How Should We Organize Care for Patients With Human Immunodeficiency Virus and Comorbidities? A Multisite Qualitative Study of Human Immunodeficiency Virus Care in the United States Department of Veterans Affairs.

BACKGROUND: With human immunodeficiency virus (HIV) now managed as a chronic disease, health care has had to change and expand to include management of other critical comorbidities. We sought to understand how variation in the organization, structure and processes of HIV and comorbidity care, based on patient-centered medical home (PCMH) principles, was related to care quality for Veterans with HIV. RESEARCH DESIGN: Qualitative site visits were conducted at a purposive sample of 8 Department of Veterans Affairs Medical Centers, varying in care quality and outcomes for HIV and common comorbidities. Site visits entailed conduct of patient interviews (n=60); HIV care team interviews (n=60); direct observation of clinic processes and team interactions (n=22); and direct observations of patient-provider clinical encounters (n=45). Data were analyzed using a priori and emergent codes, construction of site syntheses and comparing sites with varying levels of quality. RESULTS: Sites highest and lowest in both HIV and comorbidity care quality demonstrated clear differences in provision of PCMH-principled care. The highest site provided greater team-based, comprehensive, patient-centered, and data-driven care and engaged in continuous improvement. Sites with higher HIV care quality attended more to psychosocial needs. Sites that had consistent processes for comorbidity care, whether in HIV or primary care clinics, had higher quality of comorbidity care. CONCLUSIONS: Provision of high-quality HIV care and high-quality co-morbidity care require different care structures and processes. Provision of both requires a focus on providing care aligned with PCMH principles, integrating psychosocial needs into care, and establishing explicit consistent approaches to comorbidity management.

How hospitals select their patient safety priorities: An exploratory study of four Veterans Health Administration hospitals.

BACKGROUND: Hospitals face ongoing pressure to reduce patient safety events. However, given resource constraints, hospitals must prioritize their safety improvements. There is limited literature on how hospitals select their safety priorities. PURPOSE: The aim of this research was to describe and compare the approaches used by Veterans Health Administration (VA) hospitals to select their safety priorities. METHODOLOGY: Semistructured telephone interviews with key informants (n = 16) were used to collect data on safety priorities in four VA hospitals from May to December 2016. We conducted a directed content analysis of the interview notes using an organizational learning perspective. We coded for descriptive data on the approaches (e.g., set of cues, circumstances, and activities) used to select safety priorities, a priori organizational learning capabilities (learning processes, learning environment, and learning-oriented leadership), and emergent domains. For cross-site comparisons, we examined the coded data for patterns. RESULTS: All hospitals used multiple approaches to select their safety priorities; these approaches used varied across hospitals. Although no single approach was reported as particularly influential, all hospitals used approaches that addressed system level or national requirements (i.e., externally required activities). Additional approaches used by hospitals (e.g., responding to staff concerns of patient safety issues, conducting a multidisciplinary team investigation) were less connected to externally required activities and demonstrated organizational learning capabilities in learning processes (e.g., performance monitoring), learning environment (e.g., staff's psychological safety), and learning-oriented leadership (e.g., establishing a nonpunitive culture). PRACTICE IMPLICATIONS: Leaders should examine the approaches used to select safety priorities and the role of organizational learning in these selection approaches. Exclusively relying on approaches focused on externally required activities may fail to identify safety priorities that are locally relevant but not established as significant at the system or national levels. Organizational learning may promote hospitals' use of varied approaches to guide their selection of safety priorities and thereby benefit hospital safety improvement efforts.

Barriers and facilitators to implementing a pragmatic trial to improve advance care planning in the nursing home setting.

