Telemedicine Outreach for PTSD (TOP)
Telemedicine-based collaborative care successfully engaged Veterans who lived in rural settings in evidence-based psychotherapy to improve PTSD treatment adherence and symptoms. During a 12-month randomized effectiveness trial, 55% of the Veterans randomized to TOP received cognitive processing therapy (CPT) via interactive video compared to 12% of Veterans in usual care. Veterans in the TOP group also had significantly larger decreases in PTSD symptoms compared to those in usual care. Fortney et al., JAMA Psychiatry, 2015
Three million Veterans living in rural areas receive VA healthcare. Factors such as overburdened facilities, long travel distances, and lack of available specialists can be major barriers to care for these Veterans. To improve their access to specialty care, the Office of Rural Health’s (ORH) Veteran Rural Health Resource Centers develop programs that utilize virtual care technologies developed by the Office of Connected Care. The Virtual Specialty Care National QUERI Program works with ORH and VA’s Office of Mental Health and Suicide Prevention to implement and evaluate these programs, including Telemedicine Outreach for PTSD (TOP) – a multi-site quality improvement project that promotes evidence-based psychotherapies for Veterans with PTSD who receive their care in VA’s community-based outpatient clinics (CBOCs).
Thus far, Virtual Specialty Care QUERI has trained staff at 25 CBOCs that have treated 874 Veterans with PTSD who live in rural settings. Virtual Specialty Care QUERI also includes a Veteran Advocate, Mr. John Paul Nolan, Jr., who has become an invaluable part of the external facilitation team. Below, Mr. Nolan discusses his experience working as part of the QUERI team on the TOP project, as well as his work with the HSR&D Center for Mental Health and Outcomes Research (CeMHOR) Steering Committee.
Veteran Advocate, Mr. John Paul Nolan, Jr.
"The efficiency of and compassion expressed by my care manager was inspiring."
My involvement in HSR&D’s Telemedicine Outreach for PTSD (TOP) initiative began in May 2010. By that time, my VA therapist and I had worked for approximately four years on my PTSD symptoms, but due to the massive number of patients they needed to serve, my local VA community-based outpatient clinic (CBOC) was unable to properly attend to my specific issues.
“As a Veteran Advocate on the TOP project, Mr. Nolan was a member of the external facilitation team. This role involves making sure that the perspective of Veterans is embedded in the decision-making process about intervention adaptation and roll out. The Veteran Advocate is extremely effective at prioritizing accountability to Veterans, keeping the discussion patient-centered, and instilling a sense of urgency into the conversation. In addition to increasing the efficiency and effectiveness of implementation efforts, working side by side with a Veteran Advocate can be highly motivating and rewarding for both researchers and front-line clinicians.”
- John C. Fortney, PhD, Principal Investigator, Virtual Specialty Care QUERI.
Lack of access to care was becoming a systemic issue VA-wide. TOP was created to help address this issue. The enormity of the program, in conjunction with the lack of success within my previous treatment regimen, is not lost on me. While enrolled in the TOP trial—and in treatment from June 2010 to June 2011, I was contacted bi-weekly via telephone by a care manager. The efficiency of, and compassion expressed by my care manager was inspiring. I also had 14 sessions with my telepsychologist, who was fully up to speed and in close communication with my care manager. This is an intrinsic element, not only of TOP, but of all successful outreach and care coordination. Communication is key. Each day, I still use the information from TOP to cope and grow.
In November 2015, Dr. John Fortney invited me to participate in research as a Veteran Advocate. I was honored to be asked and gladly accepted. As the effort was made to implement TOP on a national level, I was invited to provide input as part of an ongoing dialogue with many high-level VA personnel. This has been an incredible glimpse into the massive effort to combat mental health issues faced by Veterans. At no point in this complex, multi-faceted approach to outreach did I ever hear a single individual “phone it in” or only give the bare minimum. The providers assisting the implementation team are equally invested, if not more so. They are face-to-face with us daily, and their input reflects this. I hold them in the highest regard on a personal level. Having said that, the data on TOP is disappointing at this time. There are several factors that have influenced this, including personnel changes and hiring freezes. Stigma and a maze of personal variables from the Veterans’ side are also major barriers to outreach. I believe we can do this more efficiently and effectively through continued open dialogue with all parties, as well as continued support. I will make myself available to assist in this as we move forward. I believe in TOP. It has worked and can continue to work, but the VA system must change to be more flexible to allow new programs time to bear fruit within Veterans’ lives.
