Preventing Psychological Disorders in Service Members and Their Families An Assessment of Programs (2014) / Chapter Skim
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5 MEASUREMENT OF DEPARTMENT OF DEFENSE PREVENTION INTERVENTIONS RELATED TO PSYCHOLOGICAL HEALTH
5 MEASUREMENT OF DEPARTMENT OF DEFENSE PREVENTION INTERVENTIONS RELATED TO PSYCHOLOGICAL HEALTH
Pages 135-164
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From page 135... ...
Prevention interventions are on a continuum and can include population health risk reduction carried out through policy changes as well as indicated riskreduction screening combined with early intervention. Although "performance measurement" is typically used to refer to the assessment of health delivery services, the committee adapted this term in this chapter to refer to the metrics appropriate to all prevention initiatives.
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From page 136... ...
Although the committee's charge was to examine existing performance measures, current quality measurement initiatives cover only a narrow slice of possible measures for prevention activities. Given this situation, the committee provides a discussion of how to broaden measurement to include prevention programs and proposes that DOD stakeholders engage in this process as a necessary starting point.
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. In short, there is no systematic use of extant data as part of strategic DOD prevention initiatives.
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1 In October 2013 DOD established the DHA to manage the activities of the Military Health System, including those previously managed by TRICARE Management Activity, which was disestablished. 2 There are seven divisions in OCMO: Behavioral Health, Clinical Quality, Health Care Benefits and Risk Management, Information Management, Patient Centered Medical Home, Patient Safety, and Population Health and Medical Management.
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. Evidence-Based Program Development Recognizing these limitations and the current status of DOD prevention program assessment, the committee developed the Model for Prevention Program Development and Measurement (see Figure 5-1)
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and includes measurements of structure, process, and both proximal and distal outcomes of DOD prevention programs. These types of measurements or assessments are needed across the full continuum of programs and policies (including local commanders' initiatives)
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From page 141... ...
, prevention components may include installation-level policy changes, new protocols for enhanced screening and risk-reduction counseling, and also preventive approaches aimed at community climate and family support. Given that many prevention programs have targets in multiple domains, it is often important to assess and monitor a range of relevant outcomes, and the assessment must be done relative to the preventive intervention, the population, and the context.
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From page 142... ...
Such assessment should be linked to a mechanism for prevention program oversight, with a structure for routine reporting and review to enable ongoing quality improvement, increased adoption and dissemination of the most effective prevention programs and strategies, and discontinuance of ineffective or harmful programs and strategies. Resilience In addition to direct health outcomes, DOD prevention and resilience programs are frequently focused on domains thought to be protective, such as positive psychological attitudes, or domains related to theoretical models of individual and family resilience (Masten, 2001; Walsh, 2006)
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From page 143... ...
, were found to be of only moderate quality at best, to focus primarily on individual capacities, and to not measure systemic domains noted to be relevant to resilient processes in the context of stress or adversity. Child Outcomes Selective and indicated prevention programs designed to mitigate risk and enhance resilience in children often include standardized psychological health outcome measures, such as screening measures of emotional and behavioral symptoms (e.g., Strengths and Difficulties Questionnaire or the Pediatric Symptom Checklist; see, respectively, Goodman, 1997, and Jellinek et al., 1988)
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The amount of resources (costs) needed to effect a change in outcomes must be known and compared among programs to determine the cost-effectiveness of DOD prevention interventions.
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Ideally, DOD would be able to assess the value of all of its resilience and prevention programs for psychological health using a core set of metrics that reflect its highest-priority target outcomes. That would permit the department, using cost-effectiveness analysis based on current program operations, to determine how to maximize the outcomes for the resources it expends.
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Consumer input from the target population (patient centered) Consistent messaging across other Army suicide prevention efforts (coordinated)
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Nonetheless, the framework provides a useful and systematic approach to the development and selection of measures to assure the quality and effectiveness of DOD prevention programs. MEASURES IDENTIFIED IN REVIEW OF NATIONAL QUALITY INITIATIVES This final section presents the findings from the committee's review of existing performance measures from three national efforts to organize, manage, and promulgate the use of performance measures: the NBHQF, developed by SAMHSA (2013b)
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After examining measure sets from multiple sources, the committee found two categories of measures: process and outcome. The process measures address depression screening.
