Figuring out the nuts and bolt

inte

g g ratin

g mental health in

PACT: a QI approach 

Evelyn Chang, MD, MSHS 

VISN 22 Veterans Assessment and Im

prov

Laboratory (VAIL)

October 17, 2012
V22 Demo Lab: Veterans Assessme

Improvement Laboratory (VAIL) 

• VAIL promotes structured, evidence-base

PACT quality improvement at primary carpractices 

– Phase 1: (FY 2011) 

• 3 medical centers (VA GLA VA Loma Lind

3 medical centers (VA GLA, VA Loma LindSan Diego) each pick a demonstration site 

– Phase 2: S

pread 

(FY 2012

) 

• Each medical center adds one practice 

– Phase 3: Sustainability (FY 2013) 
V22 Demo Lab Focus on Mental 

Health 

(MH

)

• In Phase 1, MH in PACT emerged as a m

focus through two projects: focus through two projects: 

–Economic evaluation of Ambulatory Ca

Sensitive conditions from VAIL 

(Yoon, 

–VAIL innovation proposed by GLA on 

inte

gratin

g MH into PACT 

prioritized b

y 

(led by Lisa Altman, MD) 

3 
Overview 

• Review the problem of co-morbid men

medical illness as described in VAIL (national VISN local) (national, VISN, local) 

• Describe primary care-mental health 

integration activities at Sepulveda integration activities at Sepulveda 

Ambulatory Care Center (demonstratio

–Collocation of mental health (MH) prov

Collocation of mental health (MH) prov

into primary care (PC) 

–Investigation of communication betwee

and PC using quality improvement (QI
Problem: Preventable Adverse Events Am

Veterans with MH, Drug Use, and Chronic 

• VAIL economic analysis of costs for 

hospitalizations and ED visits for chronic 

medical illness (e.g., CHF, diabetes) s

–A significant increase associated wi

having a chronic mental health (MHcondition documented the prior yea

and b th ff t f di b t d above the effect of diabetes 

–Depression (OR 1.09) and drug use 

1 40) have most impact 1.40) have most impact 

Yoon, et al. Med C
Prior Evidence: Care Among Vetera

with MH/SUD is More Costly 

• The 15.4% veterans with MH/SUD acc

32.9% of VA costs (2007) 

• Most costs are for medical, not MH car

Watkins, et al. Health Affairs. 2011. 
Possible solution: Primary Care an

Mental Health Inte

gration 

• VA endorsed collocation National Model Spre

and collaborative care models (CCM) to integrate PC/MH in 2006 

•CCM (e g TIDES BHL) CCM (e.g., TIDES, BHL) 

improves outcomes and is cost-effective 

• Half of the sites 

implemented collocation rather than CCM rather than CCM 

Chang ET et al. JGIM 2012. 

TIDES 

14 

21 

Colloca

BHL 

3 10 

4 

Colloca

72 
–

Prior Evidence: Collocation Alone is Not Effective

• VA encouraged adoption of “collocated 

collaborative care”

– Evidence suggests in most sites, this is si

collocated, not collaborative, care 

• Meta-analysis: analysis: Bi-directional directional 

communication is a critical componencollaboration 

– Improves outcomes in primary care patien

mental illness Results in joint care planning Results in joint care planning 

Foy, et al. Ann Intern Med. 2010; 152: 247-258.
care

Setting: Se

pulveda Ambulator

y Care Cen

• A multi-specialty academic community

outpatient clinic that: 

– Serves 16 000 veterans in Los Angeles C

Serves 16,000 veterans in Los Angeles, C

– Has trainees in internal medicine, psychia

psychology 

– 

Has 

2 primary care PACT teams 

– Has specialty mental health and substanc

outpatient services in a different building f

primary care 

• Historically has tried to integrate MH a
Local P robl em:Focus Groups L

Recognition of Collaboration Issu

• Focus groups (Sep 2011) of 1) MH patients; 2) 

social workers 

• Cross-cutting themes—pts and providers 

– Issues with MH specialists’ continuity and av

when scheduled when scheduled 

– Issues with PCP comfort with MH 

care/communication

– Perceived long wait time for new MH consu

• PCPs 

– Lack of understandable MH treatment plan – “Not a lot of coordination of care” 
t

