Transcript Primary Care/Mental Health Integration

Behavioral and Mental Health
Services in Interdisciplinary
Primary Care at the
Department of Veterans Affairs
Presentation at Association for Contextual
Behavioral Science, July 2012, Washington, DC
Antonette Zeiss, Ph.D.
Chief Consultant, Office of Mental Health Services
Veterans Health Administration
Department of Veterans Affairs
Teamwork for the Presentation
Colleagues - THANKS
Sonja Batten, Ph.D
Jeff Burk, Ph.D.
Lisa Kearney, Ph.D.
Jan Kemp, Ph.D.
Andrew Pomerantz, M.D.
Edward Post, M.D.
Mary Schohn, Ph.D.
No conflicts to report
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VA 101
• VA = Department of Veterans Affairs (since 1989)
• Three subcomponents:
– Veterans Benefits Administration
– National Cemetery Administration
– Veterans Health Administration
• Vet Centers
• Medical facilities and their associated Community Based Outpatient Clinics (CBOCs)
– Organized into 21 regions called Veterans Integrated Service Networks (VISNs)
• Crucial distinction between Department of Defense Care and
VA care
– DoD provides care to active duty Servicemembers and their families, and after
discharge to some who had a significant career in the military
– VA provides lifetime care to all eligible Veterans who choose to seek VA health
care
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Veteran Population Facts
• 23.8 million US veterans
– 1.8 million women (and growing)
– Almost 60% of American men > 65 are veterans
• Not all Veterans are eligible for VA health care
– Main factors: type of discharge, presence of a Service
Connected disability, low income, deployment to
OEF/OIF
• 7.8 million enrolled for health care in VHA
– ~ 6.2 million seen FY 2011 (October 1, 2010 – September
30, 2011)
– 22% of all veterans
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VA’s Commitment: Quality Care
• Our nation’s commitment to Veterans, for their lifetime:
– Treat returning Veterans early in the course of mental heath
problems
– Serve all Veterans with accessible, evidence-based mental health
services when they need them
– Provide holistic, integrated care for physical and mental health
problems:
Mental health is an essential component of
overall health care
• Be there for the lifetime of all Veterans we are serving, from
all eras
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Brief Recent History of MH Care in VA
• Attrition of VA MH services in the late 1990s up to about 2003
• Major Rebuilding & Innovation since 2004
– VHA Comprehensive MH Strategic Plan: Developed in 2003-04 and
approved November, 2004
– Uniform MH Services Package: Developed in 2008
• Defines mental health services to be provided to all enrolled veterans
• Completes implementation of Strategic Plan for patient services
• Current status
– Huge increase in mental health staffing and services since 2003
– RAND/Altarum external review confirms that VA surpasses private
mental health care quality of care on almost all dimensions reviewed
– Challenges remain: High aspirational goals, greatly increasing
demand for services
– Current hiring efforts underway for further expansion of staff and
services
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VA Users Of Mental Health Services
FY2011
Year
Total Service
Users
Number of
Service
Users who
Received
Specialized
MH Services
Percent of
Service Users
who Received
Specialized
MH Services
2011
5,376,591
1,338,482
25%
2010
5,236,495
1,259,303
24%
2009
5,030,301
1,157,732
23%
2008
4,884,250
1,072,186
22%
2007
4,830,564
990,215
20%
2006
4,789,341
927,052
19%
2005
4,710,853
897,643
19%
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Users Of Mental Health Services
Among Veterans Who Served In Iraq,
Afghanistan, or Support Locations
• Among 1,478,370 separated OEF/OIF/OND
Veterans
– 804,704 (~54%) have obtained VA health care since FY 2002
– Of those, 495,774 Veterans accessed care during the past twelve
months (April 1, 2011-March 31, 2012).
• This represents about 8% of the ~6.2 million individuals who
received VA health care during FY 2011 (October 1, 2010 –
September 30, 2011).
