Veterans with serious mental illness and substance abuse (SMI/SA) present unique challenges to the Veterans Health Administration (VHA) in a time when mental health care (MHC) delivery is rapidly changing from an inpatient-based system to a greater focus on outpatient treatment. Current initiatives are designed to transform the VHA into a more efficient and patient-centered health care system. As outpatient treatment becomes the normative mode of services provision, an important goal for outpatient-based SMI/SA care is to involve the patients in the active management of their conditions. Patient-centered approaches are ideal for this purpose. They place the patient at the center of the health care process, increase access to care, emphasize patient direction of treatment, patient-provider collaboration and rapport, and recognize the importance of environmental supports in obtaining positive MHC outcomes. To date, research examining the application of PCC strategies to the provision of MHC have shown the effectiveness of this approach with a variety of patient samples, mental health issues, and treatment settings; however, much less research has directly studied the associations among PCC and various important factors, including empowerment, satisfaction, and compliance, and their combined relation to the MHC outcomes of individuals with SMI/SA. This study is among the first to examine these associations in veterans with SMI/SA who are receiving treatment in the VHA health care system.
1) To determine whether the provision of MHC that is accessible, patient-directed, and enhances patient-provider collaboration and rapport is related to positive mental health outcomes among veterans with SMI/SA; 2) to construct and validate the measures of patient-centered care; and 3) to compare primary providers selected using two procedures, one in which the patient is asked to identify the person they feel is their primary provider, and a second in which a standard protocol based on amount of patient-provider interaction is used to identify each patient’s primary provider.
A cross-sectional design will be used to examine the association between patient-centered MHC, empowerment, satisfaction, compliance and positive MHC outcomes, and to construct and validate the measures of patient-centered care. Data will be collected from patients, treatment providers, and medical records at the Ann Arbor, Battle Creek, Detroit, and Brecksville Veterans Administration Medical Centers. Patients and their primary MHC provider will be interviewed once. Concurrent treatment provision and patient mental health and substance abuse outcomes will be assessed. A total of 560 veterans and 50-70 providers will be recruited.
Four existing measures of patient/provider alliance were tested but failed to demonstrate structural validity. Analyses used items from these measures to identify a 22-item measure of alliance that demonstrated construct validity with data from this sample of patients with schizophrenia. Also, analyses examined the association between patient-centered care, elements of the process of care, and mental health outcomes. Generally, higher scores on the measures of patient-centered mental healthcare predicted better mental health outcomes. In particular, access to care and social support had direct associations with mental health outcomes. The role of alliance between the patient and provider was more closely related to the process of care, indicating the importance of the patient/provider relationship relative to maintaining treatment.
The results of this research will provide important information regarding the effectiveness of patient-centered approaches to the treatment of veterans with SMI with and without substance abuse that will inform policy and treatment protocol development.
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