While the efficacy and effectiveness of Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) for PTSD have been established, an implementation gap remains. A decade into VHA's CPT and PE training initiatives, the majority of Veterans diagnosed with PTSD still do not receive either of these EBPs. As part of the Evidence-Based Therapies for PTSD (EBT4PTSD) CREATE, we conducted a mixed-method study of clinic and organizational factors associated with high rates of utilization, or reach, of CPT and PE in outpatient PTSD teams. Now, in collaboration with our partners in the Office of Mental Health and Suicide Prevention (OMHSP) and the National Center for PTSD (NCPTSD), we plan to build on this CREATE project by spreading the clinic practices we identified in high reach PTSD teams to low reach PTSD teams.
Specific aims are to: (1) Increase the reach of CPT and PE in 2 PTSD teams where reach of CPT and PE is low (< 16%) using external facilitation and a PTSD EBP Implementation Toolkit to spread the clinic practices of high reach teams; (2) Conduct formative evaluation to inform the implementation strategy, monitor implementation progress, and examine contextual factors associated with the success of our implementation strategy; and (3) Refine the PTSD EBP Implementation Toolkit for national distribution. The PTSD EBP Implementation Toolkit will be a living document that can be updated to include additional promising strategies and resources to improve CPT and PE reach and ensure sustainability over time.
This study uses a quasi-experimental, repeated measure (pre-post) design. Each of 2 low-reach intervention sites will be matched to 3 low-reach control sites using VHA administrative data for a total of 2 intervention and 6 control sites. The intervention includes a site visit and 6 months of toolkit-guided external facilitation to implement the strategies and tools of high reach PTSD teams in the 2 low reach intervention teams. We will monitor reach of CPT and PE defined as the number of Veterans with PTSD who receive CPT and/or PE over the number who receive any form of psychotherapy. To quantify reach, we will use natural language processing of unstructured therapy notes and health factors from EBP templates using methods developed for our CREATE study. The implementation outcome will be CPT and/or PE reach during the 6 months before and after toolkit-guided external facilitation. To estimate the effect of this implementation strategy on changes in reach, we will use mixed effects logistic regression to model the probability of patients' receipt of CPT and/or PE using time (pre, post), condition (intervention, control), and their interaction as fixed effects, with the matched sets and sites within matched sets as random effects. Because site selection is non-random, we will augment this estimate with the estimated average treatment effect (ATE, causal effect). We will use formative evaluation to inform quantitative findings and refine the toolkit for national distribution.
This project will increase the number of Veterans with posttraumatic stress disorder (PTSD) who receive an evidence-based psychotherapy (EBP) for PTSD and produce a toolkit and implementation strategy to improve EBP reach that can be used in larger implementation and quality improvement initiatives.
External Links for this Project
- Sayer NA, Bernardy NC, Yoder M, Hamblen JL, Rosen CS, Ackland PE, Kehle-Forbes SM, Clothier BA, Schnurr PP, Orazem RJ, Noorbaloochi S. Evaluation of an Implementation Intervention to Increase Reach of Evidence-Based Psychotherapies for PTSD in US Veterans Health Administration PTSD Clinics. Administration and policy in mental health. 2021 May 1; 48(3):450-463. [view]