Implementing Posttraumatic Stress Disorder Screening, Brief Intervention, and Referral in Primary Care

Abstract

Background: Posttraumatic Stress Disorder (PTSD) has a prevalence of 8.7% in the United States. This disorder is associated with increased social, occupational, and physical impairments which lead to increased healthcare utilization and expense. Ethnic minorities, individuals with inadequate social support, those of low-income, and urban residents are at greater risk of developing PTSD. Identifying PTSD in the primary care setting can lead to improved overall patient health, improve overall population health, and alleviate the economic and healthcare utilization burden. However, this disorder often goes unrecognized and untreated due to a lack of formal screening in primary care.

Local Problem: A mobile primary clinic serving an uninsured population that is predominately Latino with limited English proficiency did not have a consistent PTSD screening process. Clients whose screening score was positive for possible PTSD did not have a consistent followup that included a brief intervention and referral for treatment.

Interventions: The purpose of this Doctor of Nursing Practice project was to pilot the implementation of the Primary Care PTSD Screen (PC-PTSD) in either English or Spanish and provide a brief intervention with referral for treatment (PTSD SBIRT) in the patient’s preferred language. This project was implemented over a period of 15 weeks via the PTSD SBIRT protocol. The inclusion criteria for those screened included all newly admitted patients age 18 or older with no cognitive impairment and the ability to understand and speak English or Spanish. The estimated sample size (n=36) for the pilot period was based on the average rate of three new patient admissions per week over 12 weeks. The University of Maryland Baltimore Institutional Review Board gave a Non-Human Subjects Research determination for project implementation.

Results: The total number of new patients meeting the inclusion criteria was 46 (n=46). The percentage of new patients screened was 97.8% (n=45). Of those screened, 6.7% (n=3) had a positive screen score, and 100% of patients with positive screening received the brief intervention with referral for treatment. Some barriers to the project implementation included scheduling conflicts, initial staff resistance, lack of protocol clarity, and confusion over the fourth item of the Spanish PC-PTSD. The main facilitators of the project were collaboration between project leader and staff, staff’s proactivity with communication, ease of screen use, and high compliance rate.

Conclusions: The PC-PTSD was an easy tool to administer, interpret, and incorporate within the intake process of the mobile primary care unit. The project highlighted the lack of available treatment resources for this patient population. After the pilot period, the project leader met with the director and staff to discuss sustainability of the protocol for new admissions and to begin implementation annually for current patients. The mobile clinic director made plans to integrate the PTSD SBIRT protocol into their electronic health record with modified item-4 in the Spanish PC-PTSD. The clinic director’s goal is to continue integrating screenings with regular practice as a means to advance primary care behavioral health integration, increase mental health awareness, and improve population health outcomes through enhanced quality of care.