Collaborative Care and Patient-Centered Medical Home within

the Veterans Health Administration

Andrew S. Pomerantz, MD, National Mental Health Director for Integrated Care, Office of Mental Health Service, VA Central Office

David A. Hunsinger, MD, MSHA, Member, National Consultation Team, VA Transformation to PACT

Margaret Dundon, PhD, National Program Manager for Health Behavior, National Center for Health Promotion and Disease Management, VACO

Larry J. Lantinga, PhD, Associate Director, Center for Integrated Healthcare, OMHS Center of Excellence

Collaborative Family Healthcare Association 13th Annual ConferenceOctober 27-29, 2011 Philadelphia, Pennsylvania U.S.A.

Session # H1bOctober 28, 201111:15 AM

Faculty Disclosure

We have not had any relevant financial relationships during the past 12 months.

Need/Practice Gap & Supporting Resources

The Department of Veterans Affairs, the largest unified healthcare system in the United States, has undertaken a major transformation that embraces primary care-mental

health integration within the context of the patient-centered medical home. National leaders within the Veterans Health

Administration will describe VA’s efforts to date.

Objectives

Upon completion of this presentation, participants will be able to:

• Describe VA’s implementation of collaborative care--Primary Care-Mental Health Integration (PC-MHI)

• Describe VA’s implementation of the patient-centered medical home--Patient Aligned Care Team (PACT)

• Describe the role of VA’s newly established Health Behavior Coordinators (HBC) and how they interact with PC-MHI & PACT

Expected Outcome

We expect that you will take away a better understanding of what VA is doing to further collaborative care.

We expect that you will learn what VA resources are available to your patients who are Veterans.

We expect that you will now know with whom to network within VA in order to obtain access to VA knowledge and

information.

Learning Assessment

A learning assessment is required for CE credit. In lieu of a written pre-post-test based on our learning objectives, I will moderate a Question & Answer period at the conclusion of our presentation. Please hold your questions until then.

Thank you.

Session Evaluation

Please complete and return theevaluation form to the classroom monitor

before leaving this session.

Thank you!

Primary Care-Mental Health Integration in VA: Past, Present

and Maybe FutureAndrew S. Pomerantz, MD

National Mental Health Director, Integrated CareOffice of Mental Health Services

VA Central Office&

Associate Professor of PsychiatryDartmouth Medical School

MODELS OF MH IN PC AT DAWN OF

21ST CENTURY

• Referral• Consultation/Liaison• Co-location• Collaborative Care• Integrated Care

CORE STUDIES IN INTEGRATED/COLLABORATIVE

CARE

• PROSPECT• IMPACT• PRISM-E• RESPECT

Demonstrate improved outcomes with care management.

DEVELOPMENT OF PC-MHI IN VA

• MANY INDIVIDUAL PROGRAMS IN MANY SITES OVER MANY YEARS

• SOME VERTICAL INTEGRATION• SOME HORIZONTAL INTEGRATION

VA MODELS• TIDES– utilizes Care Management to

support PCP treatment of depression • Behavioral Health Laboratory (BHL) –

Structured telephone interview for triage and support of PC treatment of Depression, anxiety, at-risk drinking, etc

• Co-located collaborative care – the White River Junction Model

• “Blended models”• Health Psychology

• Integrated Care for physical and mental health in one setting

• Evaluation and treatment for mild to moderate mental health conditions (depression, substance misuse, anxiety, PTSD)

• Follow-up evaluation for positive MH screens • Behavioral health interventions for chronic disease• Care management• Referral management

• Screening for mental health conditions

• Initiation of pharmacological treatment for mild to moderate mood symptoms

• Co-management of Veteran care with PC-MHI and specialty MH providers

• Health Behavior

Secondary and Tertiary Care:• Outpatient Care for treatment resistant, severe or

complex illnesses• PTSD specialty treatment; Substance dependence

treatment• Treatment of serious mental illness (including MHICM)• Full spectrum of psychosocial rehabilitation and recovery

services• Inpatient psychiatric care• Residential treatment• Supported and therapeutic employment• Homeless programs

PRIMARY CARE

SPECIALTY MH

PC-MHI

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Emerging View

• Like other medical disciplines, Mental Health can be divided into PRIMARY, SECONDARY and TERTIARY care.

