Developing a brief assessment of social risks for the Veterans Health Administration Survey of Healthcare Experiences of Patients.

OBJECTIVE: To determine whether a 6- or 12-month look-back period affected rates of reported social risks in a social risk survey for use in the Veterans Health Administration and to assess associations of social risks with overall health and mental health. STUDY DESIGN: Cross-sectional survey of respondents randomized to 6- or 12-month look-back period. DATA SOURCES AND STUDY SETTING: Online survey with a convenience sample of Veterans in June and July 2021. DATA COLLECTION/EXTRACTION METHODS: Veteran volunteers were recruited by email to complete a survey assessing social risks, including financial strain, adult caregiving, childcare, food insecurity, housing, transportation, internet access, loneliness/isolation, stress, discrimination, and legal issues. Outcomes included self-reported overall health and mental health. Chi-squared tests compared the prevalence of reported social risks between 6- and 12-month look-back periods. Spearman correlations assessed associations among social risks. Bivariate and multivariable logistic regression models estimated associations between social risks and fair/poor overall and mental health. PRINCIPAL FINDINGS: Of 3418 Veterans contacted, 1063 (31.10%) responded (87.11% male; 85.61% non-Hispanic White; median age = 70, interquartile range [IQR] = 61-74). Prevalence of most reported social risks did not significantly differ by look-back period. Most social risks were weakly intercorrelated (median |r| = 0.24, IQR = 0.16-0.31). Except for legal issues, all social risks were associated with higher odds of fair/poor overall health and mental health in bivariate models. In models containing all significant social risks from bivariate models, adult caregiving and stress remained significant predictors of overall health; food insecurity, housing, loneliness/isolation, and stress remained significant for mental health. CONCLUSIONS: Six- and 12-month look-back periods yielded similar rates of reported social risks. Although most individual social risks are associated with fair/poor overall and mental health, when examined together, only adult caregiving, stress, loneliness/isolation, food, and housing remain significant.

Primary care experiences of veterans with opioid use disorder in the Veterans Health Administration.

BACKGROUND: While patients with substance use disorders (SUDs) are thought to encounter poor primary care experiences, the perspectives of patients with opioid use disorder (OUD), specifically, are unknown. This study compares the primary care experiences of patients with OUD, other SUDs and no SUD in the Veterans Health Administration. METHODS: The sample included Veterans who responded to the national Patient-Centered Medical Home Survey of Healthcare Experiences of Patients, 2013-2015. Respondents included 3554 patients with OUD, 36,175 with other SUDs, and 756,386 with no SUD; 742 OUD-diagnosed patients received buprenorphine. Multivariable multinomial logistic regressions estimated differences in the probability of reporting positive and negative experiences (0-100 scale) for patients with OUD, compared to patients with other SUDs and no SUD, and for OUD-diagnosed patients treated versus not treated with buprenorphine. RESULTS: Of all domains, patients with OUD reported the least positive experiences with access (31%) and medication decision-making (35%), and the most negative experiences with self-management support (35%) and provider communication (23%). Compared to the other groups, patients diagnosed with OUD reported fewer positive and/or more negative experiences with access, communication, office staff, provider ratings, comprehensiveness, care coordination, and self-management support (adjusted risk differences[aRDs] range from |2.9| to |7.0|). Among OUD-diagnosed patients, buprenorphine was associated with more positive experiences with comprehensiveness (aRD = 8.3) and self-management support (aRD = 7.1), and less negative experiences with care coordination (aRD = -4.9) and medication shared decision-making (aRD = -5.4). CONCLUSIONS: In a national sample, patients diagnosed with OUD encounter less positive and more negative experiences than other primary care patients, including those with other SUDs. Buprenorphine treatment relates positively to experiences with care comprehensiveness, medication decisions, and care coordination. As stakeholders encourage more primary care providers to manage OUD, it will be important for healthcare systems to attend to patient access and experiences with care in these settings.

Providing Positive Primary Care Experiences for Homeless Veterans Through Tailored Medical Homes: The Veterans Health Administration's Homeless Patient Aligned Care Teams.

