Session # H1b
October 28, 2011
11:15 AM
Collaborative Care and PatientCentered Medical Home within the
Veterans Health Administration
Andrew S. Pomerantz, MD, National Mental Health Director for
Integrated Care, Office of Mental Health Service, VA Central Office
David A. Hunsinger, MD, MSHA, Member, National Consultation Team,
VA Transformation to PACT
Margaret Dundon, PhD, National Program Manager for Health Behavior,
National Center for Health Promotion and Disease Management, VACO
Larry J. Lantinga, PhD, Associate Director, Center for Integrated
Healthcare, OMHS Center of Excellence
th
Collaborative Family Healthcare Association 13 Annual Conference
October 27-29, 2011 Philadelphia, Pennsylvania U.S.A.
Faculty Disclosure
We have not had any relevant financial relationships
during the past 12 months.
Need/Practice Gap & Supporting Resources
The Department of Veterans Affairs, the largest unified
healthcare system in the United States, has undertaken a
major transformation that embraces primary care-mental
health integration within the context of the patient-centered
medical home. National leaders within the Veterans Health
Administration will describe VA’s efforts to date.
Objectives
Upon completion of this presentation, participants will be able
to:
• Describe VA’s implementation of collaborative care--Primary
Care-Mental Health Integration (PC-MHI)
• Describe VA’s implementation of the patient-centered medical
home--Patient Aligned Care Team (PACT)
• Describe the role of VA’s newly established Health Behavior
Coordinators (HBC) and how they interact with PC-MHI &
PACT
Expected Outcome
We expect that you will take away a better understanding of
what VA is doing to further collaborative care.
We expect that you will learn what VA resources are available to
your patients who are Veterans.
We expect that you will now know with whom to network within
VA in order to obtain access to VA knowledge and
information.
Learning Assessment
A learning assessment is required for CE credit. In lieu of a
written pre-post-test based on our learning objectives, I will
moderate a Question & Answer period at the conclusion of
our presentation. Please hold your questions until then.
Thank you.
Session Evaluation
Please complete and return the
evaluation form to the classroom monitor
before leaving this session.
Thank you!
Primary Care-Mental Health
Integration in VA: Past, Present and
Maybe Future
Andrew S. Pomerantz, MD
National Mental Health Director, Integrated Care
Office of Mental Health Services
VA Central Office
&
Associate Professor of Psychiatry
Dartmouth Medical School
MODELS OF MH IN PC AT DAWN OF
21ST CENTURY
•
•
•
•
•
Referral
Consultation/Liaison
Co-location
Collaborative Care
Integrated Care
CORE STUDIES IN
INTEGRATED/COLLABORATIVE CARE
•
•
•
•
PROSPECT
IMPACT
PRISM-E
RESPECT
Demonstrate improved outcomes with care
management.
DEVELOPMENT OF PC-MHI IN VA
• MANY INDIVIDUAL PROGRAMS IN MANY
SITES OVER MANY YEARS
• SOME VERTICAL INTEGRATION
• SOME HORIZONTAL INTEGRATION
VA MODELS
• TIDES– utilizes Care Management to support
PCP treatment of depression
• Behavioral Health Laboratory (BHL) –
Structured telephone interview for triage and
support of PC treatment of Depression,
anxiety, at-risk drinking, etc
• Co-located collaborative care – the White
River Junction Model
• “Blended models”
• Health Psychology
SPECIALTY MH
Secondary and Tertiary Care:
• Outpatient Care for treatment resistant, severe or complex illnesses
• PTSD specialty treatment; Substance dependence treatment
• Treatment of serious mental illness (including MHICM)
• Full spectrum of psychosocial rehabilitation and recovery
services
• Inpatient psychiatric care
• Residential treatment
• Supported and therapeutic employment
• Homeless programs
• Integrated Care for physical and mental health in one
setting
PC-MHI
• Evaluation and treatment for mild to moderate mental
health conditions (depression, substance misuse, anxiety,
PTSD)
• Follow-up evaluation for positive MH screens
• Behavioral health interventions for chronic disease
• Care management
• Referral management
PRIMARY CARE
• Screening for mental health conditions
• Initiation of pharmacological treatment
for mild to moderate mood symptoms
• Co-management of Veteran care with
PC-MHI and specialty MH providers
• Health Behavior
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Emerging View
• Like other medical disciplines, Mental Health
can be divided into PRIMARY, SECONDARY
and TERTIARY care.
