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Evaluation of the Department of Veterans Affairs Mental Health Services (2018)

Chapter: 10 Patient-Centered Care and the Veteran Experience

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Suggested Citation:"10 Patient-Centered Care and the Veteran Experience." National Academies of Sciences, Engineering, and Medicine. 2018. Evaluation of the Department of Veterans Affairs Mental Health Services. Washington, DC: The National Academies Press. doi: 10.17226/24915.
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10

Patient-Centered Care and the Veteran Experience

Providing care centered on the needs and expectations of patients is a key attribute of quality health care (IOM, 2001). The patient-centered care model is a shift away from a “disease-based” approach to health care, instead targeting multiple determinants of health, including physical, emotional, mental, social, spiritual, and environmental influences. Important features of patient-centered care include increasing the engagement of patients in care and shared decision making between patients and clinicians. Research shows that patient-centered care approaches to health care delivery improve health outcomes, increase patient satisfaction, and enhance health care–seeking behavior and self-management (Rathert et al., 2013). Various initiatives in the private sector and under the Patient Protection and Affordable Care Act have driven efforts to promote a patient-centered health care system in the United States (Millenson and Macri, 2012). This chapter describes key patient-centered care initiatives at the Department of Veterans Affairs (VA).

In addition, this chapter includes findings from the committee’s survey and site visit research about veterans’ and clinicians’ perceptions of and experiences with patient-centered care within VA mental health services. Understanding the patient experience is an important step in moving toward patient-centered care (AHRQ, 2017). The patient experience includes several aspects of health care delivery that patients value highly when they seek and receive care, such as getting timely appointments, having easy access to information, and having good communication with health care providers. By looking at the interactions that patients have with the health care system as a whole and with doctors, nurses, and staff, it is possible to assess the extent to which patients are receiving care that is respectful of and responsive to individual patient’s preferences, needs, and values (AHRQ, 2017).

Suggested Citation:"10 Patient-Centered Care and the Veteran Experience." National Academies of Sciences, Engineering, and Medicine. 2018. Evaluation of the Department of Veterans Affairs Mental Health Services. Washington, DC: The National Academies Press. doi: 10.17226/24915.
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PATIENT-CENTERED CARE AT THE VETERANS HEALTH ADMINISTRATION

Whole Health Initiative

The number one strategic goal of the VA for fiscal years 2013–2018 is to provide veterans personalized, proactive, and patient-driven health care (VA, 2013). The VA has organizational structures and initiatives dedicated to delivering care that is driven by the individual needs of the veteran. The lead agency in this regard is the Office of Patient Centered Care and Cultural Transformation (OPCC&CT), established in 2011. A major system-wide initiative under way is Whole Health, which is described as placing the veteran at the center of the health care experience and health care practice, with healing environments, healing relationships, and a focus on creating a personalized, proactive, patient-driven experience (Rindfleisch, 2016).

OPCC&CT works with VA leadership and program offices to engage veterans and staff in order to advance the Whole Health approach at all VA facilities. In addition to facilitating collaborative patient-centered care, OPCC&CT provides educational offerings to clinicians and staff (Dobscha et al., 2016). In a VA all-employee survey of 135,000 staff members, over 83 percent said they understand their role in providing personalized, proactive, and patient-driven health care (VA, 2016b).

As discussed in the section on patient experiences below, a significant number of veterans talk about VA care in positive terms. However, continued leadership and innovation are needed to firmly establish a new culture of patient-centered care consistent with the Whole Health approach. Veterans and staff participating in the committee’s survey and site visit research described various system- and facility-level obstacles to patient-centered care at the VA. For example, short staffing, employee turnover, professional burnout, and other workforce issues discussed in Chapter 8 were reported to interfere with the quality of the relationship between the veteran and clinician. More attention to these areas will improve the quality of the care given and the patient’s experience.

Patient-Centered Mental Health Care

Collaborative Care Models

The VA offers veterans primary care and mental health care using a patient-centered model of team-based care. In the U.S. health care system, the patient-centered medical home (PCMH) is a widely accepted model for improving care coordination, quality, access, and cost effectiveness. PCMH implementation places the primary care provider in the key role of managing and coordinating a person’s overall health care (Patient-Centered Primary Care Collaborative, 2015). The integration of mental health care and primary care, or “integrated care,” is a component of the patient-centered medical home model (Gerrity, 2016).

In primary care clinics, the VA implements the medical home model through the Patient Aligned Care Team (PACT) initiative, which was launched nationally in 2010 (Yano et al., 2014). Mental health providers are integral to PACTs, as they support collaborative, primary care–based treatment of mental health conditions. For veterans seen in outpatient mental health clinics, the VA provides integrated care through the Behavioral Health Interdisciplinary Program (BHIP). BHIP teams serve as the clinical home for veterans using outpatient general mental health services, in the same way that PACT serves as the clinical home for patients using primary care services. BHIP teams, which can include psychologists, psychiatrists, psychiatric nurses, social workers, peer support specialists, and administrative staff, hold regular interdisciplinary team meetings to facilitate teamwork and provide the staff with dedicated time to discuss veteran care, establish treatment goals, and review other issues as they arise (Barry et al., 2016).

