Collaborative Care and Patient-Centered Medical Home within the Veterans Health Administration

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Collaborative Care and Patient-Centered Medical
Home within the Veterans Health Administration
Session H1b October 28, 20111115 AM

• Andrew S. Pomerantz, MD, National Mental Health
  Director for Integrated Care, Office of Mental
  Health Service, VA Central Office
• David A. Hunsinger, MD, MSHA, Member, National
  Consultation Team, VA Transformation to PACT
• Margaret Dundon, PhD, National Program Manager
  for Health Behavior, National Center for Health
  Promotion and Disease Management, VACO
• Larry J. Lantinga, PhD, Associate Director,
  Center for Integrated Healthcare, OMHS Center of
  Excellence

Collaborative Family Healthcare Association 13th
Annual Conference October 27-29, 2011
Philadelphia, Pennsylvania U.S.A.
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Faculty Disclosure

• We have not had any relevant financial
  relationships during the past 12 months.

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Need/Practice Gap Supporting Resources

• The Department of Veterans Affairs, the largest
  unified healthcare system in the United States,
  has undertaken a major transformation that
  embraces primary care-mental health integration
  within the context of the patient-centered
  medical home. National leaders within the
  Veterans Health Administration will describe VAs
  efforts to date.

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Objectives

• Upon completion of this presentation,
  participants will be able to
• Describe VAs implementation of collaborative
  care--Primary Care-Mental Health Integration
  (PC-MHI)
• Describe VAs implementation of the
  patient-centered medical home--Patient Aligned
  Care Team (PACT)
• Describe the role of VAs newly established
  Health Behavior Coordinators (HBC) and how they
  interact with PC-MHI PACT

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Expected Outcome

• We expect that you will take away a better
  understanding of what VA is doing to further
  collaborative care.
• We expect that you will learn what VA resources
  are available to your patients who are Veterans.
• We expect that you will now know with whom to
  network within VA in order to obtain access to VA
  knowledge and information.

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Learning Assessment

• A learning assessment is required for CE credit.
  In lieu of a written pre-post-test based on our
  learning objectives, I will moderate a Question
  Answer period at the conclusion of our
  presentation. Please hold your questions until
  then. Thank you.

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Session Evaluation

• Please complete and return theevaluation form to
  the classroom monitor before leaving this
  session.
• Thank you!

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Primary Care-Mental Health Integration in VA
Past, Present and Maybe Future

• Andrew S. Pomerantz, MD
• National Mental Health Director, Integrated Care
• Office of Mental Health Services
• VA Central Office
• Associate Professor of Psychiatry
• Dartmouth Medical School

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MODELS OF MH IN PC AT DAWN OF 21ST CENTURY

• Referral
• Consultation/Liaison
• Co-location
• Collaborative Care
• Integrated Care

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CORE STUDIES IN INTEGRATED/COLLABORATIVE CARE

• PROSPECT
• IMPACT
• PRISM-E
• RESPECT
• Demonstrate improved outcomes with care
  management.

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DEVELOPMENT OF PC-MHI IN VA

• MANY INDIVIDUAL PROGRAMS IN MANY SITES OVER MANY
  YEARS
• SOME VERTICAL INTEGRATION
• SOME HORIZONTAL INTEGRATION

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VA MODELS

• TIDES utilizes Care Management to support PCP
  treatment of depression
• Behavioral Health Laboratory (BHL) Structured
  telephone interview for triage and support of PC
  treatment of Depression, anxiety, at-risk
  drinking, etc
• Co-located collaborative care the White River
  Junction Model
• Blended models
• Health Psychology

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Emerging View

• Like other medical disciplines, Mental Health can
  be divided into PRIMARY, SECONDARY and TERTIARY
  care.
• Primary MH care can be delivered in the same
  setting as general Primary Care by expert
  clinicians horizontal and vertical integration.
• Secondary/tertiary MH care are specialized and
  require multiple disciplines.

