Statement of Dave Underriner
Chief Executive, Delivery System
Providence Health & Services, Oregon Region
Portland, Oregon

Before

Committee on Veterans Affairs
Of The United States Senate

Concerning:  “VA Mental Health Care: Closing the Gaps”

July 14, 2011

Introduction
Chairwoman Murray, Ranking Member Burr and Distinguished Members of the Senate Committee on Veterans Affairs:

Thank you for providing me, on behalf of Providence Health & Services, the opportunity to offer testimony on the very important topic of behavioral health care for American Veterans and how the Veterans Administration can take steps to improve access to behavioral health services through increased integration of care delivery. My name is Dave Underriner and I currently serve as Chief Executive, Delivery System for the Oregon Region of Providence Health & Services.  In this role I am responsible for management and oversight of our eight hospitals in the state, as well as statewide functions including nursing, pharmacy, information systems, ethics and foundations.

Providence Health & Services is a Catholic-sponsored, not-for-profit health system serving communities across the states of Oregon, Washington, Montana, California and Alaska.  Founded by Mother Joseph of the Sacred Heart in 1856 in Vancouver, Washington, Providence provides health care across the full continuum.  Today, Providence Health & Services comprises 27 hospitals, more than 34 non-acute facilities, physician clinics, a health plan, a liberal arts university, a high school, approximately 50,000 employees, and numerous other health, housing, and educational services.  
Our mission calls for us to place a special emphasis on serving the poor and vulnerable in our communities.  As such, Providence has striven since our founding to ensure that people suffering from mental illness are able to access the care they need, regardless of their circumstances.  In 1861, the Sisters of Providence opened the first mental health facility in the Washington Territory.  The sisters ran the hospital for five years and were commended by the territorial governor for their humane, conscientious and compassionate care of the mentally ill.  This commitment continues today across our system.

Our vision for behavioral health is as follows: “Providence Behavioral Health Services will be an advocate and leader in developing a patient-centered system of care for people with mental health and substance use needs.  The system of care will be evidence-based, focus on recovery and work in partnership with our community of providers, educators and consumers.  This connected experience of care will achieve superior outcomes and patient satisfaction.” 

This vision is pursued through a comprehensive organizational structure led by physician and administrative leadership focused on patient outcomes, population health, care coordination, patient satisfaction, strategic partnerships in our communities, advocacy, ongoing clinical transformation and physician integration, research and education.
 
Integrating Behavioral Health with Physical Health Care in the State of Oregon
More than 25 years ago, as part of Providence’s development of an integrated delivery system in Oregon, the decision was made to include behavioral health as a distinct service line/program due to its importance as a clinical area.  Providence Health & Services in Oregon has eight service lines, including heart and vascular, cancer, brain and spine, and behavioral health. Each of these service lines has defined leadership and strategic plans for delivery of services and programs in a coordinated, efficient, high quality and cost-effective fashion through development of a continuum of programs and care models.

This decision, perhaps more than any other, facilitated the integration of behavioral health services into our larger delivery system by elevating it as a key clinical program that requires  overarching leadership and strategic focus.   It also set us on the path toward full integration of behavioral health in our regional delivery system.  

Among the noteworthy integrated behavioral health models developed over the past two decades include:
1. Consult Liaison Team:  The Consult Liaison Services (CLS) team has long been seeing patients who are admitted to Medical/Surgical floors in both Providence Portland Medical Center and in Providence St Vincent Medical Center.  In 2005, the team was expanded to include Psychiatrists, Nurse Practitioners, Social Workers and Counselors. These practitioners meet with patients who have been admitted for physical medical procedures, but who have been identified as having some related mental health or chemical dependency care needs. The CLS assess the patient’s symptoms or problems and make recommendations regarding “next steps” in the treatment of the behavioral health issues. Often times, the CLS is able to connect the patient with follow up care for these needs within Providence Health and Services or in the community.
2. Access Triage Call Center:  Since 1997, this service has been staffed by masters prepared social workers and counselors and is available to members of the community including referred patients, potential patients, concerned family members and primary care physicians or other healthcare providers. The call center staff have these primary roles:
• Assess the caller’s current situation, including risk for harm to self or others;
• Facilitate the involvement of other agencies (police, crisis team, EMTs) as needed;
• Triage to the next level of care needed;
• Whenever possible, engage the caller in an intake process for one of the Mental Health or Chemical Dependency services offered at PH&S.

In 2007, the Access Triage Call Center initiated a “pilot” program with the Providence Medical Group (PMG) Clinic in Sherwood, Oregon as a mechanism to respond to medical care providers concerns about depressed patients who may be thinking of suicide.  The call center supported a dedicated line that PMG health care providers could utilize either in consultation, or to have the patient speak directly to a behavioral health clinician. 

In 2010, the Access Triage Call Center piloted a project to provide follow up calls to people who visited the Emergency Department at Providence Portland Medical Center for mental health or chemical dependency reasons. The goal of the project is to reduce the frequency of visits by individuals who presented repeatedly for care.  Call center staff call out to the identified individuals and offered support for the person in completing their discharge plan.

