Employing external facilitation to implement cognitive behavioral therapy in VA clinics: a pilot study

Michael R Kauth,Greer Sullivan,Dean Blevins,Jeffrey A Cully,Thomas A Teasdale,Qayyim Said,Reid D Landes

doi:10.1186/1748-5908-5-75

Abstract

BackgroundAlthough for more than a decade healthcare systems have attempted to provide evidence-based mental health treatments, the availability and use of psychotherapies remains low. A significant need exists to identify simple but effective implementation strategies to adopt complex practices within complex systems of care. Emerging evidence suggests that facilitation may be an effective integrative implementation strategy for adoption of complex practices. The current pilot examined the use of external facilitation for adoption of cognitive behavioral therapy (CBT) in 20 Department of Veteran Affairs (VA) clinics.MethodsThe 20 clinics were paired on facility characteristics, and 23 clinicians from these were trained in CBT. A clinic in each pair was randomly selected to receive external facilitation. Quantitative methods were used to examine the extent of CBT implementation in 10 clinics that received external facilitation compared with 10 clinics that did not, and to better understand the relationship between individual providers' characteristics and attitudes and their CBT use. Costs of external facilitation were assessed by tracking the time spent by the facilitator and therapists in activities related to implementing CBT. Qualitative methods were used to explore contextual and other factors thought to influence implementation.ResultsExamination of change scores showed that facilitated therapists averaged an increase of 19% [95% CI: (2, 36)] in self-reported CBT use from baseline, while control therapists averaged a 4% [95% CI: (-14, 21)] increase. Therapists in the facilitated condition who were not providing CBT at baseline showed the greatest increase (35%) compared to a control therapist who was not providing CBT at baseline (10%) or to therapists in either condition who were providing CBT at baseline (average 3%). Increased CBT use was unrelated to prior CBT training. Barriers to CBT implementation were therapists' lack of control over their clinic schedule and poor communication with clinical leaders.ConclusionsThese findings suggest that facilitation may help clinicians make complex practice changes such as implementing an evidence-based psychotherapy. Furthermore, the substantial increase in CBT usage among the facilitation group was achieved at a modest cost.

Highlights

For more than a decade healthcare systems have attempted to provide evidence-based mental health treatments, the availability and use of psychotherapies remains low
Potential clinic sites in Veterans Integrated Service Network 16 were identified by clinical leaders at the 10 Veteran Affairs (VA) medical centers in order to promote evidence-based psychotherapies (EBPs) in newly integrated primary care (PC) clinics
Two-thirds reported having received previous training in cognitive behavioral therapy (CBT) since graduate school. (We did not solicit the type of training, which could have ranged from a formal lecture to an intensive training plus supervision)

Summary

Introduction

For more than a decade healthcare systems have attempted to provide evidence-based mental health treatments, the availability and use of psychotherapies remains low. Emerging evidence suggests that facilitation may be an effective integrative implementation strategy for adoption of complex practices. Overall efforts to increase the provision of evidencebased mental health (MH) treatments by intervening with providers to change practices have been met with modest success [1,2,3], more recent intensive and organizational levels (e.g., changes in technology, decision-support tools) have been shown to be effective [7]. Facilitation has emerged recently as a promising integrative implementation strategy in quality-improvement and health services research. Facilitation, in this context, refers to ‘the process of enabling (making easier) the implementation of evidence into practice’ within a complex system of care [11]. In four of five randomized controlled studies, facilitation has shown a modest-tostrong effect on adoption of new clinical procedures, such as health screenings, monitoring procedures, and motivational interviewing across diverse settings [13,14,15,16,17]

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Results

Conclusion