Christopher J. Miller

Background: Collaborative chronic care models (CCMs) are an evidence-based way to structure care in outpatient mental health settings. This project investigated whether implementation facilitation (IF) can enhance CCM-consistent outpatient mental health care and reduce mental health hospitalizations compared with centralized technical assistance (CTA). Methods: This was a stepped wedge hybrid 2 implementation-effectiveness trial in outpatient mental health clinics at eight US Department of Veterans Affairs (VA) medical centers (four waves, two sites each) conducted from 2022 to 2024. Staff participants included clinicians involved in delivering team-based outpatient mental health care. The patient sample consisted of US military veterans treated by 42 participating mental health teams. IF was used for 8–9 months to increase alignment with CCM principles at each participating site. All the sites (including eight comparison sites that were nonrandomized but matched on key variables) had access to CTA. The coprimary outcomes were (a) alignment with CCM-based care evaluated using the Role Clarity and Team Primacy subscales of the Team Development Measure [TDM], and (b) mental health hospitalizations extracted from the electronic health record during the year following initiation of IF. Results: The sample included n = 20,835 patients at participating sites and n = 60,221 patients at comparison sites. The pre-implementation TDM was completed by 134 staff members, and post-implementation TDM was completed by 109 staff members. Role Clarity and Team Primacy subscales of the TDM demonstrated small, nonstatistically significant improvement after completing IF ( p = 0.33[ t -value: 0.97] and 0.14 [ t -value: 1.48], respectively). Multivariate generalized linear mixed models indicated participating sites had similar mental health hospitalization rates following IF initiation compared to sites receiving CTA alone. Conclusion: This trial revealed that IF to enhance CCM-consistent clinical practices in outpatient mental health teams was associated with small improvements in team functioning that did not achieve statistical significance. Mental health hospitalization rates did not differ for sites using IF versus CTA. TDM-based assessments of team functioning at baseline were similar to post-implementation results from a prior trial, suggesting that CTA to support team-based care may have increased team functioning in these settings prior to trial initiation. Trial registration: NCT05997836. Retrospectively registered 18 August 2023: https://clinicaltrials.gov/study/NCT05997836?term=NCT05997836%26rank=1 . Ethical approval: This evaluation was conducted as a quality improvement activity for VA and was deemed by the R&D Committee at the VA Boston Healthcare System not to be research; therefore, it was not subject to IRB review.

Introduction: Bipolar disorder is a chronic, complex mental health condition. Chronic Care Models were developed to treat chronic medical conditions in primary care. Several clinical trials have assessed their effects in treating individuals with bipolar disorder. Methods: A systematic literature review identified randomized controlled trials that tested interventions utilizing at least three of the five Chronic Care Model clinical elements. Random effects meta‐analysis assessed impact on six outcome domains: overall mental health, mania, depression, mental health‐related quality of life, physical health‐related quality of life, and treatment costs. Risk of bias for individual trials and confidence in the point estimate for outcome domains were determined following the Cochrane methodology. Results: Eight randomized controlled trials were identified, resulting in six meta‐analyses of two to eight trials each. The single‐blind methodology resulted in a high overall risk of bias for each trial. Statistically significant benefit was seen for overall mental health (standardized mean difference (SMD) = 0.28, 95% CI = 0.13–0.43, p < 0.01), mania (SMD = 0.16, 95% CI = 0.01–0.30, p = 0.03), and mental health‐related quality of life (SMD = 0.24, 95% CI = 0.08–0.41, p < 0.01). No evidence of an effect was seen for depression, physical health‐related quality of life, or costs. Confidence was moderate for overall mental health outcome, mania, depression, and mental health‐related quality of life; low for physical health‐related quality of life; and very low for costs. Conclusions: Trials in diverse health care systems indicate that Chronic Care Model elements may improve mental health outcomes for bipolar disorder. This meta‐analysis highlights the need for research to further explore the effectiveness and implementation of these models of care.

