Background
Many veterans and their families struggle with behavioral health problems, family reintegration difficulties, and relationship problems. Yet veterans and their families face barriers to receiving adequate care for these problems. Notably, although many veterans are eligible to receive care at Department of Veterans Affairs (VA) facilities, family members are not eligible and therefore must seek care elsewhere. This situation can pose a barrier to family members' access to care and also make it more difficult for veterans and families to receive high-quality services that are coordinated and integrated across providers.
Will a new model of care that colocates and coordinates behavioral health services for veterans and their families address these barriers? This study presents an evaluation of one instance of such a model, the Unified Behavioral Health Center (UBHC) for Military Veterans and Their Families. The UBHC, located in New York state (NYS), is a public-private partnership between the Northwell Health System and the Northport Veterans Affairs Medical Center (VAMC) that is providing colocated and coordinated care with the goal of improving behavioral health care for veterans and their families. There is evidence that NYS veterans have unmet behavioral health needs. NYS has the fourth-highest number of resident veterans nationwide (U.S. Department of Defense [DoD], 2010), and there is evidence that NYS veterans and their families are at risk for behavioral health problems and in need of services (see, e.g., Vaughan et al., 2011). While more than one-half of NYS veterans could likely benefit from some type of behavioral health care, a study found that only about one-third actually received behavioral health services, and of those receiving services, only one-half received minimally adequate care (Schell and Tanielian, 2011). In addition, nearly one-half of spouses reported difficulties dealing with their partners' behavioral health issues, and one-third reported concerns regarding veteran's reintegration into the daily family routine. Spouses of veterans in NYS also reported depression and limited engagement in behavioral health services.
Purpose and Approach
The public-private partnership model embodied in the UBHC is an innovative approach to expanding services for veterans and their families. To foster understanding of the UBHC model and shed light on how it is serving veterans and their families, RAND evaluated the center's activities. The evaluation was intended to document the implementation of a unique public-private collaborative approach for providing care to veterans and their families, in order to assess the approach's viability, identify implementation challenges and successes that the program can learn from, and facilitate its replication in other communities should it prove successful. This study presents the results of RAND's evaluation.
The evaluation addressed four questions:
- What resources and capacities were available for providing care in the UBHC?
- What barriers and facilitators to implementing this model of care did the center encounter?
- What services were delivered, and what were the characteristics of the patients who received these services?
- How did receiving care affect patients' health outcomes?
The evaluation had two components. The first component focused on documenting the structures of care (the capacities and resources that the center developed and employed—e.g., facilities, staff, technology, infrastructure) and the processes of care (the services delivered—e.g., individual psychotherapy, medication management—and who received them). The second component focused on outcomes of care. These outcomes refer to the measures of functioning and symptoms that patients experience as a result of the types of care they received—in other words, measuring the improvements in health that the processes are intended to produce. For the first component, the evaluation used data from site visits and focus groups, as well as administrative data. For the second, it used patient-reported outcome data that were collected and shared by UBHC staff.
Key Findings
Capacity for Care
- The UBHC treated its first patient in late 2012, after approximately five months of construction. As of July 2016, the center is up and running and delivering a range of behavioral health services to veterans and their families (e.g., individual and group psychotherapy, family therapy, medication management).
- The center colocates and coordinates care across two independently governed sides: One side, the VA Clinic at Bay Shore, a community-based outpatient clinic, is operated by the VA; the other side, the Mildred and Frank Feinberg Division, is operated by Northwell Health, a private-sector provider. The two sides have two different managing authorities, sets of procedures, and reporting requirements. One side serves veterans, while the other side is available to service members, veterans, and their families but primarily serves family members. Each side has separate entrances, information systems, and processes for monitoring performance.
- The partnership between the Feinberg Division and the VA Clinic at Bay Shore sides of the UBHC allows for convenient access to behavioral health services for veterans and family members and facilitates exchange of information between the different sides of the center, which can improve coordination of care. The information exchange occurs primarily through team meetings, other in-person contacts, and the phone. These communication mechanisms are effective in the context of a relatively small center, but communication "infrastructure" would likely have to be enhanced for a larger program to be successful (see the "Recommendations for Improving or Replicating the UBHC Model" section).
Barriers to Implementation and Service Delivery
- Gaining senior level buy-in from the local VAMC and VA Central Office took time but was ultimately achieved by focusing on the potential benefits of the program for veterans and their families.
- Coordinating the construction of a new facility that met the needs of both Northwell Health and the Northport VAMC was challenging because of numerous regulatory considerations, some of which were not clear up front.
