Organizational Factors Differentiating VHA PTSD Outpatient Teams with High and Low Delivery of Evidence Based Psychotherapy 9 th Annual Conference on the Science of Dissemination and Implementation in Health December 15, 2016 Craig S. Rosen, PhD Nina A. Sayer, PhD NCPTSD CCDOR VA Palo Alto HCS Minneapolis VAHCS Funded by VA HSR&D (grant no. CRE 12-021)
VA HSR&D Grant: Promoting Effective, Routine, and Sustained Implementation of Stress Treatments (PERSIST) Investigators Team members Nina Sayer (PI) Robert Orazem (Coordinator) Craig Rosen (Co-PI) Brandy Smith (Research Assistant) Paula Schnurr Sean Nugent (Programmer) Nancy Bernardy Barbara Clothier (Statistician) Kathleen Chard Lindsay Trent (Postdoctoral fellow) Joan Cook Jill Crowley Shannon Kehle-Forbes Afsoon Eftekhari David Mohr Siamak Noorbaloochi VETERANS HEALTH ADMINISTRATION 1
Background: VHA’s Evidence -Based Care Training Initiatives Over past decade, VHA has worked to implement two evidence- based psychotherapies (EBPs) for PTSD: Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) VHA policy mandates that all veterans with PTSD have access to CPT or PE Resources to promote local implementation include EBP Coordinators at every facility and a national PTSD mentoring program Primary strategy has been clinician training > 6,300 clinicians have completed CPT and/or PE training VETERANS HEALTH ADMINISTRATION
Background: The Problem • Reach of EBPs for PTSD is low, even in specialized outpatient PTSD clinics • In PTSD clinics, adoption appears better than reach • Majority of therapists responding to a survey reported using EBPs, but with few patients ( Finley et al., 2015) • Shiner et al. (2013) found that 6% of patients newly diagnosed with PTSD in VA New England PTSD clinics received an EBP within 6 months (range 4% -- 14%) VETERANS HEALTH ADMINISTRATION
Background: The Research Gap • Majority of prior research on factors affecting CPT and PE implementation in VHA has focused on provider and patient variables (Rosen et al., 2016) • Local contextual factors are important to implementation success (e.g., Damschroder et al., 2009) VETERANS HEALTH ADMINISTRATION
Primary Research Objective To identify organizational and clinic factors that promote high levels of reach of EBPs for PTSD • Used reach as an indicator of implementation success (Glasgow et al., 1999) • Focused on outpatient PTSD teams VETERANS HEALTH ADMINISTRATION 5
Methods • Design: Rapid Assessment Process (RAP; Beebe, 2001) – close collaboration with a field liaison – triangulation (multiple researchers; multiple data sources) – iterative data collection and analysis • Data sources: Administrative data, staff surveys and individual interviews with staff during site visits • Study proceeded in two phases VETERANS HEALTH ADMINISTRATION 6
Methods Phase 1 – site selection: Quantified extent of use or discussion of EBPs for PTSD across VHA outpatient PTSD clinics • Regular expression searches of psychotherapy chart notes for all (N = 109,113) veterans with PTSD who received psychotherapy over an 18- month period (4/ 2011-10/2012) • Purposive sampling to identify 9 sites with PTSD teams that varied in region, patient volume and EBP reach Oversampled high reach sites • Identified 9 sites which included 10 outpatient PTSD teams VETERANS HEALTH ADMINISTRATION 7
Methods Phase 2: In-depth study through site-visit interviews to understand organizational factors affecting EBP implementation/reach • Pre-site visit – Field liaison and online, anonymous staff surveys • Natural Language Processing (NLP) to quantify EBP reach during 12- months encompassing site visits – Low (n = 3), medium (n = 2) and high (n =5) reach • Semi-structured interviews with 7 to 15 staff at each site, including front line staff, referring clinicians and senior leaders (N = 96) – Conducted in teams of two (2 teams of 2) • In person at 7 sites; phone for 2 sites VETERANS HEALTH ADMINISTRATION 8
Methods: NHS Sustainability Model • Semi-structure interview guide based on the British NHS Sustainability Model (Maher et al., 2010) • NHS Sustainability Model • Identifies strengths and weaknesses in an implementation plan within a specific organizational and workgroup context • 10 determinants that play a critical role in sustaining an innovation in healthcare settings and are grouped into 3 domains: • The process (the intervention) (e.g., credibility and adaptability) • Staff involved (e.g., leadership) • Organizational support (e.g., policies) VETERANS HEALTH ADMINISTRATION 9
