Families, Systems, & Health

Integrated primary care meets health reform.
It is common for each era to see itself as a time of profound change. Currently, in the world of the integration of behavioral health and primary care services, it seems that the profound change is from a period of successful pilots of new models to a time of attempted implementations in large systems. This is written at the point that the new health reform law may have cast the die for large system impact, though many knowledgeable people in health care do not know what the law contains and no one has an authoritative prediction of what that impact will be long term. This special issue is designed to be a first summary of an implementation of national scope. While the Department of Veterans Affairs (VA) serves a population that is not representative demographically of the U.S. as a whole, from the point of view of the level of medical and behavioral health need, it could be argued that the VA population is as much in need of the successful integration of these services as any large population one could name. It is suggested that readers consider what these papers say about the importance of fidelity to a model as compared to the importance of variability within a system that has to learn and improve, the importance of interdisciplinary approaches versus the importance of a patient’s relationship with one primary care provider, and the importance of specific disciplinary training matched to a prescribed role versus the importance of new sets of skills that can be learned by people from different disciplines to be able to work in new ways that fit new approaches. (PsycINFO Database Record (c) 2010 APA, all rights reserved)
Primary care-mental health integration in healthcare in the Department of Veterans Affairs.
The U.S. Department of Veterans Affairs (VA) has been undergoing tremendous transformation in the past 15 years with regard to the delivery of health care. This special issue describes one aspect of this transformation of the largest health system in the U.S.; the system-wide efforts to integrate mental health treatment into the primary care setting in VA. This primary care-mental health integration (PC-MHI) is being accomplished through the central VA system support and implementation of three primary models developed in the field: the White River Colocated models, the Behavioral Health Laboratory, and TIDES (Translating Initiatives in Depression into Effective Solutions). The papers in this special issue describe the development of these models, local and regional efforts to prepare medical centers to adapt and implement PC-MHI, and the impact of the integration on mental health care in these settings. These efforts could represent a national model of PC-MHI implementation for health care systems throughout the U.S. (PsycINFO Database Record (c) 2010 APA, all rights reserved)
Integrating mental health into primary care within the Veterans Health Administration.
The Veterans Health Administration (VHA) has been undertaking a major transformational program of integrating collaborative mental health resources into primary care settings. Key components of the program include colocated collaborative care provided by mental health professionals; care management; and blended programs that combine elements of these two components, whose functions are highly complementary to each other. The program has grown since 2007 from an initiative implementing pilot programs at participating facilities, to a routine expectation of primary care within all VHA medical centers and large community-based outpatient clinics. The national program office supports this VHA initiative in multiple ways, including technical assistance to sites, program and policy development, dissemination of informational tools to facilitate continuous quality improvement, education and training, and partnerships with other existing and emerging VHA programs such as postdeployment health clinics and the patient-centered medical home. (PsycINFO Database Record (c) 2010 APA, all rights reserved)
Using evidence-based quality improvement methods for translating depression collaborative care research into practice.
Objective: Translating Initiatives in Depression into Effective Solution (TIDES) aimed to translate research-based collaborative care for depression into an approach for the Veterans Health Administration (VA). Sites: Three multistate administrative regions and seven of their medium-sized primary care practices. Intervention: Researchers assisted regional leaders in adapting research-based depression care models using evidence-based quality improvement (EBQI) methods. Evaluation: We evaluated model fidelity and impacts on patients. Trained nurse depression care managers collected data on patient adherence and outcomes. Results: Among 72% (128) of the 178 patients followed in primary care with depression care manager assistance during the 3-year study period, mean PHQ-9 scores dropped from 15.1 to 4.7 (p <.001). A total of 87% of patients achieved a PHQ-9 score lower than 10 (no major depression). 62% achieved a score lower than six (symptom resolution). Care managers referred 28% (50) TIDES patients to mental health specialty (MHS). In the MHS-referred group, mean PHQ-9 scores dropped from 16.4 to 9.0 (p <.001). A total of 58% of MHS-referred patients achieved a PHQ-9 score lower than 10, and 40%, a score less than 6. Over the 2 years following the initial development phase reported here, national policymakers endorsed TIDES through national directives and financial support. Conclusions: TIDES developed an evidence-based depression collaborative care prototype for a large health care organization (VA) using EBQI methods. As expected, care managers referred sicker patients to mental health specialists; these patients also improved. Overall, TIDES achieved excellent overall patient outcomes, and the program is undergoing national spread. (PsycINFO Database Record (c) 2010 APA, all rights reserved)
The White River model of colocated collaborative care: A platform for mental and behavioral health care in the medical home.
