Evaluating the Impact of Integrative Mental Health Treatment in Veterans with Post-Traumatic Stress Disorder

High numbers of US Veterans experience post-traumatic stress disorder (PTSD), but, many do not subsequently seek mental healthcare. Integrated mental health (IMH) models of treatment bring mental health professionals into the primary care setting, allowing Veterans to receive comprehensive treatment during primary care visits. The IMH treatment model may bridge the gap for Veterans with PTSD who need care and those who actually receive it. This study examined the impact that IMH has on Veterans with PTSD receiving care from VA. Using several methods of data collection (medical chart reviews, VA administrative databases, a mailed survey of patient perception of patient-centered care (PCC)) the present quasi-experimental evaluation study examined a national sample of Veterans with PTSD, to evaluate the impact of IMH treatment (as compared to usual mental health care) on: physical health, mental health, PTSD, health services utilization, patient perceptions of key PCC constructs, provider recommendations for treatment, and considerations of patient preferences for treatment. Outcomes were compared for Veterans receiving IMH vs. usual mental health care; a multivariate logistic regression model was conducted to assess variables independently associated with IMH treatment receipt, and; mediation analyses examined whether the relationship between IMH treatment and receipt of ‘adequate’ mental health care is driven by patient perceptions of two important PCC constructs (patient activation; shared decision-making). Collectively, results indicate that IMH treatment receipt is associated with: increased outpatient and primary care visits; decreased psychotropic medication use; increased recommendations for complementary and alternative treatment modalities; more discussion of patient preferences for mental health treatment during more VA primary care and mental health encounters; better patient-reported physical health; greater patient activation, and; better patient perceptions of shared decision-making. Combining behavioral health care with traditional primary care through an integrative mental health treatment model may be most effective in increasing health care engagement, shared decision-making, and discussion of patient preferences for mental health care among Veterans with PTSD. Integrating mental health care providers into the primary care setting may be a good strategy for encouraging Veterans with PTSD to seek out and stay the course of the treatment they need

Exploring the Mortality Salience Paradox: The Effects of High-Risk Employment on Interpersonal Decision Making

Past research concerning Terror Management Theory (TMT) has displayed self-esteem bolstering and cultural worldview validation to be the foundation of subconscious defense mechanisms against mortality salience (Solomon, Greenberg, & Pyszczynski, 1991). Recent studies have also identified intimacy and romantic commitment as form of such defense (Florian, Mikulincer & Hirschberger, 2002). The present study examines the effects of existential terror on people\u27s intimacy-related milestone time frames, as well as the distinction between naturally occurring mortality salience (in a sample of soldiers) and the more standard form of laboratory induced mortality salience. It was hypothesized that employees of high-risk fields will have a significantly greater death-thought accessability than members of the general population, and will significantly differ in the likeliness of placing the accomplishment of life milestones associated with intimacy at the top of their priorities list, time-wise. It was further hypothesized that students who recieve the death-thought prime will have a significantly greater death-thought accessability, and will significantly differ in the likeliness of placing accomplishments of life milestones associated with intimacy at the top of their priorities list, than undergraduates not primed with mortality salience. Data suggests that high-risk employees have significantly higher levels of death-thought accessibility naturally, as compared to laboratory induced levels, and that mortality salience cauases individuals to desire earlier completion of intimacy related milestones

Characterization of Telehealth Use in Veterans with Spinal Cord Injuries and Disorders

