Setting Standards for Delivering High-Quality Care to Veterans with Invisible Wounds

by Carrie M. Farmer, Sierra Smucker, Natalie Ernecoff, Hamad Al-Ibrahim: For Complete Post, Click Here…

he Veteran Wellness Alliance, an initiative of the George W. Bush Institute, is a coalition of seven veteran peer network organizations and nine clinical provider organizations that aims to improve access to high- quality care for post-9/11 veterans with invisible wounds. The alliance collaborated with RAND researchers to develop a shared definition of high-quality care and identify corresponding standards of care for treating invisible wounds.

There are four components of the shared definition of high-quality care for veterans with PTSD, depression, substance use disorders, and TBI:

  1. Veteran-centered care: High-quality care accounts for veterans’ unique needs, values, and preferences. Providers are culturally competent and assess veterans’ experiences, engage them in shared decisionmaking, and involve family members and caregivers in their treatment.
  2. Accessible care: High-quality care is both accessible and timely.
  3. Evidence-based care: High-quality care is based on the best available research and adheres to clinical practice guidelines. Providers perform a comprehensive assessment to guide treatment; conduct screenings; and take an interdisciplinary, team-based approach to care.
  4. Outcome monitoring: High-quality care promotes the use of validated measurement tools to assess and monitor clinical outcomes and veterans’ well-being, guide treatment decisions, and facilitate coordination.

Characteristics of Standards of Care for Invisible Wounds

For standards of care to be useful, they must be feasible to apply and must address important aspects of care.


From an initial list of 103 potential high-quality care measures and standards, 33 were feasible to collect—that is, the necessary data were available, and collecting these data resulted in a minimal burden on programs and providers.


Standards of care were considered important if clinicians and administrators rated them as addressing a very important element of high-quality care. Ambiguous standards and those that applied to only a subpopulation of veterans were considered of low importance. Of the 33 standards of care that were considered feasible, 17 were rated as highly important.

Incorporating feedback from clinical providers, administrators, and policymakers, the researchers consolidated and edited standards for clarity, parsimony, and specificity and recommended a set of ten standards of care (shown below) that address each of the pillars of high-quality care and all four conditions.

Veteran-Centered Care

  • Veterans report being told about treatment options.
  • Program/clinic staff who interact with veterans have completed training in military cultural competence.

Accessible Care

  • Care is available at no or minimal cost to veterans: Program accepts insurance, has resources to support veterans without insurance, or is free.
  • Veterans who request a new outpatient appointment are seen within 30 days.

Examples of Evidence-Based Treatments

  • Evidence-based psychotherapies for depression include acceptance and commitment therapy, behavioral therapy/behavioral activation, cognitive behavioral therapy (CBT), interpersonal therapy, mindfulness-based cognitive therapy, and problem-solving therapy.
  • Evidence-based trauma-focused psychotherapies for PTSD include prolonged exposure, cognitive processing therapy, eye movement desensitization and reprocessing, CBT for PTSD, brief eclectic psychotherapy, narrative exposure therapy, and written exposure therapy.
  • Psychosocial interventions for substance use disorder include behavioral couples therapy, CBT, the community reinforcement approach, motivational enhancement therapy, and 12-step facilitation. Psychosocial interventions are recommended for alcohol, cannabis, and stimulant use disorders. The evidence is unclear on the benefit of psychosocial interventions for opioid use disorder.

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