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RRP 12-509 – HSR&D Study

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RRP 12-509
Community-Based Care for OEF/OIF/OND Veterans with PTSD
Erin P Finley PhD MPH
South Texas Health Care System, San Antonio, TX
San Antonio, TX
Funding Period: February 2014 - July 2015

BACKGROUND/RATIONALE:
Recognizing that evidence-based practices (EBPs) for post-traumatic stress disorder (PTSD) can result in significant symptom reduction and improved quality of life for Veterans with the disorder, the Department of Veterans Affairs (VA) has invested in making EBPs for PTSD available at every VA facility nationwide. Such efforts to improve access to EBPs for PTSD have been stymied, however, by the fact that many recent Veterans elect to seek care in community settings rather than with VA. The fact that we know little about community providers' attitudes and practices in PTSD care, or factors affecting their adoption of EBPs, has made it difficult for VA to identify appropriate next steps to increase access to EBPs for Veterans with PTSD. We therefore conducted a needs assessment with three objectives:

OBJECTIVE(S):
Aim 1. Characterize the medication, psychotherapy, and referral practices of community providers serving Veterans with PTSD in Texas, including fee-basis providers.

Aim 2. Identify factors that predict variation in community providers' adoption of three EBPs for PTSD, namely: 1) standardized screening for Veteran status; 2) use of SSRIs or SNRIs as a first-line pharmacotherapy for PTSD; and 3) use of cognitive processing therapy or prolonged exposure as EBPs to treat PTSD.

Aim 3. Assess community providers' preferences regarding partnering with VA to provide care for Veterans with PTSD.

METHODS:
We conducted a survey with both mailed and online options informed by Rogers' Diffusion of Innovations framework among two sets of stakeholders: 1) community medical and mental health care providers working in private practice and organizational settings (e.g., group practices, clinics, etc.) across Texas; and 2) the leaders of organizations providing outpatient adult mental health care statewide. We drew upon existing literature, preliminary studies, and input from an Expert Panel to develop and refine these surveys. An invitation to participate in the Community Provider Stakeholder Survey was mailed or emailed to a stratified random sample of 5592 licensed community care providers - including psychiatrists and other medical care providers (including nurse practitioners), psychologists, social workers, professional counselors, and marriage and family therapists - selected from state licensing board rosters. Prescribers and psychotherapy providers received separate versions of the survey emphasizing medication and psychotherapy, respectively. We received 631 responses, resulting in an overall response rate of 10.1%. We also completed a systematic internet search to identify organizations providing adult mental health outpatient care across Texas in order to conduct an Organizational Leadership Stakeholder Survey of mental health clinical leadership (final n=41, response rate 18%). Both surveys included items to address: provider/agency characteristics (e.g., patient volume and characteristics); prior conditions (e.g., perceptions of Veterans' needs and attitudes to EMPs); perceived characteristics of EBPs; preferences regarding partnering with VA to provider Veterans' PTSD care; and current practices in PTSD care. Descriptive, bivariate, and multivariate analyses were used to characterize PTSD care and factors associated with EBP adoption, as well as preferences for training, education, and partnering with VA to provide PTSD care for Veterans. Content analysis was also conducted of 320 responses to an open-ended item ("Please comment on why you do or do not refer Veterans to VA facilities").

FINDINGS/RESULTS:
Of the 631 non-VA providers in this study, 88% of prescribers and 68% of psychotherapists reported treating Veterans with PTSD in the prior year, serving approximately 4574 Veterans with PTSD during that period. While the majority of providers reported at least some training in PTSD assessment (62% prescribers, 78% psychotherapists), and 68% of prescribers reported training in appropriate prescribing for patients with PTSD, relatively few psychotherapists reported any prior training in recommended EBPs for PTSD such as prolonged exposure (PE) therapy or cognitive processing therapy (CPT). Approximately half of providers reported being aware of clinical practice guidelines for PTSD (53% prescribers, 51% psychotherapists). Similarly, roughly half of respondents reported screening more than 75% of their patients for current or prior military service (49% prescribers, 56% psychotherapists). Prescribers reported significant variation in their prescribing practice for patients with PTSD, frequently providing prescriptions for SNRIs (15%), SSRIs (54%), and prazosin (19%) to their patients. Seven percent of prescribers reported prescribing benzodiazepines for more than 50% of their patients with PTSD. Among psychotherapists, cognitive behavioral therapy (CBT) was the most commonly reported therapeutic approach; fewer than one-third reported using CPT or PE with any patients with PTSD. Relatively few psychotherapists (15%) reported regularly following a treatment manual when conducting psychotherapy for PTSD. Regression analyses indicate that having prior training in an EBP and confidence in ability to use an EBP were significantly associated with use of CPT and/or PE.

With regard to perceptions of VA, fewer than half of these community providers agreed that the VA health care system provides high-quality medical and mental health services (41% prescribers, 36% psychotherapists), and only about a third agreed they were knowledgeable about how to refer to VA (31% prescribers, 38% psychotherapists). Providers did report significant interest in learning more about the medical and mental health needs of service members (66% prescribers, 71% psychotherapists), as well as increasing partnership with VA to provide mental health care to Veterans, although interest in VA partnership was lower among prescribers (38%) than psychotherapists (58%). The majority of providers reported being interested in learning about evidence-based practices in PTSD care (82% prescribers, 72% psychotherapists).

Qualitative findings revealed that providers expressed a variety of perspectives on VA mental health services for Veterans with PTSD, with some reporting appreciation for the quality and availability of low- or no-cost services and the expertise of VA providers; such comments were typically made by those who regularly work with Veterans lacking other resources or who had either prior training/employment in VA or friends/acquaintances working in VA. More often, however, community-based providers reported negative perspectives on VA, expressing concern about long wait-times, difficulties for Veterans in navigating VA bureaucracy, and reports from Veteran patients that the care ultimately received was inconsistent (frequently requiring visits with new or unfamiliar providers), overly reliant on medication and group therapy rather than individual therapy, and of poor quality (lacking in compassion or ineffective).

IMPACT:
These findings suggest that community-based providers are seeing Veterans in significant numbers, but important gaps remain in providers' knowledge and use of evidence-based psychotherapies for PTSD. Providers' prior training and confidence in ability to provide EBPs were significantly associated with use of EBPs for patients with PTSD. Fewer than half of community-based providers have positive views regarding the quality of VA care; however, the majority expressed interest in learning more about meeting the needs of service members and about evidence-based practices in PTSD care.

Efforts to partner more effectively with community providers to deliver seamless access to high-quality PTSD care for Veterans is likely to require substantial investment in: (a) training to support use of evidence-based practices for PTSD by community-based providers; (b) outreach to build more positive relationships with community providers, who frequently have little familiarity with or trust in VA services; and (c) customer service for Veterans, whose reports to community providers about negative experiences have an important impact on the willingness of providers to partner with or refer to VA.

PUBLICATIONS:
None at this time.


DRA: Mental, Cognitive and Behavioral Disorders
DRE: Prevention
Keywords: QUERI Implementation
MeSH Terms: none

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