Adaptation of intensive mental health intensive case management to rural communities in the Veterans Health Administration

Mobile Delivery Program to Prevent Relapse and Improve Functioning in Patients With Psychiatric Diseases

The term "revolving door patients" refers to those who are frequently rehospitalized for relapse. This phenomenon can be explained by a multitude of factors, including a lack of medical and/or social support. On the basis of a review of various modalities of psychiatric treatment, such as long-acting injectables, assisted outpatient treatment, and telehealth, it is clear that a major underlying issue among people with psychiatric diseases who lack insight into their mental and physical health is medication nonadherence. Therefore, we propose a mobile delivery program (MDP) in which health care professionals deliver medications and care to psychiatric patients in their own homes. The target patient population for MDP is patients with medication nonadherence, frequent emergency department visits, and missed appointments. Patients with mental illnesses, especially schizophrenia, are disproportionately represented among the homeless and incarcerated populations. By implementing MDP, we can help break the cycle of incarceration for patients with mental illnesses and homelessness. In addition, the cost of transportation and salaries for the mobile delivery team would be considerably lower than the billions of dollars spent each year due to relapses, emergency department visits, inpatient admissions, and crime leading to long-term stays in correctional facilities. This model has the potential to reduce relapse, improve functioning, and reduce excess morbidity and mortality. Substantial cost savings for health services can, in turn, be expected.

Homelessness among a nationally representative sample of US veterans: prevalence, service utilization, and correlates

PURPOSE

To examine the prevalence of lifetime homelessness among veterans and use of Veterans Affairs (VA) homeless services, as well as their association with sociodemographic and clinical characteristics.

METHODS

A nationally representative sample of 1533 US veterans was surveyed July-August 2015.

RESULTS

Among all veterans, 8.5 % reported any lifetime homelessness in their adult life, but only 17.2 % of those reported using VA homeless services. Prevalence of homelessness and VA homeless service use did not significantly differ by gender. Being low income, aged 35-44, and having poor mental and physical health were each independently associated with lifetime homelessness. Veterans who were White or lived in rural areas were significantly less likely to have used VA homeless services.

CONCLUSIONS

Homelessness remains a substantial problem across different generations of veterans. The low reported uptake of VA homeless services suggests there are barriers to care in this population, especially for veterans who live in rural areas. Governmental resources dedicated to veteran homelessness should be supported, and obtaining accurate prevalence estimates are important to tracking progress over time.

A Comparison of Homeless Male Veterans in Metropolitan and Micropolitan Areas in Nebraska: A Methodological Caveat

This study explored differences between homeless male veterans in metropolitan and micropolitan cities in Nebraska on sociodemographic, housing, clinical, and psychosocial characteristics as well as health service use. A convenience sample of 151 homeless male veterans (112 metropolitan, 39 micropolitan) were recruited from Veterans Affairs facilities and area shelters in Omaha, Lincoln, Grand Island, and Hastings in Nebraska. Research staff conducted structured interviews with homeless veterans. Results showed that compared to homeless veterans in metropolitans, those in micropolitans were more likely to be White, unmarried, living in transitional settings, and were far more transient but reported greater social support and housing satisfaction. Veterans in micropolitans also reported more medical problems, diagnoses of anxiety and personality disorders, and unexpectedly, were more likely to report using various health services and less travel time for services. Together, these findings suggest access to homeless and health services for veterans in micropolitan areas may be facilitated through Veterans Affairs facilities and community providers that work in close proximity to one another. Many homeless veterans in these areas are transient, making them a difficult population to study and serve. Innovative ways to provide outreach to homeless veterans in micropolitan and more rural areas are needed.

Clinical and Functional Outcome of Assertive Outreach for Patients With Schizophrenic Disorder: Results of a Quasi-Experimental Controlled Trial

Background

The majority of studies support modern assertive health service models. However, the evidence is limited for parts of continental Europe, as well as for the pharmacological adherence outcome parameter.

Method

We conducted a quasi-experimental controlled trial including adult patients with a schizophreniform disorder and a maximum of 60 points on the Global Assessment of Functioning Scale (GAF). Interventions (n = 176) and controls (TAU, n = 142) were assessed every six-month within one year in 17 study practices in rural areas. Mental and functional state were rated using the Brief Psychiatric Rating Scale (BPRS) and the GAF. Functional limitations and pharmacological adherence were patient-rated using the WHO-Disability Assessment Schedule II (WHODAS–II) and the Medication Adherence Report Scale (MARS). We computed multilevel mixed models.

Results

The GAF and BPRS of both groups improved significantly, yet the increase in the intervention group was significantly higher. In contrast, patient-rated variables – WHODAS–II and MARS – neither showed a stable temporal improvement nor a difference between groups.

Conclusion

Our findings only partly support the investigated AO intervention, because of conflicting results between clinician- and patient-ratings. Accordingly, the benefits of AO need to be further evaluated.

Healthcare utilization and costs of Veterans Health Administration patients with schizophrenia treated with paliperidone palmitate long-acting injection or oral atypical antipsychotics

OBJECTIVE

This study aimed to compare real world healthcare costs and resource utilization between patients with schizophrenia treated with paliperidone palmitate long-acting injection (PP) and oral atypical antipsychotics (OAT).

METHODS

Patients (18-64 years) were selected from the Veterans Health Administration dataset (1 July 2007-31 May 2012). Patients with 2+ claims for PP or 2+ claims for the same OAT comprised the two study cohorts with the first prescription date designated as the index date. Participation in the VA healthcare system for 24 months pre- and 12 months post-index, schizophrenia diagnosis (International Classification of Disease 9th Revision Clinical Modification [ICD-9-CM] code 295.1x-6x, 295.8x-9x) and ≥1 claim for an antipsychotic medication during the baseline period were required. Propensity scores and Mahalanobis metric distances with calipers were used to create two matched cohorts. All-cause healthcare utilization and costs for the 12-month follow-up period were compared between matched cohorts.

RESULTS

The matching process produced two cohorts of 335 patients with similar baseline characteristics. During the 12-month follow-up period, patients in the PP cohort had lower mean inpatient costs (18,560 vs $31,505, p = 0.002), lower frequency of hospitalization (34% vs 53%, p < 0.001) and fewer average inpatient days (13.24 vs 24.18, p = 0.002) vs matched OAT patients. While mean pharmacy costs were higher for the PP cohort ($10,063 vs $4167, p < 0.001), mean total healthcare costs were not significantly different ($45,529 vs $52,569, p = 0.128).

CONCLUSION

VA patients, diagnosed with schizophrenia and treated with PP, had lower inpatient costs and admission rates compared to a matched cohort of OAT patients. Total healthcare costs were not significantly different.