- The funding model used in the first three years is likely not sustainable. The Feinberg Division provided services at no charge, generating no revenue. This is likely not a sustainable funding model because it relies on donations and philanthropic support to pay for operating expenses. Recognizing this, Northwell Health has been working toward developing more-sustainable funding for the Feinberg Division throughout the UBHC's implementation and recently implemented a new billing system. Programs seeking to replicate the UBHC model may benefit from designing and implementing a sustainable funding plan from the initiation of the program.
- There is an absence of institutionalized and codified procedures for collaborative activities (e.g., a liaison between sides of the center), and these may present future challenges. VA Clinic at Bay Shore staff noted that there is currently no directive in the VA to implement these kinds of programs and services, and the staff expressed a desire for clear directives that would support integration and collaboration and ensure that current effective strategies are preserved in the event of staffing changes.
Facilitators of Implementation and Service Delivery
- Staff at both Northwell Health and the Northport VAMC championed and facilitated the establishment of the UBHC. Since its establishment, staff within both systems have forged strong working relationships.
- A Robert Wood Johnson Foundation grant was a critical catalyst in the establishment of the center.
- Media attention helped to advertise the availability and services offered by the center.
- The UBHC staff reported taking special pride in one achievement in particular: This was, as one provider described it, "the healing that has occurred" as a result of being able to serve veteran families through providing collaborative care.
Services Delivered
- The two sides of the center had different patterns of service utilization: The VA Clinic at Bay Shore provided fewer services to a larger number of individuals, while the Feinberg Division provided more-intensive services to a smaller number of individuals. As a result, the overall number of patient encounters was comparable across the two sides of the UBHC, despite very different patient loads.
- Both sides, however, succeeded in becoming operational and delivering a substantial amount of services (more than 7,000 behavioral health encounters on each side of the center) in a relatively short time frame (three years). This was notable considering that it was a new center ramping up its capacity to provide care (e.g., through staffing) and reaching out to potential patients in the community for the first time.
Patient Outcomes
- UBHC patients consistently expressed satisfaction with their experiences at the center and the care they received, according to our interviews and a satisfaction survey. Family members we spoke with remarked that the UBHC "is a place for families to go that is familiar with veterans' issues." Beyond the advantage of having providers who understand the issues that veteran families face, patients recognized the advantages of the family receiving coordinated care; for instance, one patient noted that "when [providers] communicate, it's fantastic."
- Adult patients treated on the Feinberg Division side of the UBHC showed improvement in key outcomes, including symptoms of depression and posttraumatic stress disorder, family functioning, and quality of life. Child patients displayed fewer behavioral health problems.
Recommendations for Improving or Replicating the UBHC Model
Institutionalize and Codify the Practices That Are Working
The UBHC has established strategies, policies, and procedures designed to enhance the collaborative effort. However, some of these practices have not been institutionalized. For example, there is currently a VA staff member informally acting as a liaison to coordinate care between the two sides of the center; although this coordination is conducted effectively, the liaison role could be formalized to ensure that strong communication between organizations continues. More broadly, the VA Clinic at Bay Shore should consider formally protecting the time that their providers spend collaborating, because this is time not spent in direct patient care or other administrative duties.
Facilitate Easier and Closer Collaboration by Enhancing Communication "Infrastructure"
Collaboration would be further enhanced if staff could integrate treatment plans across the center's two sides and could more easily communicate with each other. The organization of the physical space can also enhance communication.
Integrate treatment plans. Collaboration would be enhanced by use of integrated treatment plans that staff on both sides of the center contribute to and can readily access.
Share access to patient records. The collaboration would also be enhanced by providers on both sides of the center having easy access to each other's patient records, so that it is easier to track the care a patient is receiving from other providers.
Provide secure email. It would also be helpful if providers could securely email each other; currently, they cannot include patient names in email communications, so communicating about a shared patient requires a phone call or in-person consultation. The organizations could also consider developing new platforms for secure electronic communication between different IT systems.
Enhanced communication infrastructure that facilitates less burdensome data collection, monitoring, and sharing is critical to supporting partnerships between the VA and private organizations, particularly when they are scaled beyond a single relatively small program.
Create a Physical Space That Is Conducive to Collaboration and Family Friendly
The clinic space should be organized in a manner that facilitates clinical staff's efforts to coordinate care; the current organization, with a shared conference room and kitchen and easy staff access between the sides of the center, achieves this goal. Staff could consider organizing the clinic in such a way that the collaboration is readily apparent to patients, if this is desired. A single entrance, single reception, and uniform decor would communicate to patients that this is a collaborative center rather than two distinct entities. Regardless of the extent to which spaces are shared across organizations, there should be close communication regarding the establishment and construction of the physical space from the start of the process. Because the UBHC and other sites seek to provide services to family members of veterans, including children, it will be important to ensure that these spaces appear not only veteran friendly but also family friendly.
