User Testing of the Veteran Delegation Tool: Qualitative Inquiry.

BACKGROUND: Informal caregivers, or care partners, provide critical support to care recipients when managing health care. Veterans Health Administration (VHA) priorities identify care partners as vital in supporting veterans' care management. The Veteran Delegation Tool (VDT) is VHA's Health Insurance Portability and Accountability Act-compliant solution for care partners to comanage veterans' care through VHA's electronic health portal. Human-centered design approaches in VDT development are needed to inform enhancements aimed at promoting uptake and sustained use. OBJECTIVE: The objective of this prospective descriptive quality improvement project was to use a human-centered design approach to examine VDT use perceptions and practical experiences. METHODS: This project was conducted using a 4-phase approach: frame, discover, design, and deliver. The frame phase designed the protocol and prepared the VDT system for testing. This paper reports on the discover phase, which used semistructured and follow-up interviews and user testing to examine VDT's benefits, facilitators, and barriers. The discover phase data informed the design and deliver phases, which are underway. RESULTS: Veterans (24/54, 44%), care partners (21/54, 39%), and individuals who represented dual roles (9/54, 17%)-namely veteran care partner (4/54, 7%), veteran clinical provider (2/54, 4%), and care partner provider (3/54, 6%)-participated in semistructured interviews in the discover phase. A subsample of these participants (3/54, 6%) participated in the follow-up interviews and user testing. Analysis of the semistructured interviews indicated convergence on the respondents' perceptions of VDT's benefits, facilitators, and barriers and recommendations for improving VDT. The perceived benefits were authorized access, comanagement of care needs on the web, communication with the clinical team, access to resources, and ease of burden. Perceived barriers were nonrecognition of the benefits of VDT, technical literacy access issues, increased stress in or burden on care partners, and personal health information security. Participant experiences across 4 VDT activity domains were upgrade to My HealtheVet Premium account, registration, sign-in, and use. User testing demonstrated users' challenges to register, navigate, and use VDT. Findings informed VDT development enhancements and recommendations. CONCLUSIONS: Care partners need Health Insurance Portability and Accountability Act-compliant access to electronic health portals to assist with care management. VDT is VHA's solution, allowing communication among delegates, veterans, and clinical care teams. Users value VDT's potential use and benefits, while access and navigation improvements to ensure uptake and sustained use are needed. Future efforts need to iteratively evaluate the human-centered phases, design and deliver, of VDT to target audiences. Continued efforts to understand and respond to care partners' needs are warranted.

Mobile and Web-Based Partnered Intervention to Improve Remote Access to Pain and Posttraumatic Stress Disorder Symptom Management: Recruitment and Attrition in a Randomized Controlled Trial.

BACKGROUND: Increasing access to nonpharmacological interventions to manage pain and posttraumatic stress disorder (PTSD) is essential for veterans. Complementary and integrative health (CIH) interventions can help individuals manage symptom burden with enhanced accessibility via remotely delivered health care. Mission Reconnect (MR) is a partnered, self-directed intervention that remotely teaches CIH skills. OBJECTIVE: The purpose of this paper is to describe the recruitment, onboarding phase, and attrition of a fully remote randomized controlled trial (RCT) assessing the efficacy of a self-directed mobile and web-based intervention for veterans with comorbid chronic pain and PTSD and their partners. METHODS: A total of 364 veteran-partner dyads were recruited to participate in a mixed methods multisite waitlist control RCT. Qualitative attrition interviews were conducted with 10 veterans with chronic pain and PTSD, and their self-elected partners (eg, spouse) who consented but did not begin the program. RESULTS: At the point of completing onboarding and being randomized to the 2 treatment arms, of the 364 recruited dyads, 97 (26.6%) failed to complete onboarding activities. Reported reasons for failure to complete onboarding include loss of self-elected partner buy-in (n=8, 8%), difficulties with using remote data collection methods and interventions (n=30, 31%), and adverse health experiences unrelated to study activities (n=23, 24%). Enrolled veterans presented at baseline with significant PTSD symptom burden and moderate-to-severe pain severity, and represented a geographically and demographically diverse population. Attrition interviews (n=10) indicated that misunderstanding MR including the intent of the intervention or mistaking the surveys as the actual intervention was a reason for not completing the MR registration process. Another barrier to MR registration was that interviewees described the mailed study information and registration packets as too confusing and excessive. Competing personal circumstances including health concerns that required attention interfered with MR registration. Common reasons for attrition following successful MR registration included partner withdrawal, adverse health issues, and technological challenges relating to the MR and electronic data collection platform (Qualtrics). Participant recommendations for reducing attrition included switching to digital forms to reduce participant burden and increasing human interaction throughout the registration and baseline data collection processes. CONCLUSIONS: Challenges, solutions, and lessons learned for study recruitment and intervention delivery inform best practices of delivering remote self-directed CIH interventions when addressing the unique needs of this medically complex population. Successful recruitment and enrollment of veterans with chronic pain and PTSD, and their partners, to remote CIH programs and research studies requires future examination of demographic and symptom-associated access barriers. Accommodating the unique needs of this medically complex population is essential for improving the effectiveness of CIH programs. Disseminating lessons learned and improving access to remotely delivered research studies and CIH programs is paramount in the post-COVID-19 climate. TRIAL REGISTRATION: ClinicalTrials.gov NCT03593772; https://clinicaltrials.gov/ct2/show/NCT03593772.

