced practice nurses. Interviews were analyzed by using an emergent thematic strategy to identify barriers and facilitators related to clozapine prescribing. RESULTS: High utilization was associated with integration of nonphysician psychiatric providers and clear organizational processes and infrastructure for treatment of severe mental illness, for example, use of clozapine clinics and mental health intensive case management. Low utilization was associated with a lack of champions to support clozapine processes and with limited-capacity care systems. Obstacles identified at both high- and low-utilization sites included complex, time-consuming paperwork; reliance on a few individuals to facilitate processes; and issues related to transportation for patients living far from care facilities. CONCLUSIONS: Implementation efforts to organize, streamline, and simplify clozapine processes; development of a multidisciplinary clozapine clinic; increased capacity of existing clinics; and provision of transportation are reasonable targets to increase clozapine utilization

Is Variation in Resident-Centered Care and Quality Performance Related to Health System Factors in Veterans Health Administration Nursing Homes?

The purpose of this research was to explore and compare common health system factors for 5 Community Living Centers (ie Veterans Health Administration nursing homes) with high performance on both resident-centered care and clinical quality and for 5 Community Living Centers (CLC) with low performance on both resident-centered care and quality. In particular, we were interested in “how” and “why” some Community Living Centers were able to deliver high levels of resident-centered care and high quality of care, whereas others did not demonstrate this ability. Sites were identified based on their rankings on a composite quality measure calculated from 28 Minimum Data Set version 2.0 quality indicators and a resident-centered care summary score calculated from 6 domains of the Artifacts of Culture Change Tool. Data were from fiscal years 2009-2012. We selected high- and low-performing sites on quality and resident-centered care and conducted 12 in-person site visits in 2014-2015. We used systematic content analysis to code interview transcripts for a priori and emergent health system factor domains. We then assessed variations in these domains across high and low performers using cross-site summaries and matrixes. Our final sample included 108 staff members at 10 Veterans Health Administration CLCs. Staff members included senior leaders, middle managers, and frontline employees. Of the health system factors identified, high and low performers varied in 5 domains, including leadership support, organizational culture, teamwork and communication, resident-centered care recognition and awards, and resident-centered care training. Organizations must recognize that making improvements in the factors identified in this article will require dedicated resources from leaders and support from staff throughout the organization

Supplemental_Materials – Supplemental material for Is Variation in Resident-Centered Care and Quality Performance Related to Health System Factors in Veterans Health Administration Nursing Homes?

<p>Supplemental material, Supplemental_Materials for Is Variation in Resident-Centered Care and Quality Performance Related to Health System Factors in Veterans Health Administration Nursing Homes? by Jennifer L. Sullivan, Ryann L. Engle, Denise Tyler, Melissa K. Afable, Katelyn Gormley, Michael Shwartz, Omonyêlé Adjognon and Victoria A. Parker in INQUIRY: The Journal of Health Care Organization, Provision, and Financing</p

Virtual external implementation facilitation: successful methods for remotely engaging groups in quality improvement

BACKGROUND: Relatively little guidance exists on how to use virtual implementation facilitation to successfully implement evidence-based practices and innovations into clinical programs. Yet virtual methods are increasingly common. They have potentially wider reach, emergent public health situations necessitate their use, and restrictions on resources can make them more attractive. We therefore outline a set of principles for virtual external implementation facilitation and a series of recommendations based on extensive experience successfully using virtual external implementation facilitation in a national program. MODEL AND RECOMMENDATIONS: Success in virtual external implementation facilitation may be achieved by facilitators applying three overarching principles: pilot everything, incorporate a model, and prioritize metacognition. Five practical principles also help: plan in advance, communicate in real time, build relationships, engage participants, and construct a virtual room for participants. We present eight concrete suggestions for enacting the practical principles: (1) assign key facilitation roles to facilitation team members to ensure the program runs smoothly; (2) create small cohorts of participants so they can have meaningful interactions; (3) provide clarity and structure for all participant interactions; (4) structure program content to ensure key points are described, reinforced, and practiced; (5) use visuals to supplement audio content; (6) build activities into the agenda that enable participants to immediately apply knowledge at their own sites, separate from the virtual experience; (7) create backup plans whenever possible; and (8) engage all participants in the program. These principles represent a novel conceptualization of virtual external implementation facilitation, giving structure to a process that has been, to date, inadequately described. The associated actions are demonstrably useful in supporting the principles and offer teams interested in virtual external implementation facilitation concrete methods by which to ensure success. Our examples stem from experiences in healthcare. But the principles can, in theory, be applied to virtual external implementation facilitation regardless of setting, as they and the associated actions are not setting specific