MINT began operation at Long Beach in January 2003 and at Sepulveda in April 2003. At 14 months, MINT is managing data for 165 intervention patients. It is being used by two nurse quality managers who conduct brief assessments and manage the study sites. It is used by 29 psychiatrists who are receiving the EQUIP intervention. MINT is also managing research enrollment for an additional comparison group of 19 psychiatrists and 127 patients that is continuing with usual care.
As shown in the , clinicians have entered 1,223 brief assessments and 1,100 messages into the database. The pop-up has been displayed to psychiatrists 2,201 times. Psychiatrists often view the pop-up more than once while treating a patient. The window appears when they first open the medical record at the start of the visit. They sometimes choose to recall the pop-up again during the visit. If they write a patient note at a later time in the day, it will appear again. Psychiatrists have disagreed with 49 of the nurses' brief assessments and have written 78 messages back to other clinicians. The median time that psychiatrists have spent viewing each pop-up has been 7 seconds. Twenty-five percent of viewings are less than 3 seconds and 75% are less than 17 seconds. As psychiatrists have become accustomed to the interface, the median viewing duration has decreased gradually from 11 seconds during the first month to 4 seconds during month 14. The number of messages sent by psychiatrists has increased gradually over this time.
Use of MINT Service during Months 1 through 14 of Care Model Implementation*
Clinician and psychiatrist use of the pop-up, messaging system, and reports has remained steady throughout implementation. During implementation, users have made numerous suggestions regarding improving the interfaces. Feedback has ranged from adjustments in visual aspects of the pop-up (e.g., increase font sizes) to addition of new features (e.g., add a “to do list” of urgent problems to be addressed). Changes have been made based on user feedback. An iterative process of quality enhancement appears to have promoted active participation and motivation of those using the system.
Nine months after implementation of MINT, a sample (53%) of intervention clinicians were interviewed by an independent researcher regarding human factors characteristics, use, usability, and usefulness of the informatics system. The interview included established informatics questionnaires47
plus qualitative items regarding MINT components and the impact of MINT on treatment.
With regard to the collaborative care model, the majority of psychiatrists found the informatics system intuitive and easy to use and believed that it provided relevant clinical information in a visually appealing format. Although some psychiatrists viewed the pop-up only quickly due to time constraints, virtually all stated that they learned important new information about their patients, especially related to the patients' social circumstances. Most stated that the assessment data reminded them to discuss side effects and medical problems with their patients. Some psychiatrists specifically stated that there was a better level of patient care due to the additional information. One psychiatrist pointed out that the assessments were especially helpful with patients whose clinical stability varies. Psychiatrists acknowledged that they rarely accessed the treatment guidelines, and a few stated that they should use the guidelines more. The messaging system was used mostly by nurse quality managers to communicate information to psychiatrists. Overall, psychiatrists stated that MINT provided them with specific information that they used to improve their treatment decision making.
Nurse quality managers report that MINT has made it possible to proactively monitor the care of a population of chronically ill patients. Assertive outreach has been made to patients who have missed appointments or who have had inadequate follow-up given the severity of their illness. There have been anecdotal reports from clinicians and nurses that communication has been enhanced among the clinicians regarding the care of individual patients, facilitating teamwork and provision of appropriate services.
MINT has also been very helpful to staff who manage the clinical and research components of the EQUIP project. With several clinicians and hundreds of patients enrolled in the project, staff have reported that MINT has been invaluable in ensuring that participants have research follow-up interviews on time and that problems with implementation of the intervention can be quickly identified and resolved.
With regard to improving care, MINT Web site reports indicated that there was a severe, pervasive problem with overweight at both clinics. At the Sepulveda and Long Beach clinics, 74% of people with schizophrenia were overweight (BMI >25) and 40% were obese (BMI >30). This is even worse than the general U.S. adult population, in which about 65% of people are overweight and 31% are obese.48
Acting on these MINT data, clinic managers identified resources for counseling regarding nutrition and exercise. Since this time, 73% of the patients who are overweight have received individual and/or group wellness counseling, often under a standardized protocol. Additionally, psychiatrists have been alerted to address weight problems in their medication treatment. Guideline-concordant approaches to this include changing to a medication with less weight gain liability, or adding medications that can reduce weight gain.
MINT Web site reports have also indicated that many patients have severe, persistent psychotic symptoms, despite trials of numerous medications. Clozapine is a medication that is substantially more effective for these patients, but its use requires regular blood monitoring. Specific organizational structures need to be in place to check these blood tests and dispense medication refills, yet these are lacking at many clinics. The implementation of MINT raised awareness of these barriers. A centralized clozapine clinic was created at Sepulveda and referral procedures for clozapine at Long Beach were improved. In total, 43 patients have been referred for clozapine and two have been switched to this medication.
Additionally, MINT Web site reports identified that many patients with ongoing clinical problems (severe psychotic symptoms, noncompliance, or family stress) have family contact at least once per week. The majority of these patients consented to the clinical team contacting their family. All patients who gave consent were offered a family intervention, resulting in 67 referrals. Twelve have received family or caregiver counseling, three families refused any intervention once contacted, and two families were provided with education and information regarding community resources.