BACKGROUND: In 2012, select Veterans Health Administration (VHA) facilities implemented a homeless-tailored medical home model, called Homeless Patient Aligned Care Teams (H-PACT), to improve care processes and outcomes for homeless Veterans. OBJECTIVE: The main aim of this study was to determine whether H-PACT offers a better patient experience than standard VHA primary care. RESEARCH DESIGN: We used multivariable logistic regressions to estimate differences in the probability of reporting positive primary care experiences on a national survey. SUBJECTS: Homeless-experienced survey respondents enrolled in H-PACT (n=251) or standard primary care in facilities with H-PACT available (n=1527) and facilities without H-PACT (n=10,079). MEASURES: Patient experiences in 8 domains from the Consumer Assessment of Healthcare Provider and Systems surveys. Domain scores were categorized as positive versus nonpositive. RESULTS: H-PACT patients were less likely than standard primary care patients to be female, have 4-year college degrees, or to have served in recent military conflicts; they received more primary care visits and social services. H-PACT patients were more likely than standard primary care patients in the same facilities to report positive experiences with access [adjusted risk difference (RD)=17.4], communication (RD=13.9), office staff (RD=13.1), provider ratings (RD=11.0), and comprehensiveness (RD=9.3). Standard primary care patients in facilities with H-PACT available were more likely than those from facilities without H-PACT to report positive experiences with communication (RD=4.7) and self-management support (RD=4.6). CONCLUSIONS: Patient-centered medical homes designed to address the social determinants of health offer a better care experience for homeless patients, when compared with standard primary care approaches. The lessons learned from H-PACT can be applied throughout VHA and to other health care settings.

The Role of Primary Care Experiences in Obtaining Treatment for Depression.

BACKGROUND: Managing depression in primary care settings has increased with the rise of integrated models of care, such as patient-centered medical homes (PCMHs). The relationship between patient experience in PCMH settings and receipt of depression treatment is unknown. OBJECTIVE: In a large sample of Veterans diagnosed with depression, we examined whether positive PCMH experiences predicted subsequent initiation or continuation of treatment for depression. DESIGN AND PARTICIPANTS: We conducted a lagged cross-sectional study of depression treatment among Veterans with depression diagnoses (n = 27,362) in the years before (Y1) and after (Y2) they completed the Veterans Health Administration's national 2013 PCMH Survey of Healthcare Experiences of Patients. MAIN MEASURES: We assessed patient experiences in four domains, each categorized as positive/moderate/negative. Depression treatment, determined from administrative records, was defined annually as 90 days of antidepressant medications or six psychotherapy visits. Multivariable logistic regressions measured associations between PCMH experiences and receipt of depression treatment in Y2, accounting for treatment in Y1. KEY RESULTS: Among those who did not receive depression treatment in Y1 (n = 4613), positive experiences in three domains (comprehensiveness, shared decision-making, self-management support) predicted greater initiation of treatment in Y2. Among those who received depression treatment in Y1 (n = 22,749), positive or moderate experiences in four domains (comprehensiveness, care coordination, medication decision-making, self-management support) predicted greater continuation of treatment in Y2. CONCLUSIONS: In a national PCMH setting, patient experiences with integrated care, including care coordination, comprehensiveness, involvement in shared decision-making, and self-management support predicted patients' subsequent initiation and continuation of depression treatment over time-a relationship that could affect physical and mental health outcomes.

Differences in Experiences With Care Between Homeless and Nonhomeless Patients in Veterans Affairs Facilities With Tailored and Nontailored Primary Care Teams.

BACKGROUND: Homeless patients describe poor experiences with primary care. In 2012, the Veterans Health Administration (VHA) implemented homeless-tailored primary care teams (Homeless Patient Aligned Care Team, HPACTs) that could improve the primary care experience for homeless patients. OBJECTIVE: To assess differences in primary care experiences between homeless and nonhomeless Veterans receiving care in VHA facilities that had HPACTs available (HPACT facilities) and in VHA facilities lacking HPACTs (non-HPACT facilities). RESEARCH DESIGN: We used multivariable multinomial regressions to estimate homeless versus nonhomeless patient differences in primary care experiences (categorized as negative/moderate/positive) reported on a national VHA survey. We compared the homeless versus nonhomeless risk differences (RDs) in reporting negative or positive experiences in 25 HPACT facilities versus 485 non-HPACT facilities. SUBJECTS: Survey respondents from non-HPACT facilities (homeless: n=10,148; nonhomeless: n=309,779) and HPACT facilities (homeless: n=2022; nonhomeless: n=20,941). MEASURES: Negative and positive experiences with access, communication, office staff, provider rating, comprehensiveness, coordination, shared decision-making, and self-management support. RESULTS: In non-HPACT facilities, homeless patients reported more negative and fewer positive experiences than nonhomeless patients. However, these patterns of homeless versus nonhomeless differences were reversed in HPACT facilities for the domains of communication (positive experience RDs in non-HPACT versus HPACT facilities=-2.0 and 2.0, respectively); comprehensiveness (negative RDs=2.1 and -2.3), shared decision-making (negative RDs=1.2 and -1.8), and self-management support (negative RDs=0.1 and -4.5; positive RDs=0.5 and 8.0). CONCLUSIONS: VHA facilities with HPACT programs appear to offer a better primary care experience for homeless versus nonhomeless Veterans, reversing the pattern of relatively poor primary care experiences often associated with homelessness.

