Team-based Primary Care and Suicide Prevention in the Veterans Health Administration. May 18 th, 2016

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1 Team-based Primary Care and Suicide Prevention in the Veterans Health Administration May 18 th, 2016

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2 Technical Tips Audio is broadcast through computer speakers If you experience audio issues, dial (866) and mute computer speakers Download resources from File Share pod You are muted ] Use the Q & A to ask questions at any time This session is being recorded suicideprevention-icrc-s.org 2

3 The Impact of Team-based Collaborative Care on Suicide Prevention Efforts in the VHA: Provider Perspectives May 18, 2016 PRESENTATION TO URMC S INJURY CONTROL RESEARCH CENTER FOR SUICIDE PREVENTION VETERANS ADMINISTRATION VISN2 CENTER OF EXCELLENCE FOR SUICIDE PREVENTION Brooke A. Levandowski, PhD, Research Assistant Professor, Department of Family Medicine, SUNY Upstate Medical University and Marsha Wittink, MD, MBE, Assistant Professor, Departments of Psychiatry and Family Medicine, University of Rochester Medical Center

4 Acknowledgements No external funding or conflicts of interest to declare. This presentation is based upon the work supported by the Department of Veterans Affairs, Veterans Health Administration, Center of Excellence for Suicide Prevention, and Office of Mental Health Services. The views expressed in this presentation are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

5 Acknowledgements Center of Excellence for Suicide Prevention in Canandaigua, NY: Jane Wood, RN Melanie Chelenza, MS Wil Pigeon, PhD VISN2 Primary Care Council: Lynn Wetterau, BSMT, MHA John Langenberg, MD VISN2 Behavioral Health Careline: Bruce Nelson, PhD Center for Integrated Healthcare in Syracuse, NY: Larry Lantinga, PhD Jen Funderburk, PhD

6 Poll #1- about you What is your primary role? Research investigator Data manager/analyst Project coordinator Clinician 6

7 Poll #2: Who do you think Veterans would feel most comfortable talking about suicide with? Primary Care Support Staff Nurses Primary Care Providers Behavioral Health Providers Social Workers Peer Support Specialists 7

8 Poll #3: Who do you think Veterans would feel most comfortable talking about hopelessness or life challenges with? Primary Care Support Staff Nurses Primary Care Providers Behavioral Health Providers Social Workers Peer Support Specialists 8

9 Background Veterans are at increased risk for suicide compared to the general population Primary care has been identified as a critical venue for prevention of suicide among Veterans Over the last decade the VHA has made great strides in developing new primary care-based interventions for screening and prevention of suicide None-the-less, suicide rates among Veterans enrolled in VHA care have not changed significantly In contrast, suicide rates among Veterans outside VHA have risen 9

10 Provision of primary care is changing Patients with multiple chronic conditions Changing medical landscape Mental health and quality of life concerns Models of team-based care with integrated mental health providers 10

life concerns VHA has used Patient Aligned Care Teams (PACT) since

11 Provision of primary care is changing Patients with multiple chronic conditions Changing medical landscape Mental health and quality of life concerns VHA has used Patient Aligned Care Teams (PACT) since 2010 Models of team-based care with integrated mental health providers 11

12 Stakeholder Collaboration Center of Excellence for Suicide Prevention Center for Integrated Health care VISN 2 Mental Health lead VISN 2 leadership Commitment to reducing Veteran deaths at regional level VISN 2 Primary Care lead 12

13 Study objectives To evaluate primary care based suicide prevention efforts in one geographical region of the VHA To assess provider stakeholder perspectives to ascertain how suicide prevention processes are being implemented in the context of newer team-based/ collaborative care initiatives, in order to: To identify best practices and enhance care provision and reduce suicide

14 Methods: Qualitative Assessment What do key provider stakeholders (PCPs, nurses and BH specialists) see as the facilitators and barriers to current suicide prevention efforts within primary care? Emphasis on screening, communication between clinicians and between clinicians and Veterans within the PACT model Competence and autonomy with screening and protocols

15 Focus group participants Providers from six regions located within one Veterans Administration catchment area in the northeastern US Nurses RNs and LPNs Behavioral health specialists Integrated behavioral health specialists, psychiatrists, psychologists, social workers Primary care providers MDs (internists, geriatricians) Data collection 8 focus groups with nurses and behavioral health providers 8 in-depth interviews with primary care providers and integrated behavioral health providers