Suggested Citation:"10 Patient-Centered Care and the Veteran Experience." National Academies of Sciences, Engineering, and Medicine. 2018. Evaluation of the Department of Veterans Affairs Mental Health Services. Washington, DC: The National Academies Press. doi: 10.17226/24915.
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Chapter 12 further discusses care integration at the VA and the evidence supporting patient-centered, collaborative care models.

In other examples of patient-oriented care delivery, the VA has replaced its legacy day treatment and day hospital programs with recovery-oriented psychosocial rehabilitation and recovery centers (PRRCs). PRRCs are outpatient treatment programs that serve an important role in the continuum of care from inpatient services to outpatient services. PRRCs deliver group and individual recovery services for veterans with serious mental illnesses and significant functional impairment, with the goal being to help the veteran integrate into his or her community (VA, 2017a). In addition, the VA has deployed local recovery coordinators (LRCs) in every VA health care system. LRCs provide education, training, and consultation in an effort to transform the VA’s mental health services to a recovery-oriented system of care (VA, 2017a).

Finally, as discussed later in the chapter, the VA provides standardized “soft skills” training (focused on communication skills, stress reduction, and veteran suicide prevention) for mental health support staff and appointment schedulers across the health system (VA, 2017a).

Patient Engagement in Mental Health Care

Studies show that “activated” individuals engage more in self-management (through medication adherence, diet, exercise), disease prevention (such as health screenings), and health information seeking (Chinman et al., 2017). Having effective strategies to better engage veterans in their care is critical to improving the quality of care at the VA. As discussed in Chapter 11, studies show that a large proportion of veterans are not receiving adequate treatment following a diagnosis of posttraumatic stress disorder (PTSD), alcohol or other substance use disorder, or depression—suggesting a need for greater patient engagement in care.

The VA’s recent efforts to improve patient-centered care and increase engagement include the creation of treatment decision aids. The National Center for PTSD launched an online PTSD treatment decision aid in March 2017.1 This decision aid helps patients learn about the benefits and risks of evidence-based treatment options and guides them in clarifying their preferences and treatment goals (VA, 2017a).

The VA is also expanding its peer support program to support veterans needing care and to further position the mental health system toward recovery-oriented services. Peer specialists are veteran employees who have made a significant recovery from mental illness or substance use disorders and who are trained to provide ongoing support to other veterans with similar disorders. There is emerging evidence that peer specialists improve patient activation or engagement in care (Chinman et al., 2017). The VA now has almost 1,100 peer specialists deployed in a variety of mental health programs. Pilot programs are under way to integrate peer specialists into primary care and also into wellness recovery action planning (VA, 2017a).

Other engagement activities at the VA include a public awareness campaign, Make the Connection,2 which encourages veterans, service members, and their families to use information and resources, including mental health treatments, and other sources of support, such as veterans like themselves (VA, 2017a). The VA is also giving attention to physical space improvements through efforts to update the standards for state-of-the-art outpatient mental health facilities. This “design guide” provides specifics on how to make mental health treatment settings warm, inviting, and patient centered (VA, 2017a).

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1 See www.ptsd.va.gov/decisionaid (accessed January 7, 2018).

2 See www.maketheconnection.net (accessed January 7, 2018).

Suggested Citation:"10 Patient-Centered Care and the Veteran Experience." National Academies of Sciences, Engineering, and Medicine. 2018. Evaluation of the Department of Veterans Affairs Mental Health Services. Washington, DC: The National Academies Press. doi: 10.17226/24915.
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Complementary and Integrative Health

Complementary and integrative health (CIH), also known as complementary and alternative medicine, includes an array of interventions—such as yoga, equine therapy, meditation, acupuncture, and nutritional supplements—that are not considered standard practice in medicine. Promising findings exist for some CIH approaches for some conditions (Bergen-Cico et al., 2014; Engel et al., 2014; Serpa et al., 2014); however, more effectiveness research on CIH approaches is needed (IOM, 2013; Strauss et al., 2011). CIH therapies are often used to supplement more conventional, evidence-based medicine (Libby et al., 2012).

CIH approaches are frequently requested and used by veterans receiving mental health care, and the VA is responding to this interest in alternative modalities of care. Under the VA OPCC&CT, the Integrated Health Coordinating Center serves as the principal advisor to the Under Secretary for Health on CIH-related strategy and operations. The center supports clinical standardization and coordinates the expansion of CIH throughout the VA system (VA, 2016a). A recent policy directive (VA, 2017b) stipulates that practitioners are to offer veterans, as appropriate, any of the CIH approaches approved by the Under Secretary for Health. There is a specified set of CIH modalities that must be available to veterans (either in a VA facility or in the community) and a list of optional approaches that may be provided within the limits of individual VAMCs (VA, 2017a).

