Readiness of Soldiers and Adult Family Members Who Receive Behavioral Health Care: Identifying Promising Outcome Metrics

Behavioral health (BH) conditions-such as posttraumatic stress disorder, depression, and anxiety-are the second most common medical reasons for nondeployability in the U.S. Army. The authors of this report aimed to identify promising metrics to assess readiness among soldiers and adult family members who receive BH care. These metrics would expand the Army's outcome monitoring, which currently includes symptom improvement metrics, for patients who received BH care. The authors developed rigorous criteria to evaluate candidate readiness metrics, conducted interviews with stakeholders (Army subject-matter experts and BH providers), reviewed existing sources of data that could support the development of a readiness metric, and conducted a literature review to identify instruments that have been used to measure readiness-related domains in both military and civilian populations. The authors found that no existing data source or patient self-report instrument met criteria for implementation of a readiness metric for soldiers, but one instrument, the Walter Reed Functional Impairment Scale (WRFIS), is promising. No existing data source or patient self-report instrument met criteria for Army-wide implementation of a readiness metric for adult family members. Stakeholders reported that psychiatric symptoms, diagnosis, treatment, and impaired functioning are important indicators of lack of readiness among soldiers and adult family members. BH providers reported variability in assessing readiness and applying profiles, but behavioral experts provided suggestions for improving readiness assessment. The authors recommend that the Army conduct a pilot evaluation of a soldier readiness metric based on the WRFIS and increase standardization in applying profiles by continuing provider training.

Alignment Between Objective and Subjective Assessments of Health System Performance: Findings From a Mixed-Methods Study

EXECUTIVE SUMMARY

The article examines whether subjective performance assessments from health system executives match objective performance assessments and qualitatively explores ways to achieve high performance. We interviewed 138 C-suite executives of 24 health systems in California, Minnesota, Washington, and Wisconsin between 2017 and 2019. We used maximum variation sampling to select health systems to achieve diversity in performance on objective measures of clinical performance. Our interviews focused on executives' perceptions of their own health system's performance and factors they thought generally contributed to high performance. In our analysis, we grouped health systems based on objective performance levels (high, medium, and low) used in sampling, compared objective performance ratings with executives' subjective performance assessments, and used thematic analysis to identify reasons for subjective assessment of health system performance and levers of high performance in general. There was poor agreement between objective and subjective performance assessments (kappa = 0.082). Subjective assessments were higher than objective assessments and captured more factors than are typically considered in performance accountability and value-based payment initiatives. Executives whose views were inconsistent with objective performance assessments did not cite clinical care quality per se as the basis for their assessment, focusing instead on market competition, financial performance, and high customer satisfaction and loyalty. Executives who cited clinical quality metrics as the basis of their assessment offered subjective ratings consistent with objective ratings. Executives identified organizational culture, organizational governance, and staff engagement as levers for achieving high performance. Future research should explore the benefits and drawbacks of considering subjective performance assessments in value-based payment initiatives.

Optimizing health IT to improve health system performance: A work in progress

BACKGROUND

Despite significant investments in health information technology (IT), the technology has not yielded the intended performance effects or transformational change. We describe activities that health systems are pursuing to better leverage health IT to improve performance.

METHODS

We conducted semi-structured telephone interviews with C-suite executives from 24 U.S. health systems in four states during 2017-2019 and analyzed the data using a qualitative thematic approach.

RESULTS

Health systems reported two broad categories of activities: laying the foundation to improve performance with IT and using IT to improve performance. Within these categories, health systems were engaged in similar activities but varied greatly in their progress. The most substantial effort was devoted to the first category, which enabled rather than directly improved performance, and included consolidating to a single electronic health record (EHR) platform and common data across the health system, standardizing data elements, and standardizing care processes before using the EHR to implement them. Only after accomplishing such foundational activities were health systems able to focus on using the technology to improve performance through activities such as using data and analytics to monitor and provide feedback, improving uptake of evidence-based medicine, addressing variation and overuse, improving system-wide prevention and population health management, and making care more convenient.

CONCLUSIONS AND IMPLICATIONS

Leveraging IT to improve performance requires significant and sustained effort by health systems, in addition to significant investments in hardware and software. To accelerate change, better mechanisms for creating and disseminating best practices and providing advanced technical assistance are needed.

Factors Influencing Physician Practices' Adoption of Behavioral Health Integration in the United States: A Qualitative Study

BACKGROUND

Behavioral health integration is uncommon among U.S. physician practices despite recent policy changes that may encourage its adoption.

OBJECTIVE

To describe factors influencing physician practices' implementation of behavioral health integration.

DESIGN

Semistructured interviews with leaders and clinicians from physician practices that adopted behavioral health integration, supplemented by contextual interviews with experts and vendors in behavioral health integration.

SETTING

30 physician practices, sampled for diversity on specialty, size, affiliation with parent organizations, geographic location, and behavioral health integration model (collaborative or co-located).

