Double Standards

Credentials, Training and Competence of Community PTSD Providers Are Less Than Those For Veterans Health Administration Providers


January 23, 2019

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The VA MISSION Act intended to fix a glaring omission in the hastily enacted Veterans Choice Program – its failure to set any standards for providers who treat veterans in the private sector or Veterans Health Administration (VHA) facilities.

Nowhere was this gap more important than with posttraumatic stress disorder (PTSD). Previous RAND1 and other studies2 revealed that, when compared with VHA providers, psychotherapists in the community who treat PTSD are unlikely to have the skills necessary to deliver high-quality care. Section 133 of the MISSION Act aimed to correct the deficit. It instructed the VHA to establish competency standards for Community Care Network (CCN) providers who deliver PTSD treatment. The VHA formed a workgroup to develop criteria, due out this spring, which will be handed to Optum Public Sector Solutions, the entity contracted to administrate the CCN. Success hinges on two big questions: (1) Will standards for CCN providers equal what the VHA requires of its own PTSD clinicians, and (2) Will Optum adhere to the standards?

Qualification and Training Standards

To be hired as a VHA mental health provider who treats veterans with PTSD, a professional must meet strict qualification standards. The candidate must have graduated from a discipline accredited graduate program (e.g. for psychologists, candidates must complete an American Psychological Association (APA)-approved doctoral program) and a discipline accredited training program (e.g. for psychologists, an APA-approved internship.)3 Once on board, s/he must undertake trainings in suicide prevention and military cultural experience.

The VHA also has clear guidelines for treating veterans with PTSD. An evidence-based psychotherapy (EBP) should be offered from a clinician who has completed advanced training. The veteran may elect with his/her provider an alternative to this standard of care, in which case a clinically indicated rationale should be documented in the medical record.4

VHA designates a provider’s EBP competence based on two sequential components: (a) attendance at an in-person 3-day experiential workshop, and (b) 6+ months of weekly follow-up ongoing consultation and feedback from an expert, including review of audiotape and/or progress notes of the trainee’s sessions. To date, more than 4,600 VHA providers have completed advanced PTSD EBP training.

VHA adopted this training model because studies5 6 7 8 demonstrate that follow-up consultation and feedback are the key factors – and gold standard – in sustained proficiency in delivering psychotherapy. While one-time training workshops briefly improve therapist’s skills, those skills generally decay back to pre-training ability without follow-up feedback and consultation.

The only way to ensure the competence of network providers who treat veterans with PTSD is for CCN standards to be equivalent to VHA’s. As such, Optum ought to verify whether a CCN clinician has a degree from an approved program, suicide prevention training and military cultural knowledge. Optum should verify whether a CCN clinician’s EBP training includes 6 months of follow up consultation, and whether an EBP is offered as a first line psychotherapy option. The danger is that Optum may forego these standards in order to enlarge the panel of CCN providers (and repeat Health Net and TriWest’s failure in the Choice Program to verify the competence of providers.) Quicker access to care of inferior or unknown quality has life-impacting – and potentially life-threatening – consequences.

Ongoing Quality of Care

In addition to upgrading PTSD providers’ initial qualifications, the MISSION Act instructed the VHA to evaluate providers’ ongoing effectiveness. Last month, the VHA announced that “The CCN will also enable the designation of high performing preferred providers by identifying providers that meet specific quality and performance metrics.”6 That’s an empty promise when it comes to PTSD treatment. Optum is not tracking what PTSD care is delivered by a provider or how much his/her patients improve. If the data aren’t collected, Optum cannot attest to the quality of its PTSD providers. By MISSION Act’s intended launch this June, veterans won’t have relevant information to make healthcare decisions about the quality of PTSD treatment provided by CCN, which was one of the main objectives of the MISSION Act.

If at a future date information is collected, Optum must make sure to report healthcare outcomes only of veterans. It would be invalid to report scores on non-veterans and then compare those to VHA veterans, who are, on average, older, poorer and have far more medical and mental health conditions.

