Helping Soldiers Heal

How the US Army Created a Learning Mental Health Care System

Jayakanth Srinivasan, Christopher Ivany

• Publisher: ILR Press
• Year: 2021
• Print ISBN: 9781501760501, 9781501760501
• eBook ISBN: 9781501760518
• Topic: Psychology
• Subtopic: Military & Maritime History
• Index: Psychology

Helping Soldiers Heal tells the story of the US Army's transformation from a disparate collection of poorly standardized, largely disconnected clinics into one of the nation's leading mental health care systems. It is a step-by-step guidebook for military and civilian health care systems alike. Jayakanth Srinivasan and Christopher Ivany provide a unique insider-outsider perspective as key participants in the process, sharing how they confronted the challenges firsthand and helped craft and guide the unfolding change.

The Army's system was being overwhelmed with mental health problems among soldiers and their family members, impeding combat readiness. The key to the transformation was to apply the tenets of "learning" health care systems. Building a learning health care system is hard; building a learning mental health care system is even harder. As Helping Soldiers Heal recounts, the Army overcame the barriers to success, and its experience is full of lessons for any health care system seeking to transform.

Chapter 1

ORGANIZED ANARCHY IN ARMY MENTAL HEALTH CARE

While serving as the chief of the Department of Behavioral Health at the hospital at Fort Carson, Colorado, Chris received a call from the chief of one of the behavioral health clinics on the post. She pleasantly asked Chris to drive the mile or so over to see something unusual that had just arrived in her clinic. She preferred not to describe it over the phone. Slightly annoyed at the disruption to his morning schedule, Chris arrived a few minutes later. Sitting on the desk in the office of one of the psychologists was a large rock, about ten pounds, nearly a foot around and painted bright pink. Not understanding what he was looking at, Chris asked the psychologist for an explanation.

She said that a private first class (a very junior soldier who has been in the Army less than two years) had lugged the curious object with him to an appointment with her earlier this morning. Confused, she asked him why he had the conspicuous object. He calmly stated that his first sergeant (a noncommissioned officer serving in an important leadership role) had made a new rule in his company (a small Army unit of about one hundred soldiers).

“What’s the new rule?” the psychologist inquired.

Matter-of-factly, the soldier explained that anyone in his company who is unable to train with the unit, or who has a pending medical discharge for a mental health condition, is required to carry a large pink rock everywhere he or she goes.

The year is 2010.

Shocked, Chris wondered, “Why was this first sergeant, an experienced leader, intentionally embarrassing his soldiers and discouraging them from taking advantage of mental health care the Army offered?” If we take a step back and consider the situation from the first sergeant’s perspective, we may be able to see the full scope of the problem.

The first sergeant, like all Army leaders in charge of combat units, was under incredible pressure to get his company ready for its next deployment, now only six months away. He had felt the pain of losing soldiers in combat in the past, and this time he was determined to bring all of his soldiers home alive. That meant everyone had to be fully trained and ready.

But mental health problems kept cropping up, often in his best soldiers. Some appeared depressed, angry, and less interested in the mission. They’d miss critical training events to go to appointments at the Army hospital. Sometimes, they’d come back with paperwork that said they couldn’t be around weapons for the next month or two—no small thing in an infantry unit. And most of them didn’t seem to be getting any better anyway—at least not as the first sergeant saw it.

At one point, he had fifteen of his soldiers in treatment. He would call the hospital to track down the twelve different behavioral health providers (psychiatrists, psychologists, clinical social workers, or nurse practitioners) treating those soldiers, trying to find out which of them were not going to be able to deploy with the rest of the company when the time came. When he left voice mails, only a few of the providers called him back. When he did reach someone, he got little more than a cryptic “lecture” about the difficulty of predicting how mental health conditions respond to treatment—meaning no answer to his question. Frustrated, confused, and angry, he decided to take matters into his own hands and discourage any more of his soldiers from getting tangled up in what seemed to him the morass that was Army behavioral health care.

Why would the first sergeant decide to make an already difficult situation for soldiers worse by attaching even more stigma to their conditions? Because the Army had failed to offer a system that helped him to take care of his soldiers and address his primary concern of getting his company ready for their next deployment.

This real story reveals a few of the numerous problems that plagued the Army’s early attempts to combat the rising tide of mental illness brought on by the wars in Iraq and Afghanistan. Overcoming these and many others would take a near total transformation of the clinical system that organized, delivered, and monitored the care.

Understanding Learning Health Systems

In 2013, the National Academy of Medicine published a consensus report that articulated the vision for a learning health system as one “in which science, informatics, incentives, and culture are aligned for continuous improvement and innovation, with best practices seamlessly embedded in the care process, patients and families active participants in all elements, and new knowledge captured as an integral by-product of the care experience.”¹ This report consolidated the findings from a series of eleven learning health systems publications, beginning with the proceedings of the first workshop in 2007 that described the need for building a learning health system and including ten subsequent volumes addressing specific components of the learning health system model, ranging from evidence generation to leadership.² Figure 1.1 shows a schematic of a learning health system. With this series, the National Academies Press continues to capture insights from the nation’s leading experts on the components of building learning health systems (LHS).³

LHS represent a fundamental shift in the design of health systems in general and mental health systems in particular, because of the historical separation between mental health care and other medical care, the disciplinary fragmentation that exists within mental health care, and the stigma associated with having a mental health condition.⁴

FIGURE 1.1. Learning health system. Adapted from Institute of Medicine, Best Care at Lower Cost.

