Primary Care-Mental Health Integration Research Articles

Integrated care: treatment initiation following positive depression screens.

Primary Care-Mental Health Integration (PC-MHI) may improve mental health services access and continuity of care. To assess whether receipt of integrated PC-MHI services on the date of an initial positive depression screen influences receipt of depression treatment among primary care (PC) patients in the Veterans Health Administration. Retrospective cohort study. Thirty-six thousand, two hundred and sixty-three PC patients with positive depression screens between October 1, 2009 and September 30, 2010. Subjects were assessed for depression diagnosis and initiation of antidepressants or psychotherapy on the screening day, within 12weeks, and within 6months. Among individuals with PC encounters on the screening day, setting of services received that day was categorized as PC only, PC-MHI, or Specialty Mental Health (SMH). Using multivariable generalized estimating equations (GEE) logistic regression, we assessed likelihood of treatment initiation, adjusting for demographic and clinical measures, including depression screening score. Patients who received same-day PC-MHI services were more likely to initiate psychotherapy (OR: 8.16; 95% CI: 6.54-10.17) and antidepressant medications (OR: 2.33, 95% CI: 2.10-2.58) within 12weeks than were those who received only PC services on the screening day. Receipt of same-day PC-MHI may facilitate timely receipt of depression treatment.

VA primary care-mental health integration: patient characteristics and receipt of mental health services, 2008-2010.

In 2007, the U.S. Department of Veterans Affairs (VA) health system began nationwide implementation of primary care-mental health integration (PC-MHI) programs to enhance mental health access and promote treatment of common mental health conditions for patients in primary care settings. This report describes patients initiating PC-MHI services in fiscal years (FYs) 2008-2010, including those who received prior mental health services. Using VA administrative records, the investigators examined characteristics and services utilization of individuals who initiated PC-MHI services in FY 2008 (N=76,985), FY 2009 (N=107,417), or FY 2010 (N=149,938). PC-MHI service initiation increased by 95%, from 76,985 to 149,938 veterans. Over time, new user cohorts were increasingly younger, newer to VA services, and less likely to have received VA mental health treatment in the prior year. This study documents substantial expansion in VA PC-MHI program activity. PC-MHI program expansion may increase access to mental health services in primary care settings.

Continuation of care following an initial primary care visit with a mental health diagnosis: differences by receipt of VHA Primary Care–Mental Health Integration services

ObjectiveFor patients with an initial primary care (PC) encounter in the Veterans Health Administration (VHA) that included a mental health diagnosis, we evaluate whether same-day receipt of Primary Care–Mental Health Integration (PC-MHI) services is associated with the likelihood of receiving a subsequent mental-health-related encounter in the following 90 days. MethodUsing VHA administrative data, we identified 9046 patients who received VHA care for the first time in fiscal year 2009, received a PC encounter that included a mental health diagnosis on the first day of their VHA services and initiated care at a VHA facility that provided PC-MHI services. Using multivariable generalized estimating equations logistic regression, we examined whether receipt of same-day PC-MHI was associated with receipt of a subsequent encounter with a mental health diagnosis within 90 days. Analyses adjusted for Operation Enduring Freedom/Operation Iraqi Freedom Veteran status, demographic characteristics, service-connected disability, psychiatric and non-psychiatric diagnoses, and psychotropic medication initiation on the index day of service use. ResultsReceipt of same-day PC-MHI services was positively associated with having a mental-health-related encounter in the following 90 days (adjusted odds ratio=2.05; 95% confidence interval=1.66–2.54). ConclusionsPC-MHI services may enhance mental health continuation of care among PC patients with mental health conditions who initiate VHA services.

Determinants of Readiness for Primary Care-Mental Health Integration (PC-MHI) in the VA Health Care System

