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Connecting Veterans with Care through the HOME Program Bridget Matarazzo, Psy. D 1, 2; Connecting Veterans with Care through the HOME Program Bridget Matarazzo, Psy. D 1, 2; Georgia Gerard, LCSW 1; Mira Brancu, Ph. D 3, 4; Joy Close, LCSW 3; Amy Horrex, Psy. D 5 1 Rocky Mountain Mental Illness, Research, Education and Clinical Center (MIRECC); 2 University of Colorado, School of Medicine; 3 Mid-Atlantic MIRECC; 4 Duke University; 5 WJB Dorn VA Medical Center Bi-Annual Do. D/VA Suicide Prevention Conference August 2017 – Denver, CO

Disclaimer This presentation is based on work supported, in part, by the Department of Disclaimer This presentation is based on work supported, in part, by the Department of Veterans Affairs, but does not necessarily represent the views of the Department of Veterans Affairs or the United States Government. This work was in part supported by the Military Suicide Research Consortium (MSRC), funded through the Office of the Assistant Secretary of Defense for Health Affairs. Opinions, interpretations, conclusions and recommendations are those of the author and are not necessarily endorsed by the MSRC or the Department of Defense. Sponsors & Partners Office of Mental Health & Suicide Prevention

Agenda • • • The HOME Program • Background & Overview • Expansion Timeline Agenda • • • The HOME Program • Background & Overview • Expansion Timeline Research Findings • Program Evaluation • Multi-Site Clinical Trial • Effectiveness • Implementation Clinical Implementation • Rural Veterans • Diffusion of Excellence

The HOME Program The HOME Program

Trajectory of Suicide Risk Following Psychiatric Hospitalization Discharge from inpatient psychiatric unit Lack of Trajectory of Suicide Risk Following Psychiatric Hospitalization Discharge from inpatient psychiatric unit Lack of treatment engagement Heightened risk of death by suicide

Enrollment while on the inpatient unit Telephone follow-up within one day of discharge Home Enrollment while on the inpatient unit Telephone follow-up within one day of discharge Home visit during first week post-discharge Ongoing telephone follow-up until engaged in care

HOME Expansion Timeline 2012 Denver (MHS) 2013 Salt Lake City (MHS) 2013 Multi -Site HOME Expansion Timeline 2012 Denver (MHS) 2013 Salt Lake City (MHS) 2013 Multi -Site Clinical Trial (MSRC) Expanded to serve rural Veterans 2014 Durham (MHS & ORH) 2017 Columbia (Facility) USH Gold Status Practice

Research Findings Program Evaluation Research Findings Program Evaluation

Evaluation of HOME Clinical Demonstration Project Evaluation of HOME Clinical Demonstration Project

Research Findings Multi-Site Clinical Trial Research Findings Multi-Site Clinical Trial

Research Question and Hypotheses Does the HOME program increase treatment engagement? Hypothesis 1 - Research Question and Hypotheses Does the HOME program increase treatment engagement? Hypothesis 1 - Veterans in the HOME program will be significantly more likely to engage in treatment (i. e. , attendance at two mental health appointment) as compared to those in the E-CARE group Hypothesis 2 - Veterans in the HOME program will have attended significantly more individual mental health appointments relative to the E-CARE group Hypothesis 3 - Veterans participating in the HOME program will have attended significantly more individual mental health appointments three months postdischarge relative to the E-CARE group as evidenced by documentation in the VA medical record.

Methods Study Design: Two-arm interventional trial; 2 active sites and 2 E-CARE sites Data Methods Study Design: Two-arm interventional trial; 2 active sites and 2 E-CARE sites Data Collection Primary Outcome - Treatment Engagement 90 days post-hospitalization Attendance at one individual and one group OR two individual MH appts VA’s Corporate Data Warehouse Secondary Outcomes and Exploratory Aims

Enrollment Active Site n ECARE Site n Western VAMC 108 Central VAMC 70 Eastern Enrollment Active Site n ECARE Site n Western VAMC 108 Central VAMC 70 Eastern VAMC 71 Western VAMC 74 Total 179 Total 144 Total n 323