– 12% of those seeking care are women Veterans
– Mental Health problems are the second most frequent diagnoses,
behind musculoskeletal problems as the most frequent
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Diagnoses of Veterans Who Come to
VA for Health Care
% OEF/OIF/OND
(n=804,704)
Disease Category (ICD-9-CM Categories)
Number Percent
Infectious and Parasitic Diseases (001-139)
124,968
15.5
Malignant Neoplasms (140-209)
11,156
1.4
Benign Neoplasms (210-239)
53,946
6.7
Diseases of Endocrine/Nutritional/Metabolic Systems (240-279) 260,330
32.4
Diseases of Blood and Blood Forming Organs (280-289)
30,504
3.8
Mental Disorders (290-319)
424,803
52.8
Diseases of Nervous System/ Sense Organs (320-389)
360,644
44.8
Diseases of Circulatory System (390-459)
171,955
21.4
Diseases of Respiratory System (460-519)
211,449
26.3
Diseases of Digestive System (520-579)
289,303
36.0
Diseases of the Genitourinary System (580-629)
121,861
15.1
Diseases of Skin (680-709)
172,651
21.5
Diseases of Musculoskeletal System Connective Tissue (710-739)
456,006
56.7
Symptoms, Signs and Ill Defined Conditions (780-799)
417,703
51.9
Injury/Poisonings (800-999)
232,142
28.8
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Mental Health Diagnoses of Veterans
Who Come to VA for Health Care
Diagnosis (ICD-9-CM)
Number of
OEF/OIF/OND
Veterans
228,361
Post-traumatic stress disorder (PTSD) (309.81)
Depressive Disorders (311)
174,799
Neurotic Disorders (300)
152,346
Affective Psychoses (296)
105,841
Alcohol Dependence Syndrome (303)
49,797
Nondependent Abuse of Drugs (305)15
35,360
Special Symptoms, Not Elsewhere Classified (307)
30,166
Specific Nonpsychotic Mental Disorder due to Organic Brain Damage (310)
27,880
Drug Dependence (304)
26,445
Sexual Deviations and Disorders (302)
25,424
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VA’s Mental Health System
• Vet Centers
– Provide readjustment counseling
– Located in community settings
– Mobile Vet Centers to take care to rural areas
• Medical Centers & Community Based Outpatient
Clinics have multiple ways of delivering mental
health care
– Direct VA staffing
– Telemental health in CBOCs
– Fee basis and contract care as needed
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Mental Health is an Integral Part of
Overall Health
• Mental health is an essential component 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
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Mental Health Integrated In Physical
Health Settings
•
Primary care/Mental Health integration
– VA’s overarching primary care system: Patient Aligned Care Teams (PACTs)
– Home Based Primary Care
– Women’s health clinics
– Geriatric Primary Care Clinics
•
Physical Rehabilitation
– Polytrauma units
– Spinal Cord Injury units
– Blindness Rehabilitation Centers
•
Interdisciplinary medical specialty clinics, e.g.:
– Pain clinics
– Oncology
– Endocrinology
•
Long term care and end-of-life care
– Hospice
– Community Living Centers
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Integration in Specialty Mental Health
Settings
•
Outpatient clinics
•
Specialty Outpatient
– Post traumatic stress disorder (PTSD) care teams with a Substance Use
Disorder (SUD) specialist on every team
– Mental Health Intensive Care Management: Team to provide
community-based care for Serious Mental Illness patients
•
SUD care
– Detox (often in medical units)
– Outpatient clinics
– Intensive Outpatient services for SUD
•
Residential Rehabilitation Treatment Programs
– Population with extensive comorbid diagnoses across mental health
problems, SUD problems, homelessness, etc.