BACKGROUND: The PRagmatic trial Of Video Education in Nursing homes (PROVEN) aims to test the effectiveness of an advance care planning (ACP) video intervention. Relatively little is known about the challenges associated with implementing ACP interventions in the nursing home (NH) setting, especially within a pragmatic trial. To address this research gap, this report sought to identify facilitators of and barriers to implementing PROVEN from the perspective of the Champions charged with introducing the ACP video program delivery to patients and families. METHODS: In semi-structured telephone interviews at 4 and 15 months of the 18-month implementation period, ACP Champions at all PROVEN intervention facilities (N = 119) were asked about their perceptions of program implementation. Forty interviews were purposively sampled, transcribed, and analyzed using a hybrid deductive/inductive approach to thematic analysis incorporating the Consolidated Framework for Implementation Research's domains: Intervention Characteristics (IC), Inner Setting (IS), Characteristics of Individuals (CI), Outer Setting (OS), and Process (P). RESULTS: Implementation facilitators identified by Champions included: the intervention's adaptable mode of presentation and minimal time burden (IC) as well as the program's customizable delivery to patients and families and opportunity for group reflection on implementation among ACP Champions (P). Barriers included mandated protocol-driven aspects of the program (OS), limited time to deliver the intervention (IS), and lack of perceived relevance and emotional readiness for ACP amongst stakeholders (CI). CONCLUSIONS: Despite the promise of PROVEN's intervention for improving ACP in nursing homes, unchangeable setting and characteristics of Champions, patients, and family members presented implementation barriers. Researchers need to engage all program participants (i.e., facility staff, patients, and families), in addition to corporate-level stakeholders, in early pragmatic trial design to minimize such obstacles. Further, despite the facilitating nature of PROVEN's implementation processes, the study encountered tension between scientific rigor and real-world demands. Researchers need to optimize the real-world authenticity of pragmatic trial design while avoiding excessive implementation protocol deviations. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02612688. Registered 19 November 2015.

Is Variation in Resident-Centered Care and Quality Performance Related to Health System Factors in Veterans Health Administration Nursing Homes?

The purpose of this research was to explore and compare common health system factors for 5 Community Living Centers (ie Veterans Health Administration nursing homes) with high performance on both resident-centered care and clinical quality and for 5 Community Living Centers (CLC) with low performance on both resident-centered care and quality. In particular, we were interested in "how" and "why" some Community Living Centers were able to deliver high levels of resident-centered care and high quality of care, whereas others did not demonstrate this ability. Sites were identified based on their rankings on a composite quality measure calculated from 28 Minimum Data Set version 2.0 quality indicators and a resident-centered care summary score calculated from 6 domains of the Artifacts of Culture Change Tool. Data were from fiscal years 2009-2012. We selected high- and low-performing sites on quality and resident-centered care and conducted 12 in-person site visits in 2014-2015. We used systematic content analysis to code interview transcripts for a priori and emergent health system factor domains. We then assessed variations in these domains across high and low performers using cross-site summaries and matrixes. Our final sample included 108 staff members at 10 Veterans Health Administration CLCs. Staff members included senior leaders, middle managers, and frontline employees. Of the health system factors identified, high and low performers varied in 5 domains, including leadership support, organizational culture, teamwork and communication, resident-centered care recognition and awards, and resident-centered care training. Organizations must recognize that making improvements in the factors identified in this article will require dedicated resources from leaders and support from staff throughout the organization.

Resident Choice: A Nursing Home Staff Perspective on Tensions and Resolutions.

A central component of person-centered care, resident choice in daily life, has received little research attention in the U.S. CONTEXT: This study investigated nursing home staff experiences in realizing resident choice. Twenty-six qualitative staff interviews were conducted in an opportunistic sample from two Veterans Health Administration (VHA) Community Living Centers (CLCs, i.e., nursing homes) implementing the Green House Model. Thematic content analysis surfaced several key tensions at the intra-personal, inter-personal, and organizational levels. Most salient were staff mental models within the intra-personal level. Staff conveyed a lack of clarity on how to realize resident choice when faced with varying tensions, especially the competing goal of resident medical and safety needs. Staff-employed resolutions to resident choice-related tensions also emerged (e.g., preventive practices, staff reinforcement, and staff deliberation). This study offers specific and concrete insights on how resident choice in daily life, and thus resident quality of life, can be advanced.

Social Network Structures of Breast Cancer Patients and the Contributing Role of Patient Navigators.

