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Using Virtual Care Technologies to Increase Access to Evidence-Based PTSD Treatments for Veterans in Rural Settings

Rural Veterans with post-traumatic stress disorder (PTSD) treated at VA community-based outpatient clinics (CBOCs) experience little to no improvement in their symptoms over time. A major contributor of poor outcomes is that trauma-focused evidence-based psychotherapy is often not available to Veterans in the CBOC setting. Moreover, long travel distances and other travel barriers prevent most rural Veterans from receiving trauma-focused psychotherapy at parent VAMCs. An HSR&D multi-site randomized clinical trial evaluated the Telemedicine Outreach for PTSD (TOP) intervention - a virtual collaborative care model designed to enhance access to evidence-based pharmacotherapy and psychotherapy (Cognitive Processing Therapy - CPT). The virtual care team was comprised of on-site CBOC providers and off-site telephone care managers, telepsychologists, and telepsychiatrists. Study findings showed that more than half (55%) of 133 Veterans randomized to TOP initiated CPT compared with only 12% of Veterans randomized to usual care. Likewise, 27% of patients randomized to TOP completed > 8 or more sessions of CPT compared with only 5% of patients randomized to usual care. As a result, Veterans randomized to TOP had significantly larger reductions in PTSD symptom severity at the 6- and 12-month follow-ups.¹

Based on these results, QUERI and the Office of Rural Health (ORH) have funded an implementation trial of TOP in six VISNs as part of the Virtual Specialty Care QUERI Program. The primary aim of this program is to develop, evaluate, and refine implementation strategies for ORH, Telehealth Services, and the Connected Health Office in order to deploy promising clinical practices for Veterans residing in rural settings that incorporate teleheath, ehealth, and mhealth technologies. The rollout of TOP will incorporate emerging virtual care technologies, such as clinical video telehealth-to-home, mobile apps (CPT Coach, PE Coach) and My HealtheVet's Secure Messaging. This research agenda aligns with multiple priorities outlined in VA's Blueprint for Excellence, including: "Expand virtual medical modalities to enhance high-performance, patient-centered care for rural, homebound, or otherwise isolated Veterans."

This implementation trial will be conducted in close partnership with the ORH, Telehealth Services, Connected Health Office, Mental Health Services, and the National Center for PTSD. In addition, Mr. John Nolan, a Veteran living in rural Arkansas who had participated in the intervention arm of the TOP trial, will serve as a key consultant.

For more information, please contact John Fortney, PhD, Principal Investigator, Virtual Specialty Care QUERI Program, at John.Fortney@va.gov .

1. Fortney J, Pyne J, Kimbrell T, et al. Telemedicine-based collaborative care for post-traumatic stress disorder: A randomized clinical trial. JAMA Psychiatry. January 2015;72(1):58-67, 2015.