Learning from women veterans who navigate invisible injuries, caregiving, and reintegration challenges.

BACKGROUND: As women comprise a greater proportion of military service members, there is growing recognition of how their experiences in the early phase of military to civilian transitions have an important influence on their health and reintegration outcomes. Qualitative accounts of women veterans can inform programs that support transitioning service members. OBJECTIVES: We examined narratives of civilian reintegration among women veterans to understand their experiences of adjusting to community life while coping with mental health challenges. METHODS/PARTICIPANTS: We interviewed 16 post-911 era women who were within 5 years of separating from military service and developed a case study based on three participants. MAIN APPROACH: Interviews were audio-recorded and transcribed verbatim. Inductive thematic analysis was conducted to establish categories about reintegration. Immersion/crystallization techniques were used to identify exemplary cases that illustrated salient themes. KEY RESULTS: Women veterans identified establishing a future career direction, drawing on social support, and navigating health care services as major factors influencing how they adjusted to civilian life. In addition, participants also highlighted the navigation of complex and intersecting identities (i.e., wife, mother, employee, friend, veteran, patient, etc.), further magnified by gender inequalities. These women performed emotional labor, which is often rendered invisible and oriented toward their family and loved ones, while simultaneously monitoring self-care activities. During the early period of reintegration, they described how they felt marginalized in terms of accessing healthcare compared to their military spouses and male veteran peers. CONCLUSIONS: Our case study suggests that there are key gaps in addressing healthcare and readjustment needs for women servicemembers, a high priority VA group, as they transition into post-military life. It is important to consider innovative ways to address specific needs of women in veteran-focused policies and programs.

A developmental formative evaluation of a pilot participatory music program for veterans with housing insecurity.

BACKGROUND: Interventions are needed to improve well-being and promote community reintegration among Veterans with housing insecurity. The objective was to conduct a developmental formative evaluation of a participatory music program. METHODS: This single-site, pilot study implemented a participatory music program at a U.S. Department of Veterans Affairs (VA) Homeless Domiciliary that included one-hour sessions (group music instruction and ensemble playing), 3 times per week for 3 months. Intervention development was guided by the Model of Human Occupation (MOHO). Evaluation was guided by the MOHO and the Consolidated Framework for Implementation Evaluation (CFIR). Qualitative data were collected via semi-structured interviews from participants and non-participants, and were analyzed using an interdisciplinary, constant comparison qualitative analysis technique. RESULTS: Sixteen program participants and 8 non-participants were enrolled, age range 26-59 (mean 41; standard deviation, 11) years; 75% were White. The sample for this study (N = 12) included five participants and seven non-participants. Semi-structured interview responses produced three salient themes illuminating Veterans' perspectives: (1) key characteristics of the intervention (the relative advantage of the participatory program over other problem-focused programs; the importance of a supportive, encouraging teaching; the group setting; the role of music); (2) the therapeutic power of the program (based on it being enjoyable; and serving as an escape from preoccupations); and (3) the context and culture (which included Veterans supporting each other and the Domiciliary setting). CONCLUSIONS: Veterans described the benefits of a participatory music intervention compared to problem-based groups, which included enjoyment, skill acquisition facilitating pride, escape, reconnecting with their identity prior to current problems, and experiencing positive aspects of Veteran culture such as mutual support and discipline. These data support ongoing research about participatory music programs to support Veterans with housing insecurity.

"I Don't Want to Spend the Rest of my Life Only Going to a Gender Wellness Clinic": Healthcare Experiences of Patients of a Comprehensive Transgender Clinic.

