Building the Plane While Flying It: Implementation of the Medical Home in VA Healthcare

1. Building the Plane While Flying It: Implementation of the Medical Home in VA Healthcare Joanna Dognin, Psy.D. Julia Buckley, PhD Craig Tenner, MD Kelly Crotty, MD, MPH Margaret Horlick, MD VA New York Harbor Healthcare System October 28, 2011 Collaborative Family Healthcare Association 13th Annual Conference October 27-29, 2011 Philadelphia, Pennsylvania U.S.A.

2. Who we are… • Joanna Dognin, Psy.D. – Health Behavior Coordinator • Julia Buckley, PhD – Former Health Coordinator • Craig Tenner, MD – Health Promotion Disease Prevention Program Manager • Kelly Crotty, MD, MPH – Health Promotion Disease Prevention Program Manager • Margaret Horlick, MD – Associate Program Director of NYU Internal Medicine Residency Program

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

4. The Medical Home: Building the Plane… • Joint principles of patient-centered medical care • Personal relationship with MD • MD-directed practice • Whole person orientation • Coordinated care • Quality & safety • Enhanced access

5. The Medical Home: …While Flying It • Patient-centered medical home = patient aligned care team (PACT) • Core “teamlet” • Extended team • Revamping PC/MH integration • Health Promotion / Disease Prevention focus • HPDP Program manager position • HBC position • HPDP Committee

6. Objectives • Describe the Veterans Health Administration’s (VA) Medical Home model • Demonstrate increasing levels of collaboration between primary care and mental health providers • Highlight the role of behavioral health specialists as collaborators and educators in this new model • Introduce unique training opportunities for the next generation of medical and mental health providers

7. Primary Care in the VA • US’s largest integrated health care system • Comprehensive electronic medical record • 820 sites of Primary Care • 152 Medical Centers • 668 Community Based Outpatient Clinics (CBOC) • 4.5 million primary care patients - each assigned to an individual primary care provider PCMM/VSSC data as of 5/15/09

8. Primary Care in the VA • 12 million encounters/year • Revisit rate (visits/yr): 2.5 • 21% had encounter in Mental Health • 6.3% had admission • 5,000 provider FTEE • 72% physician • 20% Nurse Practitioner • 8% Physician Assistants PCMM/VSSC data as of 5/15/09

9. Primary Care in the VA by Age & Gender 44% 6.1% Female 25% 21% had encounter in Mental Health

10. Education at the VA • Over 100,000 medical and associated health students, residents and fellows • Physicians, PAs, nurses, NPs, pharmacists, dentists, dietitians, psychologists, PTs, SWs, optometrists, podiatrists, and respiratory therapists • 50% of US psychologists have had VA training prior to employment • 1200 educational institutions, including 112 medical schools

11. IM Training at NY Harbor • One of three primary training sites for the NYU IM Residency Program • Primary Care Clinic for 60 IM residents • Weekly continuity clinic sessions • Month-long ambulatory care rotations (1 in the intern year, 2 in the R2 and R3 years) • Inpatient rotations: General Medicine, ICU, CCU • 3 Chief Resident positions: outpatient, inpatient, patient safety and quality

12. Psychology Training at NY Harbor • APA accredited psychology internship program, currently 6 interns a year • Primary care mental health/health psychology is one of three major rotations • Psychology externships • Health psychology externship • Neuropsychology externship • Suicide prevention externship • Postdoctoral fellowship in Health Psychology

13. Old Primary Care Model

14. Case Vignettes • “Mr. Roberts” is a 62-year-old male with paranoid schizophrenia, hypertension, difficulty following up with primary care due to frequent psychiatric admissions (10 in past year). • “Mr. Lato” is a 48-year-old male with uncontrolled diabetes, osteoarthritis, sleep apnea, obesity, addiction & long history of noncompliance with care.

15. Case Vignettes • “Mr. Smith” is a 50-year-old male with poorly controlled diabetes. No psychiatric diagnosis or interpersonal issues. Ambivalent around taking medications & insulin injections. Tells pharmacist “my medications are like a ball and chain”. • “Ms. Ramirez” is a 52-year-old Hispanic female with no significant past medical history. She has not been receiving regular primary care for a number of years.

16. MH/PC Integration Options • Level 1:Minimal Collaboration • Level 2: Basic Collaboration from a Distance • Level 3: Basic Collaboration On-Site • Level 4:Close Collaboration in a Partly Integrated System • Level 5 : Close Collaboration in a Fully Integrated System Doherty W., McDaniel S., & Macaran A.B., 1995

17. Primary care - mental health integration • FY07 Goal of VA’s Mental Health Strategic Plan: “develop a collaborative care model for mental health disorders that elevates mental health care to the same level of urgency/intervention as medical health care” • PC-MHI programs: • Increase in co-located mental health & substance abuse services in primary care clinics • Primary care added to mental health clinic

18. MH/PC Integration before PACT:Basic collaboration on-site • Separate systems but same facility • Communication over shared pts when necessary • Lack of a common language or in-depth understanding of each other’s roles • Same day triage available • Benefit of warm hand-off, although not necessarily with treating provider

19. New Primary Care Model

20. Aspirations for Care in PACT Model • Empower Veteran as a partner in the team • Redesign primary care practice • Efficient access • Care coordination • Care management • Panel management

