Primary Care-Mental Health Integration in the Department of Veteran Affairs By Dr. Pomerantz

Primary Care-Mental Health Integration in the Department of Veteran Affairs By Dr. Pomerantz


-Good afternoon, everyone. For those who’ve joined us
this morning, welcome back. We also welcome anyone who is
joining us this afternoon on the HHS Virtual Meeting on the “State of the Art: Research, Models,
Promising Practices and Sustaining Integrated Care.” Our next presentation is going
to be from Dr. Andrew Pomerantz from the Department
of Veteran Affairs. Dr. Pomerantz. -Hey, thank you very much. So we only have a short time,
so why don’t we skip straight to the next slide, which raises the question that I often get in many
of these slides of, is the VA’s experience relevant? You know, we’re often seen
as an organization that is somehow different than other health
care organizations, but I think, if you look
at us fairly closely, you’ll find an awful lot
of what we do is very similar. In many ways, we’re a very large
Accountable Care Organization, caring for a defined
population patient, traditionally bearing almost
all the responsibility for care of those patients, although, in recent years, increasing sharing
with the community. And it’s important that
the VA population tends to be, from a number of studies, sicker
and carrying a higher disease burden than most populations. Even though we are
a capitated system, we do measure our RVUs, and I’ll get back to more
about the RVUs later. Next slide, please. So a couple
of definitions first, the Patient Aligned Care Team, the PACT, is the VA’s version of the Patient-Centered
Medical Home. And it conforms pretty
closely to the PCMH as originally outlined
by Bodenheimer and others and is the traditional model of the patient-centered
medical home. Primary Care-Mental Health
Integration, we call PCMHI, and that is the major component of our integrated care
initiative in VA. A number of different types
of providers are then added on to be, as part of the PACT, I’ll use that term from now on, as part of the PACT
and the team, to bring mental health services to patients in primary care. Next slide, please. So what are we doing? Here’s what we’re trying to do. One is provide open access
to mental health care in primary care. And mental health care,
as we all know, the longer you wait before you see
a mental health clinician, the less likely you are
as a patient to attend that appointment
and engage in care, so what we aim for in our goal is to have care immediately
available at the time the need is identified
in primary care. One thing this helps
to do really is, by managing a lot of common conditions
in primary care, we can serve those scarcer but highly specialized
mental health resources for the people
who really need them so that not everybody
with a mental health problem needs to go on the whole 9 yards of full mental health
assessment and treatment. We’re bringing service
directly to the patient, and more importantly, the patients are learning in the VA that, you know,
mental health is no different. It’s just part of primary care. The biggest challenge
in our system and many others is organizing
our mental health care services in a stepped care fashion. You heard a little bit
about this this morning, the importance
of stepped care. I think most of us were trained to treat everybody
with a mental illness, a mental health
condition the same way with a comprehensive assessment, lots of treatment, and it’s not
really necessary. If we start with
patient self-care, self-management,
community supports, helping people manage
their own illnesses and mental health services as needed to the severity
of the problem, you can avoid a lot of those
high-cost services being used on people
who don’t really need them. Next slide, please. So the components, one is the
co-located collaborative care. I think many people
are familiar with the term behavioral health consultant. These are the mental health
clinicians who are embedded in the patient-aligned
care team, and they provide, you know,
a lot of advice. They’re expected to be present
in the team huddle whenever they happen, either beginning of the day
or at the end, providing advice. In some cases, they may
provide direct assessment as well as brief
treatment intervention. The model has been kind of based
around population-based care for, you know, common, uncomplicated mental illness and substance use disorders as well as addressing
health behavior change, and it’s important, and I think that just
because you don’t see us doesn’t mean we’re not part
of your care team or taking care of you. There are a lot of people
who benefit from our advice who we never see. There’s no real panel for us. If there is a panel, it’s the
entire primary care population, whether we see them or not. So next slide, please. The second component
is one you heard about from Dr. Unuetzer this morning, and that’s the collaborative
care model, and ours is no different
from what he was describing. There are a lot
of different brands, within VA and elsewhere, of the collaborative care model, whether it’s impact, respect, prospect or the ones that we predominantly use in VA. They’re all the same thing,
