Tri-service Integrator of Outpatient g p Programming Systems (TrIOPS)

Tri-service Integrator
g
of Outpatient
p
Programming Systems (TrIOPS)
Improving Psychological Health Outcomes for Service
Members through Synchronization and Service Delivery Integration
CDR Jerry O’Toole
Division Chief
22 May 2013
Deployment Health Clinical Center (DHCC)
Brief History
Gulf War Health Center ̶ 1994
• Clinical care for 1991 Gulf War veterans with chronic pain and medically
unexplained physical symptoms (MUPS)
• Track I of Specialized Care Program (SCP) developed in 1995
--- Three-week multi-disciplinary care for MUPS
Deployment Health Clinical Center ̶ 1999
• HA Policy 99-028, Policy - Establishment of DoD Centers for
Deployment Health
Health, 30 Sep 99
• DHCC is involved in direct clinical care, health services delivery
research, and clinical education/outreach
• SCP b
becomes ttertiary
ti
llevell off care iin th
the D
DoD/VA
D/VA P
Post-Deployment
tD l
t
Health Clinical Practice Guideline
• Track II developed in 2005 to address deployment-related stress, Post
Traumatic Stress Disorder (PTSD) and/or difficulties adjusting to rere
deployment
2
Deployment Health Clinical Center (DHCC)
Brief History continued
DHCC Becomes Component Center – 2008
• Defense Centers of Excellence for Psychological Health and
Traumatic Brain Injury (DCoE)
Replication of the DHCC Program proposed – 2009
• Replicate the DHCC SCP Track II and disseminate throughout DoD
• DHCC leadership recommends change to replication mission
• Change recommended based on multiple existing programs
• Recommendation accepted
• R
Replication
li ti initiative
i iti ti ttransitioned
iti
d tto a S
Synchronization
h i ti & O
Optimization
ti i ti
of all existing SCPs across the Department of Defense
• TrIOPS launched in 2011
3
A Thousand Flowers Blooming
Army Vice Chief of Staff GEN Peter W. Chiarelli
Army Medical Symposium in San Antonio
Antonio, 2009
“The problem is there’s a thousand flowers blooming, and unless you are
a trained behavioral health person you have no idea which one to pick.”
2010 RAND Report: Programs Addressing PH and TBI
Among
g U.S. Military
y Servicemembers and Their
Families
•
Despite
p the p
proliferation of p
programs
g
and related efforts, an ongoing
g g
challenge for DoD is to identify and characterize the scope, nature, and
effectiveness of these various and ever-evolving activities. Prior to this
report, there has been no full accounting of what programs exist and
programs
g
complement
p
“traditional” service p
provision and
how these p
routine care.
4
TrIOPS Precursor
Force Health Protection Conference – 2010
• DHCC sponsored special meeting at the Arizona conference
• 11 Army SCP directors, staff, and other stakeholders
• Identification
Id tifi ti off obstacles,
b t l
challenges,
h ll
and
d recommendations
d ti
Obstacles & Challenges
• Joint Federal Behavioral Health
• Staffing – Quality & Quantity
• Support
S
t – Command
C
d
• Space – Not Conducive to Treatment Needs
• Productivity – Coding & RVUs
5
Their Recommendations
 Create a coalition or network of intensive outpatient programs
 Facilitate communication and collaboration amongst and between
programs
 Promulgate evidence and recommendations for best practices across
the DoD
 Develop a centralized evidence base regarding program practice
guidelines, standards of care, and program effectiveness
 Provide technical assistance and program consultation based on the
k
knowledge
l d and
d experience
i
gained
i d iin th
the course off synchronizing
h i i care
 Evaluate and track new and existing programs
6
Our Recommendations
✓ Create a coalition or network of intensive outpatient programs

✓ Facilitate communication and collaboration amongst and between

programs
✓
 Promulgate evidence and recommendations for best practices across
the DoD
✓ Develop a centralized evidence base regarding program practice

guidelines, standards of care, and program effectiveness
✓ Provide technical assistance and program consultation based on the

