Reengaging Veterans With Serious Mental Illness Into Care: Preliminary Results From a National Randomized Trial Amy M. Kilbourne, Ph.D., M.P.H., David E. Goodrich, Ed.D., Zongshan Lai, M.P.H., Daniel Almirall, Ph.D., Kristina M. Nord, L.M.S.W., Nicholas W. Bowersox, Ph.D., Kristen M. Abraham, Ph.D.

Objective: This study compared effectiveness of an enhanced versus standard implementation strategy (Replicating Effective Programs [REP]) on site-level uptake of Re-Engage, a national program for veterans with serious mental illness. Methods: Mental health providers at 158 Veterans Affairs (VA) facilities were given REP-based manuals and training in Re-Engage, which involved identifying veterans who had not been seen in VA care for at least one year, documenting their clinical status, and coordinating further health care. After six months, facilities not responding to REP (N588) were randomized to receive six months of facilitation (enhanced REP)

Persons with serious mental illness are disproportionately burdened by general medical conditions (1,2) and subsequent premature mortality (3). Two out of every five veterans with serious mental illness experience substantial gaps in care (4). Improving access to and continuity of health services may mitigate these risks (3). To address this disparity, the U.S. Department of Veterans Affairs (VA) tested the effectiveness of the Re-Engage outreach program, in which veterans with serious mental illness who had dropped out of care (defined as not seen by a VA provider for at least one year) were identified and encouraged to return to care (5). Re-Engage consists of documentation of patients’ clinical status and of outreach to assess need for health care (6); in a previous study, Re-Engage was associated with a greater proportion of veterans returning to VA care and with a sixfold reduction in mortality (5). Subsequently, in 2012 the VA approved a policy directive that authorized the national implementation of Re-Engage across VA facilities (7). [A copy of this directive is available in an online supplement.] VA program leaders sought to ensure that Re-Engage was effectively sustained nationally by local providers. VA program leaders sought to identify strategies to help providers implement Re-Engage and to ensure that this national program was effectively sustained by local providers. 90

or continued standard REP. Site-level uptake was defined as percentage of patients (N51,531) with updated documentation or with whom contact was attempted. Results: Rate of Re-Engage uptake was greater for enhanced REP sites compared with standard REP sites (41% versus 31%, p5.01). Total REP facilitation time was 7.3 hours per site for six months. Conclusions: Added facilitation improved short-term uptake of a national mental health program. Psychiatric Services 2015; 66:90–93; doi: 10.1176/

However, standardized implementation strategies (7) have not been widely tested for their effectiveness. Taking advantage of the VA’s national implementation of Re-Engage, this study compared the effectiveness of a standard versus enhanced implementation strategy to promote the uptake of Re-Engage among sites not initially responding to six months of the standard implementation strategy. METHODS The randomized controlled implementation intervention trial, described elsewhere (7), was reviewed and approved by local VA institutional review boards. Sites not initially responding to an established implementation strategy (Replicating Effective Programs [REP]) were randomized (8) at the VA regional network level to either continue with standard REP implementation of the intervention or receive an enhanced version of REP that included a facilitator to promote uptake of the ReEngage intervention. Using previously established population management techniques (9), Re-Engage involved making initial queries of VA national administrative databases to identify veterans with a diagnosis of serious mental illness who had not been seen by a VA provider for a year or more. The intervention Psychiatric Services 66:1, January 2015



