Maintaining an appropriate and adequate workforce can be challenging for any health care system. Staffing the many programs and services that the Department of Defense (DoD) and the Department of Veterans Affairs (VA) have for the prevention, diagnosis, and treatment for posttraumatic stress disorder (PTSD) requires a large and diverse workforce that is trained and capable of providing the best care available and that is led by effective, engaged, and knowledgeable leaders. But having sufficient numbers of mental health providers is not enough to ensure that patients receive comprehensive care using best practices. An effective workforce requires that all mental health care providers be qualified and able to provide the best care and that they have the time and incentives to deliver it. Mental health care providers (such as, psychiatrists, psychologists, nurse practitioners, and social workers) need to be well qualified, appropriately licensed and credentialed, and trained to recognize and treat for PTSD using best practices.
Mental health care providers need adequate resources (such as time and money) to attend training in evidence-based treatments and deliver the treatments with fidelity and to improve their competence by continuing supervision and consultation with master trainers or mentors (Foa et al., 2013; Karlin et al., 2010; Ruzek et al., 2012). Training in evidence-based treatments without sufficient time for coursework and direct supervised clinical experience may instill an unwarranted sense of competence in providers and may ultimately do more harm than good (Foa et al., 2013). Seasoned providers need to be given opportunities to be mentors and
newly trained providers need time to work with mentors when this is recommended.
An often overlooked aspect of providing optimal mental health care is the need to maintain the mental well-being of providers themselves, who may experience “compassion fatigue” or “secondary traumatic stress.” The risk of secondary (or vicarious) trauma can be reduced by providing appropriate training, ensuring manageable caseloads, and encouraging provider consultations when treating difficult patients (Munroe et al., 1995).
In this chapter, the committee discusses the role of leaders in ensuing the best care available for PTSD and highlights the training needs of providers to manage PTSD. Other issues that might affect the DoD and VA workforce but are not considered in this report are organizational approaches to recruitment and retention of staff and the use of performance incentives to encourage specific activities. Recruitment and retention may be particularly important for installations and medical facilities located in underserved areas because an estimated 77% of U.S. counties have a severe shortage of mental health professionals (Thomas et al., 2009) and these shortages are most acute in rural areas (Hunt et al., 2012). However, the committee does not have data to assess these needs. The committee highlights ways in which each department is attempting to ensure an adequate and competent workforce and the challenges that they face in trying to do so.
DEPARTMENT OF DEFENSE
In the sections below, the role of leadership in managing and coordinating PTSD programs and services in and between the service branches is discussed, followed by the types and numbers of direct care providers and purchased care providers and their qualifications and training. The importance of understanding military culture and other factors that may affect a service member’s engagement in and response to PTSD treatment is then considered. The section ends with a synopsis of caring for mental health care providers in DoD.
Responsibilities for prevention of and treatment for PTSD are shared by military and civilian leaders at many levels in the DoD hierarchy (see Figure 3-1). The top levels of leadership in DoD and its service branches establish priorities and strategies for PTSD recognition and treatment, and they shape the cultures within which PTSD care is delivered. The responsibilities begin at the highest organizational levels (joint chiefs, under secretary of defense for personnel and readiness, assistant secretary of defense for health affairs) and are transmitted via chains of authority through the
military surgeons general, the medical officer of the Marine Corps, and commanders of medical regions and military treatment facilities (MTFs), to the leaders and administrators of clinics and treatment programs of all types.
In the last decade, DoD has greatly expanded its mental health services, including those targeting PTSD, but this expansion presents military leaders with many challenges. These include an infusion of new mental health staff on installations, many of whom are civilian contractors or temporary employees who may be unfamiliar with PTSD or military culture; embedding of mental health care providers in line-unit organizational structures; frequent turnovers in leadership at all levels because of deployments and attrition; increased use of TRICARE purchased-care providers to treat active-duty service members; lack of standards for specialized PTSD programs; and the growth of military and civilian programs that address PTSD.
Because many DoD installations, National Guard members, and reservists are in rural areas, DoD leaders face difficulties in maintaining an adequate number of trained clinicians in the MTFs and in surrounding communities to meet the mental health needs of these populations. Military installations in rural and geographically less desirable areas can be chronically understaffed. To recruit qualified providers, DoD leaders must be able to offer compensation and incentives to compete with other potential employers in desirable areas and to encourage providers to move to and remain in less desirable ones.
MTFs are commanded by senior medical leaders who answer to their service branches’ surgeons general, whereas prevention and resilience programs for the same military population are managed through an entirely separate chain of command. Other mental health resources may be under the installation command. Most PTSD programs were developed at local levels and operate under the authority of local commanders. Such fragmentation and stovepiping of components of PTSD-related care hampers communication, coordination, and efforts to address population needs. No central point of contact in DoD appears to be cognizant of all efforts to prevent, screen for, or treat PTSD in the military, let alone have sufficient knowledge, responsibility, and authority to ensure the quality and consistency of efforts to manage PTSD in all service branches or at the national level, including resilience and stress prevention programs.
