Implementing Evidence-Based Psychotherapies for PTSD in VA: A Story of Research and Practice
Erin P. Finley, PhD MPHUTHSCSA Department of Psychiatry
September 20, 2016
Learning Objectives• Describe evidence-based psychotherapies for PTSD and their implementation in
the Department of Veterans Affairs• Discuss strategies for implementation planning and research
Dr. Finley has no relevant financial or nonfinancial relationship with any proprietary interests
Implementing Evidence-Based Psychotherapies for PTSD in VA: A Story of Research and Practice
Erin P. Finley, PhD MPHUTHSCSA Department of Psychiatry
September 20, 2016
Disclosure
The views expressed here are solely my own and do not represent the views of or an endorsement by the Department of Veterans Affairs or the U.S. Government.
I have no financial conflicts of interest.
Once upon a time…
• America’s largest integrated health care system
• Serving 8.76 million Veterans per year
• Across 152 medical centers (1700 total sites of care)
• Including 230 specialized PTSD programs
• Total mental health care workforce of 20,000
VA’s Goal
Make two evidence-based psychotherapies (EBPs) for PTSD – cognitive processing therapy (CPT) and prolonged exposure therapy (PE) – available for Veterans at every medical center across the country.
Case Story
Bridging research and practice System change Culture change Implementation science
Overview
Brief history of the EBP rollouts Review of outcomes Lessons learned Implications for emerging research
Setting the Scene….
Outer ContextCharacteristics of the Intervention
Implementation PlanClinical Context
Outcomes
Outer Context
HISTORY & POPULATION HEALTH• 2001: A nation at war…• As Veterans of Iraq and Afghanistan began returning
home, PTSD became “signature injury”• Number of Veterans with PTSD diagnosis
• 2002-2005 doubles• 2005-2014 doubles again
Outer Context
POLICY• 2001: IOM Quality Chasm report• 2003: President’s New Freedom Commission on
Mental HealthBoth noted the gap between what we know about effective treatments and what we use in routine care
• 2004: VA’s Comprehensive Mental Health Strategic Plan
• 2005: VA funding to support implementation of EBPs for mental health conditions
Outer Context
RESEARCH • 2006-2007: Clinical trials demonstrating efficacy of
treatments for PTSD with Veterans• 2006: Emergence of implementation science
• AKA translational research, knowledge translation• Actively supports movement of evidence-based
health care and prevention strategies from clinical or public health knowledge base into routine use (Rubenstein & Pugh, 2006)
“The lack of routine uptake of research findings is strategically important…because it places an invisible ceiling on the potential for research to enhance health.”
(Implementation Science, founded 2006)
Status quo
Tension for change
Cognitive Processing Therapy (CPT)
Prolonged Exposure (PE) Therapy
10-15 sessions 8-15 sessions60/90 mins 90 mins (individual)
• PTSD symptoms• Relationship between
thought and feeling• Challenging trauma beliefs
• Psychoeducation and rationale
• Breathing retraining• In vivo exposure• Imaginal exposure
Options:• Individual or group format• With or without trauma
rehearsal
Characteristics of the Interventions
Level Focus Selected Strategies(Adapted from Karlin et al., 2014)
Policy National requirements for EBP availability
• Uniform MH Services Handbook• VHA Mental Health Initiative
Operating Plan
Provider Staff training and support
• Staff training workshops• 6-month phone consultation
Local Systems
Local clinical infrastructures and buy-in
• Local EBP Coordinators, PTSD Mentors
• Selected external facilitation• VHA Handbook 1160.05: Local
Implementation of EBPs for Mental and Behavioral Health Conditions
Accountability Monitoring and evaluating implementation and impact
• Surveys of EBP delivery• Computerized EBP documentation
templates• EBP training program evaluation
CPT Rollout
Summer 2006• VA Office of Mental Health Services with CPT developer
