Health Systems

, Volume 6, Issue 2, pp 148–160 | Cite as

Workforce design in primary care-mental health integration: a case study at one veterans affairs medical center

  • Renata Konrad
  • Christine Tang
  • Brian Shiner
  • Bradley V Watts
Case Study


Many Veterans screen positive for mental health disorders in primary care, yet it appears that only a fraction of those who could benefit receive treatment. One potential way to ensure that a larger proportion of these Veterans receive appropriate care would be to increase access to mental health services through primary care-mental health integration (PC-MHI) clinics. Yet a systematic method to evaluate the impact of projected increases in patient volumes on PC-MHI clinics is lacking. As a first step, we develop and validate a discrete-event simulation model to understand how the clinic could respond to a projected increase in PC-MHI utilization at one Veterans Affairs Medical Center. Numerical results illustrate the impact of increased patient volume and the availability of providers on patient wait times and patients seen by mental health providers outside of clinic hours. We also note that although discrete-event simulation has a long history in health care, it is rarely used in the assessment of the resource allocation decisions in mental health.


mental health veterans integrated primary care discrete-event simulation workforce allocation 



The authors would like to thank the staff at the White River Junction PC-MHI Clinic for their assistance in data collection.


  1. Banks J (Ed) (1998) Handbook of Simulation. Wiley, New York.CrossRefGoogle Scholar
  2. Banks J, Carson J, Nelson B and Nicol D (2009) Discrete-Event System Simulation. Pearson Education, Toronto, Canada.Google Scholar
  3. Berg B et al (2010) A discrete event simulation model to evaluate operational performance of a colonoscopy suite. Medical Decision Making 30(3), 380–387.CrossRefGoogle Scholar
  4. Bodin L, Carroll T, Lee A and Stout S (1972) Financing mental-health services in the state of New York. Operations Research 20(5), 942–954.CrossRefGoogle Scholar
  5. Cocozza JJ et al (2000) Successful systems integration strategies: the ACCESS program for persons who are homeless and mentally ill. Administration and Policy in Mental Health and Mental Health Services Research 27(6), 395–407.CrossRefGoogle Scholar
  6. Coyne JC, Palmer SC, Shapiro PJ, Thompson R and DeMichele A (2004) Distress, psychiatric morbidity, and prescriptions for psychotropic medication in a breast cancer waiting room sample. General hospital psychiatry 26(2), 121–128.CrossRefGoogle Scholar
  7. Davies R and Davies H (1994) Modelling patient flows and resource provision in health systems. Omega 22(2), 123–131.CrossRefGoogle Scholar
  8. England W and Roberts S (1978) Applications of computer simulation in health care. In Proceedings of the 10th Conference on Winter Simulation-Volume 2, (Hull L and Nielsen N, Eds), IEEE Computer Society Press, Los Alamitos, CA.Google Scholar
  9. Fenger M, Mortensen E, Poulsen S and Lau M (2011) No-shows, drop-outs and completers in psychotherapeutic treatment: demographic and clinical predictors in a large sample of non-psychotic patients. Nordic Journal of Psychiatry 65(3), 183–191.CrossRefGoogle Scholar
  10. Fialho A, Oliveira M and Sá A (2011) Using discrete event simulation to compare the performance of family health unit and primary health care centre organizational models in Portugal. BMC Health Services Research 11(1), 274–285.CrossRefGoogle Scholar
  11. Fisher RA (1955) Statistical methods and scientific induction. Journal of the Royal Statistical Society. Series B (Methodological) 17(1), 69–78.Google Scholar
  12. Fone D et al (2003) Systematic review of the use and value of computer simulation modelling in population health and health care delivery. Journal of Public Health 25(4), 325–335.CrossRefGoogle Scholar
  13. Gallucci G, Swartz W and Hackerman F (2005) Brief reports: impact of the wait for an initial appointment on the rate of kept appointments at a mental health center. Psychiatric Services 56(3), 344–346.CrossRefGoogle Scholar
  14. Gilbert R (1987) Statistical Methods for Environmental Pollution Monitoring. Wiley, New York.Google Scholar
  15. Glowacka K, Henry R and May J (2009) A hybrid data mining/simulation approach for modelling outpatient no-shows in clinic scheduling. Journal of the Operational Research Society 60(8), 1056–1068.CrossRefGoogle Scholar
  16. Gordon AJ et al (2007) The Allegheny initiative for mental health integration for the homeless: integrating heterogeneous health services for homeless persons. American journal of public health 97(3), 401.CrossRefGoogle Scholar