The success of senior leadership of PTSD programs depends heavily on the knowledge, skills, and attitudes of more junior leaders in the military organizations in which they operate. The response of unit leaders, from junior noncommissioned officers to commanding officers, can have a substantial effect on whether service members who have PTSD are properly evaluated, offered treatment, or allowed to comply with treatment. For example, pressures to complete operational or training missions may conflict
with a service member’s need to have time off from his or her duties to complete the prescribed PTSD treatments. Even if a unit commander encourages compliance with the treatment protocols for subordinates’ PTSD, small-unit leaders may not believe that PTSD is a bona fide medical problem and may view a service member’s report of PTSD symptoms as a problem of character or motivation.
Such negative perceptions of mental health by service members and their leaders continue to be a major obstacle to the effective management of PTSD in DoD. The 2011 Army mental health advisory team (MHAT)in-theater survey of deployed soldiers showed that of those who screened positively for a mental health problem, 46% thought their leaders would view them differently if they sought care, 34% thought their unit leaders would blame the service member for the problem, and 14% of soldiers and 10% of marines reported that their leaders discouraged the use of mental health services (MHAT-7, 2011). The military recognizes the critical role of junior leaders in the propagation of stigma, and each service branch has enacted education programs for noncommissioned officers to reduce stigma. For example, the Marine Corps Combat and Operational Stress Control and Operational Stress Control and Readiness (OSCAR) programs provide education on stress reactions to leaders at all levels to reduce barriers to PTSD care. On site visits, some service members stated that their commanders were supportive of their seeking care for their PTSD, but others acknowledged that though there had been improvements in commanders’ attitudes toward PTSD, many commanders were not sympathetic to the issue.
Mental Health Care Providers
Direct Care Providers
DoD health facilities are staffed by nearly 146,400 personnel—about 60,400 civilians and 86,000 uniformed providers, including about 31,800 officers (TRICARE Management Activity, 2013). A variety of uniformed and civilian mental health care providers deliver inpatient and outpatient PTSD care in the military health system (MHS). Some providers in specialized PTSD programs and services are also trained in complementary and alternative treatments, such as biofeedback, meditation, and acupuncture. Service members who have PTSD and family members may also receive counseling at family support and counseling centers and the chaplain service that are not part of the medical system.
In 2007, the DoD Task Force on Mental Health examined mental health care resources and concluded that DoD funding and personnel were both insufficient (DoD Task Force on Mental Health, 2007). In response, DoD developed a population-based model, the Psychological Health Risk-
Adjusted Model for Staffing (PHRAMS), to estimate mental health staffing needs in both the MHS and the TRICARE purchased-care network (Harris and Marr, 2011). Although the model has not been validated, it has been used by the Army, Navy, and Air Force to estimate their mental health staffing needs (GAO, 2010; U.S. Air Force, 2012; U.S. Army, 2012). PHRAMS takes into account demographic and deployment risk factors to forecast mental health staffing needs throughout the MHS (DoD et al., 2013), and users can modify it to apportion direct versus purchased care, adjust productivity metrics, account for underuse, and alter the distribution of projected service members in different risk groups (IOM, 2013). The Institute of Medicine (IOM) report Substance Use Disorders in the U.S. Armed Forces found PHRAMS to be a useful tool for assessing mental health staffing needs in DoD (IOM, 2012).
In theater, only uniformed providers offer mental health services. In the early years of the conflicts in Afghanistan and Iraq, the Air Force provided the majority of the deployed mental health care providers, but by 2013 the Army provided 84% of them, the Navy 10%, and the Air Force 7% (U.S. Army, 2013). The MHATs, which conduct periodic assessments of mental health issues in theater found that the overall ratio of mental health care providers to service members among all service branches in theater has increased from 1:1,756 in 2005 to 1:567 in 2013 (MHAT-7, 2011; MHAT-9, 2013). The increase in staff was, in part, to accommodate the surge in U.S. forces in Afghanistan. The 2013 MHAT-9 report recommended that a staffing ratio of one mental health care provider for 700–800 soldiers (the Army model) is appropriate, but different services may need different staffing ratios depending on their mental health care delivery models (MHAT-9, 2013). The report acknowledged that the larger issue is to find the best way to use the mental health personnel so that service members know who they are and how to contact them if care is needed.
Mental health staff in DoD increased from about 4,000 in 2007 to almost 6,500 in 2010 (Dinneen, 2011), and the number has continued to increase. As of June 2012, the Army had 5,438 mental health care providers (psychologists, psychiatrists, social workers, mental health nurses and nurse practitioners, technicians, counselors, and other licensed mental health providers), including those who serve primarily in wellness or prevention roles; 1,594 of the providers were in mental health clinics. There were twice as many civilian as uniformed direct care providers (3,308 vs 1,713) (U.S. Army, 2012). The Air Force reported having 855 mental health care providers (psychologists, psychiatrists, social workers, and others) in May 2012—including uniformed, civilian, and contract personnel—assigned to 75 Air Force bases (numbers were not broken out by type of provider) (U.S. Air Force, 2012). The Navy, which also provides the vast majority of mental health services for the Marine Corps, in November 2013 had
1,524 military and civilian mental health care providers (psychologists, psychiatrists, social workers, mental health nurses and nurse practitioners, technicians, counselors, and other licensed mental health providers). The Marine Corps is also served by 60 marine mental health care providers and 22 OSCAR providers (U.S. Navy, 2013).