BACKGROUND: Transgender individuals are less likely to have had a primary care visit in the last year than cisgender individuals. While the importance of multidisciplinary clinics for transgender care has been established, little is known about the healthcare experiences of transgender patients with these clinics. OBJECTIVE: To describe how patients experience transgender clinics and how these experiences compare to those experiences in other settings. PARTICIPANTS: Twenty-one adult patients of a gender health program. DESIGN AND APPROACH: Semi-structured interviews of transgender patients. The interviews focused on two domains: healthcare experiences and relationships with healthcare providers. KEY RESULTS: Overall, transgender patients expressed a need for healthcare services, particularly for primary care, that are partially met by the comprehensive care clinic model. Limitations in access included the lack of willing providers, where the patients live, and long wait times for appointments. Participants recounted a range of experiences, both positive and negative, with providers outside of the transgender clinic, but only positive experiences to share about providers from the transgender clinic. CONCLUSION: Outside specialty transgender settings, many patients had negative experiences with providers who were unwilling or unable to provide care. This study speaks to the need for primary care providers who can and will treat transgender patients, as well as the need for healthcare spaces that feel safe to transgender patents.

The Perils of a "My Work Here is Done" perspective: a mixed methods evaluation of sustainment of an evidence-based intervention for transient ischemic attack.

BACKGROUND: To evaluate quality improvement sustainment for Transient Ischemic Attack (TIA) and identify factors influencing sustainment, which is a challenge for Learning Healthcare Systems. METHODS: Mixed methods were used to assess changes in care quality across periods (baseline, implementation, sustainment) and identify factors promoting or hindering sustainment of care quality. PREVENT was a stepped-wedge trial at six US Department of Veterans Affairs implementation sites and 36 control sites (August 2015-September 2019). Quality of care was measured by the without-fail rate: proportion of TIA patients who received all of the care for which they were eligible among brain imaging, carotid artery imaging, neurology consultation, hypertension control, anticoagulation for atrial fibrillation, antithrombotics, and high/moderate potency statins. Key informant interviews were used to identify factors associated with sustainment. RESULTS: The without-fail rate at PREVENT sites improved from 36.7% (baseline, 58/158) to 54.0% (implementation, 95/176) and settled at 48.3% (sustainment, 56/116). At control sites, the without-fail rate improved from 38.6% (baseline, 345/893) to 41.8% (implementation, 363/869) and remained at 43.0% (sustainment, 293/681). After adjustment, no statistically significant difference in sustainment quality between intervention and control sites was identified. Among PREVENT facilities, the without-fail rate improved ≥2% at 3 sites, declined ≥2% at two sites, and remained unchanged at one site during sustainment. Factors promoting sustainment were planning, motivation to sustain, integration of processes into routine practice, leadership engagement, and establishing systems for reflecting and evaluating on performance data. The only factor that was sufficient for improving quality of care during sustainment was the presence of a champion with plans for sustainment. Challenges during sustainment included competing demands, low volume, and potential problems with medical coding impairing use of performance data. Four factors were sufficient for declining quality of care during sustainment: low motivation, champion inactivity, no reflecting and evaluating on performance data, and absence of leadership engagement. CONCLUSIONS: Although the intervention improved care quality during implementation; performance during sustainment was heterogeneous across intervention sites and not different from control sites. Learning Healthcare Systems seeking to sustain evidence-based practices should embed processes within routine care and establish systems for reviewing and reflecting upon performance. TRIAL REGISTRATION: Clinicaltrials.gov ( NCT02769338 ).

Seeding Structures for a Community of Practice Focused on Transient Ischemic Attack (TIA): Implementing Across Disciplines and Waves.

