Organizational Factors Differentiating VHA PTSD Outpatient Teams - - PowerPoint PPT Presentation

Organizational Factors Differentiating VHA PTSD Outpatient Teams with High and Low Delivery of Evidence Based Psychotherapy

Funded by VA HSR&D (grant no. CRE 12-021)

Nina A. Sayer, PhD CCDOR Minneapolis VAHCS Craig S. Rosen, PhD NCPTSD VA Palo Alto HCS

9th Annual Conference on the Science of Dissemination and Implementation in Health

December 15, 2016

VETERANS HEALTH ADMINISTRATION

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

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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

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Background: The Problem

• Reach of EBPs for PTSD is low, even in specialized
• utpatient 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%)

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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)

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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

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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

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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

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Methods

Phase 2: In-depth study through site-visit interviews to understand

• rganizational 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

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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)

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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

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Results: Site Characteristics

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Site Reach group EBP Reach US Census Region # PTSD patients seen in site # PTSD patients seen by PTSD team Number providers on 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

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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

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Clinic Mission

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High Reach Teams Low Reach Teams Treatment Model

• Purpose to deliver

EBPs

• Recovery model

with discharge expected

• Range of services (EBPs,

skills, supportive care)

• Chronic disease model

with no discharge

It’s always been made clear the kind of program this is, we are evidence- based, we are cognitive- behavioral based. The shared value that we attempt to promote is that we are treating people and not symptoms, that we have the veteran until they do not need us anymore.

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Team Engagement in EBPs

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High Reach Teams Low Reach Teams Clinic Leader

• Expert in EBPs
• Champion
• Shaped clinic
• perations
• Not EBP-trained
• EBPs viewed as one of

many treatment options

Staff

• Most/all therapists

trained in PE or CPT

• Staff committed to

EBP mission

• Some (not all) EBP

trained

• Variable commitment

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Clinic Operations

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High Reach Low Reach

Patient selection

• Screen EBP interest before

intake

• Don’t screen for

EBP interest Preparation for EBP

• None or brief psychoed

(0-4 sessions)

• Psychoed required

(4-10 sessions) Monitoring

• Processes and outcomes

Clinic Leaders shared data with senior leaders

• Processes only

EBP Peer Consultation

• All
• 1 site, recent

addition to promote EBPs

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Staff Perceptions of EBPs

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High Reach Teams Low Reach Teams Patient Benefit

• EBPs beneficial for

majority of patients

• EBPs superior to other

treatments

• Not work for everyone
• Often partial benefits
• Still need other services

Patient Interest

• Many patients want
• Vary on whether

dropout a problem

• Few patients interested
• Dropout a big problem

Clinic Benefit

• Helps recruit staff
• Improves efficiency, flow
• Reduces burnout
• Helps recruit staff
• Can add to workload

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Fit with the Practice Environment

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High Reach Teams Low Reach Teams Services

• utside

team

Options in other clinics for patients who do not want an EBP or have

• ther needs; flow

between clinics Responsible for nearly all mental health services their patients receive; minimal flow between clinics

We have two tracks in the Mental Health Service Line… an evidence- based track and case management supportive therapy track…Sometimes people don’t want evidence-based treatment. Once someone assigned to our clinic they are always assigned to our clinic…We don’t have a general mental health clinic…that is a massive barrier… I get bogged down in doing all this other stuff…We are all watered down… I’m both a specialist and generalist.

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Fit with the Practice Environment

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High Reach Teams Low Reach Teams Services

• utside

team

Options on other teams for patients who do not want an EBP or have

• ther needs; flow

between clinics Responsible for nearly all mental health services their patients receive; minimal flow between clinics

Senior Leaders

Most Chiefs of Mental Health supportive of EBP mission and division of responsibilities across clinics Most Chiefs of Mental Health did not see feasibility or, in some cases, the value of PTSD team with an EBP mission

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Summary

Mission

Clinic

Practice Environment

Engagement Perceptions

• f EBPs

Operations

Leader Support Services Outside Clinic

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Conclusions and Research Questions

• High reach teams adapted to EBPs rather than adapting the

EBPs to existing clinic structures and processes

• Team mission emerged as central though not included in the

NHS Sustainability Model which informed our interview guide

– Is team mission also instrumental to implementation of evidence-based care in practice settings that address a diverse set of medical problems?

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Implications for VHA

• How can VHA spread the success of high reach teams to low reach

teams?

• Team and mental health leaders need training and support to:

– Establish clinics that normalizes and reinforce EBP delivery – Integrate the EBP clinic model into the broader practice environment

• National policy and individual provider training is not sufficient to

ensure high levels of implementation of EBPs. Strategies to improve reach should also focus on organizational and team factors

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References

• Beebe, J. (2001). Rapid assessment process: An introduction. Walnut Creek, CA: Altamira Press.
• Damschroder L.J. et al.(2009). Fostering implementation of health services research findings into

practice: A consolidated framework for advancing implementation science. Implementation Science, 4(50), 1-15

• Finley, E.P., et al. (2015). Utilization of evidence-based psychotherapies in Veterans Affairs

posttraumatic stress disorder outpatient clinics. Psychological Services, 12, 73-82.

• Glasgow, R. E., et al. (1999). Evaluating the public health impact of health promotion interventions:

The REAIM framework. American Journal of Public Health, 89, 1322-1327.

• Maher, L., et al. (2010). NHS sustainability model and guide. London, England: NHS Institute for

Innovation and Improvement. Retrieved from http://www.qihub.scot.nhs.uk/media/162236/sustainability_model.pdf.

• Rosen, C.S., 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. Administration and Policy in Mental Health and Mental Health Services Research, 43, 957-977.

• Shiner, B., et al. (2013). Measuring use of evidence based psychotherapy for posttraumatic stress
• disorder. Administration and Policy in Mental Health and Mental Health Services Research, 40,

311-318.

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Thank you! nina.sayer@va.gov