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Appendix C: Mental and Substance Use Health for Veterans: Experience with Performance Evaluation in the Department of Veterans Affairs
Pages 423-482

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From page 423...
... The staff of NEPEC is responsible for most of the work reported here (but not for the errors, which are my own) , specifically project directors Mayur Desai PhD, Rani Desai PhD, Alan Fontana PhD, Greg Greenberg PhD, Wesley Kasprow PhD, Douglas Leslie PhD, Alvin Mares PhD, James McGuire PhD, Michale Neale PhD, Sandra Resnick PhD.
From page 424...
... Development of MH/SA Quality Measurement and Quality Management in VA During the past 20 years there have been two notable phases in the development of VA MH/SA services. The first was initiated by the leader of mental health programs in VA central office from 1985­1994 and involved expansion of specialized mental health programs such as Assertive Community Treatment, homeless
From page 425...
... Front-Line Experience Performance management in health care is sometimes experienced ambivalently by front line managers and clinicians. While they often feel empowered by access to data and find it allows them to improve the care they provide, there is also concern that measures are imperfect; that they do not take account of differences across facilities in case mix and in available community resources; that measures can be manipulated or "gamed," resulting in unfair comparisons; and that managerial pressure to improve performance sometimes creates an atmosphere of personal criticism more than joint problem solving.
From page 426...
... People with serious mental illness often have needs for diverse services including psychiatric care, substance abuse care, primary and specialty medical care, and numerous social services including income supports, employment, education, and housing assistance, as well as help negotiating with the criminal justice system. And yet each of these needs is addressed by a different set of agencies at different levels of government.
From page 427...
... Having presented the context of mental health performance management, in the next section (5) we present evidence concerning the safety, effectiveness, person-centeredness, timeliness, efficiency and equitability of VA mental health and substance abuse care as it has changed in recent years and as it compares to other health care systems.
From page 428...
... . Findings of greater rates of mental illness and especially substance abuse among veterans of the AVF are consistent with several studies showing greater substance use among military personnel in the immediate post
From page 429...
... . Similarly, an epidemiologic study that compared homeless veteran and nonveteran men in Los Angeles found that veterans were less likely to have nonsubstance abuse mental health disorders (47.5% vs.
From page 430...
... . Finally, the Connecticut Outcome Study compared 196 VA patients and 337 non-VA patients treated at nearby state-operated Community Mental Health Centers and also found no significant differences in measures of psychiatric symptoms or substance abuse, after adjustment for age, race and income (Desai et al., in press)
From page 431...
... and showing that, contrary to what was once popular belief, veterans with PTSD related to their military service do not avoid using VA mental health services. The PORT survey of the treatment of schizophrenia in Ohio and Georgia allows further comparison, with the group of severely mentally ill veterans, of those who used VA services (N = 350)
From page 432...
... II. TREATMENT OF MENTAL HEALTH AND SUBSTANCE ABUSE IN THE VA: PATIENTS, ADMINISTRATION, RELATIONSHIPS WITH OTHER FEDERAL AGENCIES, STAKEHOLDERS, AND CHANGES SINCE 1995 The VA is a cabinet level federal department that includes two major subdivisions that provide services to people with mental illness: (1)
From page 433...
... to FY 2000 (Seibyl et al., 2001) showed that almost 30% of VA psychiatric inpatients, and almost 50% of those in inpatient substance abuse programs, had been homeless at the time of admission.
From page 434...
... and day treatment centers were established as alternatives to hospitalization along with specialized inpatient and outpatient substance abuse programs and a transitional employment program that offered veterans the opportunity to work, first in workshop settings and subsequently at community jobs. More recently, specialized programs have been established to treat military-related PTSD; to conduct outreach and provide residential treatment for homeless veterans; to provide residential rehabilitation in community settings and to deliver specialized services to veterans with substance abuse problems.
From page 435...
... accreditation are VISN and VAMC responsibilities, in which the mental health service line managers are responsible for the performance of the mental health programs. Relationships with Other Federal Departments Collaboration to facilitate the transition from Department of Defense (DoD)
From page 436...
