Management of Mental Disorders in VA Primary Care Practices

VA Pittsburgh Healthcare System, Pittsburgh, PA 15240, USA.
Administration and Policy in Mental Health and Mental Health Services Research (Impact Factor: 3.44). 04/2006; 33(2):208-14. DOI: 10.1007/s10488-006-0034-6
Source: PubMed


The association between facility-level organizational features and management of mental health services was assessed based on a survey of directors from 219 VA primary care facilities. Overall, 26.4% of VA primary care facilities referred patients with depression, while 72.6% and 46.1% referred patients with serious mental illness and substance use disorders, respectively Staffing mix (i.e., physician extenders such as nurse practitioners) was associated with a lesser likelihood of mental health referral. Managed care (preauthorization requirement) was associated with a greater likelihood of referral for depression. VA primary care programs, while tending to refer for more serious mental illnesses, may also be using mental health specialists and physician extenders to provide mental health care within general medical settings.

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    • "Contextual factors include measures of practice size (number of office locations), urban/non-urban location, and academic affiliation from the Primary Care Practices Survey [9]. All of these factors were found to be associated with depression care referral practices [63]. "
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    ABSTRACT: Evidence-based quality improvement models for depression have not been fully implemented in routine primary care settings. To date, few studies have examined the organizational factors associated with depression management in real-world primary care practice. To successfully implement quality improvement models for depression, there must be a better understanding of the relevant organizational structure and processes of the primary care setting. The objective of this study is to describe these organizational features of routine primary care practice, and the organization of depression care, using survey questions derived from an evidence-based framework. We used this framework to implement a survey of 27 practices comprised of 49 unique offices within a large primary care practice network in western Pennsylvania. Survey questions addressed practice structure (e.g., human resources, leadership, information technology (IT) infrastructure, and external incentives) and process features (e.g., staff performance, degree of integrated depression care, and IT performance). The results of our survey demonstrated substantial variation across the practice network of organizational factors pertinent to implementation of evidence-based depression management. Notably, quality improvement capability and IT infrastructure were widespread, but specific application to depression care differed between practices, as did coordination and communication tasks surrounding depression treatment. The primary care practices in the network that we surveyed are at differing stages in their organization and implementation of evidence-based depression management. Practical surveys such as this may serve to better direct implementation of these quality improvement strategies for depression by improving understanding of the organizational barriers and facilitators that exist within both practices and practice networks. In addition, survey information can inform efforts of individual primary care practices in customizing intervention strategies to improve depression management.
    Implementation Science 12/2009; 4(1):84. DOI:10.1186/1748-5908-4-84 · 4.12 Impact Factor
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    • "One potential explanation is that mental health disorders are common among veterans and because it is a common condition, there may be less of a physician bias in the VHA compared to non-VHA settings. Finally, prior studies have shown that a collaborative care model between primary care and mental health providers for VHA patients with depression is associated with more rapid improvement in symptoms as well as mental health status [18,19]. Additional studies are needed to determine if such a care model for patients with concomitant cardiovascular and severe mental illness will lead to improved patient outcomes. "
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    ABSTRACT: Severe mental illness (SMI) has been associated with more medical co-morbidity and less cardiovascular procedure use for older patients with myocardial infarction. However, it is unknown whether SMI is associated with increased long term mortality risk among patients presenting with acute coronary syndromes (ACS). We tested the hypothesis that SMI is associated with higher one-year mortality following ACS hospitalization. All ACS patients (n = 14,194) presenting to Veterans Health Administration (VHA) hospitals between October 2003 and September 2005 were included. Survival analysis evaluated the association between SMI and one-year all-cause mortality, adjusting for demographics, co-morbidities, in-hospital treatment, and discharge medications. Overall, 18.4 % of ACS patients had SMI. Patients with SMI were more likely female, younger, Caucasian race, have a history of alcohol abuse, liver disease, dementia, hypertension and more likely to be a current smoker; however, prior cardiac history was similar between the 2 groups. There were no significant differences in cardiac procedure use, including coronary angiogram (38.7% vs. 40.3%, p = 0.14) or coronary revascularization (31.0% vs. 32.3%, p = 0.19), and discharge medications between those with and without SMI. One-year mortality was lower for patients with SMI (15.8% vs. 19.1%, p < 0.001). However, in multivariable analysis, there were no significant differences in mortality (HR 0.91; 95% CI 0.81-1.02) between patients with and without SMI. Among ACS patients in the VHA, SMI is prevalent, affecting almost 1 in 5 patients. However, patients with SMI were as likely to undergo coronary revascularization and be prescribed evidence-based medications at hospital discharge, and were not at elevated risk of adverse 1-year outcomes compared to patients without SMI.
    BMC Health Services Research 09/2007; 7(1):146. DOI:10.1186/1472-6963-7-146 · 1.71 Impact Factor
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    ABSTRACT: The formal mission and strategic goals of the Center for the Study of Healthcare Provider Behavior (see bottom of this page) guide our activities in the do- mains of research, dissemination, technical assis- tance and training. Our mission and activities are also guided by the strategic priorities and mission of the Veterans Health Administration (VHA). VHA's current strategic emphasis is provided by the "Eight for Excellence" framework, comprising eight broad goals and associated strategies and initiatives. This overview article highlights selected Center activities supporting key goals and strategies in the Eight for Excellence initiative. Many of the Eight for Excellence goals emphasize continuous improvement in healthcare quality and safety. For example, Goal 1 broadly addresses continuous improvement in the quality and safety of health care for veterans, while Goal 5 calls for in- creased focus of VHA research and development activities on clinical and system improvements, including increased collaboration between VHA research and health care delivery and increased targeting of VHA health services research and the QUERI model to improve care delivery. These goals entail substantial overlap with our Cen- ter's core mission and activities: our portfolio of projects in research, technical assistance and train- ing are designed to strengthen VHA's ability to improve quality and safety through implementation of evidence-based practices. Center researchers are pursing improvement in tobacco use (Judith Katz-
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