QUERI – Quality Enhancement Research Initiative

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

Houston, TX


Providing adequate access to mental health for Veterans is one of the most important problems facing VA. To improve access, there is a need to better target existing mental health resources toward care for Veterans in most need of specialty mental health services. Mental health patients who are stabilized and recovered should be transitioned back to primary care to increase availability in mental health for new patients. Because there are currently no methods to identify who is recovered – or tools and processes to assist in transitions, few patients ‘graduate’ mental health. The FLOW (not an acronym) program consists of:

  • 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.

The Evaluation of Implementing FLOW in VISN 19 QUERI National Partnered Evaluation is collaborating with VISN 19 (VA Rocky Mountain Network) to evaluate this program within nine VA sites. Sites will receive an evidence-based implementation facilitation approach. Specific aims include evaluating the impact of FLOW, such as the successful transition to primary care and impact on clinic access for future patients, the number of providers in the selected clinics transitioning patients to primary care, and the sustainment of FLOW after withdrawal of external facilitation. Investigators also will examine the structural and process implementation factors, including organizational readiness to change, staffing levels, interservice agreements about care, leadership support, and internal facilitation.


Investigators are utilizing the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework to guide the measurement of implementation outcomes.

Anticipated Impacts

FLOW will be implemented at nine VISN 19 facilities, with all specialty mental health providers anticipated to participate. Pilot data indicates that FLOW will impact approximately 6-7% of specialty mental health patients at each site. Given that pilot data indicated substantial increases in timely care for new mental health patients, investigators expect strong improvement in SAIL metrics and VISN performance plan metrics related to access. They also anticipate future rollout of FLOW across the VA healthcare system. 

Corresponding Principal Investigator: Natalie Hundt, PhD; contact at Natalie.Hundt@va.gov .

Operations Partners: VISN 19 (VA Rocky Mountain Network).