https://hdl.handle.net/1721.1/102516 2026-04-03T20:31:44Z https://hdl.handle.net/1721.1/104904 A Dynamic Model of Post-Traumatic Stress Disorder for Military Personnel and Veterans Ghaffarzadegan, Navid; Ebrahimvandi, Alireza; Jalali, Mohammad Post-traumatic stress disorder (PTSD) stands out as a major mental illness; however, little is known about effective policies for mitigating the problem. The importance and complexity of PTSD raise critical questions: What are the trends in the population of PTSD patients among military personnel and veterans in the postwar era? What policies can help mitigate PTSD? To address these questions, we developed a system dynamics simulation model of the population of military personnel and veterans affected by PTSD. The model includes both military personnel and veterans in a “system of systems.” This is a novel aspect of our model, since many policies implemented at the military level will potentially influence (and may have side effects on) veterans and the Department of Veterans Affairs. The model is first validated by replicating the historical data on PTSD prevalence among military personnel and veterans from 2000 to 2014 (datasets from the Department of Defense, the Institute of Medicine, the Department of Veterans Affairs, and other sources). The model is then used for health policy analysis. Our results show that, in an optimistic scenario based on the status quo of deployment to intense/combat zones, estimated PTSD prevalence among veterans will be at least 10% during the next decade. The model postulates that during wars, resiliency-related policies are the most effective for decreasing PTSD. In a postwar period, current health policy interventions (e.g., screening and treatment) have marginal effects on mitigating the problem of PTSD, that is, the current screening and treatment policies must be revolutionized to have any noticeable effect. Furthermore, the simulation results show that it takes a long time, on the order of 40 years, to mitigate the psychiatric consequences of a war. Policy and financial implications of the findings are discussed. 2016-10-07T00:00:00Z https://hdl.handle.net/1721.1/102662 Model-Based Policy Analysis to Mitigate Post-Traumatic Stress Disorder Ghaffarzadegan, Navid; Larson, Ricahrd C.; Fingerhut, Henry; Jalali, Mohammad; Ebrahimvandi, Alireza; Quaadgras, Anne; Kochan, Thomas A wide range of modeling methods have been used to inform health policies. In this chapter, we describe the use of three models for understanding the complexities of post-traumatic stress disorder (PTSD), a major mental disorder. The models are: 1) a qualitative model describing the social and psychological complexities of PTSD treatment; 2) a system dynamics model of a population of PTSD patients in the military and the Department of Veterans Affairs (VA); and 3) a Monte Carlo simulation model of PTSD prevalence and clinical demand over time among the OEF/OIF population. These models have two characteristics in common. First, they take systems approaches. In all models, we set a large boundary and look at the whole system, incorporating both military personnel and veterans. Second, our models are informed by a wide range of qualitative and quantitative data. Model I is rooted in qualitative data, and models II and III are calibrated to several data sources. These models are used to analyze the effect of different policy alternatives, such as more screening, more resiliency, and better recruitment procedures, on PTSD prevalence. They also provide analysis of healthcare costs in the military and the VA for each policy. Overall, the developed models offer examples of modeling techniques that can utilize a wide range of data sources and inform policy makers in developing programs for mitigating PTSD. 2016-05-24T00:00:00Z https://hdl.handle.net/1721.1/102660 PTSI Final Report Executive Summary: Transforming the Psychological Health System of Care in the US Military Kochan, Thomas; Carroll, John; Glasmeier, Amy; Larson, Richard C.; Quaadgras, Anne; Jayakanth, Srinivasan 2016-05-24T00:00:00Z https://hdl.handle.net/1721.1/102603 The Impact of Individual-, Unit-, and Enterprise-Level Factors on Psychological Health Outcomes: A System Dynamics Study of the U.S. Military Wang, Judy Y H Post-traumatic stress disorder (PTSD) and other psychological health issues have emerged as a signature pathology of combat operations in Iraq and Afghanistan. However, the full continuum of care in the U.S. military for PTSD and related disorders is reported to be insufficient to meet the current and future needs of service members and their beneficiaries. The influence of external factors such as pre-traumatic risk factors and the availability of unit-level and enterprise-level resilience resources on eventual mental health outcomes have been previously considered individually, but not together in an enterprise-wide context. Although systems thinking has been applied to transform general health care systems in the United States and recommended for the military health system, there has been limited application of such