D.42- MENTAL HEALTH STEPPED CARE PROCEDURES- JUNE 2024.pdf

MENTAL HEALTH STEPPED CARE PROCEDURES

SOP 528a7-116-015

Syracuse VA Medical Center Syracuse, NY 13210

Signatory Authority:

Associate Chief of Staff for Mental Health

Responsible Owner:

Associate Chief of Staff for Mental Health

Service Line:

Mental Health

Effective Date:

June 2024

Recertification Date:

June 2029

1. SUMMARY OF CONTENT

a. This SOP describes patient flow within the Mental Health ICC. This includes care between Primary Care Mental Health Integration (PCMHI), Behavioral Health Interdisciplinary Program (BHIP) and Specialty Care (to include, specialized Substance Use Disorder Clinic, PTSD Clinic, Mental Health Intensive Case Management and Psychosocial Recovery Services).

b. This SOP establishes criteria for the eligibility and discharge process for each program within the Mental Health Integrated Clinical Community (ICC).

2. PURPOSE AND JUSTIFICATION

a. The purpose of this SOP is to establish Syracuse VA Medical Center (SVAMC) guidelines for implementing a stepped-care treatment approach based on best-practice models of service delivery across the VA Continuum of Care (CoC). Additionally, the purpose is to provide the appropriate level of care to maximize the efficiency of mental health service delivery across the CoC. This SOP must be followed by all Syracuse VAMC personnel.

b. There is no mandate for this SOP.

3. PROCEDURES

a. PCMHI Level of Care.

(a) Objectives.

1. To enable optimal functioning of Patient-Aligned Care Team (PACT) through collaborative decision support and interdisciplinary consultation using co-located mental health providers with PACT teams.

Attachment D.42 RFP 36C24224R0049

June 2024 SOP 528a7-116-015

2. To practice collaborative, stepped, and measurement-based care within primary care.

3. To prevent the development of more severe symptoms through early recognition and intervention for behavioral health problems and bio psychosocially influenced health conditions.

4. To operate from a population-based perspective, with the goal of addressing relevant concerns of as many Veterans as possible in the primary care setting, and thereby, promote greater access for mental health clinics to treat Veterans with more complex mental health needs.

(2) Services.

(a) Available to Veterans who are enrolled in a PACT Team.

(b) PCMHI will evaluate, provide recommendations, and assist PACT teamlets with management of Veterans who present with mild-to-moderate symptoms, including the diagnoses listed below:

1. Mild-to-moderate depressive symptoms.

2. Mild-to-moderate anxiety or panic symptoms.

3. Mild-to-moderate trauma-related symptoms.

4. Mild substance use disorders.

5. Uncomplicated adjustment disorders.

6. Uncomplicated relationship stressors.

7. Uncomplicated grief or bereavement concerns.

8. Insomnia or other sleep concerns.

9. Chronic pain.

10. Other medical concerns (e.g., hypertension, diabetes, migraines) that are exacerbated or influenced by mental health or psychosocial factors.

11. Veterans who seek to set health-related goals surrounding exercise, weight loss, smoking cessation, or medication/treatment adherence.

12. Veterans who would benefit from a brief screening for cognitive concerns prior to referral to a specialty service (e.g., memory clinic or neuropsychology assessment).

13. Indicators for PCMHI involvement may include the Veteran’s historical mental health diagnosis, and/or if primary care is requesting consultation to clarify MH diagnosis.

(3) Veterans who self-refer for mental health evaluation or request assistance with health behavior change are candidates for PCMHI.

(4) Veterans eligible for PCMHI services typically present with chief complaints or diagnoses that are expected to improve within one to six sessions, each lasting around 20-30 minutes.

(5) Collaborative Care Management (CoCM) in primary care at PCMHI focuses on evidence-based protocols for treating common disorders, including support for prescribing psychotropic medications, patient education, and monitoring adherence, side effects, and treatment effectiveness through objective measurements. The program utilizes measurement-based care tools to track progress throughout treatment, with services accessible to all Veterans in primary care, primarily through telephone but also in-person or via VA Video Connect as needed.

(a) Emergency Mental Health Triage.

1. PCMHI provides same-day suicide and violence risk assessment for Veterans who present to the primary care setting. The PCMHI team will follow up on positive suicide screens via the Columbia-Suicide Severity rating Scale (CSSRS) via same-day completion of the Comprehensive Suicide Risk Evaluation (CSRE) and Safety Plan as required by suicide risk identification guidelines.

2. For Veterans who present to primary care and are at imminent risk for harming themselves or others, PCMHI will collaborate with the PACT teamlet to ensure emergency services are contacted and the Veteran is appropriately dispositioned.

