Providing Ongoing EBP Consultation Across a Large Dispersed Care System Experiences from The Center for Deployment Psychology David Riggs, Ph.D.

Center for Deployment Psychology Mission Train military and civilian mental health providers to deliver high-quality deployment-related behavioral health services to military personnel, veterans and their families Goals Increase the number of mental health providers prepared to treat military personnel and their families Train providers to use evidence-based psychotherapy Educate providers on the unique stress of deployment Prepare civilian providers to treat military personnel

Training in Evidence Based Psychotherapy Protocols as CDP Face-to-Face Workshops Mobile Training Teams 20-25 Multi-day workshops annually (peak 40-45 annually) Held at DoD facilities Throughout US, Europe, Asia Teach protocols and basic skills Combines didactic instruction, demonstration, skill rehearsal Data indicate increased knowledge, confidence, readiness

Training in Evidence Based Psychotherapy Protocols as CDP Online Workshops Three online platforms 12-15 Multi-day workshops annually Replicate the material & delivery of face-to-face workshops Teach protocols and basic skills Combines didactic instruction, demonstration, skill rehearsal Data indicate increased knowledge, confidence, readiness Gains are comparable to face-to-face workshops

Limited implementation Training workshops in the absence of coaching and/or consultation leads to … Limited implementation Protocols used but not with all appropriate cases Protocols not used at all Mixed fidelity to protocols Omitting elements from the protocol Adding in elements not originally in the protocol Unknown competence in treatment delivery Borah et al., 2013; Wilk et al, 2013

Coaching and Consultation In a Large and Dispersed System Low Cost – PRN Coaching Broad Distribution | Drop-in Coaching Regular (monthly?) Coaching Drop-in coaching + Expert Weekly Expert Consultation High Cost – Weekly Expert Consultation + Narrow Distribution Sessions Review

Coaching and Consultation Efforts at the CDP PRN Expert Coaching Telephonic/email Q & A Drop-in Expert Coaching “Office Hours” Regular (monthly?) Coaching Refresher Classes Local Coaching + Expert EBP Champions Weekly Expert Consultation Advanced Proficiency Project / BBTI Training for Imbedded Providers Weekly Expert Consultation + Sessions Review CBT for Depression Pilot

Coaching When You Want (Need) It Low-Cost Options: Coaching When You Want (Need) It PRN Coaching Telephonic and/or online support Expert response in a short time (24-48 hours) Allows posting of FAQs Drop-In Coaching Regularly scheduled telephonic coaching sessions Providers call in when they wish to Can call as often as they desire Infrequently used Few providers call repeatedly Refresher Courses Regularly scheduled webinars Didactic presentation to reinforce workshop lesson Discussion of case material increased attendance with CEU for didactic material

Coaching When You Want (Need) It Low-Cost Options: Coaching When You Want (Need) It PRN Coaching Drop-in Coaching Refresher Courses Positive – Expert is available to answer questions when they arise Allows providers dispersed around the system to consult Limited commitment of time for both provider and expert Providers learn and find it helpful Negative – Lack of continuity No easy way to establish fidelity/competence Providers’ may not call when they might benefit most “Dead” time for experts Barriers - Time Lack of provider awareness Willingness to ask for help Limited number of expert

All (Most) of the Bells and Whistles High End Options: All (Most) of the Bells and Whistles Advanced Proficiency Project Regularly scheduled expert consultation (face-to-face or telephonic) Experts located at clinic or centrally 19 providers treated 1 or 2 cases Consultants provided ratings of proficiency

All (Most) of the Bells and Whistles High End Options: All (Most) of the Bells and Whistles CBT-D Consultation Project Regularly scheduled expert consultation (telephonic) Experts located centrally Attendance at 75% of calls was required (20/26) 20 Providers identified Support from clinic management Recordings of sessions submitted for review/ratings of competency Outcome Only 4 of 20 providers attended required number of consultation calls 5 providers did not attend any consultation calls The 4 providers who attended 75% of calls were all rated as competent – as were 3 others who did not attend the required number of calls Required > 400 hours of expert time

All (Most) of the Bells and Whistles High End Options: All (Most) of the Bells and Whistles Advanced Proficiency Project / BBTI Training for Imbedded Providers / CBT for Depression Pilot Positive – Continuity in provider-consultant relationship Able to establish fidelity/competence Allows providers to exchange information Providers learn and find it helpful Negative – Significant time commitment particularly for expert Scheduling challenges with dispersed workforce Providers drop out/miss sessions Barriers - Time Limited number of experts Limits on sharing sessions materials Patient availability

Looking for the Sweet Spot Blended Models: Looking for the Sweet Spot EBP Champion Program Champion-Consultant placed in clinic Champion trained in one EBP as well as basic consultation skills Champion supported by small network of EBP experts (central) Champion promotes use of EBPs Champion provides “first-line” of consultation (usually PRN) Champion can consult with expert (or refer provider to expert)

Looking for the Sweet Spot Blended Models: Looking for the Sweet Spot EBP Champion Program Positive – Consultant is available to answer questions when they arise Allows expertise to be distributed across the system Increases implementation Does not require expert in each EBP at each clinic Negative – Requires substantial coordination among champions Requires network of EBP experts Requires infrastructure to support communication between champions and experts Barriers - Resources Clinic administration Training in consultation skills

So What Do We Think We Have Learned Consultation / Coaching can serve to … promote the adoption and use of an intervention promote fidelity and (potentially) efficacy of intervention assess and understand barriers to adoption/use assess and understand modifications to intervention No single model of consultation/coaching will fit all situations Consultation/coaching may be a significant rate limiting factor Consultation/coaching has its own barriers that must be addressed Across large distributed care systems multiple models may be necessary