Virtual Care Coordination in VA Primary Care-Mental Health Integration

背景资料： 在新启动的初级保健-心理健康整合（PC-MHI）患者中， 从初级保健或其它选择的医疗诊所（例如，急诊科/紧急护理）是退伍军人 卫生管理局（VA）战略分析改进和学习（SAIL）绩效指标 （助记符：pcmhi 7）。就医后立即开始精神卫生保健会增加 随后的心理健康随访，提高护理质量。然而，尽管快速的VA虚拟护理 在COVID-19期间的扩张，影响PC-MHI虚拟当天访问的因素尚不清楚。 重要性： 该研究小组的初步研究发现，在一个大型VA医疗中心，PC-MHI同一天 亲自访问的访问率几乎是虚拟访问的两倍。PC-MHI 开始治疗的患者实际上可能会经历更差的医疗和心理健康结果， 随访这一发现反映了VA和非VA设置中存在的跨学科知识差距 关于虚拟护理协调的有效策略。拟议的研究涉及多个HSR&D 优先领域：获得护理、心理健康、初级保健实践、虚拟护理/远程保健。 创新与影响： 拟议的研究将是第一个描述影响当天获得PC-MHI的因素的研究 在使用虚拟护理启动心理健康服务的患者中，包括可变的临床特征 可能会受到干预。 通过确定从初级保健当天获得PC-MHI的特定预测因素，拟议的研究将 进一步了解影响虚拟同一天访问的因素，同时确定 未来的干预措施，提高护理质量，以及相关的医疗和心理健康结果， 寻求PC-MHI虚拟护理的退伍军人。此外，这项研究将通过提供 数据为有效的跨学科虚拟护理协调战略提供信息。 具体目标： 1)确定与虚拟和亲自PC-MHI当天访问相关的多层次特征， 全国退伍军人样本 2)评估障碍，促进者，并在PC-MHI成功的虚拟护理协调策略。 方法学： 本研究将采用混合方法设计。对于目标1（定量），一个全国性的退伍军人队列， 将确定2019 - 2021财年期间启动的PC-MHI心理健康服务。PC-MHI当天访问 将根据是否存在初级保健或其他选定的医疗诊所访视来确定 根据心理健康SAIL定义，与首次PC-MHI预约同一天。多层次 广义线性模型将用于评估虚拟和亲自当天访问的预测因素。为宗旨 2（定性），与PC-MHI心理健康提供者和初级保健的半结构化定性访谈 来自两个VA医疗保健系统（一个城市，一个农村）的提供者将进行识别障碍， 促进者，和战略的虚拟护理协调在PC-MHI。 后续步骤/实施： 在与心理健康和自杀预防办公室，连接护理办公室和 初级保健办公室，调查结果将适用于HSR&D优秀审查奖拨款提案， 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.