by Jeanne Gabriele, PhD
I have the exciting role of helping to increase the implementation of evidence-based psychotherapies within a VA medical center. In working with providers and administrators, I have to come realize that everyone has a similar goal: they want to help the Veteran. However, viewpoints on the best methods to reach this goal differ. Some individuals put more weight on research. Others put more weight on clinical experience. When this debate is going on, the patient is often left on the side lines.
The central component of evidence-based practice is shared-decision making. This means that the patient should be moved from the sidelines to the playing field and be active in his or her treatment planning. In order to assist the patient in making an informed decision, the patient needs to be fully informed of all the treatment options. All treatment options, does not mean just those evidence-based approaches in which a particularly provider is trained but rather those treatments that have sufficient evidence for a given condition.
The Veteran’s Health Administration takes a multilevel approach to help implement more evidence-based psychotherapies. However, sometimes it is difficult for providers to see the forest from the trees. When polices are put in place that from a close perspective seem to dictate how to provide care, there can be some initial resistance. This resistance can be due to a lack of understanding of the purpose of the policies or how the policies are a component of a bigger picture aimed at improving patient involvement in care. I have found the three-circle model to be helpful in illustrating to providers how the VA system and its policies can help to increase the implementation of evidence-based practice and enable to Veteran to have greater information, options, and decision-making power for care. Below is an explanation of how the VHA targets all aspects of the three-circle model: Best Available Research, Resources including Practitioner Expertise, and Client Characteristics and Preferences.
Examining the Research Evidence and Incorporating Research into Practice. The VHA established programs to synthesize research and use research to guide policy. Two examples include the VHA/DoD’s Evidence-Based Practice Guideline Work Group and the VA’s Health Services Research and Development Evidence-Based Practice Synthesis program. The VHA/DoD’s Evidence-Based Practice Guideline Work Group coordinates evidence reviews that are used to develop VA/DoD Evidence-Based Clinical Practice Guidelines and promotes the use of medical informatics to support clinical decision making. Current guidelines can be found at http://www.healthquality.va.gov/index.asp.
The VA’s Health Services Research and Development Evidence-Based Practice Synthesis Program identifies topics of importance to VA managers and policy makers and conducts syntheses of research. Findings are then used to develop clinical policies informed by evidence, to help implement services to improve patient outcomes, and to set the direction for future research to address gaps in clinical knowledge. Reports can be found at www.hsrd.research.va.gov/publications/esp/reports.cfm.
Using Policy to Change the Environmental Context. Regarding the Evidence-Based Psychotherapy initiative, the VHA has policies in place to help create and distribute resources within Mental Health. These policies ensure that each VA medical center establishes a local system to support the implementation of evidence-based psychotherapies. The Uniform Mental Health Services Handbook (VHA Handbook 1106.01, issued in 2008) outlines requirements for VHA Mental Health Services. These requirements help to create the capacity for medical centers and large community outpatient clinics (CBOCs) to deliver core evidence-based psychotherapies. Thus, Veterans, wherever they obtain care in the VHA, have access to core mental health care services. Here are a few of the statements included in this document outlining requirements for evidence-based psychotherapies:
· “All Veterans with PTSD must have access to Cognitive Processing Therapy or Prolonged Exposure as designed and shown to be effective.”
· “All Veterans with depression or anxiety disorders must have access to Cognitive Behavioral Therapy, Acceptance and Commitment Therapy, or Interpersonal Therapy”,
· “Social Skills Training is an evidence-based psychosocial intervention that must be provided when clinically indicated at all medical centers and very large CBOCs.”
· “Social Skills Training must be available to all Veterans with Severe Mental Illness who would benefit from it…”
· “Medical Centers and very large CBOCs must have the capacity to allow for the delivery of evidence-based psychotherapy when indicated.”
In addition, to outlining requirements for services, the Uniformed Mental Health Services Handbook also requires each VA Medical Center to have a Local Evidence-Based Psychotherapy Coordinator. This individual helps to help coordinate the implementation of Evidence-Based Psychotherapies at their local VA medical center and serves as a liaison between the VA Central Office’s Office of Mental Health Services and the local VA. The Evidence-Based Coordinators roles include educating providers and upper level management about evidence-based psychotherapy; encouraging clinicians to attend evidence-based psychotherapy trainings; working with clinicians, team leaders, and mental health leadership to determine methods to implement more evidence-based psychotherapies within clinical care; and helping identify and overcome system barriers to implementing evidence-based psychotherapy.