Dr. Patricia Resick• Develop CPT manual adapted for Veterans/Service
Members• July 2007: staff training begins• Additional web resources (including including CPTWeb)
and manual for CPT in group format introduced• CPT site consultation made available to facilities• By 2015, 2685 clinicians completed CPT case consultation
Sources: Karlin et al., 2010; Rosen et al., 2016
Lesson #1: Adapting the CPT Plan
• Problem: Inconsistent participation in consultation• Solution: Formalizing expectations for consultation –
required weekly participation over 6 months with an assigned consultant – to increase involvement and solidify skills; also fulfill function of a learning collaborative
• Problem: Little initial plan for evaluation of training program
• Solution: Active evaluation of training pre-, post-, and follow-up
Source: Chard et al., 2012
PE Rollout
Mid-to-late 2007• Working with intervention developer, Dr. Edna Foa• Emphasis on program evaluation and building
capacity for training and consultation• Clearly defined expectations: training; weekly
consultation; review of two recorded patient sessions• Similar development of training materials, web
resources, video aimed at increasing provider receptivity, and materials to aid program directors in integrating PE into their clinics
• 1865 clinicians completed training
Clinical Context
STRUCTURE• Clinic scheduling based on 60-minute sessions• Many clinics had long patient waits• Consecutive weekly sessions• Time for providers to integrate new treatment, attend
consultations
Clinical Context
CULTURE• “One of the most significant initial obstacles to
implementing evidence-based psychotherapies for PTSD was the maintenance view of PTSD held by some therapists and patients, suggesting that PTSD is a lifetime disorder and that recovery is not possible.” (Karlin et al., 2010)
Clinical Context
CULTURE• Difficult shift to the recovery model (Finley 2011, 2014)
• Poor compatibility with common ideas of PTSD care:• Long-term care required• Direct discussion of the trauma may be harmful• Manualized approach as challenge to provider judgment
• Operations (e.g., phasing out of long-standing support groups)
Lesson #2: Adaptations to Intervention Clinic structures
• PTSD 101 groups
PE• Group format• 60 minute sessions
Provider adaptations• Tailoring• Adding sessions
Formal and informal
Some adaptations fed back into funded research
Sources: Cook et al., 2014; Finley 2011; Hamblen et al., 2015
PracticePractice
Implement-ation
Implement-ation
Clinical ResearchClinical
Research
Lesson #3: Patient Engagement
ABOUT FACE
http://www.ptsd.va.gov/apps/AboutFace/questions--who-i-am--2.html
Lesson #4: Change is Constant
INTERVENTION
CLINICAL CONTEXT
Source: Adapted from Chambers, Glasgow, and Stange 2013
OUTER CONTEXT
T0 T0 T0T1 T1 T1Tn Tn Tn
So… what happened?
Facility-Level
Outcomes
Facility-Level
Outcomes
Provider-Level
Outcomes
Provider-Level
OutcomesPatient
OutcomesPatient
Outcomes
Facility-Level Outcomes
As of 2009, national study of VA medical centers found:• 96% of facilities reported use of CPT or PE• 72% reported both
Continued monitoring remains a challenge: • Codes for medical billing do not indicate type of
psychotherapy delivered• Clinical note template was introduced in late 2014• More comprehensive monitoring, audit, and feedback
Source: Karlin et al., 2010; Rosen et al., 2016
Provider-Level Outcomes
National survey of clinicians in PTSD specialty programs• Hours per week reported by psychotherapy type:
• 4.5 hours PE• 3.9 hours individual CPT • 1.3 hours group CPT• 13.4 hours supportive care
National training program evaluation surveys• Most providers were using CPT, but 69% using “rarely” or
“less than half the time”• Most providers using PE, but with 1-2 cases at a time
Sources: Finley et al., 2015; Rosen et al., 2015, 2016; Ruzek et al., 2015
Provider-Level Outcomes
Barriers• Orientation to
maintenance vs. recovery model
• Workload• Lack of protected time
