When Functional Impairment Develops Early: Perspectives from Middle-Aged Adults.

BACKGROUND: Difficulty performing basic daily activities such as bathing and dressing ("functional impairment") affects more than 15% of middle-aged people, and this proportion is increasing. Little is known about the experiences and needs of individuals who develop functional impairment in middle age. OBJECTIVE: To examine the experiences and needs of adults who developed functional impairment in middle age. DESIGN: Qualitative study using semi-structured interviews. PARTICIPANTS: Forty patients aged 50-64 years who developed functional impairment in middle age, recruited from four primary care clinics in San Francisco. APPROACH: Interviews included open-ended questions about participants' daily life, ability to perform activities of daily living (ADLs), and needs related to functional impairment. We analyzed interviews using qualitative thematic analysis. KEY RESULTS: Interviews revealed several themes related to the psychosocial and physical impacts of developing functional impairment in middle age. Participants noted that losses associated with functional impairment, such as loss of independence, control, and social roles, caused conflict in their sense of identity. To cope with these losses, participants used strategies including acceptance, social comparison, adjusting standards, and engaging in valued life activities. Participants reflected on the intersection of their functional impairment with the aging process, noting that their impairments seemed premature compared to the more "natural" aging process in older adults. In terms of physical impacts, participants described how a lack of accommodations in the built environment exacerbated their impairments. While participants used behavioral strategies to overcome these challenges, unmet needs remained, resulting in downstream physical and psychological impacts including safety risks, falls, frustration, and fear. CONCLUSIONS: Unmet psychosocial and physical needs were common among middle-aged adults with functional impairment and led to negative downstream effects. Eliciting and addressing unmet needs may help mitigate downstream health consequences for this growing population, optimizing function and quality of life.

Women Veterans' Experiences with Integrated, Biopsychosocial Pain Care: A Qualitative Study.

OBJECTIVES: Biopsychosocial, integrated pain care models are increasingly implemented in the Veterans Health Administration to improve chronic pain care and reduce opioid-related risks, but little is known about how well these models address women veterans' needs. DESIGN: Qualitative, interview-based study. SETTING: San Francisco VA Health Care System Integrated Pain Team (IPT), an interdisciplinary team that provides short-term, personalized chronic pain care emphasizing functional goals and active self-management. SUBJECTS: Women with chronic pain who completed ≥3 IPT sessions. METHODS: Semistructured phone interviews focused on overall experience with IPT, perceived effectiveness of IPT care, pain care preferences, and suggested changes for improving gender-sensitive pain care. We used a rapid approach to qualitative thematic analysis to analyze interviews. RESULTS: Fourteen women veterans (mean age 51 years; range 33-67 years) completed interviews. Interviews revealed several factors impacting women veterans' experiences: 1) an overall preference for receiving both primary and IPT care in gender-specific settings, 2) varying levels of confidence that IPT could adequately address gender-specific pain issues, 3) barriers to participating in pain groups, and 4) barriers to IPT self-management recommendations due to caregiving responsibilities. CONCLUSIONS: Women veterans reported varied experiences with IPT. Recommendations to improve gender-sensitive pain care include increased provider training; increased knowledge of and sensitivity to women's health concerns; and improved accommodations for prior trauma, family and work obligations, and geographic barriers. To better meet the needs of women veterans with chronic pain, integrated pain care models must be informed by an understanding of gender-specific needs, challenges, and preferences.

Tailored to Fit: How an Implementation Framework Can Support Pragmatic Pain Care Trial Adaptation for Diverse Veterans Affairs Clinical Settings.

