Effects of Virtual Care and Same-Day Access to Integrated Care on Specialty Mental Health Engagement in the Veterans Health Administration

Abstract

Background:

In the Veterans Health Administration (VA), Primary Care-Mental Health Integration (PC-MHI) clinics offer mental health services embedded in primary care, a strategy shown to reduce overall specialty mental health clinic burden while facilitating prompt referrals when indicated. Among newly initiated patients, same-day access to PC-MHI from primary care increases subsequent specialty mental health engagement. However, the impact of virtual care on the association between same-day access to PC-MHI and subsequent mental health engagement remains unclear.

Objective:

To examine the effects of same-day access to PC-MHI and virtual care use on specialty mental health engagement.

Methods:

We used administrative data from 3066 veterans who initiated mental health care at a large, California VA PC-MHI clinic during 3/1/2018 to 2/28/2022 and had no previous mental health visits for at least 2 years prior to the index appointment. We conducted Poisson regression analyses to examine the effects of same-day access to PC-MHI, virtual access to PC-MHI and their combined effect on subsequent specialty mental health engagement.

Results:

Same-day access to PC-MHI from primary care was positively associated with specialty mental health engagement (IRR = 1.19; 95% CI 1.14-1.24). Virtual access to PC-MHI was negatively associated with specialty mental health engagement (IRR = 0.83; 95% CI 0.79-0.87). The positive effect of same-day access on specialty mental health engagement was smaller among patients who initiated PC-MHI in a virtual visit (IRR = 1.07) compared to in-person visits (IRR = 1.29; 95% CI 1.22-1.36).

Conclusions:

Although same-day access to PC-MHI increased overall specialty mental health engagement, the magnitude of this effect varied between in-person and virtual modalities. More research is needed to understand mechanisms of the association between virtual care use, same-day access to PC-MHI, and specialty mental health engagement.

Keywords

access to care behavioral health primary care managed care medical informatics

Background

Telehealth facilitated access to integrated healthcare in the wake of the COVID-19 pandemic, but impacts on interdisciplinary care coordination remain unclear. In the United States, the COVID-19 pandemic was declared a national emergency in March 2020.¹ In response, major health organizations, including the U.S. Department of Health and Human Services and the Center for Medicare and Medicaid Services, developed guidelines to facilitate telehealth access.² As reports of negative mental health outcomes from the pandemic proliferated,^3,4 healthcare systems mobilized innovative strategies to ensure continued mental healthcare access via virtual care.^5,6 Although virtual care utilization increased sharply after the onset of COVID-19,⁷ few studies have explored how virtual care may have affected referrals within integrated care settings that provide both medical and mental health services.

This issue is relevant to VA primary care-mental health integration (PC-MHI) clinics, where mental health services are embedded in primary care settings.⁸ PC-MHI clinics offer short-term, evidence-based mental health treatment and care management.⁹ Many PC-MHI patients are primary care referrals who are new to mental health care or are re-establishing mental health care after an extended period without services. Ideally, patients with mild-to-moderate symptoms receive brief assessment and therapy in PC-MHI, while patients with complex mental health needs are referred to specialty mental health (eg, substance use disorder treatment).⁹ The approach therefore reduces specialty mental health clinic burden while improving mental health access for the general VA population.¹⁰

Same-day access to PC-MHI from primary care is integral to effective care, as PC-MHI provides an entry point for newly identified patients to initiate mental health services.⁹ Because same-day access is beneficial to care continuity, during the COVID-19 pandemic both the VA and civilian healthcare systems have maintained same-day access clinics across diverse clinical specialties.^11-13 Traditionally, physically embedding PC-MHI clinics in primary care facilitated same-day warm patient handoffs between providers.⁹ However, this process may be disrupted when healthcare services are accessed by virtual care because providers and patients may not be physically located in the same space.

