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Implementation of Tailored Collaborative Care for Women Veterans

Almost half (48%) of women Veterans have at least one mental health (MH) condition, with depression being the most common among women Veteran VA healthcare users (24% in FY14), followed by PTSD (14%) and anxiety (8%). Depression and anxiety are substantially more prevalent among women Veterans than men. Women Veterans also are more likely than men to have comorbid mental health conditions, and they are more likely to have experienced military sexual trauma (MST) and intimate partner violence (IPV).

Women Veterans’ distinctive mental health needs challenge VA to appropriately connect women to MH providers who understand their unique vulnerabilities and strengths, and to support their navigation of often fragmented MH care options offered across VA primary care (PC) and MH settings. Depending on the VA site, women may have access to integrated MH care in general PC clinics, in a separate portion of a general PC clinic set aside for women, or in stand-alone women-only clinics, with variable access to women-only care options and same-gender providers when preferred. Collaborative care models have a strong evidence base for enhancing patient engagement and retention in PC-based MH care for depression, and the VA has extended application of collaborative care to many other mild to moderate conditions, including anxiety disorders and alcohol misuse.

The Enhancing Mental and Physical Health of Women through Engagement and Retention (EMPOWER) QUERI program’s “Collaborative Care for Women Veterans” (CCWV) study is designed to enhance primary care-mental health integration for women Veterans. The specific aims of this study are to:

• Blend and tailor existing primary care-based collaborative care models with a PC-friendly evidence-based, computer-assisted cognitive behavioral treatment (CBT) platform for women Veterans with anxiety, PTSD and/or depression;
• Implement the tailored CCWV in four Women’s Health Practice-Based Research Network sites; and
• Evaluate CCWV implementation using a modified stepped-wedge design, and conduct an implementation-focused evaluation to further refine CCWV in order to facilitate future spread.

Secondary study aims focus on factors that empower Women Veterans to engage in and benefit from collaborative care. Specifically, EMPOWER QUERI investigators are evaluating: 1) effects of patient activation and engagement with care on retention in and experiences of CCWV, and 2) changes in mental health symptoms, patient activation, health-related quality of life, and care experiences as a function of participation in CCWV.

Addressing the treatment needs of women with depression and anxiety is a key strategic priority for EMPOWER QUERI’s operations partners in VA Women’s Health Services, Office of Mental Health & Suicide Prevention, and Patient Care Services. These policy partners have specifically identified a need for novel, gender-sensitive primary-care based treatment models for women with these relatively common and understudied mental health problems. They will use these findings to inform policy and practice in MH care for women Veterans. Further, it is expected that participating sites will find the collaborative care training and implementation useful additions to their arsenal of services for women Veterans in need of MH care in primary care settings. Should this implementation be successful, there will be many opportunities for scale up and spread of the innovative care model.