Pact-101712

Moderator:I would like to introduce our speakers.  Speaking first we have Dr. Evelyn Chang, she is in internal medicine at UCLA and VA Health Services and Primary Care Research Fellow. Speaking second will be Elif Sonel, she is the physician for internal medicine and the Medical Director for Primary Care and OEF / OIF / OND Clinic in the Pittsburgh Healthcare System. I would like to thank our presenters for lending their expertise today. At this time, Evelyn are you prepared to share your screen? 

Dr. Evelyn Chang:Yep, I am. 

Moderator:Excellent. You are going to see a pop-up now, just go ahead and click on the button Share My Screen. Great and you are set to go. 

Dr. Evelyn Chang:My name is Evelyn Chang and I am an Internist in the Health Services Research Fellow at the Sepulveda of Excellence in Los Angeles. I work closely with Dr. Lisa Rubenstein, Primary Care and Mental Health Integration Issues. I am not claiming that we have all the answers at Sepulveda but today I would like to share with you our approach at Sepulveda trying to figure out the nuts and bolts of integrating mental health into PACT using a quality improvement approach. 

Just to give you a little background on our demo lab at VISN 22 we call it the Veterans Assessment and Improvement Laboratory or VAIL. VAIL promotes a structured evidence based PACT Quality Improvement at primary care practices. We have been unfolding it in three phases. In our initial start up period we had three medical centers in southern California, each with a demonstration site. In our second phase which we are currently are in now, we are spreading where each medical center as a practice and will be heading soon into the sustainability phase. 

Early on in our demo lab mental health in PACT emerged as a major focus through two projects. The first one was an economic evaluation of ambulatory care sensitive conditions from VAIL performed by Dr. Yoon at HERC. Also VAIL innovation proposed by the Greater Los Angeles Medical Center on integrating mental health into PACT. This is led by Dr. Lisa Altman. 

Just to give you an overview of what I like to talk about today, we will be reviewing the problem of co-morbid mental and medical illness as described in VAIL on a national, VISN and local level. Then we will describe the primary care and mental health activities at Sepulveda Ambulatory Care Center, which is our demonstration site. We have two integration activities, one of which is the collocation of mental health providers into primary care, which is led by Dr. Altman. Also our investigation communication between mental health and primary care using quality improvement tools and we will be focusing most of the talk on this. 

Many of you probably already know this but it is always a good idea to just restate some significant research findings. The VAIL Economic announced the cost for hospitalizations and ED visits for chronic medical illness such as congestive heart failure and diabetes showed that there was a significant increase associated with also having a chronic mental health condition over and above the effect of diabetes. In particular depression and drug use had the most impact. Veterans with mental health conditions have higher utilizations of health care and costs. 

Moderator:Evelyn I apologize for interrupting. Can I ask you to speak up a little bit. 

Dr. Evelyn Chang:Uh-huh.

Moderator:Thank you.

Dr. Evelyn Chang:Care among Veterans with mental health or substance abuse disorders are more costly. Even though Veterans with mental health or substance abuse disorders only make up 15% of Veterans overall, they account for almost a third of VA costs. Most of the costs are for medical not mental healthcare. 

As you know primary care mental health integration is thought to be a possible solution. The VA endorsed collocation and collaborative care models to integrate primary care and mental health in 2006. As many of you know collaborative care models such as TIDES and BHL have been shown to improve outcomes and is cost-effective. 

A year after the VA endorsement, half of the primary care sites implemented collocation rather than collaborative care model. Some of them had implemented TIDES or BHL and there were also some clinics that had implemented more than one primary care mental health integration model. The problem is that collocation alone is not as effective. The VA had actually encouraged adoption of “collocated collaborative care”. However, evidence suggests in most sites, this is simply collocated, but *not*collaborative, care. Now what that means is that in collocated care providers are simply practicing in parallels but not necessarily working together or communicating but just using the same space. According to a meta-analysis bi-directional communication****is a critical component of

Collaboration. It improves outcomes in primary care patients with mental illness. It also results in joint care planning.

I want to tell you about our demonstration sites, the Sepulveda Ambulatory Care Center where we have carried out some of these interventions. It is a multi-specialty academic community-based

outpatient clinic that serves 16,000 Veterans in Los Angeles, CA; has trainees in internal medicine, psychiatry, and psychology. We have two primary care PACT teams and it has specialty mental health and substance use outpatient services in a different building from primary care.  Historically this site has tried to integrate mental health and primary care. 

We realized that there were problems with collaboration at the sites through focus groups. We performed three focus groups about a year ago with mental health patients, primary care providers and social workers. There were some crosscutting themes including issues with mental health specialists’ continuity and availability when scheduled. There were also issues with primary care provider comfort with mental health care and communication. There was a perceived long wait time for new mental health consult on the order of months.  Primary care providers said that there was a lack of understandable mental health treatment plans and there just did not seem to be a lot of coordination of care. 

