Background

Burnout among primary care clinicians (PCPs) is associated with negative health and productivity consequences. The Veterans Health Administration (VA) embedded mental health specialists and care managers in primary care to manage common psychiatric diseases. While challenging to implement, mental health integration is a team-based care model thought to improve clinician well-being.

Objective

To examine the relationships between PCP-reported burnout (and secondarily, job satisfaction) and mental health integration at provider and clinic levels DESIGN: Analysis of 286 cross-sectional surveys in 2012 (n = 171) and 2013 (n = 115) PARTICIPANTS: 210 PCPs in one VA region MAIN MEASURES: Outcomes were PCP-reported burnout (Maslach Burnout Inventory emotional exhaustion subscale), and secondarily, job satisfaction. Two independent variables represented mental health integration: (1) PCP-specialty communication rating and (2) proportion of clinic patients who saw integrated specialists. Using multilevel regression models, we examined PCP-reported burnout (and job satisfaction) and mental health integration, adjusting for PCP characteristics (e.g., gender), PCP ratings of team functioning (communication, knowledge/skills, satisfaction), and organizational factors.

Key results

On average, PCPs reported high burnout (29, range = 9-54) across all VA healthcare systems. In total, 46% of PCPs reported "very easy" communication with mental health; 9% of primary clinic patients had seen integrated specialists. Burnout was not significantly associated with mental health communication ratings (β coefficient = - 0.96, standard error [SE] = 1.29, p = 0.46), nor with proportion of clinic patients who saw integrated specialists (β = 0.02, SE = 0.11, p = 0.88). No associations were observed with job satisfaction either. Among study participants, PCPs with poor team functioning, as exhibited by low team communication ratings, reported high burnout (β = - 1.28, SE = 0.22, p < 0.001) and low job satisfaction (β = 0.12, SE = 0.02, p < 0.001).

Conclusions

As currently implemented, primary care and mental health integration did not appear to impact PCP-reported burnout, nor job satisfaction. More research is needed to explore care model variation among clinics in order to optimize implementation to enhance PCP well-being.

Background

To improve mental health care access, the Veterans Health Administration (VA) implemented Primary Care-Mental Health Integration (PC-MHI) in clinics nationally. Primary care clinical leader satisfaction can inform model implementation and may be facilitated by collaborative care managers and technology supporting cross-specialty collaboration.

Objective

(1) To determine primary care clinical leaders' overall satisfaction with care from embedded mental health providers for a range of conditions and (2) to examine the association between overall satisfaction and two program features (care managers, technology).

Design

Cross-sectional organizational survey in one VA region (Southern California, Arizona, and New Mexico), 2018.

Participants

Sixty-nine physicians or other designated clinical leaders in each VA primary care clinic (94% response rate).

Main measures

We assessed primary care clinical leader satisfaction with embedded mental health care on four groups of conditions: target, non-target mental health, behavioral health, suicide risk management. They additionally responded about the availability of mental health care managers and the sufficiency of information technology (telemental health, e-consult, instant messaging). We examined relationships between satisfaction and the two program features using χ² tests and multivariable regressions.

Key results

Most primary care clinical leaders were "very satisfied" with care for targeted anxiety (71%) and depression (69%), but not for other common conditions (37% alcohol misuse, 19% pain). Care manager availability was significantly associated with "very satisfied" responses for depression (p = .02) and anxiety care by embedded mental health providers (p = .02). Highly rated sufficiency of communication technology (only 19%) was associated with "very satisfied" responses to suicide risk management (p = .002).

Conclusions

Care from embedded mental health providers for depression and anxiety was highly satisfactory, which may guide improvement among less satisfactory conditions (alcohol misuse, pain). Observed associations between overall satisfaction and collaborative care features may inform clinics on how to optimize staffing and technology based on priority conditions.

BACKGROUND: Healthcare systems and their primary care practices are redesigning to achieve goals identified in Patient-Centered Medical Home (PCMH) models such as Veterans Affairs (VA)s Patient Aligned Care Teams (PACT). Implementation of these models, however, requires major transformation. Evidence-Based Quality Improvement (EBQI) is a multi-level approach for supporting organizational change and innovation spread. OBJECTIVE: To describe EBQI as an approach for promoting VAs PACT and to assess initial implementation of planned EBQI elements. DESIGN: Descriptive. PARTICIPANTS: Regional and local interdisciplinary clinical leaders, patient representatives, Quality Council Coordinators, practicing primary care clinicians and staff, and researchers from six demonstration site practices in three local healthcare systems in one VA region. INTERVENTION: EBQI promotes bottom-up local innovation and spread within top-down organizational priorities. EBQI innovations are supported by a research-clinical partnership, use continuous quality improvement methods, and are developed in regional demonstration sites. APPROACH: We developed a logic model for EBQI for PACT (EBQI-PACT) with inputs, outputs, and expected outcomes. We describe implementation of logic model outputs over 18 months, using qualitative data from 84 key stakeholders (104 interviews from two waves) and review of study documents. RESULTS: Nearly all implementation elements of the EBQI-PACT logic model were fully or partially implemented. Elements not fully achieved included patient engagement in Quality Councils (4/6) and consistent local primary care practice interdisciplinary leadership (4/6). Fourteen of 15 regionally approved innovation projects have been completed, three have undergone initial spread, five are prepared to spread, and two have completed toolkits that have been pretested in two to three sites and are now ready for external spread. DISCUSSION: EBQI-PACT has been feasible to implement in three participating healthcare systems in one VA region. Further development of methods for engaging patients in care design and for promoting interdisciplinary leadership is needed.