Changing patterns of care for war-related post-traumatic stress disorder at Department of Veterans Affairs Medical Centers: The use of performance data to guide program development

This study traces the development of services for war-related post-traumati c stress disorder (PTSD) provided at Department of Veterans Affairs (VA) me dical centers. During the 1980s, long-stay inpatient programs were the majo r source of specialized VA treatment for PTSD, and an initial effort at dev elopment of specialized outpatient clinics resulted in incomplete implement ation. In 1988, a full continuum of inpatient and outpatient services was d esigned and a national program of performance monitoring and outcome assess ment was implemented to standardize program structure, monitor delivery, an d evaluate outcomes, A series of multisite outcome studies showed significa nt but modest improvement in association with specialized outpatient treatm ent; they also showed that traditional long-term inpatient programs were no more effective and were far more costly than short-term specialized inpati ent programs. Since 1995, the VA has shifted the emphasis of care substanti ally from inpatient to outpatient settings. National monitoring efforts hav e documented maintenance of specialized PTSD treatment capacity, increased access, improvement on available administrative measures of quality of care , and improved inpatient outcomes. Although there have been major changes i n the treatment of mental illness in most health care systems in recent yea rs, change in the treatment of PTSD at VA medical centers is unique in that it has been guided by the results of multisite outcome studies conducted i n a "real-world" setting and has been supported by ongoing nationwide perfo rmance monitoring.