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AUSA Talk 7/25/2017
System Foundations for Translating Research to Practice
Prof. Jayakanth “JK” SrinivasanInstitute for Health System Innovation and Policy
Questrom School of BusinessBoston University
The research presented here was supported in part by grant cooperative agreement W81XWH-12-2-0016. The views expressed in this presentation are those of the author(s) and may not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.
AUSA Talk 7/25/2017
DRAMATIC CHANGE IN OPERATIONAL ENVIRONMENT AND DISEASE BURDEN
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0
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Sep-01 Sep-02 Sep-03 Sep-04 Sep-05 Sep-06 Sep-07 Sep-08 Sep-09 Sep-10 Sep-11 Sep-12 Sep-13 Sep-14
Deployed
Servicemem
bers(inthou
sand
s)
FY2014
FY2003
Growth in Soldier PTSD prevalence to 3.5%
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50
100
150
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Sep-01 Sep-02 Sep-03 Sep-04 Sep-05 Sep-06 Sep-07 Sep-08 Sep-09 Sep-10 Sep-11 Sep-12 Sep-13 Sep-14
Deployed
Servicemem
bers(inthou
sand
s)
Cha
nge
in A
mbu
lato
ry D
iagn
oses
AUSA Talk 7/25/2017
Consistent policy emphasis and leader engagement to drive change
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Pre 2010 2010 2011 2012 2013 2014
Executive Order --Improving Access to
Mental Health Services for
Veterans, Service
Members, and Military Families
Dep
artm
ent o
f the
Arm
y
AUSA Talk 7/25/2017
Change efforts accelerated fragmentation of behavioral healthcare in the Army
4
1) Government Accountability Office. "Defense Health Coordinating Authority Needed for Psychological Health and Traumatic Brain Injury Activities." 2012
2) Weinick, Robin M., Ellen Burke Beckjord, Carrie M. Farmer, Laurie T. Martin, Emily M. Gillen, Joie Acosta, Michael P. Fisher, et al. Programs Addressing Psychological Health and Traumatic Brain Injury among U.S. Military Servicemembers and Their Families. Santa Monica, CA: Rand Corporation, 2011..
4 Years$ 2.7 Billion1
211 programs2
2007 2010
Psy
chia
try
Psy
chol
ogy
Soc
ial W
ork
Office of the Surgeon General
Fiscal Discipline Policy Compliance
“Traditional” Mental Healthcare
Military Treatment Facility
Multiple Provider-Patient Dyads with Ad-Hoc Coordination of Services
Compliance to Business plansFocus on Volume-Based Productivity
Policy GuidanceFunding
Business Plan Performance to Plan
Provider-Centered Practices Organized by Discipline
Before 2004
Patient Experience of Care
Clinical Microsystem
Healthcare Organization
Healthcare Environment
Psy
chia
try
Psy
chol
ogy
Soc
ial W
ork
Office of the Surgeon General
Fiscal Discipline Policy Compliance
“Traditional” Mental Healthcare
Care in Non Traditional Settings
Military Treatment Facility
Multiple Provider-Patient Dyads with Ad-Hoc Coordination of Services
Compliance to Business plansFocus on Volume-Based Productivity
Policy GuidanceFunding
Business Plan Performance to Plan
Provider-Centered Practices Organized
by Discipline
New Programs Due to Congressionally
Directed Funding
2011
TBI
Sleep Clinic
Pain ClinicPTS
D C
linic.
.
. …
AUSA Talk 7/25/2017
Learning health system capabilities for bridging research, policy and practice
AUSA Talk 7/25/2017
Translating research evidence to practice is challenging
• Research evidence is typically generated in a “clean room setting” that does not easily map to the real world context
• Evidence-based practice involves integrating: the best-available research evidence, clinical judgment, and patient preference
• Differences in the research community on appropriate treatments• Example: DoD/VA CPG recommends SSRIs as a first line treatment,
while WHO recommends SSRI after a first course of psychotherapy• Nonresponse rates have been high, and trauma-focused interventions
show marginally superior results (Steenkamp et al, 2015) 6
AUSA Talk 7/25/2017
1) Department of Defense. "Final Report to the Secretary of Defense Military Health System Review." Washington DC, 2014.