Hypothesis 1 Veterans in the HOME program will be significantly more likely to engage Hypothesis 1 Veterans in the HOME program will be significantly more likely to engage in treatment (i. e. , attendance at two mental health appointment) as compared to those in the E-CARE group Raw Data Summary HOME (N=166) 152 (92%) Engaged in Care E-CARE (N=136) 102 (75%) Nonlinear Mixed Model Results Parameter Estimate (SE) Group* Odds Ratio (95% CI) p-value 1. 15 (0. 35) 3. 15 (1. 05, 9. 48) 0. 045 *Controlling for Inpatient Length of Stay

Hypothesis 2 Veterans in the HOME program will have attended significantly more individual mental Hypothesis 2 Veterans in the HOME program will have attended significantly more individual mental health appointments relative to the E-CARE group Raw Data Summary- Medians and Ranges HOME E-CARE # Individual MH Appointments 5 (0, 28) 3 (0, 25) # Group MH Appointments 1 (0, 72) 0 (0, 42) # Combined Individual and Group MH Appointments 7 (0, 93) 3. 5 (0, 63)

Hypothesis 2 Veterans in the HOME program will have attended significantly more individual mental Hypothesis 2 Veterans in the HOME program will have attended significantly more individual mental health appointments relative to the E-CARE group Mixed-effects Negative Binomial Regression Model Individual MH Appointments Parameter Estimate (SE) Group MH Appointments* Combined MH Appointments *Controlling for Inpatient Length of Stay 0. 32 (0. 10) 0. 17 (0. 33) 0. 24 (0. 12) Exp(Beta) 1. 37 (1. 002, 1. 88) 1. 18 (0. 41, 3. 40) 1. 27 (0. 86, 1. 87) p-value 0. 049 0. 65 0. 15

Hypothesis 3 Veterans participating in the HOME program will have attended significantly more individual Hypothesis 3 Veterans participating in the HOME program will have attended significantly more individual mental health appointments three months post-discharge relative to the E-CARE group as evidenced by documentation in the VA medical record. Kaplan-Meier analysis Group Median (days) 95% CI Log-Rank Chi-square value HOME 16. 5 25. 5 (14, 22) (20, 34) 12. 18 Control p-value 0. 0005

Implementation Outcomes: Acceptability & Feasibility Implementation Outcomes: Acceptability & Feasibility

Implementation Outcomes • Acceptability and feasibility data were collected for active participants • Client Implementation Outcomes • Acceptability and feasibility data were collected for active participants • Client Satisfaction Questionnaire-8 at Time 2 -4 (Acceptability) • HOME Clinical Database (e. g. , frequency of phone calls, completion of a home visit) (Feasibility) • The Narrative Evaluation of Intervention Interview (NEII) was administered at Time 3 or 4 to collect (Feasibility and Acceptability)

CSQ-8 Results CSQ Scores- mean (SD) Both Sites Western VAMC Eastern VAMC p-value Time CSQ-8 Results CSQ Scores- mean (SD) Both Sites Western VAMC Eastern VAMC p-value Time 2 (n=99) 27. 4 (3. 8) 28. 3 (3. 5) 25. 7 (3. 9) 0. 003 Item average 3. 4 3. 5 3. 2 Time 3 (n=72) 28. 2 (3. 6) 29. 0 (3. 5) 26. 5 (3. 3) Item average 3. 5 3. 6 3. 3 Time 4 (n=63) 27. 7 (3. 2) 28. 1 (3. 1) 26. 6 (3. 3) Item average 3. 4 3. 5 3. 3 0. 006 0. 09

CSQ-8 • Overall, across both sites participants: • Were satisfied with the quality of CSQ-8 • Overall, across both sites participants: • Were satisfied with the quality of service (mean 3. 5) • Would recommend the HOME program (mean 3. 6) • Felt the program helped them deal more effectively with problems (mean 3. 4)

Feasibility Data- Phone Calls • HOME Study clinician called Veteran one business day post Feasibility Data- Phone Calls • HOME Study clinician called Veteran one business day post discharge and at least once a week until the Veteran engaged in care • These calls included: • Conducting a risk assessment • Reviewing Safety Plan and update as needed • Assessing mood, substance/alcohol/medication use, and sleep • Reviewing discharge plan and any barriers to accessing care

Feasibility Data- Phone Calls Sites Western VAMC (n=101) %, Mean (SD) or Median (range) Feasibility Data- Phone Calls Sites Western VAMC (n=101) %, Mean (SD) or Median (range) Eastern VAMC (n=65) %, Mean (SD) or Median (range) 91% 82% Number of HOME Intervention phone calls 3. 1 (2. 4) 2. 8 (2. 7) 2 (1 -11) 2 (1 -13) Length of time of phone calls (in minutes) 21. 9 (9. 2) 29. 0 (11. 5) 20 (5 -65) 25 (5 -60) At least 1 phone call

