VA MENTAL HEALTH PRIMARY CARE

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VA MENTAL HEALTH PRIMARY CARE INTEGRATION 6/24/200
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• Clinical Care
• CONTINUUM OF CARE
• Inpatient
• Residential
• Partial Hospitalization
• Outpatient
• Community/ Outreach

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CAPACITY PATIENTS/ DOLLARS  
FY 1996 FY 2000   Patients Dollars Patie
nts Dollars     PTSD 39,653 101.9M 48,322 94
.3M     H-less 24,539 75.1M 30,922 110.6M    
SMI 269,009 2.1B 290,819 1.9B    SA 107,074
575.9M 94,603 364.5M

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CAPACITY MH SPECIAL EMPHASIS PROGRAMS  
Dis. Setting FY96 FY98 FY99 FY00   SMI IP 117
,088 95,068 88,319 83,396 OP 251,216 278,
674 284,937 281,679 TOT. 269,009 290,961 295,29
6 290,819   S/A IP 50,628 30,021 25,812
22,949 OP 90,916 99,337 96,307
90,087 TOT. 107,074 106,599 102,178
94,603   H IP 5273 7,072 7226
7506 OP 21,913 23,763 25,450
27,950 TOT. 24,539 27,201 28,542
30,922   PTSD IP 4,312 4,694 4,522
4,088 OP 37,768 41,224 43,327
46,862 TOT. 39,653 43,187 45,188
48,322
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CAPACITY, NETWORK VARIATION   SMI       
Seventeen VISNs decreased spending in FY 2000
compared to FY 1996.        Eighteen VISNs
increased numbers of SMI veterans
treated.        The decrease in mental health
costs primarily reflects a 29 decrease in SMI
veterans who are treated in inpatient settings
along with decreased overall lengths of stay over
the last four years (from 21.7 days in FY 1996 to
15.8 days in FY2000). SA      Five of 22 VISNs
allocated resources at or above the 90 level in
FY 2000 compared to FY 1996.      Eight of 22
VISNs had allocations in FY 2000 of less than 50
of the their FY 1996 allocations.      Ten of 22
VISNs showed a 90 or greater number of veterans
treated with a diagnosis of substance abuse seen
in FY 2000 as compared to FY 1996.      Three
of 22 VISNs treated more individuals than in FY
1996.   H        In FY 2000 18 of 22 VISNS
increased funding for SMI Homeless Veterans these
increases ranged from 9- 130.        Four
VISNs appeared to treat fewer SMI Homeless
Veterans in FY 2000 compared to FY
1996.   PTSD        Six VISNs decreased
expenditures for patients by one third or more
over the last five years.        Four of those
six VISNs increased the number of veterans
receiving specialized care while another VISN
treated only 2 fewer veterans.  

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Mental Health Measures     SMI MDD screen
87 Positive Depression Screen F/U 51 (4th Q
2002)   SA Alcohol Screen 78 (4th Q
2002)   PTSD PTSD Sx Decrease by Mississippi
Scale 3.82 Violence Decrease 42.38 Pt
Satisfaction 15.66 (Overall Satisfied) (FY
2002)   Homeless Domiciled at Discharge
76 Improved Psychiatric Symptoms
72.5 Improved Alcohol Symptoms 78.6 (FY
20002)
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Patient Safety         Workplace Violence
Prevention Management of Disturbed Behavior
collaborations with Occupational Safety
Health          Suicide Prevention Satellite
broadcasts, assessment and treatment across care
settings          Patient Personal Freedom and
Security assessment for dangerousness in mental
health, med /surg and Long Term Care settings
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Education          1,300 VA trainees in mental
health disciplines per year          Psychiatry
Resident Primary Care Education gt30 facilities,
11 of VA psychiatry residents
enrolled          Employee Education       
Satellites Workplace Violence, Family
Violence        Teleconferences Monthly PTSD
Hotline        Face to Face Impact of Mental
Health on Medical Illness in the Primary Care
Setting and the Aging Veteran MIRECC/GRECC
Conf.  
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Research          National Center for
PTSD        Neurobiological, physiological,
psychological research        Health care
delivery research (group therapy collaborative
study)        Education PTSD in Native
Americans videos          Quality Enhancement
Research Initiative (QUERI)        Translation
of research into practice        Depression,
Schizophrenia, Substance Abuse projects         
Mental Illness Research Education Clinical
Centers (MIRECCs)        Basic research,
clinical research and education        8 current
sites, diverse and complementary agendas       
Research Fellows from both Psychiatry
Psychology          Collaborations with Other
Agencies        VA SAMHSA, HRSA MH/SA care in
primary care vs. MH sites        National
Collaborative Study of Early Psychosis and
Suicide (NCSEPS) VA, DOD, NIMH
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Major Initiatives    
Community Care Mental Health Intensive Care
Management (MHICM) 71 Active Programs (FY
2003) 10 In Development MHICM Plans from all
VISNs  
Mental Health/ Primary Care   Community Based
Outpatient Clinics (CBOCs) FY 2000 CBOC MH
Visits 990,146 (0.66 gt FY98) MH Visits
17.3 ( 5.8 lt FY98) MH Expansion in CBOCs in FY
2001 VISN Plans  
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VA Initiatives in Mental Health Primary Care

