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C19 20-216 – HSR Study

C19 20-216
Adapting Caring Contacts to Counteract Adverse Effects of Social Distancing Among High-Risk Veterans During the COVID-19 Pandemic
Alan R. Teo, MD MS
VA Portland Health Care System, Portland, OR
Portland, OR
Funding Period: July 2020 - December 2020
In the COVID-19 pandemic, social distancing-a deliberate increase in physical distance between people and avoidance of gathering in groups-has been widely instituted to avoid spreading the virus. At the same time, lack of social connection (an umbrella term for social isolation and loneliness) is a major public health threat. It is linked to increased risk of all-cause mortality, suicide, and a host of conditions ranging from depression to dementia. Subpopulations of Veterans who use Department of Veterans Affairs (VA) services are likely to be vulnerable to the impacts of social distancing (and the crisis more generally) including those who are elderly, have a history of mental health or substance use disorders, or live alone. The adverse psychosocial effects of COVID-19 are likely to accumulate long after the acute phase of the crisis has resolved. All of this coalesces to stress the importance of a sustained, longer-term mental health response to this type of crisis.

A promising approach that can promote social connection while maintaining social distancing is the use of Caring Contacts. The traditional Caring Contacts intervention involves sending brief letters or postcards to at-risk individuals who had contact with the hospital system (e.g., recent psychiatric admission). Messages emphasize that the provider cares for the patient's well-being. Previous interventions have most commonly sent 8 letters or post cards over 12 months. Caring Contacts is one of the only interventions proven to reduce suicide mortality and suicide attempts.

Caring Contacts recently became a component of VA's enhanced care package for Veterans at high risk for suicide. Caring Contacts has the potential to be adapted to, and implemented within, a broader at-risk population in the midst of COVID-19. The Behavioral Health QUality Enhancement Research Initiative (QUERI) has developed a Planning Guide to adapt and implement Caring Contacts, which has been used in VA emergency departments. However, adaptation of Caring Contacts to the current crisis requires consideration of a number of issues including: who should send and sign the letters, what medium to use (i.e., paper vs. electronic), how often to send and how to manage replies, and how to adjust content to an acute crisis or emergency impacting social connection.

In this planning project, we conducted the following foundational research activities:

Aim 1: Convene a panel of subject matter experts and Veterans who will develop an adapted intervention ("Crisis Caring Contacts").

a) The panel consisted of the research team, invited experts in suicide prevention, Caring Contacts, health communication, and pragmatic trials & interventions, as well as 3 veterans.

b) Panel conducted weekly virtual meetings and used the Behavioral Health QUERI Planning Guide to make iterative revisions to the intervention.

Aim 2: Identify a cohort of high-risk Veterans from which to recruit participants for an RCT of Crisis Caring Contacts. The cohort consists of veterans who are: 1)age 60 years or older; 2) have at least four appointments in the prior 12 months in primary care or mental health; 3) have at least two comorbidities contained in the Elixhauser Index; and 4) in the 90th percentile or higher in terms of no-shows or appointments canceled by patient. The only exclusion criteria will be: 1) no valid mailing address; 2) inclusion in an existing Caring Contacts program; and 3) diagnosis of neurocognitive disorder or other significant cognitive impairment.

Aim 3: Create data collection instruments, human subjects and safety protocols, and all other procedures and documents required for conduct of a pragmatic randomized controlled trial (RCT) of Crisis Caring Contacts.

We used the Corporate Data Warehouse (CDW) to identify the Veteran cohort and obtain current contact information. We developed a data collection instrument and data procedures for the subsequent RCT. This included a survey for patient-reported psychosocial outcomes (e.g., loneliness, social isolation, suicidal ideation, and anxiety and depressive symptoms) and administrative data collection. To fully leverage administrative data, we will link CDW data with:

a) the VA-DoD (Department of Defense) Mortality Data Repository for suicide and all-cause mortality; and

b) state databases to extract emergency department visits, hospitalizations, and other care not contained in CDW. Linkage to these databases has been completed successfully in our team's recent HSR&D-funded projects.

We have completed expert panel meetings, created data collection instruments, human subjects and safety protocols, and all other procedures and documents required for conduct of a pragmatic randomized controlled trial (RCT) of Crisis Caring Contacts, and submitted a trial grant for the newly developed Crisis Caring Contacts.

Though there is effectiveness data for Caring Contacts interventions, the novel nature of the current COVID-19 pandemic means there are no studies of how to and adapt and implement Caring Contacts to the current crisis. A direct outcome of this project is a trial intervention that has the potential to be tested at significant scale, taking advantage of the integrated VA healthcare system.


None at this time.

DRA: Mental, Cognitive and Behavioral Disorders
DRE: TRL - Applied/Translational
Keywords: Social Support, Suicide
MeSH Terms: None at this time.

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