Provider reported value and use of virtual resources in extended primary care prior to and during COVID-19.

BACKGROUND: A proactive approach to delivering care using virtual resources, while reducing in-person contact, is needed during the COVID-19 pandemic. OBJECTIVE: In the current study we describe pre- to post- COVID-19 pandemic onset related changes in electronic delivery of primary care. METHODS: A longitudinal, pre-post within-subjects design was used. Patient-aligned care team providers from one VA medical center, a primary care annex, and four affiliated community-based outpatient clinics completed both a baseline and follow up survey (N = 62) or the follow-up survey only (N = 85). The follow-up survey contained questions about COVID-19. RESULTS: The majority of providers (88%) reported they would continue virtual care once pandemic restrictions were lifted. Most (83%) felt prepared to transition to virtual care when pandemic restrictions began. Use of My HealtheVet, Telehealth, and mobile apps showed a significant increase (22.7%; 31.1%; 48.5%). Barriers to virtual care included (1) internet connectivity; (2) patients' lack of technology comfort and skills; and (3) technical issues. Main supports to provide virtual care to patients were (1) peers/ colleagues; (2) technology support through help desk; (3) equipment such as laptops and dual screens; (4) being able to use doximety and virtual care manager, and (5) training. CONCLUSIONS: Overall, provider-use and perceptions related to using virtual care improved over time. Providers adapted quickly to providing virtual care during COVID-19 and planned to provide virtual care long-term.

Reliability and validity of the Veterans Administration Mobility Screening and Solutions Tool.

OBJECTIVES: The Veterans Administration (VA) Mobility Screening and Solutions Tool (VA MSST) was developed to screen a patient's safe mobility level 'in the moment' and provide clinical decision support related to the use of safe patient handling and mobility (SPHM) equipment. This evidence-based flowchart tool is a common language tool that enables any healthcare worker at any time to accurately measure and communicate patient mobility and transfer equipment needs across disciplines and settings. METHODS: The VA MSST has four levels and differentiates between the need for powered and non-powered equipment depending on the patient's independence. Subject matter experts wrote scenarios for interrater reliability and validity testing. The initial VA MSST draft iteration was reviewed by 163 VA staff (mostly physical therapists and occupational therapists) amongst simulation scenarios and provided content validity, and additional insight and suggestions. Revisions were made to create the final VA MSST which was evaluated by over 200 healthcare workers from varied disciplines (including medical doctors, advanced practice registered nurses, registered nurses, licensed practical nurses, certified nursing assistants, occupational therapists, physical therapists, speech therapists, radiology and ultrasound technicians, etc.). An instruction video and eighteen scenario videos were embedded in an online survey. The survey intended to demonstrate the interrater reliability and validity (concurrent and construct) of the VA MSST. Over 500 VA staff (raters) received a survey invitation via email. RESULTS: Raters (N = 230) from multiple disciplines and healthcare settings independently screened patient mobility status for each of 18 scenarios using the VA MSST. The raters were diverse in their age and years of experience. The estimated interrater reliability (IRR) for VA MSST was excellent and statistically significant with an estimated Krippendorff's alpha (ICC (C, k)) of 0.998 [95% CI: 0.996-0.999]. Eighty-two percent of raters reported that overall VA MSST instructions were clear or very clear and understandable. VA MSST ratings made by technicians and nursing assistants group correlated strongly (r = 0.99, p < 0.001) with the 'gold standard' (experienced physical therapists), suggesting a high concurrent validity of the tool. The VA MSST significantly discriminated between the different levels of patient mobility required for safe mobilization as intended (each difference, p < 0.0001); this suggests a good construct validity. CONCLUSIONS: The VA MSST is an evidence-based flowchart screening and decision support tool that demonstrates excellent interrater reliability across disciplines and settings. VA MSST has strong face and content validity, as well as good concurrent and construct validity.