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One size does not fit all

• Organizational Ethics The intentional use of
  values to guide the decisions of a system.
• From Clinical Ethics to Organizational Ethics
  The Second Stage of the Evolution of Bioethics.
  Potter, Robert Lyman, in Bioethics Forum.
  Summer, 1996

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ONE SIZE DOES NOT FIT ALL

• ADHERENCE TO THE BASIC PRINCIPLES
• EASY ACCESS IN PRIMARY CARE
• PROBLEM FOCUSED ASSESSMENT AND TREATMENT
• ONSITE CLINICIANS IN PC
• STEPPED CARE
• MEASUREMENT BASED CARE
• CARE MANAGEMENT
• ENHANCED REFERRALS
• LEADS TO CONSISTENT OUTCOMES
• IMPROVED RECOGNITION AND TREATMENT IN PC
• IMPROVED ENGAGEMENT IN SPECIALTY MH CARE
• CONSERVES SCARCE SPECIALTY RESOURCES

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WHAT ABOUT SERIOUS PERSISTENT MENTAL ILLNESS?

• VISION
• Veterans with Serious Mental Illness will enjoy
  health status identical to the general
  population.

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Community
Public health agencies, non-profit agencies, etc.
Non-VA Provide
PCPs, specialists, etc.
Cardiology, podiatry, etc.
PC-MHI, HBC, SW, pharmacy, etc.
PCP, RN CM, clinical assoc, admin assoc
Includes significant others and caregivers
The Patient Aligned Care Team (PACT)
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MODELS OF CARE

• Cohort model SMI patients receive PC in general
  primary care clinics from providers with specific
  interest skill in working with this population
• Consultative model PCMHI and/or Primary MH
  provider is consultant for PACT team/teamlet
• Enhanced Coordination between specialty MH and
  Patient centered medical home
• Specialty Care Team PC providers and services
  embedded in special care team. In VA, this model
  is limited mostly to screening e.g. PC APN
  located in SMI clinic, PCMHI providers in Post
  Deployment clinic
• Combination of above routine preventive
  screening in specialty clinic, advanced access
  to PACT, Care/Case management in MH.

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NEXT

• A single brand of PC-MHI
• Clear definition of blended
• Staffing guidelines
• Develop the Evidence Base for Brief Treatments
• Rural Models
• Integration with the rest of Mental Health

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Patient Aligned Care TeamVHAs implementation of
the Patient Centered Medical Home
David A. Hunsinger, MD, MSHA Medical Director,
Binghamton VA Outpatient Clinic
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VA kick-off off Patient Centered Medical
Homeinitiative

• Las Vegas, NV
• April 2010

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Veteran Centered Care
Definition A fully engaged partnership of
veteran, family and health care team, established
through continuous healing relationships and
provided in optimal healing environments, in
order to improve health outcomes and the
veterans experience of care
Universal Services Task Force, 2009
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Joint Principles of the Patient-Centered Medical
Home AAFP, AAP, ACP, AOA

• Ongoing relationship with personal physician
• Physician directed medical practice
• Whole person orientation
• Enhanced access to care
• Coordinated care across the health system
• Quality and safety
• Payment

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Principle 1Personal Physician (Provider)

• Every patient has a designated primary care
  provider.
• Relationship is ongoing continuous over time
• Patient choice
• Each physician has a Panel of patients

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Principle 2Physician (Provider) Directed

• Provide clinical direction
• Shared-Decision making
• Team-based care, leading the team
• Flattening the hierarchical structures
• Equal Value, Different Roles
• Championing principles of Medical Home
• Example Facilitating Care Coordination

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Principle 3Whole Person Orientation

• Health as a focus, not just Health Care
• Personal preferences of the patient drive care
  interventions
• Patient self-management skills and education
• Culturally relevant and sensitive
• Shared goal setting with health care team
• Health literacy and numeracy
• Family engaged in care
• Mental Health and Primary Care Integration

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Principle 4 Enhanced Access to Care

• Open Access principles (ACA)
• Ready and timely access to non face-to-face care
• Telephone, Messaging, Secure e-mail
• Web-based access to scheduling, information,
  records, labs
• System Redesign

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Principle 5Coordinating Care

• Transitions within and without
• Identifying and managing highest risk
• Chronic Disease Management
• Population-based Health Care
• Predicative Modeling
• Health Risk Assessment Tools
• Patient/Disease Registries

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Principle 6Quality and Safety

• Clinical performance
• Value Quality/Cost
• Medication reconciliation
• Quality and Safety are outcomes
• Effectively managing transitions
• Team dynamic drives performance
• Effective implementation of Medical Home
• Data driven, team-based, system redesign
• Continuous improvement