The VA’s Office of Mental Health Services recently proposed a performance measure to assess the number of OIF/OEF Veteran’s with PTSD who receive 8 sessions of an evidence- based psychotherapy in 15 weeks. Each year targets will be set. This performance measures provides an incentive for VAs to deliver more evidence-based psychotherapies. In addition, in a large health care system that addresses a variety of health conditions, this performance measure helps to highlight the importance of mental health, particularly evidence-based psychotherapy. Thus when local hiring and funding decisions are made, hiring additional mental health staff to increase capacity of delivering these therapies becomes a higher priority.
Training Providers in Evidence-Based Psychotherapies to Increase Provider Resources. Once policies are in place to require medical centers to have these services, the next step is to determine how to train providers to deliver these services. The VA developed a national Evidence-Based Psychotherapy Training Initiative to disseminate and provide training for the identified evidence-based psychotherapy initiatives. This initiative is funded by the VA Central Office’s Office of Mental Health Services. Thus, individual VA medical centers do not have to cover costs of these trainings ensuring that all VA medical centers have equal opportunity to send providers to trainings regardless of the budgetary demands at the individual VA medical center. These trainings are intensive, high quality trainings with both didactic and competency-based components. Trainees attend a 3-4 day workshop where they receive initial knowledge about the therapy and practice skills. Afterwards, trainees return to their VA setting and receive at least 6 months of weekly telephone consultation while they practice delivering these psychotherapies to patients. For most of the training programs, sessions are audiotaped so consultants can provide feedback and assess adherence to treatment protocols and treatment fidelity. If practitioners complete the consultation process and meet criteria for illustrating competence in the psychotherapy, they are identified as a VA provider in that therapy. This training uses a train-the-trainer model. Individuals who completed training and showed mastery of skills can apply to become a consultant and assist in providing training to other providers. The long-term goal is to increase the number of trainers so there is the capacity to provide trainings on a regional or local level rather than a national level which in turn will decrease the costs of training and increase the capacity to train other clinicians.
Empowering the Patient to Allow for Shared-Decision Making. Through the evidence-based psychotherapy initiative, the VA has created educational materials to help fully inform Veterans about evidence-based psychotherapies for Post-Traumatic Stress Disorder, Depression, and Severe Mental Illness. These materials include a Treatments That Work brochure containing a menu of evidence-based psychotherapy services, brochures for a specific evidence-based psychotherapies, and videos which describe the psychotherapies and include statements from Veterans about their experience with the psychotherapies. These educational materials help to promote a system in which Veterans are provided with information on treatment options, have the opportunity to discuss the therapies with providers, and are offered the option of receiving one of the VA’s evidence-based psychotherapies. Although the intent is for all Veterans to be informed about the evidence-based psychotherapies, their treatment options are not limited to evidence-based psychotherapies. Psychotherapies that are not listed as one of the VA’s evidence-based psychotherapies may be offered and appropriate in some instances such as an adjunct to evidence-based psychotherapy, when there is no evidence-based psychotherapy for the presenting condition, or when the Veteran specifically requests another treatment approach. By having a mental health system in place which has the capacity to offer a variety of evidence-based psychotherapies to Veterans, the decision about whether to receive an evidence-based psychotherapy and the type of treatment is shifted from the provider to the Veteran. This approach empowers the Veteran and allows the Veteran to be take an active role in treatment decisions.
Putting it all together. Figure 1 outlines how the VA addresses each of the components of the Three-Circle Model. The VA’s approach requires medical centers and very large CBOCs to be have the capability of providing identified evidence-based psychotherapies. An intensive Evidence-Based Psychotherapy Training initiative has been established to provide necessary training to providers. Together, these components create the capacity to deliver evidence-based psychotherapies. By having multiple treatment options available, Veterans can be informed about their treatment options and can work with their provider to decide what approach will best meet their preferences and needs. Thus, this approach allows the Veteran to take an active role in decisions about his or her care.