Navy Medicine: A Strategic Roadmap for Implementing a Virtual Mental Health Program

FEBRUARY 24, 2020
CAPT Valerie Riege, MSC, Chief Innovation and Integration Officer, BUMED, U.S. Navy
Jeffrey Millegan, MD

Jeffrey Millegan, MD

Mental and behavioral health have always been a topic of great concern and are just as critical as an Active Duty Service Member’s (ADSM) physical health.

Today, there is greater focus on preventative education and providing early intervention and support to those exhibiting signs of mental illness. However, the public stigma surrounding mental health remains a barrier for many Sailors and Marines to reach out for treatment, although the likelihood for them to experience mental health disruptions at some point in their career is formidable.

According to the Defense Health Agency’s Psychological Health Center of Excellence, unique barriers exist for service members who seek treatment. These barriers include the fear that seeking treatment will affect their career, the fear of losing support from their command, a culture of "toughing it out," which can interfere with the perception of need, and the fear of being separated from military service due to treatment.

Navy Medicine is taking much-needed steps to reduce or eliminate those fears, bringing health care to a global community with a Virtual Mental Health Program designed to cross borders and drastically reduce or eliminate the stigma.

AN ESSENTIAL NEED

Military service can be challenging for families as well as the ADSM. According to the National Council for Behavioral Health, 46% of adults will experience a mental illness during their lifetime. From 2017 to 2019, the percentages of active duty Sailors and Marines with mental health issues have remained relatively close in comparison ranging from 5.5% to 6.1%.

In fiscal year 2019, nearly 6% (Table 1) of Active Duty Service Members (Navy/Marines) received a diagnosis of a mental health disorder. Remote hazardous locations, traumatic events, changing environments, and other pressures present ever-increasing dangers to the mental health of Sailors and Marines.

Additionally, many active duty Sailors and Marines are outside “access to care” regions - located more than 60 minutes of drive time to a military medical treatment facility in the continental United States or more than 40 miles from a military medical treatment facility outside the continental United States. This further demonstrates a need for virtual mental health services which can operate efficiently in real-time (synchronous) or at “store and forward” delayed communications which are stored then later routed (asynchronous) depending on the case presented.
 
Mental Health (New Patients) by Fiscal Year
Branch Fiscal Year Active Duty Patients Total Active Duty % of Total Active Duty
Marine Corps 2016 12,288 191,150 6.4%
  2017 11,589 191,010 6.1%
  2018 11,630 191,717 6.1%
  2019 10,687 192,162 5.6%
Navy 2016 21,885 345,993 6.3%
  2017 19,987 342,183 5.8%
  2018 20,733 341,467 6.1%
  2019 19,158 347,913 5.5%

In the past, addressing mental health issues has been dependent on the number of health care providers and the needs of the location. ADSMs scheduled an appointment and in some locations, had to wait weeks to see a behavioral health specialist. For instance, if ADSMs are on smaller combatant ships, in remote locations, or on an assignment without direct access to a clinician, this wait time may be even longer.

If the presenting case required immediate intervention and treatment, then transporting to the emergency room or military medical treatment facility via medical evacuation would allow access to care. Early access to mental health support (whether virtually or in-person) can lead to fewer instances of mental health disruptions that may lead to suicide; thereby improving mission readiness.

The National Defense Authorization Act of 2017 (NDAA 2017) requires the Department of Defense to increase the use of telehealth services, making it possible to have virtual health encounters. NDAA 2017 allows for the maximization of the use of such services to provide real-time interactive communications between patients and health care providers and remote patient monitoring.

Recognizing the barriers to mental health treatment in the global organization, the U.S. Navy’s Bureau of Medicine and Surgery (BUMED) Operational Virtual Mental Health Work Group was established in October 2018.

The work group strategized and standardized the delivery of virtual mental health care services to ensure that Sailors and Marines are able to receive the most appropriate mental health care anytime and anywhere. This work group sought to find a solution to answering the question: In what ways can Navy Medicine contribute and make an immediate impact to overall reductions in suicides, depression, stress, anxiety, and the divorce rate so commonly associated with our Nation’s military?

