Providing care to individuals with serious mental illness can be challenging, requiring ongoing monitoring, treatment adjustments, and coordination of various medical and social services. Rates of emergency service and hospital use are high due to unexpected social, medical, and mental health crises. Stressors and poor adherence with treatment are common and can lead to rapid worsening in symptoms, job loss, homelessness, incarceration, or suicide. Clinician visits can be infrequent. Patient-clinician contact between visits is challenging and often nonexistent. As such, illness exacerbations usually occur with no clinician awareness in real time, leaving limited opportunity to provide services. Clinicians need interventions that are capable of monitoring and quickly detecting worsening behaviors and illness, to improve care coordination, outreach, and treatment. This project studies the effectiveness of enhanced care coordination using passive mobile data monitoring and support from peer specialists, with the goal of improving outcomes and reducing the need for acute care.

Overview: Providing care to individuals with serious mental illness (SMI) can be challenging, requiring ongoing monitoring, treatment adjustments, and coordination of various medical and social services. Rates of emergency service and hospital use are high due to unexpected social, medical, and mental health crises. A variety of stressors and poor adherence with treatment are common and can lead to rapid worsening in symptoms, job loss, homelessness, incarceration, or suicide. Clinician visits can be infrequent. Patient-clinician contact between visits is challenging and often nonexistent. As such, illness exacerbations usually occur with no clinician awareness in real time, leaving limited opportunity to provide services. This project studies, in Veterans with SMI and high risk for acute care, the effectiveness of an enhanced care coordination mobile intervention (CCM) that uses passive mobile data and support from peer coaches. The investigators hypothesize that CCM will reduce the need for acute care services in comparison to usual care.

Specific Aims:

Among Veterans with SMI:

1. Engage Veterans and clinicians in co-design activities that adapt previously tested protocols and tools to guide implementation of enhanced care coordination with mobile (CCM intervention) that includes passive mobile monitoring of Veterans' mental health status, technology and behavioral supports from peer coaches, and care coordination within a Behavioral Health Interdisciplinary Program (BHIP).
2. Determine the effectiveness of CCM on acute care use. Implement CCM using protocols and tools from Aim 1 and randomize high-risk patients with SMI to CCM or usual care for 9 months.
3. Evaluate implementation of CCM.
4. Conduct a budget impact analysis of CCM.

Methodology:

Population: patients with SMI and high risk for acute care use. Intervention: enhanced care coordination within a VA BHIP program using passive mobile monitoring and supports from peer coaches Comparison: effectiveness trial with randomization to CCM or usual care for 9 months Outcome: reduction in use of urgent care services (emergency visits, hospitalization, or death) Qualitative and quantitative methods

Inclusion Criteria:

• a medical record diagnosis of Serious Mental Illness (SMI)

  • defined as schizophrenia, schizoaffective disorder, or bipolar disorder

• receipt of care at the VA site during the prior 9 months

• a Care Assessment Need (CAN) score over the 75th percentile, indicating high risk for hospitalization or death in the upcoming year

• ownership of a smart phone

Exclusion Criteria:

• none

A Limited Dataset (LDS) will be created and shared pursuant to a Data Use Agreement (DUA) appropriately limiting use of the dataset and prohibiting the recipient from identifying or re-identifying (or taking steps to identify or re-identify) any individual whose data are included in the dataset.

Analytic datasets will be made available in accordance with local and national VA policy and compliance regulations. Mechanisms for sharing datasets will be based on infrastructure and resources available through either the local VA facility or VHA nationally. Researchers interested in accessing datasets will be required to sign a Data Use Agreement.

Preservation and sharing of analytic datasets will allow other researchers to replicate published results and/or perform additional analyses. Researchers will be provided with a limited dataset as well as documentation regarding methods used for dataset creation and analytic procedures.

Final datasets will be stored on the local secure VA Research server for the period required by the VA Records Control Schedule. Analytic datasets will be made available in accordance with local and national VA policy and compliance regulations.

Mechanisms for sharing datasets will be based on infrastructure and resources available through either the local VA facility or VHA nationally. Researchers interested in accessing datasets will be required to sign a Data Use Agreement.

Outcomes assessors are not informed of the participant's participation in intervention or control