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OBJECTIVE: To examine the relationship between the penetration (or reach) of a national program aiming to integrate mental health clinicians into all primary care clinics (PC-MHI) and rates of guideline-concordant follow-up and treatment among clinic patients newly identified with depression in the Veterans Health Administration (VA). DATA SOURCES/STUDY SETTING: 15,155 screen-positive patients 607,730 patients with 2-item Patient Health Questionnaire scores in 82 primary care clinics, 2015-2019. STUDY DESIGN: In this retrospective cohort study, we used established depression care quality measures to assess primary care patients who (a) newly screened positive (score ≥3) and (b) were identified with depression by clinicians via diagnosis and/or medication (n = 15,155; 15,650 patient-years). Timely follow-up included ≥3 mental health, ≥3 psychotherapy, or ≥3 primary care visits for depression. Minimally appropriate treatment included ≥4 mental health visits, ≥3 psychotherapy, or ≥60 days of medication. In multivariate regressions, we examined whether higher rates of PC-MHI penetration in clinic (proportion of total primary care patients in a clinic who saw any PC-MHI clinician) were associated with greater depression care quality among cohort patients, adjusting for year, healthcare system, and patient and clinic characteristics. DATA COLLECTION/EXTRACTION METHODS: Electronic health record data from 82 VA clinics across three states. PRINCIPAL FINDINGS: A median of 9% of all primary care patients were seen by any PC-MHI clinician annually. In fully adjusted models, greater PC-MHI penetration was associated with timely depression follow-up within 84 days (∆P = 0.5; SE = 0.1; p < 0.001) and 180 days (∆P = 0.3; SE = 0.1; p = 0.01) of a positive depression screen. Completion of at least minimal treatment within 12 months was high (77%), on average, and not associated with PC-MHI penetration. CONCLUSIONS: Greater PC-MHI program penetration was associated with early depression treatment engagement at 84-/180-days among clinic patients newly identified with depression, with no effect on already high rates of completion of minimally sufficient treatment within the year.
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Rural women veterans are less likely than men and nonrural veterans to access Veterans Health Administration (VHA) care. This qualitative study describes rural women veterans' barriers to accessing care and explores whether participants viewed a peer specialist intervention as having the potential to facilitate access to care. We recruited rural veterans who identified as women with psychological distress and social needs, women peer specialists, and VHA primary care professionals working with rural veterans. We conducted two veteran focus groups, two peer specialist focus groups, and 11 individual Patient Aligned Care Team professional interviews using semistructured interview questions. One of the veteran focus groups was exclusive to veterans of color. We used a rapid qualitative data analysis approach to analyze the results. Data analysis revealed barriers affecting perceived access to services for rural women veterans, especially veterans of color, including transportation, finances, childcare, long travel distance to clinics, lack of access to gender-specific services, ineligibility for services, and lacking information about available resources. Participants also reported challenges accessing community services outside of the VHA. The rural women veterans reported a strong preference for gender-specific services. Leveraging existing VHA resources with rural women veterans may mitigate some of the identified barriers. In particular, participants agreed that increasing availability of peer specialists who are both women and veterans could bridge some perceived barriers to accessing care among rural women veterans. (PsycInfo Database Record (c) 2024 APA, all rights reserved).
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Embedding a behavioral health consultant (BHC) into primary care settings is a common way to address the challenge of providing mental health services to primary care patients. Systematic research on the mechanisms of change that underlie the relationship between the active components of these integrated models of care delivery on patient outcomes is needed to help maximize effectiveness and, in turn, guide future implementation efforts. Using the existing primary care behavioral health (PCBH) literature, this article provides a conceptual framework using a common presenting problem, depression and identifies the active ingredients of PCBH and hypothesized mechanisms of patient change that result in decreased depressive symptoms and improved functioning within a patient. Eight hypothesized mechanisms (i.e., belief that PCBH services provided by BHC is a standard part of care within primary care; increased credibility of BHC and PCBH care provided; increased receptivity to the PCBH services offered; increased understanding of problem and options; realignment of patient expectations for care; increased readiness to change; decrease stigma; increase capacity to cope and manage symptoms) are proposed within this conceptual framework along with four potential mediators/moderators (i.e., team processes, PCBH factors, common factors, treatment engagement). The theoretical conceptualization included calls for future research to provide an evidence base to inform clinical practice. An increased understanding of the relationship between these active ingredients and the identified mechanisms of change is essential to maximize PCBH's effectiveness. (PsycInfo Database Record (c) 2024 APA, all rights reserved).
