BACKGROUND/RATIONALE:
Serious mental illnesses (SMI), including schizophrenia, bipolar disorder, and other psychoses are associated with substantial functional impairment and health care costs, and can lead to premature morbidity and mortality. While high rates of co-occurring conditions (i.e., substance use and medical comorbidities) contribute to these adverse outcomes, patients with SMI are less likely to receive adequate care for these conditions. Integrated care for co-occurring conditions is considered essential for improving quality of care for persons with SMI, especially since they are primarily managed in mental health specialty settings. However, empirically-tested models to integrate care mainly rely on costly organizational or structural changes (e.g., co-location of different providers in mental health clinics) rather than augmenting linkages across existing providers and settings. Identifying specific features of integration that serve to augment these linkages and improve patient-level outcomes can inform the refinement and implementation of appropriate and cost-efficient integrated treatment models for SMI and co-occurring conditions.
OBJECTIVE(S):
Based on a theoretical framework that describes the underlying organizational and clinical factors of integrated care, there are two immediate objectives of this study. The first objective is to evaluate the association between underlying organizational characteristics (e.g., staffing, information technology, performance incentives), degree of clinical integration (e.g., coordination, comprehensiveness, and continuity of care), and patient-level outcomes (e.g., quality of care) for substance use and general medical services among veterans diagnosed with SMI receiving care within VHA mental health programs. The second objective is to describe in detail and compare variations in clinical integration through qualitative interviews of frontline providers among a subsample of VHA mental health programs with high and low levels of quality of care for veterans with SMI.
METHODS:
This study will first survey mental health program leaders in VHA facilities across the United States to assess the organization and degree of integrated care for substance use and general medical services in VHA mental health programs. To determine the association between organization, degree of integration, and patient-level outcomes, this survey data will be linked to patient-level outcomes data on a national cohort of veterans diagnosed with SMI identified from the VHA's National Psychosis Registry (NPR), Patient-level data on guideline-concordant quality of care for substance use and general medical services (e.g., prevention, diabetes and cardiovascular disease management) will be obtained from the VHA National External Peer Review Program (EPRP). Data on patient satisfaction and demographics will be ascertained from the VHA Survey of Healthcare Experiences of Patients (SHEP). We will then identify a subsample of VHA programs with high and low levels of quality of care for patients with SMI, and collect in-depth data on integration from interviews with frontline providers. Multilevel regression analyses will be used to determine the specific organization and clinical integration features associated with patient outcomes for co-occurring conditions. Additional qualitative analyses from the in-depth provider interviews will be conducted to identify the most and least effective integrated treatment models.
FINDINGS/RESULTS:
MH program leaders from 108 out of 133 programs (81%) completed the MH program survey in fiscal year 2007. Program leaders were asked to identify whether providers in their MH program as opposed to external general medical (GM) providers were primarily responsible for screening for diabetes and cardiovascular disease (CVD) risk factors (i.e., associated with atypical antipsychotics), Hepatitis C screening, and obesity/weight management for patients with SMI. Of the 108 MH programs, 58% require patients to call in to arrange next mental health appointment, 51% use a transcription service, 42% can obtain GM referral information in 1-5 days on patients typically, 24% can obtain information on patient suicidality in 1-5 days typically, and the mean # hours available for walk-in appointments = 7.2 (SD=8.7). In addition, 48% offer peer support programs, 64% family psycho-education, 77% MHICM, 50% telephone care management, 42% had at least 1 full-time GM clinician (MD, PA, or NP), the mean # addiction specialists in Program = 4.3 (SD=3.2), and 11% had a GM Clinic within the MH Program
In addition, 36% reported they were primarily responsible for diabetes/CVD screening, 10% for Hepatitis C screening, and 12% for obesity/weight management. In contrast, 78% were primarily responsible for psychotropic drug-level monitoring. Nationally, 18%,15%, and 6% of MH leaders received financial bonuses for achieving target levels of diabetes/CVD risk screening, Hepatitis C screening, and obesity/weight management, respectively. After controlling for co-location of general medical providers, staffing, academic affiliation, and size, receiving a financial bonus for CVD risk screening was independently associated with primary accountability for providing CVD screening services (OR= 2.01;p=0.005).
IMPACT:
Financial incentives to improve performance on quality measures related to CVD risk assessment may lead to greater perceived accountability and subsequent improved integration of general medical services for veterans with SMI.
Integrated general medical care for veterans with chronic mental illness is essential for improving outcomes and enhancing recovery. Incentives such as bonuses (i.e., pay-for-performance) may encourage integrated care practices for veterans with SMI. Improving the integration of care for co-occurring conditions is a priority articulated by the VHA Mental Health Strategic Healthcare Group. To date, there has been no naturalistic study in the VHA or elsewhere assessing how care for co-occurring conditions is typically integrated in mental health programs for persons with SMI. Findings from this study will inform our long-term objectives to identify best practices in integrated care that lead to improved outcomes across the spectrum of conditions experienced by patients with SMI.
PUBLICATIONS:
Journal Articles
- Altshuler L, Tekell J, Biswas K, Kilbourne AM, Evans D, Tang D, Bauer MS. Executive function and employment status among veterans with bipolar disorder. Psychiatric Services. 2007; 58(11): 1441-7.