... Between 1995 and 2003, 66% of all general psychiatry inpatient beds and 96% of all inpatient substance abuse beds were closed. The number of long-term psychiatric patients, that is, those hospitalized for more than a year, declined by 81% and the number with psychiatric diagnoses on inpatient medical units declined by 93%.
From page 437...
... III. LINKAGE OF VETERANS WITH THE DOD AND OTHER MENTAL HEALTH, MEDICAL, AND SOCIAL SERVICE SYSTEMS As noted in the Introduction, VA is unique in American mental health care as an integrated national system providing comprehensive services to a designated population.
From page 438...
... Primary Care and Specialty Medical Services It might be expected that in an integrated system that provides both MH/SA and general medical services, access to medical services might be superior. However, two studies that used survey data to compare access to medical services among severely mentally ill patients in VA and non-VA MH systems failed to find any significant differences (Desai et al., in press-b; Rosenheck et al., 2000a)
From page 439...
... Outreach to these veterans did not result in substantially increased service use or costs as compared to outreach to other homeless veterans, although the benefit of this type of intervention has not been evaluated. Collaborative Relationships with Other Agencies There has been substantial emphasis on integrating systems of care, especially for homeless people with mental illness.
From page 440...
... Through CHALENG, all agencies concerned with services for homeless veterans are invited to meet at the local VAMC to review the unmet needs of homeless veterans and to plan collaborative interventions to address those needs. Analysis of data gathered at these meetings has suggested that interorganizational relationships are strongest where VA has invested funds in contracts with nonVA providers (McGuire et al., 2002)
From page 441...
... Errera took this exhortation to heart and in the final negotiations obtained agreement that he would use his Yale colleagues to evaluate new programs he might initiate. The VA's Northeast Program Evaluation Center (NEPEC)
From page 442...
... It was also effective in winning legitimacy for the programs in VA and in the Congress, which began to require annual reports on newly funded initiatives. During Errera's nine years in Washington, Congress funded hundreds of new programs for Vietnam veterans with PTSD; outreach and residential treatment for homeless veterans; both inpatient and outpatient substance abuse treatment; and community-oriented work restoration programs.
From page 443...
... Although performance monitoring and management of clinical practice runs counter to norms of professional autonomy, it seems to be accepted. Constraints on the funding decisions of local managers, however, especially over extended periods of time, have been far less acceptable.
From page 444...
... While reductions in general psychiatry inpatient beds were similar to those in non-MH specialties, almost all of the SA inpatient beds were closed. To provide alternative care, residential rehabilitation and domiciliary programs were expanded, and residential treatment for homeless veterans was purchased through contracts with local providers.
From page 445...
... , Kizer mandated the development of a National Mental Health Program Performance Monitoring System to be developed by the Northeast Program Evaluation Center, which has continued to monitor the programs begun during Errera's tenure. The "VA mental health report card" (Rosenheck and Cicchetti, 1995; Greenberg and Rosenheck, 2004a)
From page 446...
... 446 HEALTH CARE FOR MENTAL AND SUBSTANCE-USE CONDITIONS to be used to realize goals that are simultaneously professional (improving patient health) and more broadly political (changing organizational power configurations and values)
From page 447...
... The Appendix presents a more comprehensive set of program-specific measures used at the Northeast Program Evaluation Center to monitor and evaluate VA MH/SA care. Safety Suicide is perhaps the most serious safety risk in MH/SA care and is the eighth leading cause of death among men aged 45-64 nationally in the United States, with 22.4 deaths per 100,000 annually (U.S.
From page 448...
... However, allcause mortality is an imprecise measure of the quality of MH care. Another safety issue that has been systematically monitored in VA is the use of excessive doses of antipsychotic medication and antipsychotic polypharmacy, both of which pose increased risk of side effects.
From page 449...
... Further, while there is broad agreement on the need for case management and residential treatment for homeless people with mental illness (especially if direct placement in permanent housing is not available) , operational guidelines for the duration and intensity of such services have not been developed.
From page 450...
... . The monitoring of outcomes of residential treatment for homeless veterans poses a bigger challenge, since over 10,000 episodes of residential treatment are provided each year, through several different programs, at over 100 VA medical centers.
From page 451...
