Michelle and Barbara facilitated a department redesign initiative for case managers, utilization management nurses, social workers, chronic condition coaches, behavioral health specialists, and community health workers. They guided this multi-disciplinary team through a discovery of new models of care for behavioral health integration, transitions of care, care pathways for chronic conditions, home safety checks for frail populations, and a streamlined process of risk assessment of new enrollees. AllCare also employed Attune’s expertise to upgrade and customize their care management software to accommodate new work flows, improve documentation of care management activities, and monitor staff performance and outcomes.
The short-term strategy that Attune developed allowed the health plan to avert a wave of acute care expense, and to provide new members the care and attention they needed in a Patient Centered Primary Care Home. The Care Management staff were able to use the Health Risk Assessment to identify new members in dire need of care and expedite intervention to avoid medical crises. Care Pathways support management of AllCare members at an intermediate level of risk, and stabilizes their condition with coordination from their primary care providers. The business intelligence tools developed with Attune provide a longitudinal tactic for risk management that decreases the development of health risks into active illness with acute, costly episodes.
Although there are few published studies of the rates of PTSD among military personnel soon after their return from combat duty, studies of veterans conducted years after their service ended have shown a prevalence of current PTSD of 15 percent among Vietnam veterans and 2 to 10 percent among veterans of the first Gulf War. Rates of PTSD among the general adult population in the United States are 3 to 4 percent, which are not dissimilar to the baseline rate of 5 percent observed in the sample of soldiers responding to the survey before deployment. Research has shown that the majority of persons in whom PTSD develops meet the criteria for the diagnosis of this disorder within the first three months after the traumatic event. In our study, administering the surveys three to four months after the subjects had returned from deployment and at least six months after the heaviest combat operations was probably optimal for investigating the long-term risk of mental health problems associated with combat. We are continuing to examine this risk in repeated cross-sectional and longitudinal assessments involving the same units.
Our findings indicate that a small percentage of soldiers and Marines whose responses met the screening criteria for a mental disorder reported that they had received help from any mental health professional, a finding that parallels the results of civilian studies. In the military, there are unique factors that contribute to resistance to seeking such help, particularly concern about how a soldier will be perceived by peers and by the leadership. Concern about stigma was disproportionately greatest among those most in need of help from mental health services. Soldiers and Marines whose responses were scored as positive for a mental disorder were twice as likely as those whose responses were scored as negative to show concern about being stigmatized and about other barriers to mental health care.
The survey instruments used to screen for mental disorders in this study have been validated primarily in the settings of primary care and in clinical populations. The results therefore do not represent definitive diagnoses of persons in nonclinical populations such as our military samples. However, requiring evidence of functional impairment or a high number of symptoms, as we did, according to the strict case definitions, increases the specificity and positive predictive value of the survey measures. This conservative approach suggested that as many as 9 percent of soldiers may be at risk for mental disorders before combat deployment, and as many as 11 to 17 percent may be at risk for such disorders three to four months after their return from combat deployment.
Does the application challenge and seek to shift current research or clinical practice paradigms by utilizing novel theoretical concepts, approaches or methodologies, instrumentation, or interventions? Are the concepts, approaches or methodologies, instrumentation, or interventions novel to one field of research or novel in a broad sense? Is a refinement, improvement, or new application of theoretical concepts, approaches or methodologies, instrumentation, or interventions proposed? Are innovative models proposed for (a) enhancing the skills of researchers and technical personnel to conduct implementation research in mental health, and (b) enhancing the skills of LMIC policymakers and technical personnel in using science-based methods and information to develop mental health policies and programs?
Does the proposed program of research and capacity-building activities address an important problem or a critical barrier to progress in the field? Is there a strong scientific premise for the project? If the aims of the program are achieved, how will scientific knowledge, technical capability, and/or clinical practice be improved? How will successful completion of the aims change the concepts, methods, technologies, treatments, services, or preventative interventions that drive this field? Are the results of the proposed program (i.e., research and capacity building) likely to inform future attempts to scale up and improve mental health care and policy in other LMICs? Is the program focused on (a) conducting implementation research that increases the evidence base for scaling up mental health interventions, and (b) building capacity in LMICs to conduct implementation research and apply research to developing mental health policies and programs? Are the program goals important in the geographic region in which the Scale-Up Study and Capacity-Building component will take place? Will the Scale-Up Study and Capacity-Building component involve collaboration with appropriate LMIC government agencies and nongovernmental organizations? Are there coordination and synergy of the Scale-Up Study, Capacity-Building component, and Administrative Core towards the achievement of the overall program aims?
NIH encourages the use of common data elements (CDEs) in basic, clinical, and applied research, patient registries, and other human subject research to facilitate broader and more effective use of data and advance research across studies. CDEs are data elements that have been identified and defined for use in multiple data sets across different studies. Use of CDEs can facilitate data sharing and standardization to improve data quality and enable data integration from multiple studies and sources, including electronic health records. NIH ICs have identified CDEs for many clinical domains (e.g., neurological disease), types of studies (e.g., genome-wide association studies (GWAS)), types of outcomes (e.g., patient-reported outcomes), and patient registries (e.g., the Global Rare Diseases Patient Registry and Data Repository). NIH has established a “Common Data Element (CDE) Resource Portal" () to assist investigators in identifying NIH-supported CDEs when developing protocols, case report forms, and other instruments for data collection. The Portal provides guidance about and access to NIH-supported CDE initiatives and other tools and resources for the appropriate use of CDEs and data standards in NIH-funded research. Investigators are encouraged to consult the Portal and describe in their applications any use they will make of NIH-supported CDEs in their projects.
Approach: The research Capacity-Building component is intended to (a) enhance the skills of LMIC researchers for conducting mental health implementation research, and (b) enhance LMIC policymakers' skill in using science to inform policy and program development. Applicants should describe the feasibility of the proposed Capacity-Building activities to achieve these ends, the advantages of any innovative features, and the potential pitfalls and alternative approaches.
Significance: Describe the role of the Capacity-Building component in achieving the overall long-term aim of closing the mental health treatment gap through development of regional capacity to conduct mental health care implementation research and to use science-based procedures and information in developing mental health programs and policies.