"What We're Doing Now Is More Than Water Cooler": Perspectives of Primary Care Leaders on Leading Through (and Beyond) COVID-19.

BACKGROUND: COVID-19 presented numerous challenges to primary care, but little formal research has explored the experience of practice leaders and their strategies for managing teams as the crisis unfolded. OBJECTIVE: Describe the experience of leaders in US primary care delivery organizations, and their strategies for leading teams during COVID-19 and beyond. DESIGN: Qualitative study using semi-structured interviews performed between 9/15/2020 and 8/31/2021. PARTICIPANTS: Purposive sample of 17 clinical leaders in a range of US primary care organizations. APPROACH: An iterative grounded review of interview transcripts was performed, followed by immersion/crystallization analysis. KEY RESULTS: Early in the pandemic, practice leaders reported facing rapid change and the need for constant decision-making, amidst an environment of stress, fear, and uncertainty, but this was buffered by a strong sense of purpose. Later, leaders noted the emergence of layered crises, and evolving challenges including fatigue, burnout, and strained relationships within their organizations and with the communities they serve. Leaders described four interrelated strategies for supporting their teams: (1) Being intentionally present, physically and emotionally; (2) Frequent and transparent communication; (3) Deepening and broadening relationships; (4) Increasing adaptive decision-making, alternating between formal hierarchical and flexible participatory processes. These strategies were influenced by individual leaders' perceived autonomy, which was impacted by the leader's specific role, and organizational size, complexity, and funding model. CONCLUSIONS: As the burnout and workforce crises have accelerated, the identified strategies can be useful to leaders to support teams and build organizational resilience in primary care moving forward.

Early Impact of VA MISSION Act Implementation on Primary Care Appointment Wait Time.

BACKGROUND: Through Community Care Networks (CCNs) implemented with the VA MISSION Act, VA expanded provider contracting and instituted network adequacy standards for Veterans' community care. OBJECTIVE: To determine whether early CCN implementation impacted community primary care (PC) appointment wait times overall, and by rural/urban and PC shortage area (HPSA) status. DESIGN: Using VA administrative data from February 2019 through February 2020 and a difference-in-differences approach, we compared wait times before and after CCN implementation for appointments scheduled by VA facilities that did (CCN appointments) and did not (comparison appointments) implement CCNs. We ran regression models with all appointments, and stratified by rural/urban and PC HPSA status. All models adjusted for Veteran characteristics and VA facility-level clustering. APPOINTMENTS: 13,720 CCN and 40,638 comparison appointments. MAIN MEASURES: Wait time, measured as number of days from authorization to use community PC to a Veteran's first corresponding appointment. KEY RESULTS: Overall, unadjusted wait times increased by 35.7 days ([34.4, 37.1] 95% CI) after CCN implementation. In adjusted analysis, comparison wait times increased on average 33.7 days ([26.3, 41.2] 95% CI, p < 0.001) after CCN implementation; there was no significant difference for CCN wait times (across-group mean difference: 5.4 days, [-3.8, 14.6] 95% CI, p = 0.25). In stratified analyses, comparison wait time increases ranged from 29.6 days ([20.8, 38.4] 95% CI, p < 0.001) to 42.1 days ([32.9, 51.3] 95% CI, p > 0.001) after CCN implementation, while additional differences for CCN appointments ranged from 13.4 days ([3.5, 23.4] 95% CI, p = 0.008) to -15.1 days ([-30.1, -0.1] 95% CI, p = 0.05) for urban and PC HPSA appointments, respectively. CONCLUSIONS: After early CCN implementation, community PC wait times increased sharply at VA facilities that did and did not implement CCNs, regardless of rural/urban or PC HPSA status, suggesting community care demand likely overwhelmed VA resources such that CCNs had limited impact.

Caring for high-need patients.

