How Innovators Manage Real World Push-Back: Lessons from VA Integrated Care Implementers

How Innovators Manage Real World Push-Back: Lessons from VA Integrated Care Implementers Andrew Pomerantz, MDNational Mental HealthDirector, Integrated Services Veterans Health AdministrationAssociate Professor of Psychiatry, Geisel School of Medicine at Dartmouth

Laura O. Wray, PhDDirector, Education/Clinical Core, VA Center for Integrated HealthcareAssistant Professor of Clinical Mediicine, University at Buffalo

VETERANS HEALTH ADMINISTRATION

Patient Aligned Care Team

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VETERANS HEALTH ADMINISTRATION

Principles of Integrated Care in VA• Open or advanced access (temporal and spatial

integration) in VA medical homes [PACT]• Problem-focused assessment and treatment: tend to

what the Veteran wants tended to• On-site clinicians in primary care: Consultation,

collaboration, assessment• Stepped care• Measurement-based care• Care management• Referral management when needed

VETERANS HEALTH ADMINISTRATION

Primary Care-Mental Health Integration[PC-MHI] in VA

• Two components:• Care management• Co-located collaborative care

• Blended programs link these complementary components as appropriate

• Focus primarily on common mental health conditions:• Depressive and anxiety disorders• Alcohol misuse and abuse• PTSD screening/assessment

• Health Behavior Coordinators implement health psychology programs along with Health Promotion/Disease Prevention Program Managers

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VETERANS HEALTH ADMINISTRATION

Center for Integrated Healthcare Training Events

• Six National Training Events 2009 through 2010• Facilitated break-out sessions on implementation challenges• Each participant gave 1 challenge and 1 success (may be have

been multiple participants from same site)• Participants shared ideas to overcome challenges described as

time allowed• Unidentified lists of challenges/successes were reviewed and

grouped into themes• 9 Challenge Themes and 5 Success Themes

VETERANS HEALTH ADMINISTRATION

Challenges• Staffing

– Insufficient to meet demand– No additional staffing to expand– Missing key role

• Therapist• Prescriber• Nurse/Care Manager

– Lack of administrative or clerical support• No ability to pull program data• No help with scheduling

Integrating Mental Health into Primary Care:

What are your challenges?

VETERANS HEALTH ADMINISTRATION

Challenges

• “Overselling” or Fear of “Overselling”– Advertise as generalist– Open door– Slammed with referrals once PCPs understand what’s

available

VETERANS HEALTH ADMINISTRATION

Challenges

• Mental Health Specialty Programs– Frequently mentioned– Access to care, waiting times– Managers and staff don’t understand the role of PCMHI

program• Attitudes towards integrated care• Require coverage of walk-ins, ER, urgent care for

patients already in SMH• Require full MH intake assessments• Open access grids seen as not busy enough

VETERANS HEALTH ADMINISTRATION

Challenges

• Training– Not available prior to starting program– Poor understanding of different role in PCMHI

• Mini-Mental Health Clinics– Tried to function in traditional model once in PC– Quickly filled scheduling grid

• No open access• Long waiting lists• Provider burn-out

VETERANS HEALTH ADMINISTRATION

Challenges

• Leadership Support*– Middle management– MH management/leadership– Medical Center leadership

• Systems Challenges– Accessing resources– Ensuring good continuity of care– Disjointed systems– Poor communication

*Also listed under Successes

VETERANS HEALTH ADMINISTRATION

Challenges

• Role Definition– Unclear role of PCP

• “PCP wants to dump patients”• PSP does not want to prescribe• PCP does not refer or use warm hand-off

– Unclear role of PCMHI• Maintaining traditional MH roles• Unclear about which patients should be referred to SMH• SMH expectations of PCMHI staff

• Care Management– Implementation varies within a health care system– Need for protocols for problems other than depression

VETERANS HEALTH ADMINISTRATION

Successes

• Leadership Support*– Motivated managers*– Chief Medical Officer– Chief of Ambulatory Medicine– Chief of Mental Health*– Primary Care Chief

*Also listed under Challenges

VETERANS HEALTH ADMINISTRATION

Successes

• Primary Care Providers– Good relationships– Program developed with their input– “Hanging out with them”– PCPs happy to have program– PCPs excited, supportive

VETERANS HEALTH ADMINISTRATION

Successes

• Teamwork/Collaboration:– Within the PC team– Good communication– Good working relationships

• Personal Connections– Positive interpersonal working relationships with

at least some teammates and/or across teams

VETERANS HEALTH ADMINISTRATION

Successes

• Process Markers of Success:– Warm hand-offs, no consults– PCPs are referring– PCMHI is available and helpful– Flexible gateway to MH– Defined our roles (PCMHI)– Linkage to Psychiatry via CM, teamwork helped solve

staffing issues– Good access

Integrating Mental Health into Primary Care:

What are your successes?