Complexity of patients with mental healthcare needs cared for by mental health clinical pharmacist practitioners in Veterans Affairs.

PURPOSE: The complexity of patients with mental healthcare needs cared for by clinical pharmacists is not well delineated. We evaluated the complexity of patients with schizophrenia, bipolar disorder, and major depressive disorder (MDD) in Veterans Affairs (VA) cared for by mental health clinical pharmacist practitioners (MH CPPs). METHODS: Patients at 42 VA sites with schizophrenia, bipolar disorder, or MDD in 2016 through 2019 were classified by MH CPP visits into those with 2 or more visits ("ongoing MH CPP care"), those with 1 visit ("consultative MH CPP care"), and those with no visits ("no MH CPP care"). Patient complexity for each condition was defined by medication regimen and service utilization. RESULTS: For schizophrenia, more patients in ongoing MH CPP care were complex than those with no MH CPP care, based on all measures examined: the number of primary medications (15.3% vs 8.1%), inpatient (13.7% vs 9.1%) and outpatient (42.6% vs 29.7%) utilization, and receipt of long-acting injectable antipsychotics (36.7% vs 25.8%) and clozapine (20.5% vs 9.5%). For bipolar disorder, more patients receiving ongoing or consultative MH CPP care were complex than those with no MH CPP care based on the number of primary medications (27.9% vs 30.5% vs 17.7%) and overlapping mood stabilizers (10.1% vs 11.6% vs 6.2%). For MDD, more patients receiving ongoing or consultative MH CPP care were complex based on the number of primary medications (36.8% vs 35.5% vs 29.2%) and augmentation of antidepressants (56.1% vs 54.4% vs 47.0%) than patients without MH CPP care. All comparisons were significant (P < 0.01). CONCLUSION: MH CPPs provide care for complex patients with schizophrenia, bipolar disorder, and MDD in VA.

Knowledge, practice and attitudes regarding substance use disorder treatment and harm reduction strategies among pharmacists: a scoping review protocol.

INTRODUCTION: Pharmacists provide a spectrum of services and comprehensive medication management for patients with substance use disorders (SUDs) with many providing timely and increased access to care for patients. Prior studies have evaluated other healthcare professionals' attitudes, knowledge and practice in regard to SUD treatment and harm reduction services. However, no reviews to date summarise the available literature on the attitudes, knowledge and practice in regard to SUD treatment and harm reduction services from the pharmacist perspective. This scoping review aims to systematically map the extent, range and nature of available evidence and identify and describe gaps in knowledge, practice and attitudes towards SUD treatment among pharmacists with the goal of providing information for meaningful integration of pharmacists into SUD care. METHODS AND ANALYSIS: We will use the framework proposed by Arksey and O'Malley (2005) updated with recommendations by Levac et al (2010) and the Joanna Briggs Institute (2020). The protocol is registered via Open Science Framework (https://osf.io/92dek). We will search for peer-reviewed literature containing empirical evidence investigating SUD treatment or harm reduction with outcomes pertaining to the knowledge, practice or attitudes of pharmacists. Findings will be guided and assessed by research objectives and summarised using descriptive statistics and thematically for quantitative and qualitative findings, respectively. This review will be conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews. ETHICS AND DISSEMINATION: Our findings will provide crucial information and support for future interventions and programmes which aim to meaningfully integrate pharmacists into SUD care. We will disseminate findings at conferences and publish in a peer-reviewed journal. In addition, we will integrate feedback on search strategy, data extraction and our dissemination approach from multidisciplinary collaborators including those within our team's institution and outside experts with clinical or administrative knowledge in SUD care.

Connecting the disconnected: Leveraging an in-home team member for video visits for older adults.

