Implementing and Evaluating Computer-Based Interventions for Mental Health

背景资料。基于计算机的干预(CBIS)提供了一个潜在的有效平台 退伍军人获得初级保健中常见疾病(如抑郁症)的循证治疗， 焦虑和失眠。由于它们的优势，国会要求退伍军人管理局通过 然而，2008.3退伍军人心理健康和其他护理改进法案，评估战略的努力 对于退伍军人事务部初级保健的CBI实施一直是有限的。受支持的CBI实施战略 是为了在初级保健中实施一系列精神健康CBIS而开发的，由四个组成部分组成： (1)患者支持的临床中介，(2)提供者/工作人员的便利和教育，(3)患者教育， 以及(4)为那些需要额外治疗的人提供阶梯式护理。VACT最近的一项试点研究表明， 退伍军人事务部门诊失眠的CBI治疗的可行性。 目标。这项工作的重点将是将CBIS用作干预平台，而不是一个特定的计划 或者说是混乱。然而，治疗失眠的RESTORETM计划将用于测试。那里 有三个目标：(1)使受支持的CBI适应当前退伍军人管理局初级保健组织，(2)测试 支持的CBI的有效性和RESTORETM在VACT初级保健中的临床结果，以及(3) 探索开发基于信息学的流程，以跟踪CBI在退伍军人管理局的使用扩散情况。 假设。 1.支持-通过确定以下内容揭示的障碍/促进者，可以将CBI修改为用于退伍军人管理局的初级保健 国家和地方初级保健提供者和管理者。 2.支持--相对于控制实施战略，CBI将表现出(A)CBI的优越比率 患者的参与，(B)通过转诊至CBI的提供者采用，以及(C)患者完成 CBI，以及(D)改善患者失眠结果。 3.退伍军人管理局组织/提供者是CBI使用的早期采用者和非采用者，可以从退伍军人管理局医疗中心确定 记录文档。一旦确定，面谈将验证信息学发现，确定其他 障碍/促进者，并揭示对支持的CBI的多站点试验感兴趣的站点。 方法：研究方法。支持CBI实施的障碍/促进者将通过定性确定 与退伍军人事务部初级保健领导层和成员进行的半结构化访谈和焦点小组分析 当地的VACT初级保健团队。支持性脑血流显像的初步疗效及临床疗效 RESTORETM(与低强度[控制]策略相比)将在混合类型3中进行评估 实施--效果试验。总结性和流程级实施结果以及临床 将在六个月的时间内评估失眠结果，并在 额外的一年。将使用国家信息检索来评估跨退伍军人事务部使用CBI传播情况 VA临床记录的数据集，以确定使用CBI的实例并针对VA的半结构化访谈 是CBIS的早期采用者和非采用者的提供商。 冲击力。这项研究将修改和测试退伍军人初级保健中CBI实施的战略，该战略可以是 由退伍军人管理局、管理人员和政策制定者使用，以增加对循证心理咨询的访问 医疗保健，减少护理障碍，并提高临床工作效率。这项研究将直接影响退伍军人事务部 通过扩大治疗轻度至中度精神健康的有效、非药物替代方案提供服务 有问题。这项研究将通过增加获得精神卫生保健的机会来影响退伍军人的健康，特别是在 初级保健治疗中常见的疾病的早期阶段。退伍军人的福祉将通过 与干预相关的健康结果和自我效能的改善。退伍军人面临的风险也可能会降低 通过减少潜在有害的精神药物的使用。

Background. Computer-based interventions (CBIs) provide a potentially effective platform for increasing Veteran access to evidence-based treatment for disorders common in primary care such as depression, anxiety, and insomnia. Because of their advantages, Congress mandated that VA implement CBIs via the Veterans' Mental Health and Other Care Improvements Act of 2008.3 However, efforts to evaluate strategies for CBI implementation in VA primary care have been limited. The Supported-CBI Implementation Strategy was developed to implement a range of mental health CBIs in primary care and consists of four components: (1) a clinical intermediary for patient support, (2) provider/staff facilitation and education, (3) patient education, and (4) stepped-care for those requiring additional treatment. A recent pilot study at VACT demonstrated the feasibility of a CBI for insomnia in VA outpatient care when implemented via Supported-CBI. Objectives. The focus of this work will be on using CBIs as intervention platforms and not a specific program or disorder. However, the RESTORETM program for the treatment of insomnia, will be used for testing. There are three objectives: (1) adapt Supported-CBI to current VA primary care organizations, (2) test the effectiveness of Supported-CBI and the clinical outcomes of RESTORETM in VACT primary care, and (3) explore the development of informatics-based processes to track the diffusion of CBI use throughout VA. Hypotheses. 1. Supported-CBI can be modified for use in VA primary care by identifying barriers/facilitators revealed by national and local primary care providers and administrators. 2. Supported-CBI, relative to a control implementation strategy, will demonstrate superior rates of (a) CBI engagement by patients, (b) provider adoption through referral to the CBI, and (c) patient completion of the CBI, as well as (d) improved patient insomnia outcomes. 3. VA organizations/providers who are early- and non-adopters of CBI use can be identified from VA medical record documentation. Once identified, interviews will validate informatics findings, identify additional barriers/facilitators, and reveal sites interested in a multi-site trial of Supported-CBI. Methods. Barriers/facilitators to Supported-CBI implementation will be identified through the qualitative analysis of semi-structured interviews and focus groups with VA-wide primary care leadership and members of local VACT primary care teams. The preliminary effectiveness of Supported-CBI and clinical outcomes of RESTORETM (compared to a low-intensity [control] strategy) will be evaluated in a hybrid type 3 implementation-effectiveness trial. Summative and process-level implementation outcomes as well as clinical insomnia outcomes will be evaluated over a six-month period and the sustainment of implementation over an additional year. The diffusion of CBI use across VA will be evaluated using information retrieval from a national dataset of VA clinical notes to identify instances of CBI use and to target semi-structured interviews of VA providers who are early- and non-adopters of CBIs. Impact. This research will modify and test a strategy for CBI implementation in VA primary care, which can be used by VA providers, administrators, and policy makers to increase access to evidence-based mental healthcare, decrease barriers to care, and increase clinic productivity. This research will directly impact VA providers by expanding efficacious, non-pharmacologic alternatives for treating mild to moderate mental health problems. This research will impact Veteran health by increasing access to mental healthcare, particularly in the early stages of disorders common in primary care treatment. Veteran well-being will be improved through intervention-related improvements in health outcomes and self-efficacy. Risk to Veterans may also lessen through the decreased use of potentially harmful psychotropic medications.