Mental Health Intensive Case Management Research Articles

Evaluation of disparities in impact of mental health intensive case management on 6-month symptoms, functioning, and quality of life between black and white veterans diagnosed with schizophrenia.

Substantial health disparities have been reported between Black and White Americans diagnosed with schizophrenia. The nature and extent of these disparities among individuals receiving services in an equal-access health care system remains understudied. The purpose of this study was to examine disparities in enrollment characteristics, service delivery and clinical outcomes between Black and White veterans diagnosed with schizophrenia who received care in the Veterans Health Administration (VHA), an equal-access health care system. National program evaluation data from the VHA Intensive Community Mental Health Recovery (ICMHR) program were used to evaluate disparities between 2436 Black and 3565 White veterans who enrolled between 1999 and 2013. Veterans and case managers completed measures of sociodemographic factors, clinical history, clinical characteristics, and justice system involvement at enrollment and six months. Chi square and ANOVAs were used to evaluate enrollment and service delivery differences. Six-month changes were evaluated using multiple regression controlling for potentially confounding baseline characteristics. Effect sizes were evaluated with Cohen's d. Results indicated differences between Black and White veterans in clinical history, justice system involvement, and clinical characteristics at enrollment. Minimal differences in service delivery were noted and longitudinal analyses revealed no significant differences between Black and White veterans on the majority of outcomes. Fewer racial disparities in service use and outcomes were observed in ICMHR than in standard non-VA clinic settings. This study demonstrates that disparities may emerge more strongly from systemic rather than individual-level differences.

The Impact of Mental Health Intensive Case Management on Functioning and Clinical Outcomes of Older Black and White Veterans With Serious Mental Illness

ObjectivesTo examine differences in service delivery, functioning, and clinical outcomes between older Black and White veterans participating in a national Veterans Health Administration (VHA) program of intensive case management. DesignSecondary analysis of national program evaluation data. SettingVHA Intensive Community Mental Health Recovery (ICMHR) program. ParticipantsBlack (n = 1327) and White (n = 4402) veterans age 55 and older who enrolled in ICMHR between 2000-2013. MeasurementsMeasures evaluated sociodemographic factors, service delivery, functioning, and clinical outcomes. ANOVA and chi-squares were used to evaluate differences in enrollment characteristics and service delivery between Black and White veterans. Regression analyses were used to examine changes in outcomes over 6 months controlling for confounding baseline differences and service delivery. Cohen's d of .20 was used as a threshold for a clinically meaningful effect. ResultsBlack veterans were more likely to be diagnosed with schizophrenia, alcohol use disorder, and drug use disorder. Although case managers spent significantly less time with Black veterans, there was no difference in the frequency of contacts. Medication management and substance use treatment were more often provided to Black veterans. Black veterans experienced substantially greater improvement in anxiety/depression than White veterans with a small effect size (Cohen's d =-0.25). Changes in all other outcome measures did not meet criteria for clinically meaningful differences. ConclusionsBlack veterans experienced meaningfully greater improvements than White veterans on anxiety/depression but not on other measures. Provision of high-intensity services in an equal-access setting may reduce health disparities between Black and White older adults with serious mental illness.

Increasing physical activity for veterans in the Mental Health Intensive Case Management Program: A community-based intervention

