Soldier Attitudes Toward Behavioral Health Profiles in the US Army.

Behavioral health (BH) readiness is a critical component of U.S. Army personnel readiness. Medical providers issue BH profiles in order to communicate BH-related duty limitations to the commander and reflect BH force readiness on both micro/macro-levels. A recent report indicates BH profile underutilization may be significantly elevating U.S. Army safety and mission-failure risks, and a study of BH provider decision-making suggests some providers may be hesitant to use profiles due to concerns that soldiers' attitudes toward BH profiles may negatively impact treatment utilization. This potential link, however, has not been empirically examined. This study addresses this gap by assessing soldiers' attitudes towards BH profiles to better understand how BH profiles may impact treatment utilization and explore for any BH profile-related stigma effect. Approved by the Walter Reed Army Institute of Research (WRAIR) Institutional Review Board as part of the Land Combat Study II, the survey specific to this study included eight WRAIR-developed items assessing soldier attitudes toward BH profiles. Soldiers (N = 1,043) from two active duty U.S. Army brigades completed cross-sectional, anonymous surveys in 2017-2018. Soldier self-reported BH care utilization was assessed and used to create sub-groups for analysis. A majority of soldiers indicated that being placed on a BH profile would make them as or more likely to seek (71%) and no more or less likely to drop out (84%) of BH care. Among soldiers who had received BH care, BH profiles were associated with more favorable treatment seeking attitudes among those inclined to access conventional BH services and less favorable treatment seeking and maintenance attitudes among those inclined to access BH services from sources incapable of issuing profiles. Negative attitudes towards BH profiles were significantly more prevalent when compared to physical injury profiles, except in the group who had received BH care from a source incapable of issuing a profile. No significant proportional differences were observed among soldiers toward the rationale for BH profiles. Almost all soldiers (95% or greater) preferred their BH condition not come to the commander's attention during pre-deployment screening (SRP), choosing either BH profile or crisis options instead. Results suggest soldiers who would be less likely to seek or more likely to drop out of BH care due to a BH profile may be those that are less likely to access conventional BH services in the first place. This may provide some preliminary reassurance to conventional providers that increased BH profiling practices may not be inversely proportional to the amount of BH care delivered and may encourage treatment-seeking behaviors among the population they serve. Soldiers seeking BH care from sources incapable of issuing a profile may be sensitive to a potential BH profile-related stigma effect (possibly more global profile-related effect in this group), which should be factored into policy outreach efforts. A BH profile represents a more palatable BH duty limitation disclosure option for many soldiers, and supports the merits of a disclosure process that is earlier than SRP for promoting risk mitigation and more honest appraisals of BH mission-readiness levels.

Curley JM ，McDonald JL ，Nugent KL ，Clarke-Walper KM ，Penix EA ，Riviere LA ，Kim PY ，Wilk JE ... -  《-》

Behavioral Health Provider Attitudes Toward Behavioral Health Profiles in the U.S. Army.

U.S. Army healthcare providers' use of profiles to document and communicate behavioral health (BH) condition limitations to commanders is vital to understanding both the individual soldier's BH readiness for missions and, as an aggregate, the unit's overall BH readiness status. Quantitative work exploring the link between soldier attitudes toward BH profiles and treatment utilization found that profiles may actually promote increases in treatment-seeking behavior in those receiving conventional BH services. BH provider attitudes on the subject, however, have not been quantitatively explored. Using data from the recently described Behavioral Health Readiness and Decision-Making Instrument (B-REDI) study, the current inquiry addresses this by examining BH providers' pre-/post-B-REDI attitudes toward BH profiles, including therapeutic alliance, to better understand how BH profiles may impact BH treatment. This study was approved by the WRAIR Institutional Review Board and is part of the larger B-REDI study. BH providers (n = 307) across five installations supporting active duty U.S. Army Divisions completed surveys longitudinally across three time points from September 2018 to March 2019. The survey specific to this study included five items, developed by WRAIR, assessing BH provider attitudes toward BH profiles. Of the providers who completed the survey, 250 (81%) consented to participate in the study and 149 (60%) completed the 3-month follow-up survey. Over 80% of BH providers expressed agreement with each of three items assessing rationale for issuing BH profiles in both the pre- and post B-REDI period. Specifically, most providers agreed that profiles facilitate commander support to the soldier, afford soldiers resources for recovery, and give commanders increased understanding of soldier health for mission planning. Twenty-six percent of BH providers agreed, 46% were neutral, and 28% disagreed on whether profile impact on the soldier was positive or not in the pre-B-REDI period, but there was a significant positive trend relative to baseline in the post B-REDI period. The vast majority of providers (≥94%) did not endorse agreement that BH profiles negatively impact therapeutic alliance in either the pre- or post-B-REDI period. Assuming that therapeutic alliance and perceptions of BH profile impact on soldiers are useful proxy measures of how treatment utilization may be affected by profiling, this inquiry fails to establish any meaningful negative association between them. This may provide some additional reassurance to BH providers and policymakers that efforts to improve readiness decision-making, such as B-REDI, and increased profiling in conventional military BH settings may not negatively impact treatment utilization rates.

