The DoD and VA Practice-Based Implementation Network: A Novel Procedure to Facilitate Rapid Translation of Psychological Health Research Into Clinical

Practice in the Military Health and Veteran Health Systems Department of Defense1, Veterans Health Administration2

1Deployment Health Clinical Center, Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, Defense Health Agency, Silver Spring, MD , 2 National Center for Posttraumatic Stress Disorder, Dissemination and Training Division, VA Palo Alto Health Care System, Menlo Park, CA

BACKGROUND

A 2014 Institute of Medicine (IOM) report noted that nearly two decades may pass before psychological health research findings become part of routine clinical practice in the Departments of Defense (DoD) and Veterans Affairs (VA).

DoD had already started working with the VA in 2012 to study research translation structures in both departments, to development a collaborative framework to rapidly translate psychological health (PH) research findings into clinical practice. This poster focuses primarily on DoD efforts.

GOALS

Since 2012, the VA and DoD Practice Based Implementation Network (PBI Network) team has worked to achieve three overarching goals: 1. Develop and implement the PBI Network clinical and operational support

infrastructure, and information technology (IT) platform 2. Deploy the PBI Network to test the speed of its translation efforts, and

effectiveness of its model and structure through piloting use of the Posttraumatic Stress Disorder Checklist (PCL) to monitor PTSD treatment outcomes

3. Implement the sustainment plan to institutionalize the PBI Network to facilitate practice change in the VA and DoD

METHODS

• The PBI Network was based on Stetler’s 2011 framework for Promoting Action on Research Implementation in Health Services (PARiHS) to implement psychological health evidence-based practices (EBPs), and the VA Quality Enhancement Research Initiative (QUERI) model

• The PBI Network implemented practice change initiatives at 12 behavioral health (BH) clinics and two primary care (PC) clinics in the DoD Military Health System (MHS), and at 18 VA BH and PC clinics

• The PBI Network training and facilitation process helps the larger system identify operational barriers and solutions for selected practice changes, to inform feasibility and capacity-building decisions prior to widespread enterprise dissemination

• The PBI Network used the PCL to monitor PTSD treatment outcomes in BH clinics as a pilot to test and evaluate PBI Network effectiveness

• A PBI Network information technology platform and website enhances communication and knowledge exchange between implementation-trained providers at PBI Network sites and across departments

RESULTS

• Evaluation indicated practice changes were successfully introduced to clinicians within one year by the PBI Network

• Results showed significantly increased PTSD outcomes monitoring by providers in outpatient settings six months after PBI Network training and facilitation ended

• Findings suggest the PBI Network is a viable medium to facilitate clinical practice changes

CONCLUSIONS

• The PBI Network facilitation and training along with a collaborative website facilitates knowledge translation and promotes coordination and information sharing, while creating a community of practice

• The PBI Network enhances enterprise operations because it is an enduring structure, thus increasing efficiency of future practice changes using existing implementation trained clinicians to assist with identifying barriers and facilitators prior to broader practice change dissemination across DoD and VA

FIG. 1 Bar graph of PCL administration each visit pre- and post-facilitation for Navy and Air Force sites.

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41%

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Proportion of Patients

Pre (three months prior to training) Post (three to six months after training)

FIG 2. Bar graph of PCL administration each visit pre- and post-facilitation for Army sites.

30%

35%

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5%

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Proportion of Patients

Pre (three months prior to training) Post (three to six months after training)