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Prestação Integrada de Cuidados de Saúde , Serviços de Saúde Mental , Atenção Primária à Saúde , Humanos , Atenção Primária à Saúde/organização & administração , Prestação Integrada de Cuidados de Saúde/organização & administração , Serviços de Saúde Mental/organização & administraçãoRESUMO
BACKGROUND: Anxiety is highly prevalent, but undertreated, in primary care. Brief, non-pharmacological interventions are needed. Modular Anxiety Skills Training (MAST), a cognitive-behavioral anxiety intervention, was developed for primary care and tailored for a Veteran sample (MAST-V). The purpose of this mixed methods pilot study was to evaluate MAST-V's feasibility, acceptability, and implementation potential, and preliminarily examine its effectiveness compared to Primary Care Behavioral Health (PCBH) usual care. METHODS: This hybrid I randomized controlled trial (conducted 2019-2021) assigned 35 primary care patients (Mage = 47, 17 % female, 27 % racial/ethnic minority) with clinically significant anxiety symptoms to receive MAST-V or PCBH usual care. Participants completed validated measures of anxiety symptoms and functional impairment at 0, 4, 8, 12, and 16 weeks. RESULTS: Participants attended more sessions in MAST-V than usual care. After necessary adjustments to reduce session duration, MAST-V will likely fit within PCBH practice parameters. Participants in both conditions valued treatment, but treatment satisfaction, credibility, and therapeutic alliance were higher for MAST-V. Study therapists achieved high treatment fidelity and rated MAST-V as highly feasible, acceptable, and appropriate for PCBH. They identified ways to address potential barriers to implementation. MAST-V was more effective than usual care in reducing anxiety symptoms and impairment. LIMITATIONS: This was a small pilot study at a single site using study therapists. Results should be considered preliminary until replicated in a full-scale clinical trial. CONCLUSIONS: This brief modular anxiety intervention, which was designed with implementation in mind, may help to address the anxiety treatment gap in primary care.
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Ansiedade , Terapia Cognitivo-Comportamental , Estudos de Viabilidade , Atenção Primária à Saúde , Humanos , Feminino , Masculino , Projetos Piloto , Pessoa de Meia-Idade , Terapia Cognitivo-Comportamental/métodos , Adulto , Ansiedade/terapia , Transtornos de Ansiedade/terapia , Resultado do Tratamento , Veteranos/psicologia , Aceitação pelo Paciente de Cuidados de SaúdeRESUMO
Stressful events can exacerbate symptoms of psychiatric disorders among primary care patients, putting them at increased risk for suicide. In a pilot study that ran from August to December of 2020, researchers evaluated the acceptability and implementation of Managing Emotions in Disaster and Crisis (MEDIC), a self-help intervention designed to assist at-risk primary care patients. A total of 108 at-risk veterans completed baseline and 6-week assessments. Results were promising, with high patient acceptability and engagement along with improvement in all measures of mental illness symptoms from baseline to posttreatment. Self-help interventions like MEDIC may offer a low-burden way for primary care providers to support more patients.
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COVID-19 , Atenção Primária à Saúde , Veteranos , Humanos , Projetos Piloto , Veteranos/psicologia , COVID-19/prevenção & controle , Masculino , Pessoa de Meia-Idade , Feminino , Adulto , Transtornos Mentais/terapia , Intervenção em Crise/métodos , AutocuidadoRESUMO
Chronic pain and unhealthy alcohol use commonly co-occur and are associated with negative health outcomes. Veterans may be particularly vulnerable to these conditions, yet limited research has examined factors involved in their co-occurrence. This cross-sectional study aimed to examine the role of affective pain interference and alcohol pain-coping perceptions in the relationship between pain and hazardous alcohol use. As informed by the catastrophizing, anxiety, negative urgency, and expectancy model, we hypothesized that the relationship between pain and hazardous alcohol consumption is mediated by affective pain interference and stronger among those with greater perceptions that alcohol helps cope with pain. Participants were 254 VA primary care patients (87.8% male, Mage = 64.03, 76.4% White) with a history of chronic musculoskeletal pain, past-year alcohol use, and past-week pain. Veterans completed a mailed survey including measures of pain, affective pain interference, alcohol pain-coping perceptions, and hazardous alcohol use. Hypotheses were tested with regression models and PROCESS macros. As hypothesized, affective pain interference mediated the pain-hazardous alcohol use association. Contrary to hypotheses, results showed no moderating effect of alcohol pain-coping perceptions. Findings partially support relationships among theorized constructs and suggest that for Veterans with co-occurring pain and alcohol use it may be important to target pain-related affective interference and perceptions that alcohol helps cope with pain. PERSPECTIVE: This article presents a test of factors involved in the pain and alcohol relationship, as informed by the CANUE model. Findings suggest that for Veterans with co-occurring pain and past-year alcohol use, it may be important to target pain-related affective interference and perceptions that alcohol helps cope with pain.