Curley JM ，Clarke-Walper KM ，Nugent KL ，Wilk JE ... -  《-》

Minor Behavioral Health Readiness and Profiling Barriers in the U.S. Army.

Medical readiness for deployment is arguably the most important component of personnel readiness in the U.S. Army. Administrative documents called profiles provide individualized medical recommendations to the commander regarding how to best provide for a soldier's health and welfare, and contribute to an aggregated enumeration of a unit's overall readiness to deploy. Profiles that convey behavioral health (BH) limitations thus reflect what can be called the "behavioral health readiness" of the force. In the Army, BH profiles are further broken into major (more severe BH conditions) and minor (less severe) categories. Recent reporting indicates that current profiling (both major and minor) substantially underestimates BH readiness, presenting a significant safety and personnel issue for the Army. Currently, little is understood regarding barriers to profiling. The intent of this paper is to establish a basis for understanding these barriers by examining provider perceptions on the issue. While the results may have broad applicability in determining BH profiling barriers in general, minor BH improvement efforts stand to benefit the most due to more reliance on provider judgment and less on mandatory guidelines. Selected themes and provider quotes regarding barriers to BH profiling from a qualitative study, "Return to Duty Practices of Behavioral Healthcare Providers in Garrison," are presented. Fourteen semi-structured interviews and three focus groups were conducted with a diverse convenience sample of Army BH providers in October 2015, resulting in input from 29 practitioners. Four general profiling barrier categories were identified and include provider proficiency level, environmental factors, stigma concern, and clinical time constraints. Suboptimal BH profiling rates suggest that a preponderance of factors currently tip the scale of BH profiling in a lopsided fashion that comes at the cost of soldier safety and increased risk of mission failure. Relief from one or more of the identified profiling barriers would likely be necessary to tip the scale of clinical judgment in favor of increased profiling, and may be more beneficial for improving minor BH profiling deficits in particular. Quantitative exploration of provider and soldier attitudes on this subject is worthy of further pursuit and would shed light on which of the identified barriers are most crucial to reducing BH profile deficits.

Curley JM ，Crouch C ，Wilk JE 《-》

Predictors of Temporary Profile Days Among U.S. Army Active Duty Soldiers.

