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All Veterans with Invisible Wounds Should Receive High-Quality Care That Meets These Standards

The Bush Institute’s Veteran Wellness Alliance collaborated with RAND to generate the first definition for high-quality care for post-traumatic stress and traumatic brain injury. This definition now sets a standard for health providers who serve veterans and provides policymakers a source to reference.

Article by Carrie Farmer, Lu Dong, and Kacie Kelly October 29, 2020 //   5 minute read

Millions of post-9/11 U.S. military veterans experience invisible wounds, including post-traumatic stress disorder (PTSD) and chronic issues resulting from traumatic brain injuries (TBIs). These invisible wounds are life-changing, and can significantly interfere with veterans’ abilities to function across health, occupational, and family domains.  If left untreated, these wounds can result in billions of dollars of direct and indirect costs to society.  While effective treatments are available, many veterans lack access to high-quality care. And what high-quality care means, exactly, has been elusive.  

The George W. Bush’s Institute’s Veteran Wellness Alliance links veteran peer networks and best-in-class clinical programs  to help more veterans connect to high-quality care for their invisible wounds when they need it.  Research indicates that outside of the Department of Veteran Affairs (VA), high-quality mental and brain-related health programs for veterans are limited.  Therefore, in order to establish transparent and consistent expectations for care that is delivered, the Bush Institute collaborated with RAND to generate the first definition for high-quality care for PTSD and TBI.  This sets the bar for all mental and brain-injury health providers who serve veterans. Additionally, it should be a source for policymakers, funders, veteran advocacy groups, and other key stakeholders.     

The definition is based on published literature, consumer input, and interviews with Veteran Wellness Alliance clinical partners. The consensus-based definition focuses on four pillars: 

  • Veteran-centered care addresses the unique needs, values, and preferences of veterans. It means that care providers attend to the exposures and implications of veterans’ prior military service, involve veterans in shared decision making, and involve family members or caregivers as part of the care team whenever appropriate. Effective veteran-centered care can be achieved through training providers on military cultural competency and patient-centered communication.  
  • Accessible care is easy to navigate and timely for veterans. It means that providers reduce or eliminate barriers to care, including geographic, financial, cultural, and other barriers. For example, many Veteran Wellness Alliance clinical partners maintain a short or have no waitlist for an appointment and eliminate any out-of-pocket costs for veterans. 
  • Evidence-based care integrates the best research evidence with clinical expertise and patient values. Programs that provide evidence-based care conduct comprehensive assessments to inform treatment planning, provide treatments for PTSD and TBI according to clinical practice guidelines, and perform appropriate screenings for risks such as suicide, and ensure continuity of care.
  • Outcome monitoring Outcome monitoring can guide clinical decision making, which is associated with increased quality and effectiveness of care. This is achieved by using validated measures to assess symptoms, functioning, and well-being.  

Having a shared definition of high-quality care for invisible wounds is the first step in setting the standard for and improving access to high-quality care for veterans. The standard for care could be used in a number of ways. It can be used to identify or ‘certify’ high-quality care providers. This definition can also be used in consumer decision-making. Veterans who are seeking care and veteran-serving organizations that refer veterans to care can use this definition to guide selection of providers and to set expectations for what care should include. Payers can use this definition for network inclusion or reimbursement criteria, requiring that providers demonstrate that they provide care that meets this standard. 

An important next step will be to put this definition into practice and further delineate best ways to measure whether a clinical program is providing high-quality care. This process will involve determining common quantitative measures to collect across clinical programs/partners, drawing from various data sources that are available and feasible, to provide a comprehensive assessment of the veterans’ needs, experiences, treatment progress, and various outcomes.  

In addition to using the definition in Alliance operations, the Bush Institute’s Veteran Wellness Alliance will use this definition to drive policy to establish quality standards for mental and brain health care programs.  All veterans experiencing invisible wounds should have access to high quality care. With quality care, veterans can recover and continue to serve their country even after they have taken off the uniform.   

Carrie Farmer, Ph.D., is a senior policy researcher and director of the Health Care Quality Measurement and Improvement Program at the nonprofit, nonpartisan RAND Corporation. Lu Dong, Ph.D., is an associate behavioral scientist at RAND and a licensed clinical psychologist. Kacie Kelly,  is the Director of Health and Wellbeing in the Military Service Initiative at the George W. Bush Institute.