Primary care virtual resource use prior and post COVID-19 pandemic onset.

BACKGROUND: The COVID-19 pandemic has been a catalyst for rapid uptake of virtual care through the use of virtual health resources (VHR). In the Department of Veterans Affairs (VA) Healthcare System, virtual care has been critical to maintaining healthcare access for patients during COVID-19. In the current study we describe primary care patient aligned care team (PACT) VHR use patterns within one VA medical center (i.e., hospital facility and five community-based outpatient clinics) pre- and post-COVID-19 onset. METHODS: VHR provider and patient use data from 106 individual PACTs were extracted monthly between September 2019 to September 2020. Data were extracted from VHA web-based project application and tracking databases. Using longitudinal data, mixed effect models were used to compare pre- and post-COVID onset slopes. RESULTS: Findings highlight an increase in patient users of secure messaging (SM) and telehealth. The rate of utilization among these patients increased for SM but not for telehealth visits or online prescription refill (RxRefill) use. Finally, VetLink Kiosk check ins that are done at in person visits, diminished abruptly after COVID-19 onset. CONCLUSIONS: These data provide a baseline of VHR use at the PACT level after the initial impact of the COVID-19 pandemic and can inform healthcare delivery changes within the VA systems over time. Moreover, this project produced a data extraction blueprint, that is the first of its kind to track VA VHR use leveraging secondary data sources.

Informing Proactive integrated virtual healthcare resource use in primary care.

BACKGROUND: Proactive integrated virtual healthcare resource (VHR) use can improve efficiency, maximize resource capacity for delivering optimal coordinated care and improve patient outcomes. Proactive integrated VHR use is vital for delivering high quality care. Our objectives were to identify proactive integrated VHR use among primary care teams, best practices and targeted implementation strategies to promote proactive integrated VHR use. METHODS: This is a mixed-method descriptive study. We employed a community-based participatory approach to collect data and the Consolidated Framework for Implementation Research to analyze and contextualize findings. A cross-sectional sample of primary care team members (n = 65) from a Department of Veterans Affairs medical center participated in focus groups, follow-up interviews (n = 16), and respond to self-report surveys. Operational subject matter experts (n = 15) participated in informant interviews. RESULTS: Survey data described current use and factors that influenced singular VHR use and were convergent with qualitative findings. Focus group and interview data described no evidence of proactive integrated VHR use. Differences and similarities were identified between both utilization groups, such as facilitators and barriers, recommendations, patient education and preferred implementation strategies. All groups reported issues around VHR availability knowledge and access and functionality. Participants identified the need for best practices that are specific to care tasks and performance measures. Expert informant interviews identified a list of VHR tools that could be proactively integrated across the healthcare continuum. CONCLUSIONS: Health systems are leveraging technologies to proactively integrate VHR to maximize information exchange, clinical decision support and patient engagement. VHR is critical during global pandemics, such as COVID-19, to maintain access to care coordination and delivery while abiding by public health recommendations. Though recent requirements for reducing contact create an intrinsic motivation, cultural change through education and best practices of proactive integrated use across the healthcare continuum is needed to create a culture of VHR super users.

Exploring the role complexity and workforce needs of doctoral-prepared nurses.

Veterans Health Administration (VHA) Office of Nursing Services (ONS) is committed to encouraging and sustaining a positive culture that values doctoral-prepared nurses. Responding to needs cited in open-ended responses from the first ever survey of VHA's doctoral-prepared nurse workforce will require: providing and encouraging formal advanced degree achievement recognition; further opportunities for professional development and potential promotion; and support for nurse research activities at the local and national level. ONS recognizes the need for further research and evaluation related to VHA doctoral-prepared nurses to better understand both the outcomes they drive and what drives them.

A preliminary evaluation of full practice authority of advance practice registered nurses in the Veterans Health Administration.

