Infusing geriatrics in Indian Health Service general primary care clinics: Extending VA workforce development training.

As federal partners, the Veterans Health Administration (VA) and the Indian Health Service (IHS) agreed to share resources, such as education. The VA Geriatric Scholars Program, a workforce development program, provides one of its training programs on team-based primary care of elders to clinicians working in IHS and Tribal Health Programs. The practical impact of that training is described. A mixed methods approach was applied to the course's evaluation survey at five clinics in the Northwestern Plains, Southwest, Pacific Coast, and Alaska. Quantitative approaches assessed participants' self-reported intention to improve recognition and assessment of common geriatric syndromes. A qualitative approach applied to open-ended text responses revealed intensions to improve team-based care. Among the 51 respondents in our sample, we found significant improvements in self-reported ability to recognize previously unfamiliar potential risks to elders' health and safety, t(49) = 8.0233, p < .001, as well as increased comfort with conducting geriatric assessments and increased confidence in interprofessional team-based communication. Improvements to team-based care included enhanced clinical skills, organizational factors and the need to train additional employees. This evaluation demonstrates the value of sharing resources among federal partners and its value for participants in IHS and Tribal Health Programs.

Enhancing specialty training in geropsychology competencies: An evaluation of a VA Geriatric Scholars Program advanced topics workshop.

There is a growing need for psychologists with specialized training in geriatric mental health competencies. The Geriatric Scholars Program for Psychologists (GSP-P) was created to address this shortage within a large integrated healthcare system. In 2019, GSP-P piloted an advanced workshop designed to enhance expertise in geriatric mental health competencies among graduates of its foundational competencies core course. The workshop included 3.5 days of expert-led seminars regarding the biopsychosocial needs of older adults with chronic medical illness and was followed by completion of an individualized learning plan. This paper describes the evaluation of the course using a mixed methods with data collected prior to the workshop, immediately post-workshop, and six months post-workshop. Results indicated enthusiasm for the workshop, significant improvements in four geropsychology domains on the Pikes Peak Geropsychology Knowledge and Skill Assessment Tool, and benefit from completion of the independent learning plans. Our findings demonstrate that continued enhancement of geropsychology competencies through advanced coursework is feasible and improves knowledge and skill, particularly when combined with individualized learning plans.

Developing a program to increase geropsychology competencies of Veterans Health Administration (VHA) psychologists.

There is an alarming supply and demand gap for geropsychology expertise within the United States. Health policy experts called for increasing geriatric mental health competencies for all mental health providers, including within Veterans Health Administration (VHA), to address this problematic gap. The VHA Geriatrics Scholar Program (GSP) Psychology Track was developed because there were no commercially available trainings in geropsychology for licensed psychologists. Developing the GSP Psychology Track was based on an evidence-based educational model for the VHA primary care workforce; and included a stepwise curriculum design, pilot implementation, and program evaluation. The educational program was pilot tested with eight VHA psychologists. Evaluation results demonstrated feasibility of implementing an innovative integrated multimodal educational program in geropsychology. Furthermore, this program was associated with reports of increased confidence in geropsychology competencies and self-reported implementation of geropsychology knowledge, indicating the potential for this educational model to improve mental health care for older Veterans.

The rural interdisciplinary team training program: a workforce development workshop to increase geriatrics knowledge and skills for rural providers.

The Rural Interdisciplinary Team Training Program (RITT) is a team-based educational component of the Veterans Health Administration (VHA) Office of Rural Health Geriatric Scholars Program. It is a workforce development program to enhance the geriatrics knowledge and skills of VA primary care clinicians and staff caring for older veterans in rural communities. The RITT workshop, accredited for 6.5 hours, is interactive and multi-modal with didactic mini-lectures, interactive case discussions and role play demonstrations of assessments. Clinic teams also develop and implement a small quality improvement project based on common challenges faced by older persons. This report is an evaluation of the effect of the RITT Program on geriatrics knowledge and team development as well as success in developing and implementing the quality improvement projects in 80 VHA rural outpatient clinics in 38 states.

Community fall prevention programs: comparing three InSTEP models by levels of intensity.