Veterans show higher mental health diagnosis prevalence rates than the general population^14,15; accordingly, the VA prioritized maximizing access to mental health services during the COVID-19 pandemic via virtual care.⁵ This strategy potentially alleviated pandemic-related access barriers (eg, social distancing guidelines, limited schedule flexibility due to work/family obligations),¹⁶ and VA mental health clinics, including PC-MHI, showed sharp increases in telehealth access.^5,6,17 However, our research team found lower PC-MHI same-day access rates among patients who used virtual care.¹⁸ This is problematic given evidence of associations between PC-MHI access and positive health outcomes, and subsequent specialty mental health engagement when needed.^10,19 However, although past theoretical research noted the potential of integrated care for mitigating adverse mental health effects from the COVID-19 pandemic,²⁰ no known studies apply electronic health record (EHR) data to examine interrelations between virtual care delivery, same-day access to integrated care, and subsequent specialty mental health engagement. Increased understanding of these associations can inform efforts to maximize mental healthcare access and improve associated outcomes.

Our study examines the separate and combined effects of same-day access to PC-MHI and virtual care on subsequent specialty mental health engagement. As an integrated healthcare system with few access barriers and an EHR that is shared among providers from different specialties, the VA offers an optimal setting to examine cross-disciplinary patient handoffs. Using data from a representative PC-MHI clinic located in one of the largest VA healthcare systems, we used Poisson regression analyses to evaluate the effects of same-day access to PC-MHI, virtual care modality, and their interaction on specialty mental health engagement. Identifying factors that affect utilization patterns among new PC-MHI patients is a necessary step to increase mental health care continuity in the virtual care context.

Methods

We collected data from a large VA clinic that services approximately 1200 PC-MHI patients per year. The study used a retrospective observational design. We extracted clinical data from patients who initiated PC-MHI services during 3/1/2018 to 2/28/2022. This time range was selected to include observations both before and during the COVID-19 pandemic, which greatly impacted virtual care utilization.⁵ Because PC-MHI aims to provide services to new mental health patients, the sample comprised patients who were newly initiated to mental health care, that is, they had not visited PC-MHI during the 2 years prior to the index appointment. The study was approved by the VA Greater Los Angeles Healthcare System Institutional Review Board. No participants were recruited for the study, as it involved secondary analysis of data from the VA EHR.

Measures

Demographics

We obtained patient age at the time of their initial PC-MHI visit, race, ethnicity, and gender from the EHR.

Virtual care modality

We determined the modality of each patient’s initial PC-MHI visit (virtual vs in-person) using VA clinic codes (See Supplemental Appendix 1). PC-MHI visit modality was included in regression models as a binary variable (0 = in-person, 1 = virtual).

Same-day access to PC-MHI

Same-day access to PC-MHI from primary care (0 = no, 1 = yes) was determined based on the presence of a primary care visit on the same day as the patient’s initial PC-MHI visit. The variable was derived from a VA performance measure. Primary care and PC-MHI visits were defined using VA clinic codes (see Supplemental Appendix 1).

Specialty mental health engagement

Specialty mental health engagement was measured based on the number of specialty mental health visits that occurred during the 6 months following the patient’s initial PC-MHI visit. To identify specialty mental health follow-up visits, we used VA clinic codes associated with select mental health clinics (see Supplemental Appendix 1). Both virtual and in-person visits were counted.

Mental health history

To control for prior mental health history, we identified patients with mental health diagnoses in the EHR using ICD-10 codes from documentation by the VA Office of Mental Health and Suicide Prevention (see Supplemental Appendix 2). We identified the presence or absence of depression, PTSD, and substance use disorders, commonly treated mental health diagnoses in PC-MHI,¹⁰ during the 2 years prior to each patient’s initial PC-MHI visit.

Time in months

We included a monthly time variable ranging from month 0 (March 2018) to month 47 (February 2022) to control for the onset of COVID-19 as well as potential seasonal variation in same-day access to PC-MHI.

Analyses

First, we conducted bivariate analyses to compare sample characteristics (age, gender, race/ethnicity, mental health diagnoses) across modalities (virtual vs in-person). We then ran 2 Poisson regression models with specialty mental health engagement as the dependent variable. Poisson regression analysis is used to model discrete count variables that follow a Poisson distribution and have equal means and variances.²¹ The first model included predictor terms for same-day access and initial PC-MHI visit modality (virtual vs in-person). The first model also included demographic and clinical covariates. To examine whether the effect of same-day access to PC-MHI on specialty mental health engagement varied by modality, the second model added a same-day access by virtual care modality interaction term. All analyses were conducted using Stata version 17.0.²²