During site visits to multiple military installations, mental health care providers reported an ever-increasing demand for PTSD services, which often resulted in an inability to schedule patients for evidence-based treatment according to protocols. As a consequence, more active-duty service members are being referred to the TRICARE network of purchased care providers.
Purchased Care and Contract Providers
There are about 478,000 purchased care providers in the TRICARE network, of whom 62,000 are mental health care providers—psychiatrists, clinical psychologists, certified psychiatric nurse specialists, clinical social workers, certified marriage and family therapists, pastoral counselors, and mental health counselors (IOM, 2010; TRICARE Management Activity, 2013). TRICARE Management Authority (as of October 2013, incorporated into the newly established Defense Health Agency) was originally designed as a way to treat DoD retirees and dependents who could not be seen at MTFs because of lack of provider availability. In recent years, however, TRICARE has expanded to include purchased care for active-duty service members in areas where installations do not have the capacity or expertise to deliver appropriate and timely care.
During site visits, DoD providers reported that referral of active-duty service members to purchased care providers was rare before Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), but this practice is now common as a result of direct care staffing shortages. It was unclear how decisions were made about whether a service member would be treated on the installation or referred to purchased care. Purchased care referrals are also used when there is a need for specialized programs that are not available on the installation, such as dual-diagnosis programs for PTSD and substance abuse. The referral process appeared to be ad hoc, informal, and nonspecific, that is, installation providers cannot recommend a specific purchased care provider who might meet a service member’s needs best. Although purchased care providers must meet state licensing and other certification requirements to treat TRICARE beneficiaries (Humana Military, 2013), the quality of PTSD care given by these providers, including the use of evidence-based approaches, is largely unknown and unmonitored by installation mental health leaders or TRICARE management.
DoD offers two contracted programs—Military OneSource and Military and Family Life Counselors (MFLCs)—that offer counseling for adjustment problems to service members and their families. The programs provide confidential support services and referrals but are not supposed to provide clinical PTSD care. Military OneSource staff are available 24 hours per day, 7 days per week, and offer supportive, nonmedical counseling via telephone, in person, or online to active-duty, National Guard, and reserve service members and their families (Military OneSource, 2013). MFLCs are credentialed civilians who work close to units (often brigades) and offer short-term counseling on military life issues, such as coping with deployment and reintegration stress, and referrals as necessary.
Provider Training and Qualifications
The IOM report Provision of Mental Health Counseling Services Under TRICARE (2010) concluded that a comprehensive quality management system was needed in DoD because of “widespread deficiencies in the training of providers and in the infrastructure that supports their practice.” Such a quality management system would include focused training in mental and related medical conditions, competency in military culture, and a systematic process for continued education and training on changes in evidence-based practices. To address these training needs, DoD provides a variety of workshops on prolonged exposure (PE) therapy, cognitive processing therapy (CPT), and eye movement desensitization and reprocessing (EMDR) therapy for PTSD, but it does not require that trainees participate in subsequent consultation (supervision or mentoring) to ensure that they use the therapies effectively or with fidelity. The gold standard of training typically involves 2- to 3-day experientially based workshops followed by weekly consultation sessions with a mentor, but this expensive training approach restricts the number of participants.
TRICARE providers are not required to be trained in evidence-based practices, nor is there any systematic method to ascertain a provider’s training before military patients may be referred to them. The 2007 DoD Task Force on Mental Health recommended that DoD require that TRICARE contractors have training that is equivalent to that of its direct care providers (DoD Task Force on Mental Health, 2007). Some purchased care providers are trained in at least one evidence-based psychotherapy and report that they use it with their military patients. Although DoD pays for direct care staff to be trained in evidence-based therapies, it will not pay for purchased care providers to receive similar training.
The DoD Center for Deployment Psychology (CDP) is a primary training resource, offering in-person and Web-based training on PTSD for military and civilian mental health professionals in “high-quality, cultur-
ally-sensitive, evidence-based behavioral health services.” The online PE and CPT courses are 75-minute introductory sessions that comprise primarily text-based content (http://www.deploymentpsych.org/training). As of 2013, more than 8,000 providers had taken either the CPT or PE online course. These courses cannot be considered a substitute for the multiday experiential trainings.
The Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) also offers educational resources on evidence-based treatments via annual conferences and publicly accessible monthly webinars on specific mental health topics; providers may obtain continuing education credits for both the conferences and the webinars. DCoE has developed toolkits to promote the use of VA/DoD clinical practice guidelines and to enhance training (DCoE, 2013). None of these training approaches has been subject to rigorous evaluations or assessments of their participation rates or impact.