BACKGROUND: Individuals with spinal cord injuries and disorders (SCI/D) require frequent interdisciplinary health care to address impairments in mobility, autonomic functions, and secondary complications. Telehealth has the capacity to substantially transform healthcare delivery and improve care by increasing access and communication. However, relatively little is known about telehealth use in this specific population. Here, we attempt to fill part of this gap. OBJECTIVE: To investigate the frequency and characteristics associated with telehealth use in Veterans with SCI/D. DESIGN: Cross-sectional, descriptive project SETTING: Veterans Health Administration (VHA) facilities. Participants: 15,028 Veterans living with SCI/D whom received services from the VHA SCI/D System of Care. Intervention: Not applicable Outcome Measures: Frequency and characteristics associated with VHA telehealth utilization. Results: Of the 15,028 Veterans with SCI/D included in the evaluation, 17% used some form of telehealth in VHA Fiscal Year (FY)2017. Veterans over the age of 65 had lower odds (OR = 0.88, p \u3c 0.05, CI: 0.80-0.98) of using telehealth. Being Caucasian (OR = 1.29, p \u3c 0.01, CI: 1.09-1.52), living in rural areas (OR =1.16, p \u3c 0.01, CI: 1.05-1.28), living greater distances away from the VHA (p \u3c 0.01 for all distances), and being in priority group 8, meaning that Veterans have higher copayment requirements (OR=1.46, p \u3c 0.001, CI: 1.19-1.81), were all significantly associated with greater odds of telehealth use. The most frequent types of telehealth used were real-time clinical video and store-and-forward between a provider and patient within the same hub network. Conclusion: There are opportunities to increase telehealth adoption in the SCI/D arena. The findings from this project highlight which Veterans are currently using telehealth services, as well as gaps regarding telehealth adoption in this population

How Do Patients with Mental Health Diagnoses Use Online Patient Portals? An Observational Analysis from the Veterans Health Administration

Online patient portals may be effective for engaging patients with mental health conditions in their own health care. This retrospective database analysis reports patient portal use among Veterans with mental health diagnoses. Unadjusted and adjusted odds of portal feature use was calculated using logistic regressions. Having experienced military sexual trauma or having an anxiety disorder, post-traumatic stress disorder, or depression were associated with increased odds of portal use; bipolar, substance use, psychotic and adjustment disorders were associated with decreased odds. Future research should examine factors that influence portal use to understand diagnosis-level differences and improve engagement with such tools

Supporting the Implementation of Connected Care Technologies in the Veterans Health Administration: Cross-Sectional Survey Findings from the Veterans Engagement with Technology Collaborative (VET-C) Cohort

BACKGROUND: Widespread adoption, use, and integration of patient-facing technologies into the workflow of health care systems has been slow, thus limiting the realization of their potential. A growing body of work has focused on how best to promote adoption and use of these technologies and measure their impacts on processes of care and outcomes. This body of work currently suffers from limitations (eg, cross-sectional analyses, limited patient-generated data linked with clinical records) and would benefit from institutional infrastructure to enhance available data and integrate the voice of the patient into implementation and evaluation efforts. OBJECTIVE: The Veterans Health Administration (VHA) has launched an initiative called the Veterans Engagement with Technology Collaborative cohort to directly address these challenges. This paper reports the process by which the cohort was developed and describes the baseline data being collected from cohort members. The overarching goal of the Veterans Engagement with Technology Collaborative cohort is to directly engage veterans in the evaluation of new VHA patient-facing technologies and in so doing, to create new infrastructure to support related quality improvement and evaluation activities. METHODS: Inclusion criteria for veterans to be eligible for membership in the cohort included being an active user of VHA health care services, having a mobile phone, and being an established user of existing VHA patient-facing technologies as represented by use of the secure messaging feature of VHA\u27s patient portal. Between 2017 and 2018, we recruited veterans who met these criteria and administered a survey to them over the telephone. RESULTS: The majority of participants (N=2727) were male (2268/2727, 83.2%), White (2226/2727, 81.6%), living in their own apartment or house (2519/2696, 93.4%), and had completed some college (1176/2701, 43.5%) or an advanced degree (1178/2701, 43.6%). Cohort members were 59.9 years old, on average. The majority self-reported their health status as being good (1055/2725, 38.7%) or very good (524/2725, 19.2%). Most cohort members owned a personal computer (2609/2725, 95.7%), tablet computer (1616/2716, 59.5%), and/or smartphone (2438/2722, 89.6%). CONCLUSIONS: The Veterans Engagement with Technology Collaborative cohort is an example of a VHA learning health care system initiative designed to support the data-driven implementation of patient-facing technologies into practice and measurement of their impacts. With this initiative, VHA is building capacity for future, rapid, rigorous evaluation and quality improvement efforts to enhance understanding of the adoption, use, and impact of patient-facing technologies

