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- Unproductive patient-provider communication and low patient engagement are key drivers of disparities in mental health and substance use disorder treatment for individuals of ethnic and racial minority backgrounds.
- To address these disparities, PARTNER-MH pilot tested a peer-led patient navigation program for racial and ethnic minority Veterans at Roudebush VA Medical Center.
- PARTNER-MH peers work with Veterans to prepare them for their service visits by setting goals, writing questions in advance, and making a brief summary of their symptoms and experiences with past treatments.
Acknowledgment: The authors acknowledge the contribution of the Richard L. Roudebush VA Medical Center, HSR&D Center for Health Information and Communication, and the following individuals for their contribution to PARTNER-MH: John Akins, James Miller, Caitlin O’Connor, Scott Patterson, Matthew J. Bair, Teresa Damush, and Diana Burgess.
Despite efforts to address mental healthcare inequalities, disparities persist.1 Individuals of ethnic and racial minority backgrounds are less likely to receive mental health or substance use disorder treatment, and once they enter treatment, they are more likely to receive poor quality care or to terminate treatment prematurely compared to whites. Similar disparities are also present in the VA.2 While many patient, provider, and healthcare system factors account for these disparities, unproductive patient-provider communication and low patient engagement in care are key drivers. These factors are also modifiable; thus, interventions focused on improving communication and patient engagement in healthcare have the potential to increase health equity. PARTNER-MH: (Pro-Active, Recovery-oriented Treatment Navigation to Engage Racially Diverse Veterans in Mental Healthcare) is a mental healthcare intervention focused on modifying these factors for Veterans.
PARTNER-MH is a six-month, peer-led, patient navigation program that we are currently pilot testing in a randomized controlled trial at the Roudebush VA Medical Center and affiliated community-based clinics (CBOCS). PARTNER-MH is offered to racial and ethnic minority Veterans across diagnostic categories in VHA outpatient mental health clinics. The program targets Veterans who are relatively new to VHA mental health services because these settings are often the first pathway to specialty mental health services, yet, there is little support to help Veterans navigate these services. PARTNER-MH’s goals are: 1) to engage Veterans in mental healthcare; 2) to increase patient activation by giving Veterans the tools to become active collaborators in their care; and 3) to improve their communication skills, including their participation in shared decision-making. Guided by concepts introduced in the PARTNER-MH Veteran handbook (e.g., information about VHA services, engagement in treatment, mental health visit preparation, and shared decision-making), peer support specialists (peers) meet with Veterans virtually or in person once weekly, bi-weekly, and then monthly.
Patient engagement refers to patients actively taking steps to gather health information, making decisions about their health conditions and treatment options, and practicing positive healthcare behaviors, such as obtaining preventive care or exercising regularly. Growing evidence suggests that patient engagement can contribute to health equity by improving patient experience and population health.3 To facilitate minority Veterans’ activation and engagement in VA mental health services and work towards mental health equity, we used a three-pronged approach in PARTNER-MH that includes: peer support services, social determinants of health framework, and patient navigation care model.
We use the VHA peer support care model to facilitate Veterans’ empowerment, social support, and behavior change. Peers share a common identity with other Veterans and have first-hand experience with mental health and substance use treatment. This places peers in a unique position to offer support to Veterans.
We use a social determinants of health framework to guide our approach to patient engagement. As part of our program, PARTNER-MH peers conduct a screening for Veterans’ unmet social needs that might be preventing engagement in care. These include food and housing insecurity as well as social needs such as social isolation and legal support. Once they identify the Veterans’ needs, they then connect Veterans to resources in the VA, such as referral to a VA social worker or a community-based food pantry or shelter. The social needs screening also serves as a catalyst to engage Veterans in conversations about their social worlds and how their social environment and experiences may affect their health, and to identify Veterans who may need additional support before they reach a crisis point. We also use discussions about what matters to Veterans to help them invest in their mental health treatment and collaborate with their providers to achieve their goals.
To help Veterans make the most of their mental health services, PARTNER-MH peers use their assessment of social needs to navigate Veterans to VHA mental health or other social services by sharing information about available resources and empowering them to use these resources. The education and navigation component of PARTNER-MH has been crucial in our efforts to engage Veterans in mental health services. Due to stigma associated with mental illness, Veterans may not readily discuss their mental health concerns or seek advice from friends and family members. Consequently, many have never learned about the mental health services that may be available to them and are often left to navigate a complex mental healthcare system on their own. In PARTNER-MH, our goal is to offer the guidance and support needed by these Veterans.
To support Veterans in making the most of their mental health visits, we focus on improving their communication with their mental health providers and encourage their participation in shared decision-making processes. Our PARTNER-MH peers work with Veterans to prepare for their visits by setting goals for the visit, writing questions in advance, and providing a brief summary of their experience, symptoms, or observations of past treatments that worked or did not work. Veterans use worksheets and role playing to practice these activities and to prepare for interactions with providers.
In our ongoing pilot of PARTNER-MH, Veterans have shared how they have benefitted from the intervention. Below are selected quotes in which they discuss how PARTNER-MH helped them get the most of their mental health treatments and acquire the knowledge, skills, and support needed to improve their mental health and quality of life.
“[PARTNER-MH] helped me be more focused on what I think I need to work on, how to go about getting services – things that are going to augment the treatment that I’m already getting, and get the most benefit from everything.”
“I didn’t really have any clear-cut ideas about what I should be doing or anything to work towards as far as my mental health is concerned. So, it [PARTNER-MH] did help me organize my thoughts, and my concerns, and get a game plan.”
“What was the most helpful was understanding how I’m responsible for my own mental health and how to talk to a doctor, and it should be a partnership.”
“We don’t talk about mental health in the communities of people of color. You don’t go to anyone and talk about your problems. … this program not only shows people that they can work through their mental health issues, [but also] there are people that can help. [They] also give them the tools to facilitate it. I feel that this is great because this [mental health] is so taboo, especially amongst men.”
- Cook BL, et al. “Trends in Racial-Ethnic Disparities in Access to Mental Health Care, 2004-2012,” Psychiatric Services 2017; 68(1):9-16.
- Kondo K, et al. “Health Disparities in Veterans: A Map of the Evidence.” Medical Care 2017 Sep;55 Suppl 9 Suppl 2:S9-S15. doi: 10.1097/MLR.0000000000000756.
- Murali NS, Deao CE. “Patient Engagement,” Primary Care 2019; 46(4):539-47. doi: 10.1016/j.pop.2019.07.007.