The Fall Prevention Center of Excellence designed three progressive-intensity fall prevention program models, Increasing Stability Through Evaluation and Practice (InSTEP), to reduce risk in community-dwelling older adults. Each model included physical activity, medical risk, and home safety components and was implemented as a 12-week program for small class sizes (12-15 people) in community and senior centers. Change in fall rates and fall risk factors was assessed using a battery of performance tests, self-reports of function, and fall diaries in a 3-group within-subjects (N = 200) design measured at baseline, immediately postintervention, and at 3 and 9 months postintervention. Overall, participants experienced a reduction in falls, improved selfperception of gait and balance, and improved dynamic gait function. The medium-intensity InSTEP model significantly (p = .003) reduced self-reported falls in comparison with the other models. InSTEP is a feasible model for addressing fall risk reduction in community-dwelling older adults.

A multisite geriatric education program for rural providers in the Veteran Health Care System (GRECC-Connect).

Older patients who live in rural areas often have limited access to specialty geriatric care, which can help in identifying and managing geriatric conditions associated with functional decline. Implementation of geriatric-focused practices among rural primary care providers has been limited, because rural providers often lack access to training in geriatrics and to geriatricians for consultation. To bridge this gap, four Geriatric Research, Education, and Clinical Centers, which are centers of excellence across the nation for geriatric care within the Veteran health system, have developed a program utilizing telemedicine to connect with rural providers to improve access to specialized geriatric interdisciplinary care. In addition, case-based education via teleconferencing using cases brought by rural providers was developed to complement the clinical implementation efforts. In this article, the authors review these educational approaches in the implementation of the clinical interventions and discuss the potential advantages in improving implementation efforts.

Preparing Veterans Health Administration Psychologists to Meet the Complex Needs of Aging Veterans.

Background: There are significant workforce shortages for geriatric mental health care. The imbalance is particularly pronounced in the Veterans Health Administration (VHA) due to the large number of aging veterans receiving care. Workforce-based educational programs are needed to train existing clinicians to meet the mental health needs of aging veterans. Observations: This article describes an expansion of the Geriatric Scholars Program to train VHA psychologists to care for aging veterans. The multicomponent program includes an introductory course and opportunities to apply geriatric knowledge and skills through quality improvement initiatives. The Geriatric Scholars Program-Psychology Track evolved to incorporate ongoing specialized elective learning opportunities for scholars. A webinar series extends the educational programs to reach the entire VHA workforce. Conclusions: The Geriatric Scholars Program-Psychology Track represents a longitudinal educational approach to training VHA psychologists in clinical geropsychology. Other community-based organizations can use this model to construct and implement similar programs.

Health care workforce development in rural america: when geriatrics expertise is 100 miles away.

The Geriatric Scholar Program (GSP) is a Department of Veterans Affairs' (VA) workforce development program to infuse geriatrics competencies in primary care. This multimodal educational program is targeted to primary care providers and ancillary staff who work in VA's rural clinics. GSP consists of didactic education and training in geriatrics and gerontology and in quality improvement (QI) and support to implement a local QI project; in addition, elective options include webinars, audio conferences, clinical practica, and mentoring. The program is effective in improving core competencies in geriatrics and in improving clinical care for older Veterans who receive health care in rural clinics.

Experiences of Sleep Problems Among Older Korean Immigrants.

Despite poor sleep among older adults, little is known about the sleep habits of older immigrants living in the United States. The current pragmatic qualitative descriptive study explored sleep among older Korean immigrants, using a focus group with six participants and individual phone interviews with 22 Korean immigrants aged ≥60 years. Transcripts were coded to identify underlying themes. Several thematic categories were identified under six domains: daytime function, getting ready for bed, falling asleep, awakenings during sleep, going back to sleep, and seeking advice from peers. Unhealthy sleep behaviors were found during daytime and bedtime, particularly among those who were retired/unemployed or living alone. Seeking advice from peers was common but none of the advice helped participants sleep. Sleep education programs in Korean-speaking communities can be used to target those who are socially isolated and may benefit older Korean immigrants with sleep difficulties. [Research in Gerontological Nursing, 15(4), 193-202.].

Associations of Self-Reported Sleep Quality with Demographic and Other Characteristics in Older Korean Immigrants.

