Intervention Helps Identify Specialty Mental Health Patients Ready for Transition to Primary Care
Current mental health (MH) staffing shortages – both inside and outside VA – highlight the need to maximize the efficient use of existing MH human resources. Primary care (PC) providers have the capability to manage maintenance of uncomplicated psychotropic medications and can monitor for symptom relapse. In VA, embedded behavioral health providers offer co-located, collaborative care services and care management through Primary Care-Mental Health Integration clinics. This pilot project tested the implementation of electronic medical record (EMR)-based criteria to identify Veterans currently receiving treatment in the specialty MH setting who might be considered for transition to primary care. The intervention, called FLOW (not an acronym), espouses a process of shared decision-making in which MH providers, patients, and, ideally, PC providers collaboratively determine whether primary care is the most appropriate setting for ongoing treatment once a patient has recovered or stabilized from his/her MH treatment. Since the FLOW EMR criteria use administrative data (i.e., medication use, inpatient and outpatient visits), they provide important but limited information about the patient. Therefore, the project emphasizes that the clinical decision to transition rests with the Veteran and his/her MH treatment team. Study investigators used a multicomponent implementation strategy to implement FLOW at a very large VA community-based outpatient clinic in Texas.
- FLOW combined with sound clinical practices can be used to identify mental health patients who are candidates for primary care and foster their effective transition.
- During the 12-month pilot study, 424 Veterans with mental illness transitioned from MH to PC; of those patients only 9 (2%) returned to MH care after the transition. Most of those patients (n=335; 79%) were first identified on the MH FLOW report, but 89 (21%) were other MH patients.
Before FLOW, there was no systematic way to measure the numbers of patients treated in MH who had their care transitioned to PC. The FLOW model benefits from a shared electronic medical record and a shared leadership hierarchy, in that the chiefs of mental health and primary care report to the same senior leader. VA's Office of Mental Health is supporting development of a national version of the online MH-FLOW report and the FLOW development team is developing a national implementation plan based on knowledge gained from this pilot.
- Due to observational design, causality of pre-post changes should be interpreted with caution.
- Patient perspective should be better understood, and longitudinal follow-ups with Veterans are needed to determine if the transition to primary care continues to meet their needs.
This study was partly funded by HSR&D. Dr. Smith is part of HSR&D's Center for Innovations in Quality, Effectiveness and Safety (IQuESt), and Dr. Kim is part of HSR&D's Center for Healthcare Organization and Implementation Research (CHOIR).
Smith T, Kim B, Benzer J, et al. FLOW: Early Results from a Clinical Demonstration Project to Improve the Transition of Patients with Mental Health Disorders Back to Primary Care. Psychological Services. March 14, 2019;epub ahead of print.