OBJECTIVE: We aimed to explore the construct of "high need" and identify common need domains among high-need patients, their care professionals, and healthcare organizations; and to describe the interventions that health care systems use to address these needs, including exploring the potential unintended consequences of interventions. METHODS: We conducted a modified Delphi panel informed by an environmental scan. Expert stakeholders included patients, interdisciplinary healthcare practitioners (physicians, social workers, peer navigators), implementation scientists, and policy makers. The environmental scan used a rapid literature review and semi-structured interviews with key informants who provide healthcare for high-need patients. We convened a day-long virtual panel meeting, preceded and followed by online surveys to establish consensus. RESULTS: The environmental scan identified 46 systematic reviews on high-need patients, 19 empirical studies documenting needs, 14 intervention taxonomies, and 9 studies providing construct validity for the concept "high need." Panelists explored the construct and terminology and established that individual patients' needs are unique, but areas of commonality exist across all high-need patients. Panelists agreed on 11 domains describing patient (e.g., social circumstances), 5 care professional (e.g., communication), and 8 organizational (e.g., staffing arrangements) needs. Panelists developed a taxonomy of interventions with 15 categories (e.g., care navigation, care coordination, identification and monitoring) directed at patients, care professionals, or the organization. The project identified potentially unintended consequences of interventions for high-need patients, including high costs incurred for patients, increased time and effort for care professionals, and identification of needs without resources to respond appropriately. CONCLUSIONS: Care for high-need patients requires a thoughtful approach; differentiating need domains provides multiple entry points for interventions directed at patients, care professionals, and organizations. Implementation efforts should consider outlined intended and unintended downstream effects on patients, care professionals, and organizations.

"The SUMMIT Team is All I Got": perspectives of medically and socially complex patients seen in intensive primary care.

Context: There is great interest in intensive primary care (IPC) interventions to address the needs of medically and socially complex patients, however it is unknown how these interventions impact patient experience. Objective: Describe the experience of patients on the Streamlined Unified Meaningfully Managed Interdisciplinary Team (SUMMIT), an IPC for patients with complex needs at a federally qualified health center serving patients with high rates of homelessness. Study Design: Qualitative study using semi-structured interviews with 25 patients enrolled in the SUMMIT intervention. We conducted a thematic analysis using a hybrid inductive/deductive approach. Results: Prior to SUMMIT, patients often felt it was difficult to engage with the healthcare system, in part due to their complex medical conditions, but also factors including prior trauma, poverty, substance use, and providers' stigma. We identified four themes related to how and why patients felt SUMMIT improved their care: 1) Investment: Patients perceived the team as truly invested in them and expressed how the team walked side by side in their care journeys to overcome stigma, low-self efficacy, and prior negative experiences with the healthcare system 2) Family: Patients reported feeling a strong sense of family with SUMMIT team members and believed that the team had genuine duty and obligation toward them, interacting with them in a non-judgmental, culturally competent manner. 3) Feeling valued: Patients expressed that the team's flexible design, continuity of team membership, care coordination and addressing unmet needs and social determinants led them to feel valued and hope. 4) Evolution of self-efficacy: Patients experienced improved self-efficacy, and were able to engage with health care proactively, instead of avoiding care. Conclusion: Medically and socially complex patients experience trauma and stigma that shape perceptions of care. Patients appreciated humanizing interactions with team members along with the additional support SUMMIT provided to overcome barriers to care. They spoke of the team as family members who valued them and they recognized how the program had helped them take a more active role in improving their own health. Our findings suggest that effectiveness of IPC interventions may lie, in part, on the use of team members who have the skills and commitment to deliver non-judgemental, culturally competent, longitudinal relationship-focused care.

Hospital Readmissions Among Veterans Within 90 Days of Discharge Following Initial Hospitalization for COVID-19.

INTRODUCTION: Some patients experience ongoing sequelae after discharge, including rehospitalization; therefore, outcomes following COVID-19 hospitalization are of continued interest. We examined readmissions within 90 days of hospital discharge for veterans hospitalized with COVID-19 during the first 10 months of the pandemic in the US. METHODS: Veterans hospitalized with COVID-19 at a Veterans Health Administration (VA) hospital from March 1, 2020, through December 31, 2020 were followed for 90 days after discharge to determine readmission rates. RESULTS: Of 20,414 veterans hospitalized with COVID-19 during this time period, 13% (n = 2,643) died in the hospital. Among survivors (n = 17,771), 16% (n = 2,764) were readmitted within 90 days of discharge, with a mean time to readmission of 21.6 days (SD = 21.1). Characteristics of the initial COVID-19 hospitalization associated with readmission included length of stay, mechanical ventilator use, higher comorbidity index score, current smoking, urban residence, discharged against medical advice, and hospitalized from September through December 2020 versus March through August 2020 (all P values <.02). Veterans readmitted from September through December 2020 were more often White, lived in a rural or highly rural area, and had shorter initial hospitalizations than veterans hospitalized earlier in the year. CONCLUSION: Approximately 1 of 6 veterans discharged alive following a COVID-19 hospitalization from March 1 through December 31, 2020, were readmitted within 90 days. The longer the hospital stay, the greater the likelihood of readmission. Readmissions also were more likely when the initial admission required mechanical ventilation, or when the veteran had multiple comorbidities, smoked, or lived in an urban area. COVID-19 hospitalizations were shorter from September through December 2020, suggesting that hospital over-capacity may have resulted in earlier discharges and increased readmissions. Efforts to monitor and provide support for patients discharged in high bed-capacity situations may help avoid readmissions.

