Kathy's blog is the third
post in a series on
integrated care for
military and veterans.
When I began my training as a clinical
psychologist, I did not envision myself working for the Department of
Veterans Affairs. In fact, I would have predicted that I would end up
in almost any other setting. The myths or stereotypes described by Dr.
Pomerantz’s prior blog predominated my thinking. As I suspect happens
to many of us, my early career projections were wrong, as were my
stereotypes of the VA.
the lens of a clinician, I hope that I can further dispel some of the
common myths and present a clear picture of integrated care within the
VA. There is a great deal of variation across our large network of
facilities, and my thoughts may not be consistent with the experiences
of clinicians at every location. However, I do believe that there are
common themes experienced in most VA integrated care settings.
it has been my experience that providers within the VA care deeply
about Veterans and Veteran healthcare. I consistently see primary care
colleagues going to extraordinary lengths to ensure high quality,
patient-centered care. In a recent hallway conversation with two of my
primary care colleagues, we ended up discussing the overwhelming sense
of duty and responsibility to provide exceptional care for the Veterans
and how this translates not only into direct service delivery, but also
into interactions with patients in hallways, over the phone, and in
the community. The reality is that VA employees care tremendously about
Veterans and about providing high quality care.
We also have a high
degree of accountability built into the system through policy and
programmatic expectations. It is experienced as a system of checks and
balances with multiple requirements and high levels of accountability
and oversight. Integrated care, including both collocated collaborative
care and care management, are not options, but programmatic
integral part of functioning as a behavioral health provider in a VA
primary care clinic is communicating and working closely with all
primary care team members. Typically, this means that days begin with a
team huddle, including the primary care provider, the RN, LPN,
administrative support, and other primary care-based professionals
(e.g., dieticians, pharmacists, medical social workers). Fully
consistent with the tenants of the medical home, we are implementing
team-based care. Skills in collaborating with other medical professions
are necessary to be successful. Indeed, several of my colleagues who
were not used to team-based care have had to change their practice
management styles or risk becoming irrelevant to the clinic.
huddles we usually review patients who are scheduled to be seen by the
team that day and discuss the plan for care. As the integrated
clinician, and the behavioral change expert, I provide input for mental
health concerns as well as medical conditions that have a strong
behavioral component. I might discuss potential ways for the other team
members to approach these concerns, offer to join the provider or one
of the nurses in their appointment with the patient, or offer to see
the patient individually the same day.
day, or open/advanced access is another integral component of
integrated care within the VA. There are many ways this can be
achieved and this has been structured differently in various locations.
The clinics in which I have become most familiar, have structured
schedule grids such as scheduled 30 minute appointment slots on the
hour, with the back half of the hour usually unscheduled. This allows
access to appointments for Veterans the same day that they see their
primary care team.
Although there is much variation in implementation,
Veterans and the other primary care team members value this scheduling
feature. It provides direct access to a behavioral health specialist not
only allowing the Veteran to start an intervention the same day that
symptoms were identified by the primary care team, but also allows the
primary care team members to have direct communication and
consultation with a mental health provider. This process de-mystifies
mental health service delivery.
the VA primary care setting, we see a surprisingly diverse population
of Veterans, including women, reservists, individuals who served in the
National Guard, and younger individuals recently returning from active
duty who have young families. If you visit expecting to find the image
of the Veteran conjured up from the song, "Take Me to the Mountains”,
you will be surprised. Clinics are busy, vibrant locations with diverse
patient populations, that have dramatically moved beyond the
stereotypical view of Veteran healthcare settings.
part of meeting the needs of the diverse population we have
incorporated technology into our communication and interventions for
patients. We routinely use telephone, video teleconferencing, and
secure instant messaging to communicate with Veterans and provide
service delivery. As the Veteran population has shifted to include
younger individuals, who communicate primarily through advanced
technological platforms, the VA has embraced these technologies and has
remained relevant to this population by finding ways to incorporate
technology into care within and outside of the primary care setting.
Further, these innovative advancements allows us to increase access to
and communication with Veterans living in rural locations, who may not
be able to make routine visits to medical centers to obtain mental
health services. As a clinician, I like having to capacity to serve
Veterans who may not be engaged in treatment without the use of
types of services being provided in VA integrated care are
complementary. Through the provision of collocated, collaborative care,
and care management, we combine same day access to a therapist who may
provide a brief intervention, with the use of evidence-based screening,
assessment, decision support, and symptom monitoring . Thus, patients
receive a unique blend of evidence-based services that are tailored to
their individual needs, are tracked over time, and adjusted based on
symptom severity. This system, when optimally functioning, creates a
feedback loop between the patient and all team members.
closing, I hope through a combination of our posts, we have dispelled
many of the myths and outdated stereotypes about VA service delivery
while providing a picture of a modern, patient-centered, results-driven
healthcare system. I am honored to work for the Department of Veterans
Affairs, as are my colleagues and co-team members. I am thankful that
my career projections were just as erroneous as my stereotypical views
of the VA. Through continued implementation of the medical home model,
the VA continues to be a leader in patient-centered, team-based,
results-driven, innovative care.
Katherine M. Dollar, PhD is the Clinical Coordinator at the VA Center for Integrated Healthcare (CIH) and a Research Assistant Professor, in the Department of Community Health & Health Behavior at SUNY Buffalo. Dr. Dollar is also a Consultant to the VA Office of Mental Health Operations (OMHO). CIH is VA Center of Excellence
devoted to advancing research, education, and clinical consultation to
enhance the integration of mental health and primary care services for
America's Veterans. She provides consultation, education,
and technical assistance, for facilities, networks, and individuals
requesting program assistance to achieve full implementation of VA
integrated care components.