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)

QUESTIONS?

Erin P. Finley, PhD MPHfinleye@uthscsa.edu