Results

Sample Characteristics

The sample comprised 3066 veterans who initiated PC-MHI during the study period (Table 1). The mean age was 48.6 (SD = 17.0). Women accounted for 24.3% of the sample. The racial composition of the sample was as follows: 41.9% non-Hispanic White, 40.1% non-Hispanic Black, 3.6% Asian, 2.0% multiple races, 1.4% Native Hawaiian/Other Pacific Islander (NHOPI), 1.0% American Indian/Alaskan native (AIAN) and 9.9% unknown race. Among all patients in the sample, 15.7% identified as Hispanic. Historic mental health diagnosis rates varied by condition; 16.2% received a PTSD diagnosis during the prior 2 years, 16.2% received a depression diagnosis, and 9.1% received a substance use disorder diagnosis.

Table 1.

Patient Characteristics by Initial Visit Modality.

	Initial visit modality
	In-person		Virtual care		Total
	No.	%	No.	%	No.	%	χ(1)	P-value
N	1691	55.2	1375	44.8	3066	100.0
Same-day access to PC-MHI
Did not receive same-day access to PC-MHI	1340	79.2	1114	81.0	2454	80.0	1.5	.22
Received same-day access to PC-MHI	351	20.8	261	19.0	612	20.0
Specialty MH follow-up visit
Did not receive specialty MH follow-up visit	702	41.5	627	45.6	1313	42.8	5.2	.023
Received specialty MH follow-up visit	989	58.5	750	54.4	1753	57.2
Gender
Male	990	58.5	1330	96.7	2320	75.7	600.5	.00
Female	701	41.5	45	3.3	746	24.3
Age group
18-39	713	42.2	464	33.7	1177	38.4	53.9	.00
40-64	697	41.2	543	39.5	1240	40.4
65-74	230	13.6	318	23.1	548	17.9
75+	51	3.0	50	3.6	101	3.3
Race
Native American/Alaska Native	16	0.9	15	1.1	31	1.0	13.6	.03
Asian	61	3.6	49	3.6	110	3.6
Black	717	42.4	513	37.3	1230	40.1
Multiple races	39	2.3	23	1.7	62	2.0
Native Hawaiian/Other Pacific Islander	18	1.1	26	1.9	44	1.4
Unknown	162	9.6	142	10.3	304	9.9
White	678	40.1	607	44.1	1285	41.9
Ethnicity
Not Hispanic	1332	78.8	1070	77.8	2402	78.3	0.4	.81
Hispanic	261	15.4	221	16.1	482	15.7
Unknown	98	5.8	84	6.1	182	5.9
Depression
No depression	1422	84.1	1146	83.3	2568	83.8	0.3	.58
Depression	269	15.9	229	16.7	498	16.2
PTSD
No PTSD	1435	84.9	1135	82.5	2570	83.8	3.0	.08
PTSD	256	15.1	240	17.5	496	16.2
Substance use disorder
No substance use disorder	1568	92.7	1218	88.6	2786	90.9	15.7	.00
Substance use disorder	123	7.3	157	11.4	280	9.1

Across the sample, 20.0% received same-day access to PC-MHI from primary care. Out of all patients, 44.8% initiated PC-MHI in a virtual care visit. During the 6 months after the initial PC-MHI visit, 57.2% of the overall sample attended at least 1 specialty mental health visit.

Bivariate analyses

Unadjusted bivariate analyses showed similar rates of same-day access to PC-MHI from primary care for veterans who initiated PC-MHI in person (20.8%) and veterans who initiated PC-MHI in a virtual care visit (20.0%; χ(1) = 1.5, P = .22). Veterans who initiated PC-MHI in a virtual visit showed lower rates of specialty mental health usage (54.4% vs 58.5%; χ(1) = 5.2, P = .02) in unadjusted analyses. The mean number of specialty mental health follow-up visits within 6 months was 5.1 for veterans who initiated PC-MHI in person, compared to 4.1 for veterans who initiated PC-MHI in a virtual care visit (t = 2.05, P = .04). Regarding patient characteristics, veterans who initiated PC-MHI via virtual care were more likely to be men (96.7% vs 58.5%; χ(1) = 600.5, P < .001) and showed higher rates of substance use disorders (11.4% vs 7.3%; χ(1) = 15.7, P < .001). No other group differences were found.

