1. How Innovators Manage Real World Push-Back: Lessons from VA Integrated Care Implementers Andrew Pomerantz, MD National Mental HealthDirector, Integrated Services Veterans Health Administration Associate Professor of Psychiatry, Geisel School of Medicine at Dartmouth Laura O. Wray, PhD Director, Education/Clinical Core, VA Center for Integrated Healthcare Assistant Professor of Clinical Mediicine, University at Buffalo

2. VETERANS HEALTH ADMINISTRATION Patient Aligned Care Team 2

3. 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

4. VETERANS HEALTH ADMINISTRATION 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 4

5. VETERANS HEALTH ADMINISTRATION 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

6. VETERANS HEALTH ADMINISTRATION 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

7. Integrating Mental Health into Primary Care: What are your challenges?

8. VETERANS HEALTH ADMINISTRATION Challenges “Overselling” or Fear of “Overselling” – Advertise as generalist – Open door – Slammed with referrals once PCPs understand what’s available

9. VETERANS HEALTH ADMINISTRATION 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

10. VETERANS HEALTH ADMINISTRATION 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

11. VETERANS HEALTH ADMINISTRATION 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

12. VETERANS HEALTH ADMINISTRATION 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

13. VETERANS HEALTH ADMINISTRATION Successes Leadership Support* – Motivated managers* – Chief Medical Officer – Chief of Ambulatory Medicine – Chief of Mental Health* – Primary Care Chief *Also listed under Challenges

14. VETERANS HEALTH ADMINISTRATION Successes Primary Care Providers – Good relationships – Program developed with their input – “Hanging out with them” – PCPs happy to have program – PCPs excited, supportive

15. VETERANS HEALTH ADMINISTRATION 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

16. VETERANS HEALTH ADMINISTRATION 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

17. Integrating Mental Health into Primary Care: What are your successes?