Literature Collection

PURPOSE: The population with serious mental illness has high risk for hospitalization or death due to unhealthy behaviors and inadequate medical care, though the level of risk varies substantially. Programs that integrate medical and psychiatric services improve outcomes but are challenging to implement and access is limited. It would be useful to know whether benefits are confined to patients with specific levels of risk. METHODS: In a population with serious mental illness and increased risk for hospitalization or death, a specialized medical home integrated services and improved treatment and outcomes. Treatment quality, chronic illness care, care experience, symptoms, and quality of life were assessed for a median of 385 days. Analyses examine whether improvements varied by baseline level of patient risk. RESULTS: Patients with greater risk were more likely to be older, more cognitively impaired, and have worse mental health. Integrated services increased appropriate screening for body mass index, lipids, and glucose, but increases did not differ significantly by level of risk. Integrated services also improved chronic illness care, care experience, mental health-related quality of life, and psychotic symptoms. There were also no significant differences by risk level. CONCLUSIONS: There were benefits from integration of primary care and psychiatric care at all levels of increased risk, including those with extremely high risk above the 95th percentile. When developing integrated care programs, patients should be considered at all levels of risk, not only those who are the healthiest.

Randomized controlled trials have demonstrated that the collaborative care model for depression in primary care is more effective than usual care, but little is known about the effectiveness of this approach in real-world settings. We used patient-reported outcome data from 11,303 patients receiving collaborative care for depression in 135 primary care clinics to examine variations in depression outcomes. The average treatment response across this large sample of clinics was substantially lower than response rates reported in randomized controlled trials, and substantial outcome variation was observed. Patient factors such as initial depression severity, clinic factors such as the number of years of collaborative care practice, and the degree of implementation support received were associated with depression outcomes at follow-up. Our findings suggest that the level of implementation support could be an important influence on the effectiveness of collaborative care model programs.

BACKGROUND: Virtual health care models that incorporate registered nurse triage with rapid access to same-day virtual visits with clinicians represent a growing innovation in health care delivery. While traditional telephone advice lines focus primarily on registered nurse-led triage and care navigation, systems such as the Department of Veterans Affairs (VA) are beginning to embed physicians and advanced practice providers directly into these platforms. This hybrid model has the potential to enhance clinical responsiveness, reduce unnecessary emergency department and urgent care visits, and increase patient satisfaction by providing timely care from home. OBJECTIVE: This study aimed to explore Veterans' experiences and perceptions of the VA's integrated virtual triage and urgent care model, specifically through the VA Health Connect platform. We sought to understand how Veterans learned about and interacted with these services and to gather their insights on aspects to preserve or improve. METHODS: We conducted in-depth qualitative interviews with 24 Veterans from various geographical regions served by 6 VA health care systems. Interviews were carried out between June 18 and August 8, 2024. Data were analyzed using a qualitative descriptive approach with constant comparison to identify emergent themes and representative quotes. RESULTS: Participants reported high satisfaction with VA Health Connect's nurse triage and virtual clinical visit services. Key benefits included timeliness of care, personal time savings, efficient service organization, and positive interactions with nurses and providers. Veterans appreciated the convenience of resolving health issues quickly and remotely, often citing significant travel burdens avoided. They also highlighted the knowledgeable and personalized clinical advice received. However, several areas for improvement were identified. Some Veterans expressed frustration about being routed to nurse triage instead of directly scheduling with their primary care providers. Moreover, many were initially unaware of the full range of services available through VA Health Connect and suggested enhanced outreach and communication strategies. CONCLUSIONS: Veterans are highly satisfied with the VA Health Connect model, valuing its timeliness, convenience, and the professionalism of clinical staff. Effective promotion and clear communication about the capabilities and limitations of the service could further enhance user experience and uptake. As this integrated care model continues to evolve, its success will depend on effectively integrating virtual services into routine care and ensuring Veterans are well-informed and confident in using these resources.

Aiming to increase care access, the national Primary Care-Mental Health Integration (PC-MHI) initiative of the Veterans Health Administration (VHA) embedded specialists, care managers, or both in primary care clinics to collaboratively care for veterans with psychiatric illness. The initiative's effects on health care use and cost patterns were examined among 5.4 million primary care patients in 396 VHA clinics in 2013-16. The median rate of patients who saw a PC-MHI provider was 6.3 percent. Each percentage-point increase in the proportion of clinic patients seen by these providers was associated with 11 percent more mental health and 40 percent more primary care visits but also with 9 percent higher average total costs per patient per year. At the mean, 2.5 integrated care visits substituted for each specialty-based mental health visit that did not occur. PC-MHI was associated with improved access to outpatient care, albeit at increased total cost to the VHA. Successful implementation of integrated care necessitates significant investment and multidisciplinary partnership within health systems.

Substance use and illicit drug use are a growing problem in the United States. SUDs occur when the recurrent use of alcohol or drugs causes significant impairment, such as health problems. The veteran population has been particularly at risk. Veterans are 1.5 times more likely to die from opioid overdose than the general population, according to VA and Centers for Disease Control and Prevention data. Furthermore, veterans live in rural areas at a higher rate than the general population, which may affect their ability to access SUD services. VA is the largest integrated health care system in the United States, providing care to about 6.2 million veterans. VA provides SUD services through outpatient, inpatient, and residential care settings and offers various treatment options, including individual and group therapy, medication-assisted treatment, and naloxone kits to reverse overdoses. This report describes (1) trends in the number of and expenditures for veterans receiving SUD services, including specialty SUD services; and (2) any differences between veterans' use of SUD services in rural and urban areas, and the issues affecting access to those services in rural areas.; Background. -- Number of veterans receiving, and expenditures for, VHA specialty SUD services have remained unchanged in recent years, community care SUD services have increased. -- Veterans' usage differed between urban and rural areas for some specialty SUD services; VHA is taking steps to address access issues in rural areas. -- Agency comments. -- Appendices.

With the rapid expansion of veterans' access to community care under the Veterans Affairs Maintaining Internal Systems and Strengthening Integrated Outside Networks (VA MISSION) Act of 2018, ensuring that veterans receive high-quality community care has become a national priority. Using Veterans Health Administration (VHA) data and Medicare performance scores, we assessed how clinicians' performance on quality measures differed between those who treated veterans within the VHA Community Care Network and those who did not. We found that in 2022, 66.0 percent of community-based clinicians treated VHA enrollees. These clinicians were more likely to be male, have less practice experience, be affiliated with group practices, and be based in rural and socially vulnerable areas compared with clinicians who did not treat VHA enrollees. Notably, clinicians in the lowest quartile of quality performance measures were 8.8 percentage points more likely to treat VHA enrollees than those in the highest quartile. This pattern was most pronounced among primary care and mental health clinicians, and it persisted across VHA Community Care Network regions. These results underscore the need for federal efforts to ensure that veterans receive care from high-performing community clinicians.