Anxiety, Depression, Substance Use Disorders
Conditions
Brief summary
This research project is a pragmatic, randomized evaluation of a quality improvement initiative which seeks to evaluate the effects of standardizing the use of a BH-VPN program among patients with a telepsychiatric consult. The outcomes evaluation of this intervention has been designed to integrate with routine care and minimize frontline staff burden by deploying an evaluation in a real-world setting.
Detailed description
Hospital admissions are common amongst those with mental illness. Significant morbidity exists for patients who are being admitted to a psychiatric hospital from the Emergency Department (ED).Additionally, commitment to a hospital setting may have adverse effects on patients psychologically, degrade relationships with therapists, and disrupt continuity of care. ED providers often decide to admit to a psychiatric hospital because of limited availability of behavioral health resources. To better enhance transitions of care for those with mental illness, Atrium Health has designed a behavioral health virtual patient navigation (BH-VPN)program that helps coordinate services and follow-up care, while facilitating the safe discharge of patients. Patients presenting to an ED that have a tele psychiatric consult who are recommended for discharge are eligible for services. The Behavioral health Service line is expanding the program to additional rural emergency departments. Using an outcomes evaluation, the investigators will inform Atrium Health on the effect of the BH-VPN program to reduce hospital admissions among patients with a tele psychiatric consult in the ED. The proposed hypothesis is that by having the BH-VPN program available in an ED, more patients will be discharged from the ED than admitted.
Interventions
BEHAVIORALBehavioral Health - Virtual Patient Navigation
Patients are identified by a clinician in the ED as needing psychiatric evaluation and a referral is made to a tele-psych provider for a virtual consult. Patients can be enrolled to the intervention arm based on a randomization scheme that randomly allocates days that navigators are available. The psychiatrist will make a recommendation to admit or discharge the patient. For patients that have a discharge recommendation on days that BH-VPN is available, patients will be offered the BH-VPN program. Enrolled patients are followed for up to 45 days. On days where the navigator is available, all patients who meet eligibility criteria will be considered exposed to the intervention.
Sponsors
The Duke Endowment
Wake Forest University Health Sciences
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
HEALTH_SERVICES_RESEARCH
Masking
SINGLE (Subject)
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
Eligible patients must meet each of the following criteria: * Present to an ED at participating sites * Complete a telepsychiatric consult as captured in the electronic medical record * Complete a telepsychiatric consult during the navigator's hours of operation * ≥ 18 years of age at time of ED admission
Exclusion criteria
• Patients currently enrolled in the BH-VPN program upon their index ED encounter \-
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Assessing Hospital Admissions | Up to 2 weeks from initial ED admission | Compare the effectiveness of having the Behavioral Health - Virtual Patient Navigation (BH-VPN) program available compared to usual care, on admission rates among patients in the ED with a telepsychiatric consult |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| 45-day Post Discharge Utilization Rate | 45 days | Comparing the 45-day utilization (ED, IP, OBS encounter) rate after the ED encounter between the 2 arms of the study |
| 45-day Post Discharge Utilization Rate With a Self-harm Diagnosis | 45 days | Compare the frequency of patients with any encounter with a self-harm diagnosis within 45 days of the ED visit between the 2 arms of the study |
| 45-day Post Discharge ED Utilization Rate With a Behavioral Health Crisis | 45 days | Compare the frequency of patients who return to the ED and have a telepsychiatric consult within 45 days of their initial ED visit between the 2 arms of the study |
Countries
United States
Participant flow
Participants by arm
| Arm | Count |
|---|---|
| Behavioral Health - Virtual Patient Navigation All patients who meet eligibility criteria at sites where the virtual patient navigation behavioral health program is offered will be considered exposed to the intervention.
