Helping Soldiers Heal: How the US Army Created a Learning Mental Health Care System

By Jayakanth Srinivasan and Christopher Ivany

Helping Soldiers Heal tells the story of the US Army's transformation from a disparate collection of poorly standardized, largely disconnected clinics into one of the nation's leading mental health care systems. It is a step-by-step guidebook for military and civilian health care systems alike. Jayakanth Srinivasan and Christopher Ivany provide a unique insider-outsider perspective as key participants in the process, sharing how they confronted the challenges firsthand and helped craft and guide the unfolding change.

The Army's system was being overwhelmed with mental health problems among soldiers and their family members, impeding combat readiness. The key to the transformation was to apply the tenets of "learning" health care systems. Building a learning health care system is hard; building a learning mental health care system is even harder. As Helping Soldiers Heal recounts, the Army overcame the barriers to success, and its experience is full of lessons for any health care system seeking to transform.

• Language: English
• Publisher: ILR Press
• Release date: Dec 15, 2021
• ISBN: 9781501760518

Jayakanth Srinivasan

JAYAKANTH SRINIVASAN is a Research Scientist at MIT's Lean Advancement Initiative.

Book preview

HELPING SOLDIERS HEAL

How the US Army Created a Learning Mental Health Care System

Jayakanth Srinivasan

Christopher Ivany

ILR PRESS

AN IMPRINT OF CORNELL UNIVERSITY PRESS ITHACA AND LONDON

Contents

Acknowledgments

Introduction

1. Organized Anarchy in Army Mental Health Care

2. A Brief and Incomplete History of US Army Mental Health Care

3. Organizing a Learning Health Care System

4. Five Levels of Learning

5. Building Analytics Capabilities to Support Decision Making

6. Managing Performance in a Learning Behavioral Health System

7. Creating Dissemination and Implementation Capabilities

8. Leading a Learning System

9. Translating Learning from the Army

10. The Path Ahead

Notes

Bibliography

Index

Acknowledgments

This book tells the story of the Army’s transformation into a learning mental health care system, a journey possible only because of the tireless dedication of behavioral health clinicians and the courage of soldiers and their families. In the end, it comes down to clinicians and patients working together to solve problems.

We would like to thank General Peter Chiarelli (retired) and General James C. McConville, who provided support and guidance throughout the transformation. Lieutenant General Patricia Horoho (retired), the 43rd Army surgeon general, set the vision of the Army’s operating company model and empowered the Army team to translate her vision into action. Lieutenant General Howard Bromberg (retired) and Lieutenant General Joseph Anderson (retired) pushed us to incorporate the operational perspective and to remember the true north of improving the lives of soldiers and their families.

We would like to thank Dr. Jonathan Woodson, who as the assistant secretary of defense for health affairs drove us to understand truly the experience of care and to use data to support our observations. He was instrumental in creating the Department of Defense’s policy architecture for measurement-based care. Dr. Michael Dineen pushed us to think big, see the truth, and use policy to create change.

We want to thank the Army’s Behavioral Health leadership team. Colonel Millard Brown, the principal force behind the Army’s transition to measurement-based care, spent countless hours educating and arguing with us. Colonel Samuel Preston and Colonel Dennis Sarmiento are not only incredible clinicians, but also great soldiers and teachers; they continue to improve the Army’s behavioral health system. Command Sergeant Major Ron Dean (retired) taught us how real change happens in the Army, unafraid of ruffling a few feathers along the way. Drs. Kay Beaulieu, Doris Lancaster, and Kelly Moss formed the first Embedded Behavioral Health leadership team at Fort Carson and, by doing so, launched it on an unprecedented scale. Colonel Fred Reeves (retired) saw the impact of behavioral health care transformation on other parts of the Army’s resilience framework and pushed to expand the learning across the Army. Among many other accomplishments, Colonel David Orman (retired) and Lieutenant Colonel Ed Brusher (retired) had the vision to build a leadership team well before anyone else even saw the need for one. Colonel Charles Hoge (retired) was the unflappable voice of the scientific literature. He kept all the changes grounded in what could be proven to help the soldier. Thank you all.

