Understanding Pathways to Care for Veterans who Screen Positive for PTSD: The PTSD Access To Healthcare (PATH) Study

背景：在VA初级保健诊所筛查PTSD阳性的退伍军人中，近一半没有接受 心理健康治疗。为了增加及时获得VA护理的机会，我们必须了解退伍军人的访问 途径（提供给退伍军人的一系列选择，以及退伍军人在积极的PTSD筛查后做出的选择， 可能会导致他们的VA护理）。绘制这些途径是了解谁正在失去VA护理的关键， 他们正在丢失的地方。此外，通过研究预测谁和在哪里的背景和个人因素， 退伍军人正在脱离这些途径，我们将能够确定为什么这些退伍军人正在失去。 意义：拟议的IIR响应了HSR&D的精神健康和获得 护理，并将提供深入了解使命法对精神卫生服务的影响。完成时 在这个项目中，我们将提供三个不同的可交付成果：1）关于在何处以及向谁访问干预措施的指导 2）为援助提供者提供政策和实践指导，将筛查呈阳性的退伍军人与 有效的VA护理;以及3）用于将退伍军人从筛选分类到VA心理健康护理的方法，其 可以扩展到其他情况（例如自杀）。 创新和影响：过去的研究旨在提供信息，以改善获得创伤后应激障碍护理， 由于专注于最终目标（无论这些退伍军人是否获得护理），而不是 退伍军人达到这一目标的过程（访问途径）。该项目不仅是一个 这是第一个将获得医疗服务视为一个过程而不是终点的研究，也是唯一一个提出 全面检查访问过程中使用的方法，将推广到VA系统作为一个 整体，并将适用于通过基于VA的筛选确定的其他医疗保健状况。 具体目标：拟议的混合方法研究有以下目标： 1.目标1：确定区分退伍军人的背景和个人层面的变量， 访问步骤（在初级保健中对可能导致VA护理的阳性PTSD筛查的立即反应; 例如，在一个实施例中，转介到PC-MHI），包括通过 使命法案。 2.目标2：了解VA提供者和患者的经验，以及对退伍军人流失原因的看法 在PTSD筛查阳性后立即接受VA后续护理，包括使命法案的作用。 3.目标3：绘制假设遵循六个初始VA入路步骤的入路路径步骤 作为一个步骤，假设导致通过使命法案提供社区护理，通过利用 在我们的试点工作中， 方法：目标1将包括2017-2019财年期间在初级保健中进行新PTSD筛查的所有退伍军人。 来自VA公司数据仓库（CDW）的数据将用于确定退伍军人访问步骤 分类，并确定上下文和个人变量，显着预测分类。目标2将 使用目标1中的数据来确定高绩效和低绩效的网站，并进行定性访谈 与现场利益相关者一起了解访问障碍和促进因素。目标3将使用提取的定量数据 从VA CDW映射访问路径中的剩余步骤，以确定哪些退伍军人丢失， 后续，以及在哪里。将使用目标1和2中确定的相关访问变量运行预测模型。 后续步骤/实施：拟议IIR的结果将为部署和定制的最佳方式提供信息 现有的获取干预措施（例如PC-MHI、直接面向退伍军人的媒体宣传活动）。我们将与办公室合作， 制定政策和实践指导，并与初级保健办公室和 NCPTSD领导向VA初级保健和PC-MHI传播指南和我们的方法 国家一级的领导。我们将在随后的IIR中开始测试实现策略。

Background: Nearly half of Veterans who screen positive for PTSD in VA primary care clinics do not receive VA mental health treatment. To increase timely access to VA care, we must understand Veterans’ access pathways (the series of options offered to, and choices made by, Veterans after a positive PTSD screen that may lead them to VA care). Mapping these pathways is key to understanding who is being lost to VA care and where they are being lost. Further, by examining contextual and individual factors that predict who and where Veterans are falling off these pathways, we will be able to ascertain why these Veterans are being lost. Significance: The proposed IIR is responsive to the HSR&D priorities of both mental health and access to care and will provide insight into the impact of the MISSION Act on mental health access. At the completion of this project, we will provide three distinct deliverables: 1) guidance on where and to whom access interventions should be targeted; 2) policy and practice guidance to aid providers in linking Veterans who screen positive to effective VA care; and 3) a method for classifying Veterans from screening to VA mental health care, which could be extended to other conditions (e.g. suicidality). Innovation and Impact: Past research designed to provide information to improve access to PTSD care has been limited by focusing on the end goal (whether these Veterans do or do not access care) rather than the process by which Veterans arrive at this goal (the access pathways). The proposed project is not only one of the first to consider access to care as a process rather than an end point, it is the only study to propose examining the process of access comprehensively using a method that will generalize to the VA system as a whole, and will be applicable to other healthcare conditions identified by VA-based screening. Specific Aims: The proposed mixed methods study has the following aims: 1. Aim 1: Identify contextual- and individual-level variables that differentiate Veterans classified into a VA initial access step (an immediate response to a positive PTSD screen in primary care likely to lead to VA care; e.g., referral to PC-MHI) from those who were not, including those referred to community care via the MISSION Act. 2. Aim 2: Understand VA providers’ and patients’ experiences with, and perspectives on, why Veterans are lost to VA follow-up care immediately after screening positive for PTSD, including the role of the MISSION Act. 3. Aim 3: Map the access pathway steps hypothesized to follow each of the six initial VA access steps, as well as the step hypothesized to lead to community care provided via the MISSION Act, by leveraging the methods developed in our pilot work. Methodology: Aim 1 will include all Veterans with new PTSD screens in primary care between FY 2017-2019. Data from the VA Corporate Data Warehouse (CDW) will be used to determine Veteran access step classification and to identify contextual and individual variables that significantly predict classification. Aim 2 will use the data from Aim 1 to identify high- and low-performing sites, and qualitative interviews will be conducted with site stakeholders to understand access barriers and facilitators. Aim 3 will use quantitative data extracted from the VA CDW to map the remaining steps in the access pathways to identify which Veterans are lost to follow-up, and where. Predictive models using relevant access variables identified in Aims 1 and 2 will be run. Next Steps/Implementation: Results from the proposed IIR will inform the best ways to deploy and tailor existing access interventions (e.g. PC-MHI, direct-to-Veteran media campaigns). We will work with the Office of Primary Care to develop policy and practice guidance, and work with both the Office of Primary Care and NCPTSD leadership to disseminate guidelines and our methodology to VA primary care and PC-MHI leadership at the national level. We will begin testing implementation strategies in a subsequent IIR.