Based on the principles of implementation science, the PBI Network was designed as a means to engage clinicians and leaders in the piloting of evidence-based treatments and other emerging best practices to help service members and veterans address psychological health-related problems. It increases provider knowledge and accountability, promotes coordination and information sharing, and aims to reduce costs by testing practice change initiatives prior to broader dissemination throughout the MHS. Activities include recruiting providers to participate in implementation pilots, developing implementation plans, resources and training materials, providing consultation and technical assistance, and conducting ongoing monitoring.
Pilot Program Selection Process
The PBI Network team conducts piloting of interventions and practice change initiatives at a small number of clinical sites around the world prior to broader dissemination throughout the Military Health System (MHS). The purpose of the pilots is to test for appropriateness and effectiveness and to collect lessons learned prior to extensive implementation. The PBI Network welcomes pilot proposals from organizations, researchers, and clinicians both internal and external to the Department of Defense. Pilot proposals must go through a selection process – a months-long endeavor to select the most relevant, evidence-based psychological health intervention. The process involves:
Call for Proposals
A formal Call for Proposals is formally sent out once per year to PBI Network contacts, psychological health associations, medical organizations, academic institutions and posted on the PBI Network webpage. Proposal submissions are welcome year-round; however, the formal call for proposals is open for 6 weeks in September and October. Proposals submitted at other times of the year will be held to be considered after the formal call for proposals closes.
Proposal Compliance Checks
Once the formal call for proposals window has closed, the applications received are reviewed by the Psychological Health Center of Excellence (PHCoE) for submission compliance, relevance and feasibility. The PBI Network team will contact applicants if additional information is needed to move forward in the proposal selection process.
Practice Change Prioritization Work Group
After meeting compliance check requirements, each proposal is formally evaluated by the Practice Change Prioritization Working Group, a group of psychological health experts who work in both DoD and non-DoD agencies, to score and rank each proposal submission using a process adapted from the National Institutes of Health scoring system. The following weighted evaluation criteria will be used:
- Established Need: nature of the problem, including service/implementation gaps, and document the extent of the need
- Mission Alignment: The solution aligns to the Defense Health Agency and PHCoE missions
- Quality of Evidence: Evidence presented from at least one well designed, adequately powered, randomized controlled trial or quasi-experimental study, published in a peer reviewed journal
- Readiness for Dissemination: Associated resource(s)/product(s) for the practice change initiative are in final or near final form and have been utilized with at least one population
- Sustainment Plan: Articulation of a plan for sustainability of practice change post pilot testing
Behavioral Health Clinical Community
The ranked proposals are then forwarded, along with results from the annual Provider Needs and Assessment Survey, to the Behavioral Health Clinical Community (BHCC) for review. The BHCC selects a pilot to be implemented by the PBI Network team.
The final proposal selection will be made within 120 days of the closing date of the call for proposals. The selected proposal’s applicant(s) will be contacted by the PBI Network to begin planning the pilot.
Please note: proposal submissions are welcome year-round; however, they will only be ranked and considered for implementation immediately following the closing of the formal call for proposals.
Proposal submissions should be sent to email@example.com.
Outcomes Monitoring, PTSD Check List Pilot
In order for clinical treatment of posttraumatic stress disorder (PTSD) to be effective, treatment outcomes must be monitored. The evaluation of PTSD treatment effectiveness via outcomes measures was not routinely conducted in the VA and DoD, but is a critical gap in care quality monitoring. For this reason, PTSD outcomes monitoring was selected as the first focus of practice change for the PBI Network.
In many other general and specialty areas of medicine, measurement of responses to treatment (e.g., ongoing measurement of insulin levels in diabetic patients) is more routinely used. However, in mental health treatment, routine use of formal treatment progress monitoring through use of standardized measures is infrequent, and lags behind other fields. A report by the Institute of Medicine states that outcomes monitoring of mental health treatment is not the norm in the DoD and VA, and concludes that “in order to study the efficacy of treatment and to move toward measurement-based PTSD care in the DoD and the VA, assessment data should be collected before, during, and after treatment and should be entered into patients’ medical records.” In 2013, DoD mandated clinicians to use outcome measures in the treatment of mental health conditions to include PTSD. Specifically, DoD mental health clinicians are expected to use the PTSD Checklist (PCL) when providing treatment for PTSD. Despite this mandate, currently available performance measure data indicate that the practice is inconsistently implemented across the enterprise.
