Improving and sustaining delivery of CPT for PTSD in mental health systems: a cluster randomized trial

Abstract

BackgroundLarge-scale implementation of evidence-based psychotherapies (EBPs) such as cognitive processing therapy (CPT) for posttraumatic stress disorder can have a tremendous impact on mental and physical health, healthcare utilization, and quality of life. While many mental health systems (MHS) have invested heavily in programs to implement EBPs, few eligible patients receive EBPs in routine care settings, and clinicians do not appear to deliver the full treatment protocol to many of their patients. Emerging evidence suggests that when CPT and other EBPs are delivered at low levels of fidelity, clinical outcomes are negatively impacted. Thus, identifying strategies to improve and sustain the delivery of CPT and other EBPs is critical. Existing literature has suggested two competing strategies to promote sustainability. One emphasizes fidelity to the treatment protocol through ongoing consultation and fidelity monitoring. The other focuses on improving the fit and effectiveness of these treatments through appropriate adaptations to the treatment or the clinical setting through a process of data-driven, continuous quality improvement. Neither has been evaluated in terms of impact on sustained implementation.MethodsTo compare these approaches on the key sustainability outcomes and provide initial guidance on sustainability strategies, we propose a cluster randomized trial with mental health clinics (n = 32) in three diverse MHSs that have implemented CPT. Cohorts of clinicians and clinical managers will participate in 1 year of a fidelity oriented learning collaborative or 1 year of a continuous quality improvement-oriented learning collaborative. Patient-level PTSD symptom change, CPT fidelity and adaptation, penetration, and clinics’ capacity to deliver EBP will be examined. Survey and interview data will also be collected to investigate multilevel influences on the success of the two learning collaborative strategies. This research will be conducted by a team of investigators with expertise in CPT implementation, mixed method research strategies, quality improvement, and implementation science, with input from stakeholders in each participating MHS.DiscussionIt will have broad implications for supporting ongoing delivery of EBPs in mental health and healthcare systems and settings. The resulting products have the potential to significantly improve efforts to ensure ongoing high quality implementation and consumer access to EBPs.Trial registration NCT02449421. Registered 02/09/2015

The Value Equation: Three complementary propositions for reconciling fidelity and adaptation in evidence-based practice implementation

“…By focusing on value, we suggest that implementation success can be defined as the ability to optimize value across the different levels and stakeholders. This perspective on implementation success aligns with recent definitions of sustainability, which highlight the ability to continuously deliver benefits as key part of the construct [74], with adaptations being a strategy to promote it [75]. The value equation proposes that effects on certain clinical outcomes are necessary but not sufficient.…”

An analysis of adaptations to multi-level intervention strategies to enhance implementation of clinical practice guidelines for treating tobacco use in dental care settings

“…Several recent articles have incorporated Stirman's model in their protocols [ [27] , [28] , [29] ] and a growing number of studies have used the model to monitor and report modifications [ 27 , 30 ], and link type of adaptations to outcome data [ 31 ]. Other models that suggest methods for systematically tracking adaptations include the Dynamic Adaptive Process Model and the Managing and Adapting Practice approach to evidence-based practice [ 1 , 32 ].…”

Supporting Mental Health Providers: the Feasibility and Promise of a Virtual Professional Learning Community

“…Similar use of virtual communities to increase, or maintain, access to support, advice, and resources is an idea that has been suggested in the medical field (see Barnett, Jones, Bennett, Iverson, & Bonney, 2012; Mair et al, 2013) and is being studied in rural communities in Australia (see Penn et al, 2005). Virtual collaborative learning strategies to impact sustainability in mental health services is also ongoing and will provide vital information on effective strategies to sustain effective practices in community settings (see Wiltsey-Stirman, et al, 2017). Continuing to explore the potential of VPLCs and the additional support needed to expand provider advice networks across agencies to create access to additional resources is especially important for any provider who does not have access to informed colleagues or materials, such as those working in rural communities, in smaller agencies in urban or suburban communities, or even in larger agencies where colleagues may be working in relative isolation on a variety of programs; not uncommon in even larger social service agencies (Grady & Chen, 2006).…”