Local Problem: Led to RecognitioCollaboration Issues at Sepulveda 

• Local management identified MH follow

stable MH patients as a potential accestable MH patients as a potential acce

barrier 

–Attempt to transfer patients chronica

followed in MH for transfer of responsibility to their PCPs for management of stable MH disorder

–Project revealed major resistance fr

PC d MH ll i l PC and MH as well as practical pro

–No standard way to guide communi
–

VAIL Projects 

• Collocation of MH providers into 

–Improve access for new consults Improve access for new consults 

• Investigation of communication 

between MH and PC for shared between MH and PC for shared 

patients using quality improvem

(QI) t l (QI) tools 
–

Step #1: Project Initiated through Sepulveda Quality Council 

• Interdisciplinary project workgroup form• Includes 11 members Includes 11 members 

– Primary care providers, psychiatrists – Researchers Researchers – Administrators 

• Began meeting monthly with intervenin

Began meeting monthly with intervenin

“homework” 
–

Step #2: Used QI Tools to “Diagthe Communication Problems the Communication Problems 

• Workgroup brainstorming and focused 

interviews interviews 

– Fishbone diagram: root cause of problem – Flow mapping of communication strategie

Flow mapping of communication strategiedescribe process 

• Chart review 

– Patients followed in both MH and PC – Consult requests to MH 

• Survey of MH and PC providers 
Communication tools Process

No standard operating procedure 

Psychiatry residents do not have No consistent backup

VA e‐mail or phone numbers

Non‐existent tool? Cannot identify PCP or MHP

esp when residents are invo

Preferences are

provider‐dependent Lack of continuity for su

Poor cAmon

k f i i f C

p p

Leadership structure Lack of MH training for PCPs

Medicine vs MH practice style

Lack of relationship between services

Apathy

p

Providercharacteristics Culture

Counseling at Vet Center

Non‐VA provider
Top barriers: PCPs and MHP

agree on the problems agree on the problems 

• Who is on the patient care team? 

– Who is the correct attendin

g? 

– Who is the correct resident? – Who is the backup in case the above are not a

be reac

h

ed? 

• How do you contact the other provider? • What is the role of the team members? 

(MHPs 

that PCPs are uncomfortable with MH therapies) 

• What do you do in case of emergencies? (PCP

believe that MHPs are inaccessible during emergbelieve that MHPs are inaccessible during emerg
Survey: What are some barriers to 

collaboration? 

• Primary care providers perceived barri

– “Not having enough providers to do therapy” – “Unable to reach a MH provider when paged by be

and even sometimes overhead pages” 

• Mental health providers perceived barr

Mental health providers perceived barr

– “PCPs have indicated an aversion to prescribing a

psychiatric medications to psychiatric patients, eve

routinely prescribe these medications for other proroutinely prescribe these medications for other pro

– “There is NO communication. When I have atte

to talk with MDs, most are confused what I'm e

attempting to achieve attempting to achieve. ”
   

   

Survey: Over the last 3 months, did you perfollowing for at least half of your patients: 

35% Primary care 30%

Mental healt

25%20%15%

10%

5%0%

(n=9)

Mental

(n=6)

Share

responsibility

for patient’s

outcome

Actively and

explicitly

share clinical

information

Jointly

develop a

treatment

plan
Step #3: Rapid Review For 

Innovative Evidence-based Strat

• Literature showed

–Integrated treatment plans for share

Integrated treatment plans for share

patients 

–Regularly scheduled joint case Regularly scheduled joint case 

conferences 

–Joint patient consultation Joint patient consultation–Multidisciplinary team meetings

VAIL-PACT VISN22 
Step #4: PDSA a Tool for Joint Ca

Planning for Com plex MH & PC P

• Integrated treatment plan template ide

– Which provider is primarily responsible fo

guiding care overall? 

