Therapeutic
Measures
Required
To Ensure Millions of
Veterans and Their
Families Get HighQuality Care, Community
Mental Health Providers
Need More Training,
Support, and Resources
With policies shifting to permit millions of veterans and their families to seek mental
health services in the private sector, the civilian providers they turn to in communities
across the country will need more training, support, and resources so they can
deliver culturally competent, high-quality care, RAND research has found. The study
found very few community providers surveyed met key thresholds for military cultural
competency and use of evidence-based care, indicating few are ready overall to
assist this important group of patients.
C O R P O R AT I O N
Training alone does
not ensure delivery
of high-quality care
Getting to effective care
Building on RAND’s extensive portfolio of studies on veterans, their
families, and their physical and mental health needs, the researchers
expanded their focus beyond access to services to also include how
care for veterans and their families might be most effective and whether
community providers have the capacity to deliver it. Are they comfortable
working with this unique group of patients? What do they know about
the military and the lives and experiences of veterans and their families?
Have they treated veterans or their families before? Are they trained in,
and do they regularly practice, evidence-based therapies for prominent
conditions affecting veterans and their families, such as posttraumatic
stress disorder (PTSD) and major depressive disorder (MDD)?
Building cultural competence
Licensed counselors, clinical social workers, psychologists, and
psychiatrists in the sample varied in their knowledge and cultural
competence to treat veterans and their families, the survey-based RAND
study showed. Providers were asked, for example, what they knew about
military ranks, slang, deployments, services, and other information
and experiences common to veterans and their families. Only 1 in 4
(or 25 percent) of those responding to the online questionnaire reported
being very familiar with general and deployment-related stressors for
service members and veterans; only about one-third had prior training
in military culture; and fewer than one-fifth had high military cultural
competence. Not surprisingly, providers who work for or had experience
with the Department of Defense (DoD) or the Department of Veterans
Affairs (VA) reported the greatest cultural competence to work with
veterans or their families as patients.
Applying evidence-based therapies
While veterans and their families benefit from evidence-based treatments
for PTSD and MDD, and DoD and VA recommend them, 65 percent
of psychotherapists sampled had not received training or supervision
in these therapies. Even among those with training, only 41 percent
reported delivering evidence-based therapies to most of their patients;
training alone does not ensure delivery of high-quality care. Newer
psychotherapists were more likely to report providing evidence-based
therapies, perhaps reflecting both the more recent emphasis on these
treatments in graduate schools and a gap that policymakers may seek
to address more systematically for all providers, particularly those
already in the field.
4
4
FOUR STEPS FOR POLICY AND PROGRAM OFFICIALS
Based on an assessment of this survey’s data and RAND’s existing work in this field,
researchers identified steps policymakers may wish to consider to ensure veterans and
their families receive high-quality care in the private, civilian sector.
1
Improve assessments of the workforce
providing mental health care
As the VA presses to hire more and expand access to civilian providers to treat veterans and their
families, policymakers and personnel experts would benefit from having sound data on the size and
characteristics of the U.S. mental health workforce, and, in particular, whether the civilian sector
can meet expectations for the quality of care. Professional groups and organizations that maintain
provider registries are in a position to assess the knowledge, skills, and practice patterns within
memberships, focusing on access and quality of care provided. Data on the provider workforce is
important so policymakers not only know if the pipeline will provide an adequate supply of providers,
in number and quality, but also to address gaps, for example, affecting rural and remote areas.
Access
3
2
Expand access to
effective training
in evidence-based
PTSD and MDD
therapies
This study points to the need for more
training on evidence-based approaches
for community-based mental health
providers, particularly if they underwent
formal professional training some time ago.
The current training programs in military
culture and evidence-based approaches
for PTSD and MDD varies greatly and
includes short, online courses to longer,
in-person programs. While participation in
continuing education may help to expand
their skills and capacities, providers may
need incentives and motivation to obtain
training and to apply their learning in routine
practice, particularly because this effort can
cost them time and money. Policymakers
may need to find ways to keep course costs
low, and they must ensure the programs’
quality and effectiveness, especially
through rigorous evaluation.
Assess
Determine the
impact of culturalcompetence training
for providers
Federal officials have pledged to step up
programs to train community providers
about the unique needs of service
personnel, veterans, and their families.
But training by itself will not necessarily
increase providers’ cultural competency
or expand access or quality of care for
veterans, and it does not replace provider
experience in treating these patients. And
while initial interest in training programs
can be high, sustained and rigorous
evaluation is needed to assess their
effectiveness in changing and influencing
provider competency and capacity.
Impact
4
Facilitate providers’ use
of evidence-based therapies
Even when providers have been trained in evidence-based approaches, they may
not use these therapies in their routine practices. So, motivation and incentives
may be called for to ensure the therapies are adopted: In larger, managed
practices, these might include system- or practice-level monitoring and quality
improvement efforts; in smaller or lone practitioner settings, payers may supply the
impetus, with quality-of-care monitoring and adjustments to reimbursements and
referrals. Research shows that there is a business case for these steps: Improved
care for veterans and their families has been cost-saving and cost-effective.
Motivate
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e practice
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This research was sponsored by the United Health Foundation, which partnered with the Military Officers Association of America (MOAA), in commissioning this study.
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© RAND 2014
This brief describes work done in RAND Health, documented in Ready to Serve: Community-based Provider Capacity to Deliver
Culturally Competent, Quality Mental Health Care to Veterans and Their Families by Terri Tanielian, Coreen Farris, Caroline
Epley, Carrie M. Farmer, Eric Robinson, Charles C. Engel, Michael William Robbins, and Lisa H. Jaycox, RR-806-UNHF
(available at www.rand.org/t/RR806), 2014. To view this brief online, visit www.rand.org/t/RB9809. The RAND Corporation is
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