Improving Mental Health and Substance Abuse Treatment in VA Primary Care Clinics: The Behavioral Hea

1
Improving Mental Health and Substance Abuse
Treatment in VA Primary Care Clinics The
Behavioral Health Laboratory
J. Ross 1,2, E. Ingram1, C. Beswick1, S.
Sayers1,2,, J Seppelt1,2, J. Murphy1,2, I. R
Katz1,2, V. Kane1, D. W. Oslin1,2
1. Philadelphia VA Medical Center 2. University
of Pennsylvania, Philadelphia, PA
Abstract
A System of Care Roles for the BHL
Outcomes cont.

• Objectives The purpose of this project was to
  assess the utility and feasibility of a telephone
  based systematic clinical assessment service, the
  Behavioral Health Laboratory (BHL), in the
  context of primary care. The BHL is a service
  that provides Primary Care Providers (PCPs) with
  decision support for mental health and substance
  abuse (MH/SA) symptoms. The BHL was implemented
  to assist in the evaluation and management of
  patients who screened positively for depression,
  alcohol use, or other behavioral health needs.
• Conclusions Introducing the BHL into primary
  care was associated with a change in clinical
  practice in primary care at the Philadelphia VA
  Medical Center. There have been improvements in
  screening rates, improved access to care, and
  improved monitoring of patients. The BHL offers a
  practical, low cost method of assessment,
  monitoring, and treatment planning for patients,
  identified in primary care, with MH/SA needs.

Table 2. Appropriate Management of patients
interviewed by the BHL who were not actively
under MH/SA care and referred for evaluation of
depression or alcohol misuse.
Patient Identification By screening or clinical
assessment
Patient Education and Promote self-care
BHL Initial Assessment
Provider Recommendations
Disease Management in Primary Care
There were no differences in the proportion of
patients who could be managed in each of the 4
general categories of treatment.
Referral to MH/SA care
Watchful Waiting/ Brief Interventions
No treatment / False positive screen
Depression Monitoring New treatment cases of
depression are enrolled in a depression
monitoring module to enhance adherence to good
clinical practice and evidenced based care. Over
the 6 month time frame 102 patients were enrolled
with 90 having 2 or more follow-up visits. Each
follow-up visit leads to a report outlining the
monitoring of symptoms and decision support.
Issues / Clinical Needs

• Routine screening for depressive disorders and
  alcohol misuse in primary care settings is an
  important mechanism for reducing morbidity and
  mortality. However, screening is valuable only
  when assessment, treatment, and monitoring are
  available for those identified with problems.
• These disorders are common in the VA with
  depression affecting 10-15 of those who are
  screened and alcohol misuse affecting 10 20.
• However, only 50 of positive depression screens
  are followed up by an assessment and only 30 of
  those screening positive for alcohol misuse
  receive any advice or management about their
  drinking.
• Moreover, of those treated for depression
  one-third are solely managed within primary care
  with less than 20 being followed monthly after
  treatment initiation. And among older veterans,
  only 50 of those accepting an appointment to
  specialty care and 30 of those accepting an
  appointment for alcohol misuse actually get seen
  in specialty MH/SA clinics.
• Co-occurring problems are seldom assessed or
  addressed particularly in milder cases.
• Thus, despite the availability of specialty MH/SA
  care the majority of patients identified by
  screening mechanisms either go untreated or are
  solely managed in primary care.
• The purpose of the BHL was to implement a cost
  effective model that would substantially increase
  the number of patients assessed after screening,
  provide a mechanism to support entry into disease
  management services and/or specialty care, and to
  provide easy access to monitoring and decision
  support.

• Business Models
• There are 2 business models 1) a comprehensive
  model including all clinical aspects and review
  and 2) a decentralized model in which the BHL
  completes assessments but the clinical
  interpretation and care is delivered locally.
• Comprehensive Model (1). Considering cost of
  staffing, laboratory maintenance, administrative
  expenses, and program level expenses, the total
  cost of the BHL per assessment is approximately
  70 per initial assessment and 35 per follow-up
  assessments.
• Decentralized Model (2). The total cost of the
  BHL per assessment is approximately 50 per
  initial assessment and 25 per follow-up
  assessments.