• Primary MH care can be delivered in the same setting as general Primary Care by expert clinicians – horizontal and vertical integration.

• Secondary/tertiary MH care are specialized and require multiple disciplines.

One size does not fit all

Organizational Ethics: “…The intentional use of values to guide the decisions of a

system.”

“From Clinical Ethics to Organizational Ethics: The Second Stage of the Evolution of Bioethics.” Potter, Robert Lyman, in “Bioethics

Forum.” Summer, 1996

ONE SIZE DOES NOT FIT ALL• ADHERENCE TO THE BASIC PRINCIPLES

– EASY ACCESS IN PRIMARY CARE– PROBLEM FOCUSED ASSESSMENT AND TREATMENT– ONSITE CLINICIANS IN PC– STEPPED CARE– MEASUREMENT BASED CARE– CARE MANAGEMENT– ENHANCED REFERRALS

• LEADS TO CONSISTENT OUTCOMES– IMPROVED RECOGNITION AND TREATMENT IN PC– IMPROVED ENGAGEMENT IN SPECIALTY MH CARE– CONSERVES SCARCE SPECIALTY RESOURCES

WHAT ABOUT SERIOUS PERSISTENT MENTAL ILLNESS?

VISION:

Veterans with Serious Mental Illness will enjoy health status identical to the general population.

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The Patient Aligned Care Team (PACT)

Community

PC-MHI, HBC, SW, pharmacy, etc.

Cardiology, podiatry, etc.

PCPs, specialists, etc.

Public health agencies, non-profit agencies, etc.

Non-VA Provide

PCP, RN CM, clinical assoc, admin assoc

Includes significant others and caregivers

MODELS OF CARE

– Cohort model: SMI patients receive PC in general primary care clinics from providers with specific interest & skill in working with this population

– Consultative model: PCMHI and/or Primary MH provider is consultant for PACT team/teamlet

– Enhanced Coordination between specialty MH and Patient centered medical home

– Specialty Care Team: PC providers and services embedded in special care team. In VA, this model is limited mostly to screening; e.g. PC APN located in SMI clinic, PCMHI providers in Post Deployment clinic

– Combination of above: routine preventive screening in specialty clinic;, advanced access to PACT, Care/Case management in MH.

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NEXT

A single brand of PC-MHIClear definition of “blended”

Staffing guidelinesDevelop the Evidence Base for Brief

TreatmentsRural Models

Integration with the rest of Mental Health

Patient Aligned Care TeamPatient Aligned Care TeamVHA’s implementation of theVHA’s implementation of the

Patient Centered Medical Home Patient Centered Medical Home

David A. Hunsinger, MD, MSHA

Medical Director, Binghamton VA Outpatient Clinic

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VA kick-off off Patient VA kick-off off Patient Centered Medical HomeCentered Medical Home

initiativeinitiative

Las Vegas, NV

April 2010

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Veteran Centered CareVeteran Centered Care

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Definition: A fully engaged partnership of veteran, family and health care team, established through continuous healing relationships and provided in optimal healing environments, in order to improve health outcomes and the veteran’s experience of care

Universal Services Task Force, 2009

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Joint Principles of the Joint Principles of the Patient-Centered Medical Home Patient-Centered Medical Home

AAFP, AAP, ACP, AOAAAFP, AAP, ACP, AOA

• Ongoing relationship with personal physician• Physician directed medical practice• Whole person orientation• Enhanced access to care• Coordinated care across the health system• Quality and safety• Payment

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Principle 1Principle 1Personal Physician (Provider)Personal Physician (Provider)

• Every patient has a designated primary care provider.

