Mental Health Care at the Providence VA Medical Center: Providing ...

Mental Health Care at the Providence VA Medical Center:Providing Integrated Comprehensive Mental Health ServicesMichael G. Goldstein, MDThough mental health care has alwaysbeen a core element of the Veterans Affairs(VA) health care system, in recentyears mental health care has receivedgreatly increased attention, support andresources from the Veterans Health Administration(VHA). TheVHA’s 2004Comprehensive Mental Health StrategicPlan (MHSP) 1 included over 200initiatives designed to enhance mentalhealth care and integrate mental healthcare with other VHA healthcare services,particularly in Primary Care. The MHSPled to the funding of the VA’s MentalHealth Enhancement Initiative, whichallocated funds to create a number ofnew mental health services and the expansionof several others at PVAMC.The VHA Handbook, Uniform MentalHealth Services in VA Medical Centersand Clinics, issued in June 2008 and updatedin September 2008, 2 establishesminimum clinical requirements for VHAmental health services and serves as a blueprintfor the implementation of the MHSPat all VA Medical Centers. The UniformMental Health Services initiative seeks tocreate “a system providing ready access tocomprehensive, evidence-based mentalhealth care.” The handbook outlines thoseservices that must be provided at each VAMedical Center (VAMC), as well as thegeneral principles that must guide thedelivery of all mental health care.These principles include: 1) mentalhealth care is an essential component ofoverall health care: 2) mental health caremust be integrated or coordinated withother health care, especially primary care;3) care must be patient-centered, recovery-focusedand strength-based and mustemphasize the importance of engaging patientsin decision-making, treatment planningand self-management; 4) cliniciansmust be culturally competent, includinghaving an understanding of military andveterans’ culture; 5) care should be evidence-basedand consistent with currentresearch and practice guidelines; 6) familyinvolvement in care and treatment decisionsshould be offered when desiredby the veteran; and 7) program and servicesshould be linked to programs andresources in the community to enhancethe veteran’s access to these resources andto allow him or her to become a more engagedand supported member of community-basedsocial networks.In this paper, we will provide severalexamples of these new services.THE GROWTH OF MENTAL HEALTHSERVICES AT THE PVAMCOf the 30,000 veterans enrolled at thePVAMC, more than 8,000 received mentalhealth care in the fiscal year 2008-2009.We are on track to record over 90,000 outpatientencounters in 2008-9 within a widevariety of outpatient mental health treatmentprograms. The majority of these veterans aretreated at the Providence VA MedicalCenter’s main campus, while a rapidly growingnumber of veterans receive care at our 3Community-Based Outpatient Clinics(CBOCs) in Middletown, RI, and in NewBedford and Hyannis, MA. Veterans requiringsupervised living receive clinical and caremanagement services within VA-approvedcommunity-based residential care facilitiesthroughout Rhode Island and southeasternMassachusetts. Figures 1 and 2 show substantialgrowth of our patient population andthe number of outpatient mental healthencounters at PVAMC over the last 7 years.Since 2003, we have experienced a 68%increase in the number of veterans servedand a 58% increase in outpatient encounters.PVAMC supports 115 full time equivalentpositions across MHBSS programs, adramatic increase over the past 7 years. Ourstaff includes social workers, psychologists,psychiatrists, nurses, pharmacists, administrative/clericalstaff and addiction and vocationalcounselors. We also provide trainingopportunities for trainees from virtually allthese disciplines and we enjoy academic affiliationswith the Warren Alpert MedicalSchool of Brown University, the Universityof Rhode Island, and Rhode Island College.These increases in patients and staffingare largely a result of significant expansionand enhancement of mental health programsand services at PVAMC, spurred by theVHA’s Comprehensive Mental Health StrategicPlan and Mental Health EnhancementInitiatives. As noted, the VHA is deeply committedto putting mental health care on apar with