BACKGROUND: Older adults are interested and able to complete video visits, but often require coaching and practice to succeed. Data show a widening digital divide between older and younger adults using video visits. We conducted a qualitative feasibility study to investigate these gaps via ethnographic methods, including a team member in older participants' homes. METHODS: This ethnographic feasibility study included a virtual medication reconciliation visit with a clinical pharmacist for Veterans aged 65 and older taking 5 or more medications. An in-home study team member joined the participant and recorded observations in structured fieldnotes derived from the Updated Consolidated Framework for Implementation Research and Age-Friendly Health Systems. Fieldnotes included behind-the-scenes facilitators, barriers, and solutions to challenges before and during the visits. We conducted a thematic analysis of these observations and matched themes to implementation solutions from the Expert Recommendations for Implementing Change. RESULTS: Twenty participants completed a video visit. Participants were 74 years old (range 68-80) taking 12 daily medications (range 7-24). Challenges occurred in half of the visits and took the in-home team member and/or pharmacist an average of 10 minutes to troubleshoot. Challenges included notable new findings, such as that half of the participants required technology assistance for challenges that would not have been able to be solved by the pharmacist virtually. Furthermore, although many participants had a device or had used video visits before, some did not have a single device with video, audio, Internet, and access to their email username and password. CONCLUSIONS: Clinicians may apply these evidence-based implementation solutions to their approach to video visits with older adults, including having a team member join the visit before the clinician, involving tech-savvy family members, ensuring the device works with the visit platform ahead of time, and creating a troubleshooting guide from our common challenges.

Proactively tailoring implementation: the case of shared decision-making for lung cancer screening across the VA New England Healthcare Network.

BACKGROUND: Shared Decision-Making to discuss how the benefits and harms of lung cancer screening align with patient values is required by the US Centers for Medicare and Medicaid and recommended by multiple organizations. Barriers at organizational, clinician, clinical encounter, and patient levels prevent SDM from meeting quality standards in routine practice. We developed an implementation plan, using the socio-ecological model, for Shared Decision-Making for lung cancer screening for the Department of Veterans Affairs (VA) New England Healthcare System. Because understanding the local context is critical to implementation success, we sought to proactively tailor our original implementation plan, to address barriers to achieving guideline-concordant lung cancer screening. METHODS: We conducted a formative evaluation using an ethnographic approach to proactively identify barriers to Shared Decision-Making and tailor our implementation plan. Data consisted of qualitative interviews with leadership and clinicians from seven VA New England medical centers, regional meeting notes, and Shared Decision-Making scripts and documents used by providers. Tailoring was guided by the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS). RESULTS: We tailored the original implementation plan to address barriers we identified at the organizational, clinician, clinical encounter, and patient levels. Overall, we removed two implementation strategies, added five strategies, and modified the content of two strategies. For example, at the clinician level, we learned that past personal and clinical experiences predisposed clinicians to focus on the benefits of lung cancer screening. To address this barrier, we modified the content of our original implementation strategy Make Training Dynamic to prompt providers to self-reflect about their screening beliefs and values, encouraging them to discuss both the benefits and potential harms of lung cancer screening. CONCLUSIONS: Formative evaluations can be used to proactively tailor implementation strategies to fit local contexts. We tailored our implementation plan to address unique barriers we identified, with the goal of improving implementation success. The FRAME-IS aided our team in thoughtfully addressing and modifying our original implementation plan. Others seeking to maximize the effectiveness of complex interventions may consider using a similar approach.

Addressing clinician moral distress: Implications from a mixed methods evaluation during Covid-19.