The implementation of CIH modalities within VA mental health services is determined at the local level based upon identified demand and available resources. Many facilities have implemented yoga, relaxation training, and tai chi, for example (VA, 2017a). In 2015, 93 percent of VA parent facilities offered at least one CIH service (VA, 2017a). A 2011 survey found that nearly all (96 percent) of VA PTSD treatment programs offered at least one CIH approach. The most commonly offered CIH modalities were mindfulness, stress-management relaxation therapy, progressive muscle relaxation techniques, and guided imagery (Libby et al., 2012).

One recent study, however, found that while many veterans are using CIH, a majority of them are doing so outside the VA (Reinhard et al., 2014). Another study found great variation regarding which CIH modalities are used by Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) veterans (Park et al., 2016). While 40.5 percent of the veterans surveyed used CIH in the 12 months prior to the survey, more than half used massage and nearly half used a nutritional product or meditation. Women were more likely to use CIH than men for nearly all modalities, particularly yoga, meditations and prayer, and acupuncture. Experiencing sexual harassment was also a predictor of CIH usage, as was poorer physical or mental health and higher perceived stress (Park et al., 2016).

VETERAN EXPERIENCES WITH RECEIVING MENTAL HEALTH CARE AT THE VETERANS HEALTH ADMINISTRATION

As mentioned above, understanding the patient experience is key to improving patient-centered care. Using data from the committee’s survey of veterans and site visit interviews, this section examines perspectives from veterans and VA staff on various aspects of patient-centered care at the VA. The information gathered provides insights into the extent to which veterans are receiving care that is respectful of and responsive to individual patient preferences, needs, and values.

Findings from the committee’s survey and site visit research demonstrate that a significant number of veterans describe VA patient care in positive terms. The survey asks veterans about their experiences with VA mental health services in terms of, for example, the helpfulness of the provider, satisfaction with care, and the impact on the veteran’s quality of life. Some questions were asked of all service users, including VA and non-VA. Other questions were asked only about VA services for those who used them.

Suggested Citation:"10 Patient-Centered Care and the Veteran Experience." National Academies of Sciences, Engineering, and Medicine. 2018. Evaluation of the Department of Veterans Affairs Mental Health Services. Washington, DC: The National Academies Press. doi: 10.17226/24915.
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TABLE 10-1 Experience of Care Among OEF/OIF/OND Veterans Who Use VA Mental Health Services

Experience of Care Survey Questions Unweighted n Weighted N Weighted % SE %
Did a VA mental health provider tell you there was more than one choice for your treatment?
Yes 371 203,961 44.5% 1.8%
Did the VA mental health provider you have seen most recently help you?
A lot 293 154,005 33.6% 1.7%
Some 241 133,282 29.1% 1.6%
A little 146 86,326 18.9% 1.5%
Not at all 114 71,242 15.6% 1.5%
Refused 7 4,436 1.0% 0.4%
Missing 17 8,672 1.9% 0.5%
How satisfied are you with your mental health care at the VA in the past 24 months?
Completely satisfied 132 70,359 15.4% 1.4%
Very satisfied 183 97,713 21.3% 1.4%
Somewhat satisfied 200 110,680 24.2% 1.9%
Neither satisfied nor dissatisfied 85 49,168 10.7% 1.3%
Somewhat dissatisfied 77 44,877 9.8% 1.1%
Very dissatisfied 55 36,483 8.0% 1.2%
Completely dissatisfied 68 39,454 8.6% 1.1%
Refused 3 1,843 0.4% 0.2%
Missing 15 7,385 1.6% 0.5%
In the past 24 months, what effect has VA treatment you got had on your quality of life?
Very helpful 256 135,101 29.5% 2.0%
A little helpful 283 163,152 35.6% 2.1%
Not helpful or harmful 198 112,698 24.6% 1.6%
A little harmful 37 22,329 4.9% 0.8%
Very harmful 17 10,550 2.3% 0.6%
Refused 5 2,909 0.6% 0.3%
Don’t know 1 930 0.2% 0.2%
Missing 21 10,293 2.2% 0.6%
In the past 24 months, did you end VA mental health treatment before the provider wanted you to?
Yes 209 122,272 26.7% 1.7

NOTE: Responses may not sum to 100% due to rounding. Missing includes skipped items.

SOURCE: Committee to Evaluate VA Mental Health Services, Veteran Survey, 2017.

Overall, veterans who use VA mental services reported positive care experiences on a number of questions, but there is substantial room for improvement. As Table 10-1 shows, 63 percent of survey respondents who use VA mental services indicated that their VA mental health provider helped them either some or a lot, and 61 percent were at least somewhat satisfied with the care they received. Sixty-five percent reported that they found the effect of care on their quality of life at least a little helpful. Seventy-three percent of users indicate that they did not end treatment before their mental health providers wanted them to. However, less than half (45 percent) of VA users said they were offered more than one choice for mental health care.