Ensure Adequate Capacity (Staffing and Space) to Meet Patient Needs
The UBHC may benefit from an expansion in both staffing and physical space, if patient interest in the center continues to grow. In particular, increased staff at the VA Clinic at Bay Shore would ensure that there is availability to serve veterans who have family members receiving services on the Feinberg Division side of the UBHC. Increasing the overall capacity of the VA Clinic at Bay Shore through increasing staff hours there (e.g. more full-time staff instead of part-time staff) would ensure that the VA Clinic at Bay Shore has adequate capacity to serve veterans participating in the collaboration, without affecting capacity to serve veterans whose families do not receive care on the Feinberg Division side of the center.
Provide a Continuum of Evidence-Based Services
As more settings work to serve veterans and their families experiencing behavioral health problems, it will be important not only to ensure the provision of evidence-based interventions but also to provide a continuum of services, including prevention (e.g., psychoeducation and other programs), in addition to referrals to other types of support (e.g., financial and legal support, other family support services). For both prevention and treatment services, community-based organizations and clinical settings should adopt a systematic approach for selecting, training, delivering, supervising, and monitoring the fidelity of evidence-based practices relevant to the population. Systematic use of evidence-based practices could ensure the effectiveness of treatment, provided that training is also systematic and that the interventions are delivered with fidelity. In selecting evidence-based approaches, organizations wishing to replicate the UBHC model may want to focus on time-limited (i.e., short-term) approaches and techniques or services that require lower-level (i.e., less expensive) staff to increase capacity and reduce costs.
Prioritize Outcome Monitoring and Quality Improvement for the Center as a Whole
The UBHC and other similar centers should carefully and routinely reevaluate their battery of measures to choose the ones that are least burdensome to patients and most helpful for informing clinical decisionmaking and outcome monitoring. To increase the integration and coordination of services, as well as to enable better tracking of patient outcomes over time, we recommend that the entire UBHC (both the VA Clinic at Bay Shore and Feinberg Division sides) implement the same set of patient-reported outcome measures to inform patient care and enable ongoing quality-improvement efforts across all partnering entities. For example, if families who received some care from both sides of the UBHC completed the same set of measures, it would facilitate setting and tracking higher-order, family-system–level treatment goals. Consistent measurement across the entire UBHC would also facilitate program monitoring and evaluation.
Conclusions
Overall, the UBHC has successfully implemented a promising public-private partnership model for providing behavioral health care for veterans and their families in the same facility. Providers coordinated efforts to deliver high-quality care, the center geared up to deliver a range of therapeutic services for a large number of patients in a relatively short time, patients were happy with the services they received, and their symptoms and functioning improved significantly over time.
Providing colocated and coordinated care can potentially address barriers to care for veterans and their families. Although many veterans are eligible for VA services, most veterans' families are not, leading different members of families to seek care in different settings, with no easy way to exchange information and coordinate care between VA providers and family members' providers (see Pedersen et al., 2015, for a review). The UBHC addresses this barrier by providing care that is colocated and coordinated.
The UBHC provides care that is oriented toward the needs of veteran families. Family members we spoke with expressed that the UBHC plays a vital role in their communities, citing that, in their experience, providers not affiliated with the VA are insensitive to the impact of posttraumatic stress disorder and other special issues facing the families of veterans. Family members we interviewed saw the UBHC as a unique place where military families could receive care and be understood. UBHC staff and patients alike touted the advantages of coordinated care in which the different providers treating a family are in close communication with one another; all interviewees felt that this coordination greatly improved the quality of care that family members received. Patients expressed high levels of satisfaction with the care they received.
Although the model has been successfully implemented, with strong preliminary outcomes, there are areas that could be improved as the UBHC continues to grow and develop. While staff and patients were happy with the collaborative relationships between providers, collaboration could still be closer than it currently is. Staff members regularly have to circumvent various challenges to collaboration.
Other partnerships between local VAMCs and private health systems that want to accomplish similar objectives can learn from the UBHC launch and implementation. In addition to the issues related to barriers to collaboration and the lack of codified practices, there were barriers to establishing the center that other programs may be able to circumvent. Building the center was a complicated process, but many of the barriers the UBHC faced could potentially be avoided by having close communication between the private organization and the appropriate VA staff through all phases of establishing the center, with key players at the table from the start. Another potential barrier for other potential partnerships is cost. However, initial expenses could be reduced by using an existing facility rather than building a new one. Further, ongoing expenses could be reduced by billing patients from the start and potentially using less expensive staff (e.g., fewer members of the psychiatry staff, greater use of interns) and providing less expensive care (e.g., less individual therapy and more groups; however, this may not be feasible for small centers).
Our evaluation suggests that, overall, the model has been successfully implemented by the UBHC and has great potential to be helpful to the veteran families it serves.