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VHA Implementation strategy

• Three pronged approach to education/ team
  building
• Regional collaboratives
• Centers of excellence
• Consultation/facilitation teams

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VHA Implementation strategy

• Regional collaboratives
• Structured learning
• Focus on a core team from each Medical Center
• Emphasis on teach back

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VHA Implementation strategy

• Centers of Excellence
• Goal to train ALL teamlets
• Trainings scheduled at sites chosen for ease of
  access
• Emphasis on team building, understanding key
  principles, and skill acquisition

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VHA Implementation strategy

• Consultation/facilitation teams
• Five teams
• Physician, Nurse, Administrative staff
• Trained in facilitation
• Deployed to sites by site request

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Patient Centered Medical Home

• Practice Redesign
• Redesign team
• Roles
• Tasks
• Enhance
• Communication
• Teamwork
• Improve Processes
• Visit work
• Non-visit work

• Care Management Coordination
• Focus on high-risk pts
• Identify
• Manage
• Coordinate
• Improve care for
• Prevention
• Chronic disease
• Improve transitions between PCMH and
• Inpatient
• Specialty
• Broader Team

Access Offer same day appointments Increase
shared medical appointments Increase
non-appointment care
Patient Centeredness Mindset and Tools
Improvement Systems Redesign, VA TAMMCS
Resources Technology, Staff, Space, Community
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Principles of the Patient-Centered Medical Home

• Ongoing relationship with personal physician
• Physician directed medical practice
• Whole person orientation
• Enhanced access to care
• Coordinated care across the health system
• Quality and safety
• Payment

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Patient Aligned Care TeamObjective

• To improve patient satisfaction, clinical
  quality, safety and efficiencies by becoming a
  national leader in the delivery of primary care
  services through transformation to a medical home
  model of health care delivery.

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Team RedesignThe Patients Primary Care Team

• Teamlet assigned to
• 1200 patients (1 panel)
• Provider
• RN Care Manager
• Clinical Associate
• LPN
• Medical Assistant
• Health Tech
• Clerk

• Team members
• Clinical Pharmacy Specialist
• 3 panels
• Medical Social Work
• 2 panels
• Nutrition
• 5 panels
• Mental Health
• Case Managers
• Trainees

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For each parent facility HPDP Program
Manager Health Behavior Coordinator My HealtheVet
Coordinator
Other Team Members Pharmacy Social Work
Nutrition Case Managers Integrated Behavioral
Health
Panel size adjusted for rooms and staffing
The Patient Aligned Care Team
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Essential Transformational ElementsPatient
Aligned Care Team

• Delivering health in addition to disease care
• Veteran as a partner in the team
• Empowered with education
• Focus on health promotion and disease prevention
• Self-management skills
• Patient Advisory Board
• Efficient Access
• Visits
• Non face-to-face
• Telephone
• Secure messaging
• Telemedicine
• Others?

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Essential Transformational Elements

• Care coordination
• Optimizes hand-offs between inpatient and
  outpatient care
• Facilitates interface with specialty care
• Seamless co-management (Dual Care) with outside
  providers
• Incorporates tele-health, and HBPC services
• Emphasizes home care rural health

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Essential Transformational Elements

• Care Management/ Panel Management
• Disease management and interface with specialty
  care
• Chronic Care Model
• Disease registries
• Identification of outliers
• Team RN partnering closely with providers
• Veterans at high risk for adverse outcomes
• Pain management
• Returning combat veteran care
• Depression
• Substance abuse

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Essential Transformational Elements

• Improve technological clinician support
• Decision support
• Predictive modeling
• CPRS user-friendliness
• Information processing
• Develop new measurement and evaluation tools
• Patient Satisfaction
• Staff satisfaction
• Processes of care
• Manager and Provider Report Cards
• Continuity and comprehensiveness

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Whole Person Orientation
you ought not to attempt to cure the eyes
without the head or the head without the body, so
neither ought you to attempt to cure the body
without the soul . . . for the part can never be
well unless the whole is well.
Plato
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Mental Health is an Integral Part of Overall
Health

