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

2. VA Primary Care-Mental Health Integration (PC-MHI) Edward Post, MD, PhD National PC-MHI Medical Director

3. “Primary care practitioners are a critical link in identifying and addressing mental disorders... Opportunities are missed to improve mental health and general medical outcomes when mental illness is under-recognized and under-treated in primary care settings.” - Former Surgeon General David Satcher “The greatest mistake in the treatment of diseases is that there are physicians for the body and physicians for the soul, although the two cannot be separated.” - Plato Primary Care-Mental Health Integration

4. Chronic disease • Multiple comorbidities • Need for interdependent skills across medical disciplines and teams • Patient outcomes are interdependent • Multiple studies show depression has an independent effect on all-cause mortality(Gallo et al., 2005; Penninx et al., 1999; Bruce and Leaf, 1989) • Data from late-life depression trial shows integrated care can decrease mortality (Gallo et al., 2007) Primary Care Landscape

5. Integrated mental health care... • Improves identification of prevalent mental health conditions • Improves access to appropriate evaluation and treatment • Improves treatment engagement and adherence • Increases probability of receiving high quality care • Improves clinical and functional outcomes • Increases patient satisfaction Why Integrate Mental Health Services into Primary Care?

6. Improved identification • Improved identification of depression, psychiatric co-morbidities and substance misuse (Oslin et al., 2006) • Improved identification of depression (Watts et al., 2007) • Improved access • Increased rates of treatment (Alexopoulos et al., 2009; Watts et al., 2007; Bartels et al., 2004; Hedrick et al., 2003; Liu et al. 2003; Unützer et al., 2002) • Reduced wait times (Pomerantz et al., 2008) PC-MHI Evidence Base

7. Improved engagement and adherence • Improved engagement in mental health treatment (Zanjani et al., 2008) • Improved engagement and adherence in treatment for depression and at-risk alcohol use (Bartels et al., 2004) • Greater antidepressant adherence (Hunkeler et al., 2006; Katon et al., 1999, 2002) • Improved no-show rates (Pomerantz et al., 2008; Zanjani et al., 2008; Guck et al., 2007) • Higher quality care • Increased probability of receiving guideline-concordant treatment (Watts et al., 2007; Roy-Byrne et al., 2001) • Higher patient perceptions of quality of care (Katon et al., 1999) PC-MHI Evidence Base

8. Better clinical and functional outcomes • Improved short and long term clinical (remission; symptom reduction) and functional outcomes compared to standard care for depression (Alexopoulos et al., 2009; Gilbody et al., 2006; Hunkeler et al., 2006; Katon et al., 2002; Unützer et al., 2002; Roy-Byrne et al., 2001; Katon et al., 1999) • Similar remission rates and symptom reduction for depression compared to enhanced specialty referral (Krahn et al., 2006) • Decrease in at-risk alcohol use comparable to enhanced specialty referral (Oslin et al., 2006) • More rapid clinical response (Alexopoulos et al., 2009; Hedrick et al., 2003) • Higher fidelity to integrated care model resulted in better patient response and remission rates (Oxman et al., 2006) • Increased patient satisfaction (Pomerantz et al., 2008; Hunkeler et al., 2006; Chen et al., 2006; Areán et al., 2002; Unützer et al., 2002) PC-MHI Evidence Base

9. Complementary Settings: VA Vision for Mental Health Services

10. Two PC-MHI Components: • Co-located Collaborative Care • White River Junction • Care Management • TIDES, Behavioral Health Laboratory • Blended programs have both of these complementary components • Focus on common conditions: • Depressive and Anxiety Disorders • Alcohol Misuse and Abuse • PTSD Screening/Assessment Primary Care-Mental Health Integration

11. Identification • Screening in primary care • Assessment and triage to appropriate level of service • A spectrum of services • Monitoring or watchful waiting • Brief interventions (e.g., for alcohol misuse) • Medication therapies • Psychotherapies • Follow-up and monitoring • Quality control and efficiency Necessary Integrated Care Processes 11

12. Co-location/Co-located ServiceAbehavioral health provider working in a space that is in close proximity to (or embedded in) a primary care clinic.Collaborative Care/CollaborationThe interactions between primary care and behavioral health providers for the purpose of developing treatment plans, providing clinical services and coordinating care to meet the physical and behavioral health needs of patients Introduction to Co-located Collaborative Care (CCC) What is Co-located Collaborative Care in PC-MHI?

13. CCC vs. Traditional MH

14. Translating Initiatives for Depression into Effective Solutions (TIDES) • Evidence-based collaborative care model supporting depression management in the primary care setting • Has promoted improvements in treatment adherence for Veterans with depression in several VISNs • Behavioral Health Laboratory (BHL) • Evidence-based clinical service supporting mental health and substance abuse management in the primary care setting • Associated with a significant increase in screening and identification of patients needing MH/SA services (Oslin, et. al. 2005) Care Management Models in PC-MHI

15. Care Managers Role of the Care Manager • Nurses and social workers are core profession, but others serve as care managers also • Interact directly with patients and PCPs, facilitating ongoing evaluation and communication allowing care to remain in primary care • Assessment and triage • Decision support • Patient education and activation • Monitor adherence to treatment, treatment outcomes, and medication side effects • Referral management • Support patient self-management

16. Blended programs combine both care management and co-located collaborative care • In the blended program, the co-located collaborative mental health provider evaluates patients and offers treatment when needed, while the PC-MHI care manager provides complementary services including education, assessment, monitoring of adherence, use of medication and referral to specialty care when necessary Introduction to Blending PC-MHI Programs What is a Blended PC-MHI Program?

17. Strong collaborative system between primary care, mental health and other health care specialists • Stepped care approached to providing a continuum of care within the PC-MHI program • Ability to rapidly evaluate and stabilize patient in primary care clinic • Ability to do seamless referral, if needed • Ability to implement evidence-based treatment plans • Ability to collect objective clinical and administrative outcome data Core Components of an Effective Blended MH Integration Program

18. Large-scale implementation began in 2007 with RFP funding for pilot programs of a single component at 94 of 139 VA health systems • Late 2008: Uniform MH Services Package extended focus • VHA Handbook 1160.01 requires that VAMCs, extra large CBOCs, and large CBOCs integrate primary care and mental health by blending both co-located collaborative care and care management History of VA PC-MHI Implementation 18

19. VAMCs & extra large CBOCs (>10K uniques) need full-time availability of both co-located services & care management • Large CBOCs (5K-10K uniques) need co-located services & care management, availability as appropriate • Medium-sized CBOCs (1.5K-5K uniques) need on-site MH services, configured (integrated vs. MH clinic) as appropriate • Small CBOCs need to provide access to MH services Uniform Mental Health Services Package

20. Service Utilization Data Service Utilization Data reported from facility stop code usage

22. PC-MHI: State of the Field The PC-MHI Penetration Rate is the number of unique PC-MHI encounters divided by the number of unique Primary Care encounters →Please note that there is not a PC-MHI penetration rate performance measure or target

23. Principal Contact: Maureen Metzger, PhD, MPH National Program Manager Maureen.Metzger@va.gov 734-845-5719 • Thank you to many faculty who collaborate in presenting our training programs, and to innumerable persons who are implementing PC-MHI throughout VA! National PC-MHI Program Office

24. Questions?