Implementation Lessons Learned: Distress Behaviors in Dementia Intervention in Veterans Health Administration.

BACKGROUND AND OBJECTIVES: Evidence-based practices to manage distress behaviors in dementia (DBD) are not consistently implemented despite demonstrated effectiveness. The Veterans Health Administration (VA) trained teams to implement Staff Training in Assisted Living Residences (STAR)-VA, an intervention to manage DBD in VA nursing home settings, or Community Living Centers (CLCs). This paper summarizes multiyear formative evaluation results including challenges, adaptations, and lessons learned to support sustained integration into usual care across CLCs nationwide. RESEARCH DESIGN AND METHODS: STAR was selected as an evidence-based practice for DBD, adapted for and piloted in VA (STAR-VA), and implemented through a train-the-trainer program from 2013 to 2018. Training and consultation were provided to 92 CLC teams. Evaluation before and after training and consultation included descriptive statistics of measures of clinical impact and survey feedback from site teams regarding self-confidence, engagement, resource quality, and content analysis of implementation facilitators and challenges. RESULTS: STAR-VA training and consultation increased staff confidence and resulted in significant decreases in DBD, depression, anxiety, and agitation for Veterans engaged in the intervention. Implementation outcomes demonstrated feasibility and identified facilitators and barriers. Key findings were interpreted using implementation frameworks and informed subsequent modifications to sustain implementation. DISCUSSION AND IMPLICATIONS: STAR-VA successfully prepared teams to manage DBD and resulted in improved outcomes. Lessons learned include importance of behavioral health-nursing partnerships, continuous engagement, iterative feedback and adaptations, and sustainment planning. Evaluation of sustainment factors has informed selection of implementation strategies to address sustainment barriers. Lessons learned have implications for integrating team-based practices into system-level practice.

Patient and Treatment Characteristics Associated With Receipt of Core Patient-Reported Outcome Measures in VA Mental Health.

OBJECTIVE: Measurement-based care (MBC) has been implemented in Veterans Affairs since 2016 and is increasingly used in other mental health care organizations. Little quantitative research exists that assesses patient-level barriers and facilitators of MBC. This study examines correlates of receiving patient-reported outcome measures (PROMs) among veterans receiving both psychotherapy and pharmacotherapy (Both), psychotherapy only (Psychotherapy), and pharmacotherapy only (Pharmacotherapy). METHODS: Data on PROM administration were obtained for a 12-month period for 1,726,578 veterans who initiated outpatient mental health care during fiscal year 2019. Clinical, treatment, and PROM data were extracted from the electronic health record. Logistic regression was used to model the association between veteran and treatment characteristics and PROM administration. RESULTS: Thirty-two percent of veterans in Both, 26.0% in Psychotherapy, and 8.8% in Pharmacotherapy received at least one PROM. The probability of PROM administration was positively associated with the number of treatment encounters during the fiscal year 2019. Major depressive, generalized anxiety, and other depressive disorders were associated with an increased probability of PROM administration. Psychotic disorders, personality disorders, older age, dementia, and electronic health record suicide risk flag were associated with decreased odds of PROM administration across treatment types. CONCLUSIONS: Rates of PROM administration differ depending on the type of treatment received. The probability of PROM administration is influenced by the frequency of encounters and, to a lesser extent, having a diagnosis congruent with symptoms assessed in the set of PROMs considered. Consistent with hypotheses from the MBC implementation literature, potential indicators of clinical severity and cognitive impairment decrease the likelihood of PROM utilization.

Impact of STAR-VA on Staff Injury and Disruptive Behavior Reports in VA Nursing Homes.

