Based on an internal system-wide review of mental health services, and consistent with the Mental Health Action Plan submitted to Congress in November, 2011, the Office of Mental Health Operations (OMHO) has undertaken an effort to establish Behavioral Health Interdisciplinary Program teams, (BHIPs) to provide General Mental Health (GMH) care throughout VHA. The goal is to build effective interdisciplinary teams that will provide the majority of care for Veterans in order to provide continuous access to recovery-oriented services consistent with the VA Handbook on Uniform Mental Health Services. Implementing BHIP teams is complex because it entails work role changes under resource constraints while attending to, and anticipating, Veteran needs and coordinating where necessary with specialty mental health care, Primary Care Patient-Aligned Care Teams (PACTs), and other clinical resources.
Collaborative Care Models (CCMs) provide a patient-centered, evidence-based framework that can address these needs. CCMs were initially developed to provide anticipatory, continuous, collaborative, evidence-based care for chronic medical illness treated in primary care. Thus CCMs provide a feasible, evidence-based model to support BHIP development. Importantly, implementation strategies, such as the CDC's Replicating Effective Programs (REP) strategy, have been used to establish CCMs for mental health care both within in and beyond VHA. The current project was unique in its efforts to use REP to apply CCM principles to the formation of BHIPs.
Building on our experience both in clinical trials of the CCM and in CCM implementation trials using REP, we proposed a program of research consisting of a QUERI one-year Rapid Response Project (RRP) to be followed by subsequent application for a multi-year Services-Directed Project (SDP) supporting a Hybrid Type II controlled trial to test the intervention and accompanying facilitation strategy. This RRP specifically supported this protocol development by:
- Piloting facilitation procedures in one VAMC
- Establishing formative and summative evaluation measures
- Developing analytic methods and sample size calculations for the trial
We specifically hypothesized that REP-based implementation to establish CCM-based BHIPs, compared to dissemination of CCM material alone, would:
- H1: Result in greater fidelity to the CCM model, and
- H2: Improve patient-level health outcome measures in CCM-based BHIPs.
In conjunction with OMHO and VISN 1, our Methods for this RRP were three-fold:
a) First, we used REP-based implementation of a CCM-based BHIP at one VISN 1 site (featuring a blended facilitation model), using formative evaluation methods to fine-tune our implementation process.
b) Second, we used qualitative interview techniques with mental health staff to measure implementation outcomes at the facility and provider level. This process included the following interviews:
- 6 pre-intervention interviews at the same site that we then helped implement BHIP.
- 4 interviews at another VISN 1 site with a pre-existing BHIP.
- 4 interviews at another VISN 1 site that had not yet developed a BHIP.
- We are also in the process of conducting a set of post-intervention interviews at the same site that we helped implement BHIP.
c) Third, to inform our SDP data collection (including estimating sample size and analytic plan), we mailed a survey battery to 300 Veterans in VISN 1, and received back 75 completed surveys (25% response rate, comparable to response rates in clinical trials).
a) We have completed our REP-based implementation of a CCM-based BHIP at one VISN 1 site. Our blended facilitation model involved study staff working closely with mental health staff from that site to help them build their BHIP team. The team launched in April of 2014 and is currently up and running, including twice-weekly team meetings and daily huddles.
b) We are in the process of completing qualitative analyses on the interviews we have conducted. These analyses include both grounded thematic analysis and directed content analysis.
c) We have used the results from the Veteran surveys to estimate sample size calculations and expected response rates for our follow-up SDP.
The overarching goal of this program of research is to establish an evidence-based foundation for BHIPs, emphasizing patient-centered, collaborative care and improving patient-level health outcomes. This RRP represents a pivotal first step toward reaching that goal. Concretely, as part of this RRP we have helped one VISN 1 site establish a BHIP informed by CCM principles, and honed our methods to expand these efforts through our recent SDP resubmission.
- Bauer MS, Weaver K, Kim B, Miller C, Lew R, Stolzmann K, Sullivan JL, Riendeau R, Connolly S, Pitcock J, Ludvigsen SM, Elwy AR. The Collaborative Chronic Care Model for Mental Health Conditions: From Evidence Synthesis to Policy Impact to Scale-up and Spread. Medical care. 2019 Oct 1; 57 Suppl 10 Suppl 3:S221-S227.
- Stolzmann K, Meterko M, Miller CJ, Belanger L, Seibert MN, Bauer MS. Survey Response Rate and Quality in a Mental Health Clinic Population: Results from a Randomized Survey Comparison. The journal of behavioral health services & research. 2019 Jul 1; 46(3):521-532.
- Kim B, Miller CJ, Elwy AR, Holmes SK, Bauer MS. Examining the Experiences of General Mental Health Clinic Staff in Implementing Collaborative Care. Poster session presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 8; Philadelphia, PA.
- Miller CJ, Elwy AR, Holmes SK, Kim B, Bauer MS. Rapid framework assessment of VA policy implementation of interdisciplinary mental health care. Poster session presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 8; Philadelphia, PA.
- Kim B, Miller CJ, Elwy AR, Holmes SK, Bauer MS. Examining Interrelated Perceptions of Mental Health Staff to Identify Concerns in Delivering Collaborative Interdisciplinary Care. Poster session presented at: AcademyHealth Annual Research Meeting; 2015 Jun 14; Minneapolis, MN.