Integration of Mental health

Services into Primary Care:

Experiences of a national

healthcare system

Mary Schohn, PhD

Objectives

Understanding of what VA has done to integrate mental health

services into primary care on a large scale

Identification of factors that need to be considered in

promoting local implementation

The Department of Veterans Affairs, the largest unified

healthcare system in the United States, has undertaken a

major transformation that embraces primary care-mental

health integration within the context of the patient-centered

medical home.

Background

Mental Health is an Integral Part of

Overall Health

• Physical problems can be risk factors for mental

health problems

• Mental health problems can be risk factors for

physical health problems

• Patient Centeredness means a holistic view of

the Veteran, recognizing the interrelationships of

all health problems and how they individually and

interactively affect quality of life

5

VETERANS HEALTH ADMINISTRATION

Prevalence of Chronic Conditions in VHA Primary Care

6

Source: Primary Care Almanac, VHA Support Service Center, 2011

VETERANS HEALTH ADMINISTRATION

Underlying Causes of Diseases

7

Other causes52%

Tobacco18%

Poor diet and physical inactivity

17%

Other preventable

10%

Alcohol consumption

3%

Mokdad et al. JAMA 2004

48%

potentially

preventable

VETERANS HEALTH ADMINISTRATION

Health Impact of Unhealthy Behaviors

The World Health Organization estimates that...

– at least 80% of all heart disease, stroke, and type 2 diabetes, and

– more than 40% of cancer

would be prevented if people were to

Stop smoking

Start eating healthy

Get into shape

8

WHO. Preventing Chronic Disease: A Vital Investment, 2005

MODELS OF MH IN PC AT DAWN OF

21ST CENTURY

• Referral

• Consultation/Liaison

• Co-location

• Collaborative Care

• Integrated Care

CORE STUDIES IN

INTEGRATED/COLLABORATIVE CARE

• PROSPECT

• IMPACT

• PRISM-E

• RESPECT

Demonstrate improved outcomes with care management.

DEVELOPMENT OF PC-MHI IN VA

• MANY INDIVIDUAL PROGRAMS IN MANY

SITES OVER MANY YEARS

• SOME VERTICAL INTEGRATION

• SOME HORIZONTAL INTEGRATION

VA MODELS

• TIDES– utilizes Care Management to support PCP treatment of depression

• Behavioral Health Laboratory (BHL) – Structured telephone interview for triage and support of PC treatment of Depression, anxiety, at-risk drinking, etc

• Co-located collaborative care – the White River Junction Model

• “Blended models”

• Health Psychology

CCC and Care Management

Co-Located Collaborative MH Care Care Management

Location On site, embedded in the PC clinic On site, or telephone based

Population* Most are healthy, mild-mod symptoms, behaviorally

influenced problems.

High volume mental health conditions, anxiety, depression, alcohol abuse

Inter-Provider Communication

Collaborative & on-going consultations via PCP’s

method of choice (phone, note, conversation). Focus

within PACT.

Collaborative, consultations as need with psychiatrist

Service Delivery Structure*

Brief appointments (20-30’) Limited # of appointments (avg. 2-3) Open Access

Brief check-ins, standard number of sessions

Approach Problem-focused, solution oriented, functional

assessment. Focused on PCP question/concern and

enhancing PCP care plan. Population health model.

Medication adherence; Problem solving

Treatment Plan Leader PCP continues to be lead PCP

Primary Focus Support the over-all health of the Veteran. Focus on function.

Chronic care conditions

Uniform Mental Health Services

in VA Medical Centers and Clinics

• Published in 2008

• Required that all VA medical centers and

very large community outpatient clinics

(10,000 or more patients) must have

integrated mental health services that

operate within primary care full time.

• Required use of the “blended model” which

includes co-located collaborative care and

care management

Emerging View

• Like other medical disciplines, Mental Health can be divided into PRIMARY, SECONDARY and TERTIARY care.

