Health Services Research & Development

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FORUM - Translating research into quality health care for Veterans

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Research Highlight

The "population impact" of a treatment depends not only on its clinical effectiveness, but also on the degree to which it reaches the target population. Highly effective treatments that are delivered face to face in specialty health care settings often have limited population impact due to barriers to care. To maximize population impact, it is critical that VA develop treatments that are both clinically effective and highly accessible. Participants of VA's 2010 State of the Art (SOTA) Conference on Improving Access to Care envisioned a new conceptualization of access for the digital age. Participants redefined access as the potential ease of having virtual or face-to-face interactions with a broad array of health care providers, including clinicians, caregivers, peers, and computer applications.1 By adopting mHealth and eHealth technologies, VA can improve digital access to care in order to overcome geographical, temporal, and cultural barriers to care.

Protocol-driven, evidence-based psychotherapy is an example of an efficacious specialty care treatment that could potentially have a greater population impact if it were more accessible to Veterans. Psychotherapy lends itself well to virtual delivery. While VA has been an early adopter of interactive video, relatively few telepsychiatry encounters entail the delivery of psychotherapy.2 In two recent HSR&D-funded randomized non-inferiority trials (PIs: Agha, Morland) conducted in Community Based Outpatient Clinics (CBOCs), cognitive processing therapy (CPT) was shown to generate equivalent PTSD outcomes when delivered face to face and via interactive video. HSR&D investigators need to replicate these findings for home-based computer video technologies, which have the potential to improve digital access to psychotherapy even more than clinic-based interactive video technologies.

Building on these non-inferiority trials, investigators at the HSR&D Center of Innovation (COIN) at the Central Arkansas Veterans Healthcare System recently completed the Telemedicine Outreach for PTSD (TOP) study (PI: Fortney), which focused on improving digital access to CPT for rural Veterans with PTSD. Embedded within a telemedicine-based collaborative care management model, CPT was offered to Veterans at CBOCs via interactive video. Nurse care managers encouraged initiation of CPT and promoted session attendance and homework adherence. Over half of the Veterans randomized to the intervention group initiated CPT, which contributed to improved outcomes compared to treatment as usual. This randomized trial demonstrates that one evidence-based model of integrating mental health into primary care (Collaborative Care Management) can be delivered virtually to increase population impact. Building on these findings, investigators at HSR&D's COIN at the Central Arkansas Veterans Healthcare System recently received funding approval for a study (PI: Fortney) designed to test whether the other predominant model of integrated care (Co-Located Collaborative Care) can be delivered virtually to CBOC patients. The co-located collaborative care model involves primary care providers facilitating warm handoffs of patients with mental health problems to physically co-located mental health specialists staffing open access clinics, thereby maximizing both geographic and temporal access.3 This study will test whether an open access clinic can be staffed with "virtually co-located" mental health specialists delivering brief evidence-based psychotherapies.

Protocol-driven psychotherapy can also be delivered effectively by a computer program, further improving digital access for Veterans. Based on a recent literature review conducted by the Evidence Based Synthesis program, HSR&D implementation researchers should consider developing strategies to promote the adoption of computer-delivered Cognitive Behavioral Therapy programs. SmartPhone apps are another technology that have great potential to improve digital access to evidencebased psychotherapy. Investigators at the Palo Alto VA Medical Center have developed a suite of SmartPhone apps designed to deliver or augment provider-delivered, evidence-based psychotherapies. Apps include CPT Coach for Cognitive Processing Therapy, PE Coach for Prolonged Exposure Therapy, ACT Coach for Acceptance and Commitment Therapy, CBT-I Coach for cognitive behavioral therapy for insomnia, Mood Coach for Behavioral Activation, Moving Forward for Problem Solving Therapy, and Stay Quit Coach for smoking cessation. These apps have the potential to greatly improve both temporal and geographic access for Veterans and are in the early stages of empirical testing.

Two ongoing pilot studies are underway at the HSR&D COIN at the Central Arkansas Veterans Healthcare System. The Moving Forward app is being evaluated with HSR&D pilot funding (PI: Grubbs) and the Mood Coach app is being evaluated with pilot funding (PI: Brady) from the South Central Mental Illness Research, Education, and Clinical Center (MIRECC). Due to the potential for these SmartPhone apps to be highly cost-effective, HSR&D implementation researchers should consider developing strategies to promote adoption among Veterans and their providers.

  1. Fortney, J.C. et al. "A Re-conceptualization of Access for 21st Century Healthcare," Journal of General Internal Medicine 2011; 26(Suppl 2): 639-47.
  2. Deen, T.L., Godleski L., and Fortney J.C. "A Description of Telemental Health Services Provided by the Veterans Health Administration in 2006-2010," Psychiatric Services 2012; 63[11]: 1131-3.
  3. Pomerantz, A.S. and S. L. Sayers. "Primary Care- Mental Health Integration in Healthcare in the Department of Veterans Affairs," Families, Systems, and Health 2010; 28(2): 78-82.