OBJECTIVES: Workplace disruptive behavior incidents can be costly for organizations, employees, and customers. Persons with dementia living in long-term care settings have a high risk of exhibiting distressed behaviors. We examined whether a resident-centered, behavioral intervention for residents with dementia led to a reduction in reported workplace disruptive behaviors and staff injury rate due to assault. Impactful interventions are important for quality of care. DESIGN: We examined whether a team-based behavioral program in community living centers (CLCs), where a nurse champion and behavioral coordinator were trained to work with the clinical team to understand and manage distressed behaviors commonly associated with dementia, was associated with reductions in behavior incidents. SETTING AND PARTICIPANTS: The setting was Veterans Health Administration CLCs. The sample consisted of 120 aggregated CLCs operating between 2012 and 2017 with 62 completing training. CLCs were distributed across the United States. METHODS: Outcomes included CLC-level rates of staff injury and number of workplace disruptive behavior incidents. Outcomes were regressed on measures of intervention completion, time since intervention, and several CLC characteristics. RESULTS: The intervention was significantly associated with lower incidence of assault with staff injury rates overall, particularly following the first year of training, but not with other reported workplace disruptive behavior incident rates. CONCLUSIONS AND IMPLICATIONS: A team-based behavioral intervention was associated with reduction of employee assaults, a critical repercussion of distressed behavior in dementia. Given rapid growth in patients with dementia in nursing homes, effective treatment practices, such as interdisciplinary behavioral management approaches may be impactful and valuable to implement.

Access to timely mental health care treatment initiation among Veterans Health Administration patients with and without serious mental illness.

Timely care initiation is a priority within the Veterans Health Administration (VHA). Patients with serious mental illnesses (SMI) are a group that benefits from timely care initiation due to elevated risks of negative outcomes with delayed care. However, no evaluation has assessed whether VHA SMI patients disproportionately experience delays in mental health care initiation. VHA administrative care data were used to compare delays in mental health care initiation for VHA patients with and without SMI who had newly identified mental health needs. Analyses assessed rates of delayed initial mental health appointments within five settings (General Mental Health [GMH], Primary Care Mental Health Integration [PC-MHI], Post-Traumatic Stress Disorder [PTSD], Substance Use Disorder [SUD], and Psychosocial Rehabilitation clinics [PSR]). SMI patients were more likely to receive delayed initial appointments in three of five clinical settings (PTSD, SUD, PSR) and had significantly longer average wait times for an initial appointment when referred to the PTSD clinic for an initial appointment. Overall, SMI patients were equally as likely to receive delayed initial appointments. While VHA SMI patients were not more likely to experience delayed mental health care initiation overall, they were more likely to experience delays within three of the five treatment settings. Findings suggest that the majority of VHA SMI patients experience equivalent timeliness, though those with more complex needs, and particularly those with trauma-related care needs, may be more likely to experience treatment initiation delays. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Impact of an interdisciplinary intervention for distress behaviors in dementia on psychotropic drug use in Veterans Health Administration Community Living Centers: STAR-VA impact on psychotropic drug utilization.

STAR-VA is an interdisciplinary behavioral approach for managing distress behaviors in residents with dementia, implemented at Veterans Health Administration nursing homes. This study evaluated the impact of STAR-VA implementation on psychotropic drug use. The study design is a retrospective, quasi-experimental cohort analysis of residents enrolled as STAR-VA training cases compared with eligible residents at untrained sites to evaluate treatment effects on psychotropic medication use. We matched 229 STAR-VA cases with 1,163 comparisons. STAR-VA cases experienced an average reduction of 0.92 "as-needed" doses per month (95% confidence interval [CI] -1.82, -0.02) compared with controls. No significant effect on non-STAR-VA cases in trained facilities was detected. STAR-VA programs are an important option for reducing potentially inappropriate psychotropic use.

An MDS 3.0 Distressed Behavior in Dementia Indicator (DBDI): A Clinical Tool to Capture Change.