• Primary MH care can be delivered in the same setting as general Primary Care by expert clinicians – horizontal and vertical integration.

• Secondary/tertiary MH care are specialized and require multiple disciplines.

• Integrated Care for physical and mental health in one

setting

• Evaluation and treatment for mild to moderate mental

health conditions (depression, substance misuse, anxiety,

PTSD)

• Follow-up evaluation for positive MH screens

• Behavioral health interventions for chronic disease

• Care management

• Referral management

• Screening for mental health conditions

• Initiation of pharmacological treatment

for mild to moderate mood symptoms

• Co-management of Veteran care with

PC-MHI and specialty MH providers

• Health Behavior

Secondary and Tertiary Care:

• Outpatient Care for treatment resistant, severe or complex illnesses

• PTSD specialty treatment; Substance dependence treatment

• Treatment of serious mental illness (including MHICM)

• Full spectrum of psychosocial rehabilitation and recovery

services

• Inpatient psychiatric care

• Residential treatment

• Supported and therapeutic employment

• Homeless programs

PRIMARY CARE

SPECIALTY MH

PC-MHI

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Revolution in Primary Care

Veteran Centered Care

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Definition: A fully engaged partnership of

veteran, family and health care team,

established through continuous healing

relationships and provided in optimal healing

environments, in order to improve health

outcomes and the veteran’s experience of care

Universal Services Task Force, 2009

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Joint Principles of the

Patient-Centered Medical Home AAFP, AAP, ACP, AOA

• Ongoing relationship with personal physician

• Physician directed medical practice

• Whole person orientation

• Enhanced access to care

• Coordinated care across the health system

• Quality and safety

• Payment

19

VETERANS HEALTH ADMINISTRATION

Assumes knowledge drives change

Clinician sets agenda

Goal is compliance

Decisions made by caregiver

Assumes knowledge + confidence drives change

Patient sets agenda

Goal is enhanced confidence

Decisions made collaboratively

PACT Transformation

A Fundamental Shift in the Process of Care

Traditional Care Collaborative Care

(Bodenheimer et al, CA Health Care Foundation, 2005)

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Patient Centered Medical Home

Practice Redesign

Redesign team: oRoles oTasks

Enhance:

oCommunication oTeamwork

Improve Processes:

oVisit work oNon-visit work

Care Management & Coordination

Focus on high-risk pts: oIdentify oManage oCoordinate

Improve care for: oPrevention

oChronic disease Improve transitions between PCMH and:

oInpatient oSpecialty oBroader Team

Patient Centeredness: Mindset and Tools

Improvement: Systems Redesign, VA TAMMCS

Resources: Technology, Staff, Space, Community

Access

Offer same day appointments

Increase shared medical appointments

Increase non-appointment care

22

Principles of the

Patient-Centered Medical Home

• Ongoing relationship with personal physician

• Physician directed medical practice

• Whole person orientation

• Enhanced access to care

• Coordinated care across the health system

• Quality and safety

• Payment

22

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Patient Aligned Care Team: Objective

To improve patient satisfaction, clinical

quality, safety and efficiencies by

becoming a national leader in the delivery

of primary care services through

transformation to a medical home model

of health care delivery.

Team Redesign

The Patient’s Primary Care Team:

• Teamlet: assigned to

±1200 patients (1 panel)

– Provider

– RN Care Manager

– Clinical Associate • LPN

• Medical Assistant

• Health Tech

– Clerk

• Team members – Clinical Pharmacy

Specialist ± 3 panels

– Medical Social Work ± 2 panels

– Nutrition ± 5 panels

– Mental Health

– Case Managers

– Trainees

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25 25

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Essential Transformational Elements Patient Aligned Care Team

• Delivering “health” in addition to “disease

care”