Suggested Citation:"10 Patient-Centered Care and the Veteran Experience." National Academies of Sciences, Engineering, and Medicine. 2018. Evaluation of the Department of Veterans Affairs Mental Health Services. Washington, DC: The National Academies Press. doi: 10.17226/24915.
×

TABLE 10-2 Statistically Significant Predictors of Mental Health Outcomes

Among OEF/OIF/OND veterans who use VA mental health care, adjusted odds ratios of responding that their VA mental health provider helped them a lot
Variable Variable Value Odds Ratio Lower CL Upper CL
Education Some college 0.431* 0.194 0.961
Education Associate’s or bachelor’s degree 0.448* 0.210 0.958
Income $25,000 to $49,999 1.820* 1.046 3.168
Depression score Continuous 0.862* 0.757 0.981
ATSPPH Continuous 1.181** 1.133 1.231
NOTES: 849 unweighted cases initially available, 188 unweighted cases excluded due to missing responses. Model includes 661 unweighted cases representing weighted N of 373,009. Reference categories for the variables are shown in Tables 6-10 and 6-20. *p,.05; **p,.01; CL 5 confidence limit; standard error units are not comparable to odds ratio.

Among OEF/OIF/OND veterans who use VA mental health care, the adjusted odds ratio of responding being very or completely satisfied with mental health care at VA
Variable Variable Value Odds Ratio Lower CL Upper CL
Race Non-Hispanic black only 2.048* 1.100 3.816
Alcohol dependence score Continuous 0.956* 0.922 0.993
Depression score Continuous 0.755** 0.650 0.877
ATSPPH Continuous 1.126** 1.083 1.170
NOTES: 849 unweighted cases initially available, 188 unweighted cases excluded due to missing responses. Model includes 661 unweighted cases representing weighted N of 373,366. Reference categories for the variables are shown in Tables 6-10 and 6-20. *p,.05; **p,.01; CL 5 confidence limit; standard error units are not comparable to odds ratio.

Among OEF/OIF/OND veterans who use VA mental health care, the adjusted odds ratio of responding that their VA treatment had a very helpful effect on their quality of life
Variable Variable Value Odds Ratio Lower CL Upper CL
Race Non-Hispanic black only 2.654** 1.492 4.721
Deployment Time 25–36 months 0.383* 0.180 0.813
Depression score Continuous 0.709** 0.613 0.821
ATSPPH Continuous 1.147** 1.095 1.201
Encouraged to get help Continuous 0.519* 0.286 0.942

NOTES: 849 unweighted cases initially available, 190 unweighted cases excluded due to missing responses. Model includes 659 unweighted cases representing weighted N of 371,524. Reference categories for the variables are shown in Tables 6-10 and 6-20. *p<.05; **p<.01; CL 5 confidence limit; standard error units are not comparable to odds ratio.

SOURCE: Committee to Evaluate VA Mental Health Services, Veteran Survey, 2017.

Three of the above variables—how much your VA mental health provider helped you, how satisfied you were with the care you received, and the effect of your treatment on your quality of life—constitute the patient-reported outcomes of care. To determine whether these outcomes differed by gender, race, or other veteran characteristics, the committee conducted logistic regression analyses to identify the predictors of these outcomes. (See Chapter 6, Tables 6-10 and 6-20, for a complete list of independent variables, including reference categories, used in the regression models.) A summary of statistically significant predictors is presented in Table 10-2. For all three of the outcomes more favorable attitudes toward seeking mental health treatment predicted better outcomes (provider helped a lot, more satisfied

Suggested Citation:"10 Patient-Centered Care and the Veteran Experience." National Academies of Sciences, Engineering, and Medicine. 2018. Evaluation of the Department of Veterans Affairs Mental Health Services. Washington, DC: The National Academies Press. doi: 10.17226/24915.
×

with care, and very helpful effect on quality of life). In contrast, for all three self-reported outcomes, higher depression scores predicted worse outcomes. Further research is needed to understand why veterans with higher reported levels of depressive symptoms report lower satisfaction with mental health care at the VA. For two of the three self-reported outcomes (more satisfied with care and very helpful effect on quality of life), being of non-Hispanic black race predicted better outcomes, indicating that non-Hispanic blacks reported higher satisfaction and helpfulness of mental health treatment than whites, thus not supporting concerns about racial disparities in perceived mental health treatment. Income from $25,000 to $49,000 predicted a higher likelihood of being helped a lot by the veteran’s VA mental health provider. Other variables that significantly predicted worse outcomes on one of the three outcome measures included some college or bachelor’s degree, higher alcohol dependence score, deployment time of 25–36 months, and encouragement from others to get help.

Interview data collected on the site visits illustrates some of the challenges that the VA faces in meeting patients’ preferences, needs, and values. The overwhelming demand for mental health services in some areas is one of the biggest factors in this regard. In fact, the most common complaint of veterans interviewed by the site visit teams was that their mental health appointments were rushed and their concerns were not heard by providers. A veteran explained, “As you’re talking, they’re sitting there typing the whole time” [Cleveland, Ohio]. Yet another veteran noted: “It’s simply check the box. . . . ‘Are you suicidal?’ ‘No.’ ‘All right, I’ll schedule you for 6 months [from now]’” [Cleveland, Ohio]. Veterans described service as “impersonal” [Hampton, Virginia; Palo Alto, California; Washington, DC], “cold, indifferent” [Palo Alto, California], or “robotic” [Temple, Texas]. Veterans described “assembly-line counseling” [Nashville, Tennessee]. One commented:

[If] you don’t fit in the box, get into the next box. This box doesn’t work, [so go to] the next box.” Once you get to the end of the boxes, they go, “Let’s start over. Maybe this one will work again.” They tried EMDR [eye movement desensitization and reprocessing]. Did not work. I just started again about a week ago with prolonged exposure. [Cleveland, Ohio]

Another veteran explained that the psychotherapy groups at the VA are so highly structured that they prevent members from getting their needs addressed: “[There is] no kind of meaningful exchange about any of this stuff.” [Washington, DC]

VA providers likewise expressed frustration with not being able to provide treatments that are more personalized to individual needs. A VA clinician explained,

[There’s] not a lot of support to do things that are therapeutically indicated sometimes. A lot of times we’re pigeonholed into certain things . . . when people may need some more out-of-the-box interventions. [Palo Alto, California]

A VA provider in Charleston, South Carolina, explained, “Sometimes veterans may feel as though they are being referred to as non-compliant if they don’t make it through—like an evidence-based treatment program, PE [prolonged exposure] protocols, that kind of thing—when they may not exactly fit the mold.”

The quotes above reveal some of the challenges of delivering evidence-based care, which is best evidence integrated with clinical expertise and patient values (IOM, 2001). The balance between the use of standardized, validated treatment protocols and the desire for flexibility to maintain patient engagement is further examined in Chapter 11, which describes research examining provider adherence to treatment protocols (fidelity to treatment) and reports on veteran and clinician perceptions about evidence-based treatments.

With respect to the VA’s lack of capacity to meet the demand for psychotherapy (see discussion about staffing levels in Chapter 8 and studies showing undertreatment in Chapter 11), systemic strains

Suggested Citation:"10 Patient-Centered Care and the Veteran Experience." National Academies of Sciences, Engineering, and Medicine. 2018. Evaluation of the Department of Veterans Affairs Mental Health Services. Washington, DC: The National Academies Press. doi: 10.17226/24915.
×

seem to contribute to the perception among veterans that the VA would treat mental health symptoms with medication rather than with psychotherapy. For example, a veteran in Palo Alto, California, said, “It’s ‘take these pills, and we’ll get you when we can,’ but I still don’t have a mental health person to talk to.” Veterans frequently said they were able to get appointments for medication evaluation much sooner than for psychotherapy.

VA clinician interviewees also reported that psychotherapy is in great demand and thus frequently in short supply, whereas medication management is relatively more available. However, medications are not always a desired treatment option. One clinician from Palo Alto explained that among the OEF/OIF/OND veterans, “A lot of young guys do not want to be on medications. They find it stigmatizes. They’re worried about addiction to it, being reliant on it, or the side effects. The thought of doing it for the rest of their life is scary.”

Many veterans interviewed said they preferred receiving mental health services from providers with experience in the military culture, a preference that the VA is not always able to meet. At a fundamental level, veterans did not want to have to waste time explaining military basics to the person who was supposed to be able to help them with issues derived from that military experience. A veteran explained her experience with a VA psychiatrist:

This guy didn’t know the first thing about rank structure. I saw him about three times spread out over 3 months. I gave it a try. [Temple, Texas]

More profoundly, however, veteran interviewees described the frustration of trying to put their combat experiences into words:

They [non-veteran clinicians] don’t know the experience . . . they will never know the truth. There are a lot of things we don’t know how to express in words. [Palo Alto, California]

. . . you’re talking about experiences that are haunting you. . . . [They need to] understand what a bullet sounds like flying by your head. All they’re doing is: “Mm-hmm,” and “Wow. Okay, what was your experience like?” It’s like talking to a wall . . . why even dig deeper if you’re not understanding this? [San Diego, California]

When non-veteran providers failed to understand the psychological and emotional difficulty of combat experiences, veterans were likely to leave therapy feeling offended. For example, a veteran who dropped out of treatment at the VA explained, “They weren’t a vet . . . and it just wasn’t working at all. It felt like they were patronizing me” [Altoona, Pennsylvania]. Another veteran explained: “She’s never served a d— day in her life and yet she’s trying to sit there, ‘I understand.’ What the f— do you understand? I went to combat. I’ve been blown up. Our bodies got blown up to pieces.” [Washington, DC]

Similarly, some veterans worried about being morally judged by non-veteran providers for actions committed in combat. One veteran in Washington, DC, told an interviewer, “If I go into the [mental health clinic] there, as often as not, I feel like I’m getting judged. I think that’s a big problem.” A provider currently in private practice who had completed a clinical internship at a VA explained that psychotherapists need to suspend “non-veteran morality”:

[Veterans] get a lot of that “Whoa, how could you have done that?” There can’t be any reactions like that. . . . Killing is what they do in combat. . . . You cannot put that non-veteran morality on them. [Washington, DC]

However, as reported in Chapter 8, data from the committee’s survey show that the majority of VA users with a mental health need have a positive experience with VA mental health providers. For example, Table 8-4 shows 69 percent reported their mental health provider understands their background and val-

Suggested Citation:"10 Patient-Centered Care and the Veteran Experience." National Academies of Sciences, Engineering, and Medicine. 2018. Evaluation of the Department of Veterans Affairs Mental Health Services. Washington, DC: The National Academies Press. doi: 10.17226/24915.
×

ues. However, about one in five veterans feel less positive: 23 percent believed that their provider looks down on them, and 21 percent indicated they do not feel welcome in their mental health provider’s office.

