Edward P. Post, MD, PhD National Medical Director, PC-MHI

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Edward P. Post, MD, PhDNational Medical
Director, PC-MHI

• VA Primary Care-Mental Health
• Integration (PC-MHI)
• Update

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Introduction

• Integrating collaborative mental health expertise
  into primary care is increasingly recognized as
  essential to improving quality.
• Studies have identified systems-based approaches,
  but sustaining these evidence-based changes
  outside of research is difficult.
• VA has responded by fielding the largest effort
  toward integration to date.
• PC-MHI is a joint effort of the Office of Mental
  Health Services and the Primary Care Service.

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Purpose

• Purpose of the VA PCMHI program is to promote
  the effective treatment of common mental health
  and substance use disorders in the primary care
  environment, and thus improve access and quality
  of care for Veterans across the spectrum of
  illness severity.

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Purpose (cont.)

• Consistent with the New Freedom Commission on
  Mental Health, which emphasized that mental
  health and physical health conditions are
  interrelated aspects of overall health and are
  best treated in a coordinated system.
• Mental health services delivered in the primary
  care environment have the potential for reducing
  stigma, provide increased convenience, and thus
  increase patient participation and adherence.

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Components

• PC-MHI components provide collaborative expertise
  to primary care providers (PCPs), building on
  population-based screening for depression,
  alcohol misuse, and PTSD.
• VA facilities implementing PC-MHI include either
  co-located collaborative care or care management,
  and increasingly a blended program that combines
  these two evidence-based components.

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Co-located Collaborative Care

• Co-located collaborative care is exemplified by
  the White River Model.
• Winner of 2005 APA Gold Award
• This component embeds psychologists,
  psychiatrists, advanced practice nurses and
  social workers within the primary care setting.
• Assist primary care providers (PCPs) with
  evaluation and management of common mental health
  conditions.
• Provide brief counseling and psychosocial
  treatments as needed.

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Care Management

• Care management components include the Behavioral
  Health Laboratory (BHL) and Translating
  Initiatives for Depression into Effective
  Solutions (TIDES).
• BHL is centered on a software-based structured
  assessment interview, often implemented using a
  telephone call center.
• Health technicians typically perform these
  interviews designed to meet PCP needs for
  post-screening assessment, treatment monitoring,
  watchful waiting, and other on-demand needs.
• BHL psychologists and psychiatrists oversee these
  clinical functions, provide clinical expertise
  and crisis intervention as needed, and direct
  implementation in concert with primary care
  leadership.

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Care Management (cont.)

• TIDES is usually centered on a registered nurse
  telephone care manager, who collaborates with
  PCPs in providing protocol-driven assessment,
  monitoring and facilitation of treatment
  modification when needed.
• Program supervision occurs through a mental
  health specialist, consistent with the published
  evidence base for integrated care.
• Previously, TIDES had focused on depression now
  its scope has now expanded to include alcohol
  misuse, anxiety disorders, and screening for
  PTSD.

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Blended Programs

• VHA is currently placing emphasis on blending
  both co-located collaborative and care management
  components within PC-MHI programs.
• These components provide highly complementary
  activities that assist PCPs in delivering
  high-quality care for common mental health
  conditions.
• Co-located collaborative providers bring
  experience including diagnostic evaluation,
  management of suicidality, brief counseling and
  psychosocial treatments, and psychopharmacology
  support.
• Care managers offer expertise including
  algorithm-based assessment, patient activation
  and disease education, structured follow-up, and
  facilitation of treatment changes and specialty
  referral as needed.

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History

• PCMHI pilot program funding began during FY 2007
  under the mental health enhancement initiative.
• Enhancement initiative pilot program funding
  represented 409 full-time employee equivalents
  (FTEE) throughout programs located in 94
  facilities.
• Program growth outside of the enhancement
  initiative occurred at additional facilities
  through VISN and local initiatives.
• VHA targeted further expansion of PC-MHI under
  the enhancement initiative with the Uniform
  Mental Health Services Handbook (VHA Handbook
  1160.01) in September 2008.
• Set clinical expectations and structural
  requirements for FY 2009 and beyond.
• Directs that PC-MHI programs continue as routine
  practice.
• Presently, 478 FTEE are funded through the mental
  health enhancement initiative for PC-MHI.

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Progress
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Growth

• National implementation of PCMHI began during FY
  2007, with 94 of the 139 VHA facilities funded
  for pilot programs implementing evidence-based
  co-located collaborative or care management
  programs.
• In an implementation survey fielded in September
  2009, 131 of the 139 VHA facilities reported an
  operational PC-MHI program.

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National Program Office

• The National PC-MHI Program Office initially
  began to provide oversight and assistance with
  implementation of the pilot program proposals.
• As the program has grown, the Program Office has
  developed a multifaceted portfolio of activities
  supporting implementation
• ongoing program consultation and technical
  assistance
• education and training centered on both program
  implementation and training of frontline
  integrated care staff
• development of service delivery models blending
  both co-located collaborative care and care
  management
• identification and dissemination of best
  practices
• development and dissemination of information
  tools that support continuous quality
  improvement.

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Education and Training

• These programmatic efforts have been supported by
  a variety of education and training activities,
  in collaboration with the VHA Employee Education
  System and multiple PC-MHI program stakeholders.
  