  17. Green L (2006) Queueing analysis in healthcare. In Patient Flow: Reducing Delay in Healthcare Delivery (Hall R, Ed), pp 281–307, Springer, Los Angeles, CA.CrossRefGoogle Scholar
  18. Günal M (2010) Discrete event simulation for performance modelling in health care: a review of the literature. Journal of Simulation 4(1), 42–51.CrossRefGoogle Scholar
  19. Hermes E, Rosenheck R, Desai R and Fontana A (2012) Recent trends in the treatment of posttraumatic stress disorder and other mental disorders in the VHA. Psychiatric Services 63(5), 471–476.CrossRefGoogle Scholar
  20. Jacobson S, Hall S and Swisher J (2006) Discrete-event simulation of health care systems. In Patient Flow: Reducing Delay in Healthcare Delivery (Hall R, Ed), pp 211–252, Springer, Los Angeles, CA.CrossRefGoogle Scholar
  21. Jun J, Jacobson S and Swisher J (1999) Application of discrete-event simulation in health care clinics: a survey. Journal of the Operational Research Society 50(2), 109–123.CrossRefGoogle Scholar
  22. Kelton W, Sadowski R and Sturrock D (2007) Simulation with Arena. McGraw-Hill Higher Education, Boston.Google Scholar
  23. Kessler R, Chiu W, Demler O, Merikangas K and Walters E (2005) Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the national comorbidity survey replication. Archives of General Psychiatry 62(6), 617–627.CrossRefGoogle Scholar
  24. Kim B, Elstein Y, Shiner B, Konrad R, Pomerantz A and Watts B (2013) Use of discrete event simulation to improve a mental health clinic. General Hospital Psychiatry 35(6), 668–670.CrossRefGoogle Scholar
  25. Kolker A (2008) Process modeling of emergency department patient flow: effect of patient length of stay on ED diversion. Journal of Medical Systems 32(5), 389–401.CrossRefGoogle Scholar
  26. Kroenke K, Spitzer R and Williams J (2003) The patient health questionnaire-2: validity of a two-item depression screener. Medical Care 41(11), 1284–1292.CrossRefGoogle Scholar
  27. Kuno E, Koizumi N, Rothbard A and Greenwald J (2005) A service system planning model for individuals with serious mental illness. Mental Health Services Research 7(3), 135–144.CrossRefGoogle Scholar
  28. Mann HB (1945) Nonparametric tests against trend. Econometrica: Journal of the Econometric Society 13, 245–259.CrossRefGoogle Scholar
  29. Oxman T, Dietrich A and Schulberg H (2005) Evidence-based models of integrated management of depression in primary care. Psychiatric Clinics of North America 28(4), 1061–1078.CrossRefGoogle Scholar
  30. Pomerantz A, Cole B, Watts B and Weeks W (2008) Improving efficiency and access to mental health care: combining integrated care and advanced access. General Hospital Psychiatry 30(6), 546–551.CrossRefGoogle Scholar
  31. Pomerantz AS et al (2010) The white river model of colocated collaborative care: a platform for mental and behavioral health care in the medical home. Families, Systems & Health 28(2), 114–129.CrossRefGoogle Scholar
  32. Post E, Metzger M, Dumas P and Lehmann P (2010) Integrating mental health into primary care within the veterans health administration. Families, Systems & Health 28(2), 83.CrossRefGoogle Scholar
  33. Rau C (2013) Using discrete-event simulation in strategic capacity planning for an outpatient physical therapy service. Health Care Management Science 16(4), 352–365.CrossRefGoogle Scholar
  34. Roberts S (2011) Tutorial on the simulation of healthcare systems. In Proceedings of the 2011 Winter Simulation Conference (Jain S, Creasey RR, Himmelspach J, White KP and Fu M, Eds), Institute of Electrical and Electronics Engineers (IEEE), Piscataway, NJ.Google Scholar
  35. Robinson S (2014) Simulation: The Practice of Model Development and Use. Palgrave Macmillan, UK.CrossRefGoogle Scholar
  36. Rohleder T, Lewkonia P, Bischak D, Duffy P and Hendijani R (2011) Using simulation modeling to improve patient flow at an outpatient orthopedic clinic. Health Care Management Science 14(2), 135–145.CrossRefGoogle Scholar
  37. Rosenheck R and Fontana A (2007) Recent trends in VA treatment of post-traumatic stress disorder and other mental disorders. Health Affairs 26(6), 1720–1727.CrossRefGoogle Scholar
  38. Roy-Byrne P et al (2010) Delivery of evidence-based treatment for multiple anxiety disorders in primary care: a randomized controlled trial. JAMA: Journal of the American Medical Association 303(19), 1921–1928.CrossRefGoogle Scholar
  39. Rust T, Saeed K, Bar-On I and Pavlov O (2012) Re-designing policy and process in health care service delivery: a system dynamics case study. In Proceedings of the 30th International Conference of the System Dynamics Society (Husemann E and Lane D, Eds), Wiley Blackwell, St. Gallen, Switzerland.Google Scholar
  40. Seal K, Bertenthal D, Miner C, Sen S and Marmar C (2007) Bringing the war back home: mental health disorders among 103 788 US veterans returning from Iraq and Afghanistan seen at department of veterans affairs facilities. Archives of Internal Medicine 167(5), 476–482.CrossRefGoogle Scholar