Poisson Regression Analyses

Same-day access to PC-MHI from primary care was positively associated with specialty mental health engagement ([Table 2, Model 1] IRR = 1.19; 95% CI 1.14-1.24). Initiating PC-MHI via virtual care was negatively associated with specialty mental health engagement (IRR = 0.83; 95% CI 0.79-0.87). A significant interaction between same-day access to PC-MHI and initiation of PC-MHI via virtual care indicated that the magnitude of the positive association between same-day access to PC-MHI and specialty mental health engagement was significantly larger for in-person visits (IRR = 1.29) than for virtual visits (IRR = 1.07), change in IRR = 0.83; 95% CI 0.77 to 0.91 ([Table 2, Model 2], [Figure 1]). As shown in Figure 1, the predicted mean number of specialty MH visits was over 40% larger for patients who initiated care in-person compared to patients who initiated care virtually.

Table 2.

Poisson Regression of Association Between Same Day Access and Specialty Mental Health Follow-up Visit Count for Virtual Care and Non-virtual Care Modalities.

	Model 1		Model 2
	IRR	95% CI	IRR	95% CI
Same day access to PC-MHI	1.19*	1.14-1.24	1.29*	1.22-1.36
Virtual care modality	0.83*	0.79-0.87	0.86*	0.81-0.90
Same day access to PC-MHI × virtual care modality			0.83*	0.77-0.91
Time	1.00*	0.99-1.00	1.00*	0.99-1.00
Age	1.00	1.00-1.00	1.00	1.00-1.00
Women (Ref: Men)	0.99	0.95-1.04	0.97	0.93-1.02
Race (Ref: White)
Native American/Alaska Native	0.74*	0.61-0.90	0.74*	0.61-0.90
Asian	1.33*	1.22-1.45	1.34*	1.23-1.46
Black	0.95*	0.91-0.98	0.95*	0.91-0.98
Multiple Races	0.83*	0.73-0.95	0.83*	0.73-0.95
Native Hawaiian/Other Pacific Islander	0.71*	0.59-0.84	0.71*	0.60-0.85
Unknown	0.84*	0.78-0.90	0.84*	0.78-0.90
Ethnicity (Ref: Non-Hispanic)
Hispanic	1.05*	1.00-1.11	1.06*	1.01-1.11
Unknown	1.01	0.93-1.11	1.01	0.92-1.10
Depression	1.14*	1.09-1.19	1.15*	1.10-1.20
PTSD (Ref: No PTSD)	1.23*	1.17-1.28	1.23*	1.18-1.29
Substance Use Disorder (Ref: No Substance Use Disorder)	2.15*	2.05-2.25	2.15*	2.05-2.25
Constant	4.56*	4.25-4.89	4.53*	4.22-4.86

Abbreviations: CI, confidence interval; PC-MHI, Primary Care-Mental Health Integration.

The sample included patients who initiated PC-MHI during 3/1/18 to 2/28/22. Specialty Mental Health Follow-up Visit Count includes visits that occurred during the 6 months after the initial PC-MHI visit. Time predictor indicates number of months elapsed since 3/1/18.

P < .05.

Figure 1.

Association between same-day access to PC-MHI and specialty mental health engagement for virtual care and non-virtual care modalities.

In addition, we found significant associations between several demographic/clinical covariates and specialty mental health engagement (Table 2). In both Models 1 and 2, prior depression (Model 2 IRR = 1.15; 95% CI 1.10-1.20), PTSD (IRR = 1.23; 95% CI 1.18-1.29), and substance use disorder diagnoses (IRR = 2.15; 95% CI 2.05-2.25) were positively associated with specialty mental health engagement. Black veterans (IRR = 0.95; 95% CI 0.91-0.98), Native American/Alaska Native veterans (IRR = 0.74; 95% CI 0.61-0.90), Native Hawaiian/Other Pacific Islander veterans (IRR = 0.71; 95% CI 0.60-0.85), Multi-racial veterans (IRR = 0.83; 95% CI 0.73-0.95) and veterans of Unknown race (IRR = 0.84; 95% CI 0.78-0.90) showed lower specialty mental health engagement after their initial PC-MHI visit than White Veterans. Asian veterans showed higher specialty mental health engagement (IRR = 1.34; 95% CI 1.23-1.46) than White veterans, as did Veterans of Hispanic ethnicity (IRR = 1.06; 95% CI 1.01-1.11). We did not find age or gender differences in specialty mental health engagement.