BACKGROUND: Responding to National Academy of Medicine and National Council of State Boards of Nursing recommendations, the Department of Veterans Health Affairs (VHA) implemented full practice authority (FPA) for Advanced Practice Registered Nurses in VHA medical centers (VAMCs) in 2017. PURPOSE: To evaluate FPA policy implementation's impact on quality indicators including access to care as measured by new patient appointments in primary, specialty and mental health services. METHODS: Linear growth models compared early (n = 85) vs. late (n = 55) FPA implementing VAMCs on the trajectories of each of the three quality indicators. FINDINGS: Early FPA implementing VAMCs showed greater rates of improvement over time in new patient appointments completed within 30 days of preferred date for primary care (p = .003), specialty care (p = 0.05), and mental health (p = 0.001). DISCUSSION: VAMCs that started implementation of FPA policy early showed greater improvement in access to care for Veterans over time than VAMCs that did not.

Veterans' Preferences for Exchanging Information Using Veterans Affairs Health Information Technologies: Focus Group Results and Modeling Simulations.

BACKGROUND: The Department of Veterans Affairs (VA) has multiple health information technology (HIT) resources for veterans to support their health care management. These include a patient portal, VetLink Kiosks, mobile apps, and telehealth services. The veteran patient population has a variety of needs and preferences that can inform current VA HIT redesign efforts to meet consumer needs. OBJECTIVE: This study aimed to describe veterans' experiences using the current VA HIT and identify their vision for the future of an integrated VA HIT system. METHODS: Two rounds of focus group interviews were conducted with a single cohort of 47 veterans and one female caregiver recruited from Bedford, Massachusetts, and Tampa, Florida. Focus group interviews included simulation modeling activities and a self-administered survey. This study also used an expert panel group to provide data and input throughout the study process. High-fidelity, interactive simulations were created and used to facilitate collection of qualitative data. The simulations were developed based on system requirements, data collected through operational efforts, and participants' reported preferences for using VA HIT. Pairwise comparison activities of HIT resources were conducted with both focus groups and the expert panel. Rapid iterative content analysis was used to analyze qualitative data. Descriptive statistics summarized quantitative data. RESULTS: Data themes included (1) current use of VA HIT, (2) non-VA HIT use, and (3) preferences for future use of VA HIT. Data indicated that, although the Secure Messaging feature was often preferred, a full range of HIT options are needed. These data were then used to develop veteran-driven simulations that illustrate user needs and expectations when using a HIT system and services to access VA health care services. CONCLUSIONS: Patient participant redesign processes present critical opportunities for creating a human-centered design. Veterans value virtual health care options and prefer standardized, integrated, and synchronized user-friendly interface designs.

A qualitative understanding of patient falls in inpatient mental health units.

BACKGROUND: Falls are the leading cause of injury-related deaths among people age 65 and older, and fractures are the major category of serious injuries produced by falls. OBJECTIVE: Determine market segment-specific recommendations for "selling" falls prevention in acute inpatient psychiatry. DESIGN: Descriptive using focus groups. SETTING: One inpatient unit at a Veterans' hospital in the Southeastern United States and one national conference of psychiatric and mental health nurses. PATIENTS: A convenience sample of 22 registered nurses and advanced practice nurses, one physical therapist and two physicians participated in one of six focus groups. INTERVENTION: None. MEASUREMENTS: Focus groups were conducted by expert facilitators using a semistructured interview guide. Focus groups were recorded and transcribed. Content analysis was used to organize findings. RESULTS: Findings were grouped into fall risk assessment, clinical fall risk precautions, programmatic fall prevention, and "selling" fall prevention in psychiatry. Participants focused on falls prevention instead of fall injury prevention, were committed to reducing risk, and were receptive to learning how to improve safety. Participants recognized unique features of their patients and care settings that defined risk, and were highly motivated to work with other disciplines to keep patients safe. CONCLUSIONS: Selling fall injury prevention to staff in psychiatric settings is similar to selling fall injury prevention to staff in other health care settings. Appealing to the larger construct of patient safety will motivate staff in psychiatric settings to implement best practices and customize these to account for unique population needs characteristics.

Veterans' lived experiences with the VA's Whole Health system and perceived impact on dimensions of wellness.