Also, local management at Sepulveda identified mental health follow-up of stable mental health patients as a potential access barrier to new consults for specialty mental health. Primary care patients had to wait a long time for a new consult. There was an attempt to transfer patients chronically followed in mental health for a transfer of responsibility to their primary care provider for management of stable mental health disorders. Their primary care providers would actually prescribe stable psychotropics. However, the project revealed major resistance from primary care and mental health as well as practical problems. We realized that there was no standard way to guide communication. 

We undertook the two projects at VAIL one of which was to collocate mental health providers into primary care; to improve access for new consults and also the investigation of communication between mental health and primary care providers for shared patients using quality improvement tools, which I will talk about first. 

Our first step in this quality improvement project was to initiate it through the Sepulveda Quality Council. We formed an Interdisciplinary Project Workgroup, which included primary care providers, psychiatrists, researchers and administrators. The reason why we included all these members that it is important there are major stakeholders in the intervention. Primary care providers and psychiatrists provide the ground level view of what is actually going on. Researchers can provide a theoretical framework or an idealistic view and also administrators can actually do something about what we find. Then we began meeting monthly with intervening homework. 

The next thing that we did was that we used quality improvement tools to diagnose the communication problems. We had a workgroup brainstorming and focus interviews. We created fishbone diagrams to understand the root cause of problem. We also created flow mapping of communication strategies to describe process. We also performed chart reviews for patients followed in both mental health and primary care as well as consult requests to mental health. Then we performed a survey of mental health and primary care providers for the site. 

I want to show you the fishbone diagram that we created. Just in case you are not familiar with looking at fishbone diagrams, if you squint really, really hard, you can see a fish head on the right, the spine going down the middle here and then here are the bones. Each of these slanted bones are the heading for our categories of contributors to problems, contributing to poor communication among primary care, mental health providers. Then these little bones are the contributors to the problem. Just to go over some of the things that we found in terms of contributors to poor communication among primary care mental health providers. In terms of communication tools we found that psychiatry residents who provide a majority of the psychotropic management at Sepulveda do not have the VA email or phone numbers. It was almost impossible for primary care providers to even contact them if they had any questions. In terms of process, most primary care mental health providers found that they could not identify who was their correct provider especially when residents were involved. Also with residents, there was a lack of continuity for supervising attending. Even if there was a resident and you could not reach them, and you wanted to see if you could contact at least the attending, the problem is that the attending changed every time so it was hard to know who to contact. In terms of provider characteristics, there is a lack of mental health training for primary care providers in terms of cultural differences. As you know, there is a big difference between the medicine and the mental health practice style. Then we performed a survey at the whole site to see if other providers agreed on some of these problems. The interesting thing that we found was that primary care mental health providers agreed on the problems. 

They agreed that they did not know who was on the patient care team. They were wondering who is the correct attending, who is the correct resident and who is the backup in case the above cannot be reached. Also, they wondered how do you even contact the other provider and there were some other discipline specific problems in terms of team member roles. Mental health providers believe that primary care providers were uncomfortable with mental health therapies and in cases of emergencies; primary care providers believe that mental health providers were inaccessible during emergencies. 

In terms of, I just want to give you some quotes from the surveys that are very telling as well. In terms of primary care providers perceived barriers to communication and collaboration, they thought that there were not enough providers to do therapy. Also, they wrote they were unable to reach a mental health provider when paged by beeper and even sometimes overhead pages.  Mental health providers perceived barriers included primary care providers have indicated an aversion to prescribing any psychiatric medications to psychiatric patients, even if they routinely prescribe these medications for other problems. And the most striking quote was “There is NO communication. When I have attempted to talk with MDs, most are confused what I am even

attempting to achieve.”

Next, after we established the problems of communication / collaboration we performed a rapider view for innovative and evidence based strategies to come up with possible solutions. The literature shows that integrated treatment plans for shared patients, regularly scheduled joint case conferences, joint patient consultation and multidisciplinary team meetings can be very helpful. 

Next, we embarked on a Plan Due Study Act or PDSA for joint care planning for complex mental health and primary care patients. We developed an integrated treatment plan template which identifies which provider is primarily responsible for guiding care overall? Who the backup providers are and what are the treatment goals for mental health and primary care problems. The PDSA cycles revealed that process was helpful to providers caring for the shared patient but it was too time-consuming. There was a low acceptability rate.

Next what we are going to try to do is to PDSA is a Tool for Joint Grand Rounds. This will provide opportunities for primary care and mental health providers to interact and learn from each other. It will allow education or providers on common primary care mental health issues and also provide a platform for discussion about systems, provider and patient level issues for primary care mental health integration. Our first Joint Grand Rounds will be November so we will see how that goes so stay tuned. 

Next, I want to talk about the collocation effort that is led by Dr. Lisa Altman at Sepulveda. In this intervention, it was modeled loosely after the White River Junction Collocated Collaborative Care Model where we offer same day access. We have a psychiatrist, two half-time nurses and part time social worker and psychologist. We are offering group therapies in primary care setting including meditation, mindfulness and coping. We have developed a new consult note and we are currently working a new treatment plan note. Most importantly, it is guided by weekly interdisciplinary meetings under VAIL. This is where all stakeholders meet so they can troubleshoot any issues that have come up. 

