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，对 退伍军人、他们的家人和退伍军人健康管理局(VA)。尽管对创伤后应激障碍的治疗很有效 尽管目前仍存在较高的治疗辍学率和普遍的次优应答率，但仍很普遍。合并 接受治疗的家庭成员是改善结果和提供以退伍军人为中心的 护理，以及对退伍军人创伤后应激障碍门诊护理人员的调查显示，80%的人对家庭感兴趣 参与其中。然而，国家行政数据显示，尽管有这种强烈的兴趣和潜在的好处 接受退伍军人创伤后应激障碍治疗的退伍军人中，有1%的人甚至只有一次家庭参与的会议。要了解 影响家庭参与创伤后应激障碍治疗的因素，项目组提出了一项研究 用定性的方法评估相关的背景因素。 意义/影响：该项目高度响应高铁和研发的研究重点，特别是 整体健康护理方法，强调退伍军人作为基石的更广泛背景的突出 健康和健康。该项目还有可能通过蒸馏来促进退伍军人的创伤后应激障碍的治疗 来自在实施家庭包容护理方面取得相对较大成功的设施的智慧。给定 VA患者的创伤后应激障碍带来的巨大疾病负担，加强我们对这种疾病的治疗将 有意义地改善数百万退伍军人的生活。 创新：尽管研究记录了创伤后应激障碍症状之间的重要双向影响 和社会支持，以及家庭功能和行为如何影响创伤后应激障碍的治疗(在两者中 积极和消极的方向)，据我们所知，还没有系统的研究来理解 在退伍军人事务部，家庭参与在实践中得到了落实。 具体目标：(1)确定当前的做法、态度、促进者和家庭参与的障碍 通过在5个“积极偏差”和5个“低参与度”退伍军人管理局的关键利益相关者访谈(总计n≥30)。 (2)找出最佳的临床做法和建议，以加强推行家庭计划 通过利益攸关方咨询委员会的投入参与。 方法：该项目由i-PARIHS框架指导。利益相关者咨询委员会(SAB) 由业务合作伙伴、退伍军人和家属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。关于方法，采访将是 与临床医生和管理人员在“阳性偏差”VA机构(在第90%位数)进行 在全国范围内，将家庭成员纳入退伍军人的创伤后应激障碍治疗)，以及在“较低-- 参与度“设施(第10个百分位数的设施)。积极偏离方法的前提是一些 社区成员已经为面临的问题找到了创新的解决方案 社区，并且这些策略或改变可以被应用来改善其他人的表现。 将使用快速分析方法对面谈记录进行编码，从而实现高效的数据减少和 确定关键主题。然后将结果转换为矩阵，以便进行以下比较 设施。在确定了促进或抑制实施家庭参与的因素之后， 将选择可能针对每个具体情况变量的量身定做的战略。 执行：关于加强以下方面的临床/行政最佳做法的建议 家庭参与创伤后应激障碍治疗将被汇编成面向提供者的提示表，由我们的 业务合作伙伴以及通过创伤后应激障碍国家中心的网站。调查结果将直接导致 随后的IIR建议中，我们将测试已确定的实施战略的使用情况，以增加 家庭参与创伤后应激障碍的治疗，最终促进退伍军人从创伤后应激障碍中恢复过来。

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.