# Presentation: 824978

## Session 125My Recovery Plan-Using MyHealtheVet to Support Veterans with Mental Health and Substance Use Disorders

- Kenneth R. Weingardt, Ph.D.
- Kathleen M. Lysell, Ph.D.

## MyHealtheVet

**MyHealth**_***e***_**Vet Mental Health Executive Committee**
**Antonette Zeiss****	****	**
**Ken Weingardt****	****	**
**Katy Lysell****	****	**
**Gretchen Haas **
**Joe Ruzek**
**Ken Jones**
**Linda Godleski**
**Bill Daniels**
**Brian Shenal**
**Bruce Levine**
**Jessica Hamblen**
**Mara Kushner-Davis**
**Bill Daniels**
**Larry Lehman**

## Overview of Presentation

- 1. My Health_***e***_Vet (MHV) Personal Health Record
- 2. MHV Mental Health Content and Screening Tools
- 3. My Recovery Plan (MRP)

## MHV Personal Health Record

- www.myhealth.va.gov

## MHV Current Functionality

| Personal Information | Set up user profile and enter past medical information.  
Currently relies entirely on Self-Entered Information (SEI)
 |
| --- | --- |
| Pharmacy | Allows veterans to refill prescriptions online.  
Currently the most popular feature of MHV, and the only one that involves writing data back to ViSTA
 |
| Research Health | Access libraries of health information including: VA Health Education Library, Healthwise® and MedlinePlus®
 |
| Get Care | Locate VA health care providers.   |
| Track Health | Provides a variety of user-friendly templates which allow veterans to enter health data such as blood pressure, blood sugar, cholesterol, pulse oximetry  |

## MHV Mental Health Content

_**Goal:**_  To provide information and education to veterans and family members on health, wellness and recovery as it relates to:
- Common mental health disorders
- Successfully coping with psycho-social stressors
- Partnering with health care providers
- Taking responsibility for ones own recovery

## MHV Mental Health Content

- VA Mental Health and Healthwise collaboration
- Purpose is to develop recovery focused informational/ educational materials on:
- Depression
- PTSD
- Substance Use Disorders
- Schizophrenia

## PTSD Content

## MHV Mental Health Screening Tools

_**Disorder**_**	****	****	****	**_**Screening Instrument**_
- Post Traumatic Stress Disorder	PTSD Checklist (PCL)
- Depression** **				Patient Health Questionnaire
- 						(PHQ-9)
- Alcohol problems	** **		Alcohol Use Disorders Identification 					Test (AUDIT-C)
- Drug problems			Alcohol, Smoking, and Substance 					Involvement Screening Test 						(ASSIST)

## MHV Mental Health Screening Tools

## PTSD Screen

- Post Traumatic Stress Disorder Checklist (PCL-M)
-  17 item self-administered questionnaire
-  Uses diagnostic criteria from Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) for PTSD
-  First created for Vietnam combat veterans.
-  Has strong psychometric properties (well-validated for the assessment of PTSD symptoms)
- _Reference:_ Blanchard EB, Jones-Alexander J, Buckley TC, et al. Psychometric properties of the PTSD Checklist (PCL). *Behav Res Ther.* 1996;34:669-673

## Depression Screen

- Patient Health Questionnaire -9 (PHQ-9)
- 9-item self administered depression questionnaire (included in the MHA located in CPRS)
- Based on the diagnostic criteria for major depressive disorder in the Diagnostic and Statistical Manual Fourth Edition (DSM-IV).
- Well-validated and widely-used in medical settings such as primary care
- Development funded by Pfizer Inc
- _Reference:_ Spitzer R, Kroenke K, Williams J. Validation and utility of a self-report version of PRIME-MD:  the PHQ Primary Care Study. *Journal of the American Medical Association* 1999; 282: 1737-1744.

## Alcohol Screen

- Alcohol Use Disorders Identification Test (AUDIT-C)
- AUDIT – 10 item screen developed by the World Health Organization
- AUDIT-C is the first 3 items from the AUDIT that focus on alcohol consumption
- Identifies patients who are hazardous drinkers or have active alcohol use disorders (including alcohol abuse or dependence).
- Good psychometric properties – recommended replacement for CAGE
- Current CPRS clinical reminder – required screening in primary care
- _Reference:_ Bradley KA, et al., *Screening for problem drinking: comparison of CAGE and AUDIT.* J Gen Intern Med, 1998. 13(6): p. 379-388.

