Impacts - This project provides primary care providers with the tools necessary to fully partner with mental health providers in the care of their patients. It will address the preference of some patients to receive mental health care from their primary care provider, involve primary care providers more directly in the mental health care of their patients and may expand pharmacotherapy services into mental health care professional shortage areas. Background - The VA/DoD clinical practice guidelines for PTSDstrongly recommend the use of selective serotonin reuptake inhibitors (SSRI) and serotonin norepinephrine reuptake inhibitors (SNRI) as first line pharmacotherapy for PTSD. In our recently completed HSR&D study of treatment participation among 7,645 veterans recently diagnosed with PTSD, we found that the rate of SSRI/SNRI prescription rates were nearly twice as high among PTSD patients diagnosed in mental health clinics compared to those diagnosed in primary care (50% vs. 28%). Controlling for differences in demographics, access barriers, treatment need, treatment preferences and beliefs, veterans diagnosed in primary care clinics received SSRI/SNRI prescriptions at one-half the rate of those veterans diagnosed in mental health clinics, and any mental health care at less than one-third the rate. The primary aim of this proposal is to increase the prescription rate of evidence based pharmacotherapy for Veterans diagnosed with PTSD by primary care providers in VA Community Based Outpatient Clinics (CBOC). We propose to test a multi-component implementation intervention designed to facilitate use of evidence-based pharmacotherapy for Veterans with PTSD by primary care providers in CBOCs. Dissemination and implementation of evidence-based pharmacotherapy for Veterans with PTSD will directly contribute to VA HSR&D's priority initiatives for Post-Deployment Health and for Mental and Behavioral Health. According to the Uniform Mental Health Services in VA Medical Centers and Clinics handbook issued by the Office of Mental Health Services, mental health treatment, including pharmacotherapy, must be available in all primary care clinics. However, few CBOCs have a full time onsite mental health prescriber. Objectives - 1). Increase the proportion of Veterans diagnosed with PTSD in CBOCs who receive a guideline recommended medication from their primary care provider. 2). Gather information to refine the intervention and for future dissemination and implementation. Secondary Aim: 1). Among those primary care providers who ever prescribe guideline recommended medications for their patients with PTSD, demonstrate an increase the proportion of patients for whom they prescribe. Methods - The Intervention Evaluation involves testing the effectiveness of a multi-component intervention designed to facilitate use of VA/DoD PTSD clinical practice guideline recommended pharmacotherapies among primary care providers. The Intervention addresses organizational and provider factors affecting intervention implementation, increases provider motivation to provide pharmacotherapy services by increasing patient demand via patient outreach, and eases access to PTSD guideline pharmacotherapy recommendations at the point-of-care by development and use of a PTSD pharmacotherapy Consult Template in CPRS. The effectiveness of this multicomponent intervention will be assessed using a clustered group randomized pre- post intervention design. The Implementation Evaluation will use formative evaluation methods to evaluate organizational and provider variables prior to the intervention, identify and address implementation barriers during the intervention, modify the intervention as needed to meet the needs of participating CBOC primary care providers and assess factors related to sustainability of the intervention one year after the onset of the intervention.
In a recently completed HSR&D funded study, we found that Veterans diagnosed with posttraumatic stress disorder (PTSD) received medications recommended by VA/DoD PTSD clinical practice guidelines at one-half the rate of Veterans who received their diagnoses in a mental health clinic even after differences in demographics, illness severity, and patient treatment beliefs were accounted for. This project tests a multicomponent intervention designed to help primary care providers develop greater expertise in treating their PTSD patients with guideline recommended medications. We propose to compare the ability of the intervention to increase the rate that Veterans receive guideline recommended medications in CBOCs that receive the intervention vs. those that do not.