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Dor Crônica , Veteranos , Humanos , Masculino , Feminino , Veteranos/psicologia , Estudos Transversais , Dor Crônica/epidemiologia , Dor Crônica/psicologia , Capacidades de Enfrentamento , Atenção Primária à SaúdeRESUMO
Background: Brief alcohol interventions (BAIs) are an evidence-based practice for addressing hazardous alcohol use in primary care settings. However, numerous barriers to implementation of BAIs in routine practice have been identified, including concerns about patient receptivity to BAIs. Despite this being a commonly identified barrier to BAI implementation, little BAI implementation research has focused on patient receptivity. Objectives: This study aimed to identify the treatment preferences of primary care patients who screened positive for hazardous alcohol use and to evaluate factors that may influence patients' receptivity to BAIs delivered in primary care. We conducted a mailed survey of primary care patients (N = 245) who screened positive for hazardous alcohol use on annual screening measures based on electronic medical record data. Patients completed measures assessing treatment preferences and a conjoint analysis questionnaire designed to evaluate the relative importance of three factors (focus of the BAI, tailoring of the BAI, and familiarity with the provider delivering the BAI) for patient receptivity. Results: Conjoint analysis results revealed that familiarity with provider (with patients preferring BAIs delivered by providers they have previously met) was the most important factor in predicting patients' receptivity to BAIs. Additionally, patients preferred to discuss alcohol use in the context of another concern (focus of the BAI) and preferred personalized information tailored based on their specific health concerns (tailoring of the BAI), although these factors were not statistically significant when accounting for familiarity with provider. Conclusions: Findings of the present study have potential to inform future research on implementation of BAIs.
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Consumo de Bebidas Alcoólicas , Programas de Rastreamento , Humanos , Consumo de Bebidas Alcoólicas/prevenção & controle , Programas de Rastreamento/métodos , Registros Eletrônicos de Saúde , Atenção Primária à SaúdeRESUMO
INTRODUCTION: Close relationship problems play a key role in many contemporary theories of suicide. However, the potential of relationship support in suicide prevention is understudied. This study explores the feasibility, safety, acceptability, and promise of utilizing the 3-session Relationship Checkup (RC) in veterans with mental health and romantic relationship concerns. METHODS: We conducted a single-arm pilot of telehealth RC in veterans with a positive mental health screen and their romantic partners. Couples completed baseline and post-treatment assessments of study outcomes. RESULTS: Feasibility analyses showed we were able to recruit an elevated-risk sample (30% history of attempts or interrupted attempts), take them through the service (90% treatment completion), and had minimal harm events (no suicidal behavior, no physical harm in arguments). Multimethod acceptability analyses suggested high satisfaction with the program, though some desired more intensive services. Couples reported improvements in relationship functioning, emotional intimacy, thwarted belongingness, depression, and posttraumatic stress. Perceived burdensomeness only improved for identified patients and drinking did not change for either partner. CONCLUSION: The RC is a feasible, safe, and acceptable strategy for providing relationship support to couples at elevated risk. Although further randomized trials are needed, RC shows promise to reduce relationship-level and individual-level suicide risk factors.
