Promoting Effective, Routine, and Sustained Implementation of Stress Treatments

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DESCRIPTION (provided by applicant): Impact: This research will provide VHA with needed information about factors that interfere with and promote adoption and sustained use of evidence-based psychotherapies for PTSD and a clinical tool to help teams more readily identify challenges associated with delivery of evidence based psychotherapies and actionable solutions to those challenges. It will also pilot an implementation strategy in which PTSD Mentors use this clinical tool to help PTSD teams in their VISNs improve reach of evidence-based psychotherapies to more Veterans with PTSD. Background: In 2006, VA began national rollouts of two evidence based psychotherapies for PTSD, Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE). Since that time, VA issued a policy requiring all Veterans with PTSD to have access to CPT or PE. Over 4,600 VA clinicians have been trained to provide CPT and/or PE. However, evaluation data from the rollouts indicates that the majority of trained clinicians use these therapies with only a small proportion of their eligible patients. Therefore CPT and PE are reaching only a small portion of the VA users with a primary PTSD diagnosis. Objectives: (1) Identify through site visit interviews specific team-level structures and practices that influence levels of use of CPT and PE in specialized PTSD outpatient programs and CBOCs; (2) Create the PERSIST Facilitator, a tool to help mental health teams identify actionable solutions to challenges they encounter when attempting to implement PTSD evidence-based psychotherapies. (3) Pilot test an implementation strategy to increase penetration of CPT and PE. This implementation strategy includes integration of the PERSIST Facilitator, goal setting activities that are part of VHA's PTSD Mentoring Program, and internal/external facilitation to improve PTSD Mentors' coaching skills. Methods: We are proposing a mixed method study conducted over two phases to develop tools and strategies for helping teams identify and address local context factors that limit sustained and widespread use of CPT and/or PE. In phase 1, we will use site visit interviews and survey data to understand barriers to implementation and sustained use of evidence-based psychotherapies and to identify structures and processes that can help teams overcome these challenges. Participants will include 81-117 clinicians from 9 PTSD teams and associated CBOCs. In phase 2, we will use this information, along with the British National Health Service Sustainability Index, to create the PERSIST Facilitator. This tool will help teams more readily identify challenges and actionable solutions to those challenges to increase spread and sustained implementation of CPT and PE. Then, we will pilot a multi-modal implementation strategy in which six current PTSD Mentors will use the PERSIST Facilitator in their work with two PTSD teams in their VISN over a 10- month period to expand reach of CPT and PE in these clinics. Formative evaluation will focus on the implementation process and progress as well as PTSD Mentor recommendations for improving the implementation strategy. Summative evaluation will examine change in reach of evidence-based psychotherapies in the target clinics compared with matched control clinics. The PARIHS Framework serves as our overall conceptual model, with Phase 1 focused on the "Context" and Phase 2 focused on the "Facilitation" and "Context" components of the PARIHS Framework.