Barriers and Enablers to Implementing Peer Specialists in Veterans Health Administration Primary Care: a Qualitative Study.

BACKGROUND: Peer specialists (PSs) are increasingly deployed in a variety of settings to provide patient-centered care. In the Veterans Health Administration (VHA), efforts are underway to integrate PSs into primary care settings. Little is known about the barriers and enablers to implementing PS services in primary care. OBJECTIVE: To characterize barriers and enablers to implementing PSs in primary care. DESIGN: Qualitative study using semi-structured interviews. PARTICIPANTS: PSs and their supervisors from 25 VHA primary care settings. APPROACH: PSs and supervisors were interviewed about their experiences integrating PSs in primary care. Rapid analysis was conducted to identify barriers and enablers to PS integration, as well as to examine the role of external facilitation in implementation experiences. KEY RESULTS: Fifty-two interviews were completed (25 PSs from 19 sites and 27 supervisors from 24 sites). Barriers and enablers to PS integration in VHA primary care settings included PS role clarity and constraints, provider buy-in, supervision, leadership support, and primary care culture. The barriers and enablers were consistent across both external facilitation and control sites. CONCLUSIONS: Results describe how the characteristics of the innovation, the recipients, and the context impact successful implementation of PSs in primary care settings. The identification of barriers and enablers holds promise for improving future efforts to embed PSs in primary care. TRIAL REGISTRATION: This project is registered at ClinicalTrials.gov with number NCT02732600 (URL: https://clinicaltrials.gov/ct2/show/NCT02732600 ).

How do US military veterans with serious mental illness manage insomnia? A phenomenological analysis.

Insomnia is a prevalent experience for individuals with serious mental illness, and is one of the most common reasons for mental health referrals in the Veterans Health Administration. Insomnia also critically impacts psychiatric, cognitive and somatic outcomes. However, there is limited information about how people with serious mental illness (i.e. schizophrenia spectrum, bipolar, or major depressive disorders, with serious functional impairments) understand and respond to problems with their own sleep. Bringing this information to light will yield novel methods of research and treatment. The purpose of this study was to examine reactions to insomnia among veterans with serious mental illness and insomnia. An inductive phenomenological approach was used to collect data from 20 veterans with serious mental illness and insomnia using semi-structured interviews. Six themes were identified: Becoming Aware that Insomnia is a Problem; Response to and Dissatisfaction with Medications; Strategies to Get Better Sleep: Contrary to Usual Guidelines; Personal Responsibility for Getting Sleep; Resigned and Giving Up; and Acceptance and Persistence. These results provide insight into the process of identifying insomnia and the subsequent cognitive and behavioural responses that are used to manage sleep disturbances among veterans with serious mental illness, a group often excluded from gold-standard treatments for chronic insomnia. Clinical implications and recommendations for improving treatment efficacy are discussed.

Peer and Non-Peer Co-Facilitation of a Health and Wellness Intervention for Adults with Serious Mental Illness.

Peer specialists, or individuals with lived experience of mental health conditions who support the mental health recovery of others, often work side-by-side with traditional providers (non-peers) in the delivery of treatment groups. The present study aimed to examine group participant and peer provider experiences with peer and non-peer group co-facilitation. Data from a randomized controlled trial of Living Well, a peer and non-peer co-facilitated intervention for medical illness management for adults with serious mental illness, were utilized. A subset of Living Well participants (n = 16) and all peer facilitators (n = 3) completed qualitative interviews. Transcripts were coded and analyzed using a general inductive approach and thematic analysis. The complementary perspectives of the facilitators, teamwork between them, skillful group pacing, and peer facilitator self-disclosure contributed to a warm, respectful, and interactive group atmosphere, which created an environment conducive to social learning. Guidelines for successful co-facilitation emerging from this work are described.

"It's a lot!" the universal worker model and dementia care in assisted living.

The culture change movement aims to create a more home-like environment in long-term care settings, promote person-centered care, and support the well-being of staff and residents. One feature of Culture Change is the Universal Worker (UW) model where direct care workers (DCWs) are responsible for housekeeping, laundry, and activities in addition to administering medication and personal support. The longitudinal approach in the ethnographic study on which this paper is based compares data collected from one assisted living across three NIA-supported research grants. This paper focuses on modifications to the UW model following the implementation of culture change over a period of ten years. As DCWs cared for residents with increasing levels of dementia, time constraints under the UW model led to sporadic attention to housekeeping chores and challenged person-centered care. Modifying the UW model, by using dedicated cleaning staff and other support workers, better preserves the intent of the culture change movement.

Mental Healthcare Provider Perceptions of Race and Racial Disparity in the Care of Black and White Clients.

Black-white disparities in mental healthcare persist, despite efforts to eliminate them via culturally competent care. To gain insight into how providers implement culturally competent care practices, interviews were conducted with mental healthcare providers' about their self-reported behaviors with black and white clients and their perceptions of how race affects the treatment they provide. Thematic analysis was used to analyze 12 semi-structured interviews with providers from a Veterans Affairs healthcare system. Three sets of themes emerged: providers' general beliefs and behaviors (discomfort discussing race; belief that socioeconomic differences explained disparities; and use of coded language for race groups), providers' clinical beliefs and behaviors (race-matching enhances care and recognition of intersecting cultural identities), and providers' professional beliefs and behaviors (participation in passive racism facilitated by provider-provider alliance). Mental healthcare providers showed good awareness of intersectionality and subtle racism but held limiting beliefs that led to avoidance of discussions of race.

