Presentation at Association for Contextual Behavioral Science, July 2012, Washington, DC

1. Behavioral and Mental Health Services in Interdisciplinary Primary Care at the Department of Veterans Affairs Presentation at Association for Contextual Behavioral Science, July 2012, Washington, DC Antonette Zeiss, Ph.D. Chief Consultant, Office of Mental Health Services Veterans Health Administration Department of Veterans Affairs

2. Teamwork for the Presentation Colleagues - THANKS Sonja Batten, Ph.D Jeff Burk, Ph.D. Lisa Kearney, Ph.D. Jan Kemp, Ph.D. Andrew Pomerantz, M.D. Edward Post, M.D. Mary Schohn, Ph.D. No conflicts to report

3. VA 101 • VA = Department of Veterans Affairs (since 1989) • Three subcomponents: • Veterans Benefits Administration • National Cemetery Administration • Veterans Health Administration • Vet Centers • Medical facilities and their associated Community Based Outpatient Clinics (CBOCs) • Organized into 21 regions called Veterans Integrated Service Networks (VISNs) • Crucial distinction between Department of Defense Care and VA care • DoD provides care to active duty Servicemembers and their families, and after discharge to some who had a significant career in the military • VA provides lifetime care to all eligible Veterans who choose to seek VA health care

4. Veteran Population Facts • 23.8 million US veterans • 1.8 million women (and growing) • Almost 60% of American men > 65 are veterans • Not all Veterans are eligible for VA health care • Main factors: type of discharge, presence of a Service Connected disability, low income, deployment to OEF/OIF • 7.8 million enrolled for health care in VHA • ~ 6.2 million seen FY 2011 (October 1, 2010 – September 30, 2011) • 22% of all veterans

5. VA’s Commitment: Quality Care • Our nation’s commitment to Veterans, for their lifetime: • Treat returning Veterans early in the course of mental heath problems • Serve all Veterans with accessible, evidence-based mental health services when they need them • Provide holistic, integrated care for physical and mental health problems: Mental health is an essential component of overall health care • Be there for the lifetime of all Veterans we are serving, from all eras

6. Brief Recent History of MH Care in VA • Attrition of VA MH services in the late 1990s up to about 2003 • Major Rebuilding & Innovation since 2004 • VHA Comprehensive MH Strategic Plan: Developed in 2003-04 and approved November, 2004 • Uniform MH Services Package: Developed in 2008 • Defines mental health services to be provided to all enrolled veterans • Completes implementation of Strategic Plan for patient services • Current status • Huge increase in mental health staffing and services since 2003 • RAND/Altarum external review confirms that VA surpasses private mental health care quality of care on almost all dimensions reviewed • Challenges remain: High aspirational goals, greatly increasing demand for services • Current hiring efforts underway for further expansion of staff and services

9. VA Users Of Mental Health Services FY2011

11. Users Of Mental Health Services Among Veterans Who Served In Iraq, Afghanistan, or Support Locations • Among 1,478,370 separated OEF/OIF/OND Veterans • 804,704 (~54%) have obtained VA health care since FY 2002 • Of those, 495,774 Veterans accessed care during the past twelve months (April 1, 2011-March 31, 2012). • This represents about 8% of the ~6.2 million individuals who received VA health care during FY 2011 (October 1, 2010 – September 30, 2011). • 12% of those seeking care are women Veterans • Mental Health problems are the second most frequent diagnoses, behind musculoskeletal problems as the most frequent

12. Diagnoses of Veterans Who Come to VA for Health Care

13. Mental Health Diagnoses of Veterans Who Come to VA for Health Care

14. VA’s Mental Health System • Vet Centers • Provide readjustment counseling • Located in community settings • Mobile Vet Centers to take care to rural areas • Medical Centers & Community Based Outpatient Clinics have multiple ways of delivering mental health care • Direct VA staffing • Telemental health in CBOCs • Fee basis and contract care as needed

15. Mental Health is an Integral Part of Overall Health • Mental health is an essential component 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

16. Mental Health Integrated In Physical Health Settings • Primary care/Mental Health integration • VA’s overarching primary care system: Patient Aligned Care Teams (PACTs) • Home Based Primary Care • Women’s health clinics • Geriatric Primary Care Clinics • Physical Rehabilitation • Polytrauma units • Spinal Cord Injury units • Blindness Rehabilitation Centers • Interdisciplinary medical specialty clinics, e.g.: • Pain clinics • Oncology • Endocrinology • Long term care and end-of-life care • Hospice • Community Living Centers

