An estimated 22 million military Veterans comprise 7% of the U.S. population (U.S. Department of Veterans Affairs [VA], 2016c). These Veterans experience disparities from the civilian population in rates of physical, mental, and social conditions, including posttraumatic stress disorder (PTSD), substance use, and depression (Trivedi et al., 2015; Vazan, Golub, & Bennett, 2013). Moreover, Kang et al. (2015) found that Veterans had a 41% to 61% higher suicide rate than the general population. The purpose of the current article is to demonstrate how psychiatric–mental health nurse practitioner (PMHNP) residents implemented measurement-based care (MBC) and improved quality mental health outcomes in a VA mental health outpatient resident clinic.
Veterans have earned the right to access what is arguably the largest, most technologically advanced, and education-friendly comprehensive health system in the nation, the Veterans Health Administration. Despite its many positive attributes, the VA has been under scrutiny for the difficulty it has faced in having Veterans evaluated by providers in a timely manner. In addition, media have negatively portrayed the VA, especially mental health, for inadequate accessibility by Veterans (Slack, 2016).
The VA has launched several initiatives to improve access to mental health services for Veterans. One strategy that will impact access to all areas of health services is the recent passage of AP-44 in December 2016, which permits full scope of practice authority for advanced practice RNs (APRNs) in the roles of Certified Nurse Practitioners, Clinical Nurse Specialists, and Certified Nurse-Midwife in the VA Healthcare System (AP-44, 2016). Proposed initially with a goal of increasing Veterans' access to high-quality care, AP-44 follows practice authority already implemented in 21 states, the Department of Defense, and the District of Columbia. The increased use of nurse practitioners (NPs) will help meet critical staffing gaps and bring the discipline into the spotlight.
Citing the critical shortage of primary care practitioners in Federally Qualified Health Centers, Flinter (2012) discussed the country's first NP residency based in Connecticut's Community Health Center, Inc. for graduates of family NP programs, which began in 2007. The VA initiated primary care NP residencies in 2010, followed by PMHNP residencies in 2013. NP residencies are now an emerging trend among academic–practice partnerships.
Harper et al. (2016) described the University of Alabama at Birmingham (UAB) School of Nursing—Birmingham VA Medical Center (BVAMC) partnership, the VA Nursing Academic Partnership program, and their Veteran-centric educational initiatives. This collaboration inspired the establishment of one of the country's first PMHNP residencies and the subsequent formation of a PMHNP staffed Resident Continuity Clinic (RCC) at the BVAMC. Post-licensure NP residencies could help bridge existing clinical- and systems-level gaps in care (Flinter, 2012). Moreover, the Institute of Medicine (2010) recommended the implementation of more advanced practice nurse residency programs. A key component of the BVAMC's psychiatric NP residency is the use of measurement-based care (MBC).
MBC is “enhanced precision and consistency in disease assessment, tracking, and treatment to achieve optimal outcomes” (Harding, Rush, Arbuckle, Trivedi, & Pincus, 2011, p. 1137). It offers a method of quantifying psychiatric symptoms where few objective data exist and helps reduce the assessment gap between psychiatric and medical conditions. In addition, MBC offers a systematic method to track outcomes to improve quality care over time. The VA, as well as numerous professional organizations, such as the American Psychiatric Association (APA), Substance Abuse and Mental Health Services Administration (SAMHSA), and The Joint Commission, endorse the use of MBC.
MBC is not a novel practice in mental health. Validated psychiatric rating scales have been in existence for at least 20 years (The Kennedy Forum, 2015). MBC was a key component of the landmark National Institutes of Health Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trials (Trivedi et al., 2006). STAR*D used the Hamilton Depression Rating Scale and Quick Inventory of Depressive Symptomatology–Self-Report in the assessment of depression in approximately 3,000 participants. The STAR*D study found that MBC facilitated positive clinical outcomes in depression by guiding clinical decision making and, thus, decreasing time to response and remission. In addition, the Clinical Outcomes in Measurement-Based Treatment study also corroborated the use of MBC in promoting feedback to facilitate decision making, again leading to decreased time to response and remission (Yeung et al., 2012). MBC can facilitate communication between provider and patient, which results in improved treatment adherence in the mental health care setting (Thompson & McCabe, 2012).
In a VA study focusing on quality improvement outcomes of patients with schizophrenia, Young et al. (2011) strongly recommended use of patient self-report measures, citing that they are efficient, feasible, and accurate in clinical assessment. The VA acknowledged the value of MBC and began a nationwide initiative to adopt its use (VA, 2016a). Furthermore, The Joint Commission has proposed that the use of MBC be a requirement in the monitoring of mental health outcomes in 2017 (Ault, 2016). Despite the recognized value of MBC, <20% of mental health practitioners nationwide routinely use these tools in practice (The Kennedy Forum, 2015).