BACKGROUND: Veterans Affairs (VA) has rolled out a holistic, multicomponent Whole Health care model nationwide, yet no pragmatic trials have been conducted in real-world clinical settings to compare its effectiveness against other evidence-based approaches for chronic pain management in veterans. OBJECTIVES: We describe the adaptation of the first large pragmatic randomized controlled trial of the Whole Health model for chronic pain care for diverse VA clinical settings. RESEARCH DESIGN: Informed by the Promoting Action on Research Implementation in Health Systems implementation framework, we conducted qualitative semistructured interviews to obtain feedback on trial design from VA leadership, frontline clinicians, and veterans with chronic pain at 5 VA enrollment sites. Next, we convened in-person evidence-based quality improvement (EBQI) meetings with study stakeholders (including frontline clinicians and administrators) at each site to discuss study design; review interview themes; and identify site-specific barriers, facilitators, and approaches to implementation. Ethnographic observations from EBQI meetings provided additional insight into implementation strategies. SUBJECTS: Seventy-four veteran and VA staff stakeholders were interviewed; 71 stakeholders participated in EBQI meetings. RESULTS: At each site, unique clinical contexts and varying resources for Whole Health and pain care delivery affected plans for trial implementation. We present examples of local adaptations that emerged through the formative evaluation process to facilitate implementation and yield a more pragmatic trial design. CONCLUSIONS: A systematic formative evaluation can facilitate engagement and buy-in of study stakeholders. Locally tailored pragmatic implementation strategies may improve the likelihood of successful trial execution as well as future implementation of evidence-based pain care approaches in real-world clinical settings.

An Integrated Pain Team Model: Impact on Pain-Related Outcomes and Opioid Misuse in Patients with Chronic Pain.

OBJECTIVE: Biopsychosocial integrated pain team (IPT) care models are being implemented in Veterans Health Administration (VA) and other health care systems to address chronic pain and reduce risks related to long-term opioid therapy, with little evaluation of effectiveness to date. We examined whether IPT improves self-reported pain-related outcomes and opioid misuse. DESIGN: Single-group quality improvement study. SETTING: Large VA health care system. SUBJECTS: Veterans with chronic pain (N = 99, 84% male, mean age [SD] = 60 [13] years). METHODS: Using paired t tests and Wilcoxon matched-pairs signed-ranks tests, we examined pain experience (Brief Pain Inventory, Pain Catastrophizing Scale), opioid misuse (Current Opioid Misuse Measure), treatment satisfaction (Pain Treatment Satisfaction Scale), and pain management strategies among patients with chronic pain before and after three or more IPT encounters. RESULTS: After an average (SD) of 14.3 (9) weeks engaged in IPT, patients reported improvement in pain interference (mean [SD] = 46.0 [15.9] vs 40.5 [16.2], P < 0.001), pain catastrophizing (mean [SD] = 22.9 [13.0] vs 19.3 [14.1], P = 0.01), treatment satisfaction (i.e., "very satisfied" = 13.1% at baseline vs 25.3% at follow-up, P = 0.01), and reduced opioid misuse (mean [SD] = 11.0 [7.5] vs 8.2 [6.1], P = 0.01). Patients reported increased use of integrative (i.e., acupuncture, 11% at baseline vs 26% at follow-up, P < 0.01) and active pain management strategies (i.e., exercise, 8% at baseline vs 16% at follow-up, P < 0.01) and were less likely to use only pharmacological pain management strategies after IPT engagement (19% at baseline vs 5% at follow-up, P < 0.01). CONCLUSIONS: Biopsychosocial, integrated pain care may improve patient-centered outcomes related to opioid misuse and the subjective experience and nonpharmacological self-management of chronic pain.

Stakeholder Engagement in Pragmatic Clinical Trials: Emphasizing Relationships to Improve Pain Management Delivery and Outcomes.