More than 40,000 soldiers cannot deploy every year, which undermines readiness. The medical readiness of soldiers is a critical component of the overall operational readiness of the U.S. Army. Acute musculoskeletal injuries (MSIs) are the greatest threat to medical readiness. Medical providers place soldiers on temporary profiles to facilitate treatment and recovery of acute MSIs. Poorly managed temporary profiles negatively impact a soldier's work attendance, resulting in the loss or limitation of over 25 million workdays annually. Upgrading the electronic profile system and implementing the Army Medical Home has led to improvements in managing temporary profiles over the last decade. The Army Medical Home encompasses care delivery platforms, including the Patient-Centered Medical Home (PCMH) and Soldier-Centered Medical Home (SCMH). The structure of U.S. Army PCMHs and SCMHs differ in ways that may affect care processes and patient outcomes. Temporary profile management is an important soldier health outcome that has not been studied in relation to the U.S. Army's PCMH and SCMH structures or care processes. Access to care, continuity, and communication are three care processes that have been described as essential factors in reducing lost workdays and functional limitations in workers after an acute injury. Understanding the impact of the medical home on temporary profile days is vital to medical readiness. This study aimed to (1) compare temporary profile days between the U.S. Army PCMHs and SCMHs and (2) determine the influence of medical home structures and care processes on temporary profile days among active duty U.S. Army soldiers receiving care for MSIs. This was a retrospective, cross-sectional, and correlational study guided by Donabedian's conceptual framework. We used secondary data from the Military Data Repository collected in 2018. The sample included 27,214 temporary profile records of active duty U.S. Army soldiers and 266 U.S. Army PCMH and SCMH teams. We evaluated bivariate and multivariate associations between outcomes and predictors using general and generalized linear mixed regression models. The U.S. Army Medical Department Center and School Institutional Review Board approved this study. Total temporary profile days ranged from 1 to 357, with a mean of 37 days (95% CI [36.2, 37.0]). There was a significant difference in mean temporary profile days between PCMHs (43) and SCMHs (35) (P < 0.001). Soldiers in PCMHs were more likely to have temporary profiles over 90 days (OR = 1.54, 95% CI [1.17, 2.03]). Soldiers in the heavy physical demand category had fewer temporary profile days (P < 0.001) than those in the moderate physical demand category. Age, sex, rank level, physical demand category, profile severity, medical home type, the "explain things" communication subscale, and primary care manager continuity were significant predictors of temporary profile days. Excessive temporary profile days threaten medical readiness and overall soldier health. Aspects of the medical home structure and care processes were predictors of temporary profile days for musculoskeletal conditions. This work supports continued efforts to improve MSI-related outcomes among soldiers. Knowledge gained from this study can guide future research questions and help the U.S. Army better meet soldier needs.

Taylor-Clark TM ，Loan LA ，Swiger PA ，Hearld LR ，Li P ，Patrician PA ... -  《-》

Results of the Behavioral Health Readiness Evaluation and Decision-Making Instrument Study.

Recent reports have demonstrated behavioral health (BH) system and individual provider challenges to BH readiness success. These pose a risk to winning on the battlefield and present a significant safety issue for the Army. One of the most promising areas for achieving better BH readiness results lies in improving readiness decision-making support for BH providers. The Walter Reed Army Institute of Research (WRAIR) has taken the lead in addressing this challenge by developing and empirically testing such tools. The results of the Behavioral Health Readiness Evaluation and Decision-Making Instrument (B-REDI) field study are herein described. The B-REDI study received WRAIR Institutional Review Board approval, and BH providers across five U.S. Army Forces Command installations completed surveys from September 2018 to March 2019. The B-REDI tools/training were disseminated to 307 providers through random clinic assignments. Of these, 250 (81%) providers consented to participate and 149 (60%) completed both initial and 3-month follow-up surveys. Survey items included a wide range of satisfaction, utilization, and proficiency-level outcome measures. Analyses included examinations of descriptive statistics, McNemar's tests pre-/post-B-REDI exposure, Z-tests with subgroup populations, and chi-square tests with demographic comparisons. The B-REDI resulted in broad, statistically significant improvements across the measured range of provider proficiency-level outcomes. Net gains in each domain ranged from 16.5% to 22.9% for knowledge/awareness (P = .000), from 11.1% to 15.8% for personal confidence (P = .001-.000), and from 6.2% to 15.1% for decision-making/documentation (P = .035-.002) 3 months following B-REDI initiation, and only one (knowledge) failed to maintain a statistically significant improvement in all of its subcategories. The B-REDI also received high favorability ratings (79%-97% positive) across a wide array of end-user satisfaction measures. The B-REDI directly addresses several critical Army BH readiness challenges by providing tangible decision-making support solutions for BH providers. Providers reported high degrees of end-user B-REDI satisfaction and significant improvements in all measured provider proficiency-level domains. By effectively addressing the readiness decision-making challenges Army BH providers encounter, B-REDI provides the Army BH health care system with a successful blueprint to set the conditions necessary for providers to make more accurate and timely readiness determinations. This may ultimately reduce safety and mission failure risks enterprise-wide, and policymakers should consider formalizing and integrating the B-REDI model into current Army BH practice.

Curley JM ，Nugent KL ，Clarke-Walper KM ，Penix EA ，Macdonald JB ，McDonald JL ，Wilk JE ... -  《-》