PROJECT INNOVATION 2: EBT ADAPTATIONS FOR COGNITIVE CHALLENGES

A toolkit of evidence-based resources to support behavioral health providers working with individuals who experience cognitive challenges.

THE QUALITY OF CARE GAP

  • Individuals with traumatic brain injuries (TBI) and other types of cognitive challenges often experience difficulties that limit their ability to benefit from traditional, evidence-based treatments for conditions that are commonly experienced after brain injury.
  • There are relatively few behavioral health providers with training to manage cognitive difficulties when providing treatment for chronic pain, sleep disorders, post-traumatic stress disorder (PTSD), and depression, which limits access for persons with cognitive challenges.
  • Post traumatic brain health conditions are linked to worse recovery and increased risk of suicide, making access to care critical.

  • Guidelines from professional organizations mandate that treatments be delivered equitably for persons with disability, but do not include conditions that are often commonly experienced after brain injury.
  • Despite mandates, providers are unaware of information on how to adapt treatments for persons with cognitive challenges or the existing adaptations.

  • Directing providers toward a website that contains evidence-based therapies adapted for individuals with cognitive challenges can increase high-quality care for those with TBI.

"It is challenging to get comorbidities treated by providers who understand cognitive disability that come along with brain injury…finding a therapist who can take into consideration the cognitive limitations is hard to find."

VA Neuropsychologist

PROJECT INNOVATION: HOW ARE WE SOLVING THE PROBLEM?

“EBT ADAPTATIONS FOR COGNITIVE CHALLENGES” INNOVATION: ADAPTING EVIDENCE-BASED THERAPIES FOR COGNITIVE CHALLENGES

Developing a toolkit for providers to promote high quality equitable treatment for behavioral health concerns for persons with cognitive challenges.

This project’s innovation includes the following objectives:

  1. Identify existing recommendations and evidence-based treatment adaptations for persons with cognitive challenges, including common conditions that accompany TBI (sleep, PTSD, depression, and chronic pain) for inclusion in a web-based toolkit.
  2. Engage with subject matter experts to identify products for inclusion in the toolkit based on user-driven criteria.
  3. Pilot the toolkit among diverse end users to evaluate and revise the toolkit.
  4. Determine key strategies to disseminate the toolkit to practitioners, educational institutions, healthcare systems, and other identified groups to increase awareness and potential use.
Image 1

The I-HEAL team will conduct an environmental scan to identify adaptations to evidence-based behavioral health treatment for persons with cognitive challenges. Products will undergo extensive review by subject matter experts to identify inclusion in toolkit.

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The I-HEAL team will partner with potential users to prototype the toolkit, defining its scope, elements, and function to increase access to high quality behavioral health treatment for persons with cognitive challenges.

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We will engage our Community Engagement Council and partner with key stakeholders to conduct a formal review of the Toolkit to validate the design and identify implementation strategies.

HEAR FROM OUR ENGAGEMENT PARTNERS

Individual Engagement Partner, Dr. Shannon Miles who is partnering with the research team describes the important of this work:  “Busy providers often do not have the resources to adapt mental health treatments for their patients who have sustained a TBI. This results in patients with TBI receiving lower quality of care or no care at all for common mental health comorbidities. We are providing a solution to this challenge by gathering, vetting, and providing a “toolshed” for busy clinicians. We are building a one-stop shop for evidence based psychotherapies for common mental health  disorders that have been adapted for TBI patients. By supporting our clinicians, we are caring for our patients with TBI. “

Meet I-HEAL's Second Innovation Team

Photograph of Dr. Hoffman

Jeanne M. Hoffman, PhD, ABPP-RP

Principal Investigator

Professor, University of Washington. Dr Hoffman is a clinical psychologist and the Project Director of the University of Washington TBI Model System and has extensive expertise in studying and working with individuals with TBI, including Veterans, and has led adaptation of behavioral interventions to address cognitive limitations associate with TBI with a focus on chronic pain and depression. She has led a large study of Veterans from the VA Puget Sound Health Care System (VAPSHCS) using an adapted CBT intervention for chronic pain treatment and is currently involved in research on Veterans with mild TBI including treatments to manage cognitive limitations which interfere with access to healthcare.

