Overview

A computerized provision of weight management with peer coaching for VA patients with serious mental illness

Organization Name

Greater Los Angeles Veterans’ Administration Medical Center Mental Health Clinic & Los Angeles County Department of Mental Health Edelman Center

Organization Type
  • Academic Hospital
  • Academic Medical Center
  • Community outpatient clinic
  • Public Health System
National/Policy Context

  • Up to 75% of individuals with schizophrenia are overweight or obese secondary to illness-related and therapy-related factors.
    • People with schizophrenia lose 25+ years of life expectancy, predominantly due to cardiovascular disease but also obesity, diabetes, hypertension, and dyslipidemia at rates 1.5-4x that of the general populations.
  • Use of evidence-based weight management services is garnering considerable attention in specialty mental health care.
    • However, enrollment and retention rates in such outpatient programs had been consistently lower than those studied in the previous literature, leaving room for quality improvement.
  • The national VA system is split into 21 VISNs (Veterans Integrated Service Networks), and 4 of these VISNs participated in the study of the WebMOVE intervention.
    • In each of these 4 VISNs, 2 mental health clinics and their leaders were nominated to participate.

Local/Organizational Context

  • The VA Greater Los Angeles Healthcare System (VAGLAHS), one of the largest health care facilities in the Department of Veterans Affairs, is one component of the VA Desert Pacific Healthcare Network (VISN22).
    • It provides services to Veterans residing in both Southern California and Southern Nevada. It consists of two ambulatory care centers, a tertiary care facility, and 8 community-based outpatient clinics.
    • VAGLAHS serves Veterans living in 5 counties, including Los Angeles, Ventura, Kern, Santa Barbara, and San Luis Obispo. 1.4 million Veterans live in this service area.
    • VAGLAHS is affiliated with UCLA School of Medicine, USC School of Medicine, and more than 45 colleges, universities and vocational schools in 17 different medical, nursing, paramedical and administrative programs.
  • This particular intervention implementation was led by the VA Desert Pacific Mental Illness Research Education and Clinical Center (MIRECC); VA Health Services Research and Development Center of Excellence for the Study of Healthcare Provider Behavior; Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles (UCLA); and VA VISN 4 Mental Illness Research Education and Clinical Center (MIRECC).

Patient Population Served and Payor Information

Adult patients served by the Veterans’ Administration with schizophrenia, schizoaffective disorder, major depression with psychosis, or persistent PTSD.

Funding

Funding was provided internally from within the Department of Veterans Affairs Health Services Research and Development Service and Desert Pacific MIRECC, the National Institute of Mental Health.

Research + Planning

    • The team tested the efficacy of WebMOVE (computerized) vs. MOVE SMI (in-person weight management programs) vs. usual care and hypothesized that WebMOVE would result in lower patient weight.
    • Recruitment:
      • Created a list of patients who met inclusion criteria for psychiatric diagnosis, age, and psychotropic medication in the practice.
        1. Inclusion criteria:
          • Diagnosis of schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorder with psychosis, or posttraumatic stress disorder
          • 18 years or older
          • Prescribed an antipsychotic medication
          • BMI above 30 (obese) or a BMI of 28–30 (overweight) with self-reported weight gain of at least 10 pounds in the last 3 months
          • Received medical clearance to participate from a physician if they received a score ≥ 1 on the Physical Activity Readiness Questionnaire (PAR-Q)
        2. Exclusion criteria included a history of bariatric surgery; pregnant or nursing mothers; dementia; current participation in weight loss groups; psychiatric hospitalization during the prior month; or very limited control over food preparation. Limited control was defined as more than 50%of an individual’s lunches or dinners being eaten at a place where they had no choice in what or how much was served.
      • Study flyers were also posted in mental health clinics.
      • A total of 1429 individuals were screened for eligibility, and 19% were eligible, interested, enrolled, and randomized
        1. Written informed consent was obtained.
      • The study was approved by the VA Institutional Review Board.

