Improving Access to High-Quality Mental Health Care for Veterans: Proceedings of a Workshop (2023)
Chapter: 6 Taking Innovative Strategies to Scale: Achieving Institutional Adoption
This chapter highlights opportunities for scaling some of the innovative strategies and partnerships discussed throughout the workshop. Participants discussed increasing access to mental health services by leveraging CHWs, using community pharmacists, and taking steps to institutionalize digital health innovations.
IMPROVING ACCESS WITH COMMUNITY HEALTH WORKERS
Denerale Jones and Anthony Davis, representing the Penn Center for Community Health Workers in Philadelphia, described the mission of advancing health equity through effective and sustainable CHW programs. CHWs understand the problems of their patients and community and use their empathy and knowledge to help them to better reach their health goals, said Jones. To provide more context, Jones shared the story of a 45-year-old veteran single mother of three, who was living with depression and PTSD. As the CHW, Davis worked with her to get caught up on utilities and home repairs, helped connect her to behavioral health care services, and ensured she received her medications throughout the pandemic. After a 6-month period, which is typical for VA’s CHW program, Davis connected her with the VA Whole Health program in Philadelphia, where she was able to complete an intake and introduction. Jones said they have supported 800 veterans since 2015 and been able to demonstrate their effectiveness through randomized control led trials. For example, one study found that patients in the CHW program had a third fewer total hospital days compared to matched controls, improved self-reported mental health, and a return of $2.47 for every dollar invested in the program. This works out to $2,500 savings per person annually (Kangovi et al., 2020).
Davis shared information about one of the support groups with VA in Philadelphia. Although it had focused mainly on physical health goals, such as weight loss, diabetes, and hypertension, it recently shifted to more mental and behavioral health. It noticed that many of the veterans are socially isolated and grew up in households that did not typically share feelings or emotions. In collaboration with VA, the CHW program created a group (Renegades) that meets off campus, listens to music, engages in conversation, gardens, or sometimes just walks on trails together. It also arranges monthly social events to get people to interact and go outside of their comfort zone, such as bowling or attending museums and, more recently, going to classrooms to mentor students. Because of the financial limitations of some, the program also provides admissions and transportation for these events. Their main goal, through these outings, regular meetings, and even home visits, Davis said, is to ensure that the participants are socially connected, and their care continues
to be coordinated. Jones noted the strong value proposition of scaling CHWs nationally across VA and using its triple aim results as a use case. To do this well, he recommended a program management structure that consolidates expenses and returns across inpatient and outpatient settings and integration with existing whole-health initiatives to ensure holistic support for behavioral health and for other health needs.
USING PHARMACISTS AS ENTRY POINTS
Over the past 10 years, pharmacists have been involved in offering comprehensive medication management services in telehealth, finding value-based care, and collaborating with primary care providers, said Andre Montes, clinical instructor of pharmacy at the University of Texas at El Paso. Since 2020, they have worked even further to improve drug safety and advance access to quality mental health. He shared results from studies that used pharmacists on an integrated care team as entry points into services. In one study, beginning in 2010, a VA patient-centered medical home model integrated clinical pharmacy specialists with prescribing authority into the larger clinical care team, which increased access and quality of care (McFarland et al., 2020). This was seen through improvements in clinical outcomes and cost-effectiveness, use of virtual care modalities, and interdisciplinary team satisfaction. Another study evaluated a pharmacist-led substance use disorder transition of care telephone clinic on retention after inpatient initiation (Smith et al., 2021). Researchers found improvements in retention rates through engagement during and after hospitalization. Expanding care teams might lead to cost concerns, said Montes, but using pharmacists is associated with a cost reduction. Looking at hospital environments and management within the community, studies have found reduced costs, even with the pharmacy team still providing similar types of comprehensive medication management visits.
Within this context, Montes shared potential future models where pharmacists could be added to clinical teams. First, adding pharmacists to acute care improved workflow efficacy, reduced the delays in treatment initiation (Vandenberg and Mullis, 2014), and improved outcomes and decreased discrepancies in the medication reconcilation process in the emergency department (Accomando et al., 2022). In another study in an acute care setting with substance use disorder and addiction triage teams, when a pharmacist joined the consult team, adding additional consult opportunities each week, researchers found improved medication initiation rates, access, and patient education (Ehrhard et al., 2022). Montes also shared a map showing that 90 percent of the U.S. population lives within 5 miles of a pharmacy, meaning that pharmacists are accessible to nearly everyone (see Figure 6-1).
SOURCES: Andre Montes presentation, April 21, 2023; Berenbrok et al., 2022.
One community pharmacy model worked with patients with a history of opioid use disorder who were referred, in a variety of pathways, to begin buprenorphine induction instead of going to their opioid treatment program. After 1 month of using these pharmacy services, 89 percent of those receiving pharmacy-based care were retained, compared to only 17 percent of those assigned to the usual care pathway (Green et al., 2023). Montes said that new innovative models are expanding the pharmacist’s role further in acute and community settings, resulting in improved access and management for behavioral health care services.
DIGITAL HEALTH INNOVATIONS
Although digital health can be a tool, said Andrey Ostrovsky, managing partner at Social Innovation Ventures, it is not the solution. He referenced a recent study that tried to characterize Medicare and Medicaid populations—two important populations at risk of disparities. It found that despite twice as many people receiving Medicaid, far more funding is going toward Medicare Advantage (Norden et al., 2023). He argued that an enormous market remains
in the Medicaid space, as well as with veterans, and that there is an opportunity to bolster the innovation ecosystem serving veterans specifically.