• Veteran as a partner in the team – Empowered with education

– Focus on health promotion and disease prevention

– Self-management skills

– Patient Advisory Board

• Efficient Access – Visits

– Non face-to-face • Telephone

• Secure messaging

• Telemedicine

• Others? 26 26

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• Care coordination

– Optimizes hand-offs between inpatient and outpatient care

– Facilitates interface with specialty care

– Seamless co-management (Dual Care) with outside providers

– Incorporates tele-health, and HBPC services

– Emphasizes home care & rural health

Essential Transformational Elements

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• Care Management/ Panel Management – Disease management and interface with specialty

care • Chronic Care Model

• Disease registries

• Identification of outliers

• Team RN partnering closely with providers

– Veterans at high risk for adverse outcomes

– Pain management

– Returning combat veteran care

– Depression

– Substance abuse

Essential Transformational Elements

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• Improve technological clinician support

– Decision support

– Predictive modeling

– CPRS user-friendliness

– Information processing

• Develop new measurement and evaluation tools

– Patient Satisfaction

– Staff satisfaction

– Processes of care

– Manager and Provider Report Cards

– Continuity and comprehensiveness

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Essential Transformational Elements

Whole Person Orientation

Family and other

supportive relationships

Physical abilities

and limitations

Emotional, Spiritual,

Psychological aspects

Work, recreation and other interests

Culture

“ …you ought not to attempt to cure the eyes without the

head or the head without the body, so neither ought you to attempt

to cure the body without the soul . . . for the part can never be well

unless the whole is well.”

Plato

Primary Care – Mental Health

Integration

• PC-MHI embodies the principles and focus

of the Patient Centered Medical Home

• Work on PC-MHI implementation

facilitated PACT implementation

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• Completely integrated within primary care

• Occupy the same space

• Share the same resources

• Participate in Team Meetings

• Share responsibility for care of the whole

patient

True Integration Features of PC-MHI

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Sounds good but…

One size does not fit all

Organizational Ethics: “…The intentional use of values to guide the decisions of a system.”

“From Clinical Ethics to Organizational Ethics: The Second Stage of the Evolution

of Bioethics.” Potter, Robert Lyman, in “Bioethics Forum.” Summer, 1996

Required Elements

• ADHERENCE TO THE BASIC PRINCIPLES

– EASY ACCESS IN PRIMARY CARE

– PROBLEM FOCUSED ASSESSMENT AND TREATMENT

– ONSITE CLINICIANS IN PC

– STEPPED CARE

– MEASUREMENT BASED CARE

– CARE MANAGEMENT

– ENHANCED REFERRALS

• LEADS TO CONSISTENT OUTCOMES

– IMPROVED RECOGNITION AND TREATMENT IN PC

– IMPROVED ENGAGEMENT IN SPECIALTY MH CARE

– CONSERVES SCARCE SPECIALTY RESOURCES

WHAT ABOUT SERIOUS PERSISTENT MENTAL

ILLNESS? Or HOMELESS VETERANS?

VISION: All Veterans with will enjoy health

status identical to the general population.

Solution: PACT teams offering tailored care

37

What about rural healthcare?

• Vision: development of a telemental health

system including:

– In-home messaging

– Telemental health

– Mobile apps

– Web based care

How about prevention?

VETERANS HEALTH ADMINISTRATION

Prevalence of Health Behaviors

40

VETERANS HEALTH ADMINISTRATION

Preparing a Cadre of Prevention Staff to Train, Coach and Consult with Clinicians

• Health coaching

• Motivational interviewing

• Health literacy

• Evidence-based health

promotion/disease prevention

• Problem solving approaches

All aimed to support clinical staff members in promoting patient self-management of health behavior.

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Ongoing development

Unified Model of care

Staffing guidelines – what disciplines

Develop the Evidence Base for Brief

Treatments

Integration with the rest of Mental Health

Conclusion

• Primary Care - Mental Health

Integration is and will continue to

be an essential component of the

team delivery of effective care

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Thanks to

• Andrew Pomerantz, MD

• John Hunsinger, MD

• Margaret Dundon, PhD

• VHA Center for Integrated Care