Our formative evaluation involved 22 participants, including 11 potential interventionists (6 clinical social workers, 2 psychologists, 3 CWAs), and 11 key stakeholders (6 PCPs, 5 clinic leaders, and administrators representing psychology, psychiatry, social work, and operations). No participants refused to participate or dropped out. Sociodemographic information was not collected to preserve employee privacy.
Surveys
Table 2 provides details of the survey findings. Overall, participants noted strong organizational support (CFIR inner setting) for implementation of evidence-based practices (ICS Total M=2.06, SD=0.42), with ratings similar or higher than ratings of implementation climate observed in other mental health34 and substance use settings.44Participants reported low ratings on the ICS subscales staff selection (M=1.74, SD=0.77) and rewards (M=0.62, SD=0.64) subscales, suggesting that although participants favorably rated their organization’s attitudinal support of evidence-based practices, the organization does not explicitly seek to hire staff who are trained in or value evidence-based practices (CFIR characteristics of individuals involved), nor does the organization provide financial incentives for adoption of these approaches (CFIR inner setting). These findings were slightly below average for selection and similar for rewards compared to other studies utilizing ICS.34,44,45 Among IBH participants (N=13), there was strong attitudinal support for adoption of evidence-based behavioral health treatments (EBPAS M=2.8, SD=0.72), with ratings comparable to those observed among community mental health service providers.36,46 Overall, participants reported slightly positive ratings of behavioral health integration (LIM M=3.51, SD=0.37), which were comparable to other safety net settings47 but indicate the need for improvement in behavioral health integration.
Interview Findings
Although our interview guide focused on barriers to implementation of a brief cognitive behavioral therapy for PTSD, responses were often pertinent to the overall provision of brief mental health interventions in the integrated primary care setting, and not specific to PTSD treatment. See Table 3 for more detail on CFIR constructs that were identified as influencing implementation, and initial recommendations generated through interviewee feedback and CAB engagement.
CFIR: Intervention Characteristics
Relative Advantage. Respondents affirmed that a brief five-session manualized intervention was appropriate for use in primary care for several reasons. As an IBH provider shared, the structure of a manualized treatment would help orient patients to the short-term therapy while also providing effective care: “if we’re [IBH] already planning for five sessions, then we [IBH] can market it [manualized PTSD intervention] that way for patients when they come in for the intake... plus, manualized treatments are super convenient.”
They expressed how low intensity and brief treatment in IBH may be more suitable for patients with barriers to engagement in high intensity specialty care (e.g., stigma, mental health literacy, affective avoidance, or suppression). They hypothesized that patients may be more open to engage in stepped-up care if needed after STAIR-PC, as one PCP stated: “[for] people who will never ‘land’ in [specialty care], if we give this [manualized PTSD treatment] and they have a good experience, they may be more willing to do the next level.”
Adaptability. Respondents shared how the proposed intervention could fit the local practice. As one PCP noted, “[physicians] want this [type of therapy]. [When we] have a very short [and] effective way to treat PTSD — where we teach people these skills they can practice at home to reduce their symptoms — [PCPs] can [offer this treatment option] and keep an eye on [treatment progress].”
CFIR: Outer Setting
Patient Needs and Resources. Respondents noted that socioeconomic determinants of health were common barriers to engagement in and prioritization of PTSD treatment. As one IBH provider explained, “[engagement] could be challenging given the complexity of working with [patients experiencing] …homelessness or financial instability.” Additionally, respondents described transportation and caregiving barriers that contribute to late or missed appointments, resulting in less provider contact and high dropout. As one PCP emphasized, “the biggest thing for a lot of patients is competing priorities, living in a world where finding a job and being safe is the first priority and convincing people that it [mental health] is worth their time [comes second].”
CFIR: Inner Setting
Networks and Communications. Respondents emphasized the importance of care coordination, including the need for clear internal and external referral processes.
Referrals to IBH. The process for referring to IBH utilized warm handoffs. Several mentioned that, while ideal, warm handoffs can be logistically difficult: “I think there’s a kind of subtle disincentive to use [a warm handoff] in that no matter how fast it [a warm handoff] is, you’re grabbing a room and you’re taking time, [an] extra 10 or 15 minutes to have that warm handoff take place.” Despite these challenges, the majority of providers supported the use of warm handoffs and recognized their role in improving patient engagement. As another PCP explained, “the opportunity to do long warm handoff[s] will definitely increase that [patient] buy in.”
Referrals to Specialty Care. By contrast, the referral process to specialty care (i.e., outpatient psychiatry clinic) is less specified and rarely utilizes warm handoffs. Respondents reported that the practice of relying on patients to spontaneously disclose trauma history or PTSD symptoms during routine primary care visits may detect higher severity cases but not among patients with mild-to-moderate PTSD symptom severity or those who are reluctant to disclose. High severity referrals going to IBH, and access issues when attempting to refer out to specialty care, led some respondents to believe that patients seen in IBH may be higher in symptom severity than typically seen in IBH models of care. IBH respondents also voiced reservations about referring out to specialty care, noting concerns about patient dropout or uncertainty about current therapies offered in specialty care. One IBH provider described the siloed nature of IBH and specialty care: “I’ve only ever been to [the specialty care clinic] once or twice, and I don’t know that many people who work there, so…I have very little idea what actually goes on over there.”