•
Inpatient mental health care
– At risk to self or others
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Themes: Mental Health as an Integral
Component of Overall Health
•
Interdisciplinary team care
•
Recovery-oriented mental health services
and Patient Centeredness in all health care
in VA
•
Primary Care/Mental Health Integration
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Theme 1: Interdisciplinary Team
Care
• Interdisciplinary Health Care emphasizes a high
degree of collaboration in:
– Patient evaluation
– Treatment planning
– Outcome evaluation
• NOT Multidisciplinary
• Ideally, the patient and family members (when
appropriate) are included as team members
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Multidisciplinary vs. Interdisciplinary
• Multidisciplinary =
– Multiple professions in a shared work site,
– Sharing a patient load and overall vision of care,
– BUT working independently and sharing information
on a minimal basis (e.g., weekly report)
• Interdisciplinary =
– Multiple professions in a shared work site,
– Sharing a patient load and overall vision of care,
– AND working continuously to share and integrate
information to guide coordinated care
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Interdisciplinary Health Care Model
Individual
Assessments
Shared information
Team goals
Intervention plan &
strategies
Individual Delivery
of Care
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Skills and Training
• Understanding the roles of other team members
– Each profession has its unique areas of expertise
– Each profession shares considerable health care knowledge and
care delivery roles with other professions
• Team members need to be able to
– Convey their own special skills and knowledge, that serve the
patient's and family’s needs
– Know that shared knowledge and skills are an opportunity for
coordinated care, not a threat to one’s own “turf”
– Appreciate the importance of skills that are far from one’s own
range
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It’s Not Just Skills And Knowledge
• Conflict among team members can strengthen or weaken
team functioning
– Learn to embrace and appreciate disagreement; it protects from
“group think”
• Predictable stages of team development:
– Forming
– Storming
– Norming
• Conflict is highest during storming, but can occur at any point
• Team leadership is not defined by professional title, and
leadership may be distributed according to different tasks and
leadership skills and needs
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Theme 2: Recovery-Oriented Mental Health
Services And Patient Centeredness In All
Health Care In VA
 Defined originally in mental health settings, but the
concept has important relevance for all health care
 Recovery-oriented care focuses on strengths, needs,
abilities, and preferences
 Assist individual to define, achieve, and maintain personal goals
 All Veterans can be guided to identify important personal goals
and supported in accomplishing them, including those with
 Mental illness/disability (including serious mental illness)
 Physical illness/disability
 Both mental and physical illness/disability
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Mental Health Recovery
• “Mental health recovery is a journey of healing and
transformation enabling a person with a mental health
problem to live a meaningful life in a community of the
person's choice while striving to achieve ... full potential.”
– National Consensus Statement on Mental Health Recovery
(http://mentalhealth.samhsa.gov/publications/allpubs/sma05-4129/ )
 All veterans have recovery potential: a maximum degree
of self-sufficiency that can be attained
 Recovery involves attainment of life goals
 In relationships, employment, schooling, housing, community
involvement
 Beyond symptom management
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Patient Centeredness In All VA Health
Care
• VA’s Overall Commitment of Patient Centered Health
Care
– Led by Tracey Gaudet, M.D., Director of the Office of
Patient Centered Care
– Core concepts:
• Old model: “Problem Based Disease Care”
• Transformation to “Patient Centered Health Care”
– Patient Centered Health Care core change: “Start with the
Veteran and What Matters to Them”
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Delivering Patient Centered Health
Care in PACTs and In Specialty Care
• Steps suggested:
–
–
–
–
Mission: Get clear about what matters in the patient’s life
Plan: Create a personalized health plan to get there
Train in the skills and resources needed
Patient and Provider Support and rely on one another
• Patient Centered Health Care concepts =
Recovery-oriented Mental Health Care concepts
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Competencies for Providing RecoveryOriented, Patient Centered Health Care
 Work collaboratively with the veteran
 Veteran expertise, e.g.:
 Goals
 Personal strengths
 Supports and resources available to them
 Health Care Provider expertise, e.g.:
 Education and support for veteran and family
 Knowledge of best, evidence-based Interventions: Psychotherapy,
Medication
 Training in the skills and resources needed
 Respect and empower the veteran in self-managed
recovery efforts
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Theme 3: Primary Care/Mental
Health Integration
• A Natural Fit
– Over 25% of Veterans who use VA health care have a
mental health diagnosis for which they are being treated
in a specialty mental health setting
– Patients initially bring their mental health concerns to
primary care – Patient Aligned Care Teams (PACTs) in
VA
– Screening for mental health problems takes place in
primary care
– Referrals from primary care to specialty mental health
result in a high rate of no-shows
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Benefits of Integration of Mental
Health Staff in PACT
• Promotes early identification/ management of
mental health issues
• Supports coordination of care across conditions
• Facilitates engagement
– Increases convenience
– Reduces stigma
– Embodies for the patient the concept that mental
health is an integral component of overall health
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Mental Health Enhancement to
Support Primary Care Teams/PACTs
• Initial funding for integration of mental health in
the primary care setting in FY2007
• Requirement for all sites as of FY2009 “Blended Model”:
– Care Management: Patient education and longitudinal
monitoring, primarily of medication-based care
– Co-located, Collaborative mental health provider:
Education, consultation for the team, provide
behavioral medicine and psychosocial services
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Core VA PACT Membership
• Primary care provider
– Physician
– Physician Assistant
– Advanced Practice Nurse
•
•
•
•
•
•
•
•
RN care manager
LPN (or similar) “clinical associate”
Clerk
Clinical pharmacist
Social worker
Dietician
Health psychologist
Mental health professional
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PACT Structure Principles
•
Role differentiation of providers, administrative requirements, and other
general operational and design elements of the new practice model.