DoD is supporting projects to develop computer-based virtual-patient simulation training (see Chapter 9 and Appendix E) (Talbot et al., 2012). Such approaches include static-image supported and text- or menu-interactive case presentations, low-fidelity interactive patient scenarios, high-fidelity software simulations, virtual-human conversational agents, and live-human standardized patients. The effectiveness of these new approaches is still being studied, but should they prove useful, virtual-patient technology could help supplement current in-person training.
The Army Medical Department Center and School trains its mental health care providers in PTSD treatments. During 2008–2011, the Office of the Surgeon General of the Army reported that more than 2,800 mental health care providers had been trained in evidence-based psychotherapies. Table 6-1 shows the annual number of Army providers trained in psychotherapy for PTSD.
The Office of the Surgeon General of the Air Force reported that as of May 2012, all Air Force MTFs had mental health care providers who had been trained in evidence-based treatments for PTSD. Providers, including all psychology and social-work residents, are sent to master clinician development courses for PE and CPT. A mobile training team also travels to Air Force bases around the world to train providers on these psychotherapies. Between 2007 and 2011, the CDP trained 706 Air Force providers, and between 2008 and 2010, an additional 704 received training in PE from the University of Texas Health Science Center. The Air Force intends to continue to provide CPT and PE training to all of its clinicians (U.S. Air Force, 2012).
TABLE 6-1 Number of Army Mental Health Care Providers Trained in Evidence-Based Treatments for PTSD
|Eye movement desensitization and reprocessing||68||313||267||273|
|Cognitive processing therapy||30||282||388||228|
|Prolonged exposure therapy||129||220||194||233|
|Cognitive behavioral conjoint therapy||30||30||132||42|
SOURCE: U.S. Army, 2012.
The Navy reported that all of its direct care providers (military and civilian), including its psychiatry and psychology residents and interns, have been trained in cognitive-based treatments, exposure-based treatments, or both, and it trains about 30–40 providers a year in them. However, it does not keep statistics on the number of contract providers trained in evidence-based psychotherapies for PTSD, specifically. The Navy Bureau of Medicine and Surgery supports providers in their continuing education by funding online cognitive behavioral therapy and CPT training (U.S. Navy, 2013).
Each service branch trains most of its prescribers (psychiatrists, nurse practitioners, and physicians’ assistants) in pharmacotherapies for PTSD through military psychiatry and psychology training programs. All military psychiatry residency training programs have additional training in treating PTSD in military contexts, but there is no specific certification for prescribing PTSD medications.
Training staff in evidence-based psychotherapies is a necessary but not sufficient condition for ensuring that evidence-based treatments are delivered to patients. DoD does not document trainee mentoring or whether those trained in evidence-based care use it in clinical practice. Therefore, it is not clear that their level of training is sufficient to provide evidence-based treatments effectively or with fidelity.
All DoD direct care and purchased care mental health providers need to be knowledgeable about military culture and the particular contextual issues, such as era of service, that may influence a service member’s response to stress or treatment. The assistant secretary of defense for health affairs issued guidance that specifies that within the first year of hire, all direct care civilian and new military providers “have sufficient training or experience
in military culture and terminology to deliver context-sensitive care for the treatment of psychological conditions related to war trauma” (Office of the Assistant Secretary of Defense, 2010). Although the guidance may ensure that direct care providers are knowledgeable about military culture, it does not address the need for such training for purchased care providers.
Providers who are on active duty, are veterans themselves, or have family members who are service members will have an appreciation of military culture and may be comfortable treating active-duty and retired service members, but nonveteran civilian providers may lack that understanding and could benefit from education about military culture. Service members reported frustration and lack of trust with providers who did not have an understanding of their military experiences.
DoD and VA are collaborating with CDP to develop educational modules and a website about military culture. The first module, Military Culture Core Competencies for Healthcare Professionals: Self-Awareness and Introduction to Military Ethos, is available online from the center (CDP, 2014). The website offers educational supplements, references from the modules, and additional professional tools, such as videos (CDP, 2013a). CDP has partnered with such organizations as the Indiana National Guard, the National Guard Psychological Health Program, and the Military Family Research Institute to develop and conduct provider training specific to the needs of military members and their families. More than 200 mental health clinicians have completed the training program and are listed in the Star Behavioral Health Providers registry, which service members can search to locate those clinicians in four states: California, Georgia, Indiana, and Michigan (CDP, 2013b). However, the impact of the registry on changing provider methods and improving quality of care is unknown.
Care of Providers
Military mental health care providers are considered to be higher risk for secondary trauma or stress reactions than are civilian mental health professionals because of their exposure to a highly stressed patient population and military operational stressors, such as multiple deployments, ethical dilemmas, and inadequate reprieve time (Ballenger-Browning et al., 2011; Pechacek et al., 2011; Rubin and Weiss, 2012). Cieslak and colleagues (2013) found that about 20% of mental health care providers who treat military patients have secondary traumatic stress. A higher frequency of secondary traumatic stress was seen in providers who had a personal history of trauma, reported having too many patients, and had more negative appraisals of the impact of indirect exposure to trauma. One approach to dealing with secondary trauma is the Overcoming Adversity and Stress Injury Support (OASIS) peer support program for both civilian and uniformed mental
health care providers, which is led by an external counselor. OASIS leaders noted that time for peer support is not built into the providers’ work environment, but it is necessary for keeping the workforce healthy and able to focus on patients (Naval Medical Center San Diego, 2013).