also required a mental health clinician to FIGURE 1. Re-Engage outcomes for veterans at 158 VA sites that followed Replicating Effective Program (REP) document veterans’ clinical status and to at- the enhanced or standard implementation strategya tempt to contact and link veterans to appro80 Enhanced, updated documentation priate VA health care when needed (5). Standard, updated documentation Investigators generated an initial list of 70 Enhanced, attempted contact Standard, attempted contact veterans with either an inpatient or outpatient 60 ICD-9-CM diagnosis for serious mental illness (schizophrenia, codes 295.0–295.9, or bipolar 50 disorder, codes 296.0–296.1 or 296.4–296.89) 40 recorded between fiscal year (FY) 2008 and 30 FY 2011 who were last seen at a VA facility in the 50 United States, who remained alive 20 throughout that period according to U.S. 10 death records, and who as of FY 2011 had not received VA outpatient care for at least one 0 Sept Oct Nov Dec Jan Feb March year. The list was stratified by VA site where 2012 2012 2012 2012 2013 2013 2013 each patient was last seen, and the list was a Outcomes were percentage of veterans (N51,531) with updated clinical status and pertransmitted securely to a designated VA mental centage of veterans to whom outreach contact was attempted via the Re-Engage prohealth clinician at that facility. These VA clinigram among 158 VA sites receiving REP. Seventy sites received standard REP; 88 sites not responsive after six months received facilitation (enhanced REP). cians, known as local recovery coordinators, were identified by the VA national policy directive to implement the Re-Engage program. As licensed facilitators, who provided coaching for six months. Providers independent practitioners, a vast majority (96%) of local refrom sites assigned to standard REP continued to have accovery coordinators were master’s-level social workers or cess to REP materials and could contact a separate techdoctoral-level psychologists, and they had the clinical expertise nical assistant for Re-Engage program support but did not to implement the core components of the Re-Engage program, receive coaching from facilitators. All personnel who opernotably reviewing medical records, updating the patient’s ationalized and provided the enhanced and standard REP clinical status in a Web-based registry, and assessing the vetimplementation strategies, including facilitators and trainers, eran’s current medical and psychosocial needs in order to were located at one site. Facilitators were collaborators on contact him or her and schedule needed appointments. a research project that was funded independently of national The primary focus of this study was to compare the two leadership, and they were not part of the local providers’ implementation strategies on the basis of improved uptake of chain of supervision. Re-Engage (rather than on improvements in patient-level On implementing Re-Engage at a site, facilitators for enoutcomes due to the Re-Engage program itself ). The primary hanced REP provided coaching to local recovery coordinators outcomes for this study were defined as the percentage of via semistructured weekly calls (9). During the calls, facilipatients with an updated documentation of clinical status and tators assessed site-level barriers to Re-Engage uptake, repercentage with an attempted contact by the provider. These viewed progress, provided support and encouragement, and measures represent core components of the Re-Engage prodeveloped action plans to resolve barriers to implementation. gram and were ascertained from the Web-based registry (5,9). Facilitators also provided negotiation skills to help with seAt the time the Re-Engage directive was implemented curing time and resources from local leadership. Each facili(March 2012), local recovery coordinators at all VA facilities tator recorded on a weekly log form the total time spent on (N5158 sites) in the United States were given the standard facilitation activities, including attempted and completed calls REP strategy, which included a toolkit, Web-based registry with providers and meetings with national leadership to gain link, training in the Re-Engage program via conference calls, insight into local issues. as-needed technical assistance to support implementation, and Descriptive statistics were used to compare the facilities bimonthly progress reports on Re-Engage program impleachieving adequate reengagement after six months: permentation (5). After six months of standard REP, 42% (N570) centage of patients with documentation of updated clinical of sites had achieved minimum program implementation, status and percentage with at least one attempted contact which was defined as initial effort to update clinical status for within six months. Longitudinal repeated-measures analysis $80% patients in the Web-based registry. Sites that did not was used to compare site-level overall percentages between achieve minimum implementation (58%; N588) were then standard REP and enhanced REP groups, adding enhanced randomized (September 1, 2012), with stratification by VA net(versus standard) REP, time (in months), the enhanced REP 3 work level, to receive enhanced REP or continuation of standard time interaction, facility size (overall number of unique paREP. tients at the site before site randomization), number of vetLocal recovery coordinators from sites randomized to erans on the site’s list for re-engagement, and whether the enhanced REP were assigned to one of three doctoral-level facility had an inpatient unit. Psychiatric Services 66:1, January 2015



RESULTS As of September 1, 2012, a total of 1,531 veterans had been lost to care in the 88 VA sites not initially responding to six months of standard REP, with a median of 17 veterans lost per site (range from four to 44 veterans). Six months later, sites receiving enhanced REP, compared with those receiving standard REP, had a greater percentage of veterans with updated documentation of clinical status (61% versus 47%; t51.57, df587, p5.01) and a greater percentage (N5579) with an attempted contact (41% versus 31%; t51.58, df587, p5.01) (Figure 1). Results from the adjusted repeated-measures analysis indicated a greater rate of change among enhanced REP compared with standard REP sites in percentage of veterans with updated documentation (enhanced REP 3 time interaction, b5.03, t53.17, df5462, p,.001) and attempted contact (enhanced REP 3 time interaction, b5.02, t52.37, df5520, p5.01). The total amount of time all facilitators spent across the 39 sites during the six-month enhanced REP period was 284.6 hours, or a total of 7.3 hours per VA site for a sixmonth “dose” of facilitation support. Limiting the analyses to sites with $20 veterans who were lost to care produced similar results (data not shown). Common barriers to Re-Engage program uptake addressed by facilitators included limited provider time to contact veterans because of multiple role responsibilities. Subsequently, facilitators provided guidance on delegating responsibilities. Providers also reported a loss in momentum when initial veteran contact efforts were unsuccessful, and facilitators encouraged providers to enlist peer specialists to help find veterans. Others reported a lack of appointment availability once veterans were contacted. Here, facilitators encouraged providers to meet with clinic leadership to secure scheduling assistance.