RESEARCH QUESTION: What are the lived experiences and wellness related outcomes of veterans engaged in the Department of Veterans' Affairs (VA) Whole Health (WH) system of care? THEORETICAL FRAMEWORK: This qualitative work was conducted with a pragmatic phenomenological approach to understand patients' lived experience within the WH system of care. Data were contextualized within a multi-dimensional wellness model. METHODOLOGY: This descriptive quality improvement project used semi-structured telephone interviews. Interview script elicited veterans' WH participation experiences and perceived wellness related outcomes. CONTEXT: Data were collected within a WH Service, at a large Veterans Health Administration Hospital in the Southeast United States. SAMPLE SELECTION: Data were collected with a purposive sample of veterans that participated in at least 2 WH activities. DATA COLLECTION: Patients were recruited by WH clinical team collaborators to participate in qualitative data collection. ANALYSIS AND INTERPRETATION: Rapid content analysis and interpretation of results were conducted in alignment with dimensions of wellness constructs. MAIN RESULTS: WH offers veterans' non-pharmacological tools to improve mental, physical, and social wellness. Participants (n = 50) represented the larger veteran population. Most veterans perceived a positive WH experience with improvement of three primary dimensions including mental and emotional, physical, and social wellness - impacts on other dimensions gleaned less perceived impact. Veterans reported adopting mindfulness and coping strategies, better mobility, pain management, and sleep quality, and enhanced social engagement. Even those who did benefit personally from all aspects of WH, felt the services are needed to support the larger veteran population. Reduced suicidal ideation and pain medication use emerged as a WH effect among approximately 10% of the sample.

Enhancing Veteran Community Reintegration Research (ENCORE): Protocol for a Mixed Methods and Stakeholder Engagement Project.

BACKGROUND: Veteran community reintegration (CR) has been defined as participation in community life, including employment or other productive activities, independent living, and social relationships. Veteran CR is a Veterans Health Administration priority, as a substantial proportion of veterans report difficulties with veteran CR following discharge from military service. OBJECTIVE: Enhancing Veteran Community Reintegration Research (ENCORE) is a project funded by Veterans Health Administration's Health Service Research and Development Service. The goal of ENCORE is to maximize veteran and family reintegration by promoting innovative research and knowledge translation (KT) that informs and improves equitable Department of Veterans Affairs (VA) policies, programs, and services. Overall, 2 strategic objectives guide ENCORE activities: mobilize veteran CR research and promote innovation, relevance, and acceleration of veteran CR research and KT. METHODS: ENCORE uses a mixed methods and stakeholder-engaged approach to achieve objectives and to ensure that the KT products generated are inclusive, innovative, and meaningful to stakeholders. Project activities will occur over 5 years (2019-2024) in 5 phases: plan, engage, mobilize, promote, and evaluate. All activities will be conducted remotely owing to the ongoing COVID-19 pandemic. Methods used will include reviewing research funding and literature examining the gaps in veteran CR research, conducting expert informant interviews with VA program office representatives, and assembling and working with a Multistakeholder Partnership (MSP). MSP meetings will use external facilitation services, group facilitation techniques adapted for virtual settings, and a 6-step group facilitation process to ensure successful execution of meetings and accomplishment of goals. RESULTS: As of December 2022, data collection for ENCORE is ongoing, with the team completing interviews with 20 stakeholders from 16 VA program offices providing veteran CR-related services. ENCORE developed and assembled the MSP, reviewed the VA funding portfolio and veteran CR research literature, and conducted a scientific gap analysis. The MSP developed a veteran CR research agenda in 2021 and continues to work with the ENCORE team to prepare materials for dissemination. CONCLUSIONS: The goal of this program is to improve the impact of veteran CR research on policies and programs. Using a stakeholder-engaged process, insights from key stakeholder groups are being incorporated to set a research agenda that is more likely to result in a relevant and responsive veteran CR research program. Future products will include the development of an effective and relevant dissemination plan and the generation of innovative and relevant dissemination products designed for rapid KT. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/42029.

Traumatic Brain Injury Intensive Evaluation and Treatment Program: Protocol for a Partnered Evaluation Initiative Mixed Methods Study.

