1. Competency of Psychiatry Residents in the Treatment of Severe Mental Illness Before and After a Psychiatric Rehabilitation Community Rotation Melinda Randall MD, Mauricio Romero-Gonzalez MD, Gerardo Gonzalez-Haddad MD, Anne Klee PhD, Paul Kirwin MD Department of Psychiatry, Yale University Results Table 2: Differential Improvement in CAI competencies by group Cases Controls N=8 N=15 F p-value Goal setting.33.04 5.0.04 Client preferences.13.01 4.8.04 Intensive Case M..19.00 3.4.08 Holistic Approach.20.03 4.1.05 Skills.18 -.06 9.8.005 Team Value.10 -.00 7.7.01 Conclusions During the PG-2 year, residents’ competence in Goal Functioning, Holistic Approach, and Family Education significantly improve. PGY-2 residents’ competence in Family Involvement significantly declined. A 3 month rotation in psychiatric rehabilitation significantly improved PGY-2 residents’ competence in Goal Functioning, Client Preferences, Holistic Approach, Skills, and Team Value. Limitations include response rate, selection bias, survey scoring issues, small n, comparability of cases and controls due to difference in time from pre to post. Educational Intervention Each resident acts as a CRP coordinator, within a multidisciplinary team, with responsibility for the holistic care of 4-10 veterans. This holistic approach includes pharmacotherapy, psychotherapy, and case management, including home and workplace visits. The resident also facilitates two groups: cognitive therapy and psychoeducation. The resident also participates in formal didactics in psychiatric rehabilitation and is exposed to other evidence-based services in the ECCC: the ACT team, supported housing, supported employment, and the homeless team. Methods The cases are Yale PGY-2 psychiatry residents attending a three month rotation at the Community Reintegration Program (CRP), a psychiatric rehabilitation day program at the Errera Community Care Center (ECCC) at VA Connecticut. We administered the Competency Assessment Instrument (CAI) at the beginning and the end of their three month rotation. The CAI is a self-report survey which measures 15 provider competencies critical to recovery, rehabilitation, and empowerment in people with SMI, providing a score (0-1) for each competency where 0=no competency and 1=competent (Chinman et al, 2003). We compared the CAI scores of the CRP group to those second year psychiatry residents who never rotated through CRP, and therefore had no formal training in psychiatric rehabilitation during the second year. This control group completed the CAI survey at the beginning and the end of the year. Background  Psychiatric Rehabilitation is the field of evidence- based interventions with the goal of recovery for people with severe mental illness (SMI).  Recovery from SMI refers to the pursuit of a meaningful life despite the persistence of symptoms of SMI.  Psychiatric Rehabilitation services include Assertive Community Treatment, Supportive Employment, Supportive Housing, and Illness Management and Recovery based on CBT, Relapse prevention, and Motivational techniques.  There have been no controlled or prospective studies of psychiatry residents’ attitudes, skills, or knowledge about SMI or psychiatric rehabilitation.  Minkoff and Stern noted the following “paradox” residents may face when treating people with SMI: doctors treat illness but symptoms of SMI often persist despite treatment. They raise the concern that focusing on adaptation and rehabilitation, therefore, leads residents to feel “helpless, hopeless, and ineffective” (Minkoff, Stern, 1985).  They recommended providing psychiatry residents with experience and supervision to help them value rehabilitation and a holistic approach, and to evaluate their own feelings about working with people with SMI.  Psychiatry residents are interested in community psychiatry, but their career paths are focused on urban, hospital-based practice despite economic pressures to treat people with SMI in the community (Freeland et al, 2000).  