Can Specialized Support Improve PTSD Treatment in Veterans Healthcare?

What you need to know

• Implementation facilitation provided by specialized mentors improved the use of evidence-based psychotherapies for PTSD in Veterans Health Administration clinics more than other quality improvement strategies.

• Clinics that received implementation facilitation also showed greater improvements in using measurement-based care to track patient progress.

• Integrating implementation facilitation into an existing national mentoring program may be an effective way to improve PTSD treatment quality across a large healthcare system.

Background

Post-traumatic stress disorder (PTSD) is a mental health condition that can develop after experiencing or witnessing a traumatic event. It is particularly common among military veterans. To ensure veterans have access to high-quality PTSD care, the Veterans Health Administration (VHA) has invested significant resources in specialized mental health services and the nationwide implementation of evidence-based psychotherapies (EBPs) for PTSD.

The two main EBPs for PTSD used in the VHA are:

1. Cognitive Processing Therapy (CPT): This therapy helps patients learn to challenge and modify unhelpful beliefs related to their trauma.

2. Prolonged Exposure (PE): This therapy involves gradually confronting trauma-related memories, feelings, and situations that the patient has been avoiding.

Despite these efforts, many veterans with PTSD still do not receive these highly effective treatments. To address this issue, researchers and VHA leaders collaborated on a project called PERSIST (Promoting Effective, Routine, and Sustained Implementation of Stress Treatments) to improve the use of EBPs in VHA PTSD clinics.

The PERSIST Project

The PERSIST project had several phases:

1. Identifying factors associated with high use of EBPs in some clinics compared to low use in others.

2. Developing and testing an implementation facilitation approach tailored for PTSD clinics with low EBP use.

3. Integrating the successful strategies into the VHA’s national PTSD mentoring program.

This study evaluated the third phase, where implementation facilitation was incorporated into the existing mentoring program and compared to other quality improvement strategies.

What is Implementation Facilitation?

Implementation facilitation is an evidence-based approach to help healthcare teams identify barriers to using best practices and make changes to overcome those barriers. It typically involves:

1. An external facilitator who provides guidance and support
2. A local champion who leads change efforts within the clinic
3. A structured process to assess needs, set goals, and implement changes
4. Ongoing monitoring and problem-solving

For this project, the facilitators were regional PTSD mentors who received special training. They worked closely with a champion at each target clinic to improve the use of EBPs.

The Study

The researchers evaluated whether implementation facilitation delivered by regional PTSD mentors improved the use of EBPs more than other quality improvement strategies. They looked at 51 PTSD clinics across the VHA system that had low rates of EBP use at the start of the study.

These clinics were grouped into four conditions:

1. Implementation Facilitation (IF): 6 clinics received intensive support from a trained facilitator.

2. Learning Collaborative (LC): 15 clinics participated in a structured program to share best practices.

3. IF_VISN: 15 clinics in the same regions as IF clinics, but not receiving facilitation directly.

4. Mentoring as Usual (MAU): 15 clinics continued with standard support from the mentoring program.

The main outcome measured was the proportion of PTSD patients in each clinic who received at least one session of CPT or PE (called “EBP reach”). The researchers compared this before and after the intervention period.

Key Findings

1. EBP reach improved across all conditions from the baseline period to the follow-up period. This suggests that even the enhanced standard mentoring (MAU) may have had some positive effect.

2. Clinics that received implementation facilitation showed the largest improvements in EBP reach. After accounting for other factors, the odds of a patient receiving an EBP in IF clinics improved 1.35 to 1.69 times more than in the other conditions.

3. The improvements seen in IF clinics did not spread to other clinics in the same region (IF_VISN) that didn’t receive facilitation directly. This indicates that the intensive support provided through facilitation was necessary to achieve the larger gains.

4. IF clinics also showed greater improvements in measurement-based care compared to the other conditions. Measurement-based care involves regularly assessing patients’ symptoms to track progress and guide treatment decisions.

Why Implementation Facilitation Was More Effective

There are several reasons why implementation facilitation may have been more successful than the other strategies:

1. Intensive, tailored support: Facilitators worked closely with each clinic to identify their specific barriers and develop customized solutions.

2. Dedicated time: Facilitators had protected time (about 4 hours per week) to focus on supporting their target clinics. Mentors in other conditions did not have this dedicated time for improvement activities.

3. Structured process: The facilitation approach provided a clear framework for assessing needs, setting goals, and implementing changes.

4. Local champion: Having a designated champion within each clinic helped drive and sustain change efforts.

5. Existing relationships: The regional mentors who served as facilitators already had established connections with the clinics in their areas, which may have enhanced their effectiveness.

Implications for Healthcare Systems

This study demonstrates that implementation facilitation can be successfully integrated into an existing quality improvement program within a large healthcare system. Some key implications include:

1. Scalability: Training regional mentors as facilitators provides a way to expand the reach of this intensive support approach.

2. Targeted approach: Facilitation may be most useful for clinics that are struggling to improve with less intensive strategies.

3. Resource allocation: While facilitation requires more time and resources, the larger improvements may justify the investment for low-performing clinics.

4. Complementary strategies: A combination of system-wide mentoring and targeted facilitation may be an effective way to drive improvements across a healthcare system.

Limitations and Future Directions

Some limitations of this study include:

1. Clinics were not randomly assigned to conditions, so there may have been unmeasured differences between groups.

2. The study took place during the COVID-19 pandemic, which could have affected results in ways that are difficult to measure.

3. The researchers did not conduct in-depth interviews with staff in all conditions to understand their experiences with the different improvement strategies.

Future research could address these limitations and explore questions such as:

1. What is the optimal “dose” of facilitation needed to achieve and sustain improvements?

2. How can facilitation be most efficiently targeted to clinics that need it most?

3. What factors help spread improvements from facilitated clinics to others in the same region?

Conclusions

• Implementation facilitation delivered by trained regional mentors was more effective at improving the use of evidence-based psychotherapies for PTSD than less intensive quality improvement strategies.

• This approach can be successfully integrated into an existing mentoring program within a large healthcare system.

• A combination of system-wide mentoring and targeted facilitation may be an effective way to improve mental health care quality, particularly for clinics struggling to implement best practices.