In the past two decades a great deal of research has demonstrated improved quality of care when mental health care is integrated into primary care. To date, most of the literature has addressed care management for specific mental illnesses. Such programs can be difficult to implement and sustain. We describe a program of “Colocated Collaborative Care,” implemented in 2004 that has been sustained and grown over the 6 years since inception. The Primary Mental Health Care clinic at the White River Junction (Vermont) Veterans Affairs Medical Center offers a full spectrum of mental health care that allows 75% of referred patients to receive all of their care within the primary care clinic, thus conserving scarce specialty services for the most complex patients. The clinic is staffed by a therapist and a psychiatrist (or advanced practice nurse) and complemented by care management and health psychology. It makes use of technology to streamline assessment and track outcomes. The clinic provides a mix of care management, specialty expertise and chronic disease management. Originally developed in a capitated health care system, adherence to general principles that guided its development may be useful in any system of care. (PsycINFO Database Record (c) 2010 APA, all rights reserved)
The behavioral health laboratory: Building a stronger foundation for the patient-centered medical home.
The Veterans Health Affairs is in the process of implementing a new model for the delivery of primary care: The Patient-Centered Medical Home (PCMH). One critical challenge of any PCMH model will be the integration of basic mental health treatment into primary care. Such a mental health integration program must be flexible enough to incorporate new evidence-based treatments as patient demographics and health care needs evolve over time. This paper summarizes the Behavioral Health Laboratory (BHL) care management model, a program already in place in more than 20 Veterans Affairs facilities along with private sector insurance providers, as ideally suited to fill this role in the PCMH. The BHL uses a platform of standardized, software-aided mental health assessments and clinical care managers to deliver evidence-based treatments for depression, anxiety, and substance abuse in primary care settings. The authors review this comprehensive program of screening, assessment, treatment, and referral to specialty care when needed. The BHL program is consistent with the guiding principles of the Patient-Centered Medical Home: applying chronic illness disease management principles to provide more continuous, coordinated, and efficient primary care services to patients with diverse needs. Just as importantly, the authors review how this standardized platform for delivering integrated mental health services provides the flexibility to incorporate novel interventions for a changing population. (PsycINFO Database Record (c) 2010 APA, all rights reserved)
The description and evaluation of the implementation of an integrated healthcare model.
Two studies were conducted to examine the practical implementation of an integrated health care model in five primary care clinics in the Upstate New York Veterans Affairs (VA) system. The aims of the studies were: (a) to describe the basic clinical elements of the integrated health care service offered by behavioral health providers (BHPs) in the primary care setting, and (b) to evaluate the perceptions of providers and patients regarding integrated health care practices in their primary care clinics. In Study 1, we reviewed 180 electronic medical records of patients who met with a BHP in primary care. In Study 2, we used semistructured interviews and self-report questionnaires to collect information from 46 primary care providers, 12 BHPs, and 140 patients regarding their perceptions of integrated health care in their primary care clinics. Both studies illustrate a useful method for evaluating the practical implementation of integrated health care models. (PsycINFO Database Record (c) 2010 APA, all rights reserved)
Using a multi-level approach to implement a primary care mental health (PCMH) program.
Successfully spreading innovation across large health care systems is a complex process requiring participation of stakeholders from a broad spectrum of professional backgrounds, skill sets, and organizational levels. We describe a process for engaging and activating stakeholders across individual, team, organization, and system levels to implement primary care-mental health integrated care programs in one regional Veterans Affairs health care network. Key stakeholders and researchers collaborated to propose and implement the program. Preliminary findings indicate that the program may reduce referrals to specialty mental health care. (PsycINFO Database Record (c) 2010 APA, all rights reserved)
St. Louis Initiative for Integrated Care Excellence (SLI²CE): Integrated-collaborative care on a large scale model.
The primary care health setting is in crisis. Increasing demand for services, with dwindling numbers of providers, has resulted in decreased access and decreased satisfaction for both patients and providers. Moreover, the overwhelming majority of primary care visits are for behavioral and mental health concerns rather than issues of a purely medical etiology. Integrated-collaborative models of health care delivery offer possible solutions to this crisis. The purpose of this article is to review the existing data available after 2 years of the St. Louis Initiative for Integrated Care Excellence; an example of integrated-collaborative care on a large scale model within a regional Veterans Affairs Health Care System. There is clear evidence that the SLI²CE initiative rather dramatically increased access to health care, and modified primary care practitioners' willingness to address mental health issues within the primary care setting. In addition, data suggests strong fidelity to a model of integrated-collaborative care which has been successful in the past. Integrated-collaborative care offers unique advantages to the traditional view and practice of medical care. Through careful implementation and practice, success is possible on a large scale model. (PsycINFO Database Record (c) 2010 APA, all rights reserved)
Book reviews.