and I think they’re already, you know, pretty thoroughly
described earlier today, so we’ll go to the next slide. There are other parts
of integrated care. In the corner, the health
behavior coordinator. And the vast majority of the health behavior
coordinators are psychologists. This is a program
that was rolled out separately in VA around the time that the PACT was developing, and their role is to support
primary care in learning how to better manage conditions with a prominent
behavioral component. They provide a lot of training
for primary care, teaching them skills
in motivational interviewing. Technically, on paper,
by policy, only 25% of the HBC’s time is expected to be
in one-to-one clinical care, and that varies a lot
around population because even though we may teach
some of these skills to the primary care providers, they may not have time
to implement them with every patient every time. They’re also health promotion
disease prevention program managers who are overseeing
and coordinating the prevention efforts
in the PACT. So the next slide, please. If they’re taken together,
all of those components make up integrated care in VA. It was also mentioned
this morning by Dr. Moran, I think, that, you know,
universal screening is great, but if there’s no
clinical pathway following it, it may do more harm than good. So what this program has done
in VA is it has created an actual clinical pathway so that when the PCP or other primary
care team members see that there’s a problem
that needs to be addressed, there’s a way to do it,
you know, either getting advice from us or actually having us
see one of the patients. We do provide a lot
of brief treatments. I’ll talk more about
that in a moment. We’re also there to support
mental health treatment when it’s provided by the PCP. I mean, that may be, you know,
the primary care provider or primary care team. It may be using
the collaborative care model with our care managers. It may be providing some advice. It may be even seeing
that patient or a visit just to kind of reinforce
what’s already going on. We’re there to provide
education and training for primary care teams
on mental health issues, and very important
is how we’re there to support the primary care team after people have
completed a course of specialty mental health care. And this is one
of the common problems that limits access
to mental health services in many systems is that patients
often get referred to mental health services and never come back. Their care remains
in mental health. Having us as part
of the primary care team makes it easier to transition
patients back to, you know, back into
primary care. We’re always there. You know, primary care
folks would often say to me, “Well, I’m afraid
if we take them back, we’ll have to wait months
if something goes wrong again.” So we’re there for
immediate help as well as to help coordinate care for those who are in specialty
mental health services, along with their primary care. So the next slide. This slide is just another way
of demonstrating stepped care. We can go on to the next slide. So how are we monitoring this? We’re still working
on universal outcome measuring. In the meantime, we use a lot
of other measures to gauge how our programs are doing. One is a measure
of the percentage of primary care patients
who see one of the providers, and as of right now, 7.9% of the entire
primary care population in VA had an appointment
with one of us. The other thing that’s
important, as I mentioned before, is the percent of patients
whose first visit with us is on the same day
as their primary care encounter. Both measures are flawed. They are the best we can do
with available data. You know, for instance,
the same-day access one, if somebody can’t come that day or if somebody
comes in independent of their primary care
provider visit, that’s a zero on the numerator. So programs that are open-access
over all patients with mental health disorders, those programs
don’t look as good. The same with the PACT 15, the percentage of patients
who actually see us, there’s no workload credit
or nothing recorded if we provide some advice
that helps primary care do a better job of taking care
of an individual patient, but for now, they’re the best
measures we have. So next slide, please. So this is one of those
building the airplane while you’re flying it, the evidence base for co-located
collaborative care, the behavioral
health-embedded provider outside of the collaborative
care person, the care manager. You know, there were not a lot
of brief treatments available. What you see here, you know, is what has happened
in the 10 years since this program first
rolled out, a lot of research going on
condensing 12-week protocols into one-to-four
session protocols of 30 minutes or less, so all these that are listed, other than insomnia, are going on now. In fact, the units are meant
to call attention to the opiate crisis,
that last bullet there, really shifting substance-abuse care to a broader understanding that that, too, is stepped care and that many patients
with opiate-use disorders can be successfully