DEPARTMENT OF VETERANS AFFAIRS
As with DoD, VA has a large and diverse workforce of mental health care providers and support staff. Although the majority of mental health care in VA is delivered by employees, the VA also uses purchased care providers to supplement direct care in underserved areas, and to provide specialty care. Managing this workforce requires VA leaders at all management levels to foster the use of best practices, maintain a competent workforce, and encourage innovation. In the sections below, the role of VA leaders is discussed. The remaining sections describe the VA workforce, including direct care providers, purchased care providers, and training efforts in VA (particularly for evidence-based treatments).
The organizational structure of VA encourages accountability at all levels of management. Accountable leadership extends through all levels, from PTSD program managers, to directors of mental health departments, and to facility, VISN, and central office leadership. VA leaders are responsible for all potential veterans who could use VA health services, not only those who are currently using services. VA leaders need to plan for managing veterans who have PTSD and respond to acute treatment, but they also need to plan for those who have chronic PTSD and comorbidities and will require mental health and other services into the future.
The VA Office of Mental Health Operations (OMHO) and the Office of Mental Health Services are the lead offices for developing and implementing strategies for addressing current and future PTSD management demands. OMHO is collaborating with other VA program offices, including offices for primary care, patient-aligned care teams, and rehabilitation and poly-trauma services. In response to a query about the mechanisms that are used to ensure that local mental health leaders are able to plan, implement, and evaluate PTSD programming, OMHO replied that “performance review is the major mechanism for incentivizing leadership at all levels to implement clinical policy” (OMHO, 2013b). OMHO reviews PTSD care via site visits and provides feedback on good practices and needs for improvement to VISN and facility mental health leadership both directly and through a SharePoint site. VA’s Northeast Program Evaluation Center provides data on specialized PTSD programs in its annual report The Long Journey Home
and works with PTSD mentors in each veteran integrated service network (VISN) to assist in coordinating PTSD services and implementing strong clinical practices. Other VA offices such as the National Center for Analysis and Statistics and the Veterans Benefits Administration collect and analyze extensive amounts of data that can potentially be useful to managers in strategic planning and program implementation.
Executive Order 13625 (August 31, 2012) called for enhanced partnerships between VA and community providers, and increased VA mental health staffing. It also calls for VA and the Department of Health and Human Services to develop a plan for a rural mental health recruitment initiative. VA leaders face many of the same challenges in recruiting and retaining mental health professionals in a highly competitive environment as does DoD. The OMHO site visit report indicated that 60% of VA medical centers had problems with recruitment or retention of qualified staff, particularly psychiatrists, but also clerical and administrative staff who handle patient scheduling and staff for primary care–mental health integration programs (OMHO, 2013a). National vacancy rates were greatest in psychiatry (14.2%), followed by psychology (13.2%), social work (9.9%), and nursing (9.1%). In 2009, annual turnover of VA mental health staff was 26% (Watkins et al., 2011).
Some medical center leaders are aware of and concerned about the growing numbers of veterans of current and previous conflicts that need PTSD services and are strategizing about resource allocation to meet this growing need. However, other local medical center and mental health service leaders have not actively embraced a population-based approach to PTSD care for all the veterans who were living in their catchment areas, and they appeared naive with respect to the possibility of a large influx of veterans who need treatment for PTSD and other mental health services as the current conflict in Afghanistan comes to a close. That range of response by medical center leaders to PTSD demand and consequent treatment availability and adequacy underscores the need for more consistent strategic planning and implementation for PTSD management among and within VA administrative levels.
A National Academy of Public Administration report on the VA purchased care program recommended that senior VA management “provide clear policy direction about performance goals and expectations for VA purchased care, including the allocation of resources between VA-provided and purchased care to best meet strategic goals” (Pane et al., 2011). To accomplish that, the VA Chief Business Office should establish a more effective performance management system—including a portfolio of performance metrics to assess productivity, accuracy, timeliness, and customer satisfaction—and improved accountability for data accuracy and management. Furthermore, the report emphasized that accountability and respon-
sibility for purchased care management and outcomes need to be better defined, communicated, understood, and executed by all involved in the program. The need for accountability and responsibility extends to enacting and enforcing staffing standards, business rules, and standard operating procedures. Clear lines of authority should span the office of the deputy under secretary for health for operations and management, the Chief Business Office, the VISNs, and the consolidated claims-processing sites (Pane et al., 2011).
Communication issues can arise with regard to care for veterans who have PTSD. Veterans generally have some choice of where to access PTSD care in VA, whether through a medical center, a community-based outpatient clinic (CBOC), or a Vet Center. Vet Center staff do not report to medical center directors (they report up a different line directly to the under secretary for health). Because of that organizational structure, it may be difficult to coordinate treatment for patients seen in Vet Centers if they receive other care at the medical center. There appears to be considerable variation in coordination and communication between Vet Centers and local VA medical facilities, ranging from a close working relationship to virtually no interaction between the two. Vet Center representatives at a few sites noted that access to the veterans’ electronic health records in VA was “spotty” but that when they were able to access patient information, it was helpful; VA providers in CBOCs or medical centers cannot access Vet Center data systems.
