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VA Primary Care-Mental Health Integration (PC-MHI). Edward Post, MD, PhD National PC-MHI Medical Director.

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VA Primary Care-Mental Health Integration (PC-MHI)

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va primary care mental health integration pc mhi

VA Primary Care-Mental Health Integration (PC-MHI)

Edward Post, MD, PhD

National PC-MHI Medical Director

primary care mental health integration

“Primary care practitioners are a critical link in identifying and addressing mental disorders... Opportunities are missed to improve mental health and general medical outcomes when mental illness is under-recognized and under-treated in primary care settings.”

- Former Surgeon General David Satcher

“The greatest mistake in the treatment of diseases is that there are physicians for the body and physicians for the soul, although the two cannot be separated.”

- Plato

Primary Care-Mental Health Integration
primary care landscape

Chronic disease

  • Multiple comorbidities
  • Need for interdependent skills across medical disciplines and teams
  • Patient outcomes are interdependent
    • Multiple studies show depression has an independent effect on all-cause mortality(Gallo et al., 2005; Penninx et al., 1999; Bruce and Leaf, 1989)
    • Data from late-life depression trial shows integrated care can decrease mortality (Gallo et al., 2007)
Primary Care Landscape
why integrate mental health services into primary care

Integrated mental health care...

  • Improves identification of prevalent mental health conditions
  • Improves access to appropriate evaluation and treatment
  • Improves treatment engagement and adherence
  • Increases probability of receiving high quality care
  • Improves clinical and functional outcomes
  • Increases patient satisfaction
Why Integrate Mental Health Services into Primary Care?
pc mhi evidence base

Improved identification

    • Improved identification of depression, psychiatric

co-morbidities and substance misuse (Oslin et al., 2006)

    • Improved identification of depression (Watts et al., 2007)
  • Improved access
    • Increased rates of treatment (Alexopoulos et al., 2009; Watts et al., 2007; Bartels et al., 2004; Hedrick et al., 2003; Liu et al. 2003; Unützer et al., 2002)
    • Reduced wait times (Pomerantz et al., 2008)
PC-MHI Evidence Base
pc mhi evidence base7

Improved engagement and adherence

    • Improved engagement in mental health treatment

(Zanjani et al., 2008)

    • Improved engagement and adherence in treatment for depression and at-risk alcohol use (Bartels et al., 2004)
    • Greater antidepressant adherence (Hunkeler et al., 2006; Katon et al., 1999, 2002)
    • Improved no-show rates (Pomerantz et al., 2008; Zanjani et al., 2008; Guck et al., 2007)
  • Higher quality care
    • Increased probability of receiving guideline-concordant treatment (Watts et al., 2007; Roy-Byrne et al., 2001)
    • Higher patient perceptions of quality of care (Katon et al., 1999)
PC-MHI Evidence Base
pc mhi evidence base8

Better clinical and functional outcomes

    • Improved short and long term clinical (remission; symptom reduction) and functional outcomes compared to standard care for depression (Alexopoulos et al., 2009; Gilbody et al., 2006; Hunkeler et al., 2006; Katon et al., 2002; Unützer et al., 2002; Roy-Byrne et al., 2001; Katon et al., 1999)
    • Similar remission rates and symptom reduction for depression compared to enhanced specialty referral (Krahn et al., 2006)
    • Decrease in at-risk alcohol use comparable to enhanced specialty referral (Oslin et al., 2006)
    • More rapid clinical response (Alexopoulos et al., 2009; Hedrick et al., 2003)
    • Higher fidelity to integrated care model resulted in better patient response and remission rates (Oxman et al., 2006)
  • Increased patient satisfaction

(Pomerantz et al., 2008; Hunkeler et al., 2006; Chen et al., 2006; Areán et al., 2002; Unützer et al., 2002)

PC-MHI Evidence Base
primary care mental health integration10

Two PC-MHI Components:

    • Co-located Collaborative Care
      • White River Junction
    • Care Management
      • TIDES, Behavioral Health Laboratory
  • Blended programs have both of these complementary components
  • Focus on common conditions:
    • Depressive and Anxiety Disorders
    • Alcohol Misuse and Abuse
    • PTSD Screening/Assessment
Primary Care-Mental Health Integration
necessary integrated care processes