• Primary MH care can be delivered in the
same setting as general Primary Care by
expert clinicians – horizontal and vertical
integration.
• Secondary/tertiary MH care are specialized
and require multiple disciplines.
One size does not fit all
“…The intentional use of
values to guide the decisions of a system.”
Organizational Ethics:
“From Clinical Ethics to Organizational Ethics: The Second Stage of the Evolution
of Bioethics.” Potter, Robert Lyman, in “Bioethics Forum.” Summer, 1996
ONE SIZE DOES NOT FIT ALL
•
ADHERENCE TO THE BASIC PRINCIPLES
– EASY ACCESS IN PRIMARY CARE
– PROBLEM FOCUSED ASSESSMENT AND TREATMENT
– ONSITE CLINICIANS IN PC
– STEPPED CARE
– MEASUREMENT BASED CARE
– CARE MANAGEMENT
– ENHANCED REFERRALS
• LEADS TO CONSISTENT OUTCOMES
– IMPROVED RECOGNITION AND TREATMENT IN PC
– IMPROVED ENGAGEMENT IN SPECIALTY MH CARE
– CONSERVES SCARCE SPECIALTY RESOURCES
WHAT ABOUT SERIOUS PERSISTENT MENTAL
ILLNESS?
VISION:
Veterans with Serious Mental Illness will enjoy
health status identical to the general
population.
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Community
Public health
agencies, non-profit
agencies, etc.
Non-VA Provide
PCPs, specialists,
etc.
Specialty Care
Team Members
PC-MHI, HBC, SW,
pharmacy, etc.
Includes significant others
and caregivers
Cardiology,
podiatry, etc.
Interdisciplinary
Team Members
Core Primary Care
Team Members
Patient/family
PCP, RN CM,
clinical assoc,
admin assoc
The Patient Aligned Care Team (PACT)
MODELS OF CARE
– Cohort model: SMI patients receive PC in general primary care
clinics from providers with specific interest & skill in working with
this population
– Consultative model: PCMHI and/or Primary MH provider is
consultant for PACT team/teamlet
– Enhanced Coordination between specialty MH and Patient centered
medical home
– Specialty Care Team: PC providers and services embedded in
special care team. In VA, this model is limited mostly to screening;
e.g. PC APN located in SMI clinic, PCMHI providers in Post
Deployment clinic
– Combination of above: routine preventive screening in specialty
clinic;, advanced access to PACT, Care/Case management in MH.
19
NEXT
A single brand of PC-MHI
Clear definition of “blended”
Staffing guidelines
Develop the Evidence Base for Brief
Treatments
Rural Models
Integration with the rest of Mental Health
Patient Aligned Care Team
VHA’s implementation of the
Patient Centered Medical Home
David A. Hunsinger, MD, MSHA
Medical Director, Binghamton VA Outpatient Clinic
21
VA kick-off off Patient
Centered Medical Home
initiative
Las Vegas, NV
April 2010
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Veteran Centered Care
Definition: A fully engaged partnership of
veteran, family and health care team,
established through continuous healing
relationships and provided in optimal healing
environments, in order to improve health
outcomes and the veteran’s experience of care
Universal Services Task Force, 2009
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Joint Principles of the
Patient-Centered Medical Home
AAFP, AAP, ACP, AOA
•
•
•
•
•
•
•
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Ongoing relationship with personal physician
Physician directed medical practice
Whole person orientation
Enhanced access to care
Coordinated care across the health system
Quality and safety
Payment
Principle 1
Personal Physician (Provider)
• Every patient has a designated primary care
provider.
