Identifying Innovations for Managing High-Cost Mental Health Patients

目标：使用精神危机管理服务--即急诊科[ED]和 急性住院精神病学--极大地增加了退伍军人精神疾病患者的护理费用。此外， 退伍军人管理局以外的先前研究表明，使用这些服务的患者中有一小部分 在总成本中贡献了不成比例的份额(“高利用率者”)。尽管成本很高，但已经有了 退伍军人管理局没有努力确定使用PCM服务的退伍军人精神健康患者的患者特征 重复，或(2)形式化地评估PCM服务中对这些患者的护理背景。目前的飞行员 项目将寻求获得这些信息，以确定治疗需求，以及质量方面的差距 关爱这些患者，并制定实施项目，以降低退伍军人心理健康的成本 关心。在这样做的过程中，这些试点数据将为PI重点研究的新兴项目奠定基础 制定和实施管理难以治疗的精神疾病患者的护理做法。 目的1：使用退伍军人管理局管理数据库来确定患者的特征(人口统计学；心理社会； 临床)的PCM服务的高利用率。 目标2：使用实施研究综合框架(CFIR)进行形成性研究 评估对高使用率的PCM服务的护理背景，以更好地了解(A)患者的需求，(B) 现有实践的决定因素，以及(C)与患者一起实践变化的障碍和促进者 人口。 研究设计与方法：将采用混合方法来实现所提出的目标。 为了解决目标1，我们将使用退伍军人管理局管理数据库来识别所有接受治疗的独特精神健康患者 在2009-2012财年退伍军人管理局(估计N=1,740,000人)中；选择那些PCM服务利用率高的人 (即在上述任何一个财政年度内，有五次或以上的急症或住院精神病病症)，以及 测试人口统计学、心理社会和临床变量作为高利用率组成员的预测因素。 为解决目标2，我们将于年内与PCM服务的董事和精神健康提供者进行面谈 退伍军人事务部。我们将从最低四分位数和最高四分位数中随机选择10个VA设施 高利用率的PCM服务与在本财年接受治疗的独特精神卫生患者总数的比率 2012年。从选定的20个设施中，我们将分别采访四个主要线人(董事和前线 来自急诊室和急性住院精神病学的精神健康提供者；总计N=80)，涉及患者需求和 使用CFIR相关领域的护理连续性(即护理协调、出院和持续护理规划) 到护理的背景下。对定量和定性结果的比较将确定其特征 和高利用率的退伍军人PCM服务的需求，这些患者的护理质量差距，以及指导 随后与这些高成本的精神疾病患者一起实施项目。

Objectives: Use of psychiatric crisis management (PCM) services - i.e., emergency departments [ED] and acute inpatient psychiatry - contributes substantially to the cost of care for VA mental health patients. Further, prior research outside the VA has shown that a small percentage of patients who utilize these services contribute a disproportionate share of the total cost ("high utilizers"). Despite their high cost, there have been no efforts in the VA to identify the patient characteristics of VA mental health patients who utilize PCM services repeatedly, or (2) formatively evaluate the context of care for these patients in PCM services. The current pilot project will seek to obtain this information in order to identify the treatment needs of, and gaps in the quality of care for, this patient population and develop implementation projects to reduce the cost of VA mental health care. In so doing, this pilot data will lay the groundwork for the PI's emerging program of research focused on the development and implementation of care practices for managing difficult to treat mental health patients. Aim 1: Use VA administrative databases to identify the patient characteristics (demographic; psychosocial; clinical) of high utilizers of PCM services. Aim 2: Use the Consolidated Framework for Implementation Research (CFIR) to conduct a formative evaluation of the context of care for high utilizers of PCM services to better understand (a) patient needs, (b) determinants of existing practices, and (c) barriers and facilitators to practice change with this patient population. Research Design & Methods: A mixed-methods approach will be employed to achieve the proposed aims. To address Aim 1, we will use VA administrative databases to identify all unique mental health patients treated in the VA in FY 2009-2012 (estimated N = 1,740,000); select those who were high utilizers of PCM services (i.e., five or more ED or inpatient psychiatry episodes during any one of the aforementioned fiscal years), and test demographic, psychosocial, and clinical variables as predictors of membership into the high utilizer group. To address Aim 2, we will conduct interviews with directors and mental health providers from PCM services in the VA. We will randomly select 10 VA facilities from the lowest quartile and 10 from the highest quartile in terms of ratio of high utilizers of PCM services to total number of unique mental health patients treated in FY 2012. From each of the 20 facilities selected, we will interview four key informants (directors and front-line mental health providers from EDs and acute inpatient psychiatry; total N = 80) on issues of patient needs and continuity of care (i.e., care coordination; discharge and continuing care planning) using CFIR domains related to the context of care. A comparison of the quantitative and qualitative findings will identify the characteristics and needs of high utilizers of VA PCM services, gaps in the quality of care for these patients, and directions for subsequent implementation projects with these high-cost mental health patients.