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

1. Session # H1b October 28, 201111:15 AM Collaborative Care and Patient-Centered Medical Home within the Veterans Health Administration 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 VA’s efforts to date.

4. Objectives Upon completion of this presentation, participants will be able to: • Describe VA’s implementation of collaborative care--Primary Care-Mental Health Integration (PC-MHI) • Describe VA’s implementation of the patient-centered medical home--Patient Aligned Care Team (PACT) • Describe the role of VA’s 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. Secondary and Tertiary Care: • Outpatient Care for treatment resistant, severe or complex illnesses • PTSD specialty treatment; Substance dependence treatment • Treatment of serious mental illness (including MHICM) • Full spectrum of psychosocial rehabilitation and recovery services • Inpatient psychiatric care • Residential treatment • Supported and therapeutic employment • Homeless programs SPECIALTY MH PC-MHI • Integrated Care for physical and mental health in one setting • Evaluation and treatment for mild to moderate mental health conditions (depression, substance misuse, anxiety, PTSD) • Follow-up evaluation for positive MH screens • Behavioral health interventions for chronic disease • Care management • Referral management • Screening for mental health conditions • Initiation of pharmacological treatment for mild to moderate mood symptoms • Co-management of Veteran care with PC-MHI and specialty MH providers • Health Behavior PRIMARY CARE

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 TeamVHA’s 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 veteran’s 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 Access Offer same day appointments Increase shared medical appointments Increase non-appointment care • 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 • Practice Redesign • Redesign team: • Roles • Tasks • Enhance: • Communication • Teamwork • Improve Processes: • Visit work • Non-visit work 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 Team:Objective 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. 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 Team RedesignThe Patient’s Primary Care Team:

39. For each parent facility HPDP Program Manager Health Behavior Coordinator My HealtheVet Coordinator Other Team Members Pharmacy Social Work Nutrition CaseManagers Integrated Behavioral Health Panel size adjusted for rooms and staffing *The Patient Aligned Care Team

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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. 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 Essential Transformational Elements

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. 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 Essential Transformational Elements 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