Home-based primary care–mental health integration in the Veterans Health Administration: An updated evaluation of practice patterns.

Abstract

Starting in 2008, the U.S. Veterans Health Administration required the integration of mental health providers (MH providers) in Home-Based Primary Care (HBPC) programs to promote access to and quality of mental health services for veterans enrolled in HBPC. Surveys were administered in both 2010 and 2019 to HBPC program directors and MH providers to evaluate the status of mental health practice in HBPC programs and inform the continued development of program resources. Findings reported here summarize responses to the 2019 survey and highlight changes compared to 2010 in key areas (e.g., mental health staffing and workload, services provided, training needs, and integration with and impact on the HBPC team). In 2019, approximately half of invited HBPC program directors (n = 66) and MH providers (n = 136) completed the voluntary, anonymous, and confidential surveys. Descriptive and bivariate analyses of quantitative data, and thematic analyses of open-text responses, were conducted. Comparisons of survey responses were made between the 2019 surveys and those collected in 2010 from MH providers (n = 132) and program directors (n = 112), and indicated similar patterns of variability in program staffing and practices across sites, with ongoing behavioral/mental health education and training needs reported for both MH providers and teams. The perceived degree and value of mental health integration in HBPC also remained high. Survey responses suggest integration of mental health services into HBPC continues to be feasible and improves access to key services. Findings may inform the expansion of home-based mental health services for meeting the needs of an aging population. Impact StatementIntegrated mental health services in Veterans Health Administration Home-Based Primary Care (HBPC) programs remain strongly valued, and with variable practice patterns, according to HBPC program directors and mental health providers surveyed in both 2019 and 2010. This operational feedback will guide ongoing development of HBPC mental health program resources and may inform expansion of home-based mental health services for an aging population.

Home-based primary care providers’ perspectives on the unique challenges of working with late life posttraumatic stress disorder within their population of Veterans.

“…Further, the limitations of HBPC clinics, such as inability to see veterans on a weekly or even biweekly basis make it difficult for providers to implement standardized EBP for PTSD. These results are consistent with past studies showing that the nature of HBPC and provider–patient time limitations makes it difficult to implement treatments requiring regular visits (Hicken & Plowhead, 2010; Mavandadi et al, 2023). As most evidence-based treatments recommend weekly or biweekly therapy, it often is not feasible within the HBPC clinic structure to follow these protocols, especially for providers who care for rural veterans.…”

“…Resoundingly, participants attributed their hesitancy to lack of competence and/or thorough training in trauma treatment, which led to concerns of "re-opening old wounds" and not having the time or skills to help the veteran heal. Similar provider hesitations and treatment challenges with this patient population were found by both Hicken and Plowhead (2010) and Mavandadi et al (2023). Underscoring this issue, psychologists and/or social workers are often the sole mental health providers on the HBPC team, requiring them to be an expert in many areas, which is not always feasible.…”

“…In 2008, Veterans Health Administration mandated the inclusion of a mental health provider, a psychiatrist or psychologist, on HBPC teams. HBPC mental health providers conduct brief cognitive assessments, capacity evaluations, individual therapy, caregiver support, and provide consultation to other team members (Hicken & Plowhead, 2010; Mavandadi et al, 2023). Due to large caseloads (around 100 veterans) that span wide geographic regions requiring long drive times, HBPC mental health providers often are unable to see veterans weekly or even biweekly, and supplement in-person sessions with video and phone check-ins.…”

“…A key feature of the HBPC program is its emphasis on interdisciplinary care. HBPC teams are generally comprised of physicians, physician assistants and/or nurse practitioners, registered nurses, social workers, registered dieticians, pharmacists, rehabilitations therapists, and psychologists (Mavandadi et al, 2023).…”

“…Thus, veterans in HBPC with PTSD may face increased challenges managing symptoms due to decreased ability to use coping strategies that were helpful in the past, increased feelings of powerlessness, loss of control, and social isolation. Additionally, veterans in HBPC often have less access to specialized PTSD treatment options (Mavandadi et al, 2023).…”