Feasibility Data- Home Visit HOME Study clinician conducted a home visit within one week Feasibility Data- Home Visit HOME Study clinician conducted a home visit within one week of discharge Sites Completed home visit Length of time Western VAMC (n=101) Eastern VAMC (n=65) %, Mean (SD) or Median (range) 78% 46% 45. 3 (12. 6) 50. 7 (21. 3) 40 (20 -90) 45 (20 -90)

Feasibility Data- Home Visit • Why home visits did not occur: • • Veteran Feasibility Data- Home Visit • Why home visits did not occur: • • Veteran was not at home when the clinician arrived Visit needed to be cancelled due to: a) Not being able to get in touch with the Veteran post-discharge b) VA appointment overlapped with visit c) Veteran chose to cancel visit d) Veteran completed HOME program prior to scheduled visit e) Veteran had a change in discharge plan

Narrative Accounts • The NEII was administered once, either during the Time 3 or Narrative Accounts • The NEII was administered once, either during the Time 3 or Time 4 assessment • Administered by another member of the research team, not the clinician working with the participants • Questions focus on components of the intervention that were useful or helpful or not useful, changes that took place after participating in the intervention, what the intervention contributed to the participant, etc.

Narrative Accounts General theme: Confidence in using and better understanding of the safety plan Narrative Accounts General theme: Confidence in using and better understanding of the safety plan “Better understanding of the safety plan and also motivation to have the safety plan available so I can look at it anytime I want and pay attention to some of the elements on the safety plan. ” “It gave me confidence that I had a good emergency plan on hand. It allowed me to not have it weighing on my mind because I know I had something in place. ”

Narrative Accounts General theme: Feeling cared for “Well it gave me the opportunity to Narrative Accounts General theme: Feeling cared for “Well it gave me the opportunity to take care of myself and it has helped me a lot. I don’t know where I would be right now without the support. ” “That would be hard to pinpoint, just having someone care about me when I didn’t care about myself. ” “The follow up calls, I anticipated them or looked forward to them and continuing to feel more competent and I guess I would say cared for. ”

Narrative Accounts General theme: “Better outlook on life”, more positive/hopeful “It gave me first Narrative Accounts General theme: “Better outlook on life”, more positive/hopeful “It gave me first of all a safe place to go when I really needed it, and it has been able to teach me how to handle things, like disappointment and crises that go on and it gave me a better outlook on life. ” “Well [provider] helped me feel hopeful. I was in a really down place in my life, and she helped me stay in a positive influence; just picking up the phone was very helpful for me. ” “I think her calling once a week helped me to have something to look forward to and have the week go a little bit better. It helped me work harder to be a better person. ”

Narrative Accounts • Overall, participants were accepting of this intervention, found it helpful and Narrative Accounts • Overall, participants were accepting of this intervention, found it helpful and that it had an impact on them • A few participants stated that discussing suicidal thoughts/behaviors and current stressors was difficult for them and an “undesirable” component of the intervention

Discussion • These results suggest that: • The intervention is acceptable to this cohort Discussion • These results suggest that: • The intervention is acceptable to this cohort of Veterans and feasible to conduct at these two geographically distinct VAMCs • Overall, HOME providers maintained fidelity to the HOME treatment manual

Clinical Implementation Rural Veterans Clinical Implementation Rural Veterans

33 Implementing HOME at a New Site Assess the feasibility & acceptability of the 33 Implementing HOME at a New Site Assess the feasibility & acceptability of the HOME Program at a new site and with a rural Veteran population Assess the effectiveness of the HOME Program with respect to treatment engagement Explore potential differences between rural & non-rural Veterans participating in the HOME program

34 Rural Veterans Are at Elevated Risk Rural Veterans comprise >25% of all Veterans 34 Rural Veterans Are at Elevated Risk Rural Veterans comprise >25% of all Veterans (CDC, 2012) Rural veterans are at a 20% increased risk for suicide compared to non-rural Veterans (Mc. Carthy et al. , 2012) Possible contributing factors: Geographic and interpersonal isolation Economic and social distress Rural culture (hardiness, independence)