Patient Stress Questionnaire
The RCC used the Patient Stress Questionnaire (PSQ) as its sole MBC tool in the assessment of Veterans in the clinic. The PSQ is a self-report form that incorporates the following valid, public domain screening tools: (a) Patient Health Questionnaire-9 (PHQ-9) for depression, (b) Generalized Anxiety Disorder-7 (GAD-7), (c) Primary Care (PC) screen for PTSD (PTSD-PC), and (d) Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) for alcohol use assessment. A brief assessment for pain is also included. Lower scores on all scales represent clinical improvement. SAMHSA endorses the use of the PSQ, and the tool is available from their website (access http://www.integration.samhsa.gov/Patient_Stress_Questionnaire.pdf).
The PSQ includes five assessment tools; however, there is no literature on the effectiveness in using this combined tool. Evidence exists, however, concerning the validity of its PHQ-9, GAD-7, PTSD-PC, and AUDIT-C components. In 2001, a major study showed that the PHQ-9 had a sensitivity of 88% and specificity of 88% indicating major depressive disorder for scores ≥10 in primary care and obstetric/gynecological populations (Kroenke, Spitzer, & Williams, 2001). Findings were based on structured interviews with 580 participants, and showed that an increased score indicated an increase in depressive symptoms, with scores ≤4 indicating a decreased likelihood of depression. Likewise, research with a sample of 975 patients shows that the GAD-7 is a valid assessment tool for severity of anxiety, with a sensitivity of 89% and specificity of 82% for a cutoff point of ≥10 indicating generalized anxiety disorder (per criteria in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders [DSM-IV]), with ≤5 indicating mild anxiety and ≥15 indicating severe anxiety (Spitzer, Kroenke, Williams, & Löwe, 2006).
In further consideration of the effectiveness of the screening tools incorporated in the PSQ, a 2008 study of 352 combat Veterans validated the 4-question PTSD-PC in diagnosing PTSD, with two positive responses producing a sensitivity of 91% and specificity of 72% and three positive responses generating a sensitivity of 78% and specificity of 87% (Bliese et al., 2008). AUDIT-C findings are different concerning sensitivity and specificity in both men and women, and in African American, White, and Hispanic racial/ethnic groups (Frank et al., 2008). For African American, White, and Hispanic women, the sensitivity was 67%, 70%, and 85%, respectively, and the specificity was 92%, 91%, and 88%, respectively. For African American, White, and Hispanic men, the sensitivity was 76%, 95%, and 85%, respectively, and the specificity was 93%, 89%, and 88%, respectively. Although sensitivity varies, specificity scores are relatively the same across the populations. Due to the variation, validated cutoff points indicating a positive screen are ≥3 for women and ≥4 for men. The final component of the PSQ is the one question screen for pain, asking if pain is present and requiring only a yes or no answer.
PSQ and Comorbidity. The PSQ also aids in identifying Veterans with comorbid psychiatric diagnoses. Screening and treatment of comorbid mental illnesses is a goal of the APA addressed in the DSM-5 (APA, 2013). Comorbid psychiatric diagnoses are common in the Veteran population. In an examination of the records of 4 million Veterans seen in primary care, 25.7% had at least one psychiatric diagnosis, with approximately one half of these Veterans diagnosed with depression, followed by PTSD, substance use, anxiety, and serious mental illnesses (Trivedi et al., 2015). Upon further examination of the data, Trivedi et al. (2015) found that among Veterans with one primary diagnosis for a mental illness, many had at least one co-occurring mental illness, with the largest group (55%), reporting a co-occurrence of depression and anxiety.
Identification of comorbid psychiatric illnesses is of particular importance in the Veteran population. Veterans with more than one psychiatric diagnosis are at an increased risk for suicide and substance use (Conner et al., 2012; Seal et al., 2011). Veterans with PTSD are at higher risk for mood and anxiety disorders, substance use, suicidal ideation, and suicide attempts (Wisco et al., 2014). Identification of comorbid mental illnesses is especially noteworthy when providing care for Veterans returning from Iraq and Afghanistan because evidence indicates that these Veterans are four times more likely to have a comorbid mental health illness, and thus, they are at a higher risk for suicide and substance use (Seal et al., 2011). Using an MBC tool such as the PSQ to identify comorbid psychiatric diagnoses in the Veteran population enhances the treatment and resolution of these disorders.