Depression management can be challenging for primary care (PC) settings. While several evidence-based models exist for depression care, little is known about the relationships between PC practice characteristics, model characteristics, and the practice's choices regarding model adoption. We examined three Veterans Affairs (VA)-endorsed depression care models and tested the relationships between theoretically-anchored measures of organizational readiness and implementation of the models in VA PC clinics. 1) Qualitative assessment of the three VA-endorsed depression care models, 2) Cross-sectional survey of leaders from 225 VA medium-to-large PC practices, both in 2007. We assessed PC readiness factors related to resource adequacy, motivation for change, staff attributes, and organizational climate. As outcomes, we measured implementation of one of the VA-endorsed models: collocation, Translating Initiatives in Depression into Effective Solutions (TIDES), and Behavioral Health Lab (BHL). We performed bivariate and, when possible, multivariate analyses of readiness factors for each model. Collocation is a relatively simple arrangement with a mental health specialist physically located in PC. TIDES and BHL are more complex; they use standardized assessments and care management based on evidence-based collaborative care principles, but with different organizational requirements. By 2007, 107 (47.5%) clinics had implemented collocation, 39 (17.3%) TIDES, and 17 (7.6%) BHL. Having established quality improvement processes (OR 2.30, [1.36, 3.87], p = 0.002) or a depression clinician champion (OR 2.36, [1.14, 4.88], p = 0.02) was associated with collocation. Being located in a VA regional network that endorsed TIDES (OR 8.42, [3.69, 19.26], p < 0.001) was associated with TIDES implementation. The presence of psychologists or psychiatrists on PC staff, greater financial sufficiency, or greater spatial sufficiency was associated with BHL implementation. Both readiness factors and characteristics of depression care models influence model adoption. Greater model simplicity may make collocation attractive within local quality improvement efforts. Dissemination through regional networks may be effective for more complex models such as TIDES.

Brief cognitive behavioral therapy in primary care: a hybrid type 2 patient-randomized effectiveness-implementation design.

BackgroundDespite the availability of evidence-based psychotherapies for depression and anxiety, they are underused in non-mental health specialty settings such as primary care. Hybrid effectiveness-implementation designs have the potential to evaluate clinical and implementation outcomes of evidence-based psychotherapies to improve their translation into routine clinical care practices.MethodsThis protocol article discusses the study methodology and implementation strategies employed in an ongoing, hybrid, type 2 randomized controlled trial with two primary aims: (1) to determine whether a brief, manualized cognitive behavioral therapy administered by Veterans Affairs Primary Care Mental Health Integration program clinicians is effective in treating depression and anxiety in a sample of medically ill (chronic cardiopulmonary diseases) primary care patients and (2) to examine the acceptability, feasibility, and preliminary outcomes of a focused implementation strategy on improving adoption and fidelity of brief cognitive behavioral therapy at two Primary Care-Mental Health Integration clinics. The study uses a hybrid type 2 effectiveness/implementation design to simultaneously test clinical effectiveness and to collect pilot data on a multifaceted implementation strategy that includes an online training program, audit and feedback of session content, and internal and external facilitation. Additionally, the study engages the participation of an advisory council consisting of stakeholders from Primary Care-Mental Health Integration, as well as regional and national mental health leaders within the Veterans Administration. It targets recruitment of 320 participants randomized to brief cognitive behavioral therapy (n = 200) or usual care (n = 120). Both effectiveness and implementation outcomes are being assessed using mixed methods, including quantitative evaluation (e.g., intent-to-treat analyses across multiple time points) and qualitative methods (e.g., focus interviews and surveys from patients and providers). Patient-effectiveness outcomes include measures of depression, anxiety, and physical health functioning using blinded independent evaluators. Implementation outcomes include patient engagement and adherence and clinician brief cognitive behavioral therapy adoption and fidelity.ConclusionsHybrid designs are needed to advance clinical effectiveness and implementation knowledge to improve healthcare practices. The current article describes the rationale and challenges associated with the use of a hybrid design for the study of brief cognitive behavioral therapy in primary care. Although trade-offs exist between scientific control and external validity, hybrid designs are part of an emerging approach that has the potential to rapidly advance both science and practice.Trial registrationNCT01149772 at http://www.clinicaltrials.gov/ct2/show/NCT01149772

Primary Care–Mental Health Integration Programs in the Veterans Affairs Health System Serve a Different Patient Population Than Specialty Mental Health Clinics

To assess whether Primary Care-Mental Health Integration (PC-MHI) programs within the Veterans Affairs (VA) health system provide services to patient subgroups that may be underrepresented in specialty mental health care, including older patients and women, and to explore whether PC-MHI served individuals with less severe mental health disorders compared to specialty mental health clinics. Data were obtained from the VA National Patient Care Database for a random sample of VA patients, and primary care patients with an ICD-9-CM mental health diagnosis (N = 243,806) in 2009 were identified. Demographic and clinical characteristics between patients who received mental health treatment exclusively in a specialty mental health clinic (n = 128,248) or exclusively in a PC-MHI setting (n = 8,485) were then compared. Characteristics of patients who used both types of services were also explored. Compared to patients treated in specialty mental health clinics, PC-MHI service users were more likely to be aged 65 years or older (26.4% vs 17.9%, P < .001) and female (8.6% vs 7.7%, P = .003). PC-MHI patients were more likely than specialty mental health clinic patients to be diagnosed with a depressive disorder other than major depression, an unspecified anxiety disorder, or an adjustment disorder (P < .001) and less likely to be diagnosed with more severe disorders, including bipolar disorder, posttraumatic stress disorder, psychotic disorders, and alcohol or substance dependence (P < .001). Primary Care-Mental Health Integration within the VA health system reaches demographic subgroups that are traditionally less likely to use specialty mental health care. By treating patients with less severe mental health disorders, PC-MHI appears to expand upon, rather than duplicate, specialty care services.