The first PBI Network pilot, Outcomes Monitoring, addressed the DoD mandate for PTSD monitoring. Additionally, it identified system-specific barriers and solutions that affect the adoption of new practices for PTSD treatment, primarily PCL administration, review, interpretation, and treatment adjustments. Facilitations and training for the pilot were held at 10 DoD sites (four Army, three Navy, and three Air Force) in an effort to expedite implementation of PTSD outcomes monitoring across the DoD.
Screening Brief Intervention and Referral to Treatment Pilot
The Substance Abuse and Mental Health Services Administration (SAMHSA) developed the evidence-based process of Screening, Brief Intervention and Referral to Treatment (SBIRT) for use in the civilian sector. SBIRT is defined as:
“…a comprehensive, integrated, public health approach to the delivery of early intervention for those with risky alcohol and/or drug use, and the timely referral to more intensive substance abuse treatment for those who have substance abuse disorders.”
PHCoE conducted an SBIRT implementation pilot to test the approach for addressing alcohol misuse in Military Health System primary care in 2015. The pilot found that SBIRT is a feasible and effective process and is improved through the use of ongoing training for providers and clinical tools to help providers educate beneficiaries.
Tech into Care Pilot
The need for psychological health care among service members, veterans and their families outstrips the available supply of DoD, Department of Veterans Affairs (VA) and community-based treatment resources. Technology can be used as a support to ongoing care, a link to care and as an alleviating/stop-gap measure when care is inaccessible. The DoD and VA have developed a large and growing suite of web and mobile interventions for behavioral health concerns, yet clinicians have limited guidance on how to implement these resources.
The objective of the Tech into Care pilot is to implement a program designed to facilitate the use and integration of mobile and web applications. The pilot will roll out in 2017 and has five objectives:
Conduct formative evaluation to develop a training and implementation program using the Practice Based Implementation (PBI) Network.
Design and deliver a dissemination and training program on bringing technology into care to individual clinicians in DoD and VA.
Assist clinicians in creating individual technology implementation plans that will be supported by the facilitation process.
Assess implementation progress and outcomes in order to refine training and implementation strategies and to enable widespread dissemination of technology-facilitated care.
Initiate development of a Community of Practice comprised of DoD and VA providers interested in using mental health interventions and support technologies.
Provider Needs Survey
In 2017, the PBI Network will also roll out an annual DoD Psychological Health Provider Needs and Preferences Survey to continue collection of service specific clinician feedback. The PCPWG will then analyze the provider feedback and use it along with surveillance data and research gap reviews to inform subsequent DoD Psychological Health Practice Change Prioritization Work Group recommendations to the DoD BHCC.
Opioid Prescriber Training:
Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (PHCoE) was tasked in April 2016 to prepare a response to the October 2015 Presidential Memorandum - Addressing Prescription Drug Abuse and Heroin Use.
Sec.2. directs all executive departments and agencies to "provide training on the appropriate and effective prescribing of opioid medications to all employees who are health care professionals and who prescribe controlled substances as part of their Federal responsibilities and duties." It also states that "training adopted by agencies should be consistent with consensus guidelines on pain medication prescribing developed by the CDC." CDC published the guidelines in March 2016..
The DoD Opioid Prescriber Safety Training Program was developed by PHCoE with consultation and assistance from the substance use, pain, and primary care service representatives, the National Capital Region's Opioid Safety Program, and Defense & Veterans Center for Integrative Pain Management. The training consists of two modules that are each approximately one hour long and covers guidelines for safe opioid prescribing, including guidelines for prescribing opioids for chronic pain.
As of June 1, 2017, 12,632 prescribers, out of a total of 19,282 who prescribe controlled substances, have completed the training.
For more information, contact the Psychological Health Center of Excellence.