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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
16
Revolution in Primary Care
Veteran Centered Care
18
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
19
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)
20
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
23
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
24
25 25
26
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
27
• 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
28
• 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
29
• 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
29
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
31
• 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
32
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.
41
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
43
Thanks to
• Andrew Pomerantz, MD
• John Hunsinger, MD
• Margaret Dundon, PhD
• VHA Center for Integrated Care