The Integrated Care Team Approach of the Department of Veterans Affairs (VA): Geriatric Primary Care

Abstract

Historically, integrated mental and behavioral healthcare in the Department of Veterans Affairs (VA) commenced with initiatives in geriatrics. Innovation and system-wide expansion has occurred over decades and culminated in a unified vision for training and practice in the VA medical home model: Patient Aligned Care Team or PACT approach. In one VA hospital, the integration of neuropsychological services in geriatric primary care is pivotal and increases access for patients, as well as contributing to timely and effective care on an interprofessional team. The development and innovative use of an algorithm to identify problems with cognition, health literacy, and mental and behavioral health has been pragmatic and provides useful information for collaborative treatment planning in GeriPACT, VA geriatric primary care. Use of the algorithm also assists with decision-making regarding brief versus comprehensive neuropsychological assessment in the primary care setting. The model presented here was developed by supervising neuropsychologists as part of a postdoctoral residency program in geropsychology. However, postdoctoral residency programs in neuropsychology, as well as neuropsychological clinics, can also use this model to integrate neuropsychological assessment and interventions in geriatric primary care settings.

Mental Health Integration in Geriatric Patient-Aligned Care Teams in the Department of Veterans Affairs

“…For example, GeriPACT mental health providers likely need a longer visit length given patient complexity, ambulatory and sensory changes, greater involvement of families and caregivers, etc. Thoughtful stepped-care models 33 may be useful for confronting these complexities and adapting the model to the realities of the individual healthcare institution and geriatric workforce shortage. To this point, no single model has emerged as a best practice, and this needs further study.…”

Acute Care for Elders (ACE) Team Model of Care: A Clinical Overview

“…Future opportunities may also include merging patient safety teamwork curriculum such as TeamSTEPPS ® (Team Strategies & Tools to Enhance Performance & Patient Safety) with ACE team training. Available from the Agency for Healthcare Research and Quality [33], TeamSTEPPS ® use has resulted in sustained improvements in patient safety [34]. In addition to the challenges of providing geriatric education to all healthcare providers, other barriers hospitals face in developing ACE Units include lack of hospital-based geriatric providers with protected time and effort to lead program development, challenges in securing dedicated unit space, and the need for some start-up funding, despite published evidence of return on this investment.…”

Integration of neuropsychological assessment and intervention services into a specialty geriatric medicine clinic.

“…The description of integrated Neuropsychology services by Rasin-Waters et al (2018) offers several benefits, such as a screening approach that could be expanded to other consultative clinics. However, it is unclear if colocated Neuropsychology services can be feasibly carried out within a consultative clinic, and to what extent assessment results can lead to follow-up interventions within a time-limited framework.…”

“…The availability of assessment and intervention services may provide greater benefit than either one alone, in order to meet the complex needs of older adults. Of the cases included in the special series, Rasin-Waters et al (2018) described a colocated Neuropsychology integration model within Geri-PACT that provided assessment and intervention services. Specifically, services were provided utilizing a screening approach that informed the need for follow-up care.…”

“…Similar to the Rasin-Waters et al (2018) clinic development, a tiered supervision approach was established with a supervising clinical neuropsychologist and a 2nd-year Clinical Neuropsychology postdoctoral fellow; the fellow was physically present and available within the clinic and following greater mastery and integration within the team, the supervisor gradually transitioned out of the clinic but remained available within the hospital for consultation. This graded approach provided direct observation of the trainee and modeling of communication and consultation with providers, along with an increasing amount of independence fitting with the developmental level of an advanced trainee.…”