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2015 HSR&D/QUERI National Conference Abstract

1021 — A Hybrid Effectiveness-Implementation Study of a Referral Management System to Address Barriers to Treatment Seeking among Veterans with PTSD

Possemato K, Center for Integrated Healthcare; Johnson EM, Center for Integrated Healthcare; Wray LO, Center for Integrated Healthcare;

Veterans Affairs (VA) primary care patients have low rates of engagement in evidence-based treatment (EBT) for PTSD. We conducted a hybrid effectiveness- implementation study of a Referral Management System (RMS) to address patient and system-level barriers to the uptake of EBT for PTSD.

RMS addressed patient-level barriers with the delivery of a 1-session cognitive behavioral therapy (CBT) intervention to identify and change treatment seeking beliefs. This intervention was delivered by primary care-mental health integration (PC-MHI) providers. System-level barriers were addressed by 1) care manager phone contacts to assist Veterans in attending appointments and 2) PC staff trainings focused on how to implement VA/ DOD Clinical Practice Guidelines and discuss barriers to treatment with their patients.

Over the 6 month implementation in one primary care clinic, 59 veterans were referred to RMS. Study outcomes were analyzed using the RE-AIM framework. Reach of RMS in primary care was minimal at 13%. RMS implementation was associated with a 100% increase in PTSD clinic referrals and a 76% increase in EBT receipt in PTSD specialty care. RMS participants who received EBTs reported clinically significant decreases in PTSD symptoms (average 10 point decrease on PTSD Checklist), while those who did not receive EBTs reported an average 3 point decrease. Adoption of RMS was moderate among primary care providers and high among PC-MHI providers. RMS was implemented with high fidelity by all providers. Local and national stakeholders provided feedback on study results.

Results provide guidance on further adaptation that is needed for future larger scale implementation efforts, including using a case-finding procedure to expand reach, providing additional PC-MHI sessions to ambivalent patients, and incorporating peer support specialists to help engage Veterans in care.

Patient and system-level modifications can be made within VA primary care to improve mental health treatment engagement and Veteran's health among primary care patients with PTSD.