Behavioral Health - Virtual Patient Navigation: Patients are identified by a clinician in the ED as needing psychiatric evaluation and a referral is made to a tele-psych provider for a virtual consult. Patients can be enrolled to the intervention arm based on a randomization scheme that randomly allocates days that navigators are available. The psychiatrist will make a recommendation to admit or discharge the patient. For patients that have a discharge recommendation on days that BH-VPN is available, patients will be offered the BH-VPN program. Enrolled patients are followed for up to 45 days. On days where the navigator is available, all patients who meet eligibility criteria will be considered exposed to the intervention. | 534 |
| Usual Care Behavioral Health All patients who meet eligibility criteria at sites where the virtual patient navigator behavioral health program is not offered will be considered exposed to usual care. | 555 |
| Total | 1,089 |
Baseline characteristics
| Characteristic | Behavioral Health - Virtual Patient Navigation | Usual Care Behavioral Health | Total |
|---|---|---|---|
| Age, Continuous | 41.1 years STANDARD_DEVIATION 16 | 41.6 years STANDARD_DEVIATION 15.9 | 41.4 years STANDARD_DEVIATION 16 |
| Race (NIH/OMB) American Indian or Alaska Native | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Asian | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Black or African American | 91 Participants | 92 Participants | 183 Participants |
| Race (NIH/OMB) More than one race | 16 Participants | 18 Participants | 34 Participants |
| Race (NIH/OMB) Native Hawaiian or Other Pacific Islander | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Unknown or Not Reported | 7 Participants | 8 Participants | 15 Participants |
| Race (NIH/OMB) White | 420 Participants | 437 Participants | 857 Participants |
| Region of Enrollment United States | 534 Participants | 555 Participants | 1089 Participants |
| Sex: Female, Male Female | 222 Participants | 248 Participants | 470 Participants |
| Sex: Female, Male Male | 312 Participants | 307 Participants | 619 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| deaths Total, all-cause mortality | 0 / 534 | 0 / 555 |
| other Total, other adverse events | 0 / 534 | 0 / 555 |
| serious Total, serious adverse events | 0 / 534 | 0 / 555 |
Outcome results
Primary
Assessing Hospital Admissions
Compare the effectiveness of having the Behavioral Health - Virtual Patient Navigation (BH-VPN) program available compared to usual care, on admission rates among patients in the ED with a telepsychiatric consult
Time frame: Up to 2 weeks from initial ED admission
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Behavioral Health - Virtual Patient Navigation | Assessing Hospital Admissions | 332 Participants |
| Usual Care Behavioral Health | Assessing Hospital Admissions | 326 Participants |
p-value: 0.2795% CI: [0.9, 1.47]Mixed Models Analysis
Secondary
45-day Post Discharge ED Utilization Rate With a Behavioral Health Crisis
Compare the frequency of patients who return to the ED and have a telepsychiatric consult within 45 days of their initial ED visit between the 2 arms of the study
Time frame: 45 days
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Behavioral Health - Virtual Patient Navigation | 45-day Post Discharge ED Utilization Rate With a Behavioral Health Crisis | 40 Participants |
| Usual Care Behavioral Health | 45-day Post Discharge ED Utilization Rate With a Behavioral Health Crisis | 36 Participants |
p-value: 0.5195% CI: [0.73, 1.86]Mixed Models Analysis
Secondary
45-day Post Discharge Utilization Rate
Comparing the 45-day utilization (ED, IP, OBS encounter) rate after the ED encounter between the 2 arms of the study
Time frame: 45 days
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Behavioral Health - Virtual Patient Navigation | 45-day Post Discharge Utilization Rate | 88 participants |
| Usual Care Behavioral Health | 45-day Post Discharge Utilization Rate | 89 participants |
p-value: 0.8395% CI: [0.75, 1.43]Mixed Models Analysis
Secondary
45-day Post Discharge Utilization Rate With a Self-harm Diagnosis
Compare the frequency of patients with any encounter with a self-harm diagnosis within 45 days of the ED visit between the 2 arms of the study
Time frame: 45 days
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Behavioral Health - Virtual Patient Navigation | 45-day Post Discharge Utilization Rate With a Self-harm Diagnosis | 47 Participants |
| Usual Care Behavioral Health | 45-day Post Discharge Utilization Rate With a Self-harm Diagnosis | 35 Participants |
p-value: 0.1295% CI: [0.91, 2.26]Mixed Models Analysis