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

Chang, Ernest S.; Rose, Danielle E.; Yano, Elizabeth M.; Wells, Kenneth B.; Metzger, Maureen E.; Post, Edward P.; Lee, Martin L.; Rubenstein, Lisa V.

doi:10.1007/s11606-012-2217-z

Cited by 53 publications

(48 citation statements)

References 51 publications

(67 reference statements)

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Mental health, the other specialty with the highest ease-of-communication rating, is also closely tied with primary care due to the VHA's efforts to integrate mental health into primary care clinics. 29 PCPs emphasized the importance of existing relationships between providers as facilitative of referral communication. Therefore, due to their close physical proximity, PCPs and mental health providers working in integrated primary care-mental health clinics may function more as face-to-face collaborators rather than dispersed collaborators, thereby facilitating communication.…”

Section: Discussionmentioning

confidence: 99%

Challenges in Referral Communication Between VHA Primary Care and Specialty Care

et al. 2014

Self Cite

View full text Add to dashboard Cite

BACKGROUND:Poor communication between primary care providers (PCPs) and specialists is a significant problem and a detriment to effective care coordination. Inconsistency in the quality of primary-specialty communication persists even in environments with integrated delivery systems and electronic medical records (EMRs), such as the Veterans Health Administration (VHA). OBJECTIVE: The purpose of this study was to measure ease of communication and to characterize communication challenges perceived by PCPs and primary care personnel in the VHA, with a particular focus on challenges associated with referral communication. DESIGN:The study utilized a convergent mixed-methods design: online cross-sectional survey measuring PCPreported ease of communication with specialists, and semi-structured interviews characterizing primary-specialty communication challenges. PARTICIPANTS: 191 VHA PCPs from one regional network were surveyed (54 % response rate), and 41 VHA PCPs and primary care staff were interviewed. MAIN MEASURES/APPROACH: PCP-reported ease of communication mean score (survey) and recurring themes in participant descriptions of primary-specialty referral communication (interviews) were analyzed. KEY RESULTS: Among PCPs, ease-of-communication ratings were highest for women's health and mental health (mean score of 2.3 on a scale of 1-3 in both), and lowest for cardiothoracic surgery and neurology (mean scores of 1.3 and 1.6, respectively). Primary care personnel experienced challenges communicating with specialists via the EMR system, including difficulty in communicating special requests for appointments within a certain time frame and frequent rejection of referral requests due to rigid informational requirements. When faced with these challenges, PCPs reported using strategies such as telephone and e-mail contact with specialists with whom they had established relationships, as well as the use of an EMR-based referral innovation called "eConsults" as an alternative to a traditional referral.CONCLUSIONS: Primary-specialty communication is a continuing challenge that varies by specialty and may be associated with the likelihood of an established connection already in place between specialty and primary care. Improvement in EMR systems is needed, with more flexibility for the communication of special requests. Building relationships between PCPs and specialists may also facilitate referral communication.

show abstract

Section: Discussionmentioning

confidence: 99%

Challenges in Referral Communication Between VHA Primary Care and Specialty Care

et al. 2014

Self Cite

View full text Add to dashboard Cite

show abstract

“…24,52 In addition, VA sites have adopted varying models for PC-MH integration, which has resulted in tremendous variation in local pathways and barriers. 24,28,53,54 Other VA sites, however, have reported similar barriers, including cultural barriers 26,28 and the need for PCP training in MH. 28 The national mandate to identify MH Treatment Coordinators additionally validates the fishbone branch related to process as a national issue.…”

Section: Discussionmentioning

confidence: 99%

The Anatomy of Primary Care and Mental Health Clinician Communication: A Quality Improvement Case Study

