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

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


1
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.
2
Faculty Disclosure
  • We have not had any relevant financial
    relationships during the past 12 months.

3
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.

4
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

5
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.

6
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.

7
Session Evaluation
  • Please complete and return theevaluation form to
    the classroom monitor before leaving this
    session.
  • Thank you!

8
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

9
MODELS OF MH IN PC AT DAWN OF 21ST CENTURY
  • Referral
  • Consultation/Liaison
  • Co-location
  • Collaborative Care
  • Integrated Care

10
CORE STUDIES IN INTEGRATED/COLLABORATIVE CARE
  • PROSPECT
  • IMPACT
  • PRISM-E
  • RESPECT
  • Demonstrate improved outcomes with care
    management.

11
DEVELOPMENT OF PC-MHI IN VA
  • MANY INDIVIDUAL PROGRAMS IN MANY SITES OVER MANY
    YEARS
  • SOME VERTICAL INTEGRATION
  • SOME HORIZONTAL INTEGRATION

12
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

13

14
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.

15
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

16
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

17
WHAT ABOUT SERIOUS PERSISTENT MENTAL ILLNESS?
  • VISION
  • Veterans with Serious Mental Illness will enjoy
    health status identical to the general
    population.

18
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)
19
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.

20
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

21
Patient Aligned Care TeamVHAs implementation of
the Patient Centered Medical Home
David A. Hunsinger, MD, MSHA Medical Director,
Binghamton VA Outpatient Clinic
22
VA kick-off off Patient Centered Medical
Homeinitiative
  • Las Vegas, NV
  • April 2010

23
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
24
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

24
25
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

26
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

27
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

28
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

29
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

30
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

31
VHA Implementation strategy
  • Three pronged approach to education/ team
    building
  • Regional collaboratives
  • Centers of excellence
  • Consultation/facilitation teams

32
VHA Implementation strategy
  • Regional collaboratives
  • Structured learning
  • Focus on a core team from each Medical Center
  • Emphasis on teach back

33
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

34
VHA Implementation strategy
  • Consultation/facilitation teams
  • Five teams
  • Physician, Nurse, Administrative staff
  • Trained in facilitation
  • Deployed to sites by site request

35
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
36
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

36
37
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.

38
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

39
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
40
40
41
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?

41
41
42
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

43
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

44
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

44
45
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
46
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

47
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

48
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

49
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

50
Conclusion
  • Primary Care - Mental Health Integration is and
    will continue to be an essential component of the
    team delivery of effective care

51
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

52
Words of Wisdom
  • If Id known I was going to live so long, Id
    have taken better care of myself.
  • - Leon Eldred

53
Prevalence of Chronic Conditions in VHA Primary
Care
Source Primary Care Almanac, VHA Support Service
Center, 2011
54
Underlying Causes of Diseases
48 potentially preventable
55
Prevalence of Health Behaviors
56
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
57
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!

58
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)
59
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

60
(No Transcript)
61
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.

62
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
63
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.

64
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).

65
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.
66
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.

67
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

68
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

69
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
  • (919) 383-7874 or (716) 604-5446 (m)
  • www.prevention.va.gov
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