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While the need for more mental health workers for veterans is no doubt essential, some in the field think the Veterans Administration’s (VA’s) announcement about hiring more mental health counselors will mean more competition for recruiting and retaining mental health professionals in a field already struggling with a critical workforce shortage.

The VA announced on April 19 that it intends to add 1,600 mental health clinicians — to include nurses, psychiatrists, psychologists and social workers — and 300 support staff to its existing workforce of 20,590 mental health staff as part of an ongoing review of mental health operations.

Less than a week later, on April 23, the VA announced that the department is expanding its mental health services to include marriage and family therapists (MFTs) and licensed professional mental health counselors (LPMHCs). Both fields will be included in this round of hiring, the VA stated.

The new staff will provide mental health diagnostic and psychosocial treatment services for veterans and their families in coordination with existing mental health professionals at the VA’s medical centers, community-based outpatient clinics and vet centers, according to the VA.

“The VA’s efforts to expand its workforce are clearly needed but we have mixed feelings about it,” David Birney, Ph.D., president of the Wyoming Association of Mental Health and Substance Abuse Centers (WAMHSAC) and executive director of the Peak Wellness Center in Cheyenne, told MHW.

Birney added, “We obviously want veterans who need mental health care to get the care they need. The state has a pretty large contingent of veterans and families.” The state’s veteran population numbered 407,624 in 2011, according to the Wisconsin Department of Veterans Affairs.

The local VA can hire mental health staff around the state and offer them higher salaries, said Birney. “We’re all competing for the same pool of workers; this puts us at a competitive disadvantage,” he said. “While we applaud their efforts, we hope we won’t be understaffed.”

The state’s community mental health centers (CMHCs) are responsible for a large sector of other consumers of mental health in the community, Birney said. “We want to make sure everybody in need of mental health care is able to access services,” he said.

Birney added: “We depend on people who are committed to [our field]; they’re not in it for the financial reward. Still they need to buy food, and send their children to colleges.”

The goal is to provide as many services to the overall population as the CMHCs can deliver, said Birney. “It’s certainly a needed expansion,” he said. “But sometimes we forget [just what a] limited pool we all have to work with; it just continues to be a challenge.”

Currently, Montana’s four CMHCs, which provide services for the state’s 55 counties, also serve the veteran population, said Kathy McGowan, executive director of the Montana Council of Mental Health Centers. Nearly 10 years ago, the Department of VA Medical Center approached the South Central Montana Regional Mental Health Center to provide mental health services for patients served at the VA following the retirement of the VA’s physician, said McGowan.

The local VA has authorized the CMHCs to provide the full gamut of services for veterans, said McGowan, including outpatient individual and group services and the Program of Assertive Community Treatment (PACT).

Before the VA contract with CMHCs, veterans typically had to wait six to eight months for services on an outpatient basis. The turnaround time reported then was 10 days or less if urgent care is needed, which still holds true today, added McGowan. “Once the VA makes a referral to one of our CMHCs, the [veteran] is given priority,” she said.

A main concern is for the state to open its inpatient facility at the Fort Harrison VA Medical Center, one of the state’s “most serious deficiencies,” said McGowan. “We need a stronger system out there at Fort Harrison for people who need to be hospitalized.”

The American Mental Health Counselors Association (AMHCA), citing recent advocacy efforts to urge the VA to hire more mental health counselors, said it is pleased with the news. “It’s a great step forward for us and for our membership.” Mark Hamilton, executive director and CEO, told MHW.

James K. Finley, director of public policy for the AMHCA, said the association does greet the news with caution. “Based on the VA’s actions to date, we expect similar small numbers of marriage and family therapists and mental health counselors will be hired within the next few years,” Finley told MHW. The AMHCA has been pressing the VA to hire more of its members for years, said Finley.

Nationally, the VA has more than 300 total vacancies listed for psychiatrists, psychologists and social workers, and four listings for mental health counselors, Finley said. “The VA released job requirements and authorization for hiring licensed mental health counselors at the independent practice level back in September 2010, so their performance in recruiting these professionals has been abysmal,” Finley said.

Finley added: “A majority of psychotherapists in the VA are clinical social workers, and many mental health units are supervised by psychologists. The HR staff tends to display a high level of misunderstanding and unfamiliarity with the mental health counseling profession and its competencies.”

The VA Inspector General released a blistering report on April 23 that found that the Veterans Health Administration (VHA) did not provide first-time patients with timely mental health evaluations, and existing patients often waited more than 14 days past their desired date of care for their treatment appointment.