Lessons Learned From VHA\u27s Rapid Implementation of Virtual Whole Health Peer-Led Groups During the COVID-19 Pandemic: Staff Perspectives

Background: Committed to implementing a person-centered, holistic (Whole Health) system of care, the Veterans Health Administration (VHA) developed a peer-led, group-based, multi-session Taking Charge of My Life and Health (TCMLH) program wherein Veterans reflect on values, set health and well-being-related goals, and provide mutual support. Prior work has demonstrated the positive impact of these groups. After face-to-face TCMLH groups were disrupted by the COVID-19 pandemic, VHA facilities rapidly implemented virtual (video-based) TCMLH groups. Objective: We sought to understand staff perspectives on the feasibility, challenges, and advantages of conducting TCMLH groups virtually. Methods: We completed semi-structured telephone interviews with 35 staff members involved in the implementation of virtual TCMLH groups across 12 VHA facilities and conducted rapid qualitative analysis of the interview transcripts. Results: Holding TCMLH groups virtually was viewed as feasible. Factors that promoted the implementation included use of standardized technology platforms amenable to delivery of group-based curriculum, availability of technical support, and adjustments in facilitator delivery style. The key drawbacks of the virtual format included difficulty maintaining engagement and barriers to relationship-building among participants. The perceived advantages of the virtual format included the positive influence of being in the home environment on Veterans\u27 reflection, motivation, and self-disclosure, the greater convenience and accessibility of the virtual format, and the virtual group\u27s role as an antidote to isolation during the COVID-19 pandemic. Conclusion: Faced with the disruption caused by the COVID-19 pandemic, VHA pivoted by rapidly implementing virtual TCMLH groups. Staff members involved in implementation noted that delivering TCMLH virtually was feasible and highlighted both challenges and advantages of the virtual format. A virtual group-based program in which participants set and pursue personally meaningful goals related to health and well-being in a supportive environment of their peers is a promising innovation that can be replicated in other health systems

Relational empathy and holistic care in persons with spinal cord injuries

<p><b>Objective</b>: Describe perceptions of persons with SCI on their receipt of holistic care and relational empathy during health care encounters.</p> <p><b>Design</b>: Mailed survey.</p> <p><b>Participants/Setting</b>: Individuals with SCI who received care from the largest suppliers of SCI care and rehabilitation (Veterans Health Administration and SCI Model Systems).</p> <p><b>Outcome Measures</b>: Using a survey and administrative databases, we collected demographic and injury characteristics, health status, health conditions, and the main outcome: <i>Consultation and Relational Empathy (CARE) measure</i>.</p> <p><b>Results</b>: The sample included 450 individuals with SCI (124 Veterans and 326 civilians). Response rate was 39% (450/1160). Analyses were conducted on patients with complete data (n = 389). Veterans and civilians with SCI differed across many demographic characteristics, age at injury, and etiology, but mean CARE scores were equivalent. Fewer than half of the full SCI cohort had CARE scores above the normative value of 43. Having a recent pressure ulcer showed a trend for lower odds of having a normative or higher CARE score. Odds of having an above-normative CARE score were nearly 2 times greater for individuals with tetraplegia, and odds were higher for those with higher physical and mental health status.</p> <p><b>Conclusions</b>: Higher physical and mental health status and tetraplegia were each independently associated with greater perceptions of holistic care and empathy in the therapeutic patient-provider relationship. Limited empathy, communication, and holistic care may arise when providers focus on disease/disease management, rather than on patients as individuals. Frequent health care use and secondary conditions may affect empathy and holistic care in encounters, making it essential to understand and employ efforts to improve the therapeutic relationship between patients with SCI and their providers.</p