Karen L. Drummond

Monitoring and managing metabolic effects of antipsychotics: a cluster randomized trial of an intervention combining evidence-based quality improvement and external facilitation

BackgroundTreatment of psychotic disorders consists primarily of second generation antipsychotics, which are associated with metabolic side effects such as overweight/obesity, diabetes, and dyslipidemia. Evidence-based clinical practice guidelines recommend timely assessment and management of these conditions; however, research studies show deficits and delays in metabolic monitoring and management for these patients. This protocol article describes the project ‘Monitoring and Management for Metabolic Side Effects of Antipsychotics,’ which is testing an approach to implement recommendations for these practices.Methods/DesignThis project employs a cluster randomized clinical trial design to test effectiveness of an evidence-based quality improvement plus facilitation intervention. Eligible study sites were VA Medical Centers with ≥300 patients started on a new antipsychotic prescription in a six-month period. A total of 12 sites, matched in pairs based on scores on an organizational practice survey, were then randomized within pairs to intervention or control conditions.Study participants include VA employees involved in metabolic monitoring and management of patients treated with antipsychotics at participating sites. The intervention involves researchers partnering with clinical stakeholders to facilitate tailoring of local implementation strategies to address barriers to metabolic side-effect monitoring and management. The intervention includes a Design Phase (initial site visit and subsequent development of a local implementation plan); Implementation Phase (guided by an experienced external facilitator); and a Sustainability Phase. Evaluation includes developmental, implementation-focused, progress-focused and interpretative formative evaluation components, as well as summative evaluation. Evaluation methods include surveys, qualitative data collection from provider participants, and quantitative data analysis of data for all patients prescribed a new antipsychotic medication at a study site who are due for monitoring or management of metabolic side effects during the study phases. Changes in rates of recommended monitoring and management actions at intervention and control sites will be compared using time series analyses.DiscussionImproving monitoring for metabolic side effects of antipsychotics, as well as promoting timely evidence-based management when these effects emerge, will lead to improved patient safety and long-term outcomes. This article discusses key strengths and challenges of the study.Trial registrationNCT01875861

HIV patient and provider feedback on a telehealth collaborative care for depression intervention

ABSTRACT In the HIV Translating Initiatives for Depression into Effective Solutions project, we conducted a randomized controlled effectiveness and implementation trial comparing depression collaborative care with enhanced usual care in Veterans Health Administration HIV clinics in the US. An offsite HIV depression care team including a psychiatrist, a depression care manager (DCM), and a clinical pharmacist provided collaborative care using a stepped-care model of treatment and made recommendations to providers through the electronic health record system. The DCM delivered care management to HIV patients through phone calls, performing routine assessments and providing counseling in self-management and problem-solving. The DCM documented all calls in each patient’s electronic medical record. In this paper we present results from interviews conducted with patients and clinical staff in a multi-stage formative evaluation (FE). We conducted semi-structured FE interviews with 26 HIV patients and 30 clinical staff at the three participating sites during and after the trial period to gather their experiences and perspectives concerning the intervention components. Interviews were transcribed verbatim and analyzed using rapid content analysis techniques. Patients reported high satisfaction with the depression care manager (DCM) phone calls. Both HIV and mental health providers reported that the DCM’s chart notes in the electronic health record were very helpful, and most felt that a dedicated DCM for HIV patients is ideal to meet patient needs. Sites encountered barriers to achieving and maintaining universal depression screening, but had greater success when such screening was incorporated into routine intake processes. FE results demonstrated that depression care management via telehealth from an offsite team is acceptable and helpful to both HIV patients and their providers. Given that a centralized offsite depression care team can deliver effective, cost-effective, cost-saving services for multiple HIV clinics in different locations with high patient and provider satisfaction, broad implementation should be considered.

Provider Opinions Regarding the Development of a Stigma-Reduction Intervention Tailored for Providers

Interventions involving contact with a person who has recovered from mental illness are most effective at reducing stigma. This study sought input from health care providers to inform the design of a contact intervention intended to reduce provider stigma toward persons with serious mental illness. Using a purposive sampling strategy, data were collected from providers at five Veterans Affairs hospitals in the southeastern United States. Seven focus groups were conducted, and 83 health care providers participated. A semistructured interview guide was used to elicit providers’ opinions about the target group of a contact intervention for providers, what providers would consider a credible contact, the preferred format for delivery, the usefulness of potentially tailoring the intervention to a specific facility, and how to measure change in clinical behaviors. Focus group data were analyzed using rapid data analysis techniques. Participants uniformly recommended a broad target audience for the stigma-reduction intervention, including all primary care and specialist providers. They suggested that the person providing the “lived experience” for the contact intervention should be either a health care provider or a patient with serious mental illness. Face-to-face presentation was favored, but video presentation was considered more feasible. Participants stated that information about local disparities in care rendered to patients with or without mental illness would convince providers of how stigma may be a contributing factor to these disparities. Multiple training opportunities were favored, while mandatory training was disliked. Standard stigma-reduction interventions with subgroups of the general public (e.g., providers) may need to be modified for optimum subgroup effectiveness.

Assessing Collaborative Care in Mental Health Teams: Qualitative Analysis to Guide Future Implementation

The Collaborative Care Model (CCM) is an evidence-based approach for structuring care for chronic health conditions. Attempts to implement CCM-based care in a given setting depend, however, on the extent to which care in that setting is already aligned with the specific elements of CCM-based care. We therefore interviewed staff from ten outpatient mental health teams in the US Department of Veterans Affairs to determine whether care delivery was consistent or inconsistent with CCM-based care in those settings. We discuss implications of our findings for future attempts to implement CCM-based outpatient mental health care.

Assessing Culture and Climate of Federally Qualified Health Centers: A Plan for Implementing Behavioral Health Interventions

Abstract:Objective. This study examines organizational factors relating to climate and culture that might facilitate or impede the implementation of evidence-based practices (EBP) targeting behavioral health in federally qualified health centers (FQHCs). Methods. Employees at six FQHCs participating in an evidence-based quality improvement (EBQI) initiative for mood disorders and alcohol abuse were interviewed (N=32) or surveyed using the Organizational Context Survey (OCS) assessing culture and climate (N=64). Results. The FQHCs scored relatively well on proficiency, a previously established predictor of successful EBP implementation, but also logged high scores on scales assessing rigidity and resistance, which may hinder implementation. Qualitative data contextualized scores on FQHC culture and climate dimensions. Conclusions. Results suggest that the unique culture of FQHCs may influence implementation of evidence-based behavioral health interventions.