Clinician moral distress has been documented over the past several decades as occurring within numerous healthcare disciplines, often in relation to clinicians' involvement in patients' end-of-life decision-making. The resulting harms impact clinician well-being, patient well-being, and healthcare system functioning. Given Covid-19's catastrophic death toll and associated demands on end-of-life decision-making processes, the pandemic represents a particularly important context within which to understand clinician moral distress. Thus, we conducted a convergent mixed methods study to examine its prevalence, associations with clinicians' demographic and professional characteristics, and contributing circumstances among Veterans Health Administration (VA) clinicians. The study, conducted in April 2021, consisted of a cross-sectional on-line survey of VA clinicians at 20 VA Medical Centers with professional jurisdiction to place life-sustaining treatment orders working who were from a number of select specialties. The survey collected quantitative data on respondents' demographics, clinical practice characteristics, attitudes and behaviors related to goals of care conversations, intensity of moral distress during "peak-Covid," and qualitative data via an open-ended item asking for respondents to describe contributing circumstances if they had indicated any moral distress. To understand factors associated with heightened moral distress, we analyzed quantitative data using bivariate and multivariable regression analyses and qualitative data using a hybrid deductive/inductive thematic approach. Mixed methods analysis followed, whereby we compared the quantitative and qualitative datasets and integrated findings at the analytic level. Out of 3,396 eligible VA clinicians, 323 responded to the survey (9.5% adjusted response rate). Most respondents (81%) reported at least some moral distress during peak-Covid. In a multivariable logistic regression, female gender (OR 3.35; 95% CI 1.53-7.37) was associated with greater odds of moral distress, and practicing in geriatrics/palliative care (OR 0.40; 95% CI 0.18-0.87) and internal medicine/family medicine/primary care (OR 0.46; 95% CI 0.22-0.98) were associated with reduced odds of moral distress compared to medical subspecialties. From the 191 respondents who completed the open-ended item, five qualitative themes emerged as moral distress contributors: 1) patient visitation restrictions, 2) anticipatory actions, 3) clinical uncertainty related to Covid, 4) resource shortages, and 5) personal risk of contracting Covid. Mixed methods analysis found that quantitative results were consistent with these last two qualitative themes. In sum, clinician moral distress was prevalent early in the pandemic. This moral distress was associated with individual-, system-, and situation-level contributors. These identified contributors represent leverage points for future intervention to mitigate clinician moral distress and its negative outcomes during future healthcare crises and even during everyday clinical care.

Clinical pharmacist practitioners on primary care teams play an important role in caring for complex patients with diabetes.

PURPOSE: To evaluate whether clinical pharmacist practitioners (CPPs) are being utilized to care for patients with complex medication regimens and multiple chronic illnesses, we compared the clinical complexity of diabetes patients referred to CPPs in team primary care and those in care by other team providers (OTPs). METHODS: In this cross-sectional comparison of patients with diabetes in the US Department of Veterans Affairs (VA) healthcare system in the 2017-2019 period, patient complexity was based on clinical factors likely to indicate need for more time and resources in medication and disease state management. These factors include insulin prescriptions; use of 3 or more other diabetes medication classes; use of 6 or more other medication classes; 5 or more vascular complications; metabolic complications; 8 or more other complex chronic conditions; chronic kidney disease stage 3b or higher; glycated hemoglobin level of ≥10%; and medication regime nonadherence. RESULTS: Patients with diabetes referred to one of 110 CPPs for care (n = 12,728) scored substantially higher (P < 0.001) than patients with diabetes in care with one of 544 OTPs (n = 81,183) on every complexity measure, even after adjustment for age, sex, race, and marital status. Based on composite summary scores, the likelihood of complexity was 3.42 (interquartile range, 3.25-3.60) times higher for those in ongoing CPP care (ie, those with 2 or more visits) versus OTP care. Patients in CPP care also were, on average, younger, more obese, and had more prior outpatient visits and hospital stays. CONCLUSION: The greater complexity of patients with diabetes seen by CPPs in primary care suggests that CPPs are providing valuable services in comprehensive medication and disease management of complex patients.

Development and Validation of Quality Measures for Testosterone Prescribing.

