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AfterDeployment.org Community of Practice September 10, 2013
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AfterDeployment.org Community of Practice - Sept 2013

Oct 28, 2014

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The AfterDeployment.org Community of Practice (AD COP) is a group of clinicians actively using content from AfterDeployment.org in their behavioral health practice supporting service members, veterans, and military families.
This edition of the AD COP introduces the AfterDeployment.org Provider Manual, discusses the use of AfterDeployment.org in a VA primary care treatment setting, and introduces the new AD COP online LinkedIn group.
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Page 1: AfterDeployment.org Community of Practice - Sept 2013

AfterDeployment.org Community of Practice

September 10, 2013

Page 2: AfterDeployment.org Community of Practice - Sept 2013

Agenda

• Introducing AfterDeployment.org Providers Manual: David Bradshaw, PhD, and Robert Ciulla, PhD

• Using AfterDeployment.org in a VA primary care treatment setting: Annabel Prins, PhD

• AfterDeployment Community of Practice on LinkedIn: David Bradshaw, PhD

• Announcing two new websites for military, veterans, and families: Pamela Murphy, PsyD

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Page 3: AfterDeployment.org Community of Practice - Sept 2013

Web Tools Resource Guide: A Manual for

ProvidersRobert Ciulla, Ph.D.

Joint Base Lewis-McChord/ Tacoma, WA

10 September 2013

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Agenda

• Introduction to the Providers Manual for AD.org

• Organization of the Manual

• Overview of manual content/features

• A clinical example

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Our mission is to use web-based technologies to help service members, veterans, and their loved ones manage the challenges they face following a deployment and beyond.

AfterDeployment.org

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Introduction and Background

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• Why this manual?– AD.org developed for self-care but also may

be useful for providers– Provider Portal provides additional resources– How can providers use AD.org tools to

support clinical care?

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Document Structure

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Manual

Overview and Features

Clinical Case Example

FAQs

Glossary

Bibliography

Introduction and Background

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Clinical Case Example

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• Describes how to use the material on the website during a clinical encounter

• Uses the Post-Traumatic Stress topic• Step-by-step example of a clinician

working with a patient using AfterDeployment.org resources

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Multi-Modal Content

Topics are organized to provide:• Coach-driven instruction/guidance• Immersive video/text-based educational tools• Standardized assessments/tailored feedback• Peer-based, experiential accounts• Interactive exercises• Additional resources (links, books, FAQ’s)• Persistent progress indicators

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Session 1 – Introduction

“Sgt. Smith, do you have Internet access… Do you ever check into health-related websites to get information about a problem you’re having?... Have you ever heard of a website called AfterDeployment.org?... It was developed by…”

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Session 1 – Focus on PTS

“AD.org has several topics that are very pertinent to what you are going through. The one that I want you to look at between now and your next appointment is the topic called Post-Traumatic Stress.”

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The PTS Home Page

“When you click on the Post-Traumatic Stress icon from the Home page, you go to the Post-Traumatic Stress section of the site. There are videos that discuss post-traumatic stress, an online booklet that you and your spouse can read through, and personal stories from other service members and veterans about their deployment experiences.”

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Between-Session Homework:Video-Based Education

“Before your next appointment, I want you to click on ‘Start Here’ and listen to the overview [1:30]. Then I want you to view the first two video documentaries, the one called “Introduction to PTS” [3:50] and the one called “Reactions and Triggers [0:35] Here, I’ve written these down for you.”

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Between-Session Homework: Personal Stories

“Also, I want you to click on the Personal Stories tab and look through these videos—I also wrote this section down on your assignment sheet. I’m sure you’ll find that many other service members have had some experiences that are similar to yours.”

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Self-Assessment

“Now, there’s one more exercise that I want you to do on the site—and that’s also on your assignment sheet. See this tab, the one named PTS Assessments? I want you to take the PTS assessment and bring your results to our next session.”

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Next Session: Introducing the Interactive Workbook

“Good work. You viewed the coach’s introduction, and the educational videos, and you heard from other service members and families about their deployment experiences. I have a new assignment that I want you to complete between now and next week. I want you to log on to the website’s workbook. Let me show you.”

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Workbook Features

“The workbook has a number of features. In the upper right corner you will see a progress bar that tells you how many sessions you’ve completed. You can also check in on the exercises that you have completed in the My Work tab. In order for the website to save your information from one session to the next, be sure to sign up - registration is anonymous. On the bar at the bottom of the page, you can track your session progress.”

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Workbook Coach

“A persistent feature throughout the workbook is the coach. The coach provides information about the topic. And the coach serves as a guide through the sessions.”

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Workbook Session #1: Trauma Triggers

“While you can view the sessions in any order, the best approach is to start at the beginning and use the sessions in sequence. After you pull out the menu tab, click on the first session, ‘Trauma Triggers’. This workbook session will teach you about trauma triggers and how they affect your emotions and stress level.”