Since implementation in February 2012 it has been very successful. There was a strong uptake of the collocated team or the mental health Integrated Care consults averaging 46 consults per month, which was initiated by our primary care providers at Sepulveda. While there is a strong uptake of the Mental Health Integrated Care Consult, the number of specialty mental health consults initiated by primary care providers has dropped by 83%. The best is that access has improved a lot. Average days to specialty mental health consult completion has decreased from 28.3 to 8.3 days. The average day to one of the Mental Heath Integrated Care Team consults is 5.2 days. We expect that will be even faster when the e-consults are up and running as well. 

What do providers think about the collocation so far? A lead psychiatrist said that trust is being developed between primary care and mental health providers. Primary care providers are happier about the same day and onsite access to mental health providers for emergencies. 

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In terms of our next steps at Sepulveda will be tackling logistical barriers for provider communications such as resident contact information. Also, we will be assessing patient satisfaction for the collocated model of care. Then we are also working on developing outcome measures that capture symptom severity for mental health disorders and chronic medical illnesses such as visit frequencies, unnecessary ED visits and hospital length of stays. 

In conclusion integrating mental health into primary care can be challenging. Our VISN has a unique approach in that there is a joint clinical and research partnership and it promotes a learning quality improvement oriented organizational culture. We hope that it will foster success and integration efforts. We believe that this approach can be used by any medical center in any primary care setting.  

I wanted to acknowledge some of the people who worked very hard on these interventions at Sepulveda. We have our provider communication workgroup; as well as our primary care mental health integration workgroup. 

Just wanted to share with you some of our products such as manuscripts and presentations. Please let us know if you have any questions. You can email us at any time. 

Next Dr. Sonel will be telling us about her PACT Model for OEF and OIF Veterans. 

Moderator:Thank you very much Evelyn. At this time, I would like to turn it over to Dr. Sonel. You should see a pop-up, go ahead, and press Show My Screen. 

Dr. Elif Sonel:Hello everybody. I am Dr. Elif Sonel, I am a primary care provider and also, how do I make this smaller actually Molly? Do you see a screen of?

Moderator:For the dashboard just hit the orange arrow in the upper left hand corner and it will collapse it. 

Dr. Elif Sonel:Okay thank you very much. 

Moderator:Then just click back on your slides. 

Dr. Elif Sonel:I am a primary care provider and a women’s health provider in VA Pittsburgh Healthcare System. I happen to be the Medical Director for Primary Care as well as the OEF / OIF clinic. We actually got a fund from one of the PACT demonstration laboratories out of Philadelphia. We have our study named Implementation of a Patient Aligned Care Team for OEF / OIF Veterans with PTSD. Our purpose is to bridge primary care with mental health care. 

Moderator:You can click anywhere on the slide to advance it. There you go, perfect. 

Dr. Elif Sonel:So that we know the makeup of our audience, we have a polling question for you. If you could please select the option that best describes your PACT Team structure. Option A is PACT Teams consisting of primary care staff only. Option B is PACT Teams consisting of primary care staff with integrated behavioral health. Option C consisting of primary care staff with integrated specialty staff. Option D consisting of primary care staff with integrated specialty and behavioral health staff. The final Option being do not have dedicated PACT structure in my clinic. 

Moderator:Thank you. We do have about 40% of our audience that has voted so we will give them a few more seconds to click the circle that is their answer option.  We do still have a few people streaming in their votes so we will people about another ten seconds or so. Okay 55% of our audience has voted so I am going to go ahead and close the poll and share the results. Dr. Sonel you should be able to see those and talk through them real quick now. 

Dr. Elif Sonel:It looks like actually majority of the audience, 46% of the audience do have PACT Teams consisting of primary care staff with behavioral health integration. We have 21% of the audience who have primary care staff only PACT Teams. We have 13% with integrated specialty and behavioral health; 12% of our audience basically admits to not having a PACT structure. Thank you for your poll. I would like to go ahead and continue the presentation now. 

Moderator:There you go, just go ahead and click, perfect. 

Dr. Elif Sonel:As you may know the PACT Model represents an advance in coordinated, pro-active and customized care beyond the conventional care models within primary care. OEF / OIF and OND Clinic is a post-deployment clinic serving Veterans from the recent wars. 

In Pittsburgh, we have been developing an integrated PACT model of care within the OEF / OIF / clinic since 2010 as part of our project. This actually also represents the time frame where the OEF / OIF clinic also started developing into a PACT team. Our study actually had been privileged to shape the structure of the OEF / OIF PACT team into an integrated Behavioral Health-Primary Care model. In our study, a subset of Veterans with PTSD diagnoses has been targeted by a randomized clinical trial comparing outcomes between the two PACT structures within the same clinic, as well as comparing outcomes with all other primary care locations in VA Pittsburgh Healthcare System. 