Discussion

PC-MHI is a key entry point to mental health care among new VA patients. We found that for the overall sample, same-day access to PC-MHI from primary care was associated with increased specialty mental health engagement, and initiating PC-MHI via virtual care was associated with decreased specialty mental health engagement. The positive effect of same-day access to PC-MHI on specialty mental health engagement was larger among patients who initiated care in person. Overall, our findings suggest that the association between same-day access and subsequent mental health engagement varies between in-person and virtual care modalities.

The differential effect of virtual versus in-person care on subsequent mental health engagement is a novel finding that could reflect differences in patient characteristics and/or clinical workflows between the 2 modalities. The findings contrast with prior research reporting higher mental health engagement among virtual care patients relative to patients who accessed care in person.²³ However, in contrast to traditional mental health clinics, PC-MHI is designed to decrease specialty mental health clinic burden by retaining patients with low acuity mental health concerns in clinic. Rapid adoption of virtual care may be one of the factors that facilitated access for a wider pool of patients with lower acuity needs that could be treated in PC-MHI, hence, decreasing specialty mental health engagement among patients seen via virtual care. More research is needed to disentangle whether workflow, scheduling practices, clinical needs, patient characteristics (eg, age, sex, race) or other factors contributed to the findings.

Although the positive association between same-day access to PC-MHI and specialty mental health engagement found in our study corresponds with prior research,²⁴ ours is the first known study to show that this effect is less pronounced for virtual care visits.¹⁹ It is possible that the attenuated effect of same-day access on specialty mental health engagement among patients who initiated PC-MHI virtually reflects differences in provider-provider, or patient-provider, interactions during virtual versus in-person visits. For example, although PCMHI documentation suggests that co-locating primary care and mental health providers facilitates same-day access to PC-MHI and, relatedly, mental health engagement by encouraging warm hand-offs,⁹ the influence of virtual care delivery is unclear. More work is needed to understand whether mechanisms of the association between same-day access and mental health engagement vary for in-person and virtual visits. Future research should also evaluate associations between same-day access to PC-MHI, virtual care versus in-person care, and clinical outcomes.

Limitations

The data capture visits during a prescribed 6-month period after the initial mental health visit. Therefore, we cannot comment on longer term trends. Although we included a time covariate to account for the onset of the COVID-19 pandemic, it is not possible to disentangle the extent to which COVID-19 and associated safety protocols around social distancing affected patients’ decisions to obtain in-person or virtual care. Our analyses do not account for presenting symptom severity at the initial PC-MHI visit; therefore, we could not explore whether patients who initiated PC-MHI virtually had milder mental health symptoms, reducing their need for follow-up specialty mental health care. Our data did not capture specialty mental health clinic appointment availability. We also could not capture clinic workflows that may explain decisions around whether to refer patients to specialty mental health, and when.

Conclusion

Virtual care may affect patient journeys from initial primary care referral to specialty mental health; it is therefore important to identify strategies for minimizing potential negative impacts. Our study supports same-day access to PC-MHI as a strategy for mental health care continuity. However, the magnitude of the same-day access effect varied for in-person versus virtual initial visits. Because mental and physical health are interconnected, successful transitions between care settings—both virtual and in-person—are necessary for the provision of high quality care.

Supplemental Material

sj-docx-1-jpc-10.1177_21501319231159311 – Supplemental material for Effects of Virtual Care and Same-Day Access to Integrated Care on Specialty Mental Health Engagement in the Veterans Health Administration

Supplemental material, sj-docx-1-jpc-10.1177_21501319231159311 for Effects of Virtual Care and Same-Day Access to Integrated Care on Specialty Mental Health Engagement in the Veterans Health Administration by Taona P. Haderlein, Aram Dobalian, Pushpa V. Raja and Claudia Der-Martirosian in Journal of Primary Care & Community Health

Footnotes

Acknowledgements

The views expressed in this article are those of the authors and do not necessarily represent the position or policy of the U.S. Department of Veterans Affairs or the United States government.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Taona P. Haderlein

Claudia Der-Martirosian

Supplemental Material

Supplemental material for this article is available online.

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Supplementary Material

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