Veterans' perceptions of behavioral health care in the veterans health administration: a national survey

Satisfaction with health and community services among homeless and formerly homeless individuals in Quebec, Canada

User satisfaction is a crucial quality indicator in health service provision. Few studies have measured user satisfaction among homeless and formerly homeless individuals, despite the high prevalence of mental health disorders (MHD) in this population. The purpose of this study was to assess overall satisfaction among 455 homeless and formerly homeless individuals who were receiving health and community services, and to identify factors associated with user satisfaction. Data collection occurred between January and September 2017. Study participants were 18 years old or over, with experience of homelessness in the current or recent past. They completed a questionnaire eliciting socio-demographic information, and data on residential history, service use and satisfaction and health profiles. Multivariate linear analysis was performed on overall satisfaction with health and community services in the previous 12 months. Independent variables were organised as predisposing, enabling and needs factors based on the Gelberg-Andersen Behavioral Model. The mean satisfaction score was 4.11 (minimum: 1; maximum: 5). Variables associated with greater user satisfaction included: older age, residence in permanent housing, common MHD (e.g., depression, anxiety), having a family physician, having a case manager, strong social network, good quality of life and, marginally, male sex and having substance use disorders (SUD). By contrast, frequent users of public ambulatory health services were the most dissatisfied. User satisfaction was more strongly associated with enabling factors. Strategies for improving satisfaction include: promoting more tailored primary care programmes (including family physician) adapted to the needs of this population, better integrating primary care with specialised services including SUD integrated treatment and enhancing continuity of care through the reinforcement of case management services. Further efforts aimed at increasing access to permanent housing with supports, and eliciting more active involvement by relatives and friends may also improve user satisfaction with services, and reduce unnecessary service use.

Behavioral Health Treatment Receipt Among a Community Sample of Young Adult Veterans

Young adult veterans are at risk for behavioral health problems such as depression, posttraumatic stress disorder (PTSD), and substance misuse. Despite this, studies of veterans within the Veterans Affairs Healthcare System (VA) indicate that about half of those warranting treatment receive it in any form, with few receiving an adequate dose of care. For this study, the behavioral health screening status and behavioral health usage (including care outside of VA settings) among a community sample of 812 young adult veterans recruited from the Internet is described. Although approximately 70% of the sample screened positive for behavioral health problems, only one fifth to three fifths of those screening positive reported any mental health or substance use treatment in the past year, with one third or less receiving a dose of minimally adequate psychotherapy or psychotropic care. Findings expand on prior work and suggest that more effort is necessary to engage young veterans in behavioral health services.

Measuring and improving the quality of mental health care: a global perspective

Mental disorders are common worldwide, yet the quality of care for these disorders has not increased to the same extent as that for physical conditions. In this paper, we present a framework for promoting quality measurement as a tool for improving quality of mental health care. We identify key barriers to this effort, including lack of standardized information technology-based data sources, limited scientific evidence for mental health quality measures, lack of provider training and support, and cultural barriers to integrating mental health care within general health environments. We describe several innovations that are underway worldwide which can mitigate these barriers. Based on these experiences, we offer several recommendations for improving quality of mental health care. Health care payers and providers will need a portfolio of validated measures of patient-centered outcomes across a spectrum of conditions. Common data elements will have to be developed and embedded within existing electronic health records and other information technology tools. Mental health outcomes will need to be assessed more routinely, and measurement-based care should become part of the overall culture of the mental health care system. Health care systems will need a valid way to stratify quality measures, in order to address potential gaps among subpopulations and identify groups in most need of quality improvement. Much more attention should be devoted to workforce training in and capacity for quality improvement. The field of mental health quality improvement is a team sport, requiring coordination across different providers, involvement of consumer advocates, and leveraging of resources and incentives from health care payers and systems.

Improving Quality Outcomes in Veteran-Centric Care

The University of Alabama at Birmingham (UAB) School of Nursing and the Birmingham Veterans Affairs Medical Center (BVAMC) created a Psychiatric-Mental Health Nurse Practitioner (PMHNP) Residency Continuity Clinic tasked with providing Veteran-centric mental health outpatient treatment informed by measurement-based care (MBC) to provide quality outcomes. Approved by the BVAMC, the UAB Institutional Review Board also approved and exempted the project as quality improvement. PMHNP residents administered the Patient Stress Questionnaire (PSQ)-an MBC tool that incorporates validated tools for assessing depression, anxiety, posttraumatic stress, alcohol use, and pain-to each Veteran from March to August 2016. Patient outcomes focused on depression and anxiety. PSQ scores were reviewed retrospectively via descriptive statistics, paired t tests, and Wilcoxon signed ranks tests. Analysis showed improvement in depression and anxiety that approached significance, and in several national Veterans Affairs mental health performance measures, reinforcing the importance of using MBC in psychiatric assessment. [Journal of Psychosocial Nursing and Mental Health Services, 55(1), 37-44.].

The association of mental health program characteristics and patient satisfaction

OBJECTIVES

Satisfaction with care is an important patient-centered domain of health system quality. However, satisfaction measures are costly to collect and not directly modifiable. Therefore, we assessed the relationships between veterans' satisfaction and measures of modifiable aspects of Veterans Health Administration (VHA) mental health care programs.

