1. The American Legion Survey of Patient Healthcare Experiences Jeff Greenberg, Ph.D. Data Recognition Corporation (DRC) Institute for the Advancement of Military and Veteran Healthcare

2. Introduction Data Recognition Corporation (DRC) is a large, woman- owned business which focuses on survey and healthcare research, educational testing, and document production. Jeff Greenberg, Ph.D., Senior Director of Research and Director of the DRC Institute for the Advancement of Military and Veteran Healthcare, is a clinical psychologist who completed his training in the Boston VA system, the National Center for PTSD, Harvard University Medical School, and Boston University Medical School. 2

3. Introduction Dr. Greenberg is a researcher whose focus has been on Military and Veteran mental healthcare, posttraumatic stress disorder (PTSD), Traumatic Brain Injury (TBI), complex co- occurring disorders, depression, anxiety, substance abuse, suicide, and healthcare quality and fidelity. Dr. Greenberg has published on PTSD and TBI and depression amongst Military and Veteran populations. He has served as a subject matter expert for Navy Medicine and DoD Medicine, where he has focused and advised senior leaders on mental health, clinical care, training, and policy. 3

4. Overview of the Survey Collaboration between the American Legion and Data Recognition Corporation (DRC) Exploratory research regarding Type of care patients report receiving for PTSD and TBI Patients’ perceptions of effectiveness of treatment Patients’ reports of access to a range of treatment options, including Complementary and Alternative Medicine (CAM) Quick turnaround study First step in long-range program to encourage treatment options and fidelity to treatment protocols 4

5. Need for the Research Limited information on types of treatment Veterans receive Limited research documenting fidelity to treatment models Limited knowledge about use of CAM Limited evidence of effectiveness of CAM 5

6. Purpose of the Survey To obtain a snapshot of what treatments Veterans are receiving and how they perceive them; and To obtain information to help guide more rigorous, in-depth research to support the establishment of treatment models and an eventual system of fidelity modeling. 6

7. Methodology Web survey (opt-in) Content: demographics, treatment received, access to CAM, perceived change in symptoms and reasons for treatment termination Press releases and social marketing to recruit respondents 30-day field period Analysis: frequencies and other descriptive statistics 7

8. Key Findings Respondents reported common symptoms: Elevated Anger, Pain, Sleep Problems, Anxiety, Depression and Irritability. For PTSD, individuals are receiving multiple therapy types with fewer than a quarter of respondents receiving treatment in conformity to DoD/VA evidence-based practice models of care.

9. Key Findings (continued) For TBI, individuals are receiving a wide array of treatment types. Medication appears to be the front line treatment reported by respondents. A sizable proportion of respondents reported prescriptions of up to 10 medications for PTSD/TBI across their treatment experience.

10. Key Findings (continued) Broadly, respondents reported limited change following treatment for PTSD and TBI: Following therapy, the majority of respondents reported no change or worsening of symptoms; Following medication, a slight majority reported no change or worsening of symptoms; and In general, approximately half of all respondents reported no change or minimal improvement in symptoms.

11. Key Findings (continued) Nearly half of all respondents had discussed some type of CAM-based treatment with their providers. Respondents reported numerous types of CAM treatments, especially Meditation, Relaxation, and Stress Reduction.

12. Key Findings (continued) 30 percent of respondents indicated they had terminated treatment prior to completion. An array of rationales for treatment termination were reported. In declining order, the rationales cited were: Lack of Improvement, Side Effects, Dissatisfied with Provider, Solve Problems on My Own, Time Burden or Distance to Treatment, and Stigma

13. Survey Response 14,734 views overall, with nearly 480 per day 3,209 starts 3,116 completions (nearly 22 percent of viewers became completers) 17-minute average completion time 98 percent of completers in the United States 74 percent used laptop,16 used percent smart phone, 10 percent used tablet 97 percent Veteran, 3 percent spouse or other

14. Respondent Characteristics

16. Service-Connected Disability

18. Community

19. Location of Care Received

20. Care Received at a Private Facility

21. Frequency of Care for PTSD and/or TBI

22. Provider Type

23. Symptom Architecture and Severity

25. Symptom Ratings

26. Level of Perceived Improvement 10 point Likert scale: 1= I got worse, 5 = No change, and 10 = I got better

27. Symptom Change Following Therapies N = 2,309 (41% report improvement and 59% report no change or worsened)

28. Symptom Change Following Medication N = 2,212 (48% report improvement and 52% report no change or worsened)

29. PTSD Treatment Type

30. TBI Treatment Type

31. Prescriptions for PTSD and TBI

32. Discussed CAM Treatments with Provider

33. CAM Treatment Type for PTSD

34. CAM Treatment Type for TBI

35. Terminated Treatment Prior to Completion

36. Reason Given for Terminating Treatment

37. Recommendations To establish a knowledge base on the care of Veterans with PTSD and TBI, a multi-step program of research is needed over a period of years: Establishment of baseline date, building on information gathered here, but probing more deeply and capturing data suitable for correlations and statistical modeling; Surveys to track progress over time; Funding of demonstration programs to test effectiveness of alternative treatments and to generate best practices and models of care as well as update practice guidelines with new findings; and Establishment of system for monitoring and evaluating fidelity of care.

38. Recommendations (continued) Simultaneously, a second track of research and development is needed to ensure the availability of a trained work force prepared to treat PTSD and TBI. That will entail steps parallel to the development of models of care: Ancillary research on professional development related to treatment of PTSD and TBI; Development of professional standards and collaboration with schools to build curricula that support standards of care; Establishment of a National Advisory Group to plan the multi- step research program; and Regular tracking surveys. 38

39. Next Steps Establish a National Advisory Group to plan the multi-step research program. Refine survey design in preparation for collection of baseline data and tracking surveys. 39

40. Timeline FY 2015: Establish National Advisory Group. FY 2016: Begin Research: Conduct Research to Establish Baseline on Treatment of PTSD and TBI; and Conduct Research on Professional Development. FY 2017: Announce 3-Year Demonstration Program; and Establish Work Group to Collaborate with Professional Schools. FY 2018: First Tracking Survey. 40

41. Timeline (continued) FY 2020: Second Tracking Survey. FY 2021: Establish Practice Guidelines/Models of Care. FY 2022: Establish Monitoring and Evaluation System to Measure Fidelity to Models of Care, Examining both Treatment Provided and Professional Development of Health Care Providers. FY 2022 and Beyond: Continue Bi-annual Tracking Surveys/Integrate with Monitoring. Process for Ongoing Integration of Tested Innovations. 41

42. Thank You 42

43. Backup Slides

44. Anger

45. Pain

46. Sleep Problems

47. Anxiety

48. Depression

49. Irritability

50. Tour of Duty

51. Telehealth

52. Travel Time

53. Treatment Mode