1
VA Primary CareMental Health
Integration (PC-MHI)
Edward Post, MD, PhD
National PC-MHI Medical Director
2
“Primary care practitioners are a critical link in
identifying and addressing mental disorders...
Opportunities are missed to improve mental health and
general medical outcomes when mental illness is underrecognized and under-treated in primary care settings.”
- Former Surgeon General David Satcher
“The greatest mistake in the treatment of diseases is that
there are physicians for the body and physicians for the
soul, although the two cannot be separated.”
- Plato
Primary Care-Mental Health Integration
3

Chronic disease

Multiple comorbidities

Need for interdependent skills across medical
disciplines and teams

Patient outcomes are interdependent
◦ Multiple studies show depression has an independent effect
on all-cause mortality (Gallo et al., 2005; Penninx et al., 1999; Bruce
and Leaf, 1989)
◦ Data from late-life depression trial shows integrated care can
decrease mortality (Gallo et al., 2007)
Primary Care Landscape
4
Integrated mental health care...






Improves identification of prevalent mental
health conditions
Improves access to appropriate evaluation and
treatment
Improves treatment engagement and adherence
Increases probability of receiving high quality
care
Improves clinical and functional outcomes
Increases patient satisfaction
Why Integrate Mental Health Services
into Primary Care?
5

Improved identification
o Improved identification of depression, psychiatric
co-morbidities and substance misuse (Oslin et al., 2006)
o Improved identification of depression (Watts et al., 2007)

Improved access
o Increased rates of treatment (Alexopoulos et al., 2009; Watts et al.,
2007; Bartels et al., 2004; Hedrick et al., 2003; Liu et al. 2003;
Unützer et al., 2002)
o Reduced wait times (Pomerantz et al., 2008)
PC-MHI Evidence Base
6

Improved engagement and adherence
o Improved engagement in mental health treatment
(Zanjani et al., 2008)
o Improved engagement and adherence in treatment for depression
and at-risk alcohol use (Bartels et al., 2004)
o Greater antidepressant adherence (Hunkeler et al., 2006; Katon et al., 1999,
2002)
o Improved no-show rates (Pomerantz et al., 2008; Zanjani et al., 2008; Guck et
al., 2007)

Higher quality care
o Increased probability of receiving guideline-concordant treatment
(Watts et al., 2007; Roy-Byrne et al., 2001)
o Higher patient perceptions of quality of care (Katon et al., 1999)
PC-MHI Evidence Base
7

Better clinical and functional outcomes
o Improved short and long term clinical (remission; symptom
reduction) and functional outcomes compared to standard care for
depression (Alexopoulos et al., 2009; Gilbody et al., 2006; Hunkeler et
al., 2006; Katon et al., 2002; Unützer et al., 2002; Roy-Byrne et al., 2001;
Katon et al., 1999)
o Similar remission rates and symptom reduction for depression
compared to enhanced specialty referral (Krahn et al., 2006)
o Decrease in at-risk alcohol use comparable to enhanced specialty
referral (Oslin et al., 2006)
o More rapid clinical response (Alexopoulos et al., 2009; Hedrick et al.,
2003)
o Higher fidelity to integrated care model resulted in better patient
response and remission rates (Oxman et al., 2006)

Increased patient satisfaction
(Pomerantz et al., 2008; Hunkeler et al., 2006; Chen et al., 2006; Areán
et al., 2002; Unützer et al., 2002)
PC-MHI Evidence Base
8
Complementary Settings:
VA Vision for Mental Health Services
Specialty MH
Services in VAMCs
and Clinics
Integrated MH
Services in Primary
Care
Focus on recovery &
rehabilitation for SMI
Focus on improved
access to care for
common mental
illnesses
Evidence-Based Psychotherapy
Clinical Neuroscience
9

Two PC-MHI Components:
◦ Co-located Collaborative Care
 White River Junction
◦ Care Management
 TIDES, Behavioral Health Laboratory

Blended programs have both of these
complementary components

Focus on common conditions:
◦ Depressive and Anxiety Disorders
◦ Alcohol Misuse and Abuse
◦ PTSD Screening/Assessment
Primary Care-Mental Health Integration
10

Identification
◦ Screening in primary care

Assessment and triage to appropriate level of service

A spectrum of services
◦
◦
◦
◦
Monitoring or watchful waiting
Brief interventions (e.g., for alcohol misuse)
Medication therapies
Psychotherapies

