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IAB 07-115 – HSR&D Study

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IAB 07-115
Implementing Integrated Care for Veterans with Serious Mental Illness
Amy M. Kilbourne PhD MPH
VA Ann Arbor Healthcare System, Ann Arbor, MI
Ann Arbor, MI
Funding Period: January 2008 - December 2009

BACKGROUND/RATIONALE:
Serious mental illnesses (SMI), including schizophrenia, bipolar disorder, and other psychoses are associated with substantial functional impairment and health care costs, and can lead to premature morbidity and mortality. While high rates of co-occurring conditions (i.e., substance use and medical comorbidities) contribute to these adverse outcomes, patients with SMI are less likely to receive adequate care for these conditions. Integrated care for co-occurring conditions is considered essential for improving quality of care for persons with SMI, especially since they are primarily managed in mental health specialty settings. However, empirically-tested models to integrate care mainly rely on costly organizational or structural changes (e.g., co-location of different providers in mental health clinics) rather than augmenting linkages across existing providers and settings. Identifying specific features of integration that serve to augment these linkages and improve patient-level outcomes can inform the refinement and implementation of appropriate and cost-efficient integrated treatment models for SMI and co-occurring conditions.


OBJECTIVE(S):
Based on a theoretical framework by Shortell and colleagues that describes the underlying organizational and clinical factors of integrated care, there were two immediate objectives of this study. The objective was to assess the organization and degree of integrated care for substance use and general medical services in VHA mental health programs and to evaluate the association between underlying organizational characteristics (e.g., staffing, information technology, performance incentives), degree of clinical integration (e.g., coordination, comprehensiveness, and continuity of care), and patient-level outcomes (e.g., quality of care) for substance use and general medical services among veterans diagnosed with SMI receiving care within VHA mental health programs.

METHODS:
As a preliminary study to this project, we conducted a national survey of all VHA mental health programs using previously established questions on organization and integration of care. During Phase I of this study, survey data from the preliminary study were linked to patient-level utilization, quality and outcomes data from the National Psychosis Registry, VHA's External Peer Review Program (EPRP), and Survey of Healthcare Experiences of Patients (SHEP) survey for all patients with a diagnosis of serious mental illness. Multilevel regression analyses were used to determine the specific organization and clinical integration features of integrated care for co-occurring conditions associated with patient utilization, quality, and outcomes for co-occurring conditions. During Phase II, we collected in-depth data on integration from qualitative telephone interviews of frontline mental health providers sampled from sites with high and low EPRP scores from Phase I to identify specific integrated care practices, to develop a rich understanding of how integrated care differs across facilities with higher and lower levels of quality of care, and to identify best practices of integrated care.


FINDINGS/RESULTS:
Overall, mental health programs reported a wide range of organizational and integrated care features in managing co-occurring conditions. Notably, we examined the use of pay-for-performance for incentivizing care for co-occurring conditions as well as co-location, coordination, and communication of these services. Notably, 18%, 15%, and 6% of mental health program leaders received financial bonuses for diabetes/cardiovascular disease risk screening, hepatitis C screening, and obesity screening/weight management, respectively. It was most common for financial incentives to be used for substance use treatment and alcohol screening, and least commonly used for pneumococcal vaccination or colorectal cancer screening. Receiving financial bonuses for diabetes/cardiovascular disease risk screening was independently associated with mental health program leaders' perceived accountability for diabetes/cardiovascular disease monitoring (OR= 5.01; p<.05). In additon, only nine percent of mental health programs had co-located general medical services; however, co-location was one of the strongest correlates of patient-level utilizaton and quality. Lower counts of medical/surgical hospitalizations for ambulatory care sensitive conditions was associated with co-location of general medical care ( =-0.29, 95% CI -0.523 to -0.050, p=0.017). Patients diagnosed with SMI from mental health programs with co-located general medical providers were more likely to receive preventive services notably breast cancer screening (OR=3.28, 95% CI: 1.23-8.75; 1.43-4.20) and colorectal screening (OR=1.80, 95% CI: 1.23-2.64). In addition, SMI patients with diabetes receiving care in mental health programs with collocated general medical care were more likely to receive foot exams (OR=2.26, 95% CI: 1.16, 4.38). Degree of integration (coordination and communication scores) did not explain the association between collocation and quality of preventive care or diabetes services.


