Overview

Collaboration and communication among the health care team members is central to integrated health care. Integrated health care teams work together to establish treatment plans addressing patients' biological, psychological, and social needs. The interdisciplinary health care team can include many types of providers, such as physicians, psychologists, social workers, and occupational and physical therapists, etc. The team makeup is dependent on the patient's needs.

Addressing the high prevalence of mental health and substance use disorders (MH/SUD) in Veterans with HIV by increasing the availability of services for such disorders is critically important for successful treatment. Mental health providers in particular can add the following services to an integrated care team (adapted from an American Psychological Association fact sheet for policymakers):

• Cognitive, capacity, diagnostic, and personality assessments that differentiate normal processes from pathologic states, side effects of medications, adjustment reactions, or combinations of these problems
• Behavioral health assessment and treatment that provide individuals with the self-management skills necessary to effectively manage their chronic conditions
• Diagnosis and treatment of mental and behavioral health problems (e.g., depression, suicide risk, anxiety disorders, addiction, and insomnia)
• Consultation and recommendations to family members, significant others, and other health care providers

Ongoing substance use and active psychiatric disorders are common barriers to HIV treatment among Veterans.

Given the high prevalence of MH/SUD in Veterans with HIV, increasing the availability of services to address this need is of critical importance in their successful treatment as research shows that integrated mental health care can increase HIV treatment adherence and improve overall health outcomes.

Integrating mental health services into HIV clinical care settings can take many forms. Ojikutu et al. (2014) have emphasized the following aspects for successful models of integrated HIV care:

• Patient centered with integrated or co-located services
• Diverse teams of clinical and nonclinical providers
• A site culture that promotes a stigma-reducing environment
• Availability of comprehensive medical, behavioral health, and psychosocial services
• Effective communication strategies
• Focus on quality

Bonner et al. (2012) propose three models for treatment of patients with chronic hepatitis C virus (HCV) infection. Although treatment of HCV has evolved, these models can be adapted for current HIV treatment. They encourage clinics to select the model best suited to local resources and expertise. Some of the advantages of each of these models of care are outlined in the following table.

Across all models of integrated care, a specialty staff is critical for improving treatment outcomes, retention in care, and quality of life for patients. Social work and case management staff are vital to facilitating communication among providers, monitoring treatment outcomes, recognizing concerns that may not present during clinic visits, and connecting Veterans to important resources necessary for continued engagement in care as well as overall health outcomes. Liaison with mental health and substance use staff is also crucial, as primary care is responsible for many patients with comorbid disorders who may not have been diagnosed or treated for MH/SUD. When concerns are identified during clinic visits, access to same day MH/SUD evaluation is optimal.

Integrated care models also utilize Tele-Mental Health services to facilitate access to and delivery of MH/SUD services, especially with regard Veterans who face significant barriers to accessing care. Increased use of telehealth could significantly increase Veterans' access to mental health services by addressing critical barriers to care such as stigma, distance from care providers, and disability.

General Clinician Tools

• SAMHSA-HRSA Center for Integrated Health Solutions (CIHS)
  • Resources for Integrating Behavioral Health into HIV Care
  • SAMHSA: Service Members, Veterans, and their Families Technical Assistance Center
• American Psychological Association: HIV/AIDS ResourcesIncludes blog posts, fact sheets, podcasts, and other resources
• American Academy of HIV Medicine: HIV Specialist Special Issue on HIV and Mental Health

Clinician Tools for Addressing Substance Use

Reducing Alcohol Use

• Brief Interventions for Alcohol Use Disorder
• Self-Administered Screening for Substance Abuse
• Addiction Pharmacotherapy for Alcohol Use Disorders:

Treating PTSD in the Context of Complex Medical Issues

• VA's National Center for PTSD
• VA PTSD Consultation Program for Providers inside and outside VA who are treating Veterans; Services are free

Health Psychology/Behavioral Medicine

• Medication Adherence
• Obesity
• Crisis Intervention
• Pain Management
• Tobacco Cessation

For Patients:

• Make the Connection

Journal Articles

Bonner JE, Barritt AS 4th, Fried MW, et al. Time to rethink antiviral treatment for hepatitis c in patients. Dig Dis Sci. 2012 Jun;57(6):1469-74.

Fix GM, Asch SM, Saifu HN, et al. Delivering PACT-principled care: are specialty care patients being left behind? J Gen Intern Med. 2014 Jul;29 Suppl 2:S695-702.

Hoang T, Goetz MB, Yano EM, et al. The impact of integrated HIV care on patient health outcomes. Med Care. 2009 May;47(5):560-7.

Ojikutu B, Holman J, Kunches L, et al. Interdisciplinary HIV care in a changing healthcare environment in the USA. AIDS Care. 2014;26(6):731-5.

Willenbring ML. Integrating care for patients with infectious, psychiatric, and substance use disorders: concepts and approaches. AIDS. 2005 Oct;19 Suppl 3:S227-37.

Zaller N, Gillani FS, Rich JD. A model of integrated primary care for HIV-positive patients with underlying substance use and mental illness. AIDS Care. 2007 Oct;19(9):1128-33.

External Websites

• American Psychological Association: Office of HIV/AIDS
• Centers for Disease Control and Prevention: HIV/AIDS Compendium of Evidence-Based HIV Behavioral Interventions
• HIV.gov: Mental Health
• National Institute of Mental Health: HIV/AIDS and Mental Health
• The Substance Abuse and Mental Health Services Administration (SAMHSA)

References

Primary Care of Veterans with HIV

Health Care Reform: Integrated Health Care

Bonner JE, Barritt AS 4th, Fried MW, et al. Time to rethink antiviral treatment for hepatitis c in patients with coexisting mental health/substance abuse issues. Dig Dis Sci. 2012 Jun;57(6):1469-74.

Ojikutu B, Holman J, Kunches L, et al. Interdisciplinary HIV care in a changing healthcare environment in the USA. AIDS Care. 2014;26(6):731-5.