Mental Health in the Department of Defense: From Policy to Programs and Patients

1. Mental Health in the Department of Defense: From Policy to Programs and Patients CAPT Robert DeMartino CDR Meena Vythilingam CDR Robert Marietta CAPT Paul Andreason

2. Challenges and Opportunities for PHS Officers at the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury(DCoE) CDR Meena Vythilingam Director, PH CSoC June 2012

3. Who We Are Mission, Vision and Values Organization What We Do Functions Programs Products Opportunities Contact Information Overview

4. DCoE - Who Are We? • Mission • Improve the lives of our nation’s service members, families and veterans by advancing excellence in psychological health and traumatic brain injury prevention and care. • Vision • To be the Defense Department’s trusted source and advocate for psychological health and traumatic brain injury knowledge and standards, and profoundly improve the system of care. • Values • Excellence • Integrity • Teamwork

5. DCoE* Governance & Authority Secretary of Defense Mr. Leon Panetta Dep. Secretary of Defense Mr. Ashton Carter Undersecretary of Defense Personnel & Readiness Dr. Jo Ann Rooney (acting) Dr. Jonathan Woodson Assistant Secretary of Defense - HA Capt. Paul Hammer Director, Defense Centers of Excellence PH/TBI DD- PH DD- TBI Col Robinson Ms. Helmick Dr. Mark Bates TBI-CSoC Ms. Kathy Helmick R&P PH-CSOC CDR Meena Vythilingam Education Mr. Carlton Drew * Undergoing organizational restructuring and will be transitioning to MRMC

6. PH Clinical Standards of Care 320/07 GS-13 320/06 GS-14 320/05 O-4 320/04 GS-13 310/05 GS-11 Health Analyst 320/03 E-7 310/04 GS-13 310/07 GS-13 310/03 GS-13 Psych. Consult. Lead 320/02 O-4 Clinical Psychologist 310/06 GS-14 310/02 GS-14 Nurse Case Manager Sr. Enlist. MH Advisor Clinical Support Tools Health Analyst Clinical Guide. Coord. Healthcare Admin Cons. Psychologist (SME) Psychiatrist (SME) Social Science Analyst GS-13 300A/04 GS-14 300A/03 RES. ASST PROG ANAL. Senior advisor ph CDR Vythilingam (USPHS) Director Program Effectiveness Clinical Guidelines Dr. Kathy McGraw Deputy Director - Division Chief- Program Effectiveness - Division Chief- Clinical Guidelines 320/01 GS-14 310/01 GS-14 Psychiatrist Consultant

7. What We Do • Serve as the principal integrator and authority on psychological health and TBI knowledge and standards for the Defense Department • Uniquely positioned to accelerate improvements in psychological health and TBI outcomes and policy to impact the continuum of care across the services Continuum of Care Treatment AcuteRecovery Diagnosis Reintegration Surveillance Rehabilitation Prevention Screening Resilience

8. DCoE: PH/TBI Integrator in the System of Care

9. CLINICAL GUIDELINES DIVISION Mission: To develop and provide evidence based PH clinical guidelines to the Military Health System. Functions:Identify, develop, monitor, and revise psychological health Clinical Practice Guidelines (CPGs), Clinical Support Tools (CSTs), and other forms of evidence based guidance designed to assist clinicians in delivering quality care to patients.

10. The VA/DoD CPGs were developed in an effort to standardize the management of PTS and MDD. Some of the same topics are emphasized for both disorders • Patient centered care • Emphasis on screening • Emphasis on early identification and intervention • Functional assessment • Evidence-based pharmacology recommendations • Providers trained in evidence-based treatment provide care • Patient and family education VA/DoD CPGs are available at: www.qmo.amedd.army.mil/pguide.htm www.healthquality.va.gov/ www.dcoe.health.mil

11. A “Toolkit” is comprised of a group of related CSTs. Evidence-based recommendations from the CPGs provide the foundation for the content of these tools

12. A stepped care treatment plan includes a recommended timeline for psychotherapy and pharmacotherapy interventions

13. PTSD Care Pathway Model Care Pathway for PTSD Acute Stabilization (Hosp or Amb) Initial Treatment (Recovery) Pre-Treatment Rehabilitation Post Acute Prevention Maintenance EXAMPLES OF METRICS/MEASURES: Outcome Measures (Porter’s Model) One Year Mortality Rate Suicide Rate Expanded Porter’s Model on Next Slide Process / alerts Time from Positive Screen to Treatment Follow-Up With in 4-6 Weeks Cost Inpatient Hospitalization Costs Prescription Medication Costs Patient satisfaction/trust /activation Patient Satisfaction Patient Activation Measure Patient data captured regularly by clinician Electronic medical records data Structured documentation