Context: Accurate measures to assess appropriateness of testosterone prescribing are needed to improve prescribing practices. Objective: This work aimed to develop and validate quality measures around the initiation and monitoring of testosterone prescribing. Methods: This retrospective cohort study comprised a national cohort of male patients receiving care in the Veterans Health Administration who initiated testosterone during January or February 2020. Using laboratory data and diagnostic codes, we developed 9 initiation and 7 monitoring measures. These were based on the current Endocrine Society guidelines supplemented by expert opinion and prior work. We chose measures that could be operationalized using national VA electronic health record (EHR) data. We assessed criterion validity for these 16 measures by manual review of 142 charts. Main outcome measures included positive and negative predictive values (PPVs, NPVs), overall accuracy (OA), and Matthews Correlation Coefficients (MCCs). Results: We found high PPVs (>78%), NPVs (>98%), OA (≥94%), and MCCs (>0.85) for the 10 measures based on laboratory data (5 initiation and 5 monitoring). For the 6 measures relying on diagnostic codes, we similarly found high NPVs (100%) and OAs (≥98%). However, PPVs for measures of acute conditions occurring before testosterone initiation (ie, acute myocardial infarction or stroke) or new conditions occurring after initiation (ie, prostate or breast cancer) PPVs were much lower (0% to 50%) due to few or no cases. Conclusion: We developed several valid EHR-based quality measures for assessing testosterone-prescribing practices. Deployment of these measures in health care systems can facilitate identification of quality gaps in testosterone-prescribing and improve care of men with hypogonadism.

Using a person-centered approach in clinical care for patients with complex chronic conditions: Perspectives from healthcare professionals caring for Veterans with COPD in the U.S. Veterans Health Administration's Whole Health System of Care.

BACKGROUND: The largest nationally integrated health system in the United States, the Veterans Health Administration (VHA), has been undergoing a transformation toward a Whole Health (WH) System of Care. WH Clinical Care, a component of this system, includes holistically assessing the Veteran's life context, identifying what really matters to the Veteran, collaboratively setting and monitoring personal health and well-being goals, and equipping the Veteran with access to conventional and complementary and integrative health resources. Implementation of WH Clinical Care has been challenging. Understanding healthcare professionals' perspectives on the value of and barriers and facilitators to practicing WH Clinical Care holds relevance for not only VHA's efforts but also other health systems, in the U.S. and internationally, that are engaged in person-centered care implementation. OBJECTIVES: We sought to understand perspectives of healthcare professionals at VHA on providing WH Clinical Care to Veterans with COPD, as a lens to understand the broader issue of WH Clinical Care for Veterans living with complex chronic conditions. DESIGN: We interviewed 25 healthcare professionals across disciplines and services at a VA Medical Center in 2020-2021, including primary care providers, pulmonologists, palliative care providers, and chaplains. Interview transcripts were analyzed using qualitative content analysis. KEY RESULTS: Each element of WH Clinical Care raised complex questions and/or concerns, including: (1) the appropriate depth/breadth of inquiry in person-centered assessment; (2) the rationale for elicitation of what really matters; (3) the feasibility and appropriate division of labor in personal health goal setting and planning; and (4) challenges related to referring Veterans to a broad spectrum of supportive services. CONCLUSIONS: Efforts to promote person-centered care must account for healthcare professionals' existing comfort with its elements, advocate for a team-based approach, and continue to grapple with the conflicting structural conditions and organizational imperatives.

Clinical pharmacy practitioners' semi-visible labor: building referral relationships in interprofessional collaborative care.

Clinical pharmacy practitioners (CPP) in the Veterans Health Administration (VHA) prescribe medications and help manage chronic conditions such as diabetes, and they are increasingly working as part of interprofessional clinical teams. The challenges of integrating a new role in a clinical team are documented, but we know less about strategies new healthcare providers use to overcome these challenges. We studied how clinical pharmacy practitioners integrated into clinical teams. We conducted telephone interviews with clinical pharmacy practitioners (n = 53) and members of their clinical teams (n = 74), which were recorded, transcribed, and coded for concepts and themes. We identified four major themes. We found CPP perceived VHA as a "safe haven" for interprofessional care but found it necessary to build other prescribers' trust and confidence in their clinical skills to establish the referral relationships they needed for full integration. To facilitate their integration, CPP engaged in relational, untracked labor, which we characterize as semi-visible labor. While both CPP and clinical team members perceived CPPs' semi-visible labor as vital for implementing and maintaining strong interprofessional collaborations, such labor may be unsustainable as a long-term strategy for integrating CPP in clinical teams.