BACKGROUND: The NIH-DOD-VA Pain Management Collaboratory (PMC) supports 11 pragmatic clinical trials (PCTs) on nonpharmacological approaches to management of pain and co-occurring conditions in U.S. military and veteran health organizations. The Stakeholder Engagement Work Group is supported by a separately funded Coordinating Center and was formed with the goal of developing respectful and productive partnerships that will maximize the ability to generate trustworthy, internally valid findings directly relevant to veterans and military service members with pain, front-line primary care clinicians and health care teams, and health system leaders. The Stakeholder Engagement Work Group provides a forum to promote success of the PCTs in which principal investigators and/or their designees discuss various stakeholder engagement strategies, address challenges, and share experiences. Herein, we communicate features of meaningful stakeholder engagement in the design and implementation of pain management pragmatic trials, across the PMC. DESIGN: Our collective experiences suggest that an optimal stakeholder-engaged research project involves understanding the following: i) Who are research stakeholders in PMC trials? ii) How do investigators ensure that stakeholders represent the interests of a study's target treatment population, including individuals from underrepresented groups?, and iii) How can sustained stakeholder relationships help overcome implementation challenges over the course of a PCT? SUMMARY: Our experiences outline the role of stakeholders in pain research and may inform future pragmatic trial researchers regarding methods to engage stakeholders effectively.

The Integrated Pain Team: A Mixed-Methods Evaluation of the Impact of an Embedded Interdisciplinary Pain Care Intervention on Primary Care Team Satisfaction, Confidence, and Perceptions of Care Effectiveness.

Objective: To evaluate the impact of the Integrated Pain Team (IPT)-an interdisciplinary chronic pain care intervention embedded in primary care at a large Veterans Affairs health care system. Outcomes evaluated included IPT's impact on the perceived effectiveness of chronic pain care; provider self-confidence; and primary care team satisfaction, stress, and burnout. Method: This mixed-methods quality-improvement study employed: 1) qualitative semistructured interviews of 61 primary care providers, other primary care team members, and organizational stakeholders; and 2) a supplementary quantitative survey of 65 providers, comparing those who had referred patients to IPT with those who had not. Results: Most interview participants reported that IPT improved chronic pain care by providing patients with a comprehensive pain treatment plan, educating them about opioid risks, and introducing multimodal treatment options. Interviewed care team members reported improved patient education and fewer emotionally charged contacts from patients. Interviewed providers felt that IPT allowed them to focus their time on health concerns other than pain. However, our supplemental survey found that IPT-utilizing providers were no more confident than other providers in their own pain care skills or in their relationships with chronic pain patients. Conclusions: Integrating an interdisciplinary chronic pain care intervention into primary care can provide needed support to care teams and may improve chronic pain care. Elements of the IPT model identified as important to its effectiveness include its interdisciplinary biopsychosocial approach and attentive patient follow-up. However, enhancing providers' confidence and self-efficacy in chronic pain care may require educational and support resources beyond the current IPT model.

Veteran-centered barriers to VA mental healthcare services use.

BACKGROUND: Some veterans face multiple barriers to VA mental healthcare service use. However, there is limited understanding of how veterans' experiences and meaning systems shape their perceptions of barriers to VA mental health service use. In 2015, a participatory, mixed-methods project was initiated to elicit veteran-centered barriers to using mental healthcare services among a diverse sample of US rural and urban veterans. We sought to identify veteran-centric barriers to mental healthcare to increase initial engagement and continuation with VA mental healthcare services. METHODS: Cultural Domain Analysis, incorporated in a mixed methods approach, generated a cognitive map of veterans' barriers to care. The method involved: 1) free lists of barriers categorized through participant pile sorting; 2) multi-dimensional scaling and cluster analysis for item clusters in spatial dimensions; and 3) participant review, explanation, and interpretation for dimensions of the cultural domain. Item relations were synthesized within and across domain dimensions to contextualize mental health help-seeking behavior. RESULTS: Participants determined five dimensions of barriers to VA mental healthcare services: concern about what others think; financial, personal, and physical obstacles; confidence in the VA healthcare system; navigating VA benefits and healthcare services; and privacy, security, and abuse of services. CONCLUSIONS: These findings demonstrate the value of participatory methods in eliciting meaningful cultural insight into barriers of mental health utilization informed by military veteran culture. They also reinforce the importance of collaborations between the VA and Department of Defense to address the role of military institutional norms and stigmatizing attitudes in veterans' mental health-seeking behaviors.