In an effort to promote community collaboration, each VA medical center hosts a mental health summit to promote awareness and use of VA mental health resources and to help veterans to gain access to community services (VA, 2013b). These summits began in 2013.
Mental Health Care Providers
Direct Care Providers
Most health care for veterans is provided by VA employees. VA employs 3,088 psychiatrists, 3,675 psychologists, 3,966 psychiatric nurses, 5,278 social workers, and 3,142 other mental health care providers (such as licensed marriage and family therapists and licensed professional counselors) (OMHO, 2013b). VA increased its outpatient mental health staffing from about 6,500 full-time equivalents in 2005 to more than 11,500 in 2012, including an influx of 1,600 mental health care providers and 300 support staff in 2012–2013. Increases in staffing in general mental health programs and specialized outpatient PTSD programs (SOPPs) have not kept pace with the substantial increase in numbers of veterans who have a diagnosis of PTSD and are seeking care in VA facilities. In 2012, clinicians
in the SOPPs were seeing an average of 136 patients in a year, 24% of them new patients (VA, 2012a).
VA does not have an explicit staffing model for mental health (Schohn, 2013), but in 2011, it began piloting guidance on general outpatient staffing levels. OMHO expects to retain specialized PTSD clinical programs in all VA medical centers and clinics while adapting to the new guidance (OMHO, 2013b). The guidance recommended a ratio of 6.6–7.5 clinical and clerical full-time equivalent staff for every 1,000 veterans who use mental health services (not PTSD specific). Facilities have flexibility to establish their own staffing programs but are instructed to use interdisciplinary teams to provide comprehensive general outpatient mental health care. VA is expanding the guidance to address staffing for specialty mental health services and is piloting this guidance in four VISNs (OMHO, 2013b).
In 2012, the OMHO visited all 140 VA health care systems (medical centers and some of their large CBOCs) to evaluate the implementation of the VHA handbook Uniform Mental Health Services in VA Medical Centers and Clinics (see Chapter 3 for a description of the survey process). In the site visit report, the need for PTSD care providers was noted by 31% of all sites and 34% of CBOCs. Some CBOCs also reported problems in obtaining adequate telehealth services for mental health (30%) and difficulties in providing evidence-based psychotherapy (36%). These numbers do not mean that the remaining sites do not have staffing issues, merely that staffing was not specifically mentioned at the sites as a strength or weakness. CBOC clinical staff reported that they often performed multiple roles with little backup support. Staffing shortages also result in less than optimal fidelity in the delivery of evidence-based treatments (OMHO, 2013a).
In addition to licensed and trained direct care providers, VA uses other types of providers to augment its clinicians. In November 2013, VA announced that it had hired 815 peer specialists and peer apprentices. The newly hired employees are veterans who have successfully dealt with their own mental health recovery for at least a year and now are helping to guide fellow veterans through their difficult issues. Peer specialists are trained and certified (VA, 2013d).
In response to the DoD/VA Integrated Mental Health Strategy, VA has begun incorporating chaplains into mental health care as part of a collaborative model. Nieuwsma et al. (2013) found that both DoD and VA chaplains care for people with mental health problems, although DoD chaplains tended to see people with less severe life stressors and mental health issues, whereas VA chaplains were seeing people with more psychiatric issues. Some VA and DoD facilities reported that chaplain services were well integrated into mental health services and that personal relationships facilitated referrals to each service, but at other facilities, barriers to integration
included a lack of trust, chaplains feeling that mental health professionals did not understand or value their work, and chaplain staffing shortages.
Some veterans choose to receive PTSD management services at Vet Centers. In 47 of the 300 Vet Centers, VA medical staff provide regularly scheduled services, and 69 provide readjustment services at their supporting medical centers or CBOCs (Fisher, 2014). Vet Centers employ over 1,900 people, about 72% of whom are veterans, and most of the veterans are combat veterans. About one-third of all Vet Center staff served in OEF, OIF, or both. Furthermore, about 60% of direct counseling staff in Vet Centers are licensed and qualified mental health professionals, such as psychologists and social workers (Fisher, 2014). The Readjustment Counseling Service reported that not all of its providers are trained in PE or CPT, but it continues to offer training and supervision for providers working toward certification in these treatments. The Readjustment Counseling Service is in the process of hiring a qualified and licensed clinician to provide family counseling in every Vet Center (Fisher, 2014).
Purchased Care Providers
Like DoD, VA contracts with purchased care providers, primarily to serve veterans who live long distances from VA facilities or for highly specialized services not available in a local or preferred VA medical center. Use of those providers has expanded recently to compensate for VA staffing shortages that have led to long waits for appointments. A 2013 Government Accountability Office (GAO) report found that the number of veterans receiving purchased services increased from 821,000 in 2008 to 976,000 in 2012, a 19% increase (GAO, 2013). Although the VA was asked to provide specific data on the use of purchased care for PTSD for this report, it did not do so.