Individuals with severe mental illness (SMI), experience increased mortality-20 years greater disparity for men and 15 years greater disparity for women-compared to the general population (Thornicroft G. Physical health disparities and mental illness: The scandal of premature mortality. Br J Psychiatr. 2011;199:441-442). Numerous factors contribute to premature mortality in persons with SMI, including suicide and accidental death (Richardson RC, Faulkner G, McDevitt J, Skrinar GS, Hutchinson D, Piette JD. Integrating physical activity into mental health services for persons with serious mental illness. Psychiatr Serv. 2005;56(3):324-331; Thornicroft G. Physical health disparities and mental illness: The scandal of premature mortality. Br J Psychiatr. 2011;199:441-442), but research has shown that adverse health behaviors-including smoking, low rate of physical activity, poor diet, and high alcohol consumption-also significantly contribute to premature deaths (Jones J. Life expectancy in mental illness. Psychiatry Services. 2010. Retrieved from http://psychcentral.com/news/2010/07/13/life-expectancy-in-mental-illness). This quality improvement (QI) project sought to improve health and wellness for veterans in the Mental Health Intensive Case Management Program (MHICM), which is a community-based intensive program for veterans with SMI at risk for decompensation and frequent hospitalizations. At the time of this QI project, the program had 69 veterans who were assessed and treated weekly in their homes. The project introduced a pedometer steps intervention adapted from the VA MOVE! Program-a physical activity and weight management program-with the addition of personalized assistance from trained mental health professionals in the veteran's home environment. Because a large percentage of the veterans in the MHICM program had high blood pressure and increased weight, these outcomes were the focus of this project. Through mental health case management involvement and the comfort of their familiar living environment, veterans were assisted to meet their physical and mental health goals with a program that could easily be integrated into their daily lives. Healthy People 2020 developed goals to improve levels of physical activity and has ranked physical activity as a leading health indicator (US DHHS. Office of Disease Prevention and Health Promotion. Physical activity topic overview. In Healthy People 2020. 2016. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/physical-activity). Individuals with SMI are significantly less active than the general population (Shor and Shalev, 2014). It is sometimes difficult for the average individual to obtain the recommended 10,000 steps and even more difficult for those with SMI. Lifestyle modifications, in particular diet and exercise, are recommended for improvement of chronic disease outcomes (US Preventive Services Counseling Task Force, 2016). The health benefits of physical activity for people with SMI are mixed (Pearsall R, Smith D, Pelosi A, Geddes J. Exercise therapy in adults with serious mental illness: A systematic review and meta-analysis. BMC Psychiatr. 2014;14:117). Some studies found significant physical health benefits, while others did not. However, according to a review by Soundy etal., physical exercise is shown to not only have physical benefits but also psychosocial benefits. One of the barriers that hinder participation in physical activities is accessibility (Shor and Shalev, 2014). Integrating a more personalized supported, and in-home pedometer program into mental healthcare should ensure better access to interventions that could possibly reverse the causes of premature death. The program was offered to 69 veterans in the MHICM. Forty-nine agreed to start the program and 20 declined. Twenty-five clients actually started the program with 17 veterans completing it. Preimplementation data included collecting blood pressure and weight measures for all veterans in the MHICM program. Additionally, a focus group was held with case managers to obtain a group perspective on motivating veterans to participate in this program. Further, a teaching session was held to review pedometers use, the client video, the client booklet, methods for getting veterans started, and the progression of the walking intervention. The pedometer physical activity intervention continued for 2 months. At the end of the 2 months, aggregate de-identified data on number of steps, blood pressure, and weight were collected. At the end of the program, the data were reviewed, synthesized, and analyzed, being careful to account for potentially intervening conditions and other chronic illnesses. The postimplementation data revealed that the mean weight decreased by 9 lbs. The percentage of controlled blood pressure increased from 60 to 84, while the percentage of uncontrolled blood pressure decreased from 40 to 16. Implementation of a multiple component personalized exercise intervention program for veterans with SMI contributed to reduction in weight and blood pressure.

Impact of Paliperidone Palmitate Versus Oral Atypical Antipsychotics on Health Care Resource Use and Costs in Veterans With Schizophrenia and Comorbid Substance Abuse

