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Building the Plane While Flying It: Implementation of the Medical Home in VA Healthcare Joanna Dognin, Psy.D. Julia Buckley, PhD Craig Tenner, MD Kelly Crotty, MD, MPH Margaret Horlick, MD VA New York Harbor Healthcare System October 28, 2011 Collaborative Family Healthcare Association 13 th Annual Conference October 27-29, 2011 Philadelphia, Pennsylvania U.S.A.

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Who we are Joanna Dognin, Psy.D. Health Behavior Coordinator Julia Buckley, PhD Former Health Coordinator Craig Tenner, MD Health Promotion Disease Prevention Program Manager Kelly Crotty, MD, MPH Health Promotion Disease Prevention Program Manager Margaret Horlick, MD Associate Program Director of NYU Internal Medicine Residency Program

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Faculty Disclosure We have not had any relevant financial relationships during the past 12 months.

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The Medical Home: Building the Plane Joint principles of patient-centered medical care Personal relationship with MD MD-directed practice Whole person orientation Coordinated care Quality & safety Enhanced access

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The Medical Home: While Flying It Patient-centered medical home = patient aligned care team (PACT) Core teamlet Extended team Revamping PC/MH integration Health Promotion / Disease Prevention focus HPDP Program manager position HBC position HPDP Committee

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Objectives Describe the Veterans Health Administrations (VA) Medical Home model Demonstrate increasing levels of collaboration between primary care and mental health providers Highlight the role of behavioral health specialists as collaborators and educators in this new model Introduce unique training opportunities for the next generation of medical and mental health providers

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Primary Care in the VA USs largest integrated health care system Comprehensive electronic medical record 820 sites of Primary Care 152 Medical Centers 668 Community Based Outpatient Clinics (CBOC) 4.5 million primary care patients - each assigned to an individual primary care provider PCMM/VSSC data as of 5/15/09

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Primary Care in the VA 12 million encounters/year Revisit rate (visits/yr): 2.5 21% had encounter in Mental Health 6.3% had admission 5,000 provider FTEE 72% physician 20% Nurse Practitioner 8% Physician Assistants PCMM/VSSC data as of 5/15/09

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Primary Care in the VA by Age & Gender 44% 25% 6.1% Female 21% had encounter in Mental Health

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Education at the VA Over 100,000 medical and associated health students, residents and fellows Physicians, PAs, nurses, NPs, pharmacists, dentists, dietitians, psychologists, PTs, SWs, optometrists, podiatrists, and respiratory therapists 50% of US psychologists have had VA training prior to employment 1200 educational institutions, including 112 medical schools

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IM Training at NY Harbor One of three primary training sites for the NYU IM Residency Program Primary Care Clinic for 60 IM residents Weekly continuity clinic sessions Month-long ambulatory care rotations (1 in the intern year, 2 in the R2 and R3 years) Inpatient rotations: General Medicine, ICU, CCU 3 Chief Resident positions: outpatient, inpatient, patient safety and quality

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Psychology Training at NY Harbor APA accredited psychology internship program, currently 6 interns a year Primary care mental health/health psychology is one of three major rotations Psychology externships Health psychology externship Neuropsychology externship Suicide prevention externship Postdoctoral fellowship in Health Psychology

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Old Primary Care Model

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Case Vignettes Mr. Roberts is a 62-year-old male with paranoid schizophrenia, hypertension, difficulty following up with primary care due to frequent psychiatric admissions (10 in past year). Mr. Lato is a 48-year-old male with uncontrolled diabetes, osteoarthritis, sleep apnea, obesity, addiction & long history of noncompliance with care.

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Case Vignettes Mr. Smith is a 50-year-old male with poorly controlled diabetes. No psychiatric diagnosis or interpersonal issues. Ambivalent around taking medications & insulin injections. Tells pharmacist my medications are like a ball and chain. Ms. Ramirez is a 52-year-old Hispanic female with no significant past medical history. She has not been receiving regular primary care for a number of years.

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MH/PC Integration Options Level 1:Minimal Collaboration Level 2: Basic Collaboration from a Distance Level 3: Basic Collaboration On-Site Level 4:Close Collaboration in a Partly Integrated System Level 5 : Close Collaboration in a Fully Integrated System Doherty W., McDaniel S., & Macaran A.B., 1995

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Primary care - mental health integration FY07 Goal of VAs Mental Health Strategic Plan: 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 PC-MHI programs: Increase in co-located mental health & substance abuse services in primary care clinics Primary care added to mental health clinic

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MH/PC Integration before PACT: Basic collaboration on-site Separate systems but same facility Communication over shared pts when necessary Lack of a common language or in-depth understanding of each others roles Same day triage available Benefit of warm hand-off, although not necessarily with treating provider

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New Primary Care Model

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Aspirations for Care in PACT Model Empower Veteran as a partner in the team Redesign primary care practice Efficient access Care coordination Care management Panel management

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Other Team Members Teamlet: assigned to 1 panel (1200 patients) Provider RN Care Mgr Clinical Associate (LPN, MA, or Health Tech) Clerk Patient Other Team Members Pharmacist Social Worker Nutritionist Case Managers Trainees Psychologist Other Team Members Pharmacist Social Worker Nutritionist Case Managers Trainees Psychologist For each parent facility HPDP Program Manager Health Behavior Coordinator My HealtheVet Coordinator For each parent facility HPDP Program Manager Health Behavior Coordinator My HealtheVet Coordinator

