Lessons Learned During VA’s Implementation of Integrated Care Journey

1. Lessons Learned During VA’s Implementation of Integrated Care Journey Dean Krahn, MD, MS Chief, MH Service Line, VA-Madison Professor (CHS), Psychiatry, UWSMPH

2. VA Primary Care Mental Health Programs • Background • Characteristics of VA that make it appropriate for integration • Defined population • Will be our patients in most cases for life • Unified system

3. VA Primary Care Mental Health Programs • Unified system • VACO (central authority): National PCMH providing policy guidance, some positions for sites that applied, education, monitoring of implementation • 21 VISN’s (Veterans’ Integrated Service Networks) • Facilities (over 150) • CBOC’s (over 800 ranging from 1,000 Uniques to 20,000 Uniques)

4. VA PCMH Implementation • Background • Probably 10 times as many people have low levels of depression or problem drinking than severe depression or alcohol dependence (unfortunately, your MH providers have spent all of their time with the severe group—big skill deficit)

5. VA PCMH Implementation • Nearly all studies show that integrated care is better on all measures than TAU for depressive disorders (IMPACT, PROSPECT, RESPECT); • PRISM-E showed that integrated care was equal to enhanced referral and remarkably more acceptable to pts • SBIRT is remarkably helpful for alcohol misusers • No data on PTSD, anxiety

6. VA PCMH Implementation • VA has done studies applying integrated care to VA settings (TIDES, COVES, etc) and Behavioral Health Lab (screening and disease care management)

7. But implementation is still not uniform • Even in a single system with national outcome measures, there is significant heterogeneity • Central level: lots of measures for MH causes difficulty knowing which ones to prioritize and the demand to integrate might be the hardest to understand (most psych and PC leaders have never seen a clinic like is envisioned) , the hardest to measure, and the hardest to monitor

8. But implementation is still not uniform • Big clinics: collocated, collaborative with disease care management required (blended model); less required at smaller clinics • Have a standardized “stop code” in which integrated work is counted, but how do you really count collaboration in care? Lots of integrated care happens on phone, in halls, and probably need to assess pt outcomes, not encounters

9. Problems in Implementation • Who hires and fires, supervises, and leads the MH clinicians who are working in primary care? (in VA money came from MH initiatives and that led to confusion—who protects resources?) • VISN/Facility level issues: • How do you get sites that are late adaptors to do new things? (we have a grant studying an implementation method) • Flavor of the week?: integration is now interacting with a move to Medical Home; health psychology addition should be welcome • Other issues arising in MH

10. Problems in Implementation • Finding enough MH and PC leaders who truly buy into Integrated Care: Primary Care = General Medicine plus General Mental Health. • Getting leaders who understand that co-located care isn’t collocated, collaborative care

11. Problems in Implementation • At the clinic/provider level: • PC: MH issues are part of your job (somewhat peculiar to VA where you could hit the consult tab) • MH: how do you do PCMH vs the whole 1.5 hr MH work-up (IMPACT has wonderful training site; VA/DOD has great resources on the 30 min eval and 15 min appt) • What if someone you see briefly kills themselves? (what makes you think they wouldn’t anyway?) • MH: how do you make things seamless between PCMH and MH Specialty Care

12. Problems in Implementation • What kinds of staff and staff ratios? • Need MH staff who could make rapid decisions in emergency department • Need MH staff who don’t need long connections with individual pts and who can juggle things • Need some support for PC prescribers (e.g. MD or APN) and need people who can do very brief MI or therapy • Need PC providers who can see that MH issues need some of their time.

13. Problems in Implementation • Probably need 1 MH provider FTEE for every 3,500 to 5,000 PC patients and another partial prescriber; for a 9-10,000 clinic we have a FT psychiatrist and 2 SW’s—a little rich, but we have seen a decline in specialty care which has made it possible to use our specialty resources better • What to do with small clinics where we serve MH needs via telemental health?

14. Problems in Implementation • No leaders who have led this kind of venture; they often see this as something extra, not something vital (at all levels of leadership) • While I have emphasized problems, when you get a breakthrough on this, it is very rewarding! Need to move from one breakthrough to the next! After all, we are probably only 10 yrs since the advantages of integration were known, so if we get this implemented in the next couple of years we will be 5 years ahead of time!