BACKGROUND: Minority women in the U.S. continue to experience inferior breast cancer outcomes compared with white women, in part due to delays in care delivery. Emerging cancer care delivery models like patient navigation focus on social barriers, but evidence demonstrating how these models increase social capital is lacking. This pilot study describes the social networks of newly diagnosed breast cancer patients and explores the contributing role of patient navigators. MATERIALS AND METHODS: Twenty-five women completed a one hour interview about their social networks related to cancer care support. Network metrics identified important structural attributes and influential individuals. Bivariate associations between network metrics, type of network, and whether the network included a navigator were measured. Secondary analyses explored associations between network structures and clinical outcomes. RESULTS: We identified three types of networks: kin-based, role and/or affect-based, or heterogeneous. Network metrics did not vary significantly by network type. There was a low prevalence of navigators included in the support networks (25%). Network density scores were significantly higher in those networks without a navigator. Network metrics were not predictive of clinical outcomes in multivariate models. CONCLUSION: Patient navigators were not frequently included in support networks, but provided distinctive types of support. If navigators can identify patients with poorly integrated (less dense) social networks, or who have unmet tangible support needs, the intensity of navigation services could be tailored. Services and systems that address gaps and variations in patient social networks should be explored for their potential to reduce cancer health disparities. IMPLICATIONS FOR PRACTICE: This study used a new method to identify the breadth and strength of social support following a diagnosis of breast cancer, especially examining the role of patient navigators in providing support. While navigators were only included in one quarter of patient support networks, they did provide essential supports to some individuals. Health care providers and systems need to better understand the contributions of social supports both within and outside of health care to design and tailor interventions that seek to reduce health care disparities and improve cancer outcomes.

Patterns of task and network actions performed by navigators to facilitate cancer care.

BACKGROUND: Patient navigation is a widely implemented intervention to facilitate access to care and reduce disparities in cancer care, but the activities of navigators are not well characterized. PURPOSE: The aim of this study is to describe what patient navigators actually do and explore patterns of activity that clarify the roles they perform in facilitating cancer care. METHODOLOGY/APPROACH: We conducted field observations of nine patient navigation programs operating in diverse health settings of the national patient navigation research program, including 34 patient navigators, each observed an average of four times. Trained observers used a structured observation protocol to code as they recorded navigator actions and write qualitative field notes capturing all activities in 15-minute intervals during observations ranging from 2 to 7 hours; yielding a total of 133 observations. Rates of coded activity were analyzed using numerical cluster analysis of identified patterns, informed by qualitative analysis of field notes. FINDINGS: Six distinct patterns of navigator activity were identified, which differed most relative to how much time navigators spent directly interacting with patients and how much time they spent dealing with medical records and documentation tasks. Navigator actions reveal a complex set of roles in which navigators both provide the direct help to patients denoted by their title and also carry out a variety of actions that function to keep the health system operating smoothly. PRACTICE IMPLICATIONS: Working to navigate patients through complex health services entails working to repair the persistent challenges of health services that can render them inhospitable to patients. The organizations that deploy navigators might learn from navigators' efforts and explore alternative approaches, structures, or systems of care in addressing both the barriers patients face and the complex solutions navigators create in helping patients.

Quality improvement for patient safety: project-level versus program-level learning.

BACKGROUND: Improving quality and patient safety is of increasing strategic importance to health care organizations. However, simply increasing the volume of quality improvement (QI) activity does not necessarily improve patient outcomes. There is a need for greater understanding of QI success factors. PURPOSE: This study looked for differences in QI implementation across hospitals with a range of performance on Patient Safety Indicators. METHODS: We conducted an exploratory comparative case study of 4 Veterans Health Administration hospitals including site visits and interviews with leaders and staff. FINDINGS: Two themes emerged. Project-level QI learning is assessing and modifying specific QI projects relative to expectations. Program-level QI learning is assessing and modifying the overall QI endeavor. The nature of project-level QI learning was similar across sites, whereas we identified qualitative differences across organizations in program-level QI learning. The highest performing organization was evaluating and refining its overall approach to QI, whereas the others were learning how to build and control QI programs. PRACTICE IMPLICATIONS: Program-level QI learning may be key if a QI program is to succeed in improving patient outcomes. This type of organizational learning entails a big-picture, organization-wide view of QI. It also entails second-order organizational learning based on assessment not only of whether QI is being done correctly but also whether the right QI activities are being done, for the right reasons. The organization is "learning to learn." In addition to gaining mastery and control of QI, leaders regularly engage with staff in rethinking QI and experimenting with new approaches. Leaders also assess how QI activity fits in the organization's developmental journey and how it supports realization of strategy.