• Physical problems can be risk factors for mental
  health problems
• Mental health problems can be risk factors for
  physical health problems
• Patient Centeredness means a holistic view of the
  Veteran, recognizing the interrelationships of
  all health problems and how they individually and
  interactively affect quality of life

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Mental Health and Primary CareA Natural Fit

• 26 of Veterans who use VA health care are also
  being treated for a mental health diagnosis
• 20 currently receive some or all of that care in
  a specialty Mental Health setting
• Patients initially bring their mental health
  concerns to Primary Care
• Screening for mental health problems takes place
  in primary care Clinical Reminders
• Referrals from Primary Care to Specialty Mental
  Health result in a high rate of no-shows

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Primary Care Mental Health Integration

• PC-MHI embodies the principles and focus of the
  Patient Centered Medical Home
• Work on PC-MHI implementation facilitated PACT
  implementation

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True IntegrationFeatures of PC-MHI

• Completely integrated within primary care
• Occupy the same space
• Share the same resources
• Participate in Team Meetings
• Share responsibility for care of the whole
  patient

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Conclusion

• Primary Care - Mental Health Integration is and
  will continue to be an essential component of the
  team delivery of effective care

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Collaborative Care for Health Behavior Change

• Collaborative Family Healthcare Association
  Conference, 2011
• Peg Dundon, PhD
• National Program Manager for Health Behavior
• VHA National Center for Health Promotion and
  Disease Prevention

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Words of Wisdom

• If Id known I was going to live so long, Id
  have taken better care of myself.
• - Leon Eldred

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Prevalence of Chronic Conditions in VHA Primary
Care
Source Primary Care Almanac, VHA Support Service
Center, 2011
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Underlying Causes of Diseases
48 potentially preventable
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Prevalence of Health Behaviors
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Health Impact of Unhealthy Behaviors

• The World Health Organization estimates that...
• at least 80 of all heart disease, stroke, and
  type 2 diabetes, and
• more than 40 of cancer
• would be prevented if people were to
• Stop smoking
• Start eating healthy
• Get into shape

WHO. Preventing Chronic Disease A Vital
Investment, 2005
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Where Do We Go From Here?

• Effective interventions for poor health behaviors
  exist
• Health behaviors often not addressed
  (successfully) and interventions often not
  provided
• Healthcare staff often not well-trained in
  appropriate behavior change strategies
• Traditional, directive/persuasive approaches have
  limited success
• We can shift the medical culture to one marked by
  patient-centered communication for healthier
  behaviors
• This is a major transformation!

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PACT Transformation A Fundamental Shift in the
Process of Care
Traditional Care
Collaborative Care

• Assumes knowledge drives change
• Clinician sets agenda
• Goal is compliance
• Decisions made by caregiver

• Assumes knowledge confidence drives change
• Patient sets agenda
• Goal is enhanced confidence
• Decisions made collaboratively

(Bodenheimer et al, CA Health Care Foundation,
2005)
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National Center for Health Promotion/Disease
Prevention (NCP)

• Field-based national program office in the Office
  of Patient Care Services (PCS)
• Located in Durham, NC
• Provides policies, programs, guidance, education,
  and support for field related to preventive
  health
• Provides expert input to senior VHA leadership
• Collaborates with other VHA offices and federal
  agencies

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Preparing a Cadre of Prevention Staff to Train,
Coach and Consult with Clinicians

• Health coaching
• Motivational interviewing
• Health literacy
• Evidence-based health
• promotion/disease prevention
• Problem solving approaches
• All aimed to support clinical staff members in
  promoting patient self-management of health
  behavior.

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Other Team Members Clinical Pharmacy Specialist
3 panels Clinical Pharmacy anticoagulation 5
panels Social Work 2 panels Nutrition 5
panels Case Managers Trainees Integrated
Behavioral Health Psychologist 3 panels Social
Worker 5 panels Care Manager 5
panels Psychiatrist 10 panels
For each parent facility HPDP Program Manager 1
FTE Health Behavior Coordinator 1 FTE My
HealtheVet Coordinator 1 FTE
Panel size adjusted (modeled) for rooms and
staffing per PCMM Handbook
Monitored via Primary Care Staffing and Room
Utilization Data report in VSSC
The Patients Primary Care Team
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HBC Roles and Responsibilities

• Promotes evidence-based patient-driven care in
  Health Promotion and Disease Prevention (HPDP).
• Co-chairs the facility HPDP Program Committee.
• Assists the HPDP Program Manager to coordinates
  strategic planning, program development and
  implementation, monitoring and evaluation of the
  overall HPDP Program.
• Leads and coordinates training and ongoing
  coaching for PACT staff in patient-centered
  communication, health behavior change coaching,
  and self-management support strategies, including
  TEACH for Success and Motivational Interviewing.