Balancing the benefits of patient-clinician relationships with professional boundaries in Home-based Primary Care.

In the home care setting, boundaries may be difficult to identify when behavioral changes are made to accommodate the nature of care being delivered. In this secondary qualitative study, we examined how Home-based Primary Care (HBPC) clinicians understand role and relationship boundaries with patients and how these dynamics support patient care. The data set consisted of 14 semi-structured interviews with HBPC clinicians representing multiple disciplines and field observations of 6 HBPC team meetings. Using a directed approach to content analysis, we identified and described how HBPC clinicians worked to build relationships with patients, experienced challenges with emotional attachment, and negotiated boundaries in the patient-clinician relationship. Our findings illustrate how the home care setting is a site for which strong, therapeutic patient-clinician relationships can be developed while also highlighting the work that clinicians must do to balance addressing patient needs stemming from social isolation and adherence to their own professional boundaries.

Increased Urinary IgA in Paediatric IgA Vasculitis Nephritis.

IgA vasculitis (IgAV) is the most common form of paediatric vasculitis, with up to 50% of patients experiencing kidney inflammation. Much remains unknown about IgAV, but it is believed to arise due to galactose-deficient IgA1 promoting an auto-inflammatory response. This study assesses whether urinary IgA can be detected in children with IgAV to allow further evaluation of IgA1 and whether it has any relationship with nephritis. Urinary and serum IgA concentrations were measured using commercially available ELISA kits. Patients were grouped into IgAV nephritis (IgAVN) or IgAV without nephritis (IgAVwoN). Fifty-nine children were included: IgAVN n = 12, IgAVwoN n = 35, and healthy controls (HC) n = 12, with a mean age of 8.2 ± 4.1 years. Urinary IgA concentrations were statistically significantly higher in patients with IgAV (107.1 ± 136.3 µg/mmol) compared to HC (50.6 ± 26.3 µg/mmol; p = 0.027) and IgAVN (229.8 ± 226.3 µg/mmol) compared to both IgAVwoN (65.0 ± 37.8 µg/mmol; p = 0.002) and HC (p < 0.001). Urinary IgA concentrations were able to distinguish between renal status (AUC 0.838, 95%CI [0.704−0.973], p < 0.001) and did not correlate with proteinuria (r = 0.124; p = 0.407). Urinary IgA concentrations are increased in children with IgAVN, and it has the potential to act as a non-invasive biofluid to further evaluate nephritis in this disease.

Veterans' Use of Veterans Health Administration Primary Care in an Era of Expanding Choice.

BACKGROUND: The Veterans Choice Program (VCP), aimed at improving access to care, included expanded options for Veterans to receive primary care through community providers. OBJECTIVES: The objective of this study was to characterize and compare Veterans use of Veterans Health Administration (VA) primary care services at VA facilities and through a VA community care network (VA-CCN) provider. RESEARCH DESIGN: This was a retrospective, observational over fiscal years (FY) 2015-2018. SUBJECTS: Veterans receiving primary care services paid for by the VA. MEASURES: Veteran demographic, socioeconomic and clinical factors and use of VA primary care services under the VCP each year. RESULTS: There were 6.3 million Veterans with >54 million VA primary care visits, predominantly (98.5% of visits) at VA facility. The proportion of VA-CCN visits increased in absolute terms from 0.7% in 2015 to 2.6% in 2018. Among Veterans with any VA-CCN primary care, the proportion of VA-CCN visits increased from 22.6% to 55.3%. Logistic regression indicated that Veterans who were female, lived in rural areas, had a driving distance >40 miles, had health insurance or had a psychiatric/depression condition were more likely to receive VA-CCN primary care. Veterans who were older, identified as Black race, required to pay VA copayments, or had a higher Nosos score, were less likely to receive VA-CCN primary care. CONCLUSION: As the VA transitions from the VCP to MISSION and VA facilities gain experience under the new contracts, attention to factors that impact Veterans' use of primary care services in different settings are important to monitor to identify access barriers and to ensure Veterans' health care needs are met.