BACKGROUND/OBJECTIVES: Persons with dementia frequently demonstrate distress behaviors in dementia (DBD), associated with poorer outcomes. This study aimed to create a measure of DBD from routinely administered Minimum Data Set (MDS 3.0) behavior section items that demonstrated sensitivity to change, for evaluation of intervention efforts for VA Community Living Center (CLCs) residents exhibiting DBD. SETTING: 72 VA nursing home settings, or Community Living Centers (CLCs). PARTICIPANTS: CLC residents with DBD (n = 302) were enrolled in an interdisciplinary behavioral intervention between 2013 and 2017. DESIGN: A factor analysis of MDS behavior section items from assessments closest to baseline was conducted. Internal consistency, hypothesized associations between MDS factors and clinical measures, and sensitivity to detect change over time was explored. MEASUREMENTS: Residents were assessed at baseline and post-intervention using the MDS behavior section items and a validated clinical measure of DBD. RESULTS: The Distress Behavior in Dementia Indicator (DBDI) was created as a consistent factor with internal consistency, and was related to a validated measure as predicted at baseline and post-intervention. Sensitivity to change was demonstrated by using change score correlations (r = 0.40-0.50), effect size (d = 0.63), and reliable change indices. CONCLUSION: The DBDI is recommended for routine use in CLCs to evaluate impact of intervention effectiveness and provide quality improvement feedback.

Addressing Behavioral Symptoms of Dementia Through STAR-VA Implementation: Do Outcomes Vary by Behavior Type?

OBJECTIVES: The STAR-VA program in Veterans Health Administration Community Living Centers (CLCs, nursing home settings) trains teams to implement a psychosocial intervention with residents with behavioral symptoms of dementia (BSD). METHODS: Across 71 CLCs, 302 residents selected as training cases had target behaviors categorized into one of 5 types: physically aggressive (PA), physically nonaggressive, verbally aggressive, verbally nonaggressive, and behavior deficit (BD). RESULTS: Across all groups, there were significant declines in team-rated behavior frequency (36%) and severity (44%), agitation (10%), distress behaviors (42%), depression (17%), and anxiety (20%). The magnitude of changes varied across behavior category. For example, those with a PA target behavior experienced a greater percentage decline in agitation and distress behavior scores, and those with a BD target behavior experienced a greater percentage decline in depressive and anxiety symptoms. CONCLUSIONS: STAR-VA, a multicomponent intervention, is generally effective across various types of behavioral symptoms associated with dementia.

Critical Periods for Increased Mortality After Discharge From Inpatient Mental Health Units: Opportunities for Prevention.

OBJECTIVE: Studies of patients in the U.S. Department of Veterans Affairs (VA) health system and elsewhere have documented elevated mortality from suicide during a critical period within 30 to 90 days after discharge from inpatient mental health units. To support program planning, VA evaluated whether the elevated mortality during this critical period was specific to suicide or whether there were similar increases in other causes of death. METHODS: Indicators of age, gender, inpatient diagnoses, and suicide attempts and ideation from VA records were combined with indicators of vital status and cause of death from the National Death Index. Analyses compared all-cause and cause-specific mortality in the first 30 and 90 days postdischarge with mortality in days 91 to 365 after discharge for the 106,430 VA patients discharged from inpatient mental health units in 2013-2014. RESULTS: Elevated mortality during the first 30 and first 90 days after discharge was not specific to suicide. Higher rates of all-cause mortality were noted, including elevated mortality due to external causes other than suicide among young and middle-aged patients (ages 18-64) during the first 30 days and among older patients (≥65) during the first 90 days. An increase in natural-cause mortality among older patients was attributable to greater mortality among those with dementia diagnoses. CONCLUSIONS: Elevated rates of nonsuicide external-cause mortality in the critical period within 30 to 90 days after discharge from inpatient mental health care suggest important opportunities for prevention. Greater mortality among patients with dementia or related neurodegenerative diseases raises questions regarding current strategies for managing behavioral symptoms and transitions to end-of-life care.

Effects of Mental Health Parity on High Utilizers of Services: Pre-Post Evidence From a Large, Self-Insured Employer.