– Who is the backup provider? – What are the treatment goals for MH & P

What are the treatment goals for MH & Pproblems? 

• PDSA cycles revealed that process is 

to providers caring for shared patient btime-consuming 

– Low acceptability rate Low acceptability rate 
Step #5: PDSA a Tool for Joint Gr

Rounds 

• Joint grand rounds 

– Provides opportunities for PCPs and MH

interact learn from each other 

– Educates providers on common PC and 

issues 

– Provides a platform for discussion abou

systems-, provider-, and patient-level issPC-MH integration 

• 1st PDSA cycle in November 
Collocation of MH providers to P

• Modeled loosely after WRJ Collocated Modeled loosely after WRJ Collocated

Collaborative Care

• Offers same-da

y access 

• 0.8 FTEE psychiatrist, two 0.5 FTEE R

0.5 FTEE LCSW,one 0.3 FTEE 

p

s

ycho

• Group therapies offered in primary care

–Meditation, mindfulness, co

pin

g

• Developed new consult note, working o

treatment plan note

• Guided by weekly interdisciplinary mee

under VAIL 
Initial results (Feb-July 2012) 

• Strong uptake of Mental Health Integrated Ca

(MHIC) consults, average 46 consults/month i iti t d b P i C initi

a

t

ed 

by 

P

rimary 

Care 

• Number of specialty MH consults initiated by 

Primary Care has dropped by 83% Primary Care has dropped by 83% 

• Average days to specialty MH consult comple

has decreased from 28.3 to 8.3 days 

• Average days to MHIC consult completion is 

days 

VAIL-PACT VISN22 
What do providers think about 

collocation? 

• Lead psychiatrist: “Trust is being deve

between 

primarycare and mental healt

providers 

• Primary care providers happier about s

day and on-site access to mental healtproviders for emergencies 

VAIL-PACT VISN22 
Next steps 

• Tackling logistical barriers for provider 

communication (e.g., resident contact informa

• Assessing patient satisfaction for collocated m

Assessing patient satisfaction for collocated mcare 

• Developg in outcome measures that capture

symptom severity for mental health disorders chronic medical illnesses 

– E g visit frequency unnecessary ED visit

E.g., visit frequency, unnecessary ED visit

hospital length of stays 

VAIL-PACT VISN22 
Conclusion 

• Integrating mental health into primary c

may be difficult

• J i t li i l/ h t hi Joint clinical/research partnership 

–Learning, QI-oriented organizational cu

• F t os ers success in integrati oneff orts 
PC/MH Provider Communication 

Work

group

• Workgroup members: 

– Wendell Ching, MD, Maria Davis, NP, Sue Donov

J ki Fi k l PhD M J h MD MPH K Jackie Fi

c

k

el, PhD, Megan 

J

o

hnson, MD, MPH, K

MD, Randy Mervis, MD, Mai Pham, MD, Lisa RubMD, MSPH, Susan Vivell, PhD, MBA, Maria Zamb

• Ad

visory group mem

bers: 

– Cathy Alessi, MD, Ed Chaney, PhD, Dana Melchin

LCSW, Marti Waite, LCSW, Sarah Minden Weil, L
Sepulveda PC/MH Integration 

Work

group

• Leaders: 

– Lisa Altman, MD, Steve Ganzell, PhD, Ali Kazim, 

• Facilitators: 

– Danielle Higgenbotham, JD, Robin Sohmer

• Workgroup members: Workgroup members:

– Wendell Ching, MD, Sue Donovan, RN, Jackie Fic

Megan Johnson, MD, MPH, Maria Zambrano, NP

Waite LCSW Alisa Doner Fredalin Braden RN Waite, LCSW, Alisa Doner, Fredalin Braden, RN, 

Duman, PhD, Teri Davis, PhD, Evelyn Chang, MDJavier Quintana, MD, PhD 
• 

co u cat o a a ca e a d e ta ea t o 

VAIL products: manuscripts and p resentations

• Yoon J, Yano E, Altman L, et al. Reducing costs of acute ca

ambulatory case-sensitive medical conditions: the central rocomorbid mental illness. Med Care. 2012. Chang ET Rose DE Yano EM et al Determinants of ReadChang ET, Rose DE, Yano EM, et al. Determinants of ReadPrimary Care-Mental Health Integration (PC-MHI) in the VA Care System. JGIM. 2012. 