Provider Experiences With the Identification, Management, and Treatment of Co-occurring Chronic Noncancer Pain and Substance Use in the Safety Net.

BACKGROUND: In the United States and internationally, providers have adopted guidelines on the management of prescription opioids for chronic noncancer pain (CNCP). For "high-risk" patients with co-occurring CNCP and a history of substance use, guidelines advise that providers monitor patients using urine toxicology screening tests, develop opioid management plans, and refer patients to substance use treatment. OBJECTIVE: We report primary care provider experiences in the safety net interpreting and implementing prescription opioid guideline recommendations for patients with CNCP and substance use. METHODS: We interviewed primary care providers who work in safety net settings (N = 23) on their experiences managing CNCP and substance use. We analyzed interviews using a content analysis method. RESULTS: Providers found management plans and urine toxicology screening tests useful for informing patients about clinic expectations of opioid therapy and substance use. However, they described that guideline-based clinic policies had unintended consequences, such as raising barriers to open, honest dialogue about substance use and treatment. While substance use treatment was recommended for "high-risk" patients, providers described lack of integration with and availability of substance use treatment programs. CONCLUSIONS: Our findings indicate that clinicians in the safety net found guideline-based clinic policies helpful. However, effective implementation was challenged by barriers to open dialogue about substance use and limited linkages with treatment programs. Further research is needed to examine how the context of safety net settings shapes the management and treatment of co-occurring CNCP and substance use.

The risks of opioid treatment: Perspectives of primary care practitioners and patients from safety-net clinics.

BACKGROUND: Patients with a history of substance use are more likely than those without substance use to experience chronic noncancer pain (CNCP), to be prescribed opioids, and to experience opioid misuse or overdose. Primary care practitioners (PCPs) in safety-net settings care for low-income patients with CNCP and substance use, usually without specialist consultation. To inform communication related to opioid risk, we explored PCPs' and patients' perceptions of the risks of chronic opioid therapy. METHODS: We conducted semistructured interviews with 23 PCPs and 46 of their patients, who had a history of CNCP and substance use. We recruited from 6 safety-net health care settings in the San Francisco Bay Area. We transcribed interviews verbatim and analyzed transcripts using grounded theory methodology. RESULTS: (1) PCPs feared harming patients and the community by opioid prescribing. PCPs emphasized fear of opioid overdose. (2) Patients did not highlight concerns about the adverse health consequences of opioids, except for addiction. (3) Both patients and PCPs were concerned about PCPs' medicolegal risks related to opioid prescribing. (4) Patients reported feeling stigmatized by policies aimed at reducing opioid misuse. CONCLUSION: We identified differences in how clinicians and patients perceive opioid risk. To improve the informed consent process for opioid therapy, patients and PCPs need to have a shared understanding of the risks of opioids and engage in discussions that promote patient autonomy and safety. As clinics implement opioid prescribing policies, clinicians must develop effective communication strategies in order to educate patients about opioid risks and decrease patients' experiences of stigma and discrimination.

Primary care providers' experiences with urine toxicology tests to manage prescription opioid misuse and substance use among chronic noncancer pain patients in safety net health care settings.

