Transition to low intensity case management in a VA Assertive Community Treatment model program.

OBJECTIVE: To study transition to lower intensity services in a national VA program modeled on Assertive Community Treatment (ACT). METHODS: This study uses national VA administrative data from VA's Mental Health Intensive Case Management (MHICM) program, to compare veteran characteristics, patterns of service use and early clinical changes among veterans who were formally transitioned to lower intensity treatment and veterans who were not. Bivariate comparisons and logistic regression analyses are used to identify factors associated with transition to low intensity treatment and to characterize post-transition service use. Descriptive information on the criteria for termination and subsequent service use are also presented. RESULTS: Among 2,137 veterans in the sample who enrolled in MHICM from FY 2002-2006 and who participated in at least one year of treatment, 196 (9.2%) were transitioned to lower intensity services. These veterans did not differ from others on baseline clinical characteristics but had a smaller number of program contacts during the first 6 months of participation, a higher quality of family relationships and overall quality of life after 6 months of treatment. Only 5.7% were reported to have needed to return to higher service intensity after the transition and they continued to have reduced levels of service use on several measures but no reduction in therapeutic alliance. CONCLUSION: The VA policy did not result in frequent transition to lower intensity services. Those who did transition had shown greater clinical improvement, used fewer services, had better family relationships, and rarely required a shift back to higher intensity services.

Veterans Affairs Intensive Case Management for older veterans.

BACKGROUND: There is a growing need for information on evidence-based practices that may potentially address needs of elderly people with severe mental illness (SMI), and more specifically on community-based services such as assertive community treatment (ACT). METHODS: This study examines national evaluation data from fiscal year 2001-2005 from Veterans Affairs Mental Health Intensive Case Management (MHICM) program (N = 5,222), an ACT-based service model, to characterize the age distribution of participants and the distinctive needs, patterns of service delivery, and treatment outcomes for elderly veterans. RESULTS: Altogether, 24.8% of participants were 55-64 years; 7.4% 65-74 years; and 2.8% were older than 75. Veterans over 75 formed a distinct subgroup that had a later age of onset of primarily nonpsychotic illnesses without comorbid substance abuse and had experienced more limited lifetime hospital treatment than younger participants. Older veterans were less symptomatic and more satisfied with their social relationships than younger clients. They mostly live independently or in minimally restrictive housing, but they received less recovery-focused services and more crisis intervention and medical services. They thus do not appear to be young patients with SMI who have aged but rather constitute a distinct group with serious late-onset problems. It is possible that MHICM services keep them in the community and avoid costly nursing home placement while providing a respite service that reduces family burden. CONCLUSION: These data highlight the unique characteristics of older veterans receiving ACT-like services and the need to focus greater attention on recovery-oriented services as well as community support for this subgroup.

Therapeutic limit setting and six-month outcomes in a Veterans Affairs assertive community treatment program.

OBJECTIVE: This study examined the relationship of limit-setting interventions and six-month outcomes in assertive community treatment. METHODS: Case managers from 40 Veterans Affairs assertive community treatment teams at 40 different sites documented their use of 25 limit-setting activities with 1564 clients during the first six months of treatment. Five scales were constructed representing different types of limit-setting activities: withholding certain types of assistance until the client curtailed certain behaviors; behavioral contracting in which specific goals were identified and linked to reinforcers if the goals were achieved; invocation of external authorities, such as a probation officer; seeking a declaration of incompetence to manage funds or initiation of a request for a payee; and forced hospitalization through civil commitment. Structured interviews conducted at baseline and six months documented changes in clinical status and community adjustment. Multiple regression analysis was used to examine the relationship between limit-setting interventions and outcomes at both the level of the individual client and at the level of the team, adjusting for potentially confounding baseline client characteristics. RESULTS: All five measures of specific limit-setting activities were associated with poorer outcomes on four to six of the eight outcome measures. The site-level comparison of outcomes showed more violent behavior at sites that made more extensive use of these interventions but also greater employment. CONCLUSIONS: After the analysis controlled for potentially confounding factors, clients exposed to limit-setting interventions had poorer outcomes than others on many measures, suggesting that within the limits of a nonexperimental study, such interventions do not appear to prevent adverse outcomes.

Impact of public support payments, intensive psychiatric community care, and program fidelity on employment outcomes for people with severe mental illness.

This study explored the relationship of public support payments, intensive psychiatric community care (IPCC), and fidelity of implementation to 1-year employment outcomes for 520 veterans with severe mental illness (SMI) in a clinical trial of IPCC. At study entry, 455 (87.5%) participants received public support. At 1 year, 46 (8.8%) participants met criteria to be classified as workers. A multivariate analysis indicated that baseline public support was significantly associated with a lower likelihood of employment, and baseline work was positively associated with employment at 1 year. IPCC patients were three times more likely to be working than control subjects, and a significant interaction favored well-implemented IPCC programs over others. This study points out not only the inhibiting effect of public support payment on employment but also the value of IPCC and the special importance of fidelity to program models for employment for people with SMI.