Provision of Mental Health Counseling Services Under TRICARE (2010) / Chapter Skim
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5 Research Regarding the Determinants of High-Quality Mental Health Care
5 Research Regarding the Determinants of High-Quality Mental Health Care
Pages 167-204
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From page 167... ...
reports on healthcare quality, mental health and substance-abuse care, and treatment of posttraumatic stress disorder (PTSD) were especially influential in the committee's deliberations.
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. Although it is desirable to know whether the care that is delivered to patients produces good outcomes, many factors that are independent of treatment quality can also affect a person's health status after treatment, including illness severity and the patient's ability and desire to adhere to a treatment regimen.
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3. Patient-centered -- providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.
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The health care system should make information available to patients and their families that allows them to make informed decisions when selecting a health plan, hospital, or clinical practice, or choosing among alternative treatments. This should include information describing the system's performance on safety, evidence-based practice, and patient satisfaction.
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From page 171... ...
; patients receive education about their illnesses and how to participate fully in their treatment, including self-monitoring of symptoms and behavioral change; clinicians receive continuing education and, when needed, clinical consultation; and clinicians have an information-support system that can provide reminders, monitor patient outcomes, provide feedback, and assist in treatment planning (Wagner et al., 1996)
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From page 172... ...
. It is also important for clinicians to establish a therapeutic alliance with a patient at the outset of treatment to promote the patient's engagement and adherence, and to educate the patient and his or her family members about the condition for which the patient is being treated and about how to prevent or minimize exacerbations.
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Once there is a diagnosis, clinicians must determine the most appropriate treatment for an individual patient on the basis of the clinical literature. Randomized controlled trials are an important part of the evidence base for understanding the efficacy of clinical treatments, but they are not the only evidence considered in evidence-based care.
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Following the National Guideline Clearinghouse (2009) criteria for inclusion of clinical practice guidelines (CPGs)
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compulsive disorder Panic disorder Cognitive behavioral therapy (APA, 2009b) The committee was not able to find American Psychiatric Association, Department of a Veterans Affairs, or Department of Defense practice guidelines for generalized anxiety disorder.
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Even the guidelines that do exist may not apply fully or directly to people who are seeking care. Patients may manifest varying patterns of comorbidity (such as depression and substance abuse and traumatic brain injury)
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Posttraumatic Stress Disorder Several treatment models that address symptoms, affect regulation, and beliefs related to PTSD are oriented to not only the individual service member but partners, children, and other family members. Treatment approaches include group, couple, and family therapy.
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. The 2004 VA/DoD Clinical Practice Guideline for PTSD identified one pharmacotherapy -- selective serotonin reuptake inhibitors (SSRIs)
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are useful treatment interventions. Again, including the partner in couple therapy is important in reducing shame and promoting more open communication.
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The VA/DOD substance-use disorder CPG (VA/DOD, 2009c) recognizes behavioral couple therapy, cognitive behavioral coping skills training, motivational enhancement therapy, community reinforcement approach, and twelve-step facilitation as "first line alternatives at least as effective as other bona fide active interventions or treatment as usual" for at least some disorders.
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From page 181... ...
Supportive, relationally based methods that stress the reparative nature of a positive therapeutic alliance are preferable during the period when the client's cognitive functioning is impaired. Couple and family therapy methods can help partners and children to understand the effects of polytrauma, defined as damage to more than one organ system (e.g., TBI, hearing loss, amputations, visual impairment, and burns)
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Mallinckrodt and Nelson (1991) examined novice, advanced, and experienced practitioners' therapeutic alliances and found that counseling psychologists who had higher training levels were given higher client ratings for agreement on overall goals of treatment and tasks relevant to achieving the goals but not on emotional bonds between practitioner and client.
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. whether any form of educational experience is linked to clinical judgment accuracy." STRATEgIES FOR MONITORINg AND IMPROvINg THE QuALITY OF BEHAvIORAL HEALTH CARE The IOM report Improving the Quality of Health Care for Mental and Substance-Use Conditions (2006)
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From page 184... ...
Nonetheless, the report presented a blueprint for building the infrastructure for M/SU health care that has important implications for the provision of counseling and other mental health services for TRICARE beneficiaries. Strategies for Measuring the Quality of Care Throughout the quality-improvement field, the general mantra has been that "you can't improve what you don't measure." The 2006 IOM report Improving the Quality of Care emphasized that effectively measuring quality requires structures, resources, and expertise and strategic efforts among key stakeholders to • Conceptualize the aspects of care to be measured.
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A useful approach to applying quality-measurement and qualityimprovement concepts to counseling and other psychosocial interventions in the Donabedian structure–process–outcomes model previously described is outlined below. From a structural point of view, one would want to incorporate measures in the following categories: • Are providers trained in evidence-based practices (as incorpo rated in certification, credentialing, and licensing)
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From page 186... ...
when based on the specific needs that patients bring to the therapeutic setting. Patients presents with symptoms of a condition that support a diagnosis, but the effectiveness of patient treatment is heavily influenced by myriad other factors, such as ability to establish a therapeutic alliance, patient acceptance and motivation to change, cognitive ability to participate in therapy, and ability to learn and improve adaptive skills and generalize the new skills outside the therapeutic setting.