14. Program Evaluation Division Evaluate Individuals Programs DoD Wide Program Effectiveness • National Guard Bureau • OSD CAPE • DoD Dashboard Evaluate Efficacy of CPG and CST DoD Program Review • RAND: identify, catalogue, assess, evaluate and improe the cost effectiveness of all DoD PH programs • Evaluation of tools (e.g. CST, CPG and CR) • Outcomes Assessments related to tools (e.g. CST, CPG and CR)

15. Collaboration with the VA- IMHS

16. Challenges and Opportunities at DCoE Meena Vythilingam, M.D. CDR, USPHS Director Psychological Health Clinical Standards of Care Defense Centers of Excellence (DCoE) W: 301-295-2615 Meena.vythilingam@tma.osd.mil

17. DoD and PHS Mental Health PartnershipExperiences at Langley Air Force Base COA Annual Meeting June 22, 2012 Bob Marietta, MD CDR, US Public Health Service

18. Our Mission: • Train, Organize, Equip, & Deploy Expeditionary Medics • Provide World Class Healthcare for our Beneficiaries -- Anytime; Anywhere! • Our Vision: • Be the Clinical & Expeditionary Center of Healthcare Excellence • 633 MDG is a Currency & Operational Platform for our Nation

19. 7 Currency Hospitals in the AFMS 2011 Where the Staff is: Travis AFB Wright-Patterson AFB Nellis AFB Langley AFB Elmendorf AFB Eglin AFB Keesler AFB Opportunity to recapture business: Langley: Largest Opportunity—Smallest Footprint

20. Who Are We? • Largest Beneficiary Population in AF • An Even Bigger Multi-Service Market • Largest Growth in Past 3 Years • Busiest in AF for OB • 1st C-CMRF mission in DoD & Pilot unit for GRF/HRT • 26,000 Outpatient visits/month • 83,000 Prescriptions per month • 12,000 Dental & Dental Lab Procedures/month • Surgery - 250 OR cases/month • LDRP– 100 births/month • 3,100 X-Rays/month 1 of 7 Specialty Hospitals in the AFMS

21. Multiple Capability Hospital Primary Care Medicine • Family Medicine Pediatrics • Internal Medicine Flight Medicine Specialty Services • Emergency Services General Surgery • Orthopedics OB/GYN • Ophthalmology Optometry/Audiology • Urology Mental Health • Otolaryngology (ENT) Physical Therapy • Dermatology Chiropractics (AD only) • Oral Maxillofacial Surgery Podiatry New Services Planned (2011-2012) • Pulmonology Gastroenterology • Neurology Cardiology • Allergy Pathology • Speech Pathology Peds Surgery • Colorectal SurgeryMRI/Nuclear Med

22. Tidewater Overlapping Catchment Areas Huge Population—Huge Opportunities Ft. Eustis Langley AFB 111,000 Beneficiaries Naval Medical Center Portsmouth Total Tidewater : 417,000 Beneficiaries

23. Behavioral Health Flight • Deep set of comprehensive services • Occupational medicine • Direct patient care • Fitness for duty, disability and forensic evaluations • Coordination with military officials • 24 hour on-call coverage for ER and hospital • Two mental health disaster response teams • Integration with Primary Care • Behavioral Health Optimization Program • Joint Army-Air Force Base Family Advocacy Program

24. Embedded PHS Officers • CDR Bob Marietta, Psychiatrist • Mental Health Element Chief • CDR Bryan Davidson, Psychologist • Director of Psychological Health, Behavioral Health Optimization Program • LCDR Jenny McCorkle, Clinical Social Worker • Family Advocacy Element Chief

25. Benefit to Air Force • Much needed, valued services • “Breathing room” • Reduces workload for critically manned AF personnel • Flexible support with local control • Custom tailor support to provide best fit • Stability • Longer tour length • Shorter deployments • Highly motivated • Experience • PHS providers further along in career • Diverse background

26. Benefit to PHS • High profile, visibility • Increased attention to mental health services • Provide a much appreciated service • Work in a uniformed service environment • Daily uniform wear • Deployment is part of the culture • Participation in disaster response teams • Good training for PHS mission • Skills learned carry over to PHS

27. Discussion Points • Learning curve for Air Force policies and procedures • “Purple suit” • Ex-Navy goes Air Force • Leadership roles • Integral part of Air Force officer promotion pathway • Acceptance from Air Force officials, colleagues • Ex-Air Force provider transfers in to PHS • Uniform • Good to stand out, easily identifiable • BDUs retired by Air Force • PHS headquarters support functions

28. Results • Integral part of hospital and Air Force Medical System • Trust, appreciation and acceptance • Air Force planning personnel movements around PHS personnel

29. Questions? Building The Next Generation in Healthcare