•
Each PACT provider is expected to function at the top of his or her license
or skill
– Many tasks previously performed by the PCP can be effectively and appropriately
accomplished by RNs.
– Many traditional RN tasks can be performed by LPNs or health technicians
– The clerical role is also expanded, to assume tasks that do not require
professional or clinical expertise
• Expanded PACT team includes
– Integrated mental health services
– Health behavior coordinators
– Health Promotion/Disease Prevention Program Managers
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Assessing Success: PC-MHI
Dashboard
•
Purpose = evaluate integrated mental health care implementation by tracking
–
–
–
–
–
Staffing
Compliance with key program components
Service utilization
Diagnostic data
Performance measure outcomes at the national, regional, and local level
•
Dashboard reflects the number of staff (by discipline) dedicated to integrated
mental health care in PACT with the capability of drilling down to the local
facility level
•
Service utilization data assess
–
–
–
–
number of Veterans served in a given time period
number of appointments utilized by each Veteran
number of new Veterans seen in a program
“penetration rate,” which is the number of Veterans served by PC-MHI staff in
primary care, compared to the overall number of Veterans in primary care in a
given setting
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This Integration Is The Largest Effort Of
Its Kind Ever Undertaken
• Since late 2007, in PC-MHI programs throughout the VA healthcare
system, over 1.9 million Veteran encounters to provide mental health
services in primary care have occurred
• During FY2012 so far, this program has provided care to 5.7% of all VA
primary care patients.
• Mental health providers in these settings provide same-day care for
Veterans in primary care that includes
– Screening and evaluation for mental health concerns
– Treatment of mild to moderate depression, anxiety, and substance misuse
– Behavioral interventions for medical disorders.
• The most recent aggregate staffing data for PC-MHI, as of Fall 2011,
demonstrate a total PACT mental health clinical staff of 1,469 clinicians
who cumulatively represent 950 Full Time Equivalents
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Figure 1: VHA Primary Care-Mental
Health Integration Dashboard
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Some Research Findings
•
Integrated care has not yet significantly reduced specialty mental health care
services (Pfeiffer et al., 2011)
•
Patients who received integrated care services were significantly more likely to
stay engaged in specialty mental health treatment when referred, compared to
those who did not receive integrated care services (Wray et al., in press)
– This finding suggests that much of the time previously wasted by no-shows and
patients who left treatment after only one session is now available to enhance specialty
care services
•
Most common interventions (Funderburk et al., 2011):
–
–
–
–
Cognitive-behavioral therapy interventions
Psychoeducation
Supportive psychotherapy
Pharmacological intervention,
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Themes 1, 2, & 3: Mental Health Providers Are
Part Of The Interdisciplinary, Patient
Centered, Primary Care Team
• Integrating mental health and primary care is a paradigm shift for
mental health clinicians not previously exposed to this model of care
• Such work requires a shift to population-based care, tending proactively
to the needs of an entire population of primary care patients, rather than
just a caseload of patients who have been referred
• Notably, many VA mental health providers have been trained in brief
models for health interventions and have adapted readily to the fastpaced environment of the primary care setting
• The focus is on the patient’s goals and providing rapid interventions
related to the patient’s immediate concerns
• Mental health providers also bring multiple skills for helping the team
manage group dynamics and problem-solving, in the interdisciplinary
process
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