Primary Care-Mental Health Integration Decreases Use of General Mental Health Services among Veterans with Mental Illness
BACKGROUND:
In order to improve access to mental healthcare, VA underwent a large-scale implementation of team-based primary care models through Primary Care-Mental Health Integration (PC-MHI) beginning in 2007. PC-MHI embeds nurse care managers and mental health specialists (i.e., psychologists, social workers, licensed mental health counselors) in primary care settings to provide brief evidence-based treatment to patients with low-to-moderate complexity mental health conditions. This retrospective longitudinal study examined the relationship between primary care clinic engagement in PC-MHI and patient use of different mental health services (MHS). Using VA data, investigators identified 66,638 Veterans with mental illnesses, such as anxiety (36%), depression (35%), and PTSD (22%), who were treated in any of 29 Southern California VA clinics from FY2009 through FY2013. Primary outcomes measured were the rates of patients' mental health service visits, divided into general MHS (i.e., general mental health team-based care providers) or more specialized MHS (i.e., specialty outpatient programs or residential rehabilitation). Investigators also examined patient characteristics (i.e., sex, age), homelessness, health insurance, and distance to VA healthcare.
FINDINGS:
- There was increasing clinic engagement in PC-MHI services over time, accompanied by a reduction in general MHS visits – but no change in more specialized mental health services.
- Adjusted analyses showed that a one percentage-point higher PC-MHI engagement rate was associated with a 1.2% lower general MHS visit rate per year.
- Reductions in general MHS visits were not observed in patients with serious mental illness (i.e., schizophrenia, bipolar disorder).
IMPLICATIONS:
- PC-MHI targets the most common mental illnesses (i.e., depression) faced by VA primary care patients. Findings suggest that these Veterans are receiving PC-MHI services, particularly in clinics that more highly engaged in PC-MHI.
- PC-MHI programs appear to reduce reliance on general MHS clinics, and thus may be effective in engaging those reluctant to seek mental healthcare.
LIMITATIONS:
- This study did not account for patient drop-outs or clinic switches.
- Investigators did not control for several factors related to PC-MHI that may impact healthcare use and cost, such as mental healthcare staffing patterns or PC-MHI implementation fidelity.
AUTHOR/FUNDING INFORMATION:
Dr. Yano is supported by an HSR&D Research Career Scientist Award. Drs. Leung and Yano (Director) are part of HSR&D's Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP) in Los Angeles, CA. Dr. Yoon is with HSR&D's Health Economics Resource Center (HERC) in Menlo Park, CA.
Leung L, Yoon J, Escarce J, et al., Yano E, and Rubenstein L. Primary Care-Mental Health Integration in the VA: Shifting Mental Health Services for Common Mental Illnesses to Primary Care. Psychiatric Services. December 15, 2017; e-pub ahead of print.