JK would like to thank several people specifically. The MIT Army team supported the research. Prof. John Carroll, Prof. Debbie Nightingale, and Dr. Tenley Albright were sounding boards that helped me rethink what practice-based research should be. Andrea Ippolito, John Hess, Lieutenant Colonel Shane Scott, Dr. Dhaval Adojha, Dmitry Lyan, Dr. Armen Mkrtychyan, and Prof. Julia DiBenigno traveled all over the world and learned the Army with me. I also thank my family for the love and support you have always given me. My parents Shri K. Srinivasan and Smt. Bhuvaneswari Srinivasan set the foundation for doing work that matters. My children Veylan and Kartik were born during this project and grew up hearing Army stories. My better half Neira—you are the reason I could be in the field while you kept everything together on the homefront. You and the kids make me a better person every day.

Chris would like to specifically thank several people. Colonel Peyton Hurt (retired) encouraged me to figure out what I really believed in. My parents Major General Robert Ivany (retired) and Marianne Ivany showed me how selfless leaders take care of soldiers and their families. My siblings Mark, Julianne, and Brian (and now Joe and Debra), selfless leaders in their own right, inspire me every day. My children Rachel, Nick, and Ethan have supported me throughout my career and bring fun to every endeavor. My wife Buffy has been my loving and unwavering partner through it all. The best physician in the family, she is—more importantly—the center of our family.

Finally, we would like to thank Scott Cooper, our editor, who demonstrated extraordinary patience, creativity, and skill, and managed to blend our voices to tell one story.

INTRODUCTION

On September 29, 2010, Admiral Mike Mullen, the chairman of the Joint Chiefs of Staff, the highest-ranking military advisor to the US president, convened a meeting with senior leaders from each of the armed services in the tank—his conference room at the Pentagon. In the preceding months, Mullen had grown increasingly concerned about the mental health of those serving in the armed forces and wanted a fresh look at the problem. He had heard about intriguing work Dr. Tenley Albright, the director of the Massachusetts Institute of Technology (MIT) Collaborative Initiatives, had done to examine how systems of care worked for those who had suffered strokes, and he wanted to take a similar approach to military mental health care.¹ MIT’s Lean Advancement Initiative—where one of the present authors, Dr. Jayakanth Srinivasan (JK), was then a lead researcher—had done extensive research on enterprise transformation, and they signed on with Dr. Albright to analyze the military’s system. Admiral Mullen introduced the MIT team and kicked off the project.

The team spent the first six months of the project researching the publicly available reports, policies, and academic papers related to military mental health care and talking to people with stars on their shoulders—generals and admirals—and senior civil servants in and around the Pentagon. Those conversations surfaced several recurrent themes: military hospitals could not support the new level of demand for mental health care services; there were not enough clinicians to meet the needs of service members and their families; existing data systems did not provide meaningful information about mental health care; clinics were organized around providers, not patients; and the military had no way to assess the actual quality of care it was providing. These insights also strongly mirrored public reports such as that of the Department of Defense (DoD) Task Force on Mental Health and the RAND report on quality of mental health care.² The military leadership seemed to know the problems, but they remained unsolved. The project team wondered why.

In parallel, project members had hoped to visit military treatment facilities, which provided much of the mental health care. Admiral Mullen had written a letter of introduction asking the Army, Navy, Air Force, and Marine Corps to support the researchers, which the team—following the required protocol—had sent along to the appropriate offices. But it was not leading to responses and opportunities to visit.

The following May, Dr. Jonathan Woodson, the assistant secretary of defense for health affairs and senior leader in charge of the military health system, asked for an update on the project. The MIT team delivered to him a detailed presentation of the findings from the literature review and the interviews with senior leaders. Woodson flipped through the slides. We know all these themes! What is actually going on in military treatment facilities? No one on the team had yet visited a single military installation. Hearing that, Woodson thanked the team for their time and walked out of the room. It was fifteen minutes into a meeting scheduled for an hour.

