Integrated Care Plays Role in VA Medical Home

The Veterans Health Administration (VA) has been a leader in integrated care since 2007 and continues to innovate on behalf of the millions of men and women it serves. This month, Andrew Pomerantz, M.D., one of the pioneers of integrated care, describes the evolution of integrated care at the VA and its applicability to health care in general. —Jürgen Unützer, M.D., M.P.H.

The Veterans Health Administration (VA) has the largest integrated health care system in the United States, with more than 8 million enrollees. Like the general population, most veterans with mental disorders present first in primary care settings and, also like other populations, many either decline referral to mental health clinics or do not engage in care even if they initially accept referral. Evidence developed in research trials over the past 20 years suggests that many such individuals can be successfully treated in an appropriately resourced primary care setting, without relying on often scarce specialized mental health clinics. Translation of this research into common practice has been slowly growing.

In 2007, the VA funded 97 facilities to begin providing integrated care in primary care clinics through its Primary Care–Mental Health Integration (PCMHI) initiative. PCMHI blends together two key components:

• Care management (CM), based on the collaborative care model, which has been described in previous issues of this publication. CM provides support for primary care providers as well as follow-up and, if indicated, additional assessment services for co-located collaborative care clinicians.

• Co-located collaborative care (CCC). This component adds mental health professionals to primary care teams to serve as consultants as well as deliver brief interventions to veterans identified by universal screening or during a clinical encounter. These embedded clinicians primarily treat individuals with mild to moderate symptoms of depression, anxiety, alcohol use, and other conditions such as chronic pain, insomnia, and stress. They also assist in assuring that those individuals with more complex illness whose care cannot be managed in primary care successfully engage in more specialized care. They also serve as resources for the primary care teams caring for individuals who have completed specialty mental health care.

In 2010, the VA began the transformation of primary care to the Patient Aligned Care Team (PACT), the VA’s version of the patient-centered medical home. These teams include services beyond traditional primary care, including the PCMHI providers. Although in the early years, special funding was provided to implement integrated care programs, they are now mostly built by reassigning staff from specialized mental health clinics to work in primary care. The VA is using an evidence-based blended facilitation model, developed and tested in one of its research centers, to assist development in many sites. As in other systems, experience has shown that clinicians making such a transition need training, and not all are comfortable with the brief, problem-focused assessments and interventions effective in primary care and prefer to work in specialized programs.

Although national policy outlines basic requirements, individual facilities can design and staff clinics based on local factors. Anecdotal reports from the many programs that have included psychiatrists report improved effectiveness, efficiency, and reach. The presence of a psychiatrist obviates the need to refer patients into specialty clinics when the need for direct psychiatric assessment arises, meaning more patients can be managed entirely within primary care by the interprofessional team. Psychiatrists typically serve as supervisors for care managers, consultants to the primary care providers, back-up for the non-M.D. mental health providers, and other functions. A few clinics have used psychiatrists to assist in treatment planning for complex, high-utilizing patients, mirroring a trend in the private sector.

One key to building successful integrated care clinics in the VA is immediate access within primary care. Making care immediately available at the time of a primary care visit helps to avoid the attrition invariably associated with delays of any length between problem identification and mental health assessment and treatment. Indeed, national program evaluation has demonstrated a substantial increase in the percentage of the primary care population identified with and treated for mental illness. Other national and program-specific findings have shown improved engagement in care for those who are first treated in PCMHI prior to specialty mental health care, improvement in guideline concordant care for depression in primary care, reduction of referrals to specialty care, and improved antidepressant prescribing by primary care providers.

Like any new clinical initiative, integrated care continues to evolve and mature. Medication management and psychotherapy are increasingly being delivered to patients in distant clinics and, increasingly, directly to the home, using interactive clinical video. Self-help websites and apps are now frequently used, and integrated clinicians often incorporate them in their work. Adapting traditional time-consuming treatments to this brief model of care has been a significant challenge. Reducing 12 to 16 one-hour sessions of evidence-based psychotherapy to one to four 30-minute sessions without loss of efficacy is challenging. The VA has recently begun training clinicians in brief problem-solving training, and other efforts are under way to develop brief therapeutic and care management interventions for chronic pain, insomnia, and other conditions. Some of these interventions are currently in clinical trials. A recent randomized, controlled trial of such brief therapy for posttraumatic stress disorder has yielded significantly positive results.

The VA has demonstrated that the use of integrated care for assessment and treatment of common mental health conditions preserves more intensive resources for those with more serious or complex illness and increases availability of those resources. Such a stepped-care approach can be an important tool to help solve the mental health access problem prevalent throughout much of U.S. health care as well. Although the funding mechanisms in the VA are different, the basic principles are the same and applicable to any setting. ■