BACKGROUND: Guideline recommendations to reduce prescription opioid misuse among patients with chronic noncancer pain include the routine use of urine toxicology tests for high-risk patients. Yet little is known about how the implementation of urine toxicology tests among patients with co-occurring chronic noncancer pain and substance use impacts primary care providers' management of misuse. Clinicians' perspectives on the benefits and challenges of implementing urine toxicology tests in the monitoring of opioid misuse and substance use in safety net health care settings are presented in this paper. METHODS: Twenty-three primary care providers from 6 safety net health care settings whose patients had a diagnosis of co-occurring chronic noncancer pain and substance use were interviewed. Interviews were transcribed, coded, and analyzed using grounded theory methodology. RESULTS: The benefits of implementing urine toxicology tests for primary care providers included less reliance on intuition to assess for misuse and the ability to identify unknown opioid misuse and/or substance use. The challenges of implementing urine toxicology tests included insufficient education and training about how to interpret and implement tests, and a lack of clarity on how and when to act on tests that indicated misuse and/or substance use. CONCLUSIONS: These data suggest that primary care clinicians' lack of education and training to interpret and implement urine toxicology tests may impact their management of patient opioid misuse and/or substance use. Clinicians may benefit from additional education and training about the clinical implementation and use of urine toxicology tests. Additional research is needed on how primary care providers implementation and use of urine toxicology tests impacts chronic noncancer pain management in primary care and safety net health care settings among patients with co-occurring chronic non cancer pain and substance use.

Improving measurement of functional status among older adults in primary care: A pilot study.

Despite its importance for clinical care and outcomes among older adults, functional status-the ability to perform basic activities of daily living (ADLs) and instrumental ADLs (IADLs)-is seldom routinely measured in primary care settings. The objective of this study was to pilot test a person-centered, interprofessional intervention to improve identification and management of functional impairment among older adults in Veterans Affairs (VA) primary care practices. The four-component intervention included (1) an interprofessional educational session; (2) routine, standardized functional status measurement among patients aged ≥75; (3) annual screening by nurses using a standardized instrument and follow-up assessment by primary care providers; and (4) electronic tools and templates to facilitate increased identification and improved management of functional impairment. Surveys, semi-structured interviews, and electronic health record data were used to measure implementation outcomes (appropriateness, acceptability and satisfaction, feasibility, fidelity, adoption/reach, sustainability). We analyzed qualitative interviews using rapid qualitative analysis. During the study period, all 959 eligible patients were screened (100% reach), of whom 7.3% (n = 58) reported difficulty or needing help with ≥1 ADL and 11.8% (n = 113) reported difficulty or needing help with ≥1 IADL. In a chart review among a subset of 50 patients with functional impairment, 78% percent of clinician notes for the visit when screening was completed had content related to function, and 48% of patients had referrals ordered to address impairments (e.g., physical therapy) within 1 week. Clinicians highly rated the quality of the educational session and reported increased ability to measure and communicate about function. Clinicians and patients reported that the intervention was appropriate, acceptable, and feasible to complete, even during the COVID pandemic. These findings suggest that this intervention is a promising approach to improve identification and management of functional impairment for older patients in primary care. Broader implementation and evaluation of this intervention is currently underway.

Trust and perceived mental health access: Exploring the relationship between perceived access barriers and veteran-reported trust.

The importance of patients' trust in health care is well known. However, identifying actionable access barriers to trust is challenging. The goal of these exploratory analyses is to identify actionable access barriers that correlate with and predict patients' lack of trust in providers and in the health care system. This article combines existing data from three studies regarding perceived access to mental health services to explore the relationship between provider and system trust and other access barriers. Data from the Perceived Access Inventory (PAI) were analyzed from three studies that together enrolled a total of 353 veterans who screened positive for a mental health problem and had a VA mental health encounter in the previous 12 months. The PAI includes actionable barriers to accessing VA mental health services. The data are cross-sectional, and analyses include Spearman rank correlations of PAI access barriers and provider and system trust, and linear regressions examining the effect of demographic, clinical, and PAI barriers on lack of trust in VA mental health providers and in the VA health care system. Age, depression, and anxiety symptoms and PAI items demonstrated statistically significant bivariate correlations with provider and system trust. However, in multivariate linear regressions, only PAI items remained statistically significant. The PAI items that predicted provider and system trust could be addressed in interventions to improve provider- and system-level trust. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Using multiple qualitative methods to inform intervention development: Improving functional status measurement for older veterans in primary care settings.

