Evaluation of Implementing FLOW in VISN 19: Transitioning Stabilized Mental Health Patients to Management in Primary Care

点击翻译按钮获取中文摘要

Adequate access to mental health treatment is one of the highest priority problems facing the Veterans Health Administration (VHA) and VISN 19. Chronic staffing shortages and some clinical practices combine to reduce access to mental health treatment. Poor access to care can contribute to suicide and disability, and long wait times contribute to patient dissatisfaction and disengagement from care. Common mental health conditions are expected to remit in many cases or to be substantially improved with evidence-based prescribing and psychotherapy such that patients no longer need intensive specialty mental health services. International clinical guidelines encourage the use of stepped care, in which patients should be treated at the least intensive level of care that is appropriate to their condition. Although VA has embraced stepped care with the recent VA Continuum of Care model, VA manuals do not provide clear guidance on which patients are appropriate for transition back to primary care or how the transition should take place. In the absence of guidance, few patients are appropriately transitioned and specialty mental health panels remain full, contributing to access problems. The FLOW program addresses these problems with an algorithm to identify patients who are potentially appropriate for transition, a user-friendly online report to communicate this information to providers, materials to explain this process to patients and providers, and an electronic medical record (EMR) note template to document the transition. In cases where providers believe continued specialty mental health treatment is warranted or patients object to the transition, patients can remain in specialty mental health. This approach also has high acceptability to remitted patients because of perception of less stigma and reduction in appointment burden when their care is managed in primary care. Preliminary data from VISNs 16 and 17 indicates that FLOW can effectively transition recovered patients to primary care and increase access for new mental health patients. Implementation success differed dramatically across the original pilot sites but data collected did not offer an explanation for this or allow examination of implementation factors associated with success. In preparation for a national rollout of FLOW, we are partnering with VISN 19 to evaluate the impact of FLOW using a stepped wedge design with 7-9 sites randomly allocated into 3 steps in the wedge. An evidence-based implementation facilitation approach will be used at each site. Outcomes assessed will include program effectiveness and the factors that are associated with implementation success across sites. Program effectiveness outcomes will be examined according to the RE-AIM model, with specific outcomes for reach (% of clinic patients transitioned), effectiveness (% of transitions that are successful and impact on future clinic access), adoption (% of providers using FLOW), implementation (fidelity to the model as planned), and maintenance over time after withdrawal of implementation facilitation. We will also evaluate implementation factors, guided by the Consolidated Framework for Implementation Research, related to implementation success across sites, including organizational readiness to change, staffing levels, interservice agreements about care, leadership support, and internal facilitation.