Strengthening organizations to implement evidence-based clinical practices.

OBJECTIVES: Despite recognition that implementation of evidence-based clinical practices (EBPs) usually depends on the structure and processes of the larger health care organizational context, the dynamics of implementation are not well understood. This project's aim was to deepen that understanding by implementing and evaluating an organizational model hypothesized to strengthen the ability of health care organizations to facilitate EBPs. CONCEPTUAL MODEL: The model posits that implementation of EBPs will be enhanced through the presence of three interacting components: active leadership commitment to quality, robust clinical process redesign incorporating EBPs into routine operations, and use of management structures and processes to support and align redesign. STUDY DESIGN: In a mixed-methods longitudinal comparative case study design, seven medical centers in one network in the Department of Veterans Affairs participated in an intervention to implement the organizational model over 3 years. The network was selected randomly from three interested in using the model. The target EBP was hand-hygiene compliance. Measures included ratings of implementation fidelity, observed hand-hygiene compliance, and factors affecting model implementation drawn from interviews. FINDINGS: Analyses support the hypothesis that greater fidelity to the organizational model was associated with higher compliance with hand-hygiene guidelines. High-fidelity sites showed larger effect sizes for improvement in hand-hygiene compliance than lower-fidelity sites. Adherence to the organizational model was in turn affected by factors in three categories: urgency to improve, organizational environment, and improvement climate. IMPLICATIONS: Implementation of EBPs, particularly those that cut across multiple processes of care, is a complex process with many possibilities for failure. The results provide the basis for a refined understanding of relationships among components of the organizational model and factors in the organizational context affecting them. This understanding suggests practical lessons for future implementation efforts and contributes to theoretical understanding of the dynamics of the implementation of EBPs.

Association Between Ambulatory Care Utilization and Coronary Artery Disease Outcomes by Race/Ethnicity.

Background Coronary artery disease is common, and there exist disparities in management and outcomes. The purpose of this study is to examine the association between ambulatory care utilizations and inpatient acute myocardial infarction (AMI) mortality. Methods and Results This is a retrospective analysis of a stratified national sample of Medicare fee-for-service enrollees aged 66 years and older from January 1, 2010 to December 31, 2011. We measured both number of ambulatory visits and presence of ambulatory cardiac tests. The primary outcome was inpatient AMI mortality. Using multivariate logistic regression models, we estimated the association between ambulatory care utilization and the main patient outcomes, adjusting for patient- and area-level demographic, geographical, and clinical characteristics. We found that a significantly lower percentage of Hispanics and Asians, relative to whites, had frequent ambulatory care visits. Among the largest 4 race/ethnic groups, Asians had the highest observed inpatient mortality rate (15.9%). Overall, low ambulatory utilization was associated with higher odds (odds ratio=1.85 [95% confidence interval: 1.11-3.08]), and ambulatory cardiac testing was associated with lower odds (odds ratio=0.73 [0.55-0.95]) of inpatient AMI mortality, after adjustment for covariates. Asians had higher odds of inpatient AMI mortality even after adjustment for covariates. Conclusions Among Medicare fee-for-service enrollees, Hispanics and Asians had lower rates of ambulatory care visits, and all minority groups had higher odds of hospitalization for AMI. Ambulatory care utilization, including both ambulatory clinic visits and outpatient cardiac tests, were associated with AMI mortality. Further research is needed to understand the causal relationship between ambulatory care utilization and cardiovascular outcomes.

Exploring Explanatory Models of Risk in Breast Cancer Risk Counseling Discussions: NSABP/NRG Oncology Decision-Making Project 1.