How the BHL works
Outcomes from Implementation

• Screening and Clinical Referral All VA medical
  centers screen for depression, alcohol misuse,
  and PTSD annually. After screening, providers may
  refer the patients to the BHL for assessment
  through the clinical reminder system.
• Conducting the BHL Assessment Health Technicians
  receive and register patient information from the
  consult in to the BHL database. Several attempts
  are made for each patient. If unsuccessful by
  phone, a letter is sent to the patients home
  address. All results, including those unable to
  contact, are documented to the PCP.
• Assessments Conducted.
• Blessed Orientation-Memory-Concentration Test
• International Neuropsychiatric Interview (MINI)
  for mania, psychosis, panic disorder, generalized
  anxiety disorder, PTSD, and alcohol abuse
• PHQ-9 for depression
• 5 item Paykel scale for suicide ideation
• Current Anti-depressant Medication
• Past and Current Use of Illicit Substances
• Medical Outcomes Study (SF-12)
• 4 item Patient Satisfaction scale
• Assessment Outcomes The computer algorithm
  scores all assessments and assigns patients into
  appropriate categories at completion of BHL
  assessment (Ongoing monitoring by PCP, appt in
  MH/SA clinic, or specialty care). Each report
  provides recommendations for management of the
  patient. All reports are reviewed by a
  clinician.
• Patient education and support Each patient
  receives a summary of the assessment with advice
  and education targeted to their symptoms.
• Monitoring For patients in whom depression care
  is initiated, the BHL conducts brief follow-up
  assessments at 2, 6, and 9 weeks after treatment
  initiation which include the PHQ-9, self
  reporting of adverse effects, and self-reported
  medication adherence.

Screening, Referral, and Assessment After
implementation of the BHL, the proportion of
veterans being screened rose 12 during
comparable 6 month periods. Moreover, the screen
positive rate (those identified) rose from 2.8
(pre-BHL) to 7.0 (post-BHL) (plt0.001). For
veterans screening positive for depression nearly
60 were referred to the BHL for assessment. For
alcohol misuse 40 of those with AUDIT-C gt 7 were
referred and 25 of those with an AUDIT-C lt
8. Initial assessments were completed in 75 of
those referred to the BHL (Table 1). The
completion rate did not vary by site (CBOCs vs.
Medical Center) nor the reason for referral with
patients (depression vs. alcohol misuse vs.
other).

• Quality Indicators
• EPRP measures are fluid but an important
  mechanism for demonstrating quality care. The
  flexibility of the BHL allows for targeting these
  measures in a manner that allows improvement in
  these measures. Currently the BHL addresses the
  following measures
• Access The triage and tracking mechanisms allow
  for seemless referral and the ability to reduce
  waiting times, prioritize care, and provide
  administrative support for monitoring.
• Screening The BHL has been associated with
  greater screening rates as well as changes in the
  proportion that screens positive.
• Follow-up of positive screens The BHL is
  directly addressing assessment of those with
  positive screens.
• Monitoring of new initiated treatment The
  depression monitoring provides a straightforward
  mechanism for ongoing monitoring.

• Table 1. Outcomes of 1487 referrals to the BHL
  during a 6 month period.
• Older veterans were more likely to refuse
  assessments and a greater proportion of younger
  veterans were unable to contact.

Conclusions
Selected References

• The BHL offers a practical and face-valid method
  of providing assessment and monitoring of mental
  health and substance abuse problems within
  primary care.
• The implementation of the BHL was associated with
  a significant increase in screening and
  identification of patients needing MH/SA
  services, as well as helping to prioritize
  patients into either specialty treatment or
  primary care management.
• The BHL also offers ongoing monitoring of
  symptoms for patients with specific MH needs.
• In a cost effective manner, The BHL can overcome
  some of the problems in delivering quality mental
  health care, such as the already heavy demand on
  clinician time, availability of clinicians to
  conduct brief but frequent follow-up assessments,
  and the demand on patients for attending frequent
  follow-up visits. The BHL allows for rapid and
  systematic assessment of patients and can be an
  important tool for improving the management of
  depression and other mental health problems
  common in primary care.

• Agency for Healthcare Research and Quality. U.S.
  preventive services task force now finds
  sufficient evidence to recommend screening adults
  for depression. Rockville, MD. May 20, 2002 2002.
• Department of Veterans Affairs. FY2002 end of
  year network performance measure report 2002.
• Sherman SE, Chapman A, Garcia D, Braslow JT.
  Improving recognition of depression in primary
  care a study of evidence-based quality
  improvement. Jt Comm J Qual Saf. Feb
  200430(2)80-88.
• Kroenke K, Spitzer RL, Williams JB. The PHQ-9
  validity of a brief depression severity measure.
  Journal of General Internal Medicine.
  200116(9)606-613.
• Paykel ES, Myers JK, Lindenthal JJ, Tanner J.
  Suicidal feelings in the general population a
  prevalence study. British Journal of Psychiatry.
  1974124(0)460-469.
• Bartels SJ, Coakley E, Oxman TE, et al. Suicidal
  and death ideation in older primary care patients
  with depression, anxiety, and at-risk alcohol
  use. American Journal of Geriatric Psychiatry.
  Jul-Aug 200210(4)417-427.

Values represent means (standard deviations) for
continuous measures and percentages for
categorical measures.