Implementing Mental Health Care Transformation in the Veterans Health Administration

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Implementing Mental Health Care Transformation in
the Veterans Health Administration

• Bradley Karlin, Ph.D.
• May 31, 2008

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VHA is a Health and Mental Health Care System

• VHA is
• a provider
• a payor
• a policy environment
• a member of the community

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• Presidential Commission convened in 2002 to study
  nations mental health care delivery system
• Conclusion Transformation in mental health care
  delivery in America is needed

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From Recommendation to Action

• Presidents New Freedom Commission Final Report
• ??
• VHA Action Agenda
• Achieving the Promise Transforming
• Mental Health Care in VA
• ??
• VHA Mental Health Strategic Plan
• A Road Map for Transforming VA
• Mental Health Care

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VHA Mental Health Strategic Plan

• 265 Recommendations
• Primary factors
• Equal urgency Capacity, access, elimination of
  disparities
• Integration of MH and Primary Care
• Recovery/Rehabilitation Transformation of SMI
  Care
• Implementation of Evidence-Based Practices
• OEF-OIF
• Suicide Prevention

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Transforming Mental Health Care in VA

• . . . for all veterans
• Broad and specific focus on older veterans

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Mental Health Outpatients in VA
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Equal Urgency

• Availability of substance use disorder services
• Increase buprenorphine availability
• Enhance SUD care in more rural VAMCs
• MH in CBOCs
• Use of newer technologies
• Telemental health care
• Services for homeless veterans

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Traditional Silo Model
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MH Integration with Primary Care
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Integration of MH in Primary Care

• Primary Care-MH Integration Initiative
• 100 integrated MH-Primary Care teams established
• Evidence-based models
• Care management
• Co-located/collaborative care
• Blended

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Integrated Care Outcomes

• ? Access and treatment rates
• (Bartels et al., 2004 Hedrick et al., 2003 Liu
  et al., 2003)
• ? Treatment adherence
• (Katon et al., 1999 Katon et al., 2002
  Roy-Byrne et al., 2001)
• ? Clinical and functional outcomes
• (Katon et al., 2002 Katon et al., 2006 Rollman
  et al., 2005 Roy-Byrne, Katon, Cowley, Russo,
  2001 Unützer et al., 2002)
• ? Patient satisfaction
• (Chen et al, 2006 Katon et al., 2004 Unützer
  et al., 2002)
• ? Cost-effectiveness(Katon et al., 2005 Katon,
  Roy-Byrne, Russo, Cowley, 2001
• Liu et al., 2003)

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MH Integration in Home Based Primary Care

• MH provider funded for each HBPC team (130)
• FT, integral member of HBPC team
• Psychologist on almost all teams
• General responsibilities of HBPC MH Provider
• Cognitive and psychological assessment
• Time-limited psychotherapy/psychosocial and
  behavioral medicine services
• Behavior management/caregiver interventions
• Team-focused activities

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MH Integration in Nursing Homes

• MH providers in community living centers (nursing
  homes), as part of special initiative
• Promote delivery of psychosocial services for
  behavior management
• Facilitate NH culture transformation

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MH Integration in Hospice and Palliative Care

• Psychologist part of Palliative Care Consult Team
  

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Recovery Rehabilitation

• Focus on maximizing hope, individual potential,
  and autonomy
• Recovery coordinators placed at each Medical
  Center
• Expand Mental Health Intensive Case Management
• Extend program to rural areas
• Family Psychoeducation for SMI

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Evidence-Based Psychotherapy Dissemination

• National initiatives to train MH staff in the
  delivery of EBPs for
• PTSD
• Cognitive Processing Therapy
• Prolonged Exposure Therapy
• Depression
• Cognitive Behavioral Therapy
• Acceptance and Commitment Therapy
• Serious Mental Illness
• Social Skills Training

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Training Model

• In-person workshop
• Didactic
• Experiential
• Ongoing regular consultation to build mastery and
  facilitate implementation
• Train-the-trainer component

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Implementation

• Top down bottom up approach to promote adoption
  and sustainability
• Computerized medical record templates under
  development
• Roster
• Local champions

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Suicide Prevention in VA

• Basic assumption
• Suicide prevention requires access to a high
  quality mental health care system and activities
  that specifically target suicide
• Strategy
• Overall enhancements of Mental Health programs
• Specific actions involving public health and
  clinical activities

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Specific Activities

• National priority led by Centers of Excellence
• Center of Excellence in Canandaigua, NY
• Appointment of Suicide Prevention Coordinators at
  VAMCs
• Suicide prevention hotline for veterans
• Educational activities
• Research on and dissemination of best practices
• Promoting suicide risk assessment, follow-up, and
  clinical activities
• Cognitive Therapy for Suicide Prevention
• Safety Plans

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Safety Plan 4 Steps

• Recognizing warning signs
• Using coping strategies
• Contacting friends or family members
• Contacting professionals or agencies

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Recognizing Warning Signs

• Safety plan is only useful if the patient can
  recognize the warning signs
• What are the thoughts, images, thinking styles,
  mood, or behaviors the immediately precede a
  suicidal crisis?
• List warning signs using the patients own words

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Recognizing Warning Signs

• Automatic Thoughts
• I am a nobody
• I am a failure
• I dont make a difference
• I am worthless
• I cant cope with my problems
• Things arent going to get better
• Images
• Flashbacks

• Thinking Processes
• Having racing thoughts
• Thinking about a whole bunch of problems
• Mood
• Feeling depressed
• Intense worry
• Intense anger
• Behavior
• Crying
• Isolating myself
• Using drugs

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Using Coping Strategies

• List activities that patients can do without
  contacting another person
• Activities function as a distraction technique
  and keep ideation from escalating

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Using Coping Strategies

• Examples
• Going for a walk
• Listening to inspirational music
• Drinking a milkshake
• Walking the dog

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Contacting Friends and Family

• List friends and/or family to contact during
  crisis
• Individuals and phone numbers may be prioritized

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Contacting Professionals or Agencies

• Contact professionals or agencies if coping
  strategies or contacting friends or family
  members is unhelpful
• Prioritize list of professionals

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Contacting Professionals or Agencies

• Example of Prioritized Professionals/Agencies
• Primary mental health clinician
• On-call clinician who can be reached after
  business hours
• Primary care physician, psychiatrist, or other
  physician
• 24-hour emergency treatment facility
• Other local or national support services that
  handle emergency calls 1-800-273-TALK

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Mental Health Staff Expansion

• 4331 positions funded
• 3928 positions hired (April 30, 2008)
• Psychology Training Enhancement

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Psychologists in VHA
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Uniform MH Services Package

• Designed to capture the culmination of the MHSP
• Defines MH services that must be available to all
  veterans and outlines acceptable options for
  providing them, considering
• VISN
• Facility
• CBOCs (small, medium, and large)
• Contract/fee basis care

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Uniform MH Services Package

• General Principles
• Structure Governance
• Community MH
• Gender Specific Care
• 24/7 Care
• Geographically defined services
• Inpatient
• Residential
• Ambulatory

• Substance Use Disorders
• Seriously Mentally Ill
• Rehabilitation Recovery
• Evidence-Based Psychotherapies
• Homeless Programs
• MH in Medical Care Settings
• Older Adults
• PTSD
• Suicide Prevention
• Violence Prevention
• Preparedness
• Rural Health