A national evaluation of homeless and nonhomeless veterans' experiences with primary care.

Persons who are homeless, particularly those with mental health and/or substance use disorders (MHSUDs), often do not access or receive continuous primary care services. In addition, negative experiences with primary care might contribute to homeless persons' avoidance and early termination of MHSUD treatment. The patient-centered medical home (PCMH) model aims to address care fragmentation and improve patient experiences. How homeless persons with MHSUDs experience care within PCMHs is unknown. This study compared the primary care experiences of homeless and nonhomeless veterans with MHSUDs receiving care in the Veterans Health Administration's medical home environment, called Patient Aligned Care Teams. The sample included VHA outpatients who responded to the national 2013 PCMH-Survey of Health Care Experiences of Patients (PCMH-SHEP) and had a past-year MSHUD diagnosis. Veterans with evidence of homelessness (henceforth "homeless") were identified through VHA administrative records. PCMH-SHEP survey respondents included 67,666 veterans with MHSUDs (9.2% homeless). Compared with their nonhomeless counterparts, homeless veterans were younger, more likely to be non-Hispanic Black and nonmarried, had less education, and were more likely to live in urban areas. Homeless veterans had elevated rates of most MHSUDs assessed, indicating significant co-occurrence. After controlling for these differences, homeless veterans reported more negative and fewer positive experiences with communication; more negative provider ratings; and more negative experiences with comprehensiveness, care coordination, medication decision-making, and self-management support than nonhomeless veterans. Homeless persons with MHSUDs may need specific services that mitigate negative care experiences and encourage their continuation in longitudinal primary care services. (PsycINFO Database Record

Racial/Ethnic Differences in Primary Care Experiences in Patient-Centered Medical Homes among Veterans with Mental Health and Substance Use Disorders.

BACKGROUND: Patient-Centered Medical Homes (PCMH) may be effective in managing care for racial/ethnic minorities with mental health and/or substance use disorders (MHSUDs). How such patients experience care in PCMH settings is relatively unknown. OBJECTIVE: We aimed to examine racial/ethnic differences in experiences with primary care in PCMH settings among Veterans with MHSUDs. DESIGN: We used multinomial regression methods to estimate racial/ethnic differences in PCMH experiences reported on a 2013 national survey of Veterans Affairs patients. PARTICPANTS: Veterans with past-year MHSUD diagnoses (n = 65,930; 67 % White, 20 % Black, 11 % Hispanic, 1 % American Indian/Alaska Native[AI/AN], and 1 % Asian/Pacific Island[A/PI]). MAIN MEASURES: Positive and negative experiences from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) PCMH Survey. RESULTS: Veterans with MHSUDs reported the lowest frequency of positive experiences with access (22 %) and the highest frequency of negative experiences with self-management support (30 %) and comprehensiveness (16 %). Racial/ethnic differences (as compared to Whites) were observed in all seven healthcare domains (p values < 0.05). With access, Blacks and Hispanics reported more negative (Risk Differences [RDs] = 2 .0;3.6) and fewer positive (RDs = -2 .3;-2.3) experiences, while AI/ANs reported more negative experiences (RD = 5.7). In communication, Blacks reported fewer negative experiences (RD = -1.3); AI/ANs reported more negative (RD = 3.6) experiences; and AI/ANs and APIs reported fewer positive (RD = -6.5, -6.7) experiences. With office staff, Hispanics reported fewer positive experiences (RDs = -3.0); AI/ANs and A/PIs reported more negative experiences (RDs = 3.4; 3.7). For comprehensiveness, Blacks reported more positive experiences (RD = 3.6), and Hispanics reported more negative experiences (RD = 2.7). Both Blacks and Hispanics reported more positive (RDs = 2.3; 4.2) and fewer negative (RDs = -1.8; -1.9) provider ratings, and more positive experiences with decision making (RDs = 2.4; 3.0). Blacks reported more positive (RD = 3.9) and fewer negative (RD = -5.1) experiences with self-management support. CONCLUSIONS: In a national sample of Veterans with MHSUDs, potential deficiencies were observed in access, self-management support, and comprehensiveness. Racial/ethnic minorities reported worse experiences than Whites with access, comprehensiveness, communication, and office staff helpfulness/courtesy.