BACKGROUND: The Community of Practice (CoP) model represents one approach to address knowledge management to support effective implementation of best practices. OBJECTIVE: We sought to identify CoP developmental strategies within the context of a national quality improvement project focused on improving the quality for patients receiving acute transient ischemic attack (TIA) care. DESIGN: Stepped wedge trial. PARTICIPANTS: Multidisciplinary staff at six Veterans Affairs medical facilities. INTERVENTIONS: To encourage site implementation of a multi-component quality improvement intervention, the trial included strategies to improve the development of a CoP: site kickoff meetings, CoP conference calls, and an interactive website (the "Hub"). APPROACH: Mixed-methods evaluation included data collected through a CoP attendance log; semi-structured interviews with site participants at 6 months (n = 32) and 12 months (n = 30), and CoP call facilitators (n = 2); and 22 CoP call debriefings. KEY RESULTS: The critical seeding structures that supported the cultivation of the CoP were the kickoffs which fostered relationships (key to the community element of CoPs) and provided the evidence base relevant to TIA care (key to the domain element of CoPs). The Hub provided the forum for sharing quality improvement plans and other tools which were further highlighted during the CoP calls (key to the practice element of CoPs). CoP calls were curated to create a positive context around participants' work by recognizing team successes. In addition to improving care at their local facilities, the community created a shared set of tools which built on their collective knowledge and could be shared within and outside the group. CONCLUSIONS: The PREVENT CoP advanced the mission of the learning healthcare system by successfully providing a forum for shared learning. The CoP was grown through seeding structures that included kickoffs, CoP calls, and the Hub. A CoP expands upon the learning collaborative implementation strategy as an effective implementation practice.

Acceptability of a complex team-based quality improvement intervention for transient ischemic attack: a mixed-methods study.

BACKGROUND: The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurologic Symptoms (PREVENT) program was a complex quality improvement (QI) intervention targeting transient ischemic attack (TIA) evidence-based care. The aim of this study was to evaluate program acceptability among the QI teams and factors associated with degrees of acceptability. METHODS: QI teams from six Veterans Administration facilities participated in active implementation for a one-year period. We employed a mixed methods study to evaluate program acceptability. Multiple data sources were collected over implementation phases and triangulated for this evaluation. First, we conducted 30 onsite, semi-structured interviews during active implementation with 35 participants at 6 months; 27 interviews with 28 participants at 12 months; and 19 participants during program sustainment. Second, we conducted debriefing meetings after onsite visits and monthly virtual collaborative calls. All interviews and debriefings were audiotaped, transcribed, and de-identified. De-identified files were qualitatively coded and analyzed for common themes and acceptability patterns. We conducted mixed-methods matrix analyses comparing acceptability by satisfaction ratings and by the Theoretical Framework of Acceptability (TFA). RESULTS: Overall, the QI teams reported the PREVENT program was acceptable. The clinical champions reported high acceptability of the PREVENT program. At pre-implementation phase, reviewing quality data, team brainstorming solutions and development of action plans were rated as most useful during the team kickoff meetings. Program acceptability perceptions varied over time across active implementation and after teams accomplished actions plans and moved into sustainment. We observed team acceptability growth over a year of active implementation in concert with the QI team's self-efficacy to improve quality of care. Guided by the TFA, the QI teams' acceptability was represented by the respective seven components of the multifaceted acceptability construct. CONCLUSIONS: Program acceptability varied by time, by champion role on QI team, by team self-efficacy, and by perceived effectiveness to improve quality of care aligned with the TFA. A complex quality improvement program that fostered flexibility in local adaptation and supported users with access to data, resources, and implementation strategies was deemed acceptable and appropriate by front-line clinicians implementing practice changes in a large, national healthcare organization. TRIAL REGISTRATION: clinicaltrials.gov : NCT02769338 .

Building cohesion in distributed telemedicine teams: findings from the Department of Veterans Affairs National Telestroke Program.

