Post-inpatient Attrition from Care “As Usual” in Veterans with Multiple Psychiatric Admissions

Disengagement from outpatient care following psychiatric hospitalization is common in high-utilizing psychiatric patients and contributes to intensive care utilization. To investigate variables related to treatment attrition, a range of demographic, diagnostic, cognitive, social, and behavioral variables were collected from 233 veterans receiving inpatient psychiatric services who were then monitored over the following 2 years. During the follow-up period, 88.0 % (n = 202) of patients disengaged from post-inpatient care. Attrition was associated with male gender, younger age, increased expectations of stigma, less short-term participation in group therapy, and poorer medication adherence. Of those who left care, earlier attrition was predicted by fewer prior-year inpatient psychiatric days, fewer lifetime psychiatric hospitalizations, increased perceived treatment support from family, and less short-term attendance at psychiatrist appointments. Survival analyses were used to analyze the rate of attrition of the entire sample as well as the sample split by short-term group therapy attendance. Implications are discussed

Cluster randomized trial comparing standard versus enhanced implementation strategies for improving outreach to persons with SMI: 12-month results

http://deepblue.lib.umich.edu/bitstream/2027.42/134545/1/13012_2015_Article_940.pd

Cluster randomized adaptive implementation trial comparing a standard versus enhanced implementation intervention to improve uptake of an effective re-engagement program for patients with serious mental illness

Abstract Background Persons with serious mental illness (SMI) are disproportionately burdened by premature mortality. This disparity is exacerbated by poor continuity of care with the health system. The Veterans Health Administration (VA) developed Re-Engage, an effective population-based outreach program to identify veterans with SMI lost to care and to reconnect them with VA services. However, such programs often encounter barriers getting implemented into routine care. Adaptive designs are needed when the implementation intervention requires augmentation within sites that do not initially respond to an initial implementation intervention. This protocol describes the methods used in an adaptive implementation design study that aims to compare the effectiveness of a standard implementation strategy (Replicating Effective Programs, or REP) with REP enhanced with External Facilitation (enhanced REP) to promote the uptake of Re-Engage. Methods/Design This study employs a four-phase, two-arm, longitudinal, clustered randomized trial design. VA sites (n = 158) across the United States with a designated Re-Engage provider, at least one Veteran with SMI lost to care, and who received standard REP during a six-month run-in phase. Subsequently, 88 sites with inadequate uptake were stratified at the cluster level by geographic region (n = 4) and VA regional service network (n = 20) and randomized to REP (n = 49) vs. enhanced REP (n = 39) in phase two. The primary outcome was the percentage of veterans on each facility outreach list documented on an electronic web registry. The intervention was at the site and network level and consisted of standard REP versus REP enhanced by external phone facilitation consults. At 12 months, enhanced REP sites returned to standard REP and 36 sites with inadequate participation received enhanced REP for six months in phase three. Secondary implementation outcomes included the percentage of veterans contacted directly by site providers and the percentage re-engaged in VA health services. Discussion Adaptive implementation designs consisting of a sequence of decision rules that are tailored based on a site’s uptake of an effective program may produce more relevant, rapid, and generalizable results by more quickly validating or rejecting new implementation strategies, thus enhancing the efficiency and sustainability of implementation research and potentially leading to the rollout of more cost-efficient implementation strategies. Trial registration Current Controlled Trials ISRCTN21059161 .http://deepblue.lib.umich.edu/bitstream/2027.42/112609/1/13012_2013_Article_711.pd

Treatment Attrition and Relapse Readmission in Psychiatric Inpatients: Predictors of Treatment Engagement and Psychiatric Relapse

A large-scale study was conducted to investigate the causes of relapse readmission and treatment attrition in psychiatric inpatients. Two hundred thirty-three veterans receiving care within the VA medical system completed questionnaires related to their expectations of treatment and their planned level of investment in treatment efforts. Follow-up information was collected over two years following discharge from intensive psychiatric treatment via computerized medical records. This information was used in survival analyses to identify risk factors for psychiatric relapse and treatment dropout. Over the course of the follow-up period, 86.7% lost contact with treatment professionals and 63.5% of veterans were readmitted for an additional psychiatric inpatient treatment. A combination of demographic, illness, social, cognitive, and behavioral factors were found to be predictive of both relapse and attrition, although treatment attrition was not found to be related to psychiatric readmission. Implications of these findings are discussed and recommendations are made to help clinicians identify and respond to veterans most likely to leave treatment or need additional intensive psychiatric care

Predictors of Rehospitalization in High-Utilizing Patients in the VA Psychiatric Medical System

233 high-service-utilizing (HSU) psychiatric patients were recruited during an inpatient psychiatric treatment. They completed a questionnaire related to their treatment beliefs and were tracked via computerized medical records over 2 years. During the follow-up period, 79.8% were readmitted for additional inpatient psychiatric treatment. Survival analysis techniques were used to examine patients’ rates of readmittance during the follow-up period. Number of previous year inpatient psychiatric days served as a significant predictor of readmittance status and time to readmission. The survival plot was split by previous-year inpatient days to examine the effect of this variable on readmission. Implications of findings are discussed

Enhancing outreach for persons with serious mental illness: 12-month results from a cluster randomized trial of an adaptive implementation strategy

Abstract Background Few implementation strategies have been empirically tested for their effectiveness in improving uptake of evidence-based treatments or programs. This study compared the effectiveness of an immediate versus delayed enhanced implementation strategy (Enhanced Replicating Effective Programs (REP)) for providers at Veterans Health Administration (VA) outpatient facilities (sites) on improved uptake of an outreach program (Re-Engage) among sites not initially responding to a standard implementation strategy. Methods One mental health provider from each U.S. VA site (N = 158) was initially given a REP-based package and training program in Re-Engage. The Re-Engage program involved giving each site provider a list of patients with serious mental illness who had not been seen at their facility for at least a year, requesting that providers contact these patients, assessing patient clinical status, and where appropriate, facilitating appointments to VA health services. At month 6, sites considered non-responsive (N = 89, total of 3,075 patients), defined as providers updating documentation for less than <80% of patients on their list, were randomized to two adaptive implementation interventions: Enhanced REP (provider coaching; N = 40 sites) for 6 months followed by Standard REP for 6 months; versus continued Standard REP (N = 49 sites) for 6 months followed by 6 months of Enhanced REP for sites still not responding. Outcomes included patient-level Re-Engage implementation and utilization. Results Patients from sites that were randomized to receive Enhanced REP immediately compared to Standard REP were more likely to have a completed contact (adjusted OR = 2.13; 95% CI: 1.09–4.19, P = 0.02). There were no differences in patient-level utilization between Enhanced and Standard REP sites. Conclusions Enhanced REP was associated with greater Re-Engage program uptake (completed contacts) among sites not responding to a standard implementation strategy. Further research is needed to determine whether national implementation of Facilitation results in tangible changes in patient-level outcomes. Trial registration ISRCTN: ISRCTN21059161http://deepblue.lib.umich.edu/bitstream/2027.42/110218/1/13012_2014_Article_163.pd