Understanding How Contingency Staffing Programs Can Support Mental Health Services in the Veterans Health Administration.

Introduction: Beginning in 2019, the Department of Veterans Affairs (VA) prioritized improving access to care nationally to deliver virtual care and implemented 18 regionally based Clinical Resource Hubs (CRHs) to meet this priority. This observational study describes the quantity and types of care delivered by CRH Mental Health teams, and the professions of those hired to deliver it. Methods: A retrospective cohort study, based on national VA CRH mental health care utilization data and CRH staffing data for CRH's first 3 years, was conducted. Results: CRH Mental Health teams primarily used Telemental Health (TMH) to provide care (98.1% of all CRH MH encounters). The most common disorders treated included depression, post-traumatic stress disorder, and anxiety disorders. The amount of care delivered overtime steadily increased as did the racial and ethnic diversity of Veterans served. Psychologists accounted for the largest share of CRH staffing, followed by psychiatrists. Conclusions: CRH TMH delivered from a regional hub appears to be a feasible and acceptable visit modality, based on the continuously increasing CRH TMH visit rates. Our results showed that CRH TMH was predominantly used to address common mental health diagnoses, rather than serious mental illnesses. Traditionally marginalized patient populations increased over the 3-year window, suggesting that CRH TMH resources were accessible to many of these patients. Future research should assess barriers and facilitators for accessing CRH TMH, especially for difficult-to-service patient populations, and should consider whether similar results to ours occur when regional TMH is delivered to non-VA patient populations.

Successful ingredients of effective Collaborative Care programs in low- and middle-income countries: A rapid review.

Integrating mental health care in primary healthcare settings is a compelling strategy to address the mental health treatment gap in low- and middle-income countries (LMICs). Collaborative Care is the integrated care model with the most evidence supporting its effectiveness, but most research has been conducted in high-income countries. Efforts to implement this complex multi-component model at scale in LMICs will be enhanced by understanding the model components that have been effective in LMIC settings. Following Cochrane Rapid Reviews Methods Group recommendations, we conducted a rapid review to identify studies of the effectiveness of Collaborative Care for priority adult mental disorders of mhGAP (mood and anxiety disorders, psychosis, substance use disorders and epilepsy) in outpatient medical settings in LMICs. Article screening and data extraction were performed using Covidence software. Data extraction by two authors utilized a checklist of key components of effective interventions. Information was aggregated to examine how frequently the components were applied. Our search yielded 25 articles describing 20 Collaborative Care models that treated depression, anxiety, schizophrenia, alcohol use disorder or epilepsy in nine different LMICs. Fourteen of these models demonstrated statistically significantly improved clinical outcomes compared to comparison groups. Successful models shared key structural and process-of-care elements: a multi-disciplinary care team with structured communication; standardized protocols for evidence-based treatments; systematic identification of mental disorders, and a stepped-care approach to treatment intensification. There was substantial heterogeneity across studies with respect to the specifics of model components, and clear evidence of the importance of tailoring the model to the local context. This review provides evidence that Collaborative Care is effective across a range of mental disorders in LMICs. More work is needed to demonstrate population-level and longer-term outcomes, and to identify strategies that will support successful and sustained implementation in routine clinical settings.

Learning from national implementation of the Veterans Affairs Clinical Resource Hub (CRH) program for improving access to care: protocol for a six year evaluation.

BACKGROUND: The Veterans Affairs (VA) Clinical Resource Hub (CRH) program aims to improve patient access to care by implementing time-limited, regionally based primary or mental health staffing support to cover local staffing vacancies. VA's Office of Primary Care (OPC) designed CRH to support more than 1000 geographically disparate VA outpatient sites, many of which are in rural areas, by providing virtual contingency clinical staffing for sites experiencing primary care and mental health staffing deficits. The subsequently funded CRH evaluation, carried out by the VA Primary Care Analytics Team (PCAT), partnered with CRH program leaders and evaluation stakeholders to develop a protocol for a six-year CRH evaluation. The objectives for developing the CRH evaluation protocol were to prospectively: 1) identify the outcomes CRH aimed to achieve, and the key program elements designed to achieve them; 2) specify evaluation designs and data collection approaches for assessing CRH progress and success; and 3) guide the activities of five geographically dispersed evaluation teams. METHODS: The protocol documents a multi-method CRH program evaluation design with qualitative and quantitative elements. The evaluation's overall goal is to assess CRH's return on investment to the VA and Veterans at six years through synthesis of findings on program effectiveness. The evaluation includes both observational and quasi-experimental elements reflecting impacts at the national, regional, outpatient site, and patient levels. The protocol is based on program evaluation theory, implementation science frameworks, literature on contingency staffing, and iterative review and revision by both research and clinical operations partners. DISCUSSION: Health systems increasingly seek to use data to guide management and decision-making for newly implemented clinical programs and policies. Approaches for planning evaluations to accomplish this goal, however, are not well-established. By publishing the protocol, we aim to increase the validity and usefulness of subsequent evaluation findings. We also aim to provide an example of a program evaluation protocol developed within a learning health systems partnership.

