November 2017

In this Issue: Improving Care of Mental Health Conditions
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PACT to Improve Healthcare for People with Serious Mental Illness

Feature Article

People with serious mental illness (SMI) die many years prematurely, with rates of premature mortality two to three times greater than the general population. Too often, Veterans with SMI do not attend needed healthcare appointments or fail to engage in primary care treatment, and consequently do not get high-value preventive and primary care services. Primary care in VA has undergone a significant transformation under the Patent-Aligned Care Team (PACT) model, based on the Patient-Centered Medical Home concept; however, it remains unclear how PACT impacts the large populations of Veterans who receive the majority of their care in specialty settings, such as people with SMI. While people with SMI do poorly with usual primary care arrangements, research has suggested that integrated care and medical care management can improve healthcare treatment and outcomes – and reduce treatment costs in people with SMI.

Investigators in this ongoing study (2014-2018) partnered with leadership at a VA medical center to develop and implement SMI PACT, with the goal of improving treatment and outcomes among people with SMI, while reducing unnecessary use of emergency and hospital services. Evidence-based quality improvement strategies were used to reorganize processes of care. Patients were recruited to receive primary care through the SMI PACT team based on having both a serious mental illness that is controlled with treatment, and having elevated medical risk. The SMI PACT team offers assertive medical nurse care management. Psychiatric care is offered in the primary care team, using a collaborative care model with an integrated psychiatrist. 

In a site-level controlled trial, this project is studying the effect – relative to usual care – of SMI PACT implementation on:

• Provision of appropriate preventive and medical treatments,
• Patient health-related quality of life and satisfaction with care, and
• Medical and mental health treatment utilization and costs.

The project includes an evaluation of usual care and SMI PACT implementation to strengthen the intervention and assess barriers and facilitators. Investigators are examining the relationships between organizational context, intervention factors, and patient and provider outcomes – and identifying patient factors related to successful patient outcomes.

Findings: Prior to implementation, 26 providers and staff were interviewed at intervention and comparison sites. The SMI PACT model was defined and initiated. To date, 304 Veterans have enrolled and completed baseline interviews. Of these, 137 patients have received their care in the SMI PACT.  Thus far, findings show that patients with SMI can successfully transition to a primary care medical home. Under this care model, care coordination has improved. About half of patients have had all their psychiatric care integrated into the primary care home. Patient engagement in care and preventive and medical treatments are improving. Patient experience has been positive.

Impact: It has been difficult to coordinate care for people with SMI, while improving their health and reducing the need for high intensity medical services. The SMI PACT model has the potential to transition patients with SMI to a tailored primary care health home, while also improving care coordination, treatments, and outcomes.

Principal Investigator:  Alexander S. Young, MD, MSHS, is part of the executive leadership for HSR&D’s Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP) in Los Angeles, CA.

PACT to Improve Healthcare for People with Serious Mental Illness project abstract