BACKGROUND: As telemedicine adoption increases, so does the importance of building cohesion among physicians in telemedicine teams. For example, in acute telestroke services, stroke specialists provide rapid remote stroke assessment and treatment to patients at hospitals without stroke specialty care. In the National Telestroke Program (NTSP) of the U.S. Department of Veterans Affairs, a virtual (distributed) hub of stroke specialists throughout the country provides 24/7 consultations nationwide. We examined how these specialists adapted to distributed teamwork, and we identified cohesion-related factors in program development and support. METHODS: We studied the virtual hub of stroke specialists employed by the NTSP. Semi-structured, confidential interviews with stroke specialists in the virtual hub were recorded and transcribed. We explored the extent to which these specialists had developed a sense of shared identity and team cohesion, and we identified factors in this development. Using a qualitative approach with constant comparison methods, two researchers coded each interview transcript independently using a shared codebook. We used matrix displays to identify themes, with special attention to team cohesion, communication, trust, and satisfaction. RESULTS: Of 13 specialists with at least 8 months of NTSP practice, 12 completed interviews; 7 had previously practiced in telestroke programs in other healthcare systems. Interviewees reported high levels of trust and team cohesion, sometimes even more with their virtual colleagues than with co-located colleagues. Factors facilitating perceived team cohesion included a weekly case conference call, a sense of transparency in discussing challenges, engagement in NTSP development tasks, and support from the NTSP leadership. Although lack of in-person contact was associated with lower cohesion, annual in-person NTSP meetings helped mitigate this issue. Despite technical challenges in establishing a new telehealth system within existing national infrastructure, providers reported high levels of satisfaction with the NTSP. CONCLUSION: A virtual telestroke hub can provide a sense of team cohesion among stroke specialists at a level comparable with a standard co-located practice. Engaging in transparent discussion of challenging cases, reviewing new clinical evidence, and contributing to program improvements may promote cohesion in distributed telemedicine teams.

Beyond Discharge Summaries: Communication Preferences in Care Transitions Between Hospitalists and Primary Care Providers Using Electronic Medical Records.

BACKGROUND: Ineffective transitions of care continue to be a source of risk for patients. Although there has been widespread implementation of electronic medical record (EMR) systems, little is currently known about hospitalists' and primary care providers' (PCPs) direct communication preferences at discharge using messaging capabilities in a shared EMR system. OBJECTIVE: We examined how hospitalists and PCPs with a shared EMR prefer to directly communicate at the time of hospital discharge by identifying preferred modes, information prioritization, challenges, facilitators, and proposed solutions. DESIGN: A sequential, explanatory mixed methods study with surveys and semi-structured interviews. PARTICIPANTS: Thirty-eight academic hospitalists and 63 PCPs working in outpatient clinics in a single safety net hospital system with a shared EMR. MAIN APPROACH: Descriptive statistics were used to analyze survey responses. Interviews were analyzed using immersion/crystallization and a mixture of inductive and deductive thematic analysis. KEY RESULTS: PCPs preferred direct communication at discharge through a message within the EMR while hospitalists preferred a message within the EMR and email. Qualitative results identified key themes related to patient care and direct communication: value of direct communication, safety, social determinants of health, and clinical judgment. Both groups prioritized direct communication for high-risk medications, pending and follow-up studies, and high-risk patients that hospitalists were concerned about. Overall, both hospitalists and PCPs reported that ensuring patient safety, flagging patients with social challenges, and expressing concerns about patients based on clinical judgment were key communication priorities. CONCLUSIONS: Hospitalists and primary care providers report considerable overlap in preferences for direct communication at the time of hospital discharge through a shared EMR. Specifically, both groups reported similar concerns regarding patient safety and continuity during transitions. Direct messaging within the EMR could enable "closed loop" communication that helps ensure safe transitions of care for high-risk patients.

Empowering Implementation Teams with a Learning Health System Approach: Leveraging Data to Improve Quality of Care for Transient Ischemic Attack.

