A multi-year process has led to successful implementation of an innovative, evidence-based approach to improve care for veterans with mental health conditions in the US Department of Veterans Affairs (VA) healthcare system, reports a study in a special October supplement to Medical Care. The journal is published in the Lippincott portfolio by Wolters Kluwer.
"Evidence synthesis provided the basis for implementation of the Collaborative Chronic Care Model (CCM) for mental health conditions in VA mental health clinics," according to the report by Mark S. Bauer, MD, of the Center for Healthcare Organization & Implementation Research (CHOIR) at the VA Boston Healthcare System and colleagues. Titled 'Evidence Synthesis in a Learning Health Care System,' the supplement includes 14 original articles, presenting new insights and perspectives from the VA Evidence Synthesis Program (ESP). The ESP is dedicated to making high-quality evidence accessible inform efforts to improve health and healthcare for veterans.
Implementing CCM for mental health care in the VA – Toward a 'Learning Health Care System'
Originally developed to improve care for patients with chronic medical illnesses, the CCM approach focuses on health care changes to promote teamwork and increase patients' involvement in their own care. Dr. Bauer and colleagues outline the multistage process – from evidence synthesis, to testing in a formal implementation trial, to policy impact, to scale-up and spread – by which the CCM model was implemented for managing mental health conditions in veterans.
The process started with an evidence synthesis produced by the ESP, focused on emerging research applying the CCM approach to mental health care.
This evidence synthesis indicated that CCMs can improve outcome among various mental health conditions treated in various treatment settings."
Mark S. Bauer, MD, and coauthors
However, they noted that the evidence supporting the CCM came from randomized controlled trials – with little information about whether it could be implemented in routine clinical practice.
To address this knowledge gap, a health system/researcher partnership between Dr. Bauer's research team and VA mental health national leadership was established. This collaborative researcher/leadership approach led to the development of a step-by-step guide to implementing the CCM approach – "focusing on creating conditions under which locally designed solutions for local challenges can be developed in accordance with CCM-based guidance."
The next step was a formal implementation trial, addressing both the implementation and outcomes of the CCM model by Behavioral Health Interdisciplinary Program (BHIP) teams at nine VA medical center mental health clinics. The results demonstrated improvement in key outcomes with the CCM approach, including fewer hospitalizations for veterans with mental health conditions.
The evidence had a policy impact, as the VA Office of Mental Health and Suicide Prevention (OMHSP) adopted the CCM as the "foundational model" for improving integration of mental health care by BHIP teams throughout the VA system. Based on early experience, the CCM approach was scaled up and spread to other VA medical centers, with strong support from VA mental health leadership. To date, implementation efforts have reached 30 VA medical centers, most of which have aligned their mental health care processes with the CCM model. The VA-wide Plan for Modernization, which was launched this year, includes a milestone based in part on this CCM work. Dr. Bauer and colleagues discuss the relevance of their experience to the development of a "learning health system" – a key aspect of the VA's commitment to continuous improvement in care for veterans, including real-world implementation guided by a solid evidence base.
The Guest Editors of the Medical Care are Mark Helfand, MD, MS, MPH, and Nicole Floyd, MPH, of the Evidence Synthesis Program Coordinating Center at the Portland (Ore.) VA Health Care System and Amy M. Kilbourne, PhD, MPH, of the VA Quality Enhancement Research Initiative, Washington, D.C. In an introductory editorial, they write: "The articles in this series demonstrate what can be accomplished when research synthesis is integrated with qualitative information from health system personnel and patients and quantitative data from health systems in the context of an overarching framework for health system learning."