IMPACT:
Findings from this study inform the ongoing discussion around developing veteran-centered treatment models for patients with SMI. Notably, veterans with SMI, who often consider the mental health setting their primary "home" site for services, may benefit from co-location of general medical providers. However, our study found that only 10% of VA mental health programs offered co-located services. Nonetheless, in this study, co-location was most strongly associated with quality of care for veterans with SMI. VHA policymakers leaders should consider further implementing co-location and similar mental health home models to improve access and quality of care for veterans with SMI.

PUBLICATIONS:

Journal Articles

  1. Bowersox NW, Lai Z, Kilbourne AM. Integrated care, recovery-consistent care features, and quality of life for patients with serious mental illness. Psychiatric services (Washington, D.C.). 2012 Nov 1; 63(11):1142-5.
  2. Kilbourne AM, Greenwald DE, Bauer MS, Charns MP, Yano EM. Mental health provider perspectives regarding integrated medical care for patients with serious mental illness. Administration and policy in mental health. 2012 Nov 1; 39(6):448-57.
  3. Kilbourne AM, Neumann MS, Waxmonsky J, Bauer MS, Kim HM, Pincus HA, Thomas M. Public-academic partnerships: evidence-based implementation: the role of sustained community-based practice and research partnerships. Psychiatric services (Washington, D.C.). 2012 Mar 1; 63(3):205-7.
  4. Kilbourne AM, Lai Z, Bowersox N, Pirraglia P, Bauer MS. Does colocated care improve access to cardiometabolic screening for patients with serious mental illness? General hospital psychiatry. 2011 Nov 1; 33(6):634-6.
  5. Kilbourne AM, Pirraglia PA, Lai Z, Bauer MS, Charns MP, Greenwald D, Welsh DE, McCarthy JF, Yano EM. Quality of general medical care among patients with serious mental illness: does colocation of services matter? Psychiatric services (Washington, D.C.). 2011 Aug 1; 62(8):922-8.
  6. Pirraglia PA, Kilbourne AM, Lai Z, Friedmann PD, O'Toole TP. Colocated general medical care and preventable hospital admissions for veterans with serious mental illness. Psychiatric services (Washington, D.C.). 2011 May 1; 62(5):554-7.
  7. Bohnert AS, Zivin K, Welsh DE, Kilbourne AM. Ratings of patient-provider communication among veterans: serious mental illnesses, substance use disorders, and the moderating role of trust. Health communication. 2011 Apr 1; 26(3):267-74.
  8. Zivin K, Bohnert AS, Mezuk B, Ilgen MA, Welsh D, Ratliff S, Miller EM, Valenstein M, Kilbourne AM. Employment status of patients in the VA health system: implications for mental health services. Psychiatric services (Washington, D.C.). 2011 Jan 1; 62(1):35-8.
  9. Kilbourne AM, Farmer Teh C, Welsh D, Pincus HA, Lasky E, Perron B, Bauer MS. Implementing composite quality metrics for bipolar disorder: towards a more comprehensive approach to quality measurement. General hospital psychiatry. 2010 Nov 1; 32(6):636-43.
  10. Goodrich DE, Lai Z, Lasky E, Burghardt AR, Kilbourne AM. Access to weight loss counseling services among patients with bipolar disorder. Journal of affective disorders. 2010 Oct 1; 126(1-2):75-9.
