Engaging Veterans With Serious Mental Illness in Primary Care

Veterans with serious mental illness (SMI) are at substantial risk for premature mortality. Engagement in primary care can mitigate these mortality risks. However, veterans with SMI often become disengaged from primary care. The US Department of Veterans Affairs (VA) measures and reports at VA facilities primary care engagement among enrolled veterans with SMI. This quarterly metric enables VA facilities to identify targets for quality improvement and track their progress. To inform quality improvement at our VA facility, we sought to identify promising practices for supporting engagement in primary care among veterans with SMI.

We conducted semistructured telephone interviews from May 2019 through July 2019 with a purposeful sample of key informants at VA facilities with high levels of engagement in primary care among veterans with SMI. All interviews were recorded, summarized using a structured template, and summaries placed into a matrix. An interdisciplinary team reviewed and discussed matrices to identify and build consensus around findings.

We interviewed 18 key informants from 11 VA facilities. The strategies used to engage veterans with SMI fell into 2 general categories: targeted outreach and routine practices. Targeted outreach included proactive, deliberate, systematic approaches for identifying and contacting veterans with SMI who are at risk of disengaging from care. In targeted outreach, veterans were identified and prioritized for outreach independent of any visits with mental health or other VA services. Routine practices included activities embedded in regular clinical workflows at the time of veterans' mental health visits, assessing, and connecting/reconnecting veterans with SMI into primary care. In addition, we identified extensive formal and informal ties between mental health and primary care that facilitated engaging veterans with SMI in primary care.

VA facilities with high levels of primary care engagement among veterans with SMI used extensive engagement strategies, including a diverse array of targeted outreach and routine practices. Intentionally designed organizational structures and processes and facilitating extensive formal and informal ties between mental health and primary care teams supported these efforts. Additional organizational cultural factors were especially relevant to routine practice strategies. The practices we identified should be evaluated empirically for their effects on establishing and maintaining engagement in primary care among veterans with SMI.