PurposeAlmost half of all patients diagnosed with schizophrenia have a history of substance abuse (SA). However, data on treatment of schizophrenia with paliperidone palmitate (PP) among patients with comorbid SA are limited. The objective of this study was to compare all-cause and SA-related health care resource utilization and costs in veterans with schizophrenia and co-occurring SA who were treated with PP versus oral atypical antipsychotics (OAAs). MethodsVeterans Health Administration electronic health record data were used to conduct a retrospective longitudinal study in veterans with schizophrenia who initiated PP or OAA between January 1, 2010 and June 30, 2016, had ≥12 months of enrollment before treatment initiation (baseline), were diagnosed with SA, and had ≥1 Global Assessment of Functioning score during baseline. Differences in baseline characteristics were adjusted for using inverse probability of treatment weighting. Adjusted cost differences and incidence rate ratios (IRR) for the association between PP versus OAA and all-cause and SA-related health care costs and health care resource utilization in the 12 months after treatment initiation were estimated with corresponding 95% CIs using weighted linear and Poisson regression models, respectively. FindingsOf 6872 veterans in the study, 1684 (25%) and 5188 (75%) were treated with PP and OAA, respectively. After adjustment, PP was associated with fewer all-cause inpatient (IRR = 0.88; 95% CI, 0.85 to 0.90), mental health-related inpatient (IRR = 0.88; 95% CI, 0.85 to 0.91), and long-term care stays (IRR = 0.53; 95% CI, 0.44 to 0.64), but more frequent mental health intensive case management visits (IRR = 1.51; 95% CI, 1.49 to 1.53) compared with OAA (all P < 0.001). Similarly, PP was associated with significantly lower rates of SA-related inpatient stays (IRR = 0.80; 95% CI, 0.77 to 0.83), mental health stays (IRR = 0.85; 95% CI, 0.82 to 0.88), long-term care stays (IRR = 0.22; 95% CI, 0.15 to 0.32), and outpatient visits (IRR = 0.78; 95% CI, 0.77 to 0.79) than OAA (all P < 0.001). Relative to OAA, patients treated with PP also had lower mean annual all-cause (cost difference = −$10,473; 95% CI, −$17,827 to −$3491) and SA-related (cost difference = −$8457; 95% CI, −$12,710 to −$3638) medical costs (all P < 0.001). ImplicationsPP was associated with significant total medical cost savings resulting from fewer hospitalizations and lower rates of SA-related health care resource utilization compared with OAA in patients with schizophrenia and comorbid SA. Thus, PP appears to be a valuable treatment option for patients in this subpopulation.

Comparing the Costs and Acceptability of Three Fidelity Assessment Methods for Assertive Community Treatment.

Successful implementation of evidence-based practices requires valid, yet practical fidelity monitoring. This study compared the costs and acceptability of three fidelity assessment methods: on-site, phone, and expert-scored self-report. Thirty-two randomly selected VA mental health intensive case management teams completed all fidelity assessments using a standardized scale and provided feedback on each. Personnel and travel costs across the three methods were compared for statistical differences. Both phone and expert-scored self-report methods demonstrated significantly lower costs than on-site assessments, even when excluding travel costs. However, participants preferred on-site assessments. Remote fidelity assessments hold promise in monitoring large scale program fidelity with limited resources.

Organizational Characteristics of Veterans Affairs Clinics With High and Low Utilization of Clozapine.

Twenty to thirty percent of patients with schizophrenia experience treatment resistance. Clozapine is the only medication proven effective for treatment-resistant schizophrenia. However, in most settings less than 25% of patients with treatment-resistant schizophrenia receive clozapine. This study was conducted to identify facilitators of and barriers to clozapine use to inform development of interventions to maximize appropriate clozapine utilization. Seventy semistructured phone interviews were conducted with key informants of clozapine processes at U.S. Department of Veterans Affairs medical centers in various U.S. regions, including urban and rural areas, with high (N=5) and low (N=5) rates of clozapine utilization. Interviewees included members of mental health leadership, psychiatrists, clinical pharmacists, and advanced practice nurses. Interviews were analyzed by using an emergent thematic strategy to identify barriers and facilitators related to clozapine prescribing. High utilization was associated with integration of nonphysician psychiatric providers and clear organizational processes and infrastructure for treatment of severe mental illness, for example, use of clozapine clinics and mental health intensive case management. Low utilization was associated with a lack of champions to support clozapine processes and with limited-capacity care systems. Obstacles identified at both high- and low-utilization sites included complex, time-consuming paperwork; reliance on a few individuals to facilitate processes; and issues related to transportation for patients living far from care facilities. Implementation efforts to organize, streamline, and simplify clozapine processes; development of a multidisciplinary clozapine clinic; increased capacity of existing clinics; and provision of transportation are reasonable targets to increase clozapine utilization.