17. Integration in Specialty Mental Health Settings • Outpatient clinics • Specialty Outpatient • Post traumatic stress disorder (PTSD) care teams with a Substance Use Disorder (SUD) specialist on every team • Mental Health Intensive Care Management: Team to provide community-based care for Serious Mental Illness patients • SUD care • Detox (often in medical units) • Outpatient clinics • Intensive Outpatient services for SUD • Residential Rehabilitation Treatment Programs • Population with extensive comorbid diagnoses across mental health problems, SUD problems, homelessness, etc. • Inpatient mental health care • At risk to self or others

19. Themes: Mental Health as an Integral Component of Overall Health • Interdisciplinary team care • Recovery-oriented mental health services and Patient Centeredness in all health care in VA • Primary Care/Mental Health Integration

20. Theme 1: Interdisciplinary Team Care • Interdisciplinary Health Care emphasizes a high degree of collaboration in: • Patient evaluation • Treatment planning • Outcome evaluation • NOT Multidisciplinary • Ideally, the patient and family members (when appropriate) are included as team members

21. Multidisciplinary vs. Interdisciplinary • Multidisciplinary = • Multiple professions in a shared work site, • Sharing a patient load and overall vision of care, • BUT working independently and sharing information on a minimal basis (e.g., weekly report) • Interdisciplinary = • Multiple professions in a shared work site, • Sharing a patient load and overall vision of care, • AND working continuously to share and integrate information to guide coordinated care

22. Interdisciplinary Health Care Model IndividualAssessments Shared information Team goals Intervention plan & strategies Individual Delivery of Care

23. Skills and Training • Understanding the roles of other team members • Each profession has its unique areas of expertise • Each profession shares considerable health care knowledge and care delivery roles with other professions • Team members need to be able to • Convey their own special skills and knowledge, that serve the patient's and family’s needs • Know that shared knowledge and skills are an opportunity for coordinated care, not a threat to one’s own “turf” • Appreciate the importance of skills that are far from one’s own range

24. It’s Not Just Skills And Knowledge • Conflict among team members can strengthen or weaken team functioning • Learn to embrace and appreciate disagreement; it protects from “group think” • Predictable stages of team development: • Forming • Storming • Norming • Conflict is highest during storming, but can occur at any point • Team leadership is not defined by professional title, and leadership may be distributed according to different tasks and leadership skills and needs

26. Theme 2: Recovery-Oriented Mental Health Services And Patient Centeredness In All Health Care In VA • Defined originally in mental health settings, but the concept has important relevance for all health care • Recovery-oriented care focuses on strengths, needs, abilities, and preferences • Assist individual to define, achieve, and maintain personal goals • All Veterans can be guided to identify important personal goals and supported in accomplishing them, including those with • Mental illness/disability (including serious mental illness) • Physical illness/disability • Both mental and physical illness/disability

27. Mental Health Recovery • “Mental health recovery is a journey of healing and transformation enabling a person with a mental health problem to live a meaningful life in a community of the person's choice while striving to achieve ... full potential.” • National Consensus Statement on Mental Health Recovery (http://mentalhealth.samhsa.gov/publications/allpubs/sma05-4129/ ) • All veterans have recovery potential: a maximum degree of self-sufficiency that can be attained • Recovery involves attainment of life goals • In relationships, employment, schooling, housing, community involvement • Beyond symptom management

28. Patient Centeredness In All VA Health Care • VA’s Overall Commitment of Patient Centered Health Care • Led by Tracey Gaudet, M.D., Director of the Office of Patient Centered Care • Core concepts: • Old model: “Problem Based Disease Care” • Transformation to “Patient Centered Health Care” • Patient Centered Health Care core change: “Start with the Veteran and What Matters to Them”

29. Delivering Patient Centered Health Care in PACTs and In Specialty Care • Steps suggested: • Mission: Get clear about what matters in the patient’s life • Plan: Create a personalized health plan to get there • Train in the skills and resources needed • Patient and Provider Support and rely on one another • Patient Centered Health Care concepts = Recovery-oriented Mental Health Care concepts

30. Competencies for Providing Recovery-Oriented, Patient Centered Health Care • Work collaboratively with the veteran • Veteran expertise, e.g.: • Goals • Personal strengths • Supports and resources available to them • Health Care Provider expertise, e.g.: • Education and support for veteran and family • Knowledge of best, evidence-based Interventions: Psychotherapy, Medication • Training in the skills and resources needed • Respect and empower the veteran in self-managed recovery efforts