Poor sleep is common among older adults, affecting a wide range of health outcomes. However, little is known about sleep issues among older Korean immigrants, the fastest growing Asian American subgroup in the United States. We aimed to explore multiple factors associated with sleep among this group. We analyzed cross-sectional survey data from 43 older immigrants living in two large Korean communities in Southern California. Perceived sleep quality was significantly associated with gender, living arrangement, employment status, mental health, and sleep-related beliefs (all p-values < 0.05). Living with someone and being employed for wages were significantly uniquely associated with better sleep quality, accounting for demographic and health-related factors (R2 = 51.8%, adjusted R2 = 38.7%, p = 0.002). These findings suggest a potential role of sociocultural factors on sleep. Further studies are needed to confirm these findings and to inform a sleep intervention program tailored to the characteristics of older Korean immigrants.

Developing the VA Geriatric Scholars Programs' Clinical Dashboards Using the PDSA Framework for Quality Improvement.

BACKGROUND: Involving clinician end users in the development process of clinical dashboards is important to ensure that user needs are adequately met prior to releasing the dashboard for use. The challenge with following this approach is that clinician end users can undergo periodic turnover, meaning, the clinicians that played a role in the initial development process may not be the same individuals that use the dashboard in future. OBJECTIVES: Here, we summarize our Plan, Do, Study, Act (PDSA)-guided clinical dashboard development process for the VA Geriatric Scholars Program (GSP) and the value of continuous, iterative development. We summarize dashboard adaptations that resulted from two PDSA cycles of improvement for the potentially inappropriate medication dashboard (PIMD), one of many Geriatric Scholars clinical dashboards. We also present the evaluative performance of the PIMD. METHODS: Evaluation of the PIMD was performed using the system usability scale (SUS) and through review of user interaction logs. Routine end users that were Geriatric Scholars and had evidence of 5 or more dashboard views were invited to complete an electronic form that contained the 10-item SUS. RESULTS: The proportion of Geriatric Scholars that utilized the PIMD increased for each iterative dashboard version that was produced as a byproduct from feedback (31.0% in 2017 to 60.2% in 2019). The overall usability of the PIMD among routine users was found to be above average (SUS score: 75.2 [95% CI 70.5-79.8]) in comparison to the recommended standard of acceptability (SUS score: 68) CONCLUSION: The solicitation of feedback during dashboard orientations led to iterative adaptations of the PIMD that broadened its intended use. The presented PDSA-guided process to clinical dashboard development for the VA GSP can serve as a valuable framework for development teams seeking to produce well-adopted and usable health information technology (IT) innovations.

Do correlates of dual use by American Indian and Alaska Native Veterans operate uniformly across the Veterans Health Administration and the Indian Health Service?

OBJECTIVE: To determine if the combined effects of patient-level (demographic and clinical characteristics) and organizational-level (structure and strategies to improve access) factors are uniformly associated with utilization of Indian Health Service (IHS) and/or Veterans Health Administration (VHA) by American Indian and Alaska Native (AIAN) Veterans to inform policy which promotes dual use. METHODS: We estimated correlates and compared two separate multilevel logistic regression models of VHA-IHS dual versus IHS-only and VHA-IHS dual versus VHA-only in a sample of 18,892 AIAN Veterans receiving care at 201 VHA and IHS facilities during FY02 and FY03. Demographic, diagnostic, eligibility, and utilization data were drawn from administrative records. A survey of VHA and IHS facilities defined availability of services and strategies to enhance access to healthcare for AIAN Veterans. RESULTS: Facility level strategies that are generally associated with enhancing access to healthcare (e.g., population-based services and programs, transportation or co-location) were not significant factors associated with dual use. In both models the common variable of dual use was related to medical need, defined as the number of diagnoses per patient. Other significant demographic, medical need and organizational factors operated in opposing manners. For instance, age increased the likelihood of dual use versus IHS-only but decreased the likelihood of dual use versus VHA-only. CONCLUSIONS: Efforts to enhance access through population-based and consumer-driven strategies may add value but be less important to utilization than availability of healthcare resources needed by this population. Sharing health records and co-management strategies would improve quality of care while policies allow and promote dual use.

Engaging community-based organizations in fall prevention education.