“You Might Lose Him Through the Cracks”: Clinicians’ Views on Discharge from Assertive Community Treatment

Assertive Community Treatment (ACT) teams are increasingly interested in improving access to ACT through discharge of improved clients to less intensive mental health care services. We report results from a process evaluation of three teams in the VA's ACT program, Mental Health Intensive Case Management (MHICM), that began to implement discharge. MHICM clinicians (n=15) describe significant barriers to discharge. Clinicians support the concept of discharge but raise concerns about clients' future stability, clients' feelings about discharge, and other aspects of the discharge process. We propose strategies that can be used to support clinicians and clients in discharge decision-making.

Implementation of consumer providers into mental health intensive case management teams.

In mental health care, consumer providers (CPs) are individuals with serious mental illness (SMI) who draw upon their lived experiences while providing services to others with SMI. Implementation of CPs has proven to be challenging in a variety of settings. The PEER project (Peers Enhancing Recovery) involved rolling out CPs using an implementation science model and evaluating implementation and impact in mental health treatment settings (three intervention, three control). In qualitative interviews, facilitators and challenges to implementation were described by the CPs, their team members, clients, and study researchers. Site preparation, external facilitation, and positive, reinforcing experiences with CPs facilitated implementation. Role definitions and deficiencies in CPs' technical knowledge posed challenges to implementation. Sustainability was not realized due to insufficient resources. However, implementation was positive overall, characterized by diffusion of innovation concepts of high relative advantage, strong trialability, compatibility with prevailing norms, compelling observability, and relatively low complexity. By preparing and working systematically with intervention sites to incorporate new services, implementation was strengthened and challenges were minimized.

Case Management for Frequent Emergency Department Users

Case Management for Frequent Emergency Department Users

Adaptation of Intensive Mental Health Intensive Case Management to Rural Communities in the Veterans Health Administration

There has been increasing concern in recent years about the availability of mental health services for people with serious mental illness in rural areas. To meet these needs the Department of Veterans Affairs (VA) implemented the Rural Access Networks for Growth Enhancement (RANGE) program, in 2007, modeled on the Assertive Community Treatment (ACT) model. This study uses VA administrative data from the RANGE program (N = 343) to compare client characteristics at program entry, patterns of service delivery, and outcomes with those of Veterans who received services from the general VA ACT-like program (Mental Health Intensive Case Management (MHICM) (N = 3,077). Veterans in the rural program entered treatment with similar symptom severity, less likelihood of being diagnosed with schizophrenia and having had long-term hospitalization, but significantly higher suicidality index scores and greater likelihood of being dually diagnosed compared with those in the general program. RANGE Veterans live further away from their treatment teams but did not differ significantly in measures of face-to-face treatment intensity. Similar proportions of RANGE and MHICM Veterans were reported to have received rehabilitation services, crisis intervention and substance abuse treatment. The rural programs had higher scores on overall satisfaction with VA mental health care than general programs, slightly poorer outcomes on quality of life and on the suicidality index but no significant difference on other outcomes. These data demonstrate the clinical need, practical feasibility and potential effectiveness of providing intensive case management through small specialized case management teams in rural areas.

Who Terminates From ACT and Why? Data From the National VA Mental Health Intensive Case Management Program

Who Terminates From ACT and Why? Data From the National VA Mental Health Intensive Case Management Program

Who Terminates From ACT and Why? Data From the National VA Mental Health Intensive Case Management Program

Who Terminates From ACT and Why? Data From the National VA Mental Health Intensive Case Management Program

Who Terminates From ACT and Why? Data From the National VA Mental Health Intensive Case Management Program

One of the original principles of assertive community treatment (ACT) is that treatment should be time unlimited. Although termination is not uncommon in ACT, it has not been empirically studied. This study examined termination from a large program based on ACT. This study used national data from the Department of Veterans Affairs Mental Health Intensive Case Management program modeled on ACT to compare veteran characteristics, patterns of service delivery, and early clinical changes among veterans who terminated early (less than one year) and later (one to three years) with those of veterans had not terminated after three years. Bivariate comparisons and multinomial logistic regression analyses were used to identify factors associated with early and later termination. Among 1,402 veterans enrolled in fiscal years (FY) 2002-2004, 16% terminated early, 26% terminated later, and 57% had not terminated after three years. Compared with those who had not terminated, those who terminated early showed higher suicidality scores, and participants who terminated early and those who terminated later were less likely to have a diagnosis of schizophrenia and were more likely to have lower quality of life at entry. Stronger differentiating effects were observed for program participation. Those who terminated received less intensive services during the first six months of participation and had a weaker therapeutic alliance. Although participants who terminated early showed more violent behavior at follow-up than the other two groups, there were no other differences in early clinical changes. Rates of both early and later termination were substantial, and less active participation was a stronger predictor of termination than either patient characteristics or clinical changes. A diagnosis of schizophrenia was associated with continued treatment. Further research is needed to determine the impact of termination on longer-term outcomes.

