Implementation of new practices—especially evidence-based practices (EBPs)—requires large-scale change in provider behavior. Empirical studies have repeatedly demonstrated that inattention to implementation issues for these novel practices can cause implementation failure, leading to poor outcomes. Therefore, based upon multiple theories of dissemination/implementation of new practices (e.g., Diffusion of Innovations, PRECEDE), and empirical evidence, the impact of dissemination efforts will be maximized when they:

1) are based on assessed needs, barriers, and incentives of targeted end users (i.e., service members, veterans, families, providers, and organizations);

2) involve local representatives of diverse stakeholder groups—service members, veterans, families, line providers, administrators and DoD command—in the planning process for implementation;

3) use implementation expert involvement in planning, especially for complex practices;

4) use marketing principles for developing and disseminating intervention tools to providers, clinics, facilities, VISNs and DoD command;

5) secure support and involvement from top-level management and champions at all levels (clinic, facility, medical center, VISN, DoD command)

6) monitor the delivery of services (e.g., amount, fidelity) and the outcomes at the individual service member/veteran, clinic, facility, and VISN levels. Analyze the data at those multiple levels, give it back to staff at those levels, and train staff at those levels on how to use that data to make improvements.

It is recommended that VA and DoD adopt these principles using a an organizational change framework (there are many to chose from) for all innovation dissemination efforts, regardless of the innovation. These frameworks take into account the personal motivations of staff and resources provided by the institution (e.g., training, leadership), organizational characteristics such as “climate for change” (e.g., staff cohesion, presence of opinion leaders, openness to change), staff attributes (e.g., adaptability, self-efficacy), and characteristics of the innovations themselves (e.g., complexity, relative benefit, observability).

Further, the adoption of these principles could be bolstered by the development of a systematic and comprehensive “implementation support system”, whose aim would be to support successful dissemination at the local level. Key elements of such a system would be:
1. Human training and support infrastructure. To change behavior and build skills, providers need opportunities to not only learn information, but to practice newly learned skills. To accomplish this, providers need protected time to learn and ongoing access to a cadre of dedicated personnel who could provide training and supervision in the relevant treatments, and technical assistance (often called coaching, and/or facilitation) in how to build support for local adoption (e.g., how to use a champion).
2. An easy to use online training and knowledge management system. Providers could be further supported by access to online trainings, tools, and documents. This will require adequate programming support as well as development of a practical learning management system within VHA.

It is also recommended that efforts at widespread organizational change/implementation utilize existing resources. For example, the Quality Enhancement Research Initiatives for Mental Health (MH QUERI) and Substance Use Disorder (SUD) (http://www.queri.research.va.gov/) have experience using such frameworks and stand ready to assist those in VA or DoD in implementing effective practices. QUERI is a national implementation and implementation research program funded by the Health Services Research and Development Service of the Department of Veterans Affairs. In addition, the VA Center for Implementation Practice and Research Support (CIPRS, http://www.queri.research.va.gov/ciprs.cfm) is a new QUERI resource center that provides education, technical assistance and consultation to VA practitioners in support of implementing evidence-based practices. The National Center for PTSD and Sierra-Pacific MIRECC also has experience in national training projects (e.g., training providers in evidence-based interventions for PTSD and depression), web resource and online training development, and facilitation of online communities of practice (http://www.mirecc.va.gov/visn21.asp).

Thank you so much for providing us with the opportunity to post these ideas.

All too many warriors have lost their ability to trust governmental systems, as a direct result of their traumas.

These warriors will not access any aid that looks, feels or smells like a government service.

Conclusion: To help this class of warriors, the government must dedicate a significant portion of its resources to supporting and building the capacity of NGOs that understand how to earn the trust of these warriors and provide effective service to them.

Measurement: What percentage of the budget for dealing with invisible injuries is going to NGOs?

I am the CEO of notalone.com, an NGO that deserves this sort of support. carter@notalone.com

Implementation of evidence-based practices (EBPs), innovations, and other emerging best practices requires large-scale change in practitioner behavior. Just a few of the various service improvements now envisaged in MH care include addition of problem-solving (prevention) interventions, new guidance related to management of co-occurring mild traumatic brain injury and PTSD, expansion of services to include family interventions, and hiring of a new provider group to address substance abuse among PTSD patients. These and other important changes call for effective practitioner behavior change, for it is the line provider that will be responsible for delivering the evolving services.