Those interviewees on the site visits who were satisfied with their care often pointed to ways their values and preferences had been accommodated by their individual providers. These veterans reported that they felt that their provider respected their preferences for treatment, honored their experiences as former military members, understood what they (the veteran) felt was important, and cared about them. One veteran from Charleston, South Carolina, explained, “The person who I talked to was very open and welcoming, and from there on, it’s been nothing but good.” A veteran in Tampa, Florida, described his doctor this way: “She was very knowledgeable and kept me in mind. . . . I trusted her completely and things worked out pretty good.” Yet another veteran in Seattle, Washington, said, “I’m thoroughly impressed and amazed by the treatment I have received at this hospital . . . it’s always been my option to do what I want to do [for treatment].”

Those who reported accepting pharmacotherapy said they felt more confident about the medication when the prescriber had made an effort to get to know them, rather than only “throwing pills” at them. For example, a veteran who was being treated by a psychotherapist outside of the VA system said she consulted a VA provider for medication:

When I went into the CBOC, I said “I’m only here because I need a prescription.” . . . [S]he wanted to talk to me and get to know me as a human before giving me pills—which I appreciated. [Seattle, Washington]

Veterans who worked successfully with non-veteran providers at the VA found that non-veteran providers’ attitudes of respect and humility during veterans’ combat disclosures went a long way toward making up for a lack of experiential understanding of war. A veteran who was among the first group to return from Iraq explained how, while his therapy was a little “bumpy in the beginning,” his VA psychotherapist was honest and humble about his lack of firsthand understanding:

He [therapist] said, “. . . because we haven’t experienced being in a combat zone, we can’t really get a picture of what that is like.” I brought in some photos that I had. I said, “This is what I used to see every day.” Then he was like, “Okay, now I get it.” [Washington, DC]

This veteran reported he was “100 percent satisfied” with his mental health care at the VA, largely because of the excellent relationship he had been able to establish with his individual therapist.

Interactions with Support Staff

In response to the committee’s inquiry about efforts to provide customer service training and to evaluate the performance of front-line staff (VA, 2017a), the VA responded that a standardized “soft skills” training (focused on communication skills, stress reduction, and veteran suicide prevention) for medical support assistants (MSAs) has been disseminated nationally. Another required training (consisting of a series of webinars and a video), called My VA Access Mental Health Initiative: The Critical Role of Schedulers in Getting Veterans to Care, was launched in 2016 and has been completed by over 50,000 scheduling staff. The VA reported that there is currently no national metric for assessing MSAs on customer service skills; however, supervisors are expected to conduct ongoing reviews of staff members’ competency in providing customer service.

Despite the VA’s customer service training efforts, the committee found challenges with communications about the appointment process, which are discussed in Chapter 9, as well as frequent veteran reports of negative interactions with VA support staff. Results from the committee’s survey showed that 16 percent of veterans with mental health needs rated the staff’s courtesy and respect toward patients

Suggested Citation:"10 Patient-Centered Care and the Veteran Experience." National Academies of Sciences, Engineering, and Medicine. 2018. Evaluation of the Department of Veterans Affairs Mental Health Services. Washington, DC: The National Academies Press. doi: 10.17226/24915.
×

as being somewhat or extremely negative. On the other hand, more than three-quarters of all veterans surveyed indicated that better quality services (78 percent) and better customer service (77 percent) are important changes that the VA could make (see Table 6-34). Similarly, veterans on all 21 site visits complained about poor interactions with support staff at the VA, typically from front desk clerks and receptionists. Veterans reported that they often have interactions with front line VA staff that are off-putting, and some reported leaving before they even completed their clinical appointments. Common words used by veterans to describe interactions with these VA staff members include “rude,” “bad attitude,” “unprofessional,” “unhelpful,” “insensitive,” and “disrespectful.” Behaviors that elicited complaints included not knowing the answers to questions and not offering to find out, taking personal phone calls while at their desk, using social media to connect with their friends while at work, acting like the veteran is inconveniencing them, and not making eye contact with the veteran.

These actions can directly affect a veteran’s willingness to continue to seek care from the VA. As one veteran from Washington, DC, said, “To treat me the way they did made me want to leave. I didn’t want to be part of the VA.”

