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Assumptions behind outsourcing veterans to community providers

By Dr. Josef Ruzek VHPI Advisory Board

As the current VA leadership uses the MISSION Act of 2018 to increase the outsourcing of more and more veteran care from the Veterans Health Administration (VHA) to the private sector, more and more psychologists and other mental health providers insist that they are willing, eager, and prepared to do their bit for veterans.

This widespread enthusiasm for supporting those who have served could effectively supplement – rather than substitute for – VHA-delivered mental health care and could be an important part of a comprehensive community-supported public health approach to care.

What we see happening today are not, however, efforts to supplement VHA care, but rather a significant displacement of care from VA to non-VA providers. In the mental and behavioral health arenas many providers have joined or support this displacement because they believe, as do their medical counterparts, that they can deliver the same high quality of care to veterans that they provide their other patients. They believe that the care they deliver will be roughly equivalent in relevance and quality to that offered within VA. According to this framing of healthcare delivery, a patient is a patient is a patient. If you deliver high quality care to one kind of patient, then you can of course be effective with a patient who’s a veteran.

Some mental health providers admit that they have little experience treating veterans, little knowledge of veteran-specific conditions or health problems, and little familiarity with military culture. Many seem to believe – or are told – that they can fill these knowledge gaps by taking quick online courses offered by a new cohort of credentialing or educational entities that are clamoring to help non-VA providers understand military-related health conditions and gain military cultural competency.

If veterans are to receive high-quality health care, the assumptions grounding these ideas need to be explored.

First is the idea that delivering care to a VA patient – say a Vietnam or Iraq combat veteran suffering from PTSD – is the same as delivering care to a non-VA patient. PTSD is a complex problem that is arguably more difficult to treat than more common problems of depression and anxiety that make up much of the focus of mental health services.

Veterans with PTSD commonly experience many additional problems that co-occur with their PTSD symptoms and add to the complexity of their care. These include traumatic brain injury, alcohol and substance abuse, physical pain, social withdrawal and isolation, suicidal ideation, anger problems, marital and family problems, and employment problems, as well as depression and other forms of anxiety disorder.

Many veterans also have co-occurring physical health problems whose care must be integrated with the mental and behavioral health care they receive. Quality of care for veterans requires a much more intensive treatment program than that usually available outside the VA. It requires the integrated involvement of specialists familiar with a range of the different problems that afflict many veterans.

A second assumption is that the care routinely provided by most mental providers in the community is evidence-based and effective, as well as consistent with best practices in treatment of PTSD and the other problems that often challenge returning veterans. In fact, the most powerful treatments for PTSD, such as Prolonged Exposure, Cognitive Processing Therapy, and Eye Movement Desensitization Reprocessing are often not available outside the VA.

Most non-VA mental health professionals are not specialists in post-traumatic stress, but rather generalists who try to work with a wide array of clients. Very often, they offer a listening ear and non-directive emotional support. Or they offer a brief exposure to stress management training and mindfulness exercises. Training in PTSD treatment in graduate programs generally fails to inculcate skills to deliver the best interventions that are best supported in research.

By contrast, the VA has, for more than 10 years, delivered some of the most ambitious and carefully designed training programs designed to enable the entire mental health workforce to offer Prolonged Exposure and Cognitive Processing Therapy treatments.

The third assumption is that brief online training can substitute for the years it takes for VA providers to become familiar with the culture, problems and treatment of military veterans. While there it is heartening that some providers are aware that veterans may, in fact, be more complex than non-veteran patients, it is naïve to believe that taking a short on-line course or brief workshop to help understand military culture (”military cultural competency”) will do the trick in readying them to serve veterans. Effective training and experience should be encouraged. What we see today bears no resemblance to the kind of effective training programs needed to affect the ability of clinicians to treat veterans.

To date, no study has shown that such short training courses will enable mental health providers to connect with veterans and engage them in treatment, let alone improve the effectiveness of their services.

In contrast, VA providers treating PTSD work in specialized PTSD clinics where they see only veterans. Over time, they become intimately familiar with the special concerns of veterans, the military experiences that affect their wellbeing, and the nuances of offering specific PTSD interventions to different individuals with differing presentations and needs. This kind of real ongoing contact with veterans is much more likely to enable veterans to feel understood and welcome and to encourage them to take a risk on participating in treatment.

This is particularly important because most veterans are skeptical about – or downright resistant to – participating in mental health care. Most are not well informed about the nature of PTSD or psychological treatment. Most also most question whether someone who is not a veteran and has never served in the military can really understand their situation and make a difference in their lives.

Therefore, what veterans often value most about the VA treatment experience is their powerful connection to the many other veterans they encounter at the VA, in their support groups and in clinics and canteens. This wonderful kind of instantly accessible and often quite profound mutual support is cannot be reproduced in most non-VA treatment settings.

When it comes to providing care to veterans, there seems to be little real appreciation of the differences between delivering mental health care to veterans and providing care for the very different problems for which civilians seek help. While the possibility of “choice” for veterans represents a central value in mental health treatment, we must recognize that not all choices are wise or good ones. We must also recognize that for choice to be meaningful, there has to be a real choice between well-tested and powerful treatment options. There is very real support outside the VA for the welfare of our veterans. And increasingly, there will be funds made available to non-VA health care systems and treatment providers that will, understandably, motivate them to offer help for veterans.

Above, I suggest that it seems most unlikely that non-VA providers, operating in private practices, or embedded in community clinics and hospitals, can match the advantages offered in VA. For this reason, if more veterans receive care outside of VA, we need to know how they fare. We need to be able to compare the effectiveness of care inside and outside of VA, so that we do not proceed to accelerate the unwise choices of veterans to participate in ineffective care. All mental health programs, VA and community-based, should agree to evaluate their outcomes using well-established methods that are uniform across VA and non-VA clinics and clinicians.

This will not be easy because, as VHPI has pointed out, “measurement-based care” in which mental health practitioners continuously monitor the effects of their treatments and formally evaluate outcomes has not been widely implemented in mental health treatment systems. No one really knows whether their treatments are benefitting patients or not, and how their treatment compares to that offered by others. This needs to change. Congress has an opportunity to mandate such evaluations and in the process improve mental health treatment everywhere, inside VA and out.

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