Implementation of Primary Care-Mental Health Integration Services in the Veterans Health Administration: Program Activity and Associations with Engagement in Specialty Mental Health Services

This paper describes the status of the Veterans Health Administration (VHA) Primary Care-Mental Health Integration (PC-MHI) services implementation and presents an assessment of associations between receipt of PC-MHI services and likelihood of receiving a second specialty mental health (SMH) appointment following an initial SMH encounter. The total PC-MHI service recipients and encounters/month rose substantially between October 2007 and April 2011. Adjusting for important covariates, the likelihood of receiving a second SMH encounter within 3 months of an index SMH appointment was 1.37 times greater among individuals who had received a PC-MHI encounter within 3 months of the initial SMH appointment. Implementation of VHA PC-MHI services has substantially increased VHA capacity to deliver mental health services in primary care and findings indicate that PC-MHI services are associated with greater engagement in SMH treatment. Implementation of VHA PC-MHI services is progressing with new technical assistance strategies being deployed.

Primary care–mental health integration and treatment retention among Iraq and Afghanistan war veterans.

Despite the high prevalence of posttraumatic stress disorder (PTSD) and medical comorbidity among veterans from Iraq/Afghanistan (OEF/OIF), keeping these patients engaged in health care is challenging. Primary Care-Mental Health Integration (PC-MHI), an initiative in the Veterans Health Administration (VA), sought to improve access to mental health care from within primary care. This study examined the lag between first PC-MHI visit and next mental/medical care visit, if any, and the relationship of PC-MHI with short-term (subsequent year) and long-term (4 years later) use of VA. We identified 2,470 OEF/OIF veterans receiving care during fiscal year 2006 (FY06) in a regional VA health care system. Unconditional survival analysis modeled time to next mental/medical visit and logistic regression modeled short- and long-term care as a function of PC-MHI, demographics, and clinical covariates. Of 181 patients in the PC-MHI program, 60%/18% returned for mental/medical care within 1 month, and 82%/74% within 1 year. Sixty-one percent (1,503) were still using the VA in FY09. Short-term mental care was related to prior-year PC-MHI. Consistent correlates of short- and long-term mental/medical care included physical comorbidity and Priority 1 status. Most patients attended mental health appointments subsequent to PC-MHI, and PC-MHI was correlated with mental health treatment retention in adjusted models for our cohort. Need for treatment, notably VA Priority 1 status and physical comorbidity, were the primary correlates of care-seeking. Developing innovative approaches to engaging new veterans in care remains imperative as multiple options will be necessary to meet the needs of these complex patients.

2010 VA/DOD Clinical Practice Guideline for Management of Post-Traumatic Stress: How busy clinicians can best adopt updated recommendations

