Challenging the Status Quo Through Policy, Education,
Research, and Program Implementation Assistance in the
Veterans Health Administration
Andrew Pomerantz, MD
VHA Mental Health Services
Katherine M. Dollar, PhD
VHA Office of Mental Health Operations
Larry J. Lantinga, PhD and Laura O. Wray, PhD
VHA Center for Integrated Healthcare
Challenging the Status Quo in VHA:
Policy (that began with a
disruptive innovation)
The Policy Challenge
Policy to guide program development in over
1000 clinics, with 8 million enrolled patients in
50 states (plus Puerto Rico and Philippine
Islands)
Healthcare is local
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VA 101
• VA = Department of Veterans Affairs (since 1989)
• Three subcomponents:
– Veterans Benefits Administration (VBA)
– National Cemetery Administration
– Veterans Health Administration (VHA)
• Vet Centers
• Medical facilities and their associated Community Based Outpatient Clinics (CBOCs)
– Organized into 22 regions called Veterans Integrated Service Networks (VISNs)
• Distinction between Department of Defense Care and VA care
– DoD provides care to active duty Service members and their families, and after
discharge to some who had a significant career in the military
– VA provides lifetime care to all eligible Veterans who choose to seek VA health
care
• VHA does not determine benefits but does provide relevant clinical
information to VBA
VETERANS HEALTH ADMINISTRATION
Enhancing the Way We Provide Care
“We are creating a healthcare system that is,
first and foremost, patient centered and
characterized by team care…
We’re also striving, every day, for a healthcare
system that is continuously improving, data
driven, evidence based, and characterized by
excellence at every level.”
Robert A. Petzel, M.D.
Under Secretary for Health
Department of Veterans Affairs
VETERANS HEALTH ADMINISTRATION
Future of VA Health Care
Past
Present
Future
VA
VA
VA
“What can I fix?”
“How can we help what is
wrong with you?”
“How can we help you live
the life you want to live?”
Physician
Clinical Team
Veteran, Family and
Health Care Team
Case-Based Paper Medical
Record
Disease-Based Electronic
Medical Record
Whole-Person Electronic
Health Record
“We’ll address your
immediate concern.”
“You have a risky problem,
please follow this plan to
improve by your next visit.”
“We can design your
personalized health plan to
meet your goals.”
VETERANS HEALTH ADMINISTRATION
PACT Team
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Primary Care-Mental Health Integration
[PC-MHI] in VA
• Two required components:
• Care management
• Co-located collaborative care
• Blended programs link these complementary
components
• Focus primarily on common mental health conditions:
• Depressive and anxiety disorders
• Alcohol misuse and abuse
• Psychological Trauma, including PTSD
• Health Behavior Coordinators implement health
psychology programs along with Health
Promotion/Disease Prevention Program Managers
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Principles of Integrated Care in VA
• Open or advanced access (temporal and spatial
integration) in VA medical homes [Patient Aligned Care
Teams]
• Problem-focused assessment and treatment: tend to what
the Veteran wants tended to
• On-site clinicians in primary care: Consultation,
collaboration, assessment; Part of treatment team, not
enhanced referral
• Stepped care
• Measurement-based care
• Care management
• Referral
VETERANS
HEALTHmanagement
ADMINISTRATION when needed
Challenging the Status Quo in VHA:
Implementation Support
Office of Mental Health Operations Consultative Site Visits
•
All facilities visited in FY 12
– After initial visit , 1/3 of facilities to be visited each subsequent fiscal year
•
Process of Visits
– Assess program implementation to ensure consistent with policy and fidelity to evidence
base
– Consultative
– Identified areas of strength (Strong Practices for further dissemination)
– Identified areas of growth
•
•
Primary Care- Mental Health Integration frequently emerged as both an area for
continued growth and was identified as a strength in several locations
In response, technical assistance options for PCMHI implementation are being
provided
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Implementation Support: A Stepped Care Process
Multiple technical assistance options designed to meet a range of needs
Facilitation: Most resource
intensive option. Best for sites that
could not implement without
intensive support
Consultation: Mid-level, best
for sites needing more than
education, who are likely to benefit
from individualized technical
assistance and program review
Education: Least intensive
option . Should be available in some
form to all locations
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Triage: Matching Site-Level Needs to Level of Assistance
• A data-driven triage process to ensure that locations get the level of
support needed, wanted, and most appropriate
• Data
– OMHO consultative site visit findings
– Progress to date
– Penetration rates
• Per clinic
• Per provider
– Unique and encounters
– Interest and willingness to engage
– Program operational status
• CCC
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Consultation
• Provided by PCMHI experts
• Varies depending on the needs and requests of the site
• Phone calls
– Individual
– Group/Team
• Might include a site visit or training and educational
components
• Discuss strong practices, link with similar locations
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Facilitation
• A bundled set of implementation strategies
– Combined skills of
• A network or facility based internal facilitator familiar with local
organizational structures, climates, clinical processes and,
• An external facilitator who is an expert in evidence-based PC-MHI
care models and facilitation
• Techniques adapted for local needs, e.g.:
– Education
– Audit and Feedback
– Mentoring
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Facilitation
• Not all facilities need this level of support
• Extremely resource intensive
• Best for locations that have not yet been successful with
education, or consultation alone and are unlikely to achieve
full implementation without intensive technical assistance
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Facilitation
•
Reflects partnerships among
–
–
–
–
–
Researchers (CIH and MH QUERI),
Policy Developers (e.g. MHS, PCMHI Program Office,)
and those tasked with program and policy implementation technical assistance (OMHO)
