Background
Collaborative approaches to depression treatment in VA
Research questions (RQ)
RQ1: What does a dedicated care manager offer in addition to an embedded model?
RQ2: What are the barriers to implementing a dedicated care manager?
Methods
Research team
Study site and sample selection
Data collection
Coding
Analysis
Results
Characteristics of collaborative care
CM Site (1)
n = 9 | EMBED Site (2)
n = 6 | |
---|---|---|
Leadership | 2 | 1 |
Primary Care Cliniciansa
| 3 | 2 |
Care Management Staff | 2 | 2b
|
Mental Health Staff | 2 | 1 |
Gender | Male: 3; Female: 6 | Male: 1; Female: 5 |
Theme | CM Site | EMBED Site |
---|---|---|
Same Day Access | “And then we also have NPs, psychiatric NPs available, 2 or 3, depending on our staffing levels, who see walk-in patients with medication needs, and they also refer to care management” [Primary Care Psychologist] “In the VA system I’m in, they have a behavioral health counselor…if I feel they need to be seen in Psychiatry, I filter through her. And it’s actually fabulous. She is right in the same building as me. I can say, “Hey, BHC. Can you do me a favor? This guy, I’m afraid if we send him home right now, he’s going not follow up,” and she says, ‘I’ll get that at two o’clock. I’ve got a one o’clock. Tell him whatever.’ Fabulous - she works him in.” [Primary Care Provider] | “We actually have a mental health nurse practitioner… within our primary care clinic and they are available to see patients who really need, you know, mental health evaluation or intervention that day.” [Physician’s Assistant] “…a primary care patient…gets screened by the LPN when they come in…they asked the generic questions of depression screening…if they trigger positive then they let us know as the providers….if they seem like they need to be referred or if they seem like they are at risk immediately, then we have the luxury…of having a nurse practitioner and a mental health team available in our primary care area. So we can…evaluate that patient the same day.” [Nurse Practitioner] |
Support for Primary Care Providers around mental health assessments, referrals, treatment planning, and psychiatric medications | “…[referring to an embedded psychologist] then she assesses, ‘Hey, [PCP], I think maybe you were overestimating,’ or ‘Yeah, I think you’re accurate. This person needs Psychiatry, this person needs SATP [Substance Abuse Treatment Program], this person should be treated at the PTSD clinic.” [Primary Care Doctor] “So I’m an embedded or co-located MH provider in PC, and so each one of our PC [providers] …has one behavioral health provider embedded, and so we all would refer to the care management program.” [Primary Care Psychologist] | “…so if the primary care provider can’t or doesn’t feel comfortable managing the depression…then they would contact the primary care mental health nurse practitioner.” [Physician’s Assistant] “So, if the provider, the primary care provider, is, you know, after they assess the patient and if they’ve determined that this is something that can be managed, that they’re comfortable managing in primary care, that’s one route that they’ll go. And so, you know, they would prescribe the med and then set up a follow-up, typically phone with their PACT nurse” [Physician’s Assistant] |
What does incorporating a dedicated care manager offer?
At the CM site, informants described how the program provides core functions of patient activation, patient education, and monitoring of patients over time.“I think [the Veterans] just appreciated the fact that there were people checking up on them. There's kind of a trust that you build, and there's a comfort from them knowing that you care and you're actually trying to help them that goes a long way towards helping them be as compliant as they can be. And again, there's also the points of information because many months can go by between our visits, to just have another data point from where they are is always valuable.” [CM site]
Patient activation
“The first time [care manager] called him this morning he said, ‘Why in the hell are you calling me? I’ve got my hands full…,’ and just extreme anger. Well, he’s overwhelmed with everything. And she just said, “Look you don’t need another aggravating phone call at this point,” and just kind of calmed him down and just said, “…I know you don’t want to talk to me and that, but what I can do is I can just call back in a couple of weeks and just see how you’re doing,” and he acquiesced to that”[CM site]
“Well, during that initial call, they are asked for a kind of what their goal is, what they want assistance with in improving in their life... So, I don't want to say it's a treatment plan. It's kind of a quasi-treatment plan where the veteran develops what their goal is, and then the Care Manager will help facilitate that, you know, in whichever way. We also really emphasize a recovery-based philosophy, and trying to instill a sense of independence with these Veterans and not dependence that we're going to be calling you forever.” [CM site]
Patient education
“On all their calls, [care managers] do health education, whether it's symptomatology or about their medications or coping strategies or healthy living strategies. Those are all discussed with the veterans.” [CM Site]
Monitoring of adherence and progress over time
“If their score on the PHQ-9 is 9 or below and the GAD-7 is 9 or below, generally they will stay with the LPN and go through what we call ‘the watchful waiting.’ And they will stay in the program for approximately 3 months…she’ll conduct the PHQ-9 and the GAD-7 with them, and … a few more questions about, you know, if they’re on alcohol …if their scores are 9 or above, then they’re turned over to one of the RNs, and then we would follow them for a period of 6 months. And we would discuss medications, side effects if they’re having any, any resources available, go through coping skills, that type of thing.”[CM site]
Are care management functions being carried out at the EMBED site?