The continued wars in Iraq and Afghanistan have brought an increased focus on posttraumatic stress disorder (PTSD) and have made PTSD a part of a national conversation. Since the first edition of the Department of Veterans Affairs (VA)/Department of Defense (DOD) Clinical Practice Guideline (CPG) for PTSD was issued in 2004 at the beginning of these conflicts, more than 750,000 returning new Veterans have sought mental health care in the VA. It is anticipated that this number will climb dramatically as more than 1 million Veterans will leave the military in the next 5 years. This makes it all the more important that VA and DOD healthcare providers have clear guidance on best management practices for PTSD and an understanding of how they can best use the revised VA/DOD Clinical Practice Guideline for Management of Post-Traumatic Stress issued in the fall of 2010. As coeditors, our goal with the production of this special issue of JRRD is to publish a series of articles that go beyond the recommendations in the new CPG by providing, in addition to a comprehensive overview of the latest scientific evidence, practical guidance for busy clinicians who wish to adopt the CPG recommendations within their various clinical settings. The Veterans Health Administration (VHA) has taken significant steps to meet the needs of returning Veterans. In the guest editorials that follow, leadership in VHA's Office of Mental Health Services outlines the transformation that has occurred in the effectiveness of mental health care in the VA. For the first time, a standard for providing mental health treatments across VHA was established in the Uniform Mental Health Services Handbook that defines the clinical services any Veteran can expect from any VA facility. Foremost among available treatments are very effective evidence-based psychotherapies for PTSD. As reviewed in the guest editorials, large numbers of clinicians have been trained in PTSD first-line psychotherapy treatments, such as prolonged exposure and cognitive processing therapies. In addition, substance use disorder (SUD)/PTSD specialists have been hired to manage the common co-occurring disorders. Post-deployment clinics have been created to address specific reintegration needs of returning Veterans. Primary Care Mental Health Integration Teams have been established to assess and offer brief mental health treatments in an interdisciplinary, coordinated primary care environment. PTSD residential treatment settings have gone through significant system redesigns to meet the needs of returning Veterans, and their treatments have significantly improved outcomes. Perhaps the biggest paradigm shift has been the emphasis on a recovery-oriented model in which individually-focused treatment plans, services that go well beyond symptom management, are developed that also address the unique needs of the Veteran and his or her family. The National Center for PTSD (NCPTSD) has worked within the VA's Office of Mental Health Services to meet the demands of increasingly complex clinical presentations in which PTSD is often accompanied by comorbid diagnoses (such as depression, SUD, and traumatic brain injury [TBI]) and co-occurring problems (such as insomnia, pain, and aggressive behavior). Specifically, NCPTSD has developed new programs, such as the PTSD Mentoring Program and the PTSD Consultation Program. …

Initiation of Primary Care—Mental Health Integration Programs in the VA Health System: Associations With Psychiatric Diagnoses in Primary Care

Initiation of Primary Care—Mental Health Integration Programs in the VA Health System: Associations With Psychiatric Diagnoses in Primary Care

Enhancing entrance into PTSD treatment for post-deployment veterans through collaborative/integrative care

High rates of posttraumatic stress disorder (PTSD) among post-deployment veterans and the associated long-term consequences highlight the importance of early identification and treatment. The Veterans Health Administration (VHA)'s Primary Care Mental Health Integration (PCMHI) program aims to increase identification and access to care for veterans with mental illness, decrease stigma, improve continuity of care, and the efficiency of healthcare utilization. This project examines PCMHI's progress towards these goals within the Operation Iraqi Freedom/Operation Enduring Freedom (OEF/OIF) population. We examined data from consults to the OEF/OIF PTSD clinic for 18months. PCMHI placed 129 consults and 91 (70.5%) were completed. Veterans referred by PCMHI tended to have increased consult completion in specialty care, higher rates of confirmed PTSD, however, no significant differences in reported PTSD symptoms, or follow-up visits in the OEF/OIF PTSD clinic compared to Veterans referred from the hospital at large. PCMHI potentially preserve resources, increases continuity of care, and increases treatment access for OEF/OIF/OND veterans.

The role of mental and behavioral health in the application of the patient-centered medical home in the Department of Veterans Affairs

The patient-centered medical home, which is termed the Patient Aligned Care Team (PACT) in the Department of Veterans Affairs (VA), is a transformational initiative with mental and behavioral health as integral components. Funding has been provided to VA medical facilities to assist with the transformation and process redesign of primary care into interdisciplinary teams focused on increased access, Veteran-centered care, and active incorporation of collaborative expertise from specialists within primary care. Primary care clinics are not simple machines that change by merely replacing parts or colocating additional resources. Rather, they are complex systems with a relationship infrastructure among members of the team that is critically important to the change process. Mental health professionals are integral, mandated members of the PACTs providing needed mental and behavioral health care to Veterans as an integrated component of primary care. They also work to catalyze a quality improvement process that encourages collaboration, innovation, and adoption of best practices that promote transformation based on patient-centered principles of care. The purpose of this article is to describe the evolution of VA primary care settings toward interdisciplinary teams that provide patient-centered care in collaboration with Primary Care-Mental Health Integration providers and Health Promotion Disease Prevention team members.

