VA Primary Care-Mental Health Integration (PC-MHI) Edward Post, MD, PhD National PC-MHI Medical Director

Primary 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 Primary Care-Mental Health Integration

Primary Care Landscape Chronic disease Multiple comorbidities Need 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) Primary Care Landscape

Why Integrate Mental Health Services into Primary Care? Integrated mental health care... Improves identification of prevalent mental health conditions Improves access to appropriate evaluation and treatment Improves treatment engagement and adherence Increases probability of receiving high quality care Improves clinical and functional outcomes Increases patient satisfaction Why Integrate Mental Health Services into Primary Care?

Improved identification Improved identification of depression, psychiatric co-morbidities and substance misuse (Oslin et al., 2006) Improved identification of depression (Watts et al., 2007) Improved access 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) Reduced wait times (Pomerantz et al., 2008) PC-MHI Evidence Base

Improved engagement and adherence Improved engagement in mental health treatment (Zanjani et al., 2008) Improved engagement and adherence in treatment for depression and at-risk alcohol use (Bartels et al., 2004) Greater antidepressant adherence (Hunkeler et al., 2006; Katon et al., 1999, 2002) Improved no-show rates (Pomerantz et al., 2008; Zanjani et al., 2008; Guck et al., 2007) Higher quality care Increased probability of receiving guideline-concordant treatment (Watts et al., 2007; Roy-Byrne et al., 2001) Higher patient perceptions of quality of care (Katon et al., 1999) PC-MHI Evidence Base

Better clinical and functional outcomes 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) Similar remission rates and symptom reduction for depression compared to enhanced specialty referral (Krahn et al., 2006) Decrease in at-risk alcohol use comparable to enhanced specialty referral (Oslin et al., 2006) More rapid clinical response (Alexopoulos et al., 2009; Hedrick et al., 2003) 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) PC-MHI Evidence Base

Complementary Settings: VA Vision for Mental Health Services Specialty MH Services in VAMCs and Clinics Integrated MH Services in Primary Care Focus on recovery & rehabilitation for SMI Focus on improved access to care for common mental illnesses Evidence-Based Psychotherapy Clinical Neuroscience

Primary 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 CCC: Mental health provider embedded in primary care clinic with shared responsibility for evaluation, treatment planning and monitoring outcomes Consultation to the PCP Immediate evaluation as needed Brief treatment Educational function Care Mgt: Designated Care Manager supporting longitudinal mental health care, commonly an RN Evaluation and triage, often telephone-based Patient activation, education for self-management Telephone follow-up includes on-going assessment and monitoring of adherence to medication, treatment plan Guideline-based treatment support Referral management Blended Programs: Combine care management & co-located, collaborative care (mental health provider and care manager) Mental health provider evaluates patients and offers psychosocial treatment when preferred or needed Care manager provides complementary services (education, ongoing assessment, monitoring of adherence, algorithm-based use of medication, referrals as necessary) Primary Care-Mental Health Integration

Necessary 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 Necessary Integrated Care Processes 11

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

CCC vs. Traditional MH Co-Located Collaborative MH Care Mental Health Specialty Care Location On-site A different floor or building 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-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) Both TIDES & BHL were developed by VA clinicians and researchers Care Management Models in PC-MHI

Care Managers Role of the Care Manager Nurses 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 triage Decision support Patient education and activation Monitor adherence to treatment, treatment outcomes, and medication side effects Referral management Support patient self- management

Introduction to Blending PC-MHI Programs 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 Introduction to Blending PC-MHI Programs What is a Blended PC-MHI Program?

Core Components of an Effective Blended 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 plans Ability to collect objective clinical and administrative outcome data Core Components of an Effective Blended MH Integration Program

History 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 History of VA PC-MHI Implementation 18

Uniform 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 Uniform Mental Health Services Package

Service Utilization Data Unique Patients (Uniques) Each patient only counted once in a time period Aggregating unique patients over time is tricky Encounters Average Number of Encounters per Unique Patient New Patients PC-MHI Penetration Rate Calculates proportion of Primary Care patients who were seen in PC-MHI program over last 12 months PC-MHI uniques divided by PC uniques Rolling calculation over last 12 months of data Service Utilization Data Service Utilization Data reported from facility stop code usage

VHA Dashboard VISN Dashboard Facility Dashboard Division Dashboard

PC-MHI: State of the Field Penetration Rate calculates proportion of Primary Care patients who were seen in PC-MHI program over last 12 months PC-MHI uniques divided by PC uniques Rolling calculation over last 12 months of data PC-MHI: State of the Field The 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

National PC-MHI Program Office Principal Contact: Maureen Metzger, PhD, MPH National Program Manager Maureen.Metzger@va.gov 734-845-5719 Thank you to many faculty who collaborate in presenting our training programs, and to innumerable persons who are implementing PC-MHI throughout VA! National PC-MHI Program Office

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