How Innovators Manage Real World Push-Back: Lessons from VA Integrated Care Implementers Andrew...
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![Page 1: How Innovators Manage Real World Push-Back: Lessons from VA Integrated Care Implementers Andrew Pomerantz, MD National Mental HealthDirector, Integrated.](https://reader035.fdocuments.us/reader035/viewer/2022070403/56649f305503460f94c4b976/html5/thumbnails/1.jpg)
How Innovators Manage Real World Push-Back: Lessons from VA Integrated Care Implementers Andrew Pomerantz, MDNational Mental HealthDirector, Integrated Services Veterans Health AdministrationAssociate Professor of Psychiatry, Geisel School of Medicine at Dartmouth
Laura O. Wray, PhDDirector, Education/Clinical Core, VA Center for Integrated HealthcareAssistant Professor of Clinical Mediicine, University at Buffalo
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VETERANS HEALTH ADMINISTRATION
Patient Aligned Care Team
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VETERANS HEALTH ADMINISTRATION
Principles of Integrated Care in VA
• Open or advanced access (temporal and spatial integration) in VA medical homes [PACT]
• Problem-focused assessment and treatment: tend to what the Veteran wants tended to
• On-site clinicians in primary care: Consultation, collaboration, assessment
• Stepped care• Measurement-based care• Care management• Referral management when needed
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VETERANS HEALTH ADMINISTRATION
Primary Care-Mental Health Integration[PC-MHI] in VA
• Two components:• Care management• Co-located collaborative care
• Blended programs link these complementary components as appropriate
• Focus primarily on common mental health conditions:• Depressive and anxiety disorders• Alcohol misuse and abuse• PTSD screening/assessment
• Health Behavior Coordinators implement health psychology programs along with Health Promotion/Disease Prevention Program Managers
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VETERANS HEALTH ADMINISTRATION
Center for Integrated Healthcare Training Events
• Six National Training Events 2009 through 2010• Facilitated break-out sessions on implementation challenges• Each participant gave 1 challenge and 1 success (may be have
been multiple participants from same site)• Participants shared ideas to overcome challenges described as
time allowed• Unidentified lists of challenges/successes were reviewed and
grouped into themes• 9 Challenge Themes and 5 Success Themes
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VETERANS HEALTH ADMINISTRATION
Challenges
• Staffing– Insufficient to meet demand– No additional staffing to expand– Missing key role
• Therapist• Prescriber• Nurse/Care Manager
– Lack of administrative or clerical support• No ability to pull program data• No help with scheduling
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Integrating Mental Health into Primary Care:
What are your challenges?
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VETERANS HEALTH ADMINISTRATION
Challenges
• “Overselling” or Fear of “Overselling”– Advertise as generalist– Open door– Slammed with referrals once PCPs understand what’s
available
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VETERANS HEALTH ADMINISTRATION
Challenges
• Mental Health Specialty Programs– Frequently mentioned– Access to care, waiting times– Managers and staff don’t understand the role of PCMHI
program• Attitudes towards integrated care• Require coverage of walk-ins, ER, urgent care for
patients already in SMH• Require full MH intake assessments• Open access grids seen as not busy enough
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VETERANS HEALTH ADMINISTRATION
Challenges
• Training– Not available prior to starting program– Poor understanding of different role in PCMHI
• Mini-Mental Health Clinics– Tried to function in traditional model once in PC– Quickly filled scheduling grid
• No open access• Long waiting lists• Provider burn-out
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VETERANS HEALTH ADMINISTRATION
Challenges
• Leadership Support*– Middle management– MH management/leadership– Medical Center leadership
• Systems Challenges– Accessing resources– Ensuring good continuity of care– Disjointed systems– Poor communication
*Also listed under Successes
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VETERANS HEALTH ADMINISTRATION
Challenges
• Role Definition– Unclear role of PCP
• “PCP wants to dump patients”• PSP does not want to prescribe• PCP does not refer or use warm hand-off
– Unclear role of PCMHI• Maintaining traditional MH roles• Unclear about which patients should be referred to SMH• SMH expectations of PCMHI staff
• Care Management– Implementation varies within a health care system– Need for protocols for problems other than depression
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VETERANS HEALTH ADMINISTRATION
Successes
• Leadership Support*– Motivated managers*– Chief Medical Officer– Chief of Ambulatory Medicine– Chief of Mental Health*– Primary Care Chief
*Also listed under Challenges
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VETERANS HEALTH ADMINISTRATION
Successes
• Primary Care Providers– Good relationships– Program developed with their input– “Hanging out with them”– PCPs happy to have program– PCPs excited, supportive
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VETERANS HEALTH ADMINISTRATION
Successes
• Teamwork/Collaboration:– Within the PC team– Good communication– Good working relationships
• Personal Connections– Positive interpersonal working relationships with
at least some teammates and/or across teams
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VETERANS HEALTH ADMINISTRATION
Successes
• Process Markers of Success:– Warm hand-offs, no consults– PCPs are referring– PCMHI is available and helpful– Flexible gateway to MH– Defined our roles (PCMHI)– Linkage to Psychiatry via CM, teamwork helped solve
staffing issues– Good access
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Integrating Mental Health into Primary Care:
What are your successes?