Woodson’s rebuke was stunning. The brief had simply reiterated that the military health system was broken, but offered no new insights as to the reasons why, or any recommendations to fix it. The team had done what numerous consultants and experts had done before—offered a superficial analysis to senior DoD leaders that did not reflect the lived experience of care providers, leaders, or health care users. To truly help the military health system change, the team needed to understand what was actually happening in military treatment facilities. That would require an entirely new approach—one that examined behavioral health care in the military from the inside out and from the bottom up.

In 2011, the Army, Navy, and Air Force operated distinct health care systems (the Marines receive medical support from the Navy), each with a different approach to organizing and delivering mental health care, so the MIT team partitioned the study by service branch and JK took on the Army portion of the study. The Army has the largest burden of psychological health injuries among all the service branches.

JK set out to identify the root causes underlying the inability of individual Army hospitals to deliver the needed mental health care and work with the Army to address them. Only talking to the people involved in mental health care could do the former; the latter would require establishing collaborative working relationships with the people who were trying to change it for the better.

At the kickoff meeting in the tank months earlier, General Peter Chiarelli, the Army vice chief of staff, had promised to intervene if MIT researchers faced any hurdles when arranging visits to Army installations. He had told JK to reach out directly if there were problems gaining access. Having followed all the required protocols to get access to sites, and not making any progress, JK emailed General Chiarelli and asked for help. Soon after, JK received a call from Dr. Kathleen Quinkert, General Chiarelli’s special assistant.

The Vice asked me to work with you to get the visits set up, she said. Where do you want to go? When can you leave? Who do you need to talk to?

JK requested access to at least six Army posts that deployed large numbers of soldiers to Iraq and Afghanistan.³ The MIT team wanted to determine whether there was variation in how medical treatment facilities provided mental health services to soldiers and their families. With Dr. Quinkert’s intervention, JK and four of his graduate students visited Army installations across the country, from Walter Reed Army Medical Center in Washington, D.C., to Tripler Army Medical Center in Hawaii, between July and September 2011. (It came as little surprise when the Hawaii facility was the only place where all the graduate students volunteered to collect data.)

In each visit, the MIT researchers traced the steps soldiers and their families actually took to access mental health care services. They spoke with clinicians, case managers, front desk staff, commanders, chaplains, personnel at other support agencies (such as the substance abuse and suicide prevention offices), military treatment facility leaders, and other senior leaders—including generals and their staffs. During each seven-day visit, the MIT team spoke with more than one hundred people.

From the visits, it became clear that each Army hospital delivered different care in different ways. One hospital’s primary approach was group therapy; another relied on individual appointments. One hospital emphasized alternative approaches such as meditation and yoga, while another offered only traditional psychotherapies with relatively strong links to evidence of their effectiveness in recent trials. By talking to and observing people on each post, the MIT researchers began to understand the rationale for these differences, which were sometimes based on the preferences of the providers in leadership positions, opinions of the line commanders assigned there at the time, and even advice from nonexperts. In other places, the MIT team discovered clinical programs based on innovative ideas and designed around real problems facing soldiers with behavioral health problems. Those solutions tended to be more effective and were probably worthy of being implemented across the Army, but no one else—especially leaders back in Washington—seemed to know much about them.

What was very clear was that the Army lacked an Army-wide system of care that soldiers and their families could count on to deliver, no matter where they might find themselves assigned, let alone a health care system that continually learned and improved its performance. It was an organized anarchy, the result of reactive evolution as each hospital tried independently to address the needs of its local population.⁴ Unfortunately, the team frequently encountered disappointed patients, unhappy commanders, and frustrated clinicians.