PBI NETWORK INITIAL PILOT SITES

REFERENCES

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Aug 2017. 5. Department of Defense and Department of Veterans Affairs. (2011). DoD/VA integrated m ental health strategy (IMHS): Strategic action summaries. Department of Defense and Department of Veterans Affairs. Washington, DC. https://www.mentalhealth.va.gov/docs/VA-DoD_IMHS_Action_Summaries_040814.pdf. Accessed 09 Aug 2017. 6. Department of Defense. Practice-based implementation network outcome monitoring project: Internal Implementation Plan for the DoD PBI Network Management. Silver Spring, Maryland; Unpublished Report, Deployment Health Clinical Center, Defense Centers of Excellence for Psychological Health and TBI: 2014. 7. Stetler CB, Damschroder LJ, Helfrich CD, Hagedorn HJ. A guide for applying a revised version of the PARIHS framework for implementation. Implementation Science. 2011 Aug 30;6(1):99. 8. Department of Veterans Health Administration, Health Services Research & Development. Quality enhancement research initiative: Implementation guide. Washington, DC; Health Services Research & Development Service. 2013. http://www.queri.research.va.gov/implementation/ImplementationGuide.pdf. Accessed 09 Aug 2017. 9. Blanchard EB, Jones-Alexander J, Buckley TC, Forneris CA. Psychometric properties of the PTSD Checklist (PCL). Behaviour research and therapy. 1996 Aug 31;34(8):669-73. 10. Ruzek JI, Karlin BE, Zeiss A. Implementation of evidence-based psychological treatments in the Veterans Health Administration. Dissemination and implementation of evidence-based psychological interventions. 2012 Apr 15:78-96. 11. Institute of Medicine. Treatment for posttraumatic stress disorder in military and veteran populations: Final assessment. Washington, DC: The National Academies Press; 2014. 12. Woodson J. Military treatment facility mental Health Clinical Outcomes Guidance. Washington, DC: Assistant Secretary of Defense, Health Affairs, Department of Defense; 2013. 13. Hepner KA, Roth CP, Farris C, Sloss EM, Martsolf GR, Pincus HA, Watkins KE, Batka C, Mandel D, Hosek SD, Farmer CM. Measuring the Quality of Care for Psychological Health Conditions in the Military Health System: Candidate Quality Measures for Posttraumatic Stress Disorder and Major Depressive Disorder. Rand health quarterly. 2015

Nov 30;5(2). 14. Hepner KA, Sloss EM, Roth CP, Krull H, Paddock SM, Moen S, Timmer MJ, Pincus HA. Quality of care for PTSD and depression in the military health system: Phase I report. Rand health quarterly. 2016 Jun 20;6(1). 15. Boswell JF, Kraus DR, Miller SD, Lambert MJ. Implementing routine outcome monitoring in clinical practice: Benefits, challenges, and solutions. Psychotherapy research. 2015 Jan 2;25(1):6-19. 16. Wang W, Saldana L, Brown CH, Chamberlain P. Factors that influenced county system leaders to implement an evidence-based program: A baseline survey within a randomized controlled trial. Implementation Science. 2010 Oct 6;5(1):72. 17. Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, J. A., & Lowery, J. C. (2009). Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implementation Science, 4(1), 50. 18. Chamberlain, P. Brown, CH, Saldana L, Reid J. Wang W. Marsenich L. Bouwman, G. (2008). Engaging and recruiting counties in an experiment on implementing evidence-based practice in California. Administration and Policy in Mental Health and Mental Health Services Research, 2008; 35(4): 250-260. 19. Department of Defense. Final report: DoD and VA establishment of a practice-based implementation network in mental health. Unpublished Report, Silver Spring, MD. Deployment Health Clinical Center, Defense Centers of Excellence for Psychological Health and TBI. 2016. 20. Cohen J. Statistical power analyses for the social sciences. Hillsdale, NJ, Lawrence Erlbauni Associates. 1988. 21. Wilcoxon F, Katti SK, Wilcox RA. Critical values and probability levels for the Wilcoxon rank sum test and the Wilcoxon signed rank test. Selected tables in mathematical statistics. 1970;1:171-259. 22. Benjamini Y, Hochberg Y. Controlling the false discovery rate: a practical and powerful approach to multiple testing. Journal of the royal statistical society. Series B (Methodological). 1995 Jan 1:289-300

Point of Contact: Kate McGraw, Ph.D., Deputy Director, Deployment Health Clinical Center (DHCC), kathy.l.mcgraw2.civ@mail.mil

The views expressed in this presentation are those of the authors and do not necessarily represent the official policy or position of the DoD Deployment Health Clinical Center, Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, Department of Defense, VA Palo Alto Health Care System or any other organization public or private. PUID #4395