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Implementing Telemedicine Outreach for PTSD for Veterans in Rural Settings

Over half a million Veterans (n=502,546, 9%) enrolled in the VA healthcare system are diagnosed with PTSD, including 119,482 Veterans (24%) who served in Iraq and/or Afghanistan.  The Virtual Specialty Care QUERI program works to implement and evaluate technology-facilitated clinical interventions designed to improve outcomes for rural Veterans. The VA healthcare system provides care to 3.3 million Veterans living in rural areas, comprising 36% of all VA enrollees. Moreover, a large portion (38%) of VA enrollees diagnosed with PTSD live in rural areas, and two thirds live closer to a community-based outpatient clinic (COBC) than a VAMC. While it is typically not feasible to hire onsite psychiatrists or psychologists with PTSD expertise at many CBOCs, it is critical to improve PTSD treatment in the accessible CBOC setting.

The objective of this QUERI multi-site quality improvement project is to support the deployment of the Telemedicine Outreach for PTSD (TOP) evidence-based practice and evaluate its clinical effectiveness in routine care at six VA medical centers and 12 CBOCs. The ultimate goal is to identify the most effective implementation strategy for the national rollout of TOP as one of the Office of Rural Health’s designated Rural Promising Practices, which will: increase access to care and services for rural Veterans and their families in the communities in which they live; share clinical and operational knowledge among providers serving rural Veterans; and enhance the rural healthcare delivery system. To achieve this goal, this Virtual Specialty Care QUERI project is: 

• Comparing the cost and effectiveness of a standard VA implementation strategy to an enhanced implementation strategy in promoting uptake of TOP, and
• Determining whether successful implementation of TOP in routine care improves PTSD outcomes for Veterans living in rural settings.

Implementing Telemedicine Outreach for PTSD

The low resource standard implementation strategy includes internal facilitators, operational manuals and resource guides, training, technical support, a patient case-finder, and funding for new care managers. The high-resource enhanced implementation strategy adds formative evaluation (rapid assessment procedures), external facilitation, and systems redesign methods (i.e., clinical workflow mapping). The project uses an adaptive implementation strategy with a stepped-wedge design. In the first step, QUERI investigators use a standard VA implementation strategy at all sites. A performance metric is then used to determine whether the standard implementation effort is successful. If the performance metric benchmark is not met in the prior step, the site is randomized to either continued standard VA implementation strategy or the enhanced implementation strategy in the next step.

A brief telephone survey is being administered at baseline and follow-up to a sample of Veterans in the case-finder (n=600).  The case-finder is a registry of CBOC patients with a diagnosis of PTSD, a recent positive screen for PTSD, and no recent specialty mental healthcare. The survey asks Veterans about their PTSD symptoms, and perceived access to and satisfaction with care. Summative evaluation activities also include chart review and qualitative interviews with Veterans and their providers. Study results – expected to show that TOP improves rural Veterans’ access to optimal treatment for PTSD – will be provided when available.

For more information, please contact John Fortney, PhD, at John.Fortney@va.gov .