With clinical subject matter expertise
To directly support implementation at the facility level
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Challenging the Status Quo in VHA:
Education and Training
Formal Program Rollout 20072010
• Large scale training, Denver Colorado
• PC-MHI program office formed
– Quarterly national trainings in multiple sites
– Primary focus on operational issues
• CIH accelerates its training and education mission
– Quarterly trainings in Buffalo, NY
– Focus on operational and clinical issues
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2011-present
PACT trainings
Shift to local and regional based PC-MHI trainings
Recognized need to establish a training and education
vision and strategic planning
Growing recognition of “siloing” as “just another
program
Need to go beyond PC-MHI and incorporate as
healthcare
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Mental and Behavioral Health in PACT
Education and Training Workgroup
• Convened in June 2012
• Composed of mixed group of integration subject
matter experts (MH and PC) and experts in education,
transformation, prevention, and systems redesign
• Reviewed status of implementation of PCMHI
• Strategies taken by a variety of VA offices to change
• Made recommendations for national leadership and
for workgroup’s continued activities
VETERANS HEALTH ADMINISTRATION
Mental and Behavioral Health in PACT
Education and Training Workgroup:
Recommendations for National Leaders:
• Clarify PCMHI policy expectations
• Fully communicate the long-term vision of integration
• Direct program evaluation and research efforts
toward:
• Barriers to implementing Care Management
• Strategies to promote sustainment
• Implementation in CBOCs
• Support nationally organized education efforts under
the supervision of the Workgroup
VETERANS HEALTH ADMINISTRATION
Mental and Behavioral Health in PACT
Education and Training Workgroup:
National Education Workgroup Plans
• Workgroup to serve as an oversight body
• Identify current education needs of the field and gaps
in portfolio of trainings being offered
• Direct the development of products and/or events to
address gaps as they are identified
• Review all proposed training activities for consistency
with national training needs
• Oversee development of an inventory of current
training resources
• Remain abreast of status of implementation and make
adjustments as progress continues
VETERANS HEALTH ADMINISTRATION
Mental and Behavioral Health in PACT
Education and Training Workgroup:
National Education Workgroup Plans:
– Identify current education needs of the field and gaps
in portfolio of trainings being offered
• Work with VA’s Employee Education System to perform
an education needs assessment of:
– All PACT Members
– PCMHI Staff
– CBOC Staff
– Mental Health Specialty Providers
– Facility Administration and Leadership
VETERANS HEALTH ADMINISTRATION
Mental and Behavioral Health in PACT
Education and Training Workgroup:
National Education Workgroup Plans:
– Based on Education Needs Assessment:
• Identify short and long term national training goals and
objectives
• Identify specific training products/events to address
needs identified
– From within inventory of current resources
– Lead the development of new products/events
VETERANS HEALTH ADMINISTRATION
Mental and Behavioral Health in PACT
Education and Training Workgroup:
National Education Workgroup Plans:
– Education/Training Resources Needed:
• Web-based Orientation Modules for PCMHI Staff
1. Skills-based Training
» Brief Assessment
» Evidence And Measurement-based Practice
» Practice Management
2. Transformation to Patient-Centered and PACT Culture
»
»
»
»
PACT Principles
Advanced Clinic Access Strategies
Collaboration and Teamwork
Patient-centered Care and Prevention
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TRAINING METHODOLOGY in an
era of F2F restrictions
•
•
•
•
•
Webinars
Mentoring groups
Audioconferencing
Video (live and archived)
Manuals
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Challenging the Status Quo in VHA:
Research
PC-MHI Research in VA
– In 1995 when some early VA adopters initiated
primary care mental health integration the evidence
base was in its infancy and VA was NOT supporting
research in this area
– In the early half of 2000 that began to change with VA
beginning to fund research into care management of
depression (TIDES)
– At that same time VA clinician researchers also began
to develop and test alternative care management
models, e.g., Behavioral Health Laboratory (BHL)
VETERANS HEALTH ADMINISTRATION
PC-MHI Research in VA
– Also during this time still other VA clinical researchers
were developing and implementing one of the first colocated collaborative care models of PC-MHI, i.e., the
White River Junction Model
– VA’s initial policy calling for integrated primary care
was based upon this early work and called for a
national implementation based upon the White River
Junction Model, TIDES, & BHL
VETERANS HEALTH ADMINISTRATION
PC-MHI Research in VA
– VA recognized that more needed to be done to fully
integrate mental health in primary care and in 2004
established the Center for Integrated Healthcare, a
VA-designated Center of Excellence devoted to
conducting research, education / training, and clinical
consultation
– The Center is now the locus of a large part of VA’s
research focusing on how best to design and establish
PC-MHI in all VA facilities
VETERANS HEALTH ADMINISTRATION
PC-MHI Research in VA
– Center personnel are researching new & innovative
ways to provide brief mental health interventions in
the VA primary care setting targeting problems that
Veterans often present with, e.g., PTSD, alcohol
misuse, depression, insomnia, TBI, chronic pain
– Center personnel are also examining the processes of
the delivery of integrated primary care, e.g., whose
doing it?, how does one assess fidelity to the model?,
etc.
VETERANS HEALTH ADMINISTRATION
PC-MHI Research in VA
– Center personnel are conducting studies to determine
how best to implement PC-MHI in VA’s very large
health care system, e.g., Blended Facilitation
– VA has embraced PC-MHI for the long run.
– It has devoted significant resources for the hiring of
new personnel, it has establish a Center of Excellence
to conduct research, education and training, and it
has established a PC-MHI Program Office to track
implementation across the nation
VETERANS HEALTH ADMINISTRATION
Challenging the Status Quo in VHA
Questions/Comments?