From implementation to sustainment: A large-scale adverse event disclosure support program generated through embedded research in the Veterans Health Administration

Formative evaluation prior to implementation of a brief treatment for posttraumatic stress disorder in primary care

BACKGROUND

Successful implementation of evidence-based treatments (EBT) for posttraumatic stress disorder (PTSD) in primary care may address treatment access and quality gaps by providing care in novel and less stigmatized settings. Yet, PTSD treatments are largely unavailable in safety net primary care. We aimed to collect clinician stakeholder data on organizational, attitudinal, and contextual factors relevant to EBT implementation.

METHODS

Our developmental formative evaluation was guided by the Consolidated Framework for Implementation Research (CFIR), including (a) surveys assessing implementation climate and attitudes towards EBTs and behavioral health integration and (b) semi-structured interviews to identify barriers and facilitators to implementation and need for augmentation. Participants were hospital employees (N = 22), including primary care physicians (n = 6), integrated behavioral health clinicians (n = 8), community wellness advocates (n = 3), and clinic leadership (n = 5). We report frequency and descriptives of survey data and findings from directed content analysis of interviews. We used a concurrent mixed-methods approach, integrating survey and interview data collected simultaneously using a joint display approach. A primary care community advisory board (CAB) helped to refine interview guides and interpret findings.

RESULTS

Stakeholders described implementation determinants of the EBT related to the CFIR domains of intervention characteristics (relative advantage, adaptability), outer setting (patient needs and resources), inner setting (networks and communication, relative priority, leadership engagement, available resources), and individuals involved (knowledge and beliefs, cultural considerations). Stakeholders described strong attitudinal support (relative advantage), yet therapist time and capacity restraints are major PTSD treatment implementation barriers (available resources). Changes in hospital management were perceived as potentially allowing for greater access to behavioral health services, including EBTs. Patient engagement barriers such as stigma, mistrust, and care preferences were also noted (patient needs and resources). Recommendations included tailoring the intervention to meet existing workflows (adaptability), system alignment efforts focused on improving detection, referral, and care coordination processes (networks and communication), protecting clinician time for training and consultation (leadership engagement), and embedding a researcher in the practice (available resources).

CONCLUSIONS

Our evaluation identified key CFIR determinants of implementation of PTSD treatments in safety net integrated primary care settings. Our project also demonstrates that successful implementation necessitates strong stakeholder engagement.

Involving Stakeholders as Communication Partners in Research Dissemination Efforts

Moving evidence into practice requires the support of stakeholders, who are critical actors in the research process. Yet, research teams need strategies for determining who these stakeholders are, what their roles should be, and how to involve them in research and dissemination activities. In this Perspective, we discuss steps for identifying, categorizing, and including stakeholders in the research process, as a precursor to involving them as communication partners in research dissemination efforts. Effectively communicating the results of research is critical for increasing stakeholders' buy-in for the adoption and sustainment of this evidence. However, this communication is best if it comes from the end-users themselves, the stakeholders, who have a specified involvement in the research process. Combining elements from dissemination, implementation, and management science literature, we identify specific tools and strategies for researchers to (1) understand the roles of various stakeholders potentially impacted by their work, and (2) recognize the specific communication activities these stakeholders could be engaged in, to support the dissemination of research findings. We present a 3-Step Plan for identifying, categorizing, and involving stakeholders in the research process in a way that will lead to their role as communication partners when results are ready to be disseminated widely.