Organization of pulmonary hypertension care in non-expert care settings: Lessons learned from a multi-site study.

OBJECTIVE: To examine how select Veterans Health Administration (VA) sites organized care for patients with pulmonary hypertension (PH), with a focus on describing existing practices and identifying unmet needs within the sites. DATA SOURCES AND STUDY SETTING: Semi-structured interviews across seven diverse VA sites. STUDY DESIGN: Qualitative multiple-site study. DATA COLLECTION/EXTRACTION METHODS: We interviewed 54 key informants including pulmonologists, cardiologists, primary care providers, advanced care practitioners, pharmacists, and clinical leaders to assess the structures and processes of PH care delivery. We analyzed transcripts using directed content analysis and constructed site profiles for each site, comparing profiles to existing guidelines for PH expert centers. PRINCIPAL FINDINGS: Sites varied considerably in how they organized PH care, with wide variation in the availability of structures and processes recommended for expert centers, including availability of PH expertise and PH-specific resources, multidisciplinary approach to care, establishment of clear referral pathways, and presence of PH education. Further, participants identified three areas of unmet need not directly addressed within current guidelines, including better integration of pharmacists into multidisciplinary teams, early and routine involvement of palliative care, and improved care coordination efforts. CONCLUSIONS: The rising prevalence of PH and evolution of treatments for common PH subgroups underscore the need to standardize PH care delivery in non-expert care settings to improve care quality and patient outcomes. The insight gained from this study may inform the development of guidance appropriate for care settings outside of expert centers.

Direct Observation Methods: a Practical Guide for Health Researchers.

OBJECTIVE: To provide health research teams with a practical, methodologically rigorous guide on how to conduct direct observation. METHODS: Synthesis of authors' observation-based teaching and research experiences in social sciences and health services research. RESULTS: This article serves as a guide for making key decisions in studies involving direct observation. Study development begins with determining if observation methods are warranted or feasible. Deciding what and how to observe entails reviewing literature and defining what abstract, theoretically informed concepts look like in practice. Data collection tools help systematically record phenomena of interest. Interdisciplinary teams--that include relevant community members-- increase relevance, rigor and reliability, distribute work, and facilitate scheduling. Piloting systematizes data collection across the team and proactively addresses issues. CONCLUSION: Observation can elucidate phenomena germane to healthcare research questions by adding unique insights. Careful selection and sampling are critical to rigor. Phenomena like taboo behaviors or rare events are difficult to capture. A thoughtful protocol can preempt Institutional Review Board concerns. INNOVATION: This novel guide provides a practical adaptation of traditional approaches to observation to meet contemporary healthcare research teams' needs.

Stakeholder Research Priorities to Promote Implementation of Shared Decision-Making for Lung Cancer Screening: An American Thoracic Society and Veterans Affairs Health Services Research and Development Statement.

Rationale: Shared decision-making (SDM) for lung cancer screening (LCS) is recommended in guidelines and required by Medicare, yet it is seldom achieved in practice. The best approach for implementing SDM for LCS remains unknown, and the 2021 U.S. Preventive Services Task Force calls for implementation research to increase uptake of SDM for LCS. Objectives: To develop a stakeholder-prioritized research agenda and recommended outcomes to advance implementation of SDM for LCS. Methods: The American Thoracic Society and VA Health Services Research and Development Service convened a multistakeholder committee with expertise in SDM, LCS, patient-centered care, and implementation science. During a virtual State of the Art conference, we reviewed evidence and identified research questions to address barriers to implementing SDM for LCS, as well as outcome constructs, which were refined by writing group members. Our committee (n = 34) then ranked research questions and SDM effectiveness outcomes by perceived importance in an online survey. Results: We present our committee's consensus on three topics important to implementing SDM for LCS: 1) foundational principles for the best practice of SDM for LCS; 2) stakeholder rankings of 22 implementation research questions; and 3) recommended outcomes, including Proctor's implementation outcomes and stakeholder rankings of SDM effectiveness outcomes for hybrid implementation-effectiveness studies. Our committee ranked questions that apply innovative implementation approaches to relieve primary care providers of the sole responsibility of SDM for LCS as highest priority. We rated effectiveness constructs that capture the patient experience of SDM as most important. Conclusions: This statement offers a stakeholder-prioritized research agenda and outcomes to advance implementation of SDM for LCS.