3. Behavioral Health Interface with PMG – In 2004, one of the masters-prepared counselors from Access Triage was placed in the PMG Gateway Clinic in Portland as a pilot. The counselor’s appointment times were quickly booked up by the health care providers who had active patients that needed counseling support.  This position has continued through the current time as a result of the pilot. It also has laid the foundation for a current plan which PMG has recently launched. 

In 2010, the Access Triage Call Center provided telephone support to PMG patients who were participating in an on-line depression study. Patients were identified by their primary care physician, invited to participate, and then began the study. Patients were able to contact Access Triage for support and/or intervention, if needed, at any time during the study.

In 2011, seven clinics were identified for a project which would staff each of the chosen clinics with a Behavioral Health Specialist.  The specialist is tasked with assessing the level of care needed by the PMG patient and facilitating the patient’s entry into treatment, particularly into the Partial Hospital or Intensive Outpatient levels of care, before the patient’s symptoms develop to a level that requires a hospital admission.

Both individually and collectively, these initiatives support improving access for mental health patients such that they can receive the right level of care when they needed – to be directed to the “right door” the first time.  This goal of creating a single point of access has evolved to provide points of access from other settings within the Providence delivery system and allows Providence providers to act in concert to ease the way of patients in need of behavioral health services.

Current Integration Efforts: Patient-Centered Medical Home
Consistent with our vision of a connected patient experience through a coordinated model of “team based” behavioral health services, Providence in Oregon has set about to fully weave behavioral health into our Patient-Centered Health Home model for primary care. This not only includes adding a behavioral health specialist into our primary care clinics; it also includes standardization of how we identify patients in need of assistance, development of clinical guidelines and creation of a team-based model of holistic care for patients being served in our clinics.

This model involves the entire care team in the primary care clinic, with the primary care provider (PCP) in an oversight role in the management of the patient, both in terms of his or her medical and behavioral health needs. Providence Medical Group has developed a tiered approach to assessment and treatment that is both standardized and flexible:
1. The patient is referred to the clinic’s behavioral health provider by his/her PCP to address any behavioral health issues that may be exacerbating a current physical health condition.
2. The patient, with a behavioral health provider and medical assistant, completes a questionnaire and screening packet;
3. The behavioral health provider then determines the intensity of the necessary intervention based on the screening;
4. The Care Team, led by the PCP, is activated – treatment is planned and implemented, including facilitating connection to the community and specialty care if needed. This also includes consultation on drug therapy management with a pharmacist who is also part of the team.

The behavioral health provider also educates members of the care team on documentation, coordination and treatment support for behavioral health concerns. Providence began developing the fully integrated PCMH model at four of our PMG clinic sites, with three additional clinic pilot sites scheduled to be on line by September of 2011.

The PCMH integration initiative will measure effectiveness using a variety of metrics, including:
• Improvement in patients’ Patient Health Questionnaire  (PHQ-9) scores from first to last session with their behavioral health provider;
• Patient and provider satisfaction improvement;
• Reduction of Emergency Department (ED) visits for patients seen by the behavioral health provider;
• Reduction of hospital visits for patients seen by the behavioral health provider
• Improvement in chronic care conditions for those patients seen by the behavioral health provider;
• Process and other measures, such as number of handoffs to behavioral health specialist, average time to initial appointment with behavioral health specialist, percentage of use of community support networks and medication adherence.

For the patient, the team approach provides for a comfortable, connected experience in which his or her whole person can be addressed in the clinic visit: the care team knows them, cares for them and eases their journey to improved health.

Conclusion: Implications for the VA Health Care System
Despite the significant challenges resulting from low reimbursement and inadequate numbers of mental health providers in the communities, Providence has remained steadfast in its commitment to behavioral health as a priority service line program in Oregon.  Integrating behavioral health into the medical home model will provide an important, seamless point of access for patients – particularly those whose medical concerns are intertwined with a mental health condition, in some cases one that is undiagnosed.

The VA health system, in our view, has both an imperative and unique opportunity to fully integrate behavioral health care into its delivery models. According to recent statistics, 48 percent of veterans returning from duty in Afghanistan and Iraq are diagnosed with a mental health condition.

Over the past two decades, the VA has greatly strengthened its primary care capacity and has taken important steps by developing integrated health networks across the nation and re-focusing the system on population-based care delivery, rather than a hospital-oriented system.  From 1995 to 2005, the VA expanded its primary care access points by 350 percent. The VA has been a leader in the use of electronic medical records (EMRs) and automating care processes.

Additionally, the VA health system’s utilization of employed physicians provides a key structural component that allows the system to integrate its service lines more rapidly – including behavioral health.  By emphasizing the primary care clinic setting as the focal point of diagnosis, care planning and referral for veterans’ health concerns, there is a strong opportunity to create a more comfortable, safe and efficacious environment to meet their needs.

It is our hope that the Providence experience in clinically integrating behavioral health with physical health in our Oregon region can offer some perspective that will benefit the VA health system as it moves forward in redesigning care systems and structures in order to better serve the current and future health needs of America’s military veterans.

Thank you for the opportunity to speak to you today.