Table 5 Factors that influence implementation of an EBT for PTSD in safety net primary care
CFIR constructs | Definition | Examples |
|---|---|---|
Intervention characteristics | ||
 Relative advantage | Stakeholders’ perception of advantages of implementing the five-session, manualized intervention versus an alternative solution | Positive attitudes about the intervention compared to alternative EBTs (brevity, flexibility, transdiagnostic application, effectiveness) and compared to current standard of care (primarily psychoeducation, relaxation training only) Although some patients may need higher intensity therapies, this is an effective lower intensity treatment which may have engagement advantages |
 Adaptability | The degree to which an intervention can be adapted, tailored, refined, or reinvented to meet local needs | Interventions needs to fit current practice, including session length and scheduling frequency |
Outer setting | ||
 Patient needs and resources | The extent to which patient needs, as well as barriers and facilitators to meet those needs, are accurately known and prioritized by the organization | May experience challenges with prioritizing PTSD-focused treatment in the context of social determinants of health and related barriers to engagement (transportation, caregiving responsibilities, socioeconomic status) Emergent theme: Mental health stigma, language, literacy, care setting preferences, patient treatment priorities, especially in context of social determinants, were mentioned as important considerations |
Inner setting | ||
 Networks and communications | The nature and quality of webs of social networks and of formal and informal communications within an organization | Challenges with internal and external referral processes for behavioral health treatment and the inability of PCPs to access therapy notes have led to issues with care coordination Challenges unique to a teaching hospital, where staff rotate and turnover frequently, have resulted in problems with communication. Need for ongoing and repeated training and communication about treatment options and clinic processes |
 Relative priority | Individuals’ shared perception of the importance of the implementation within the organization | ACO has led to organizing around depression care management; PTSD is not currently a quality metric. This is both a barrier and facilitator, since some of the improvements are good for all mental health services (e.g., routine depression screening) |
 Leadership engagement | Commitment, involvement, and accountability of leaders and managers participating in the implementation | Need to gain support from operations managers and population health leaders in the practice for implementation success, especially in regard to protecting time and modifying workflows to accommodate EBTs |
 Available resources | The level of resources dedicated for implementation and on-going operations, including money, training, education, physical space, and time | By nature, IBH prioritizes access (brief screening, treatment referral); however, accommodating routine appointments typical for EBTs can be a challenge Due to time and resource burdens, screening is not feasible in most PCP or IBH therapist visits. Need to consider the role of medical assistants in initial screening for PTSD Difficulties securing protected time for training and consultation Need to embed researcher on clinical support time for training purposes and to respond to implementation challenges in real-time |
Characteristics of individuals | ||
 Knowledge and beliefs about the intervention | Individuals’ attitudes toward and value placed on the intervention as well as familiarity with facts, truths, and principles related to the intervention | PCP knowledge gap of best practices for assessment, treatment options, and referral process for PTSD (e.g., rely on heuristics of stereotypes to determine who needs assessment; asking too much detail about trauma events in screening process; lack of knowledge of referral pathways) PCPs unsure of their ability to assess for PTSD. Express concerns about distressing patients and not knowing how to respond or support PCPs expressed positive attitudes about co-learning with IBH therapists and how this project may foster improvements in collaborative care Most IBH therapists expressed that trauma-focused cognitive behavioral therapy is a good fit for their patients, especially if it can be delivered in a brief format Some IBH therapists expressed attitudes that brief treatments are not appropriate for PTSD (requires long-term therapy) |