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Research Questions

  1. To what degree is RESPECT-Mil being implemented in the Army's primary care settings?
  2. What are the facilitators and barriers to RESPECT-Mil's implementation?
  3. How sustainable is RESPECT-Mil according to the perspectives of key stakeholders in the military health system?

A RAND team conducted an independent implementation evaluation of the Re-Engineering Systems of Primary Care Treatment in the Military (RESPECT-Mil) Program, a system of care designed to screen, assess, and treat posttraumatic stress disorder and depression among active duty service members in the Army's primary care settings. Evaluating the Implementation of the Re-Engineering Systems of Primary Care Treatment in the Military (RESPECT-Mil) presents the results from RAND's assessment of the implementation of RESPECT-Mil in military treatment facilities and makes recommendations to improve the delivery of mental health care in these settings. Analyses were based on existing program data used to monitor fidelity to RESPECT-Mil across the Army's primary care clinics, as well as discussions with key stakeholders. During the time of the evaluation, efforts were under way to implement the Patient Centered Medical Home, and uncertainties remained about the implications for the RESPECT-Mil program. Consideration of this transition was made in designing the evaluation and applying its findings more broadly to the implementation of collaborative care within military primary care settings.

Key Findings

RESPECT-Mil Is Identifying a Considerable Number of Service Members Who Are Reporting Depression and PTSD Symptoms.

  • Of those who visited primary care, 93 percent of service members were screened for PTSD and depression.
  • Of the screened visits, 13 percent resulted in a positive screen.
  • Of the positive screens, 61 percent resulted in a probable diagnosis of a mental health disorder.

Army Installations Sometimes Varied with Respect to the Identification and Referral of Service Members with Mental Health Needs.

  • A majority of installations (25 out of 37) were screening a high proportion of visits (ranging from 91 to 99 percent); 31 of 37 installations were screening at least 80 percent of their visits.
  • For ten of the 37 installations, at least 20 percent of positive screens resulted in an accepted referral to RESPECT-Mil; 24 of the installations had rates between 10 percent and 19 percent.

Rates of Treatment Response and Remission Seen in RESPECT-Mil Were Within the Range of Other Collaborative Care Studies.

  • Of service members in the "depression prominent" category, 42 percent experienced a 50 percent reduction in depression symptoms from baseline to the last follow-up assessment. Other studies have reported a range of 19 percent to 53 percent of patients showing similar improvement.
  • Of service members in the "PTSD prominent" category, 33 percent experienced similar decreases in symptoms. In a civilian collaborative care study with PTSD patients, 50 percent experienced decreases in symptoms with a less stringent criterion and with a longer follow-up period.

Recommendations

  • Improve the recognition and assessment of depression and PTSD by streamlining screening and assessment, determining the value of screening service members already in enrolled in behavioral health care, enhancing command support, and expanding routine screening and evidence-based primary care management practices for depression and PTSD.
  • Improve referrals and the management of depression and PTSD in primary care by increasing primary care provider engagement and comfort, incentivizing and supporting primary care champions, modifying program criteria given the range of symptom severity among service members referred to the program, strengthening the handoff between the primary care provider and the care facilitator, facilitating engagement and communication with service members, enlisting command in support of service members' treatment engagement and adherence, fortifying communication between providers, ensuring that the behavioral health champion role is adequately supported, and enhancing the behavioral champion role.
  • Improve quality assurance monitoring by augmenting individualized and real-time performance feedback, creating incentives for sites and providers to buy in to quality improvement processes, continuing to support the RESPECT-Mil Implementation Team or similar centralized quality improvement programs, and establishing a self-monitoring process for the RESPECT-Mil Implementation Team oversight efforts.

Table of Contents

  • Chapter One

    Introduction

  • Chapter Two

    Methodological Approach

  • Chapter Three

    RESPECT-Mil Implementation: Findings from Monthly Screening and Referral Clinic Reports and FIRST-STEPS

  • Chapter Four

    Facilitators and Barriers to RESPECT-Mil Implementation: Findings from Provider Discussions

  • Chapter Five

    Facilitators and Barriers to RESPECT-Mil Implementation: Findings from RMIT Discussions

  • Chapter Six

    RESPECT-Mil Sustainability: Findings from Stakeholder Discussions

  • Chapter Seven

    Discussion and Recommendations

  • Appendix A

    Department of Defense MEDCOM Form 774

  • Appendix B

    Patient Health Questionnaire-9 (PHQ-9) for Depression

  • Appendix C

    RESPECT-Mil Scoring for PHQ-9 for Depression

  • Appendix D

    PTSD Checklist (PCL)

  • Appendix E

    RESPECT-Mil Scoring for PTSD Checklist (PCL)

  • Appendix F

    Stage-by-Topic Discussion Protocol for RESPECT-Mil Behavioral Health Champions

  • Appendix G

    Stage-by-Topic Discussion Protocol for RESPECT-Mil Nurse Care Facilitators

  • Appendix H

    Stage-by-Topic Discussion Protocol for RESPECT-Mil Primary Care Champions

  • Appendix I

    Discussion Protocol for Primary Care Providers

  • Appendix J

    RMIT Internal Process Discussion Protocol

  • Appendix K

    Discussion Protocol for Stakeholder Discussions

  • Appendix L

    Qualitative Analysis Details

  • Appendix M

    Baseline and Last Follow-Up PCL Scores

  • Appendix N

    Crosswalk of Recommendations and Findings

This research was sponsored by the Assistant Secretary of Defense for Health Affairs and the DCoE and conducted within the Forces and Resources Policy Center of the RAND National Defense Research Institute, a federally funded research and development center sponsored by the Office of the Secretary of Defense, the Joint Staff, the Unified Combatant Commands, the Navy, the Marine Corps, the defense agencies, and the defense Intelligence Community.

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