• Relationship is ongoing – continuous over time
• Patient choice
• Each physician has a “Panel” of patients
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Principle 2
Physician (Provider) Directed
• Provide clinical direction
– Shared-Decision making
• Team-based care, leading the team
• Flattening the hierarchical structures
– Equal Value, Different Roles
• Championing principles of Medical Home
– Example: Facilitating Care Coordination
26
Principle 3
Whole Person Orientation
• Health as a focus, not just Health Care
• Personal preferences of the patient drive care
interventions
• Patient self-management skills and education
• Culturally relevant and sensitive
• Shared goal setting with health care team
• Health literacy and numeracy
• Family engaged in care
• Mental Health and Primary Care Integration
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Principle 4
Enhanced Access to Care
• Open Access principles (ACA)
• Ready and timely access to non face-to-face
care
– Telephone, Messaging, Secure e-mail
– Web-based access to scheduling, information,
records, labs
• System Redesign
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Principle 5
Coordinating Care
• Transitions within and without
• Identifying and managing highest risk
– Chronic Disease Management
– Population-based Health Care
• Predicative Modeling
• Health Risk Assessment Tools
• Patient/Disease Registries
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Principle 6
Quality and Safety
• Clinical performance
– Value = Quality/Cost
• Medication reconciliation
• Quality and Safety are outcomes
–
–
–
–
Effectively managing transitions
Team dynamic drives performance
Effective implementation of Medical Home
Data driven, team-based, system redesign
• Continuous improvement
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VHA Implementation strategy
Three pronged approach to
education/ team building:
• Regional collaboratives
• Centers of excellence
• Consultation/facilitation teams
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VHA Implementation strategy
Regional collaboratives:
• Structured learning
• Focus on a ‘core team’ from each
Medical Center
• Emphasis on teach back
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VHA Implementation strategy
Centers of Excellence:
• Goal to train ALL teamlets
• Trainings scheduled at sites chosen for
ease of access
• Emphasis on team building,
understanding key principles, and skill
acquisition
33
VHA Implementation strategy
Consultation/facilitation teams:
•
•
•
•
34
Five teams
Physician, Nurse, Administrative staff
Trained in facilitation
Deployed to sites by site request
Patient Centered Medical Home
Access
Offer same day
appointments
Increase shared medical
appointments
Increase nonappointment care
Care Management &
Coordination
Focus on high-risk pts:
oIdentify
oManage
oCoordinate
Improve care for:
oPrevention
oChronic disease
Improve transitions
between PCMH and:
oInpatient
oSpecialty
oBroader Team
Practice Redesign
Redesign team:
oRoles
oTasks
Enhance:
oCommunication
oTeamwork
Improve Processes:
oVisit work
oNon-visit work
Patient Centeredness: Mindset and Tools
Improvement: Systems Redesign, VA TAMMCS
Resources: Technology, Staff, Space, Community
Principles of the
Patient-Centered Medical Home
•
•
•
•
•
•
•
36
Ongoing relationship with personal physician
Physician directed medical practice
Whole person orientation
Enhanced access to care
Coordinated care across the health system
Quality and safety
Payment
Patient Aligned Care Team:
Objective
To improve patient satisfaction, clinical
quality, safety and efficiencies by
becoming a national leader in the delivery
of primary care services through
transformation to a medical home model
of health care delivery.