ideas to the military health care system at large. This thesis expands on previous systems thinking work to transform health care systems in the United States by building a multi-level, dynamic model of the military psychological health enterprise from accession and deployment to future psychological health screening and treatment. The model demonstrates the relationships between stress, resilience and external unit-level and enterprise-level resources, and the influence of pre-traumatic risk factors, effectiveness of predeployment resilience resources and the availability of psychological health treatment in theater are evaluated using sensitivity analyses in order to formulate recommendations for upstream initiatives to improve downstream health outcomes. Increasing participation in pre-deployment resilience training and increasing unit support would have the largest effect on decreasing the number of service members predicted to develop symptoms of PTSD. Thus, it is recommended that the military consider fitting potential at-risk service members to resilience training, developing concurrent strategic short-term and long-term operational policymaking processes, and linking accession data to health outcomes to inform future psychological health policy creation. 2016-05-23T00:00:00Z https://hdl.handle.net/1721.1/102601 USING ENTERPRISE ARCHITECTING TO INVESTIGATE A COMPLEX, MULTILEVEL ENTERPRISE AND CREATE A FRAMEWORK FOR ENTERPRISE TRANSFORMATION Southerlan, Elizabeth Cilley The Department of Defense (DoD) presented a need to transform its Military Psychological Health Enterprise (MPHE) at multiple levels. It had been established that Enterprise Architecting would be used as an approach to perform the transformation but the way in which the multiple levels of the enterprise would be transformed had yet to be determined. The study began with an investigation into the current state of a low-level component of the MPHE. This investigation invoked Enterprise Architecting techniques to determine the as-is state of this low-level enterprise. Then, the results of the Enterprise Architecting analysis were combined with multilevel analysis techniques to create a framework that supported transformation of a complex, multilevel enterprise. It was determined that upon using Enterprise Architecting techniques to identify the dominant views of a low-level component of a multilevel Enterprise, the structure of the levels the enterprise as well as the interactions between the levels can be used to understand the impacts of decisions made at higher levels of the enterprise. In the specific case of the DoD MPHE, the dominant views were found to be Organization, Process, and Information. By investigating these dominant views in more depth, the ways in which its resources interacted while performing relevant tasks in this micro-level enterprise (Camp Lejeune MPHE) were determined. This information was transformed into objective data, which was then combined with the information about how the levels of the DoD MPHE interact to suggest a framework for modeling potential future states of the enterprise. This will support both the design and selection of a transformation plan for the enterprise. The descriptive application of the suggested framework provided in this thesis supports both the design and selection of a transformation plan for the enterprise. 2016-05-23T00:00:00Z https://hdl.handle.net/1721.1/102600 Network Governance for the Provision of Behavioral Health Services Scott, Shane P Under a charter from the Chairman of the Joint Chiefs of Staff, the author participated in a study of the military's behavioral health system for the purpose of determining the means and effectiveness of that system for the treatment of PTSD and related conditions. This work focuses on the architecture and means of control over the existing arrangement of semi-independent enterprises, organized into functional work groups that necessarily collaborate to provide a full spectrum of behavioral health services to service members and their families. The author suggests a rearrangement of the system architecture to enable integrated work across organizational boundaries in order to reduce waste generated through structural inefficiencies. Implementation of network architecture and control relies heavily on the development of shared strategic objectives that direct network processes in supporting overall organizational goals. Further, performance measurement systems and stakeholder behavior change through use of incentives are used as the drivers of inter-enterprise process development. Finally, a governance structure, focused on development of integrative processes and outcomes is established to foster inter-organizational relationships, direct process improvement, and resolve system conflicts. 