Care Managers Strengthen PTSD Treatment Engagement Among Rural Veterans

In a US Department of Veterans Affairs (VA) telehealth-based initiative known as the Telemedicine Outreach for PTSD (TOP) trial, rural veterans diagnosed with posttraumatic stress disorder (PTSD) reported overwhelmingly positive experiences with care managers (CMs), even though only a small percentage ultimately engaged in trauma-focused psychotherapies (TFPs) such as prolonged exposure or cognitive processing therapy. The study, which involved in-depth interviews with 43 veterans between 2017 and 2019, aimed to understand how CMs influenced patients' treatment engagement, particularly in light of persistent barriers to accessing PTSD-focused therapies among rural populations.

Despite only 6% of veterans in the broader TOP evaluation initiating a TFP, nearly all participants who recalled working with a CM spoke of the encounter in highly favorable terms. Veterans emphasized the CMs' warmth, reliability, and genuine interest in their well-being. Many described their CM as someone who made them feel heard, respected, and cared for, often contrasting those experiences with less personal interactions they’d had elsewhere in the VA system. This trust fostered an environment in which veterans felt more comfortable engaging with the health care system as a whole, even if they remained hesitant to participate in trauma-specific treatments.

The study identified 3 principal ways in which CMs were seen as helpful. Care managers acted as connectors across VA services, helping patients navigate the system and access a range of clinical and support services, including mental health appointments, physical therapy, and medication management. Veterans frequently praised their CM’s ability to coordinate care holistically, going beyond their PTSD treatment needs to address broader health concerns.

Veterans were struck by the authenticity and compassion expressed in the CMs’ voices during phone conversations. The term “voice of concern” emerged as a recurring theme in interviews, with patients highlighting the emotional reassurance conveyed in their interactions. For many, these calls did not feel like standard check-ins but rather personal conversations with someone who truly cared. This perception significantly distinguished the CMs from other providers and encouraged veterans to stay engaged with VA care in general.

For those who began a trauma-focused therapy, CMs played a vital support role by acting as informal “side counselors.” Veterans described how CMs followed up before and after sessions, checked on their emotional state, and helped them process difficult content. These check-ins were particularly valuable given the emotional intensity associated with exposure-based treatments. Some veterans even credited their CMs with helping them remain in treatment when they might otherwise have dropped out, illustrating how consistent contact and support can serve as an extension of formal therapy.

Interestingly, the same respectful, low-pressure approach that made veterans feel safe and supported may have also contributed to the low rates of TFP engagement. CMs avoided being directive, instead offering options and allowing Veterans to choose their own path. While this approach fostered trust, it may have led some patients to defer or decline treatment that might have been clinically beneficial.

The findings offer several takeaways for clinicians who care for veterans with PTSD. The CM–veteran relationship, characterized by empathy, consistency, and personalization, emerged as a key facilitator of care engagement. Even when patients did not enter trauma-focused therapy, the support provided by CMs was seen as beneficial in its own right. The study underscores the importance of viewing patient perspectives as central in designing and implementing collaborative care models and suggests that leveraging trusted relationships may be crucial to increasing treatment uptake and reducing attrition in PTSD care among veterans.

Reference

Petrova VV, Simons C, Rajan S, et al. "Voice of concern" for rural veterans with PTSD: care managers' role engaging rural veterans in evidence-based therapies via telemedicine. Psychol Trauma. Published online February 20, 2025. doi:10.1037/tra0001845