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

3. 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

4. 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

5. 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?

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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?

13. 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
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

14. 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

15. 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

16. 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?

17. 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

18. History of VA PC-MHI Implementation
Large-scale implementation began in 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 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

19. 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

20. 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

21. VHA Dashboard
VISN Dashboard
Facility Dashboard
Division Dashboard

22. 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

23. National PC-MHI Program Office
Principal Contact:
Maureen Metzger, PhD, MPH
National Program Manager
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

24. Questions?