Access to Health Care Among TRICARE-Covered Children.

TRICARE, the U.S. Department of Defense insurance program for eligible service members and their dependents, provides health care coverage to nearly 2 million children under the age of 18. Survey data and prior evaluations indicate that TRICARE-covered children face challenges in accessing pediatric health care, with the greatest challenges among children who have experienced frequent relocations and children with special health care needs. However, TRICARE has not measured pediatric patient experiences in accessing care since 2010. To fill this gap, RAND researchers analyzed national survey data on the experiences of caregivers of TRICARE-covered children and children with commercial insurance, public insurance, and no insurance to identify differences in access to pediatric care, necessary referrals, care coordination support, ability to pay medical bills, and other factors. Additional analyses highlight variations between children with different TRICARE plans, between children who have changed addresses more and less frequently, and between children with special health care needs and those without. The findings should help inform efforts to increase access to care for children across the Military Health System, as well as improvements to programs designed to support military families during relocations and those with children who have special health care needs.

Integrating Department of Defense and Department of Veterans Affairs Purchased Care: Preliminary Feasibility Assessment.

The U.S. Department of Defense (DoD) and U.S. Department of Veterans Affairs (VA) health systems provide services through a mix of direct care, delivered at government facilities, and purchased care, provided through the private sector, mainly by community-based providers who have entered into contracts with third-party administrators (TPAs). In the interest of expanding DoD-VA resource sharing that may lead to greater efficiencies and cost savings, the DoD/VA Joint Executive Committee is exploring options to integrate DoD and VA's purchased care programs. This preliminary feasibility assessment examined how an integrated approach to purchasing care could affect access, quality, and costs for beneficiaries, DoD, and VA and identified general legislative, policy, and contractual challenges to implementing an integrated purchased care program. An integrated approach to purchasing care is feasible under current legal and regulatory authorities, but policy changes may be needed-and the practicality of such an approach depends on the contract and network design. For example, legal/regulatory changes in how contracts are established would be required to achieve any real savings to the government. There are also differences in the populations served by TRICARE (DoD health care) and VA, particularly in terms of age and geographic location. Implementation would be further complicated by contractual differences in the TPA contracts for VA and DoD as they relate to network standards, provider payments, network participation requirements, and reporting requirements and incentive structures. As a result, there are significant uncertainties with respect to increased efficiency or cost savings for the government.

The Relationship Between Engagement in Online Support Groups and Social Isolation Among Military Caregivers: Longitudinal Questionnaire Study.

BACKGROUND: There is a lack of research on the effectiveness of online peer support groups for reducing social isolation and depressive symptoms among caregivers, and previous research has mixed results. OBJECTIVE: This study aimed to test whether military caregivers who joined a new online peer support community or engaged with an existing online community experienced decreased perceived social isolation and improved depressive symptoms over 6 months. METHODS: We conducted a longitudinal study of 212 military caregivers who had newly joined an online community and those who were members of other military caregiver groups. Multiple indicators of perceived social isolation and depressive symptoms were assessed at baseline and at 3 and 6 months. RESULTS: Compared with caregivers in the comparison group, caregivers who joined the new group experienced less perceived social isolation at 3 months (eg, number of caregivers in social network [unstandardized regression coefficients] b=0.49, SE 0.19, 95% CI 0.87 to 0.02), but this effect did not persist at 6 months. Those who engaged more with new or existing groups experienced less perceived social isolation over time (eg, number of caregivers in social network b=0.18, SE 0.06, 95% CI 0.02 to 0.27), and this relationship was mediated by increased interactions with other military caregivers (95% CI 0.0046 to 0.0961). Engagement with an online group was not associated with improvements in depressive symptoms. CONCLUSIONS: Online communities might help reduce social isolation when members engage with the group, but more intensive treatment is needed to improve depressive symptoms.

The US Military Health System: Promoting Readiness And Providing Health Care.

The US Military Health System (MHS) is a unique federal health care system with a critical mission: ensuring that America's military personnel are healthy; maintaining a ready medical force in support of operational forces around the world; and delivering a medical benefit to approximately 9.5 million beneficiaries. This article provides an overview of how the MHS relies upon the TRICARE program to deliver both direct care (delivered in military treatment facilities) and purchased care (delivered by network providers). The article also describes the history and evolution of the TRICARE program, presents information on the populations served and the volume and type of care rendered, and examines access and quality issues. Furthermore, it describes recent policy and operational changes that have influenced how the MHS delivers health care, placing these changes in the context of other challenges facing the US health care system.

Impact of financial reimbursement on retention rates in military clinical trial research: A natural experiment within a multi-site randomized effectiveness trial with active duty service members.

INTRODUCTION: Achieving adequate retention rates in clinical trials is essential to ensuring meaningful results. Although financial reimbursement is an effective strategy to increase participant retention, current policies restrict the use of federal funds to reimburse U.S. active duty Service members for research participation. It is unknown whether permitting financial reimbursement among this population would improve trial retention rates. A recent randomized effectiveness trial received approval to provide reimbursement to Service member participants several months after recruitment began, creating a natural experiment to study the effects of financial reimbursement on retention. MATERIALS AND METHODS: Active duty Service members recruited from six U.S. military treatment facilities (N = 666) were enrolled in a collaborative care study and completed assessments at baseline, three-, six-, and 12-months. Data on study assessment completion rates at three- and six-months were analyzed using the mixed-effects binary logit model to determine the probabilities of completing assessments based on reimbursement status. RESULTS: Participants who received reimbursement were significantly more likely to complete study assessments at both time-points than participants who did not receive reimbursement (p < 0.01). Survey completion was 5% and 4% greater among participants offered reimbursement at three- and six-month time-points, respectively. CONCLUSION: Results suggest that providing Service members with reimbursement for research participation is associated with modest increases in retention rates in clinical trials. Findings provide useful insight for researchers, funding agencies, and policy-makers in considering retention strategies to maximize the value and impact of military research.

Economic Spillover Effects of Intensive Unpaid Caregiving.

BACKGROUND: Growing evidence has documented economic spillover effects experienced by intensive caregivers across the lifecycle. These spillover effects are rarely incorporated in economic analyses of health interventions. When these costs are captured, it is shown that commonly applied methods for valuing caregiver time may be underestimating the true opportunity costs of informal care. We explore how intensive caregiving is associated with economic outcomes for caregivers aged 18 years and older. METHODS: We used the cross-sectional 2013 RAND Survey of Military and Veteran Caregivers, a survey of 3876 caregivers and non-caregivers aged 18 years and older to conduct multivariable analyses and calculate average marginal effects, focusing on the association between intensive caregiving (i.e., providing ≥ 20 h of weekly care) and six economic outcomes: schooling, labor force participation, taking unpaid time off of work, cutting back work hours, quitting a job, and early retirement. RESULTS: Intensive caregivers are 13 percentage points (95% confidence interval [CI] 8-18) less likely to be employed than non-caregivers. Intensive caregivers are 3 percentage points (95% CI 0.5-5) more likely to cut back schooling, 6 percentage points (95% CI 2-10) more likely to take unpaid time off of work, 4 percentage points (95% CI 0.1-9) more likely to cut back work hours, 12 percentage points (95% CI 8-15) more likely to quit a job, and 5 percentage points (95% CI 2-7) more likely to retire early due to caregiving responsibilities relative to non-intensive caregivers. CONCLUSIONS: Despite the difficulty of quantifying the true opportunity costs of informal care, policy makers and researchers need to understand these costs. The higher the opportunity costs of unpaid care provision, the less likely it is that caregivers will provide this care and the less economically attractive this 'free' source of care is from a societal perspective.

Bridging Gaps in Mental Health Care: Lessons Learned from the Welcome Back Veterans Initiative.

Over the past decade, there have been a growing number of efforts designed to support service members, veterans, and their families as they cope with deployments. Addressing the mental health consequences associated with these deployments has been a priority focus area across the government and nongovernment sectors. The Welcome Back Veterans (WBV) initiative was launched in 2008 by Major League Baseball and the Robert R. McCormick Foundation to support organizations that, in turn, provided programs and services to support veterans and their families. Since WBV's founding, it has issued grants to academic medical institutions around the nation to create and implement programs and services designed to address the mental health needs of returning veterans and their families. Since 2013, WBV has made strides in assisting service members, veterans, and families and in facilitating collaboration among systems of care in local communities. However, strategic efforts are needed to promote sustainability and address emerging challenges as individual programs move toward greater coordination with others in the system of care for veterans. WBV grantees and other programs must continue adapting to sustain their mental health service offerings to meet the demand for care but also to improve integration and coordination. Expanding collaborative networks and adopting a system-of-systems approach may help private mental health care programs like WBV continue to build capacity and have a positive effect going forward.

Informal Caregivers' Experiences and Perceptions of a Web-Based Peer Support Network: Mixed-Methods Study.

BACKGROUND: Web-based peer support interventions have shown promise in reducing social isolation and social support deficits among informal caregivers, but little research has examined how caregivers use and perceive these interventions. OBJECTIVE: In this study, we examined utilization and perceptions of a Web-based social support intervention for informal caregivers of wounded, ill, and injured United States military service members and veterans. METHODS: This was a mixed-methods study that used quantitative survey data and qualitative data from focus groups and interviews with informal caregivers enrolled in a Web-based peer support intervention to explore their use and perceptions of the intervention. The intervention was delivered via a website that featured interest groups organized around specific topics, webinars, webchats, and messaging functionality and was moderated by professionally trained peers. This study occurred in the context of a quasi-experimental outcome evaluation of the intervention, where intervention participants were compared with a group of military caregivers who were not enrolled in the intervention. RESULTS: Survey findings indicated that caregivers used the website infrequently, with 60.7% (128/211) visiting the website once a month or less, and passively, with a minority (32/144, 22.2%) of users (ie, those who had visited the website at least once during the past 3 months, N=144) posting comments or links to the network. Nonetheless, most users (121/144, 84.0%) endorsed moderate or greater satisfaction with the website on the survey, and focus group and interview participants reported benefiting sufficiently from passive use of the website (eg, reading posts). Quantitative and qualitative findings suggested that users viewed the website primarily as a source of informational support. Among 63.2% (91/144) of users who completed the survey, the most commonly reported network-related activity was obtaining information from the network's resource library, and focus group and interview participants viewed the network primarily as an informational resource. Focus group and interview participants expressed an unmet need for emotional support and the desire for a more personal touch in the forms of more active engagement with other caregivers in the network and the creation of local, in-person support groups for caregivers. CONCLUSIONS: These findings suggest that Web-based peer support interventions may lend themselves better to the provision of informational (vs emotional) support and may need to be supplemented by in-person peer support groups to better meet caregivers' needs for emotional support.

Online peer support groups for family caregivers: are they reaching the caregivers with the greatest needs?

Background: Online peer support groups are an increasingly common venue for caregivers supporting disabled family members to exchange informational, emotional, and instrumental support. We know very little, however, about who uses these groups and whether they are reaching those with the greatest needs. Objective: To examine whether caregiving factors (ie, caregiving demands and strain, competing demands, access to support and services, and other caregiving characteristics) are related to online community support use and intensity of use. Method: This study used data from a new survey of family caregivers who provide care to disabled military veterans. We used logistic regression models to examine the likelihood of online community support group usage and intensity of use as a function of a variety of caregiving factors. Results: Those with greater caregiving demands were more likely to use online peer support. Specifically, helping the care recipient with more activities was associated with a statistically significantly greater likelihood of visiting an online community support group. Caring for a veteran with a neurological or psychological condition, which, in prior work, suggests more complex care needs, was also positively and significantly related to visiting an online community support group. Hours of care and several other caregiving factors were related to intensity of use. Conclusions: We show that family caregivers with the most caregiving demands are most engaged with online support communities. This suggests that online communities could be used to support the most vulnerable family caregivers. The implications of this work for online support systems are discussed.

Delivering Clinical Practice Guideline-Concordant Care for PTSD and Major Depression in Military Treatment Facilities.

Providing accessible, high-quality care for psychological health (PH) conditions, such as posttraumatic stress disorder (PTSD) and major depressive disorder (MDD), is important to maintaining a healthy, mission-ready force. It is unclear whether the current system of care meets the needs of service members with PTSD or MDD, and little is known about the barriers to delivering guideline-concordant care. RAND used existing provider workforce data, a provider survey, and key informant interviews to (1) provide an overview of the PH workforce at military treatment facilities (MTFs), (2) examine the extent to which care for PTSD and MDD in military treatment facilities is consistent with Department of Veterans Affairs/Department of Defense clinical practice guidelines, and (3) identify facilitators and barriers to providing this care. This study provides a comprehensive assessment of providers' perspectives on their capacity to deliver PH care within MTFs and presents detailed results by provider type and service branch. Findings suggest that most providers report using guideline-concordant psychotherapies, but use varied by provider type. The majority of providers reported receiving at least minimal training and supervision in at least one recommended psychotherapy for PTSD and for MDD. Still, more than one-quarter of providers reported that limits on travel and lack of protected time in their schedule affected their ability to access additional professional training. Finally, most providers reported routinely screening patients for PTSD and MDD with a validated screening instrument, but fewer providers reported using a validated screening instrument to monitor treatment progress.

Supporting Veterans in Massachusetts: An Assessment of Needs, Well-Being, and Available Resources.

Massachusetts is home to approximately 380,000 of the nation's more than 21 million veterans, but there has been little research on the resources available to this population at the state level. There are numerous resources available to veterans and other military-affiliated groups in Massachusetts, but there are still pockets of unmet need in the areas of education, employment, health care, housing, financial, and legal services-particularly for newer veterans and current National Guard/reserve members. Although Massachusetts veterans fare better overall than their peers in other states, they lag behind other Massachusetts residents in terms of health and financial status. Massachusetts veterans and National Guard/reserve members who need support and services face such barriers as a lack of knowledge about how to access services, a lack of awareness about eligibility, and geographic distance from service providers. As the veteran population changes both nationally and in Massachusetts, it will be important for public- and private-sector providers serving Massachusetts veterans and service members to continue addressing unmet needs while ensuring that resources are responsive to shifts in these populations. A better understanding of the unique needs of Massachusetts veterans can help inform investments in initiatives that target these populations and guide efforts to remedy barriers to accessing available support services and other resources.

The Unified Behavioral Health Center for Military Veterans and Their Families: Documenting Structure, Process, and Outcomes of Care.

Many veterans and their families struggle with behavioral health problems, family reintegration difficulties, and relationship problems. Although many veterans are eligible to receive care at Department of Veterans Affairs health facilities, family members are generally not eligible and therefore must seek care elsewhere. This situation can pose a barrier to family members' access to care and also make it more difficult for veterans and families to receive high-quality services that are coordinated across providers. A new model of behavioral health care is trying to address these barriers: Created by the Northwell Health System and the Northport Veterans Affairs Medical Center, the Unified Behavioral Health Center (UBHC) for Military Veterans and Their Families in New York state is a public-private partnership that is providing colocated and coordinated care for veterans and their families. RAND evaluated the center's activities to document the implementation of a unique public-private collaborative approach for providing care to veterans and their families. The first component of the evaluation focused on documenting the structures of care (the capacities and resources that the center developed and employed) and the processes of care (the services delivered). The second component focused on outcomes of care. The evaluation suggests that, overall, the model has been successfully implemented by the UBHC and has great potential to be helpful to the veterans and families it serves.

Impact of TBI on caregivers of veterans with TBI: Burden and interventions.

OBJECTIVES: Describe State-of-the-Art in practice and research in caregiving with individuals, specifically, Veterans with traumatic brain injury (TBI) and the implications for current practice and future research. SOURCES: Professional literature and personal experience of review panel. MAIN OUTCOMES: Unpaid caregiving for individuals with TBI is most often provided by a spouse, parent or other blood relative; the majority of caregivers are women. Although caregiving can be rewarding, it also may create financial burden and psychological stress. Depression among family caregivers occurs four times more frequently than in the general population. Positive coping can help reduce the impact of stress, and Department of Veterans Affairs (VA) programmes are available to ease financial burden. Group interventions show promise in reinforcing and improving positive coping for both family caregivers and Veterans with TBI. CONCLUSIONS: Identifying the specific needs of caregivers and families of Veterans with TBI and other traumatic injuries, including post-traumatic stress syndrome (PTSD), will require further longitudinal research. Currently available group interventions and programmes appear to benefit injured Veterans and their family caregivers financially and psychologically. Increased understanding of characteristics of quality family caregiving and its long term costs and benefits is likely to lead to additional improvements in these interventions and programmes.

The Deployment Life Study: Longitudinal Analysis of Military Families Across the Deployment Cycle.

In 2009, RAND launched the Deployment Life Study, a longitudinal study of military families across a deployment cycle in order to assess family readiness. Family readiness refers to the state of being prepared to effectively navigate the challenges of daily living experienced in the unique context of military service. The study surveyed families at frequent intervals throughout a complete deployment cycle---before a service member deploys (sometimes months before), during the actual deployment, and after the service member returns (possibly a year or more after she or he redeployed). It assessed a number of outcomes over time, including: the quality of marital and parental relationshipsthe psychological, behavioral, and physical health of family memberschild and teen well-being (e.g., emotional, behavioral, social, and academic)military integration (e.g., attitudes toward military service, retention intentions).This culminating paper briefly reviews the study design and data collection procedures, presents results from analyses of the longitudinal data collected from some 2,700 military families, and offers recommendations for programs and future research related to military families. The research was jointly sponsored by the Office of the Surgeon General, U.S. Army, and by the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury.

Stakeholder Experiences in a Stepped Collaborative Care Study Within U.S. Army Clinics.

OBJECTIVE: This article examines stakeholder experiences with integrating treatment for posttraumatic stress disorder (PTSD) and depression within primary care clinics in the U.S. Army, the use-of-care facilitation to improve treatment, and the specific therapeutic tools used within the Stepped Treatment Enhanced PTSD Services Using Primary Care study. METHODS: We conducted a series of qualitative interviews with health care providers, care facilitators, and patients within the context of a large randomized controlled trial being conducted across 18 Army primary care clinics at 6 military installations. RESULTS: Most of stakeholders' concerns clustered around the need to improve collaborative care tools and care facilitators and providers' comfort and abilities to treat behavioral health issues in the primary care setting. CONCLUSIONS: Although stakeholders generally recognize the value of collaborative care in overcoming barriers to care, their perspectives about the utility of different tools varied. The extent to which collaborative care mechanisms are well understood, navigated, and implemented by providers, care facilitators, and patients is critical to the success of the model. Improving the design of the web-based therapy tools, increasing the frequency of team meetings and case presentations, and expanding training for primary care providers on screening and treatment for PTSD and depression and the collaborative care model's structure, processes, and offerings may improve stakeholder perceptions and usage of collaborative care.

Centrally Assisted Collaborative Telecare for Posttraumatic Stress Disorder and Depression Among Military Personnel Attending Primary Care: A Randomized Clinical Trial.

IMPORTANCE: It is often difficult for members of the US military to access high-quality care for posttraumatic stress disorder (PTSD) and depression. OBJECTIVE: To determine effectiveness of a centrally assisted collaborative telecare (CACT) intervention for PTSD and depression in military primary care. DESIGN, SETTING, AND PARTICIPANTS: The STEPS-UP study (Stepped Enhancement of PTSD Services Using Primary Care) is a randomized trial comparing CACT with usual integrated mental health care for PTSD or depression. Patients, mostly men in their 20s, were enrolled from 18 primary care clinics at 6 military installations from February 2012 to August 2013 with 12-month follow-up completed in October 2014. INTERVENTIONS: Randomization was to CACT (n = 332) or usual care (n = 334). The CACT patients received 12 months of stepped psychosocial and pharmacologic treatment with nurse telecare management of caseloads, symptoms, and treatment. MAIN OUTCOMES AND MEASURES: Primary outcomes were severity scores on the PTSD Diagnostic Scale (PDS; scored 0-51) and Symptom Checklist depression items (SCL-20; scored 0-4). Secondary outcomes were somatic symptoms, pain severity, health-related function, and mental health service use. RESULTS: Of 666 patients, 81% were male and the mean (SD) age was 31.1 (7.7) years. The CACT and usual care patients had similar baseline mean (SD) PDS PTSD (29.4 [9.4] vs 28.9 [8.9]) and SCL-20 depression (2.1 [0.6] vs 2.0 [0.7]) scores. Compared with usual care, CACT patients reported significantly greater mean (SE) 12-month decrease in PDS PTSD scores (-6.07 [0.68] vs -3.54 [0.72]) and SCL-20 depression scores -0.56 [0.05] vs -0.31 [0.05]). In the CACT group, significantly more participants had 50% improvement at 12 months compared with usual care for both PTSD (73 [25%] vs 49 [17%]; relative risk, 1.6 [95% CI, 1.1-2.4]) and depression (86 [30%] vs 59 [21%]; relative risk, 1.7 [95% CI, 1.1-2.4]), with a number needed to treat for a 50% improvement of 12.5 (95% CI, 6.9-71.9) and 11.1 (95% CI, 6.2-50.5), respectively. The CACT patients had significant improvements in somatic symptoms (difference between mean 12-month Patient Health Questionnaire 15 changes, -1.37 [95% CI, -2.26 to -0.47]) and mental health-related functioning (difference between mean 12-month Short Form-12 Mental Component Summary changes, 3.17 [95% CI, 0.91 to 5.42]), as well as increases in telephone health contacts and appropriate medication use. CONCLUSIONS AND RELEVANCE: Central assistance for collaborative telecare with stepped psychosocial management modestly improved outcomes of PTSD and depression among military personnel attending primary care. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01492348.

Barriers to Engaging Service Members in Mental Health Care Within the U.S. Military Health System.

OBJECTIVE: Over the past decade, there has been growing recognition of the mental health consequences associated with deployment and service by military service personnel. This study examined potential barriers to mental health care faced by members of the military in accessing needed services. METHODS: This qualitative study of stakeholders was conducted across six large military installations, encompassing 18 Army primary care clinics, within the context of a large randomized controlled trial. Stakeholders included patients recruited for the study (N=38), health care providers working within site clinics (N=31), and the care managers employed to implement the intervention protocol (N=7). RESULTS: Issues raised across stakeholder groups fell into two main categories: structural factors associated with the Army medical system and institutional attitudes and cultural issues across the U.S. military. Structural issues included concerns about the existing capacity of the system, for example, the number of providers available to address the population's needs and the constraints on clinic hours and scheduling practices. The institutional attitude and cultural issues fell into two main areas: attitudes and perceptions by the leadership and the concern that those attitudes could have negative career repercussions for those who access care. CONCLUSIONS: Although there have been significant efforts to improve access to mental health care, stakeholders within the military health system still perceive significant barriers to care. Efforts to ensure adequate and timely access to high-quality mental health care for service members will need to appropriately respond to capacity constraints and organizational and institutional culture.

Supporting the Mental Health Needs of Veterans in the Metro Detroit Area.

Supporting the mental health needs of veterans is a national priority. Over the past decade, there have been several studies describing the needs of the veteran population, particularly those who served in the post-9/11 era, calling for improved access to high-quality mental health services. In response, the federal government has expanded funding and services to meet increasing demand. At the same time, there has also been a proliferation of nongovernmental support to improve services for veterans in local communities. Often, in an attempt to deploy resources quickly, new programs and services are implemented without a full understanding of the specific needs of the population. This article discusses findings and recommendations from a study designed to gather information on the mental health-related needs facing veterans in the Detroit metropolitan area to identify gaps in the support landscape and inform future investments for community-level resources to fill the identified gaps.

Prevalence of, risk factors for, and consequences of posttraumatic stress disorder and other mental health problems in military populations deployed to Iraq and Afghanistan.

This review summarizes the epidemiology of posttraumatic stress disorder (PTSD) and related mental health problems among persons who served in the armed forces during the Iraq and Afghanistan conflicts, as reflected in the literature published between 2009 and 2014. One-hundred and sixteen research studies are reviewed, most of which are among non-treatment-seeking US service members or treatment-seeking US veterans. Evidence is provided for demographic, military, and deployment-related risk factors for PTSD, though most derive from cross-sectional studies and few control for combat exposure, which is a primary risk factor for mental health problems in this cohort. Evidence is also provided linking PTSD with outcomes in the following domains: physical health, suicide, housing and homelessness, employment and economic well-being, social well-being, and aggression, violence, and criminality. Also included is evidence about the prevalence of mental health service use in this cohort. In many instances, the current suite of studies replicates findings observed in civilian samples, but new findings emerge of relevance to both military and civilian populations, such as the link between PTSD and suicide. Future research should make effort to control for combat exposure and use longitudinal study designs; promising areas for investigation are in non-treatment-seeking samples of US veterans and the role of social support in preventing or mitigating mental health problems in this group.