2016-05-23T00:00:00Z https://hdl.handle.net/1721.1/102599 Performance Dynamics In Military Behavioral Health Clinics Lyan, Dmitriy Edward The prevalence of Post Traumatic Stress Disorder (PTSD) and other related behavioral health conditions among active duty service members and their families has grown over 100% in the past six years and are now estimated to afflict 18% of the total military force. A 2007 DoD task force on mental health concluded that the current military psychological health care system is insufficient to meet the needs of the served population. In spite of billions of dollars committed to hundreds of programs and improvement initiatives since then, the system continues to experience provider shortages, surging costs, poor access to and quality of care as well as persistently high serviceR related suicide rates. We developed a model to study how the resourcing policies and incentive structures interact with the operations of military behavioral health clinics and contribute to their ability to provide effective care. We show that policies and incentives skewed towards increased patient loads and improvement in access to initial care result in a number of vicious cycles that reinforce provider shortages, increase costs and decrease access to care. Additionally we argue that insufficient informational feedback contributes to incorrect attributions and the persistence of ineffective policies. Finally we propose a set of policies and enabling performance metrics that can contribute to sustained improvement in system performance by turning death spirals into virtuous cycles leading to higher provider and patient satisfaction, better quality of care and more efficient resource utilization contributing to better healthcare outcomes and increased levels of medical readiness. 2016-05-23T00:00:00Z https://hdl.handle.net/1721.1/102598 Integration and the Performance of Large-scale Health Enterprises: Field Studies of Psychological Health Delivery Systems in the U.S. Military Kamin, Cody M Large-scale health enterprises comprise multiple organizations that provide programs and services for patients. Despite the interconnectedness of these systems there is a lack of empirical research documenting how these organizations work collectively - or integrate - and how this integration impacts enterprise performance measured through quality, efficiency, and access. In the case of psychological healthcare, patients often require a number of services that span multiple departments and programs within an enterprise, increasing the complexity of maintaining a continuum of care for these patients. This paper, which is part of a larger effort to examine psychological healthcare in the U.S. Military Health System, presents a series of qualitative observations and analyses of the integration of psychological health-related organizations at two large health enterprises within the military. These qualitative inquiries take a multilevel approach for examining integration within these enterprises and address the following areas of interest: 1) the mechanisms for integration; 2) the objects of integration; 3) the dimensions of integration; 4) the contextual factors that influence integration; and 5) the impacts of integration on enterprise performance. Using semi-structured interviews, qualitative data was collected and then examined using content analysis to identify the most frequent themes for each area of interest. This data was used to validate and refine a comprehensive framework for integration that was developed to pull together multiple, distinct strands of the integration literature. This data was also used to demonstrate the relationship between different dimensions of enterprise performance and to identify areas where, in the process of optimizing enterprise performance, there is a trade-off between these dimensions. The preliminary, qualitative results of this research are intended to provide a conceptual foundation and framework for future analytic studies. 2016-05-23T00:00:00Z https://hdl.handle.net/1721.1/102596 Architecting the future telebehavioral health system of care in the United States Army Ippolito, Andrea K. Charged by the Chairman of the Joints Chief of Staff, the authors were members of a study to develop innovative recommendations for transforming the military enterprise to better manage post-traumatic stress and related conditions in support of service members and their families. The authors first began their study by performing a stakeholder analysis to understand the unmet needs of stakeholders across the enterprise. By assessing stakeholder values across the life cycle, we found that there was a strong need to improve the continuity of care and accessibility of services for service members and their families, in particular for the Reserve Component and National Guard population. Therefore, the authors investigated the role of technology to serve as a force extender to improve access and timeliness of care to psychological health care services. Specifically, they utilized a systems approach to evaluate the current state of telehealth within the Military Health System. By utilizing the enterprise lenses of strategy, policy, organization, services, processes, infrastructure, and knowledge to analyze the current state of telebehavioral health, they proposed a future state architecture for telehealth delivery. They highlight seven enterprise requirements for developing this future state architecture: 1. MEDCOM shall establish a core funding stream as a line item to support TH service line. 2. MEDCOM Telehealth Service line shall develop standard TBH metrics for deployment across the enterprise 3. MEDCOM Telehealth Service line shall identify eligible populations across the enterprise that could benefit from the expanded access that TBH services provide. 