Why did we choose Veterans with PTSD as our focus for the trial? As you may know PTSD patients have higher incidence of comorbid medical and mental health problems as well as substance abuse issues. Patients with PTSD disproportionately use medical and surgical services compared to Veterans without PTSD. There is also a much higher rates of medical and psychiatric admissions as well as high rates of suicide. 

Our Pittsburgh data shows that 25% of our patients served within the OEF / OIF clinic carry the diagnosis of PTSD. However, when we look at all medical, surgical and psychiatric admissions, we see that double that rate constitutes Veterans with PTSD diagnoses. You can see how disproportionate the service utilization is for these patients. Also we received our suicide data that showed OEF / OIF Veterans with PTSD diagnoses that constituted 17% of all suicide attempts in Pittsburgh; however 33% of all completed suicide attempts were done by patients with PTSD diagnoses. 

In our integrated PACT model for the PTSD Veterans, within our OEF / OIF clinic provides the direct access to an RN Care Manager, which we will call Intense Care Management. We also provide Individual Proactive Care Management, tracking of health outcomes, preventative health maintenance as well as an integrated and interdisciplinary care management for medical and behavioral healthcare. 

As I indicated earlier, our PACT study shaped very much how the PACT Team was formed within the OEF / OIF clinic. Therefore there is an integrated PACT model available for all Veterans within our clinic. We have an  active interdisciplinary team that meets weekly and the team consists of: Psychologists and psychiatrists; Primary Care providers and nurses; Social workers; Rehab specialists, pain, and sleep specialists as needed as well as the Behavioral Health nurse practitioner. Our clinic provides integrated and interdisciplinary management for medical and behavioral health care for Veterans but the usual PACT model does not have the added benefit of direct access to a dedicated RN nor the customized or the pro-active care the study provides.

Another unique PACT feature in Pittsburgh healthcare system is our close tie between primary care and behavioral health. All new OEF / OIF Veterans are referred to the Behavioral Health Lab for pre-visit screening phone call. In this phone call we screen Veterans with standardized mental health surveys. We encourage them to attend their scheduled appointments. We apply motivational interviewing techniques to overcome barriers that may lead to a no show. If we identify any mental health red flag, or possible Traumatic brain injury we arrange for a same day Behavioral Health and/or Traumatic Brain Injury evaluation.

The implementation aims for the study consistent of a descriptive component basically for the PACT implementation itself and we are collecting success stories, obstacles, timeframe in which the PACT Team was developed. Also we collect information on patient experiences and satisfaction with care. Also the implementation is a component of the study by itself; we wanted to see if we could successfully create a novel behavioral health primary care integrated PACT model with intense care management. 

Our clinical trial within the OEF / OIF clinic compares usual PACT model to an Intense Care Management model. We also compare both PACT models to pre-PACT implementation care. We have a separate administrative data analysis, which compares service use, and attendance between OEF / OIF Veterans with PTSD diagnoses treated within the integrated PACT Model to OEF / OIF Veterans treated at all other primary care clinic locations in Pittsburgh. 

In the clinical trial we measure the impact of the intense care management PACT on attendance, healthcare usage and satisfaction with care compared to care received in the evolving PACT model clinic. We have focused on the OEF / OIF clinic Veterans with PTSD as our high risk registry. 

Our randomized control trials focuses on Veterans with PTSD receiving care from the OEF / OIF clinic to compare Veterans who receive usual care in the developing PACT model clinics within primary care. And Veterans who receive care in the same location but with the added benefit of having access to a dedicated RN Care Manager who facilitates the integrated medical and behavioral healthcare. 

The roles of the Intense Care Manager are encouraging in helping patients overcome barriers to attend all scheduled appointments; helping Veterans identify medical, social and mental health issues to be addressed in their upcoming appointments, proactive phone calls to the patients at a minimum on a monthly basis or as indicated by their medical or psychiatric needs. We document these phone calls and bring these issues to the weekly interdisciplinary team meetings and then we inform the Veterans regarding the team discussion and we document the discussion points in the patients chart. 

We measure various outcomes. We measure service utilization with a focus on decreasing high cost emergency room and inpatient admissions. We measure attendance at scheduled medical and behavioral health appointments. We also collect information on satisfaction with care received. We also collect information on self-assessment of well being, work life adjustments and PTSD severity. 

Our participants are recruited in the clinic either through referrals by the care team or through self-referral. After signing Informed Consent and completing paper survey, the Veteran is randomly assigned to treatment or usual PACT care. The Veteran receives a letter and a phone call from the RN to inform him or her of the assignments. For those assigned to intense care management care, the dedicated RN assesses the care needs and begins the relationship with the participant. We then collect surveys at six and twelve months. 

We are in the collection phase for six-month surveys and we anticipate that the last collection will end in the May, 2013. Our surveys measure PTSD symptoms, combat exposure, work life adjustment and quality of life issues. We also conduct one-on-one interviews with patients to learn their experiences around PACT care as well as PTSD. Today I will be presenting you data, which is preliminary on the service use and appointment attendance. 

We are going to be comparing the percentage of primary care and behavioral health appointments that were attended; number of hospital admissions and ED visits within the six months of PACT care. 

