Learning From Success: How Medical Centers Keep Veterans with Serious Mental Illness Engaged In Primary Care

Brunner JW, Gable AR, Raja P, Moreau JL, Cordasco KM. Learning From Success: How Medical Centers Keep Veterans with Serious Mental Illness Engaged In Primary Care. [Abstract]. Journal of general internal medicine. 2020 Jul 28; 35(Suppl 1):S1-S779.

BACKGROUND: People with serious mental illness (SMI) are at substantial risk for premature mortality, dying on average 10-20 years earlier than the general population, primarily due to high rates of medical comorbidities. Engagement in primary care (PC) can be life-saving for this population, but many with SMI become disengaged from PC. Therefore, the Veterans Health Administration (VA) measures PC engagement among Veterans with SMI, and has identified it as a priority target for quality improvement. To inform improvement efforts at our local VA medical center, we sought to identify promising practices for supporting engagement in PC among Veterans with SMI. METHODS: We conducted semi-structured telephone interviews with 15 key informants across a national sample of 11 VA medical centers with above-median performance on engagement of patients with SMI in PC, and with substantial homeless populations ( > 1,000 Veterans). Interviewees were selected based on their involvement in engaging SMI patients in care, and included leaders of behavioral/mental health (MH) services or PC services tailored for Veterans with SMI. Interviews were conducted in May-July 2019 and audio-recorded. Using detailed notes from interview recordings, we prepared structured summaries of each interview to highlight key points in a template based on the interview guide. We organized summaries into matrices for analysis, grouping summarized points by topic to facilitate comparison across interviews. Our interdisciplinary team reviewed and discussed these tables, and iteratively developed and refined themes. RESULTS: Interviewees reported substantial and diverse efforts aimed at engaging Veterans with SMI in PC. While details differ across sites, strategies can be classified as using 1) targeted outreach, 2) routine practices, or 3) both. Targeted outreach strategies entail deliberate, systematic approaches for identifying and contacting patients with SMI at risk of disengaging from care, and facilitating their return to PC or other needed services. In contrast, routine practices embedded in normal clinical activities were also frequently described as important strategies for maintaining engagement in PC among Veterans with SMI. These routine practices include cultural norms and/or structured care pathways through which MH professionals attend to and facilitate engagement in PC, and PC staff actively monitor and manage patients' primary care provider (PCP) assignments and visit intervals. CONCLUSIONS: VA facilities with high levels of PC engagement among Veterans with SMI use extensive engagement strategies, including a diverse array of targeted outreach and routine practices. Further characterization and evaluation of the effectiveness and implementation of these strategies is needed to identify and promote practices that improve engagementand outcomes for people with SMI.