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.
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.
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.
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.
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.
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- 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.
- 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.
- 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.
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- 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.
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- 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.
- 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.
- 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.
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- 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.
- 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.
Health Systems, Mental, Cognitive and Behavioral Disorders
Organizational issues, Quality assurance, improvement, Severe mental illness