1059 — Implementation Strategies for Increasing Adoption and Fidelity of Cognitive Behavioral Therapy in Primary Care
Cully JA, Kunik M, Naik AD, Stanley MA, and Petersen N, MEDVAMC; Baylor College of Medicine; Armento M, and Nadorff M, Baylor College of Medicine; Mott J, and Kauth M, MEDVAMC; Baylor College of Medicine;
Implementation is a significant barrier to the integration of evidence-based mental health into primary care. Little is known about factors associated with implementation of cognitive behavioral therapy (CBT) in the primary care setting. As part of an HSR&D-funded multisite CBT intervention trial, the current study reports preliminary data from a theory-based implementation strategy designed to increase the adoption and fidelity of CBT as provided by VA Primary Care Mental Health Integration (PCMHI) clinicians.
Multidisciplinary clinicians from two large VA PCMHI programs have been recruited for study participation. Clinicians were trained in a structured brief CBT approach for medically ill Veterans and asked to apply these skills for patients randomized into the clinical trial. Multiple implementation interventions, based on the Promoting Action on Research implementation in Health Services (PARiHS) framework, were used to facilitate clinician training, including: a formative evaluation of clinician CBT utilization, skill needs, and clinical context; development of a comprehensive online CBT training program; audit and expert feedback of clinician CBT adherence and skills using structured fidelity ratings of session audiotapes; and bi-monthly facilitation meetings to address practice barriers and difficulties. Implementation also targeted system barriers and facilitators through PCMHI directors and administrators.
Of the PCMHI clinicians approached, all 8 have successfully completed training and are providing care to study patients. Initial clinician feedback of training indicated high satisfaction and feasibility. Formal fidelity ratings by expert reviewers suggest high levels of clinician adherence and skill. However, implementation challenges have included the need for increased in-person clinician contact, regular feedback and data on adoption and CBT use to clinicians, and better alignment with site-level PCMHI processes (e.g., selection of patients and use of therapy as a frontline treatment). Solutions to these challenges have largely focused on theory-based facilitation strategies and collaborations with clinicians, PCMHI directors, as well as VISN and national VA leadership.
Preliminary results from this HSR&D multisite trial suggest that utilization of CBT in PCMHI is feasible, but requires a multifaceted, flexible implementation approach that includes continuous feedback from stakeholders at various levels.
Theory-based implementation strategies for complex evidence-based mental health treatments such as CBT hold the potential to improve the availability and quality of evidence-based mental health practices delivered within VA.