The book review editor discusses the themes that he looks for in books, in deciding which critiques to publish, and introduces the three books whose reviews appear in this issue of Families, Systems, & Health. (PsycINFO Database Record (c) 2010 APA, all rights reserved)
Review of The inner world of medical students: Listening to their voices in poetry.
Reviews the book, The inner world of medical students: Listening to their voices in poetry by Johanna Shapiro (2009). After soliciting poetry through medical humanities faculty, the author reviewed 576 poems written by 386 medical students from years one to four. The analyses and interpretations of the poems were then organized into a thematic structure produced by grounded theory analysis. Shapiro treats the poetry as qualitative data, from which to gain patterns of insight, while highlighting the powerful nature of the students’ expressions. Based on A. W. Frank’s patient story categories, she assembles the poetry within each chapter into chaos, restitution, journey, witnessing, and transcendence stories. The sequence of the chapters represents the evolutionary process of medical education with its complex dimensions. This volume has many applications. Clearly, poetry provides a unique and personal method of making sense of the complex process of professional development. This book can be used to universalize the medical education experience for struggling students and residents. For those who are not familiar with the socialization of medical students, such as other health professionals in training, this offers a creative and thoughtful introduction. (PsycINFO Database Record (c) 2010 APA, all rights reserved)
Review of The therapist's guide to psychopharmacology: Working with patients, families and physicians to optimize care (revised edition).
Reviews the book, The therapist's guide to psychopharmacology: Working with patients, families and physicians to optimize care (revised edition) by JoEllen Patterson, A. Ari Albala, Margaret E. McCahill, and Todd M. Edwards (2009). This book is a comprehensive guide for therapists who want to provide better care for their patients by working more closely with physicians. The authors’ premise is if therapists understand psychotropic medications, this will provide a vehicle for improving collaborative relationships. The book is divided into three parts. The first, “The Mind Body Connection,” includes chapters on how the brain works and how psychotropic medications work in general. The second section is on “Psychiatric Disorders and Their Treatments.” Covered are mood and anxiety disorders, schizophrenia and other psychoses, cognitive disorders, alcoholism and substance use disorders. There is also a chapter on special populations such as chronic pain, obesity, and sleep disorders. The third section, on “Creative Collaboration,” provides basic information, such as who might prescribe medications for psychiatric disorders or which health care professionals may be part of the medical team. This book provides an excellent resource for introducing the concepts of collaborative care and for teaching specific strategies for engaging the physicians in our practice. (PsycINFO Database Record (c) 2010 APA, all rights reserved)
Review of Breaking the cycle: How to turn conflict into collaboration when you and your patients disagree.
Reviews the book, Breaking the cycle: How to turn conflict into collaboration when you and your patients disagree by George F. Blackall, Steven Simms, and Michael J. Green (see record 2009-08889-000). This book is a quick and entertaining read that practically addresses those maddening stalemate situations between you and your most difficult patients. Not only do the authors break down their methods into a standardized approach, but they also tell the story of how the approach plays out in a variety of real-life situations. The authors’ principles are simple. They start with the obvious, but often ignored, point that doctors do not have all the answers. Patient problems often persist despite our best efforts, leaving both patients and physicians frustrated. It is only in recognizing the limitations of our “doctor-as-expert” thought process, that we can begin to move into a new paradigm, helping both our patients and ourselves in the process. This is where the book, despite its focus on physicians, becomes applicable to so many other medical care providers. It helps any provider identify new ways to engage and avoid alienating patients, information that is both immediately necessary and timeless. Breaking the cycle provides an important reminder that sometimes all our patients need for us to do is to walk their medical journey with them. (PsycINFO Database Record (c) 2010 APA, all rights reserved)
Hope!
Presents a 55-word story about efforts to conceive, pregnancy, giving birth to twins, and the neonatal intensive care unit. (PsycINFO Database Record (c) 2010 APA, all rights reserved)
Miscarriage.
Presents a 55-word story about miscarriage. (PsycINFO Database Record (c) 2010 APA, all rights reserved)
Transformation.
Presents a 55-word story about giving birth. (PsycINFO Database Record (c) 2010 APA, all rights reserved)
Classroom lesson.
Presents a 55-word story about a missed diagnosis of labor by a medical student. (PsycINFO Database Record (c) 2010 APA, all rights reserved)
Ubuntu: Relational generosity.
Presents a 55-word story about rape, shame, blame, anger, and community. (PsycINFO Database Record (c) 2010 APA, all rights reserved)

Families, Systems, & Health - Vol 28, Iss 2