However, access to specific care management functions is limited at the EMBED site. With regard to patient education, a Mental Health Nurse was asked, “if you were able to design an ideal process for getting patients involved, is there anything you would change about your current system?” She responded:“And so sometimes, depending on the patient, if we know them well, we can use motivational interviewing to help them move on the continuum, regardless of the diagnosis. Whether it be eating less salt or whether it be, you know, leaving the house to get groceries. If we can figure out how to help them do that in a comfortable safe manner, then we will do that in primary care. We won’t just say, ‘Oh they need a mental health referral.’ Because, our resources are pretty tight right now for mental health. So we’ll do our best in primary care to fix that, you know, to help them.” [EMBED site]
“Well, certainly quicker access with [an] educational session right away.”[EMBED site]
“We are relying on the mental health nurse practitioner to do things that really…we should have a care manager in there. Really, I mean what’s the ideal? I would say we have an RN or a social worker also embedded within our primary care clinics to follow the people who maybe they’re newly being started on their antidepressant or who for whatever the reason the primary care team feels, just needs a little extra following a while.” [EMBED site]
What are the barriers to implementation of a dedicated care manager?
Impediments to optimal functioning
A similar issue was care management program visibility. Participants reported that primary care providers need to have a clear understanding of when and how to engage the program within their existing complex workflows. Interviewees thought that this can be difficult for primary care providers. An embedded psychologist at the CM site explained,“I think what I would want to do is really pair the care managers with the rest of Primary Care/Mental Health integration staff. What happens is since this is telephone monitoring, it’s very easy not to include them in the regular meetings because they are contacting patients by phone, they’re not there, visible on a face-to-face basis with patients, and so now I know that engaging them and placing them as part of the team, an active participant with input in that they need to be in meetings, face-to-face meetings with the rest of the providers, talking about some of the challenges and dilemmas.”[CM site]
This suggests an important system-level deficiency in support for integrated mental health. Education of individual primary care physicians is challenging in general, and the effectiveness is further limited by high workload and turnover.“PCPs in general are very confused about all of these mental health programs, and they don’t have any idea what’s what…they don’t know the difference between depression care manager, me the embedded provider, and a primary care evaluation by the psychiatric nurse practitioner. And we’re constantly trying to educate them about it, but we have turnover of providers and they’re very, very busy.”[CM site]
“It’s just you know, the old, you know, the war between primary care and mental health and that, you know, they just don’t want to work together.”[CM site]
“I have difficulty saying, ‘I’m going to start you on this medication and I’m going to have somebody follow this.’ I’m having difficulties with letting it go. …my natural inclination is to say, ‘OK, I’m going to start you on this medicine. I’m going to see you in four months and follow up’…part of my reluctance… I just don’t have that trust, I guess, of that system yet.”[CM site]
“The question is how much time do you have to deal with those multiple opportunities on many patients when there's also the rest of the business of the day to attend to…there were times I would think, "Boy, here's this point of information. I'm already trying to deal with all these other points of information about other patients…it could easily overwhelm the capacity to deal with everything that we deal with on a day-to-day basis.”[CM site]
“I get anywhere from 40-50 [computer alerts] a day, so you can imagine how many I have on my dashboard. So I get a telephone note from a nurse about something that's sandwiched in among the other 40 or 50 [computer alerts]. Well, it's sandwiched in there with the abnormal stress test and the lung mass that was seen, and it's tough to be able -- I would like a way where I could get communication saying, ‘Hey listen, this person, it isn't working. They have this side effect. They have a problem,’… getting the information to whatever provider needs to deal with it sometimes is a problem.” [CM site]
Impediments to moving beyond an embedded model
Nevertheless, participants articulated two key barriers to getting such a program started: (1) getting care management on leaders’ agendas; and (2) logistics—specifically, staffing and space.“You know, specialty mental health needs to be there for the patients who need that more intensive mental health evaluation and treatment and if we’re clogging up mental health access with simple, you know, kind of uncomplicated depression then we’re not going to be able to get the patient in who really needs that level of care…You have to build in the specialty of that mental health support for the primary care providers if we’re going to be successfully getting them to treat the uncomplicated depression.”[EMBED site]
“Let me give you this example: Do I respond to a [request for information] or a, you know, whatever crisis there is? Or you know, do some of this longer-term work?”[EMBED Site]
“We’ve really been focusing a lot of our time on the issues that have been out there in the media. So, we’re still moving forward, you know, with primary care mental health integration, but that’s really been probably the biggest local factor that has just stalled us a little bit for the last couple months.” [EMBED Site]
“…for example, we have one nurse practitioner who does triage for the Urgent Care, and consults for the Medical Unit, and Primary Care Mental Health Integration for numerous PACTs. And so there’s no way you’re gonna get that person to do real care management on top of that.” [EMBED site]
“…space has been one of our biggest challenges...the people that we’re actually hiring are not, at this point, even going to be able to be in the clinic because we don’t have space for them. So we’re going to have to get creative in how to make sure they feel tied to those clinics even though they’re not physically located there.” [EMBED site]