Testing implementation facilitation for uptake of an evidence-based psychosocial intervention in VA homeless programs: A hybrid type III trial.

BACKGROUND: Healthcare systems face difficulty implementing evidence-based practices, particularly multicomponent interventions. Additional challenges occur in settings serving vulnerable populations such as homeless Veterans, given the population's acuity, multiple service needs, and organizational barriers. Implementation Facilitation (IF) is a strategy to support the uptake of evidence-based practices. This study's aim was to simultaneously examine IF on the uptake of Maintaining Independence and Sobriety Through Systems Integration, Outreach and Networking-Veterans Edition (MISSION-Vet), an evidence-based multicomponent treatment engagement intervention for homeless Veterans with co-occurring mental health and substance abuse, and clinical outcomes among Veterans receiving MISSION-Vet. METHODS: This multi-site hybrid III modified stepped-wedge trial involved seven programs at two Veterans Affairs Medical Centers comparing Implementation as Usual (IU; training and educational materials) to IF (IU + internal and external facilitation). RESULTS: A total of 110 facilitation events averaging 27 minutes were conducted, of which 85% were virtual. Staff (case managers and peer specialists; n = 108) were trained in MISSION-Vet and completed organizational readiness assessments (n = 77). Although both sites reported being willing to innovate and a desire to improve outcomes, implementation climate significantly differed. Following IU, no staff at either site conducted MISSION-Vet. Following IF, there was a significant MISSION-Vet implementation difference between sites (53% vs. 14%, p = .002). Among the 93 Veterans that received any MISSION-Vet services, they received an average of six sessions. Significant positive associations were found between number of MISSION-Vet sessions and outpatient treatment engagement measured by the number of outpatient visits attended. CONCLUSIONS: While staff were interested in improving patient outcomes, MISSION-Vet was not implemented with IU. IF supported MISSION-Vet uptake and increased outpatient service utilization, but MISSION-Vet still proved difficult to implement particularly in the larger healthcare system. Future studies might tailor implementation strategies to organizational readiness. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02942979.

Nursing Home Residents' Relocation to Another Facility: an Exploratory Study of Family Caregiver Experiences.

Over time, family caregivers for older adults may face care transitions for their loved ones. The move from home to residential care facility is a much-studied transition. Yet we know little of family caregiver experiences when their loved ones move from one facility to another. We interviewed family caregivers of nursing home residents and inquired about caregiver experiences in prior facilities and factors that prompted moving to another facility. Our analysis identified three themes: 1) A precursor of moving to another facility was caregivers' assessment of poor fit between their family member and the facility; 2) Executing a move was demanding for the caregiver in instrumental and emotional ways; 3) Once in the new facility, caregivers adapted their caregiving to the capacity of the new facility and fostered resident-facility fit (not interfering with good care and supplementing facility care). Findings suggest that family caregivers continually assess and respond to emerging problems with resident-facility fit, which sometimes escalate and necessitate a move to another facility. Nursing home social workers are well-positioned to help families address emerging care problems, so they do not escalate. Doing so can promote care continuity, which benefits both the resident and the family caregiver.

Perceptions of clinical pharmacy specialists' contributions in mental health clinical teams.