• Chang, ET and Rubenstein LV. A quality improvement appr

comm

unication 

a

mo g p o

ng 

prim

a

ryca

re 

a

n

d m

e

ntal health 

p

r

ov

the VA. Poster Presentation. Academy for Healthcare ImproMay 2012. 

• Chang ET, Rose DE, Yano EM, et al. Determinants of Read

Primar

y Care-Mental Health Inte

gration (PC-MHI) in the VA 

Care System. Oral Presentation. Society of General InternaMay 2012. 

• Chang ET, Rose DE, Yano EM, et al. Determinants of Read

Primary Care-Mental Health Integration (PC-MHI) in the VA Care 

System. 

Oral Presentati d lth 201

on. 

Aca

demy 

Health. June 201
Thank you! 

• Any questions? E-mail us at: • Evelyn.Chang@va.gov Evelyn.Chang@va.gov • Lisa.Rubenstein@va.gov 
Number of completed consults to Sepulve

Mental Health (MH): 2011 vs 2012 
     

Number of Consults to Sepulveda Mental Healt

(Nov 2011 - May 2012) 

180200

Average number of MH consultsinitiated by PC before intervention:14.6 consults/week

Average number of MHconsults

initiated by PC afterintervention

6.6 consults/week

120140160

er month

80

100

120

r of consults p

4060

Number

0

20

Nov‐11 Dec‐11 Jan‐12 Feb‐12 Mar‐12 Apr‐12 

Date (month)

Primary Care‐Initiated Consults to MH MHIC Consults Total Consults to MH
I l t ti f P ti t Ali 

Imp

lemen

t

ation of 

a P

atient Alig

Care Team ( PACT) for OEF/OIF Veterans with PTSD: Bridging Pr& Behavioral Health Care & Behavioral Health Care 

Elif Sonel, MD Barbara H. Hanusa, PhD, Erin Ke

Kathryn Zimmerman, RN, BSN, CCRC, Stacy Faulkner, R

Jon Walker, MS, Cathleen Appelt, PhD, Cassandra Brow

John Kasckow, MD, PhD & Gretchen Haa
C. CONS S NG O M C S W N G

PLEASE SELECT THE OPTION THAT BEST DESCRIBES YOUR PACT TEAMS: 

A. CONSISTING OF PRIMARY CARE STAFF ONLY 

B. CONSISTING OF PRIMARY CARE STAFF WITH INTEG

BEHAVIORAL HEALTH (BH) 

C. CONSISTING OF PRI

MARY CARE STAFF WITH INTE

G

SPECIALTY STAFF 

D. CONSISTING OF PRIMARY CARE STAFF WITH INTEG

SPECIALTY AND BH STAFF SPECIALTY AND BH STAFF 

E. DO NOT HAVE DEDICATED PACT STRUCTURE IN MY 
Patient Aligned Care Team Model (PACT

3

 The PACT Model represents an advance 

coordinated

, pro-active & customized ca

beyond conventional care models withiPrimar

y Care clinics. 

 OEF/OIF/OND Clinic is a post OEF/OIF/OND Clinic is a post

-deploym

clinic serving Veterans from the recent w
Patient Aligned Care Team Model

4

 In Pittsburgh, we have been developing an integrate

model of care within the OEF/OIF/OND Primary ClinNovember 2010 as part of our project. 

