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提供有关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所需信息，以及帮助团队更容易识别与提供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的临床工具。它还将试行一项实施战略，其中PTSD导师使用这种临床工具帮助他们的VISN中的PTSD团队改善循证心理治疗对更多患有PTSD的退伍军人的影响。背景资料：2006年，VA开始在全国范围内推出两种基于证据的创伤后应激障碍心理疗法，认知加工疗法（CPT）和长期暴露疗法（PE）。从那时起，VA发布了一项政策，要求所有患有PTSD的退伍军人都可以获得CPT或PE。超过4，600名VA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，大多数经过培训的临床医生仅在一小部分合格患者中使用这些疗法。因此，CPT和PE只接触到一小部分患有主要PTSD诊断的VA用户。目的：（1）通过现场访问访谈确定影响专业创伤后应激障碍门诊项目和社区行为委员会中使用持续专业治疗和体育的具体团队级别结构和实践;（2）创建PERSIST促进者，这是一种帮助心理健康团队确定可行的解决方案的工具，以应对他们在尝试实施创伤后应激障碍循证心理治疗时遇到的挑战。(3)试点测试一项实施战略，以提高CPT和PE的渗透率。该实施策略包括整合PERSIST辅导员、作为VHA创伤后应激障碍辅导计划一部分的目标设定活动，以及内部/外部促进以提高创伤后应激障碍辅导员的辅导技能。研究方法：我们提出了一个混合方法的研究进行了两个阶段，以开发工具和策略，帮助团队识别和解决当地的背景因素，限制持续和广泛使用的CPT和/或PE。在第一阶段，我们将使用现场访问访谈和调查数据来了解实施和持续使用循证心理治疗的障碍，并确定可以帮助团队克服这些挑战的结构和流程。参与者将包括来自9个PTSD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，沿着英国国家卫生服务可持续发展指数，创建持久的促进者。该工具将帮助团队更容易地识别挑战和应对这些挑战的可行解决方案，以扩大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战略，其中六名目前的PTSD导师将在10个月内与VISN中的两个PTSD团队一起使用PERSIST促进者，以扩大CPT和PE在这些诊所的覆盖范围。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对改进实施战略的建议。总结性评价将检查目标诊所与匹配的对照诊所相比，循证心理治疗的覆盖范围的变化。PARIHS框架是我们的总体概念模型，第一阶段侧重于PARIHS框架的“背景”，第二阶段侧重于“促进”和“背景”组成部分。

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.