Motivational Coaching to Enhance Mental Health Engagement in Rural Veterans

Project Background: One in five Operation Enduring Freedom (OEF)/Operation Iraqi Freedom
(OIF)/Operation New Dawn (OND) Veterans resides in rural areas and primarily receives care
from VA Community-Based Outpatient Clinics (CBOCs). Compared to their urban counterparts,
rural Veterans experience a significantly greater MH burden and poorer outcomes.
Nevertheless, less than 10% of OEF/OIF/OND Veterans with a new PTSD diagnosis attend a
minimum number of sessions required for evidence-based treatment, with rurality being one of
the strongest predictors of poor engagement. The investigators' pilot study in urban
OEF/OIF/OND Veterans demonstrated that telephone Motivational Interviewing (MI) delivered by
research staff significantly improved MH treatment initiation and retention in care. However,
the investigators do not know whether telephone MI will have as strong an effect on MH
treatment engagement when implemented by VA staff in CBOCs serving rural Veterans.

Project Objectives: As a part of the Center for Mental Healthcare and Outcomes Research
(CeMOHR) CREATE application to improve rural Veterans' access to evidence-based mental
healthcare, the overall goal of this project is to adapt, implement and test an MI-based
coaching intervention to improve MH services engagement at CBOCs serving rural Veterans. The
specific aims of this project are: (1) Conduct a developmental formative evaluation of
perceived barriers to MH treatment engagement and adapt the MI-based treatment engagement
intervention and implementation strategy to the needs of stakeholders; (2) Conduct a
randomized multi-site pragmatic effectiveness trial comparing MH Referral alone with MH
Referral plus MI-based coaching; and (3) Conduct an implementation-focused formative
evaluation and use this information to make mid-course corrections to the implementation
strategy based on stakeholder and key informant input.

Methods: The investigators will conduct the pragmatic effectiveness trial of the telephone
motivational coaching intervention to determine whether, in comparison to MH Referral alone,
telephone MI coaching improves MH treatment initiation and retention, the use of e-health MH
resources, and perceived need and readiness for and access to MH treatment among rural
Veterans who use CBOCs (Aim 2).

Impact: This research will help close the knowledge gap about barriers to care and
preferences for MH services among rural Veterans. In addition, information from this project
will be used to develop implementation toolkits for MH treatment engagement interventions for
rural Veterans. Finally, this project will determine the effectiveness of a telephone
Motivational Interviewing engagement intervention using e-health adjuncts, thereby filling a
gap in the scientific literature about whether novel interventions can be used by VA staff in
CBOCs to overcome rural-urban disparities in MH treatment engagement.

Inclusion Criteria:

- a Veteran over age 18

- a resident of VISN 16 or 21 catchment areas receiving care at a CBOC with no plans to
re-locate within 8 months of enrollment

- positive for 1 or more of the following disorders: PTSD, depression, generalized
anxiety disorder, panic disorder, high-risk drinking, and/or illicit substance use

Exclusion Criteria:

- hearing- impaired,

- no working telephone,

- Veterans with self-reported (and/or CPRS-confirmed) diagnoses of schizophrenia,
psychosis or bipolar disorder, or active suicidality or homicidality

- received mental health treatment within the last 60 days and/or has future
appointments for mental health treatment in the next 30 days