for non-clinical care• Perception of clinic as
understaffed
Facilitators• Perceived effectiveness
and safety of EBPs• Self-efficacy for
delivering the treatment• Perception of emotional
support from coworkers (PE)
• Perceived fit with clinic scheduling needs (e.g., CPT allows group)
Sources: Finley et al., 2015; Hamblen et al., 2015; Ruzek et al., 2016; Cook et al., 2013; 2015a
Patient Outcomes
PE• Mean = 15-point symptom reduction
CPT• Mean = 19-point symptom reduction
Patients who receive the treatments get better Patient engagement and retention remain concerns
• Ability to attend frequent appointments (work, travel)• Receptivity to treatments
Comprehensive data still lacking
Sources: Eftekhari et al., 2013; Chard et al., 2012; Mott et al., 2014; Kehle-Forces et al., 2014; Watts et al., 2015
Research
Large-scale implementation as demonstration lab
Rosen et al. (2016) identified 32 peer-reviewed publications from 20 studies
Training/Consultation Effectiveness Implementation Program Evaluation Leadership Mentoring Provider Attitudes Patient Engagement Shared Decision-Making Fidelity Utilization/Adoption Workplace/Organizational
Factors
Lessons Learned
“Best case scenario”: well-planned implementation effort with significant top-down support and investment
Even so, implementation can be challenging• Large, diffuse systems• When significant cultural/structural change is involved
Pre-implementation work is critical• Needs assessment• Stakeholder engagement
Lack of well-integrated EMR tools for documentation, monitoring, and feedback was likely a factor in failing to achieve higher use
Epilogue
New problems New questions New research
Sustainment
“Once-in-a-generation” training investment Training isn’t enough to get EBPs into routine care
Collaboration with Stanford and Ryerson investigators on NIMH R01 to compare CPT sustainment using two learning collaborative conditions (PI: Shannon Wiltsey-Stirman)• VA PTSD Clinical Teams (Wiltsey-Stirman)• Canada Operational Stress Injury Clinics (Monson)• Texas MHMRs (Finley)
Provider Decision-Making
As PE and CPT increasingly available and other EBPs rolled out, how do providers identify (a) appropriate patients and (b) appropriate treatment?
Collaboration with investigators at Stanford and Texas A&M to conduct national survey of PTSD specialty care providers re: treatment decision-making (PI: Hector Garcia)
Responding to Policy Shifts
New mechanisms for care increasingly allow Veterans to seek PTSD treatment from non-VA providers –expanding implementation beyond VA
Collaboration with National Center for PTSD to: a) Assess Veteran perspectives on community expansion
for PTSD Care (PI: Finley) b) Develop more effective partnerships and increase EBP
capacity among community providers (PI: Finley)
Adaptation
How do we observe, document, and evaluate adaptation in progress?
EMPOWER: VA-funded center grant to examine how local site adaptations impact the effectiveness of interventions to increase women Veterans’ engagement in healthcare (PI: Alison Hamilton, UCLA; Finley, Implementation Lead)
Moral of the Story
Putting clinical research into practice poses challenges
Implementation science provides powerful tools to aid in identifying what works
In a constantly changing healthcare environment, much to learn!
Acknowledgements
Recommended source:• Rosen et al. (2016) A Review of Studies on the System-Wide Implementation of
Evidence-Based Psychotherapies for Posttraumatic Stress Disorder in the Veterans Health Administration. Adm Policy Mental Health online July 29, 2016.
Funding: • National Science Foundation DDIG BCS-0650437 (Brown and Finley)• VA Health Services Research & Development Quality Enhancement Research
Initiative RRP 12-509 (Finley) and PEC 15-243 (Finley)• NIMH/VA Implementation Research Institute Fellowship Program R25
MH080916-01A2 (Finley)• Practice-Based Research Network, UTHSCSA (Garcia)• NIMH 1 R01 MH106506-01A1 (Wiltsey Stirman)• VA QUERI QUE 15-272 (Hamilton)