Building the Plane While Flying It: Implementation of the Medical Home in VA Healthcare

Joanna Dognin, Psy.D. Julia Buckley, PhDCraig Tenner, MD

Kelly Crotty, MD, MPHMargaret Horlick, MD

VA New York Harbor Healthcare System October 28, 2011

Collaborative Family Healthcare Association 13th Annual ConferenceOctober 27-29, 2011 Philadelphia, Pennsylvania U.S.A.

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

Faculty Disclosure

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

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

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

Objectives

• Describe the Veterans Health Administration’s (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

Primary Care in the VA• US’s 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

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

Primary Care in the VA by Age & Gender

44%

25%6.1% Female

21% had encounter in Mental Health

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

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

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

Old Primary Care Model

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.

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.

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

Primary care - mental health integration

• FY07 Goal of VA’s 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

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 other’s roles• Same day triage available • Benefit of warm hand-off, although not

necessarily with treating provider

New Primary Care Model

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

Other Team Members

• Pharmacist• Social Worker• Nutritionist • Case Managers• Trainees • Psychologist

The Patient’s Primary Care Team

For each parent facilityHPDP Program ManagerHealth Behavior CoordinatorMy HealtheVet Coordinator

Collaborative opportunities in PACT

• Weekly Extended Team meetings • Population management• Behavioral Health Specialists as educators– MI– Modeling through individual consultations

• Shared medical appointments

PC MH Staff within NY site• Psychologists– Dr. Goloff – Chief– Dr. Spivack – substance abuse specialist– Dr. Ramati – Dr. Dognin - HBC– Dr. Ingenito – women’s clinic– Dr. Kehn – home based primary care– Dr. Michelson – VISN lead

• Psychiatrists– Dr. Bronson – PCMH lead– Dr. Rappaport

• Psychology interns, externs , postdoc

High Behavioral Health Needs AND

Low Physical Health Needs

High Behavioral Health NeedsAND

High Physical Health Needs

Low Behavioral Health NeedsAND

Low Physical Health Needs

Low Behavioral Health NeedsAND

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

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?

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

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?

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

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?

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 patient’s 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

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?

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

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

Lessons Learned

• Communication styles – Need to learn each other’s language

• There are different collaborative needs for different patients and types of situations

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

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

References1. 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.