The Current Military Health Care System Research Paradigm

The Current Military Health Care System Research Paradigm
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Research on military psychological health issues continues to draw attention and support for funding from government leaders. Realizing the need for an organized, coordinated approach to mental health research, the 2012 executive order directed DoD, VA, HHS and the Department of Education to develop the National Research Action Plan (NRAP), “to improve the coordination of agency research into these conditions and reduce the number of affected men and women through better prevention, diagnosis, and treatment.”

Translational Research Paradigm

Previously, the model for health research was static and linear, going from science, to evidence, to care. This method of translating research into clinical practice resulted in a loss of information and waste of resources. As a result, patients were not getting the best care possible. It took an average of 17 years for new knowledge generated by randomized controlled trials to be incorporated into practice, and even then, the application of that research was highly variable[1].

Old Pathway to Care

IOM, 2012. Best Care at Lower Cost: The Path to Continually Learning Health Care in America

A 2012 Institute of Medicine (IOM) report, encouraged changes to the current health care system research paradigm that would limit missed opportunities, waste and harm. This change was to be made possible by creating a continuously evolving health care system that linked data to research and practitioners, enhanced providers’ knowledge of research findings and provided them with real-time guidance for superior, evidence-based care. Scientific research conducted with consideration of implementation and dissemination could impact clinical care more efficiently and meaningfully.

New Pathway to Care

IOM, 2012. Best Care at Lower Cost: The Path to Continually Learning Health Care in America

IOM describes this new system of care as dynamic and circular, in that scientific research contributes to evidence, which impacts clinical care and in turn, feeds back to influence the scientific process. Stakeholders, including patients, providers and communities, all impact the system of care. Characteristics of this type of system include: real-time access to knowledge; digital capture of the care experience; engaged, empowered patients; incentives aligned for value, with full transparency; and a leadership-instilled culture of learning, supportive system competencies.

This new system of care aligns with a translational science research paradigm which envisions that the progression from bench to bedside to practice can occur within a shorter timeframe and providers can make use of knowledge findings more immediately.

The current National Institutes of Health (NIH) Roadmap for Medical Research describes how research moves into practice. Research is often tested in either bench or bedside laboratories through case studies and early phase clinical trials (T1). Often, research moves to the next stage through continuing medical education programs, pharmaceutical detailing, and guideline development (T2), instead of a systematic approach. NIH proposed that an expansion of the Roadmap (blue) include an additional research laboratory (practice-based research) and translational step (T3) to improve incorporation of research discoveries into day-to-day clinical care. This step would give research a “real world” trial, allowing for researchers one more layer of examination before practice. The research roadmap is a continuum, with overlap between sites of research and translational steps. The roadmap includes examples of the types of research common in each research laboratory and translational step. “This map is not exhaustive; other important types of research that might be included are community-based participatory research, public health research, and health policy analysis”[2].

Translational Research Paradigm

Westfall et al., JAMA 2007

Implementation Science

Implementation of new research findings into routine practice settings is not a simple process. Often, research is conducted in controlled environments with motivated participants and highly invested scientists. Clinical and community settings where new findings are to be implemented are likely to be diverse and necessitate adaptations of this information to accommodate patient preferences, provider expertise and system characteristics. There are several subsequent steps that must take place in order to translate these research findings into appropriate practice changes.

Implementation science, according to the National Institutes of Health (NIH), specifically examines one step in the translational science process – “the integration of research findings and heath evidence into health care policy and practice.” The aim of implementation science is to help organizations adopt and integrate evidence-based health interventions and change any current practices that are impeding the use of best clinical practices.

The VA/DoD Practice-Based Implementation (PBI) Network follows the precepts of implementation science best practices. Innovations and programs contained within the PBI Network follow a standardized, rigorous implementation methodology that promotes appropriate practice change. More information about the PBI Network can be found here.

Additional Resources VA Quality Enhancement Research Initiative (QUERI): Harnessing the power of research in partnership with VA operations, QUERI applies innovative strategies to more rapidly implement effective treatments and other evidence-based system improvements in routine care.

