Promoting Effective, Routine, and Sustained Implementation of Stress Treatments

描述(由申请人提供)： 影响：这项研究将为VHA提供关于干扰和促进采用和持续使用循证心理疗法治疗创伤后应激障碍的因素的必要信息，并提供一个临床工具，帮助团队更容易地识别与交付循证心理疗法相关的挑战和针对这些挑战的可行解决方案。它还将试行一项实施战略，其中创伤后应激障碍导师使用这一临床工具来帮助他们的VISN中的创伤后应激障碍团队改善循证心理治疗对更多患有创伤后应激障碍的退伍军人的影响。背景：2006年，退伍军人事务部开始在全国范围内推出两种以证据为基础的心理疗法，即认知加工疗法(CPT)和长期暴露疗法(PE)。从那时起，退伍军人管理局发布了一项政策，要求所有患有创伤后应激障碍的退伍军人都可以获得CPT或PE。超过4600名退伍军人临床医生接受了提供CPT和/或PE的培训。然而，来自推广的评估数据表明，大多数训练有素的临床医生只对一小部分符合条件的患者使用这些疗法。因此，CPT和PE只接触到一小部分被诊断为初级创伤后应激障碍的退伍军人。目标：(1)通过现场访问确定特定的团队级别的结构和做法，这些结构和做法会影响在创伤后应激障碍专科门诊项目和CBOC中使用CPT和PE的水平；(2)创建持久促进器，这是一种工具，帮助精神卫生团队确定可行的解决方案，以应对他们试图实施创伤后应激障碍循证心理疗法时遇到的挑战。(3)试点提高CPT和PE渗透率的实施策略。这一实施战略包括整合坚持促进者、作为VHA创伤后应激障碍指导计划一部分的目标设定活动，以及提高创伤后应激障碍导师的指导技能的内部/外部促进。方法：我们建议进行一项分两个阶段进行的混合方法研究，以开发工具和战略，帮助团队识别和解决限制持续和广泛使用CPT和/或PE的本地背景因素。在第一阶段，我们将使用现场访问访谈和调查数据来了解循证心理疗法实施和持续使用的障碍，并确定可以帮助团队克服这些挑战的结构和过程。参与者将包括来自9个创伤后应激障碍团队和相关CBOC的81-117名临床医生。在第二阶段，我们将使用这些信息以及英国国家卫生服务可持续发展指数来创建持久化促进器。该工具将帮助团队更容易地识别挑战和针对这些挑战的可行解决方案，以增加CPT和PE的传播和持续实施。然后，我们将试行一项多模式实施策略，在10个月的时间里，六名现任创伤后应激障碍导师将在他们的VISN中与两支创伤后应激障碍团队一起工作，以扩大CPT和PE的覆盖范围。形成性评价将侧重于实施过程和进展，以及创伤后应激障碍导师关于改进实施战略的建议。终结性评估将检查目标诊所与匹配对照诊所相比，循证心理疗法覆盖范围的变化。PARIHS框架是我们的总体概念模型，第一阶段侧重于“背景”，第二阶段侧重于PARIHS框架的“促进”和“背景”部分。

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.