Increasing Reach of Evidence-Based Psychotherapies in CBOCs: Identifying Needs and Strategies for Scale Out

循证心理疗法(EBPS)已经证明对许多表现出来的问题有效 包括创伤后应激障碍、抑郁和焦虑。这些疾病的发生率在 退伍军人，造成了重大的公共卫生影响。未经治疗的精神健康诊断增加了罹患 自杀，进一步提高了有效治疗的必要性。治疗这些精神健康问题的努力 退伍军人事务部(退伍军人事务部)在很大程度上是通过在全国推广EBP来解决的。这些 EBP的推广得到了广泛传播，但在退伍军人管理局的环境中表现出的接受度有限， 特别是在基于社区的门诊诊所(CBOC)。通过CBOCs获得EBP对以下方面至关重要 提高精神卫生保健的及时性和效率，因为超过一半的退伍军人使用VA系统 请到CBOCs寻求照顾。此外，退伍军人在农村社区组织的演讲明显减少了精神上的负担 保健预约与城市CBOCs相比，突出了按地点获得保健的差异。 虽然我们知道农村退伍军人得到的照顾较少，但大多数关于EBP实施的研究 是在CBOC设置之外完成的。确定CBOCs的退伍军人得到了什么照顾，为什么 可能得不到EBP，如何满足CBOC提供商的需求对于提高EBP的可及性至关重要 通过量身定做的实施战略。在没有这些信息的情况下，加强实施EBPS CBOCs的可能性不大，获得精神卫生保健的问题将永久化。最大限度地提高 在CBOC中广泛实施EBP的可能性，关键是实施战略是可行的 在CBOC的背景下是可以接受的，其中包括对农村和城市环境的考虑。EBP 在退伍军人制度中的实施传统上是自上而下的方法，这可能会忽视重要的 影响成功实施的背景因素。经常被忽视的重要因素包括， 可能需要适应干预措施和提供最适合护理环境的服务。鉴于CBOCs 与主要退伍军人医院显著不同，了解这些因素的影响是重要的。重要 有关这些背景因素的信息可以通过与CBOC提供商的定性访谈来获得 在农村和城市环境中。该项目将最大限度地利用独特的机会来了解 在CBOCs提供EBP的替代方法，以加强EBPS的覆盖和维持。研究将会 以循证的概念框架为指导，并将利用利益攸关方咨询委员会制定 关于加强农村和城市社区组织实施战略的专家建议。研究性学习 将由一组具有实施科学、定性分析和 退伍军人制度内的EBPS。在运营合作伙伴的投入下，最终的产品有可能 显著提高城乡CBOCs实施EBP的及时性和效率 设置。总而言之，这项拟议的研究将推动国家努力最大限度地提供最佳临床 社区组织在农村和城市环境中的做法，并将最大限度地提高心理健康的效率和及时性 关爱退伍军人。该项目的下一步将是通过IIR提交的报告来传播调查结果 允许测试临床建议和可定制的纵向扩展战略，以增加获得 在农村和城市CBOCs中使用EBPS。

Evidence-based psychotherapies (EBPs) have demonstrated effectiveness for numerous presenting problems including posttraumatic stress disorder, depression, and anxiety. Rates of these disorders are elevated in Veterans, creating a significant public health impact. Untreated mental health diagnoses increase risk of suicide, further elevating the need for effective treatments. Efforts to treat these mental health problems within the Department of Veterans Affairs (VA) have largely been addressed through national EBP rollouts. These EBP rollouts have been disseminated broadly, yet limited uptake has been demonstrated across VA settings, especially in Community Based Outpatient Clinics (CBOCs). Access to EBPs through CBOCs is crucial to increase timeliness and efficiency in mental healthcare as more than half of Veterans utilizing the VA system go to CBOCs for care. Moreover, Veterans presenting to rural CBOCs are receiving significantly less mental health appointments compared to urban CBOCs, highlighting a discrepancy in access to care by location. Although we know that rural Veterans are receiving less care, most of the research on EBP implementation has been done outside of the CBOC setting. Identifying what care Veterans in CBOCs are getting, why they may not be getting EBPs, and how to meet the needs of CBOC providers is vital to enhancing access to EBPs through tailored implementation strategies. Without this information, enhanced implementation of EBPs in CBOCs is unlikely and the access to mental health care problem will be perpetuated. To maximize the likelihood of broad EBP implementation in CBOCs, it is essential that implementation strategies are feasible and acceptable in CBOC contexts, which includes consideration for both rural and urban settings. EBP implementation in the VA system has traditionally been a top-down approach, which may ignore important contextual factors that impact successful implementation. Important factors that are often overlooked include, the potential need for adaptations to interventions and delivery to best fit context of care. Given that CBOCs differ significantly from main VA hospitals, understanding the impact of these factors is important. Important information about these contextual factors can be obtained through qualitative interview with CBOC providers in rural and urban settings. This project will maximize a unique opportunity to understand the potential fit of alternative approaches for EBP delivery in CBOCs to enhance reach and sustainment of EBPs. Research will be guided by evidence-based conceptual frameworks and will utilize a stakeholder advisory board to produce expert recommendations to enhance implementation strategies in rural and urban CBOCs. The research study will be conducted by a team of investigators with expertise in implementation science, qualitative analyses and EBPs within the VA systems. With input from operational partners, the resulting products have the potential to significantly improve timeliness and efficiency in EBP implementation in CBOCs across rural and urban settings. Over all, the proposed study will advance national efforts to maximize delivery of best clinical practices for CBOCs in rural and urban settings and will maximize efficiency and timeliness of mental health care for Veterans. Next steps for this project will be to disseminate findings through an IIR submission that will allow for testing of clinical recommendations and tailorable scale-up strategies for increasing access to, and use of, EBPs in rural and urban CBOCs.