... Because the Center for Mental Health Services' ACCESS demonstration, which served homeless people with severe mental illness, was conducted by VA's Northeast Program Evaluation Center, measures were similar to those used in studies of VA homeless programs, thus facilitating comparison of 8­12 month outcomes. These outcomes (addressing psychiatric symptoms, SA, housing, employment, and receipt of benefits, among others)
From page 452...
... . Peer education groups for mental illness, another emphasis of the recovery movement in MH, have also begun to take hold in the VA setting (Resnick et al., 2004b)
From page 453...
... Even without adjustment for inflation, per capita costs for all inpatient and outpatient mental health care declined by 28%, from $3,560 in FY 1995 to $2,562 eight years later, in FY 2003. With inflation adjustment, the reduction in per capita cost would approach 70%.
From page 454...
... VI. FRONT-LINE EXPERIENCE Although there has been no systematic survey of the experiences of front line VA managers and clinicians with the implementation of performance management for MH/SA programs, this account would be incomplete if it did not include at least a few examples of their sometimes ambivalent reactions.
From page 455...
... are applied indiscriminantly to highly variable populations (i.e., without risk adjustment for differences in patient characteristics or differences in service environments)
From page 456...
... 2001. The effect of reforms on spending for veterans' substance abuse treatment, 1993­1999.
From page 457...
... West Haven, CT: Northeast Program Evaluation Center. Fontana AF, Rosenheck RA.
From page 458...
... 2002. Continuity of care and clinical effectiveness: Outcomes following residential treatment for severe substance abuse.
From page 459...
... 1999. Inpatient treatment of comorbid psychiatric and substance abuse disorders: A comparison of public sector and privately insured populations.
From page 460...
... : The Sixth National Performance Monitoring Report: FY 2002. West Haven, CT: Northeast Program Evaluation Center.
From page 461...
... 1998. The experience of black and white veterans in a residential treatment and work therapy program for substance abuse.
From page 462...
... 2003b. Progress report on new initiatives for Homeless Veterans from the Veterans Health Administration.West Haven, CT: North east Program Evaluation Center.
From page 463...
... 2002. Comparison of homeless veterans with other homeless men in a large clinical outreach program.
From page 464...
... Population Characteristics 25,196,036 57.7 3.8% 8.8% 25.6% 24.6% 29.6% 16.4% 83.3% 4.1% 3.9% 94.1% 5.9% 11.2% 30.0% 35.8% 23.0% Characteristics or Education Veterans Graduate Graduate Degree Population All Size School of Services 1 c Age School School High College Used Yr Higher <30 30­49 50­59 60­75 >75 White Black Hispani Other Male Female
From page 465...
... 465 page) next on 25.6% 57.7% 42.2% 36.2% 33.2% 49.0% 45.1% 59.6% 48.7% 20.7% 51.0% 20.7% 40.1% 49.7% 58.5% 39.8% 38.2% 46.1% 50.4% 48.9% (continued 46.8% 39.3% 13.8% 59.1% 3.0% 25.8% 12.1% 27.9% 30.5% 41.7% 31.5% 49.3% 6.9% 8.2% 4.0% 32.1% 42.8% 25.1% 44.9% 49.8% 28.2% 42.1% 41.2% 32.3% 40.3% 45.5% 33.6% 56.4% 38.6% 25.4% 41.2% 26.0% 38.7% 45.7% 45.3% 33.5% 33.0% 39.5% 42.5% 42.6% 12.8% 30.3% 26.8% 18.6% 25.5% 29.1% 22.0% 43.8% 25.6% 10.2% 28.7% 10.8% 26.1% 27.6% 27.7% 20.0% 19.1% 24.5% 26.2% 26.0% 55.1% 39.1% 5.9% 75.1% 5.31% 12.43% 7.18% 17.0% 27.9% 55.2% 40.1% 63.3% 18.2% 7.2% 3.5% 33.2% 46.1% 20.7% 39.3% 36.7% (for or or Medicare CHAMPUS)
From page 466...