An evaluation of the purchased care program by the National Academy of Public Administration (Pane et al., 2011) found that VA used an antiquated administrative system, was not well managed at any level, and was highly decentralized and prone to substantial errors in payments. The academy stated that “high level VA management should provide clear policy direction about performance goals and expectations for VA purchased care, including the allocation of resources between VA-provided and purchased care to best meet strategic goals” and that VA “should build greater program management competence and capacity for overseeing the Fee Care Program and supporting the consolidated claims processing sites” (Pane et al., 2011). GAO (2013) has also criticized VA for lack of oversight of its purchased care program.
Local VA medical center leaders are responsible for developing and managing networks of purchased care providers. As is the case with
TRICARE providers, the quality of PTSD treatment delivered by purchased care providers for veterans is largely unknown because no standards or performance measures are in place for them (see Chapter 4). Although purchased care providers must be licensed, VA, like DoD, does not screen or assess the providers to ensure that they are trained in or offer evidence-based treatments for PTSD, that they are familiar with or adhere to the VA/DoD clinical practice guideline for PTSD, or that they are familiar with military culture. Although directors of mental health departments in some facilities acknowledged that the lack of standards for purchased care is an issue, facility leaders did not, in general, find this to be a major responsibility for them or have a strategy for increasing the accountability of their purchased care providers.
VA medical facilities do not appear to have formal referral processes to ensure that veterans receive care from purchased care providers who have expertise in deployment-related PTSD. The Reaching Rural Veterans Initiative in Pennsylvania found that primary care providers in the purchased care system frequently lacked knowledge and awareness of PTSD and were unaware of treatment resources available at VA that might help their veteran patients who had PTSD. Those gaps are important because 23% of the primary care providers reported that over one-third of their veteran patients had mental health problems, but only 8% of the providers felt that they had adequate knowledge of current mental health treatments for these problems (Boscarino et al., 2010).
To address issues of quality of care offered by purchased care providers, VA recently contracted with two health management companies as part of its Patient-Centered Community Care initiative. The contractors will provide inpatient and outpatient specialty care and mental health care services when local VA medical centers have long wait times to see specialists or when veterans live far from the nearest VA facilities. They will be responsible for consolidating and standardizing the quality of purchased care providers, and for screening them to ensure that they meet or exceed VA standards for credentialing, licensing, and specialty-care requirements. Providers must see patients within a specified period and be geographically convenient, and medical files generated by purchased care specialists must be shared with VA promptly to ensure that all care is closely monitored and coordinated by VA (VA, 2013c).
Provider Training and Qualifications
VA has implemented a national program to train its therapists in evidence-based psychotherapies for PTSD and has established formal criteria for credentialing them in PE and CPT. The criteria include participation in structured workshops and consultations (supervision) designed
by the developers of the treatment programs. VA has trained more than 6,600 VA and DoD mental health care providers in evidence-based treatments (Schohn, 2013). As of October 2013, 4,890 VA mental health care providers had received training in CPT, 1,864 in PE, and 1,204 in both (OMHO, 2013b). One survey found that more than 90% of VA providers who completed CPT or PE training were delivering these therapies more than 6 months later (Schohn, 2012). However, in a survey of 2,184 clinical staff in VA specialized PTSD programs (outpatient and inpatient), only 955 (44%) of the providers reported using PE or CPT (VA, 2012a). The OMHO survey of 140 VA medical facilities found that in 48% of the facilities, staff reported trouble in getting training in evidence-based psychotherapies or access to post-training consultations (OMHO, 2013a). VA lacks a mechanism to verify the extent to which trained staff are delivering CPT or PE, although it is attempting to improve the electronic health record to track the use of these therapies (see Chapter 4).
The VA does not track the number of VA mental health care providers who had received training in EMDR because there is no formal competence-based training program for it (OMHO, 2013b); however, in 2012, 340 providers in VA specialized PTSD programs (both outpatient and inpatient) indicated they had been trained in an evidence-based psychotherapy other than PE or CPT (VA, 2012a). VA does not have formal training for EMDR, stress inoculation training, or prescribing selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors, all rated as first-line treatments in the VA/DoD clinical practice guideline for PTSD. No national prescriber training for the medications is offered by VA.
The National Center for PTSD offers a number of training opportunities. It has sponsored monthly telephone and online lecture series on implementation of the VA/DoD Clinical Practice Guideline for Management of Post-Traumatic Stress and several lecture series on pharmacologic treatment for PTSD (including coordinating psychotherapy and medications), which were accessed by more than 15,000 contacts (OMHO, 2013b). The effectiveness of these training efforts is not known. The center is also piloting online training for evidence-based psychotherapies; however, this training program lacks the recommended consultation component. Nevertheless, more than 200 VA providers and 200 community providers have been trained by using these online programs (Kuhn and Ruzek, 2013). It also offers an online course “Understanding Military Culture When Treating PTSD” (OMHO, 2013b). Several VA providers reported that in addition to clinical staff, administrative staff who process veterans for intake would benefit from military culture training.