Treatment Engagement (N=94) *Attended two outpatient MH appointments **Equal percentages of rural & non-rural Treatment Engagement (N=94) *Attended two outpatient MH appointments **Equal percentages of rural & non-rural HOME research participants engaged in care

Reduced Utilization of Crisis Services HOME Patients (N=47) Comparison Group (N=47) Calls to crisis Reduced Utilization of Crisis Services HOME Patients (N=47) Comparison Group (N=47) Calls to crisis line 0 (0%) 2 (4%) # People who Presented to PES/ED 8 (17%) 11 (23%) # People who were re-hospitalized 4 (9%) 7 (15%) Service *PES = Psychiatric Emergency Services

37 Rural vs. Non-Rural Trends Providing care via the HOME program to rural Veterans 37 Rural vs. Non-Rural Trends Providing care via the HOME program to rural Veterans is not that different! • Program engagement & satisfaction • Treatment engagement Some possible cultural considerations in safety planning.

38 Rural vs. Non-Rural HOME Program Engagement # phone calls Length of phone calls 38 Rural vs. Non-Rural HOME Program Engagement # phone calls Length of phone calls Duration of home visits Received home visit Rural (n=55) 2. 9 (2. 1) 16. 2 (8. 5) 51. 1 (13. 6) 39 (71%) Non-Rural (n=43) Mean (SD) 2. 8 (1. 6) 16. 6 (5. 9) 45. 2 (14. 2) # (%) 30 (70%)

39 Rural vs. Non-Rural Care Engagement Rural Non-Rural # (%) (n=55) 41 (74%) (n=43) 39 Rural vs. Non-Rural Care Engagement Rural Non-Rural # (%) (n=55) 41 (74%) (n=43) 32 (74%) Mean (SD) (n=55) 23. 0 (22. 9) (n=43) 24. 0 (17. 5) Mean (SD) (n=50) 63. 5 (24. 5) (n=38) 22. 8 (11. 4) Engaged in Care Days until second appointment Distance to Durham VA

40 Rural vs. Non-Rural Veteran Satisfaction 33 Satisfaction Score (Out of Maximum 32) 31 40 Rural vs. Non-Rural Veteran Satisfaction 33 Satisfaction Score (Out of Maximum 32) 31 29 27 25 Rural Non-rural 23 21 Client Satisfaction Questionnaire (CSQ) Scores • Total Scores reported as median (range) • 8 item Likert scale, range 1 -4 19 17 15 Time 2 (n=31) Time 3 (n=31) Time 4 (n=30)

Feedback from our Veterans…. “The VA should have this service all across the country. Feedback from our Veterans…. “The VA should have this service all across the country. This is something Vets and mental health patients need. The phone calls … helped me stay on track. ” “Others never really touched on suicide or dealt with the social aspects of emotions, not really understanding the tools necessary to dealing with the social repercussions of my conditions. Other soldiers and Veterans would do well to have someone help them learn to deal with their suicidal thoughts. ” “She came to my house and. . . made sure I was safe, even in my house, and that meant a lot to me. It was great knowing people actually care; gives me hope. ” “I was at a low point. You helped me lift myself up …helped me with a work plan, gave me better outlook. I’ve never [been in a program] before that took the time like she did. ” “My clinician was very instrumental in helping me … build a plan that I could use before I slipped into a crisis. She was specific about what I can do to relieve myself of stress in any situation. ” “It’s good having contact with somebody after leaving the hospital. I have a better idea of where to go and who I need to see to get help. ”

Safety Planning Steps 2 &3: Mental & Physical Hobbies Activity Rural n=52 Non-Rural n=41 Safety Planning Steps 2 &3: Mental & Physical Hobbies Activity Rural n=52 Non-Rural n=41 Fishing Exercise/ Physical Activity (besides walk) 8 (15%) 5 (12%) 15 (29%) 16 (39%) Physically Engaging Hobby or Task 26 (50%) 11 (27%) Mentally Engaging Hobby or Task 41 (79%) 31 (76%) Step 2: Using internal coping strategies: “What can you do on your own if you become suicidal again, to help yourself not to act on your thoughts or urges? What activities could you do to help take your mind off your problems even if it is for a brief period of time? ” Step 3: Utilizing social contacts as distraction or support 42