We assessed whether a PGY-2 three month, elective rotation in a psychiatric rehabilitation center changes their competency levels in recovery, psychiatric rehabilitation, and evidence-based treatment of SMI. Response Rate Baseline 91% Completers 56% Cases who completed 73% Controls who completed 47% Table 1: PGY-2 Psychiatry Resident baseline characteristics All N=43 Cases N=11 Controls N=32 p value Age (yrs)32 34 31 n.s. Female (%)61 46 67 n.s. Caucasian (%)54 82 46 n.s. Chose to rotate at intervention site (%)21 64 6.00 Plan a career working with SMI (%)55 55 55 n.s. Competencies: mean mean mean (SD) (SD) (SD) p value Goal Functioning0.48 0.52 0.47 n.s. (.20) (.22) (.19) Stress0.57 0.53 0.58 n.s. (.24) (.22) (.19) Client Preferences0.66 0.66 0.65 n.s. (.10) (.10) (.10) Intensive Case Management (ICM)0.24 0.27 0.23 n.s. (.18) (.18) (.19) Holistic Approach0.51 0.52 0.50 n.s. (.16) (.20) (.15) Family Education0.42 0.46 0.41 n.s. (.15) (.14) (.15) Rehabilitation0.02 0.02 0.02 n.s. (.01) (.01) (.01) Skills0.39 0.43 0.37 n.s. (.16) (.13) (.17) Integration/natural supports0.38 0.44 0.36 n.s. (.20) (.17) (.21) Stigma0.80 0.80 0.80 n.s. (.12) (.06) (.13) Community Resources0.58 0.50 0.60 n.s. (.19) (.20) (.18) Medication Management0.51 0.56 0.50 n.s. (.17) (.19) (.16) Family Involvement0.59 0.55 0.60 n.s. (.18) (.14) (.19) Team Value0.66 0.68 0.66 n.s. (.10) (.07) (.11) Evidence-based practice0.65 0.62 0.66 n.s. (.18) (.19) (.18) Optimism0.40 0.42 0.39 n.s. (.11) (.12) (.11) CAI Competencies Goal Functioning Assist clients to get and achieve goals Stress Assist clients in coping with stressors Client Preferences Learn and respect clients’ preferences Intensive Case Management Leave the office to help clients obtain services Holistic Approach Elicit life experiences in trusting atmosphere Family Education Educate family members about mental illness Rehabilitation Practice psychiatric rehabilitation Skills Create opportunities for clients to practice skills Integration/natural supports Encourage clients to use their own natural supports Stigma Work with clients to cope with stigma Community Resources Refer clients to local resources to support recovery Medication Management Teach symptom and side effect self-monitoring Family Involvement Involve family and help them cope Team Value Provide services as part of a coordinated team Evidence-based practice Focus on services that are evidence-based Optimism Believe clients will have positive outcomes * * * * * p<.05 Abstract Objective: Psychiatric Rehabilitation is a field of evidence-based services with the goal of recovery for people with severe mental illness (SMI). Therefore, psychiatry residents should understand the services and be familiar with the principles of psychiatric rehabilitation. We assessed whether a three month rotation in a psychiatric rehabilitation center changes the competency level of second year psychiatry residents in recovery, psychiatric rehabilitation, and evidence-based treatment of SMI. Research Design: The study is a prospective, Case-Control comparison using a validated, self-report Survey Instrument. Methodology: The cases are second year Yale psychiatry residents attending a three month rotation at the Community Reintegration Program (CRP), a psychiatric rehabilitation day program at the Errera Community Care Center (ECCC) at VA Connecticut in West Haven. We administered the Competency Assessment Instrument (CAI) at the beginning and the end of their three month rotation in order to assess change in their competency in psychiatric rehabilitation. The CAI measures 15 provider competencies critical to recovery, rehabilitation, and empowerment in people with SMI, providing a score for each competency. We compared the CAI scores of the CRP group to those second year psychiatry residents who never rotate through CRP, and therefore have no formal training in psychiatric rehabilitation. Results: A three month rotation in psychiatric rehabilitation significantly improved PGY-2 residents’ competency in Goal Functioning, Client Preferences, Holistic Approach, Skills, and Team Value. Conclusion: A brief community psychiatry rotation in the 2nd year of residency improves some skills in treating people with severe mental illness.