Risk Stratified Enhancements to Clinical Care: Targeting Care for Patients Identified Through Predictive Modeling as Being at High Risk for Suicide, with the Office of Mental Health Operations

尽管做了加强退伍军人健康管理局(VHA)精神健康服务和自杀的工作 预防，VHA的自杀率一直保持稳定[1]。这些税率与其他国家的税率上升形成了鲜明对比 美国人，特别是中年男性[2，3]和不使用VHA服务的退伍军人[4，5]，建议 VHA计划可能缓解了预期的增长，尽管这一点尚未确定。 然而，VHA自杀率居高不下的发现表明了采取行动的强烈呼吁。小说 需要及早采取措施减少与自杀有关的事件的发生，最好是在自杀之前- 相关行为就会发生。 最近在VHA验证的一种创新方法是预测建模，它可以识别面临风险的退伍军人和 从而促进实施有针对性的预防。VHA预测模型确定了前5%的 预测自杀风险最高的VHA患者。该模型提供了有关以下方面的新信息 世卫组织处于危险之中；在被确定为高风险的5%的患者中，只有不到2%的人收到了处于危险中的临床标志。 对于那些被确定为高风险的人，VHA的自杀预防办公室已经实施了全国自杀 题为恢复参与和协调的预防外展方案--退伍军人 强化治疗(达到兽医)。REACH VET利用仪表板提供患者姓名 由模型标识给每个退伍军人医疗机构的协调员。REACH VET协调员负责 用于通知提供者患者的状态，并提示提供者重新评估护理并采取任何 如果还没有采取适当的步骤(例如，联系患者重新进行护理)。 为了进一步加强REACH VET，一种有效的、低成本的自杀预防干预措施-关爱信件，是 被添加为REACH兽医增强功能。关爱的信件包括反复发送简短的便条到 高危患者表示关心、关注，并在需要时提供帮助。这是唯一的自杀预防措施之一 在随机对照试验中降低自杀死亡率的干预措施[8-12]。 具体目标1：通过以下方式评估虚拟外部便利化相对于标准实施的影响 进行形成性评估，以确定实施的障碍和促进者，以定义和完善 虚拟外部促进战略及虚拟外部促进与标准的总结性评价 实施。 具体目标2：开发和评估使用关爱信件增强REACH VET的能力，这是一个证据-- 以自杀预防干预为基础，对REACH的扩大进行形成性评估 通过关怀信件和细化关怀信件干预，扩大到VHA范围内的VHA兽医 程序。 总体设计将是一种混合的有效性-实施受控计划评估，使用混合 方法：研究方法。REACH VET目前正在VHA中使用自适应设计实施。磨合 该阶段于11月开始，包括协调员培训和仪表盘推广。第一阶段将包括 将所有被归类为非应答者的设施随机化，以继续标准实施或 虚拟外部促进。此外，在第一阶段，将在四个地点推行关爱信件，以发展一个 用于纵向扩展的集中式模式。在第二阶段，那些没有接受虚拟外部促进的设施将 如果他们仍然被归类为非响应者，则可以收到它。待定可用预算和资源，第2阶段，30 这些站点将被随机分配，以在阶梯式楔形试验中获得对关爱信件的集中支持。 该项目对退伍军人管理局医疗保健系统的预期影响是提高退伍军人自杀的针对性 通过了解干预方案在减少自杀方面的有效性来提供预防资源 行为以及如何在整个系统中最好地实施这样的干预。

Despite work done to strengthen Veterans Health Administration (VHA) mental health services and suicide prevention, suicide rates in VHA have been stable [1]. These rates stand in contrast to increasing rates in other Americans, especially middle-aged men [2,3] and in Veterans who do not utilize VHA services [4,5], suggesting that VHA programs may have mitigated expected increases although this has not been determined. Nevertheless, the finding that suicide rates in VHA remain high represents a strong call for action. Novel approaches that reduce the incidence of suicide-related events are needed earlier, ideally before suicide- related behaviors occur. One innovative approach recently validated in VHA is predictive modeling that identifies Veterans at risk and thus facilitates implementation of targeted prevention. The VHA predictive model has identified the top 5% of VHA patients who were at the highest predicted risk for suicide. This model provides new information about who is at risk; fewer than 2% of the 5% of patients identified as high risk received clinical flags for being at risk. For those identified as high risk, VHA’s Office of Suicide Prevention has implemented a national suicide prevention outreach program entitled Recovery Engagement and Coordination for Health – Veterans Enhanced Treatment (REACH VET). REACH VET utilizes a dashboard to provide the names of patients identified by the model to coordinators at each VA medical facility. REACH VET coordinators are responsible for notifying providers of the patient’s status and prompting providers to re-evaluate care and take any appropriate steps if they are not already occurring (e.g., contacting the patient to re-engage in care). To further strengthen REACH VET, an effective, low-cost suicide prevention intervention, caring letters, is being added as a REACH VET augmentation. Caring letters involves the sending of recurring brief notes to high risk patients expressing care, concern, and offers of help if needed. It is one of the only suicide prevention interventions that have reduced suicide mortality rates in a randomized controlled trial [8–12]. Specific Aim 1: Evaluate the impact of virtual external facilitation versus standard implementation by conducting a formative evaluation to identify barriers and facilitators to implementation to define and refine virtual external facilitation strategies and a summative evaluation of virtual external facilitation versus standard implementation. Specific Aim 2: Develop and evaluate the augmentation of REACH VET using caring letters, an evidence- based suicide prevention intervention by conducting a formative evaluation of the augmentation of REACH VET with caring letters and refining the caring letter intervention for scale up to the VHA-wide REACH VET program. The overall design will be a hybrid effectiveness-implementation controlled program evaluation using a mixed methods approach. REACH VET is currently being implemented in VHA using an adaptive design. The Run-in Phase began in November and included coordinator training and dashboard rollout. Phase 1 will include randomization of all facilities classified as non-responders to either continued standard implementation or virtual external facilitation. Also during Phase 1, caring letters will be implemented at four sites to develop a centralized model for scale up. In Phase 2, those facilities that did not receive virtual external facilitation will receive it if they are still classified as non-responders. Pending available budget and resources, in Phase 2, 30 sites will be randomized to receive centralized support for caring letters in a stepped-wedge trial. The anticipated impact on the VA health care system of this project is to improve targeting of VA suicide prevention resources through understanding the effectiveness of the intervention package at reducing suicide behaviors and how to best implement such an intervention across a system.