Setting Standards for Delivering High-Quality Care to Veterans with Invisible Wounds

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Sep 12, 2022

Dr. Gregory Johnson does a neurologic exam on U.S. Army Spc. Andrew Karamatic at Tripler Army Medical Center in Honolulu, Hawaii, March 20, 2014, photo by Staff Sgt. Christopher Hubenthal/U.S. Air Force

Dr. Gregory Johnson does a neurologic exam on U.S. Army Spc. Andrew Karamatic at Tripler Army Medical Center in Honolulu, Hawaii, March 20, 2014

Photo by Staff Sgt. Christopher Hubenthal/U.S. Air Force

By Natalie C. Ernecoff, Carrie M. Farmer, Matthew F. Amidon, Margaret C. Harrell, Jennifer Silva

For veterans living with invisible wounds of war, care delivery organizations must define and measure standards for high-quality care. Posttraumatic stress disorder (PTSD), depression, traumatic brain injury (TBI), substance use disorders, and other “invisible wounds” are common among post-9/11 veterans and can interfere with their employment, family life, engagement with their communities, and overall well-being. Further, many veterans receive care at non-VA facilities, though the quality and programs in non-VA clinical settings are difficult to assess. Although there are effective treatments for these conditions, many veterans face barriers to accessing high-quality care. Therefore, care delivery organizations could work to ensure that the care and resources they provide are of high quality.

As a first step, the Veteran Wellness Alliance, a coalition of veteran peer network organizations and clinical provider organizations supported by the George W. Bush Institute, previously collaborated with RAND researchers to develop a shared definition of high-quality care consisting of four pillars: veteran-centered care, accessible care, evidence-based care, and outcome monitoring to improve access to high-quality care for post-9/11 veterans with invisible wounds.

A definition alone is insufficient for improving outcomes for veterans. Therefore, the team operationalized these tenets of high-quality care by consolidating standards for high-quality care to support veterans, policymakers, providers, and payers in identifying clinical providers who serve veterans and are currently delivering high-quality care (see shaded box). These standards of care provide a target for quality improvement: Providers who are not currently delivering high-quality care can identify gaps in the care they provide by comparing their care with the standards and implementing necessary practice changes.

By identifying standards that are both feasible (minimal burden of data collection on programs and providers) and important (rated by clinicians and administrators to be very important to delivery of high-quality care), our researchers identified a set of 10 criteria that were applicable across four conditions of focus: PTSD, depression, TBI, and substance use disorders (see shaded box). For example, veteran-centered care is indicated by program/clinic staff completing training in military cultural competence, and an indicator of evidence-based care is that veterans are assessed for suicide risk at each visit.

A shared definition and standards for high-quality care can help organizations that support veterans better assist in their recovery from invisible wounds.

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A shared definition and standards for high-quality care can help organizations that support veterans better assist in their recovery from invisible wounds. Broad dissemination of the definition and standards of high-quality care can help distinguish between care that meets the standards and care that does not. Specifically, established, evidence-based practices could be used as first-line treatments. As the field evolves, the focus on evidence-based care as a key component of high-quality care could lead to better outcomes for veterans with invisible wounds.

Not all providers are currently delivering care that meets these standards, leaving veterans at risk of receiving poor-quality and ineffective care. To improve care, some providers may need additional resources and support, such as training opportunities for staff. Incentives for quality improvement, such as provider bonuses, could also help to ensure that all veterans can access high-quality care.

The health care delivery system could develop infrastructure to provide high-quality, evidence-based care for veterans to improve their outcomes and quality of life. This work provides a framework for ensuring care systems effectively meet the needs of veterans living with invisible wounds.


Natalie C. Ernecoff is an associate policy researcher at the nonprofit, nonpartisan RAND Corporation. Carrie M. Farmer is codirector of the RAND Epstein Family Veterans Policy Research Institute, director of the Health Care Quality Measurement and Improvement Program, and a senior policy researcher at RAND. Col. Matthew F. Amidon, USMC, is the director, Veterans and Military Families at the George W. Bush Institute. Margaret Harrell is chief programs officer at the Bob Woodruff Foundation. Jennifer Silva is chief program officer at the Wounded Warrior Project.

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