4. MEDCOM Telehealth Service line shall develop an enterprise solution that supports seamless flow of operational information and the electronic health record. 5. MEDCOM Telehealth Service line shall revisit specific policies that are presenting barriers to telehealth growth and sustainability. 6. MEDCOM Telehealth Service line shall encourage learning and best practice sharing across the Army TH enterprise. 7. MEDCOM Telehealth Service line shall collaborate with other Army governance organizations to develop a mobile health strategy and pilot projects for the Army enterprise. 2016-05-23T00:00:00Z https://hdl.handle.net/1721.1/102595 Deployment Related Mental Health Care Seeking Behaviors in the U.S. Military and the Use of Telehealth to Mitigate THeir Impacts on Access to Care Hess, John Interviewees report that groups of service members returning from Iraq and Afghanistan often require substantial amounts of mental health care, causing surges in demand at military hospitals. These hospitals have difficulty keeping up with demand during the busiest periods. The exact patterns of demand during surges are difficult to measure because the military records utilization, but not actual need for services. This thesis analyzes the care seeking behaviors of service members and their families across the deployment cycle using historical data. This analysis shows that service members and their families seek more care after each deployment. More importantly, it shows that service members seek care at higher rates in predictable intervals following their deployments. New patient arrival rates are projected for several installations by multiplying actual installation populations by newly calculated care seeking rates. These projections show deployment related care seeking behaviors generate surges in demand and thereby validate qualitative findings from field work. A simulation of the military's system of care uses these demand projections to specify patient arrival patterns. Comparison of several simulated scenarios shows that surges make it very difficult for individual military hospitals to offer access to care using only their own mental health care providers. Allowing hospitals to share their providers with one another offers little improvement. As hypothesized, using a group of dedicated telehealth providers to support the most overburdened installations can offer a substantial improvement in access to care. This insight leads to four policy recommendations. First, a service wide or joint scheduling system should be created. Second, telehealth can best support overburdened hospitals when some providers are dedicated solely to surge support. Third, the services should take responsibility for meeting access to care goals instead of delegating the burden to installations. Lastly, hiring actions should be tied directly to an accurate measurement of excess demand. 2016-05-23T00:00:00Z https://hdl.handle.net/1721.1/102567 Transitional Care Needs of Army Beneficiaries using Mental Health Services Srinivasan, Jayakanth 2016-05-19T00:00:00Z https://hdl.handle.net/1721.1/102566 A Conceptual Model of the Psychological Health System for U.S. Active Duty Service Members: An Approach to Inform Leadership and Policy Decision Making Wang, Judy Y.; Glover, Wiljeana J.; Rhodes, Alison M.; Nightingale, Deborah The influence of individual-level factors such as pretraumatic risk and protective factors and the availability of unit-level and enterprise-level factors on psychological health outcomes have been previously considered individually, but have not been considered in tandem across the U.S. Military psychological health system. We use the existing literature on military psychological health to build a conceptual system dynamics model of the U.S.Military psychological health system “service-cycle” from accession and deployment to future psychological health screening and treatment. The model highlights a few key observations, challenges, and opportunities for improvement for the system that relate to several topics including the importance of modeling operational demand combined with the population’s psychological health as opposed to only physical health; the role of resilience and post-traumatic growth on the mitigation of stress; the positive and negative effects of pretraumatic risk factors, unit support, and unit leadership on the service-cycle; and the opportunity to improve the system more rapidly by including more feedback mechanisms regarding the usefulness of pre- and post-traumatic innovations to medical leaders, funding authorities, and policy makers. 