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Access to Mental Health Treatment: The Importance of Collaboration

The FY '08 budget request for VA called for nearly $3 billion in mental health services to continue improvements in access for veterans with mental health problems. Of course, much of this budget request funds mental health specialty care programs. However, there is growing awareness that a key aspect of access to mental health treatment involves the bridge between primary care and mental health specialty programs. In July 2007, then Secretary of Veterans Affairs Jim Nicholson, while announcing plans to bring VA mental health and primary care programs closer together, said, "Given the reluctance of some veterans to talk about emotional problems, increasing our mental health presence in primary care settings will give veterans a familiar venue in which to receive care--without actually going to an identified mental health clinic."

Building a Bridge from Primary to Mental Health Care

Historically, the bridge between primary and mental health care has not been easy to build. Barriers exist at the patient, provider, and system levels. Many veterans are concerned about being stigmatized if they reveal mental health concerns. Many primary care providers report that they are uncomfortable assessing and discussing mental health concerns. Early attempts to educate primary care providers to treat mental health issues themselves and to screen and refer patients with more complicated conditions to mental health specialty clinics proved unsuccessful. At the system level, although VHA is more integrated than many other managed care systems, traditional acute care models do not foster crosscare line cooperation. More than physical co-location is required.

For some years, researchers within and outside the VA have been working to build an evidence base for bringing mental health and primary care closer together to improve access and continuity. Ed Wagner's Chronic Illness Care Model helped researchers understand what changes in the system and processes of care are necessary to improve care of chronic conditions, including depression, unipolar and bipolar disorders, and schizophrenia. Key components of improving care are clinician education and decision support, patient education and selfmanagement support, active collaboration between primary care and mental health specialists, and care management. Current implementation research by VA investigators Rubenstein in depression (TIDES), Bauer in bipolar disorder (CCM), and Young in schizophrenia (EQUIP) illustrate application of these care components.

Collaborative Care Models

TIDES uses a partnership among researchers, clinicians, and administrators to foster a stepped-care model of depression care that builds on the depression screening currently practiced at high levels in VA primary care clinics. The key care system change is the introduction of Nurse Depression Care Managers (DCMs) bridging primary care and mental health specialty care. DCMs are trained to assess depression and comorbid conditions and suggest treatment alternatives to the primary care clinician. DCMs may coordinate depression care in primary care through telephone education and support to the patient or facilitate referral to specialty care in more complex cases. This model achieves high levels of patient satisfaction and efficient use of care resources. One of the primary findings is that depressed patients who were not receiving care are identified, assisted in accessing care, and trained and supported in self-management skills.

Bauer's collaborative care model for bipolar disorder also emphasizes patient selfmanagement skill enhancement, making evidence-based treatment decisions, and using care management to enhance access and continuity. Two initial multi-site studies demonstrated that involving patients with bipolar disorder in a Life Goals group psychoeducation program, assisting their mental health specialty providers with simplified practice guidelines, and introducing a nurse care coordinator significantly reduced symptomatology and duration of manic episodes. A more recent study using the same model found that if care coordination included both mental health and primary care providers, patients' physical well-being also improved. In these studies, improved access to care is reflected in reduced unplanned care episodes.

Young's EQUIP studies use a collaborative care model for schizophrenia to enhance recovery-oriented care by identifying patients in need, providing improved access to evidence- based services, and reorganizing care to support these services. The model incorporates assertive care management, provider education and decision support, and routine standardized patient assessment with feedback of information to treating psychiatrists at the time of the clinical encounter. Providers report that the intervention improves information about their patients, particularly in psychosocial domains, and assists in more effectively monitoring treatment needs.

Together, these three programs of research--each focused on a different mental health problem--demonstrate that collaborative care models can improve access and quality of mental health care. Important questions remain. Current work focuses on the implementation of these models under routine care conditions and identification of what is required to promote long-term model fidelity and sustainability.