Defining High-Quality Care for Posttraumatic Stress Disorder and Mild Traumatic Brain Injury: Proposed Definition and Next Steps for the Veteran Wellness Alliance
Oct 22, 2020
Photo by Bush Institute CC BY-NC-ND 2.0/Paul Morse
Sometimes referred to as "invisible wounds," symptoms of posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI) can endure long after military service concludes and can have a significant negative impact on veterans and their families. Yet, many veterans have difficulty accessing high-quality care for these conditions.
The Veteran Wellness Alliance, an initiative of the George W. Bush Institute, is a coalition of seven veteran peer network organizations and nine clinical provider organizations that aims to improve access to high-quality care for post-9/11 veterans with PTSD and TBI. To be successful in this mission, and to better support the broader veteran-serving community, alliance partners require a shared definition of high-quality care for these conditions.
High-quality care for invisible wounds should be veteran-centered, accessible, and evidence-based, and it should include outcome monitoring.Share on Twitter
A literature review and semistructured interviews with Veteran Wellness Alliance partners highlighted standards that can serve as a foundation for efforts to develop a definition of high-quality care for veterans with PTSD and TBI.
Operationalizing this definition and improving care for veterans will require common metrics drawing on a variety of data sources to provide a comprehensive picture of veterans' needs, experiences, treatment progress, and outcomes. Veteran Wellness Alliance partners already practice aspects of high-quality care, but a shared definition would help improve coordination and could serve as a model for the treatment of PTSD and TBI.
Similar to the traditional health care model of patient-centered care, the goal of veteran-centered care is to provide effective and timely treatment that addresses the unique needs, values, and preferences of veterans. Providing veteran-centered care requires health care providers to be familiar with veteran culture and identity, the implications of military service, and the needs of diverse populations of veterans—a concept known as cultural competence.
Veteran-centered care requires ongoing assessment of veterans' satisfaction with their care, their perceived ability to access care, their perceptions about provider communication, and other aspects of their care experience. Veterans should also be involved in treatment decisions. Ideally, there will be a protocol for shared decisionmaking. Finally, treatment decisions should include family members and caregivers, according to the veteran's preferences.
High-quality care is both accessible and timely. Veterans should not have to wait long to obtain the care they need. Furthermore, programs that provide high-quality care work to address and reduce or eliminate geographic, financial, sociocultural, and other barriers. Providing flexible payment options, transportation and lodging, and flexible scheduling can expand access to care for veterans.
High-quality care is based on the best available research evidence and adheres to clinical practice guidelines. Best available research evidence refers to scientific findings related to interventions, assessments, clinical problems, and patient populations in both laboratory and field settings, as well as clinically relevant results from basic research.
Evidence-based care begins with a comprehensive assessment to inform treatment. The research evidence strongly supports trauma-focused psychotherapy for veterans with PTSD, such as prolonged exposure, cognitive processing therapy, eye movement desensitization and reprocessing, or cognitive behavioral therapy. Veterans with TBI symptoms should receive coordinated treatment from a multidisciplinary team that includes neurology, physical therapy, neuropsychiatry, and other specialties. Appropriate screenings should be administered as needed to assess risk factors, such as suicidality and substance use. Evidence-based care also involves coordination across a veteran's health care providers to ensure treatment continuity.
High-quality care promotes the use of validated measurement tools, such as symptom rating scales, to assess and monitor clinical outcomes, guide treatment decisions, and facilitate coordination. It is also important to monitor the effects of treatment on veterans' well-being, including day-to-day functioning, relationships, and life satisfaction.
The Veterans Wellness Alliance has an opportunity to set the standard for high-quality care. Next steps should focus on developing measures to align with the high-quality care definition, determining the best path for collecting and sharing data on care quality, and disseminating the definition and measures across the veteran-serving community.