STUDY DESIGN

For a sample of 6990 patients who received mental health care from the VHA in 2013, we used survey and administrative data to investigate the association of a suite of access and encounter satisfaction measures with a large collection of measures of program characteristics.

METHODS

We estimated risk-adjusted correlations between 6 satisfaction measures (across 2 domains: access and encounter satisfaction) and 28 mental health care program characteristics (across 4 domains: program reach, psychosocial service access, program intensity, and treatment continuity).

RESULTS

We found that satisfaction with access to care was higher than experiences with care encounters, but that broad measures of mental health care program reach and intensity were positively associated with both kinds of satisfaction. No measures of psychosocial service access were positively associated with access and encounter satisfaction. Most measures of treatment continuity were consistently and positively associated with both kinds of satisfaction.

CONCLUSIONS

As the VHA strives to increase access to, and provision of, mental health care, policy makers and program managers should be aware that satisfaction with care, as it is currently measured, may not rise as more patients initiate treatment, unless continuity of care is maintained or enhanced.

"You Should Drink Less": Frequency and Predictors of Discussions Between Providers and Patients About Reducing Alcohol Use

BACKGROUND

Brief intervention is recommended for individuals who misuse alcohol, but studies vary on how frequently patients talk with their providers about alcohol use.

OBJECTIVES

We examined whether veterans who had recently screened positive for alcohol misuse reported having conversations about their alcohol use with their providers.

METHODS

Following a positive screening for alcohol misuse during a primary care visit in 2013, veterans completed a telephone interview on alcohol use, conversations with their providers about drinking, and factors potentially associated with such conversations. The final analysis sample included 881 veterans; we conducted descriptive statistics and multivariable regression analyses.

RESULTS

Most veterans (83%) reported that their provider asked about drinking. Among these, 65% reported being advised to drink less, and 36% reported being advised to abstain. Veterans who received their healthcare from Veterans Health Administration (VA) had over twice the odds of reporting advice to reduce/abstain from drinking (adjusted odds ratio (AOR) = 2.34, 95% confidence interval (CI) = 1.46, 3.75). Veterans who reported heavy episodic drinking were more likely to report advice to reduce/abstain from drinking than those who did not report (AOR = 1.83, 95% CI = 1.30, 2.57) and veterans who reported heavy drinking were more likely to report such advice (AOR = 2.40, 95% CI = 1.69, 3.40). Conclusions/Importance: Most veterans with alcohol misuse reported receiving advice to reduce or abstain from drinking. Veterans with excessive alcohol use and those receiving all or most of their care from VA were more likely to report receiving such advice. Self-report of receiving advice may be an important approach to assessing appropriate follow-up after detection of alcohol misuse.

Patient-Reported Offers of Alcohol Treatment for Primary Care Patients at High-Risk for an Alcohol Use Disorder

BACKGROUND

This study assessed patient-reported alcohol treatment offers by health care providers following routine annual screening for alcohol use in primary care.

METHODS

A telephone interview within 30 days of the annual screen assessed demographics, alcohol and other drug use, mental health symptoms, and offers of formal treatment for alcohol by a Veterans Affairs health care provider. We included male patients (n = 349) at high risk for an alcohol use disorder (AUD) who had not received alcohol treatment in the past 3 months. We assessed self-reported receipt of any offers of formal treatment for alcohol use and associations of offers of formal treatment for alcohol with demographic and clinical variables.

RESULTS

A total of 145 patients (41.5%) reported an offer of at least 1 type of formal treatment for alcohol use. More severe alcohol misuse (odds ratio, 1.07; 95% confidence interval, 1.03-1.11) and younger age (odds ratio, 0.97, 95% confidence interval, 0.95-0.99) were associated with reporting an offer of formal treatment.

CONCLUSION

Most primary care patients at high risk for an AUD were not offered treatment following annual screening. Our results highlight the importance of training primary care providers in what constitutes appropriate medical treatment for this population and the most effective ways of offering treatment.

Perceptions of behavioral health care among veterans with substance use disorders: results from a national evaluation of mental health services in the Veterans Health Administration

Understanding patients' perceptions of care is essential for health care systems. We examined predictors of perceptions of behavioral health care (satisfaction with care, helpfulness of care, and perceived improvement) among veterans with substance use disorders (SUD; n = 1,581) who participated in a phone survey as part of a national evaluation of mental health services in the U.S. Veterans Health Administration. In multivariate analyses, SUD specialty care utilization and higher mental health functioning were associated positively with all perceptions of care, and comorbid schizophrenia, bipolar, and PTSD were associated positively with multiple perceptions of care. Perceived helpfulness of care was associated with receipt of SUD specialty care in the prior 12 months (adjusted OR = 1.77, p<.001). Controlling for patient characteristics, satisfaction with care exhibited strong associations with perceptions of staff as supportive and empathic, whereas perceived improvement was strongly linked to the perception that staff helped patients develop goals beyond symptom management. Survey responses that account for variation in SUD patients' perceptions of care could inform and guide quality improvement efforts with this population.