BACKGROUND: Questions persist about how learning healthcare systems should integrate audit and feedback (A&F) into quality improvement (QI) projects to support clinical teams' use of performance data to improve care quality. OBJECTIVE: To identify how a virtual "Hub" dashboard that provided performance data for patients with transient ischemic attack (TIA), a resource library, and a forum for sharing QI plans and tools supported QI activities among newly formed multidisciplinary clinical teams at six Department of Veterans Affairs (VA) medical centers. DESIGN: An observational, qualitative evaluation of how team members used a web-based Hub. PARTICIPANTS: External facilitators and multidisciplinary team members at VA facilities engaged in QI to improve the quality of TIA care. APPROACH: Qualitative implementation process and summative evaluation of observational Hub data (interviews with Hub users, structured field notes) to identify emergent, contextual themes and patterns of Hub usage. KEY RESULTS: The Hub supported newly formed multidisciplinary teams in implementing QI plans in three main ways: as an information interface for integrated monitoring of TIA performance; as a repository used by local teams and facility champions; and as a tool for team activation. The Hub enabled access to data that were previously inaccessible and unavailable and integrated that data with benchmark and scientific evidence to serve as a common data infrastructure. Led by champions, each implementation team used the Hub differently: local adoption of the staff and patient education materials; benchmarking facility performance against national rates and peer facilities; and positive reinforcement for QI plan development and monitoring. External facilitators used the Hub to help teams leverage data to target areas of improvement and disseminate local adaptations to promote resource sharing across teams. CONCLUSIONS: As a dynamic platform for A&F operating within learning health systems, hubs represent a promising strategy to support local implementation of QI programs by newly formed, multidisciplinary teams.

Evaluating the feasibility of implementing a Telesleep pilot program using two-tiered external facilitation.

BACKGROUND: Obstructive sleep apnea (OSA) can negatively impact patients' health status and outcomes. Positive airway pressure (PAP) reverses airway obstruction and may reduce the risk of adverse outcomes. Remote monitoring of PAP (as opposed to in-person visits) may improve access to sleep medicine services. This study aimed to evaluate the feasibility of implementing a clinical program that delivers treatment for OSA through PAP remote monitoring using external facilitation as an implementation strategy. METHODS: Participants included patients with OSA at a Veteran Affairs Medical Center (VAMC). PAP adherence and clinical disease severity on treatment (measured by the apnea hypopnea index [AHI]) were the preliminary effectiveness outcomes across two delivery models: usual care (in-person) and Telehealth nurse-delivered remote monitoring. We also assessed visit duration and travel distance. A prospective, mixed-methods evaluation examined the two-tiered external facilitation implementation strategy. RESULTS: The pilot project included N = 52 usual care patients and N = 38 Telehealth nurse-delivered remote monitoring patients. PAP adherence and disease severity were similar across the delivery modalities. However, remote monitoring visits were 50% shorter than in-person visits and saved a mean of 72 miles of travel (median = 45.6, SD = 59.0, mode = 17.8, range 5.4-220). A total of 62 interviews were conducted during implementation with a purposive sample of 12 clinical staff involved in program implementation. Weekly external facilitation delivered to both front-line staff and supervisory physicians was necessary to ensure patient enrollment and treatment. Synchronized, "two-tiered" facilitation at the executive and coordinator levels proved crucial to developing the clinical and administrative infrastructure to support a PAP remote monitoring program and to overcome implementation barriers. CONCLUSIONS: Remote PAP monitoring had similar efficacy to in-person PAP services in this Veteran population. Although external facilitation is a widely-recognized implementation strategy in quality improvement projects, less is known about how multiple facilitators work together to help implement complex programs. Two-tiered facilitation offers a model well-suited to programs where innovations span disciplines, disrupt professional hierarchies (such as those between service chiefs, clinicians, and technicians) and bring together providers who do not know each other, yet must collaborate to improve access to care.

"Do You Know What I Know?": How Communication Norms and Recipient Design Shape the Content and Effectiveness of Patient Handoffs.