other health care services. AtPVAMC, we are grateful for having receivedour fair share of enhancement funds fromthe VHA. Enhancement Initiatives have ledto the launching of a number of new servicesat PVAMC over the last several years,including: the Opiate Treatment Program;an Intensive Outpatient Substance AbuseTreatment Program; a Mental Health IntensiveCase Management (MHICM) programfor patients with serious and persistentmental illness, based on the evidence-basedAssertive Community Treatment model 3 ; aReturning Veterans Mental Health program;an Integrated Mental Health-Primary CareFigure 1. Unique MHBSS Patients Served at Providence VA Medical Center, 2003-2009VOLUME 93 NO. 1 JANUARY 201013

14Figure 2. Outpatient MHBSS Clinic Encounters at Providence VA Medical Center, 2003-2009program 4 ; and an innovative Serious MentallyIll (SMI) medical clinic for patients withcombined chronic medical and psychiatricconditions, conducted in collaboration withprimary care, described by Dr. O’Toole inthis issue. In addition, enhancement fundinghas been used to: increase access to servicesin our 3 Community-Based OutpatientClinics; meet the treatment needs of patientswith co-morbid PTSD and Substance Abusedisorders; expand care management servicesthroughout outpatient programs; offer suicideprevention education, resources andtools throughout the PVAMC; and developnew programs to address homeless veterans.In concert with these new or enhancedmental health services, the PVAMC continuesto provide more “traditional” mentalhealth services, including: a 17 bed InpatientPsychiatry Unit (soon to be 21 beds ona newly renovated unit); an Interim Care(Emergency Care/Triage) service; generaland specialty outpatient mental programs(including specific programs in Post TraumaticStress Disorders, Substance AbuseDisorders, Neuropsychology); and vocationaland rehabilitative mental health services.MENTAL HEALTH SERVICES FORHOMELESS VETERANSThe VHA Uniform Mental HealthServices Handbook ambitiously requires that“all veterans who are homeless, or at risk forhomelessness, must be offered shelterthrough collaborative relationships with providersin the community. Facility staff mustensure that homeless veterans have a referralfor emergency services and shelter or temporaryhousing.” 2 To meet this mandate,MEDICINE & HEALTH/RHODE ISLANDMHBSS staff at PVAMC administer a rangeof programs, including: outreach and linkageswith local shelters and community agenciesthat offer emergency shelter and provisionsto homeless veterans; participation inthe homeless primary care clinics developedby Dr. O’Toole and described in this issue; aGrant and Per Diem transitional housingprogram that includes 24/7 on call supportand case management; and a Departmentof Housing and Urban Development(HUD)-VA Supported Housing (VASH)Program. The HUD-VASH Program isnoteworthy. Through a partnership agreement,HUD provides permanent rental assistancevouchers to homeless veterans referredby MHBSS social workers. MHBSSsocial workers also provide case managementand other clinical services to veterans in thisprogram. A case worker is provided for every35 veterans who receive HUD-VASHvouchers. In the last year, PVAMC staffdistributed 35 HUD-VASH vouchers tolocal veterans and their families; in the comingyear we expect to provide another 100vouchers. During this same period, 159patients were placed in the Grant Per Diemtransitional housing program.MEETING THE MENTAL HEALTHNEEDS OF RETURNING VETERANSTo date, over 1.6 million veterans haveserved in Operation Enduring Freedom(OEF) in Afghanistan and Operation IraqiFreedom (OIF) in Iraq. 5 According to onestudy, of the OEF/OIF veterans entering VAhealth care from 2002-2008, approximately37% received mental health diagnoses, including22% with Post Traumatic Stress Disorder,17% with depression and approximately10% with alcohol use or other druguse disorders. 