• Relationship is ongoing – continuous over time• Patient choice• Each physician has a “Panel” of patients

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Principle 2Principle 2Physician (Provider) DirectedPhysician (Provider) Directed

• Provide clinical direction– Shared-Decision making

• Team-based care, leading the team• Flattening the hierarchical structures

– Equal Value, Different Roles• Championing principles of Medical Home

– Example: Facilitating Care Coordination

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Principle 3Principle 3Whole Person OrientationWhole Person Orientation

• Health as a focus, not just Health Care• Personal preferences of the patient drive care

interventions• Patient self-management skills and education• Culturally relevant and sensitive• Shared goal setting with health care team• Health literacy and numeracy• Family engaged in care• Mental Health and Primary Care Integration

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Principle 4 Principle 4 Enhanced Access to CareEnhanced Access to Care

• Open Access principles (ACA)• Ready and timely access to non face-to-face

care– Telephone, Messaging, Secure e-mail– Web-based access to scheduling, information,

records, labs

• System Redesign

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Principle 5Principle 5Coordinating Care Coordinating Care

• Transitions within and without • Identifying and managing highest risk

– Chronic Disease Management– Population-based Health Care

• Predicative Modeling• Health Risk Assessment Tools• Patient/Disease Registries

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Principle 6Principle 6Quality and SafetyQuality and Safety

• Clinical performance– Value = Quality/Cost

• Medication reconciliation• Quality and Safety are outcomes

– Effectively managing transitions– Team dynamic drives performance– Effective implementation of Medical Home– Data driven, team-based, system redesign

• Continuous improvement

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VHA Implementation strategyVHA Implementation strategy

Three pronged approach to education/ team building:

• Regional collaboratives

• Centers of excellence

• Consultation/facilitation teams

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VHA Implementation strategyVHA Implementation strategy

Regional collaboratives:

• Structured learning

• Focus on a ‘core team’ from each Medical Center

• Emphasis on teach back

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VHA Implementation strategyVHA Implementation strategy

Centers of Excellence:

• Goal to train ALL teamlets

• Trainings scheduled at sites chosen for ease of access

• Emphasis on team building, understanding key principles, and skill acquisition

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VHA Implementation strategyVHA Implementation strategy

Consultation/facilitation teams:

• Five teams

• Physician, Nurse, Administrative staff

• Trained in facilitation

• Deployed to sites by site request

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Patient Centered Medical HomePatient Centered Medical Home

Practice Redesign

Redesign team: oRoles oTasks

Enhance: oCommunicationoTeamwork

Improve Processes:oVisit workoNon-visit work

Care Management & Coordination

Focus on high-risk pts:oIdentify oManageoCoordinate

Improve care for:oPreventionoChronic disease

Improve transitions between PCMH and:

oInpatientoSpecialtyoBroader Team

Patient Centeredness: Mindset and ToolsPatient Centeredness: Mindset and Tools

Improvement: Systems Redesign, VA TAMMCSImprovement: Systems Redesign, VA TAMMCS

Resources: Technology, Staff, Space, CommunityResources: Technology, Staff, Space, Community

Access

Offer same day appointments

Increase shared medical appointments

Increase non-appointment care

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Principles of the Principles of the Patient-Centered Medical Home Patient-Centered Medical Home

• Ongoing relationship with personal physician• Physician directed medical practice• Whole person orientation• Enhanced access to care• Coordinated care across the health system• Quality and safety• Payment

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Patient Aligned Care Team:Patient Aligned Care Team:ObjectiveObjective

To improve patient satisfaction, clinical To improve patient satisfaction, clinical quality, safety and efficiencies by quality, safety and efficiencies by

becoming a national leader in the delivery becoming a national leader in the delivery of primary care services through of primary care services through

transformation to a medical home model transformation to a medical home model of health care delivery.of health care delivery.