## Drug Screen

- Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST)
- 8-item assessment developed by the World Health Organization
- Purpose is to detect psychoactive substance use and related problems
- Substances addressed include: tobacco, alcohol, cannabis, cocaine, amphetamine type stimulants, sedatives, hallucinogens, inhalants, opioids, and other drugs.
- Strong psychometrics, both reliable and valid
- _Reference:_ WHO ASSIST Working Group. The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST): development, reliability and feasibility. Addiction 2002;97:1183-1194.

## Screening Results

**Results and Recommendations:**
- Your answers to the anonymous and confidential screen for _____ are listed below for your review.
- a
- b
- c
- d
- Your screen results are consistent with many of the symptoms of _____.  **You are advised to see your physician or a qualified mental health professional immediately for a complete assessment.**  Although many veterans/individuals cope well with symptoms like yours, effective treatments for _____ are available to help reduce your symptoms and improve your quality of life.  A mental health professional or your physician can advise you about whether you can benefit from treatment and describe different treatment alternatives.

## My Recovery Plan (MRP) 

- A component of My Health_e_Vet that will help veterans with mental health issues to:
- Take an active, collaborative role in their treatment
- Take increased responsibility for monitoring and tracking:
- the type and degree of mental health symptoms,
- medication adherence and side effects,
- progress towards recovery goals,
- as well as relapse triggers & coping plans.

## My Recovery Plan Overview

- My Recovery Plan (MRP) and how it fits into the larger MyHealtheVet project
- How MRP will support current care processes in the VA

## What does Recovery Mean?

*Mental health recovery is a journey of healing and transformation for a person with a mental health disability to be able to live a meaningful life in communities of his or her choice while striving to achieve full human potential or “personhood.”*
- 10 fundamental elements and guiding principles:
- Self-direction
- Individualized and Person-Centered
- Empowerment
- Holistic
- Non-Linear
- Strengths-Based
- Peer Support
- Respect
- Responsibility
- Hope

## My Recovery Plan: Mission

- 	To create an interactive set of web-based tools that will allow veterans who have behavioral or mental health concerns to track important aspects of their self-care and professional care.
- Be useful to all veterans with behavioral or mental health concerns, regardless of whether or not they meet DSM-IV criteria for a psychiatric disorder;
- Provide the veteran with hope of improved health and quality of life through collaborative involvement in his or her own mental health care;
- Be described on the open MHV site, but access will require a special entry key to be set up by the provider;
- Follow a Concurrent Recovery Monitoring model, in which regular outcomes monitoring is incorporated as a routine part of clinical care.

## My Recovery Plan: Audience

- _Audience:_ Veterans who are currently in, or have recently completed, an episode of VA Mental Health or SUD treatment.

## My Recovery Plan: Vision

- Will allow veterans to _**monitor and track**__,_ the type and degree of mental health symptoms, medication adherence and side effects, progress towards recovery goals, as well as relapse triggers & coping plans.

## My Recovery Plan: Vision

- Will facilitate veterans achieving _**self-identified goals**_, including the identification of larger life goals (e.g., find an apartment), breaking down those goals into concrete, sub-goals, and overcoming barriers to attaining goals

## My Recovery Plan: Vision

- Will allow veterans to engage in a program of _**guided self-change**_, which will draw upon empirically supported psychosocial treatments (e.g. Cognitive-Behavioral Therapy), provide targeted access to the instructional content necessary to successfully use the various features in each module, and to download the appropriate patient education and self-monitoring forms.

## MRP Vision

**B. MRP supports veterans receiving treatment**

**A.  MRP supports clinicians delivering treatment**

**C. MRP supports aftercare, case management**

**D. MRP supports veterans in recovery**

**Intervention****	****Aftercare**

- Clinician
- Veteran

## MRP Workgroups

- Purpose is to document the structure and dynamics of the various organizations and settings in which VA MH care is delivered.
- Settings in which care is delivered (e.g., residential)
- Important aspects of care in those settings (e.g., medication management)
- This process helps captures the current VA MH processes of care that we want MRP to support.

## MRP Care Processes

## MRP Requirements

- The goal of requirements analysis is to describe _*what*__ _MRP system needs to do to support the care processes.
- Requirements or medication management might include tracking any side effects for specific meds, changes in symptoms, etc.