A comprehensive staffing analysis can help the VHA determine if psychiatrist, or other mental health provider, vacancies are systemic issues impeding the VHA’s ability to meet mental health timeliness goals, according to the report.

The VA’s efforts to increase its mental health workforce are part of an ongoing comprehensive review of mental health operations that began months ago, said Mark Ballesteros, spokesperson for the VA. “We started with surveys of our own mental health professionals last summer, and site visits began in December to go out to every VA facility,” Ballesteros told MHW.

Ballesteros said the VA considered a number of factors to determine staffing levels, including the veteran population in the service area, the mental health needs of veterans in that population, and the range and complexity of mental health services provided in the service area.

“VA regional networks will use the same criteria to determine staffing levels at facilities,” said Ballesteros. "If it is determined that more mental health staff are needed in the coming months, more will be added.”

The AMHCA’s Finley said he doesn’t expect momentum on hiring by the VA to happen for several months. “There’s a long way to go,” said Finley. “We’re careful about watching closely. We’re hoping they do more."

For more information about VA careers visit www.va.careers.va.gov and www.usajobs.gov.

The field can expect to see opportunities for psychologists, social workers, nurses and other professionals to work with veterans as the VA gears up its recruiting efforts.

The implementation of health homes, considered a key part in the delivery setting of the future, is prompting a change in the role of the traditional mental health case manager whose skill sets are transferable to assisting consumers with chronic physical health conditions, according to field leaders.

“There’s a need for an expanded skill set in an era of health care reform,” Joan King, senior integration consultant at the National Council for Community Behavioral Healthcare, told attendees during the National Council’s annual Mental Health and Addictions Conference in Chicago earlier this month (see MHW, April 23). “Primary care and behavioral health integration is no longer optional,” she said. “The system is changing.”

Mental health case managers can integrate face to face with primary care providers, King said. “Case managers have played a critical role in the health care system up to this point,” she said during her session, “Supporting and Developing Health Navigation Skills in Case Managers and Other Community Based Staff.”

King advised the field to develop its workforce to create healthier communities. Components such as integrated primary care/behavioral health practices, Mental Health First Aid and integrated care management are essential to making that happen, she noted.

“Our understanding is that recovery is happening in the community,” said King. “Community health has a huge impact on the ability of people to recover.”

King added, “The movement to care management is part of the future of case management. Transforming the role of case managers involves using their existing skills and developing new partners (e.g., primary care physicians, federally qualified health centers (FQHCs) and accessing community-based resources, she said.

"Case managers can be mobile," King said. “It’s not an additional task but a redirection of their traditional work,” she said.

“We have to take the holistic approach and bring it up to another level. We need to work across cultures," King said. “Primary care providers [PCPs] are very solution-focused.” PCPs focus less on the process and more on plans and outcomes, she said.

Physical health care is essential to the core service of a CMHC's package, she noted. Health navigation training offered by the National Council is a one-day session with three follow-up webinars, said King. The content includes information on key health conditions for people with diabetes, heart disease and other behavioral health–related challenges, she noted. Trainees can identify current health trends that will affect their role, said King.

“We’re not trying to turn case managers into nurses,” said King. “It’s about trying to help case managers get enough health literacy skills that they can navigate and use those nurses as consultants.”

What’s in a name?

While there are many disciplines and training levels, there currently is no consistency in how terms such as care, case, health, behavioral health managers, coordinator and navigator are used across settings, said Alexander Blount, Ed.D., director of the Center for Integrated Primary Care at the University of Massachusetts Medical School. Mental health and medical cultures define the role differently because they define the needs of the patient/client differently, he said.

“There is a commonality in the role of [professionals] who keep the patient, consumer or client connected with the system,” said Blount.

The patient-centered medical home (PCMH) is an enhanced form of primary care delivered in primary care settings or in CMHCs, and requires care management that addresses all needs of “complex” patients with challenging medical and behavioral health needs, he noted.

“The patient-centered medical home is sweeping the nation,” said Blount. “The primary care medical doctor is getting back to what primary care is supposed to be. They’re now trying to make [services] attractive and flexible.”

Blount noted that functions for mental health case management generally included:

• Obtaining basic supports.
• Crisis prevention and intervention.
• Assessment to determine need for services.
• Outcome-/function-focused treatment planning.
• Referral and linkage with chosen services.
• Engaging in/developing helping, trusting relationships.
• Coordinating and adjusting service delivery.
• Advocacy.

Care management

Medicare care management for people with a serious mental illness makes a difference, said Blount. He pointed to a study published in the February 2010 issue of the American Journal of Psychiatry, in which lead author Benjamin G. Druss, M.D., and colleagues tested a population-based medical care management intervention designed to improve primary medical care in community mental health settings.