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Team Redesign
The Patient’s Primary Care Team:
• Teamlet: assigned
to
±1200 patients (1
panel)
– Provider
– RN Care Manager
– Clinical Associate
• LPN
• Medical Assistant
• Health Tech
– Clerk
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• Team members
– Clinical Pharmacy
Specialist
± 3 panels
– Medical Social Work
± 2 panels
– Nutrition
± 5 panels
– Mental Health
– Case Managers
– Trainees
Other Team
Other Team Members
Pharmacy
Social Work
Nutrition
Case Managers
Integrated Behavioral Health
Members
Teamlet: assigned to 1
panel (±1200 patients)
• Provider
• RN Care Mgr
• Clinical Associate
(LPN, MA, or
Health Tech)
• Clerk
Patient
For each parent facility
HPDP Program Manager
Health Behavior Coordinator
My HealtheVet Coordinator
Panel size
adjusted
for rooms
and
staffing
40
40
Essential Transformational Elements
Patient Aligned Care Team
• Delivering “health” in addition to “disease
care”
• Veteran as a partner in the team
–
–
–
–
Empowered with education
Focus on health promotion and disease prevention
Self-management skills
Patient Advisory Board
• Efficient Access
– Visits
– Non face-to-face
•
•
•
•
41
Telephone
Secure messaging
Telemedicine
Others?
41
Essential Transformational Elements
• Care coordination
– Optimizes hand-offs between inpatient and
outpatient care
– Facilitates interface with specialty care
– Seamless co-management (Dual Care) with
outside providers
– Incorporates tele-health, and HBPC services
– Emphasizes home care & rural health
42
Essential Transformational Elements
• Care Management/ Panel Management
– Disease management and interface with specialty
care
•
•
•
•
–
–
–
–
–
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Chronic Care Model
Disease registries
Identification of outliers
Team RN partnering closely with providers
Veterans at high risk for adverse outcomes
Pain management
Returning combat veteran care
Depression
Substance abuse
Essential Transformational Elements
• Improve technological clinician support
– Decision support
– Predictive modeling
– CPRS user-friendliness
– Information processing
• Develop new measurement and evaluation tools
– Patient Satisfaction
– Staff satisfaction
– Processes of care
– Manager and Provider Report Cards
– Continuity and comprehensiveness
44
44
Whole Person Orientation
“ …you ought not to attempt to cure the eyes without the
head or the head without the body, so neither ought you to attempt
to cure the body without the soul . . . for the part can never be well
unless the whole is well.”
Plato
Culture
Family and
other
supportive
relationships
Physical
abilities
and
limitations
Work,
recreation
and other
interests
Emotional,
Spiritual,
Psychological
aspects
Mental Health is an Integral Part of
Overall Health
• Physical problems can be risk factors for mental
health problems
• Mental health problems can be risk factors for
physical health problems
• Patient Centeredness means a holistic view of
the Veteran, recognizing the interrelationships of
all health problems and how they individually and
interactively affect quality of life
46
Mental Health and Primary Care
A Natural Fit
• 26% of Veterans who use VA health care are also
being treated for a mental health diagnosis
• 20% currently receive some or all of that care in a
specialty Mental Health setting
• Patients initially bring their mental health concerns to
Primary Care
• Screening for mental health problems takes place in
primary care [Clinical Reminders]
• Referrals from Primary Care to Specialty Mental
Health result in a high rate of no-shows
47
Primary Care – Mental Health
Integration
• PC-MHI embodies the principles and focus
of the Patient Centered Medical Home
• Work on PC-MHI implementation
facilitated PACT implementation
48
True Integration
Features of PC-MHI
•
•
•
•
•
49
Completely integrated within primary care
Occupy the same space
Share the same resources
Participate in Team Meetings
Share responsibility for care of the whole
patient
Conclusion
• Primary Care - Mental Health
Integration is and will continue to
be an essential component of the
team delivery of effective care
50
Collaborative Care for Health Behavior Change
Collaborative Family Healthcare Association Conference, 2011
Peg Dundon, PhD
National Program Manager for Health Behavior
VHA National Center for Health Promotion and Disease Prevention
Words of Wisdom
“If I’d known I was going to live so long, I’d
have taken better care of myself.”