... Used Health Past 49.3% 27.3% 28.2% 28.8% 25.7% 19.3% 18.0% 13.9% 12.1% 39.9% 19.9% 9.8% 43.1% 57.3% 43.2% 45.1% Total .5% (1) Population Characteristics 19.3% 20.5% 2.4% 12.2% 16.3% 25.6% 17.7% 4.9% 24.2% 30.2% 45.6% 1.2% 3.8% 6.2% 8.9% For Status Era Use WWII Good & Era & War continued War Health Drugs War Environmental War Era Service 1 of to Service*
From page 467...
... . than service 9.6% 2.6% of 87.8% 49.9% more in period with all at (first (veterans Connected interferes activities categories categories Connected Service health or Not <50% >50% work Service Mental *
From page 468...
... Used Odds Ratio 0.58 0.69 1.01 1.15 1.00 1.57 0.98 1.33 1.00 1.00 1.08 1.00 0.90 0.94 0.78 1.00 1.11 1.07 Analysis Higher Regression or Education Graduate Graduate Degree Logistic School 2 s School School High College ite Yr <30 30­49 50­59 60­75 >75 Black Hispanic Other Wh Male Female
From page 469...
... 469 23 21 22 9 3 5 24 6 35 34 19 37 29 20 25 12 page) next on Reference Reference Reference (continued 0.84-0.85 1.20-1.20 0.84-0.85 0.61-0.61 0.44-0.44 0.54-0.54 1.16-1.17 0.57-0.57 0.96-0.97 0.96-0.97 1.26-1.27 1.00-1.01 0.92-0.92 1.25-1.26 1.15-1.16 1.50-1.55 1.00 0.85 1.20 0.84 1.00 0.61 0.44 0.54 1.17 0.57 0.97 0.96 1.26 1.00 1.00 0.92 1.26 1.15 1.52 15 32 34 10 3 7 37 4 26 21 23 35 22 25 30 9 Reference Reference Reference 0.68-0.69 1.07-1.07 0.95-0.96 0.63-0.63 0.34-0.34 0.57-0.57 1.01-1.01 0.35-0.35 0.90-0.90 0.85-0.86 1.16-1.17 1.04-1.04 1.16-1.17 1.14-1.15 1.07-1.07 1.58-1.63 1.00 0.68 1.07 0.96 1.00 0.63 0.34 0.57 1.01 0.35 0.90 0.85 1.16 1.00 1.04 1.16 1.15 1.07 1.60 Zone Missing example, War Insurance (for or Wounded Service)
From page 470...
... For with all not Status Use at whether whether Good were Questions for Health Drugs Connected interferes for continued Service which or 2 Health activities ratios ratios Status Connected Service health or Answered Health odds years, odds 5 Fair-Poor Good Excellent-Very Alcohol PTSD Mental Not <50% >50% work to TABLE Health Self-Reported Any Service Mental Proxy *
From page 471...
... APPENDIX C 471 TABLE 3 Logistic Regression Analysis of Use of VA MH/SA Services Among Veterans Who Used Any MH/SA Care, 2001 95% Odds Confidence Rank Ratio Interval Order Sociodemographic Age <30 0.19* 0.18-0.19 3 30­49 0.38 0.37-0.38 8 50­59 0.86 0.84-0.88 34 60­75 1.21 1.19-1.24 31 >75 1.00 Reference Race Black 1.68 1.66-1.70 16 Hispanic 1.29 1.27-1.32 24 Other 1.49 1.47-1.52 19 Whites 1.00 Reference Gender Male 1.00 Reference Female 0.83 0.82-0.85 32 Education $40,000 0.37 0.37-0.38 7 Income Information Missing 0.50 0.49-0.51 10 Insurance Medicaid or Medicare 0.79 0.78-0.80 29 Private 0.24 0.24-0.25 4 Medigap 0.53 0.52-0.54 13 Military Related (for example, CHAMPUS)
From page 472...
