The Medical Interview and Illness Outcomes

1
Example of an Implementation Study Facilitating
Implementation of Cognitive Behavioral Therapy
(CBT)
Michael R. Kauth, PhD Co-Director and Associate
Director for Education, MIRECC Michael E. DeBakey
VA Medical Center, Houston Baylor College of
Medicine MIRECC Retreat, April 17, 2008
2
CBT Implementation Team

• Michael Kauth, PhD (PI) Qayyim Said, PhD
• Dean Blevins, PhD Melinda A. Stanley, PhD
• Jeffrey A. Cully, PhD Thomas Teasdale, DrPH
• JoAnn Kirchner, MD Monica Watford
• Training Committee
• Nancy Wilson, LCSW Marylois Lacey, RN
• Acknowledgements for work on previous version
• Greer Sullivan, MD, MSPH Rick Owen, MD
• Jeff Smith, PhD(c)

3
Background

• Past experience with Network-wide training
  programs
• Facilitating training
• Selection of trainees based on
  motivation Training produces marketable skill
• Trainers familiar with work environment Trainees
  set personal goals
• Consultation emphasizes goals and Modify goals
  if necessary
• performance standards
• Facilitating implementation
• Objective assessment of skills
  site- Collaboration between therapists and
• specific goals administrators
• Administrators agree to commit
  resources Clinicians need ongoing support
• Sullivan, Blevins Kauth. Implementation
  Science. In press.

4
Background

• Facilitation as an implementation intervention
• PARiHS (Promoting Action on Research
  Implementation in Health Services) framework for
  implementing evidence based practices
• Evidence research, clinical experience,
  patient preferences
• Context culture, leadership,
  feedback/evaluation
• Facilitation characteristics, role, style
• Kitson et al. Qual Saf Health Care 1998
  Rycroft-Malone et al. Qual
• Saf Health Care 2002
• The QUERI experience with external facilitation
  in implementing numerous practice changes a
  distinct intervention.
• External and internal facilitation
• Stetler et al. Implementation Science 2006

5
Background

• Depression is common among veterans
• 31 veterans in PC meet criteria for depression
• Hankin et al. Am J Psychiatry 1999
• Depression is 3rd most common problem (after
  PTSD and substance abuse) for returning veterans
• VHA. Analysis VA Health Care OIF, OEF
  2007
• Treatment of depression in PC
• CBT as effective as pharmacotherapy, with less
  relapse
• Paykel et al. Arch Gen Psychiatry 1999
• CBT is more effective than usual care at least
  as effective as other psychotherapies
• Wolf Hopko. Clin Psych Rev 2008
• Brief CBT (3-6 sessions) is effective in a
  collaborative care setting
• Barkham et al. Behavioural Psychotherapy
  1992 Fennel Teasdale. Cog
• Therapy Research 1987 Katon et al. Arch Gen
  Psychiatry 1996
• Mynors-Wallis et al. BMJ 1995 Scott et al.
  British J Psychiatry 1997

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Pilot Study

• Piggy-back on VISN 16 PC-MH initiative,
  co-located collaborative care clinics (proposal
  included training in CBT)
• Use CBT as clinical training to study
  facilitation
• Proposed a pilot study, multiple case study
  design, with sites randomized to facilitation or
  control conditions

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Study Aims

• Primary Aim Test the effect of using external
  facilitation to improve implementation of CBT in
  medical centers and community clinics.
• Hypotheses Therapists who receive facilitation
  will deliver
• 1) more hours of CBT to
• 2) more veterans
• Outcome CBT notes (admin data)
• Secondary Aims
• 1. Identify variables that may influence
  implementation of CBT at medical center vs.
  community clinics
• 2. Identify variables perceived to be important
  to the content and process of external
  facilitation, including characteristics of the
  facilitator
• 3. Estimate the direct costs of the external
  facilitation strategy
• Outcome survey data, qualitative intvw

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Site Selection

• VISN 16 PC-MH co-located care clinics mental
  health therapists
• VA medical centers Community-based clinics
• Alexandria (women gen PC) 2 Pensacola 1
• Biloxi (gen PC) 2 Ft. Smith 1
• Houston (2 gen PCs) 2 Mt. Vernon 1
• Jackson (gen PC) 2 Tulsa 1
• Oklahoma City (gen PC) 3
• 11 clinics, 15 therapists

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Site Selection

• VISN 16 PC-MH co-located clinics mental health
  therapists
• VA medical centers Community-based clinics
• Alexandria (women gen PC) 2 Pensacola 1
• Biloxi (gen PC) 2 Ft. Smith 1
• Houston (2 gen PCs) 2 Mt. Vernon 1
• Jackson (gen PC) 2 Tulsa 1
• Oklahoma City (gen PC) 3 Baton Rouge 1
• Lawton 1
• Longview 1
• 20 clinics, 25 therapists Lufkin 2
• Mobile 1
• Monroe 1
• New Orleans 1
• Panama City 1
• Texarkana 1

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Method

• Clinics matched on
• Type of facility VA medical center or community
  clinic
• Ratio of MH clinic staff to uniques (admin
  data)
• Expressed interest in CBT by therapists and
  clinic managers (1 item, 7 pt scale, survey)
• Context / readiness responses by therapists and
  clinic managers (10 item, 7 pt scale, survey)
• Randomize one of each pair to facilitation
  condition
• Everyone gets CBT training!