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HBC Roles and Responsibilities contd.

• Collaborates with the key members of the HPDP
  Program Committee to plan, develop, implement and
  assess the impact of clinical interventions to
  promote health behavior change and
  self-management.
• Works collaboratively with Mental Health Primary
  Care Integration staff to integrate behavioral
  medicine interventions and services with other
  behavioral health interventions and programs.
• Supports and contributes to existing smoking and
  tobacco use cessation clinical initiatives.
• Performs specialty health psychology
  assessment/intervention (e.g., pre-bariatric
  surgery, Veterans with unique or complex problems
  impacting self-management plans).

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CCC and HBC
Co-Located Collaborative MH Care Health Behavior Coordinator
Location On site, embedded in the PC clinic On site, embedded with PACT
Population Most are healthy, mild-mod symptoms, behaviorally influenced problems. Provider training focus. PACT clinical work focused on health behaviors and prevention.
Inter-Provider Communication Collaborative on-going consultations via PCPs method of choice (phone, note, conversation). Focus within PACT. Collaborative on-going with focus on communication skills and coaching (F2F, phone). Focus within PACT and HPDP staff.
Service Delivery Structure Brief appointments (20-30) Limited of appointments (avg. 2-3) Open Access Role focus on training PACT clinicians (70) in patient-centered communication. Limited (25-30) clinical care, prevention focused, often group. Brief appointments (30-40).
Approach Problem-focused, solution oriented, functional assessment. Focused on PCP question/concern and enhancing PCP care plan. Population health model. Health behavior focused, solution oriented, problem-solving and goal setting. Focused on PCP identified health concerns and optimizing health. Population health model.
Treatment Plan Leader PCP continues to be lead PCP continues to be lead.
Primary Focus Support the over-all health of the Veteran. Focus on function. Support the overall health of the Veteran. Focus on health behavior.
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Differences

• PC-MHI focus on mental health concerns, and HBCs
  on prevention/health behaviors.
• HBCs part-time clinical (25-30), PC-MHI
  full-time, and HPDPs administrative. Access
  options vary.
• HBCs main mission is to train and coach PACT
  staff in patient-centered communications, PC-MHI
  main mission is direct patient service via brief
  evidence-based care.
• HBCs provide specific assessments related to
  prevention, such as pre-Bariatric Surgery
  evaluations.
• HBCs often report to Primary Care PC-MHI
  generally report to Mental Health.
• HBCs are responsible for CBOCs too.

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Similarities

• Both are PACT-based, behavioral health staff
• Neither provide traditional psychotherapy
  services
• Both can offer holistic and systems perspectives,
  helping PACT staff be effective
• Both might address alcohol misuse, tobacco
  cessation, weight management, sleep difficulties,
  pain management, adherence concerns,
  problem-solvingothers?
• Both can organize interventions in 5 As model
• Both provide time-limited, solution oriented
  interventions

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In sum, what can HBCs PC-MHI staff offer their
colleagues in the medical home?

• Increased comfort in challenging interactions
  with patients (and staff!) with shift to
  collaboration vs. traditional, prescriptive
  approach
• Patient and provider behavior change
  (communication, health behaviors)
• Systems shifts to support Veteran-centered care
  (flexible delivery methods, accessible/efficient
  care delivery)
• Provider and patient skill development
• Focus on the conversation and interactions that
  address meaningful change for given individuals
• Increased clinician and patient satisfaction

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Questions or Ideas to Share?

• National Center for Health Promotion and Disease
  Prevention (NCP)
• Office of Patient Care Services
• Veterans Health Administration
• Margaret (Peg) Dundon, PhD
• margaret.dundon_at_va.gov
• 3022 Croasdaile Drive, Suite 200
• Durham, NC 27705
• [phone] or [phone] (m)
• www.prevention.va.gov