Transcript
Page 1: 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

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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

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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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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

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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

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Integrating Mental Health into Primary Care:

What are your challenges?

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Challenges

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

available

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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

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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

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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

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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

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Successes

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

*Also listed under Challenges

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Successes

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

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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

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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

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Integrating Mental Health into Primary Care:

What are your successes?


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