  41. Seila A and Brailsford S (2009) Opportunities and challenges in health care simulation. In Advancing the Frontiers of Simulation (Goldsman D and Wilson J, Eds), pp 195–229, Springer, US.CrossRefGoogle Scholar
  42. Shiner B, Drake R, Watts B, Desai R and Schnurr P (2012) Access to VA services for returning veterans with PTSD. Military Medicine 177(7), 814–822.CrossRefGoogle Scholar
  43. Shiner B et al (2009) Access to what? An evaluation of the key ingredients to effective advanced mental health access at a VA medical center and its affiliated community-based outreach clinics. Military Medicine 174(10), 1024–1032.CrossRefGoogle Scholar
  44. Shiner B, Tang C, Trapp A, Konrad R, Bar-On I and Watts B (2014) The provision of mental health treatment after screening: exploring the relationship between treatment setting and treatment intensity. General Hospital Psychiatry 36(6).Google Scholar
  45. Smits M (2010) Impact of policy and process design on the performance of intake and treatment processes in mental health care: a system dynamics case study. Journal of the Operational Research Society 61(10), 1437–1445.CrossRefGoogle Scholar
  46. Spoont M, Murdoch M, Hodges J and Nugent S (2010) Treatment receipt by veterans after a PTSD diagnosis in PTSD, mental health, or general medical clinics. Psychiatric Services 61(1), 58–63.CrossRefGoogle Scholar
  47. Szymanski B, Bohnert K, Zivin K and Mccarthy J (2013) Integrated care: treatment initiation following positive depression screens. Journal of General Internal Medicine 28(3), 346–352.CrossRefGoogle Scholar
  48. Tew J, Klaus J and Oslin D (2010) The behavioral health laboratory: building a stronger foundation for the patient-centered medical home. Families, Systems & Health 28(2), 130.CrossRefGoogle Scholar
  49. Trafton et al (2013) VHA mental health information system: applying health information technology to monitor and facilitate implementation of VHA uniform mental health services handbook requirements. Medical Care 51(Special issue), S29–S36.CrossRefGoogle Scholar
  50. Vos T et al (2012) Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the global burden of disease study 2010. Lancet 380(9859), 2163–2196.CrossRefGoogle Scholar
  51. Wagner T, Sinnott P and Siroka A (2011) Mental health and substance use disorder spending in the department of veterans affairs, fiscal years 2000–2007. Psychiatric Services 62(4), 389–395.CrossRefGoogle Scholar
  52. Wang P, Demler O, Olfson M, Pincus H, Wells K and Kessler R (2006) Changing profiles of service sectors used for mental health care in the US. The American Journal of Psychiatry 163(7), 1187–1198.CrossRefGoogle Scholar
  53. Wang J, Kamin C and Glover W (2011) A survey of systems and improvement approaches for psychological healthcare. In Proceedings of the 2011 Industrial Engineering Research Conference (Doolen T and Van Aken E, Eds), Reno, Nevada.Google Scholar
  54. Watts B, Shiner B, Pomerantz A, Stender P and Weeks W (2007) Outcomes of a quality improvement project integrating mental health into primary care. Quality and Safety in Health Care 16(5), 378–381.CrossRefGoogle Scholar
  55. Weerawat W, Pichitlamken J and Subsombat P (2013) A generic discrete-event simulation model for outpatient clinics in a large public hospital. Journal of Healthcare Engineering 4(2), 285–306.CrossRefGoogle Scholar
  56. Welch P (1983) The statistical analysis of simulation results. The Computer Performance Modeling Handbook 22, 268–328.Google Scholar
  57. Williams M, Latta J and Conversano P (2008) Eliminating the wait for mental health services. Journal of Behavioral Health Services and Research 35(1), 107–114.CrossRefGoogle Scholar
  58. Wongsammacheep T, Pichitlamken J and Weerawat W (2012) The discrete-event simulation model of a health screening center. Lecture Notes in Management Science 4, 54–63.Google Scholar
  59. Zeiss A and Karlin B (2008) Integrating mental health and primary care services in the department of veterans affairs health care system. Journal of Clinical Psychology in Medical Settings 15(1), 73–78.CrossRefGoogle Scholar

Copyright information

© The OR Society 2016

Authors and Affiliations

  • Renata Konrad
    • 1
  • Christine Tang
    • 2
  • Brian Shiner
    • 3
    • 4
  • Bradley V Watts
    • 3
    • 4
  1. 1.School of Business, Worcester Polytechnic InstituteWorcesterU.S.A.
  2. 2.Department of Manufacturing, Worcester Polytechnic InstituteWorcesterU.S.A.
  3. 3.White River Junction VA Medical CenterWhite River JunctionU.S.A.
  4. 4.Department of Psychiatry, Dartmouth Medical SchoolLebanonU.S.A.

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