3. If primary care is unsure of the severity of reported risk, the PCMHI team will be available to provide consultation and triage recommendations.

4. If PCMHI is unavailable, primary care will follow local procedure for escorting (or transporting) a Veteran to the Emergency Department.

b. Referral Procedures to PCMHI. PACT initiates a PCMHI consultation with a same day “warm handoff” directly from the PACT team. NOTE: The PCMHI warm hand-off may occur in person or thru virtual modalities e.g., Microsoft Teams chat.

(1) If a PCMHI provider is not able to meet with a Veteran on the same day as their primary care appointment and there are no urgent matters, the primary care provider may place a consult via the Electronic Health Record (EHR) to PCMHI.

c. Transition and Discharge Process. Veterans are eligible for discharge from PCMHI once they have completed their short-term mental health treatment and no longer require services.

(1) A referral for advanced mental health services (BHIP) is necessary when the PCMHI clinician concludes that the Veteran's psychiatric clinical needs surpass the scope of PCMHI. This may include:

(a) Complexity of psychiatric symptoms.

(b) Veteran clinically needs a muti-faceted mental health therapeutic intervention.

(c) Psychiatric medication management.

(d) Mental health treatment exceeds the duration of care provided by PCMHI.

d. BHIP Level of Care.

(1) Objectives.

(a) BHIP programming is intended to provide access to evidenced-based mental health treatment for Veterans in need of more specialized MH care.

(b) BHIP team provides time-limited, evidence-based treatment for mental health conditions from a recovery-oriented perspective. Any/all members of the BHIP team may be involved in the Veteran’s episode of care.

(2) Services.

(a) The BHIP Team will evaluate, treat, provide recommendations, complete mental health-related clinical reminders, and manage Veterans with active or complex mental health concerns that surpass the primary care level of care.

(b) Services include, but are not limited to: individual psychotherapy, psychotropic medication management, evidence-based psychotherapy, group psychotherapy, couples’ therapy, post-psychiatric hospitalization stabilization, and whole health support.

(c) Throughout treatment within the BHIP team, Veterans will be offered the appropriate type of measurement-based care and evidence-based practices based on presenting issue/diagnosis.

(d) Veterans will work both with therapy and/or Psychiatry during their treatment within the BHIP team. Additionally, the BHIP care coordinator will support the Veteran during their treatment phase.

(e) The BHIP team will provide comprehensive, integrated mental health services for the denied Veterans and serve as the “MH Home” during their course of treatment.

(f) There are specific diagnoses and conditions which generally require management in BHIP and are at the Moderate-to-Severe level:

1. Mood and anxiety disorders.

2. Psychotic disorders.

3. Post-Traumatic Stress Disorder (PTSD).

4. Primary and co-occurring substance use.

5. Depression.

6. Dementia with behavioral problems or psychosis.

7. Medication management to include clozapine, antipsychotic medications, lithium, and/or MAO inhibitors.

(3) Referral Procedures.

(a) Once the PCMHI provider has completed an assessment of the Veteran’s symptoms and concludes the Veteran needs a higher level of outpatient care, the PCMHI provider will submit an electronic consult to BHIP in the Veteran’s EHR.

(b) Following the BHIP consult, the BHIP care coordinator will provide initial triage, and Veteran will be assigned to a BHIP team for assessment and treatment.

(c) If it is known that the Veteran has a verified mental health treatment history in the past 2 years and is seeking care for the same concerns, primary care can refer directly to BHIP.

(d) BHIP will also receive consults directly from PACT providers if the Veteran needs additional psychiatric medications beyond what can be managed in PACT, for psychiatric medication management.

(e) BHIP will also receive consults from inpatient units, following Psychiatry consultations, or from specialty medical services when mental health treatment is being recommended.

(4) Transition and Discharge Process.

(a) Veterans will be discharged from BHIP under the following conditions:

1. Symptom stabilization for over 6 months.

2. No psychiatric hospitalizations within the last 12 months.

3. The Veteran has not engaged in an evidence-based practice (EBP) protocol within the last 6 months.

4. The Veteran has met their mental health treatment goals, and medication management can be effectively managed in primary care.

(b) Veterans may remain with Psychiatry only if the Veteran is on more than three

(3) psychotropic medications, the medication requires ongoing medication monitoring, and/or is prescribed an injectable psychotropic medication.

(c) Veterans may be referred to a higher level of outpatient treatment based on clinical indication, diagnosis and severity of symptoms and could include consults to the Substance Treatment Service, Post-Traumatic Stress Disorder Clinic Team (PCT) Psychosocial Rehabilitation and Recovery Program (PRRC) and/or Mental Health Intensive Case Management (ICMHR) program. If a consult is placed and Veteran accepted into treatment within another clinic, Veteran would be discharged from the BHIP therapist, but would remain with the BHIP Mental Health Treatment Coordinator (MHTC)/BHIP Care Coordinator.

