BACKGROUND/RATIONALE:
Suicide prevention among military Veterans has become a national priority; yet, there is a gap in suicide-specific intervention training for mental health students and professionals. The need for training in this area has become even more acute with the recent hiring by the Veterans Health Affairs (VHA) of thousands of clinicians to address the mental health needs of Veterans from all war eras. Since e-learning (online) education is more effective than traditional in-person (face-to-face) education for adult learners when methods, such as blended learning, are used, this mode of delivery may more easily meet the training and continuing education needs of busy medical professionals who may find it easier to fit online education into their daily schedules.

A well developed in-person training approach known as the Collaborative Assessment and Management of Suicidality (or CAMS) has been recommended in systematic reviews as an effective tool for assessing and managing suicidality, as well as decreasing providers' fears, improving their attitudes, increasing their knowledge, confidence, and competence, and dispelling myths.

OBJECTIVE(S):
There are four specific aims:
1. Refine a CAMS e-learning course that covers the same material and meets
the same learning objectives of CAMS in-person training.

2. Test the effectiveness of the CAMS e-learning modality compared to the
CAMS in-person modality and a concurrent non-intervention control in terms of
provider evaluation and behavior.

HO: Providers in each of the two CAMS arms will demonstrate higher
levels of content mastery and confidence in acquired skills than providers in the no
CAMS arm.

H2: In the 12 months post-training, suicidal patients of providers in each
of the two CAMS arms will receive higher rates of CAMS guideline
concordant treatment, compared with providers in the no CAMS arm.

3. Test the effectiveness of the CAMS e-Learning delivery compared to the
CAMS in-person delivery and a concurrent non-intervention control in terms of
patient outcomes.

H3, 4, 5: In the 12 months post-training, suicidal patients of CAMS e-learning
providers and CAMS in-person providers will be similar for health services
use patterns, duration of high risk episodes, and number of high risk episodes per patient.

H6: In the 12 months post training, suicidal patients of providers in the no
CAMS arm will have higher rates of emergency room use and inpatient
mental health admissions, have a longer average duration of high risk
episodes, and have more high risk episodes per patient.

4. Assess factors that facilitate or inhibit adoption of CAMS through e-Learning or
In-person.

METHODS:
Design. A trial of CAMS e-learning in comparison to CAMS in-person was conducted, using a multicenter, randomized, cluster, three group design. Outpatient mental health providers without previous CAMS training were recruited from five VA hospitals in the southeastern VA region. Following informed consent, providers who completed a CAMS Pre-Survey were randomized to one of three conditions. Those randomized to either of the CAMS training conditions were granted 6.5 hours of clinic release time, 6.5 CEUs, and the CAMS text, following successful completion of training. Those randomized to the control condition received an emergency psychiatry text.

Clinics were blocked 6-8 weeks in advance of training for providers in both training conditions. Delivery of training was then conducted over a four month period. At each site, in-person CAMS was delivered one day and e-learning was implemented over a three week period following the in-person training.

Intervention. The Collaborative Assessment and Management of Suicidality (CAMS) is a structured clinical framework for assessing, monitoring, and intervening with a patient at risk for suicide. CAMS includes the use of problem-focused interventions of patient-defined "drivers" of suicide that is guided by a multi-purposed clinical tool called the Suicide Status Form (SSF). The final e-CAMS product was an asynchronous learning course. The e-CAMS modules included: 1) Introduction to Suicidality and CAMS Approach, 2) Collaborative Suicide Risk Assessment, 3) CAMS Status Tracking and Problem-Focused Treatment (PFT), and 4) Fusion of CAMS within the VA. A CAMS Coaching Component was provided to both CAMS training conditions to encourage adoption, recognize successes, and address barriers. The coaching component was six bimonthly, lunch hour, teleconferences with the developer of CAMS.

Study Population, Sample, Response. A total of 230 (out of an eligible 309, recruitment rate 72%) providers consented. Of these, 212 providers completed the pre-survey and were randomized: 69 to the e-learning condition, 70 to the in-person condition, and 73 to the control condition. The 139 providers randomized to e-learning or in-person training were primarily female, Caucasian (67.7%) or African-American (25.6%), midlife, mid-level providers.

Settings. The study was conducted at five VA medical centers from 2009-2013 and was approved by the IRBs of all sites.

Study variables. Provider variables include, satisfaction with training, confidence in managing suicidal crises, use of SSF forms, adoption of CAMS, adherence to CAMS. Patient variables include health services use patterns, duration of high risk episodes, number of high risk episodes, emergency room use, inpatient mental health admissions, and suicidality. Intervention variables included training completion and coaching attendance.

Methods of analyses. The VA Evaluation of Training was used to evaluate satisfaction and descriptive statistics were used to analyze frequencies. Pairwise comparisons of intervention means (ANOVA-type simple-effect comparisons) at each time point were carried out based on a priori specified hypotheses. Descriptive statistics were calculated for the total and individual item scores, including means, standard deviations, and frequency distributions. A generalized linear mixed models (GLMM) approach was used to model the longitudinal CAMS Survey provider outcome data.

FINDINGS/RESULTS:
(Aim 1) We developed the CAMS-e, conducted a pilot, revised the e-CAMS, delivered the training in the first site, and again revised it. There is little difference in satisfaction ratings between the two types of training deliveries on the VA Evaluation of Training. The e-learning development, provider satisfaction, completion of training, coaching call attendance, and adoption is described in a manuscript published in Academic Psychiatry (Marshall, York, Magruder et al, 2014). This is the first evaluation of a suicide-specific e-learning training within the VA.