Follow-up and monitoring

Quality control and efficiency
Necessary Integrated Care Processes
11
Co-location/Co-located Service
A behavioral health provider working in a space that is
in close proximity to (or embedded in) a primary care
clinic.
Collaborative Care/Collaboration
The interactions between primary care and behavioral
health providers for the purpose of developing treatment
plans, providing clinical services and coordinating care
to meet the physical and behavioral health needs of
patients
Introduction to Co-located
Collaborative Care (CCC)
What is Co-located Collaborative Care in PC-MHI?
CCC vs. Traditional MH
Co-Located Collaborative
MH Care
Mental Health Specialty
Care
Location
• On-site
• A different floor or
building
Population
• Most are healthy
• Most have MH diagnoses
Inter-Provider
Communication
• Collaborative & ongoing
consultations via PCP’s
method of choice
• Consult reports
• EMR notes
Service Delivery
Structure
• Brief appointments
• Limited number of
appointments
• 50 - 90 minute
psychotherapy sessions
• 14 week minimum
Approach
• Problem-focused
• Solution-oriented
• Patient-centered
• Varies by therapy
• Diagnosis-focused
Treatment Lead
• PCP continues to be lead
• MHP is lead
Principal Focus
• Support the overall health
of the Veteran
• Focus on function
• Cure or ameliorate
mental health symptoms

Translating Initiatives for Depression into
Effective Solutions (TIDES)
• Evidence-based collaborative care model supporting
depression management in the primary care setting
• Has promoted improvements in treatment adherence
for Veterans with depression in several VISNs

Behavioral Health Laboratory (BHL)
• Evidence-based clinical service supporting mental
health and substance abuse management in the primary
care setting
• Associated with a significant increase in screening and
identification of patients needing MH/SA services (Oslin,
et. al. 2005)
Care Management Models in PC-MHI
Care Managers


Nurses and social
workers are core
profession, but others
serve as care managers
also
Interact directly with
patients and PCPs,
facilitating ongoing
evaluation and
communication allowing
care to remain in primary
care
Role of the Care Manager






Assessment and triage
Decision support
Patient education and
activation
Monitor adherence to
treatment, treatment
outcomes, and
medication side effects
Referral management
Support patient selfmanagement

Blended programs combine both care
management and co-located collaborative care

In the blended program, the co-located
collaborative mental health provider evaluates
patients and offers treatment when needed, while
the PC-MHI care manager provides
complementary services including education,
assessment, monitoring of adherence, use of
medication and referral to specialty care when
necessary
Introduction to Blending PC-MHI
Programs
What is a Blended PC-MHI Program?

Strong collaborative system between primary care,
mental health and other health care specialists

Stepped care approached to providing a continuum of
care within the PC-MHI program

Ability to rapidly evaluate and stabilize patient in
primary care clinic

Ability to do seamless referral, if needed

Ability to implement evidence-based treatment plans

Ability to collect objective clinical and administrative
outcome data
Core Components of an Effective
Blended MH Integration Program

Large-scale implementation began in 2007
with RFP funding for pilot programs of a
single component at 94 of 139 VA health systems

Late 2008: Uniform MH Services Package
extended focus
VHA Handbook 1160.01 requires that VAMCs,
extra large CBOCs, and large CBOCs integrate
primary care and mental health by blending both
co-located collaborative care and care
management
History of VA PC-MHI Implementation

18

VAMCs & extra large CBOCs (>10K uniques)
need full-time availability of both co-located
services & care management

Large CBOCs (5K-10K uniques) need co-located
services & care management, availability as
appropriate

Medium-sized CBOCs (1.5K-5K uniques) need onsite MH services, configured (integrated vs. MH clinic)
as appropriate

Small CBOCs need to provide access to MH services
Uniform Mental Health Services Package
19
Service Utilization Data
Service Utilization Data reported from facility stop code usage
20
VHA Dashboard
VISN Dashboard
Facility Dashboard
Division Dashboard
21
PC-MHI: State of the Field
The PC-MHI Penetration Rate is the number of unique PC-MHI encounters divided
by the number of unique Primary Care encounters
→Please note that there is not a PC-MHI penetration rate performance measure or target
22

Principal Contact:
Maureen Metzger, PhD, MPH
National Program Manager
Maureen.Metzger@va.gov
734-845-5719

Thank you to many faculty who
collaborate in presenting our
training programs, and to
innumerable persons who are
implementing PC-MHI
throughout VA!
National PC-MHI Program Office
23
Questions?