PERSIST Program Improves Access to Evidence-Based Treatment for PTSD among Veterans
December 3, 2021
Takeaway: In collaboration with the National Center for PTSD Mentoring Program, the HSR&D PERSIST program team measured and improved the reach of evidence-based psychotherapies (EBPs) for Veterans with PTSD. The PERSIST team developed quarterly reports to audit Veteran EBP treatment initiation that the PTSD Mentoring Program integrated into practice in VA PTSD specialty care. This collaborative work was associated with a significant increase in the absolute number of Veterans who received an EBP for PTSD in outpatient settings, in addition to increasing the proportion of therapy patients who received an EBP for PTSD.
According to VA’s National Center for PTSD, the number of Veterans with PTSD varies by the era in which they served. About 11-20% of Veterans who served in Iraq and Afghanistan have PTSD in any given year; about 12% of Veterans who served in the Gulf War have PTSD, and approximately 15% of those who served in Vietnam.
Cognitive processing therapy (CPT) is an evidence-based psychotherapy for PTSD that helps patients learn to challenge and modify unhelpful beliefs related to their trauma. Another evidence-based psychotherapy for PTSD – prolonged exposure (PE) – helps patients gradually approach trauma-related memories, feelings, and situations. While the efficacy and effectiveness of CPT and PE have been established, an implementation gap remains. A decade into VA's training initiatives for CPT and PE, the majority of Veterans diagnosed with PTSD still were not receiving either of these evidence-based psychotherapies (EBPs).
Through the Promoting Effective, Routine and Sustained Implementation of Stress Treatments – (PERSIST) program, Nina Sayer, PhD, part of HSR&D’s Center for Care Delivery and Outcomes Research (CCDOR), and her team collaborated with VA’s National Center for PTSD Mentoring Program (Kelly Maieritsch, PhD and Cynthia Yamokoski, PhD) to develop data reports detailing the use of evidence-based psychotherapies for PTSD in outpatient mental health clinic settings across the VA healthcare system – and integrated audit and feedback on EBP initiation into practice. This collaboration focuses primarily on VA’s specialized outpatient PTSD teams known as PTSD Clinical Teams (PCTs) because the provision of EBPs for PTSD is predominantly within the specialty level of care.
PERSIST reports are being distributed to all PTSD teams across the nation each quarter. These reports are being used to identify VA facilities that need assistance in making EBPs for PTSD more accessible – and to monitor changes in EBP use associated with the COVID-19 pandemic and interventions. They also allow for monitoring the use of telemedicine for delivery of EBPs, the importance of which was heightened by the COVID19 pandemic. Additionally, the reports served as a template for Measurement Based Care (MBC) reports provided quarterly to each VISN (Veterans Integrated Service Network) PTSD Mentor for broader distribution to each PTSD team, facility leadership, and chief mental health officers. [MBC is the systematic evaluation of patient symptoms before or during a healthcare encounter to inform mental health treatment.]
There was a significant change from FY2020 to FY2021 in terms of the number of PTSD Clinical Teams (PCTs) that were designated as meeting targets for high reach and low reach for EBPs for PTSD. In FY2020 there were 113 total facilities with PCTs: 39 were considered high EBP reach and 33 were low EBP reach. In FY2021 there were 118 facilities with PCTs: 64 were high reach and only 15 were low reach. HSR&D investigators will continue to provide PERSIST quarterly reports in FY2022, with a focus on supporting more PCTs to transition to and sustain high reach for evidence-based practices.
PERSIST data additionally demonstrate an overall increase in the proportion of therapy patients with PTSD receiving an EBP in outpatient PTSD Specialty Care from FY2020 to FY2021 due to the increase in PTSD Clinical Teams (PCT or PTSD Teams). The PERSIST EBP reach reports showed that PCT providers successfully transitioned to using telemedicine for EBP delivery during the COVID 19 pandemic. Specifically, 87% of EBPs provided by PCT providers were delivered using telemedicine in FY21. The proportion of therapy patients receiving an EBP for PTSD in Primary Care Mental Health Integration (PCMHI), General Mental Health (GMH), and other mental health clinics was relatively unchanged from FY2020 to FY2021.
Moreover, as of January 2021, the PTSD Mentoring Program leadership had adopted the structure of the PERSIST reports for MBC monitoring and is using the dissemination network used for PERSIST EBP reach reports for MBC reporting.
VA’s National Center for PTSD.
Sayer N, Bernardy N, Yoder M, et al. Evaluation of an implementation intervention to increase reach of evidence-based psychotherapies for PTSD in US Veterans Health Administration PTSD clinics. Administration and Policy in Mental Health. May 1, 2021; 48(3):450-463.