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Training

• Found no validated brief CBT training protocol
• Developed brief CBT training (Cully) didactic
  experiential
• 1.5 day face-face training
• not session specific treatment manual (Cully
  Teten)
• train on validated CBT modules for brief sessions
• e.g., CBT theory, case conceptualization,
  identifying maladaptive thoughts, responding to
  automatic thoughts, etc.
• receive info practice, feedback
• 12 week (biweekly) consultation
• 5-6 small groups meet with a consultant on
  treatment issues
• not for issues related to implementation

12
Training

• Training evaluation
• Pre-T Post-T Post-Consult
• Perception of knowledge (15 items, 5 pt)
  x x x
• Use of CBT techniques (14 items, 5 pt)
  x x
• Confidence to conduct brief CBT (15 items, 5 pt)
  x x x
• Training and trainers (12 items, 5 pt)
  x
• Consultation and consultants (8 items, 5 pt)
  x
• On site email

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Facilitation

• Facilitators role, style goal-focused partner,
  problem-solver, motivator, technician,
  communicator, cheerleader.
• Pre-training phase (2-4 weeks) 1-2 50 min.
  conference calls
• Objectives
• 1. Establish working relationship with
  therapists and managers
• 2. Begin to have therapists and managers think
  of goals for CBT use and anticipate barriers
• Tasks
• Establish communication with participants,
  introduce self, explain role
• Elicit reasons for participating in CBT training
  potential barriers
• Assess what motivates therapists and managers
• Encourage / suggest background reading in CBT
• Praise / encourage therapists to lay groundwork
  now for CBT later

14
Facilitation

• Training phase (2 days) in-person meeting
• Objectives
• 1. Increase comfort level with therapists
• 2. Understand the treatment that therapists will
  implement
• Tasks
• Use face-to-face meetings with therapists to
  enhance relationships
• Observe CBT training

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Facilitation

• Post-training (6 months) 6 monthly 50 min.
  conference calls
• Objectives
• 1. Get the therapists to use CBT as soon as
  possible
• 2. Focus therapists and managers on personal and
  site goals
• 3. Identify and address barriers to
  implementation ASAP
• 4. Maintain enthusiasm for CBT among therapists
• Tasks
• Maintain high attendance on facilitation calls
• Have therapists to set site-specific goal for
  implementation ASAP
• Encourage any CBT use praise all attempts
• Encourage attendance on consultation calls
• Give feedback to managers and inform Directors of
  progress
• Encourage documentation
• Present therapists as emerging experts
  contributing to best practice

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Outcomes

• Study evaluation -
• Primary Aim Test the effect of using external
  facilitation to improve implementation of CBT in
  medical centers and community clinics.
• Hypotheses Therapists who receive facilitation
  will deliver
• 1) more hours of CBT to
• 2) more veterans
• Measures Standardized progress notes for brief
  CBT, compiled monthly for 6 months (database)
• of therapists using CBT per condition
• Frequencies of CBT notes per condition
• Frequencies of patients who received any CBT per
  condition

17
Outcomes

• Study evaluation
• Secondary Aims
• Identify variables that may influence
  implementation of CBT at medical center vs.
  community clinics
• Measures Therapist pre/post surveys, training
  evaluations, qualitative interviews, facility
  type
• therapist characteristics, experience, motivation
• therapist skills, participation in consultation,
  participation in facilitation
• organizational barriers

18
Outcomes

• Study evaluation
• Secondary Aims
• Identify variables perceived to be important to
  the content and process of external facilitation,
  including characteristics of the facilitator
• Measures Therapist surveys, facilitation
  evaluation experience (5 items), Facilitator
  characteristics (22 items), Facilitator logs (
  on call, notes), qualitative interviews, facility
  type
• therapist characteristics, experience, motivation
• Facilitator characteristics, facilitation content
• organizational barriers

19
Outcomes

• Study evaluation
• Secondary Aims
• Estimate the direct costs of the external
  facilitation strategy
• Measures Facilitator logs (calls, email,
  planning meeting)
• Facilitators time x salary
• Facilitated therapists time x ave. salary

20
Implications

• Facilitation results in an observable differences
  in use of CBT
• Effect may justify additional costs of
  facilitation
• Therapist characteristics and facility type
  resulted in differential use of CBT
• Medical center and community clinics vary in
  barriers to practice change and implementation
  strategies
• Key Facilitator characteristics, roles, and style
  identified
• Generate additional hypotheses
• Larger sample to explore variations and limits
  of facilitation practice change, therapists,
  organizational structures, implementation model.
• Extend to other networks will it work outside
  of VISN 16?