Abstract
Background
Successful implementation of evidence-based treatments 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 safety net primary care settings. We aimed to collect data on four potential influences on implementation, including the degree of less-than-best practices, determinants of the current practice, potential barriers and facilitators of implementation, and the feasibility of a proposed strategy for implementing a brief treatment for PTSD.
Methods
Our mixed-methods developmental formative evaluation (Stetler et al., 2006) was guided by the Consolidated Framework for Implementation Research (CFIR), including a) surveys assessing implementation climate and attitudes towards evidence-based treatments and behavioral health integration and b) semi-structured interviews to identify barriers and facilitators to implementation and need for intervention and system augmentation. Participants were hospital employee stakeholders (N = 22), including primary care physicians, integrated behavioral health clinicians, community wellness advocates, and clinic leadership. We examined frequency and descriptive data from surveys and conducted directed content analysis of interviews. We used a concurrent mixed-methods approach, integrating survey and interview data collected simultaneously using a joint display approach to inform implementation efforts. We utilized a primary care community advisory board (CAB) comprised of employee stakeholders to refine interview guides, and apply findings to the specification of a revised implementation plan.
Results
Stakeholders described strong attitudinal support, yet therapist time and capacity restraints are major PTSD treatment implementation barriers. Patient engagement barriers such as stigma, mistrust, and care preferences were also noted. Recommendations based on findings included tailoring the intervention to meet existing workflows, system alignment efforts focused on improving detection, referral, and care coordination processes, protecting clinician time for training and consultation, and embedding a researcher in the practice.
Conclusions
Our evaluation identified key factors to be considered when preparing for implementation of PTSD treatments in safety net integrated primary care settings. Our project also demonstrated that successful implementation of EBTs for PTSD in safety net hospitals necessitates strong stakeholder engagement to identify and mitigate barriers to implementation.
Comorbid Chronic Illness and the Diagnosis and Treatment of Depression in Safety Net Primary Care Settings