OBJECTIVE: This study evaluated utilization of mental health and substance use services among enrollees at a large employee health plan following changes to benefit limits after passage in 2008 of federal mental health parity legislation. METHODS: This study used a pre-post design. Benefits and claims data for 43,855 enrollees in the health plan in 2009 and 2010 were analyzed for utilization and costs after removal of a 30-visit cap on the number of covered mental health visits. RESULTS: There was a large increase in the proportion of health plan enrollees with more than 30 outpatient visits after the cap's removal, an increase of 255% among subscribers and 176% among dependents (p<.001). The number of people near the 30-visit limit for substance use disorders was too few to observe an effect. CONCLUSIONS: Federal mental health parity legislation is likely to increase utilization of mental health services by individuals who had previously met their benefit limit.

A marketing campaign to promote screening for oral cancer.

BACKGROUND: Organizers of the Detroit Oral Cancer Prevention Project at the University of Michigan, Ann Arbor, launched a multifaceted media campaign targeted toward a high-risk population to raise awareness about oral cancer, educate the public regarding the importance of early detection and increase screening rates. The authors present data about the effectiveness of the campaign with regard to the screening behaviors of medical and dental providers. METHODS: Before the start of the campaign and during each of the three years of the campaign, the authors mailed surveys to random samples of physicians and dentists practicing in targeted and non-targeted areas. RESULTS: More dentists than physicians reported screening patients routinely, and dentists reported that they referred more patients for biopsy or further evaluation compared with physicians. A larger proportion of dentists and physicians in the targeted area than in the nontargeted area reported that their patients had seen or heard the advertisements. A larger proportion of dentists in the targeted area than in the nontargeted area reported an increase in patients' questions and requests for screening, even after the authors accounted for demographic characteristics (adjusted odds ratio = 2.47). CONCLUSIONS: The survey findings show that the media campaign was effective in influencing providers' screening for signs and symptoms of oral cancer. CLINICAL IMPLICATIONS: An increase in patients' requests for screening as a result of the implementation of mass media campaigns may promote oral cancer screening and improve patients' chances of survival.

Evaluation of a brief tailored motivational intervention to prevent early childhood caries.

OBJECTIVES: This pragmatic randomized trial evaluated the effectiveness of a tailored educational intervention on oral health behaviors and new untreated carious lesions in low-income African-American children in Detroit, Michigan. METHODS: Participating families were recruited in a longitudinal study of the determinants of dental caries in 1021 randomly selected children (0-5 years) and their caregivers. The families were examined at baseline in 2002-2004 (Wave I), 2004-2005 (Wave II) and 2007 (Wave III). Prior to Wave II, the families were randomized into two educational groups. An interviewer trained in applying motivational interviewing principles (MI) reviewed the dental examination findings with caregivers assigned to the intervention group (MI + DVD) and engaged the caregiver in a dialogue on the importance of and potential actions for improving the child's oral health. The interviewer and caregiver watched a special 15-minute DVD developed specifically for this project based on data collected at Wave I and focused on how the caregivers can 'keep their children free from tooth decay'. After the MI session, the caregivers developed their own preventive goals. Some families in this group chose not to develop goals and were offered the project-developed goals. The goals, if defined, were printed on glossy paper that included the child's photograph. Families in the second group (DVD-only) were met by an interviewer, shown the DVD, and provided with the project's recommended goals. Both groups of families received a copy of the DVD. Families in the MI + DVD group received booster calls within 6 months of the intervention. Both caregivers and the children were interviewed and examined after approximately 2 years (Wave III: 2007). RESULTS: After 6-month of follow-up, caregivers receiving MI + DVD were more likely to report checking the child for 'precavities' and making sure the child brushes at bedtime. Evaluation of the final outcomes approximately 2 years later found that caregivers receiving the MI + DVD were still more likely to report making sure the child brushed at bedtime, yet were no more likely to make sure the child brushed twice per day. Despite differences in one of the reported behaviors, children whose caregivers received the motivational intervention did not have fewer new untreated lesions at the final evaluation. CONCLUSIONS: This study found that a single motivational interviewing intervention may change some reported oral health behaviors, it failed to reduce the number of new untreated carious lesions.