Racial and ethnic disparities in telemental health usage among veterans.

It is essential for mental health services to be equitably accessible and utilized. The literature on mental health service utilization has, to date, been focused largely on in-person care. This quality assurance project evaluated telemental health (TMH) utilization rates among Veterans by race and ethnicity. Following the rapid expansion of TMH in response to the COVID-19 pandemic, we also explored whether TMH use across racial and ethnic Veteran groups changed after the onset of the pandemic. Using chi-square analyses, we compared the observed race and ethnicity of Veterans receiving TMH to the expected race and ethnicity of Veterans receiving TMH, controlling for rurality. We found that TMH was not being utilized by all racial and ethnic groups within the Veteran population as would be expected, both before and during the pandemic. Improvements were noted during the pandemic when much of outpatient mental health care was converted to telehealth. The strengths and limitations of this project, recommendations for TMH, and potential future directions are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

VA Outreach Is an Essential Area for Improving Veterans' Health Care Accessibility.

INTRODUCTION: The Veterans Health Administration (VHA) is tasked with providing access to health care to veterans of military service. However, many eligible veterans have either not yet enrolled or underutilized VHA services. Further study of barriers to access before veterans enroll in VHA care is necessary to understand how to address this issue. The ChooseVA (née MyVA Access) initiative aims to achieve this mission to improve veterans' health care access. Although veteran outreach was not specifically addressed by the initiative, it is a critical component of improving veterans' access to health care. Findings from this multisite evaluation of ChooseVA implementation describe sites' efforts to improve VHA outreach and veterans' experiences with access. MATERIALS AND METHODS: This quality improvement evaluation employed a multi-method qualitative methodology, including 127 semi-structured interviews and 81 focus groups with VHA providers and staff ("VHA staff") completed during 21 VHA medical center facility site visits between July and November 2017 and 48 telephone interviews with veterans completed between May and October 2018. Interviews and focus groups were transcribed and analyzed using deductive and inductive analysis to capture challenges and strategies to improve VHA health care access (VHA staff data), experiences with access to care (veteran data), barriers and facilitators to care (staff and veteran data), contextual factors, and emerging categories and themes. We developed focused themes describing perceived challenges, descriptions of VHA staff efforts to improve veteran outreach, and veterans' experiences with accessing VHA health care. RESULTS: VHA staff and veteran respondents reported a lack of veteran awareness of eligibility for VHA services. Veterans reported limited understanding of the range of services offered. This awareness gap served as a barrier to veterans' ability to successfully access VHA health care services. Veterans described this awareness gap as contributing to delayed VHA enrollment and delayed or underutilized health care benefits and services. Staff focused on community outreach and engaging veterans for VHA enrollment as part of their efforts to implement the ChooseVA access initiative. Staff and veteran respondents agreed that outreach efforts were helpful for engaging veterans and facilitating access. CONCLUSIONS: Although efforts across VHA programs informed veterans about VHA services, our results suggest that both VHA staff and veterans agreed that missed opportunities exist. Gaps include veterans' lack of awareness or understanding of VHA benefits for which they qualify for. This can result in delayed access to care which may negatively impact veterans, including those separating from the military and vulnerable populations such as veterans who experience pregnancy or homelessness.

Interprofessional transformation of clinical education: The first six years of the Veterans Affairs Centers of Excellence in Primary Care Education.

This paper describes the Centers of Excellence in Primary Care Education (CoEPCE), a seven-site collaborative project funded by the Office of Academic Affiliations (OAA) within the Veterans Health Administration of the United States Department of Veterans Affairs (VA). The CoEPCE was established to fulfill OAA's vision of large-scale transformation of the clinical learning environment within VA primary care settings. This was accomplished by funding new Centers within VA facilities to develop models of interprofessional education (IPE) to teach health professions trainees to deliver high quality interprofessional team-based primary care to Veterans. Using reports and data collected and maintained by the National Coordinating Center over the first six years of the project, we describe program inputs, the multicomponent intervention, activities undertaken to develop the intervention, and short-term outcomes. The findings have implications for lessons learned that can be considered by others seeking large-scale transformation of education within the clinical workplace and the development of interprofessional clinical learning environments. Within the VA, the CoEPCE has laid the foundation for IPE and collaborative practice, but much work remains to disseminate this work throughout the national VA system.