 In this time frame the OEF/OIF/OND clinic also evolv

a PACT team and has been shaped by our study into integrated Behavioral Health-Primary Care PACT mo

 In our study, a subset of Veterans with PTSD diagno

been targeted by a randomized clinical trial comparioutcomes between the two PACT structures within thclinic, as well as comparing outcomes with all other Primary Care locations in VAPHS. 
PTSD Diagnosis as a Marker of High R

5

Why did we choose Veterans with PTSD as 

focus for the trial? 

 High incidence of co-morbid medical, menta

and substance abuse issues 

 Disproportionate use of medical and surgica

services compared to Veterans without PTSD 

 Hi h f di l d hi i d i Hi

gh rates 

of medical and psychiatric a

d

mis

 High rates of suicide 
PTSD Diagnosis as a Marker of High R

6

In Pittsburgh 

 PTSD diagnosis is carried by 206 of the 838 Vet

(25%) served by the OEF/OIF/OND clinic. 

 And yet, Veterans with diagnoses of PTSD const

79 of the 144 (54%) medical, surgical or psychiahospitalizations of all OEF

/OIF

/OND Veterans, m

than twice the expected rate. 

 OEF/OIF/OND Veterans with PTSD diagnoses 

constituted 17% of all suicide attempts and 33% all completed suicides in FY2011. 
The Integrated PACT Model for the PTSD 

7

Veterans in the OEF/OIF/OND Clinic

 Di t A rec ccess t th RN C M o th

e RN Care Manage

(Intense care management-ICM) 

 Individual, pro-active care managem Tracking of health outcomes  Preventative health maintenance  Inte

grated and inter-disci

plinar

y care 

management for medical and behaviohealth care. 
The Integrated PACT Model for all Veter

the OEF/OIF/OND Clinic the OEF/OIF/OND Clinic 

8

An active interdisciplinary team that meets weekly con

 Psychologists and psychiatrists P i C id d P

rimary Care providers and nurses 

 Social workers  Rehab pain and sleep specialists as needed Rehab, pain, and sleep specialists as needed Behavioral Health nurse practitioner 

Providin

g inte

grated and inter-disci

plinar

y mana

gemen

medical and behavioral health care for veterans but; 

Without the added benefit of direct access to a dedicate

customi d d ized and pro-acti h d id ive care 

t

he stu

dy provides. 
Sc ee s a da d ed e a ea su 

The PACT Model for all Veterans in the OEF/OIF/OND Clinic OEF/OIF/OND Clinic 

9

Another uni

que feature is the close tie between Pr

Care and Behavioral Health care in Pittsburgh 

 All new OEF/OIF/OND Veterans are referred to 

Behavioral Health Lab (BHL) for pre

-visit screen

 Pre-visit screening phone call includes 

 Sc

reenin

g with s

t

a

nda

r

dized 

m

ent

al health su

 Encouragement and application of motivatio

interviewing techniques to help veterans attensch de

d

ul de appo

i

in

tmen

t. 

 If any mental health red flag, or possible Tra

brain inj y ur

y is identified, a same da

y BH and

/

evaluation is arranged. 
Funded Project to Study the PACT Mode

10

Pittsburgh VAHCS 

Implementation Aims  Descriptive component of the PACT 

implementation: 

Success stories

, obstacles

,time frame

patient experiences and satisfaction with ca

 Implementation component of creating a n

Behavior Health-Primary Care integrated PAmodel with intense care management (ICM
11

Funded Project to Study the PACT ModePittsburgh VAHCS Pittsburgh VAHCS 

Research Aims Research Aims 

 Clinical Trial within the OEF/OIF/OND clinCompare Usual PACT model to an Intense Care Compare Usual PACT model to an Intense Care 

Management (ICM) added model of PACT. 

Compare both PACT models to pre-PACT implementa Administrative Data Analysis Compare service use and attendance between the 

OEF/OIF/OND Veterans with PTSD diagnoses treatwithin the integrated PACT model to OEF/OIF/OND Veterans treated at all other primary care clinic sitePittsburgh. 
Research Components

12

 Clinical Trial 

 Measure the im

pact of the ICM-PACT on 

attendance, health care usage and satisfawith care compared to care received in thevolving PACT model clinic. 