VA Mental Health Performance Measures
The VA has several performance measures that set goals for monitoring quality of care regarding access to care. One of these performance measures is MHT12, which mandates mental health evaluation of Veterans within 7 days of discharge from inpatient mental health services. Suicide risk is greatest during the first week of post-hospitalization. In a retrospective study of 200 patients, Bickley et al. (2013) found that 55% of those who committed suicide did so within 1 week of hospital discharge.
Another performance measure, MH13, requires expedient access to care and scheduling within 30 days of a referral for all Veterans new to mental health care (Pedersen, Marshall, & Kurz, 2016). Finally, MH17 also refers to access to care, specifying that established mental health care Veterans will be seen within 30 days of the preferred follow-up date (as agreed on between provider and Veteran).
In addition to access measures, the VA also sets objectives for quality improvement. In mental health, screening for depression and PTSD are important indicators of quality care. All Veterans who are not diagnosed with depression or PTSD are screened annually for those diagnoses. The depression screening is accomplished by using the Patient Health Questionnaire (PHQ) −2 (two questions) or −9 (nine questions). The PTSD screening uses the PTSD-Primary Care (PTSD-PC) and/or PTSD Checklist-5 (PCL-5) to meet this measure. Negative attention regarding the VA via ongoing research and media reports substantiates the need for improvement in quality benchmarks (Bronstein & Griffin, 2014; Hepner et al., 2014).
The current quality improvement effort was organized around the following question:
In outpatient Veterans with psychiatric illness seen in a PMHNP RCC, how does care informed by measurement-based tools influence the following outcomes in a 5-month time period?
The outcomes examined include:
- 7-day follow up after inpatient care (MHT12);
- evaluation of new Veterans within 30 days of referral (MH13);
- follow up for established Veterans within 30 days of preferred date (MH17);
- screens for depression and PTSD (MDD40/PTSD51);
- progress toward symptom remission;
- continuity of care among providers; and
- systematic and structured health care.
To improve quality of care, MBC in the form of the PSQ was administered to each Veteran in the RCC beginning in March 2016. The authors used a program evaluation design to review key outcomes of the clinic between March 1 and August 1, 2016. Descriptive statistics were performed to characterize data. PSQ scores from each encounter were retrospectively obtained from 68 Veterans seen in the RCC. Data were recorded only for patients who completed the PSQ; anecdotally, up to three patients per each of the three providers' teams chose not to complete the PSQ. PSQ data were analyzed using SPSS (version 23). Paired t tests and Wilcoxon signed ranks tests were used to determine statistical significance of PHQ-9 and GAD-7 scores from first visit to second and third visits.
As the PSQ comprises several assessment tools, PMHNPs collected data for each. As the data were recorded, PMHNPs noted discrepancies in inter-rater reliability concerning the collection of the AUDIT-C data (i.e., notation of total versus component scores), and thus, those data were not included in the analysis. As the project progressed, it focused on patient outcomes for depression and anxiety; thus, the data analysis used findings from the PHQ-9 and GAD-7 components of the PSQ, and excluded the PTSD-PC, AUDIT-C, and pain question.
Data for VA performance measures were obtained from an internal repository of BVAMC data. Specifically, MHT12, MH13, and MH17 (as discussed above) were analyzed using a retrospective review. In addition, quality improvement measures MDD40 and PTSD51 were retrospectively assessed. Measures were compared to facility and national benchmarks.
The current project was approved and deemed a quality improvement project by the BVAMC, and was both approved and exempted from review as a quality improvement project by the UAB Institutional Review Board.
Demographics. The sample comprised 68 Veterans. The mean age of Veterans seen in the RCC was 55 years (range = 24 to 80 years), with 72% 50 or older. Men comprised 85% (n = 58) of the population and women comprised the remaining 15% (n = 10). African American individuals constituted 72% (n = 49) and the remaining 28% were Caucasian individuals (n = 19). These characteristics reflect the Veteran population served by the BVAMC.
Referral Sources. Creation of the RCC extended care to Veterans in the mental health clinic. Table 1 illustrates referral sources. The largest portion of Veterans (n = 29, 42.6%) were seen due to inability to obtain an appointment with their primary mental health provider, followed by referrals from Primary Care Mental Health Intervention (n = 24, 35.3%), self-referral (n = 8, 11.8%), post-hospital discharge follow up (n = 6, 8.8%), and women's clinic (n = 1, 1.5%).
