The Implementation and Testing of a Referral Management System to Address Barriers to Treatment Seeking Among Primary Care Veterans With PTSD
Primary care (PC) patients have low rates of engagement in evidence-based psychotherapy for PTSD due to a variety of patient- and system-level barriers. We conducted a hybrid effectiveness-implementation study of a referral management system, called coordinated and alternative pathway to engagement (CAPE), to address barriers to receiving evidence-based treatment for PTSD. CAPE included the delivery of 1 session of cognitive-behavioral therapy (CBT) within PC to identify and change treatment-seeking beliefs, phone contacts to assist veterans in attending appointments, and PC staff trainings on how to implement clinical practice guidelines for PTSD in PC. The study was conducted in 3 phases. In Phase 1, PC and mental health (MH) leaders were interviewed regarding potential barriers and facilitators to implementation. In Phase 2, CAPE was implemented for 6 months and study outcomes were analyzed using the reach, effectiveness, adoption, implementation, maintenence (RE-AIM) framework. In Phase 3, local and national stakeholders provided feedback on study results to guide future implementation research. Phase 1 feedback informed the implementation plan regarding the content of training and communication strategies for PC staff. Phase 2 results indicated CAPE clinic patients were significantly more likely to engage in psychotherapy for posttraumatic stress disorder (PTSD) than those from a similar clinic where CAPE was not implemented. Phase 3 stakeholder feedback focused on how to generate more CAPE referrals and improve rates of evidence-based psychotherapy initiation in future implementation efforts. This study provides a description of how patient and system-level modifications can be implemented within PC to improve treatment engagement and patient health outcomes.