Sleep MAPP in the Polytrauma/TBI System of Care

The Sleep MAPP Care Pathway is a multicomponent implementation strategy designed to improve delivery of guideline-concordant insomnia screening and treatment in the Veterans Health Administration Polytrauma/TBI System of Care. The first component is the Sleep MAPP decision-support tool. The tool uses existing electronic health record and scheduling information to identify Veterans with upcoming appointments who may be appropriate for insomnia symptom screening, supports electronic administration and documentation of the Insomnia Severity Index, displays screening status and results to the clinical team, and presents guideline-based follow-up options for clinician consideration. Sleep MAPP does not diagnose insomnia disorder, prescribe treatment, or automate clinical decisions. Clinicians independently review the information and make all diagnostic and treatment decisions with the Veteran. The second component is training and implementation support for Polytrauma/TBI System of Care providers to deliver Brief Behavioral Therapy for Insomnia (BBTI). BBTI is a behavioral intervention that is recommended within clinical practice guidelines as first-line treatment for insomnia disorder. BBTI improves sleep quality by modifying behaviors to enhance and regulate wakefulness, thereby strengthening the homeostatic drive. BBTI also helps structure and optimize sleep and wake times to support and align with the circadian rhythm. The Sleep MAPP Care Pathway includes a pragmatic training process provided to rehabilitation professionals who do not conventionally deliver BBTI. The training is designed to facilitate delivery of BBTI with fidelity, including an intake followed by approximately four treatment sessions focused on stimulus control, sleep restriction, sleep education, adherence problem-solving, and relapse prevention. The study includes three phases: a 6-month pre-implementation phase, a 12-month implementation phase with active support, and a 6-month post-implementation phase in which active support is withdrawn to assess maintenance. Aim 1 is designed to evaluate feasibility and acceptability. Up to 30 providers or staff involved in implementation and up to 50 Veterans who received Insomnia Severity Index screening and initiated Brief Behavioral Therapy for Insomnia will complete quantitative assessments and semi-structured interviews. Evaluation of feasibility and acceptability criteria will determine whether the care pathway is ready for larger-scale testing without modification. Aim 2 is designed to describe change in implementation outcomes after deploying the Sleep MAPP Care Pathway. Outcomes include the reach of Insomnia Severity Index screening and Brief Behavioral Therapy for Insomnia; provider adoption of screening and treatment practices; fidelity to intended care delivery; and maintenance during the post-implementation phase. Aim 3 describes preliminary clinical changes among Veterans with mild traumatic brain injury who receive BBTI as part of routine care. Insomnia severity, neurobehavioral symptoms, and participation in social roles will be assessed at treatment intake and the final treatment session and abstracted retrospectively from routinely collected clinical data. The Sleep MAPP Care Pathway will be implemented in the Polytrauma Network Site at the James A. Haley Veterans' Hospital in Tampa, Florida. Rocky Mountain Regional VA Medical Center is the coordinating site. VA Pittsburgh Healthcare System personnel will provide BBTI training and analytic expertise.