Safety Planning Steps 3 & 4: Personal Contacts Rural n=52 Non-Rural n=41 = 1 Safety Planning Steps 3 & 4: Personal Contacts Rural n=52 Non-Rural n=41 = 1 3 (6%) 3 (7%) ≥ 4 18 (35%) 12 (29%) # People Identified in Steps 3 & 4 Step 3: Utilizing social contacts that can serve as a distraction from suicidal thoughts (or intense distress) and who may offer support Step 4: Contacting family members or friends who may offer help resolving a crisis 43

Safety Planning Step 6: Access to Firearms Rural n=52 Non-Rural n=41 No Access 41 Safety Planning Step 6: Access to Firearms Rural n=52 Non-Rural n=41 No Access 41 (79%) 28 (68%) Current Access w/ Restriction 6 (12%) 3 (7%) Current Access w/o Restriction 0 (0%) 1 (2%) Blank or No Reference to Firearms 1 (2%) 2 (5%) Access to Firearms 44 Step 6: Reducing the potential for us of lethal means: “What means do you have access to and are likely to use to make a suicide attempt or to kill yourself? ”; “How can we go about developing a plan to limit your access to these means? ”

Safety Planning Steps 1 -4: Protective/Risk Factors Rural n=52 Non-Rural n=41 23 (44%) 16 Safety Planning Steps 1 -4: Protective/Risk Factors Rural n=52 Non-Rural n=41 23 (44%) 16 (39%) Grandkids 4 (8%) 4 (10%) Positive Psychotic Sx 6 (12%) 3 (7%) Substance Use 20 (38%) 15 (37%) Protective Religiosity or Spirituality Risk 45 Step 1: Warning signs Step 2: Using internal coping strategies Step 3: Utilizing social contacts as a distraction or support Step 4: Contacting family members/friends to help resolve a crisis

46 Take Away • • • The HOME program is feasible to implement at 46 Take Away • • • The HOME program is feasible to implement at another VA hospital facility. It is feasible to provide it to rural Veterans with minimal adaptation. Satisfaction is high among patients. It has shown improvements in treatment engagement (our target goal). Rural Veterans may respond in slightly different ways to safety planning steps, based on cultural considerations. Clinicians are encouraged to become familiar with those nuances.

Clinical Implementation Diffusion of Excellence Clinical Implementation Diffusion of Excellence

HOME Program Diffusion Journey USH Shark Tank Competition 435 individual applications submitted HOME Program HOME Program Diffusion Journey USH Shark Tank Competition 435 individual applications submitted HOME Program was chosen as one of the 13 Gold Status practices Dorn VAMC was selected to implement based on the need to improve mental health follow-up care in our Veteran population Diffusion of Excellence Summit Gold Status Fellows (GSFs) and Implementing Facility Fellows (IFFs) convened in Orlando, FL to develop an Action Plan, outlining the steps for implementation Facilitated Implementation Dorn VAMC (IFF), VA Eastern Colorado HCS (GSF), and Durham VAMC team members meet weekly to report on implementation progress, along with a Team Lead an Implementation Coordinator from the Diffusion of Excellence Support Team (Contractors) Facilitated Implementation lasts 6 months

HOME Program Diffusion Journey • Weekly Consultation • HOME manual • Appt. Protocol • HOME Program Diffusion Journey • Weekly Consultation • HOME manual • Appt. Protocol • Forms • Standard Operating Procedure • Added phone only option • HOME Note Templates w/ Health Factors (x 5) • HOME Clinics (x 3) • HOME Screening & Case Management Database • New Position Approval (x 2) • Functional Statement • Resource Management Board • HR Hiring Process • HOME Provider Training • HOME resources (vehicle, gunlocks, pillboxes, cell phone, laptop) • Clinical Application • Improve post-discharge engagement • Increase use of Safety Plans post-discharge • Improved understanding of rural Veteran needs postdischarge • Demonstrate high levels of Veteran satisfaction • Reduce utilization of crisis services • Reduce rates of suicide

HOME Program Next Steps Continued expansion anticipated through the Diffusion of Excellence Hub http: HOME Program Next Steps Continued expansion anticipated through the Diffusion of Excellence Hub http: //vhaindwebsim. v 11. med. va. gov/hub 2/ppd/index. html

Questions? Comments? Thank you! Bridget. Matarazzo@va. gov Georgia. Gerard@va. gov Joy. Close@va. gov Amy. Questions? Comments? Thank you! Bridget. [email protected] gov Georgia. [email protected] gov Joy. [email protected] gov Amy. La. [email protected] gov