An October 2019 Medical Care supplement describes a learning health care system: the VA Evidence Synthesis Program (ESP). The ESP is dedicated to making high-quality evidence accessible to improve health and healthcare for veterans. The articles in the issue describe the outcomes from integrating research synthesis with qualitative and quantitative data from health systems. These examples of a learning health system are starkly different than those described in older reports from the Institute of Medicine because they actively use research synthesis as a part of a wider program.
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The papers address many questions, such as which of many intervention options to pursue, clinical safety, and how changes can be evaluated. They also describe how the research itself has been evaluated–what has been learned that is of benefit to the health system. This activity can help direct resources and research to areas of the greatest potential benefit.
Implementing CCM for Mental Health Care in the VA
Originally developed to improve care for patients with chronic medical illnesses, the Chronic Care Management (CCM) approach focuses on health care changes to promote teamwork and increase patients’ involvement in their own care. Dr. Bauer and colleagues outline the multistage process by which the CCM model was implemented for managing mental health conditions in veterans. This includes evidence synthesis, testing in a formal implementation trial, and evaluating policy impact, scale-up and spread.
The process started with an evidence synthesis produced by the ESP, focused on emerging research applying the CCM approach to mental health care. “[T]his evidence synthesis indicated that CCMs can improve outcomes among various mental health conditions treated in various treatment settings,” Dr. Bauer and coauthors write. However, they noted that the evidence supporting the CCM came from randomized controlled trials – with little information about whether it could be implemented in routine clinical practice.
To address this knowledge gap, Dr. Bauer’s research team and VA mental health national leadership established a health system/researcher partnership. This collaborative approach led to the development of a step-by-step guide to implementing the CCM approach “focusing on creating conditions under which locally designed solutions for local challenges can be developed in accordance with CCM-based guidance.”
The next step was a formal implementation trial. This addressed both the implementation and outcomes of the CCM model by Behavioral Health Interdisciplinary Program (BHIP) teams at nine VA medical center mental health clinics. The result was improvement in key outcomes with the CCM approach, including fewer hospitalizations for veterans with mental health conditions.
The evidence had a policy impact. The VA Office of Mental Health and Suicide Prevention adopted the CCM as the “foundational model” for improving the integration of mental health care by BHIP teams throughout the VA system. Based on early experience, the CCM approach was scaled up and spread to other VA medical centers. It had strong support from VA mental health leadership. To date, implementation efforts have reached 30 VA medical centers, most of which have aligned their mental health care processes with the CCM model. An example of a learning health care system in action!
Jess Williams