5 Over the last 2 years, PVAMCmental health professionals have participatedin approximately 100 Returning Veteransoutreach events, reaching over 2400 veteransand almost 1200 family members, militaryleaders and civilians. Currently, over540 OEF/OIF veterans are enrolled in ourReturning Veterans mental health clinic.Meeting the mental health needs of thesereturning veterans requires close coordinationamong multiple health care serviceswithin the VA, including primary care, neurology,newly developed Traumatic BrainInjury and Polytrauma services, as well as surgical,specialty medical and rehabilitative services.MHBSS staff also coordinate care withlocal military and national guard health careproviders as well as with counselors at VetCenters in Warwick, RI and Hyannis, MA.Vet Centers (administered by the Departmentof Veterans Affairs, but not part of theVHA) offer outreach, individual, group,marital and family counseling to veterans andtheir families.RECOVERY-FOCUSED CAREAn emphasis on recovery-focused care isconsistent with recent efforts, within and outsidethe VA, to shift the focus of mental healthcare from traditional clinician-centered goals(e.g., symptom management, medication taking,following through with treatment) tobroader, patient and family-centered goals thatinclude increased social functioning and integrationwithin the patient’s community. 6,7 Accordingto the National Consensus Statementon Mental Health Recovery (http://mentalhealth.samhsa.gov/publications/allpubs/sma05-4129/ ), “Mental health recoveryis a journey of healing and transformationenabling a person with a mental healthproblem to live a meaningful life in a communityof the person’s choice while striving toachieve ... full potential.” Within the VA, cliniciansare encouraged to promote 14 fundamentalcomponents of recovery-focusedcare: 1) self-direction; 2) individualized andperson-centered; 3) empowerment; 4) holistic;5) non-linear; 6) strengths-based; 7) peersupport; 8) respect, 9) responsibility; 10)hope; 11) privacy; 12) security; 13) honor;and 14) support for VA patient rights.In 2007, each VA medical center, includingPVAMC, appointed a Local RecoveryCoordinator (LRC), who is responsiblefor promoting the integration of recoveryprinciples into all mental health services pro-

vided at PVAMC and providing training andconsultation to facility leadership, staff, veterans,and family members. At PVAMC, ourLRC conducted or supported multiple trainingsessions for MHBSS staff in recoveryfocusedprinciples and strategies. Of note isthe close alignment between the recoveryorientedmodel of mental health care andthe patient-centered, empowerment, patientactivation and self-management models thathave been associated with enhanced outcomesof care when adopted within primarycare settings. 8,9 Dr. O’Toole, Chief of PrimaryCare at the PVAMC, discusses the integrationof these patient-centered modelsinto primary care in this issue.The growth and expansion of thePVAMC’s Veterans Resource and RecoveryCenter (VRRC) provides veterans with programsand services designed to enhance theirsocial, behavioral and vocational skills. Vocationalprograms include Compensated WorkTherapy (CWT), Transitional Work Experience(TWE), Supported Employment(SE) and Incentive Work Therapy (IWT).These occupational rehabilitation, maintenanceand therapeutic programs are designedto: 1) assist the veteran to develop skillsneeded to return to competitive work; 2) facilitatethe veteran’s transition into theworkforce at-large; and (3) assist the veteranto engage in other activities that enhance selfesteem,self-worth and gainful activity. OtherVRRC programs linked to the occupationalprograms include Job Club, Computer Lab,Horticultural Program, the Vet-to-Vet PeerSupport Group Program, and the WRAPself-management support skills groups. ThePVAMC VRRC has enrolled scores of veteransinto its rehabilitative and recovery-focusedprograms. Each year the VRRC programsplace approximately 30 veterans intopermanent jobs in the community.MH-PC INTEGRATIONThe VHA’ s Uniform Mental HealthServices Handbook stipulates that all VAMedical Centers have integrated mentalhealth services co-located within primary careclinics. These programs must utilize a blendedmodel that includes collaborative care and caremanagement programs. To meet this mandate,the PVAMC has co-developed an integratedMental Health-Primary Care (MH-PC) program staffed by psychologists, socialworkers, psychiatric clinical nurse specialistsand a consulting psychiatrist to work alongsideprimary care colleagues to meet the mentalhealth needs of patients in primary careclinical settings. Primary care providers routinelyemploy mental health diagnostic screeningprotocols for substance abuse (includingtobacco), depression and PTSD. Embeddedmental health staff are available within the primarycare setting to accept “warm hand-offs”and provide follow-up mental health assessments,psychopharmacologic consultations,depression care management, brief on-sitetreatment of mental health conditions, smokingcessation interventions, and referral to moreintensive mental health services when indicated.Programmatic efforts to enhance patientself-management of chronic medical conditions,manage chronic pain, address adherenceto medical treatment and reduce riskyhealth behaviors (e.g., sedentary behavior,obesity) are being co-developed by primarycare and mental health staff at the PVAMC.In his article, Dr. O’Toole describes severalefforts at PVAMC to tailor services to meetthe combined mental health and primary careneeds of 4 especially vulnerable populations.…of the OEF/OIF[Afghanistan andIraq] veteransentering VA healthcare from 2002-2008, approximately37% receivedmental healthdiagnoses…CONCLUSIONThe Mental Health and Behavioral SciencesService (MHBSS) at the ProvidenceVA Medical Center (PVAMC) provides anarray of services, resources and programs tomeet the mental health, psychosocial and behavioralhealth needs of veterans in RhodeIsland and Southeastern Massachusetts. Recovery-focused,veteran-centered, evidencebasedmental health care is offered in a varietyof settings including an acute inpatient unit,general and specialty outpatient mental healthunits, innovative integrated Mental Health-Primary Care Programs, residential programsfor homeless and seriously mentally ill veterans,special programs for veterans returningfrom current conflicts in Afghanistan andIraq, and a Veterans Resource and RecoveryCenter, which offers vocational, rehabilitativeand self-management services. Through linksand partnerships with community and militaryservice organizations, the PVAMC alsoprovides educational and preventive servicesto veterans and their families. We are planningthe expansion of services in geriatric mentalhealth care, outpatient detoxification, mentalhealth care for women veterans, peer-peerinterventions, family involvement in care, andprimary care-based interventions to enhancechronic illness self-management and healthrisk behavior change. The VA’s approach toproviding integrated and comprehensivemental health care serves as a model for a publiclyfunded public health care system.REFERENCES1. Department of Veterans Affairs, VHA Mental HealthStrategic Plan Workgroup/Mental Health StrategicHealth Care Group, and Office of the AssistantDeputy Under Secretary for Health, A ComprehensiveVHA Strategic Plan for Mental Health Services-Revised. 2004.2. Department of Veterans Affairs, VHA Handbook1160.01, Uniform Mental Health Services in VA MedicalCenters and Clinics, D.o.V. Affairs, Editor. 2008.3. Mueser K, et al. Models of community care for severemental illness. Schizophrenia Bull 1998; 24: 37-74.4. Butler M, et al. Integration of Mental Health/SubstanceAbuse and Primary Care: Evidence Report/TechnologyAssessment No. 173 2008, Prepared by the MinnesotaEvidence-based Practice Center under Contract No.290-02-0009.: Rockville, MD.5. Seal KH, et al. Trends and risk factors for mental healthdiagnoses among Iraq and Afghanistan veterans usingDepartment of Veterans Affairs health care, 2002-2008. Am J Public Health 2009; 99:1651-8.6. Farkas M, et al. Implementing recovery oriented evidencebased programs.Community Mental Health J 2005; 41:141-58.7. Ralph RO, Corrigan PW, eds. Recovery in Mental Illness.Broadening Our Understanding of Wellness. 2005,American Psychological Association: Washington, DC.8. Bodenheimer T, et al. Patient self-management ofchronic disease in primary care. JAMA 2002; 288:2469-75.9. Stewart M, et al. The impact of patient-centered careon outcomes. J Fam Pract 2000; 49:805-7.Michael G. Goldstein, MD, is Chief,Mental Health and Behavioral SciencesService, Providence VA Medical Center,and Professor of Psychiatry and HumanBehavior, the Warren Alpert MedicalSchool at Brown University.Disclosure of Financial InterestsThe author has no financial intereststo disclose.CORRESPONDENCEMichael G. Goldstein, MDProvidence VA Medical Center830 Chalkstone Ave.Providence, RI 02908Phone: (401) 273-7100 x3156e-mail: Michael.goldstein2@va.govVOLUME 93 NO. 1 JANUARY 201015