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VA Primary Care-VA Primary Care-

Mental Health Mental Health Integration (PC-MHI)Integration (PC-MHI)

Edward Post, MD, PhDNational PC-MHI Medical Director

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Primary Care-Mental Health IntegrationPrimary Care-Mental Health Integration

“Primary care practitioners are a critical link in identifying and addressing mental disorders... Opportunities are missed to improve mental health and general medical outcomes when mental illness is under-recognized and under-treated in primary care settings.”

- Former Surgeon General David Satcher

“The greatest mistake in the treatment of diseases is that there are physicians for the body and physicians for the soul, although the two cannot be separated.”

- Plato

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Primary Care LandscapePrimary Care Landscape

Chronic diseaseMultiple comorbiditiesNeed for interdependent skills across medical

disciplines and teams

Patient outcomes are interdependent ◦Multiple studies show depression has an independent effect

on all-cause mortality (Gallo et al., 2005; Penninx et al., 1999; Bruce and Leaf, 1989)

◦Data from late-life depression trial shows integrated care can decrease mortality (Gallo et al., 2007)

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Why Integrate Mental Health Services Why Integrate Mental Health Services into Primary Care?into Primary Care?

Integrated mental health care...Improves identification of prevalent mental

health conditionsImproves access to appropriate evaluation and

treatmentImproves treatment engagement and adherenceIncreases probability of receiving high quality

careImproves clinical and functional outcomesIncreases patient satisfaction

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PC-MHI Evidence BasePC-MHI Evidence Base

Improved identificationo Improved identification of depression, psychiatric co-morbidities and substance misuse (Oslin et al., 2006)o Improved identification of depression (Watts et al., 2007)

Improved access o Increased rates of treatment (Alexopoulos et al., 2009; Watts et al.,

2007; Bartels et al., 2004; Hedrick et al., 2003; Liu et al. 2003; Unützer et al., 2002)

oReduced wait times (Pomerantz et al., 2008)

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PC-MHI Evidence BasePC-MHI Evidence Base

Improved engagement and adherenceo Improved engagement in mental health treatment (Zanjani et al., 2008)o Improved engagement and adherence in treatment for depression

and at-risk alcohol use (Bartels et al., 2004)o Greater antidepressant adherence (Hunkeler et al., 2006; Katon et al., 1999,

2002)o Improved no-show rates (Pomerantz et al., 2008; Zanjani et al., 2008; Guck et

al., 2007)

Higher quality careo Increased probability of receiving guideline-concordant treatment

(Watts et al., 2007; Roy-Byrne et al., 2001)oHigher patient perceptions of quality of care (Katon et al., 1999)

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PC-MHI Evidence BasePC-MHI Evidence Base

Better clinical and functional outcomeso Improved short and long term clinical (remission; symptom

reduction) and functional outcomes compared to standard care for depression (Alexopoulos et al., 2009; Gilbody et al., 2006; Hunkeler et al., 2006; Katon et al., 2002; Unützer et al., 2002; Roy-Byrne et al., 2001; Katon et al., 1999)

o Similar remission rates and symptom reduction for depression compared to enhanced specialty referral (Krahn et al., 2006)

o Decrease in at-risk alcohol use comparable to enhanced specialty referral (Oslin et al., 2006)

o More rapid clinical response (Alexopoulos et al., 2009; Hedrick et al., 2003)

o Higher fidelity to integrated care model resulted in better patient response and remission rates (Oxman et al., 2006)

Increased patient satisfaction (Pomerantz et al., 2008; Hunkeler et al., 2006; Chen et al., 2006; Areán et

al., 2002; Unützer et al., 2002)

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Complementary Settings: Complementary Settings: VA Vision for Mental Health ServicesVA Vision for Mental Health Services

Primary Care-Mental Health IntegrationPrimary Care-Mental Health Integration

Two PC-MHI Components:◦Co-located Collaborative Care

White River Junction◦Care Management

TIDES, Behavioral Health Laboratory

Blended programs have both of these complementary components

Focus on common conditions:◦Depressive and Anxiety Disorders◦Alcohol Misuse and Abuse◦PTSD Screening/Assessment

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Necessary Integrated Care ProcessesNecessary Integrated Care Processes

Identification ◦Screening in primary care

Assessment and triage to appropriate level of service

A spectrum of services◦Monitoring or watchful waiting◦Brief interventions (e.g., for alcohol misuse)◦Medication therapies◦Psychotherapies

Follow-up and monitoring

Quality control and efficiency

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Introduction to Co-located Introduction to Co-located Collaborative Care (CCC)Collaborative Care (CCC)What is Co-located Collaborative Care in PC-MHI?