Eligibility requirements for VA training programs in PE and CPT necessitate that clinicians be permanent, licensed mental health staff (that is, psychiatrist, psychologist, social worker, advanced practice mental health
nurse, licensed professional mental health counselor, or marriage and family therapist) and that they spend at least 50% of their time treating patients with PTSD (OMHO, 2013b). Such stringent training prerequisites may create a barrier to the wider dissemination of those psychotherapies. To address the barrier, VA is developing a decentralized PE and CPT training and consultation capacity to reach providers who may spend less than 50% of their time in treating patients who have PTSD. The new training program will be phased in in 2014 (OMHO, 2013b).
To address recruiting and training needs VA has collaborated effectively with several colleges and universities to recruit master’s-level and PhD-level social work students to work in its mental health clinics. The VA health care system is affiliated with about 110 medical schools and more than 1,200 other schools throughout the United States (VA, 2012b). The VA Office of Academic Affairs funds thousands of mental health and medical education training programs and fellowships. In 2011, nearly 117,000 mental health care providers received some of or all their clinical training in VA, and an estimated 50% of U.S. psychologists and 70% of VA psychologists received VA training before employment (VA, 2013a). Several master’s-level programs in social work have established paid clinical field internships in VA mental health clinics and Vet Centers and, to a smaller extent, in DoD medical facilities. For example, the Smith College School for Social Work maintains a network of paid and unpaid master’s in social work and PhD clinical internships at 16 DoD and VA sites. Before completing their degrees, students are immersed in educational programs that include structured training and regular supervision in cognitive behavioral therapy, PE, and CPT for PTSD.
Care of Providers
As in DoD, VA administrators and clinicians have recognized the psychological toll experienced by mental health and ancillary providers who work regularly with veterans who have trauma-related conditions and serious mental health concerns. VA leaders have recognized that staff need to maintain their own health and well-being in their work settings and avoid the potentially adverse effects of secondary trauma. A recent survey that assessed burnout among 138 mental health providers in VA PTSD clinical teams found 12% of the sample reported low professional efficacy, 50% reported high levels of exhaustion, and 47% reported high levels of cynicism (Garcia et al., 2014). Mental health providers who treat for PTSD may benefit from programs or supports aimed at preventing and addressing burnout.
Over the last decade, DoD and VA have expanded their workforces of both direct care and purchased care providers for service members and veterans who have PTSD. In the DoD, there is no central leader who has sufficient responsibility and authority to ensure the quality and consistency of efforts to manage PTSD in all service branches or at the national level; different PTSD services and programs are the responsibility of different commands and service branches. VA leaders have more authority and processes to implement organizational changes to improve PTSD services at the VISN and local medical facility levels.
DoD health facilities are staffed by nearly 146,400 personnel—about 60,400 civilians and 86,000 uniformed providers, who provide mental health care in a variety of military settings, from in theater, to embedded mental health clinics and primary care clinics, to MTFs. DoD has also expanded its use of purchased care providers, particularly for service members in underserved areas. The approximately 62,000 TRICARE mental health care providers deliver acute, outpatient, and inpatient PTSD care.
VA has many of the same workforce issues as DoD. As of 2013, it employed more than 19,000 mental health care providers, most of them in outpatient care, but this workforce has proven to be inadequate to provide the increasing number of veterans who have PTSD with adequate evidence-based treatments. In 2012, about one-third of VA medical centers and CBOCs reported inadequate staff, and 60% of VA medical centers had problems with recruitment or retention of qualified staff, including clerical and administrative staff. To supplement its clinicians, VA uses peer counselors to provide non-clinical support services. Many veterans also receive mental health services in Vet Centers, about 60% of which have licensed and qualified mental health care staff. In spite of increased numbers of direct care providers, the number of veterans receiving purchased care services increased 19% from 2008 to 2012.
In both DoD and VA, referral to purchased care providers appears to be ad hoc and not a thoughtful clinical process. The use of purchased care providers is also problematic because neither DoD or VA assesses purchased care providers to ensure that the providers are trained in or offer evidence-based treatments for PTSD, that they are familiar with or adhere to the VA/DoD clinical practice guideline for PTSD, that they are familiar with military culture, or that they assess patient outcomes and report them to the referring clinician. The VA Patient-Centered Community Care initiative may help to ensure that its purchased care providers meet the same credentialing and reporting requirements as VA direct care providers.
Each service branch provides training in evidence-based treatments for PTSD for all its direct care mental health clinicians, although the extent of
that training, particularly the use of supervised consultations for PE and CPT, is often not clear. CDP offers training, both in person and online, to DoD providers in evidence-based treatments, but the effectiveness of this training has not been evaluated. VA has implemented a national program to train its therapists in evidence-based psychotherapies, particularly PE and CPT, including participation in structured workshops and ongoing supervision. VA has trained more than 6,600 VA and DoD mental health care providers in those therapies. Working with academic institutions to provide hands-on training for their students is one mechanism that may expand the pool of potential, trained employees in both departments.
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