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Suicídio , Veteranos , Humanos , Veteranos/psicologia , Saúde Mental , Prevenção do Suicídio , Relações Interpessoais , Suicídio/psicologia , Ideação Suicida , Fatores de RiscoRESUMO
INTRODUCTION: Conjoint visits utilize the expertise of primary care providers (PCPs) and behavioral health providers (BHPs) to address complex comorbidities in patients. The objectives were to describe the use and features of conjoint visits and identify barriers and facilitators as described by BHPs in integrated settings. METHOD: Three hundred and forty-five BHPs who worked in integrated primary care, a majority identifying as female and white, completed an online survey between October 2018 and July 2019. RESULTS: Results indicated common reasons for conjoint visits were for mental or behavioral health concerns. Though they reported high comfort using conjoint visits (M = 4.3/5), 56.5% of BHPs participated in them less than monthly or never. Using a constant comparison approach, qualitative data were coded to reveal six categories of barriers and five categories of facilitators to conjoint visits. The most common barriers were a result of a lack of systemic support, such as 73.5% reporting lack of time, while the most common facilitators were coordination (60.7%) and interprofessional communication (39.3%). DISCUSSION: Although conjoint visits are used infrequently, findings suggest it is not because they are unhelpful as providers generally found this type of appointment favorable. Rather, they and their teams lack time, training, and support needed for implementation. This research provides an introduction for researchers or clinicians to better understand the use of conjoint visits for patients with high needs and complexities. Future work focused on addressing barriers cited by providers regarding conjoint visits would increase providers' ability to use this form of care when it is needed. (PsycInfo Database Record (c) 2024 APA, all rights reserved).
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Atitude do Pessoal de Saúde , Compostos Bicíclicos com Pontes , Prestação Integrada de Cuidados de Saúde , Humanos , Feminino , Atenção Primária à SaúdeRESUMO
Intimate partner violence (IPV) is a prominent public health problem in the United States, with significant health impacts that are often severe and persistent. Healthcare systems have been called upon to improve both the systematic identification and treatment of IPV largely by adopting secondary and tertiary prevention efforts. Research to date demonstrates both benefits and challenges with the current strategies employed. In this paper, we summarize current knowledge about the healthcare system's response to IPV and evaluate the strengths, limitations, and opportunities. We offer recommendations to broaden the continuum of healthcare resources to address IPV, which include a population health approach to primary prevention.
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Prestação Integrada de Cuidados de Saúde , Violência por Parceiro Íntimo , Atenção Primária à Saúde , Prevenção Primária , Humanos , Violência por Parceiro Íntimo/prevenção & controle , Saúde Pública , Estados Unidos , Programas de Rastreamento , Masculino , FemininoRESUMO
OBJECTIVE: Mild traumatic brain injuries (mTBIs) are common among Veterans. Although the majority of neurobehavioral symptoms resolve following mTBI, studies with Veteran samples demonstrate a high frequency and chronicity of neurobehavioral complaints (e.g., difficulties with attention, frustration tolerance) often attributed to mTBI. Recent opinions suggest the primacy of mental health treatment, and existing mTBI practice guidelines promote patient-centered intervention beginning in primary care (PC). However, trial evidence regarding effective clinical management in PC is lacking. This study evaluated the feasibility and acceptability of a brief, PC-based problem-solving intervention to reduce psychological distress and neurobehavioral complaints. RESEARCH METHOD/DESIGN: Mixed method open clinical trial of 12 combat Veterans with a history of mTBI, chronic neurobehavioral complaints, and psychological distress. Measures included qualitative and quantitative indicators of feasibility (recruitment and retention metrics, interview feedback), patient acceptability (treatment satisfaction, perceived effectiveness), and change in psychological distress as measured by the Brief Symptom Inventory-18. RESULTS: The protocol was successfully delivered via in-person and telehealth treatment modalities (4.3 sessions attended on average; 58% completed the full protocol). Patient interview data suggested that treatment content was personally relevant, and patients were satisfied with their experience. Treatment completers described the intervention as helpful and reported corresponding reductions in psychological distress (ES = 1.8). Dropout was influenced by the onset of the COVID-19 pandemic. CONCLUSIONS/IMPLICATIONS: Further study with a more diverse, randomized sample is warranted. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Concussão Encefálica , COVID-19 , Veteranos , Humanos , Concussão Encefálica/epidemiologia , Intervenção em Crise , Estudos de Viabilidade , Pandemias , Veteranos/psicologiaRESUMO
Cognitive-behavioral treatment for anxiety disorders and symptoms remains underutilized in integrated primary care (IPC), in part because the many treatments developed for specialty care are not readily translated to this unique setting. The objective of this study was to identify barriers and facilitators to behavioral health providers (BHPs) delivering evidence-based cognitive--behavioral anxiety interventions within IPC practice. We conducted semistructured interviews with a national sample of 18 BHPs (50% psychologists, 33% social workers, 17% registered nurses) working in IPC in the Veterans Health Administration. We assessed barriers to and facilitators of using psychoeducation, exposure, cognitive therapy, relaxation training, mindfulness/meditation, Acceptance and Commitment Therapy-based interventions, and problem-solving therapy. Qualitative coding and conventional content analysis revealed barriers and facilitators at three levels: IPC, provider, and patient. Themes suggested key barriers of poor fit with the IPC model, BHP training deficits, and lack of patient buy-in, and key facilitators of good perceived fit of the intervention (e.g., scope, duration) with the IPC model, BHPs feeling well equipped, and utility for patients. BHPs select interventions based on fit for the individual patient. Some results were consistent with prior work from specialty care, but the IPC model itself introduces significant implementation challenges. BHPs would benefit from flexible intervention options and training on IPC treatment goals and how to deliver the essence of evidence-based interventions in small doses. Our findings will help to inform adaptation of behavioral anxiety interventions to better fit IPC practice and development of beneficial training and resources for BHPs to reduce implementation challenges. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Terapia de Aceitação e Compromisso , Humanos , Transtornos de Ansiedade/terapia , Ansiedade/terapia , Atenção Primária à Saúde , CogniçãoRESUMO
Primary care (PC) settings increasingly use team-based care activities with embedded behavioral health providers (BHPs) to enhance patient care via group medical visits, conjoint appointments, team huddles, and warm handoffs. Aim 1 was to describe the variation of team-based care activities within integrated PC clinics. Aim 2 was to explore whether factors associated with the BHP (e.g., gender, training, and experience) and the PC setting (e.g., perceived teamwork) predict engagement in team-based activities. A national sample of eligible BHPs (n = 345; 14.2% response rate) completed an anonymous survey assessing the presence/intensity of team-based care activities. 90% of BHPs reported regularly engaging in team-based care activities with PC teams. Most engagement occurred when providing feedback to PC providers (90.4% at least daily) and during warm handoffs (90.4% at least once daily). Engagement in team-based care was predicted by the level of teamwork occurring within the PC clinic (ßs = .41-.47; ps < .001) and BHP characteristics, such as the number of years spent in PC (ßs = .24-.26, ps < .001). Although these data are promising, with many BHPs reportedly engaging in team-based activities with PC teams, there is significant variation. Researchers should continue to explore whether the engagement in these team-based care activities enhances patient care.
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Prestação Integrada de Cuidados de Saúde , Atenção Primária à Saúde , Humanos , Prevalência , Relações Interprofissionais , Equipe de Assistência ao PacienteRESUMO
Anxiety is undertreated in primary care, and most treatment provided is pharmacological rather than behavioral. Integrating behavioral health providers (BHPs) using the Primary Care Behavioral Health (PCBH) model can help address this treatment gap, but brief interventions suitable for use in PCBH practice are needed. We developed a modular, cognitive-behavioral anxiety intervention, Modular Anxiety Skills Training (MAST), that is evidence-based, transdiagnostic, feasible for PCBH, and patient-centered. MAST comprises up to six 30-min sessions emphasizing skills training. This article describes the rationale for and development of MAST as well as pilot work in the Veterans Health Administration (VA) to tailor and refine MAST for delivery to Veterans in VA primary care (MAST-V) to improve feasibility for VA BHPs and acceptability to Veterans. We used a convergent mixed-methods design with concurrent data collection. In phase one, we interviewed five BHPs to obtain feedback on the treatment manual. BHPs assessed MAST-V to be highly compatible with PCBH and provided suggestions to enhance feasibility. In phase two, we conducted an open trial in which six Veterans experiencing clinically significant anxiety received and provided feedback on all nine possible modules; we also assessed changes in mental health symptoms and functioning as well as treatment satisfaction and credibility. Veterans found MAST-V to be highly acceptable, and pre-post clinical outcomes were very promising with large effect sizes. Findings from this initial pilot provide preliminary support for the feasibility, acceptability, and efficacy of MAST-V and suggest further research with a randomized clinical trial is warranted. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Veteranos , Humanos , Veteranos/psicologia , Retroalimentação , Ansiedade/terapia , Atenção Primária à Saúde , CogniçãoRESUMO
OBJECTIVE: Brief alcohol interventions (BAIs) are evidence-based practices that can help reduce hazardous drinking among patients in medical settings. However, descriptions of the treatment-as-usual (TAU) control groups that BAIs are compared to in clinical trials often lack clarity and detail. This systematic review and meta-analysis quantified and compared descriptions of intervention and TAU control arms within reports of randomized controlled trials and examined whether treatment effects were affected by level of detail in narrative descriptions. METHOD: A systematic literature search to identify eligible articles was performed. Studies were rated on methodological quality, and the Template for Intervention Description and Replication (TIDieR) checklist was used to rate the level of clarity and detail included in descriptions of the intervention and TAU conditions in eligible articles. Data were extracted from articles for use in meta-analysis and meta-regression. RESULTS: Twenty-one studies met inclusion criteria. Across the studies, TIDieR ratings for intervention arms were higher than ratings for control arms. BAIs were linked to reductions in drinks per week, heavy drinking episodes, and alcohol consequences over time when compared with TAU. TIDieR ratings for control groups were significantly associated with larger treatment effects on drinks per week and alcohol consequences but were not significant for heavy drinking episodes. CONCLUSIONS: This meta-analysis reiterated the effectiveness of BAIs in medical settings. Yet the lack of clarity in TAU descriptions raises concerns regarding the validity of BAI trials, suggesting need for more detailed reporting and use of the TIDieR guidelines for support.