In the study, “A Randomized Trial of Medical Care Management for Community Mental Health Settings: The Primary Care Access, Referral, and Evaluation (PCARE) Study,” care managers served as an advocate for the patient as well as a communication conduit between the patient and specialty medical and mental health provider. During the intervention, care managers/coordinators provided information to patients about their medical conditions, and about available medical providers in the community and upcoming appointments.

According to the study, subjects assigned to usual care were given a list with contact information for local primary care medical clinics that accept uninsured and Medicaid patients. Subsequently, these subjects were permitted to obtain any type of medical care or other medical services.

At a 12-month follow-up evaluation, the intervention group received an average of 58.7 percent of recommended preventive services, compared with a rate of 21.8 percent in the usual care group. Medical care management was associated with significant improvements in the quality and outcomes of primary care. These findings suggest that care management is a promising approach for improving medical care for patients treated in community mental health settings.

Peers are also going to have many roles in the patient-centered care environment as wellness coaches and navigators, said Blount. “Peers are going to be [essential] to connecting people to behavioral health care,” he said. Peers will become involved in transportation, making appointments and reminding consumers of their appointments, and providing some health teaching, Blount said.

Blount also said that PCMHs are even more important now because “the cost of health care is strangling our economy." “Primary care can improve health and reduce costs, if people will use it,” he said. “Primary care needs to be made user-friendly, to attract rather than coerce people to use.”

Bottom Line …
The patient-centered medical home is offering new opportunities for case managers to transition their skill sets to help consumers with mental illness manage their physical health conditions, such as diabetes and heart disease, as well.

As the fundamental shift in the way health care is delivered in this country continues — whether it be in the form of accountable care organizations (ACOs) or person-centered health and medical homes — the integration of behavioral health care and physical health care, a critical component, is at its core. The behavioral health field needs to take center stage among these changes, attendees heard during the National Council Mental Health and Addictions Conference held in Chicago April 15–17.

This year’s National Council conference, with the theme, "Leading the Revolution," drew more than 3,000 attendees.

Speakers and presenters included Sen. Tom Daschle (D-S.D.); David Satcher, M.D., Ph.D., former surgeon general; and Thomas R. Insel, M.D.,director of the National Institute for Mental Health. Prevention and recovery, health information technology, health promotion, finance, children and youth, addiction, and trauma-informed care were among the featured session tracks.

“Health care has changed becasue health care  is always changing,” Linda Rosenberg, president and CEO of the National Council, told attendees during the opening session."The understanding that even individuals with the most serious mental and substance use conditions recover changed healthcare."

“Consumers are moving toward treatment on demand,” said Rosenberg. “When, where and how a consumer wants it will become the norm. This is the Facebook generation and they want to educate themselves.”

Rosenberg added, "The revolution that could pass us by if we’re not prepared to join it is a consumer-directed, technology driven revolution in the way we receive, process, and use information." Social network sites are used for recruiting staff, marketing services and engaging consumers, said Rosenberg.

“As our behavioral health system embarks on change, behavioral health providers are faced with antiquated payment and regulatory structures,” said Rosenberg. To address those issues, the council is urging its members to join them on Hill Day, June 25–26 in Washington, D.C., to support a new federal definition for the establishment of federally qualified behavioral health centers (FQBHCs) (see story, p. ___).

Business of integrated care

In the presentation “Making the Business Case for Integration” on April 16, session leaders discussed a number of key strategies on how to address the behavioral health and physical health care needs of their patients — from outreach to federally qualified health center (FQHC) partnerships to one-stop shopping services.

The core vision of The Providence Center is providing a behavioral health system in which every individual receives an array of services in order for his or her “unique needs” to be met, Dale Klatzker, Ph.D., president and CEO of The Providence Center in Rhode Island, told attendees.

“It’s a comprehensive approach,” said Klatzker. “We view ourselves as a one-stop shop.” The Providence Center has six Assertive Community Teams (ACTs) — a service-delivery model that provides comprehensive, locally based treatment to consumers with a serious and persistent mental illness — and an onsite pharmacy and medical clinic. The center, which provides housing support, is also an In Shape provider.

“We believe in wellness,” said Klatzker, who pointed to a recent study that indicated that obese people are at 55 percent more risk of developing depression. “The numbers are pretty staggering,” he said. “If you’re not dealing with someone’s medical condition, you’re really not dealing with the consumer."

The Providence Center has also hired a director of integrated services, noted Klatzker. “It’s expensive, but critical,” he said. “If you add [that position] onto an existing position, you’ll have less success than if the position were a full-time job,” he said.