Diagnostic Groupings. To analyze the data, diagnoses were categorized by groupings based on similar psychiatric nomenclature (Figure). Analysis of the groupings revealed the majority (n = 39, 57%) of Veterans had a primary psychiatric diagnosis of a mood disorder. Mood disorders were followed by PTSD groupings (n = 13, 19%), anxiety disorders (n = 4, 6%), adjustment and psychotic disorders (n = 3, 4.4%, respectively), substance use and sleep disorders (n = 2, 3%, respectively), and cognitive disorders (n = 2, 1.5%). Of 68 Veterans seen, 57% (n = 39) had more than one psychiatric comorbidity. Veterans with psychiatric comorbidities were more likely to have a primary diagnosis of a mood disorder. In contrast, when diagnoses were taken out of groupings, chronic PTSD became the most frequent primary diagnosis of those with comorbidities.
Diagnostic groupings of 68 Veterans who visited the Resident Continuity Clinic (mood disorders = 57%, PTSD = 19%, substance use disorders = 3%, psychotic disorders = 4.4%, anxiety disorders = 6%, adjustment disorders = 4.4%, sleep disorders = 3%, and cognitive disorders = 1.5%).
Note. DX = diagnosis; PTSD = posttraumatic stress disorder. Percentages may not total 100% due to rounding.
Analysis of PHQ-9 and GAD-7 Scores
Thirty-eight Veterans had at least two appointments in the RCC with completed PSQs for each visit, and their data were analyzed for mean differences in PHQ-9 and GAD-7 scores. Paired t tests were used to compare scores from first visit to second visit. PHQ-9 scores decreased from a mean of 11.58 to 9.87 (1.71-point decrease, p = 0.08). GAD-7 scores decreased from a mean of 10.26 to 8.53 (1.73-point decrease, p = 0.06) (Table 2). Lower scores are associated with symptom improvement.
Analysis of PHQ-9 And GAD-7 Scores From First Visit to Second Visit (N = 38)
Thirteen Veterans had at least three visits in the RCC during the project timeframe. Wilcoxon signed ranks tests were used to compare scores from first visit to third visit. PHQ-9 scores decreased from a mean of 13.46 to 10.85 (2.6-point decrease, p = 0.10). GAD-7 scores decreased from a mean of 12.54 to 9.15 (3.38-point decrease, p = 0.09) (Table 3).
Analysis of PHQ-9 and GAD-7 Scores From First Visit to Third Visit (N = 13)
VA Performance Measures
VA access and screening performance measures for the RCC and the facility (i.e., BVAMC) were compared to national benchmarks for the third quarter of fiscal year 2016 (Table 4). The increased availability within the clinic expedited scheduling for six Veterans, facilitating their access to mental health care within 7 days of inpatient discharge. This follow-up ensured continuity of care that emphasized inpatient therapy recommendations, such as medication changes. These six Veterans equate to 2.5% of the total patients discharged, enabling the facility to exceed the benchmark (i.e., 80%) at 81%.
Performance Measure Analysis
Regarding MH13 (i.e., seen within 30 days) and MH17 (i.e., follow up within preferred date), the RCC maintained 99% to 100% availability for the scheduling of new and established Veterans within 30 days of referral and preferred dates, respectively. There are no national benchmarks for these measures. The facility's total performance was also high—98.5% for MH13 and 98.8% for MH17.
The national benchmarks are 95% for MDD40, a requirement for annual depression screening using the PHQ-2 or PHQ-9, and PTSD51, a requirement for PTSD screening. The RCC exceeded the benchmarks by screening 99% of all Veterans seen. All Veterans within the clinic who had underlying mood and/or PTSD disorders were identified and their needs were addressed in their treatment plans.
The current quality improvement work had several noteworthy findings. Clinically significant decreases in mean PHQ-9 and GAD-7 scores were noted. The decreases of PHQ-9 and GAD-7 underscore the improvement of psychiatric symptomatology and progress toward remission, which results in improved quality of life for Veterans. It is important to note that most of these Veterans already had a treatment plan in place from a previous provider. Continuity of care is important because many Veterans drop out of treatment when their previous providers become unavailable (Hoge et al., 2014). In the BVAMC, PMHNP residents assisted in filling those voids by assuming Veterans' care in the previous provider's absence.
The outcomes of the RCC have surpassed national benchmarks set forth by the VA. The RCC provided access to evidence-based treatment by extending appointment availability to Veterans recently discharged from inpatient hospitalization. The RCC excelled at meeting national access and quality performance measures.