(Aim 2) A second manuscript is in the final stages of preparation and describes the provider survey component. This will be submitted this Spring. Findings show that there were some modest immediate improvements due to the two training conditions; however, the effects were only sustainable at three months for one question related to hospitalization beliefs. There were only two items where the e-learning and in-person conditions were different, one (hospitalization) favoring in-person, and the other (practices related to liability) favoring e-learning; thus, there were no clear differences between the e-learning and in-person modalities, suggesting that either method could be used, but both need enhancements to boost and sustain knowledge.

(Aim 3) We completed the development of a CAMS Chart Abstraction Protocol to assess provider adherence and patient outcomes. We have conducted chart reviews on 261 patients on the patient High Risk Flag who were followed by study providers in the 12 months following the training. Additional patients were eliminated because the provider did not have the minimum number of contacts post training.

(Hypothesis 6) Analysis and interpretation of these findings are currently being conducted, thus we cannot answer these questions as of yet. We have begun a manuscript on the patient outcomes.

(Aim 4) Formative evaluation was conducted. Two focus groups were conducted in Site 1 divided by training modality. The protocol addressed the following areas: impression of training experience; experience in delivery; organizational incentives, rewards, and related organizational goals; facilitating factors or barriers; implementation success; compatibility with professional beliefs, values, and practices; and fit with workflow and program. There were no discernible qualitative differences between the reports of the two training groups. Attendance at coaching goals was poor. We have identified the facilitating and inhibiting factors in the trial.

IMPACT:
To date, the project has had the following impacts:
1) success in obtaining 6.5 CEUs for the e-learning version
2) invitations to place e-CAMS on the Department of Defense learning platforms
3) VA Central Office has purchased a license to use the SSF as a clinical tool and template in the computerized electronic patient record system throughout the national VA. The template is in the developmental process.
4) Efforts are underway to move the CAMS e-learning on to the VA TMS which will facilitate system wide dissemination and has the potential to increase adoption in VAMC's or by providers.

Additional impacts may be evident with regard to improved care once we complete analysis of the patient outcomes and provider adherence data. We have also considered a short manuscript on economic analysis.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Puntil C, York J, Limandri B, Greene P, Arauz E, Hobbs D. Competency-based training for PMH nurse generalists: inpatient intervention and prevention of suicide. Journal of The American Psychiatric Nurses Association. 2013 Jul 1; 19(4):205-10. [view]
2. Marshall E, York J, Magruder K, Yeager D, Knapp R, De Santis ML, Burriss L, Mauldin M, Sulkowski S, Pope C, Jobes DA. Implementation of online suicide-specific training for VA providers. Academic Psychiatry : The Journal of The American Association of Directors of Psychiatric Residency Training and The Association For Academic Psychiatry. 2014 Oct 1; 38(5):566-74. [view]
3. Pearson GS, Evans LK, Hines-Martin VP, Yearwood EL, York JA, Kane CF. Promoting the mental health of families. Nursing Outlook. 2014 May 1; 62(3):225-7. [view]
4. York JA, Lamis DA, Pope CA, Egede LE. Veteran-specific suicide prevention. The Psychiatric quarterly. 2013 Jun 1; 84(2):219-38. [view]

VA Cyberseminars

1. Marshall EA, Grossman J, Magruder KM. Evaluation of Multisite E-learning Training for VA Mental health providers within the CAMS Study. [Cyberseminar]. 2012 Feb 21. [view]

Conference Presentations

1. Magruder KM, Marshall E, York J, Yeager D, DeSantis M, Knapp R. Can Web-based Training Improve Management of Suicidal Patients? Paper presented at: American Public Health Association Annual Meeting and Exposition; 2013 Nov 2; Boston, MA. [view]
2. De Santis M, Marshall EA, Grossman J, Magruder KM. Evaluation of Multisite E-learning Training in the Collaborative Assessment and Management of Suicidality in VA Mental Health Providers. Paper presented at: VA / Department of Defense Suicide Prevention Annual Conference; 2012 Jun 22; Washington, DC. [view]
3. Magruder KM, Yeager DE. Health Services Use Patterns of Suicidal Primary Care Patients: Can they slip through the cracks? Poster session presented at: VA HSR&D Field-Based Mental Health and Substance Use Disorders Meeting; 2010 Apr 28; Little Rock, AR. [view]
4. York JA. Inpatient Suicide prevention: State of the Science. Paper presented at: Virginia Commonwealth University Department of Psychiatry Grand Rounds; 2014 Feb 21; Richmond, VA. [view]
5. Grossman J, Jennings KW, Brooks Holliday S, Paci MC, Johnson LL, Zaveri PR, White T, Jobes DA. Using the collaborative assessment and management of suicidality (CAMS) therapeutic framework in a group format to reduce suicidal ideation and behaviors among Veterans. Paper presented at: VA Suicide Prevention Coordinator Conference; 2012 Jun 22; Washington, DC. [view]

DRA: Mental, Cognitive and Behavioral Disorders, Health Systems
DRE: Prevention, Treatment - Comparative Effectiveness, Research Infrastructure
Keywords: Education Research, Mental Health Other
MeSH Terms: none