Implementing and Evaluating Computer-Based Interventions for Mental Health

背景基于计算机的干预措施（CBIs）提供了一个潜在的有效平台， 退伍军人获得循证治疗的疾病常见的初级保健，如抑郁症， 焦虑和失眠由于其优势，国会授权VA通过 2008年退伍军人心理健康和其他护理改善法案。 在VA初级保健中实施CBI的情况有限。支持的CBI实施策略 是为了在初级保健中实施一系列心理健康CBIs而开发的，由四个组成部分组成： (1)为患者提供支持的临床中介，（2）提供者/工作人员便利和教育，（3）患者教育， 以及（4）对需要额外治疗的患者进行分级护理。VACT最近的一项试点研究表明， 通过支持性CBI实施时，CBI治疗VA门诊治疗失眠的可行性。 目标.这项工作的重点将是使用CBIs作为干预平台，而不是一个具体的计划 或紊乱。然而，RESTORETM方案用于治疗失眠，将被用于测试。那里 有三个目标：（1）使支持性CBI适应当前VA初级保健组织，（2）测试 支持性CBI的有效性和RESTORETM在VACT初级护理中的临床结局，以及（3） 探索基于信息的流程的发展，以跟踪整个VA使用CBI的扩散。 假设。 1.支持性CBI可以通过识别以下因素揭示的障碍/促进因素进行修改，以用于VA初级保健 国家和地方初级保健提供者和管理者。 2.相对于控制实施策略，支持性CBI将证明（a）CBI的上级率 患者参与，（B）通过转诊到CBI的提供者采用，以及（c）患者完成 CBI，以及（d）改善患者失眠结局。 3.可以从VA Medical中识别早期采用和未采用CBI的VA组织/提供者 记录文件。一旦确定，访谈将验证信息学发现，确定其他 障碍/促进因素，并揭示对支持性CBI的多中心试验感兴趣的中心。 方法.支持CBI实施的障碍/促进因素将通过定性 分析半结构化访谈和焦点小组与VA全初级保健领导和成员， 当地的VACT初级保健团队。支持性CBI的初步疗效和临床结局 RESTORETM（与低强度[对照]策略相比）将在混合型3中进行评价 实施效果试验。总结性和过程级实施结果以及临床 失眠的结果将在六个月内进行评估，并在一个月内维持实施。 额外的一年。CBI在VA中的使用扩散将使用来自国家的信息检索进行评估 VA临床记录数据集，以识别CBI使用实例，并针对VA的半结构化访谈 早期和非CBI采用者的供应商。 冲击这项研究将修改和测试在VA初级保健中实施CBI的策略， 由VA提供者，管理人员和政策制定者使用，以增加基于证据的心理健康 医疗保健，减少护理障碍，提高诊所生产力。这项研究将直接影响VA 提供者通过扩大有效的，非药物替代治疗轻度至中度心理健康 问题这项研究将通过增加获得精神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早期疾病。退伍军人的福利将得到改善， 与干预有关的健康结果和自我效能的改善。退伍军人的风险也可能减少 通过减少使用可能有害的精神药物。

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.