Patterns of sex and racial/ethnic differences in patient health care experiences in US Veterans Affairs hospitals.

BACKGROUND: Few studies have assessed sex or racial/ethnic differences in inpatient experiences in the Veterans Affairs (VA) Healthcare System. OBJECTIVES: This study aimed to compare inpatient experiences by sex and race/ethnicity within and between VA hospitals. RESEARCH DESIGN: We used mixed-effects multinomial regression to assess within-facility and between-facility sex and racial/ethnic differences in the 2010 VA Survey of Healthcare Experiences of Patients. SUBJECTS: 50,471 respondents from 144 VA hospitals (4.5% female; 75.4% non-Hispanic white, 14.7% non-Hispanic black, 5.4% Hispanic, and 4.4% other race/ethnicity). MEASURES: Negative and positive patient-reported experiences in 13 health care domains were included. RESULTS: Adjusted within-facility sex differences indicated that women reported more negative and less positive experiences than men in 4 domains, and less negative and more positive experiences on domains related to noise and privacy. Patients at facilities with more female patients reported more negative and less positive experiences in 4 domains. Blacks and Hispanics reported less negative and/or more positive experiences than whites within the same facility, although patients at facilities with more black and Hispanic patients reported more negative and less positive experiences overall. There were few and inconsistent within-facility differences between other racial/ethnic patients and whites. Patients at facilities with more other racial/ethnic patients reported slightly less negative and more positive experiences. CONCLUSIONS: Male, black, and Hispanic patients treated in VA hospitals tend to report more positive experiences than female and white patients treated at the same facilities. However, less positive experiences are reported by patients overall in hospitals that serve larger populations of women and racial/ethnic minorities.

Understanding racial and ethnic differences in patient experiences with outpatient health care in Veterans Affairs Medical Centers.

BACKGROUND: Racial and ethnic differences in patient health care experiences have not been well examined in the Veterans Affairs (VA) Healthcare System. OBJECTIVES: To examine racial/ethnic differences in outpatient health care experiences within and between VA medical facilities. RESEARCH DESIGN: We assessed within-facility and between-facility racial/ethnic differences in responses to the 2010 VA Survey of Healthcare Experiences of Patients using mixed-effects multinomial regression. SUBJECTS: A total of 211,459 respondents (53.2%) to a random survey of outpatients from 910 VA medical facilities (71.9% non-Hispanic white, 15.1% non-Hispanic black, 6.4% Hispanic, and 6.7% Other race/ethnicity). MEASURES: Negative and positive patient-reported experiences in 8 domains of health care. RESULTS: Between-facility effects for black race were higher for 7 domains of negative experiences [risk differences (RDs): 0.37% to 1.64%] and lower for 6 domains of positive experiences (RDs: -0.69% to -2.54%). Between-facility effects for Hispanic ethnicity were higher for 5 domains of negative experiences (RDs: 0.60%-1.34%) and lower for 5 domains of positive experiences (RDs: -1.00% to -1.88%). Hispanic ethnicity was also associated with higher within-facility rates of positive experiences for 5 domains of care (RDs: 2.97%-4.08%). Other race/ethnicity was associated with significantly higher within-facility rates of negative experiences (RDs: 2.04%-3.95%) and lower rates of positive experiences for all 8 domains (RDs: -2.05% to -4.70%). CONCLUSIONS: In a national random sample of Veterans managed in the VA Healthcare System, we demonstrated significant within-facility and between-facility racial and ethnic differences in outpatient health care experiences, with differing patterns for each minority group.