Photograph of Dr. Martin

Aaron M. Martin, PhD

Principal Investigator

Dr. Martin is an early-career clinical research psychologist at James A. Haley Veterans’ Hospital with a history of adapting behavioral EBTs for primary and specialty care clinical settings to address comorbid conditions. He has expertise in addressing sleep disorders in the context of chronic pain within outpatient polytrauma settings. His research focuses on understanding the nature of sleep and pain comorbidities in medically complex populations (e.g., TBI) with several publications to date.

Silhouette of a blue person on a white backdrop.

Daniel, Lived Experience Partner

Principal Investigator

Daniel is an individual with TBI resulting from a hiking accident in 2011. Since his severe TBI, he was unable to return to his profession due to difficulties with multitasking and attention but has returned to volunteer work with appropriate accommodations. He is committed to research and is especially interested and committed to helping others with TBI find providers who can modify their approach to work with an individual with cognitive difficulties. He has served as a lived experience stakeholder to several research teams. His role will be to provide overall lived experience guidance on this project to maximize utility and adoption of products.

INDIVIDUAL ENGAGEMENT PARTNERS

I-HEAL’s Individual Engagement Partners (IEP) ensure our work is relevant for healthcare settings. Each project has its own set of IEPs that engage with the I-HEAL project’s team throughout the grant. Project 2’s IEP are:

  1. Shannon Miles, Ph.D.
  2. Kati Pagulayan, Ph.D.
  3. Luzimar Vega, Psy, D.

I-HEAL CORE PARTNERS

  1. Cassandra Decker | DCC, Operations

I-HEAL EARLY STAGE INVESTIGATOR

  1. Dr. Natalie Gilmore

PROJECT INNOVATION 2'S INDIVIDUAL EXPERIENCE PARTNERS

Person 1

Dr. Miles has worked extensively in the developing innovative manualized treatments for common sequelae of PTSD and TBI (Anger) resulting in funding of an active multicenter RCT. She serves as the Site PI of the jointly funded DOD/VA longitudinal study of mild TBI (LIMBIC). She serves as the Chair of the Behavioral Health Task Force within the VA/DOD Networking Group within the American Congress of Rehabilitation Medicine. Dr. Miles will serve as a study specific clinical partner for adapting evidence-based PTSD and Depression treatments for persons with TBI morbidity in Project 2 in the Focused Program Award.

Kathleen Pagulayan, Ph.D. is a clinical neuropsychologist with expertise in neurobehavioral and cognitive outcomes following traumatic brain injury (TBI). I have nearly 20 years of experience working with individuals who sustained a TBI, and my research for the past 15 years has focused on understanding the neural substrates of the cognitive sequelae of blast-related mild TBI and developing and evaluating novel intervention to treat these symptoms. During this time, I have been continuously funded as the principal investigator (PI) or co-investigator on grants that have investigated aspects of neurobehavioral outcome following TBI, including clinical trials focused on treating post-mild TBI cognitive difficulties. Most recently, I led the development of a novel self-management psychotherapy intervention, called On-TRACC (Tools for Recovery and Clinical Care), with support from a Department of Defense grant. This intervention aims to fill a gap in current clinical offerings for individuals with chronic cognitive difficulties following mild TBI by providing individualized psychoeducation within a values-based framework, leading to increased understanding of the factors that are contributing to persisting cognitive difficulties and increasing motivation for engagement in care for comorbid conditions. As such, I am well-suited to contribute to the proposed study.