Fort Carson, Colorado, was one of those first six locations to which members of the MIT team traveled. There, JK met psychiatrist Chris Ivany (the other author of this book), then an Army major and chief of the Department of Behavioral Health at Evans Army Community Hospital, Fort Carson’s medical facility. Two days earlier, Chris had received an unusual call from the office of the vice chief of staff of the Army, the four-star general supporting JK’s team. Majors rarely get direct calls from offices so high up in the chain of command. Dr. Quinkert let him know that a small team from MIT would be visiting at the direction of General Chiarelli. Chris could not imagine what MIT had to do with the Army or behavioral health care, but he quickly rearranged his calendar to accommodate the request of the Army’s second-most powerful officer.

Chris and his team at Fort Carson spent several days showing their visitors from Cambridge how mental health care was delivered at the Mountain Post. The Fort Carson team highlighted Embedded Behavioral Health (EBH), a model of care they had recently developed to provide outpatient mental health care to soldiers within walking distance of their workplaces.

Observing EBH at Fort Carson was a revelation to the MIT team. They saw the power of the working relationships that had developed between the EBH providers and the command teams. They witnessed a mental health care team in Iraq conducting a conference call with the EBH team at Fort Carson to discuss the care they were providing to a soldier who would soon be returning home and into the EBH team’s care. The close coordination between providers employed by the hospital and those working as part of combat units in Iraq, even while the unit was deployed, was starkly different from what they had observed at other Army hospitals. The quantitative data analyzed by the MIT team reinforced the observation that Fort Carson was different from other locations. Patients got appointments more frequently, commanders observed that their soldiers were getting the care that they needed, and fewer needed to be placed in inpatient psychiatric wards. In a few short days, it became clear that Embedded Behavioral Health was a genuine improvement and would similarly benefit soldiers on other Army posts, but no system existed to take a best practice from one place and replicate it elsewhere.

Although it had not yet been put into practice, Army medical leaders were taking preliminary steps to create a system of mental health care built around best practices the MIT team envisioned. On March 1, 2011, Lieutenant General Eric Schoomaker, the Army surgeon general at the time, testified to the Senate Appropriations Committee about the Army’s new Comprehensive Behavioral Health System of Care (CBHSOC), which was its campaign to create an integrated, coordinated, and synchronized behavioral health service delivery system.⁵

After the first round of site visits, JK and his graduate students consolidated their initial findings and the team captured stories of the challenges soldiers and families faced in navigating a constantly changing system of care. The MIT team also reported the differences between locations in terms of volume and intensity of mental health care use. One location continued to stand out: Fort Carson. It was the only place where leaders, soldiers, and others expressed to the team confidence in their mental health care system.

General Chiarelli was set to retire in early 2012, and he asked for an update on where we were on the project before that. On January 17, 2012, the MIT team reported to him our findings: mental health care on a lot of Army posts had been reduced to doing psychiatric triage rather than actually improving soldier health. When he asked whether things were working well anywhere, the team pointed to Fort Carson and the positive impact Embedded Behavioral Health was having. He asked us to share our findings with a larger group a few days later.

The next Saturday, General Chiarelli gathered several senior leaders at the Pentagon. The MIT team wasn’t aware that he had also arranged for the meeting to include a videoconference with the commanding general on every Army post across the world. After the MIT team shared its findings and recommendation to replicate EBH, General Chiarelli gave his full-throated endorsement and directed Lieutenant General Horoho, the new Army surgeon general, to rearrange her hospital’s outpatient mental health care clinics to support the EBH model. The surgeon general’s staff reassigned Chris Ivany from Fort Carson to its headquarters in Falls Church, Virginia, to work as part of the burgeoning mental health leadership team and spearhead EBH implementation. General Chiarelli’s meeting also opened the doors for the MIT team to make visits to many other Army posts to continue to observe and learn.

In 2013, the surgeon general selected Chris to serve as the chief of the Behavioral Health Division and lead the team charged with improving mental health services throughout the Army. The partnership between JK and Chris continued over the next three years and included twenty-seven field visits to nineteen Army locations between 2012 and 2015.

Through open conversations that only outsiders could have, JK and his team won the trust of countless people involved in Army behavioral health care who frequently disclosed how things were really working at the local level. Chris and his team incorporated that perspective to identify and solve problems they may not have found otherwise. This insider-outsider relationship enabled JK to serve as a neutral observer of the change effort and understand the Army culture well enough to make relevant recommendations.

