A qualitative evaluation of Veterans Health Administration's implementation of measurement-based care in behavioral health.

Measurement-based care (MBC) in behavioral health involves the repeated collection of patient-reported data that is used to track progress, inform care, and engage patients in shared decision making about their treatment. Research suggests that MBC increases the quality and effectiveness of mental health care. However, there can be challenges to implementing MBC, such as time burden, lack of resources to support MBC, and clinician attitudes. The Veterans Health Administration (VHA) is currently undertaking a multiphase MBC roll-out, the first phase of which included 59 sites across the country. The present study examined implementation of this initiative in an effort to learn more about the process of implementation, including best practices, challenges, and innovations. Semistructured interviews were conducted with 20 MBC site champions and 60 staff members from 25 VHA medical centers across the country. Qualitative data analysis was conducted to identify key themes related to MBC implementation. Results were described for 3 components of MBC implementation: preparing for implementation, administering measures, and using and sharing data. Training and staff buy-in were key to the preparation phase. Staff members reported a variety of methods and frequencies for the collection of MBC data, with many staff members identifying a need to streamline the collection process. Staff members reported using data to track progress and adjust treatment with patients. Efforts to use data on a programmatic level were identified as a next step. Innovative solutions across clinics and sites are described in an effort to inform future MBC implementation, both within and outside of VHA. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Impact of a Service Line Management Model on Behavioral Health Care in the Military Health System.

Large health care systems are seeking to reduce variation in care delivery and improve outcomes. This column describes the U.S. Army health care system's transformation to a service line management model and the impact on behavioral health care between 2013 and 2017. An evaluation found a promising association between the service line model and greater use of standard outpatient clinical programs, more frequent engagement of patients with serious conditions, and less use of inpatient services. The observational nature of these preliminary findings does not permit causal inferences; however, the service line model may help health care systems reduce variation between geographically distinct care delivery locations and improve performance.

Transformation of Mental Health Care for U.S. Soldiers and Families During the Iraq and Afghanistan Wars: Where Science and Politics Intersect.

The cumulative strain of 14 years of war on service members, veterans, and their families, together with continuing global threats and the unique stresses of military service, are likely to be felt for years to come. Scientific as well as political factors have influenced how the military has addressed the mental health needs resulting from these wars. Two important differences between mental health care delivered during the Iraq and Afghanistan wars and previous wars are the degree to which research has directly informed care and the consolidated management of services. The U.S. Army Medical Command implemented programmatic changes to ensure delivery of high-quality standardized mental health services, including centralized workload management; consolidation of psychiatry, psychology, psychiatric nursing, and social work services under integrated behavioral health departments; creation of satellite mental health clinics embedded within brigade work areas; incorporation of mental health providers into primary care; routine mental health screening throughout soldiers' careers; standardization of clinical outcome measures; and improved services for family members. This transformation has been accompanied by reduction in psychiatric hospitalizations and improved continuity of care. Challenges remain, however, including continued underutilization of services by those most in need, problems with treatment of substance use disorders, overuse of opioid medications, concerns with the structure of care for chronic postdeployment (including postconcussion) symptoms, and ongoing questions concerning the causes of historically high suicide rates, efficacy of resilience training initiatives, and research priorities. It is critical to ensure that remaining gaps are addressed and that knowledge gained during these wars is retained and further evolved.

Predicting suicides after psychiatric hospitalization in US Army soldiers: the Army Study To Assess Risk and rEsilience in Servicemembers (Army STARRS).