Ostrovsky shared a study that surveyed state Medicaid programs that had streamlined innovative and inclusive processes for benefit coverage determination. It was able to distill 11 attributes that could be applied to VA digital solutions (see Box 6-1). Another important consideration, Ostrovsky said, is including internal experts, clinicians, peers, and veterans in the determination process; he encouraged adding nonclinical providers or care team members.
Ostrovsky also shared some examples of benefit categories that can be used with the emerging intervention type of digital therapeutics. He discussed a company that created a technology with a VR headset with a software experience that uses CBT, mindfulness exercises, and deep breathing to address chronic pain, anxiety, and other conditions. The U.S. Food and Drug Administration approved it for lower back pain specifically, but he noted off-label uses, and a Healthcare Common Procedure Code System code was recently created (E1905) that can track its use. Like some of the applications discussed in Chapter 4, Ostrovsky described the potential of shipping this tool
to someone’s home without needing access to a provider, bypassing some of the workforce shortage issues while still providing a clinical benefit.
Last, he highlighted the single front door VA has for its patients into all of health care. He saw this as a huge opportunity and encouraged VA to use digital-native contractors and design experts to help develop these digital experiences. Innovation is not just technology, Ostrovsky said; delivery innovation can also drive big value. A study in Arizona with Medicaid beneficiaries found that the further upstream a patient goes (i.e., mobile crisis facility vs. emergency department and inpatient), the more outcomes and 30-day readmission rates improve (Tomovic et al., forthcoming). Payment innovation is critical as well and cannot have a single focus on mental health without considering the broader picture of social determinants of health and structural factors. Payments need to take this into account, he emphasized, and studies have shown that the higher the neighborhood social deprivation level, the higher the 30-day readmission risk (see Figure 6-2). This social risk, and not just medical complexity, can now be built into payment models (Chen et al., in review).
DISCUSSION
Given the focus on partnerships and including different professions on care teams during this workshop session, the discussion centered mainly on the common theme of community and how some interventions might be helped or hindered by social determinants of health.
Considering the Importance of Community
Richard J. Silvia, professor at the Massachusetts College of Pharmacy and Health Sciences, asked about ways to identify community resources and how
NOTES: Note we are seeing this phenomenon in ZCTAs with demographics that are less homogeneous instead of census tracts with homogeneous demographics. ZCTA = zip code tabulation areas; SDI = social deprivation index.
SOURCES: Andrey Ostrovsky presentation, April 21, 2023; Chen et al., in review.
to help veterans receive care without necessarily finding an in-person facility. Jones replied that it is really about what a person needs and wants and delivering what is possible. Ostrovsky highlighted the example of the Renegades group in Philadelphia, saying that those people are not showing up for the food or music but are more than likely seeking out a community and people they trust. Trust is the holy grail of digital health, he added, highlighting InquisitHealth, a company building on this idea and virtualizing CHWs by leveraging people from similar backgrounds and training them in particular chronic conditions.1 It is seeing improvements in patients not because they are following a particular care pathway, Ostrovsky said, but because it has built this trust and relationship and has a shared history or identity in some way. Ostrovsky noted that virtual solutions that closely follow evidence-based practice can be a sweet spot for digital intervention for mild to moderate mental illness or addiction. Montes added that another key point that continues to emerge is that it is going to be up to the individuals—some will prefer technology and some face-to-face interactions. Community pharmacists can bring those options, he said. For example, a patient does not need to go sit in an opioid treatment building, which may be stigmatizing, but can easily go to a general pharmacy and pick up treatment with the community pharmacist.
Montes also shared opportunities to scale more integration of drug and alcohol counseling and primary care by leveraging pharmacy locations. VA is well positioned to do this, he said, because VA pharmacists can also be prescribers, either independently or in collaboration with care teams. This can supersede state barriers, he noted, where certain treatments are not provided or geographic barriers prevent patients from talking directly with providers and gaining an awareness of the programming out there. Virtual models also offer the ability to reach even more consumers by having pharmacists provide the same comprehensive medication management for mental and behavioral health as they already do for other chronic diseases.
Social Determinants of Health Considerations
When CHWs are familiar with the people in a community, they can work to make them comfortable, said Davis. It will not happen overnight, but over time, CHWs usually maintain a lot of these relationships and can keep working with community members to ensure they get the resources they need. Jones added that in the Philadelphia CHW model, the CHWs are a part of the care team and can talk directly with the providers and communicate exactly what is happening in their neighborhoods—often because they live there
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1 For more on InquisitHealth, see https://www.inquisithealth.com/ (accessed May 30, 2023).
and are affected themselves. Ostrovsky noted meaningful potential impediments to remote virtual access to consider when it comes to low-bandwidth areas. Streaming telehealth solutions may be limited to audio in these areas, but many technology-based products function well without continuous data access. For example, he stated that quarterly updates over Wi-Fi might be required, which is manageable for most people. These could include things such as prescription digital therapeutics. He mentioned evidence that any kind of connection and trust with patients is better than no access at all. He suggested creating the infrastructure to financially incentivize programs such as Renegades and other CHW work; given the flexibility of VA as a payer, he believed this was possible.