The clinic also helped fill the gap when primary care providers were unavailable. Reasons for non-availability included: (a) the provider's transfer; (b) temporary absence due to illness; and (c) insufficient appointment slots. The RCC also created the availability for walk-in appointments. This availability is also congruent with one of the VA's newest initiatives, MyVA Access, which facilitates quick access to care by Veterans in a mental health crisis (VA, 2016b).
Next, the use of MBC in the RCC played a key role in improving continuity of care among the resident providers. To illustrate, in one resident's absence, another resident could assume care for the Veteran in a structured and systematic way. Use of the PSQ eliminated the variability in assessment among residents.
Finally, MBC played a pivotal role in improving the quality of care by facilitating the assessment process. Incorporating the PSQ into routine clinical care ensures screening Veterans for common psychiatric illnesses. The use of MBC tools elucidates unreported symptoms and informs treatment. MBC engages Veterans in their care by providing a springboard for discussion and quantifying their symptoms and allowing them to better conceptualize their responses to treatment. For example, one Veteran did not report current alcohol use during the interview, but endorsed current drinking behaviors on the AUDIT-C. Thus, the resident conducted motivational interviewing regarding his current alcohol use.
This project had limitations in methodology, sampling, and time-frame. Due to the quality improvement methodology, there was no comparison or control group. The project included a convenience sample that was relatively small (N = 68). The timeframe for the project was limited to 5 months, and this limited period might not have been long enough to capture complete response to treatment. Finally, the care provided was largely a continuation of care rather than an initiation.
MBC improves quality of care for Veterans. This project demonstrates how the RCC incorporated MBC tools to improve Veterans' care by engaging them in their health care, quantifying their symptoms, and providing a basis for structured care that informs treatment of symptoms. The RCC exceeded national benchmarks for VA performance measures, providing improved care that influenced outcomes both locally and nationally. The work achieved by the RCC is sustainable and has potential for replicability at other VA facilities. The implementation of this project required no significant expenses. The MBC tool was easy to implement and did not cause significant workflow disruption. There was little to no risk to the Veterans involved.
There are several recommendations for future innovations. Implementation of MBC should occur in psychiatric care within the VA and other organizations. Concerning the assessment of substance use, a more thorough tool than the AUDIT-C currently used in the PSQ would offer a better appraisal of substance use in Veterans. In March 2016, the VA implemented an initiative to promote use of MBC in the assessment and provision of mental health care for Veterans (VA, 2016a) at selected sites that did not include the BVAMC. Currently, the pilot program is in Phase I, and includes the Brief Addiction Monitor (BAM; DePhillippis, n.d.) to assess the use of a variety of substances, including alcohol and opioid, benzodiazepine, and stimulant agents. Inclusion of the BAM could improve assessment for substance use, thereby increasing the efficacy of future RCC quality improvement projects.
Next, organizations that value the use of MBC should promote technology, such as tablets, when incorporating MBC into clinical care. User-friendly technology could make use of MBC more time-efficient, accurate, and practical for those with intellectual and/or physical limitations when compared to using traditional paper-and-pen methods. Finally, the VA should consider implementing more RCC models nationwide to promote scholarly contributions to Veteran-centric care. Through their use of structured, systematic, and quantifiable MBC tools, NP residents in either a mental health or primary care RCC can play an integral role in assisting the VA to provide high-quality care and meet local and national mental health performance measures.
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|Referral Source||Frequency (n, %)|
|Provider transition||29 (42.6)|
|Primary care mental health integration||24 (35.3)|
|Post-hospital discharge||6 (8.8)|
|Women's clinic||1 (1.5)|
Analysis of PHQ-9a And GAD-7b Scores From First Visit to Second Visit (N = 38)
|Tool (Visit)||Mean||t Test||Paired t test (p Value)|
Analysis of PHQ-9a and GAD-7b Scores From First Visit to Third Visit (N = 13)
|Tool (Visit)||Mean||Wilcoxon Signed Ranks Test (p Value)|
Performance Measure Analysis
|Access Measures||Description||Facility Q3 FY 2016||Resident Clinic Contributions||Benchmark|
|MHT12||MH inpatient 7-day follow up||81%||Six Veterans (2.5%) seen in the RCC in Q3 FY 2016 contributed to exceeding the benchmark||80%|
|MH13||New MH completed appointment within 30 days of the preferred date||98.5%||99% to 100%||No target|
|MH17||Established MH completed appointment within 30 days of the preferred date||98.8%||99% to 100%||No target|
|MDD40||Depression screening (PHQ-2 or -9) annually||94.3%||99%||95%|