Implementing Effective, Collaborative Care for Schizophrenia (EQUIP-2)

Objectives:

EQUIP-2 is a clinic-level controlled trial. From the four participating Veterans Integrated
Services Networks (VISNs), eight specialty mental health programs were enrolled and assigned
to care as usual or to receive an intervention supporting evidence-based quality improvement
and use of a chronic illness care model. Participants are VISN 3 (James J. Peters VA;
Northport VA); VISN 16 (Houston VA; Shreveport VA); VISN 17 (Waco VA; Temple VA); and VISN 22
(Long Beach VA; Greater Los Angeles VA). The objectives of this VA Quality Enhancement
Research Initiative (QUERI) Service Directed Project are 1) assist in identifying and making
available recovery-oriented services to veterans with schizophrenia; 2) implement information
systems that efficiently and accurately identify patient status and who would be appropriate
for these services; 3) implement a care model to support recovery-oriented care delivery; 4)
evaluate, in a controlled trial, the effect of implementation on treatment delivery and
patient outcomes; and 5) identify facilitators and barriers to wellness program participation
in an effort to strengthen the weight management services available to patients with
schizophrenia. The project studies intervention feasibility, acceptability, and impact on
outcomes; performs qualitative analyses examining processes and variation in care model
implementation and impact. Research includes a controlled trial of the impact of
implementation, relative to usual care, on treatment quality. Participants include clinic
staff and patients with schizophrenia. Data sources include interviews with participants,
focus groups with a sub-set of patients, implementation documentation, the project
informatics system, and VistA.

Methods:

The care model targets two clinical domains selected by the VISNs from the following:
Supported Employment (SE), caregiver support, wellness programs, or clozapine. All 4 VISNs
chose the same two targets: SE and wellness. The care model includes: 1) at each visit,
routine collection of patient outcomes data and provision of decision support using a
self-assessment kiosk; 2) provision of "psychiatric vital signs" to patients and clinicians
at the time of the clinical encounter via report that prints from the kiosk; 3) education and
activation of both clinicians and patients around the clinical targets; 4) regular reports
identifying patients appropriate for services associated with these targets; and 5)
facilitation of problem-solving and evidence-based quality improvement addressing any
barriers to utilization of these services.

To inform future wellness implementation, in-depth, semi-structured interviews are conducted
with patients who participated in wellness groups ("participants"), and with patients who
were referred (because they were overweight or obese) but did not participate
("non-participants"). Participants consist of all enrolled patients who attended the wellness
program with special attention to those patients who completed at least half of the wellness
program. Non-participants consist of patients who were referred to the wellness program but
did not attend. Clinicians were interviewed specifically regarding wellness implementation.

Inclusion Criteria:

Clinicians and Managers:

- Psychiatrists, Case Managers, Nurses, Supported Employment workers Nutritionists,
Local Recovery Coordinators, and Quality Improvement experts working at one of the
participating VA Medical Centers

Patients:

- At least 18 years old

- Diagnosis of Schizophrenia, Schizoaffective, or schizophreniform disorder

- At least 1 treatment visit with a clinician at the clinic during the 6 months prior to
enrollment and then at least 1 treatment visit with a clinician at the clinic during
the 5 months of enrollment.

Exclusion Criteria: