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Veterans Health Administration Mental Health Program Evaluation PDF

215 Pages·2011·5.5 MB·English
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Veterans Health Administration Mental Health Program Evaluation Capstone Report Katherine E. Watkins, Harold Alan Pincus Sponsored by the U.S. Department of Veterans Affairs HEALTH The research described in this report was sponsored by the U.S. Department of Veterans Affairs and was conducted by Altarum Institute and RAND Health, a division of the RAND Corporation. Altarum Institute integrates independent research and client-centered consulting to deliver comprehensive, systems-based solutions that improve health and health care. A nonprofit, Altarum serves clients in the public and private sector. The RAND Corporation is a nonprofit institution that helps improve policy and decisionmaking through research and analysis. RAND’s publications do not necessarily reflect the opinions of its research clients and sponsors. R® is a registered trademark. © Copyright 2011 RAND Corporation Permission is given to duplicate this document for personal use only, as long as it is unaltered and complete. Copies may not be duplicated for commercial purposes. Unauthorized posting of RAND documents to a non-RAND website is prohibited. RAND documents are protected under copyright law. For information on reprint and linking permissions, please visit the RAND permissions page (http://www.rand.org/publications/ permissions.html). Published 2011 by the RAND Corporation 1776 Main Street, P.O. Box 2138, Santa Monica, CA 90407-2138 1200 South Hayes Street, Arlington, VA 22202-5050 4570 Fifth Avenue, Suite 600, Pittsburgh, PA 15213-2665 RAND URL: http://www.rand.org/ To order RAND documents or to obtain additional information, contact Distribution Services: Telephone: (310) 451-7002; Fax: (310) 451-6915; Email: Program Evaluation of VHA Mental Health Services Capstone Report Authors: Katherine E. Watkins Brad Smith Susan M. Paddock Thomas E. Mannle, Jr. Abigail Woodroffe Jacob Solomon Melony Sorbero Carrie Farmer Kimberly Hepner David M. Adamson Lanna Forrest Catherine Call Harold Alan Pincus Program Evaluation of VHA Mental Health Services: Capstone Report i PREFACE U.S. policymakers and medical professionals increasingly recognize that quality mental health care is a key contributor to better, healthier lives for veterans with mental illness, and that setting measurable goals, promoting evidence-based processes of care, and monitoring performance plays a vital role in improving healthcare delivery and, ultimately, patient outcomes. In 2004, responding to the U.S. government’s New Freedom Commission on Mental Health (2002), the U.S Department of Veterans Affairs (VA) finalized a 5-year Mental Health Strategic Plan (MHSP), which emphasizes mental health as an important part of veterans’ overall health. Major goals contained in the MHSP include raising awareness of the importance of mental health, eliminating disparities in services, increasing early mental health screening, assessments, and referrals to care, and providing high-quality, evidence-based care. In 2006, to assess progress toward MHSP goals, the VA commissioned RAND and the Altarum Institute to conduct an independent evaluation of the quality of the VA’s mental health care system. The request was pursuant to the Government Performance and Results Act, which requires executive branch agencies to evaluate their programs, and was in keeping with the VA’s commitment to ensuring to providing the best care to U.S. veterans. The RAND/Altarum team conducted the study between August 2006 and November 2010. The evaluation represents the most comprehensive evaluation of a mental health care system ever undertaken. The evaluation focused on the quality of care delivered to veterans with one or more of five mental health or substance abuse diagnoses: (1) schizophrenia; (2) bipolar disorder; (3) posttraumatic stress disorder (PTSD); (4) major depressive disorder; (5) substance use disorder (SUD). The evaluation’s results should be of interest to policymakers in the areas of national defense and veterans’ affairs, to mental health professionals, and to veterans and other audiences interested in veterans’ health issues. This research was conducted within the RAND/University of Pittsburgh Health Institute under subcontract to the Altarum Institute. The research was sponsored by the United States Department of Veterans Affairs. A profile of RAND Health, abstracts of its publications, and ordering information can be found at www.rand.org/health. Program Evaluation of VHA Mental Health Services: Capstone Report ii ACKNOWLEDGEMENTS The authors would like to thank the following who contributed to the production of this report. Our Steering Committee: Antonette Zeiss, Daniel Kivlahan, Robert Gresen, Kathy Henderson, Stanlie Daniels, Lynnette Nilan, Gregory Hinrichsen, Ira Katz, and Anita Lord Barbara Stephens, the Contracting Officer Technical Representative Our RAND Corporation quality reviewers Katherine Hoggatt, Greer Sullivan, and Paul Shekelle Katherine Gechter, Marcela Horvitz-Lennon, Robyn Gerdes, Leah Caldarone, and Teryn Maddox for their work on the contract James Torr and Lynn Polite for the work on editing, proofreading, and formatting the report Program Evaluation of VHA Mental Health Services: Capstone Report iii ABBREVIATIONS AOD alcohol or other drug dependence BMI body mass index BP bipolar I disorder CAPS Clinician-Administered PTSD Scales CBOC community-based outpatient clinic CBT cognitive behavioral therapy CERT Center for Education and Research on Therapeutics, Rutgers University CM contingency management, therapy COD co-occurring [mental health and substance use] disorders CPT Current Procedural Terminology CWT compensated work therapy DHHS Department of Health and Human Services DISCH NDE Discharge National Data Extract DoD Department of Defense DSM Diagnostic and Statistical Manual of Mental Disorders DSS Decision Support System, VHA E&M evaluation and management EBP evidence-based practice ECHO Evidence of Care and Health Outcomes survey ESS effective sample size FY fiscal year GAF Global Assessment of Functioning GLMM generalized linear mixed model HEDIS Healthcare Effectiveness Data and Information Set HIV human immunodeficiency virus ICD-9-CM International Classification of Diseases, 9th Revision, Clinical Modification IOM Institute of Medicine IT information technology MCS Mental Component Summary, VR-12 MDD major depressive disorder MH mental health MHEI Mental Health Enhancement Initiatives MHICM mental health intensive case management MHSP Mental Health Strategic Plan NCQA National Committee for Quality Assurance NDC National Drug Code NPCD National Patient Care Database NQF National Quality Forum NSDUH National Survey on Drug Use and Health NTE new treatment episode OEF/OIF Operation Enduring Freedom/Operation Iraqi Freedom OPC outpatient care file OUT NDE Outpatient National Data Extract Program Evaluation of VHA Mental Health Services: Capstone Report iv ABBREVIATIONS, CONTINUED PABAK prevalence-adjusted bias-adjusted kappa statistic PCS Physical Component Summary, VR-12 PFSA parent facility service area PTF patient treatment file PTSD posttraumatic stress disorder RCT randomized controlled trial RPT relapse prevention therapy SAMHSA Substance Abuse and Mental Health Services Administration SCHIZ schizophrenia SD Standard deviation SHEP Survey of Healthcare Experiences of Patients SSRI selective serotonin reuptake inhibitor SUD substance use disorder USPHSTF United States Public Health System Task Force VA Department of Veterans Affairs VAMC Veterans Administration medical center VHA Veterans Health Administration VISN Veterans Integrated Service Network VR-12 Veterans RAND 12 Item Health Survey VR-36 Veterans RAND 36 Item Health Survey Program Evaluation of VHA Mental Health Services: Capstone Report v Table of Contents Preface ............................................................................................................................................. ii Acknowledgements ......................................................................................................................... iii Abbreviations .................................................................................................................................. iv Abbreviations, continued ................................................................................................................. v Chapter 1. Introduction .................................................................................................................... 1 Background: Quality Improvement in Mental Health Care ................................................ 1 Assessing the VA’s Mental Health and Substance Use Care ............................................. 2 Goals of the Program Evaluation and Research Questions ................................................. 3 Overall Conceptual Framework for the Evaluation ............................................................ 4 Organization of the Report .................................................................................................. 7 References ........................................................................................................................... 7 Chapter 2. Methods .......................................................................................................................... 9 The Study Population .......................................................................................................... 9 Cohort Selection............................................................................................................. 9 Study Population for Veteran Survey and Medical Record Review ............................ 11 Evidence-Based Practices ................................................................................................. 12 Assessing VHA Performance at the VISN Level ............................................................. 13 Specific Steps in Assessing the Structure, Process, and Outcomes of VA Mental Health Care ............................................................................................................. 15 Structure ....................................................................................................................... 15 Process ......................................................................................................................... 16 Outcomes ..................................................................................................................... 19 Where to Find More Information About the Evaluation Methodology ............................ 21 References ......................................................................................................................... 22 Chapter 3. Veterans in the Study Cohort: A Detailed Profile ........................................................ 24 A Demographic and Clinical Overview of the Study Cohort ........................................... 24 Residence ..................................................................................................................... 27 Clinical Complexity and Functioning .......................................................................... 29 Utilization and Costs ......................................................................................................... 30 Utilization and Costs by Utilization Category ............................................................. 34 Utilization and Costs by Cohort ................................................................................... 35 Summary ........................................................................................................................... 37 Program Evaluation of VHA Mental Health Services: Capstone Report vi References ......................................................................................................................... 37 Chapter 4. The Structure and Capacity of VA Mental Health Care ............................................... 38 Policy Context of Facility Surveys ................................................................................... 38 Facility Survey Overview ................................................................................................. 39 Reported Availability and Accessibility of Mental Health Services ............................... 39 Acute Psychiatric Inpatient Beds ................................................................................. 40 Mental Health Crisis Management .............................................................................. 40 Psychotherapy and Pharmacotherapy .......................................................................... 41 PTSD and SUD Treatment Services ............................................................................ 42 Services for Women Veterans ..................................................................................... 43 Mental Health Consumer Councils and Mental Health Executive Committees .......... 44 Drive Times from Veterans’ Residences to Mental Health Services ........................... 45 Evidence-Based Practices ................................................................................................. 48 Availability of Evidence-Based Practices .................................................................... 48 Locations at Which EBPs Are Offered ........................................................................ 54 Extent of Alignment Between the Potential Target Population and the Availability of EBPs ............................................................................................... 55 Program Characteristics of EBPs ................................................................................. 58 VA Mental Health Workforce Characteristics .................................................................. 60 Recruitment Difficulties ............................................................................................... 60 Staff Retention ............................................................................................................. 61 Psychiatrist Board Certification ................................................................................... 62 Limitations ........................................................................................................................ 62 Summary ........................................................................................................................... 63 References ......................................................................................................................... 64 Chapter 5. Documented Processes of Care .................................................................................... 65 Findings for Assessment and Diagnosis ........................................................................... 65 Initial Assessments ....................................................................................................... 68 Follow-Up Assessments ............................................................................................... 69 New Treatment Episode Performance Indicators ............................................................. 69 Evidence-Based Practices ................................................................................................. 72 Substance-Use Disorders .................................................................................................. 76 Chronic-Disease Management .......................................................................................... 80 Trends in VHA Performance Over Time .......................................................................... 80 Follow-Up After Psychiatric Hospitalization ................................................................... 83 Program Evaluation of VHA Mental Health Services: Capstone Report vii Data Limitations ............................................................................................................... 86 Summary ........................................................................................................................... 86 References ......................................................................................................................... 87 Chapter 6. Variations in Care ......................................................................................................... 90 Data and Indicators ........................................................................................................... 91 Variation by Gender .......................................................................................................... 95 Variations in Characteristics ........................................................................................ 96 Variations in Performance Indicators .......................................................................... 97 Variation by Age ............................................................................................................. 100 Variations in Characteristics ...................................................................................... 101 Variations in Performance Indicators ........................................................................ 102 Variation by OEF/OIF Status.......................................................................................... 107 Variations in Characteristics and Utilization ............................................................. 107 Variations in Performance Indicators ........................................................................ 108 Variation by Rural/Urban Status ..................................................................................... 111 Variations in Veteran Characteristics ........................................................................ 112 Variations in Performance Indicators ........................................................................ 113 Variation by Diagnostic Cohort ...................................................................................... 116 Variations in the Study Cohort .................................................................................. 116 Variations in Performance Indicators ........................................................................ 117 Variation by VISN .......................................................................................................... 119 Variations in the Study Cohort .................................................................................. 119 Variations in Performance Indicators ........................................................................ 120 Limitations ...................................................................................................................... 125 Summary ......................................................................................................................... 125 References ....................................................................................................................... 126 Chapter 7. Veterans’ Perceptions and Outcomes of Care ............................................................ 129 Timeliness ....................................................................................................................... 129 Patient-Centeredness ....................................................................................................... 130 Reasons Cited for Using VHA Services ......................................................................... 131 Patient Satisfaction.......................................................................................................... 132 Veterans’ Perceptions of Their Own Improvement and the Helpfulness of Care ........... 134 Context: The ECHO Field Test Report ........................................................................... 135 Limitations ...................................................................................................................... 137 Summary ......................................................................................................................... 137 Program Evaluation of VHA Mental Health Services: Capstone Report vii i

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