Functional status, or the ability to perform activities of daily living, is central to older adults' health and quality of life. However, health systems have been slow to incorporate routine measurement of function into patient care. We used multiple qualitative methods to develop a patient-centered, interprofessional intervention to improve measurement of functional status for older veterans in primary care settings. We conducted semi-structured interviews with patients, clinicians, and operations staff (n = 123) from 7 Veterans Health Administration (VHA) Medical Centers. Interviews focused on barriers and facilitators to measuring function. We used concepts from the Consolidated Framework for Implementation Science and sociotechnical analysis to inform rapid qualitative analyses and a hybrid deductive/inductive approach to thematic analysis. We mapped qualitative findings to intervention components. Barriers to measurement included time pressures, cumbersome electronic tools, and the perception that measurement would not be used to improve patient care. Facilitators included a strong interprofessional environment and flexible workflows. Findings informed the development of five intervention components, including (1) an interprofessional educational session; (2) routine, standardized functional status measurement among older patients; (3) annual screening by nurses using a standardized instrument and follow-up assessment by primary care providers; (4) electronic tools and templates to facilitate increased identification and improved management of functional impairment; and (5) tailored reports on functional status for clinicians and operations leaders. These findings show how qualitative methods can be used to develop interventions that are more responsive to real-world contexts, increasing the chances of successful implementation. Using a conceptually-grounded approach to intervention development has the potential to improve patient and clinician experience with measuring function in primary care.

Initial concurrent and convergent validity of the Perceived Access Inventory (PAI) for mental health services.

Access to high-quality health care, including mental health care, remains a high priority for the Department of Veterans Affairs and civilian health care systems. Increased access to mental health care is associated with improved outcomes, including decreased suicidal behavior. Multiple policy changes and interventions are being developed and implemented to improve access to mental health care. The Perceived Access Inventory (PAI) is a patient-centered questionnaire developed to understand the veteran perspective about access to mental health services. The PAI is a self-report measure that includes 43 items across 5 domains: Logistics (6 items), Culture (4 items), Digital (9 items), Systems of Care (13 items), and Experiences of Care (11 items). This article is a preliminary examination of the concurrent and convergent validity of the PAI with respect to the Hoge Perceived Barriers to Seeking Mental Health Services scale (concurrent) and the Client Satisfaction Questionnaire (CSQ; convergent). Telephone interviews were conducted with veterans from 3 geographic regions. Eligibility criteria included screening positive for posttraumatic stress disorder, alcohol use disorder, or depression in the past 12 months. Data from 92 veterans were analyzed using correlation matrices. PAI scores were significantly correlated with the Hoge total score (concurrent validity) and CSQ scores (convergent validity). The PAI items with the strongest correlation with CSQ were in the Systems of Care domain and the weakest were in the Logistics domain. Future efforts will evaluate validity using larger data sets and utilize the PAI to develop and test interventions to improve access to care. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

How VA Whole Health Coaching Can Impact Veterans' Health and Quality of Life: A Mixed-Methods Pilot Program Evaluation.

PURPOSE: To examine the impact of a pilot VA Whole Health Coaching program, including whether and how the program helps veterans improve their health and quality of life. INTERVENTION: Whole Health Coaching is a structured program to support veterans in making healthy behavior changes to promote holistic well-being. DESIGN: This mixed-methods quality-improvement evaluation combined surveys (pre- and post-coaching) with follow-up qualitative interviews. SETTING: The setting was a large VA healthcare system, encompassing a medical center and six community-based clinics in Northern California. PARTICIPANTS: 65 veterans completed surveys at both time points; 42 completed qualitative interviews. METHOD: Telephone surveys administered at baseline and 3 months assessed global health (PROMIS-10), perceived stress (PSS-4), and perceived health competency (PHCS-2). Pre- and post-scores were compared using t-tests. A subsample of participants completed a qualitative interview evaluating program experience, goal attainment, and the coaching relationship. RESULTS: Surveys showed significant improvements over baseline in mental health (p = 0.006; d = 0.36), stress (p = 0.003; d = -0.38), and perceived health competence (p = 0.01; d = 0.35). Interviewees were highly satisfied with their coaching experience, describing both effective program components and improvement opportunities. CONCLUSION: Whole Health Coaching can help participants make meaningful progress toward health goals, reduce stress, and improve quality of life. The Whole Health model's emphasis on holistic self-assessment; patient-driven goal-setting; supportive, non-judgmental inquiry; and mindful awareness contributed to program success and enhanced participants' experience.

