Reaping the Wisdom of Positive Deviants to Increase the Reach of Family Involvement in PTSD Treatment

背景：创伤后应激障碍（PTSD）是一种毁灭性的疾病， 退伍军人，他们的家人和退伍军人健康管理局（VA）。虽然创伤后应激障碍的有效治疗方法 尽管存在这些问题，但高的治疗退出率和一般而言次优的应答率仍然很常见。结合 接受治疗的家庭成员代表了改善结果和提供以退伍军人为中心的 护理，对门诊VA PTSD护理的退伍军人的调查表明，80%的人对家庭感兴趣 参与。然而，尽管有这种强烈的兴趣和潜在的利益，国家行政数据显示， 在VA PTSD治疗中，<1%的退伍军人甚至只有一个家庭参与的会议。了解 在PTSD治疗中使用家庭参与的因素，项目小组提出了一项研究， 使用定性方法评估相关的背景因素。 意义/影响：该项目高度响应HSR&D的研究重点，特别是 全健康护理方法，强调退伍军人更广泛背景的突出性作为基石 of health健康and wellness健康.该项目也有可能通过提取 在实施家庭包容性护理方面取得相对较大成功的设施的智慧。鉴于 VA患者中PTSD的重大疾病负担，加强我们对这种疾病的治疗将 改善数百万退伍军人的生活。 创新：尽管研究记录了PTSD症状之间重要的双向影响， 和社会支持，以及家庭功能和行为如何影响PTSD治疗（在这两个方面）。 积极和消极的方向），据我们所知，还没有系统的研究来了解如何 家庭参与在弗吉尼亚州的实践中得到落实。 具体目标：（1）查明家庭参与的现行做法、态度、促进因素和障碍 通过在5个“积极偏离”和5个“低参与”VA机构的关键利益相关者访谈（总n ≥ 30）。 (2)确定最佳临床实践和建议，以加强家庭 通过利益攸关方咨询委员会的投入参与。 方法：该项目以i-PARIHS框架为指导。利益相关者咨询委员会（SAB） 由业务合作伙伴、退伍军人和家庭成员以及其他具有关键知识的个人组成， 在项目的所有阶段提供指导和反馈。在方法上，面试将 在“阳性异常”VA机构（第90百分位数）的临床医生和管理人员中进行 在全国范围内，关于将家庭成员纳入退伍军人的创伤后应激障碍治疗），以及在“低- 参与”设施（第10百分位）。积极偏离方法的前提是， 一个社区的成员已经发现了解决问题的创新方法， 这些策略或改变可以应用于改善其他人的表现。 访谈记录将使用快速分析方法进行编码，以便有效减少数据， 确定关键主题。然后将结果转换为矩阵，以便进行比较 设施在确定了促进或抑制家庭参与的因素之后， 将选择有针对性的战略，这些战略有可能解决每一个具体情况的变量。 实施：关于加强临床/管理最佳实践的建议 家庭参与创伤后应激障碍治疗将被汇编成一个面向提供者的提示表，由我们的 业务合作伙伴以及通过国家创伤后应激障碍中心网站。调查结果将直接导致 随后的IIR建议，我们将测试使用确定的实施战略，以增加 家庭参与创伤后应激障碍治疗的吸收，最终提高退伍军人从创伤后应激障碍中的恢复。

BACKGROUND: Post-traumatic stress disorder (PTSD) is a devastating illness that has substantial costs to Veterans, their families, and the Veterans Health Administration (VA). Although effective treatments for PTSD exist, high rates of treatment dropout and generally sub-optimal response rates remain common. Incorporating family members in treatment represents one avenue for improving outcomes and providing Veteran-centered care, and surveys of Veterans in outpatient VA PTSD care indicate that 80% are interested in family involvement. However, despite this strong interest and potential for benefit, national administrative data show that <1% of Veterans in VA PTSD treatment have even a single family-involved session. To understand the factors contributing to the use of family involvement in PTSD treatment, the project team proposes a study using qualitative methods to assess relevant contextual factors. SIGNIFICANCE/IMPACT: The project is highly responsive to HSR&D’s Research Priorities, particularly the Whole Health approach to care which emphasizes the salience of Veterans’ broader context as a cornerstone of health and wellness. The project also has the potential to advance PTSD treatment for Veterans by distilling wisdom from facilities that have had relatively greater success in implementing family-inclusive care. Given the substantial disease burden of PTSD among VA patients, enhancing our treatment of this disorder would meaningfully improve the lives of millions of Veterans. INNOVATION: Despite research documenting the important bidirectional impacts between PTSD symptoms and social support, and the ways that family functioning and behaviors can impact PTSD treatment (in both positive and negative directions), to our knowledge there has been no systematic research to understand how family involvement is implemented in practice in VA. SPECIFIC AIMS: (1) To identify current practices, attitudes, and facilitators and barriers to family involvement through key stakeholder interviews (total n ≥ 30) at 5 “positive deviant” and 5 “lower-involvement” VA facilities. (2) To identify best clinical practices and recommendations for enhancing the implementation of family involvement through input from a Stakeholder Advisory Board. METHODOLOGY: The project is guided by the i-PARIHS framework. A Stakeholder Advisory Board (SAB) composed of operational partners, Veterans and family members, and other individuals with key knowledge will provide guidance and feedback throughout all phases of the project. Regarding methods, interviews will be conducted with clinicians and administrators at “positive deviant” VA facilities (those in the 90th percentile nationally with respect to incorporating family members into Veterans’ PTSD treatment), as well as at “lower- involvement” facilities (those in the 10th percentile). The premise of the positive deviant approach is that some members of a community have already discovered innovative solutions to problems which face that community, and these strategies or changes may be applied to improve the performance of others. Interview transcripts will be coded using a rapid analytic approach, allowing for efficient data reduction and identification of key themes. Results will then be transformed into matrices to allow for comparisons across facilities. Following the identification of factors that promote or inhibit the implementation of family involvement, tailored strategies will be selected that are likely to address each context-specific variable. IMPLEMENTATION: Recommendations for clinical/administrative best practices with regard to enhancing family involvement in PTSD treatment will be compiled into a provider-facing tip sheet, to be distributed by our operational partners as well as through the National Center for PTSD website. Findings will lead directly to a subsequent IIR proposal in which we will test the use of the identified implementation strategies to increase the uptake of family involvement in PTSD treatment, ultimately enhancing recovery from PTSD for Veterans.