Original Research

Engaging Veterans With Serious Mental Illness in Primary Care

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Background: Veterans with serious mental illness (SMI) are at substantial risk for premature mortality. Engagement in primary care can mitigate these mortality risks. However, veterans with SMI often become disengaged from primary care. The US Department of Veterans Affairs (VA) measures and reports at VA facilities primary care engagement among enrolled veterans with SMI. This quarterly metric enables VA facilities to identify targets for quality improvement and track their progress. To inform quality improvement at our VA facility, we sought to identify promising practices for supporting engagement in primary care among veterans with SMI.

Methods: We conducted semistructured telephone interviews from May 2019 through July 2019 with a purposeful sample of key informants at VA facilities with high levels of engagement in primary care among veterans with SMI. All interviews were recorded, summarized using a structured template, and summaries placed into a matrix. An interdisciplinary team reviewed and discussed matrices to identify and build consensus around findings.

Results: We interviewed 18 key informants from 11 VA facilities. The strategies used to engage veterans with SMI fell into 2 general categories: targeted outreach and routine practices. Targeted outreach included proactive, deliberate, systematic approaches for identifying and contacting veterans with SMI who are at risk of disengaging from care. In targeted outreach, veterans were identified and prioritized for outreach independent of any visits with mental health or other VA services. Routine practices included activities embedded in regular clinical workflows at the time of veterans’ mental health visits, assessing, and connecting/reconnecting veterans with SMI into primary care. In addition, we identified extensive formal and informal ties between mental health and primary care that facilitated engaging veterans with SMI in primary care.

Conclusions: VA facilities with high levels of primary care engagement among veterans with SMI used extensive engagement strategies, including a diverse array of targeted outreach and routine practices. Intentionally designed organizational structures and processes and facilitating extensive formal and informal ties between mental health and primary care teams supported these efforts. Additional organizational cultural factors were especially relevant to routine practice strategies. The practices we identified should be evaluated empirically for their effects on establishing and maintaining engagement in primary care among veterans with SMI.


 

References

People with serious mental illness (SMI) are at substantial risk for premature mortality, dying on average 10 to 20 years earlier than others.1 The reasons for this disparity are complex; however, the high prevalence of chronic disease and physical comorbidities in the SMI population have been identified as prominent factors.2 Engagement and reengagement in care, including primary care for medical comorbidities, can mitigate these mortality risks.2-4 Among veterans with SMI lost to follow-up care for more than 12 months, those not successfully reengaged in care were more likely to die compared with those reengaged in care.2,3

Given this evidence, health care systems, including the US Department of Veterans Affairs (VA), have looked to better engage these patients in care. These efforts have included mental health population health management, colocation of mental health with primary care, designation of primary care teams specializing in SMI, and integration of mental health and primary care services for patients experiencing homelessness.5-8

As part of a national approach to encourage locally driven quality improvement (QI), the VA compiles performance metrics for each facility, across a gamut of care settings, conditions, and veteran populations.9 Quarterly facility report cards, with longitudinal data and cross-facility comparisons, enable facilities to identify targets for QI and track improvement progress. One metric reports on the proportion of enrolled veterans with SMI who have primary care engagement, defined as having an assigned primary care practitioner (PCP) and a primary care visit in the prior 12 months.

In support of a QI initiative at the VA Greater Los Angeles Healthcare System (VAGLAHS), we sought to describe promising practices being utilized by VA facilities with higher levels of primary care engagement among their veterans with SMI populations.

Methods

We conducted semistructured telephone interviews with a purposeful sample of key informants at VA facilities with high levels of engagement in primary care among veterans with SMI. All project components were conducted by an interdisciplinary team, which included a medical anthropologist (JM), a mental health physician (PR), an internal medicine physician (KC), and other health services researchers (JB, AG). Because the primary objective of the project was QI, this project was designated as nonresearch by the VAGLAHS Institutional Review Board.

The VA Facility Complexity Model classifies facilities into 5 tiers: 1a (most complex), 1b, 1c, 2, and 3 (least complex), based on patient care volume, patient risk, complexity of clinical programs, and size of research and teaching programs. We sampled informants at VA facilities with complexity ratings of 1a or 1b with better than median scores for primary care engagement of veterans with SMI based on report cards from January 2019 to March 2019. To increase the likelihood of identifying lessons that can generalize to the VAGLAHS with its large population of veterans experiencing homelessness, we selected facilities serving populations consisting of more than 1000 veterans experiencing homelessness.

At each selected facility, we first aimed to interview mental health leaders responsible for quality measurement and improvement identified from a national VA database. We then used snowball sampling to identify other informants at these VA facilities who were knowledgeable about relevant processes. Potential interviewees were contacted via email.

Interviews

The interview guide was developed by the interdisciplinary team and based on published literature about strategies for engaging patients with SMI in care. Interview guide questions focused on local practice arrangements, panel management, population health practices, and quality measurement and improvement efforts for engaging veterans with SMI in primary care (Appendix). Interviews were conducted by telephone, from May 2019 through July 2019, by experienced qualitative interviewers (JM, JB). Interviewees were assured confidentiality of their responses.

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