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Determinants of Readiness for Primary Care-Mental Health Integration (PC-MHI) in the VA Health Care System

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ABSTRACT

BACKGROUND

Depression management can be challenging for primary care (PC) settings. While several evidence-based models exist for depression care, little is known about the relationships between PC practice characteristics, model characteristics, and the practice’s choices regarding model adoption.

OBJECTIVE

We examined three Veterans Affairs (VA)-endorsed depression care models and tested the relationships between theoretically-anchored measures of organizational readiness and implementation of the models in VA PC clinics.

DESIGN

1) Qualitative assessment of the three VA-endorsed depression care models, 2) Cross-sectional survey of leaders from 225 VA medium-to-large PC practices, both in 2007.

MAIN MEASURES

We assessed PC readiness factors related to resource adequacy, motivation for change, staff attributes, and organizational climate. As outcomes, we measured implementation of one of the VA-endorsed models: collocation, Translating Initiatives in Depression into Effective Solutions (TIDES), and Behavioral Health Lab (BHL). We performed bivariate and, when possible, multivariate analyses of readiness factors for each model.

KEY RESULTS

Collocation is a relatively simple arrangement with a mental health specialist physically located in PC. TIDES and BHL are more complex; they use standardized assessments and care management based on evidence-based collaborative care principles, but with different organizational requirements. By 2007, 107 (47.5 %) clinics had implemented collocation, 39 (17.3 %) TIDES, and 17 (7.6 %) BHL. Having established quality improvement processes (OR 2.30, [1.36, 3.87], p = 0.002) or a depression clinician champion (OR 2.36, [1.14, 4.88], p = 0.02) was associated with collocation. Being located in a VA regional network that endorsed TIDES (OR 8.42, [3.69, 19.26], p < 0.001) was associated with TIDES implementation. The presence of psychologists or psychiatrists on PC staff, greater financial sufficiency, or greater spatial sufficiency was associated with BHL implementation.

CONCLUSIONS

Both readiness factors and characteristics of depression care models influence model adoption. Greater model simplicity may make collocation attractive within local quality improvement efforts. Dissemination through regional networks may be effective for more complex models such as TIDES.

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Acknowledgements

Contributors

Contributors include Steven Asch, MD MPH, Ann Chou, PhD, Johanna Klaus, PhD, Edmund Chaney, PhD, John McCarthy, PhD, Michael Mitchell, PhD, Susan Stockdale, PhD, and Brian Mittman, PhD.

The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs, or the US government, or other affiliated institutions.

Funders

Funding support provided by VA Office of Academic Affiliations, Health Services Research and Development through the Health Services Fellowship Training Program (TMP 65-020). Dr. Yano’s time was funded by the VA HSR&D Service through a Research Career Scientist Award (Project # RCS 05-195). The project was also supported by VA HSR&D Project #09-082 (Yano, PI).

Prior Presentations

Oral abstracts summarizing these findings were presented at the Society of General Internal Medicine 35th Annual Meeting on May 9-12, 2012 in Orlando, Florida, and the Academy Health Annual Research Meeting on June 25–27, 2012 in Orlando, Florida.

Conflict of Interest

The authors declare that they do not have a conflict of interest.

Author information

Authors and Affiliations

  1. VA Greater Los Angeles, General Internal Medicine, Los Angeles, CA, USA

    Evelyn T. Chang MD

  2. VA HSR&D Center of Excellence for the Study of Healthcare Provider Behavior, Sepulveda, CA, USA

    Danielle E. Rose PhD, MPH, Elizabeth M. Yano PhD, MSPH, Martin L. Lee PhD & Lisa V. Rubenstein MD, MSPH

  3. UCLA School of Public Health, Department of Health Services, Los Angeles, CA, USA

    Elizabeth M. Yano PhD, MSPH, Kenneth B. Wells MD, MPH & Martin L. Lee PhD

  4. UCLA Psychiatry and Biobehavioral Sciences, Los Angeles, CA, USA

    Kenneth B. Wells MD, MPH

  5. RAND, Santa Monica, CA, USA

    Kenneth B. Wells MD, MPH & Lisa V. Rubenstein MD, MSPH

  6. VA Center for Clinical Management Research and Serious Mental Illness Treatment Resource and Evaluation Center, Ann Arbor, MI, USA

    Maureen E. Metzger PhD, MPH & Edward P. Post MD, PhD

  7. Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, MI, USA

    Edward P. Post MD, PhD

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  1. Evelyn T. Chang MD
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Correspondence to Evelyn T. Chang MD.

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Chang, E.T., Rose, D.E., Yano, E.M. et al. Determinants of Readiness for Primary Care-Mental Health Integration (PC-MHI) in the VA Health Care System. J GEN INTERN MED 28, 353–362 (2013). https://doi.org/10.1007/s11606-012-2217-z

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  • DOI: https://doi.org/10.1007/s11606-012-2217-z

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