DISCUSSION In this implementation intervention trial, providers from sites randomized to receive added facilitation coaching compared with sites receiving a standard implementation strategy were more likely to implement an outreach program for veterans with serious mental illness who had dropped out of care. Few implementation strategies have been shown to improve the uptake of clinical programs, especially at the national level. Strategies such as enhanced REP can be useful to large health care organizations that strive to roll out evidence-based programs to improve access and outcomes for high-risk patients. Assessing the effectiveness of enhanced REP among sites not initially responding to standard REP was important because not all sites needed a more intensive implementation strategy. This design also has the potential to inform the delivery of more cost-efficient implementation interventions (8). The priority to conduct a national rollout of the ReEngage program precluded more intensive monitoring of program uptake or having facilitators make in-person site 92

visits. Another study limitation was that the need to disseminate early findings mitigated the ability to wait for long-term patient-level outcomes data. Finally, there is a possibility that the effect of added facilitation resulted in more attention on the program. Nonetheless, Re-Engage was initiated as a national clinical mandate six months before facilitation was added across all sites, and all sites received reports on their implementation progress before randomization. Moreover, many local recovery coordinators saw facilitators as being in a position to ensure that Re-Engage was a priority to their local supervisors. CONCLUSIONS Added facilitation improved uptake of a national program among sites that had been less responsive to standard implementation practices. These findings have the potential to inform not only the development of more cost-efficient implementation strategies but policies around national roll-out of programs (10). Further research is needed to determine the long-term impact and value of implementation strategies on improving health of persons with mental disorders. AUTHOR AND ARTICLE INFORMATION With the exception of Dr. Almirall, the authors are with the Veterans Affairs (VA) Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, and the Department of Psychiatry, University of Michigan Medical School, Ann Arbor (e-mail: [email protected]). Dr. Abraham is also with the Department of Psychology, University of Detroit Mercy, Detroit. Dr. Almirall is with the Institute for Social Research, University of Michigan, Ann Arbor. This work was supported by the U.S. Department of Veterans Affairs, Veterans Health Administration (VHA), Health Services Research and Development Service (IIR 11-232). The authors acknowledge the VHA Mental Health Services, VHA Mental Health Operations, and VHA Office of the Medical Inspector for their support. The views expressed in this report are those of the authors and do not necessarily represent the views of the VA. This work is registered as Current Controlled Trial ISRCTN21059161. The authors report no financial relationships with commercial interests.

REFERENCES 1. Kilbourne AM, Cornelius JR, Han X, et al: General-medical conditions in older patients with serious mental illness. American Journal of Geriatric Psychiatry 13:250–254, 2005 2. O’Toole TP, Pirraglia PA, Dosa D, et al: Building care systems to improve access for high-risk and vulnerable veteran populations. Journal of General Internal Medicine 26(suppl 2):683–688, 2011 3. Copeland LA, Zeber JE, Rosenheck RA, et al: Unforeseen inpatient mortality among veterans with schizophrenia. Medical Care 44: 110–116, 2006 4. McCarthy JF, Blow FC, Valenstein M, et al: Veterans Affairs Health System and mental health treatment retention among patients with serious mental illness: evaluating accessibility and availability barriers. Health Services Research 42:1042–1060, 2007 5. Davis CL, Kilbourne AM, Blow FC, et al: Reduced mortality among Department of Veterans Affairs patients with schizophrenia or bipolar disorder lost to follow-up and engaged in active outreach to Psychiatric Services 66:1, January 2015


return for care. American Journal of Public Health 102(suppl 1): S74–S79, 2012 6. VHA Directive 2012-002: Re-Engaging Veterans With Serious Mental Illness in Treatment. Washington, DC, US Department of Veterans Affairs, Veterans Health Administration, 2012 7. Kilbourne AM, Abraham KM, Goodrich DE, et al: 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. Implementation Science 8:136, 2013

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8. Almirall D, Compton SN, Gunlicks-Stoessel M, et al: Designing a pilot sequential multiple assignment randomized trial for developing an adaptive treatment strategy. Statistics in Medicine 31: 1887–1902, 2012 9. Viggiano T, Pincus HA, Crystal S: Care transition interventions in mental health. Current Opinion in Psychiatry 25:551–558, 2012 10. Health Homes for Enrollees With Chronic Conditions. Baltimore, Md, Centers for Medicare and Medicaid Services, Nov 16, 2010. Available at downloads/SMD10024.pdf


Reengaging veterans with serious mental illness into care: preliminary results from a national randomized trial.

This study compared effectiveness of an enhanced versus standard implementation strategy (Replicating Effective Programs [REP]) on site-level uptake o...
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