BACKGROUND: Explanatory models represent patient understanding of etiology, pathophysiology, illness, symptoms, and treatments, but little attention has been paid to how they are used by patients "at risk" for future disease. OBJECTIVE: The aims of this study were to elucidate what constitutes an explanatory model of risk and to describe explanatory models of risk related to developing breast cancer. METHODS: Thirty qualitative interviews with women identified as at an increased risk for breast cancer were conducted. Interviews were coded to identify domains of explanatory models of risk using a priori codes derived from the explanatory model of illness framework. Within each domain, a grounded thematic analysis described participants' explanatory models related to breast cancer risk. RESULTS: The domains of treatment and etiology remained similar in a risk context compared with illness, whereas course of illness, symptoms, and pathophysiology differed. We identified a new, integrative concept relative to other domains within explanatory models of risk: social comparisons, which was dominant in risk perhaps due to the lack of physical experiences associated with being "at risk." CONCLUSIONS: Developing inclusive understandings of risk and its treatment is key to developing a framework for the care of high-risk patients that is both evidence based and sensitive to patient preferences. IMPLICATIONS FOR PRACTICE: The concept of "social comparisons" can assist healthcare providers in understanding women's decision making under conditions of risk. Ensuring that healthcare providers understand patient perceptions of risk is important because it relates to patient decision making, particularly due to an increasing focus on risk assessment in cancer.

Collaborative capacity and patient-centered care in the Veterans' Health Administration Community Living Centers.

INTRODUCTION: Previous research in acute care settings has shown that collaborative capacity, defined as the way providers collaborate as equal team members, can be improved by the ways in which an organization supports its staff and teams. This observational cross-sectional study examines the association between collaborative capacity and supportive organizational context, supervisory support, and person-centered care in nursing homes to determine if similar relationships exist. METHODS: We adapted the Care Coordination Survey for nursing homes and administered it to clinical staff in 20 VA Community Living Centers. We used random effects models to examine the associations between supportive organizational context, supervisory support, and person-centered care with collaborative capacity outcomes including quality of staff interactions, task independence, and collaborative influence. RESULTS: A total of 723 Community Living Center clinical staff participated in the Care Coordination Survey resulting in a response rate of 29%. We found that teamwork and collaboration-measured as task interdependence, quality of interactions and collaborative influence-did not differ significantly between Community Living Centers but did differ significantly across occupational groups. Moreover, staff members' experiences of teamwork and collaboration were positively associated with supportive organizational context and person-centered care. DISCUSSION: Our findings suggest that elements of organizational context are important to facilitating collaborative capacity. Additionally, investing in staffing, rewards, and person-centered care may improve teamwork.

Understanding implementation fidelity in a pragmatic randomized clinical trial in the nursing home setting:a mixed-methods examination.

BACKGROUND: The Pragmatic Trial of Video Education in Nursing Homes (PROVEN) is one of the first large pragmatic randomized clinical trials (pRCTs) to be conducted in U.S. nursing homes (N = 119 intervention and N = 241 control across two health-care systems). The trial aims to evaluate the effectiveness of a suite of videos to improve advance care planning (ACP) for nursing home patients. This report uses mixed methods to explore the optimal and suboptimal conditions necessary for implementation fidelity within pRCTs in nursing homes. METHODS: PROVEN's protocol required designated facility champions to offer an ACP video to long-stay patients every 6 months during the 18-month implementation period. Champions completed a video status report, stored within electronic medical records, each time a video was offered. Data from the report were used to derive each facility's adherence rate (i.e., cumulative video offer). Qualitative interviews held after 15 months with champions were purposively sampled from facilities within the highest and lowest adherence rates (i.e., those in the top and bottom quintiles). Two researchers analyzed interview data thematically using a deductive approach based upon six domains of the revised Conceptual Framework for Implementation Fidelity (CFIF). Matrices were developed to compare coded narratives by domain across facility adherence status. RESULTS: In total, 28 interviews involving 33 champions were analyzed. Different patterns were observed across high- versus low-adherence facilities for five CFIF domains. In low-adherence nursing homes, (1) there were limited implementation resources (Context), (2) there was often a perceived negative patient or family responsiveness to the program (Participant Responsiveness), and (3) champions were reticent in offering the videos (Recruitment). In high-adherence nursing homes, (1) there was more perceived patient and family willingness to engage in the program (Participant Responsiveness), (2) champions supplemented the video with ACP conversations (Quality of Delivery), (3) there were strategic approaches to recruitment (Recruitment), and (4) champions appreciated external facilitation (Strategies to Facilitate Implementation). CONCLUSIONS: Critical lessons for implementing pRCTs in nursing homes emerged from this report: (1) flexible fidelity is important (i.e., delivering core elements of an intervention while permitting the adaptation of non-core elements), (2) reciprocal facilitation is vital (i.e., early and ongoing stakeholder engagement in research design and, reciprocally, researchers' and organizational leaders' ongoing support of the implementation), and (3) organizational and champion readiness should be formally assessed early and throughout implementation to facilitate remediation. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02612688. Registered on 19 November 2015.