Transition to low intensity case management in a VA assertive community treatment model program.

To study transition to lower intensity services in a national VA program modeled on Assertive Community Treatment (ACT). This study uses national VA administrative data from VA's Mental Health Intensive Case Management (MHICM) program, to compare veteran characteristics, patterns of service use and early clinical changes among veterans who were formally transitioned to lower intensity treatment and veterans who were not. Bivariate comparisons and logistic regression analyses are used to identify factors associated with transition to low intensity treatment and to characterize post-transition service use. Descriptive information on the criteria for termination and subsequent service use are also presented. Among 2,137 veterans in the sample who enrolled in MHICM from FY 2002-2006 and who participated in at least one year of treatment, 196 (9.2%) were transitioned to lower intensity services. These veterans did not differ from others on baseline clinical characteristics but had a smaller number of program contacts during the first 6 months of participation, a higher quality of family relationships and overall quality of life after 6 months of treatment. Only 5.7% were reported to have needed to return to higher service intensity after the transition and they continued to have reduced levels of service use on several measures but no reduction in therapeutic alliance. The VA policy did not result in frequent transition to lower intensity services. Those who did transition had shown greater clinical improvement, used fewer services, had better family relationships, and rarely required a shift back to higher intensity services.

Veterans Affairs Intensive Case Management for Older Veterans

There is a growing need for information on evidence-based practices that may potentially address needs of elderly people with severe mental illness (SMI), and more specifically on community-based services such as assertive community treatment (ACT). This study examines national evaluation data from fiscal year 2001-2005 from Veterans Affairs Mental Health Intensive Case Management (MHICM) program (N = 5,222), an ACT-based service model, to characterize the age distribution of participants and the distinctive needs, patterns of service delivery, and treatment outcomes for elderly veterans. Altogether, 24.8% of participants were 55-64 years; 7.4% 65-74 years; and 2.8% were older than 75. Veterans over 75 formed a distinct subgroup that had a later age of onset of primarily nonpsychotic illnesses without comorbid substance abuse and had experienced more limited lifetime hospital treatment than younger participants. Older veterans were less symptomatic and more satisfied with their social relationships than younger clients. They mostly live independently or in minimally restrictive housing, but they received less recovery-focused services and more crisis intervention and medical services. They thus do not appear to be young patients with SMI who have aged but rather constitute a distinct group with serious late-onset problems. It is possible that MHICM services keep them in the community and avoid costly nursing home placement while providing a respite service that reduces family burden. These data highlight the unique characteristics of older veterans receiving ACT-like services and the need to focus greater attention on recovery-oriented services as well as community support for this subgroup.

VA Intensive Mental Health Case Management in Urban and Rural Areas: Veteran Characteristics and Service Delivery

The availability of mental health services in rural areas--particularly intensive services such as assertive community treatment (ACT)--has been of increasing concern and was the focus of this study. In recent decades the U.S. Department of Veterans Affairs (VA) has developed a national network of ACT-like programs called mental health intensive case management (MHICM), which have served veterans from diverse locations across the country, including urban and rural areas. This study used rural-urban commuting area codes and national VA administrative data to compare characteristics of veterans and patterns of MHICM service delivery among veterans with mental illness living in large urban, large rural, small rural, and isolated rural communities. Among veterans enrolled in MHICM from FY 2000 to FY 2005 (N=5,221), 84% (N=4,373) resided in urban areas, 8% (N=421) in large cities, 6% (N=291) in small rural towns, and 3% (N=136) in isolated rural areas. MHICM participants who lived in rural areas had clinical problems broadly similar to those in urban areas, although more rural veterans were unemployed, disabled, received VA disability compensation, and had a payee or fiduciary. MHICM clients in smaller or isolated rural areas received slightly less frequent and less intensive contacts and less recovery-oriented services than those in large urban locations. These data highlight the need for intensive case management services in rural areas and note some challenges in providing them at the intensity and frequency observed in urban areas where travel distances and times are shorter.

