# Presentation: 671877

## VA MENTAL HEALTH PRIMARY CARE

**INTEGRATION**
**6/24/2003**

## Clinical Care

- CONTINUUM OF CARE:
- Inpatient
- Residential
- Partial Hospitalization
- Outpatient
- Community/ Outreach

- 		FY 1996				FY 2000
- 		Patients		Dollars		Patients 	Dollars
- PTSD		39,653		$101.9M		48,322	$94.3M
- H-less		24,539		$75.1M		30,922	$110.6M
- SMI		269,009		$2.1B		290,819	$1.9B
-  SA		107,074		$575.9M		94,603	$364.5M

**            **

## 	Dis.		Setting	FY96	FY98	FY99	FY00

**	****Dis.****	****	****Setting****	****FY96****	****FY98****	****FY99****	****FY00**
- 	SMI		IP	117,088	  95,068	  88,319	  83,396
- 			OP	251,216	278,674	284,937	281,679
- 			TOT.	269,009	290,961	295,296	290,819
- 	S/A		IP	  50,628	  30,021	  25,812	  22,949
- 			OP	  90,916	  99,337	  96,307	  90,087
- 			TOT.	107,074	106,599	102,178	  94,603
- 	H		IP	    5273	    7,072	    7226	    7506
- 			OP	  21,913	  23,763	  25,450	  27,950
- 			TOT.	  24,539	  27,201	  28,542	  30,922
- 	PTSD		IP	    4,312	    4,694	    4,522	    4,088
- 			OP	  37,768	  41,224	  43,327	  46,862
- 			TOT.	  39,653	  43,187	  45,188	  48,322

## CAPACITY, NETWORK VARIATION

- SMI
-        Seventeen VISNs decreased spending in FY 2000 compared to FY 1996.
-        Eighteen VISNs increased numbers of SMI veterans treated.
-        The decrease in mental health costs primarily reflects a 29% decrease in SMI veterans who are treated in inpatient settings along with decreased overall lengths of stay over the last four years (from 21.7 days in FY 1996 to 15.8 days in FY2000).
- SA
-      Five of 22 VISNs allocated resources at or above the 90% level in FY 2000 compared to FY 1996.
-      Eight of 22 VISNs had allocations in FY 2000 of less than 50% of the their FY 1996 allocations.
-      Ten of 22 VISNs showed a 90% or greater number of veterans treated with a diagnosis of substance abuse seen in FY 2000 as compared to FY 1996.
-      Three of 22 VISNs treated more individuals than in FY 1996.
- H
-        In FY 2000 18 of 22 VISNS increased funding for SMI Homeless Veterans these increases ranged from 9%- 130%.
-        Four VISNs appeared to treat fewer SMI Homeless Veterans in FY 2000 compared to FY 1996.
- PTSD
-        Six VISNs decreased expenditures for patients by one third or more over the last five years.
-        Four of those six VISNs increased the number of veterans receiving specialized care while another VISN treated only 2% fewer veterans.

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## Mental Health Measures

- SMI
- 	MDD screen: 87%
- 	Positive Depression Screen F/U: 51%
- 	(4th Q 2002)
- SA
- 	Alcohol Screen: 78%
- 	(4th Q 2002)
- PTSD
- 	PTSD Sx Decrease by Mississippi Scale 3.82%
- 	Violence Decrease 42.38%
- 	Pt Satisfaction 15.66 (Overall Satisfied)
- 	(FY 2002)
- Homeless
- 	 Domiciled at Discharge: 76%
- 	Improved Psychiatric Symptoms: 72.5%
- 	Improved Alcohol Symptoms: 78.6%
- 	(FY 20002)

## Patient Safety

-       Workplace Violence: Prevention & Management of Disturbed Behavior; 	collaborations with Occupational Safety & Health
-        Suicide Prevention: Satellite broadcasts, assessment and treatment 	across care settings
-        Patient Personal Freedom and Security: assessment for 	dangerousness in mental health, med /surg and Long Term Care 	settings

## Education

-        1,300 VA trainees in mental health disciplines per year
-        Psychiatry Resident Primary Care Education : >30 facilities, 11% of VA psychiatry 	residents enrolled
-        _Employee Education_:
-        Satellites: Workplace Violence, Family Violence
-        Teleconferences: Monthly PTSD Hotline
-        Face to Face: “Impact of Mental Health on Medical Illness in the Primary Care Setting 	and the Aging Veteran” MIRECC/GRECC Conf.