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Identifying Triggers

“As you proceed through the workbook, you will be asked to answer questions and fill in information about how you’re coping. For example, you will see a checklist such as this one that prompts you to identify the things that trigger you. If you don’t find your trigger on the list, you can write it in the free text section. ”

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Examples

“To help you understand this exercise, this session provides an example trigger record. Be sure to listen to the entire session. It has been developed to be engaging, and brief. In fact, this entire session takes about 20 minutes to complete.”

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Getting Help

“If you get stuck, click on ‘help’. The coach will narrate an explanation of the section that you’re having difficulty with.”

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Trigger Record

“After you have seen the example, the workbook will prompt you to fill in your own trigger record. As you gradually learn ways to manage your triggers, the remaining sessions in the workbook will use the responses that you provided in earlier sessions.”

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Dealing with Avoidance

Because behavior change isn’t easy, the workbook has been designed to offer encouragement, ‘normalize’ the trauma, and deal with possible forms of resistance.

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How Stressful Was That Exercise?

“Periodically, the workbook will check in with you, see how you’re doing. This is a check on your stress level. AfterDeployment.org also includes skills training to help with learning how to relax. Another time, we can talk about a mobile app called Breathe2Relax.”

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“My Work”

My Work saves the user’s information within the workbook.

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Session # 1: Summation

Like a good therapist would do at the end of a session, the workbook coach reviews the session, referencing the areas that were covered and the particular take-away’s from the session. The coach then references the next session in the series.

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Other Key Points

• The site is a collaborative effort• Not all workbooks have been revised• No capability to send/transmit data• The content is versatile/customizable• Co-occurring conditions• VA conducting group sessions• Providers’ clinical approach• Clinical studies underway

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Annabel Prins, PhDClinical Psychologist/T2 Liaison

National Center for PTSD, Dissemination & Training DivisionNational Center for Telehealth and Technology (T2), ROI Division

Afterdeployment.org Community of Practice Call9/10/2013

Bringing afterdeployment.org into VA Primary Care

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Agenda Introduction

VA Primary Care Mental Health Integration

Demonstration Project

Clinical Observations/Future Direction

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Introduction Research activities

Evaluation of PTS workshops at SJSU (Bush et al., 2013)

Clinical support tool for providers○ ADAPT-T (PI-Jakupchak): telephone based

problem solving therapy for PTSD/substance abuse

○ TIDES/PTSD (PI-Felker): care management for depression and PTSD

Clinical activitiesPrimary-Care MH team: American Lake VA

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VHA Handbook RequirementsSection 21. Integrating Mental Health Into Medical Care Settings VA medical centers and very large CBOCs (serving 10,000+

uniques) must have integrated mental health services that operate in their primary care clinics on a full-time basis.

Services need to utilize a blended model that includes co-located collaborative care and care management.

Similar requirements for Large CBOCs (serving 5,000-10,000) except hours and days of availability of integrated care services can vary depending upon the clinical needs of the patient population.

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Page 34: AfterDeployment.org Community of Practice - Sept 2013

PC-MHI Services Reporting, Percent, by Site Type and Year

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CCC & CMCCC Only CM Only Neither No Program

VAMC 2009 37% 34% 8% 11% 10%

2010 42% 39% 7% 9% 4%

2011 45% 42% 2% 4% 7%

2012 53% 41% 2% 0% 4%

VL CBOC 2010 24% 24% 4% 14% 33%

2011 27% 34% 9% 5% 25%

2012 41% 41% 2% 5% 11%

L CBOC 2011 27% 25% 12% 5% 30%

2012 28% 36% 2% 6% 28%

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PC-MHI at American Lake VA Description of clinic

○ Staffing2.5 Psychologists2.5 part-time medication prescribers1.0 Care ManagerPsychology internsClosely tied to telemental health providers

○ ServicesSame day access clinicBrief assessment and treatment (4-6 sessions)Psychoeducation groupsIn-service trainings to PACT

Page 38: AfterDeployment.org Community of Practice - Sept 2013

Types of Groups

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Description of ad.org group 4 sessions open group Referrals mostly from SDAC

OEF/OIF/OND Veteran Access to internet Not in MH treatment

Co-facilitators Russel McCann, PhD (T2 - VA) Psychology Interns

Support materials Provider portal for self-assessments/handouts Workshops for self-monitoring forms

Conference room (up to 8 people) Computer access/standard screen

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Page 41: AfterDeployment.org Community of Practice - Sept 2013

Group Format (weekly) Introductions

Group MembersPast week experiences with ad.orgOverview of website (for new members)

Discussion Question Self-Assessment Video Stories Self-monitoring form Workbook recommendations and handouts

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Introductions (weekly as needed) Members

How long with VABranch of service – deploymentsCurrent living arrangement

WebsiteHistory - T2 developmentcognitive-behavioral principles

FeaturesImportance of sign-up/sign-in: demoLocate, Chat, Call features

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Sleep Introductions Discussion Questions (Board)

Why are sleep problems so common in returning veterans?