BACKGROUND: Poor communication during end-of-shift transfers of care (handoffs) is associated with safety risks and patient harm. Despite the common perception that handoffs are largely a one-way transfer of information, researchers have documented that they are complex interactions, guided by implicit social norms and mental frameworks. OBJECTIVES: We investigated communication strategies that resident physicians report deploying to tailor information during face-to-face handoffs that are often based on their implicit inferences about the perceived information needs and potential harm to patients. METHODS/PARTICIPANTS: We interviewed 35 residents in Medicine and Surgery wards at three VA Medical Centers (VAMCs). MAIN MEASURES: We conducted qualitative interviews using audio-recorded semi-structured cognitive task interviews. KEY RESULTS: The effectiveness of handoff communication depends upon three factors: receiver characteristics, type of shift, and patient's condition and perceived acuity. Receiver characteristics, including subjective perceptions about an incoming resident's training or ability levels and their assumed preferences for information (e.g., detailed/comprehensive vs. minimal/"big picture"), influenced content shared during handoffs. Residents handing off to the night team provided more information about patients' medical histories and care plans than residents handing off to the day team, and higher patient acuity merited more detailed information and the medical service(s) involved dictated the types of information conveyed. CONCLUSIONS: We found that handoff communication involves a complex combination of socio-technical information where residents balance relational factors against content and risk. It is not a mechanistic process of merely transferring clinical data but rather is based on learned habits of communication that are context-sensitive and variable, what we refer to as "recipient design." Interventions should focus on raising awareness of times when information is omitted, customized, or expanded based on implicit judgments, the emerging threats such judgments pose to patient care and quality, and the competencies needed to be more explicit in handoff interactions.

The prospectively-reported implementation update and score (PRIUS): a new method for capturing implementation-related developments over time.

BACKGROUND: Implementation of new programs within healthcare systems can be extraordinarily complex. Individuals within the same healthcare organization often have different perspectives on how implementation of a new program unfolds over time, and it is not always clear in the midst of implementation what issues are most important or how to address them. An implementation support team within the Veterans Health Administration (VHA) sought to develop an efficient method for eliciting an ongoing, detailed and nuanced account of implementation progress from multiple viewpoints that could support and inform active implementation of two new VHA programs. METHODS: The new Prospectively-Reported Implementation Update and Score ("PRIUS") provided a quick, structured, prospective and open-ended method for individuals to report on implementation progress. PRIUS updates were submitted approximately twice a month. Responding to the prompt "What are some things that happened over the past two weeks that seem relevant from your perspective to the implementation of this project?", individuals scored each update with a number ranging from + 3 to - 3. RESULTS: In 2016-17, individuals submitted over 600 PRIUS updates across the two QI projects. PRIUS-based findings included that staff from different services reported fundamentally different perspectives on program implementation. Rapid analysis and reporting of the PRIUS data led directly to changes in implementation. CONCLUSIONS: The PRIUS provided an efficient, structured method for developing a granular and context-sensitive account of implementation progress. The approach appears to be highly adaptable to a wide range of settings and interventions.

"Workin' on Our Night Moves": How Residents Prepare for Shift Handoffs.

BACKGROUND: Poor-quality handoffs have been associated with serious patient consequences. Researchers and educators have answered the call with efforts to increase system safety and resilience by supporting handoffs using increased communication standardization. The focus on strategies for formalizing the content and delivery of patient handoffs has considerable intuitive appeal; however, broader conceptual framing is required to both improve the process and develop and implement effective measures of handoff quality. METHODS: Cognitive task interviews were conducted with internal medicine and surgery residents at three geographically diverse US Department of Veterans Affairs medical centers. Thirty-five residents participated in semistructured interviews using a recent handoff as a prompt for in-depth discussion of goals, strategies, and information needs. Transcribed interview data were analyzed using thematic analysis. RESULTS: Six cognitive tasks emerged during handoff preparation: (1) communicating status and care plan for each patient; (2) specifying tasks for the incoming night shift; (3) anticipating questions and problems likely to arise during the night shift; (4) streamlining patient care task load for the incoming resident; (5) prioritizing problems by acuity across the patient census, and (6) ensuring accurate and current documentation. CONCLUSION: Our study advances the understanding of the influence of the cognitive tasks residents engage in as they prepare to hand off patients from day shift to night shift. Cognitive preparation for the handoff includes activities critical to effective coordination yet easily overlooked because they are not readily observable. The cognitive activities identified point to strategies for cognitive support via improved technology, organizational interventions, and enhanced training.

