Care Coordination and Passive Mobile Data Monitoring to Engage Veterans and Improve Mental Health Care
VA Office of Research and Development
Summary
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.
Description
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…
Eligibility
- Age range
- 18+ years
- Sex
- All
- Healthy volunteers
- No
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
Interventions
- BehavioralCare Coordination Mobile
Mobile monitoring, peer coaching, and enhanced care coordination
Locations (2)
- VA Greater Los Angeles Healthcare System, West Los Angeles, CAWest Los Angeles, California
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PAPhiladelphia, Pennsylvania