Improving Psychiatric Assessments for Veterans in An Urban Outpatient Mental Health Clinic

BackgroundThe U.S. Department of Veteran Affairs (VA) has created multiple programs to help veterans with mental health problems including, post-traumatic stress disorder (PTSD), substance abuse, and suicide. Over 1.8 million veterans received specialized mental health services in 2015. Depending on service area, rates for PTSD among veterans is between 11-20%, substance abuse is 11%, and the suicide rate for veterans is 1.5 times higher than that of non-veterans. One gap that exists for veterans seeking mental health services at an urban mental health clinic in the Intermountain West occurs during the mental health intake process. The current process focuses on obtaining patient data using closed-ended questions and entering the data into the electronic medical record, CPRS, during the interview. This process requires a structured, time-consuming interview that interferes with the development and fostering of the early therapeutic alliance. The therapeutic alliance cultivates a sense of security for veterans and motivates them towards behaviors that improve overall sense of well-being. MethodsA quality improvement project was developed to improve the mental health diagnostic interview at an urban mental health clinic in a way that would cultivate an early therapeutic alliance. Psychiatric Mental Health Nurse Practitioner students performing diagnostic interviews at the participating clinic were interviewed and surveyed using the Helping Alliance Questionnaire II (HAq-II) to determine how the current interview process affects the therapeutic alliance with veterans. The HAq-II is a 19-item instrument that measures the three main components of alliance: tasks, goals, and bond. Using feedback from these assessments, an easy-to-use 1-page, double-sided intake worksheet was created to facilitate a conversational approach with the veteran. The worksheet was introduced to participating students and implemented for future student-veteran interviews. Post-intervention interviews were conducted and students completed a post-intervention HAq-II survey. ResultsPre-intervention qualitative data showed that the current intake process is time-consuming and cumbersome. Data also showed that the current intake process interfered with getting to know the veteran. Post-intervention surveys produced feedback that the worksheet was helpful in building rapport with patients and that using a worksheet simplified the interview process. Quantitative results were limited by a sample size of five.ConclusionsThis project identified and addressed the need to improve the veteran intake assessment process. The intervention, a two-sided worksheet, improved clinical students' intake assessment satisfaction and they stated that their rapport with veterans was strengthened. This worksheet will be provided to all NP students at this urban mental health clinic in future semesters. Further research should be done to assess veteran satisfaction with the intake process and strength of therapeutic alliance following an intake assessment.