INTRODUCTION: Mental health (MH) clinical pharmacy specialists (CPS) are increasingly functioning as integral providers in MH care teams. MH providers may delegate many medication management tasks to the CPS. As there is a shortage of primary care and specialist MH providers, CPS are increasingly being utilized in MH care clinics. We assess provider and CPS perceptions of the contributions of CPS to MH clinical teams in the Veterans Health Administration. METHODS: We examined the roles and functions of CPS in MH clinics through surveys (n = 374) and semistructured interviews (n = 16) with MH CPS and other members of MH clinical teams (psychiatrists, nurse practitioners, registered nurses, social workers) to gain insight into how CPS were integrated in these settings. We assessed perceptions of CPS contributions to MH teams, interactions between CPS and other providers, and challenges of integrating CPS into MH clinical teams. RESULTS: Contributions of CPS in MH were received positively by clinical team members. Clinical pharmacy specialists providing comprehensive medication management were especially valuable in the management of clozapine. The knowledge and training of CPS reassured providers who frequently referred to them with questions about medication and medication therapy management. MH CPS were also perceived to be received well by patients. DISCUSSION: The integration of MH CPS into MH teams was well received by team members and patients alike. The MH CPS have become important members of the MH team and are widely viewed as being able to improve access, quality, and workflow.

Room of Hazards: An Interprofessional Evaluation of Safety Risks in a Simulated Patient Room.

OBJECTIVES: Approximately 3.7% of patients experience adverse events in health care facilities, many of which are preventable. Patient safety requires effective training and an interprofessional culture of safety, but few studies compare the safety skills of different hospital professions. We sought to assess skills in safety hazards identification among staff from different health care disciplines with a pilot study. METHODS: An exercise with a simulated room of an inpatient ward with a patient mannequin in a hospital bed with 34-intentionally planted safety hazards was set up. Health care staff members from various professions walked around the room and independently documented observed safety hazards. Identified hazards were separated based on staff disciplines, grouped into 5 categories (patient, medications, equipment, environment, care processes), and analyzed using analysis of variance. Because participants identified more hazards than the 34 intentionally planted hazards, these were analyzed separately. RESULTS: The study included 111 staff: nurses (n = 68), nursing students (n = 5), medical students (n = 3), physicians (n = 11), social workers (n = 5), pharmacists (n = 6), certified nursing assistants (n = 9), and psychologists (n = 4). There were significant differences among professions in the following categories: medications, equipment, and total number of safety hazards (P < 0.05 for all). Nurses found more intended equipment hazards than did social workers (38.8% versus 4.4%, P < 0.001), pharmacists (38.8% versus 11.1%, P = 0.004), medical students (38.8% versus 7.4%, P = 0.021), and psychologists (38.8% versus 8.3%, P = 0.001) and more medication hazards than nursing students (20.3% versus 16.7%, P = 0.008), whereas certified nursing assistants also found more equipment hazards than did social workers (25.9% versus 4.4%, P = 0.016). CONCLUSIONS: There were significant differences in patterns of safety hazards identified among health care professions, with nurses identifying more hazards than several other professions. This finding suggests that each health care profession's unique training and responsibilities result in varying ability to identify safety hazards and that interdisciplinary safety teams may be more effective than those from only a single profession. Our study provides a starting point to encourage diversification of hospital professions in simulation-based safety trainings, although further work is needed to validate these findings moving forward.

Strategies for Implementing Group Mental Health Interventions in a VA Community Living Center.

