# Presentation: 476025

## 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

## 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)

**Notes:**
The clinical mission of our MIRECC involves clinical and educational interventions as well as alternative ways to deliver mental health care.

•Designing, implementing, and evaluating clinical and educational interventions

•Exploring and evaluating alternative ways to deliver more effective or efficient MH care

Ensuring that veteran consumers are fully incorporated across the mental health quality improvement continuum.

Note that this mission is grounded within a collaboration with the MHPL and our Consumer Advisory Board. 

## 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.

**Notes:**
The clinical mission of our MIRECC involves clinical and educational interventions as well as alternative ways to deliver mental health care.

•Designing, implementing, and evaluating clinical and educational interventions

•Exploring and evaluating alternative ways to deliver more effective or efficient MH care

Ensuring that veteran consumers are fully incorporated across the mental health quality improvement continuum.

Note that this mission is grounded within a collaboration with the MHPL and our Consumer Advisory Board. 

## 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

**Notes:**
The clinical mission of our MIRECC involves clinical and educational interventions as well as alternative ways to deliver mental health care.

•Designing, implementing, and evaluating clinical and educational interventions

•Exploring and evaluating alternative ways to deliver more effective or efficient MH care

Ensuring that veteran consumers are fully incorporated across the mental health quality improvement continuum.

Note that this mission is grounded within a collaboration with the MHPL and our Consumer Advisory Board. 

## 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

**Notes:**
The clinical mission of our MIRECC involves clinical and educational interventions as well as alternative ways to deliver mental health care.

•Designing, implementing, and evaluating clinical and educational interventions

•Exploring and evaluating alternative ways to deliver more effective or efficient MH care

Ensuring that veteran consumers are fully incorporated across the mental health quality improvement continuum.

Note that this mission is grounded within a collaboration with the MHPL and our Consumer Advisory Board. 

## 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

**Notes:**
The clinical mission of our MIRECC involves clinical and educational interventions as well as alternative ways to deliver mental health care.

•Designing, implementing, and evaluating clinical and educational interventions

•Exploring and evaluating alternative ways to deliver more effective or efficient MH care

Ensuring that veteran consumers are fully incorporated across the mental health quality improvement continuum.

Note that this mission is grounded within a collaboration with the MHPL and our Consumer Advisory Board. 

## 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

**Notes:**
The clinical mission of our MIRECC involves clinical and educational interventions as well as alternative ways to deliver mental health care.

•Designing, implementing, and evaluating clinical and educational interventions

•Exploring and evaluating alternative ways to deliver more effective or efficient MH care

Ensuring that veteran consumers are fully incorporated across the mental health quality improvement continuum.

Note that this mission is grounded within a collaboration with the MHPL and our Consumer Advisory Board. 

## 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

**Notes:**
The clinical mission of our MIRECC involves clinical and educational interventions as well as alternative ways to deliver mental health care.

•Designing, implementing, and evaluating clinical and educational interventions

•Exploring and evaluating alternative ways to deliver more effective or efficient MH care

Ensuring that veteran consumers are fully incorporated across the mental health quality improvement continuum.

Note that this mission is grounded within a collaboration with the MHPL and our Consumer Advisory Board. 

## 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

**Notes:**
The clinical mission of our MIRECC involves clinical and educational interventions as well as alternative ways to deliver mental health care.

•Designing, implementing, and evaluating clinical and educational interventions

•Exploring and evaluating alternative ways to deliver more effective or efficient MH care

Ensuring that veteran consumers are fully incorporated across the mental health quality improvement continuum.

Note that this mission is grounded within a collaboration with the MHPL and our Consumer Advisory Board. 

## 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!*

**Notes:**
The clinical mission of our MIRECC involves clinical and educational interventions as well as alternative ways to deliver mental health care.

•Designing, implementing, and evaluating clinical and educational interventions

•Exploring and evaluating alternative ways to deliver more effective or efficient MH care

Ensuring that veteran consumers are fully incorporated across the mental health quality improvement continuum.

Note that this mission is grounded within a collaboration with the MHPL and our Consumer Advisory Board. 

## 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

**Notes:**
The clinical mission of our MIRECC involves clinical and educational interventions as well as alternative ways to deliver mental health care.

•Designing, implementing, and evaluating clinical and educational interventions

•Exploring and evaluating alternative ways to deliver more effective or efficient MH care

Ensuring that veteran consumers are fully incorporated across the mental health quality improvement continuum.