PARTICIPANTS

47 physician practice leaders and clinicians, 20 experts, and 5 vendors.

MEASUREMENTS

Qualitative analysis (cyclical coding) of interview transcripts.

RESULTS

Four overarching factors affecting physician practices' implementation of behavioral health integration were identified. First, practices' motivations for integrating behavioral health care included expanding access to behavioral health services, improving other clinicians' abilities to respond to patients' behavioral health needs, and enhancing practice reputation. Second, practices tailored their implementation of behavioral health integration to local resources, financial incentives, and patient populations. Third, barriers to behavioral health integration included cultural differences and incomplete information flow between behavioral and nonbehavioral health clinicians and billing difficulties. Fourth, practices described the advantages and disadvantages of both fee-for-service and alternative payment models, and few reported positive financial returns.

LIMITATION

The practice sample was not nationally representative and excluded practices that did not implement or sustain behavioral health integration, potentially limiting generalizability.

CONCLUSION

Practices currently using behavioral health integration face cultural, informational, and financial barriers to implementing and sustaining behavioral health integration. Tailored, context-specific technical support to guide practices' implementation and payment models that improve the business case for practices may enhance the dissemination and long-term sustainability of behavioral health integration.

PRIMARY FUNDING SOURCE

American Medical Association and The Commonwealth Fund.

Improving Disaster Resilience Among Older Adults: Insights from Public Health Departments and Aging-in-Place Efforts

This study uses interview data collected from public health departments and aging-in-place efforts-specifically, from coordinators of age-friendly communities and village executive directors-to explore how current aging-in-place efforts can be harnessed to strengthen the disaster resilience of older adults and which existing programs or new collaborations among public health departments and these organizations show promise for improving disaster resilience for older populations. Interviews with stakeholders revealed that most age-friendly communities and senior villages did not place a high priority on promoting disaster preparedness. While most public health departments conducted or took the lead on disaster preparedness and resilience activities, they were not necessarily tailored to older adults. Aligning and extending public health departments' current preparedness activities to include aging-in-place efforts and greater tailoring of existing preparedness activities to the needs of older adults could significantly improve their disaster preparedness and resilience. For jurisdictions that do not have an existing aging-in-place effort, public health departments can help initiate those efforts and work to incorporate preparedness activities at the outset of newly developing aging-in-place efforts.

Mindfulness Meditation for Chronic Pain: Systematic Review and Meta-analysis

BACKGROUND

Chronic pain patients increasingly seek treatment through mindfulness meditation.

PURPOSE

This study aims to synthesize evidence on efficacy and safety of mindfulness meditation interventions for the treatment of chronic pain in adults.

METHOD

We conducted a systematic review on randomized controlled trials (RCTs) with meta-analyses using the Hartung-Knapp-Sidik-Jonkman method for random-effects models. Quality of evidence was assessed using the GRADE approach. Outcomes included pain, depression, quality of life, and analgesic use.

RESULTS

Thirty-eight RCTs met inclusion criteria; seven reported on safety. We found low-quality evidence that mindfulness meditation is associated with a small decrease in pain compared with all types of controls in 30 RCTs. Statistically significant effects were also found for depression symptoms and quality of life.

CONCLUSIONS

While mindfulness meditation improves pain and depression symptoms and quality of life, additional well-designed, rigorous, and large-scale RCTs are needed to decisively provide estimates of the efficacy of mindfulness meditation for chronic pain.

The Unified Behavioral Health Center for Military Veterans and Their Families: Documenting Structure, Process, and Outcomes of Care

Many veterans and their families struggle with behavioral health problems, family reintegration difficulties, and relationship problems. Although many veterans are eligible to receive care at Department of Veterans Affairs health facilities, family members are generally not eligible and therefore must seek care elsewhere. This situation can pose a barrier to family members' access to care and also make it more difficult for veterans and families to receive high-quality services that are coordinated across providers. A new model of behavioral health care is trying to address these barriers: Created by the Northwell Health System and the Northport Veterans Affairs Medical Center, the Unified Behavioral Health Center (UBHC) for Military Veterans and Their Families in New York state is a public-private partnership that is providing colocated and coordinated care for veterans and their families. RAND evaluated the center's activities to document the implementation of a unique public-private collaborative approach for providing care to veterans and their families. The first component of the evaluation focused on documenting the structures of care (the capacities and resources that the center developed and employed) and the processes of care (the services delivered). The second component focused on outcomes of care. The evaluation suggests that, overall, the model has been successfully implemented by the UBHC and has great potential to be helpful to the veterans and families it serves.

The Impact of Massage Therapy on Function in Pain Populations-A Systematic Review and Meta-Analysis of Randomized Controlled Trials: Part III, Surgical Pain Populations

OBJECTIVE

Pain is multi-dimensional and may be better addressed through a holistic, biopsychosocial approach. Massage therapy is commonly practiced among patients seeking pain management; however, its efficacy is unclear. This systematic review and meta-analysis is the first to rigorously assess the quality of the evidence for massage therapy's efficacy in treating pain, function-related, and health-related quality of life outcomes in surgical pain populations.