Team RedesignTeam RedesignThe Patient’s Primary Care Team:The Patient’s Primary Care Team:

• Teamlet: assigned to ±1200 patients (1 panel)– Provider– RN Care Manager– Clinical Associate

• LPN• Medical Assistant• Health Tech

– Clerk

• Team members– Clinical Pharmacy

Specialist± 3 panels

– Medical Social Work ± 2 panels

– Nutrition± 5 panels

– Mental Health– Case Managers– Trainees

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Panel size Panel size adjusted adjusted

for rooms for rooms and and

staffingstaffing

For each parent facilityHPDP Program ManagerHealth Behavior CoordinatorMy HealtheVet Coordinator

Other Team MembersPharmacy Social Work NutritionCase ManagersIntegrated Behavioral Health

4040

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Essential Transformational ElementsEssential Transformational ElementsPatient Aligned Care TeamPatient Aligned Care Team

• Delivering “health” in addition to “disease care”• Veteran as a partner in the team

– Empowered with education– Focus on health promotion and disease prevention– Self-management skills– Patient Advisory Board

• Efficient Access– Visits– Non face-to-face

• Telephone• Secure messaging• Telemedicine• Others?

4141

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• Care coordination– Optimizes hand-offs between inpatient and

outpatient care– Facilitates interface with specialty care– Seamless co-management (Dual Care) with

outside providers– Incorporates tele-health, and HBPC services– Emphasizes home care & rural health

Essential Transformational Elements Essential Transformational Elements

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• Care Management/ Panel Management– Disease management and interface with specialty

care• Chronic Care Model• Disease registries• Identification of outliers• Team RN partnering closely with providers

– Veterans at high risk for adverse outcomes – Pain management– Returning combat veteran care – Depression– Substance abuse

Essential Transformational ElementsEssential Transformational Elements

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• Improve technological clinician support– Decision support– Predictive modeling– CPRS user-friendliness– Information processing

• Develop new measurement and evaluation tools– Patient Satisfaction– Staff satisfaction– Processes of care– Manager and Provider Report Cards – Continuity and comprehensiveness

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Essential Transformational ElementsEssential Transformational Elements

Whole Person OrientationWhole Person Orientation“ …you ought not to attempt to cure the eyes without the

head or the head without the body, so neither ought you to attemptto cure the body without the soul . . . for the part can never be well

unless the whole is well.” Plato

Mental Health is an Integral Part of Mental Health is an Integral Part of Overall HealthOverall Health

• Physical problems can be risk factors for mental health problems

• Mental health problems can be risk factors for physical health problems

• Patient Centeredness means a holistic view of the Veteran, recognizing the interrelationships of all health problems and how they individually and interactively affect quality of life

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• 26% of Veterans who use VA health care are also being treated for a mental health diagnosis

• 20% currently receive some or all of that care in a specialty Mental Health setting

• Patients initially bring their mental health concerns to Primary Care

• Screening for mental health problems takes place in primary care [Clinical Reminders]

• Referrals from Primary Care to Specialty Mental Health result in a high rate of no-shows

Mental Health and Primary CareMental Health and Primary CareA Natural Fit A Natural Fit

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Primary Care – Mental Health Primary Care – Mental Health IntegrationIntegration

• PC-MHI embodies the principles and focus of the Patient Centered Medical Home

• Work on PC-MHI implementation facilitated PACT implementation

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• Completely integrated within primary care• Occupy the same space• Share the same resources• Participate in Team Meetings• Share responsibility for care of the whole

patient

True IntegrationTrue IntegrationFeatures of PC-MHIFeatures of PC-MHI

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ConclusionConclusion

• Primary Care - Mental Health Integration is and will continue to be an essential component of the

team delivery of effective care

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Collaborative Care for Health Behavior Change Collaborative Family Healthcare Association Conference, 2011

Peg Dundon, PhDNational Program Manager for Health BehaviorVHA National Center for Health Promotion and Disease Prevention

VETERANS HEALTH ADMINISTRATION

Words of Wisdom

“If I’d known I was going to live so long, I’d have taken better care of myself.”