Learning health systems share several attributes relevant for our discussion here. They have systems of care designed around the needs and perspectives of patients and the community served. Clinicians are trained to be respectful of those needs and perspectives. LHS have digital infrastructures to capture the patient experience of care reliably. They are transparent in their use of data to improve the care experience, care quality, and care outcomes. They improve clinical decision making by providing clinicians with the best evidence available. They utilize incentives designed to promote high-value care. And finally, LHS leaders promote a culture of learning.

In 2010, the Army’s mental health care system was not designed with those attributes in mind. Each Army hospital had its own unique mental health care system that had evolved based on local needs and local provider interests. Commanders, one of the most important stakeholders, felt the mental health system was not taking care of their soldiers. Many clinicians were not trained to understand the Army culture, making it difficult for them to understand soldiers and provide culturally competent care.

The Army’s digital infrastructure was long in the tooth, and it was not designed to support mental health care. The administrative data did not map effectively to the actual clinical care provided to soldiers and family members. Known delays in the analysis and reporting of even the high-level administrative data meant that Army hospitals could not use that data to understand and address deficiencies in the patient experience or care quality.

Like most mental health systems, the Army’s had no systematic means of assessing whether the care provided was actually making patients better. Given that the Army did not have an automated process for systematically collecting patient reported outcomes, it was left to individual providers to manually collect, analyze, and incorporate data into their clinical decision making. The Army did not provide to Army hospitals incentives that were specifically focused on improving mental health outcomes; rather, it focused on process measures related to enhancing access for soldiers returning from an overseas combat tour.

From Stable Demand to Organized Anarchy

A learning health system cannot be built if there is no defined system of care. When the MIT research team initially tried to answer the simple question about how the Army organized and delivered mental health care, the team was surprised to learn that even the Army had no clear understanding for its thirty-three military treatment facilities. There was a high-level definition of the care being provided in the direct care system (care delivered in Army hospitals) or as purchased care—care sourced from civilian health care systems near an Army post, where service members could use their TRICARE insurance.

Prior to 2006, mental health care in the Army was delivered at Army hospitals in separate departments: psychiatry, psychology, and social work. This traditional organizational structure made it easier to recruit providers because the departments corresponded to national academic training programs, professional societies, licensure boards, and certification agencies with which these providers dealt outside the military. The Army could easily determine what providers could and could not do, and it could authorize them to provide care within their scope of practice. A soldier or family member would access services within a given department as needed. For complex cases requiring that a soldier or family member be seen in multiple departments, case coordination would often be left to those individual care providers.

Even though there was some variation in care offerings across the different hospitals, demand grew slowly from 4.44 percent of all active-duty soldiers using mental health care services in 2003 to 6.46 percent in 2006.⁵ The department-based design had been able to meet the needs of those soldiers and their families.

Then things began to change rapidly. The ongoing wars in Afghanistan and Iraq placed significantly more demands on the Army. By 2011, soldiers had spent more than 1.5 million troop-years in a combat setting, a 28 percent increase from 2007. About 73 percent of active and reserve soldiers and National Guard members had deployed to Iraq and Afghanistan, and most were on their second, third, or fourth year of cumulative deployed duty.⁶ The period 2007 to 2010 saw the sharpest growth in the use of mental health services. Outpatient visits nearly doubled as the percentage of active-duty soldiers using mental health care services spiked from 7.7 to 12.4 percent. Inpatient admissions also shot upward, from 16,794 to 23,680.⁷

At the same time, a number of external and internal reports about the situation created a real sense of urgency to increase access to mental health care services. The Dole-Shalala Commission, convened in response to a series of articles in the Washington Post that documented poor conditions, neglect, and bureaucratic hurdles faced by outpatients at Walter Reed Army Medical Center, released a report “proving to the American public that the Walter Reed fiasco [was] just the tip of the iceberg.”⁸ The RAND Corporation released a report as part of its Invisible Wounds of War Project that found evidence to suggest that “the psychological toll” of deployments to Afghanistan and Iraq “may be disproportionately high compared with the physical injuries of combat.”⁹ Internal findings by the Army’s mental health assessment teams and the DoD Task Force on Mental Health also stoked the calls for change.¹⁰

In 2007, when the US Congress added more than $200 million annually for Army hospitals to improve access to mental health care, there was very little direction from the Army surgeon general to Army hospitals on how to spend those funds. Army hospitals rapidly created dozens of new programs, and by 2010 there were more than sixty unique clinical programs across the Army.¹¹ Independent of the Army’s own efforts, a team of MIT students tried to figure out what all the programs actually did.¹² They had a list of program names and locations, but nothing more. Six graduate students working half-time every day for three months looked for information on the Web, found phone numbers, and then called the hospital...

Table of contents

• Acknowledgments
• Introduction
• 1. Organized Anarchy in Army Mental Health Care
• 2. A Brief and Incomplete History of US Army Mental Health Care
• 3. Organizing a Learning Health Care System
• 4. Five Levels of Learning
• 5. Building Analytics Capabilities to Support Decision Making
• 6. Managing Performance in a Learning Behavioral Health System
• 7. Creating Dissemination and Implementation Capabilities
• 8. Leading a Learning System
• 9. Translating Learning from the Army
• 10. The Path Ahead
• Notes
• Bibliography
• Index