Within the Veteran's Health Administration (VHA), primary care (PC) patients with Post-traumatic Stress Disorder (PTSD) have low rates of engagement in evidence-based psychotherapy (EBP). Low engagement rates are due to a variety of patient-level and system-level barriers. Patient-level barriers include 1) individual beliefs that treatment will not be helpful or will induce too much distress, preferred treatments will not be offered, or concerns about the stigma of mental health treatment; 2) lack of knowledge about PTSD and treatment options, 3) practical barriers (e.g., transportation); and 4) avoidance symptoms characteristic of PTSD. System-level barriers include a lack of tracking to ensure that Veterans follow through on referrals, and multiple competing demands during PC appointments resulting in PTSD being de-prioritized. Addressing PTSD symptoms can also be a low-priority when a Veteran has been ambivalent about treatment in the past or if PC staff are unsure how to manage PTSD-related concerns. Primary Care-Mental Health Integration (PC-MHI) providers are mental health (MH) experts embedded into the Patient Aligned Care Teams (PACT), therefore they are well positioned to overcome both patient and system-level barriers to EBP engagement.
We conducted a pilot hybrid effectiveness- implementation study to implement a Referral Management System (RMS) that will address patient and system-level barriers to the uptake of EBP for PTSD by VHA primary care patients. Our specific aims were to:1) Assess and improve the feasibility of implementing RMS in PC-MHI/PACT settings by diagnosing organizational and staff-level barriers and facilitators to implementing RMS and adapting RMS for the local context based on information gathered about barriers and facilitators. 2) Evaluate initial impact of implementing RMS in PC-MHI/PACT settings with the RE-AIM measures of Reach, Effectiveness, Adoption, and Implementation. 3) Refine the implementation strategy based on study findings for planned efforts to spread RMS.
We conducted this study in 3 phases. Phase 1 included interviews with PC and MH leadership about key organization variables to consider for RMS implementation from the Consolidated Framework for Implementation Research (CFIR). Also, PACT staff were trained with simple scripts on how to address PTSD symptoms and make appropriate referrals based on VA/DoD Clinical Practice Guidelines for PTSD. Phase 2 implemented RMS in one VA PC clinic and measured RE-AIM outcomes for 6 months. Primary care patients with current PTSD symptoms were eligible for RMS services. RMS addressed patient-level barriers with the delivery of an evidence-based 1-session cognitive behavioral therapy (CBT) intervention to identify and change treatment seeking beliefs that serve as barriers to treatment engagement. RMS addressed system-level barriers with PACT staff training and having a care manager track the progress of RMS referrals and contact Veterans to encourage followed thought on their chosen referral options. Phase 3 involved meetings with PC and MH Leadership and PACT staff to share study results and gather information about potential barriers and facilitators to long-term maintenance and future expansion of RMS. An expert national stakeholder panel was also convened to guide development of future implementation efforts.
Major anticipated facilitators that emerged in the Phase 1 interviews with PC and MH leadership were that there was an need to engage more PC patients in PTSD care and that RMS would address many of the current barriers to care. The implementation plan was adapted to accommodate for the anticipated barriers that were identified. PACT staff training sought to overcome a perception that behavioral health interventions were not evidence-based and to help PCPs better recognize PTSD symptoms and discuss treatment options with resistant patients. Telephone-based care management was used to compensate for the limited time that the embedded PC-MHI providers had to deliver RMS. A case-finding system was used to facilitate PCP referrals to RMS.
In Phase 2 59 patients were referred and 40 received RMS. 83% of RMS patients accepted referrals to specialty mental health treatment and 50% received an evidenced-based treatment for PTSD within the first four months after referral, with medication being 2.8 times more common than psychotherapy. Reach: Of the PC patients who may have benefited from RMS, only 18% were referred. Effectiveness: Compared to another PC clinic that RMS was not implemented in, RMS patients had 2.6 times more referrals to the PTSD specialty clinic, 3.3 times more completed PTSD intakes, and 4.2 times more evidenced-based treatments. Effectiveness: RMS participants who received specialty care treatment had larger decreases in their PTSD symptoms at 3 month follow-up with patients who EBP reporting the largest decreases (10 on the PTSD Checklist compared to 3 points among patients who did not receive EBP). Adoption: 88% of PCPs showed multiple indicators (e.g., attended training, made referrals) of RMS adoption. Implementation: brief surveys and reviews of note templates indicated that PCPs and PC-MHI providers had high fidelity in their delivery of RMS.
In Phase 3 PC-MHI providers and local leadership gave feedback on how to modify the CBT session to fit better into typical clinical services and increase engagement from ambivalent patients (e.g., keep ambivalent patients in PC-MHI treatment longer, increase therapeutic content of care manger calls). National Stakeholders provided feedback on how to increase patient engagement (e.g., use peers and technology-based resources) and PACT staff buy-in (e.g., increase case-finding efforts, work with nurses, provide patient testimonials).
The implementation of RMS leads to more engagement in PTSD treatment and more PTSD symptom relief among PC Veterans. Positive impacts on the VA healthcare system include engaging Veterans with PTSD in the most appropriate level of care and thereby relieving some of the burden of PC in managing PTSD in Veterans. Further implementation research is needed to test the effectiveness of a modified RMS on a larger scale.
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Grant Number: I21HX001403-01A1
None at this time.