managed in primary care. Next slide, please. So what have we found so far? And I think this is all,
you know, pretty straightforward
services stuff. We do find that we identify
an awful lot more patients and provide treatment
for a lot more patients once this program
is implemented. Those who are seen
by our providers, when they do get referred, need to be referred
for more specialized treatment, they are much more
likely to engage. Patients like it,
and staff likes it. So there’s been a great deal
of service-level findings. And from my perspective,
a system of this size with some 6 to 8 million patients and 1,500 or more sites
of care, you know, any positive trends that emerge
from national evaluation data given the unevenness
of implementation from site to site,
anything is very powerful. Next slide, please. So what have we found
to be important? And I think this is pretty,
you know, pretty self-evident. I have to mention
leadership support. Specifically, we’ve seen many
programs rise to the top when they’re
understood and valued and promoted by leadership and then fall precipitously
when leadership changes. Another thing that’s
very important is really understanding
the model of care. As we said earlier,
simple co-location isn’t enough. You can’t take what you do in
a specialty mental health clinic and bring it into primary care and maintain access. It has to be this brief stepped-care approach
to treatment. Next slide. These programs
have been sustained, and I think that
the bottom bullet really demonstrates something. There was funding in the first
couple of years was distributed nationally back in ’07, ’08, and most of the growth,
all of the growth, you know, particularly
in the last 5 years, has been from
facilities learning that this really
does conserve resources and shifting more
and more resources from specialty care
into primary care. Next slide. A lot of challenges, I think one
of things we struggle with, as many other settings do, is these interventions don’t demonstrate a lot of RVUs. And, you know, people often
talk about cost-effectiveness, maybe talking about
different things. Often, we’re expected
to save money, and again, as we saw earlier, it takes a long time
to demonstrate cost savings. VA has an innovative
space-design model for new primary care clinics. It’s team-based space. There are no private
administrative offices. It’s all shared space among all
members of the primary care team with separate examining areas, consultation rooms that basically belong
to the patient. So go to the next slide. There are things that — There’s a lot more
telehealth being used, particularly in rural areas. I think there’s…
We have 25 pilot sites now in VA using peer specialists
in primary care. That program we started
about a year ago. It’s been very successful
in those sites. There’s a lot more we can do,
and a couple of sites, they are participating
in care management. They’re also doing
health coaching and a number
of other activities. I think one area that we need
to move towards in our future is to really be able to work with more complicated illnesses
in primary care. You know, I think
we’ve got the basic, you know, population-based care for common,
uncomplicated illness, and I think our next challenge
is to bring more care for more seriously ill patients. And the next slide,
I’ll say a little bit about that before concluding. I’ve done a lot of focus groups
and interviews with clinicians and patients. What about people
with serious mental illness? Do we develop separate mental
health primary care homes, you know, in our mental
health clinics, or do we do something different? And they’re very,
you know, very, very interesting
comments from all, and I don’t think any of us
knows the single best answer. There are a lot of of pilots, a lot of of studies
going on looking. We do know that care
as usual isn’t very good. We go to the next slide. You see, one of the things
that we found in VA… Our choice has been, rather than to develop freestanding mental
health services that have primary care
embedded in them, to bring the resources
into primary care. We know from some
of the literature that the life expectancy
for patients with serious mental illness
in VA is a little less poor, let’s say, than it is
outside the VA. Why that is, I can’t really say. It may be that
we’re an integrated system. It may be that VA has always
invested significant funding in mental health. We really don’t know,
but we know that we’ve seen a number of findings that demonstrate that,
you know, this is working, at least, in our system
with our population. We do have the PACT,
Patient-Centered Medical Homes, for seriously mentally ill
separated out in some sites, but the expectation is that those are
transitional in nature, and the expectation
is that patients will eventually be able to transition into regular
primary care clinics. Next slide, please. So here a couple
of slides of references, and then we can skip
to the last slide, which is my contact information. Obviously, there’s no time
for questions, but I’d be very happy
to take questions by e-mail if anybody cares to e-mail me. -Thank you, Dr. Pomerantz.

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