We are also going to be comparing data one year before and after randomization in study for the same patients. We are going to be performing a separate analysis for primary care and behavioral health visits. We are going to be comparing usual PACT with the intense care management PACT. 

Our six-month data within the primary care OEF / OIF clinic shows that in the blue column you are going to be seeing pre-PACT implementation data. As you can see primary care appointments were not well attended. Just with the PACT implementation itself, primary care appointments actually increased about ten percent. Behavioral health appointments were attended at a higher percentage pre-PACT care, but they also continue to remain at a high level. In the intense care management arm, primary care appointments are attended almost 20% more than pre-PACT care. 

In our six-month data, we did not show a significant difference in the number of emergency room visits or number of hospitalizations. We just did not have enough events to show a different. 

We anticipate having a much larger administrative study comparing service use and attendance between the OEF/OIF Veterans with PTSD diagnoses treated within our integrated PACT Team to OEF / OIF Veterans treated at all other primary care locations in Pittsburgh, which is one other main site, and five CBOCs. We will include the same outcome measures such as appointment scheduled and kept; emergency room visits and hospitalizations. 

Greater numbers of Veterans will allow us to compare our integrated PACT model with clinics that are developing a conventional PACT Team. We will also be comparing data between PTSD patients with non-PTSD patients. 

At this time I will be glad to entertain any questions as will Dr. Chang. I want to thank the audience for their time. 

Moderator:Thank you for leaving plenty of time for questions. We do have about five pending at this time. for those of you that joined us after the top of the hour I just want to let you know to submit a question please go to the Go To Webinar dashboard located on the right hand side of your screen and you can just type in your question or comment and hit send and we will get to it in the order that it was received. 

This first question came in during Dr. Chang’s portion. Was there any thoughts given to include RNs and MSWs into your Quality Council. If not, how come?

Dr. Evelyn Chang:We have our Quality Council for all of Sepulveda and what it does it actually is a Board that sits and also meets weekly. I should have clarified; they are actually over many, many projects including the Primary Care MENTAL HEALTH Integration Work Group. On that Quality Council there are many interdisciplinary including nurses, nursing supervisors and social workers. For my particular quality improvement project where mostly primary care and providers and psychiatrists as well as the researchers and administrators. We did talk to nurses and social workers. The social workers participated in our Advisory Group. We did have a nurse who was only able to attend some of the sessions, but because of time constraints could not fully participate. 

Moderator:Thank you for that reply. We do have plenty of more questions streaming in and it looks like we will have time to get to all of them. 

The next one also came in I believe during your portion. It seems as if the prescribing psychiatrist would need to have a significantly reduced panel size if truly open access is the goal. Over time as this providers panel inevitably increases the need for follow up visits, will also increase which reduces “open access”. What are your thoughts on sustaining the integrated model long term?

Dr. Evelyn Chang:That is a really, really good question. I think a lot of sites, and we are kind of into this, getting to the phase where we are definitely considering those questions too where we are trying to think of now that the psychiatrists and social worker and psychologists are starting to build up a panel, they are starting to see them repeatedly for follow up. Yet we want to make sure to have some sort of same day access and to have some flexibility in the scheduling how do we handle that? We are still struggling with trying to figure that out. One thing we would like to do is to try to figure out a way to make the follow up sessions within the mental health integrated team to be time limited. They limit it to something like six sessions, however many they need, until we know if they can go back to primary care or be referred on to the specialty mental health. There has to be some way to keep the flow going so that their own caseload does not increase more and more and become too overwhelming and stressful for the team itself. You are absolutely right to think about the long-term trajectory of where these patients will go. We are working on what sort of algorithms we might use and what sort of diagnoses might be able to be shifted back to primary care or referred on to mental health. 

Dr. Elif Sonel:May I, this is Dr. Sonel, may I add to this answer? I think what we found in Pittsburgh as part of our study is that when we actually dedicate the time from the mental health providers and primary care providers to gather around the table and discuss the patients with the social workers, with the rehab specialist and all those people. It is just the 30 minute timeframe per week, we find that we can actually facilitate and coordinate care a lot better instead of having five different appointments with five different providers actually care plans could be made within five to ten minutes of our time. We find that helps our access and care coordination. 

Dr. Evelyn Chang:That is a really, really good point because that is one of those evidence based practices that are shown in literature to facilitate coordination and collaboration. That is an absolutely really great idea. 

Moderator:Thank you both for those responses. We do have nine questions left pending. 

This first one is actually just a comment. For the first presenter unless I missed it I am somewhat surprised that Veterans were evidently not included in this initiative. Similarly I am concerned that you are not reporting on any Veteran level outcome measures or even plans for measuring them including for example mental health disorder, remission rates or reduction in mental health symptoms such as reduction in PHQ scores. 

Dr. Evelyn Chang:We did talk about whether or not to include Veterans and because a lot of the effort was on the provider level, initially we thought it would be a better idea to make sure that we tackled the provider level concerns. We would like to include Veterans in the future and we are planning to look at Veteran outcomes because we do want to see if any of our interventions are actually improving mental health outcomes on the Veterans. That is our next phase of data collection, what is happening to the patents, what is happening in terms of where they are going, whether it is staying in the team, moving on to a primary care or to specialty mental health and what is actually happening to their management. 