ACT and Other Case Management Services for Veterans

Back to table of contents Previous article Next article LetterFull AccessLetterRobert A. Rosenheck M.D.Michael S. Neale Ph.D.Somaia Mohamed M.D., Ph.D.Robert A. Rosenheck M.D.Search for more papers by this authorMichael S. Neale Ph.D.Search for more papers by this authorSomaia Mohamed M.D., Ph.D.Search for more papers by this authorPublished Online:13 Jan 2015https://doi.org/10.1176/ps.2009.60.4.555AboutSectionsView articleView PDFView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail View articleACT and Other Case Management Services for VeteransTo the Editor: We agree with the conclusions of McCarthy and colleagues' study ( 1 ) published in the February issue that 2004 inpatient data from the Veterans Affairs (VA) health system suggested a need to increase the availability of assertive community treatment (ACT) services, with special attention to the needs of homeless and elderly veterans and veterans who do not live near VA facilities. However, as is often the case, reliance on administrative data can lead to oversimplification of clinical evaluation practices and incomplete consideration of the policy context. To expand on this study, we offer the following clarifications and additions. First, the clinical appropriateness of ACT services can be only roughly approximated with data on hospital use. The Mental Health Intensive Case Management (MHICM) program, as the national VA implementation of ACT is named, currently serves 7,300 veterans on the basis of detailed clinical assessments of need ( 2 ). The criteria for admission to MHICM as outlined in fiscal year 2000 (Veterans Health Administration [VHA] Directive 2000-030) include multiple indicators of difficulty with community functioning and need for intensive community-based services. Although this program may be optimally targeted at high-cost inpatients, not all veterans with a history of high hospital use need this service, and some who have not been recently hospitalized have greater need than those who have. A second consideration is that since 2005 VA's Strategic Mental Health plan has expanded the program considerably. Through the funding of 52 new teams, more than 3,000 MHICM treatment slots have been added, which is almost seven times the number of entrants recorded in McCarthy and colleagues' study of 2004 data. Third, although it is true that few homeless veterans are admitted to MHICM, this low rate of admission is largely a result of the VA's provision of specialized case management services to more than 65,000 homeless veterans per year through its specialized homeless outreach program. This program provides access to over 10,000 residential treatment beds and over 10,000 permanent supported housing units through the recently expanded HUD-VASH program (Department of Housing and Urban Development-Veterans Affairs Supportive Housing) ( 3 ). Fourth, although it is expected that veterans who live farther away from MHICM programs are less likely to receive this service, it is important to acknowledge that full MHICM or ACT teams cannot be efficiently implemented in less populated areas, especially in rural or frontier areas. Some existing programs serve substantial numbers of veterans in rural areas, and the VA has also implemented a pilot program at 19 rural sites with a modified model called Rural Access Network for Growth Enhancement (RANGE), designed to operate efficiently on a smaller scale ( 4 ). Finally, although McCarthy and colleagues found that elderly veterans were less like to be referred to MHICM, another recent study has shown that the MHICM program effectively serves a substantial number of elderly veterans—a group with quite distinctive characteristics (Mohamed S, Neale MS, Rosenheck RA, unpublished manuscript, 2009). The authors are affiliated with the Northeast Program Evaluation Center, Department of Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut.

