PCORI funds implementation projects that integrate evidence developed through PCORI-funded studies, in the context of the body of related evidence, into practice. This project focuses on implementing findings on several kinds of therapy and medicines that can reduce or stop symptoms for people with posttraumatic stress disorder (PTSD).

1. What is the eligible evidence proposed for implementation? 

Written Exposure Therapy (WET) is a five-session exposure-based EBP for PTSD that was efficacious in randomized controlled trials for treating PTSD from different types of traumas. In addition to PCORI’s recognition, WET is recommended as a first-line treatment by the Department of Veteran Affairs (VA) and the Department of Defense (DoD). In two recent trials, WET was non-inferior to the more time-intensive, gold-standard EBP, Cognitive Processing Therapy. Thus, WET seems to meet the need for alternative PTSD treatments that are brief, with little dropout, and require less clinical training. Indeed, WET’s brevity and tolerability make it an ideal first-level intervention, appealing to patients who have opted not to seek out more time- and therapist-intensive EBPs. WET addresses significant barriers to other EBPs for PTSD at the patient, provider, and system levels.

2. What is the goal of this implementation project?

The proposed project will employ a stepped wedge design to implement WET in six, large, diverse, integrated, civilian health care systems across the United States— Kaiser Permanente (KP) Hawaii, Henry Ford Health System, Kaiser Permanente Northwest, Kaiser Permanente Georgia, Essentia Health, and Baylor Scott & White Health — with all sites receiving the intervention during the project period. The healthcare systems are members of the Mental Health Research Network (MHRN), a consortium of 14 research centers. Sites will be assigned to one of two implementation groups. Every site will receive WET training, consultation, and multi-component implementation strategies, promoting equity and advancing the field of implementation science.

The specific aims of this project are to:

1. Employ multi-component implementation strategies to help mental health providers implement WET for their PTSD patients in mental health settings in six health care systems.
2. Use Consolidated Framework for Implementation Research (CFIR) to understand the determinants and process of implementation.
3. Utilize RE-AIM framework to evaluate implementation outcomes for mental health providers and patients.

3. What is the project team doing?

Participants will include mental health providers who regularly provide psychotherapy to adult populations as part of their caseload in mental health practice settings at each of the six sites. Current estimates indicate that there are approximately 485 providers across the six sites who meet eligibility. As part of selection of the implementation strategies for this project, key stakeholders at each site were given a list and definition of 73 implementation strategies and asked how essential each strategy would be to successfully implement WET at their setting. Strategies were chosen from highly rated items.

Leadership across sites have expressed unwavering cooperation and commitment to implement WET. They pledged to protect site personnel time to attend trainings, ongoing consultation, and participate in all implementation strategies to support project success. As an initial implementation step, the dual principal investigators (d-PIs), Joan Cook, PhD, from Yale School of Medicine and Vanessa, PsyD, KP Hawaii will conduct site visits to meet with key stakeholders, administer surveys, conduct qualitative interviews, and assess CFIR components. Training in WET will be hosted online by the two treatment developers, Drs. Denise Sloan and Brian Marx from the VA’s National Center for PTSD, for eight hours over a two-day period. Immediately following, providers will begin seeing training cases while strongly encouraged to attend 12-weeks of one-hour expert-led telephone consultation. Over a 12-month period, several additional implementation strategies including a monthly facilitated learning collaborative to assist providers in developing and enacting a systematic implementation plan and determine the best ways to address barriers and facilitators in implementing WET as well as a centralized online database and a WET-focused online forum.

4. How is the team evaluating this project? 

Processes and determinants of implementation will be measured and evaluated using the CFIR Framework pre- and post-training, consultation and collaboration via quantitative and qualitative measures of providers and directors through online surveys, in-person or telephone interviews, and site observation. All in-person meetings, emails, online and site visit materials will be documented. Engagement in these strategies will be measured using a checklist developed by Proctor et al.  that notates, for each strategy, who delivered it, steps taken to deliver, who received the strategy, as well as when the strategy was used and how much assistance was delivered. Implementation outcomes (reach, effectiveness, adoption and implementation) for the providers and patients will be measured using RE-AIM. This data will be derived from EHR data, quantitative surveys, and qualitative interviews.

All six health care systems utilize an electronic health record (EHR) system designed by Epic Systems Corporation. As members of the Health Care Systems Research Network, each system maintains the full set of the VDW84 uniform variables, allowing for immediate distribution of code to identify eligible PTSD patients and track implementation outcomes in all six systems simultaneously. Multiple pragmatic recruitment methods will be used to reach potential PTSD patient participants. Patients who appear to meet eligibility criteria for WET will be invited to participate. All patients who enroll in WET will be asked to complete self-report measures of PTSD, depression and psychosocial functioning within 48 hours before each scheduled WET appointment as well as immediately post-treatment, and at 3-, 6-, and 12-month follow-up. Implementation of WET within these six health care systems is expected to directly benefit the care and health outcomes of several thousands of trauma-exposed patients who are likely currently receiving inadequate or inappropriate treatments.

5. How is the team involving patients and others in making sure the findings reach people who can use them? 

This project is also built on the support of stakeholders within the MHRN, including the Patient/Consumer Engagement Committee. Findings generated from this implementation project will result in several important evaluative and empirical deliverables such as the implementation workbook, descriptive and empirical papers and presentations at national conferences, and substantive structured feedback to these six health care settings as well as the broader MHRN. If findings show strong implementation outcomes, scaling up and out of WET will take place in the remaining eight MHRN-affiliated health care systems.

6. How will this project help ensure future uptake and use of the evidence?

To maximize scalability and sustainability in the future, the team will develop an implementation guide that will provide detailed instructions about the project that can be referenced by these as well as other sites who may which to implement WET into practice. This guide will be disseminated to all sites in the MHRN as well as made accessible through their website as a resource for the public and other health care systems. It is the hope that this project will lay the groundwork for broad scale-up of WET in mental health settings across the United States. The public policy implications of this project are substantial given the unmet mental health needs of trauma survivors with PTSD.

This project is also designed to support the sustainability of WET both within and outside of these six health care systems, even after project supports are removed. For example, the provider portal, which will be accessible in perpetuity, will contain video recordings of the virtual WET trainings for future use. This will allow providers who are unable to attend or who were not hired at the time of the training to access training along with additional materials uploaded throughout the project (e.g., video demonstrations of WET, scholarly articles, materials for reaching and tailoring WET to diverse patient populations, etc.).