1315 Improving Access to Nightmare Therapy: A QI Initiative for Veterans

A quality improvement project at a Veterans Affairs sleep clinic evaluated whether a group format for narrative-enhanced imagery rehearsal therapy (N-IRT) could improve access to nightmare treatment for US Veterans. After revising triage workflows and eligibility criteria, wait times for individual sleep psychologist appointments dropped from 79.3 days in January 2024 to 28.9 days by March 2024. However, group utilization remained low: between September and October 2024, only 4 of 20 referred patients attended group N-IRT. Barriers included scheduling conflicts, medical complexity, and patient preference for individual care. The authors argue that multiple interventions and patient and provider education are needed to overcome these barriers.

Study at a glance

Abstract

One in ten US Veterans endorse trauma-related nightmares in their lifetime. Imagery rehearsal therapy is an effective and time-efficient therapy which is not widely accessible. We sought to evaluate if a group format could improve access to treatment. This quality improvement project utilized Plan-Do-Study-Act methodology to evaluate impact on access to care by creating a group format for narrative-enhanced imagery rehearsal therapy (N-IRT). Retrospective review of administrative data identified trends in wait times and clinic utilization. To explore contributors to low group utilization, we performed a secondary root-cause analysis using stakeholder brainstorming sessions and chart review. N-IRT group was first offered in July 2023. In January 2024, we revised our triage workflow, including N-IRT group eligibility criteria, to encourage group enrollment and improve wait times for individual appointments. After these updates, wait time for an individual sleep psychologist appointment decreased from 79.3 days in January 2024 to 28.9 days by March 2024. Between January and October 2024, median N-IRT group size was 3 patients. We achieved our target of 4+ patients enrolled in N-IRT group for 5 out of 10 months (50%). Between 09/01/24-10/31/2024, 20 referrals for N-IRT were received, yet only 4 patients (20%) attended N-IRT group. Of the sixteen patients who did not attend N-IRT group, 5 had scheduling issues and 11 were excluded at nurse triage. Nurse triage notes cited a variety of reasons for exclusion from group, including patient preference for individual care (N=3), request for multiple services (N=2), pending sleep medicine evaluation (N=2), medical complexity (N=1), inability to reach the patient (N=2), or lack of dream recall (N=1). Multiple interventions were necessary to achieve target wait times for nightmare therapy. Barriers to group-based nightmare therapy included scheduling issues, medical complexity/contraindications, and patient preference for individual care. Tackling these barriers will likely require a multifactorial approach that includes patient and referring provider education. This non-research operations project was conducted in accordance with VHA Program Guide 1200.21. The views expressed are solely those of the authors and do not represent the views of the US Department of Veterans Affairs or the US Government.