Some veterans said that they had attempted to report negative interactions with staff both to patient advocates and to supervisors, with little to no success. One veteran in Altoona, Pennsylvania, said that after he filed a complaint, the employee called him and “yelled at me because I called patient advocates on her.” Another veteran in Charleston, South Carolina, reported calling a supervisor about a “rude” clerk in eligibility, but did not get a call back. This apparent lack of accountability was a theme expressed by other veterans, with one veteran stating that “Nothing happened to that lady who was just rude as hell to me. There’s no accountability in the system.” [Biloxi, Mississippi]

VA clinicians also reported hearing the same complaints, noting that the lack of respect from the front-line staff was either turning veterans off or causing them to come into their appointments upset and frustrated. One VA clinician said he felt that the MSAs had “management incompetency,” and many in VA clinical leadership voiced frustration that they have no authority over their own MSA staff. One former VA employee who recently left to start her own practice noted that the MSAs’ actions were hurting the therapeutic alliance. She commented,

If they [veterans] enter a place where they’re not being treated with respect and they’re already triggered by the time they get to you, it’s hard for them to say, “Yeah, I’m going to trust you enough to tell you these things.” [Washington, DC]

Veterans also commented that they were afraid to show agitation or voice their feelings because they were afraid the clerk would call security on them. One veteran reported that when he was frustrated the clerk stated, “Sir, if you keep this up I am going to call security.” Clinicians relayed the same thing, with one adding that “the doctors wind up taking the brunt of it.” [Cleveland, Ohio]

Finally, some veterans asserted that one of the reasons for the lack of respect comes from an assumption that veterans are working the system to secure as many financial benefits as possible. One veteran commented, “[A]n attitude [that] a lot of the people at the VA have is, ‘You’re just collecting a paycheck from us, so you just hang out and watch Maury [Povich] all day.’” [Temple, Texas]

SUMMARY

Using information from the committee’s survey, site visit, and literature research, this chapter examined and described patient-centered care initiatives in place at the VA. Furthermore, it described patient and provider experiences with patient-centered care. A summary of the committee’s findings on this topic is outlined below.

Suggested Citation:"10 Patient-Centered Care and the Veteran Experience." National Academies of Sciences, Engineering, and Medicine. 2018. Evaluation of the Department of Veterans Affairs Mental Health Services. Washington, DC: The National Academies Press. doi: 10.17226/24915.
×
  • The VA has a centralized office (Office of Patient Centered Care and Cultural Transformation) and system-wide initiatives, such as Whole Health, patient-aligned care teams, and CIH modalities of care, which align with and support a focus on patient-centered care.
  • Some of the VA’s notable recent efforts to improve patient-centered care and increase engagement include the creation of a PTSD treatment decision aid and an expansion of the peer support program.
  • Findings from the committee’s survey research demonstrate that a majority of veterans (69 percent) report that their providers understand their background and values. Committee site visit interviews supported this finding.
  • However, only 45 percent of veterans reported being told they had more than one choice of treatment options.
  • Non-Hispanic black veterans were more likely to be satisfied with the care they received and more likely to report that their treatment from the VA had a very helpful effect on their quality of life than were non-Hispanic white veterans.
  • Continued leadership and innovation are needed to firmly establish a culture of patient-centered care at the VA.
  • Experiences reported by veterans and staff who do not seem to view the VA as patient-centered largely reflect system- and facility-level obstacles, including workforce issues (short staffing, employee turnover, professional burnout) and difficult interpersonal interactions such as challenging communications about the appointment process, complaints about service and attitudes from support staff, and a lack of providers with experience in the military culture.
  • Recent initiatives, such as the standardized “soft skills” training for medical support assistants, have begun to address a number of these issues.
  • The committee findings suggest the VA must continue to gather input from veterans and staff to better understand its shortcomings in meeting veterans’ expectations, needs, and values.

REFERENCES

AHRQ (Agency for Healthcare Research and Quality). 2017. What is patient experience?https://www.ahrq.gov/cahps/about-cahps/patient-experience/index.html (accessed June 25, 2017).

Barry, C. N., K. M. Abraham, K. R. Weaver, and N. W. Bowersox. 2016. Innovating team-based outpatient mental health care in the Veterans Health Administration: Staff-perceived benefits and challenges to pilot implementation of the behavioral health interdisciplinary program (BHIP). Psychological Services 13(2):148–155.

Bergen-Cico, D., K. Possemato, and W. Pigeon. 2014. Reductions in cortisol associated with primary care brief mindfulness program for veterans with PTSD. Medical Care 52:S25–S31.

Chinman, M., K. Daniels, J. Smith, S. McCarthy, D. Medoff, A. Peeples, and R. Goldberg. 2017. Provision of peer specialist services in VA patient aligned care teams: Protocol for testing a cluster randomized implementation trial. Implementation Science 12(1):57.

Dobscha, S. K., R. Cromer, A. Crain, and L. M. Denneson. 2016. Qualitative analysis of U.S. Department of Veterans Affairs mental health clinician perspectives on patient-centered care. International Journal for Quality in Health Care 28(3):355–362.

Engel, C. C., E. H. Cordova, D. M. Benedek, X. Liu, K. L. Gore, C. Goertz, M. C. Freed, C. Crawford, W. B. Jonas, and R. J. Ursano. 2014. Randomized effectiveness trial of a brief course of acupuncture for posttraumatic stress disorder. Medical Care 52:S57–S64.