Telephone veteran peer coaching for mental health treatment engagement among rural veterans: The importance of secondary outcomes and qualitative data in a randomized controlled trial.

PURPOSE: To determine the effectiveness of telephone motivational coaching delivered by veteran peers to improve mental health (MH) treatment engagement among veterans. METHODS: Veterans receiving primary care from primarily rural VA community-based outpatient clinics were enrolled. Veterans not engaged in MH treatment screening positive for ≥1 MH problem(s) were randomized to receive veteran peer-delivered feedback on MH screen results and referrals plus 4 sessions of telephone motivational coaching (intervention) versus veteran peer-delivered MH results and referrals without motivational coaching (control). Blinded telephone assessments were conducted at baseline, 8, 16, and 32 weeks. Cox proportional hazard models compared MH clinician-directed treatment initiation between groups; descriptive analyses compared MH treatment retention, changes in MH symptoms, quality of life, and self-care. FINDINGS: Among 272 veterans screening positive for ≥1 MH problem(s), 45% who received veteran peer telephone motivational coaching versus 46% of control participants initiated MH treatment (primary outcome) (hazard ratio: 1.09, 95% CI: 0.76-1.57), representing no between-group differences. In contrast, veterans receiving veteran peer motivational coaching achieved significantly greater improvements in depression, posttraumatic stress disorder and cannabis use scores, quality of life domains, and adoption of some self-care strategies than controls (secondary outcomes). Qualitative data revealed that veterans who received veteran peer motivational coaching may no longer have perceived a need for MH treatment. CONCLUSIONS: Among veterans with MH problems using predominantly rural VA community clinics, telephone peer motivational coaching did not enhance MH treatment engagement, but instead had positive effects on MH symptoms, quality of life indicators, and use of self-care strategies.

Development of the Perceived Access Inventory: A patient-centered measure of access to mental health care.

According to recent Congressional testimony by the Secretary for Veterans Affairs (VA), improving the timeliness of services is one of five current priorities for VA. A comprehensive access measure, grounded in veterans' experience, is essential to support VA's efforts to improve access. In this article, the authors describe the process they used to develop the Perceived Access Inventory (PAI), a veteran-centered measure of perceived access to mental health services. They used a multiphase, mixed-methods approach to develop the PAI. Each phase built on and was informed by preceding phases. In Phase 1, the authors conducted 80 individual, semistructured, qualitative interviews with veterans from 3 geographic regions to elicit the barriers and facilitators they experienced in seeking mental health care. In Phase 2, they generated a preliminary set of 77 PAI items based on Phase 1 qualitative data. In Phase 3, an external expert panel rated the preliminary PAI items in terms of relevance and importance, and provided feedback on format and response options. Thirty-nine PAI items resulted from Phase 3. In Phase 4, veterans gave feedback on the readability and understandability of the PAI items generated in Phase 3. Following completion of these 4 developmental phases, the PAI included 43 items addressing 5 domains: logistics (five items), culture (three items), digital (nine items), systems of care (13 items), and experiences of care (13 items). Future work will evaluate concurrent and predictive validity, test/retest reliability, sensitivity to change, and the need for further item reduction. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Sources and Impact of Time Pressure on Opioid Management in the Safety-Net.