Note that this mission is grounded within a collaboration with the MHPL and our Consumer Advisory Board. 

## 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

**Notes:**
The clinical mission of our MIRECC involves clinical and educational interventions as well as alternative ways to deliver mental health care.

•Designing, implementing, and evaluating clinical and educational interventions

•Exploring and evaluating alternative ways to deliver more effective or efficient MH care

Ensuring that veteran consumers are fully incorporated across the mental health quality improvement continuum.

Note that this mission is grounded within a collaboration with the MHPL and our Consumer Advisory Board. 

## Facilitation

- _Facilitator’s 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

**Notes:**
The clinical mission of our MIRECC involves clinical and educational interventions as well as alternative ways to deliver mental health care.

•Designing, implementing, and evaluating clinical and educational interventions

•Exploring and evaluating alternative ways to deliver more effective or efficient MH care

Ensuring that veteran consumers are fully incorporated across the mental health quality improvement continuum.

Note that this mission is grounded within a collaboration with the MHPL and our Consumer Advisory Board. 

## 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

**Notes:**
The clinical mission of our MIRECC involves clinical and educational interventions as well as alternative ways to deliver mental health care.

•Designing, implementing, and evaluating clinical and educational interventions

•Exploring and evaluating alternative ways to deliver more effective or efficient MH care

Ensuring that veteran consumers are fully incorporated across the mental health quality improvement continuum.

Note that this mission is grounded within a collaboration with the MHPL and our Consumer Advisory Board. 

## 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

**Notes:**
The clinical mission of our MIRECC involves clinical and educational interventions as well as alternative ways to deliver mental health care.

•Designing, implementing, and evaluating clinical and educational interventions

•Exploring and evaluating alternative ways to deliver more effective or efficient MH care

Ensuring that veteran consumers are fully incorporated across the mental health quality improvement continuum.

Note that this mission is grounded within a collaboration with the MHPL and our Consumer Advisory Board. 

## 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

**Notes:**
The clinical mission of our MIRECC involves clinical and educational interventions as well as alternative ways to deliver mental health care.

•Designing, implementing, and evaluating clinical and educational interventions

•Exploring and evaluating alternative ways to deliver more effective or efficient MH care

Ensuring that veteran consumers are fully incorporated across the mental health quality improvement continuum.

Note that this mission is grounded within a collaboration with the MHPL and our Consumer Advisory Board. 

## 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

**Notes:**
The clinical mission of our MIRECC involves clinical and educational interventions as well as alternative ways to deliver mental health care.

•Designing, implementing, and evaluating clinical and educational interventions

•Exploring and evaluating alternative ways to deliver more effective or efficient MH care

Ensuring that veteran consumers are fully incorporated across the mental health quality improvement continuum.

Note that this mission is grounded within a collaboration with the MHPL and our Consumer Advisory Board. 

## 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

**Notes:**
The clinical mission of our MIRECC involves clinical and educational interventions as well as alternative ways to deliver mental health care.

•Designing, implementing, and evaluating clinical and educational interventions

•Exploring and evaluating alternative ways to deliver more effective or efficient MH care

Ensuring that veteran consumers are fully incorporated across the mental health quality improvement continuum.

Note that this mission is grounded within a collaboration with the MHPL and our Consumer Advisory Board. 

## Outcomes

- Study evaluation –
- _Secondary Aims_:
- Estimate the direct costs of the external facilitation strategy
- Measures: Facilitator logs (calls, email, planning meeting)
- Facilitator’s time x salary
- Facilitated therapists’ time x ave. salary

**Notes:**
The clinical mission of our MIRECC involves clinical and educational interventions as well as alternative ways to deliver mental health care.

•Designing, implementing, and evaluating clinical and educational interventions

•Exploring and evaluating alternative ways to deliver more effective or efficient MH care

Ensuring that veteran consumers are fully incorporated across the mental health quality improvement continuum.

Note that this mission is grounded within a collaboration with the MHPL and our Consumer Advisory Board. 

## 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?

**Notes:**
The clinical mission of our MIRECC involves clinical and educational interventions as well as alternative ways to deliver mental health care.

•Designing, implementing, and evaluating clinical and educational interventions

•Exploring and evaluating alternative ways to deliver more effective or efficient MH care

Ensuring that veteran consumers are fully incorporated across the mental health quality improvement continuum.

Note that this mission is grounded within a collaboration with the MHPL and our Consumer Advisory Board.