1. Referral to the STS team could include the need for Intensive Outpatient Program, Impaired Driver assessments, justice involved within drug or Veteran treatment court, specific group therapy, and Medication Assistive Treatment with corresponding treatment. If a level of care assessment is needed, an e-consult or a referral to STS may be indicated, as example, determining if IOP is warranted vs.

referral to residential treatment.

a. Referral to the PCT team include: clear PTSD diagnosis without other co-occurring diagnoses, or the need for intensive trauma-focused treatment utilizing an evidence-based practice such as prolonged exposure, cognitive processing therapy, and/or eye movement desensitization and reprocessing.

2. Referral to the PRRC and ICMHR team could include the need for community orientated recovery-based interventions for a serious mental illness (SMI) diagnosis.

(d) Veterans may be referred to a higher level of inpatient treatment based on clinical indication, diagnosis, and severity of symptoms.

e. Specialty Mental Health Level of Care. Focuses on specific mental health diagnoses and would include moderate to serious substance use, PTSD, schizophrenia, schizoaffective disorder, and bipolar disorder.

(1) Objectives.

(a) Specialty mental health teams will evaluate, treat, and provide recommendations that surpass the complexity for a BHIP Care team.

(b) Specialty mental health teams provide specialized, time-limited, evidence-based treatment for specific mental health conditions.

(c) Services include, but are not limited to: medication evaluation, stabilization, and time-limited medication management, evidence-based psychotherapy, group psychotherapy, and peer support services.

(2) Services.

(a) Treatment within the STS clinic include specialized substance use disorder (SUD) intervention in the form of Intensive Outpatient Treatment, Early Recovery Treatment, Medication Assistive Therapy, treatment for substance use-related legal matters (i.e., Driving While Intoxicated charge [DWI]).

(b) Treatment within the PCT clinic would focus on providing specialized evidence-based therapy for complex PTSD, and/or Veterans who need additional treatment following a lower level of PTSD treatment.

(c) Treatment within the PRRC and ICHMR programming includes specific work with SMI diagnosis and focus on community integration, symptom management, and crisis intervention.

1. Referrals to PRRC come from a variety of clinics including, but not limited to, BHIP teams, inpatient hospitalizations, and ICMHR teams.

(3) Referral Procedures.

(a) Referrals to STS come from a variety of clinics including, but not limited to, BHIP teams, discharges from residential care, pain clinics, and PCMHI.

(b) Referrals to PCT come from BHIP providers after the Veteran has received an initial diagnosis of PTSD, and would benefit from a higher and more specialized PCT treatment.

(c) Referrals to PRRC come from a variety of clinics including, but not limited to, BHIP teams, inpatient hospitalizations, and ICMHR teams.

(d) Referrals to ICMHR programming come from inpatient residential treatment, both within the Syracuse VAMC and community psychiatric hospitals.

(4) Transition and Discharge Process.

(a) Veteran will be discharged from STS clinics once Veteran has completed specific SUD treatment, (i.e., finished IOP programming, resolution of legal issues). Veteran may be referred to the BHIP team for ongoing work and treatment for co-occurring mental health disorders and MAT treatment. NOTE: If Veteran needs a higher level of STS treatment, referrals to residential treatment programs may be made.

(b) Veteran will be discharged from the PCT clinic once the Veteran completes specific PCT episode of care. If additional mental health treatment is warranted, the Veteran will be referred back to the BHIP team. If Veteran needs a higher level of PCT treatment, referral to a residential treatment program may be provided.

(c) Veteran will be discharged from PRRC and ICHMR programming once treatment-specific goals are met, and Veteran no longer needs a high level of intensive treatment. Veteran will be referred back to the BHIP team for ongoing medication management.

4. ASSIGNMENT OF RESPONSIBILITIES

a. Associate Chief of Staff (ACOS) for Mental Health. The ACOS for Mental Health is responsible for:

(1) Communicating this SOP and any changes to all appropriate staff.

(2) Reviewing and ensuring all appropriate changes are made to this SOP.

(3) Ensuring all information contained herein follows any, and all governing guidance where appropriate.

(4) Ensuring all appropriate staff adhere to this SOP.

b. Mental Health Team Leaders. Mental Health Team Leaders are responsible for:

(1) Educating clinical staff on these processes.

(2) Regularly identifying any barriers to this stepped care model.

c. All Other Staff. All Other Staff are responsible for:

(1) Adhering to this SOP.

