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IIR 06-227
Promoting Recovery Using Mental Health Consumer Providers
Matthew J. Chinman, PhD VA Pittsburgh Healthcare System University Drive Division, Pittsburgh, PA Pittsburgh, PA Amy Cohen PhD MA VA Greater Los Angeles Healthcare System, West Los Angeles, CA West Los Angeles, CA Funding Period: March 2008 - May 2011 |
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BACKGROUND/RATIONALE:
Serious mental illness (SMI) is the second most costly disorder treated in the VHA, yet clinical outcomes for these patients are often poor due to a combination of low quality care and severe cognitive and functional impairments. While these problems are multifaceted, studies outside the VHA have shown that using "consumer providers" (CPs) can improve and augment care. Similar to recovering addiction counselors, CPs are individuals with SMI who use their lived experiences to provide services to others with SMI. CPs can reach out to patients that are difficult to engage, assist patients with tasks of daily living, offer a variety of rehabilitation (vocational, social, residential) services, be role models and offer hope for recovery, and facilitate support groups. Randomized controlled and quasi-experimental trials outside the VHA have shown that CPs can provide services that yield at least equivalent patient outcomes with particular benefits noted on intensive case management teams. VHA has hired about 250 CPs to date, although their impact has not been documented. Yet its success outside the VHA and the recent emphasis on recovery-oriented care suggests the need to test this model in the VHA. OBJECTIVE(S): To conduct a randomized controlled trial testing the impact on patient level and team level outcomes of the implementation of CP services on six mental health intensive case management (MHICM) teams in VISN-22. The specific aims were to: 1) Evaluate the acceptability, facilitators of and barriers to the inclusion of two CPs to each intervention MHICM team. 2) Evaluate the effect of including CPs on the degree to which MHICM teams services are recovery-oriented. 3) Evaluate the effect of including CPs on veterans' clinical and recovery-focused outcomes. Our hypotheses were that CPs would be feasible and acceptable, that teams would become more recovery-oriented, and that the involvement of CPs would lead to greater gains in recovery, quality of life, empowerment with regard to illness, and to a lesser extent, symptoms compared to patients on teams without CPs. METHODS: This project was a "cluster randomized controlled trial" comparing 3 CP-MHICM teams (with CPs) to 3 control teams (i.e., without a CP), at MHICM sites within VISN-22. All patients on the 6 MHICM teams' caseload during each site's recruitment period were eligible. 285 MHICM patients were enrolled, 152 at the intervention sites and 133 at the control sites. Each intervention MHICM team used a strategic planning process to tailor the CP intervention to local priorities and structures, involving multiple meetings to discuss the CP's role, hiring, and incorporation of CPs into the team. The project hired the CPs, provided training, assisted in their implementation on the teams and provided ongoing supervision. The CPs worked for about 12 months. Using a patient survey, the study assessed impacts of CPs on patient level outcomes including recovery-orientation of their team (Recovery Self-assessment scale), individual recovery (Mental Health Recovery Measure, Illness Self-Management Scale), quality of life (Quality of Life Interview), symptoms (BASIS-24), and patient activation (Patient Activation Measure). The patient level outcome assessments were conducted pre and post intervention. Final follow-up assessment rates ranged from 71- 95% at intervention sites and 80 - 88% at control sites. We conducted site visits with all six MHICM teams using a validated, standardized protocol, rating each team's level of recovery orientation before and after the deployment of the CPs on the Recovery-Oriented Practices Index (ROPI). We conducted 23 focus groups and interviews with patients, providers and CPs at all intervention sites (about 8 per site) at the post time point to assess barriers and facilitators to CP implementation. All focus groups and interviews were recorded, transcribed, and coded using Atlas.ti. The analyses of the patient survey data were comparisons of changes between baseline and followup scores with regression analyses of the change scores for all the outcomes mentioned above. The first analyses was whether the intervention group was significantly related to change considering only treatment group and statistically controlling for baseline score, and covariates (age, gender, race, living situation and education level). The second was the same as the first, adding site as a fixed covariate. The ROPI ratings were made on a very small number of units (6 teams), therefore the results were descriptive and involved a percent change from pre to post. The focus groups and interviews were each summarized and then summarized by site. The study team discussed the results. Using the constant comparison method, salient topics were compared within and across roles and sites. FINDINGS/RESULTS: Analyses of the change scores on the patient survey indicated that the intervention sites gained more on the PAM scale than the usual care sites (t=1.95 (df=192), p=0.05 for the model without site and t (df=185) =3.11, p=0.002 for the model adjusting for site. For the BASIS Interpersonal Relations Subscale, the site-unadjusted model did not show a between group difference in change scores however, the site-adjusted model indicated that the PEERs sites had a significant improvement (t=-2.70, p=0.0007). For all the other outcomes, the CP and Non-CP groups did not change significantly differently from each other over time. Intervention sites' ratings on the ROPI had a 20 percent change improvement from before and after the CP intervention, while the control sites had a 15 percent change improvement. The focus groups and interviews showed that the MHICM teams generally viewed the CPs as positive. All agreed that CPs connected well with patients and patients reported feeling supported by CPs during everyday tasks. Many staff and CPs talked about "growing pains" related to establishing trust, boundaries, and role delineations. Anticipated concerns about CP-patient boundary violations were not realized, in part because of considerable pre-planning of the CP's role. Sites did struggle with how to best use some of the CPs and how much structure to place on them, at times leading to under- or misutilization of the CPs. IMPACT: Deploying CPs on MHICM teams helped improve patient activation and patients' interpersonal relationships. Becoming more active in one's own care and having more of a social network are key areas of recovery from serious mental illness. Hiring more CPs to work in MHICM or other areas of the VHA mental health system could be beneficial to veterans with serious mental illness. External Links for this ProjectDimensions for VA Dimensions for VA is a web-based tool available to VA staff that enables detailed searches of published research and research projects. Learn more about Dimensions for VA. VA staff not currently on the VA network can access Dimensions by registering for an account using their VA email address. Search Dimensions for this project PUBLICATIONS:Journal Articles
DRA:
Mental, Cognitive and Behavioral Disorders, Health Systems Science
DRE: Prognosis, Treatment - Observational Keywords: Caregivers – not professionals, Mental Health Care, Mental health care delivery, Mental health care service, Organizational issues, Severe mental illness MeSH Terms: Mental Health Services |
