Effectiveness and Implementation of eScreening in Post 9/11 Transition Programs

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Background: Veterans disproportionately account for to 22% of all known suicides in the US. Screening for suicide risk at the first contact with an organization is a best practice in the national Zero Suicide framework and vital to enhancing access to appropriate care. Transition Care Management (TCM) programs are positioned to screen post-9/11 Veterans at the critical moment of enrollment in healthcare. Unfortunately, many Veterans who present for the first time in VHA with recent suicidal thoughts do not receive same day suicide risk evaluation (SRE), partly due to cumbersome screening processes. eScreening is a web-based Gold Standard Promising Practice electronic screening system with real-time scoring and integration into CPRS/VistA. Our eScreening effectiveness pilot in 1,372 post-9/11 Veterans and our 2-site multicomponent implementation strategy (MCIS) pilot showed increase speed and rate of SRE and sustainment of eScreening in two pilot sites. More research is warranted to test both. Significance/Impact: This proposal responds to HSR&D Priority Areas of: Suicide prevention, Increasing the real-world impact of research, and Implementation science. Our data will inform best practices in suicide prevention through early identification. This project will also allow for real-world integration of research into practice and inform implementation efforts for technology. Innovation: eScreening is a unique program developed with feedback from Veterans. To our knowledge, this is the first study to integrate VHA developed mobile patient-report screening technology to improve screening in TCM programs. It is also the first to examine the impact of electronic screening on rates of suicide risk evaluation and referral to care. Specific Aims: Aim 1. Evaluate the effectiveness of eScreening, compared to paper and verbal screening, on rate and speed of screening completion (suicide screening & evaluation, PTSD, depression, alcohol) and referral to mental health care in 8 TCM programs, guided by the RE-AIM outcomes of PRISM. Aim 2: Evaluate the feasibility, acceptability, and potential impact of the MCIS, guided by the RE-AIM outcomes of PRISM, adoption, implementation, and maintenance using mixed methods. We will also document and calculate replication costs across sites. Aim 3. Describe and compare high and low eScreening reach sites guided by contextual constructs of PRISM using qualitative comparative analysis to explore factors influencing the reach of eScreening and the use of the eScreening MCIS. Methodology: We propose an 8 site 4-year, stepped-wedge, mixed-method, Hybrid Type 2, pragmatic trial to compare eScreening to screening as usual while evaluating potential impact of the MCIS in TMC programs. Aim 1 outcomes will be collected via deidentified chart pull at the start and end of the pre-implementation phase, the 9-month intervention period, and 9-months post intervention. Aim 2 outcomes will be collected quantitatively from TCM staff questionnaires and qualitatively from interviews. Aim 3 data will be collected at the same intervals as Aim 2. Next Steps/Implementation: We will use the findings of this research to inform suicide prevention early identification best practices and enterprise scale-up of eScreening with our VACO partners.