- Leon Eldred
VETERANS HEALTH ADMINISTRATION
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Prevalence of Chronic Conditions in VHA
Primary Care
Source: Primary Care Almanac, VHA Support Service Center, 2011
VETERANS HEALTH ADMINISTRATION
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Underlying Causes of Diseases
Alcohol
consumption
3%
Other
preventable
10%
Poor diet and
physical
inactivity
17%
Other causes
52%
48%
potentially
preventable
Tobacco
18%
Mokdad et al. JAMA 2004
VETERANS HEALTH ADMINISTRATION
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Prevalence of Health Behaviors
VETERANS HEALTH ADMINISTRATION
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Health Impact of Unhealthy Behaviors
The World Health Organization estimates that...
– at least 80% of all heart disease, stroke, and type 2 diabetes, and
– more than 40% of cancer
would be prevented if people were to
Stop smoking
Start eating healthy
Get into shape
WHO. Preventing Chronic Disease: A Vital Investment, 2005
VETERANS HEALTH ADMINISTRATION
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Where Do We Go From Here?
• Effective interventions for poor health behaviors exist
• Health behaviors often not addressed (successfully) and
interventions often not provided
• Healthcare staff often not well-trained in appropriate
behavior change strategies
• Traditional, directive/persuasive approaches have limited
success
• We can shift the medical culture to one marked by patientcentered communication for healthier behaviors
• This is a major transformation!
VETERANS HEALTH ADMINISTRATION
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PACT Transformation
A Fundamental Shift in the Process of Care
Traditional Care
Collaborative Care
Assumes knowledge drives
change
Assumes knowledge + confidence
drives change
Clinician sets agenda
Patient sets agenda
Goal is compliance
Goal is enhanced confidence
Decisions made by caregiver
Decisions made collaboratively
(Bodenheimer et al, CA Health Care Foundation, 2005)
VETERANS HEALTH ADMINISTRATION
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National Center for Health Promotion/Disease
Prevention (NCP)
• Field-based national program office in the Office of
Patient Care Services (PCS)
• Located in Durham, NC
• Provides policies, programs, guidance, education,
and support for field related to preventive health
• Provides expert input to senior VHA leadership
• Collaborates with other VHA offices and federal
agencies
VETERANS HEALTH ADMINISTRATION
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60
Preparing a Cadre of Prevention Staff to Train,
Coach and Consult with Clinicians
• Health coaching
• Motivational interviewing
• Health literacy
• Evidence-based health
promotion/disease prevention
• Problem solving approaches
All aimed to support clinical staff members in promoting patient selfmanagement of health behavior.
VETERANS HEALTH ADMINISTRATION
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Other Team Members
Clinical Pharmacy Specialist: ± 3 panels
Clinical Pharmacy anticoagulation: ± 5
panels
Social Work: ± 2 panels
Nutrition: ± 5 panels
Case Managers
Trainees
Integrated Behavioral Health
Psychologist ± 3 panels
Social Worker ± 5 panels
Care Manager ± 5 panels
Psychiatrist ± 10 panels
Other Team
Members
For each parent facility
HPDP Program Manager: 1 FTE
Health Behavior Coordinator: 1 FTE
My HealtheVet Coordinator: 1 FTE
Teamlet: assigned to 1
panel (±1200 patients)
Monitored via
Primary Care
Staffing and Room
Utilization Data
report in VSSC
• Provider: 1 FTE
• RN Care Mgr: 1 FTE
• Clinical Associate
(LPN, MA, or
Health Tech): 1 FTE
• Clerk: 1 FTE
Patient
Panel size
adjusted
(modeled) for
rooms and
staffing per
PCMM
Handbook
HBC Roles and Responsibilities
o Promotes evidence-based patient-driven care in Health Promotion and
Disease Prevention (HPDP).
o Co-chairs the facility HPDP Program Committee.
o Assists the HPDP Program Manager to coordinates strategic planning,
program development and implementation, monitoring and evaluation of
the overall HPDP Program.
o Leads and coordinates training and ongoing coaching for PACT staff in
patient-centered communication, health behavior change coaching, and
self-management support strategies, including TEACH for Success and
Motivational Interviewing.
