A Structured Communication Tool to Improve OEF/OIF Veteran Care

描述（由申请人提供）： 背景资料：超过160万名美国军人在阿富汗或伊拉克服役，作为持久自由行动（OEF）和伊拉克自由行动（OIF）的一部分，其中高达15%的人报告了严重的心理健康症状。未能参与治疗仍然是一个重大障碍，可能导致破坏性后果，包括精神症状恶化，社会和职业功能恶化，无家可归，药物滥用和自杀（2，3，6 - 8）。由于脱离心理健康治疗可能反映了OEF/OIF退伍军人的观点，即治疗不能满足他/她的需求或不能以合作方式提供，因此越来越有必要制定和实施以退伍军人为中心的战略，以促进治疗参与，长期目标是改善新返回的退伍军人的治疗结果。这一必要性反映在所谓的退伍军人事务部行动议程（9）中规定的任务中，即建立一个以康复为导向、以病人为中心的护理系统。尽管越来越多的证据表明，旨在帮助构建和增强患者与临床医生沟通的计算机介导技术可以改善患者的健康和各种医疗条件下的功能（10），但其在精神卫生服务提供中的实施只是最近才发生的。为心理健康临床医生提供一种工具，以确保提供以患者为中心的强制性护理，并为退伍军人提供更有意义地参与确定治疗优先事项的机会，这将对改善OEF/OIF退伍军人的治疗参与和相关结果产生重大影响。目的：这一拟议的两年期试点项目的具体目标是：（1）修改现有的计算机化结构化交流工具，称为对话，以反映持久自由行动/临时自由组织退伍军人的心理健康治疗需求，并根据认知行为疗法的原则和战略加强执行程序;和2）完成32 OEF/OIF退伍军人和他们的精神提供者生成初步数据，支持我们的假设，即使用修改和增强的DIALOG工具将：a）提高心理健康治疗参与度，其定义为在指数使用该工具后参加后续心理健康预约的可能性增加;以及B）导致退伍军人报告的未满足需求减少，治疗满意度的积极评级增加，生活质量的评级提高。方法：我们的建议包括两个阶段的努力，平行于我们的具体目标。第一阶段将在第一年完成，重点是修改和加强对话工具。除了与专家咨询小组和OEF/OIF退伍军人召开多次会议外，我们还将对修改进行测试，并与该工具的退伍军人和心理健康提供者用户进行访谈和焦点小组，以评估可接受性和可行性。第二阶段在第二年完成，将涉及一个仔细监测的随机试点。OEF/OIF退伍军人将被随机分配到实验条件（通过使用DIALOG结构化沟通工具定义）或对照条件（通过在不使用DIALOG工具的情况下提供标准治疗定义）。在3个月内使用前后设计，评估的结果将包括：指数使用DIALOG工具后参加后续心理健康预约的比率，以及未满足需求的退伍军人评级，治疗满意度和生活质量。影响：拟议的计算机化结构化通信工具的开发和创新的实施增强借鉴CBT的原则和战略将有助于VA的任务，提供以病人为中心的服务OEF/OIF退伍军人，以更好地满足他们迫切的治疗需求。为临床医生提供一个简单的工具，以一致和有效地提供以患者为中心的心理健康服务，可能会对改善OEF/OIF退伍军人的治疗参与和相关结果产生重大影响。

DESCRIPTION (provided by applicant): Background: Over 1.6 million US service members have served in Afghanistan or Iraq as part of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), and up to 15% of them report significant mental health symptoms. Failure to engage in treatment remains a significant obstacle and one that can lead to devastating consequences including exacerbation of psychiatric symptoms, deteriorating social and vocational functioning, homelessness, substance abuse, and suicide (2,3,6-8). Because disengagement from mental health treatment may reflect the OEF/OIF veteran's perspective that treatment is not meeting his/her needs or not being provided in a collaborative manner, there is a growing imperative to develop and implement veteran- centered strategies for fostering treatment engagement with the longer-term goal of improving treatment outcomes for newly returning veterans. This imperative is reflected in the mandates specified in the so-called VA Action Agenda (9) to create a system of care that is recovery-oriented and patient centered. Despite the mounting evidence suggesting that computer-mediated technologies designed to help structure and enhance patient-clinician communication can lead to improved patient health and functioning across a variety of medical conditions (10), their implementation in mental health service delivery has occurred only recently. Providing mental health clinicians with a tool to ensure delivery of mandated patient-centered care and affording veterans an opportunity to more meaningfully participate in the identification of treatment priorities will have significant impact on improving treatment engagement and related outcomes for OEF/OIF veterans. Aims: The specific aims for this proposed two year pilot are to: 1) Modify an existing computerized structured communication tool called DIALOG to reflect the mental health treatment needs of OEF/OIF veterans and enhance implementation procedures based on principles and strategies of Cognitive Behavioral Therapy (CBT); and 2) Complete a randomized pilot for 32 OEF/OIF veterans and their mental providers to generate preliminary data supporting our hypotheses that use of the modified and enhanced DIALOG tool will: a) improve mental health treatment engagement as defined by increased likelihood of attending a subsequent mental health appointment following index use of the tool; and b) result in a decrease in veteran reported unmet needs, more positive ratings of treatment satisfaction, and improved ratings of quality of life. Methods: Our proposal includes a two-stage effort that parallels our Specific Aims. Stage One will be completed during year one and will focus on modifying and enhancing the DIALOG tool. In addition to convening multiple meetings with an advisory group of experts and OEF/OIF veterans, we will also beta-test modifications and complete interviews and focus groups with veteran and mental health provider users of the tool to evaluate acceptability and feasibility. Stage Two, completed during the second year, will involve a carefully monitored randomized pilot. OEF/OIF veterans will be randomized to either the experimental condition (defined by use of the DIALOG structured communication tool) or the control condition (defined by delivery of standard treatment without use of the DIALOG tool). Using a pre-post design over a 3-month period, outcomes assessed will include: rates of attending a subsequent mental health appointment following index use of the DIALOG tool, and veteran ratings of unmet needs, treatment satisfaction and quality of life. Impact: The development of the proposed computerized structured communication tool and innovative implementation enhancements drawing on the principles and strategies of CBT will contribute to the VA mandate to deliver patient-centered services to OEF/OIF veterans to better meet their pressing treatment needs. Providing clinicians with a simple tool to consistently and effectively delivery patient-centered mental health services could have significant impact on improving treatment engagement and related outcomes for OEF/OIF veterans.