    • Screening in primary care
  • Assessment and triage to appropriate level of service
  • A spectrum of services
    • Monitoring or watchful waiting
    • Brief interventions (e.g., for alcohol misuse)
    • Medication therapies
    • Psychotherapies
  • Follow-up and monitoring
  • Quality control and efficiency
Necessary Integrated Care Processes


introduction to co located collaborative care ccc

Co-location/Co-located ServiceAbehavioral health provider working in a space that is in close proximity to (or embedded in) a primary care clinic.Collaborative Care/CollaborationThe interactions between primary care and behavioral health providers for the purpose of developing treatment plans, providing clinical services and coordinating care to meet the physical and behavioral health needs of patients

Introduction to Co-located Collaborative Care (CCC)

What is Co-located Collaborative Care in PC-MHI?

care management models in pc mhi
Translating Initiatives for Depression into Effective Solutions (TIDES)
    • Evidence-based collaborative care model supporting depression management in the primary care setting
    • Has promoted improvements in treatment adherence for Veterans with depression in several VISNs
  • Behavioral Health Laboratory (BHL)
    • Evidence-based clinical service supporting mental health and substance abuse management in the primary care setting
    • Associated with a significant increase in screening and identification of patients needing MH/SA services (Oslin, et. al. 2005)
Care Management Models in PC-MHI
Care Managers

Role of the Care Manager

  • Nurses and social workers are core profession, but others serve as care managers also
  • Interact directly with patients and PCPs, facilitating ongoing evaluation and communication allowing care to remain in primary care
  • Assessment and triage
  • Decision support
  • Patient education and activation
  • Monitor adherence to treatment, treatment outcomes, and medication side effects
  • Referral management
  • Support patient self-management
introduction to blending pc mhi programs

Blended programs combine both care management and co-located collaborative care

      • In the blended program, the co-located collaborative mental health provider evaluates patients and offers treatment when needed, while the PC-MHI care manager provides complementary services including education, assessment, monitoring of adherence, use of medication and referral to specialty care when necessary
Introduction to Blending PC-MHI Programs

What is a Blended PC-MHI Program?

core components of an effective blended mh integration program

Strong collaborative system between primary care, mental health and other health care specialists

  • Stepped care approached to providing a continuum of care within the PC-MHI program
  • Ability to rapidly evaluate and stabilize patient in primary care clinic
  • Ability to do seamless referral, if needed
  • Ability to implement evidence-based treatment plans
  • Ability to collect objective clinical and administrative outcome data
Core Components of an Effective Blended MH Integration Program
history of va pc mhi implementation

Large-scale implementation began in 2007 with RFP funding for pilot programs of a single component at 94 of 139 VA health systems

  • Late 2008: Uniform MH Services Package extended focus
  • VHA Handbook 1160.01 requires that VAMCs, extra large CBOCs, and large CBOCs integrate primary care and mental health by blending both co-located collaborative care and care management
History of VA PC-MHI Implementation


uniform mental health services package

VAMCs & extra large CBOCs (>10K uniques) need full-time availability of both co-located services & care management

    • Large CBOCs (5K-10K uniques) need co-located services & care management, availability as appropriate
    • Medium-sized CBOCs (1.5K-5K uniques) need on-site MH services, configured (integrated vs. MH clinic) as appropriate
  • Small CBOCs need to provide access to MH services
Uniform Mental Health Services Package
service utilization data
Service Utilization Data

Service Utilization Data reported from facility stop code usage

pc mhi state of the field
PC-MHI: State of the Field

The PC-MHI Penetration Rate is the number of unique PC-MHI encounters divided by the number of unique Primary Care encounters

→Please note that there is not a PC-MHI penetration rate performance measure or target

national pc mhi program office

Principal Contact:

Maureen Metzger, PhD, MPH

National Program Manager


  • Thank you to many faculty who collaborate in presenting our training programs, and to innumerable persons who are implementing PC-MHI throughout VA!
National PC-MHI Program Office