k
knowledge
l d and
d experience
i
gained
i d iin th
the course off synchronizing
h i i care
✓
 Evaluate and track new and existing programs
7
TrIOPS Mission & Vision
Mission
Impact behavioral health specialty care programming
systems by integrating and optimizing care across the
Military Health System
Provide resources, products, and services to ensure that
programs
g
and the overarching
g system
y
are continuously
y
improving
Vision
Be recognized as the central and trusted agent for the
promotion of specialty care programming effectiveness and
excellence
8
Promoting a Culture of Effectiveness
4
MATUR
RITY
3
1
2
AWARENESS/
KNOWLEDGE
TIME
EXPERIENCE
CENTRALIZED
&
TRUSTED
EXPERTISE
SOURCE
TrIOPS:
O S Building a network for
f meaningful
f system change
9
Treatment Spectrum
Outpatient
Intensive
Outpatient
Partial
Hospitalization
Day
Treatment
Residential
Treatment
Inpatient
Specialty Care Programs
10
Treatment Spectrum
Outpatient
Intensive
Outpatient
IOP
•Fort Bragg
/Pope Field
•Fort Campbell
•Fort Carson
•Fort Knox
•WRNMMC
WRNMMC II
(TRP)
•NBHC Groton
•Fort Stewart
•Camp Lejeune
•Cherry
Ch
P
Point
i t
•Camp Pendleton
Partial
Hospitalization
Day
Treatment
PHP/Day Treatment
•Fort Belvoir
•Fort Benning
•Fort Bliss
•Fort Gordon
•Fort Hood I (Reset)
•Fort
Fort Hood II (IOP/DTP)
•NM Jacksonville
•Landstuhl
•NMCSD I (C5)
•Camp Pendleton *
•Fort
F t Sam
S
Houston
H
t
•Fort Stewart
Residential
Treatment
Inpatient
RTF
•Fort Jackson
•NMCSD II
(OASIS)
•Tripler AMC
11
JB Lewis-McChord
2003-2010
[4]
DHCC Track I
& II
1995-2012
[3]
Lovell FHC
WRNMMC
TRP
2006
[4]
Fort Carson
2010
[5/6]
Camp
Pendleton
2008
[6]
NBHC Groton
2012
[4]
JB McGuireDix-Lakehurst
NBHC
Portsmouth I
Fort Belvoir
2011
[4]
Fort Knox
Fort Campbell
2008
[6]
NBHC
Portsmouth II
Fort Bragg
NMC San Diego I
2010
[8]
NHC Cherry Point
Fort Gordon
2009
[3]
Fort Bliss
2007/2012
[24]→[4]
NMC San Diego II
2010
[10]
Fort Sam Houston
2012
[3]
Fort Jackson
Fort Hood I
2008
[3]
Fort Hood II
2011
[4]
Fort Benning
2012
[2]
Fort Stewart
2011/2012
[2]→[6]
NMC Jacksonville
2010
[10]
Landstuhl
L
d t hl
2009
[8]
Legend:
Tripler AMC
2006
[8]
Camp Lejeune
Army
Navy
Program
Staffing
Each program operates under
an interdisciplinary
p
y staff model
Disciplines represented
include:
•Psychology
•Social
S i lW
Work
k
•Psychiatry
•CAM
•Nursing
•Other
disciplines include:
•Occupational Therapy
•Neurology
•Physical Therapy
Professional Disciplines
Social Worker(s)
14
Psychologist(s)
14
Psych Tech(s)
10
CAM Practioner(s)
10
Psychiatrist(s)
10
8
RN/NP(s)
5
Chaplain(s)
4
Rec Therapist(s)
9
Other(s)
0
5
10
Number of Programs
15
13
Treatment Modalities
Treatment Format
17
Group
13
Individual
10
Marital/Couples
8
Family
0
5
10
Number of Programs
15
14
Treatments
Offered
Psychotherapeutic Approaches
15
CBT
12
CPT
Most programs
g
are utilizing
g
Cognitive Behavioral
Therapy (88%) and/or
Cognitive Processing
Therapy (71%)
Approximately half (53%)
of programs are also
providing
p
g Eye
y Movement
Desensitization and
Reprocessing to their
participants
9
EMDR
6
Art
5
PDT
5
PE
4
DBT
2
Equine or Animal-Assisted
9
Other
0
5
10
15
Number of Programs
15
Additional Treatment
Approaches
Treatments
Off d (Cont’d)
Offered
(C t’d)
14
CAM
14
Psycho-education
Psycho-educational sessions
cover topics such as Grief
Grief, Sleep
Hygiene, and Anger Management
11
Pharmacotherapy
Psycho-education and some form of
Complementary and Alternative
Medicine (CAM) are both offered by 14
programs (82%)
8
Recreational Ther
CAM practices include – but are
not limited to – Yoga (8; 47%),
Meditation (6; 35%), Massage (5;
29%), and Acupuncture (4;24%)
4
Occupational Ther
4
Physical Ther
0
5
10
Number of Programs
15
16
Outcome Measures
Most Common
No Commonality
The following instruments
are used by more than one
program:
Over 20 other instruments or
procedures:
PCL (15
(15; 88%)
BSI; CAPS; CD-RISC; ISI; MMPI2 SCIC;
2;
SCIC URICA,
URICA etc.
t
PHQ-9 (7; 41%)
AUDIT ((6; 35%))
Instruments Measuring:
g
BDI (6; 35%)
 Depression; PTSD; Anxiety
BAI (5; 29%)
 Function
OQ 45 (5;
OQ-45
(5 29%)
P i
 Pain
GAD-7 (3; 18%)
 Trauma
PSQI (2; 12%)
 Personality
 Relationships
17
Suggested / Recommended Core Elements of
Specialty Care Programs
• Multi-disciplinary, multi-modal approach
• Staff-to-patient ratio is sufficient to ensure necessary
therapeutic services
• P
Professional
f
i
l monitoring
it i and
d fforce h
health
lth protection
t ti th
through
h
ongoing risk assessment
• Command consultation – liaison
• Family (or significant support person) involvement in
treatment
• Case management with coordinated transition and follow-up
• Continuing
C
education and professional
f
development off staff
ff
18
Next Steps
Continue to build TrIOPS infrastructure
D t collection
Data
ll ti ttools
l and
d procedures
d
Capacity to store and analyze program data
Reporting and monitoring systems
Continue to inventory programs
Fill identified information gaps
Build rapport and knowledge base
Discover emerging
g g programs
g
and markets
19
Fixsen, Naoom, Blasé, Friedman, and Wallace (2005)
“Letting
Letting it happen”
happen –researchers
researchers publish results;
it is up to the providers to make it happen
“Helping it happen” –research findings result in
toolkits designed for providers
“Making it happen” – implementation teams
directly help providers to effectively implement
programs
20
Contact Us
Division Chief: Commander Jerry O’Toole
Jerry.M.O’Toole.mil@health.mil
22