Implementation Science Journal: an open access, peer-reviewed online journal that aims to publish research relevant to the scientific study of methods to promote the uptake of research findings into routine healthcare in clinical, organizational or policy contexts.

According to NIH, there are two specific gaps identified in implementation science:

  • "Research-to-policy" gaps, which exist when research evidence is not adequately or appropriately considered and integrated in the development of health outcomes.
  • "Research-to-program" gaps, which exist when research evidence is not adequately or appropriately considered and integrated in the development of health policy.

Implementation science is particularly important in military health research as the MHS is a unique health system with its own policies and procedures unlike any other. Many factors must be considered when integrating an innovation into a specific environment. An innovation is a promising evidence-based practice or program that can be effective when properly implemented in an identified environment.

An important determinant in the successful implementation and sustained use of an innovation is ongoing feedback and interaction with relevant stakeholders and intended end users. Stakeholder feedback provides invaluable information, and shapes the structure, delivery and readiness of the innovation to be adopted in the identified environment.

The NRAP utilizes the current research in translational and implementation science to move research findings into effective prevention strategies and clinical innovations as well as accelerated implementation of research findings, to promote the prevention and treatment of mental health conditions. The NRAP specifically lays out the need for a coordinated effort among agencies to “reduce overlap, eliminate redundancies, identify gaps, and focus new research questions.” These efforts span the research continuum from basic science to prevention, treatment, follow-up care, and research into the delivery of modality of care.

Military Health Services Research: The Way Forward

Military psychological health research has focused on developing better ways to screen for mental health conditions in the primary care setting by streamlining the screening process and validating the most up-to-date assessment tools for use in primary care. Through these research efforts aimed at improving screening in primary care, an increased number of at-risk beneficiaries can be identified and subsequently will be more likely to receive appropriate and effective care.

Another way DoD is addressing the concerns of access, continuity and quality of mental health care is by researching implementation of a collaborative care model in the military health care system, a model that has increased the reach, quality and outcomes of care in civilian settings[3],[4]. Key components include screening for mental health symptoms, use of nurse care managers to bridge the gap between patients and primary care providers, and increased access to specialty behavioral health care.  The chart below summarizes the differences between the old model of military mental health care and the new collaborative care model.

Traditional Model of Care Collaborative Care Model
  • Crisis driven model
  • Wait for patients to come for their care
  • No one on the team responsible for keeping patients in care
  • Measurement is “another duty as assigned”
  • Patients that stop coming are “lost to follow-up”
  • Providers engage the team when they can
  • Outreach & engagement model (care coordination/care management)
  • Use registries/automation to identify those with needs
  • Care facilitator job is engagement: “cheap suit”
  • Care facilitator measures while engaging needs (regular/proactive monitoring using validated clinical rating scales)
  • Reengagement intensifies when patient falls out of care  (regular systematic psychiatric caseload reviews and consultation for patients who do not show clinical improvement)
  • Care facilitator keeps team together

References

[1] IOM. (2001). Crossing the quality chasm. Retrieved from https://www.iom.edu/~/media/Files/Report%20Files/2001/Crossing-the-Quality Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf.

[2] Westfall, J.M., Mold, J., & Fagnan, L. (2007). Practice-based research-“Blue Highways” on the NIH roadmap. Journal of the American Medical Association, 297(4), 403-406.

[3]Woltmann, E., Grogan-Kaylor, A., Perron, B., Georges, H., Kilbourne, A.M., & Bauer, M.S. (2012). Comparative effectiveness of collaborative chronic care models for mental health conditions across primary, specialty, and behavioral health care settings: Systematic review and meta-analysis. Am J Psychiatry, 169(8), 790-804.

[4] Archer, J., Bower, P., Gilbody, S., Lovell, K., Richards, D., Gask, L., Dickens, C., & Coventry, P. (2012). Collaborative Care for Depression and Anxiety Problems. Cochrane Database Syst Rev, 10, CD006525.