To succeed with envisaged changes, MH leadership should develop a systematic and comprehensive approach to training and implementation within VHA. As part of this approach, they should create a Dissemination and Training Infrastructure, to include several needed resources:

1. Investment in a human training and support infrastructure, to enable delivery of training and fostering of mutual support and information sharing among communities of practice:

a. Practitioners throughout the VHA system need more than information, they need skills. Skills training required interactive workshop training followed by supervision during a learning phase. Currently, most trainers and supervisors perform these roles as collateral duties. In order to enable more widespread training that can evolve as lessons are learned and new policies and procedures are enacted, VHA should invest in dedicated trainer personnel , who will learn and transmit new skills sets as needed.
b. This personnel resource should also include facilitators, whose roles are to organize relevant materials needed by the trainee groups, encourage communication among providers, promote participation in web-based information exchange, and enable sharing of lessons learned and local solutions to mutual challenges.

2. Creation of a one-stop knowledge management website for providers. This site would provide an easy-to-navigate place where providers could quickly locate materials helpful to their jobs. Such downloadable materials would include:

a. Guidance documents (e.g., practice guidelines)
b. Treatment manuals
c. Patient and family handout materials
d. Lists of self-help resources
e. Links to key communities of practice related to new practices and skills
f. Practitioner information/experience exchange forums
g. Useful, practical summaries of recent research findings relevant to veteran care
h. Articles related to veteran care

3. A rapidly-developed menu of online training materials capable of widespread viewing by provider groups.

a. Although effective training will often require ongoing supervision/consultation, web-based training materials can perform a range of key teaching functions and supplement other forms of training. VHA requires capacity to rapidly develop an array of online training workshops related to the new skills sets needed by various provider groups. This will require adequate programming support as well as development of a practical learning management system within VHA.

4. Policy development to ensure protected time for practitioners to learn and practice new skills and information. The VHA now requires adaptive practitioners who are continuously learning and upgrading their skills. If learning is a professional responsibility, practitioners should have weekly time dedicated for the purpose of mastering new competencies. Such training time should also contribute to improved staff morale and reduced stress.

VHA has existing assets that can help OMHS develop and maintain this infrastructure, including its Centers of Excellence (e.g., National Center for PTSD, CESATEs), MH QUERI, and MIRECCs.

an existing university to put together a curriculum from which soon to separate/retire service members (i.e. 5 years out) and/or military spouses can earn their degree/certification to become a mental health care provider. This program could be delivered across military installations so wherever the service member is stationed, he/she would have continued access to the course instruction until completion.

By leveraging the experiences and availabilitly of retiring/separating service members to fill mental health care provider shortages you help the retiring service member prepare for a post-military career and you provide active duty service members with counselors who have the understanding of war zone experience and military culture.

This summit and other events like it are most welcome. Now let's move forward to genuine, substantive collaboration, sharing not just ideas, but where appropriate, staff and resources. Gaps are too numerous to mention and VA and DoD and community-based non-profits need one another. A previous contributor mentioned the problem of trust. In our Coming Home Project we've noticed how many veterans, family members and care providers want to trust, feel welcome and safe, let their hair down, tell their stories and connect with themselves, their peers, their loved ones, and their community. Given half a chance and a truly safe setting, stigma vanishes and connection takes its place. My friend says that community heals and isolation kills.