2013-01-01T00:00:00Z https://hdl.handle.net/1721.1/102564 Understanding Who, What and Where in Army Mental Health Services Delivery Srinivasan, Jayakanth 2016-05-19T00:00:00Z https://hdl.handle.net/1721.1/102563 Transitional Care Needs of Army beneficiaries using Mental Health Services Srinivasan, Jayakanth 2016-05-19T00:00:00Z https://hdl.handle.net/1721.1/102562 Preliminary Evidence on the Effectiveness of Embedded Behavioral Health Srinivasan, Jayakanth 2016-05-19T00:00:00Z https://hdl.handle.net/1721.1/102561 Lessons Learned from Implementing Embedded Behavioral Health at Four Army Installations Srinivasan, Jayakanth 2016-05-19T00:00:00Z https://hdl.handle.net/1721.1/102560 A Service-Line Approach to Managing Integrated Mental Healthcare Services in the United States Army Srinivasan, Jayakanth 2016-05-19T00:00:00Z https://hdl.handle.net/1721.1/102559 Site Charlie Behavioral Health System of Care Srinivasan, Jayakanth; DiBenigno, Julia 2016-05-19T00:00:00Z https://hdl.handle.net/1721.1/102557 Site Bravo Behavioral Health System of Care Srinivasan, Jayakanth; DiBenigno, Julia 2016-05-19T00:00:00Z https://hdl.handle.net/1721.1/102556 Site Alpha Behavioral Health System of Care Srinivasan, Jayakanth; DiBenigno, Julia 2016-05-19T00:00:00Z https://hdl.handle.net/1721.1/102555 Army Cross Case Quantitative Analysis, 2010-2013 Srinivasan, Jayakanth; DiBenigno, Julia 2016-05-19T00:00:00Z https://hdl.handle.net/1721.1/102554 Developing the Embedded Behavioral Health Checklists Srinivasan, Jayakanth; DiBenigno, Julia The Army Embedded Behavioral Health (EBH) model of care was designed to increase access to care and reduce stigma around care seeking by locating care at the point of need. The model makes the EBH clinic the nexus of clinical behavioral health care for patients that fall within that clinic’s catchment area. The aligned providers (and the care team as a whole) serve as the principal source of information for command teams about the mental health of the enrollee. Using our field research experiences, we codified the unique challenges in both the planning phase of EBH implementation, and the implementation phase in the form of two checklists that can be used to better manage the change process. The planning phase checklist is owned by an Installation’s Behavioral Health (BH) Chief, while the implementation phase checklist is owned by an Installation’s EBH Team Lead. In this document we describe both checklists, and include research findings and examples that illustrate the importance of each item on the list. 2016-05-19T00:00:00Z https://hdl.handle.net/1721.1/102553 Spatial Typologies of Care: Understanding the Implications of the Spatial Distribution of Off-Base Civilian Behavioral Health Providers Who Accept TRICARE Prime to Service Persons and Their Dependents Schultheis, Eric; Glasmeier, Amy Over the last decade, demand for services from military treatment facilities (MTFs) has frequently exceeded capacity resulting in increased usage of off-base civilian Tricare providers (OCTP). This capacity shortage has been particularly acute for mental health care. At many installations, OCTPs are the main source of mental health care for military personnel and their families. Utilizing data on the location of mental health OCTPs and demographic data, we examine the spatial accessibility of mental health OCTPs around five military installations. Variation exists in the spatial accessibility of mental health OCTPs depending on the geographic context of an installation. There is a mild correlation between the number of mental health OTCPs proximate to a base and the beneficiaries enrolled in an MTF. There is a strong correlation between the size of the general population proximate to an installation and the number of mental health OCTMPs present. Installations located in densely populated areas had high ratios of mental health OCTPs to the MTF beneficiary population but not when the civilian demand on these providers was accounted for. This study’s findings open several avenues for future research and policy aimed at increasing the effectiveness of the mental health OCTP network. 2015-01-01T00:00:00Z https://hdl.handle.net/1721.1/102549 Building a Better USMC Psychological Health System: Coordination Analysis and Design Recommendations Quaadgras, Anne; Glasmeier, Amy; Kaplan, Ken 2016-05-18T00:00:00Z https://hdl.handle.net/1721.1/102547 Depression and PTSD Co-Morbidity: What are We Missing? Itzhaky, Liat; Levin, Yafit; Fingerhut, Henry Alan; Solomon, Zahava Background: Posttraumatic stress disorder (PTSD) and depression comorbidity is highly common. Many hypotheses concerning this relation have been raised but the pertinent issues, including the wide clinical picture of this comorbidity, are still not clear. The current study aims to bridge these gaps. Method: We assessed PTSD, depression and comorbid indicators including dissociation, somatization, self- destructive behavior and suicidality among Israeli Yom Kippur war veterans at three time points (N = 349, 287, 301). Results: Dissociation, somatization, self-destructive behavior and suicidality were predicted separately by group (PTSD, depression and comorbidity) and time of measurement using ANOVA and Chi squared analyses. The ‘comorbidity’ group expressed significantly higher dissociation, somatization, self-destructive behavior and suicidality, revealing high vulnerability of this group. Somatization presented a curvilinear-like development, increasing between T1 and T2 and slightly declining at T3, especially among the ‘comorbidity’ group. Suicidality showed a constant increase along the three measurements, especially among the comorbidity group. Conclusions: A PTSD/depression comorbidity is both highly prevalent and long lasting and is often expressed concurrently with other related symptomatology, which causes further suffering and makes it more complicated for treatment. Implications for policy makers are briefly discussed. 2014-01-01T00:00:00Z https://hdl.handle.net/1721.1/102546 Architecting the Future U.S. Military Psychological Health Enterprise via Policy and Procedure Analysis Glover, Wiljeana J; Plmanabhan, Jayaprasad; Rhodes, Donna; Nightingale, Deborah Although researchers suggest that a systems approach is required to make meaningful advances in the U.S. psychological health care system for service members, limited research has considered such an approach. This research uses an enterprise architecting framework to identify the system's strengths and areas for opportunity as they relate to the Ecosystem, Stakeholders, Strategy, Process, Organization, Knowledge, Information, and Infrastructure. Codifying qualitative data from publicly available U.S. Defense Health Agency and U.S. Service Branch doctrine, policy guidance, and concepts of operations, our findings indicate that the psychological health care system is strongly process-oriented and mentions a variety of key stakeholders and their roles and responsibilities in the enterprise. Potential opportunities of improvement for the system include a stronger emphasis on the development and transfer of knowledge capabilities, and a stronger information-based infrastructure. 2015-01-01T00:00:00Z https://hdl.handle.net/1721.1/102545 The Emergent Psychological Health System at Marine Corps, Base Camp Lejeune 2012-2015: Analysis and Recommendations Glasmeier, Amy; Schultheis, Eric; Sassi, Annette; Chuvala, Christa Lee; Bell, Andrew; Fay, John 2016-05-18T00:00:00Z https://hdl.handle.net/1721.1/102544 Command-Provider Relationships in Embedded Behavioral Health. Juila, DiBenigno 2016-05-18T00:00:00Z https://hdl.handle.net/1721.1/102542 A Simulation-Based Analysis of PTSD Prevalence among US Military Personnel and Veterans in 2025 Ghaffarzadegan, Navid; Ebrahimvandi, Alireza; Jalali, Mohammad S. We developed and simulated a systems model of the population of military personnel and veterans affected by post-traumatic stress disorder (PTSD). Simulation results fit the historical data on PTSD prevalence in 2000-2014, and forecast the trends for the next decade under several scenarios of US involvement in future wars. Using the model, we tested the effects on PTSD prevalence and healthcare costs of four PTSD policies aimed at improving: 1) resiliency, 2) screening, 3) treatment, and 4) a combination of the three. Results showed that in a postwar period, there is no silver bullet for overcoming the problems of PTSD, and screening and treatment policies must be revolutionized to have any noticeable effect. One critical characteristic of this system is the long time that it takes, about 40 years, to vanquish the psychiatric consequences of a war. In a very optimistic scenario, estimated PTSD prevalence among veterans in 2025 will be at least 10%. 2016-05-18T00:00:00Z https://hdl.handle.net/1721.1/102541 A Simulation Model to Predict Long-Term Posttraumatic Stress Disorder Prevalence Following Operation Iraqi Freedom and Operation Enduring Freedom: Executive Summary Fingerhut, Henry Alan 2016-05-18T00:00:00Z https://hdl.handle.net/1721.1/102540 Postraumatic Stress Disorder: Five Vicious Cycles that Inhibit Effective Treatment Ghaffarzadegan, Navid; Larson, Richard C. Despite a wide range of studies and medical progress, it seems that we are far from significantly mitigating the problem of posttraumatic stress disorder (PTSD). The problem has major social and behavioral components. Developing innovative and effective policies requires a broad scope of analysis and consideration of the highly interconnected social, behavioral, and medical variables. In this article, we take a systems approach and offer an illustrative causal loop diagram which includes individual and social dynamics. Based on the map, we discuss 5 major barriers for effective interventions in PTSD. These barriers work as vicious cycles in the system, reduce effectiveness and therefore value of PTSD treatment. We also discuss policy implications of this perspective. 2015-11-01T00:00:00Z https://hdl.handle.net/1721.1/102538 The Marine Corps II MEF Psychological Health System: overview, findings and recommendations Fradinho, Jorge; Glasmeier, Amy; Kaplan, Ken; Quaadgras, Anne; Moga, Steve; Mealer, Clayton; Bell, Andrew; Livengood, Dan 2016-05-18T00:00:00Z