- Leon Eldred

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VETERANS HEALTH ADMINISTRATION

Prevalence of Chronic Conditions in VHA Primary Care

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Source: Primary Care Almanac, VHA Support Service Center, 2011

VETERANS HEALTH ADMINISTRATION

Underlying Causes of Diseases

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Other causes52%

Tobacco18%

Poor diet and physical inactivity

17%

Other preventable

10%

Alcohol consumption

3%

Mokdad et al. JAMA 2004

48% potentially

preventable

VETERANS HEALTH ADMINISTRATION

Prevalence of Health Behaviors

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VETERANS HEALTH ADMINISTRATION

Health Impact of Unhealthy Behaviors

The World Health Organization estimates that...– at least 80% of all heart disease, stroke, and type 2 diabetes, and – more than 40% of cancer

would be prevented if people were to

Stop smokingStart eating healthyGet into shape

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WHO. Preventing Chronic Disease: A Vital Investment, 2005

VETERANS HEALTH ADMINISTRATION

Where Do We Go From Here?

• Effective interventions for poor health behaviors exist

• Health behaviors often not addressed (successfully) and interventions often not provided

• Healthcare staff often not well-trained in appropriate behavior change strategies

• Traditional, directive/persuasive approaches have limited success

• We can shift the medical culture to one marked by patient-centered communication for healthier behaviors

• This is a major transformation!

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VETERANS HEALTH ADMINISTRATION

Assumes knowledge drives change

Clinician sets agenda

Goal is compliance

Decisions made by caregiver

Assumes knowledge + confidence drives change

Patient sets agenda

Goal is enhanced confidence

Decisions made collaboratively

PACT TransformationA Fundamental Shift in the Process of Care

Traditional Care Collaborative Care

(Bodenheimer et al, CA Health Care Foundation, 2005)58

VETERANS HEALTH ADMINISTRATION

National Center for Health Promotion/Disease Prevention (NCP)

• Field-based national program office in the Office of Patient Care Services (PCS)

• Located in Durham, NC• Provides policies, programs, guidance, education,

and support for field related to preventive health• Provides expert input to senior VHA leadership• Collaborates with other VHA offices and federal

agencies

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VETERANS HEALTH ADMINISTRATION

Preparing a Cadre of Prevention Staff to Train, Coach and Consult with Clinicians

• Health coaching

• Motivational interviewing

• Health literacy

• Evidence-based health promotion/disease prevention

• Problem solving approaches

All aimed to support clinical staff members in promoting patient self-management of health behavior.

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Other Team MembersClinical Pharmacy Specialist: ± 3 panelsClinical Pharmacy anticoagulation: ± 5 panelsSocial Work: ± 2 panelsNutrition: ± 5 panelsCase ManagersTraineesIntegrated Behavioral Health

Psychologist ± 3 panelsSocial Worker ± 5 panelsCare Manager ± 5 panelsPsychiatrist ± 10 panels

Monitored via Monitored via Primary Care Primary Care

Staffing and Room Staffing and Room Utilization DataUtilization Datareport in VSSCreport in VSSC

Panel size Panel size adjusted adjusted

(modeled) for (modeled) for rooms and rooms and staffing per staffing per

PCMM PCMM Handbook Handbook

For each parent facilityHPDP Program Manager: 1 FTE 1 FTE Health Behavior Coordinator: 1 FTE1 FTEMy HealtheVet Coordinator: 1 FTE 1 FTE

VETERANS HEALTH ADMINISTRATION

HBC Roles and Responsibilities

o Promotes evidence-based patient-driven care in Health Promotion and Disease Prevention (HPDP).

o Co-chairs the facility HPDP Program Committee.

o Assists the HPDP Program Manager to coordinates strategic planning, program development and implementation, monitoring and evaluation of the overall HPDP Program.

o Leads and coordinates training and ongoing coaching for PACT staff in patient-centered communication, health behavior change coaching, and self-management support strategies, including TEACH for Success and Motivational Interviewing.