21. Other Team Members • Pharmacist • Social Worker • Nutritionist • CaseManagers • Trainees • Psychologist For each parent facility HPDP Program Manager Health Behavior Coordinator My HealtheVet Coordinator The Patient’s Primary Care Team

22. Collaborative opportunities in PACT • Weekly Extended Team meetings • Population management • Behavioral Health Specialists as educators • MI • Modeling through individual consultations • Shared medical appointments

23. PC MH Staff within NY site • Psychologists • Dr. Goloff – Chief • Dr. Spivack – substance abuse specialist • Dr. Ramati • Dr. Dognin - HBC • Dr. Ingenito – women’s clinic • Dr. Kehn – home based primary care • Dr. Michelson – VISN lead • Psychiatrists • Dr. Bronson – PCMH lead • Dr. Rappaport • Psychology interns, externs , postdoc

24. Adapted from The Four Quadrant Clinical Integration Model • (National Council for Community Behavioral Healthcare, 2006) • Behavioral • Health Risk/ • Status Physical Health Risk/Status

25. Case Vignette: Mr. Roberts • 62-year-old male with paranoid schizophrenia, hypertension, difficulty following up with primary care due to frequent psychiatric admissions (10 in past year) • Which quadrant doe this patient fit into? • Is there an opportunity to collaborate?

26. Case Vignette: Mr. Roberts • Quadrant: High Behavioral/Low Physical Health Needs • Discussion of case in Extended Team meeting • Chart review to assess complexity of medical problems (was treated for mild hypertension) • Advocated to transfer to our Mental Health Program (Mental Health Based Primary Care) • Outcome: • Coordinated transfer to Mh based PC • Collaborate with primary care NP for support in treating medical problems

27. Case Vignette: Mr. Lato • 48-year-old male with uncontrolled diabetes, osteoarthritis, sleep apnea, obesity, addiction & long history of noncompliance with care • Which quadrant does this patient fit into? • Is there an opportunity to collaborate?

28. Case Vignette: Mr. Lato • Quadrant: High Behavioral/High Physical Health Needs • Discussion of case in Extended Team Meeting • Interventions: • Individual behavioral counseling by psychologist • Meets with RN care manager several times • Attended Diabetes Shared Medical Appointments • Enrolled in telehealth • Outcome: • Improved control of diabetes • Improved satisfaction with treating providers

29. Case Vignette: Mr. Smith • 50-year-old male with poorly controlled diabetes. No psych dx or interpersonal issues. Ambivalent around taking medications & insulin injections. Tells pharmacist “my medications are like a ball and chain” • Which quadrant does this patient fit into? • Is there an opportunity to collaborate?

30. Case Vignette: Mr. Smith • Quadrant: Low Behavioral/High Physical Health Needs • Discussion of case in Extended Team Meeting • Interventions: • Joint session with pharmacist and psychologist • MI used to assess patient’s confidence and willingness to change • Psychologist consults with pharmacist, who will continue counseling him in future • Outcome: • Pharmacist continues several more MI sessions • Continual adherence struggles • Referral to Health Psychologist for more intensive counseling

31. Case Vignette: Ms. Ramirez • 52-year-old Hispanic female with no significant past medical history. She has not been receiving regular primary care for a number of years. • Which quadrant does this patient fit into? • Is there an opportunity to collaborate?

32. Case vignette: Ms. Ramirez • Quadrant: Low Behavioral/Low Physical Health Needs • No need to discuss in Extended Team Meeting • Screenings: cervical cancer; breast cancer; lipids; depression; military sexual trauma; PTSD. • Assess for toxic habits or exposures; up-to-date with vaccinations; check lipids • Prevention services: collaborate if necessary • Outcome: • Screenings conducted • Refer to Tobacco Cessation Group and give NRT • MI around smoking

33. Lessons Learned • PACT provided an enhanced level of collaboration • Time and space are necessary • Extra man-power augments • Recognition of multiple opportunities for collaboration • Extended team meetings • Consultations • Shared Medical Appointments

34. Lessons Learned • Communication styles • Need to learn each other’s language • There are different collaborative needs for different patients and types of situations

35. Next Steps • Continue efforts to educate trainees • Immersion • Modeling • Didactics • OSCEs • Expand scope to other disciplines • Learn from other successful models • Continue to share our experience

36. Primary care-mental health integration "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

37. References • Asch et al. (2004). Comparison of quality of care for patients in the Veterans Health Administration and patients in a national sample.Annals of Internal Medicine, 2004; 141 (12): 938-945. • Doherty, McDaniel & Macaran (1995). Five levels of primary care/behaviral healthcare collaboration. Family Systems Medicine, 13, 283-298. • Grumbach and Bodenheimer (2004). Can healthcare teams improve primary care practice?JAMA ; 291(10):1246-51 • National Council for Community Behavioral Healthcare. Behavioral Health/Primary Care Integration. The Four Quadrant Model and evidence-based practices. MCPP Healthcare Consulting. Revised Feb. 2006. • Patient Centered Medical Home Concept paper. http://www.va.gov/PrimaryCare/pcmh/ accessed 3/29/11 • United States Department of Veterans Affairs Office of Academic Affiliations. eResources for Clinical Trainees. http://www.va.gov/oaa/resources_trainees.asp. Last accessed 10/25/11.