Tools or Products Developed

    • WebMOVE: weight management program developed for this study.
      • It includes:
        1. 30 interactive educational modules (30 minutes each) via internet browser
          • Based on the in-person MOVE SMI program developed by Goldberg and colleagues
          • Tailored for cognitive deficits seen in the population, including simple presentation of ideas, minimal text at fifth grade reading level, and clear navigational aids.
          • Modules include audio and video education, pedometer tracking, goal setting, homework, diet plans, and quizzes.
        2. Weekly telephonic peer coaching with strengths-based approach to motivational interviewing.
      • Participants were given a pedometer and instructed how to use the educational models. They were encouraged to complete two modules per week.
      • A peer wellness coach (i.e., individuals with lived experience with mental illness) was assigned to each WebMOVE participant. Coaches receive didactic training in the coaching manual, experiential training in coaching, and weekly individual interaction with a psychologist.
    • MOVE SMI: in-person weight management program led by a master’s level mental health clinician
      • The program includes 24 60-minute sessions (8 individual and 16 group). It also includes handouts, motivational techniques, visual learning aids, behavioral rehearsal, repetition, goal setting, homework, and diet plans. Group leaders received weekly group supervision from a psychologist.
      • Usual care consisted of one educational handout on the benefits of weight loss, given to participants after randomization. Participants were allowed to take advantage of standard services available at the medical center, which included MOVE weight management (not tailored for people with SMI).

Training

    • Five peer coaches, two females and three males, who were paid VA employees and veterans, delivered the manualized intervention over the course of the study period.
      • The coaches varied in their previous experiences with providing peer support and in their education backgrounds.
      • The coaches received five months of training by master’s- and doctoral-level study staff.
      • Each peer coach was provided with a detailed manual with specific instructions for each coaching call.
      • Training included both didactic instruction from the manual and experiential training in coaching.
      • The peer started experiential training by joining a master therapist for live coaching sessions and eventually led these sessions.
      • When the master therapist considered the peer ready to coach independently, the peer began to deliver the curriculum to others.
    • All peer coaches received weekly clinical supervision from the study’s co-principal investigator, a psychologist.

Tech Involved
  • Desktop computer
  • EMR-based registry
  • SMS
  • Telephone
Team Members Involved
  • Community Health Worker
  • Health Coach
  • Physicians
  • Psychologist
Workflow Steps

  • WebMOVE is a computerized version of the manualized MOVE SMI intervention with the same curriculum, delivered via 30 online interactive modules (15 on diet and 15 on physical activity). Modules include text and audio- or video-based information, tracking of activity and weight, and individualized goal setting.
    • Participants had access to the online system and the peer coaching support for six months.
    • Each WebMOVE participant received a pedometer.
    • Peer coaches with lived experience of serious mental illness conducted 25- to 30-minute coaching calls each week with each participant, providing individualized follow-up, positive reinforcement, motivational enhancement, specific physical activity suggestions, and problem-solving barriers—such as time constraints and mental health symptoms.

Budget
  • $100K to $500K
Budget Details

  • Labor Costs:
    • Psychologist Salary
    • Peer Coaches Salaries (Avg ~$38,000/year)
      • Employed part-time for 0.5 FTE / or full-time for 1.0 FTE
  • Technology & Development Costs:
    • WebMOVE development, evaluation, and program research costs were most likely in ~$250,000 range over the course of a few years.
  • Equipment Costs for ~300 initial pilot patients: $9000
    • Pedometer with accelerometer (Amazon: ~$10/each)
    • Bluetooth scale (Amazon: ~$20/each)

Where We Are

  • Pilot enrollment began in March 2012, and 6-month follow-up data collection ended in July 2014; 276 participants were randomized.
    • In theWebMOVE group, 22 participants did not attempt any online modules, and in the MOVE SMI group, 17 did not attend any sessions. This left 237 participants who received an intervention as randomized and who formed the analytic sample for primary analysis of intervention effectiveness.
  • The intervention is ongoing, builds on the EQUIP project (see references) and may be incorporated into other VA sites and the VA Virtual Medical Center (https://vavmc.com/) at a future date.

Outcomes

Patient Outcomes:

  • Weight Loss: 
    • At 6 months, in obese patients (n=200), there was a significant condition by visit effect (F = 4.02, p = 0.02). TheWebMOVE group had an average estimated BMI change from baseline to 6 months of 34.9 ± 0.4 to 34.1 ± 0.4. This corresponds to 2.8 kg (6.2 lbs) weight loss (t = 3.2, p = 0.001). No significant change in BMI was seen with either in-person services (t=0.10, p = 0.92), or usual care (t = −0.25, p = 0.80).
  • Patient Engagement:
    • The average percentage of modules completed in the WebMOVE group was 49% and in the in-person group was 41% (t=1.4, p = 0.17). When non-obese patients were included in the analyses, there was a trend towards a condition by visit effect (F=2.8, p = 0.06). WebMOVE was well received, while the acceptability of in-person services was mixed.
    • MOVE SMI led to increases in physical activity across types (walking and moderate and vigorous activity), whereas WebMOVE led to increases primarily in walking behavior.

