Session #E5b
Saturday, October 18, 2014
Lessons from VA Integrated Care
Implementers Part 2:
Secrets of Successful Programs
Laura O. Wray, PhD, Acting Associate Director
VA Center for Integrated Healthcare
Andrew S. Pomerantz, MD
National Mental Health Director, Integrated Services
VA Central Office
Collaborative Family Healthcare Association 16th Annual Conference
October 16-18, 2014 Washington, DC U.S.A.
Faculty Disclosure
• We currently have or have had the following
relevant financial relationships (in any amount) during
the past 12 months:
– We are both full-time employees of the US Department of
Veterans Affairs
• The views expressed in this presentation are those of
the authors and do not necessarily reflect the position
or policy of the Department of Veterans Affairs or the
United States government.
Acknowledgements:
– Mona Ritchie, MSW, Primary Qualitative Analyst
– All the members of the Team Summit planning committee
– All of the attendees, the highly successful teams who are
making integration happen in VA primary care
Learning Objectives
At the conclusion of this session, the participant will be able to:
• Describe common challenges faced when attempting to integrate
mental health services into primary care
• Describe critical factors reported by successful programs
• Understand how lessons learned at a variety of VA sites during
program implementation can be applied to other health care systems
• List implementation strategies that may be helpful at his/her own
site.
Bibliography / Reference
1. Beehler, G. P., & Wray, L. O. (2012). Behavioral health providers’ perspectives of
delivering behavioral health services in primary care: a qualitative analysis. BMC
Health Services Research, 12(1), 337. doi:10.1186/1472-6963-12-337
2. Kearney, LK. Post, EP, Pomerantz AS & Zeiss, AM (2014). Applying the Interprofessional Patient
Aligned Care Team in the Department of Veterans Affairs: Transforming Primary Care.
American Psychologist 69 (4). 399-408.
3. Pomerantz, AS, Kearney, LK, Wray, LO, Post EP & McCarthy, JF (2014). Mental health services in the
medical home in the Department of Veterans Affairs: Factors for successful integration. Psychological
Services; 11(3). 243-253.
4. Pomerantz, AS & Sayers, SL (2010). Primary care-mental health integration in healthcare in the
Department of Veterans Affairs. Families, Systems & Health, 28(2). 78-82.
5. Wray, LO, Szymanski, BR, Kearney, LK et al. (2012) Implementation of primary caremental iealth Integration services in the Veterans Health Administration: Program
activity and associations with engagement in specialty mental health services. Journal
of clinical psychology in medical settings 19(1). 105-116.
Learning Assessment
• A learning assessment is required for CE credit.
• A question and answer period will be conducted at the
end of this presentation.
But what does VA have to do with
anything outside of VA?
• VA is a single payer capitated healthcare
system
• VA is an Accountable Care Organization
• Everyone says if we have both of those things
we will have integrated care
• But it is a struggle, even when we get the
system we want
Key Points from Part 1
• Presentation at CFHA 2013 on common
challenges to implementation:
How Innovators Manage Real World Push-Back:
Lessons from VA Integrated Care Implementers
Patient Aligned Care Team
8
Principles of Integrated Care in VA
• Open or advanced access (temporal and spatial
integration) in VA medical homes [PACT]
• Problem-focused assessment and treatment: tend to
what the Veteran wants tended to
• On-site clinicians in primary care: Consultation,
collaboration, assessment
• Stepped care
• Measurement-based care
• Care management
• Referral management when needed
Primary Care-Mental Health Integration
[PC-MHI] in VA
• Two components:
• Care management (CM)
• Co-located collaborative care (CCC)
• Blended programs link these complementary
components as appropriate
• Focus primarily on common mental health conditions:
• Depressive and anxiety disorders
• Alcohol misuse and abuse
• PTSD screening/assessment
• Health Behavior Coordinators implement health
psychology programs along with Health
Promotion/Disease Prevention Program Managers
10
Implementation Status
• 2006 Initial RFP
• 2008 Uniform Mental Health Service
Handbook
• VA Medical Centers and very large Community Based
Outpatient Clinics (CBOCs) must have CCC and CM on a
full-time basis
• Large CBOCs’ hours and days of availability of integrated
care services can vary depending upon the clinical needs of
the patient population
• Where are we in 2014?