Provide patient-centered culturally competent care
• Understanding and validating the occupational context is essential for understanding Soldier stressors• New system of care design narrows the provider catchment area to a
unit or set of units, making it possible for providers to retain situational awareness on occupational context and build sustained command relationships
• Line medical assets are required to provide 20 hours of clinical care in the military treatment facility. These providers serve to mentor and educate providers in their clinics on mission information and unit culture
• Provider composition has shifted from being mostly uniformed personnel to almost 75% civilian providers1
• Established Army “101” onboarding program for all new providers• “Model of care” specific training programs on command engagement7
AUSA Talk 7/25/2017
Non$Parametric-Kendall’s-τb-
Communication-and-Follow-Up-
Work-directly-with-EBH-Team-
Able-to-meet-BH-needs-
Provides-quality-care-
Supports-Mission-Readiness-
Considers-command-feedback-
Work-directly-with-EBH-Team- 0.3234& & & & & &Able-to-meet-BH-needs- 0.6664& 0.2684& & & & &Provides-quality-care- 0.6648& 0.2954& 0.7213& & & &Supports-mission-readiness- 0.673& 0.2648& 0.672& 0.6952& & &Considers-command-feedback- 0.7365& 0.3452& 0.6508& 0.664& 0.6602& &Shares-mission-essential-information-
0.6882& 0.3774& 0.6644& 0.641& 0.6471& 0.6977&
!
Engage communities to ensure safe retention in care
8Sour
ce:
Srin
ivas
an
(201
5) “
Und
erst
andi
ng N
on-C
linic
al S
take
hold
er P
ersp
ectiv
e to
Ena
ble
Sold
ier
Rec
over
y”
238
Com
man
d te
am s
urve
ys fr
om 1
Inst
alla
tion
Communication and Follow up by provider strongly correlated with perceptions of supporting mission readiness, incorporating command feedback and sharing mission essential information
Electronic profiles are critical for communicating psychiatric readiness levels and duty limitations to command teams
AUSA Talk 7/25/2017
Understand real-time knowledge to improve patient outcomes
§ Defined accounting infrastructure to reflect patient flows§ Transitions between MTFs such
as permanent changes of station and deployments
§ Clinical care transitions across levels of care within the MTF
§ Actively addressed operational and cultural challenges to routine outcome measurement through system-wide investment in infrastructure and workflow management1§ Select common scales§ Automate charting§ Maximize patient-provider time§ Use as decision support tool
1Source: Srinivasan and Brown, “Enabling R
outine Outcom
e Measurem
ent for M
ental Health Services in the U
nited States Army”
9
Emergency)Department
Specialty)Mental)Health)Care
Inpatient)Services Emergency)Department
Specialty)Mental)Health)Care
Inpatient)Services
Direct'Care:'Military'Health'
System'is'the'service'provider
Purchased'Care:'M
ilitary'He
alth'
System
'is'th
e'insurance'provider
Military(Treatment(Facility(Catchment(Area
Selected(Inter5Catchment(Area(Transitions
Selected(Intra5Catchment(Area(Transitions
Permanent Change of
Station
Deployment/Redeployment
New Enrollees
Leave Service/ Retire
AUSA Talk 7/25/2017
Overview of Army Transformation
10
Psy
chia
try
Psy
chol
ogy
Soc
ial W
ork
Office of the Surgeon General
Fiscal Discipline Policy Compliance
“Traditional” Mental Healthcare
Care in Non Traditional Settings
Military Treatment Facility
Multiple Provider-Patient Dyads with Ad-Hoc Coordination of Services
Compliance to Business plansFocus on Volume-Based Productivity
Policy GuidanceFunding
Business Plan Performance to Plan
Provider-Centered Practices Organized
by Discipline
New Programs Due to Congressionally
Directed Funding
2011
TBI
Sleep Clinic
Pain ClinicPTS
D C
linic.
.
. …
Patient Experience of Care
Clinical Microsystem
Healthcare Organization
Healthcare Environment
Active change management
Office of the Surgeon GeneralBehavioral Health Service Line
Fiscal Discipline, Policy Compliance, BH Incentives
Military Treatment Facility
BH Policy GuidanceBH Specific Funds
BH Specific Metrics
Distributed Multi-Disciplinary Standard System of Care
2015
Military Treatment FacilityFiscal Discipline, Policy Compliance, BH Incentives
System of C
are Specification
Patient-Centered Team Based Care incorporating patient
reported outcome data
Expected Staffing
Mission-B
ased W
orkload
Level 1
Soldier Centered
Medical Home
Embedded Behavioral
Health
Child and Family
Services
Multi-Disciplinary
Clinic
Intensive Outpatient Services
Inpatient Care
Tele-behavioral
Health
Primary Care Ambulatory Specialty Care Services Residential Services
Primary Care Behavioral
Health
Family Advocacy Program
Dependent Care Pathway
Soldier Care Pathway
Note: Not all care transitions shown
Level 2
Level 3 Level 4
School Behavioral
Health
AUSA Talk 7/25/2017
Key Takeaways§ A defined system of care that integrates standard clinical
microsystems is a needed foundation for building a learning healthcare system that can translate research to practice
§ System of care can be redesigned to be patient-centered, policy-compliant and empower clinicians§ Change takes time – the Army has been on a 7 year journey
§ Decision support systems are necessary for enabling learning at multiple organizational levels§ Leverage clinical decision support tools to improve patient outcomes§ Standardize accounting infrastructure to enable practice management§ Provide traceability from system goals to patient outcomes to enable
learning