Provide all returning OIF/OEF veterans with an iPhone.
Already loaded into the iPhone would be the 1 800 273-talk crisis hotline number. There would be an app in the cell phone orienting the user to this unique application loaded iPhone. It would orient the returning veteran to the fact that a crisis hotline number was available on speed dial should the veteran become suicidal. They would be oriented by a video on the phone that could be re-watched at will-orienting them to the symptoms of PTSD; and common cause morbidities such as substance/alcohol misuse disorders and depression. Another app would instill hope in severely distressed veterans who become suicidal, where veterans tell of their recovery story from 1) PTSD; 2) PTSD plus alcohol misuse disorder out 3) vets who did not want to reach out for help but were ultimately glad they did so; 4) vignettes including significant others talking about how the patient did so much the better after getting help. Other educational videos would include a video on proper sleep hygiene and insomnia; reviewing medications commonly used for PTSD also including vignettes of veterans who had severe insomnia and recovered rather easily using appropriate medications prescribed for their insomnia; 5) vignettes of patients with PTSD and co- morbid depression. At the end of each of these vignettes; is a video from different members of different branches of the armed forces and veterans administration briefly encouraging the veteran to "reach out and get help from someone"-- the phrase is a deliberate attempt to borrow from the old telephone commercials that emotionally engaged in the viewers with the statements about “reaching out and touch someone”-but now it's "reaching out to get help from someone.” Finally the iPhone would have a PHQ-9 that could be self administered; a voiced avatar (chosen by vet during set-up orientation to iphone would speak to the seriously depressed patient about need to get mental health intervention. Similarly, a PCL M could be self-administered; positive scores and meeting criteria for PTSD, again with a voiced avatar coming on the screen recommending reaching out and getting help from someone-- the phone numbers of all vet centers and VA mental health clinics across the country/crisis TALK number could be speed dialed on a drop-down list/by state.. There are many other useful iphone Mental Health apps being developed and already available that could be included; expense would be increased. This writer would recommend that the cell phone program provide airtime minutes with unrestricted use. The author of this suggestion has no financial involvement with Apple; or any company involved with Apple. Of course; the VA would approach Apple and aggressively negotiate reduced prices for the phones; and maybe work for some carriers likewise. I would suggest allowing Apple using the notion that they are contributing cell phones to wounded warriors/returning vets in their ads; the ad's could demonstrate the versatility of the iPhone with its myriad of potential apps; these ads would also help our returning veterans/families awareness of the potential mental health implications of having served in an active military theater.

At this time in our nation’s medical insurance reimbursement diagnostic coding system (a national system utilized by all insurance providers, including Medicare/Medicaid/Tricare/etc.), all reimbursement diagnostic codes for all mental/behavioral health care are mental disorders and disease conditions. There are NO “Wellness/Preventative” reimbursement codes to apply to a mental/behavioral health counseling appointment. They are all pathological and illness labels, which no soldier especially wants, applied to his medical records which are subject to fiercely-competitive promotion and command selection review boards. THIS IS THE STIGMA. Congressman Chet Edwards was asked to propose a national task force be stood up to REWRITTE THESE DIAGNOSTIC REIMBURSEMENT CODES to be mental/behavioral “Wellness/Prevention". With the addition of “Wellness/Prevention” codes, military personnel and their families will be free from being stigmatized by these pathological diagnostic insurance-reimbursement codes, and free to acquire the support and healing they deserve as “normal human beings” who have faced “abnormal human circumstances” in this 8-year war. During the AUSA convention, LTG Eric Schoomaker, MEDCOM Surgeon and Commanding General, responded that because this is a national issue, it must come from Congress. He stated that he would like to be a part of this task force, and that it could be possibly introduced as a rider to the current Health Care bill presently being debated in Congress. The military has led the way in shifting national paradigms throughout our cultural history. It is now time to conduct a paradigm shift for our nation and its military concerning mental health care. And it starts with simple medical insurance reimbursement diagnostic codes. This is the linchpin, the cornerstone to removing the national stigma against mental/behavioral health care, and it must be removed through the addition of “wellness/prevention” provisions. It is respecting our military and their sacrifices, while honoring the protection the military must have against mental illnesses/diseases (for commands and promotion positions). It is the balance that is missing--Army Suicide Task Force

FEEDBACK TO THE
Department of Veterans Affairs and Department of Defense MENTAL HEALTH SUMMIT
Based on opening session, Monday, October 26, 2009, Washington DC

Four questions regarding suggested areas of study by VA-DOD work groups. Comments relate to issues that may well have been overlooked among the multitude of issues already identified.

A. Have VA-DOD put qualified staff to work to study in depth the voluminous drafts from Congress for the current health care reform project?
It is highly likely that Congressional proposals for health care reform laws will have a major direct or indirect impact on VA-DOD mental health programs, particularly on the boundary between military and civilian insurance and care. Multiple issues need to be checked such as eligibility for treatment, addressing stigma, electronic records and privacy, liaison between military/VA/civilian treatment, etc. Congress would probably be very receptive to VA-DOD suggestions for additions to proposed health care reform acts, but probably would not be sensitive to VA-DOD issues without explicit VA-DOD input. Perhaps most important would be ensuring that a service person's deployment to a combat zone does not give private insurance the excuse for another "preexisting condition" exclusion for him/her and even worse, for family members. Historically, insurance for mental health issues has been profoundly deficient. Mental health issues for veterans belong to our whole society, not just VA-DOD;