METHODS

Key databases were searched from inception through February 2014. Eligible randomized controlled trials were assessed for methodological quality using SIGN 50 Checklist. Meta-analysis was applied at the outcome level. A professionally diverse steering committee interpreted the results to develop recommendations.

RESULTS

Twelve high quality and four low quality studies were included in the review. Results indicate massage therapy is effective for treating pain [standardized mean difference (SMD) = -0.79] and anxiety (SMD = -0.57) compared to active comparators.

CONCLUSION

Based on the available evidence, weak recommendations are suggested for massage therapy, compared to active comparators for reducing pain intensity/severity and anxiety in patients undergoing surgical procedures. This review also discusses massage therapy safety, challenges within this research field, how to address identified research gaps, and next steps for future research.

The Impact of Massage Therapy on Function in Pain Populations-A Systematic Review and Meta-Analysis of Randomized Controlled Trials: Part II, Cancer Pain Populations

PURPOSE

Pain is multi-dimensional and may be better addressed through a holistic, biopsychosocial approach. Massage therapy is commonly practiced among patients seeking pain management; however, its efficacy is unclear. This systematic review and meta-analysis is the first to rigorously assess the quality of massage therapy research and evidence for its efficacy in treating pain, function-related and health-related quality of life in cancer populations.

METHODS

Key databases were searched from inception through February 2014. Eligible randomized controlled trials were assessed for methodological quality using the SIGN 50 Checklist. Meta-analysis was applied at the outcome level. A diverse steering committee interpreted the results to develop recommendations.

RESULTS

Twelve high quality and four low quality studies were subsequently included in the review. Results demonstrate massage therapy is effective for treating pain compared to no treatment [standardized mean difference (SMD)  = -.20] and active (SMD = -0.55) comparators. Compared to active comparators, massage therapy was also found to be beneficial for treating fatigue (SMD = -1.06) and anxiety (SMD = -1.24).

CONCLUSION

Based on the evidence, weak recommendations are suggested for massage therapy, compared to an active comparator, for the treatment of pain, fatigue, and anxiety. No recommendations were suggested for massage therapy compared to no treatment or sham control based on the available literature to date. This review addresses massage therapy safety, research challenges, how to address identified research gaps, and necessary next steps for implementing massage therapy as a viable pain management option for cancer pain populations.

The Impact of Massage Therapy on Function in Pain Populations-A Systematic Review and Meta-Analysis of Randomized Controlled Trials: Part I, Patients Experiencing Pain in the General Population

PURPOSE

Pain is multi-dimensional and may be better addressed through a holistic, biopsychosocial approach. Massage therapy is commonly practiced among patients seeking pain management; however, its efficacy is unclear. This systematic review and meta-analysis is the first to rigorously assess the quality of massage therapy research and evidence for its efficacy in treating pain, function-related and health-related quality of life outcomes across all pain populations.

METHODS

Key databases were searched from inception through February 2014. Eligible randomized controlled trials were assessed for methodological quality using SIGN 50 Checklist. Meta-analysis was applied at the outcome level. A diverse steering committee interpreted the results to develop recommendations.

RESULTS

Sixty high quality and seven low quality studies were included in the review. Results demonstrate massage therapy effectively treats pain compared to sham [standardized mean difference (SMD) = -.44], no treatment (SMD = -1.14), and active (SMD = -0.26) comparators. Compared to active comparators, massage therapy was also beneficial for treating anxiety (SMD = -0.57) and health-related quality of life (SMD = 0.14).

CONCLUSION

Based on the evidence, massage therapy, compared to no treatment, should be strongly recommended as a pain management option. Massage therapy is weakly recommended for reducing pain, compared to other sham or active comparators, and improving mood and health-related quality of life, compared to other active comparators. Massage therapy safety, research challenges, how to address identified research gaps, and necessary next steps for implementing massage therapy as a viable pain management option are discussed.

A Cluster-Randomized Trial of Restorative Practices: An Illustration to Spur High-Quality Research and Evaluation

Restorative Practices in schools lack rigorous evaluation studies. As an example of rigorous school-based research, this paper describes the first randomized control trial of restorative practices to date, the Study of Restorative Practices. It is a 5-year, cluster-randomized controlled trial (RCT) of the Restorative Practices Intervention (RPI) in 14 middle schools in Maine to assess whether RPI impacts both positive developmental outcomes and problem behaviors and whether the effects persist during the transition from middle to high school. The two-year RPI intervention began in the 2014-2015 school year. The study's rationale and theoretical concerns are discussed along with methodological concerns including teacher professional development. The theoretical rationale and description of the methods from this study may be useful to others conducting rigorous research and evaluation in this area.