Background. Computer-based interventions (CBIs) provide a potentially effective platform for increasing Veteran access to evidence-based treatment for disorders common in primary care such as depression, anxiety, and insomnia. Because of their advantages, Congress mandated that VA implement CBIs via the Veterans' Mental Health and Other Care Improvements Act of 2008.3 However, efforts to evaluate strategies for CBI implementation in VA primary care have been limited. The Supported-CBI Implementation Strategy was developed to implement a range of mental health CBIs in primary care and consists of four components: (1) a clinical intermediary for patient support, (2) provider/staff facilitation and education, (3) patient education, and (4) stepped-care for those requiring additional treatment. A recent pilot study at VACT demonstrated the feasibility of a CBI for insomnia in VA outpatient care when implemented via Supported-CBI. Objectives. The focus of this work will be on using CBIs as intervention platforms and not a specific program or disorder. However, the RESTORETM program for the treatment of insomnia, will be used for testing. There are three objectives: (1) adapt Supported-CBI to current VA primary care organizations, (2) test the effectiveness of Supported-CBI and the clinical outcomes of RESTORETM in VACT primary care, and (3) explore the development of informatics-based processes to track the diffusion of CBI use throughout VA. Hypotheses. 1. Supported-CBI can be modified for use in VA primary care by identifying barriers/facilitators revealed by national and local primary care providers and administrators. 2. Supported-CBI, relative to a control implementation strategy, will demonstrate superior rates of (a) CBI engagement by patients, (b) provider adoption through referral to the CBI, and (c) patient completion of the CBI, as well as (d) improved patient insomnia outcomes. 3. VA organizations/providers who are early- and non-adopters of CBI use can be identified from VA medical record documentation. Once identified, interviews will validate informatics findings, identify additional barriers/facilitators, and reveal sites interested in a multi-site trial of Supported-CBI. Methods. Barriers/facilitators to Supported-CBI implementation will be identified through the qualitative analysis of semi-structured interviews and focus groups with VA-wide primary care leadership and members of local VACT primary care teams. The preliminary effectiveness of Supported-CBI and clinical outcomes of RESTORETM (compared to a low-intensity [control] strategy) will be evaluated in a hybrid type 3 implementation-effectiveness trial. Summative and process-level implementation outcomes as well as clinical insomnia outcomes will be evaluated over a six-month period and the sustainment of implementation over an additional year. The diffusion of CBI use across VA will be evaluated using information retrieval from a national dataset of VA clinical notes to identify instances of CBI use and to target semi-structured interviews of VA providers who are early- and non-adopters of CBIs. Impact. This research will modify and test a strategy for CBI implementation in VA primary care, which can be used by VA providers, administrators, and policy makers to increase access to evidence-based mental healthcare, decrease barriers to care, and increase clinic productivity. This research will directly impact VA providers by expanding efficacious, non-pharmacologic alternatives for treating mild to moderate mental health problems. This research will impact Veteran health by increasing access to mental healthcare, particularly in the early stages of disorders common in primary care treatment. Veteran well-being will be improved through intervention-related improvements in health outcomes and self-efficacy. Risk to Veterans may also lessen through the decreased use of potentially harmful psychotropic medications.
VA primary care providers face critical questions regarding how to engage and treat Veterans earlier in the course of common mental health conditions such as depression, anxiety, and insomnia, without prescribing potentially harmful psychotropic medications. Computer-based mental health interventions (CBIs) provide an effective answer to such questions. However, there have been few systematic evaluations of the implementation, effectiveness, and diffusion of such interventions in VA, and no efforts to develop a generalizable strategy for their implementation in VA primary care contexts. This proposal will modify and test such a strategy, called Supported-CBI, while evaluating the diffusion of computer-based intervention use across VA. This research will increase access to effective mental health interventions for Veterans in primary care, while also producing an evidence based implementation strategy to be used by VA providers, administrators, and policy makers in future CBI implementation and dissemination efforts.