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Collaborative opportunities in PACT Weekly Extended Team meetings Population management Behavioral Health Specialists as educators MI Modeling through individual consultations Shared medical appointments

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PC MH Staff within NY site Psychologists Dr. Goloff Chief Dr. Spivack substance abuse specialist Dr. Ramati Dr. Dognin - HBC Dr. Ingenito womens clinic Dr. Kehn home based primary care Dr. Michelson VISN lead Psychiatrists Dr. Bronson PCMH lead Dr. Rappaport Psychology interns, externs, postdoc

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High Behavioral Health Needs AND Low Physical Health Needs High Behavioral Health Needs AND High Physical Health Needs Low Behavioral Health Needs AND Low Physical Health Needs Low Behavioral Health Needs AND High Physical Health Needs Adapted from The Four Quadrant Clinical Integration Model (National Council for Community Behavioral Healthcare, 2006) Behavioral Health Risk/ Status Physical Health Risk/Status

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Case Vignette: Mr. Roberts 62-year-old male with paranoid schizophrenia, hypertension, difficulty following up with primary care due to frequent psychiatric admissions (10 in past year) Which quadrant doe this patient fit into? Is there an opportunity to collaborate?

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Case Vignette: Mr. Roberts Quadrant: High Behavioral/Low Physical Health Needs Discussion of case in Extended Team meeting Chart review to assess complexity of medical problems (was treated for mild hypertension) Advocated to transfer to our Mental Health Program (Mental Health Based Primary Care) Outcome: Coordinated transfer to Mh based PC Collaborate with primary care NP for support in treating medical problems

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Case Vignette: Mr. Lato 48-year-old male with uncontrolled diabetes, osteoarthritis, sleep apnea, obesity, addiction & long history of noncompliance with care Which quadrant does this patient fit into? Is there an opportunity to collaborate?

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Case Vignette: Mr. Lato Quadrant: High Behavioral/High Physical Health Needs Discussion of case in Extended Team Meeting Interventions: Individual behavioral counseling by psychologist Meets with RN care manager several times Attended Diabetes Shared Medical Appointments Enrolled in telehealth Outcome: Improved control of diabetes Improved satisfaction with treating providers

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Case Vignette: Mr. Smith 50-year-old male with poorly controlled diabetes. No psych dx or interpersonal issues. Ambivalent around taking medications & insulin injections. Tells pharmacist my medications are like a ball and chain Which quadrant does this patient fit into? Is there an opportunity to collaborate?

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Case Vignette: Mr. Smith Quadrant: Low Behavioral/High Physical Health Needs Discussion of case in Extended Team Meeting Interventions: Joint session with pharmacist and psychologist MI used to assess patients confidence and willingness to change Psychologist consults with pharmacist, who will continue counseling him in future Outcome: Pharmacist continues several more MI sessions Continual adherence struggles Referral to Health Psychologist for more intensive counseling

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Case Vignette: Ms. Ramirez 52-year-old Hispanic female with no significant past medical history. She has not been receiving regular primary care for a number of years. Which quadrant does this patient fit into? Is there an opportunity to collaborate?

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Case vignette: Ms. Ramirez Quadrant: Low Behavioral/Low Physical Health Needs No need to discuss in Extended Team Meeting Screenings: cervical cancer; breast cancer; lipids; depression; military sexual trauma; PTSD. Assess for toxic habits or exposures; up-to-date with vaccinations; check lipids Prevention services: collaborate if necessary Outcome: Screenings conducted Refer to Tobacco Cessation Group and give NRT MI around smoking

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Lessons Learned PACT provided an enhanced level of collaboration Time and space are necessary Extra man-power augments Recognition of multiple opportunities for collaboration Extended team meetings Consultations Shared Medical Appointments

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Lessons Learned Communication styles Need to learn each others language There are different collaborative needs for different patients and types of situations

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Next Steps Continue efforts to educate trainees Immersion Modeling Didactics OSCEs Expand scope to other disciplines Learn from other successful models Continue to share our experience

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Primary care-mental health integration "The greatest mistake in the treatment of diseases is that there are physicians for the body and physicians for the soul, although the two cannot be separated. - Plato

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References 1.Asch et al. (2004). Comparison of quality of care for patients in the Veterans Health Administration and patients in a national sample. Annals of Internal Medicine, 2004; 141 (12): 938-945. 2.Doherty, McDaniel & Macaran (1995). Five levels of primary care/behaviral healthcare collaboration. Family Systems Medicine, 13, 283-298. 3.Grumbach and Bodenheimer (2004). Can healthcare teams improve primary care practice? JAMA ; 291(10):1246-51 4.National Council for Community Behavioral Healthcare. Behavioral Health/Primary Care Integration. The Four Quadrant Model and evidence-based practices. MCPP Healthcare Consulting. Revised Feb. 2006. 5.Patient Centered Medical Home Concept paper. http://www.va.gov/PrimaryCare/pcmh/ accessed 3/29/11 6.United States Department of Veterans Affairs Office of Academic Affiliations. eResources for Clinical Trainees. http://www.va.gov/oaa/resources_trainees.asp. Last accessed 10/25/11.http://www.va.gov/oaa/resources_trainees.asp