  11. Kilbourne AM, Greenwald DE, Hermann RC, Charns MP, McCarthy JF, Yano EM. Financial incentives and accountability for integrated medical care in Department of Veterans Affairs mental health programs. Psychiatric services (Washington, D.C.). 2010 Jan 1; 61(1):38-44.
  12. Stetler CB, Ritchie JA, Rycroft-Malone J, Schultz AA, Charns MP. Institutionalizing evidence-based practice: an organizational case study using a model of strategic change. Implementation science : IS. 2009 Nov 30; 4:78.
  13. Bauer MS, Biswas K, Kilbourne AM. Enhancing multiyear guideline concordance for bipolar disorder through collaborative care. The American journal of psychiatry. 2009 Nov 1; 166(11):1244-50.
  14. Schutte K, Yano EM, Kilbourne AM, Wickrama B, Kirchner JE, Humphreys K. Organizational contexts of primary care approaches for managing problem drinking. Journal of substance abuse treatment. 2009 Jun 1; 36(4):435-45.
  15. Kilbourne AM, Ignacio RV, Kim HM, Blow FC. Datapoints: are VA patients with serious mental illness dying younger? Psychiatric services (Washington, D.C.). 2009 May 1; 60(5):589.
  16. Kilbourne AM, Biswas K, Pirraglia PA, Sajatovic M, Williford WO, Bauer MS. Is the collaborative chronic care model effective for patients with bipolar disorder and co-occurring conditions? Journal of affective disorders. 2009 Jan 1; 112(1-3):256-61.
  17. Kilbourne AM, McCarthy JF, Himelhoch S, Welsh D, Hauser P, Blow FC. Guideline-concordant hepatitis C virus testing and notification among patients with and without mental disorders. General hospital psychiatry. 2008 Nov 1; 30(6):495-500.
  18. Zivin K, McCarthy JF, McCammon RJ, Valenstein M, Post EP, Welsh DE, Kilbourne AM. Health-related quality of life and utilities among patients with depression in the Department of Veterans Affairs. Psychiatric services (Washington, D.C.). 2008 Nov 1; 59(11):1331-4.
  19. Kilbourne AM, Post EP, Nossek A, Drill L, Cooley S, Bauer MS. Improving medical and psychiatric outcomes among individuals with bipolar disorder: a randomized controlled trial. Psychiatric services (Washington, D.C.). 2008 Jul 1; 59(7):760-8.
  20. Sajatovic M, Biswas K, Kilbourne AK, Fenn H, Williford W, Bauer MS. Factors associated with prospective long-term treatment adherence among individuals with bipolar disorder. Psychiatric services (Washington, D.C.). 2008 Jul 1; 59(7):753-9.
  21. Kilbourne AM, Lasky E, Pincus HA, Good CB, Cooley S, Basavaraju A, Greenwald D, Fine MJ, Bauer MS. The continuous improvement for veterans in care: Mood Disorders (civic-md) Study, a VA-academic partnership. Psychiatric services (Washington, D.C.). 2008 May 1; 59(5):483-5.
  22. Altshuler L, Tekell J, Biswas K, Kilbourne AM, Evans D, Tang D, Bauer MS. Executive function and employment status among veterans with bipolar disorder. Psychiatric services (Washington, D.C.). 2007 Nov 1; 58(11):1441-7.
  23. Hermann RC, Rollins CK, Chan JA. Risk-adjusting outcomes of mental health and substance-related care: a review of the literature. Harvard Review of Psychiatry. 2007 Mar 1; 15(2):52-69.
Conference Presentations

