Andy's blog is the second
post in a series on
integrated care for
military and veterans.
"Found him on VA ward, feelin’ kind of low.”
"A pardon from a VA ward, just ain’t so easy done…but a good old friend and doctor there said it could be done.”
Those lines, from the old song "Take Me to the Mountains,” invariably conjures images that were popular a generation or two ago when the Veterans Administration hospital system was the last vestige of hope for combat Veterans who had fallen off the rails of society. Whether the image was true even then is arguable and I don’t think worth discussion now. Suffice it to say, the Veterans Health Administration (one of three arms of the Department of Veterans Affairs, created 30 years ago) is now a highly developed single payer capitated healthcare system and the largest healthcare system in the United States, with over 8 million enrolled Veterans and nearly a thousand VA facilities and community based outpatient clinics in the US, Puerto Rico and the Philippine Islands. Now, more than half of VA care occurs in community based outpatient clinics and, by quality measures, is outperformed by no other systems.
Old perceptions die hard (and slowly), so, as we take a little time for a
few of us in VA to provide perspectives on this blog, a couple of myths
need to be tended to.
- "You can do that in the VA because you are part of the military and can do whatever you want”:False. VA is distinct from the military healthcare system and is held accountable to the same standards as any other healthcare entity.(It should note that the military health system is also an integrated care leader).
- "Only combat Veterans can get care in VA”: False again.Just about anyone who has been honorably discharged from the military can enroll for care, as can many others, like active duty national guard members returning from combat. Some Veterans have a co-pay for some of their care, just as they do in the private sector.
- "VA facilities get as much money as they want. When they need more, Congress gives it to them.”Wrong again. We do have to live within our budgeted appropriation from congress and each facility’s budget is based on workload. At times, seed money (similar to grants in the private sector) is earmarked for new program development but after a few years, the special funding ends and the programs stand or fall on their results (yes just like grants).
These myths are only the tip of the iceberg but are the three most common statements I hear when I talk with people outside of the federal sector about the development of integrated care in this system. VHA provided special funding 5 years ago to help facilities develop integrated care programs, which are now mandated to be present in every VA medical center and the larger community based clinics. Many facilities are working now to develop innovative ways to integrate mental health and primary care in the smaller and more rural clinics.
There are two core components to integrated care in the VA, both resulting from local innovations and research whose results were so positive that went viral and became requirements.
1.Collocated collaborative care: This refers to the mental health clinicians (nurses, psychiatrists, social workers, psychologists) who are members of the primary care (medical home) team. They provide consultative advice and education, as well as direct assessment and treatment as part of the primary care treatment plan. CCC clinicians have a patient-centered, problem/function focused approach that streamlines care for patients identified (clinically or by routine, required screening) in primary care, Open or advanced (same-day) access is an important feature of the program. Despite broad variation in program development and function across the country, almost half of the primary care patients seen in integrated care last year never needed referral to specialized mental health care.
2.Care Management:This is the familiar telephone based care that provides disease registries, assessment, ongoing monitoring, medication management, problem solving and behavioral activation for patients treated for depression, anxiety and at-risk drinking. Similar protocols for chronic pain and other problems are currently being honed. The CM programs are based on the familiar RESPECT, IMPACT and other integrated approaches that have shown strikingly positive results over 20 years of research. The Behavioral Health Laboratory is a care management program developed within VA and has modules for all of the above disorders plus a referral management module. TIDES (Translating Initiatives for Depression into Effective Solutions) is the VA adaptation of the other programs in the research literature.
Two related programs are also part of VA integrated care. These include health behavior coordinators and health promotion/disease prevention programs that help Veterans achieve and maintain healthy lifestyles. They provide a wide range of services including training for providers, direct clinical care (MOVE! is an effective intervention for obesity and is often provided via telemedicine), health coaching and other interventions.
As the National Mental Health Director for Integrated Services it has been my privilege not only to develop policy but also to work closely with dozens of programs across the country as they grow and mature. I have learned a great deal as I see many programs adapting the core components to fit a wide variety of local environments. Having once been a primary care physician who went into psychiatry wanting to be able to do more, it’s almost enough to make me go back to primary care. But not quite.
Some of my national colleagues are going to follow this tome with more details of integrated primary care in VA. I would also refer you to the summer, 2010 issue of Families, Systems and Health, which was dedicated to the VA programs.
S. Pomerantz, MD is the VA’s National Mental Health Director for
Integrated Services, Associate Professor of Psychiatry at the Geisel School of Medicine at Dartmouth and a current member of the CFHA board
of directors. He has been a primary care physician, Consultation and
Geriatric Psychiatrist and was Chief of Mental Health at the VA in
Vermont for nearly 20 years. He has received many local and national
awards for his work integrating mental health and primary care and other
programs and is a Distinguished Life Fellow of the American Psychiatric
Association. He telecommutes from his home base in Vermont..