A Formative Evaluation of the VA BHIP Model

BHIP teams are VA-based mental health care teams that are intended to be collaborative, veteran-centered, and coordinated. This formative evaluation gathered information from nine sites that transitioned to BHIP. Interviews were conducted at two time points-one before external facilitators began working with sites (time 1) and one after facilitation ended (time 2).

At the site level, connections to community resources (e.g., Vet Centers, alcoholism programs, and community mental health providers) were handled on a clinician-by-clinician basis.

Collaborative Care Model (CCM)

In addition to reducing the burden on staff, CCM also reduces costs by improving care quality. The model allows medical providers to work with mental health specialists to develop a treatment plan for the patient. These plans often include behavioral modifications and psychotherapy. They can also incorporate medication and referrals to support services that treat the underlying condition.

In 2017, OMHSP launched an effort to scale-up and spread CCM for general mental health BHIP teams in VA medical centers. This was done through a multistage process, in which an evidence synthesis provided leverage for implementing change. This led to a partnership between health system leadership and implementation researchers. The result was a formal implementation trial, funded by QUERI. Facilitation was provided by Transformational Coaches, who had been trained in a variety of team-building and implementation processes. Participating facilities were diverse in terms of size, complexity, and rural/urban location.

Behavioral Health Interdisciplinary Program (BHIP) Team Model

The BHIP team model is an important part of VA’s effort to provide high-quality, patient-centered care. The team-based approach is designed to support the coordination of behavioral health and primary care services for patients with complex chronic conditions. Currently, BHIP teams are providing CCM to about half of all eligible veterans. Behavioral health providers are working with Primary Care Providers to improve patient outcomes and reduce hospitalizations for mental health issues.

Three to four years post-implementation, respondents from several sites noted continued divergence among BHIP teams in terms of their implementation of CCM, as well as a lack of leadership support for the teams. Some BHIP teams have developed formal mechanisms to address this issue, such as designating one team member to serve as the contact for community resources (e.g., Alcoholics Anonymous groups or Veteran Service Organizations).

These findings are consistent with previous research on CCM implementation in VA medical centers. Using two implementation strategies, centralized technical assistance and implementation facilitation, investigators have helped outpatient mental health teams (known as BHIP teams) in nine VA medical center clinics to align their practices with the principles of the CCM model.

Implementation of CCM

CCM is a healthcare model that aims to efficiently oversee the health of patients with chronic conditions while simultaneously curbing their frequency of in-person visits. It can help reduce costs and improve outcomes by bolstering care plan adherence and providing support through regular check-ins with patients via telehealth or digital communication channels.

Despite the overall positive impact of CCM, the study’s findings were mixed regarding the extent to which CCM-consistent practices were maintained three to four years after implementation. For example, at several sites, nurse care manager roles (relevant to the CCM element of work role redesign) were either eliminated or drastically reduced in scope, primarily as a response to redirected workload pressures and the COVID-19 pandemic.

To determine the extent to which CCM elements were implemented, an analytic team independently coded transcripts for each site using a consistent framework. One team member then created a summary for each site that contained all coded transcript data and exemplar quotes. These summaries were reviewed by the full analytic team during a full-team meeting.

Implementation of BHIP

The BHIP model provides flexibility for facilities to adapt the initiative’s core care processes to local needs and priorities. This is important because the centralized guidance provides a set of broad goals, but allows individual sites to vary the implementation approach based on local conditions and resources. The present formative evaluation gathered information about the experience of staff at participating facilities during their transition to BHIP.

The model comprises 3 key components: BH education, BH consultation, and clinical and operational support for integrated practice transformation. BH education and consultation activities are typically nonreimbursable, which risks unsustainability without external grant or contract funding. In contrast, the BH integration support activity is generally reimbursable.

The BHLC didactic component was offered in 10 1- or 2-hour sessions (17 hours total). Most BHLC sessions were delivered in-person at affiliated academic medical centers, while several were delivered via televideo. BHLC participants received category 1 continuing medical education and 25 type IV maintenance of certification credits.