Moderator:Thank you for that reply. 

The next question we have – how do you assure access for same day behavioral health or TBI to level evaluation?

Dr. Elif Sonel:I assume that question is targeted towards me in Pittsburgh. Basically what really helps us is the behavioral health labs screening these Veterans in advance. If we make an appointment for a new patient we automatically send a notification to BHL and they make the phone call and they screen the patient. That gives us about a two week, typically two weeks to one week window of a period where if we get a red flag notification from BHL we can actually have the time within that week or two to make sure the rehab specialist who performs the second level TBI evaluation clears her schedule and makes the time to come to our clinic. As well as within the integrated team we find a behavioral health provider who has availability on the same day. Having that advance notification has been instrumental in trying to get the same day mental health and TBI evaluations done. I am not sure if that answers all of their question but that really has been the key component. 

Moderator:Thank you. The question submitter always has the option to write in for further clarification if they need to. 

The next question that came in, this was also during your portion Dr. Sonel. How do you explain the difference in appointments being kept between the pre-usual care and pre-ICM? Is this an issue of sample size where the difference is statistically significant?

Dr. Elif Sonel:The differences were significant. We found 17% increase with compliance to attendance kept and we think that is because of the fact that the RN Care Manager calls these patients not only to remind them of the appointment but typically these patients are young and they have a lot going on with their lives that become a barrier at times for them to attend their appointments. We are able to work with the Veterans to overcome barriers whether it is childcare or work or any other issue as such. At the end of the day if it looks like they will not be able to make the appointment, then we can actually give them an alternative appointment. We also offer evening clinics now within the OEF / OIF clinic so patients who work they are able to see us after hours as well. We believe there is a significant difference in appointment kept especially within primary care. 

Moderator:Thank you for that reply. 

The next question we have – did you notice if the suicide rate/attempts went down?

Dr. Elif Sonel:Unfortunately we do not have enough data. We just have 78 patients who were randomized in our study for six months; 42 of them received intense care management. We did not have enough events within the six months to show a significant difference as such. When we complete our twelfth month in May, we are going to be comparing our patients with all patients OEF / OIF patients receiving care at other locations as well as patients with PTSD compared to patients with non-PTSD. I believe with those numbers, we are going to have significant more power to show the potential difference. 

Moderator:Thank you for that reply.

The next question we have – what are the various full time employee allowances, primary care, social work, nursing etcetera for your post-appointment clinic and total panel size of the clinic?

Dr. Elif Sonel:Thank you for that question. I think this is a very important nuts and bolts kind of question. Our clinic structure as I indicated in my slides is very interdisciplinary. We have a full time RN who is a clinical RN. As part of the study we had a research RN who took care of the 42 intense care managed patients that was added to the clinic. The clinic model we have a full time lead physicians. We have a part time physician assistant who just started. We have a one-third FTE of another primary care physician. The clinic has roughly about fifteen hundred to sixteen hundred patients total. We have two social workers dedicated to OEF / OIF, not just to the clinic but the population wherever the patients might be. We also have one psychologist. We have one psychiatrist. The psychiatrist is not dedicated to the OEF / OIF but the psychologist is. We do have a 20% time of a psychiatrist who is dedicated to OEF / OIF. We also have a non-dedicated behavioral health nurse practitioner. The non-dedicated behavioral health practitioner and psychiatrist they attend the weekly meetings. The weekly meetings are the key to our success. They get an hour of protected time. The first half of the meeting is usually administrative in nature. They talk about the issues they need to overcome, administrative issues, training. We might have guest speakers, and the final 30 minutes is dedicated towards patient discussions. Those discussions occur based on the need of the Veterans and the same Veteran may be spoken about every week versus once a month versus less often than that. All the care discussions are documented in the chart as well as communicated back to the patients. 

Moderator:Thank you for that reply. We do have ten more questions pending and about ten minutes left in the top of the hour. 

Next question, have you ever considered having a primary care clinic located within the mental health outpatient clinic?

Dr. Elif Sonel:Do we know who that question is geared towards?

Moderator:No. 

Dr. Elif Sonel:We actually had a structure in the past where I was part of a primary care clinic, a small primary care clinic that was embedded within the psychiatric hospital. About 85% of our patients were comorbid with mental health disorders. We did not have offices next to each other but we were embedded at the time. I do find that to be beneficial because it was just four providers from primary care and all the behavioral health providers knew us and it certainly allowed for better communications. Since then we moved out of that area, behavioral health clinic, the psychiatric hospital also moved to a different location. Now we have a different integrated model where we have either general behavioral health providers or specialty behavioral health providers located within the primary care clinic in general. The OEF / OIF clinic is also within the same area and it does have its dedicated behavioral health providers separate from the primary care integrated mental health providers.  We do find this to be a beneficial set up. 

Moderator:Thank you. 