Rogers’ Diffusion of Innovation
Where are we for PCMHI
implementation??
(Rogers, 1962)
Charting the Course: Integrating PACT
Mental/Behavioral Health and Patient Centered Care
• Goal: Identify essential ingredients of high performing
integrated teams.
– Discover how they overcame barriers to integration
– Learn their perceptions of what makes them successful now
– Garner advice from these expert teams on how to assist others in the
field
• Methods:
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Competitive selection process for team attendees
Broad call for proposals
Invitation to apply preferred some teams known to be successful
Three independent, blind ratings of applications by planning
committee members
– Good agreement across ratings despite ideosyncratic scoring methods
Charting the Course: Integrating PACT
Mental/Behavioral Health and Patient Centered Care
• Methods (continued):
– Gathered 11 of the 12 highest ranked teams on
January 15-16, 2014
– Meeting facilitators fostered a spirit of collegial exchange
– Structured exercises and group discussions used to gather
team input
– Captured output of all exercises and discussions
• Group Note Sheets
• Discussion Notes from Multiple Sources
• Faculty Debriefing Notes
– Rapid, informal, team-based qualitative analysis
Attendees
• 11 different VAMCs and 2
Community Based Outpatient
Clinics
• 8 geographically diverse
VISNs (VA’s regional
organization structure)
• 42 individuals
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Nurses (APNs, RN, LPN)
Pharmacist
Physicians (PC, Psychiatry)
Psychiatrists
Psychologists
Psychology Technician
Social Workers
– Clinical Roles
• Primary Care Providers
• Integrated MH Providers with and
without prescription privileges
• MH Care Managers
• Health Behavior Coordinators
• Integrated Pain Specialist
– Leadership roles (primary or as
collateral duty to clinical role)
• Deputy Clinical Executive
• Primary Care Mental Health
program leaders, and
• PC-MHI team leader
– Facility level
– VISN level
Meeting Topics and Processes
• Team Visuals Round Robin and Discussion
• Nominal Group Process
– Team – based Exercise
– Structured brainstorming and consensus-building format
– Identify essential characteristics needed to support highly effective
interdisciplinary team function
– Whole group report-out and discussion
• Small Group Discussions
– Discipline/Role – based
– Identify challenges and successes in the transition to interdisciplinary
– Whole group report-out and discussion
• Whole Group Discussions
– Facilitated discussions focused on fleshing out some of the themes from
earlier in the meeting
– How they addressed challenges
– What support is need for new teams or those struggling with implementation
– What these teams need to continue their quality improvement efforts
– How teams would like support to maintain their newly forming community of
practice
What do you think they said?
“Secrets” of Successful Teams
• Summing up what makes it work for these
teams and what they feel others need can be
organized into recommendations for:
– VA National Leaders
– Facility and Program Leaders
– Team Members
National Leaders
• Develop and implement tools and processes for
program and outcomes monitoring
• Develop/create additional implementation tools and
materials
• Develop and implement a campaign to engage
leadership
• Support the creation of PCMHI Communities of
Practice and link with PACT COP
• Develop/create PCMHI staff and leadership
educational resources
Program and Facility Leaders
• Hire staff with appropriate skills
– Good relationship building and communication
– Flexible, adaptable
– Motivated
– Determine
• Support the team and give them ownership
• Facility Leaders
– Promote the program
– Designate program leaders with protected time
– Space and access to program data
Interprofessional Team Members
• Define and respect each team member’s role
• Be flexible and work as a team
– Cross-coverage
– Team building time and activities
• Set up structures and processes that support
collaboration
• Understand your data
• Attend PACT team huddles and build relationships
• Focus on caring for the Veterans, centering the
processes of care around the patient’s goals
• Engage all stakeholders in QI
Question & Answer
Session Evaluation
Please complete and return the
evaluation form to the classroom monitor before
leaving this session.
Thank you!