Recommendations

As a nation, we have the solemn responsibility to offer veterans with PTSD the highest quality care, whether provided in VHA or the private sector. The standard of PTSD credentials, training, and service delivery that the VHA requires of its own clinicians must be the benchmark for providers in the CCN. Dr. Heather Kelly, Director, Military and Veterans Health Policy, APA, recently underscored this necessity, “We need the outside providers to be trained to the same standards, to be collecting data to the same standards, and providing outcome measures to the same standards…All the metrics that VA psychologists have to track we would demand that outside providers track before getting VA money to do that.” 9 Likewise, in their 2019 Independent Budget roadmap to Congress, major Veterans Service Organizations recommended that competency and quality standards for non-VA providers must be equivalent to standards expected of VHA providers.10

Here’s what is needed to ensure that veterans receive high quality PTSD care wherever it’s delivered:

  • Require that the graduate degree qualifications for CCN mental health providers be identical to VHA providers.

  • Require that CCN mental health providers have military cultural competence and suicide prevention training, as occurs with VHA providers.

  • Require that veterans with PTSD referred to CCN be offered an EBP by a trained provider who has completed a 3-day workshop and 6 months of follow up consultation.

  • Require that CCN providers administer the PTSD Checklist (PCL-5) and Patient Health Questionnaire (PHQ-9) to veterans in treatment for PTSD, as occurs in the VHA.

Also, care comparison websites should list scores according to conditions (e.g. PTSD) so that veterans can readily search according to their disorder.

Conclusion

We cannot repeat the same mistake of the Choice Program and rush to expand private sector options without first being certain about the quality of that care. VHA should postpone implementation the MISSION Act until it can affirm that CCN PTSD providers — and frankly all providers — have demonstrated credentials, training and competence that is equal to VHA’s own high standards.


Author:

Russell B. Lemle, PhD, is a VHPI Senior Policy Analyst, the VA-Community Care Workgroup Lead for the Association of VA Psychologist Leaders (AVAPL) and is Clinical Professor, University of California San Francisco (UCSF) Medical School, Department of Psychiatry.

Footnotes

1 Tanielian T, Farris C, Batka C, et al; Rand Corporation. Ready to serve: community-based provider capacity to deliver culturally competent, quality mental health care to veterans and their families. https://www.rand.org/content/dam/rand/pubs/research_reports/RR800/RR806/RAND_RR806.pdf Published November 2014.

2 Finley EP, Noël PH, Lee S, et al. Psychotherapy practices for veterans with PTSD among community-based providers in Texas. Psychol Serv. 2017. https://www.ncbi.nlm.nih.gov/pubmed/28301173

3 VA Handbook 5005 Part II Appendix G18, Psychologist Qualification Standards GS-180, Veterans Health Administration, https://www.avapl.org/pub/Hybrid_38_standards.pdf Accessed January 18, 2019

4 Department of Veterans Affairs VHA Handbook 1160.05 Local Implementation of Evidence-Based Psychotherapies for Mental and Behavioral Health Conditions. revised December 8, 2015.

https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2801

Accessed January 18, 2019

5 Beidas R, Kendall PC. Training therapists in evidence-based practice: A critical review of studies from a systems-contextual perspective. Clinical Psychology: Science and Practice. 2010, 17(1):1. [PubMed: 20877441]

6 Herschell AD, Kolko DJ, Baumann BL, & Davis AC. The role of therapist training in the implementation of psychosocial treatments: A review and critique with recommendations. Clinical Psychology Review. 2010; 30(4):448–466. [PubMed: 20304542]

7 Miller, WR, Yahne, CE, Moyers, TB, Martinez, J, & Pirritano, M. A randomized trial of methods to help clinicians learn motivational interviewing. Journal of Consulting and Clinical Psychology, 2004, 72, 1050–1062. http://dx.doi.org/10.1037/0022-006X.72.6.1050

8 Nadeem, E, Gleacher, A, & Beidas, RS. Consultation as an implementation strategy for evidence-based practices across multiple contexts: Unpacking the black box. Administration and Policy in Mental Health, 2013, 40, 439–450. http://dx.doi.org/10.1007/s10488-013-0502-8

9 Department of Veterans Affairs. Minutes of the MISSION Act Public Meeting Regarding Health Care Standards for Quality, September 24, 2018.

10 The Independent Budget Veterans Agenda for the 116th Congress. DAV, PVA and VFW. January 17, 2019. http://www.independentbudget.org/ Accessed January 18, 2019