 Focusing on OEF/OIF/OND Clinic Vetera

wi h PTSD ith PTSD as our hi hi

gh i k i r

sk registry 
Research Components

13

 Randomized control trial focusing on Vetera

with PTSD receiving care from the OEF/OIFClinic to compare 

 Veterans who receive usual care in the 

developing PACT model clinics within PrimC d are, and 

 Veterans who receive care in the same locatio

with the benefit of adding access to a dedicatCare Manager who facilitates integrated medbehavioral health care (ICM-PACT). 
Research Components

14

Role of the Intense RN Care Manager (ICM) Role of the Intense RN Care Manager (ICM)  Encouraging and helping patients overcome bar

attendance prior to all appointments. 

 Helping Veterans identify medical, social, or me

issues to be addressed in their upcoming appoin

 Pro-active calls to the veterans at a minimum on 

basis, or as indicated by the medical, or psychia

 Documenting these calls and bringing the issues 

weekly inter-disciplinary team meetings. 

 Informin

gthe Veterans and documentin

gthe int

disciplinary team discussion points. 
Research Components

15

Outcomes 

 Service use with a focus on decreasing hig

cost ED and inpatient admissions 

 Attendance at scheduled medical and beha

health appointments 

 Satisfaction with care received  Self assessment of well being, work-life 

adjustment and PTSD severity
Research Components

16

Methods Participants are recruited in the clinic either through 

ref l b th li i t lf f l ferrals b

y the cli

nic team, or self re

ferral 

After signing informed consent, completing paper su

the Veteran is randoml

y assi

gned to treatment. 

The Veteran receives a letter and a phone call to info

him/her of the assignment 

For those assigned to ICM care, the dedicated RN Ca

Manager assesses needs and begins relationship wp artici

pant.
- - 

Research Components

17

 Follow up surveys are completed 6 & 12 month

after randomization 

We anticipate that the last 12 month survey will b

collected in May 2013. 

Surveys measure PTSD symptoms, combat 

exposure work exposure, work -life adjustment and quality life adjustment and quality -o

One-on-one interviews; with patients to l

their experiences with PACT care and PTS

Today we will be presenting preliminary data on se

use and appointment attendance. 
Preliminary Results

18

Preliminary results being presented todcompare compare 

 Percentage of primary care and behav

health appoints that were attended. 

 Number of hospital admissions and ED 

visits within 6 months of PACT care. 
Preliminary Results

19

Percentage of Appointments Kept 

Compare 1 year before and after 

randomization -in study data for the sampatients 

 Separate analyses for primary care and 

behavioral health visits 

Compare Usual PACT Care with ICM-PAC
20

Preliminary Results 

Percentage of Scheduled Appointments Kep

80%50%60%70%

Pre Usual Care

20%30%40% InstudyUsual 

Pre ICM PACTInstudy ICM PA

0%

10%

Primary Care Behavioral Health

Instudy ICM PA

Appointments Appointments
21

Preliminary Results 

ER visits and hospitalizations after random

Number of ER Visits 

Number of Hospitalizatio

Usual Care (n=30) ICM PACT (n=44) 

5 (17%) 

8 (18%) 

2 (7%) 

4 (9%) 
Administrative Data Analysis

22

O i L Ad i i t ti Ongoing Larger Ad

minis

trative St du

dy 

 Compare service use and attendance betwe

OEF/OIF Veterans with PTSD diagnoses treawithin the in our integrated OEF/OIF/OND Pclinic to OEF/OIF Veterans treated at other pcare clinic locations in Pittsburgh. (1 other mand 5 CBOC’s) 

Will i l h Will inclu

de t

he same measures – 

 Appointments scheduled and kept  ER i i d h i li i ER 

visits and hospitalizations 
Administrative Data Analysis

23

Greater numbers of Veterans will allow us to 

compare an our integrated PACT model clinclinics that are developing “conventional” teams 

 Comparisons will also be made between P

patients w/ non-PTSD patients