IMPORTANCE: The US Army experienced a sharp increase in soldier suicides beginning in 2004. Administrative data reveal that among those at highest risk are soldiers in the 12 months after inpatient treatment of a psychiatric disorder. OBJECTIVE: To develop an actuarial risk algorithm predicting suicide in the 12 months after US Army soldier inpatient treatment of a psychiatric disorder to target expanded posthospitalization care. DESIGN, SETTING, AND PARTICIPANTS: There were 53,769 hospitalizations of active duty soldiers from January 1, 2004, through December 31, 2009, with International Classification of Diseases, Ninth Revision, Clinical Modification psychiatric admission diagnoses. Administrative data available before hospital discharge abstracted from a wide range of data systems (sociodemographic, US Army career, criminal justice, and medical or pharmacy) were used to predict suicides in the subsequent 12 months using machine learning methods (regression trees and penalized regressions) designed to evaluate cross-validated linear, nonlinear, and interactive predictive associations. MAIN OUTCOMES AND MEASURES: Suicides of soldiers hospitalized with psychiatric disorders in the 12 months after hospital discharge. RESULTS: Sixty-eight soldiers died by suicide within 12 months of hospital discharge (12.0% of all US Army suicides), equivalent to 263.9 suicides per 100,000 person-years compared with 18.5 suicides per 100,000 person-years in the total US Army. The strongest predictors included sociodemographics (male sex [odds ratio (OR), 7.9; 95% CI, 1.9-32.6] and late age of enlistment [OR, 1.9; 95% CI, 1.0-3.5]), criminal offenses (verbal violence [OR, 2.2; 95% CI, 1.2-4.0] and weapons possession [OR, 5.6; 95% CI, 1.7-18.3]), prior suicidality [OR, 2.9; 95% CI, 1.7-4.9], aspects of prior psychiatric inpatient and outpatient treatment (eg, number of antidepressant prescriptions filled in the past 12 months [OR, 1.3; 95% CI, 1.1-1.7]), and disorders diagnosed during the focal hospitalizations (eg, nonaffective psychosis [OR, 2.9; 95% CI, 1.2-7.0]). A total of 52.9% of posthospitalization suicides occurred after the 5% of hospitalizations with highest predicted suicide risk (3824.1 suicides per 100,000 person-years). These highest-risk hospitalizations also accounted for significantly elevated proportions of several other adverse posthospitalization outcomes (unintentional injury deaths, suicide attempts, and subsequent hospitalizations). CONCLUSIONS AND RELEVANCE: The high concentration of risk of suicide and other adverse outcomes might justify targeting expanded posthospitalization interventions to soldiers classified as having highest posthospitalization suicide risk, although final determination requires careful consideration of intervention costs, comparative effectiveness, and possible adverse effects.

Academic training in a child and adolescent psychiatry fellowship: a curriculum based on leadership experience.

OBJECTIVE: The authors describe how one child and adolescent psychiatry fellowship program responded to emerging trends in clinical practice which increasingly demand that child and adolescent psychiatrists lead their colleagues through instruction and supervision. METHODS: Data from surveys of recent graduates of child and adolescent training programs were reviewed and the trends were identified. The authors describe the Academic Chief Fellow rotation, which was designed for the fellows to enhance their academic skills by teaching, guiding, and supervising their junior colleagues. RESULTS: The authors describe the implementation of the new rotation and discuss the fellows' response. They also detail the responses of the medical students and residents who rotated on the child and adolescent psychiatry service under the Academic Chief Fellow. CONCLUSION: Greater experience in teaching and supervising others can be meaningfully integrated into existing child and adolescent psychiatry fellowship curricula. Other outcomes may include greater medical student and general psychiatry resident satisfaction with their child and adolescent psychiatry rotation and greater interest among medical students in child and adolescent psychiatry as a career.

Enhancing the effectiveness of the psychiatric chief resident.

OBJECTIVE: Despite its importance in psychiatry residency training, there is little written about the role of chief resident. Invoking principles of credibility, continuity, and inclusion, and the establishment of two roles, as legislative and representative leader, this article offers a model for how a residency program can empower its chief resident to act decisively, make meaningful contributions to training, and ultimately enhance his or her effectiveness. METHOD: The authors review the literature on the psychiatry chief resident and identify ambiguity as a common and powerful impediment to effective leadership. RESULTS: The authors present a model for psychiatry residency programs to enhance chief resident effectiveness based on the three components of credibility, continuity, and inclusion, and elucidate how each improves chief resident leadership. The authors identify two integral leadership roles of the chief resident, those of the legislative and representative leader, and discuss how each empowers the chief resident to act decisively. CONCLUSIONS: The authors assert that if psychiatry residency programs elect the chief resident by involving both faculty and residents, grant a year-long term and include him or her in all major decisions that involve the residency, the chief resident is far more likely to make meaningful contributions to the training program.

Franklin Delano Jones, M.D., and war psychiatry.

Through a long career that spanned three wars and important changes in patterns of health care, Franklin Delano Jones (1935-2005) provided medical and psychiatric care to the most vulnerable members of our society, civilian as well as military. Recognizing that individuals tend to forget lessons learned in stressful situations, he compiled and codified the essential practices of wartime psychiatry into comprehensive and accessible texts. His neutrality, persistence, and sharp intellect stabilized and strengthened American military psychiatry in the post-Vietnam era. His culminating achievement, War Psychiatry, which is the codified clinical intelligence of several generations of military psychiatrists, is an essential foundation for clinical practice and for research. This article explores Jones'ss contributions, particularly the variations in the presentation of combat stress, the efficacy of the principles of forward treatment, and a comprehensive understanding of posttraumatic stress disorder.