## Research

-        _National Center for PTSD_:
-        Neurobiological, physiological, psychological research
-        Health care delivery research (group therapy collaborative study)
-        Education: PTSD in Native Americans videos
-        _Quality Enhancement Research Initiative (QUERI)_:
-        Translation of research into practice
-        Depression, Schizophrenia, Substance Abuse projects
-        _Mental Illness Research Education & Clinical Centers (MIRECCs)_:
-        Basic research, clinical research and education
-        8 current sites, diverse and complementary agendas
-        Research Fellows from both Psychiatry & Psychology
-        _Collaborations with Other Agencies:_
-        VA SAMHSA, HRSA: MH/SA care in primary care vs. MH sites
-        National Collaborative Study of Early Psychosis and Suicide (NCSEPS): VA, DOD, NIMH

## Community Care

**Community Care**
- 	Mental Health Intensive Care Management (MHICM)
- 		71 Active Programs (FY 2003)
- 		10 In Development
- 		MHICM Plans from all VISNs

**Mental Health/ Primary Care**
- 	Community Based Outpatient Clinics (CBOCs)
- 		FY 2000 CBOC MH Visits = 990,146  (0.66% > FY98)
- 		% MH Visits 17.3 ( 5.8% < FY98)
- 		MH Expansion in CBOCs in FY 2001 VISN Plans

## VA Initiatives in Mental Health Primary Care

- Consensus of Chiefs (‘94)
- PRIME (‘94)
- Primary Care Expert Consultant Teams (‘96)
- Mental Health Primary Care Team Survey (‘96-’97)

## VA Initiatives in Mental Health Primary Care

- PTSD Practice Guidelines (‘96)
- PTSD Primary Care Working Group (‘96)
- Provision of Primary Care Services for Mental Health Clinicians
- VHA Program Guide 1103.2 (‘99)

## VA Initiatives in Mental Health Primary Care

- Primary Care Mental Health Education Module (‘97-’98)
- Psychiatry Residency Primary Care Education Program (PsyPCE) (‘97)
- ISTSS (‘97)
- MH Primary Care Mini Residency (‘99)

## Collaboration & IntegrationPrimary Care, Mental Health & Geriatrics

## Essential Features of Primary Care

- Intake/assessment
- Prevention
- Management of acute & chronic conditions
- Referral
- Patient/care giver education

## Mental Health Primary Care Teams

- MH provider as primary care provider
- Continuity of care across service sites
- Comprehensive (medical & mental health) care

## “Traditional” Models Approximating Primary Care

- Consultation Liaison (multidisciplinary)
- Dual diagnosis (Gen. Psychiatry/substance abuse ) programs
- Behavioral medicine & health psychology programs

## Common MH/Primary Care Issues

- Multidisciplinary team structure & leadership
- Bridging disciplinary & programmatic boundaries
- Integration of physical & mental health specialty care
- Adaptation to VA national & VISN reorganization

## Potential Barriers

- Historical “vertical” services, little collaboration
- Expectations (staff & patients) that MDs provide all care
- Lack of IP/OP continuity
- Specialists concern over lack of primary care skills

## Bridging the Barriers

- Multidisciplinary team building across services
- Find a service model that best suits staff & patients
- A patient triage format: Med PC/ MH PC or shared by both
- Education for patients & staff on PC aims & methods

## NATIONAL MENTAL HEALTH IMPROVEMENT PROGRAM

- (NMHIP)
- Purpose:
- Coordinate and enhance existing program evaluation, performance measurement and quality of care activities.
- Goal:
- To improve quality of care received by veterans who require mental health services.
- Assessment of essential precursors to good outcomes:
- ·       Mental health care needs
- ·       Access to needed services
- ·       Structure and processes of mental health care delivery systems
- Measurement of improvements:
- ·       Clinical outcomes
- ·       Social and economic outcomes
- Patient and significant other satisfaction

## Activities:

-        Coordinate data gathering of existing MH evaluation and research centers
-        Collaborate with OQP & PBM to monitor system performance
-        Monitor system wide compliance with quality & directives
-        Work with VISN, MH Service Line and Facility leadership to identify best practices and address problems
-        Improve VA MH services through education, dissemination of best practices
-        Direct comparative studies of patient outcomes & system performance of VA & non-VA MH care systems

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