In order to ensure that Veterans have access to high-quality, evidence-based mental health services in the primary care setting, the VA has invested greatly in implementing primary care - mental health integration (PC-MHI). The VA has also implemented a patient-centered medical home model called the Patient Aligned Care Team (PACT) model, which mandates continuous, comprehensive, collaborative care for all of the Veteran's health care needs. While national evaluations of both implementation efforts have been ongoing, less is known about the interaction between these two related yet distinct initiatives. With these study results we hope to begin to fill this gap with our in-depth qualitative examination of current practices and perceptions of PC-MHI within PACT.
Our objectives were to 1) describe and contextualize current practices of primary care - mental health integration in two primary care clinics transforming to the PACT model; 2) characterize the perspectives of clinical providers, staff, and leadership regarding current and potential barriers and facilitators to successful mental health integration under the PACT model; and 3) characterize the perspectives and concerns of national PC-MHI leadership regarding mental health integration under the PACT model.
To achieve the first two objectives we conducted an ethnographic study of PC-MHI in two large primary care clinics ("Site A" and "Site B"), utilizing the qualitative methods of nonparticipant observation and semi-structured interviews. Across observations and interviews at both sites we talked to members of 14 PACT "teamlets" (6 at Site A, 8 at Site B), 10 PC-MHI providers/staff (5 at each site), and 11 members of facility leadership (6 at Site A, 5 at Site B). We also interviewed a VISN mental health lead for each site's network to obtain regional perspectives. To achieve the third objective conducted telephone interviews with 6 members of VA national leadership charged with supporting and promoting the implementation and sustainment of PC-MHI across the VA. All interviews were digitally audio-recorded and transcribed verbatim. We analyzed all data using a combination of content analysis and data extraction techniques, creating an interview summary for each interview organized by topics (e.g., implementation history, barriers, facilitators, etc.). We then compiled these summaries into detailed case studies.
While it is difficult to summarize detailed qualitative case studies in a brief manner, we will highlight a few key themes. The first concerns the PACT context in which PC-MHI is implemented in the VA. With the implementation of the PACT model, the landscape of primary care changed in significant ways. One significant change is that PACT has organized primary patient care into "teamlets," consisting of a PCP, an RN acting in a care manager role, an LPN/LVN, and a clerk, who work as a team to take care of a panel of patients. As one participant put it, primary care is now "a sea of small silos," atomized into individual units operating autonomously. This fragmenting of primary care has hindered collaboration between teamlets and PC-MHI providers at our study sites, for several reasons. First, at both sites there are a small number of PC-MHI providers vs. a larger number of teamlets. Second, there is great variation in the frequency and consistency of teamlet meetings or "huddles" to discuss patient care, making it difficult if not impossible for PC-MHI providers to meet with all teamlets. Third, teamlet meetings "belong" to the teamlet, and it is therefore dependent upon the PCP to invite PCMHI providers to join. With one exception, no teamlets were inviting any PCMHI provider to join their huddles at either study site.
A second theme is the issue of "ownership" over PC-MHI. At Site A, participants reported continuing challenges with obtaining space and resources for PC-MHI providers, despite the fact that these providers are also taking care of primary care patients. The ACOS for Mental Health at this site described the problem as a "culture of ownership." This suggests that PACT implementation may not have moved much beyond creating teamlets. Leadership at Site B worked together to overcome these issues, but front-line primary care staff were resentful when space was identified and remodeled for a PC-MHI area, feeling that "their" space was being taken by mental health.
A third theme concerns the degree to which PACT teamlets regard PC-MHI providers as part of their team vs. as a co-located specialty resource. Most teamlet members we talked to said that they view PC-MHI providers as a specialty resource, although they greatly appreciated having co-located mental health services. PACT teamlets work closely together every day, and despite the practice of warm handoffs, PCMHI providers are contacted only when needed and as noted above, are not present in huddles or teamlet meetings. With little opportunity to interact outside of "warm handoffs" of patients to PC-MHI staff (which do not always occur), it is understandable that PCMHI remains to be seen as a specialty resource. Perhaps the more significant factor here is the lack of collaboration in patient care. At both study sites, PCMHI providers were willing to collaborate, but could do little beyond co-signing PCPs and remaining available to discuss patient care when requested. Primary care at both study sites was greatly overwhelmed, further contributing to the lack of collaboration. Both sites were already down several PCPs, and the national access crisis occurred during the middle of the study, increasing primary care workload and burnout.
Because we will disseminate our study results to operations partners and other members of national leadership, our findings provide a potential complement to national PC-MHI evaluation results and may also inform national implementation facilitation and other quality improvement activities within the VA. We hope that our results will contribute helpful knowledge toward the VA's goal of ensuring that our Veterans have access to the highest quality evidence-based mental health care in their patient-centered medical homes.
None at this time.
Mental, Cognitive and Behavioral Disorders
Treatment - Observational