16 Data analyses Analysis of transcripts: Simultaneous deductive and inductive content analysis focus on across and within group differences and similarities 16

17 General Findings: Primary care as unique entry point for suicide prevention We re the first contact point of patients when they are in distress, and we are in the position to screen for the people that are under the radar and not complaining. -Primary care physician I think primary care providers will see a lot of people that won t necessarily make it to behavioral health providers. So you know, having people be aware and comfortable with how to assess for suicide is really important, because they can catch a lot of people that behavioral health s people won t get to see. -Nurse 17

facilitators relationship building between clinicians and

18 Overarching ideas discussed PACT functioning Suicide prevention within PACTs fluid communication exchanges facilitators relationship building between clinicians and Veteran-clinician dyads barriers expertise and role differentiation

19 Themes related to PACT functioning PACT functioning fluid communication exchanges relationship building between clinicians and Veteranclinician dyads Dyads: Clinician Clinician Veteran Clinician

20 Advantages of PACT: Fluid communication exchanges On the teams where it really comes along from the people who are answering the phone all the way up if they are- if the patients are connected to you guys as a team, they re dropping information all the way through. They can then get passed back. Because when the team works well, everybody trusts they ve worked together, and they ve formed relationship where there s a lot of trust involved within the team. So it s very beneficial to the patient, because then on top of it, the patient knows who to go to, and that we developed personal relationships, or she, within the team. -Nurse

21 Building relationships Clinician-Veteran dyads They [nurses and other PACT members] are pretty helpful because they ve been here for a much longer time. They know patient[s] very well, better than me The patient[s] want to talk to people who they know. They probably tell them more information than me, before they see me even. -PCP Between clinicians in PACT You develop a very close relationship with your provider [PCP], and you sort of know what they expect. They know what to expect from you. Your whole day you re just, you know, together through the whole process and discuss a lot of things about the patients. -Nurse

22 Themes related to Suicide Prevention efforts Suicide prevention within PACTs facilitators barriers expertise and role differentiation

23 Facilitators: shared responsibility PCPs I think the initiation of the behavioral health person imbedded into our clinic has really been so helpful to us that warm handoff is tremendous for us as a support Nurses having people be aware and comfortable with how to assess for suicide is really important we have an important responsibility that brings us together Behavioral health providers: everybody plays an essential role and I ve noted that PCPs are not afraid to ask for help

24 Facilitators: shared conceptualizations of roles PCP as conduit MAKING CONNECTIONS Nurse as advocate KNOWING THE PATIENT RECOGNIZING SUBLITIES AND NUANCES Behavioral health providers as actuaries RISK ASSESSMENT EXPERT COMMUNICATORS

25 Facilitators: shared conceptualizations of roles PCP as conduit it scares the living daylights out of me when they say yes but I know I have to ask - PCP I always let the PCP know but it s a definite that you re going to go find a psychologist Nurse Nurse as advocate KNOWING THE PATIENT RECOGNIZING SUBLITIES AND NUANCES Behavioral health providers as actuaries RISK ASSESSMENT EXPERT COMMUNICATORS

26 Facilitators: shared conceptualizations of roles PCP as conduit it scares the living daylights out of me when they say yes but I know I have to ask - PCP I always let the PCP know but it s a definite that you re going to go find a psychologist Nurse Nurse as advocate my nurse she is very good at finding out Oh the wife died a month ago you may want to know that - PCP we can notice the subtle changes in their personalities there s something not right we can pick up on -Nurse Behavioral health providers as actuaries RISK ASSESSMENT EXPERT COMMUNICATORS

27 Facilitators: shared conceptualizations of roles PCP as conduit it scares the living daylights out of me when they say yes but I know I have to ask - PCP I always let the PCP know but it s a definite that you re going to go find a psychologist Nurse Nurse as advocate my nurse she is very good at finding out Oh the wife died a month ago you may want to know that - PCP we can notice the subtle changes in their personalities there s something not right we can pick up on -Nurse Behavioral health providers as actuaries we really have to delve in for the suicidal issues too, because that s what they don t want to say we ll triage them, and then make a decision on what to do BHP they have a very direct communication style and know how to ask [about suicide] -PCP

28 Barriers: different barriers noted by different clinicians PCPs: Patient concern about consequences Nurses: Stigma Time constraints BHPs: Flag Fatigue

29 Barriers: different barriers noted by different clinicians PCPs: Patient concern about consequences they don t want to engage they may be afraid that they re going to be forcibly committed Nurses: Stigma Time constraints BHPs: Flag Fatigue