Objectives: Group mental health interventions are difficult to implement into rehabilitation facilities, but no one has studied the specific barriers. This mixed-methods project systematically examined the implementation of a mental health (MH) group intervention in a VA community living center (CLC) for residents on subacute rehabilitation units, using the Promoting Action on Research Implementation in Health Services (PARIHS) implementation framework.Methods: We implemented a group MH intervention, tracking team referrals, attendance rates, and reasons for declining to participate. We conducted qualitative interviews with attendees.Results: Individual barriers to attendance included acute illness (n = 67, 20%), attitudes toward MH (n = 50; 15%), and perceived busyness (n = 19; 6%). Facility barriers included competing appointments (n = 69; 21%). Interviews demonstrated challenges to implementation, including stigma toward mental health (Theme: Challenges and Supports to Implementation). Attendees found the group relatable, and noted that both positive and negative group dynamics contributed to their experience (Themes: Content Relevance and Group Dynamics).Conclusions: The results provide insight into implementing a group MH treatment into the CLC setting, with implications for the MH care of older adults residing in CLCs.Clinical Implications: 1) Group leaders should consider matching attendees for ability levels (physical or cognitive). 2) At the facility level, leaders may take steps to address stigma toward MH by adopting approaches (e.g., music) or framing MH issues (e.g., use of language) in a way that is approachable. 3) Modifiable barriers at the individual and facility level could be addressed to encourage ease of implementation.

Implementing Shared Decision-Making for Lung Cancer Screening across a Veterans Health Administration Hospital Network: A Hybrid Effectiveness-Implementation Study Protocol.

Shared decision-making (SDM) for lung cancer screening (LCS) is recommended by multiple organizations, reflecting a larger movement toward patient-centered care. Yet SDM for LCS does not routinely occur owing to barriers at multiple levels. Moreover, how best to implement SDM into routine clinical practice remains unknown. There is a need for a novel approach to overcome multilevel barriers and ensure high-quality SDM for LCS is integrated into routine practice. We present the protocol for our U.S. Department of Veterans Affairs (VA)-funded study. Our protocol is designed to implement and evaluate a multilevel, tailored approach to SDM for LCS in routine clinical practice within the VA New England Health Care Network, comprising eight medical centers. In this prospective, pragmatic hybrid implementation-effectiveness study, we will first conduct a formative evaluation of barriers to SDM for LCS at each level of the socioecological model, which will inform our tailored implementation plan. We will then sequentially introduce components of our tailored, multilevel approach to implementing SDM for LCS across VA New England. Finally, using mixed methods, we will evaluate the implementation and its impact on effectiveness (primary outcome, defined as patient-centeredness of SDM), as well as implementation outcomes informed by the RE-AIM implementation science framework (i.e., reach to patients, adoption by providers, implementation fidelity). Tailored implementation will address identified challenges to achieving policy recommendations for SDM for LCS in VA New England, inform nationwide implementation of SDM for LCS, and address stakeholder interests in promoting more patient-centered interactions across the VA.

Music for your mental health? The development and evaluation of a group mental health intervention in subacute rehabilitation.

Objectives: Short-stay residents of nursing homes experience high rates of mental health (MH) distress compared to community dwelling counterparts, yet MH interventions are difficult to implement and sustain. We modified a music therapy framework to Effective Music in Psychotherapy. Using the modified model, we integrated music listening into MH group intervention and evaluated MH outcomes. This pilot study reports the development and evaluation of the Mental Health and Music Group for short-stay nursing homes residents.Method: The group was developed and refined to be non-sequential and non-cumulative, specific to the needs of short-stay nursing home residents. Pre-/post-session ratings examined affect, quality of life, and pain. Leaders monitored engagement across and between sessions. Qualitative interviews were conducted with a selection of attendees.Results: Findings indicated decreases in irritation and worry, and increases in mood, energy, and self-as-a-whole from pre- to post-session. There were no changes in pain, perception of physical health or life-as-a-whole, energetic, sad, or happy affect, or differences in engagement. Qualitative interviews demonstrated benefits of group modality and music to group cohesion and highlighted the relevance of music for mental health outcomes.Conclusion: The Mental Health and Music group was designed around a framework of Effective Music in Psychotherapy, for short-stay nursing home settings, and demonstrated promising results. Future research can solidify the interventions generalizeability to medical and rehabilitation settings addressing the specific population needs and preferences.Supplemental data for this article is available online at https://doi.org/10.1080/13607863.2021.1935463 .