Understanding Decision Making about Breast Cancer Prevention in Action: The Intersection of Perceived Risk, Perceived Control, and Social Context: NRG Oncology/NSABP DMP-1.

BACKGROUND: Literature on decision making about breast cancer prevention focuses on individual perceptions and attitudes that predict chemoprevention use, rather than the process by which women decide whether to take risk-reducing medications. This secondary analysis aimed to understand how women's perceptions of breast cancer risk and locus of control influence their decision making. METHODS: Women were accrued as part of the NRG Oncology/National Surgical Adjuvant Breast and Bowel Project Decision-Making Project 1, a study aimed at understanding contributors to chemoprevention uptake. Thirty women participated in qualitative in-depth interviews after being counseled about chemoprevention. Deductive codes grouped women based on dimensions of risk perception and locus of control. We used a constant comparative method to make connections among inductive themes focused on decision making, deductive codes for perceived risk and perceived locus of control, and the influence of explanatory models within and across participants. RESULTS: Participants were predominantly non-Hispanic white (63%), with an average age of 50.9 years. Decision making varied across groups: the high-perceived risk/high-perceived control group used "social evidence" to model the behaviors of others. High-perceived risk/low-perceived control women made decisions based on beliefs about treatment, rooted in the experiences of social contacts. The low-perceived risk/low-perceived control group interpreted signs of risk as part of the normal continuum of bodily changes in comparison to others. Low-perceived risk/high-perceived control women focused on maintaining a current healthy trajectory. CONCLUSION: "Social evidence" plays an important role in the decision-making process that is distinct from emotional aspects. Attending to patients' perceptions of risk and control in conjunction with social context is key to caring for patients at high risk in a way that is evidence based and sensitive to patient preferences.

Communication between nurse care managers and patients who take opioids for chronic pain: Strategies for exploring aberrant behavior.

OBJECTIVE: One approach to potential misuse of prescription opioids by patients with chronic pain is team-based collaborative primary care, with primary care visits complemented by frequent visits with nurse care managers (NCMs) specializing in addiction care. However, little is known about the communication strategies NCMs employ in these visits. This study aimed to describe strategies NCMs used with patients when discussing aberrancies encountered during opioid monitoring. DESIGN: Observational study of NCM-patient interactions. Patients' primary care providers had been randomized to the treatment arm of a study evaluating an intervention, of which NCM visits were part, to change opioid prescribing patterns. The overall intervention was found to be successful. SETTING: Four primary care settings. PARTICIPANTS: Two NCMs and 41 patients. MAIN OUTCOME MEASURE: Forty one interactions between two NCMs and 41 unique patients were directly observed, and the detailed field notes coded for strategies using conventional content analysis. RESULTS: Five themes describing strategies that NCMs use to navigate aberrant patient behavior emerged: (1) NCM develops therapeutic relationship with patient; (2) NCM encourages adherence to monitoring strategies by contextualizing intensive opioid management for patient; (3) NCM inquires into discrepancies between patient's narrative and objective data to further understand aberrancy; (4) NCM assesses patient's medication use and pain to obtain more information about aberrancy and determine risk for opioid misuse; and (5) NCM educates patient and makes recommendations to guide appropriate medication use. CONCLUSIONS: These findings provide a potential model for the replication of intensive care management strategies utilizing NCMs in primary care.

The moral discourse of HIV providers within their organizational context: An ethnographic case study.