Interventions to Improve Veterans’ Access to Care: A Systematic Review of the Literature

To conduct a systematic review to address the following key questions: (1) what interventions have been successful in improving access for veterans with reduced health care access? (2) Have interventions that have improved health care access led to improvements in process and clinical outcomes? OVID MEDLINE, CINAHL, PsychINFO. English language articles published in peer-reviewed journals from 1990 to June 2010. All interventions designed to improve access to health care for US veterans that reported the impact of the intervention on perceived (e.g., satisfaction with access) or objective (e.g., travel time, wait time) access were included. APPRAISAL AND SYNTHESIS METHODS: Investigators abstracted data on study design, study quality, intervention, and impact of the intervention on access, process outcomes, and clinical outcomes. Nineteen articles (16 unique studies) met the inclusion criteria. While there were a small number of studies in support of any one intervention, all showed a positive impact on either perceived or objective measures of access. Implementation of Community Based Outpatient Clinics (n = 5 articles), use of Telemedicine (n = 5 articles), and Primary Care Mental Health Integration (n = 6 articles) improved access. All 16 unique studies reported process outcomes, most often satisfaction with care and utilization. Four studies reported clinical outcomes; three found no differences. Included studies were largely of poor to fair methodological quality. Interventions can improve access to health care for veterans. Increased access was consistently linked to increased primary care utilization. There was a lack of data regarding the link between access and clinical outcomes; however, the limited data suggest that increased access may not improve clinical outcomes. Future research should focus on the quality and appropriateness of care and clinical outcomes.

Initiation of Primary Care—Mental Health Integration Programs in the VA Health System

Providing collaborative mental health treatment within primary care settings improves depression outcomes and may improve detection of mental disorders. Few studies have assessed the effect of collaborative mental health treatment programs on diagnosis of mental disorders in primary care populations. In 2008, many Department of Veterans Affairs (VA) facilities implemented collaborative care programs, as part of the VA's Primary Care-Mental Health Integration (PC-MHI) program. To assess the prevalence of diagnosed mental health conditions among primary care patient populations in association with PC-MHI programs, overall and for patient subpopulations that may be less likely to receive mental health treatment. Using a difference-in-differences analysis, we evaluated whether the rates of psychiatric diagnoses among primary care patient populations at 294 VA facilities changed from fiscal year (FY)07 to FY08, and whether trends differed at facilities with PC-MHI encounters in FY08. Subgroup analyses examined whether trends differed by patient age and race/ethnicity. SUBJECTS, MEASURES, AND RESULTS: From FY07 to FY08, the prevalence of diagnosed depression, anxiety, post-traumatic stress disorder, and alcohol abuse increased more in the 137 facilities with PC-MHI program encounters than in the 157 facilities without these encounters. Increases were more likely among patients who were younger (18-64) and white. Initiation of PC-MHI programs was associated with elevated diagnosis patterns, which may enhance recognition of mental health needs among primary care patients. Increases in diagnosis prevalence were not uniform across patient subgroups. Further research is needed on treatment processes and outcomes for individuals receiving services in PC-MHI programs.

Primary care-mental health integration in healthcare in the Department of Veterans Affairs.

The U.S. Department of Veterans Affairs (VA) has been undergoing tremendous transformation in the past 15 years with regard to the delivery of health care. This special issue describes one aspect of this transformation of the largest health system in the U.S.; the system-wide efforts to integrate mental health treatment into the primary care setting in VA. This primary care-mental health integration (PC-MHI) is being accomplished through the central VA system support and implementation of three primary models developed in the field: the White River Colocated models, the Behavioral Health Laboratory, and TIDES (Translating Initiatives in Depression into Effective Solutions). The papers in this special issue describe the development of these models, local and regional efforts to prepare medical centers to adapt and implement PC-MHI, and the impact of the integration on mental health care in these settings. These efforts could represent a national model of PC-MHI implementation for health care systems throughout the U.S.

Veterans Health Administration Primary Care-Mental Health Integration Initiative

he Veterans Health Administration has undertaken a large national initiative to integrate primary care and mental health services. A request for proposals was disseminated throughout the Veterans Affairs (VA) system inviting proposals for new programs to promote the effective treatment of common mental health and substance use disorders in the primary care environment. Both individual facilities and Veterans Integrated Service Networks (VISNs) were eligible to apply, and proposals could encompass activities at one or multiple VA facilities. Similarly, facilities within VISNs were free to use different evidence-based models for delivering integrated care. Program funding commenced during fiscal year 2007 (FY07). The overarching rationale for the initiative is to integrate care for veterans’ physical and mental health conditions, improve access and quality of care across the spectrum of illness severity, and allow treatment in mental health specialty settings to focus on persons with more severe mental illnesses. The report of the President’s New Freedom Commission on Mental Health emphasizes that mental health and physical health problems are interrelated components of overall health and are best treated in a coordinated care system. 1 That recognition also is embedded in the VA’s Mental Health Strategic Plan and its goal to “[d]evelop a collaborative care model for mental health disorders that elevates mental health care to the same level of urgency/intervention as medical health care.” 2