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

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.

Implementation of Video Telehealth to Improve Access to Evidence-Based Psychotherapy for Posttraumatic Stress Disorder

“…6,p.650 Our results add to a growing body of literature supporting the effectiveness of external facilitation as an implementation strategy for promoting the use of evidence-based practice in complex clinical settings. 25,28,30,35,36 This pilot study has several limitations. The primary measure of implementation was based on a diagnosis of PTSD, with psychotherapy delivered via video telehealth.…”

“…23,25,28,30 An external facilitator uses a combination of strategies based on individual needs of a local setting to enable change within a complex system.…”

“…Previous research on implementing evidence-based practice supports the effectiveness of facilitation in supporting sites and providers in making practice changes. [28][29][30] An external facilitation that includes regular, supportive contact with someone trained in implementation and dedicated to helping sites solve problems is critical to effective adoption of new clinical practices. Although evidence supports delivery of psychotherapy for PTSD via video telehealth, no implementation strategy has been examined for effectiveness.…”

Conceptual Model: Evidence Based Interagency Implementation Model

“…A recent randomized controlled trial supports the use of external facilitators for the change process to manage tasks and deadlines, draft new policies or procedures, and monitor incremental progress. Having a facilitator improves the attention to change oriented tasks; groups without a facilitator made less progress (Kauth et al, 2010 ) . The advantage of the external facilitator is that the person does not have other day-to-day operational responsibilities for the agency.…”

“…5. Facilitators : guide the change process including external facilitators which keep the change process focused (Kauth et al, 2010 ) and internal facilitators that are devoted to the process. 6.…”