The group focused on strategy and foundational objectives to develop a test plan and design a Virtual Mental Health Program that provides care and support when and where needed, especially in remote, austere locations.

NAVY MEDICINE’S PILOT PROGRAM

In August 2019, Navy Medicine completed a pilot program designed to test the effectiveness of mental health care provided both virtually and in person within two different geographic regions. During the pilot which spanned a six-month period, more than 800 ADSMs held virtual visits with a behavioral health/mental health provider. Some patients received a virtual visit and follow up care from a provider located 90 miles away via a secure video teleconference connection.

Benefits to both patients and providers were immediately realized as patients didn't have to drive to see a provider, and patients were less reluctant to have a conversation virtually than in person. Providers also recognized the efficiencies of working in a virtual environment, such as reduced costs by eliminating travel between locations and maximized ability to see more patients in virtual visits. Based on experience with the pilot, it is ideal to have a clinician be dedicated to providing care to a distant site versus using multiple clinicians to cover a distant site. 

Having 1 dedicated clinician allows the on-site clinical staff more consistency in workflow procedures and more reliability in handling patient concerns that arise outside of scheduled clinical appointments.

The overall success of the program demonstrates the value to provide the same level of care to the patient regardless of the proximity to the provider. Since inception, mental health clinicians have provided virtual visits to 6691 ADSMs [4] for a multitude of conditions such as post-traumatic stress disorder (PTSD), attention deficit disorder, personality disorder, and adjustment disorder (Tables 2 and 3).
Service Branch Diagnosis FY Active Duty Total Virtually Treated
Marine Corps Anxiety Disorders (Adjustment, PTSD) 2016 140
    2017 116
    2018 285
    2019 237
  Attention Deficit Disorder and Order 2016 8
    2017 14
    2018 19
    2019 31
  Behavioral Syndromes 2016 11
    2017 15
    2018 4
    2019 6
  Delirium, Dementia, Unspecified 2018 7
  Mood Disorders 2016 57
    2017 93
    2018 18
    2019 67
  Other Psychoactive Substances 2016 4
    2017 3
    2018 13
    2019 67
  Personality Disorders 2017 3
    2018 1
    2019 2
  Psychotic Disorder 2018 1

Table 2: Total Marine Corps ADSMs Virtually Treated by Disorder
 
Service Branch Diagnosis FY Active Duty Total Virtually Treated
Navy Anxiety Disorders (Adjustment, PTSD) 2016 240
    2017 294
    2018 556
    2019 625
  Attention Deficit and Other 2016 31
    2017 56
    2018 5
    2019 55
  Behavioral Syndromes 2016 8
    2017 4
    2018 5
    2019 55
  Delirium, Dementia, Unspecified 2016 6
    2017 5
    2018 2
    2019 8
  Developmental Disorders 2018 1
  Mood Disorders 2016 146
    2017 203
    2018 374
    2019 287
  Other Psychoactive Substances 2016 10
    2017 8
    2018 26
    2019 22
  Personality Disorders 2017 17
    2018 15
    2019 21
  Psychotic Disorder 2017 3

Table 3: Total Navy ADSMs Virtually Treated by Disorder

EXPANDING THE CONTINUUM OF CARE


Now in its second year, Navy Medicine offers a full range of virtual approaches for ADSMs to receive the care and support they need, not just for mental health, but for primary and specialty care as well. Self-help is available via various smartphone applications, which offer a positive approach and techniques to improve overall well-being. 

When in the Continental United States, Navy Medicine has a well-developed TRICARE network of clinicians available to provide both in-person and virtual health care. For ADSMs who are overseas or stationed in a remote area where in-person appointments are limited, virtual options expand the continuum of care and become even more crucial to ensuring overall medical readiness. Given varied access to broadband connections during deployments, the Navy is now pursuing a second pilot investigating the feasibility and utility of asynchronous video virtual mental health. 