et al. 2014

Self Cite

View full text Add to dashboard Cite

BACKGROUND:The high prevalence of comorbid physical and mental illnesses among veterans is well known. Therefore, ensuring effective communication between primary care (PC) and mental health (MH) clinicians in the Veterans Affairs (VA) health care system is essential. The VA's Patient Aligned Care Teams (PACT) initiative has further raised awareness of the need for communication between PC and MH. Improving such communication, however, has proven challenging. OBJECTIVE: To qualitatively understand barriers to PC-MH communication in an academic communitybased clinic by using continuous quality improvement (CQI) tools and then initiate a change strategy. DESIGN, PARTICIPANTS, AND APPROACH: An interdisciplinary quality improvement (QI) work group composed of 11 on-site PC and MH providers, administrators, and researchers identified communication barriers and facilitators using fishbone diagrams and process flow maps. The work group then verified and provided context for the diagram and flow maps through medical record review (32 patients who received both PC and MH care), interviews (6 stakeholders), and reports from four previously completed focus groups. Based on these findings and a previous systematic review of interventions to improve interspecialty communication, the team initiated plans for improvement. KEY RESULTS: Key communication barriers included lack of effective standardized communication processes, practice style differences, and inadequate PC training in MH. Clinicians often accessed advice or formal consultation based on pre-existing across-discipline personal relationships. The work group identified collocated collaborative care, joint care planning, and joint case conferences as feasible, evidence-based interventions for improving communication. CONCLUSIONS: CQI tools enabled providers to systematically assess local communication barriers and facilitators and engaged stakeholders in developing possible solutions. A locally tailored CQI process focusing on communication helped initiate change strategies and ongoing improvement efforts.KEY WORDS: primary care; mental health; communication; quality improvement; ambulatory care; primary care redesign.

show abstract

“…3 The initiative provided programmatic technical assistance, education and training, and data sources for quality improvement 4 to facilitate the implementation of a "blended model that includes colocated collaborative care and care management. "…”

mentioning

confidence: 99%

Changing Patterns of Mental Health Care Use: The Role of Integrated Mental Health Services in Veteran Affairs Primary Care

et al. 2018

Self Cite

View full text Add to dashboard Cite

Objective: Aiming to foster timely, high-quality mental health care for Veterans, VA's Primary CareMental Health Integration (PC-MHI) embeds mental health specialists in primary care and promotes care management for depression. PC-MHI and patient-centered medical home providers work together to provide the bulk of mental health care for primary care patients with low-to-moderate-complexity mental health conditions. This study examines whether increasing primary care clinic engagement in PC-MHI services is associated with changes in patient health care utilization and costs.Methods: We performed a retrospective longitudinal cohort study of primary care patients with identified mental health needs in 29 Southern California VA clinics from October 1, 2008 to September 30, 2013, using electronic administrative data (n ‫؍‬ 66,638). We calculated clinic PC-MHI engagement as the proportion of patients receiving PC-MHI services among all primary care clinic patients in each year. Capitalizing on variation in PC-MHI engagement across clinics, our multivariable regression models predicted annual patient use of 1) non-primary care based mental health specialty (MHS) visits, 2) total mental health visits (ie, the sum of MHS and PC-MHI visits), and 3) health care utilization and costs. We controlled for year-and clinic-fixed effects, other clinic interventions, and patient characteristics.Results: Median clinic PC-MHI engagement increased by 8.2 percentage points over 5 years. At any given year, patients treated at a clinic with 1 percentage-point higher PC-MHI engagement was associated with 0.5% more total mental health visits (CI, 0.18% to 0.90%; P ‫؍‬ .003) and 1.0% fewer MHS visits (CI, ؊1.6% to ؊0.3%; P ‫؍‬ .002); this is a substitution rate, at the mean, of 1.5 PC-MHI visits for each MHS visit. There was no PC-MHI effect on other health care utilization and costs.Conclusions: As intended, greater clinic engagement in PC-MHI services seems to increase realized accessibility to mental health care for primary care patients, substituting PC-MHI for MHS visits, without increasing acute care use or total costs. Thus, PC-MHI services within primary care clinics may improve mental health care value at the patient population level. More research is needed to understand the relationship between clinic PC-MHI engagement and clinical quality of mental health care. (J Am Board Fam Med 2018;31:38 -48.)

show abstract

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

Cited by 53 publications

References 51 publications

Challenges in Referral Communication Between VHA Primary Care and Specialty Care

Challenges in Referral Communication Between VHA Primary Care and Specialty Care

The Anatomy of Primary Care and Mental Health Clinician Communication: A Quality Improvement Case Study

Changing Patterns of Mental Health Care Use: The Role of Integrated Mental Health Services in Veteran Affairs Primary Care

Contact Info

Product

Resources

About