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Studies have demonstrated that the therapeutic alliance has a substantial effect
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concluded that the ability to develop a therapeutic alliance can be developed during training and may improve through acquisition of specific skills, accumulated hours of clinical practice, and more complex case conceptualization. Trainees become more focused on the therapeutic alliance with greater training and clinical experience, but some aspects of the alliance, such as goal setting and task recognition, may be more learnable and teachable than bond development.
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. Most focus on structure and process measurement on the basis of best-practice guidelines and systems rather than individual providers.
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TABLE 5.4 National Institutes of Health Behavior Change Consortium Best-Practice Domains and Recommendations 0 Domain Goal Strategies Provider training Standardize training for all Standardized training manuals, materials, resources, field guides; structure practice and role provider types playing; use standardized patients; use same instructors, videotape training Ensure provider skill Observe intervention implementation with standardized patient or role-playing; score acquisition provider according to checklist; conduct debriefing; administer written pretraining and posttraining examinations; certify skills during and after training Minimize "drift" in Conduct booster sessions; conduct in vivo observations scored against checklist; supervise; provider skills obtain provider self-report; conduct patient exit interviews or otherwise obtain feedback Accommodate provider Have professional supervise paraprofessional providers; monitor dropout rates, treatment difference effectiveness Delivery of Control for provider Assess patients' perception of provider via questionnaire, give feedback to provider; audiotape treatment difference sessions, have different supervisors review; monitor patient complaints; have provider work with all treatment groups Reduce differences within Use scripted protocols, treatment manuals; have supervisors rate audiotapes, videotapes treatment Ensure adherence to Audiotape or videotape encounter, review with provider; randomly monitor audiotapes for treatment protocol protocol adherence; have provider complete checklist of intervention components Receipt of Ensure patient Have provider review participant homework, self-monitoring logs; have structured interview treatment comprehension with patient Ensure patient ability to Have providers review homework; assess, measure participant performance; use and use cognitive skills questionnaires; use hypothetical scenarios to test patient enactment of Ensure patient ability to Collect patient self-monitoring, self-report data; use behavioral-outcome measures treatment skills perform behavioral skills SOURCE: Excerpted and adapted from Bellg et al.
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, linking outcome data on patients treated for posttraumatic stress disorder with administra tive data showed that long-term, intensive inpatient treatment was not more effective than short-term treatment and cost $18,000 more per patient per year (Fontana and Rosenheck, 1997; Rosenheck and
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The analysis, based on 15,000 cases, confirmed that patients whose therapists received feedback had more than 25% greater improvement than patients whose therapists did not receive feedback. To assess the quality of behavioral health–care delivery in the TRICARE system, it would be important to use a working definition of high-quality behavioral health care that takes into account the six aims (Table 5.1)
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-- Declaration of successful training by technique, conditions, and special populations. • Use of postgraduation or postcertification continuous retrain ing techniques to ensure continued treatment effectiveness, fidelity, and training in new or enhanced treatment techniques as appropriate.
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. In 2008, the Assistant Secretary of Defense for Health Affairs, testifying on mental health before a subcommittee of the House of Representatives Committee on Armed Services, stated that DOD's quality-of-care initiative "relies on developing and disseminating clinical guidance and standards, as well as training clinicians in clinical practice guidelines and effective evidence-based methods of care" (Casscells, 2008)
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20) that "DOD's mental health providers require additional training regarding current and new state-of-the-art practice guidelines." The task force also found that there was "no consistent system for ongoing quality assessment and continuous improvement that includes substantial measurements of psychological health care outcomes" (p.
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In addition, the task force underscored the need for TRICARE providers to be specifically trained to meet the needs of their patient population: • 5.3.4.9: The Department of Defense should improve TRICARE providers' training in issues related to military experiences by: -- Requiring that TRICARE mental health contractors offer mediated training packages to all network mental health providers similar to those available through the National Center for Post-Traumatic Stress Disorder, the Department of Defense Center for Deployment Psychology, and military mental health components. -- Requiring that TRICARE mental health contractors offer training packages for specific disorders and problems such as post-traumatic stress disorder and other combat stress syndromes each time a treatment plan is approved.
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2000. Practice guideline for the treatment of patients with major depressive disorder, 2nd ed.
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2009a. Guideline watch: Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder.
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2001. Treatment choice in psychological therapies and counseling: Evidence based clinical practice guideline.
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2007. Contemporary group treatment of combat-related posttraumatic stress disorder.
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2009. Criteria for inclusion of clinical practice guidelines in nGC.
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2009a. VA/DoD clinical practice guideline for management of concussion/mild traumatic brain injury.
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2006. National survey of psychotherapy training in psychiatry, psychology, and social work.
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