"Eyes in the Home": Addressing Social Complexity in Veterans Affairs Home-Based Primary Care.

BACKGROUND: Home-Based Primary Care (HBPC) has demonstrated success in decreasing risk of hospitalization and improving patient satisfaction through patient targeting and integrating long-term services and supports. Less is known about how HBPC teams approach social factors. OBJECTIVE: Describe HBPC providers' knowledge of social complexity among HBPC patients and how this knowledge impacts care delivery. DESIGN, SETTING, AND PARTICIPANTS: Between 2018 and 2019, we conducted in-person semi-structured interviews with 14 HBPC providers representing nursing, medicine, physical therapy, pharmacy, and psychology, at an urban Veterans Affairs (VA) medical center. We also conducted field observations of 6 HBPC team meetings and 2 home visits. APPROACH: We employed an exploratory, content-driven approach to qualitative data analysis. RESULTS: Four thematic categories were identified: (1) HBPC patients are socially isolated and have multiple layers of medical and social complexity that compromise their ability to use clinic-based care; (2) providers having "eyes in the home" yields essential information not accessible in outpatient clinics; (3) HBPC fills gaps in instrumental support, many of which are not medical; and (4) addressing social complexity requires a flexible care design that HBPC provides. CONCLUSION AND RELEVANCE: HBPC providers emphasized the importance of having "eyes in the home" to observe and address the care needs of homebound Veterans who are older, socially isolated, and have functional limitations. Patient selection criteria and discharge recommendations for a resource-intensive program like VA HBPC should include considerations for the compounding effects of medical and social complexity. Additionally, staffing that provides resources for these effects should be integrated into HBPC programming.

Integrating Interprofessional Trainees into a Complex Care Program for Veterans Experiencing Homelessness: Effects on Health Services Utilization.

PURPOSE: High-quality, comprehensive care of vulnerable populations requires interprofessional ambulatory care teams skilled in addressing complex social, medical, and psychological needs. Training health professionals in interprofessional settings is crucial for building a competent future workforce. The impacts on care utilization of adding continuity trainees to ambulatory teams serving vulnerable populations have not been described. We aim to understand how the addition of interprofessional trainees to an ambulatory clinic caring for Veterans experiencing homelessness impacts medical and mental health services utilization. METHODS: Trainees from five professions were incorporated into an interprofessional ambulatory clinic for Veterans experiencing homelessness starting in July 2016. We performed clinic-level interrupted time series (ITS) analyses of pre- and post-intervention utilization measures among patients enrolled in this training continuity clinic, compared to three similar VA homeless clinics without training programs from October 2015 to September 2018. RESULTS: Our sample consisted of 37,671 patient- months. There was no significant difference between the intervention and comparison groups' post-intervention slopes for numbers of primary care visits (difference in slopes =-0.16 visits/100 patients/month; 95% CI -0.40, 0.08; p=0.19), emergency department visits (difference in slopes = 0.08 visits/100 patients/month; 95% CI -0.16, 0.32; p=0.50), mental health visits (difference in slopes = -1.37 visits/month; 95% CI -2.95, 0.20; p= 0.09), and psychiatric hospitalizations (-0.005 admissions/100 patients/month; 95% CI -0.02, 0.01; p= 0.62). We found a clinically insignificant change in medical hospitalizations. CONCLUSIONS: Adding continuity trainees from five health professions to an interprofessional ambulatory clinic caring for Veterans experiencing homelessness did not adversely impact inpatient and outpatient care utilization. An organized team-based care approach is beneficial for vulnerable patients and provides a meaningful educational experience for interprofessional trainees by building health professionals' capabilities to care for vulnerable populations.