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.
Slide 2
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
Slide 3
Faculty Disclosure We have not had any relevant financial
relationships during the past 12 months.
Slide 4
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
Slide 5
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
Slide 6
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
Slide 7
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
Slide 8
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
Slide 9
Primary Care in the VA by Age & Gender 44% 25% 6.1% Female
21% had encounter in Mental Health
Slide 10
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
Slide 11
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
Slide 12
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
Slide 13
Old Primary Care Model
Slide 14
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.
Slide 15
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.
Slide 16
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
Slide 17
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
Slide 18
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
Slide 19
New Primary Care Model
Slide 20
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
Slide 21
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
Slide 22
Collaborative opportunities in PACT Weekly Extended Team
meetings Population management Behavioral Health Specialists as
educators MI Modeling through individual consultations Shared
medical appointments
Slide 23
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
Slide 24
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
Slide 25
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?
Slide 26
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
Slide 27
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?
Slide 28
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
Slide 29
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?
Slide 30
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
Slide 31
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?
Slide 32
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
Slide 33
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
Slide 34
Lessons Learned Communication styles Need to learn each others
language There are different collaborative needs for different
patients and types of situations
Slide 35
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
Slide 36
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
Slide 37
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