Analysis • Iterative - Began after the first interview; subsequent interviews used to fill in gaps and explore emerging themes • After last interview at a site, created site summaries and whenever possible (at 6 sites) presented them to the PTSD team for additional feedback and clarification • Inter-case analysis to compare/contrast teams Focusing on themes that distinguish high from low reach teams • Medium reach teams had similarities to both VETERANS HEALTH ADMINISTRATION 10
Results: Site Characteristics # PTSD # PTSD US patients patients Number Reach EBP Census seen in seen by providers on Site group Reach Region site PTSD team PTSD Team 8 Low 14.0% South 2,986 1,570 18 1 Low 15.3% Northeast 2,370 1,264 16 6 Low 17.7% Northeast 5,042 1,470 19 9 Medium 28.8% Midwest 1,441 373 4 3 Medium 31.7% West 1,762 512 8 4 High 42.0% South 6,880 2,293 35 5a High 38.6% West 5,803 729 5 5b High 56.5% 231 3 2 High 55.9% Midwest 2,027 389 10 7 High 58.9% Midwest 3,119 1,083 22 VETERANS HEALTH ADMINISTRATION 11
Results: Major Themes • Five major themes differentiated High from Low reach teams – Clinic mission (Sense of purpose) – Team Engagement in EBPs – Clinic Operations (e.g., infrastructure) – Staff Perceptions of EBPs – Fit with the Broader Practice Environment VETERANS HEALTH ADMINISTRATION 12
Clinic Mission High Reach Teams Low Reach Teams • Purpose to deliver • Range of services (EBPs, Treatment EBPs skills, supportive care) Model • Recovery model • Chronic disease model with discharge with no discharge expected It’s always been made The shared value that we clear the kind of program attempt to promote is that we this is, we are evidence- are treating people and not based, we are cognitive- symptoms, that we have the behavioral based. veteran until they do not need us anymore. VETERANS HEALTH ADMINISTRATION 13
Team Engagement in EBPs High Reach Teams Low Reach Teams • Expert in EBPs • Not EBP-trained Clinic • Champion Leader • Shaped clinic • EBPs viewed as one of operations many treatment options • Most/all therapists • Some (not all) EBP Staff trained in PE or CPT trained • Staff committed to • Variable commitment EBP mission VETERANS HEALTH ADMINISTRATION 14
Clinic Operations High Reach Low Reach • Screen EBP interest before • Don’t screen for Patient selection intake EBP interest • None or brief psychoed • Psychoed required Preparation for EBP (0-4 sessions) (4-10 sessions) • Processes and outcomes • Processes only Monitoring Clinic Leaders shared data with senior leaders • All • 1 site, recent EBP Peer Consultation addition to promote EBPs VETERANS HEALTH ADMINISTRATION 15
Staff Perceptions of EBPs High Reach Teams Low Reach Teams • EBPs beneficial for • Not work for everyone Patient • Often partial benefits majority of patients Benefit • EBPs superior to other • Still need other services treatments • Many patients want • Few patients interested Patient • Vary on whether • Dropout a big problem Interest dropout a problem • Helps recruit staff • Helps recruit staff Clinic • Improves efficiency, flow • Can add to workload Benefit • Reduces burnout VETERANS HEALTH ADMINISTRATION 16
Fit with the Practice Environment High Reach Teams Low Reach Teams Options in other clinics Responsible for nearly all Services for patients who do not mental health services outside want an EBP or have their patients receive; team other needs; flow minimal flow between between clinics clinics We have two tracks in the Mental Once someone assigned to our clinic Health Service Line… an evidence - they are always assigned to our based track and case clinic…We don’t have a general management supportive therapy mental health clinic…that is a track…Sometimes people don’t massive barrier… I get bogged down want evidence-based treatment. in doing all this other stuff…We are all watered down… I’m both a specialist and generalist. VETERANS HEALTH ADMINISTRATION 17
Fit with the Practice Environment High Reach Teams Low Reach Teams Options on other teams Responsible for nearly all Services for patients who do not mental health services outside want an EBP or have their patients receive; team other needs; flow minimal flow between between clinics clinics Most Chiefs of Mental Most Chiefs of Mental Senior Health supportive of EBP Health did not see Leaders mission and division of feasibility or, in some responsibilities across cases, the value of PTSD clinics team with an EBP mission VETERANS HEALTH ADMINISTRATION 18
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