Introduction: Veteran patient partnerships in research improve patient‐centred healthcare outcomes within US Department of Veterans Affairs (VA) medical centres. To achieve this, researchers must contextualize perspectives, motivations, and contributions of Veteran patients engaged in research (VPERs) as valued consultants within a complex healthcare environment. Our objective was to investigate best practices for research teams partnering with VPERs by utilizing the expertise of our research team's own VPER. The parent project of this case study, Hybrid Controlled Trial to Implement Collaborative Care in General Mental Health, was approved by the VA Boston Healthcare System Institutional Review Board and deemed research. Objective: Provide three key recommendations when engaging military Veterans and/or VA Veteran Patients in research to facilitate sustained teamwork and integration. Study Design and Methodologies: This paper is structured as a qualitative descriptive data‐based case study. Two team members used a semi‐structured conversation guide to interview Dr. Colleen Turner, MSW, PhD, Lt. Col. (Ret., US Air Force Reserves) for one hour about her experience as a VPER on the 5‐year research project. This manuscript was then written collaboratively by members of the team, with heavy influence and editing from Colleen for details and accuracy. Results: Improving mental healthcare for Veterans motivated Colleen to serve as a VPER from 2015 to 2020. She used organizational and provider‐level mental health expertise gained during her Air Force service, applied her graduate social work training, and offered her experience as a VA patient. A diverse background and an ability to codeswitch helped her navigate the study and enriched the team's partnership dynamics. Through a qualitative interview with Colleen about her experience as a VPER, three recommendations emerged for research teams to better situate VPERs on studies: (1) ensure initial project literacy and provide ongoing support, (2) incorporate VPER goals into project work and (3) communicate both (a) offers of reasonable compensation and professional acknowledgement and (b) visible patient‐centred outcomes. Conclusion: This case study deepens the understanding of how to meaningfully incorporate VPERs into a partnered research study. Engagement starts early, continues throughout the study, and culminates with well‐communicated outcomes as they pertain to the researchers’ and VPERs’ goals. These recommendations closely align with widely accepted community‐engaged research practices and may guide ongoing and future studies to further improve patient engagement in research and the collaboration experiences of VPERs. Patient or Public Contribution: This manuscript focuses on Colleen's contributions to the design and conduct of a hybrid implementation/effectiveness study. Colleen also contributed to the manuscript itself. Uniquely, Dr. Turner brought her experience as a practitioner with master's and doctoral degrees in social work, as an institutional communications analyst, and as an independent author. Because of this, she was able to bring even more expertise to the project beyond just that of a patient, which is valuable in its own right. Colleen was involved in the research project from inception to conclusion, including study design, general analysis, and manuscript publication, with overall consultation throughout.

Background: Gender-related disparities in access to alcohol-related care exist in the Department of Veterans Affairs’ (VA) health care system. Understanding differences in the use of alcohol-related care in the context of potentially important covariates (e.g., race, ethnicity, younger age, and military sexual trauma [MST]) is critical to support the health and well-being of women Veterans. This study examined differences in the use of alcohol preventive care among women Veterans. Methods: From VA administrative data (2010-2016), we drew a sample of women Veterans (n = 280) who screened positive for at-risk drinking in inpatient/outpatient settings. We conducted a chart review to abstract variables from the medical record. Then, we employed logistic regression to predict receipt of any follow-up (brief intervention and/or referral to treatment) and initiation of treatment, as with covariates of race, ethnicity, age, and clinical characteristics such as MST. Results: Seventy-four percent (n = 207) of the sample received any follow-up. Of those referred to treatment (n = 115), 73% (n = 84) initiated treatment. Hispanic women were 71% less likely to receive follow-up care than non-Hispanic women. Women Veterans 21 to 24 years were less likely to initiate treatment than those 25 to 29 years. While women Veterans who endorsed MST were more likely to receive follow-up care than others, they were no more likely to initiate treatment. Conclusions: Given the rapid growth of the women Veteran population, their access to alcohol-related care is vital. Without culturally competent, clinically and developmentally appropriate alcohol prevention messaging for Hispanic and younger women Veterans with trauma, differences in access to care and disparities in outcomes will persist.

Objective: To examine site‐level differences in telemental health use within the Department of Veterans Affairs (VA). Findings aim to identify barriers to telemental health use to improve access to care.Study Setting and Design: 122 VA facilities were classified into three groups: sites with higher levels of in‐person (n = 55), video (n = 40), and phone mental health (MH) care (n = 27). We used Pearson's chi‐squared and F‐tests to assess for group differences on organizational characteristics and patient population variables.Data Sources and Analytic Sample: This was an observational study using VA administrative data from July 2021 to October 2022; analyses were conducted from June 2024 to March 2025.Principal Findings: Sites in the video group tended to be larger, high‐complexity, urban facilities that served more women, younger patients, and patients with greater broadband access. Sites in the in‐person group served more patients of lower socioeconomic status and treated the highest percentage of rural patients. The phone group served the next highest percentage of rural patients, followed by the video group.Conclusions: Larger, higher‐complexity sites may have stronger telehealth infrastructures, and urban areas have stronger broadband connectivity to support video visits. Smaller, rural sites may benefit from targeted support to increase video use.