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VETERANS HEALTH ADMINISTRATION

HBC Roles and Responsibilities contd.

o Collaborates with the key members of the HPDP Program Committee to plan, develop, implement and assess the impact of clinical interventions to promote health behavior change and self-management.

o Works collaboratively with Mental Health Primary Care Integration staff to integrate behavioral medicine interventions and services with other behavioral health interventions and programs.

o Supports and contributes to existing smoking and tobacco use cessation clinical initiatives.

o Performs specialty health psychology assessment/intervention (e.g., pre-bariatric surgery, Veterans with unique or complex problems impacting self-management plans).

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CCC and HBCCo-Located Collaborative MH Care Health Behavior Coordinator

Location On site, embedded in the PC clinic On site, embedded with PACT

Population* Most are healthy, mild-mod symptoms, behaviorally influenced problems.

Provider training focus. PACT clinical work focused on health behaviors and prevention.

Inter-Provider Communication

Collaborative & on-going consultations via PCP’s method of choice (phone, note, conversation). Focus within PACT.

Collaborative & on-going with focus on communication skills and coaching (F2F, phone…). Focus within PACT and HPDP staff.

Service Delivery Structure*

Brief appointments (20-30’)Limited # of appointments (avg. 2-3)Open Access

Role focus on training PACT clinicians (70+%) in patient-centered communication. Limited (25-30%) clinical care, prevention focused, often group. Brief appointments (30-40’).

Approach Problem-focused, solution oriented, functional assessment. Focused on PCP question/concern and enhancing PCP care plan. Population health model.

Health behavior focused, solution oriented, problem-solving and goal setting. Focused on PCP identified health concerns and optimizing health. Population health model.

Treatment Plan Leader PCP continues to be lead PCP continues to be lead.

Primary Focus Support the over-all health of the Veteran.Focus on function.

Support the overall health of the Veteran. Focus on health behavior.

VETERANS HEALTH ADMINISTRATION

Differences

• PC-MHI focus on mental health concerns, and HBCs on prevention/health behaviors.

• HBCs part-time clinical (25-30%), PC-MHI full-time, and HPDPs administrative. Access options vary.

• HBC’s main mission is to train and coach PACT staff in patient-centered communications, PC-MHI main mission is direct patient service via brief evidence-based care.

• HBCs provide specific assessments related to prevention, such as pre-Bariatric Surgery evaluations.

• HBCs often report to Primary Care; PC-MHI generally report to Mental Health.

• HBCs are responsible for CBOCs too.66

VETERANS HEALTH ADMINISTRATION

Similarities

• Both are PACT-based, behavioral health staff• Neither provide traditional psychotherapy services• Both can offer holistic and systems perspectives, helping

PACT staff be effective• Both might address alcohol misuse, tobacco cessation,

weight management, sleep difficulties, pain management, adherence concerns, problem-solving…others?

• Both can organize interventions in 5 A’s model• Both provide time-limited, solution oriented

interventions

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VETERANS HEALTH ADMINISTRATION

In sum, what can HBCs & PC-MHI staff offer their colleagues in the medical home?

• Increased comfort in “challenging” interactions with patients (and staff!) with shift to collaboration vs. traditional, prescriptive approach

• Patient and provider behavior change (communication, health behaviors…)

• Systems shifts to support Veteran-centered care (flexible delivery methods, accessible/efficient care delivery…)

• Provider and patient skill development • Focus on “the conversation” and interactions that

address meaningful change for given individuals• Increased clinician and patient satisfaction

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VETERANS HEALTH ADMINISTRATION

Questions or Ideas to Share?

National Center for Health Promotion and Disease Prevention (NCP)

Office of Patient Care ServicesVeterans Health Administration

Margaret (Peg) Dundon, PhDmargaret.dundon@va.gov

3022 Croasdaile Drive, Suite 200Durham, NC 27705

(919) 383-7874 or (716) 604-5446 (m)www.prevention.va.gov

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