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

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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.