DescriptionThe U.S. Department of Veterans Affairs (VA) recognizes the importance of mental health among the many healthcare services it delivers to Veterans. VA, Veterans Health Administration (VHA)) operates the largest integrated mental health care system in the U.S., treating more than 1.7 million Veterans for mental health needs in Fiscal Year 2018. 20% of Veterans who served in either Iraq or Afghanistan suffer from either major depression or post-traumatic stress disorder, and 19.5 % of Veterans in these two categories have experienced a traumatic brain injury (Tanielian, et al., 2008). The global pandemic affected the delivery of mental health services to patients experiencing new or worsened mental health issues due to the stresses of the crisis, the reduction in availability of in-person appointments and an exponential increase in telehealth usage.
VA’s Human Factors Engineering (HFE) Division and the Office of Mental Health and Suicide Prevention (OMHSP) therefore collaborated on a project concerning mental health. OMHSP is proactively identifying opportunities to improve the mental health care services for Veterans, specifically for psychotherapy delivery. VHA currently lacks a comprehensive method for collecting psychotherapy data, including identifying services delivered, conditions and problems addressed, and individual/aggregate patient outcomes. Lack of empirical data creates a barrier to meaningfully engaging in quality improvement initiatives, especially those that might target improving Veterans’ outcomes from psychotherapy.
Journey mapping was identified as a tool that could identify barriers and opportunities for improvement in patient experience. It presents a widely-applicable understanding of how various VA facilities are delivering mental health services and how the patient experience varies accordingly. Additionally, journey map artifacts allow HFE and the project team to communicate visually to stakeholders throughout the enterprise.
A journey map follows the storyline of a persona—a fictional character based on qualitative and quantitative data who represents a typical user of a system, product, or service, in this case VHA mental health services—as they progress through a scenario, and depicts the highs and lows of their journey, in terms of both mindset and external actions (Maddox et al., 2019).
This paper shows how VA used journey mapping methodology to discover and depict patients’ psychotherapy experiences. We conducted semi-structured interviews with Veterans, caregivers, and psychotherapy providers; and focus groups with stakeholders in OMHSP. We combined a top-down and bottom-up approach to construct the first iteration of the journey maps. The top-down, high-level needs came from the OMHSP focus groups. The bottom-up, data-driven part of the journey map construction used the qualitative interview data with Veterans, caregivers, and providers according to commonly-used user experience interview categorization techniques organizing the data along thematic lines (Manchaiah, Stephens, & Meredith, 2011; Gualandi, Masella, Viglione, & Tartaglini, 2019; Wheelock, Miraldo, Parand, Vincent, & Sevdalis, 2014).
We used the results to produce maps detailing representative patients’ mental health care experiences including a patient suffering from coronavirus (COVID-19); a patient experiencing homelessness; a highly functional patient navigating implicit racial bias; and a patient resistant to therapy and his caregiver. The initial journey maps were vetted in follow-up focus groups with OMHSP stakeholders and interview with a subset of the patients, caregivers, and providers who participated in the initial interviews. We updated the journey maps based on the feedback and identified areas of success and opportunities for improvement.
Key findings depicted in the journey maps included the importance of primary care in referrals; the desire to include family members in treatment; travel concerns in patients’ decisions about their care; the importance of viewing mental health care as part of a holistic view incorporating Veterans’ infrastructure (housing, employment, technology access, etc.); and varying levels of comfort toward technology and telehealth. The data also show opportunities to utilize health information technology to improve psychotherapy data collection. Tools showing promise include clinical decision support system that show the degree of patient progress on self-reported outcome measures such as mood scales and effect targeted quality improvement.
Our presentation will present the key points of the background and methodology as described above. We will present the journey maps created under this effort and walk through key features thereof. We will discuss ongoing updates to the journey maps and the associated persona. The updates focus even more closely than the existing artifacts on pandemic experiences and use of video telehealth.