Process Outcomes

  • Retention in Treatment:
    • In terms of retention in treatment, the average number of modules completed in WebMOVE was 14.7 (SD = 12.2), which is 49% of 30 modules, and the average number of sessions completed in MOVE SMI was 9.7 (SD = 6.2), which is 41% of the 24 sessions (t = 1.36 p = 0.17).
    • There was a significant difference in the number of participants who completed 100% of the intervention sessions/modules: in Web-MOVE, 18 participants (31%) completed the intervention, while in MOVE SMI, no participants (0%) completed the intervention (χ2 = 24.2; p < 0.0001).
    • WebMOVE participants received, on average, 7.9 (SD = 6.8) peer coaching calls.
    • Patients who were obese completed more modules than patients who were less than obese, in both the WebMOVE (14.7 ± 12.2 vs. 9.8 ± 11.3, p = 0.004) and MOVE SMI groups (9.7 ± 6.2 vs. 5.5 ± 6.2, p = 0.18).

Clinician or Patient Satisfaction

  • Patient Perspectives: Speaking about modules, participants stated, “They kept me mindful” and “I liked what I was learning, I got a lot out of it.”
  • Another main theme was positive reaction to the peer coaches.
  • One participant said, “Without one-on-one coaching, the web program would not have been as good.”
  • Another said, “[The coach] would explain things differently to me…that was the most helpful.”
  • Less prevalent themes were difficulty in accessing a computer and the desire for a walking group.

Benefits

  • Thanks to WebMOVE, patients were more likely to use weight services and used them >5 weeks sooner and continued to use services for 3x as many visits compared with usual care.
  • Clinicians could use WebMOVE data to identify, refer, and encourage patients to use services.
  • Patients could utilize WebMOVE data to inform their visits with clinicians.
  • Clinical champions, administrators and researchers could also use WebMOVE data to benchmark progress against other sites.

Unique Challenges

  • Implementation would be strengthened by integration of WebMOVE into EHRs.
  • WebMOVE participants, although satisfied with the convenience offered by the Web-based program, suggested that the program be supplemented with in-person exercise groups. These findings indicate that face-to-face or group interventions may be particularly important for the promotion of moderate and vigorous exercise among adults with serious mental illness.
  • Thus WebMOVE,which was previously shown to be feasible and effective for weight loss, could be supplemented with an in-person exercise component.

Glossary

  • EQUIP PROJECT: Cohen AN, Chinman MJ, Hamilton AB, Whelan F, Young AS. Using patient-facing kiosks to support quality improvement at mental health clinics. Med Care. 2013 Mar;51(3 Suppl 1):S13-20. doi: 10.1097/MLR.0b013e31827da859. PubMed PMID:23407006; PubMed Central PMCID: PMC3654521. (https://www.ncbi.nlm.nih.gov/pubmed/?term=Using+Patient-facing+Kiosks+to+Support+Quality+Improvement+at+Mental+Health+Clinics)
  • Young AS, Cohen AN, Hamilton AB, Hellemann G, Reist C, Whelan F: Implementing patient-reported outcomes to improve the quality of care for weight of patients with schizophrenia. Journal of Behavioral Health Services & Research. 2018; online ahead of print. PMID: 30465314. https://doi.org/10.1007/s11414-018-9641-8
  • Young AS, Cohen AN, Miotto KA: Improving the Quality of Care for Serious Mental Illness. In: O’Donohue W, Maragakis A, eds. Quality Improvement in Behavioral Health. Switzerland: Springer International; 2016: 275-288; ISBN 978-3-319-26207-9.
  • Young AS, Cohen AN, Goldberg R, Hellemann G, Kreyenbuhl J, Niv N, Nowlin-Finch N, Oberman R, Whelan F. Improving Weight in People with Serious Mental Illness: The Effectiveness of Computerized Services with Peer Coaches. J Gen Intern Med. 2017 Apr;32(Suppl 1):48-55. doi: 10.1007/s11606-016-3963-0. PubMed PMID: 28271427; PubMed Central PMCID: PMC5359157.

More work by Dr. Alexander Young can be found at his CV (Link: https://www.uclahealth.org/workfiles/Providers/Alexander-Young-CV.pdf)

Sources

Innovators
  • Alexander Young, MD
Editors
  • Ashley Shaw, MD MBA
Location

Los Angeles, CA

Talk to the Innovators