R03 – Improving the Usability of Decision Support for PTSD in Primary Care
Principal Investigators
Jessica Chen, PhD, Acting Assistant Professor, Psychiatry and Behavioral Sciences
Emily Williams, PhD, MPH, Associate Professor, Health Services
Project Description
Evidence-based psychosocial interventions (EBPIs) are first-line treatments for PTSD yet very few patients receive them, even in the Veterans Health Administration (VA) where there is excellent access to EBPIs. Patients’ preferences for and initiation of EBPIs are influenced by how providers present and discuss these PTSD treatment options. In specialty mental health settings, shared decision making (SDM) increases initiation of and adherence to EBPIs for PTSD, yet fewer than half of VA patients with PTSD are seen in specialty settings, whereas most are seen in primary care.
This R03 will use the Discover, Design/Build, and Test (DDBT) framework to adapt an existing VA SDM protocol for primary care settings. The research aims are: Aim 1 (Discover): Identify the decision support needs of service recipients (N=25 primary care patients with PTSD) and identify adaptations to an existing VA decision support tool using the “think-aloud” protocol to improve usability. Aim 2 (Design/Build): Generate initial prototypes of a primary care-based SDM protocol—Patient Readiness for Improvement through Motivation, Engagement, and Decision-making (PRIMED)—using storyboarding and clinical workflow mapping, then conduct prototype testing with service providers (N=10-12 clinicians) to identify the most usable approach(es) to incorporating decision support into routine practice. Aim 3 (Test): Conduct a single-arm test of PRIMED with N=10 patient-provider dyads.
| Setting | VA’s integrated primary care program (Primary Care Mental Health Integration) |
| Population | Primary care patients with PTSD and their healthcare providers |
Intervention and/or Implementation Strategy Designed or Redesigned
| Intervention | Development of PRIMED (Patient Readiness for Improvement through Motivation, Engagement, and Decision-making), a primary care-based shared decision making protocol adapted from existing VA decision support tools. The intervention uses storyboarding and clinical workflow mapping to improve usability for primary care settings. |
| Implementation Strategy | Three-phase approach using the Discover, Design/Build, and Test framework with iterative prototype testing involving 25 patients, 10-12 clinicians, and 10 patient-provider dyads. |
Impact
This research will support a future grant application to pilot test PRIMED in a larger randomized controlled trial. The intervention has the potential to improve access to evidence-based psychosocial interventions for PTSD by enhancing shared decision making in primary care settings where most VA patients with PTSD receive care, ultimately increasing initiation and adherence to first-line PTSD treatments.
Project Publications
Provider Perspectives on Implementing Shared Decision Making for PTSD Treatment in VA Primary Care
Administration and Policy in Mental Health and Mental Health Services Research 48; 2021 · PubMed · Publisher
Authors
Jessica A. Chen, Theresa E. Matson, Keren Lehavot, Patrick J. Raue, Jessica P. Young, Molly C. Silvestrini, John C. Fortney, Emily C. Williams
Abstract
Shared decision making is an important implementation “pull” strategy for increasing uptake of evidence-based mental health practices. In this qualitative study, we explored provider perspectives on implementing shared decision making at the point of mental health treatment initiation using a publicly available, patient-facing decision support tool for post-traumatic stress disorder (PTSD). We conducted semi-structured interviews with 22 mental health providers (psychiatrists, nurses, psychologists, and social workers) working in one of five VA primary care clinics. Interviewed were analyzed using thematic analysis. Provider were enthusiastic about using decision aids as a source of high quality information that could improve patient experience and confidence in treatment. However, providers had concerns about decision aid accessibility, time constraints to conduct shared decision making in-session, and patient motivation to engage in shared decision making. Providers stated they would prefer to use shared decision making with patients that they felt were most likely to follow through with treatment. While providers believed that shared decision making could improve PTSD treatment planning, they thought it most appropriate for patients with the highest levels of motivation and fewest barriers to care. These beliefs may limit widespread adoption and reflect missed opportunities to reach difficult-to-engage patients.
Applications in human-centered design: Shared-Decision Making for mental health treatment in primary care
Patient Education and Counseling 13; 2025 · PubMed · Publisher
Authors
Katie Tirtanadi, Kathryn A. Johnson, Amee J. Epler, Jessica A. Chen
Abstract
Objective: Shared Decision Making (SDM) is heralded as a standard for patient-centered care, but implementation of SDM in routine mental health practice has proven difficult to achieve. Human-centered design (HCD) may hold promise for improving SDM implementation in busy clinical settings. This study describes applying HCD to develop an SDM documentation support tool intended to encourage successful use of SDM by mental health clinicians.
Methods: This descriptive, proof-of-concept study utilized the Discover-Design-Build-Test HCD framework to simplify a comprehensive SDM protocol for mental health decision making. Implementation was piloted within multiple primary care clinics. The study consisted of three phases: information gathering (interviewing clinicians), solution generation and prototyping, and testing a final prototype in routine care settings.
Results: Our project proceeded through eight cycles of user design and feedback. Clinicians pilot tested the final product, a documentation note template incorporating SDM prompts and explanations. It is currently available for clinical use.
Conclusions: Clinicians were able to use the HCD-redesigned SDM documentation note template intuitively, i.e., without explicit instruction. Leveraging buy-in from users throughout the entirety of the process (from problem investigation to solution discussions) created opportunities to tailor implementation strategies and may support ownership of the end-product by primary stakeholders.
Practice implications: HCD may be a promising methodology for streamlining the adoption of complex clinical tasks like SDM.