VETERANS HEALTH ADMINISTRATION
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HBC Roles and Responsibilities contd.
o Collaborates with the key members of the HPDP Program Committee to
plan, develop, implement and assess the impact of clinical interventions
to promote health behavior change and self-management.
o Works collaboratively with Mental Health Primary Care Integration
staff to integrate behavioral medicine interventions and services with
other behavioral health interventions and programs.
o Supports and contributes to existing smoking and tobacco use
cessation clinical initiatives.
o Performs specialty health psychology assessment/intervention (e.g.,
pre-bariatric surgery, Veterans with unique or complex problems
impacting self-management plans).
VETERANS HEALTH ADMINISTRATION
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CCC and HBC
Co-Located Collaborative MH Care
Health Behavior Coordinator
Location
On site, embedded in the PC clinic
On site, embedded with PACT
Population*
Most are healthy, mild-mod symptoms, behaviorally
influenced problems.
Provider training focus. PACT clinical
work focused on health behaviors and
prevention.
Inter-Provider
Communication
Collaborative & on-going consultations via PCP’s
method of choice (phone, note, conversation). Focus
within PACT.
Collaborative & on-going with focus on
communication skills and coaching
(F2F, phone…). Focus within PACT and
HPDP staff.
Service Delivery
Structure*
Brief appointments (20-30’)
Limited # of appointments (avg. 2-3)
Open Access
Role focus on training PACT clinicians
(70+%) in patient-centered
communication. Limited (25-30%)
clinical care, prevention focused, often
group. Brief appointments (30-40’).
Approach
Problem-focused, solution oriented, functional
assessment. Focused on PCP question/concern and
enhancing PCP care plan. Population health model.
Health behavior focused, solution
oriented, problem-solving and goal
setting. Focused on PCP identified
health concerns and optimizing health.
Population health model.
Differences
• PC-MHI focus on mental health concerns, and HBCs on
prevention/health behaviors.
• HBCs part-time clinical (25-30%), PC-MHI full-time,
and HPDPs administrative. Access options vary.
• HBC’s main mission is to train and coach PACT staff in
patient-centered communications, PC-MHI main
mission is direct patient service via brief evidencebased care.
• HBCs provide specific assessments related to
prevention, such as pre-Bariatric Surgery evaluations.
• HBCs often report to Primary Care; PC-MHI generally
report to Mental Health.
• HBCs are responsible for CBOCs too.
VETERANS HEALTH ADMINISTRATION
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Similarities
• Both are PACT-based, behavioral health staff
• Neither provide traditional psychotherapy services
• Both can offer holistic and systems perspectives, helping
PACT staff be effective
• Both might address alcohol misuse, tobacco cessation,
weight management, sleep difficulties, pain
management, adherence concerns, problemsolving…others?
• Both can organize interventions in 5 A’s model
• Both provide time-limited, solution oriented
interventions
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In sum, what can HBCs & PC-MHI staff offer their
colleagues in the medical home?
• Increased comfort in “challenging” interactions with
patients (and staff!) with shift to collaboration vs.
traditional, prescriptive approach
• Patient and provider behavior change (communication,
health behaviors…)
• Systems shifts to support Veteran-centered care (flexible
delivery methods, accessible/efficient care delivery…)
• Provider and patient skill development
• Focus on “the conversation” and interactions that
address meaningful change for given individuals
• Increased clinician and patient satisfaction
VETERANS HEALTH ADMINISTRATION
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Questions or Ideas to Share?
National Center for Health Promotion and
Disease Prevention (NCP)
Office of Patient Care Services
Veterans Health Administration
Margaret (Peg) Dundon, PhD
margaret.dundon@va.gov
3022 Croasdaile Drive, Suite 200
Durham, NC 27705
(919) 383-7874 or (716) 604-5446 (m)
www.prevention.va.gov
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