Background: Guidelines suggest that, in chronic non-cancer pain (CNCP) management, non-opioid modalities should be prioritized, as there are negative consequences related to opioid use. There is a dearth of literature elucidating the risk factors for initiating opioid use amongst veterans with CNCP. Methods: Chart review on 193 patients with a new referral at a local US Department of Veterans Affairs (VA) pain clinic. Patients were required to have CNCP and not be taking opioid medication at the time of referral. The review started on 1 January 2014 and covered the year following. Data were analyzed via stepwise multiple logistic regression using Statistical Analysis System (SAS) software (Version 9.4; SAS institute Inc., Cary, NC, USA). Results: A total of 37 veterans (19%) received a new opioid prescription in the year following initial encounters at the pain clinic for CNCP. A history of substance use was associated with lower odds of receiving an opioid prescription. In contrast, being employed was associated with higher odds of receiving an opioid prescription. Conclusions: Amongst veterans treated for CNCP in a VA pain clinic, a history of substance use and a presence of vocation within the past year prior to presentation are variables associated with the initiation of opioids. Future studies to further elucidate the predictors of opioid prescriptions for CNCP are warranted.

Transferring successful implementation strategies from research to practice requires approaches for assessing fidelity to the strategy’s core components. Implementation facilitation (IF) is a strategy involving an interactive process of problem-solving, enabling, and supporting individuals in efforts to implement clinical innovations that occurs in the context of a recognized need for improvement and supportive interpersonal relationships. Because IF is a dynamic strategy involving numerous activities, our objective was to conduct a rigorous consensus development process to identify core activities for monitoring fidelity to IF when applied in clinical settings. We first conducted a scoping literature review to identify the range of activities used when IF has been applied in clinical settings, searching multiple citation databases for English-language articles including “facilitation” or other commonly-used terms for the strategy published from 1996–2015. Through multi-stage screening, 135 articles (from 94 studies) were identified for data extraction on IF activities, frequency with which IF activities were identified as ‘core’ by study authors, and study outcomes. From the literature review, we identified 32 distinct IF activities and developed definitions/examples for each. Next, we conducted a 3-stage, modified-Delphi expert panel consensus development process to identify core IF activities across three implementation phases (i.e., Pre-Implementation, Implementation, Sustainment). The expert panel identified 8 core activities for the Pre-Implementation Phase, 8 core activities for the Implementation Phase, and 4 core activities for the Sustainment Phase. This work provides an important foundation for developing measures/tools to assess use of core IF activities to ensure the strategy is delivered with fidelity.

Despite the active posttraumatic stress disorder (PTSD) screening program in Department of Veterans Affairs (VA) primary care clinics and the availability of empirically supported treatments for PTSD at VA, many veterans for whom screening suggests treatment may be indicated do not gain access to VA-based mental health care. To determine where we may be losing veterans to follow-up, we need to begin by identifying the initial action taken in response to a positive PTSD screen in primary care. Using VA administrative data and chart review, we identified the spectrum of initial actions taken after veterans screened positive for PTSD in VA primary care clinics nationwide between October 2017 and September 2018 (N = 41,570). We collapsed actions into those that could lead to VA-based mental health care (e.g., consult placed to a VA mental health clinic) versus not (e.g., veteran declined care), and then examined the association between these categories of actions and contextual- and individual-level variables. More than 61% of veterans with positive PTSD screens had evidence that an initial action toward VA-based mental health care was taken. Urban-dwelling and female veterans were significantly more likely to have evidence of these initial actions, whereas White and Vietnam-era veterans were significantly less likely to have this evidence. Our findings suggest that most veterans screening positive for PTSD in VA primary care clinics have evidence of initial actions taken toward VA-based mental health care; however, a substantial minority do not, making them unlikely to receive follow-up care. Findings highlight the potential benefit of targeted primary care-based access interventions. (PsycInfo Database Record (c) 2023 APA, all rights reserved).