Defining "peerness" in peer-delivered health and wellness interventions for serious mental illness.

Comments on the original article by Silver and Nemec (see record 2016-43088-001) regarding the recent special issue on peer-delivered services. Silver and Nemec thoughtfully raised important topics for further explanation. Especially intriguing was their commentary on what constitutes "essential peerness"; that is, what qualities or experiences are necessary/sufficient to make a peer a peer? With this editorial, the authors add to that conversation, specifically with regard to the role of peer specialists in health/wellness interventions. (PsycINFO Database Record

Visitors and Resident Autonomy: Spoken and Unspoken Rules in Assisted Living.

Purpose of the Study: This article explores resident autonomy in assisted living (AL) and the effects that visitors and visiting the AL have on that autonomy. We examine formal and informal policies that govern visiting in AL, stakeholders' views and enforcement of these policies, and the complex arrangements that visiting often entails in everyday life in the setting. Design and Methods: Data are drawn from a multiyear ethnographic study of autonomy in AL. Research from multiple sites included participant observation, informal and in-depth, open-ended interviews of various stakeholders, and the writing of field notes. Research team biweekly discussions and the Atlas.ti software program facilitated coding and analysis of interview transcripts and fieldnotes. Results: Our ethnographic data highlight complicated factors related to visitors and visiting in AL. We discuss two important aspects of visiting: (a) formal and informal policies at each setting; and (b) how resident autonomy is expressed or suppressed through rules about visiting in AL. Implications: Our data underscore the importance of resident autonomy and quality of care in relation to visitors and visiting, especially how this relationship is affected by inconsistent and confusing formal and informal visiting policies in AL.

Promoting and Protecting Against Stigma in Assisted Living and Nursing Homes.

PURPOSE OF THE STUDY: To determine the extent to which structures and processes of care in multilevel settings (independent living, assisted living, and nursing homes) result in stigma in assisted living and nursing homes. DESIGN AND METHODS: Ethnographic in-depth interviews were conducted in 5 multilevel settings with 256 residents, families, and staff members. Qualitative analyses identified the themes that resulted when examining text describing either structures of care or processes of care in relation to 7 codes associated with stigma. RESULTS: Four themes related to structures of care and stigma were identified, including the physical environment, case mix, staff training, and multilevel settings; five themes related to processes of care and stigma, including dining, independence, respect, privacy, and care provision. For each theme, examples were identified illustrating how structures and processes of care can potentially promote or protect against stigma. IMPLICATIONS: In no instance were examples or themes identified that suggested the staff intentionally promoted stigma; on the other hand, there was indication that some structures and processes were intentionally in place to protect against stigma. Perhaps the most important theme is the stigma related to multilevel settings, as it has the potential to reduce individuals' likelihood to seek and accept necessary care. Results suggest specific recommendations to modify care and reduce stigma.

The facade of stability in assisted living.

OBJECTIVES: The study sought to identify the varied types of change arising from internal and external influences in assisted living (AL) settings, expanding upon the literature's limited focus on resident decline and staff turnover and clarifying the importance of changes to life and work there. METHOD: This analysis employed qualitative interviews and observations from 4 studies involving 17 ALs to identify elements of change largely absent from the literature. Case material identified by the research team members relating to persons, groups, and settings exemplifying typical changes, as well as variations across settings, are presented. RESULTS: Multiple domains of AL change were identified, to include those in: (a) the external economic or competitive environments; (b) ownership, management, or key personnel; and (c) physical health or cognition of the aggregate resident population. In many cases, the changes influenced residents' satisfaction and perceived fit with the AL environment. DISCUSSION: Change of many types is a regular feature of AL; many changes alter routines or daily life; raise concerns of staff, residents, or families; or modify perceptions of residential normalcy. Environmental gerontology should more often extend the environment to include the social and interpersonal characteristics of collective living sites for elders.

Baby Boomers in an active adult retirement community: comity interrupted.

PURPOSE OF THE STUDY: This article explores a clash between incoming Baby Boomers and older residents in an active adult retirement community (AARC). We examine issues of social identity and attitudes as these groups encounter each other. DESIGN AND METHODS: Data are drawn from a multiyear ethnographic study of social relations in senior housing. Research at this site included in-depth, open-ended interviews (47), field notes (25), and participant observation in the field (500 hr). Research team biweekly discussions and Atlas.ti software program facilitated analysis. FINDINGS: We begin with a poignant incident that has continued to engender feelings of rejection by elders with each retelling and suggests the power and prevalence of ageism in this AARC. We identify three pervasive themes: (a) social identity and image matter, (b) significant cultural and attitudinal differences exist between Boomers and older residents, and (c) shared age matters less than shared interests. IMPLICATIONS: Our data clearly show the operation of ageism in this community and an equating of being old with being sick. The conflict between these two age cohorts suggests that cohort consciousness among Boomers carries elements of age denial, shared by the older old. It also challenges the Third Age concept as a generational phenomenon.