Health Services Research & Development

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2017 HSR&D/QUERI National Conference Abstract

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1039 — Changing Patterns of Mental Health Care: The Role of Integrated Mental Health Services in VA Primary Care

Lead/Presenter: Lucinda Leung, COIN - Los Angeles
All Authors: Leung LB (VA HSR&D Center for the Study of Healthcare Innovation, Implementation, & Policy, Los Angeles, CA) Yoon J (VA Health Economics Resource Center, Menlo Park, CA) Rubenstein LV (RAND Corporation, Santa Monica, CA) Post EP (VA Center for Clinical Management Research, Ann Arbor, MI) Metzger ME (VA Center for Clinical Management Research, Ann Arbor, MI) Wells KB (UCLA Center for Health Services and Society, Los Angeles, CA) Sugar CA (UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA ) Yano EM (VA HSR&D Center for the Study of Healthcare Innovation, Implementation, & Policy, Los Angeles, CA) Escarce JE (UCLA Division of General Internal Medicine and Health Services Research, Los Angeles, CA)

Objectives:
Aiming to increase mental health care access for Veterans, VA's Primary Care-Mental Health Integration (PC-MHI) embeds mental health specialists in primary care and promotes care management for depression. PC-MHI and patient-centered medical home providers work together to provide the bulk of mental health care for primary care patients with low-to-moderate complexity mental health conditions. This study examines if increasing primary care clinic engagement in PC-MHI services is associated with changes in patient healthcare utilization and costs.

Methods:
We performed a retrospective longitudinal cohort study of primary care patients with identified mental health needs in 29 Southern California VA clinics from October 1, 2008 to September 30, 2013, using electronic administrative data (n = 66,638). We calculated clinic PC-MHI engagement as the number of PC-MHI service users divided by total primary care patients at each clinic annually. Capitalizing on variation in PC-MHI engagement across clinics, our multivariable regression models predicted annual patient use of 1) total mental health visits, including PC-MHI visits, 2) mental health specialty (MHS) sector visits, and 3) other healthcare utilization/costs. We controlled for year- and clinic-fixed effects, other clinic interventions, and patient characteristics.

Results:
Median clinic PC-MHI engagement increased by 8.2 percentage-points over five years. At any given year, being at a clinic with one percentage-point higher PC-MHI engagement was associated with 0.5% more mental health visits overall (CI = 0.18%, 0.90%; p = 0.003) and 1.0% fewer MHS sector visits (CI = -1.6%, -0.3%; p = 0.002) -- i.e., a substitution rate, at the mean, of 1.5 PC-MHI visits for each MHS sector visit. There was no PC-MHI effect on other healthcare utilization and costs.

Implications:
As intended, greater clinic engagement in PC-MHI services appears to increase realized accessibility to mental health care for primary care patients, substituting PC-MHI for MHS sector visits without increasing acute care use or total costs.

Impacts:
As one of the largest implementations of evidence-based collaborative care, VA's PC-MHI initiative may improve mental healthcare value for primary care patients -- increasing mental health care accessibility without increasing costs. More research is needed to understand the relationship between clinic PC-MHI engagement and clinical quality of mental healthcare.