Virtual Care Coordination in VA Primary Care-Mental Health Integration

背景： 在新启动的初级保健-精神卫生一体化(PC-MHI)患者中，当天可以获得PC-MHI 来自初级保健或其他选定医疗诊所(例如，急诊科/紧急护理)的是退伍军人 卫生管理(VA)改进和学习战略分析(SAIL)绩效衡量 (助记符：pcmhi7)。就医后立即开始心理健康护理会增加 后续的精神健康随访，提高护理质量。然而，尽管退伍军人管理局虚拟医疗服务迅速发展 在新冠肺炎扩张期间，影响虚拟当天访问PC-MHI的因素尚不清楚。 重要意义： 来自该课题组的初步研究发现，在一家大型退伍军人医疗中心，PC-MHI当天 面对面访问的访问率几乎是虚拟访问的两倍。因此，PC-MHI 发起虚拟护理的患者可能会因为失去 后续行动。这一发现反映了在退伍军人管理局和非退伍军人管理局的不同学科之间存在的知识差距 关于虚拟护理协调的有效战略。拟议的研究涉及多个高铁和高铁 优先领域：获得保健、精神健康、初级保健实践、虚拟保健/远程保健。 创新与影响： 这项拟议的研究将首次对影响当天获得PC-MHI的因素进行表征 在使用虚拟护理发起精神健康服务的患者中，包括可变的临床特征 这可能是可以进行干预的。 通过确定初级保健当天获得PC-MHI的具体预测因素，拟议的研究将 深入了解影响虚拟当天访问的因素，同时确定特定目标 未来的干预措施，提高护理质量，以及与之相关的医疗和心理健康结果，用于 寻求PC-MHI虚拟护理的退伍军人。此外，这项研究将通过提供 为有效的跨学科虚拟护理协调战略提供信息的数据。 具体目标： 1)确定与虚拟PC和面对面PC-MHI当天访问相关的多层次特征 一份全国退伍军人管理局的样本。 2)评估PC-MHI中成功的虚拟护理协调的障碍、促进者和策略。 研究方法： 这项研究将采用混合方法设计。对于目标1(量化)，一个全国性的退伍军人队列 将确定2019财年−2021财年期间启动的PC-MHI精神健康服务。PC-MHI当天访问 将根据是否有初级保健或其他选定的医疗诊所就诊来确定 与首次PC-MHI预约的同一天，根据精神健康SAIL的定义。一个多层次的 使用广义线性模型对虚拟访问和面对面访问的预测因子进行评估。为了达到目标 对PC-MHI精神卫生服务提供者和初级保健人员进行2次(定性)、半结构化定性访谈 将对来自两个退伍军人管理局医疗系统(一个城市，一个农村)的提供者进行调查，以确定障碍， PC-MHI中虚拟护理协调的促进者和策略。 后续步骤/实施： 与心理健康和自杀预防办公室、互联护理办公室和 初级保健办公室，调查结果将应用于HSR&D功绩审查奖拨款提案，以 制定干预措施，以改善PC-MHI中的虚拟护理协调。

Background: Among newly initiated Primary Care-Mental Health Integration (PC-MHI) patients, same day access to PC-MHI from primary care or other select medical clinics (e.g., emergency department/urgent care) is a Veterans Health Administration (VA) Strategic Analytics for Improvement and Learning (SAIL) performance measure (mnemonic: pcmhi7). Prompt initiation of mental health care after a medical visit increases the likelihood of subsequent mental health follow-up visits, enhancing quality of care. Yet, despite the rapid VA virtual care expansion during COVID-19, factors that influence virtual same day access to PC-MHI are unknown. Significance: Preliminary studies from this research group found that in a large VA medical center, PC-MHI same day access rates were nearly twice as high for in-person visits compared to virtual visits. Accordingly, PC-MHI patients who initiate care virtually may experience poorer medical and mental health outcomes from loss to follow-up. This finding reflects a knowledge gap that exists across disciplines in both VA and non-VA settings regarding effective strategies for virtual care coordination. The proposed study addresses multiple HSR&D Priority Areas: Access to Care, Mental Health, Primary Care Practice, Virtual Care/Telehealth. Innovation & Impact: The proposed research would be the first to characterize factors that influence same day access to PC-MHI among patients who use virtual care to initiate mental health services, including mutable clinic characteristics that may be amenable to intervention. By identifying specific predictors of same day access to PC-MHI from primary care, the proposed study will advance understanding of factors that affect virtual same day access while also identifying specific targets for future interventions, improving quality of care, and relatedly, medical and mental health outcomes, for Veterans who seek PC-MHI care virtually. Moreover, the study will advance scientific knowledge by providing data to inform strategies for effective interdisciplinary virtual care coordination. Specific Aims: 1) Identify multi-level characteristics associated with virtual and in-person PC-MHI same day access in a national VA sample. 2) Assess barriers, facilitators, and strategies for successful virtual care coordination in PC-MHI. Methodology: The study will use a mixed methods design. For Aim 1 (Quantitative), a national cohort of Veterans who initiated PC-MHI mental health services during FY2019 − FY2021 will be identified. PC-MHI same day access will be determined based on the presence or absence of a primary care or other select medical clinic visit on the same day as the initial PC-MHI appointment, per the Mental Health SAIL definition. A multi-level generalized linear model will be used to evaluate predictors of virtual and in-person same day access. For Aim 2 (Qualitative), semi-structured qualitative interviews with PC-MHI mental health providers and primary care providers from two VA healthcare systems (one urban, one rural) will be conducted to identify barriers, facilitators, and strategies for virtual care coordination in PC-MHI. Next Steps/Implementation: In partnership with the Office of Mental Health and Suicide Prevention, the Office of Connected Care, and the Office of Primary Care, the findings will be applied toward an HSR&D Merit Review Award grant proposal to develop an intervention to improve virtual care coordination in PC-MHI.