This one is directed at Dr. Chang. What happens next for those patients seen the same day by MHIC in terms of treatment? What percent of mental health specialty consults are generated by MHIC after initial contact?

Dr. Evelyn Chang:That is a good question. We do not have all the data from that yet. I think it was something like six-fifty new consults to the MHIC team would be for patients with psychoses or hallucinations and would definitely require some sort of referral to specialty mental health. We do not have everything in terms of how many of those that were severely depressed, how many with severe substance abuse disorders would need referral onto a specialty mental health yet. We hope to that soon too. 

Moderator:Thank you. 

Next question. Please describe more fully the ICM role, if the ICM, the PACT RN Team member or another full time employee added to the PACT behavioral health integration. 

Dr. Elif Sonel:Thank you for that question. As part of our study we were able to afford a research RN and she is the one that because the Intense Care Manager. For all other clinic patients, the fifteen hundred, sixteen hundred Veterans receiving care from the OEF / OIF clinic there is FTE for a full time RN and a part time RN. They manage all regular PACT models. We are not at a point within the regular PACT to be able to say okay I am going to be calling these patients on a monthly basis even if they do not call us back to see what they are doing. Let us see if I can problem solve an issue, make sure to follow up on certain issues. We are not at that point. But having this additional research RN helps us be able to afford the intense care management to the 42 patients we enrolled in the study. She was able to call them up, problem solve the issues, do medicine reconciliation, remind them of appointments, overcome any issues. Then if she identified any red flags, suicide ideology or worsening depression issues around adjustments, work life issues, benefits issues, obviously the needs of these Veterans are very complex in nature. Having that RN in the setting where the issues are very complex and the patients really are very different from the other populations we are used to taking care of within primary care, they really are not familiar with the VA system. They get lost, they really do not know how to navigate between the layers of care and benefits and all the other things. Having that RN Care Coordinator Care Management has been instrumental. Then once we actually are in the process of transitioning all these patients back to usual PACT care, and we feel that we have been able to teach them how to navigate around the VA system and benefits and so forth we are now transitioning them back to usual PACT. 

Moderator:Thank you. We do have eight more pending questions and this one is also directed at you. 

ICM role why not use social workers since social function is included in monthly phone calls?

Dr. Elif Sonel:Very good question. As we transition care to usual PACT we actually identified the main care needs of these Veterans. As you can imagine our focus is patients with PTSD. We d have a proportion of our patients who had mainly mental health issues. I think those patients could be transitioned back to a social worker. That is what we are going to do. But we also identified these patients have a significant number of medical issues as well. we had within this population we had significant TBI, we had significant polytrauma, we had significant back pain, substance abuse, complex care needs whether infectious in nature or GI or pulmonary. When we look at the reasons why we do the care management it is not all mental health. I would still say out of the 42, thirty-some of them still required very much medical care management as compared to primary  mental health care management. As we transition them back we will be dividing the so-called PACT usually case management to a social worker for the ten we feel would be primarily mental health and the other remaining 30 will transition back to the regular RN care team. 

Moderator:Thank you. Are you all working with the National Primary Care Mental Health Integration Program?

Dr. Elif Sonel:I am not. We received our funding through the PACT Demonstration Laboratory in Philadelphia. 

Dr. Evelyn Chang:I do not think we are either, not these particular projects. 

Moderator:Thank you. Next question this is also fro Dr. Sonel. 

Do you have a sense of whether any of the sample is still in need of specialty mental health visits for their PTSD?

Dr. Elif Sonel:Thank you for the question. The answer is yes, we do have a few patients who are still very much active with their PTSD. They also seem to have multiple other comorbid mental health diagnoses such as depression, anxiety, substance abuse. We are continuing to coordinate their care through substance, rehab, through admissions to various facilities to help them overcome their mental health disorders. 

Moderator:Thank you for that response. This is a clarifying statement to an earlier question. 

It looked like there were differences between the usual care and ICM group before the intervention was delivered. Were the results statistically significant?

Dr. Elif Sonel:Molly, how do I go back to that slide please. Maybe I can pull that slide back. 

Moderator:in the lower left hand corner of your slides there is an arrow to the left. There you go. 

Dr. Elif Sonel:Okay. Would you please repeat the question so that we can look at it at the same time. 

Moderator:It said in response, I mean it looked like there were differences between usual care and ICM. Were the results statistically significant?

Dr. Elif Sonel:Thank you for the question. The differences were reaching statistical significance but not there quit yet. Again this is preliminary data of six months only. It looks like we are going to find a significant difference when the study is about 12 months. We have about ten percent difference and overall we can identify the significance between pre-implementation and post, which is 17% of a difference. We are not there yet between ICM and usual care. Thank you. 

Moderator:Thank you. We just have five pending questions left. Are you two available to stay on for a few minutes?

Dr. Evelyn Chang:Yes.

Dr. Elif Sonel:Sure.

Moderator:Great. Thank you. 

Regarding the OEF / OIF / OND Study how do OEF / OIF Program Case Mangers fit in with this model?

