CDMRP Investigator Vignette

Title: Integrating Primary Care and Mental Health for OEF/OIF/OND Veterans

Investigator: Karen Seal, MD, MPH; San Francisco VA Medical Center/UCSF

In 2007 it became very apparent that we were starting to see more and more returning Iraq and Afghanistan veterans into our general medical practice clinic. And basically these veterans were, for lack of a better term, getting lost. Many of them were in need of mental health services in addition to medical services, but there was no easy mechanism to get them into mental health care because basically they didn't want to go. So doing the usual referral to mental health did not work for this particular group, and it became more and more obvious to a group of us that we really needed to establish a dedicated clinic and place for the returning combat veterans when they came to the San Francisco VA Medical Center.

So in April of 2007, a group of us got together and established the Integrated Care Clinic. And basically we decided to have a three-part visit in the primary care clinic that would consist of a social services visit by the combat case manager, a primary care appointment by the primary care provider, which would be followed by a mental health appointment by the combat stress specialist, who was actually a PTSD psychologist.

We do what's called a warm handoff, and actually this is a model of care that naturally developed within our clinic in which clinicians were walking patients over to the next provider. The patient doesn't feel that they have to repeat their story over and over again. It's very efficient and it also makes the coordination of care very transparent for the patient.

Another very important point in our mission was to decrease stigma among-about mental health treatment in general. So if you are essentially telling patients that when they come to primary care, the visit is actually primary care, mental health, and social services for everyone then nobody feels particularly singled out or stigmatized because they somehow have a mental health problem and need to see a mental health provider.

So after the mental health visit, the patient-if mental health care is indicated-will then be referred on to more intensive mental health treatment. And basically this is sort of the place where my research begins is-does this three-part visit-does this wraparound care really increase the likelihood that these combat veterans will accept and go to the mental health appointment and-and enter mental health treatment.

So our retrospective cohort study was our first CDMRP grant. It was specifically to just look at data that had already been collected. So what we did was, we looked back in time. We looked at 347 newly returned combat veterans who came into the clinic, and we used their medical records to do our research.

And you can see that there's a significantly greater proportion of veterans who are seen on the same day by a mental health clinician if they presented to the Integrated Care Clinic versus the Usual Care Clinic. In other words, 89% veterans who were seen in our Integrated Care Clinic had a same-day mental health visit versus 51% who were seen in our Usual Care Clinic. And so essentially patients seen in our Integrated Care Clinic were 74% more likely to be seen by a mental health provider.

When we allotted 30 days for the Usual Care people to eventually see a mental health provider, we still found that now 92% of our returned veterans had seen a mental health provider within 30 days whereas only 59% had seen-who were see in the Usual Care Clinic-had seen a mental health provider within 30 days.

We were fortunately funded by CDMRP to conduct a prospective study of mental health utilization in patients that were seen in our Integrated Care Clinic versus our Usual Primary Care Clinic. So between December 2009 and October 2011, we saw 131 Iraq and Afghanistan veterans in our primary care clinic at the San Francisco VA Medical Center.

We found that little over 40% had a mental health visit within 30 days if they were seen in Usual Care and over 90% had a mental health visit within 30 days if they had been seen in our Integrated Care Clinic. And you were two times more likely to be seen by a mental health specialist if you presented to the Integrated Care Clinic.

You could see that the mean number of mental health visits was greater in the Integrated Care Clinic versus the Usual Care Clinic within a 6-month follow-up period. You were two and a half times more likely to have more visits if you had been seen in the Integrated Care Clinic.

So to conclude, these two studies provided convergent evidence that an integrated colocated primary care, mental health, and social work clinic improved utilization of psychosocial services for combat veterans, particularly mental health care.

I am now applying for more funds to focus the lens specifically on this issue of-of retention in mental health treatment because I really feel like it's great to get people engaged but you really don't achieve your outcomes unless you can help them stay in therapy.