Providers of the current system of care for consumers with chronic conditions aren’t reimbursed well, said Klatzker. Integration is a “moving target” for payers, he said. “Focus on the coordination of care for high-cost consumers.”

The behavioral health field has to “embrace” integration, Klatzker added. “You have to believe in recovery; it can work and it does.”

Collaborative care

Missouri’s efforts to identify and reach out to consumers who are chronically ill is a key part of the state’s collaborative care initiative, said Joseph Parks, M.D., medical director of the Missouri Department of Mental Health.

Missouri has pioneered a program for Medicaid beneficiaries with severe mental illness that is based in community mental health centers (CMHCs) and provides care coordination and disease management to address the "whole person," including those with mental illness and chronic medical conditions.

In the state’s Chronic Care Improvement Program (CCIP), the aim is to enroll the “sickest people,” said Parks. A typical enrollee is a 47-year-old male with mental illness who likely has a major cardiovascular diagnosis and diabetes, he said. The enrollee may have typically experienced a major cardiac event, Parks said.

The goal is to find consumers and ensure they receive appropriate health care services, said Parks. The old business model involves a client, family or health care referrals for consumers seeks services, and they have to be evaluated for eligibility to receive services, he noted.

The new model is high-cost, high-risk outreach to selected consumers that the payer has selected for services, noted Parks. The target population has a diagnosis of schizophrenia, bipolar disorder, schizoaffective disorders or recurrent major depression. Also the individual has not been a consumer of the public mental health system in the previous 12 months. 

“We select high-risk people and go looking for them,” said Parks. “We go knocking on doors, and [go to] pharmacies,” he said. “We’ve been able to engage 50 percent of the people we’re looking for.”

Statewide, community mental health centers (CMHCs) have approved 10 percent of the health care home plans of care in the state’s Medicaid program, said Parks. More than 70 percent of patients have had a primary care visit within a 12-month period, according to claims, he said.

Enrollees with coronary artery disease in the CCIP program received recommended treatment with beta blocker medications at nearly twice the rate of non-enrollees, he noted. The outcomes review of the Missouri Psychiatric Rehabilitation programs indicate substantial cost savings for the overall health care cost after admission other program, Parks said.

In an analysis of Medicaid costs for 6,757 people, actual pharmacy services decreased by $9.2 million, or 23 percent, said Parks. “We had the biggest reduction in pharmacy,” he said. “It’s not what you’d expect in care management.” Actual general hospital services decreased by $1.5 million, or 6.8 percent, he said. Primary care services increased by $774,000, or 21 percent, Parks noted.

“Your CMHC can do the same kind of disease management,” said Parks. “It’s an ongoing development effort. We do it as a partnership with CMHCs, Medicare, Medicaid and the Department of Mental Health.”

Community-based organizations

Peter C. Campanelli, Psy.D., founding president and CEO of the Institute for Community Living, Inc., in Brooklyn, N.Y., told attendees his interest in collaborative care stems from the need to provide services that people need in order for them to be stable in the community.

The Institute, a not-for-profit agency, provides rehabilitation, housing, vocational and support services to over 9,000 New Yorkers with serious mental illness and/or developmental disabilities in all five boroughs. The consumers also may be homeless, have HIV or experience chronic comorbid conditions. “We link them to the community and stabilize them,” Campanelli told session attendees.

The Institute for Community Living, Inc., a community-based organization (CBO), integrates supportive services and primary care, and provides client access to a network of services, Campanelli said. In his discussion to make the case for safety-net CBOs, Campanelli said the organizations can help foster development of ACOs, and reduce high-cost Medicaid and Medicare services.

CBOs are essential because they can help improve health care integration for high-cost users and lead to community stabilization, Campanelli said. The Institute has also launched a health home in New York City, he said. Campanelli said he and his staff are talking to colleagues to get them interested in joining his network for collaborative care. They are also developing partnerships with FQHCs, he said.

“If you’re thinking about [working with FQHCs] in your agency, it’s quite an investment,” he said, adding that attendees should seek out the services of a national consultant. “Find out HRSA's [the Department of Health and Human Services’ Health Resources and Services Administration’s] priorities and gear your application [appropriately]; for us, it was the homeless populations,” said Campanelli.

The financial case for collaborative care involves the reduction of emergency department and inpatient use. It also involves the reinvestment of shared savings into more community-based ambulatory and social support resources, said Campanelli.

Working with consumers to address or coordinate their behavioral health and physical health care needs is essential in moving forward in an era of new health care delivery systems, session leaders said.