Co-location/Co-located Service A behavioral health provider working in a space that is in close proximity to (or embedded in) a primary care clinic.

Collaborative Care/Collaboration The interactions between primary care and behavioral health providers for the purpose of developing treatment plans, providing clinical services and coordinating care to meet the physical and behavioral health needs of patients

CCC vs. Traditional MHCCC vs. Traditional MHCo-Located Collaborative MH Care

Mental Health Specialty Care

Location • On-site • A different floor orbuilding

Population • Most are healthy • Most have MH diagnoses

Inter-Provider Communication

• Collaborative & ongoing consultations via PCP’s method of choice

• Consult reports• EMR notes

Service Delivery Structure

• Brief appointments• Limited number of appointments

• 50 - 90 minute psychotherapy sessions• 14 week minimum

Approach • Problem-focused• Solution-oriented• Patient-centered

• Varies by therapy• Diagnosis-focused

Treatment Lead • PCP continues to be lead • MHP is lead

Principal Focus • Support the overall health of the Veteran• Focus on function

• Cure or ameliorate mental health symptoms

Care Management Models in PC-MHICare Management Models in PC-MHI

Translating Initiatives for Depression into Effective Solutions (TIDES)• Evidence-based collaborative care model supporting

depression management in the primary care setting• Has promoted improvements in treatment adherence

for Veterans with depression in several VISNs

Behavioral Health Laboratory (BHL)• Evidence-based clinical service supporting mental

health and substance abuse management in the primary care setting

• Associated with a significant increase in screening and identification of patients needing MH/SA services (Oslin, et. al. 2005)

Care Managers Role of the Care ManagerNurses and social

workers are core profession, but others serve as care managers also

Interact directly with patients and PCPs, facilitating ongoing evaluation and communication allowing care to remain in primary care

Assessment and triageDecision supportPatient education and

activationMonitor adherence to

treatment, treatment outcomes, and medication side effects

Referral managementSupport patient self-

management

Introduction to Blending PC-MHI Introduction to Blending PC-MHI ProgramsPrograms

What is a Blended PC-MHI Program?

Blended programs combine both care management and co-located collaborative care

In the blended program, the co-located collaborative mental health provider evaluates patients and offers treatment when needed, while the PC-MHI care manager provides complementary services including education, assessment, monitoring of adherence, use of medication and referral to specialty care when necessary

Core Components of an Effective Core Components of an Effective Blended MH Integration ProgramBlended MH Integration Program

Strong collaborative system between primary care, mental health and other health care specialists

Stepped care approached to providing a continuum of care within the PC-MHI program

Ability to rapidly evaluate and stabilize patient in primary care clinic

Ability to do seamless referral, if needed Ability to implement evidence-based treatment plansAbility to collect objective clinical and administrative

outcome data

History of VA PC-MHI ImplementationHistory of VA PC-MHI Implementation

Large-scale implementation began in 2007 with RFP funding for pilot programs of a single component at 94 of 139 VA health systems

Late 2008: Uniform MH Services Package extended focus

VHA Handbook 1160.01 requires that VAMCs, extra large CBOCs, and large CBOCs integrate primary care and mental health by blending both co-located collaborative care and care management

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Uniform Mental Health Services PackageUniform Mental Health Services Package

VAMCs & extra large CBOCs (>10K uniques) need full-time availability of both co-located services & care management

Large CBOCs (5K-10K uniques) need co-located services & care management, availability as appropriate

Medium-sized CBOCs (1.5K-5K uniques) need on-site MH services, configured (integrated vs. MH clinic) as appropriate

Small CBOCs need to provide access to MH services

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Service Utilization DataService Utilization Data reported from facility stop code usage

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VHA Dashboard VISN Dashboard Facility Dashboard Division Dashboard

PC-MHI: State of the FieldThe PC-MHI Penetration Rate is the number of unique PC-MHI encounters divided by the number of unique Primary Care encounters→Please note that there is not a PC-MHI penetration rate performance measure or target

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National PC-MHI Program OfficeNational PC-MHI Program Office

Principal Contact:Maureen Metzger, PhD, MPHNational Program ManagerMaureen.Metzger@va.gov734-845-5719

Thank you to many faculty who collaborate in presenting our training programs, and to innumerable persons who are implementing PC-MHI throughout VA!

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Questions? Questions?