title: Primary Care-Mental Health Integration in the VA Health System: Associations Between Provider Staffing and Quality of Depression Care.
abstract: OBJECTIVE
  The study examined whether staffing of Primary Care-Mental Health Integration (PCMHI) services in the Department of Veterans Affairs (VA) health system is related to quality of depression care.
  
  
  METHODS
  Site surveys and administrative data from 349 VA facilities for fiscal year 2013 were used to calculate PCMHI staffing (full-time equivalents) per 10,000 primary care patients and discipline-specific staffing proportions for PCMHI psychologists, social workers, nurses, and psychiatric medication prescribers. Multivariable regression analyses were conducted at the facility level and assessed associations between PCMHI staffing ratios and the following indicators of depression treatment in the three months following a new episode of depression: any antidepressant receipt, adequacy of antidepressant receipt, any psychotherapy receipt, and psychotherapy engagement (three or more visits).
  
  
  RESULTS
  Higher facility PCMHI staffing ratios were associated with a greater percentage of patients who received any psychotherapy treatment (B=1.16, p<.01) and who engaged in psychotherapy (B=.39, p<.01). When analyses controlled for total PCMHI staffing, the proportion of social workers as part of PCMHI was positively correlated with the percentage of patients with adequate antidepressant treatment continuation (B=3.16, p=.03). The proportion of nurses in PCMHI was negatively associated with the percentage of patients with engagement in psychotherapy (B=-2.83, p=.02).
  
  
  CONCLUSIONS
  PCMHI programs with greater overall staffing ratios demonstrated better performance on indicators of psychotherapy for depression but not on indicators of antidepressant treatment. Further investigation is needed to determine whether differences in discipline-specific staffing play a causal role in driving associated differences in receipt of treatment.
authors.affiliation: Dr. Levine, Dr. McCarthy, Ms. Cornwell, and Ms. Brockmann are with the Office of Mental Health Operations, Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), and Dr. Pfeiffer is with the Center for Clinical Management Research, all at the Department of Veterans Affairs (VA), Ann Arbor, Michigan. Dr. Pfeiffer is also with the Department of Psychiatry, University of Michigan, Ann Arbor, where Dr. McCarthy is affiliated. Send correspondence to Dr. Pfeiffer (e-mail: paul.pfeiffer@va.gov ).
authors.forename: Debra S
authors.initials: DS
authors.lastname: Levine
authors.affiliation: Dr. Levine, Dr. McCarthy, Ms. Cornwell, and Ms. Brockmann are with the Office of Mental Health Operations, Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), and Dr. Pfeiffer is with the Center for Clinical Management Research, all at the Department of Veterans Affairs (VA), Ann Arbor, Michigan. Dr. Pfeiffer is also with the Department of Psychiatry, University of Michigan, Ann Arbor, where Dr. McCarthy is affiliated. Send correspondence to Dr. Pfeiffer (e-mail: paul.pfeiffer@va.gov ).
authors.forename: John F
authors.initials: JF
authors.lastname: McCarthy
authors.affiliation: Dr. Levine, Dr. McCarthy, Ms. Cornwell, and Ms. Brockmann are with the Office of Mental Health Operations, Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), and Dr. Pfeiffer is with the Center for Clinical Management Research, all at the Department of Veterans Affairs (VA), Ann Arbor, Michigan. Dr. Pfeiffer is also with the Department of Psychiatry, University of Michigan, Ann Arbor, where Dr. McCarthy is affiliated. Send correspondence to Dr. Pfeiffer (e-mail: paul.pfeiffer@va.gov ).
authors.forename: Brittany
authors.initials: B
authors.lastname: Cornwell
authors.affiliation: Dr. Levine, Dr. McCarthy, Ms. Cornwell, and Ms. Brockmann are with the Office of Mental Health Operations, Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), and Dr. Pfeiffer is with the Center for Clinical Management Research, all at the Department of Veterans Affairs (VA), Ann Arbor, Michigan. Dr. Pfeiffer is also with the Department of Psychiatry, University of Michigan, Ann Arbor, where Dr. McCarthy is affiliated. Send correspondence to Dr. Pfeiffer (e-mail: paul.pfeiffer@va.gov ).
authors.forename: Laurie
authors.initials: L
authors.lastname: Brockmann
authors.affiliation: Dr. Levine, Dr. McCarthy, Ms. Cornwell, and Ms. Brockmann are with the Office of Mental Health Operations, Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), and Dr. Pfeiffer is with the Center for Clinical Management Research, all at the Department of Veterans Affairs (VA), Ann Arbor, Michigan. Dr. Pfeiffer is also with the Department of Psychiatry, University of Michigan, Ann Arbor, where Dr. McCarthy is affiliated. Send correspondence to Dr. Pfeiffer (e-mail: paul.pfeiffer@va.gov ).
authors.forename: Paul N
authors.initials: PN
authors.lastname: Pfeiffer
mesh_terms: D000928:Antidepressive Agents / Q000627:therapeutic use; D019033:Delivery of Health Care, Integrated / Q000706:statistics & numerical data*; D003866:Depressive Disorder / Q000188:drug therapy / Q000628:therapy*; D005260:Female; D006280:Health Workforce / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008605:Mental Health Services / Q000706:statistics & numerical data*; D008875:Middle Aged; D009740:Nursing Staff / Q000706:statistics & numerical data; D011320:Primary Health Care / Q000706:statistics & numerical data*; D011613:Psychotherapy / Q000706:statistics & numerical data; D011787:Quality of Health Care / Q000706:statistics & numerical data*; D000068217:Social Workers / Q000706:statistics & numerical data; D014481:United States; D014493:United States Department of Veterans Affairs / Q000706:statistics & numerical data*
chemical_list: D000928:Antidepressive Agents
keywords: Antidepressants; Depression; Integrated care; Psychotherapy; Quality of care; Veterans issues