1. Primary Care-Mental Health Integration in the Department of Veterans Affairs Andrew Pomerantz, MD National Mental Health Director for Integrated Services, VA Office of Mental Health Services Edward Post, MD, PhD National Medical Director for Primary Care-Mental Health Integration, VA Office of Primary Care and VA HSR&D Center of Excellence, Ann Arbor MI April 20, 2012

2. VETERANS HEALTH ADMINISTRATION Integrated Care: Why? Primary care is still the de facto mental health [MH] system in the United States Most people referred to mental health either do not show up or do not engage in care Only so much time in the primary care provider’s day Comorbidity impairs medical, social, societal outcomes

3. VETERANS HEALTH ADMINISTRATION What is Integrated Care? From Agency for Healthcare Research and Quality [AHRQ] report (2008): “…Unifies care for physical and mental concerns” (Cautionary Statement: Avoid “…Premature Orthodoxy.”)

4. VETERANS HEALTH ADMINISTRATION Contribution to Premature Mortality in the United States Schroeder N Engl J Med 2007

5. VETERANS HEALTH ADMINISTRATION Mental Health Services in the Medical Home “… the Patient Centered Medical Home will not reach its full potential without adequately addressing patients’ mental health needs. Doing so, however, will likely shift responsibility for the delivery of much mental health care from the mental health sector into primary care….” Croghan TW, Brown JD. Integrating Mental Health Treatment Into the Patient Centered Medical Home. AHRQ Publication No. 10-0084-EF. Rockville, MD: Agency for Healthcare Research and Quality. June 2010.

6. VETERANS HEALTH ADMINISTRATION Mental Health in Primary Care Can include acute or chronic disease management Brief, problem-focused treatment of mental disorders Comorbidities Psychosocial/behavioral issues: Insomnia, pain, unexplained somatic symptoms, smoking, stress of all kinds, etc.

7. VETERANS HEALTH ADMINISTRATION Principles of Integrated Care in VA Open or advanced access (temporal and spatial integration) in VA primary care medical home, i.e. PACT [Patient Aligned Care Teams] Problem-focused assessment and treatment: tend to what the Veteran wants tended to On-site clinicians in primary care Stepped care Measurement-based care Care management Referral management when needed

8. VETERANS HEALTH ADMINISTRATION Objectives More patients served Scarce resources preserved for those who need them Reduced waste Reduced stigma Satisfied patients

9. VETERANS HEALTH ADMINISTRATION Levels of Care In well-developed primary care-mental health integration programs, 70-80% of all mental illness is effectively managed in primary care But we still need secondary and tertiary care: specialty mental health care Referral management bridges transitions

10. VETERANS HEALTH ADMINISTRATION 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 intensive case mgmt.) 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 10

11. VETERANS HEALTH ADMINISTRATION Primary Care-Mental Health Integration [PC-MHI] in VA Two PC-MHI components: Care management Co-located collaborative care Blended programs have both of these complementary components Focus primarily on common mental 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 11

12. VETERANS HEALTH ADMINISTRATION Mental Health Care Management Disease-specific Care Management Evaluation and triage, usually telephone-based Guideline-based treatment support Patient activation, education for self-management Telephone follow-up includes on-going assessment and monitoring of adherence to medication, treatment plan, behavioral activation, problem solving Referral management VA: Translating Initiatives for Depression into Effective Solutions [TIDES] and Behavioral Health Laboratory [BHL]

13. VETERANS HEALTH ADMINISTRATION Co-located Collaborative Care Mental health provider(s) embedded in primary care clinic with shared responsibility for evaluation, treatment planning and monitoring outcomes Consultation and education to medical home [PACT] teams Open or advanced (same day) access Assessment and brief treatments within PACT

14. VETERANS HEALTH ADMINISTRATION Primary Care-Mental Health Integration Use: Fiscal Year [FY] 2008 to FY 2012 14

15. VETERANS HEALTH ADMINISTRATION The Biggest Barrier of All: The Other “Shift” The much maligned medical model Primary/secondary/tertiary care Begins with the assumption of health/wellness Requires a shift in thinking from a diagnosis-centered approach to patient/problem/function-centered (AHRQ: “… a change many stakeholders will likely oppose”) Such a shift conserves specialty and subspecialty resources Eliminates waste Enhances engagement

16. VETERANS HEALTH ADMINISTRATION Some Principles that Guide Program Development Healthcare providers are mental health care providers Mental health care providers are healthcare providers Patient-centered care is centered around the patient