Access to health services for moderate to severe TBI in Indiana: patient and caregiver perspectives.

OBJECTIVE: We examined patient and caregiver experiences of health services for moderate to severe traumatic brain injury (TBI) in Indiana. The objective was to provide an understanding of their lived experiences and to inform policies and practices for health services delivery for TBI. METHODS: We conducted qualitative, semi-structured interviews with 62 participants (34 patients and 28 caregivers). Data analysis was guided by constructive grounded theory. RESULTS: Three interrelated themes emerged from the data and characterised participants' experiences accessing health services for TBI: 1) inadequate access to health services; 2) unavailability of specialised, age-appropriate, and long-term health services; and 3) transportation barriers to health services that limit access to care and amplify rural health disparities for patients. CONCLUSION: Our findings identified significant barriers to health services for patients with TBI at different points in the care continuum. Gaps in health services and barriers to care transcend geographical boundaries within the state. We suggest ways to improve access to TBI care including: 1) decentralisation of trauma centers; 2) development of neurobehavioural and age-appropriate long-term care facilities; 3) increased workforce with expertise in TBI treatment; and 4) improved access to transportation services for patients with a TBI.

Content counts, but context makes the difference in developing expertise: a qualitative study of how residents learn end of shift handoffs.

BACKGROUND: Handoff education is both formal and informal and varies widely across medical school and residency training programs. Despite many efforts to improve clinical handoffs, little evidence has shown meaningful improvement. The objective of this study was to identify residents' perspectives and develop a deeper understanding on the necessary training to conduct safe and effective patient handoffs. METHODS: A qualitative study focused on the analysis of cognitive task interviews targeting end-of-shift handoff experiences with 35 residents from three geographically dispersed VA facilities. The interview data were analyzed using an iterative, consensus-based team approach. Researchers discussed and agreed on code definitions and corresponding case examples. Grounded theory was used to analyze the transcripts. RESULTS: Although some residents report receiving formal training in conducting handoffs (e.g., medical school coursework, resident boot camp/workshops, and handoff debriefing), many residents reported that they were only partially prepared for enacting them as interns. Experiential, practice-based learning (i.e., giving handoffs, covering night shift to match common issues to handoff content) was identified as the most suited and beneficial for delivering effective handoff training. Six skills were described as critical to learning effective handoffs: identifying pertinent information, providing anticipatory guidance, applying acquired clinical knowledge, being concise, incorporating delivery strategies, and appreciating the styles/preferences of handoff recipients. CONCLUSIONS: Residents identified the immersive performance and the experience of covering night shifts as the most important aspects of learning to execute effective handoffs. Formal education alone can miss the critical role of real-time sense-making throughout the process of handing off from one trainee to another. Interventions targeting senior resident mentoring and night shift could positively influence the cognitive and performance capacity for safe, effective handoffs.

Subjective Experiences of the Benefits and Key Elements of a Cognitive Behavioral Intervention Focused on Community Work Outcomes in Persons With Mental Illness.

New research suggests that group-based cognitive behavioral therapy (CBT) may help improve employment outcomes in persons with mental illness, yet the effects and potential key elements facilitating change in such interventions are unclear. Using a mixed methods approach, this study examined the perspectives of persons with mental illness after participating in a pilot study of the "CBT for Work Success" intervention. Findings demonstrate that participants valued the intervention and perceived that it assisted them in achieving work goals. Therapeutic effects included improved self-efficacy, work motivation, enhanced sense of self as workers, and increased beliefs that work success is attainable. CBT for Work Success elements perceived to be important in facilitating work goals included cognitive restructuring, behavioral coping strategies, problem solving work barriers, meaningful reflection on oneself as a worker, and important factors associated with the group process. The authors discuss the implications of these findings and future research directions.

Crossing the Communication Chasm: Challenges and Opportunities in Transitions of Care from the Hospital to the Primary Care Clinic.

