Regular Research Articles
Interdisciplinary Team Perspectives on Mental Health Care in VA Home-Based Primary Care: A Qualitative Study

https://doi.org/10.1016/j.jagp.2018.10.006Get rights and content

Highlights

  • What is the primary question addressed by this study?

    This qualitative study sought to examine the question: What are the attributes and gaps in mental health services for Veterans in the U.S. Department of Veteran's Affairs (VA) Home-Based Primary Care Program (HBPC)?

  • What is the main finding of this study?

    The study identifies four themes related to the provision of mental health care in HBPC: 1) HBPC Veterans have not only complex physical needs but also co-occurring mental needs; 2) the multi-faceted role of psychologists on HBPC teams that includes providing care for Veterans and support for colleagues; 3) collaboration between medical and mental health providers as a means of caring for HBPC Veterans with mental health needs; and 4) gaps in providing mental health care on HBPC teams, primarily related to a lack of team psychiatrists and/or need for specialized medication management for psychiatric illness.

  • What is the meaning of the finding?

    Mental health providers are an essential component of HBPC teams. Improved understanding of HBPC mental health provider models will be valuable to optimizing care of homebound adults.

Objectives

This qualitative study describes the structure and processes of providing care to U.S. Department of Veterans Affairs (VA) Home-Based Primary Care (HBPC) enrollees with mental health care needs; explains the role of the HBPC psychologist; and describes how mental health treatment is integrated into care from the perspective of HBPC team members.

Design

HBPC programs were selected for in-person site visits based on initial surveys and low hospitalization rates.

Setting

Programs varied in setting, geographic locations, and primary care model.

Participants

Eight site visits were completed. During visits, key informants including HBPC program directors, medical directors, team members, and other key staff involved with the HBPC program participated in semi-structured individual and group interviews.

Measurements

Recorded interviews, focus groups, and field observation notes.

Results

Qualitative thematic content analysis revealed four themes: 1) HBPC Veterans have not only complex physical needs but also co-occurring mental health needs; 2) the multi-faceted role of psychologists on HBPC teams, that includes providing care for Veterans and support for colleagues; 3) collaboration between medical and mental health providers as a means of caring for HBPC Veterans with mental health needs; and 4) gaps in providing mental health care on HBPC teams, primarily related to a lack of team psychiatrists and/or need for specialized medication management for psychiatric illness.

Conclusions

Mental health providers are essential to HBPC teams. Given the significant mental health care needs of HBPC enrollees and the roles of HBPC mental health providers, HBPC teams should integrate both psychologists and consulting psychiatrists.

Section snippets

INTRODUCTION

In 1972, the U.S. Department of Veteran's Affairs (VA) established the Home-Based Primary Care (HBPC) Program to provide in-home interdisciplinary, comprehensive, longitudinal primary care for frail, chronically ill or disabled Veterans with complex medical, social and behavioral conditions.1 The goal of HBPC is to allow Veterans to achieve the highest practicable function while minimizing institutionalization and maintaining quality of life.2 Veterans enrolled in HBPC are predominantly older

Sample: Site Selection

This study is part of a multi-phase VA Health Services Research and Development (HSR&D) funded study, “Factors Associated with Institutional use by Veterans in Home-Based Primary Care.” In Fall 2015, HBPC program directors representing 395 HBPC sites across the US were invited to complete a survey on their site's Background, Structures, and Processes (BSP Survey).17 We received 236 completed surveys from HBPC sites (response rate 60%). As part of that survey, directors identified members of

RESULTS

The analysis revealed four themes related to provision of care for Veterans with mental health needs from HBPC teams. These included: 1) HBPC Veterans have not only complex physical needs but also co-occurring mental health needs; 2) the multi-faceted role of psychologists on HBPC teams that includes providing care for Veterans and support for colleagues; 3) collaboration between medical and mental health providers as a means of caring for HBPC Veterans with mental health needs; and 4) gaps in

DISCUSSION

The VA has been a pioneer in the advancement of high quality HBPC. The experiences of VA HBPC teams in integration of home-based mental health care furthers this tradition by informing the work of other practices and systems. This is the first qualitative study of VA HBPC team member insights on mental health care. The themes identify important features of mental health care in HBPC with policy implications beyond VA programs and underscore what many health systems that assume responsibility

References (43)

  • BE Karlin et al.

    Meeting the mental health needs of older adults: implications for primary care practice

    Geriatrics

    (2007)
  • S Bartels et al.

    Improving access to geriatric mental health dervices: a randomized trial comparing treatment engagement with integrated versus enhanced referral care for depression, anxiety, and at-risk alcohol use

    Am J Psychiatry

    (2004)
  • KM Skultety et al.

    The treatment of depression in older adults in the primary care setting: an evidence-based review

    Health Psychology

    (2006)
  • W Katon et al.

    Long-term effects of a collaborative care intervention in persistently depressed primary care patients

    J Gen Intern Med

    (2002)
  • A Zeiss et al.

    Integrating mental health and primary care services in the Department of Veterans Affairs Health Care System

    J Clin Psychol Med Settings

    (2008)
  • EP Post et al.

    Integrating mental health into primary care within the Veterans Health Administration

    Fam Syst Health

    (2010)
  • Veterans Health Administration: Handbook 1411: Home-based primary care special population patient aligned care team...
  • Handbook VHA Handbook 1160.01: Uniform mental health services in VA medical centers and clinics

    (2008)
  • J Karuza et al.

    National structural survey of Veterans Affairs home‐based primary care programs

    J Am Geriatri Soc

    (2017)
  • Centers for Medicare and Medicaid Services: Independence at Home Demonstration. Available at:...
  • B Kinosian et al.

    Projected savings and workforce transformation from converting independence at home to a medicare benefit

    J Am Geriatr Soc

    (2016)
  • Cited by (16)

    • The role of the clinical pharmacist in mental health hospital-in-the-home: A scoping review

      2022, Research in Social and Administrative Pharmacy
      Citation Excerpt :

      This scoping review confirmed that there is a paucity of literature discussing the role of a CP in MH services that are specifically conducted at home, and more especially in MH-HiTH programs. The few studies that were identified provided preliminary evidence that CPs can contribute to the MH-HiTH MDTs34,35,79,83 in improving patient care. Literature surrounding the roles of pharmacists in general home care services and in other non-dispensing roles are more developed.

    • Home, but Not Homebound: A Prospective Analysis of Persons Living With Dementia

      2022, Journal of the American Medical Directors Association
      Citation Excerpt :

      Although depression is a treatable illness, treating depression in homebound older adults has unique challenges. The social isolation experienced by the homebound may in and of itself contribute to depression,23 yet home-based treatment options for depression are limited and mental health needs may not be adequately met by existing home-based medical care programs.24–26 Although virtual care options may improve access to mental health care,27 the homebound face difficulties accessing virtual care including poor access to broadband and high reliance on caregivers to access technology.28

    View all citing articles on Scopus

    Funding: This work was supported by a Veterans Affairs Health Science Research & Development grant. HSR5-011-13S, Project ID 1193873, VACO No. IIR12-152-3.

    View full text