Designing and Implementing TeleBehavioral Health Training to Support Rapid and Enduring Transition to Virtual Care in the COVID Era.

As telebehavioral health continues to advance and become part of routine care, there is a need to develop effective training methods. While a consensus on how to best train telebehavioral health has not yet been achieved, this commentary will describe how evidence-based implementation strategies were used to develop a framework to create and implement a telebehavioral health training program that is relevant and enduring for a given audience. Evidence-based implementation strategies included the PARiHS criteria which were used to organize the project. Re-AIM criteria was used to organize chosen outcome measures. Important partnerships were formed to help support infrastructure as well as regional and national reach. A series of Plan-Do-Study-Act loops were used to inform progressive training series. Since April 2020, the Behavioral Health Institute has developed and offered 6 unique telebehavioral health training series, employing both webinar and online formats, and addressing core components as well as more advanced concepts. These series have provided over 19,100 accredited continuing education hours of training through June 2022, to almost 3000 unique learners via webinar and nearly 6800 unique online learners, across 45 states. Evaluations rated these trainings as high quality, relevant, and that material would likely be implemented. Feedback from attendees was considered vital in series planning. This commentary discusses how evidence-based implementation strategies can be used to create a framework upon which to base a training program for health care providers. An example is given on how this framework was used to create successful, relevant, and enduring telebehavioral health training.

Deploying a telemedicine collaborative care intervention for posttraumatic stress disorder in the U.S. Department of Veterans Affairs: A stepped wedge evaluation of an adaptive implementation strategy.

OBJECTIVE: To address barriers to trauma-focused psychotherapy for veterans with posttraumatic stress disorder (PTSD), we compared two implementation strategies to promote the deployment of telemedicine collaborative care. METHOD: We conducted a Hybrid Type III Effectiveness Implementation trial at six VA medical centers and their 12 affiliated Community Based Outpatient Clinics. The trial used a stepped wedge design and an adaptive implementation strategy that started with standard implementation, followed by enhanced implementation for VA medical centers that did not achieve the performance benchmark. Implementation outcomes for the 544 veterans sampled from the larger population targeted by the intervention were assessed from chart review (care management enrollment and receipt of trauma-focused psychotherapy) and telephone survey (perceived access and PTSD symptoms) after each implementation phase. The primary outcome was enrollment in care management. RESULTS: There was no significant difference between standard implementation and enhanced implementation on any of the implementation outcomes. 41.6% of sampled veterans had a care manager encounter, but only 6.0% engaged in trauma-focused psychotherapy. CONCLUSIONS: While telemedicine collaborative care was shown to be effective at engaging veterans in trauma-focused psychotherapy in a randomized controlled trial, neither standard nor enhanced implementation strategies were sufficient to support successful deployment into routine care. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02737098.

A comparison of patient-reported mental health outcomes for the Department of Veterans Affairs' regional telehealth and Community Care Programs.

OBJECTIVES: To compare patient-reported outcomes for veterans with limited access to Department of Veterans Affairs (VA) mental health services referred to the Veterans Community Care Program (VCCP) or regional telehealth Clinical Resource Hubs-Mental Health (CRH-MH). DATA SOURCES: This national evaluation used secondary data from the VA Corporate Data Warehouse, chart review, and primary data collected by baseline survey between October 8, 2019 and May 27, 2020 and a 4-month follow-up survey. STUDY DESIGN: A quasi-experimental longitudinal study design was used to sample 545 veterans with VCCP or CRH-MH referrals for new treatment episodes. Patient-reported outcomes included symptom severity, perceived access, utilization, and patient-centeredness. DATA COLLECTION: During the baseline and follow-up surveys, all veterans were administered the Patient Health Questionnaire-8 (PHQ-8) to assess depression severity, and veterans with a provisional diagnosis of posttraumatic stress disorder (PTSD) were also administered the PTSD Checklist for DSM-5 (PCL-5) to assess PTSD symptom severity. The 4-month follow-up survey also asked about perceived access using the Perceived Access Inventory, the number of encounters, and patient-centeredness of care using the Patient-Centered Care portion of the Veterans Satisfaction Survey. PRINCIPAL FINDINGS: Results indicated that compared to VCCP consults, veterans with CRH-MH consults reported 0.65 (CI95  = 0.51-0.83, p < 0.01) times the number of barriers to care, but a non-significant lower number of encounters (-0.792, CI95 -2.221, 0.636, p = 0.28). There was no significant (p = 0.24) difference in satisfaction with patient-centeredness, with both groups "agreeing" on average to positively worded questions. Veterans in both groups experienced little improvement in depression or PTSD symptom severity, and there were no clinically meaningful differences between groups. CONCLUSIONS: Overall findings indicate that the CRH-MH and VCCP generate similar patient-reported outcomes. Future research should compare the quality and cost of care delivered by the VCCP and CRH-MH programs.

An examination of suicidal behaviour among veterans receiving mental-health appointments in person versus clinical video telehealth.

INTRODUCTION: The US Department of Veterans Affairs (VA) is a national leader in the implementation of clinical video telehealth (CVT) services. Despite the growth of mental-health services offered via CVT, it is unclear to what extent these services are offered and accessed by veterans with previous suicidal behaviour. METHODS: The current quality improvement project examined this question within a local VA health-care system using data from suicide behaviour reports (SBRs), the Veteran Health Administration's official reporting and surveillance system. The frequency of SBRs was compared during two different time points among veterans who received individual mental-health appointments in person only or via CVT during the 2017 calendar year. Among veterans with a SBR, time in days elapsed from their first mental-health appointment to a SBR was examined as a function of treatment modality. RESULTS: Results indicated veterans who received in-person treatment only were more likely to present with a SBR six months prior to their first mental-health appointment compared to those who received CVT during the observation period. There were no differences in SBRs during the 12 months after the first appointment or the time from the first appointment to the SBR as a function of treatment modality used. DISCUSSION: Although veterans who received in-person mental-health services were more likely to have had a SBR six months prior to treatment, suicide risk throughout the observation period did not differ between groups. Clinical implications that arise from these findings are described in the discussion.

Brief Cognitive-Behavioral Therapy for Suicide Prevention (BCBT-SP) via Video Telehealth: A Case Example During the COVID-19 Outbreak.

Although veterans living in remote/rural areas are at elevated risk for suicide, there is very little research specific to treating suicidal veterans who present with barriers to in-person care. The current study aims to examine the delivery of brief cognitive-behavioral therapy for suicide prevention (BCBT-SP) via Clinical Video Telehealth (CVT) to the home of a veteran discharged from the psychiatric inpatient unit after a recent suicide attempt. Preliminary data on acceptability, feasibility, and changes in symptoms were gathered. The veteran received treatment during the 2020 COVID-19 outbreak and additional adaptations were made accordingly. The veteran did not engage in any suicidal behavior during the course of treatment, and suicidal ideation, depression, and anxiety decreased as treatment progressed. The results provide initial support for the feasibility of BCBT-SP via CVT to the home.

Posttraumatic stress disorder collaborative care: A quality improvement study in veterans affairs primary care.

Introduction: Collaborative care improves depression and anxiety outcomes. In this naturalistic, observational case study, we adapted an evidence-based depression collaborative care protocol for the assessment and treatment of posttraumatic stress disorder (PTSD) and sought to demonstrate that the protocol could be implemented in Veterans Affairs (VA) primary care. Method: Based on feedback from a content expert panel, clinical stakeholders, and a pilot study conducted in a postdeployment clinic, the original depression collaborative care protocol was modified to include PTSD assessment and support for PTSD medication adherence, self-management, and engagement in evidence-based PTSD care. Results: The modified program was implemented from November 2012 to March 2017, and 239 patients with PTSD were referred. Nearly two thirds (n = 185) enrolled, and they participated in the program for an average of 4 to 5 months and completed calls approximately once per month. Among patients with more than one assessment of clinical outcomes, 53.4% (n = 94) reported clinically significant improvement in depression on the Patient Health Questionnaire-9 (≥ 5-point decrease), and 42.2% (n = 35) reported clinically significant improvement on the PTSD Checklist (≥ 10-point decrease). Veterans and clinical staff described the modified collaborative care program positively in qualitative interviews. Discussion: Our findings suggest that a depression collaborative care program can be modified to support treatment of PTSD in primary care. The modified program was acceptable to both veterans and clinical staff and showed potential for positive clinical change in an uncontrolled quality improvement study. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Implementation of a Telemental Health Training Program Across a Mental Health Department.

Introduction: Telemental health (TMH) has increased substantially. However, health care systems have found it challenging to implement TMH ubiquitously. A quality improvement project guided by implementation science methodology was used to design and implement a TMH training program. Materials and Methods: Implementation science methodology (Promoting Access to Research Implementation in Health Services, Reach-Effectiveness-Adoption-Implementation-Maintenance, Implementation/Facilitation) provided the framework to design and implement the training program. A total of 100 interdisciplinary mental health providers from outpatient mental health clinics participated. Results: Providers reported satisfaction with the training program. Results indicated that the training increased providers' TMH knowledge and competence. The number of providers using TMH and patients who received TMH nearly doubled. Conclusions: Implementation science methodology was important in creating an organizational framework at this facility to design, evaluate, and implement an innovative TMH training program.