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Etanol , Projetos de Pesquisa , Humanos , Grupos ControleRESUMO
This study explores differences in characteristics and relationship treatment preferences across different levels of intimate partner violence (IPV) among Veterans Affairs (VA) primary care patients. In Fall 2019, we sent a mail-in survey assessing relationship healthcare needs to N = 299 Veterans randomly sampled from 20 northeastern VA primary care clinics (oversampling female and younger Veterans). We compared those reporting past year use or experience of physical/sexual aggression, threats/coercion, or injury (Severe IPV; 21%), to those only reporting yelling and screaming (Verbal Conflict; 51%), and denying any IPV (No IPV; 28%). Participants across groups desired 2-6 sessions of face-to-face support for couples' health and communication. No IPV participants were older and had preferred treatment in primary care. The Verbal Conflict and Severe IPV groups were both flagged by IPV screens and had similar interest in couple treatment and relationship evaluation. The Severe IPV group had higher rates of harms (e.g., depression, alcohol use disorder, relationship dissatisfaction, fear of partner) and higher interest in addressing safety outside of VA. Exploratory analyses suggested differences based on use vs. experience of Severe IPV. Findings highlight ways integrated primary care teams can differentiate services to address dissatisfaction and conflict while facilitating referrals for Severe IPV.
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Violência por Parceiro Íntimo , Veteranos , Humanos , Feminino , Agressão , Inquéritos e Questionários , Atenção Primária à SaúdeRESUMO
Evidence-based psychotherapies (EBPs) are underused in health care settings. Aligning implementation of EBPs with the needs of health care leaders (i.e., operational stakeholders) can potentially accelerate their uptake into routine practice. Operational stakeholders (such as hospital leaders, clinical directors, and national program officers) can influence development and oversight of clinical programs as well as policy directives at local, regional, and national levels. Thus, engaging these stakeholders during the implementation and dissemination of EBPs is critical when targeting wider use in health care settings. This article describes how research-operations partnerships were leveraged to increase implementation of an empirically supported psychotherapy - brief Cognitive Behavioral Therapy (brief CBT) - in Veterans Health Administration (VA) primary care settings. The partnered implementation and dissemination efforts were informed by the empirically derived World Health Organization's ExpandNet framework. A steering committee was formed and included several VA operational stakeholders who helped align the brief CBT program with the implementation needs of VA primary care settings. During the first 18 months of the project, partnerships facilitated rapid implementation of brief CBT at eight VA facilities, including training of 12 providers who saw 120 patients, in addition to expanded program elements to better support sustainability (e.g., train-the-trainer procedures).