This book tells the story of the Army’s transformation of that disparate collection of poorly standardized and largely disconnected clinical microsystems into a well-defined mental health care system with patient-centered, recovery-oriented care as its foundation, which uses real-time knowledge to improve patient outcomes, measure performance, and reward high-value care. It is a step-by-step explication of how this was accomplished that offers profound lessons about the provision of behavioral health services and can help guide other mental health care systems across the country as well to transform into learning mental health care systems.

Today, the Army has overcome what was once a kind of organized anarchy to achieve a standardized system of care—an important step toward ensuring a consistent care experience irrespective of care location. It also establishes care ownership, a necessary prerequisite for patient-centered care. The Army’s transformed system of care provides transparency of patient flows, visibility to care delivered, and conformance to workload standards. The Army is building the capability to go beyond proxy measures to use patient-reported outcomes to answer whether beneficiaries are actually getting better. The foundations of a learning health care system that can measure performance and improve quality of care have taken root.

Who This Book Is For

We’ve written this book for health systems leaders and policy makers looking to make the major changes to their health care systems necessary for them to become learning health care systems. The profound desire to address the mental health crises that have manifested in soldiers and their families over the last twenty years created an opportunity to change the Army’s mental health system more extensively and more rapidly than in any other period of history. This book tells the story of the Army’s transformation of that disparate collection of poorly standardized and largely disconnected clinics into a well-defined mental health care system with patient-centered, recovery-oriented care as its foundation, using real-time knowledge to improve patient outcomes, measure performance, and reward high-value care. This book is a step-by-step explication of how this was accomplished. The Army’s experience offers profound lessons about the provision of behavioral health services and can help guide mental health care systems across the country in their own transformations into learning mental health care systems.

This book codifies what did and did not work in the Army’s transformation efforts. The framework we develop here is based on the Army’s experience, but we believe the lessons are applicable to all health systems—civilian systems, other public health systems such as the Veterans Affairs system, and the other branches of the military.

The Army is a useful case example because it is an integrated care delivery system in which policy guidance and management are centralized. We do not suggest that health systems try to replicate the Army’s behavioral health system of care exactly, but rather take the core ideas and use them to build their own learning mental health care systems. These ideas include gaining an accurate, empirically supported understanding of the current state of their mental health care system, including the flow of patients across levels of care; proactively redesigning the system of care around patient needs to create a consistent, culturally competent patient experience of care; focusing on reducing and ultimately eliminating the stigma of using mental health care services; systematically collecting and using patient-reported outcomes as the foundation for the learning health care system; and implementing a practice management system that provides leaders with a clear understanding of the actual clinical care provided.

In understanding the Army’s journey, we believe leaders and policy makers can guide their own health systems to make the major changes necessary for building learning health care systems.

As we completed this book, health systems around the world were grappling not just with treating patients with Covid-19, but also with the pandemic’s impact on the mental health of patients, clinical care teams, and the public writ large. It is even more important now to treat mental health care and medical care within a unified health system. Unfortunately, civilian health care systems are still dealing with the aftereffects of deinstitutionalization, when much of mental health care shifted away from the hospitals and into independent community-based clinics and practices.⁶ This created a fissure between medical and mental health care that was widened even further by funding approaches, such as mental health carve-outs, established to manage the growing costs of mental health care. Efforts to restore parity, such as the Mental Health Parity and Addiction Equity Act of 2008, increased access to mental health care services and accelerated the adoption of patient-centric care models such collaborative care models that provide behavioral health care in primary care settings.⁷ Unfortunately, these successes have generally been limited to single initiatives and have not achieved the redesign of the entire system that is required to fix the country’s profound mental health care challenges.

In contrast, the Army did redesign its entire mental health care system. We describe the transformation from a provider-centric, stovepiped system with unchecked variation between its clinics to a patient-centered, integrated, and cohesive system