... 472 HEALTH CARE FOR MENTAL AND SUBSTANCE-USE CONDITIONS TABLE 3 continued 95% Odds Confidence Rank Ratio Interval Order Military Experience Active Duty 0­2 years 1.00 Reference 3­5 years 1.27 1.26-1.28 26 5 years or more 1.36 1.34-1.38 22 Served in a Combat or War Zone 1.01 1.00-1.02 38 Exposed to Dead or Wounded 1.19 1.18-1.20 33 Prisoner of War 1.34 1.29-1.39 23 Health Status Self-Reported Health Status Fair-Poor 1.85 1.82-1.87 14 Good 1.95 1.93-1.98 11 Excellent-Very Good 1.00 Reference Any Health Service Use For Alcohol or Drugs 1.02 1.00-1.03 36 PTSD 1.50 1.48-1.51 18 Mental Health 1.25 1.24-1.26 30 Service Connected Not Service Connected 1.00 Reference <50% 7.08 6.99-7.16 2 >50% 16.56 16.28-16.85 1 Mental health interferes with work 0.64 0.64-0.65 17 or activities at all Proxy Answered Questions 1.93 1.88-1.99 12 * All odds ratios were significant at p <.0001 except for an employment status of unemployed or other, which was not significant.
From page 473...
... 473 only (9) Percent with secondary Dx 24% 27% 6% 23% 3% 4% 7% 5% 13% 36% 3% 29% 20% 21% 8% 5% 17% 20% 15% 11% by 1.4 only 2003, 5,427 4,321 5,664 3,500 8,221 1,170 15,402 55,129 21,398 79,560 52,107 43,925 10,669 10,267 77,936 48,454 18,218 11,264 (8)
From page 474...
... Care Treated of (FY vocational 3,961 6,218 9,436 5,763 4,302 5,430 5,156 and 14,389 72,849 61,123 38,302 12,771 10,982 Patients 115,954 283,930 Episodes 87,002 126,250 Programs Assistance psychiatry, Health d management Vocational general Contracts treatment case Mental abuse, (ACT) Treatment day and Therapy, VA and Program b Residential substance Diem substance outreach, Incentive Veterans Management Per and PTSD, Specialized a Veterans c and Veterans homeless Therapy, for of Case Care Rehabilitation Abuse Homeless Inpatient Abuse Grant Work Programs for maintenance housing, programs Intensive Center Homeless Homeless Teams Workload Substance Residential for Rehabilitation Residential for PTSD Care Substance Veterans 5 Health Clinical Care Psychiatry Care methadone supported Compensated residential Hospital Treatment Outpatient Mental Day Day PTSD Community Health Psychosocial General Psychosocial Inpatient Specialized Homeless Health Domiciliary TABLE Program Outpatient/Community Total Inpatient/Residential Total Includes Includes Includes a b cIncludes d
From page 475...
... Percent with no time homeless (HCHV = 8.1%; DCHV mean = 4.1%) Percent with a psychiatric disorder, substance abuse problem, or medical illness (HCHV mean = 82%; DCHV mean = 99.8%)
From page 476...
... Outcome Measures Percent with clinical improvement in alcohol problems (HCHV = 73.1%; DCHV mean = 84% unadjusted) Percent with clinical improvement in non-substance abuse psychiatric problems (HCHV = 70.7%; DCHV mean = 83% unadjusted)
From page 477...
... Percent with clinical improvement in drug problems (CWT mean = 63% unadjusted) Percent with clinical improvement in nonsubstance abuse psychiatric problems (CWT mean = 47.3% unadjusted)
From page 478...
... Outpatient Care Measures (All VA PTSD treatment, specialized and nonspecialized) Service Utilization and Continuity of Care Six Months Following Inpatient Index Stay Any outpatient stop in 6 months after discharge (DC)
From page 479...
... Bed days six months after DC (5.6) Number of admissions 6 months after DC (.45)
From page 480...
... V PERFORMANCE MEASURES FROM THE NATIONAL MENTAL HEALTH PROGRAM PERFORMANCE MONITORING SYSTEM Population Coverage Proportion of All U.S.
From page 481...
... Outpatient Care Measures Service Utilization and Continuity of Care Six Months Following Inpatient Index Stay Any outpatient stop in 6 months after DC (82.1%) Any outpatient stop in 30 days after DC (63.3%)
From page 482...
... OUTCOMES ON THE GLOBAL ASSESSMENT OF FUNCTIONING (GAF) SCALE Improvement after inpatient discharge Change from inpatient GAF to last outpatient GAF in first six months after discharge (4.9)


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