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INTRODUCTION: Women Veterans experience a broad range of stressors (e.g., family, relationship, and financial) and high rates of mental health and physical health conditions, all of which contribute to high levels of stress. Personalized Support for Progress (PSP), an evidence-based intervention, is well suited to support women Veterans with high stress as it involves a card-sort task to prioritize concerns as well as pragmatic and emotional support to develop and implement a personalized plan addressing those concerns. Our aims were to explore the population and context for delivery and evaluate the feasibility, acceptability, and utility of PSP delivered by a peer specialist to complement existing services in a Veterans Health Administration (VHA) Women's Wellness Center. MATERIALS AND METHODS: This randomized controlled pilot trial compared treatment as usual plus PSP to treatment as usual and used the a priori Go/No-Go criteria to establish success for each outcome. We interviewed staff regarding the population and delivery context at a VHA Women's Wellness Center and analyzed interviews using a rapid qualitative approach. For the rapid qualitative analysis, we created templated summaries of each interview to identify key concepts within each a priori theme, reviewed each theme's content across all interviews, and finally reviewed key concepts across themes. We evaluated feasibility using recruitment and retention rates; acceptability via Veteran satisfaction, working relationship with the peer, and staff satisfaction; and utility based on the proportion of Veterans who experienced a large change in outcomes (e.g., stress, mental health symptoms, and quality of life). The Syracuse VA Human Subjects Institutional Review Board approved all procedures. RESULTS: Staff interviews highlight that women Veterans have numerous unmet social needs and concerns common among women which increase the complexity of their care; call for a supportive, consistent, trusting relationship with someone on their health care team; and require many resources (e.g., staff such as social workers, services such as legal support, and physical items such as diapers) to support their needs (some of which are available within VHA but may need support for staffing or access, and some of which are unavailable). Feasibility outcomes suggest a need to modify PSP and research methods to enhance intervention and assessment retention before the larger trial; the recruitment rate was acceptable by the end of the trial. Veteran acceptability of PSP was high. Veteran outcomes demonstrate promise for utility to improve stress, mental health symptoms, and quality of life for women Veterans. CONCLUSIONS: Given the high acceptability and promising outcomes for utility, changes to the design to enhance the feasibility outcomes which failed to meet the a priori Go/No-Go criteria are warranted. These outcomes support future trials of PSP within VHA Women's Wellness Centers.
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Primary care is well-poised to address unmet social needs that affect health. Integrated primary care is increasingly common and can be leveraged to facilitate identification of practice and clinician-level modifiable characteristics and assist practices to address unmet social needs for patients and families. A recent National Academies of Sciences, Engineering, and Medicine (NASEM)'s consensus report identified 5 critical system-level activities to facilitate the integration of addressing social needs into health care: awareness (ask patients), adjustment (flexible intervention delivery), assistance (intervention to address the social need), alignment (link with community resources), and advocacy (policy change). This article outlines how integrated primary care characteristics, such as routine screening, functional workflows, interprofessional team communication, and patient-centered practices, exemplify the NASEM report's activities and offer robust biopsychosocial tools for addressing social needs. We provide a case to illustrate how these strategies might be used in practice.
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Comunicação , Atenção à Saúde , Humanos , Programas de Rastreamento , National Academy of Sciences, U.S. , Atenção Primária à Saúde , Estados UnidosRESUMO
BACKGROUND: Veterans enrolled in Veterans Health Administration (VHA) Home Based Primary Care (HBPC), a program providing in-home medical and mental health care by an interdisciplinary care team, often face substantial physical, cognitive, and mental health challenges. This program evaluation examined the impact of a brief problem-solving intervention on depressive symptoms, quality of life, and problem-solving abilities for Veterans enrolled in HBPC. DESIGN: Pre- and post-intervention outcomes for Veterans, and qualitative feedback from Veterans and clinicians regarding program satisfaction. PARTICIPANTS AND SETTING: A total of 230 HBPC patients (mean age in years = 72.1, SD = 11.6) within the U.S. national VHA health care system. INTERVENTION: Six-session, individual Problem-Solving Training (PST-HBPC). METHOD: Licensed psychologists and social workers (n = 115) completed training and administered the treatment with HBPC Veterans between 2014 and 2017. MEASUREMENTS AND RESULTS: From baseline to post-intervention, Veterans completing five or more PST-HBPC sessions (n = 199) reported significant reductions in depressive symptoms on the Patient Health Questionnaire 9-item (PHQ-9), in difficulty functioning due to depressive symptoms (PHQ-9 item 10), and in thoughts of death (PHQ-9 item 9). They also reported more effective problem-solving on the Social Problem-Solving Inventory - Revised: Short form (total score and subscales), and improved quality of life across life domains on the World Health Organization Quality of Life-BREF (WHOQOL-BREF) scale. Both clinicians and Veterans also reported satisfaction with the program. CONCLUSIONS: Preliminary findings support the continued dissemination and implementation of this brief PST intervention for HBPC Veterans, and its potential for use with non-VA home care populations with complex comorbidities.