What are most common reasons for sleep problems? Complete 10-item American Academy of Sleep Medicine:

Rate Your Sleep Scale Review Video Stories (at least 3 out of 5) Review Sleep Diary (for one week) Developing Good Sleep Habits Handout Workbook exercises

Must sign-up/sign-in to access If not, sleep library for reading

Page 45: AfterDeployment.org Community of Practice - Sept 2013
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Depression Introductions Discussion Question (Board)

What is depression?How is depression different from sadness?

Complete PHQ-9 (SI item) Review Video Stories (1,2 and 4) Review Depression Monitoring Form Workbook exercises/selection

Behavior and Mood for help with monitoring form Depression triggers for help with behavioral activation Challenging negative thoughts for changing cognitions

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PTS Introductions Discussion Question (Board)

What is PTS?How is PTS different from PTSD?

Complete PCL-M Review Video Stories (all 5) Review Trigger Record Workbook exercises/selection

RID tool – managing triggers PLAN tool – planning for triggers Writing tool – addressing “haunting” experiences

PTSD Coach (RID and Plan tool)

Page 49: AfterDeployment.org Community of Practice - Sept 2013
Page 50: AfterDeployment.org Community of Practice - Sept 2013

Anger Introductions Discussion Question (Board)

How is anger different from anxiety and depression? (Different triggers and what we think, feel, and do)

Complete Dimensions of Anger (DAR) scale NO video stories – examples of defining features

on board along with coping strategies Handouts

Create an Anger Control Plan How to Use a Time out

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Charting Background information Presenting Problem

Problem list and/or VCODE: Hx of military deployment

Description of group/topic Individual issues

Completed exercises in past week Results of self-assessment (acuity level) Most salient (most bothersome) feature Group participation level – engagement Insight

Risk Assessment Plan

Recommended workbook activities Specialty care referral

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Clinical Observations

Best “fit” for groupRecently retired/discharged veteranNew to VASymptomatic but functioningLooking for support from other veteransFamiliar with online materials (e.g., student)Not sure about MH treatment

○ Medications○ Psychotherapy

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Clinical Observations Possible outcomes

Drop-out rateSatisfaction with group (feedback)

○ Appreciate online resource/phone app too○ Learned more about postdeployment issues○ Support from others

Referral to specialty care○ Participation in orientation○ Engagement into treatment (EBT)

“Sweet spot” for clinical benefit○ Baseline level of distress○ Engagement/practice with workbook

Page 54: AfterDeployment.org Community of Practice - Sept 2013

Future Direction

Establish network of PCMHI providers interested in group

Identify technological challenges Develop provider manual for group Develop ways to support exercises with

mobile apps Develop “research enabled” feature on

ad.org

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AD.org Community of Practice LinkedIn Group

• Objective:– To provide a forum for health care providers

currently using or interested in learning about the tools available on the AfterDeployment.org website as part of the care they provide.

– To promote discussion about health care practice using AD.org tools, mobile apps, and other technology-based methods

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Who Can Join?

• Current members of the AD.org Community of Practice

• Any health care providers who:– Provide care to the military community: active

duty, guard and reserves, veterans, and military families.

– Are interested in using AD.org tools and resources in their clinical practice.

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How Do I Join? Current COP Participants

• Look for email from LinkedIn inviting you to join the AD.org COP group

• Click the link to accept the invitation and follow the directions

• If you don’t have a LinkedIn account you will need to create one prior to accepting the invitation (www.LinkedIn.com)

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How Do I Join? Non-COP Members

• Sign in to LinkedIn– If you do not have a LinkedIn account, you will need

to create one: www.LinkedIn.com

• Search list of LinkedIn groups for AfterDeployment Community of Practice

• Click “Join” on the group page• You will receive a confirmation message

once your request to join is accepted

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IMHS Integrated Mental Health Strategy

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StartMovingForward.org

A web-based self-help training that teaches problem solving skills to help individuals better handle life’s challenges.

MilitaryParenting.org VeteranParenting.org

A web-based course that provides parenting information and strategies for service member and veteran parents.

IMHS is a DoD-VA initiative to advance a coordinated public health model to improve mental health services for members of the DoD and VA. T2 was tasked with actions to promote access to web technologies and self-help strategies.

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Contacts and Links

• Today’s presenters:– Robert Ciulla, PhD [email protected]– Annabel Prins, PhD [email protected]– David Bradshaw, PhD

[email protected]– Pam Murphy, PsyD

[email protected]

• For a copy of today’s presentations:www.slideshare.net/t2health

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