Person 2
Person 1

Dr. Luzimar Vega is the outpatient TBI psychologist in the Polytrauma Network Site clinic at the James A. Haley Veterans’ Hospital. Within her role, Dr. Vega has provided psychotherapy to Veterans who have experienced a traumatic brain injury and are coping with comorbid mental health concerns (e.g., adjustment to injury, interpersonal discord, posttraumatic stress disorder, depression, anxiety, anger, sleep issues, chronic pain). Within this scope, she has provided a variety of Evidenced Based Treatments to this population to include Cognitive Behavioral Therapies (e.g., depression, sleep, chronic pain), Cognitive Processing Therapy, Prolonged Exposure, and Eye Movement Desensitization and Reprocessing. While predominantly outpatient, Dr. Vega has also provided inpatient care to TBI survivors within the Post-Deployment Rehabilitation and Recovery Program (PREP). Dr. Vega’s subject matter expertise in delivering clinical care to those after traumatic brain injury will be invaluable as a collaborator on the “Improving Healthcare Engagement and Access to Optimize Long-Term Outcomes: Supporting Veterans and Service Members with TBI Morbidity (I-HEAL)” research initiative.

Dr. Natalie Gilmore is an early career investigator at the James A. Haley Veterans’ Hospital in Tampa, Florida. Dr. Gilmore draws on prior experiences in the areas of psychological health and TBI, including a study on the effects of repeated blast exposure on active-duty Special Operations Forces personnel, and her clinical experience as an SLP. On Project 2, she serves as a study specific clinical partner for adapting evidence-based PTSD and depression treatments for persons with TBI.

Person 2

PROJECT INNOVATION "EBT" PROGRESS & PRODUCTS

Progress and Achievements

  • Project 2 collaborated with the Data and Communication Core to track the impact of engagement using subject matter experts. We consulted with the Implementation Science Core to finalize selection criteria and review considerations that informed a “Product Review Grid” for vetting materials in the environmental scan.
  • Awareness of the toolkit was generated with presentations in 2024 at the Military Health Science Research Symposium; American Congress of Rehabilitation Medicine; VHA Office of Disability and Medical Assessment Clinical Leadership Call; and VHA’s Northwest Mental Illness Research, Education and Clinical Center talk (“MIRECC Presents” https://www.mirecc.va.gov/visn20/Education/2023-2024.asp).
  • In Year 1 of I-HEAL funding, the team has identified 119 products for possible inclusion in the toolkit. Using the product review grid, 41 products were selected to undergo subject matter review for possible inclusion in the toolkit.

Products Supporting the “Provider Toolkit Innovation”

Project 2 Overview

Introduction to the Provider Toolkit Innovation: aims, methods, and people.

Provider perspectives for delivering high-quality care to persons with cognitive challenges.

Web-based repository of adaptations for delivering evidence-based behavioral health treatments.

References

Nakase-Richardson R, Cotner BA, Agtarap SD, Martin AM, Ching D, O'Connor DR, Tweed A, Haun JN, Hanks RA, Bergquist TF, Hammond FM, Zafonte RD, Hoffman JM. Provider Perceived Facilitators and Barriers to Identifying, Perceiving, and Seeking Healthcare for Chronic Pain After TBI: A Qualitative NIDILRR and VA TBI Model Systems Collaborative Project. J Head Trauma Rehabil. 2024 Jan-Feb 01;39(1):E1-E14. doi: 10.1097/HTR.0000000000000922. PMID: 38167718; PMCID: PMC10768806.

Nakase-Richardson R, Cotner BA, Martin AM, Agtarap SD, Tweed A, Esterov D, O'Connor DR, Ching D, Haun JN, Hanks RA, Bergquist TF, Hammond FM, Zafonte RD, Hoffman JM. Provider Perspectives of Facilitators and Barriers to Reaching and Utilizing Chronic Pain Healthcare for Persons With Traumatic Brain Injury: A Qualitative NIDILRR and VA TBI Model Systems Collaborative Project. J Head Trauma Rehabil. 2024 Jan-Feb 01;39(1):E15-E28. doi: 10.1097/HTR.0000000000000923. PMID: 38167719; PMCID: PMC10768799.

The views expressed are those of the authors and do not necessarily represent the official policy or position of the Department of Veterans Affairs or any other U.S. government agency. This work is funded by DOD CDMRP Award Number HT9425-23-1-0621 for Improving Health Care Access and Engagement for Veterans and Service Members with TBI Morbidity (I-HEAL). This material is the result of work supported with resources and the use of facilities at the James A. Haley Veterans’ Hospital. The administering institution for this work is the Tampa VA Research and Education Foundation.