30 Barriers: different barriers noted by different clinicians PCPs: Patient concern about consequences they don t want to engage they may be afraid that they re going to be forcibly committed Nurses: Stigma There is unfortunately a lot of negative stigma still associated with any kind of mental health issue Time constraints Their appointments are just loaded to the hilt, every half hour that s where we lose in primary care the most important things all around things you should be asking [about suicide]. And I think it s not their fault There s not enough time. BHPs: Flag Fatigue

31 Barriers: different barriers noted by different clinicians PCPs: Patient concern about consequences they don t want to engage they may be afraid that they re going to be forcibly committed Nurses: Stigma There is unfortunately a lot of negative stigma still associated with any kind of mental health issue Time constraints Their appointments are just loaded to the hilt, every half hour that s where we lose in primary care the most important things all around things you should be asking [about suicide]. And I think it s not their fault There s not enough time. BHPs: Flag Fatigue it s almost like we have our own system. We know who s really high risk and then who carries a flag simply because they said they were suicidal simply to get help now it s so overkill, everybody is being monitored

32 Overall findings to influence future studies Across all focus groups, similar facilitators for suicide prevention in primary care were identified as shared responsibility and differentiated roles within PACTs. Suicide prevention was seen as a priority for primary care. Team approach and shared responsibility seen as helpful. Team members noted importance of: coordination and vigilance across the team the convenience of having co-located behavioral health resources Clinicians were seen as having unique roles to play in prevention. How can these various roles be leveraged? 32

clinicians and Veteran-clinician dyads Suicide prevention

33 Overarching Ideas Discussed: Next Steps PACT functioning Fluid communication exchanges Relationship building between clinicians and Veteran-clinician dyads Suicide prevention within PACTs Barriers Facilitators Expertise and role differentiation

34 Next Steps: Mixed Methods Hypothesis generating testing Quantitative electronic survey given to all clinicians(pcp, nurses, BHP) in VISN 2; n=138 complete surveys No difference across providers or sites in confident with depression/suicide screening No difference in feeling supported by VHA BHPs were more likely than PCPs and nurses to feel confident in their ability to talk with patients who are suicidal. Preliminary data on role-differentiation/expertise: PCPs least recognized as playing a unique role Patient stakeholder perspectives Chart review to determine time-line of care In-depth interviews to obtain perspective of care and recommendations 34

Intervention development and testing (capitalizing on the added value of PACT) Capitalize on expertise of each member in primary care Further integrate suicide prevention into overall healthcare

35 Intervention development and testing (capitalizing on the added value of PACT) Capitalize on expertise of each member in primary care Further integrate suicide prevention into overall healthcare team function Might further explore nurses unique relationships to patients Nurses and PCMHI providers in particular might be well-positioned to help link the care team to the patient s community. 35

36 Selected references Fortin M, Bravo G, Hudon C, Vanasse A, Lapointe L. Prevalence of multimorbidity among adults seen in family practice. Ann Fam Med. May-Jun 2005;3(3): Fortin M, Lapointe L, Hudon C, Vanasse A, Ntetu AL, Maltais D. Multimorbidity and quality of life in primary care: a systematic review. Health and quality of life outcomes. 2004;2:51. Bodenheimer T, Ghorob A, Willard-Grace R, Grumbach K. The 10 building blocks of high-performing primary care. Ann Fam Med. Mar-Apr 2014;12(2): Willard-Grace R, Hessler D, Rogers E, Dube K, Bodenheimer T, Grumbach K. Team structure and culture are associated with lower burnout in primary care. J Am Board Fam Med. Mar-Apr 2014;27(2): Misra-Hebert AD, Rabovsky A, Yan C, Hu B, Rothberg MB. A Team-based Model of Primary Care Delivery and Physician-patient Interaction. The American journal of medicine. Sep 2015;128(9): Zeiss AM, Karlin BE. Integrating mental health and primary care services in the Department of Veterans Affairs health care system. Journal of clinical psychology in medical settings. Mar 2008;15(1): Rosland AM, Nelson K, Sun H, et al. The patient-centered medical home in the Veterans Health Administration. The American journal of managed care. Jul 2013;19(7):e Ladebue AC, Helfrich CD, Gerdes ZT, Fihn SD, Nelson KM, Sayre GG. The experience of Patient Aligned Care Team (PACT) members. Health care management review. Dec

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