"[Serving as a Veteran Advocate] has been an incredible glimpse into the massive effort to combat mental health issues faced by Veterans."
In the spring of 2016, I was contacted by Dr. Rick Owen, Director of HSR&D’s Center for Mental Health and Outcomes Research (CeMHOR), who asked me to be a member of the Steering Committee. I credit CeMHOR’s support of Dr. Fortney in the original TOP trial – among other projects addressing Veteran PTSD and substance abuse – with my success becoming a Veteran Advocate, so after meeting with Dr. Owen, I agreed to join. Of particular interest to me is the recently developed Veterans Advisory Council. After many months of discussion with a group of peers and Veterans, Dr. Owen established this group. The original framework allowed for not only bi-directional information flow, but also Veteran engagement for idea generation to inform future research. If VA is to truly move forward to patient-centered care, this model is of immense value to clinicians and researchers. While only in its first year, the Veterans Advisory Council has provided both input and letters of support to many regional as well as national endeavors. I am hopeful the individuals within the CeMHOR Veterans Advisory Council will be committed long-term to not only help conceive the research, but to see it disseminated and implemented.
"If VA is to truly move forward to patient-centered care, this model [Veteran engagement] is of immense value to clinicians and researchers."
As I look back at the different research programs I’ve been involved with, there are several areas that I suggest need further study.
- Peer Support: While there are peer-support specialists within VA, I believe we are missing a huge untapped resource. Veterans need to be needed. Where available, VA should harness these forces to make meaningful change. Volunteering to educate other Vets or caregivers is paramount. We all have some experience in personnel management, as well as logistical expertise. While not an option for those in crisis now, positive responses to treatment lend credibility to VA's outreach. Don't let us sit idly by when you need our help, as we need yours.
- Marketing:There is a serious disconnect between the VA care I have received and the perception of VA at large. . I could have had an unlimited insurance policy, but no amount of money could have bought better care than what I received from my VA providers. This is where peer support should be brought into play. As a force multiplier, we can connect with those who served. This is also an excellent opportunity to reach so many caregivers who have no context of the language of VA or the military.
- Veteran Engagement:Neither peer support nor marketing can happen without Veteran engagement. VA is a very difficult institution to navigate. We owe the men and women who've been in constant urban combat for almost two decades a stable, modern healthcare system. This requires fundamental change within VA. We must incentivize providers to commit to their positions. Constant provider turnover breeds distrust within the Veteran community. It has been my experience that the massive red tape met by Veterans pales in comparison to that faced by providers. This needs to change. Veterans need to know about the challenges faced by their providers. Above all, we need an overarching plan to address this. However, I have talked to many people on all sides with nothing to report except confusion. But with long-term commitment and meaningful conversation between Veterans, clinicians, researchers, and VA Central Office, we can change the VA.
"Don’t let us [Veterans] sit idly by when you need our help, as we need yours."
As I look back at the efforts I have participated in, I am struck by the incredible impact of researchers across the country. These researchers have collaborated with groups of providers to bring cutting-edge care to many Veterans. Their collective efforts should be recognized and emulated. While I applaud VA’s leadership in engaging recently returning Veterans, we can do better by those older Veterans still with us, with added emphasis on their caregivers/family (peer support opportunity). These suggestions may sound critical, but they are not intended in that vein. I am humbled and amazed at the personal effort I have seen. As a proud Veteran, I need the VA healthcare system, as do millions of others. The providers are doggedly determined to do their part. We simply must address the lack of resources available to them, while bringing a positive message to all involved.
Thank you for what you do. When possible, continue to work the miracles you do every day. VA can evolve. You can – and do – make a difference.
John Paul Nolan, Jr.
Veteran Advocate, Virtual Specialty Care QUERI program