Dr. Elif Sonel:Thank you for that question. We have a structure within the OEF / OIF clinic where the social workers belong to the community based care service line. Behavioral health providers obviously belong to behavioral health and the primary care providers and the nurses belong to primary care. We have a much interdisciplinary model. We have two social workers who are dedicated to OEF / OIF but not only to the clinic. What they do is they actually call all OEF / OIF patients who may be receiving care at any clinic location in the VA Pittsburgh and they offer case management. They do actually case management, they have patients they case manage. If you are familiar with the centre database they definitely have a few hundred patients they follow. The needs are a little different than what we do for the study component where we take care of all mental health and medical issues. The social workers obviously have been a great resource for the clinic. They have been instrumental in helping us manage our patients within the clinic as well as any either mental health or benefits or social or adjustment issues we might have. They are certainly actively involved in the care of the Veterans who receive care from the OEF / OIF Veterans, but they are not limited to those patients and they do have a separate list of patients they manage through the Centre database. 

Moderator:Thank you for that reply. 

Any suggestions for excessive consults directly to specialty care?

Dr. Evelyn Chang:I am guessing that might be directed to me. For a specialty mental health care, I think if you were to use an approach similar to what we used, what I would probably start with is taking a look at the consult requests and looking at what the reasons for consults would be. Look at which are the ones that are the most common, least common. Which ones are the most important and should be directed towards specialty mental health and which are the ones that may be, could be handled by a non-specialty mental health provider or maybe a staff member. Maybe parsing out the reasons for consults in those ways and also seeing if maybe there are duplicates, are there something administrative that could be handled otherwise. Taking a look at the data that way to see where some of the reasons for I guess the excessiveness might be. Then maybe taking a look at that data together with the specialty mental health providers as well as primary care providers to see what is better triage or how to better triage them and what could be handled in primary care versus specialty mental health. 

Moderator:Thank you. 

Have you figured out to get workload credit for the folks at the team meetings? 

Dr. Elif Sonel:That is a good question. In the environment we are in with workload. Unfortunately the team meeting does not count towards clinical time. However, the phone calls that we make to the patients that counts toward workload so the team meetings go towards our administrative time. 

Moderator:Thank you. 

How connected are you to the OOO Program? Are the RN Care Managers part of this program?

Dr. Elif Sonel:If that question is directed towards me, if the writer could explain what the OOO Program is because I am not familiar with it. 

Moderator:No problem. 

The final thing that was written in is a statement. Post Deployment Integrated Care Initiative Hunt and Burgo would like to congratulate Dr. Sonel in this work. It is so important that we better understand how to put the pieces together in an integrated fashion for the comorbid concerns for our OEF / OIF / OND Vets. 

Dr. Elif Sonel:Thank you so much Dr. Hunt and Mr. Burgo. I know that you are the influence in me because I attended first ever OEF / OIF Post Deployment Conference and I listened to you and all these ideas are stemming from that. I very much appreciate even though you may be on the other side of the universe from me, in Pittsburgh you have been instrumental in developing these ideas in my  mind. I very much appreciate the comment. 

For anybody else who might have any questions for me I am a passionate provider about mental health and primary care integration. I am on Outlook so if somebody wants to drop an email to me last name is Sonel S-o-n-e-l and I am the second Sonel in alphabetical order. I would be glad to get in touch with them and I would love to continue the discussion if anybody would like to. 

Moderator:Thank you very much. We did get a clarification from Dr. Burgo. The OOO Program is the OEF / OIF / OND Program. The question again was – are you connected to that program and are the RN Care Managers part of the program?

Dr. Elif Sonel:Oh yes we are the OOO Program then. We are the OEF / OIF / OND clinic. We are within the primary care clinic but we are the Post Deployment Clinic and we were part of the study. The OOO Program is within the primary care clinic in one of the three parts that we have. The study was consisting of part of that community. 

Moderator:Thank you. Those are the remaining questions and comments. Several people did write in saying thank you this was an excellent presentation. At this time I would like to give either of you the opportunity to make any concluding comments to our audience. 

Dr. Evelyn Chang:Thank you so much for listening and for participating we really appreciate it. 

Dr. Elif Sonel:Same here. I want to thank everybody for their time and interest and again if anybody wants to continue as discussion offline I would be glad to do that as well. Best of luck to everybody,. I think the more message we get across with the mental health integration into primary care and evolving PACT Teams the better it will be for our Veterans. Thank you so very much for the opportunity allowing us to present this topic, appreciate it. 

Moderator:I also would like to thank our presenters and our attendees for joining us and staying on. I invite our attendees to join us for the next PACT Cyber Seminar. They take place every third Wednesday of the month at Noon Eastern. The next one will be on November twenty-first and it is Integrating Tele-Health into PACT Care Model, Thinking Outside the Box. You can always go to the HSR home page to locate the Cyber Seminar catalog in order to register for that session. Finally as you exit the Cyber Seminar a survey will pop up on your web browser, please do take a moment to provide us some feedback, it  does help us improve our program for your needs. 

Thank you to everyone and have a wonderful day. 

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