Falls are a major public health problem for older adults, and community-based organizations play a key role in educating seniors about falls prevention (FP). We conducted a qualitative process evaluation at six sites to report community-based centers' perspectives on adoption, adaptation, and sustainability of an evidence-based multifactorial FP model. Wide dissemination of new health-oriented programs requires marketing to center directors, who must consider sustainability options. The diversity and independence of community-based organizations, together with current staffing and funding limitations, suggest that fidelity to multifactorial evidence-based interventions will be difficult to achieve.

Improving Geropsychology Competencies of Veterans Affairs Psychologists.

Older adults are more likely to seek mental health care through integrated care settings such as primary care. Currently, there exists a significant shortage of mental health providers trained in geropsychology and integrated care competencies. To address this need within the Veterans Health Administration, a national workforce development program was extended to include psychologists, which is called the Geriatric Scholars Program-Psychology Track (GSP-P). The GSP-P has two overarching educational program aims: (1) to improve geropsychology competencies of practicing VA psychologists, particularly those working within integrated settings (e.g., primary care) and (2) enrich psychologists' abilities to enact change in their clinical settings. Ninety-eight VA clinicians participated in the GSP-P, which includes a multi-day in-person course, from 2014 to 2018. Participants completed measures assessing confidence and self-reported knowledge in geropsychology and integrated care competencies pre-course and 3-months post-completion. Two-weeks post-course participants responded to open-ended survey questions regarding their perceptions of the course and potential applications of learning. Significant improvements in confidence in and knowledge of geropsychology and integrated care competencies emerged from pre-course to 3-months post-completion. Qualitative findings demonstrated that participants valued the face-to-face, integrated multimodal educational program. Findings provided insights regarding clinicians' planned application of the knowledge acquired, such as modifying treatments for older patients. Specialized workforce programs such as the GSP-P have a significant, positive impact on the care of older Veterans.

Development of a fall prevention survey to determine educational needs for primary care providers.

Quality indicators are standardized measures of health care quality. We designed a survey to assess how knowledge, attitude, and organizational practices might affect healthcare provider behaviors in meeting quality indicators for fall prevention to plan curricula for a continuing educational intervention. The survey was pilot tested in the Veterans Affairs (VA) in a small stratified sample. Some items that had been previously used in assessments for continuing education among community physicians were not well matched to the VA practice environment or to midlevel clinicians, suggesting that instruments need to be adapted for relevance to the health care setting as well as discipline.

Usability Testing a Potentially Inappropriate Medication Dashboard: A Core Component of the Dashboard Development Process.

BACKGROUND: With the increased usage of dashboard reporting systems to monitor and track patient panels by clinical users, developers must ensure that the information displays they produce are accurate and intuitive. When evaluating usability of a clinical dashboard among potential end users, developers oftentimes rely on methods such as questionnaires as opposed to other, more time-intensive strategies that incorporate direct observation. OBJECTIVES: Prior to release of the potentially inappropriate medication (PIM) clinical dashboard, designed to facilitate completion of a quality improvement project by clinician scholars enrolled in the Veterans Affairs (VA) workforce development Geriatric Scholars Program (GSP), we evaluated the usability of the system. This article describes the process of usability testing a dashboard reporting system with clinicians using direct observation and think-aloud moderating techniques. METHODS: We developed a structured interview protocol that combines virtual observation, think-aloud moderating techniques, and retrospective questioning of the overall user experience, including use of the System Usability Scale (SUS). Thematic analysis was used to analyze field notes from the interviews of three GSP alumni. RESULTS: Our structured approach to usability testing identified specific functional problems with the dashboard reporting system that were missed by results from the SUS. Usability testing lead to overall improvements in the intuitive use of the system, increased data transparency, and clarification of the dashboard's purpose. CONCLUSION: Reliance solely on questionnaires and surveys at the end stages of dashboard development can mask potential functional problems that will impede proper usage and lead to misinterpretation of results. A structured approach to usability testing in the developmental phase is an important tool for developers of clinician friendly systems for displaying easily digested information and tracking outcomes for the purpose of quality improvement.

Veterans Health Administration and Indian Health Service: healthcare utilization by Indian Health Service enrollees.