BACKGROUND: Transitions of care from specialty and acute settings to primary care abound. Compared to the continuity in end-of-shift handoffs, care transitions involve provider communication between practices and facilities with their own cultures and bureaucracies. Using the transition from acute care to outpatient primary care for stroke/transient ischemic attack (TIA) patients as a case study, this qualitative research explored communication practices and institutional arrangements among clinical providers responsible for longitudinal management of hypertension. In this study, researchers investigated the barriers and facilitators of effective communication between acute stroke/TIA inpatient and primary care providers at a Veterans Affairs Medical Center. METHODS: A multidisciplinary team conducted consensus-based coding and thematic analysis of semistructured interviews with 21 clinical providers (9 with primary responsibilities for inpatient care and 12 with primary responsibilities in outpatient, primary care). RESULTS: Thematic analysis of responses identified three factors that influenced communication between clinical providers: (1) consistent, concise but complete medication and treatment plans; (2) reliable, standardized discharge documentation; (3) use of multiple modes of communication. Participants identified cultural barriers, including challenges with rotating providers at a teaching hospital and local discharge practices. CONCLUSION: Ambiguity about who is being handed off to and time pressures in the acute setting may lead inpatient providers to give lower priority to discharge communication, leaving outpatient providers with low-quality information. While electronic templates have standardized key components of discharge documentation, improvement opportunities remain. Increased awareness of the challenges and opportunities on each side of the care transfer could foster communication practices that systematically account for the information needs of inpatient and outpatient providers.

Family caregiving challenges in advanced colorectal cancer: patient and caregiver perspectives.

PURPOSE: Family caregivers of advanced colorectal cancer patients may be at increased risk for psychological distress. Yet their key challenges in coping with the patient's illness are not well understood. Soliciting both patient and caregiver perspectives on these challenges would broaden our understanding of the caregiving experience. Thus, the purpose of this research was to identify caregivers' key challenges in coping with their family member's advanced colorectal cancer from the perspective of patients and caregivers. METHODS: Individual, semi-structured qualitative interviews were conducted with 23 advanced colorectal cancer patients and 23 primary family caregivers. Interview data were analyzed via thematic analysis. RESULTS: In nearly all cases, patient and caregiver reports of the caregiver's key challenge were discrepant. Across patient and caregiver reports, caregivers' key challenges included processing emotions surrounding the patient's initial diagnosis or recurrence and addressing the patient's practical and emotional needs. Other challenges included coping with continual uncertainty regarding the patient's potential functional decline and prognosis and observing the patient suffer from various physical symptoms. CONCLUSIONS: Findings suggest that eliciting the perspectives of both patients and caregivers regarding caregivers' challenges provides a more comprehensive understanding of their experience. Results also point to the need to assist caregivers with the emotional and practical aspects of caregiving.

Fostering Alignment and the Catalytic Potential of Community-Engaged Research With US Military Veterans and Advocates.

This paper explores the concept of "community-engaged research" (CEnR) within the context of Veteran health care delivery and reintegration programs. A multi-sector expert panel (msExP) was formed to evaluate and make recommendations on Veteran community reintegration research and programs. The panel consisted of Veterans, care partners, clinical providers, researchers, community stakeholders, and subject matter experts. The paper examines the composition and lifecycle of the panel, highlighting the characteristics and experiences of the participants. Shifts in the panel's purpose and engagement levels occurred in response to unanticipated disruptions, particularly the COVID-19 pandemic. The transformation of the panel emphasizes the importance of aligning individual and group needs and deepening intrapersonal relationships Findings based on observations, surveys, and interviews with panel members contribute to the field of community-engaged research by demonstrating the utility of catalytic validity that balances group and individual development. As part of a broader study on Veteran reintegration, the panel and its development over time allowed for various perspectives on Veteran experiences and reintegration within the community that shaped the overall project. Despite the challenges of developing and maintaining a panel alongside a research study, feedback from the panel members on their participation provides insight into the potential for future working alliances in community-engaged health research.