Gerrity, M. 2016. Evolving models of behavioral health integration: Evidence update 2010–2015. New York: Milbank Memorial Fund.

IOM (Institute of Medicine). 2001. Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.

IOM. 2013. Returning home from Iraq and Afghanistan: Assessment of readjustment needs of veterans, service members, and their families. Washington, DC: The National Academies Press.

Suggested Citation:"10 Patient-Centered Care and the Veteran Experience." National Academies of Sciences, Engineering, and Medicine. 2018. Evaluation of the Department of Veterans Affairs Mental Health Services. Washington, DC: The National Academies Press. doi: 10.17226/24915.
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Libby, D. J., C. E. Pilver, and R. Desai. 2012. Complementary and alternative medicine in VA specialized PTSD treatment programs. Psychiatric Services 63(11):1134–1136.

Millenson, M. L., and J. Macri. 2012. Will the Affordable Care Act move patient-centeredness to center stage? Timely Analysis of Immediate Health Policy Issues. Urban Institute. https://www.rwjf.org/content/dam/farm/reports/reports/2012/rwjf72412 (accessed October 6, 2017).

Park, C. L., L. Finkelstein-Fox, D. M. Barnes, C. M. Mazure, and R. Hoff. 2016. CAM use in recently-returned OEF/OIF/OND U.S. veterans: Demographic and psychosocial predictors. Complementary Therapies in Medicine 28:50–56.

Patient-Centered Primary Care Collaborative. 2015. Defining the medical home. https://www.pcpcc.org/about/medical-home (accessed April 29, 2015).

Rathert, C., M. D. Wyrwich, and S. A. Boren. 2013. Patient-centered care and outcomes: A systematic review of the literature. Medical Care Research and Review 70(4):351–379.

Reinhard, M. J., T. H. Nassif, K. Bloeser, E. K. Dursa, S. K. Barth, B. Benetato, and A. Schneiderman. 2014. CAM utilization among OEF/OIF veterans: Findings from the National Health Study for a new generation of U.S. veterans. Medical Care 52(12 Suppl 5):S45–S49.

Rindfleisch, J. A. 2016. Passport to whole health: A personal health planning reference manual. Madison, WI: University of Wisconsin Integrative Health.

Serpa, J. G., S. L. Taylor, and K. Tillisch. 2014. Mindfulness-based stress reduction (MBSR) reduces anxiety, depression, and suicidal ideation in veterans. Medical Care 52:S19–S24.

Strauss, J. L., R. Coeytaux, J. McDuffie, A. Nagi, and J. W. Williams, Jr. 2011. Efficacy of complementary and alternative medicine therapies for posttraumatic stress disorder. Washington, DC: Department of Veterans Affairs.

VA (Department of Veterans Affairs). 2013. VHA strategic plan: FY 2013–2018. Washington, DC: Department of Veterans Affairs.

VA. 2016a. Advancing complementary and integrative health. https://www.va.gov/PATIENTCENTEREDCARE/features/Advancing_Complementary_and_Integrative_Health_in.asp (accessed April 19, 2017).

VA. 2016b. Spotlight: Employee engagement in depth. https://www.hsrd.research.va.gov/news/feature/engagement-indepth.cfm (accessed April 4, 2017).

VA. 2017a. Response to committee request for information. Department of Veterans Affairs.

VA. 2017b. VHA directive 1137: Provision of complementary and integrative health (CIH). Washington, DC: Department of Veterans Affairs.

Yano, E. M., M. J. Bair, O. Carrasquillo, S. L. Krein, and L. V. Rubenstein. 2014. Patient aligned care teams (PACT): VA’s journey to implement patient-centered medical homes. Journal of General Internal Medicine 29(2):547–549.

Suggested Citation:"10 Patient-Centered Care and the Veteran Experience." National Academies of Sciences, Engineering, and Medicine. 2018. Evaluation of the Department of Veterans Affairs Mental Health Services. Washington, DC: The National Academies Press. doi: 10.17226/24915.
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Suggested Citation:"10 Patient-Centered Care and the Veteran Experience." National Academies of Sciences, Engineering, and Medicine. 2018. Evaluation of the Department of Veterans Affairs Mental Health Services. Washington, DC: The National Academies Press. doi: 10.17226/24915.
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Approximately 4 million U.S. service members took part in the wars in Afghanistan and Iraq. Shortly after troops started returning from their deployments, some active-duty service members and veterans began experiencing mental health problems. Given the stressors associated with war, it is not surprising that some service members developed such mental health conditions as posttraumatic stress disorder, depression, and substance use disorder. Subsequent epidemiologic studies conducted on military and veteran populations that served in the operations in Afghanistan and Iraq provided scientific evidence that those who fought were in fact being diagnosed with mental illnesses and experiencing mental health–related outcomes—in particular, suicide—at a higher rate than the general population.

This report provides a comprehensive assessment of the quality, capacity, and access to mental health care services for veterans who served in the Armed Forces in Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn. It includes an analysis of not only the quality and capacity of mental health care services within the Department of Veterans Affairs, but also barriers faced by patients in utilizing those services.

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