  1. Bowersox NW, Visnic SL, Grindle C, Armstrong B, McCarthy JF. Changes in antipsychotic prescribing practices among patients with serious mental illness in the Veterans Health Administration medical system, FY2000-FY2013. Poster session presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 9; Philadelphia, PA.
  2. Brockmann LM, Laskey EC, Mach J, Cornwell BL, McCarthy JF. Implementation of VHA Primary Care-Mental Health Integration Services: Findings from the 2014 PACT PC-MHI Survey. Paper presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 9; Philadelphia, PA.
  3. Bohnert KM, Sripada RK, Mach J, McCarthy JF. Same-day integrated mental health services for those who screen positive for PTSD in VHA primary Care: Implications for diagnosis and treatment. Poster session presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 8; Philadelphia, PA.
  4. Cornwell BL, Brockmann LM, Lasky EC, Mach J, McCarthy JF. Evaluating Associations between Primary Care-Mental Health Integration Program Characteristics and Program Performance. Poster session presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 8; Philadelphia, PA.
  5. Bowersox NW, Visnic SL, Grindle C, Armstrong B, McCarthy JF. Changes in antipsychotic prescribing practices among patients with serious mental illness in the Veterans Health Administration medical system, FY2000-FY2013. Poster session presented at: University of Michigan Albert J. Silverman Annual Research Conference; 2015 May 27; Ann Arbor, MI.
  6. Cornwell BL, Brockmann LM, Lasky EC, Mach J, McCarthy JF. Evaluating Associations between Primary Care-Mental Health Integration Program Characteristics and Program Performance. Paper presented at: University of Michigan Albert J. Silverman Annual Research Conference; 2015 May 27; Ann Arbor, MI.
  7. Oishi S, Rose DE, Post EP, Schectman G, Stark R, Rubenstein LV, Chaney E, Canelo IA, Yano EM. National Implementation of VA’s Primary Care-Mental Health Integration: Expanding Beyond Depression Care Management? Poster session presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 16; National Harbor, MD.
  8. Kilbourne AM, Pirraglia P, Lai Z, Bauer MS, Charns M, Greenwald DE, Welsh D, McCarthy JF, Yano E. Quality of General Medical Care in Patients with Serious Mental Illness: Does Co-Location of Services Matter? Paper presented at: VA HSR&D National Meeting; 2011 Feb 18; National Harbor, MD.
  9. Kilbourne AM. A public health model for implementation evidence-based treatment models for mood disorders: replicating effective programs (REP). Paper presented at: University of Pittsburgh School of Medicine Prevention of Depressive Disorders Invitational Conference; 2009 Jun 25; Pittsburgh, PA.
  10. Bauer M, Kilbourne AM, Biswas K. Improving Long-Term Quality of Care for Serious Mental Illness through Collaborative Care Models. Paper presented at: VA HSR&D National Meeting; 2009 Feb 13; Baltimore, MD.
  11. Bohnert A, Zivin KZ, Welsh D, Kilbourne AM. Patient-Provider communication among Veterans with Serious Mental Illnesses and Substance Use Disorders. Poster session presented at: VA HSR&D National Meeting; 2009 Feb 13; Baltimore, MD.
  12. Kilbourne AM, Morden N, Austin K, Ilgen MA, Welsh D, McCarthy JF. Excess Cardiovascular Disease-Related Mortality in Veterans with Serious Mental Illness: Are Behavioral or Treatment Factors to Blame? Poster session presented at: VA HSR&D National Meeting; 2009 Feb 13; Baltimore, MD.
  13. Kilbourne AM, Greenwald D, Hermann RC, Charns MP, McCarthy JF, Yano EM. VA Financial Incentives and Accountability for Integrated Medical Care in VA Mental Health Programs. Poster session presented at: VA QUERI National Meeting; 2008 Dec 8; Phoenix, AZ.
  14. Bauer MS, Sajatovic M, Kilbourne AM. Developing Collaborative Care Models for Bipolar Disorder: Workshop on Patient-Centered Changes to Improve Outcomes for Serious Mental Illness. Presented at: American Psychiatric Association Institute on Psychiatric Services Annual Conference; 2008 Oct 4; Chicago, IL.
  15. Kilbourne AM. Integrating General Medical Services for Veterans with Serious Mental Illness: What is the Role of Accountability? Paper presented at: VA MIRECC Annual Best Practices in Mental Health Conference; 2008 Jul 1; Washington, DC.
  16. Greenwald DE, Kilbourne AM, McCarthy JF, Hermann RC, Blow FC, Charns MP, Yano EM. Integrating General Medical Services for Veterans with Serious Mental Illness: What is the Role of Accountability? Poster session presented at: VA HSR&D National Meeting; 2008 Feb 1; Baltimore, MD.


DRA: Mental, Cognitive and Behavioral Disorders, Health Systems
DRE: none
Keywords: Care Coordination, Organizational issues, Organizational Structure, Quality assurance, improvement, Quality Improvement, Serious Mental Illness, Severe mental illness
MeSH Terms: none