BACKGROUND: The Veterans Health Administration (VHA) and Indian Health Service (IHS) have executed an agreement to share resources to improve access and health outcomes for American Indian and Alaska Native (AIAN) veterans. OBJECTIVES: To describe the extent of dual use, health needs, and utilization patterns for IHS-enrollees served by VHA and IHS. Our objective is to fill those gaps in knowledge to inform strategic planning between these federal agencies. METHODS: Secondary data analysis of linked and merged VHA and IHS centralized administrative data from FY02 and FY03. RESULTS: Of 64,746 IHS enrollees who used VHA and/or IHS, 25% accessed care at both healthcare organizations, whereas most used either the VHA (28%) or the IHS (46%). The proportion of dual users varied markedly by state. Like all other VHA users, these AIAN veterans have the same 3 most frequent diagnoses associated with healthcare encounters: posttraumatic stress disorder, hypertension, and diabetes. VHA-IHS dual users were more likely to receive primary care from IHS and to receive diagnostic and behavioral healthcare from VHA. Many dual users who had been diagnosed with diabetes, hypertension, and/or cardiovascular disease received overlapping attention in VHA and IHS. CONCLUSIONS: Strategies to improve outcomes for AIAN veterans should target those receiving care in both systems and include information sharing or coordination of clinical care to reduce the potential for duplication and for treatment conflicts. Strategies to improve access may differ regionally.

Dual use of veterans health administration and Indian Health Service: healthcare provider and patient perspectives.

BACKGROUND: Many American Indian and Alaska Native veterans are eligible for healthcare from Veterans Health Administration (VHA) and from Indian Health Service (IHS). These organizations executed a Memorandum of Understanding in 2003 to share resources, but little was known about how they collaborated to deliver healthcare. OBJECTIVE: To describe dual use from the stakeholders' perspectives, including incentives that encourage cross-use, which organization's primary care is "primary," and the potential problems and opportunities for care coordination across VHA and IHS. PARTICIPANTS: VHA healthcare staff, IHS healthcare staff and American Indian and Alaska Native veterans. APPROACH: Focus groups were conducted using a semi-structured guide. A software-assisted text analysis was performed using grounded theory to develop analytic categories. MAIN RESULTS: Dual use was driven by variation in institutional resources, leading patients to actively manage health-seeking behaviors and IHS providers to make ad hoc recommendations for veterans to seek care at VHA. IHS was the "primary" primary care for dual users. There was little coordination between VHA and IHS resulting in delays and treatment conflicts, but all stakeholder groups welcomed future collaboration. CONCLUSIONS: Fostering closer alignment between VHA and IHS would reduce care fragmentation and improve accountability for patient care.

Health care for American Indian and Alaska native women.

BACKGROUND: Many American Indian and Alaska Native (AIAN) women serve in the military and are eligible for healthcare from both the Veterans Health Administration (VHA) and the Indian Health Service (IHS). Little was known about these women's patterns of health care utilization when VHA and IHS executed a resource-sharing agreement in 2003 to improve access and health outcomes. OBJECTIVE: We sought to describe women's healthcare utilization in VHA and IHS. METHODS: We conducted a descriptive secondary data analysis of linked IHS and VHA administrative records from fiscal years 2002 and 2003 for women among all IHS beneficiaries who were veterans or used VHA for health care (n = 64,746). RESULTS: Among these IHS beneficiaries, 4,338 (6.7%) were female veterans and 1,518 (2.8%) were female nonveterans. Comparing IHS services to VHA, the VHA provided the majority of outpatient specialty care to veterans, providing 89.9% of diagnostic and imaging services, 84.4% of mental health care, and 78.1% of physical medicine and rehabilitation. Conversely, the IHS provided the majority of ambulatory and inpatient care for obstetrics and gynecology to these veterans. Dual users received primary care from both organizations. Nonveterans generally accessed VHA under sharing agreements and their use of health care was generally limited to outpatient diagnostic and imaging. CONCLUSIONS: The VHA seems to supplement healthcare provided by the IHS for female AIAN veterans, as well as for a small proportion of nonveterans. The VHA and the IHS have developed specialized and complementary expertise, which might be aligned to serve the needs of female AIAN veterans.