BACKGROUND/RATIONALE:
Development of effective models for delivering integrated care remains a high priority for VHA. VHA's Post-Deployment Integrated Care Initiative (PDICI) was launched in 2008 to improve quality of care for OEF/OIF Veterans via enhanced integration of mental health (MH), social work (SW) and other services with primary care (PC). Recognizing the variability in VHA facilities, national PDICI program staff issued guidance for facility program design, suggesting three models: "clinic" (specialized interdisciplinary OEF/OIF clinic), "cohort" (providers designated for the care of OEF/OIF Veterans), and "consultative" (expert clinicians who provide consultation to providers on OEF/OIF issues). This guidance was based primarily on PDICI leaders' experiential expertise. Intensive study of PDICI will generate information regarding implementation of PD integrated care activities.

OBJECTIVE(S):
This pilot study focused on PD integrated care activities, with a focus on PC, MH, and SW. The primary goal of the study was to document and characterize (a) the introduction of PDICI into VHA facilities and (b) the organizational arrangements chosen by these facilities.

METHODS:
We conducted (1) an in-depth comparative case study of PDICI organizational arrangements in a sample of 6 VAMCs through telephone and in-person interviews with key facility leaders and staff, and (2) a national survey administered to a key stakeholder at each VAMC or healthcare system (n=111) on the topic of PDICI organizational arrangements.

From June to December 2010 we conducted semi-structured interviews with 53 key informants at six VAMCs, randomly selected from sampling strata comprising geographic regions and the three suggested program models. Interviewees included OEF/OIF Program Managers (PM), OEF/OIF Case Managers (CM), PC providers (PCP), MH providers (MHP's), as well as other stakeholders and support staff. Interview topics included development of PD care activities, barriers and facilitators to implementation, and recommendations for improvement. Interview transcriptions were analyzed for key themes.

Between December 2010 and February 2011, we fielded a national survey (77% response rate). The majority of survey respondents were OEF/OIF Program Managers (60%) and Physicians (24%). Survey topics included organizational arrangements of PD care activities, with a focus on coordination of care between PC, MH, and SW, and sufficiency of resources. Survey data wer uploaded into STATA and analyzed for key themes.

FINDINGS/RESULTS:
Interview and survey analyses examined (1) the structural and organizational care arrangements for PD care and (2) coordination of care activities, primarily between PC, MH, and SW.

(1) Findings related to structural and organizational care arrangements of PD care. PDICI program leader suggested implementation of one of three suggested program models, Clinic, Cohort and Consultative. 84% of survey respondents reported using one or both of the first two models (Clinic, 23%, Cohort 25%, or both, 36%). 89% of facilities indicated the presence of Consultative experts.

(2) Findings Related to Coordination of Care Activities. Site interview data revealed that providers from different service groups, who previously had limited contact, felt more comfortable contacting each other for complex cases after initial experience coordinating care through PDICI-related arrangements. Respondents from almost all sites suggested that the unique role of the OEF/OIF PM and CM's as "go-to people" was integral to coordinating care.

IMPACT:
The unique needs of the PD population pose challenges to achieving effective integration of services. Recognizing these needs, most VHA facilities have established specific mechanisms to coordinate PD care between services; Social Work Service plays a central role in many facilities. Further study to generate increased understanding of evolving approaches to coordination of care is critical for improving care for complex patient populations. .

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External Links for this Project

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PUBLICATIONS:

Conference Presentations

1. Wyte T, MacGregor C, Hunt SC, Burgo L, Mittman BS. Coordinating Care for Returning Veterans: VA's Post-Deployment Integrated Care Initiative. Paper presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 19; National Harbor, MD. [view]
2. Wyte T, MacGregor C, Mittman BS. Evaluating the Implementation of Models for Delivering Post-Deployment Integrated Care. Paper presented at: VA HSR&D National Meeting; 2011 Feb 16; National Harbor, MD. [view]

DRA: Military and Environmental Exposures, Mental, Cognitive and Behavioral Disorders
DRE: Treatment - Observational, Research Infrastructure
Keywords: Care Management, Deployment, Quality assessment
MeSH Terms: none