A Structured Communication Tool to Improve OEF/OIF Veteran Care

描述(由申请人提供)： 背景：作为持久自由行动(OEF)和伊拉克自由行动(OIF)的一部分，超过160万美国军人曾在阿富汗或伊拉克服役，其中高达15%的人报告了严重的心理健康症状。不进行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、滥用药物和自杀(2、3、6-8)。由于脱离精神健康治疗可能反映了OEF/OIF退伍军人的观点，即治疗没有满足他/她的需求或没有以合作的方式提供，因此越来越有必要制定和实施以退伍军人为中心的战略，以促进治疗参与度，并以改善新归来退伍军人的治疗结果为长期目标。这一当务之急反映在所谓的退伍军人行动议程(9)中规定的任务中，即创建一个以康复为导向和以病人为中心的护理系统。尽管越来越多的证据表明，旨在帮助构建和加强患者-临床医生沟通的计算机中介技术可以在各种医疗条件下改善患者的健康和功能(10)，但它们在精神卫生服务提供中的实施只是最近才发生的事情。为心理健康临床医生提供一种工具，以确保提供强制的以患者为中心的护理，并使退伍军人有机会更有意义地参与确定治疗优先事项，这将对改善OEF/OIF退伍军人的治疗参与度和相关结果产生重大影响。目标：这项拟议的两年试点的具体目标是：1)修改现有的名为DIALOG的计算机化结构化通信工具，以反映OEF/OIF退伍军人的精神健康治疗需求，并基于认知行为疗法(CBT)的原则和策略增强实施程序；以及2)完成对32名OEF/OIF退伍军人及其精神提供者的随机试验，以产生支持我们的假设的初步数据，即使用修改和增强的DIALOG工具将：a)改善心理健康治疗参与度，其定义是在使用该工具的指数之后，参加后续精神健康预约的可能性增加；以及b)导致退伍军人报告的未得到满足的需求减少，治疗满意度评分更积极，生活质量评分提高。方法：我们的建议包括两个阶段的努力，与我们的具体目标相一致。第一阶段将在第一年内完成，重点是修改和改进对话工具。除了与专家顾问组和OEF/OIF资深人员召开多次会议外，我们还将对该工具的资深和精神健康提供者用户进行Beta测试，并完成对该工具的访谈和焦点小组，以评估该工具的可接受性和可行性。第二阶段将在第二年完成，将涉及一项受到仔细监测的随机试验。OEF/OIF退伍军人将被随机分为实验条件(通过使用对话结构通信工具定义)或控制条件(通过提供标准治疗而不使用对话工具定义)。使用为期3个月的员额前设计，评估的结果将包括：在使用对话工具的指数之后参加随后的精神健康预约的比率，以及对未得到满足的需求、治疗满意度和生活质量的退伍军人评级。影响：根据CBT的原则和战略开发拟议的计算机化结构化通信工具和创新的执行改进，将有助于退伍军人管理局的任务，向OEF/OIF退伍军人提供以患者为中心的服务，以更好地满足他们紧迫的治疗需求。为临床医生提供持续有效地提供以患者为中心的心理健康服务的简单工具，可能会对提高OEF/OIF退伍军人的治疗参与度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.