In 2006, VHA began national training initiatives for two evidence-based psychotherapies (EBPs) for PTSD, Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE). Since that time, VHA issued a policy requiring that its medical centers make CPT and PE available to all veterans with PTSD and over 4,000 mental health clinicians have completed competency based training to become approved CPT and PE providers. Despite efforts to increase capacity to delivery CPT and PE, only a small proportion of veterans with PTSD receive CPT or PE. An understanding of factors that lead to successful implementation of CPT and PE in specialized outpatient PTSD clinics could set the stage for policy and programs to increase the penetration of evidence-based treatments within and possibly outside of VHA.
The primary objective of this study was to identify organizational and clinic level factors that promote high levels of use of CPT and PE in specialized outpatient PTSD programs.
Secondary objectives were to:
(2) Explore the relationship between patient, facility and PTSD team characteristics and the likelihood of sustainability of EBPs for PTSD.
(3) Explore the relationship between patient, facility and PTSD team characteristics and reach of EBPs for PTSD.
(4) Describe variation in CPT and PE delivery in terms of patient selection, reach and dose.
This was a mixed method study. Objective 1 involved Rapid Assessment Process methodology. We used VHA administrative data to select 10 PTSD teams from 9 VA medical centers that reflected a range of geographic regions, patient volume, and high, medium, and lower reach of CPT and PE. Over a 14 month period roughly corresponding to FY 2015, we conducted 100 individual interviews with 7 to 15 staff from each of the 9 medical centers, 3 staff with roles in overseeing national CPT and PE training initiatives and 1 staff involved in an EBP change initiative at an additional site. The study's interview guide was based on the National Health Service Sustainability Model. We used constant comparison to compare and contrast high, medium and low-use sites in terms of identified themes. Objective 2 through 4 data sources included an anonymous online survey of PTSD team clinicians to assess team processes and sustainability of CPT and PE using standardized measures as well as FY 2015 VHA administrative data. We used chart note templates and Natural Language Processing to determine whether or not a patient had received CPT or PE and to calculate EBP reach among therapy patients. We used factor analysis to create one overall team processes measure with higher scores indicating better team functioning. Because CPT and PE sustainability scores were highly correlated (r=.95, p < 0.0001), we combined CPT and PE into one sustainability score. Objective 2 analyses involved descriptive statistics and linear mixed models, with providers clustered within teams. Adjusted models used all independent variables with p < 0.2 from simpler models. Objective 3 analyses involved descriptive statistics and generalized linear mixed models with patients clustered within teams. Objective 4 analyses involved descriptive statistics and logistic and negative binomial regression models for dichotomous or count outcomes, respectively.
Primary Objective: Reach was associated with how the clinic defined its "mission", clinic operations (e.g., patient selection and monitoring), staff beliefs about the benefits of CPT and PE, and the broader practice environment (medical center culture and priorities).Team mission was central to CPT and PE implementation as it influenced clinic operations, was reflected in staff beliefs, and tailored for fit with the broader practice environment. High reach teams described a unifying mission to deliver evidence-based psychotherapies for PTSD, which are by definition time-limited. This mission was embraced by a credible team leader, enacted through EBP specific clinic procedures, reflected in the belief that CPT and PE benefited both patients and the clinic, and required collaboration with teams and programs outside of the PTSD team. Thus, implementation of a high reach PTSD team required team structures and processes developed to optimize use of CPT and PE, but also support from facility-level mental health leadership and agreement with other teams regarding flow of patients between programs. Lower reach teams had a broader mission, less specialized operations and were situated in mental health ecosystems with less movement of patients between teams.
Objective 2: Seventy eight out of 140 (56%) PTSD clinicians completed the staff survey. About two-thirds of responders were female and the majority (81%) identified as White. About two thirds had been working at the VA for at least six years. The difference between teams in CPT and PE sustainability was significant. Better team functioning was associated with greater sustainability; greater patient volume per provider was associated with lower sustainability. Team functioning and patient volume remained significant predictors of EBP sustainability in the multivariable adjusted model.
Objective 3: The 10 PTSD teams provided psychotherapy to 6,251 patients with PTSD during FY 2015. The majority of these patients (81.5%) were male; there was variation in terms of race, marital status and period of service. Across teams, 2174 (35%) of therapy patients received an EBP for PTSD, with more patients receiving CPT than PE. In the final model, patient but not team characteristics were associated with EBP reach. Patient variables associated with reduced odds of receiving an EBP included Hispanic ethnicity, Vietnam service era, service connected for PTSD, living more than 50 miles from a VA, past year psychiatric hospitalization and psychiatric co-morbidities.
Objective 4: EBP reach, characteristics of patients who receive an EBP, and the average number of EBP sessions varied by team. Patients seen in low reach teams received fewer EBP sessions than those in medium and high reach teams, but patients seen in medium reach teams received the most EBP sessions.
Efforts to expand reach and ensure sustainability of CPT and PE should focus on local contextual factors. Research is needed to determine whether there is an optimal level of reach to facilitate delivery of an adequate EBP dose.
- Rosen CS, Bernardy NC, Chard KM, Clothier B, Cook JM, Crowley J, Eftekhari A, Kehle-Forbes SM, Mohr DC, Noorbaloochi S, Orazem RJ, Ruzek JI, Schnurr PP, Smith BN, Sayer NA. Which patients initiate cognitive processing therapy and prolonged exposure in department of veterans affairs PTSD clinics? Journal of anxiety disorders. 2019 Mar 1; 62:53-60.
- Mohr DC, Rosen CS, Schnurr PP, Orazem RJ, Noorbaloochi S, Clothier BA, Eftekhari A, Bernardy NC, Chard KM, Crowley JJ, Cook JM, Kehle-Forbes SM, Ruzek JI, Sayer NA. The Influence of Team Functioning and Workload on Sustainability of Trauma-Focused Evidence-Based Psychotherapies. Psychiatric services (Washington, D.C.). 2018 Aug 1; 69(8):879-886.
- Sayer NA, Rosen CS, Bernardy NC, Cook JM, Orazem RJ, Chard KM, Mohr DC, Kehle-Forbes SM, Eftekhari A, Crowley J, Ruzek JI, Smith BN, Schnurr PP. Context Matters: Team and Organizational Factors Associated with Reach of Evidence-Based Psychotherapies for PTSD in the Veterans Health Administration. Administration and policy in mental health. 2017 Nov 1; 44(6):904-918.
- Sayer NA, Rosen C, Bernardy N, Chard K, Crowley J, Eftekhari A, Mohr D, Kehle-Forbes SM, Cook J, Orazem RJ, Smith B, Schnurr PP. The Role of Local Policies in Promoting Use of Evidence-Based Psychotherapies for PTSD in the U.S. Veterans Health Administration. Presented at: International Society for Traumatic Stress Studies Annual Symposium; 2015 Nov 5; New Orleans, LA.
- Sayer NA, Rosen CS, Nugent S, Kehle-Forbes SM, Chard K, Bernardy NC, Schnurr P, Orazem R, Mohr D. A Preliminary Look at Use of PE and CPT in VHA Specialty Outpatient PTSD Programs. Paper presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 9; Philadelphia, PA.
Mental, Cognitive and Behavioral Disorders, Health Systems