Background: Chronic insomnia, one of the most common health problems among Veterans, significantly impacts health, function, and quality of life. Cognitive Behavioral Therapy for Insomnia (CBTI) is the first line treatment; however, despite efforts to train hundreds of VA clinicians to deliver CBTI, there are still significant barriers to providing adequate access to insomnia care. Up to 44% of Veterans seen in Primary Care report insomnia, making it an optimal clinical setting for improving access to insomnia care. Furthermore, Brief Behavioral Treatment for Insomnia (BBTI), adapted from CBTI as a briefer, more flexible treatment, is easily delivered by Primary Care Mental Health Integration (PCMHI) clinicians and can greatly improve access to care for Veterans with insomnia. Yet, simply training PCMHI clinicians to deliver BBTI is not enough. Implementation strategies are needed for successful uptake, adoption, and sustainable delivery of care. Significance/Impact: BBTI is effective, developed for non-specialty care settings, and easier to deliver than CBTI. If delivered sustainably within Primary Care, BBTI can help increase access to evidence-based insomnia care and overcome barriers related to accessing CBTI. The proposed study has potential to significantly impact, and improve, how insomnia care is delivered in VA. It is responsive to VA ORD priorities of expanding access to high quality clinical trials and increasing the real-world impact of VA research. Also, it targets HSR&D research, and ORD clinical, priority areas (access to care, mental health, primary care practice, virtual care/telehealth) using a cross-cutting health services research methodology, implementation science. Innovativeness: The study design is rigorous, pragmatic, and features innovative methods, notably a stepped- wedge, hybrid implementation-effectiveness design. This study is unique?a search of VA ORD and NIH funded studies found there are no studies testing implementation strategies to improve the delivery of BBTI in Primary Care. Focusing on implementation outcomes and treatment effectiveness will help produce results that can improve access to care for a prevalent disorder and more rapidly translate results into practice and policy.
Specific Aims :
Aim 1 will compare the impact of PCMHI clinicians trained to deliver BBTI vs. the impact of BBTI training plus 12-months of access to an implementation strategy bundle (BBTI+IS). BBTI+IS vs. BBTI training alone is expected to result in more Veterans with access to insomnia care in the Primary Care setting.
Aim 2 will identify specific strategies that promote successful implementation of BBTI in PCMHI through the use of qualitative interviews and surveys with clinical stakeholders at each study site. Methodology: This stepped-wedge, hybrid III implementation-effectiveness trial involves four VA Medical Centers/Health Care Systems: Baltimore, Durham, Minneapolis, and Philadelphia. The stepped-wedge design allows for fewer sites to achieve adequate power as all sites are exposed to BBTI training and BBTI+IS. The hybrid design allows for testing of implementation and treatment effectiveness, guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. The target sample are PCMHI clinicians and the impact of a bundle of strategies on the success of sustainably delivering BBTI in Primary Care. Retrospective data collected from VA electronic health records will be used to obtain variables of interest related to Veteran treatment outcomes and data related to how PCMHI clinicians deliver BBTI. Implementation/Next Steps: Findings will be used to better understand specific implementation strategies that can help increase uptake and sustainable delivery of BBTI in PCMHI through research and quality improvement efforts on a larger scale. Through collaborations with operations partners in the Office of Mental Health and Suicide Prevention, the study team will work towards the development of products to educate VA stakeholders (local, VISN, VACO) and methods to widely disseminate BBTI training for PCMHI clinicians, efforts that will further contribute towards the improvement of insomnia care and Veteran health overall.
Chronic insomnia, one of the most common health problems among Veterans, significantly impacts health, function, and quality of life. However, a gap exists between the high prevalence of insomnia and access to the recommended treatment, Cognitive Behavioral Therapy for Insomnia (CBTI), which is often only available in specialty care settings. Brief Behavioral Treatment for Insomnia (BBTI), adapted from CBTI, is effective, brief, flexible, and easy to deliver in the Primary Care setting by embedded mental health clinicians (Primary Care Mental Health Integration [PCMHI]). Yet, simply training PCMHI clinicians to deliver BBTI is rarely enough. Specific strategies are often necessary to ensure that evidence-based practices, like BBTI, are successfully adopted and sustainably delivered. Identifying and applying these strategies to implement BBTI into routine clinical care in VA Primary Care settings, where insomnia is typically first recognized, may effectively and efficiently increase access to care and help decrease the risks and burdens related to chronic insomnia.
