A big part of providing effective integrated care is knowing who your population is. With more than 1,000 outpatient clinics, the Veterans Health Administration (VA) is the largest health care system in the United States, and the VA has a very clear sense of its population. Over the past 15 years, the VA has not only participated in some of the biggest studies of integrated care, but has made a commitment to provide patient-centered integrated care to its population. This month’s column provides a wonderful introduction to integrated care as it is practiced in the VA. —Jürgen Unützer, M.D., M.P.H.
In 2007, the Veterans Affairs (VA) health system started an initiative to integrate primary care with mental health services and developed PC-MHI programs nationwide. Along with integration of care, the goals were to improve access to mental health care, provide high-quality mental health care, enhance treatment adherence, promote an accepting atmosphere for patients, and reserve mental health specialty settings for treatment of more severe mental illness. In fact, to “develop a collaborative care model for mental health disorders that elevates mental health care to the same level of urgency/intervention as medical health care” is a goal embedded in the VA’s 2004 Mental Health Strategic Plan.
The VA PC-MHI model, in place for several years, is a well-developed and well-funded model offering an ideal example of a collaborative care program.
At the VA Palo Alto Health Care System (VAPAHCS) in California, seven of the primary care clinics offer the PC-MHI program, which has adopted a blended model of care that combines co-located collaborative care with care management. A clinical psychologist and psychology technician are embedded full time in the primary care clinic. In addition, at some clinics, a psychiatrist is embedded in the primary care clinic on a part-time basis. These clinicians collaborate with the primary care staff and offer a wide range of mental health services, including same-day “walk-in access” for patients referred by a primary care provider, initial psychological/psychiatric assessment, referral management such as appointment reminders and transitioning patients to other services if needed, watchful waiting—which encompasses motivational interviewing, psychoeducation, and supportive techniques—and psychologist-led brief therapies to facilitate the fastest attainment of maximal and enduring improvement.
The psychiatrist’s role, currently held by the first author of this article, is partly clinical and partly administrative. The psychiatrist acts as a consultant to her primary care colleagues in the PC-MHI program by being “embedded” in primary care two days a week. She offers psychiatric evaluation and medication management services for primary care patients struggling with mild to moderate signs and symptoms of mental illness.
The psychiatrist also provides administrative direction and oversight as the medical director of the entire PC-MHI team. This includes ongoing collaboration with administrative leaders in specialty mental health (the third author), in addition to the chiefs of primary care, engaging in overall program evaluation and quality-improvement strategies, standardization of services across clinics to ensure provision of evidence-based services, and hiring, recruiting, and training program staff.
The care-management aspect of the model is typically provided by the psychology technician team members and focuses on patient symptoms, treatment engagement, and treatment response monitoring.
The PC-MHI program at VAPAHCS typically serves veterans with mild to moderate psychological symptoms and psychosocial problems that can be addressed using brief interventions. The PC-MHI program does not provide long-term therapy, and interventions can be as infrequent as one session. We’ve found that individuals with complex histories or a diagnosis of serious mental illness are best treated in specialty mental health settings. However, the PC-MHI team can act as a bridge for some patients and provide brief services focusing on engaging and preparing patients for a specialty mental health referral.
So, here’s what we want our colleagues to know about integrated care:
Our colleagues in primary care place very high value on psychiatric and psychological consultation from colleagues who are available, affable, and able.
VA clinics are excellent sites for psychiatry residents to learn about integrated care and models of how to provide this service. Our clinic has served as a teaching clinic for psychiatry residents (second author), fellows, and physician assistant trainees to learn about integrated care.
The clinical work is very rewarding and in many ways bypasses a lot of the frustrations we often feel as physicians working in fragmented health care systems.
As a specialist, your experience and knowledge can add enormous benefit in making health care more streamlined and patient-centric. There are many opportunities for psychiatrists to act as educators to both colleagues and patients about common misperceptions surrounding mental disorders and mental health care.
Being a consultant for and working closely with a team of professionals from various specialty backgrounds helps your own career development. It prevents you from getting rusty in areas of medicine other than psychiatry and keeps you on the cutting edge of how health care systems are evolving to meet the needs and demands of all stakeholders. ■