Telemental health training in the Veterans Administration Puget Sound Health Care System.

As a pioneer of training in the field of psychology, the Veterans Affairs (VA) HealthCare System serves as a leader in the training in and provision of Telemental Health (TMH) services in the United States. To meet goals toward continued expansion of these services, the VA TMH training program includes both web-based didactic courses and a skills competency test at a basic level with supervision and consultation in TMH for more advanced training and is available to staff psychologists and psychologist trainees. Despite these efforts, barriers for training in and implementation of TMH occur at the provider, system, and patient level. At the national level, the VA is actively working to resolve these barriers and we share site-specific examples implemented by the VA Puget Sound Health Care System promoting access through TMH team to further address barriers to training and implementation.

Recommendations for Using Clinical Video Telehealth with Patients at High Risk for Suicide.

There is increasing evidence that the delivery of mental health services via clinical video telehealth (CVT) is an effective means of providing services to individuals with access barriers, such as rurality. However, many providers have concerns about working with individuals at risk for suicide via this modality, and many clinical trials have excluded individuals with suicide risk factors. The present article reviews the literature, professional guidelines, and laws that pertain to the provision of mental health services via CVT with high-risk patients and provides suggestions for adapting existing best-practice recommendations for assessing and managing suicide risk to CVT delivery.

Practical and Regulatory Considerations of Teleprescribing via CVT.

PURPOSE OF REVIEW: Clinical video teleconferencing (CVT) represents a robust mechanism for more accessible medical care. Providers who practice medicine via CVT, including teleprescribing, should understand a number of core practical and regulatory factors. This paper aims to review these core factors, such that providers new to CVT may offer teleprescribing services in a manner consistent with current clinical standards and regulatory requirements. RECENT FINDINGS: A number of practical factors relate to the setup and delivery of teleprescribing services that are contextually influenced by federal and state law. This review will elucidate the practical and regulatory factors relevant to teleprescribing and encourage the use of CVT for patient care. Through consideration of these factors, providers may better implement teleprescribing and prepare for future technology and policy changes relevant to practice.

A pilot trial of telephone-based collaborative care management for PTSD among Iraq/Afghanistan war veterans.

BACKGROUND: Collaborative care and care management are cornerstones of Primary Care-Mental Health Integration (PC-MHI) and have been shown to reduce depressive symptoms. Historically, the standard of Veterans Affairs (VA) collaborative care was referring patients with posttraumatic stress disorder (PTSD) to specialty care. Although referral to evidence-based specialty care is ideal, many veterans with PTSD do not receive such care. To address this issue and reduce barriers to care, VA currently recommends veterans with PTSD be offered treatment within PC-MHI as an alternative. The current project outlines a pilot implementation of an established telephone-based collaborative care model-Translating Initiatives for Depression into Effective Solutions (TIDES)-adapted for Iraq/Afghanistan War veterans with PTSD symptoms (TIDES/PTSD) seen in a postdeployment primary care clinic. MATERIALS AND METHODS: Structured medical record extraction and qualitative data collection procedures were used to evaluate acceptability, feasibility, and outcomes. RESULTS: Most participants (n=17) were male (94.1%) and white (70.6%). Average age was 31.2 (standard deviation=6.4) years. TIDES/PTSD was successfully implemented within PC-MHI and was acceptable to patients and staff. Additionally, the total number of care manager calls was positively correlated with number of psychiatry visits (r=0.63, p<0.05) and amount of reduction in PTSD symptoms (r=0.66, p<0.05). Overall, participants in the pilot reported a significant reduction in PTSD symptoms over the course of the treatment (t=2.87, p=0.01). CONCLUSIONS: TIDES can be successfully adapted and implemented for use among Iraq/Afghanistan veterans with PTSD. Further work is needed to test the effectiveness and implementation of this model in other sites and among veterans of other eras.

VA Puget Sound Telemental Health Service to rural veterans: a growing program.

The VA Puget Sound Health Care System Telemental Health program connects veterans with psychologists, psychiatrists, and social workers via live clinical video teleconferencing. Providers deliver care to veterans in rural Veteran Affairs medical centers, community-based outpatient clinics and residences, and thus, increase access to specialty mental health care for rural and medically underserved veteran communities.