• National conferences have been held annually
  since 2007.
• Monthly educational conference calls have
  addressed a range of clinical issues.
• Key implementation challenges are ubiquitous
  topics of discussion.
• Dissemination of best practices and highlighting
  well-performing programs have been key objectives
  during both formal and informal education and
  training experiences.

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Training

• The developers of the BHL and TIDES programs have
  offered training for front-line PC-MHI providers
  for a number of years, drawing participants from
  across the VA system.
• These skills-based trainings have focused on care
  management, use of assessment tools, and patient
  activation.
• During FY 2009, coordination of PC-MHI-related
  training activities was brought under the
  umbrella of the National PC-MHI Program Office,
  and a national training strategy developed.
• These trainings now incorporate not only care
  management content but also discussion of
  co-located collaborative care and blended
  programs.
• In addition to these collaborations with BHL and
  TIDES, the PC-MHI Program Office is also
  coordinating with the VISN 2 Center for
  Integrated Healthcare to provide skills-based
  training for co-located collaborative care
  providers.
• A national-level training needs assessment and
  further curriculum development are planned for
  the coming year.

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Evaluation

• Formative program evaluation has assisted
  implementation greatly, and is coordinated
  through the VA National Serious Mental Illness
  Treatment Research and Evaluation Center in Ann
  Arbor, Michigan.
• National PC-MHI Evaluation Office has analyzed
  encounter activity and diagnoses from the
  national VA claims database, tracked program
  uptake across facilities, and undertaken field
  visits to programs at VHA facilities.
• Analysis of diagnoses associated with PC-MHI
  encounters suggests that programs typically
  address the intended core conditions for PC-MHI
  (depression, anxiety, PTSD and alcohol problems).
  
• Qualitative interviews with program leaders from
  pilot program sites demonstrated characteristics
  of the most successful programs
• high functioning teams
• a passion for integration of services
• strong partnering of primary care and mental
  health providers and leaders .

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Stop Code

• Workload is captured through use of the PC-MHI
  stop code clinic identifier.
• Institution of a distinct stop code for PC-MHI
  was pursued upon commencement of the mental
  health enhancement initiative funding for
  tracking these pilot programs, and became
  effective 1 October 2007 (FY 2008).

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PC-MHI Encounters

• Encounter volumes from stop code use data reflect
  one measure of PC-MHI implementation.
• In FY 2008, stop code encounter data indicated
  that PC-MHI programs served a total of 76,942
  unique Veterans in 182,040 encounters.
• Data for FY 2009 showed considerable growth, with
  a total of 125,652 unique Veterans served in
  302,825 encounters.

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Expansion

• However, it should also be noted that in both
  policy and implementation, FY 2009 was a year of
  rapid change given the transition from pilot
  programs to the requirements of the Uniform
  Mental Health Services Handbook.
• VHAs Decision Support System Office approved
  modification of the PC-MHI stop code to drop the
  prior restriction in use to only enhancement
  initiative-funded sites.
• This change to allow its use at all VHA
  facilities became effective 1 October 2009 (FY
  2010).

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Partnerships

• The PC-MHI program has also partnered with other
  important VHA initiatives
• Post-deployment health clinics (PDHCs)
• PDHCs provide comprehensive and coordinated
  services for physical, mental health and
  psychosocial needs, within a primary care
  setting, for these returning combat Veterans.
• Mental health support at many PDHCs is provided
  by existing SeRV-MH Teams and PC-MHI staff.

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Partnerships

• Patient-centered medical home
• The medical home concept began as a method of
  coordinating complex care needs for children with
  chronic illness, but subsequently has been
  endorsed by all major primary care disciplines as
  a model of redesigning health care systems to be
  more responsive, efficient, coordinated, and
  preference-driven.
• Major VA implementation effort is commencing.

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Looking Forward

• The future of PC-MHI ultimately rests on
  fostering effective strategies for data-driven,
  continuous, and collaborative quality
  improvement.
• The program office is collaborating with the VHA
  Support Service Center (VSSC) in developing an
  electronic dashboard that will provide integrated
  feedback of key program attributes including
  structural characteristics, workload statistics
  and performance metrics to each facility's PC-MHI
  program.
• Information elements from the dashboard also play
  a key part in discussions that are commencing
  with the VISN-level primary care and mental
  health leadership to establish an ongoing process
  of regional facilitation of continuous program
  improvement.

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Looking Forward

• National PC-MHI education and training program
  continues to develop and refine high-quality
  products by not only engaging in continuous
  improvement of curricula, but also a clear
  communications strategy about what resources are
  best suited to an individual based on both their
  clinical discipline and their role within PC-MHI.
  
• One notable example of this strategy is the
  current development of modules aimed at enhancing
  the understanding of PC-MHI among collaborating
  PCPs, and promoting more effective and efficient
  interaction with co-located and care management
  integration staff.

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Conclusion

• VHA implementation effort continues to be the
  largest ever undertaken to integrate
  collaborative mental health resources into
  primary care.
• Since its inception as a national initiative of
  pilot programs in FY 2007, the PC-MHI Program has
  grown into a routine expectation of care at all
  VHA medical centers and large community-based
  outpatient clinics.
• The National Program Office supports the growth
  and development of PC-MHI.