In the proposed pilot, senior enlisted medical personnel will have access to a list of questions to pose to the ADSM and the responses are recorded. The video is then uploaded to a secure site and sent to a mental health provider who then views and analyzes the responses. The mental health provider can take a proactive approach and manage the transition of care through options ranging from e-mail /phone consultation to the ship or direct, synchronous audio or video virtual mental health support to the Sailor if required.
Since 2016, the virtual mental health program has been facing a steady incline.

The Marine Corps has experienced a 59% increase in mental health virtual visits from 2016 to 2019, while the Navy has witnessed a resounding 140% increase in these visits (Table 4).
 
Branch of Service FY # of Virtual Visits
Marine Corps 2016 355
  2017 332
  2018 556
  2019 565
 
Branch of Service FY # of Virtual Visits
Navy 2016 733
  2017 765
  2018 1628
  2019 1757

Table 4: Number of Mental Health Virtual Visits by Branch of Service
MOVING FORWARD
Technology being implemented now allows for flexible collaboration via life-size video on a 23-inch touchscreen. The provider and the patient can meet and talk as if they are in the same room. Virtual treatment for families, telepsychiatry, is now being provided utilizing smartphones or tablets in select locations with future plans to expand globally. Self-help mobile apps, 24/7 crisis lines, asynchronous video therapy, and synchronous virtual visits provide simple, effective, and confidential access to care and support.

Presently in the testing phase and receiving positive response, select providers are utilizing Virtual Reality (VR) headsets with a biofeedback mechanism which assesses a patient’s breathing and provides relaxation techniques, reduces stress and anxiety, and desensitizes neurons to minimize pain occurrences. This paradigm shift with technology takes connected care to a new level and is essential in eliminating the barriers to care that have traditionally existed.

CONCLUSION

Whether military or civilian, more and more people are accustomed to interacting with others via some form of technology. Navy Medicine is working to make health care increasingly convenient and accessible utilizing the technologies Active Duty Service Members have readily available such as smart phones, tablets, or laptops. In his November 15, 2016 address in Falls Church, Virginia to present his new Mission, Vision, Principles and Priorities for Navy Medicine, Vice Adm.

Forrest Faison, former Navy Surgeon General and Chief, Bureau of Medicine and Surgery (BUMED) stated, “My vision for the Navy and Marine Corps family is to have the best readiness and health in the world and that we provide the best care our nation can offer, whenever and wherever needed."

The goal for the Virtual Mental Health Program is to essentially normalize and drastically reduce the stigma and the barriers surrounding mental health to improve and facilitate conversation. Based on the initial Virtual Mental Health pilots, substantial benefits were observed to include a more than 100% increase in provider to patient encounters per month, thereby allowing patients to be in front of the provider and receive quicker diagnosis, which is crucial. This increase in provider availability via virtual mental health services may alleviate future emergency and severe mental health scenarios and will provide a reduction in travel time and expenses for both provider and patient. The Virtual Mental Health pilots offer fact-based evidence that with greater access to care, better patient outcomes are expected.

Captain Valerie J. Riege, MHA, is the Chief Innovation and Integration Officer of the Bureau of Medicine and Surgery. The presented analysis reflects his/her views, not necessarily those of the publication. 

Co-author Jeffrey Millegan, MD, is the chair of Operational Virtual Mental Health at the Bureau of Medicine and Surgery of the US Navy. 

Co-author Prima Baines, MPH, is a project manager at ASM Research.
 
Health care professionals and researchers interested in responding to this piece or similarly contributing to HCPLive® can reach the editorial staff by submitting a request here. 

Riege is a military service member or federal/contracted employee of the United States government. This work was prepared as part of my official duties. Title 17 U.S.C. 105 provides that “copyright protection under this title is not available for any work of the United States Government.” Title 17 U.S.C. 101 defines a U.S. Government work as work prepared by a military service member or employee of the U.S. Government as part of that person's official duties.
 

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