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Depression: No No Process Percentage of eligible patients who are VA Screeningb screened annually for depression with the PHQ-2 or PHQ-9. Depression: No No Process Percentage of veterans who have a VA Screening positive screen during their annual Documentationb depression screening and have a disposition documented in the record.
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TABLE 5-2 PTSD Measures NQF NBHQF Endorsed Recommended/ Owner/ Title (measure #) Category Type Description Developer PTSD: No No Process Percentage of eligible patients who are VA Screeninga screened for PTSD at required intervals.
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Effective, older with a new diagnosis or recurrent Medical Disorder: Safe episode of MDD who had a suicide risk Association -- Suicide Risk assessment completed at each visit during Physician Assessmenta the measurement period. Consortium for Performance Improvement Suicide Risk No No Process Percentage of patients who screen positive VA Assessment: on a screen for major depressive disorder Positive PHQ (PHQ-2 or PHQ-9 or endorsement of Screensb question 9 on the PHQ-9)
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Category Type Description Developer Alcohol Use: No No Process Percentage of eligible patients who are seen VA Screeninga in outpatient or inpatient settings and screened annually for alcohol misuse with the three-item AUDIT-C. Alcohol No No Process Percentage of veterans who are screened for VA Misuse: Brief alcohol misuse with AUDIT-C and meet or Counselinga exceed a threshold score of 5 and who have timely brief alcohol counseling.
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From page 153... ...
Outside DOD other treatment process measures have been adopted by the National Committee for Quality Assurance and NIATx which focus on engagement and ease of access. NIATx is an example of a system quality-improvement approach applied to substance use disorder facilities which typically are not covered by other quality-assurance programs.
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From page 154... ...
Category Type Description Developer Domestic No No Process Percentage of adult and adolescent patients Futures Violence: who received health care services in the Without Disclosurea clinical setting within the past year and who Violence were screened for IPV who disclosed that they were victims of abuse. Domestic No No Process Percentage of adult and adolescent patients Futures Violence: seen by a provider who received health care Without Assessmenta services in the clinical setting within the Violence last year who were assessed*
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Domestic No No Process Percentage of adult and adolescent patients Futures Violence: who received health care services in the Without Specified clinical setting who screened positive for Violence Intervention and current or past IPV for whom records Treatment Plansa indicate that intervention and treatment plans were offered including Verbal and/or written information about safety planning (current victims only) An option to talk with an advocate in person or on the phone (current victims only)
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Category Type Description Developer Developmental Yes No Process The measure assesses whether the Maternal and screening (#1385) parent or caregiver completed a Child Health using a parent- developmental screening tool meant to Bureau, Health completed identify children at risk for Resources and screening tool developmental, behavioral, and social Services (parent report, delays.
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. Yet, few adolescents receive recommended comprehensive preventive counseling and screening services on key topics such as alcohol use, depression, sexual activity, smoking, injury prevention, physical activity, and diet (National Quality Measures Clearinghouse, 2013b)
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Risky Behavior Yes Yes/Healthy Process Percentage of children with National Assessment or (#1507) Living documentation of assessment or Committee for Counseling by counseling for risky behaviors by 18 Quality Age 18 Yearsa years of age.
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TABLE 5-8 Measures for Suicide Risk for Children and Adolescents NQF NBHQF Endorsed Recommended/ Owner/ Title (measure #) Category Type Description Developer Child and Yes Yes/Safe Process Percentage of patient visits for those American Adolescent (#1365)
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CONCLUSION As DOD advances its efforts to evaluate and improve psychological health programming for service members and their families, it faces a number of challenges, such as insufficient empirical evidence for many of the prevention programs it has implemented, no systematic use of national performance measures to assess current DOD screening programs, and the lack of a systematic process for selecting validated measures for use in judging performance of the structure, process, and outcomes of all prevention initiatives for enhancing psychological health. The measurement of performance is not as advanced in psychological health as it is in other types of care (Pincus et al., 2011; Watkins et al., 2010)
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:76–82. DCOE (Defense Centers of Excellence for Psychological Health & Traumatic Brain Injury)
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. National Quality Measures Clearinghouse.
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2011. Programs Addressing Psychological Health and Traumatic Brain Injury Among U.S.
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