PURPOSE: This study sought to understand clinicians' and patients' experience managing chronic noncancer pain (CNCP) and opioids in safety-net primary care settings. This article explores the time requirements of safer opioid prescribing for medically and socially complex patients in the context of safety-net primary care. METHODS: We qualitatively interviewed 23 primary care clinicians and 46 of their patients with concurrent CNCP and substance use disorder (past or current). We also conducted observations of clinical interactions between the clinicians and patients. We transcribed, coded, and analyzed interview and clinical observation recordings using grounded theory methodology. RESULTS: Clinicians reported not having enough time to assess patients' CNCP, functional status, and risks for opioid misuse. Inadequate assessment of CNCP contributed to tension and conflicts during visits. Clinicians described pain conversations consuming a substantial portion of primary care visits despite patients' other serious health concerns. System-level constraints (eg, changing insurance policies, limited access to specialty and integrative care) added to the perceived time burden of CNCP management. Clinicians described repeated visits with little progress in patients' pain or functional status due to these barriers. Patients acknowledged clinical time constraints and reported devoting significant time to following new opioid management protocols for CNCP. CONCLUSIONS: Time pressure was identified as a major barrier to safer opioid prescribing. Efforts, including changes to reimbursement structures, are needed to relieve time stress on primary care clinicians treating medically and socially complex patients with CNCP in safety-net settings.

Patient Experiences With Integrated Pain Care: A Qualitative Evaluation of One VA's Biopsychosocial Approach to Chronic Pain Treatment and Opioid Safety.

BACKGROUND: Mounting concern about the risks and limited effectiveness of opioid therapy for chronic pain has spurred the implementation of novel integrated biopsychosocial pain care models in health-care systems like the Department of Veterans Affairs (VA). However, little is known about patient experiences with these new care models. OBJECTIVE: We conducted a qualitative study to examine patient experiences with a pain care model currently being disseminated at the VA: interdisciplinary, integrated pain teams (IPTs) embedded in primary care. METHOD: We interviewed 41 veterans who received care from VA's first IPT to learn how working with the team impacted their pain care and quality of life. We asked about their overall experience with IPT, what worked and did not work for them, and what changes they would recommend to improve IPT care. RESULTS: The interviews revealed a wide spectrum of patient experiences and varying perspectives on the extent to which the new model improved their pain and quality of life. Thematic analysis shed light on factors impacting patients' experiences, including pretreatment goals and expectations as well as attitudes toward opioids and nonpharmacological treatments. CONCLUSION: We discuss the implications of our findings for national efforts to implement biopsychosocial pain care, and we offer recommendations to promote patient-centered implementation.

Veterans' experiences initiating VA-based mental health care.

Military veterans who could benefit from mental health services often do not access them. Research has revealed a range of barriers associated with initiating United States Department of Veterans Affairs (VA) care, including those specific to accessing mental health care (e.g., fear of stigmatization). More work is needed to streamline access to VA mental health-care services for veterans. In the current study, we interviewed 80 veterans from 9 clinics across the United States about initiation of VA mental health care to identify barriers to access. Results suggested that five predominant factors influenced veterans' decisions to initiate care: (a) awareness of VA mental health services; (b) fear of negative consequences of seeking care; (c) personal beliefs about mental health treatment; (d) input from family and friends; and (e) motivation for treatment. Veterans also spoke about the pathways they used to access this care. The four most commonly reported pathways included (a) physical health-care appointments; (b) the service connection disability system; (c) non-VA care; and (d) being mandated to care. Taken together, these data lend themselves to a model that describes both modifiers of, and pathways to, VA mental health care. The model suggests that interventions aimed at the identified pathways, in concert with efforts designed to reduce barriers, may increase initiation of VA mental health-care services by veterans. (PsycINFO Database Record (c) 2019 APA, all rights reserved).