5. DEFINITIONS

a. Behavioral Health Interdisciplinary Program (BHIP). BHIP is an interdisciplinary team of professionals that work together with the Veteran and the Veteran’s support system to provide continuous access to ongoing, recovery-oriented, evidence-based mental health care.

6. REFERENCES

a. VHA Directive 1163, Psychosocial Rehabilitation and Recovery Services, dated August 13, 2019. DIRECT LINK. NOTE: This is an internal VA website that is not available to the public.

b. VHA Directive 1160.04, Programs for Veterans with Substance Use Disorders, dated December 8, 2022. DIRECT LINK. NOTE: This is an internal VA website that is not available to the public.

c. VHA Directive 1160.03, Treatment for Veterans with Post Traumatic Stress Disorder, dated October 16, 2023. DIRECT LINK. NOTE: This is an internal VA website that is not available to the public.

Attachment D.42 RFP 36C24224R0049 https://vaww.va.gov/vhapublications/index.cfm https://vaww.va.gov/vhapublications/index.cfm https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=8438 https://vaww.va.gov/vhapublications/index.cfm https://vaww.va.gov/vhapublications/index.cfm https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=10070 https://vaww.va.gov/vhapublications/index.cfm https://vaww.va.gov/vhapublications/index.cfm https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=11499

d. VHA Directive 1160.01, Uniform Mental Health Services in VHA Medical Points of Service, dated April 2023. DIRECT LINK. NOTE: This is an internal VA website that is not available to the public.

e. Team-Based Care VHA Operational Memoranda 2022-06-27: Expanded Implementation of Outpatient Behavioral Health Interdisciplinary Program – Collaborative Chronic Care Model BHIP-CCM) (VIEWS 7302913) dated June 28, 2022.

DIRECT LINK. NOTE: This is an internal VA website that is not available to the public.

f. Department of Veterans Affairs Behavioral Health Interdisciplinary Program (BHIP) Team-Based Care: 2022 BHIP Memo Package. Available on the Department of Veterans Affairs BHIP SharePoint Page. DIRECT LINK. NOTE: This is an internal VA website that is not available to the public.

g. VHA Handbook 1163.06, Intensive Community Mental Health Recovery Services, dated January 7, 2016. DIRECT LINK. NOTE: This is an internal VA website that is not available to the public.

7. REVIEW

This SOP will be reviewed at minimum at recertification, when there are changes to the governing document (e.g., Controlled National Policy or a health care accreditation body mandate), and any regulatory requirement for more frequent review.

8. RECERTIFICATION

This SOP is scheduled for recertification on or before the last working day of June 2029.

In the event of contradiction with national policy, the national policy supersedes and controls.

9. SIGNATORY AUTHORITY

LAUREN LOVE-DUBEAU, LCSW-R

Associate Chief of Staff for Mental Health Syracuse VA Medical Center Date Approved: June 14, 2024

NOTE: The signature remains valid until rescinded by an appropriate administrative action.

DISTRIBUTION: Automated distribution email sent weekly to VHASYR Managers & Supervisors email group at SYR-M&S@med.va.gov. SOPs are available at: Syracuse Medical Center Document Control SharePoint (DCS).

https://dvagov.sharepoint.com/sites/VHASYR/svdc. NOTE: This is an internal VA website that is not available to the public.

Attachment D.42 RFP 36C24224R0049 https://vaww.va.gov/vhapublications/index.cfm https://vaww.va.gov/vhapublications/index.cfm https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=10280 https://vaww.va.gov/vhapublications/index.cfm https://vaww.va.gov/vhapublications/index.cfm https://vaww.va.gov/vhapublications/index.cfm https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=9843 https://dvagov.sharepoint.com/sites/VACOMentalHealth/BHIP/SitePages/BHIP.aspx https://dvagov.sharepoint.com/sites/VACOMentalHealth/BHIP/SitePages/BHIP.aspx https://dvagov.sharepoint.com/sites/VACOMentalHealth/BHIP/resourcedocs/Forms/AllItems.aspx?csf=1&web=1&e=ga8x6T&cid=3a483a65%2D886a%2D439d%2D9d86%2D25e48d74a51d&FolderCTID=0x01200032D26798727873419CF9D6968E08E8BA&id=%2Fsites%2FVACOMentalHealth%2FBHIP%2Fresourcedocs%2F2022%20BHIP%20Memo%20Package https://vaww.va.gov/vhapublications/index.cfm https://vaww.va.gov/vhapublications/index.cfm https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=3164 mailto:SYR-M&S@med.va.gov https://dvagov.sharepoint.com/sites/VHASYR/svdc/ https://dvagov.sharepoint.com/sites/VHASYR/svdc/