The Case for Integrated Care: A Look at the VA

Posted on March 31, 2011

Howard Owens, MD
Board of Directors, Fountain House

The integration of medical and psychiatric outpatient care is now standard procedure in the Veterans Administration clinics in New York and New Jersey. On January 13 Dr. Brian Bronson gave a presentation at the NYU School of Medicine describing the new approach taken at the VA. (Dr. Bronson is the Director of Psychosomatic Medicine at the New York VA Medical Center.)
The VA has had to approach the problem of integrated care from the opposite direction, compared to Fountain House. At Fountain House, we have had from the beginning a group of people who are recognized as having psychiatric disorders. In recent years, however, it became increasingly clear that many of our members also had untreated medical problems. The establishment of the Sidney R. Baer, Jr. Center and our overall wellness programs were designed in part to address medical problems, such as obesity and diabetes, within the context of our clubhouse program. The VA hospital clinics, on the other hand, have a recognized population of people with medical complaints, who often have unrecognized psychiatric disorders. Within this group of veterans, there is extensive denial and stigmatization of psychiatric illness, with the result that there is often much resistance on the part of the patient to obtain psychiatric treatment or rehabilitation.
Dr. Bronson first described the major problems that the VA clinics have had in the past with referrals for psychiatric consultation. Appointments to psychiatric clinics were often not kept. Medical doctors became pessimistic about obtaining effective psychiatric care for their patients. When faced with an uncertainty about whether a patient needed referral, the physician would often not bother to make a referral, because of the low expectation that the patient would follow through. Research has indicated that compliance with follow-up appointments is clearly affected by time and distance: the compliance rate goes down as the waiting time for an appointment goes up, and it also goes down with distance – even if the psychiatric clinic in only across the street in another building.
To address this problem, the VA clinics in New York and New Jersey have instituted a simple change in procedure by locating the consulting psychiatrist within the medical clinic, so that the patient can be seen in the same setting and often on the same day that the referral is made. The results in the VA system have been dramatic: compliance with follow-up psychiatric treatment has improved significantly, and so has the morale of the medical doctors, who now report a sense of optimism about psychiatric care and are more inclined to make the referral in doubtful cases, where they can expect to get a quick opinion from the consulting psychiatrist.
Isolation of psychiatric care has been a long-standing problem in this country (as exemplified by the history of state hospitals and the more recent and protracted political battles over parity of coverage.) Fountain House has, of course, been a pioneer in integrated care through our collaboration with Dr. Ralph Aquila and the Center for Reintegration at the Baer Center. Dr. Bronson’s presentation demonstrated that it is easily possible for a large, organized health care system to provide similarly integrated care with fairly simple administrative changes.

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