## Example of Requirement

**Monitoring and tracking of mental state**
**The system shall: **
- Support assessment of psychiatric symptoms,
- Support assessment of quality of life,
- Support assessment of level of functioning,
- Issue an alert when a milestone is missed, and
- Present assessment trends.

## Identify Common Domains/Themes

- Medical Management—symptoms and medications
- Healthy Living
- Managing Medical Problems
- Interpersonal/Problem Solving
- Family/Caregiver Relationships and Support
- Developing Natural Supports
- Housing
- Vocational Issues
- Substance Abuse

## My Recovery Plan: Profile Set-Up

## My Recovery Plan: Profile Set-Up

## My Recovery Plan: Profile Set-Up

- This screen prompts the user to collect any information and documentation that will
- be required in order to set up his or her Recovery Plan.

## My Recovery Plan: Setup

## My Recovery Plan: Setup

**Mental health diagnosis**.
-  The veteran and or his/her primary MH provider will pick his or her primary psychiatric diagnosis from a drop-down menu
-  that includes a short list of 5-7 general diagnostic categories
-  Entering primary diagnosis will ensure that the veteran is prompted to enter only that information which is most relevant for his or her situation.
- Entering more than one diagnosis is certainly possible.

## MRP: Setup

**Scheduled appointments: **Ideally this information would be pulled from the MHV database
- Alternately, clicking on this field should pop-up a three month calendar that allows the veteran
- to click on the dates of upcoming appointments, and also presents a memo field for them to type in the time of the
- Appointment and what it is for (medication check, case management etc.)

## MRP Setup

**Medication List.  **This will be populated with the veteran’s current medication list in his/her medical record.

## MRP Setup

## MRP Setup

**PART A: Diagnosis specific components **
- These components will be specific to the **primary diagnosis **entered during Step 1: Profile setup (SUD in this example)
- Each MHV Dx MGMT subgroup could identify the disorder-specific components that need to be tracked
- Each subgroup should discuss which components will be mandatory or required (if any).
- *NOTE:  **Medication adherence** **and follow-up appointments could be included in all recovery plans **regardless
- of primary diagnosis or individual preferences.

## MRP Setup

**PART B: General domains of life functioning**
- These optional components will be available to all participating veterans
***NOTE Staying Clean & Sober **module could allow dually-diagnosed veterans to add SUD to their recovery plan
- in addition to material that is specific to their primary diagnosis.  The Staying Clean and Sober option would not actually
- appear in our example because the patient has a primary diagnosis of SUD and this would be redundant.

## MRP Setup

## My Recovery Plan

- Joseph P. Veteran

_**My Schedule**_

_**NOTES:**_
*Medications, schedule and tasks for TODAY in center box update daily.  *
*My Schedule is a link to a detailed monthly calendar. *
*My Goals are links to corresponding pages*
*My Care is a link to that function on the larger MHV website*
*My Messages is link to the secure provider messaging feature*

_**My Care**_
- Prescription refills
- Schedule an appointment
- Personal Health Record

_**My Messages**_
- Inbox
- Sent
- Deleted

## MRP Design Recommendations

- Development Recommending Naming and Conventions Changes to My HealtheVet for the Mental Health Community

- My Recovery Plan Tab and Page

- Explicit Labeling

## MRP Design Recommendations

- Quick Related Links

- Integrated Calendar and Reminders

## MRP Design Recommendations

## MRP Design Recommendations

## Lessons Learned

- For this project to be successful, it requires coordination and validation of requirements with the IT Program Office
- The Clinical Advisory Board needs to be included in status updates of the project to ensure requirements developed under the contract will be included in the My Health_***e***_Vet Product Roadmap for software development.
- Immediately review contracting resources when we identify areas of collaboration to ensure these efforts are scheduled and within the scope of work on each contract.
- Coordination between East Coast and West Coast entities can be a challenge within itself in scheduling meetings and facilitating work groups that are inclusive of diverse geographic areas and potential demographics.
- There is often overlap between this project and other initiatives within the VHA and My Health_***e***_Vet Program that can provide us with valuable information in the development of business requirements.
- Reaching consensus with a Working Group whose members have different focuses or opinions on patient care or differing priorities for My Recovery Plan can be a challenge that affects the timeframe of delivery.

## Questions ?