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Summary of the RESPECT-Mil Evaluation

Core Content

The Re-Engineering Systems of Primary Care Treatment in the Military (RESPECT-Mil) is a collaborative care model designed to screen, assess, and treat posttraumatic stress disorder (PTSD) and depression among active duty service members in the Army's primary care settings. The program builds on the RESPECT-D model, which is a well-established system for depression care, and expands it to include PTSD. This report presents an independent evaluation of RESPECT-Mil's implementation, focusing on its reach, adoption, implementation fidelity, and sustainability.

The evaluation was conducted by the RAND Corporation at the request of the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE). It aimed to assess the effectiveness of DoD-sponsored programs promoting psychological health, with RESPECT-Mil as a key focus.

Main Objectives

The evaluation had three primary aims:

1. Assess the degree of RESPECT-Mil implementation in Army primary care settings.
2. Identify facilitators and barriers to RESPECT-Mil implementation from the perspectives of providers and the Implementation Team.
3. Examine the sustainability of RESPECT-Mil within the military health system.

These aims were mapped onto the RE-AIM framework, which evaluates the reach, efficacy, adoption, implementation, and maintenance of evidence-based interventions.

Key Findings

Aim 1: Implementation Extent

• Reach: From August 2011 to March 2012, 93% of primary care visits included PTSD and depression screening.
• Positive Screens: Of the screened visits, 13% resulted in a positive screen.
• Probable Diagnoses: 61% of positive screens led to a probable diagnosis of a mental health disorder, with 46% indicating PTSD, depression, or both, and 15% indicating other diagnoses.
• Referrals: 16% of positive screens resulted in referrals to RESPECT-Mil, behavioral health, or other psychosocial resources; 8% were declined; 5% were addressed in primary care "as usual"; 13% had no identified behavioral health need; and 55% were already in treatment.

Aim 2: Facilitators and Barriers

• Provider Perspectives: Primary care providers and care facilitators generally viewed RESPECT-Mil positively, seeing it as a way to improve mental health care access and coordination.
• Care Facilitators: They played a crucial role in supporting service members with treatment adherence and follow-up.
• Behavioral Health Champions: These specialists provided clinical and pharmacological guidance to primary care providers and facilitated referrals.
• Challenges: Despite positive impressions, care facilitators faced difficulties in maintaining the recommended number of follow-up contacts, and there was variability in referral and diagnosis rates across installations, suggesting potential differences in provider behavior or service member preferences.

Aim 3: Sustainability

• Stakeholder Insights: Discussions with key stakeholders highlighted the importance of sustaining RESPECT-Mil within the broader military health system.
• Program Expansion: RESPECT-Mil was implemented in 15 Army installations in 2007 and expanded to 37 installations by 2012.
• Transition to PCMH: The program's sustainability is tied to the military's transition to the Patient Centered Medical Home (PCMH) model, which emphasizes coordinated care and integrated services.

Recommendations

The report made several recommendations to improve the implementation and sustainability of RESPECT-Mil and similar collaborative care models:

• Primary Care Providers and Prepared Practice: Enhance training and support for primary care clinicians to improve their ability to identify and manage mental health needs.
• Respect-Mil Care Facilitators (RCF): Improve follow-up contact rates and ensure consistent support for service members.
• Behavioral Health Champions (BHC): Strengthen their role in providing clinical oversight and facilitating referrals.
• Monitoring: Implement more robust monitoring systems to track fidelity and outcomes effectively.

Methodology

• Data Sources: Monthly Screening and Referral Clinic Reports and the FIRST-STEPS electronic case-management tool were used to assess implementation.
• Stakeholder Discussions: Interviews with providers, care facilitators, and key stakeholders provided insights into challenges and opportunities.
• Sample Size: The study included data from 84 primary care clinics across 37 Army installations and involved 35 providers and 11 Implementation Team members.

Limitations and Conclusions

• Limitations: The study noted variability in referral and diagnosis rates across installations, and the reasons for these differences were not fully explored.
• Conclusion: RESPECT-Mil has successfully identified a significant number of service members with mental health needs, and while implementation is ongoing, there are opportunities to enhance fidelity, engagement, and sustainability. The findings may inform the development and implementation of similar models in other military and civilian health systems.

Appendices and References

• The report includes appendices with forms, screening tools, and discussion protocols used during the study.
• It references various studies and reports on mental health care integration and collaborative care models in both military and civilian settings.

Figures and Tables

• Figures illustrate the overview of RESPECT-Mil, screening and referral data, and flow diagrams of implementation and efficacy analyses.
• Tables provide detailed timelines, constructs and definitions, and rates of referrals, medication use, counseling, and self-management.