Initiation of Assertive Community Treatment Among Veterans With Serious Mental Illness: Client and Program Factors

Initiation of Assertive Community Treatment Among Veterans With Serious Mental Illness: Client and Program Factors

Clinical Characteristics and Health Service Use of Veterans With Comorbid Bipolar Disorder and PTSD

Clinical Characteristics and Health Service Use of Veterans With Comorbid Bipolar Disorder and PTSD

VA Says `Culture Change' Will Transform MH Services

Back to table of contents Previous article Next article Government NewsFull AccessVA Says `Culture Change' Will Transform MH ServicesKate MulliganKate MulliganSearch for more papers by this authorPublished Online:5 Nov 2004https://doi.org/10.1176/pn.39.21.00390029Federal agencies were asked to respond to the recommendations of the New Freedom Commission on Mental Health after submission of the commission's report to President George W. Bush in July 2003.Among the first federal agencies to come up with an action agenda was the Department of Veterans Affairs (VA), which released “Achieving the Promise: Transforming Mental Health in the VA” on December 1, 2003.Frances M. Murphy, M.D., M.P.H., emphasizes the need for a culture change that focuses on “functional recovery.”Photo courtesy of the Department of Veterans AffairsDeputy Under Secretary for Health for Health Policy Coordination Frances M. Murphy, M.D. M.P.H., who served on the commission and chaired the work group that produced the VA report, told Psychiatric News that before the commission's work, “the VA had already begun a process for transformation” that is not yet complete.She emphasized the importance of a “culture change” that focuses on the idea of functional recovery, rather than merely symptom reduction.Work group members offered a candid assessment of key challenges.Mental health workloads increased by 34 percent between 1995 and 2002.Murphy said, “During Fiscal 2003, a total of 794,581 veterans, 16.9 percent of all VA patients, received specialized VA mental health [services].”According to the report, “[Veterans] may have a higher prevalence of multiple diagnoses [and] mental health problems, such as PTSD and substance abuse, when compared with the general population.”The group wrote, “To date, the VA has not developed enough capacity in outpatient or community-based programs to adequately serve enrolled veterans' needs for screening, prevention, crisis treatment, and coordinated chronic health care.”The inadequacy of the capacity is exacerbated by the“ variability” in quality and extent of mental health services, including those for substance abuse, depending on geographic location.“[O]nly about one-third of the veterans who meet utilization criteria for Mental Health Intensive Case Management are currently enrolled in such programs. Consistent access to mental health care in Community-Based Outpatient Clinics (CBOCs) has not yet been achieved. Of 616 CBOCs in Fiscal 2001, 258 had no mental health visits, and an additional 78 report that mental health care accounts for under 5 percent of their workload.”Murphy pointed out that the VA also has substantial strengths.“Parity is not an issue. There is no restriction on the number of visits [to a mental health practitioner].”She added that VA Secretary Anthony Principi “is such a champion for mental health.”(In 2002, Principi was the recipient of the APA Speaker's Award. He was praised particularly for his support of services for veterans with PTSD and for homeless veterans with serious mental illness.)The work group agreed on a nine-item agenda to guide action (see box).Murphy noted that the work group had identified a target date of 2008 to eliminate variability in access to mental health, substance abuse, and homeless services and to long-term psychiatric care.That change will require expansion of specialty mental health services to all CBOCs. Telepsychiatry might be used in rural areas where it is difficult to recruit specialists who can treat such illnesses as PTSD.The emphasis of the commission's report on promoting recovery and on greater involvement of patients and family members in making treatment choices is reflected in the recommendations of the VA's work group in the 2003 report.The work group singled out 12 recommendations “of such high importance that implementation should begin in January 2004.”Among them are to adopt the recovery model in VA mental health programs nationwide, to educate VA staff on recovery, to develop a strategic plan for mental health research that supports VA recovery-based mental health, to initiate a national Recovery and Rehabilitation Task Force, and to develop a manual on establishing a peersupport program.Murphy said that supported employment programs are a particular priority in terms of promoting recovery and the ability of veterans to live productively in the community.Several recommendations promote the integration of mental and primary health care services.How can mental health practitioners be confident that integration of services will not result in further erosion of resources for mental health care?Murphy said, “Everyone worries they might lose something, but the VA is trying to increase access to high-quality care... .There will always be a need for mental health and substance abuse specialists.”She said that the goal is to “detect mental health problems early” and “keep care integrated as long as possible.”Murphy added that the veterans' population is aging. Those veterans prefer to have a primary care team coordinate their treatment.“By involving mental health practitioners in the work of primary care clinics, veterans get a clear message that mental health is essential to their overall health.” ▪ ISSUES NewArchived