Relative Priority. At the time of this evaluation, the hospital was shifting to an Accountable Care Organization (ACO), which links reimbursements to quality metrics and reductions in the cost of care. Some respondents felt that the central focus on ACO quality metrics may pose challenges to adding a screener for PTSD. Under the ACO, depression care screening is prioritized, and hospitals are evaluated, scored, and provided funding based on the frequency and consistency of PHQ-2 and -9 administration. Other respondents felt positively that the ACO shift may be a stepping stone to improving PTSD outcomes. One PCP noted how the redesigned system prompted by the ACO may allow greater access to behavioral health services, stating, “one of the real opportunities [of] the ACO is in restructuring the way that we think about [the] clinic more broadly and more aggressively than we thus far have.”
Leadership Engagement. Respondents also noted that buy-in from operations managers and population health leaders was critical to successful implementation, including securing protected time and resources to support adoption of the new practice. One PCP noted the importance of regular communication with leadership to support implementation: “there's a lot going on, and…. [as part of the leadership team] … I have a good handle of all the programs ...but, I think I'm probably the minority. The PCPs who are there once a week may not know of all the resources that are available to our patients.”
Available Resources. Workflow and productivity demand, documentation and case management tasks, and administrative meetings create extensive time pressures on all providers that limit availability for trainings needed for successful implementation. As such, respondents emphasized the need for additional protected time for training and suggested, in the meantime, that researchers capitalize on existing protected times for various groups to fit training into current schedules.
Respondents also identified the availability of appointments for ongoing therapy as a major barrier to PTSD intervention implementation. Further, rescheduling missed appointments in a timely fashion is challenging due high patient volume, lowering accessibility and efficiency. Respondents emphasized the need to address these workflow challenges to accommodate EBT scheduling demands (at least two visits per month).
Respondents also noted the importance of embedding the researcher (study PI) in the practice, with one IBH therapist stating, “I would find [it] really helpful [to have the PI embedded in the clinical support team] because …if there’s anything wrong or different later [that impacts the roll-out], …that could help keep the momentum going.”
CFIR: Characteristics of Individuals Involved - Providers
Knowledge and Beliefs about the Intervention. Respondents described the need for educational trainings tailored to PCPs and IBH clinicians to improve understanding of trauma, PTSD diagnosis, and effective treatments. As one IBH provider expressed, “providers… just don’t know what to do with trauma.”
PTSD Assessment. Respondents explained how some providers applied variable heuristics and clinical judgement to decide which patients to screen for trauma and PTSD. PCPs described gathering a thorough trauma history with full details of index events, which is not the standard (or advised) process for screening. Others described screening for PTSD symptoms only when PCPs knew or suspected trauma exposure based on voluntary disclosure or patient characteristics (race and immigration status). As one PCP shared: “the only people I know [who] have PTSD are the ones who volunteer it [trauma history or diagnosis].” Respondents also described how some PCPs assign a PTSD diagnosis based on trauma exposure alone, without directly assessing for symptoms. Still, other PCPs may avoid asking patients about trauma due to concerns around distressing patients or insufficient time to respond to anticipated distress.
Current Treatment Options. PCPs also described lack of knowledge on the types of treatments available via each referral pathway, partly due to lack of access to therapy notes in the EMR. PCPs shared their general enthusiasm for co-learning with their IBH colleagues and how this project might help them to stay abreast of PTSD treatment options and better meet the needs of their patients.
CFIR: Characteristics of Individuals Involved - Patients
Cultural Considerations. Several themes regarding cultural considerations emerged, most notably those of race and racism, stigma, shame related to mental health care, and language and literacy barriers. Respondents described how patients may be hesitant to disclose trauma and seek treatment for PTSD due to mental health stigma and stigma of referral to specialty care. As one CWA shared, “the word [name of specialty care clinic] is very stigmatized.” Respondents felt that a stepped care approach to PTSD treatment, with triaged levels, may help patients engage at their preferred setting and intensity of treatment.
Providers additionally described the role of race and racism in the patient-provider relationship. As one CWA stated: “a lot of patients have mentioned to me, especially if [they’re] a person of color, [that] they [patients] want to be able to relate [to] and see someone of color.” This perspective highlights how systems in which providers do not reflect diversity of patients may face additional challenges earning trust and engaging patients.
Contextualization of Findings
The CAB helped to contextualize interview findings, including providing more detail on current shortcomings of internal and external behavioral referral processes. The CAB made suggestions on how to improve referral pathways including defining the scope of practice in nonspecialty versus specialty care and provider education on referral procedures via electronic medical chart. The CAB also clarified that the hospital would be moving to open notes, allowing primary care physicians to better understand the focus of therapy and potentially assist with collaboration. Staff turnover is high in this setting, both due to the highly stressful clinical environment as well as the nature of teaching hospitals—therefore, the CAB recommended that intervention trainings should be delivered in an ongoing fashion. The CAB also explained that prioritization of PTSD screener was not feasible at this time, but agreed that it is a worthy long-term goal for the practice. The CAB made many suggestions to support therapist engagement, including blocking schedules for training and consultation, and modifying clinical templates to allow for more regular visits.