B. It is really true that 400,000 veterans from our current wars require mental health care, as suggested at the VA-DOD Mental Health Summit opening on October 26, 2009?
`If so, all the issues in "A" above are massive. There is a devil's advocate position that probably should be considered: are we certain that we are not manufacturing excessive mental illness as an unintended consequence of our appropriate attention to military mental illness? The potential problem could be compounded by the massive amounts of money involved. In the real world, there are often predators attracted to large government programs, regardless of purpose. It is entirely possible, in the case of minor to moderate mental illness, for inappropriate evaluation and treatment to, in effect, "manufacture" mental illness. How many of these 400,000 were in active combat and suffer from classic "combat stress reaction?" Is it still PTSD if symptoms are more consequent to separation from family, jobs, education and other activities of normal peacetime life? To extend this devil's advocate position, Army psychiatrists used to have a black humor diagnosis: "compensation neurosis," i.e. when one is paid to be sick, one tends to get sick and stay sick. This phenomenon is not necessarily dishonesty or malingering, only human nature. An obvious parallel would be how quickly a professional football player can recover from a knee injury because he wants to return to his game and high income, as opposed to how slowly an identical industrial accident patient will recover if recovery means losing medical benefits and compensation, or returning to an onerous job. PTSD is a very real and very common condition, but the consequences of both accurate and inaccurate diagnosis of it are profound.

C. Do VA-DOD work groups realize that the terms "Unseen Injury" and "Invisible Wounds" are functional, but ultimately inaccurate?
They are definitely needed today as programs are developed and stigma addressed. It should be noted, however, that pathological behavioral and speech patterns are just as obvious to a trained mental health clinician or supervisor (= commander) as blood and broken bones are to a surgeon. The reasons for "blindness" to mental illness consequent to deployment and combat stress are complex but well known. As stigma is reduced and as medical and service persons are educated, service persons and their supporters will no longer require "blindness" to maintain self esteem and military competence. Thus, paradoxically, a goal of mental health planning should be the eventual elimination of these currently useful terms.

D. If "leaning forward" is the ethic of VA-DOD, is it time for VA-DOD to take initiative and demand that the President and Congress end legislated sexual orientation discrimination within the armed forces?
There are good estimates that 65,000 service persons with a homosexual orientation are currently serving honorably and successfully among our active duty, reserves, and National Guard. From time to time, some are "outed" and fired from service (13,000+ since Don't Ask Don't Tell, DADT, started, among hundreds of thousands who have served successfully). These firings usually come as a detriment to the military and an injustice to the service person. Unless he has a failed presidency, President Obama will end DADT. Both the President and Congress are, however, slow to act. Why are not VA-DOD taking the initiative to demand an end to DADT this year? "Dithering" is a common word being bandied about in today's media. Dithering may be appropriate to politicians like the President and Congress, but it has no place in VA-DOD during wartime. This issue is important because it appears that our mental health programs have not addressed the population serving under DADT. Its members serve with severe daily stress from the risk of capricious loss of honor and job. When deployed, they may be at increased risk from "stress within stress." Because of DADT, however, there is probably no good research being done as to whether this group of 65,000 is at greater or lesser risk for PTSD and other mental illness. Arguably, they could be more resilient because of successful adaptation to the stress of living secret personal lives in a hostile service environment. Equally, they might be less resilient because they deploy with their "stress within stress." Most mental health professionals and commanders alike appear to be ignorant or in denial about this topic. For them, there are two good references which say it all:
1. "Ending Don't Ask, Don't Tell---Practical Steps to Repeal the Ban on Openly Gay Men and Women in the U.S. Military," a 31 page, June 2009 publication from the Center for American Progress in Washington D.C. The author is Lawrence Korb, a military expert widely known and respected in the military community. It can be found as a PDF at http://www.americanprogress.org/issues/2009/06/pdf/dadt.pdf
2. Unfriendly Fire, How the Gay Ban Undermines the Military and Weakens America, a, widely available, 342 page, 2009 book. The author is Nathaniel Frank, a senior research fellow at the Palm Center of the University of California, Santa Barbara. ISBN-10: 0-312-37348-1 ISBN-13: 978-0-312-37348-1

William Cline MD (psychiatry), Col, US Army (retired)
Wednesday, October 28, 2009