CO-LOCATED COLLABORATIVE CARE THE WHITE RIVER JUNCTION MODEL THEN AND NOW

1. CO-LOCATED COLLABORATIVE CARETHE WHITE RIVER JUNCTION MODELTHEN AND NOW Andrew Pomerantz, MD Chief, Mental Health and Behavioral Sciences White River Junction VA Medical Center White River Junction, Vermont Associate Professor of Psychiatry Dartmouth Medical School Hanover, New Hampshire

3. Features of WRJ co-located collaborative care Fully open access � same day service (helps overcome ambivalence) Tx begins at first visit � most continue care in PC Spectrum of providers � therapist, MD Full spectrum of patients/diagnoses Colocated/collaborative in PC � avoids stigma Therapy and f/u care in PC if indicated Presumption of health � null hypothesis applied to MH care (�you think like PCPs!�) THIS IS PRIMARY MENTAL HEALTH Use of technology for assessment and outcomes Multiple models: referral, C/L, care management, case management, collaboration, health psychology, (telepsychiatry for distant clinic) Treats 75% of people with MH diagnoses with 10% of staff Implementation in 2004 enhanced capacity and led to enhanced MH programs in an era of declining resources ($$$$$)

4. Patient flow through clinicTHEN : (2004) ID in PCP (via screening, other) Brought to PMHC � appt made by clerk Self report on electronic touchpad � results immediately available See therapist for psychosocial assessment, problem definition, etc See psychiatrist (or APN) for medically oriented interview Tx plan developed and begun � f/u interval set (or referral for secondary level of care (25%) Clinicians responsible for tracking pt

6. What did it do? Wait time for new appt dropped from 5 weeks to 17 minutes Decompressed specialized programs, Able to build new programs & enhance existing ones during a time of staff attrition Enhanced patient choice of care Eliminated missed appointment Improved staff morale Improved care Reduced cost of care

7. Workload trends

8. Patient flow through clinicTHEN (again) : (2004) ID in PCP (via screening, other) Brought to PMHC � appt made by clerk Self report on electronic touchpad � results immediately available See therapist for psychosocial assessment, problem definition, etc See psychiatrist (or APN) for medically oriented interview Tx plan developed and begun � f/u interval set (or referral for secondary level of care (25%) Clinicians responsible for tracking pt

9. WRJ model NOW (2009) Same as before but last step changed (�Clinicians responsible for tracking pt�) Care Management needs identified, documented in note template Care Manager contacts new pts after 1 week, and/or follows specific requests noted above PC may choose TIDES Care management for depression if desired CM also tracks Depression Case Finder � alerts PCPs, follows pt if requested. Telemental health to CBOCs to enhance Integrated care. PLUS

10. Other Additions Health psychologist ongoing member of chronic disease management teams in PC and specialties (oncology, podiatry, diabetes) Above clinicians also provide direct case consultation in PC as needed Brief �talking� treatment in Primary Mental Health � developing new protocols

11. Challenges Managing imbalance in supply and demand equation Educating (�brainwashing?�) new employees Refining criteria for special program referrals Enhanced access for very rural and frontier veterans

12. Bibliography (for the WRJ model) 2005 APA Gold Award: Improving treatment engagement and integrated care of veterans. Psychiatric Services 10:1306-1308, 2005 Watts, B.V., Shiner, B., Pomerantz, A., Stender, P. & Weeks. W.B. (2007) Outcomes of a quality improvement project integrating mental health into primary care. Quality and Safety in Health Care 2007; 16: 378-381, 2007. Pomerantz AS, Cole BC, Watts BV, Improving efficiency and access to mental health care: combining integrated primary care and advanced access. General Hospital Psychiatry 30:546-551, 2008 Pomerantz AS, Corson JA, Detzer MJ. The challenge of integrated care for mental health: Leaving the 50 minute hour and other sacred things? Journal of Clinical Psychology in Medical Settings, 16(1):40-46, 2009