32. Theme 3: Primary Care/Mental Health Integration • A Natural Fit • Over 25% of Veterans who use VA health care have a mental health diagnosis for which they are being treated in a specialty mental health setting • Patients initially bring their mental health concerns to primary care – Patient Aligned Care Teams (PACTs) in VA • Screening for mental health problems takes place in primary care • Referrals from primary care to specialty mental health result in a high rate of no-shows

33. Benefits of Integration of Mental Health Staff in PACT • Promotes early identification/ management of mental health issues • Supports coordination of care across conditions • Facilitates engagement • Increases convenience • Reduces stigma • Embodies for the patient the concept that mental health is an integral component of overall health

34. Mental Health Enhancement to Support Primary Care Teams/PACTs • Initial funding for integration of mental health in the primary care setting in FY2007 • Requirement for all sites as of FY2009 - “Blended Model”: • Care Management: Patient education and longitudinal monitoring, primarily of medication-based care • Co-located, Collaborative mental health provider: Education, consultation for the team, provide behavioral medicine and psychosocial services

35. Core VA PACT Membership • Primary care provider • Physician • Physician Assistant • Advanced Practice Nurse • RN care manager • LPN (or similar) “clinical associate” • Clerk • Clinical pharmacist • Social worker • Dietician • Health psychologist • Mental health professional

36. PACT Structure Principles • Role differentiation of providers, administrative requirements, and other general operational and design elements of the new practice model. • Each PACT provider is expected to function at the top of his or her license or skill • Many tasks previously performed by the PCP can be effectively and appropriately accomplished by RNs. • Many traditional RN tasks can be performed by LPNs or health technicians • The clerical role is also expanded, to assume tasks that do not require professional or clinical expertise • Expanded PACT team includes • Integrated mental health services • Health behavior coordinators • Health Promotion/Disease Prevention Program Managers

37. Assessing Success: PC-MHI Dashboard • Purpose = evaluate integrated mental health care implementation by tracking • Staffing • Compliance with key program components • Service utilization • Diagnostic data • Performance measure outcomes at the national, regional, and local level • Dashboard reflects the number of staff (by discipline) dedicated to integrated mental health care in PACT with the capability of drilling down to the local facility level • Service utilization data assess • number of Veterans served in a given time period • number of appointments utilized by each Veteran • number of new Veterans seen in a program • “penetration rate,” which is the number of Veterans served by PC-MHI staff in primary care, compared to the overall number of Veterans in primary care in a given setting

38. This Integration Is The Largest Effort Of Its Kind Ever Undertaken • Since late 2007, in PC-MHI programs throughout the VA healthcare system, over 1.9 million Veteran encounters to provide mental health services in primary care have occurred • During FY2012 so far, this program has provided care to 5.7% of all VA primary care patients. • Mental health providers in these settings provide same-day care for Veterans in primary care that includes • Screening and evaluation for mental health concerns • Treatment of mild to moderate depression, anxiety, and substance misuse • Behavioral interventions for medical disorders. • The most recent aggregate staffing data for PC-MHI, as of Fall 2011, demonstrate a total PACT mental health clinical staff of 1,469 clinicians who cumulatively represent 950 Full Time Equivalents

39. Figure 1: VHA Primary Care-Mental Health Integration Dashboard

40. Some Research Findings • Integrated care has not yet significantly reduced specialty mental health care services (Pfeiffer et al., 2011) • Patients who received integrated care services were significantly more likely to stay engaged in specialty mental health treatment when referred, compared to those who did not receive integrated care services (Wray et al., in press) • This finding suggests that much of the time previously wasted by no-shows and patients who left treatment after only one session is now available to enhance specialty care services • Most common interventions (Funderburk et al., 2011): • Cognitive-behavioral therapy interventions • Psychoeducation • Supportive psychotherapy • Pharmacological intervention,

41. Themes 1, 2, & 3: Mental Health Providers Are Part Of The Interdisciplinary, Patient Centered, Primary Care Team • Integrating mental health and primary care is a paradigm shift for mental health clinicians not previously exposed to this model of care • Such work requires a shift to population-based care, tending proactively to the needs of an entire population of primary care patients, rather than just a caseload of patients who have been referred • Notably, many VA mental health providers have been trained in brief models for health interventions and have adapted readily to the fast-paced environment of the primary care setting • The focus is on the patient’s goals and providing rapid interventions related to the patient’s immediate concerns • Mental health providers also bring multiple skills for helping the team manage group dynamics and problem-solving, in the interdisciplinary process