# Evaluation of Implementing FLOW in VISN 19: Transitioning Stabilized Mental Health Patients to Management in Primary Care

> **NIH VA I50** · MICHAEL E DEBAKEY VA MEDICAL CENTER · 2021 · —

## Abstract

Adequate access to mental health treatment is one of the highest priority problems facing the Veterans Health
Administration (VHA) and VISN 19. Chronic staffing shortages and some clinical practices combine to reduce
access to mental health treatment. Poor access to care can contribute to suicide and disability, and long wait
times contribute to patient dissatisfaction and disengagement from care. Common mental health conditions are
expected to remit in many cases or to be substantially improved with evidence-based prescribing and
psychotherapy such that patients no longer need intensive specialty mental health services. International
clinical guidelines encourage the use of stepped care, in which patients should be treated at the least intensive
level of care that is appropriate to their condition. Although VA has embraced stepped care with the recent VA
Continuum of Care model, VA manuals do not provide clear guidance on which patients are appropriate for
transition back to primary care or how the transition should take place. In the absence of guidance, few
patients are appropriately transitioned and specialty mental health panels remain full, contributing to access
problems. The FLOW program addresses these problems with an algorithm to identify patients who are
potentially appropriate for transition, a user-friendly online report to communicate this information to providers,
materials to explain this process to patients and providers, and an electronic medical record (EMR) note
template to document the transition. In cases where providers believe continued specialty mental health
treatment is warranted or patients object to the transition, patients can remain in specialty mental health. This
approach also has high acceptability to remitted patients because of perception of less stigma and reduction in
appointment burden when their care is managed in primary care. Preliminary data from VISNs 16 and 17
indicates that FLOW can effectively transition recovered patients to primary care and increase access for new
mental health patients. Implementation success differed dramatically across the original pilot sites but data
collected did not offer an explanation for this or allow examination of implementation factors associated with
success. In preparation for a national rollout of FLOW, we are partnering with VISN 19 to evaluate the impact
of FLOW using a stepped wedge design with 7-9 sites randomly allocated into 3 steps in the wedge. An
evidence-based implementation facilitation approach will be used at each site. Outcomes assessed will include
program effectiveness and the factors that are associated with implementation success across sites. Program
effectiveness outcomes will be examined according to the RE-AIM model, with specific outcomes for reach (%
of clinic patients transitioned), effectiveness (% of transitions that are successful and impact on future clinic
access), adoption (% of providers using FLOW), implementation (fidelity to the m...

## Key facts

- **NIH application ID:** 10181063
- **Project number:** 5I50HX002865-02
- **Recipient organization:** MICHAEL E DEBAKEY VA MEDICAL CENTER
- **Principal Investigator:** NATALIE E HUNDT
- **Activity code:** I50 (R01, R21, SBIR, etc.)
- **Funding institute:** VA
- **Fiscal year:** 2021
- **Award amount:** —
- **Award type:** 5
- **Project period:** 2019-10-01 → 2022-09-30

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10181063

## Citation

> US National Institutes of Health, RePORTER application 10181063, Evaluation of Implementing FLOW in VISN 19: Transitioning Stabilized Mental Health Patients to Management in Primary Care (5I50HX002865-02). Retrieved via AI Analytics 2026-05-23 from https://api.ai-analytics.org/grant/nih/10181063. Licensed CC0.

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