OBJECTIVE: Providers make judgments to inform treatment planning, especially when adherence is crucial, as in HIV. We examined the extent these judgments may become intertwined with moral ones, extraneous to patient care, and how these in turn are situated within specific organizational contexts. METHODS: Our ethnographic case study included interviews and observations. Data were analyzed for linguistic markers indexing how providers conceptualized patients and clinic organizational structures and processes. RESULTS: We interviewed 30 providers, observed 43 clinical encounters, and recorded fieldnotes of 30 clinic observations, across 8 geographically-diverse HIV clinics. We found variation, and identified two distinct judgment paradigms: 1) Behavior as individual responsibility: patients were characterized as "good," "behaving," or "socio-paths," and "flakes." Clinical encounters focused on medication reconciliation; 2) Behaviors as socio-culturally embedded: patients were characterized as struggling with housing, work, or relationships. Encounters broadened to problem-solving within patients' life-contexts. In sites with individualized conceptualizations, providers worked independently with limited support services. Sites with socio-culturally embedded conceptualizations had multidisciplinary teams with resources to address patients' life challenges. CONCLUSIONS AND PRACTICE IMPLICATIONS: When self-management is viewed as an individual's responsibility, nonadherence may be seen as a moral failing. Multidisciplinary teams may foster perceptions of patients' behaviors as socially embedded.

What Makes Patient Navigation Most Effective: Defining Useful Tasks and Networks.

Given the momentum in adopting patient navigation into cancer care, there is a need to understand the contribution of specific navigator activities to improved clinical outcomes. A mixed-methods study combined direct observations of patient navigators within the Patient Navigation Research Program and outcome data from the trial. We correlated the frequency of navigator tasks with the outcome of rate of diagnostic resolution within 365 days among patients who received the intervention relative to controls. A focused content analysis examined those tasks with the strongest correlations between navigator tasks and patient outcomes. Navigating directly with specific patients (r = 0.679), working with clinical providers to facilitate patient care (r = 0.643), and performing tasks not directly related to their diagnostic evaluation for patients were positively associated with more timely diagnosis (r = 0.714). Using medical records for non-navigation tasks had a negative association (r = -0.643). Content analysis revealed service provision directed at specific patients improved care while systems-focused activities did not.

Developing the Supporting Choice Observational Tool (SCOT): A Formative Assessment Tool to Assist Nursing Home Staff in Realizing Resident Choice.

Quality of care in nursing homes has begun to address the importance of resident choice in daily life, yet there are no published tools to teach nursing home staff how to offer such choice. In the current study, a formative assessment tool was developed that can provide staff with detailed and concrete feedback on how to realize resident choice. The tool was created and refined through 22 hours of ethnographic observation in two Veterans Health Administration Community Living Centers (CLCs), 22 hours of developmental testing in two CLCs, review by a modified Delphi panel, and use of an algorithm to assess its logical structure. The resulting Supporting Choice Observational Tool (SCOT) documents how choice is or is not offered and is or is not enabled within a singular staff-resident interaction. SCOT findings could be used in clinical teaching, quality improvement, or research efforts intent on enhancing nursing home resident quality of life. [Res Gerontol Nurs. 2017; 10(3):129-138.].

Identifying barriers to culture change: A qualitative analysis of the obstacles to delivering resident-centered care.

A growing number of healthcare organizations have moved from traditional, institutional nursing home models to ones that emphasize culture change, or resident-centered care (RCC). In 2006, the Department of Veterans Affairs (VA) began implementing a number of changes to VA nursing homes, now called Community Living Centers (CLCs), to provide veterans with a more resident-centered and homelike environment. This study aimed to understand the barriers CLC staff face when delivering RCC. Ten CLCs were included on the basis of their performance levels on RCC and quality of care. Semistructured interviews that focused on facility efforts in RCC and quality were conducted with all levels of staff. Interviews were systematically content coded. We found similarities and differences in barriers reported at high- and low-performing sites. Staff across all performance levels cited 5 main categories of barriers to delivering RCC: staffing, resources, acuity of residents, RCC and quality of care conflicts, and regulations. Staff in high-performing sites reported fewer barriers to RCC, although 1 barrier cited was difficulty coordinating RCC across departments. Staff in low-performing sites reported additional categories of barriers related to administrator turnover/lack of guidance, CLC culture/staff morale, and difficulty working with residents and families. As RCC continues to spread, it is important to anticipate the barriers to implementing these practices. Particular focus on regulatory, leadership, organizational, workforce, and process factors may help organizations avoid or reduce barriers to RCC. Given their training and skill set, mental health providers may be uniquely situated to assist staff in overcoming these barriers. (PsycINFO Database Record