• Consensus of Chiefs (94)
• PRIME (94)
• Primary Care Expert Consultant Teams (96)
• Mental Health Primary Care Team Survey (96-97)

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VA Initiatives in Mental Health Primary Care

• PTSD Practice Guidelines (96)
• PTSD Primary Care Working Group (96)
• Provision of Primary Care Services for Mental
  Health Clinicians
• VHA Program Guide 1103.2 (99)

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VA Initiatives in Mental Health Primary Care

• Primary Care Mental Health Education Module
  (97-98)
• Psychiatry Residency Primary Care Education
  Program (PsyPCE) (97)
• ISTSS (97)
• MH Primary Care Mini Residency (99)

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Collaboration IntegrationPrimary Care, Mental
Health Geriatrics
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Essential Features of Primary Care

• Intake/assessment
• Prevention
• Management of acute chronic conditions
• Referral
• Patient/care giver education

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Mental Health Primary Care Teams

• MH provider as primary care provider
• Continuity of care across service sites
• Comprehensive (medical mental health) care

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• Traditional Models Approximating Primary Care
• Consultation Liaison (multidisciplinary)
• Dual diagnosis (Gen. Psychiatry/substance abuse )
  programs
• Behavioral medicine health psychology programs

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Common MH/Primary Care Issues

• Multidisciplinary team structure leadership
• Bridging disciplinary programmatic boundaries
• Integration of physical mental health specialty
  care
• Adaptation to VA national VISN reorganization

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• Potential Barriers
• Historical vertical services, little
  collaboration
• Expectations (staff patients) that MDs provide
  all care
• Lack of IP/OP continuity
• Specialists concern over lack of primary care
  skills

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• Bridging the Barriers
• Multidisciplinary team building across services
• Find a service model that best suits staff
  patients
• A patient triage format Med PC/ MH PC or shared
  by both
• Education for patients staff on PC aims
  methods

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NATIONAL MENTAL HEALTH IMPROVEMENT
PROGRAM (NMHIP)   Purpose   Coordinate and
enhance existing program evaluation, performance
measurement and quality of care activities.
  Goal   To improve quality of care received
by veterans who require mental health services.
  Assessment of essential precursors to good
outcomes          Mental health care
needs          Access to needed
services          Structure and processes of
mental health care delivery systems   Measurement
of improvements          Clinical
outcomes          Social and economic
outcomes   Patient and significant other
satisfaction
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Activities          Coordinate data gathering
of existing MH evaluation and research
centers          Collaborate with OQP PBM to
monitor system performance          Monitor
system wide compliance with quality
directives          Work with VISN, MH Service
Line and Facility leadership to identify best
practices and address problems          Improve
VA MH services through education, dissemination
of best practices          Direct comparative
studies of patient outcomes system performance
of VA non-VA MH care systems          
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