This report is a comprehensive assessment of the quality of care delivered by the Military Health System (MHS) in 2013–2014 for active-component service members with posttraumatic stress disorder (PTSD) or depression. The assessment includes performance on 30 quality measures, which draw on multiple data sources to evaluate the receipt of recommended assessments and treatments. The assessment identified strengths and areas for improvement.

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Quality of Care for PTSD and Depression in the Military Health System

Final Report

by Kimberly A. Hepner, Carol P. Roth, Elizabeth M. Sloss, Susan M. Paddock, Praise O. Iyiewuare, Martha J. Timmer, Harold Alan Pincus

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Research Questions

  1. Are service members with PTSD or depression receiving evidence-based care from the Military Health System?
  2. Are there disparities in care quality by branch of service, geographic region, or service member characteristics?
  3. Where could MHS focus its efforts to continuously improve the quality of care provided to all service members?

The U.S. Department of Defense (DoD) strives to maintain a physically and psychologically healthy, mission-ready force, and the care provided by the Military Health System (MHS) is critical to meeting this goal. Attention has been directed to ensuring the quality and availability of programs and services for posttraumatic stress disorder (PTSD) and depression. This report is a comprehensive assessment of the quality of care delivered by the MHS in 2013–2014 for over 38,000 active-component service members with PTSD or depression. The assessment includes performance on 30 quality measures to evaluate the receipt of recommended assessments and treatments. These measures draw on multiple data sources including administrative encounter data, medical record review data, and patient self-reported outcome monitoring data. The assessment identified strengths and areas for improvement for the MHS. In particular, the MHS excels at screening for suicide risk and substance use, but rates of appropriate follow-up for service members with suicide risk are lower. Most service members received at least some psychotherapy, but less than half of psychotherapy delivered was evidence-based. In analyses focused on Army soldiers, outcome monitoring increased notably over time, yet preliminary analyses suggest that more work is needed to ensure that services are effective in reducing symptoms. When comparing performance between 2012–2013 and 2013–2014, most measures demonstrated slight improvement, but targeted efforts will be needed to support further improvements. RAND provides recommendations for strategies to improve the quality of care delivered for these conditions.

Key Findings

  • The MHS performed well in providing initial screening for suicide and substance use, but needs to improve at providing adequate follow-up to service members with suicide risk.
  • Most service members with PTSD or depression received at least some psychotherapy, but fewer received psychotherapy that was evidence-based.
  • Service members with PTSD or depression use a high volume of health services and see multiple providers, suggesting the need to ensure coordination of care.
  • The MHS continues to be a leader in achieving high rates of follow-up after psychiatric hospitalization.
  • Less than half of service members receive an adequate amount of initial care when beginning treatment for PTSD or depression.
  • Army demonstrated increased outcome monitoring over time and preliminary analyses suggest that more effort is needed to ensure service members who receive care achieve positive outcomes.
  • Performance on most administrative data–based quality measures improved slightly between 2012–2013 and 2013–2014, but targeted efforts are needed to support further improvements.
  • Quality of care for PTSD and depression varied by service branch, TRICARE region, and service member characteristics, suggesting opportunities for quality improvement.

Recommendations

  • Improve the quality of care delivered by the Military Health System for psychological health conditions by immediately focusing on specific care processes identified for improvement.
  • Expand efforts to routinely assess quality of psychological health care: Establish an enterprise-wide performance measurement, monitoring, and improvement system that includes high-priority standardized measures to assess care for psychological health conditions; and routinely report quality measure scores for psychological health conditions internally, enterprise-wide, and publicly to support and incentivize ongoing quality improvement and facilitate transparency.
  • Expand efforts to monitor and use treatment outcomes for service members with psychological health conditions: Integrate routine outcome monitoring for service members with PH conditions as structured data in the medical record as part of a measurement-based care strategy; monitor implementation of outcome monitoring across service branches and evaluate how providers use symptom data to inform clinical care; and build strategies to effectively use outcome data and address the limitations of these data.
  • Investigate the reasons for significant variation in quality of care for PH conditions by service branch, region, and service member characteristics.

Table of Contents

  • Chapter One

    Introduction

  • Chapter Two

    Methods

  • Chapter Three

    Characteristics of Service Members in PTSD and Depression Cohorts, and Their Care Settings and Treatments

  • Chapter Four

    Quality of Care for PTSD

  • Chapter Five

    Quality of Care for Depression

  • Chapter Six

    Use of Symptom Questionnaires and Relationship Between Evidence-Based Care and Symptom Scores

  • Chapter Seven

    Summary and Recommendations

Research conducted by

This research was sponsored by the Department of Defense's Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (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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