BACKGROUND: The traumatic brain injury (TBI) Intensive Evaluation and Treatment Program (IETP) is an innovative modality for delivering evidence-based treatments in a residential, inpatient format to special operational forces service members and veterans with mild TBI. IETPs provide bundled evidence-based assessment, treatment, referral, and case management in concordance with the existing guidelines for mild TBI and commonly co-occurring comorbidities. To date, there has been no formal characterization or evaluation of the IETP to understand the determinants of implementation across the system of care. The goal of our partnered evaluation initiative (PEI) with an operational partner, the Physical Medicine and Rehabilitation National Program Office, is to facilitate the full implementation of the IETP across all 5 Veterans Health Administration TBI-Centers of Excellence (TBI-COE) and to inform minimum standards while supporting the unique characteristics of each site. OBJECTIVE: This IETP partnered evaluation will describe each of the 5 TBI-COE IETP services and state of implementation to identify opportunities for adaptation and scale, characterize the relationship between patient characteristics and clinical services received, evaluate the outcomes for participants in the IETP, and inform ongoing implementation and knowledge translation efforts to support IETP expansion. In alignment with the goals of the protocol, ineffective treatment components will be targeted for deimplementation. METHODS: A 3-year concurrent mixed methods evaluation using a participatory approach in collaboration with the operational partner and TBI-COE site leadership will be conducted. Qualitative observations, semistructured focus groups, and interviewing methods will be used to describe IETP, stakeholder experiences and needs, and suggestions for IETP implementation. Quantitative methods will include primary data collection from patients in the IETP at each site to characterize long-term outcomes and patient satisfaction with treatment and secondary data collection to quantitatively characterize patient-level and care system-level data. Finally, data sets will be triangulated to share data findings with partners to inform ongoing implementation efforts. RESULTS: Data collection began in December 2021 and is currently ongoing. The results and deliverables will inform IETP characterization, evaluation, implementation, and knowledge translation. CONCLUSIONS: The results of this evaluation seek to provide an understanding of the determinants affecting the implementation of IETPs. Service member, staff, and stakeholder insights will inform the state of implementation at each site, and quantitative measures will provide options for standardized outcome measures. This evaluation is expected to inform national Physical Medicine and Rehabilitation Office policies and processes and knowledge translation efforts to improve and expand the IETP. Future work may include cost evaluations and rigorous research, such as randomized controlled trials. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/44776.

Delivery of Complementary and Integrative Health Using Virtual Health Resources: A Scoping Review.

Introduction: Complementary and integrative health (CIH) modalities promote overall health and well-being and can be beneficial for individuals with a range of conditions. Traditionally, CIH has been delivered in person. COVID-19 created a need to identify sustainable remote delivery options to assure access to CIH while practicing public health recommendations. This scoping review maps the opportunities and challenges to remotely delivered CIH. Materials and methods: A scoping review was conducted between June 2020 and October 2020 using the following search engines: PubMed, Academic Search Premier, PsycINFO, CINAHL, Cochrane Reviews, and the Cochrane Clinical Trial Collections. Search results investigating remote CIH delivery were restricted to articles written in English, published after 1990. Results: Of the 10,884 articles identified, after review for content and methods, 330 articles were included. Most articles were randomized controlled trials (n = 170), applied mindfulness (n = 203), and targeted mental and behavioral health conditions (n = 182). Interventions were primarily delivered through mobile applications (n = 151) and web-based platforms (n = 86). Most commonly reported barriers were adherence (n = 24), resource requirements (e.g., time and space) (n = 23), and technology-related issues (n = 21). Although most studies did not report facilitators (n = 217), most commonly reported facilitators were social and technologic supports, accessibility, usability, perceptions, and rewards. Participant outcomes measured were broad and included movement (n = 88), stress (n = 68), and pain (n = 54). Intervention characteristic outcomes most often measured were satisfaction and usability (n = 5). Conclusions: This scoping literature review identified many articles addressing remote delivery of CIH, but few reporting on the implementation of remotely delivered CIH. Findings suggest remotely delivered CIH, specifically mindfulness and meditation-based modalities, is a viable treatment option for a diverse range of health conditions. Feasibility studies and larger sample sizes are recommended to strengthen the scientific evidence.

Preliminary Evidence on the Association of Complementary and Integrative Health Care Program Participation and Medical Cost in Veterans.

INTRODUCTION: Transforming Health and Resilience through Integration of Values-based Experiences (THRIVE) is a complimentary and integrative health program. THRIVE is delivered through shared medical appointments where participants engage in provider-led education and group discussion on wellness-related topics. THRIVE has been associated with improved patient-reported outcomes in a female veteran cohort. This quality improvement study evaluated the association between THRIVE participation and Veterans Health Administration (VHA) healthcare costs across a 1 year period. MATERIALS AND METHODS: A cohort study design (n = 184) used VHA administrative data to estimate the cost difference between 1 year pre- and post-THRIVE participation. The 1 year post-cost of the THRIVE cohort was then compared to the 1 year cost of a quasi-experimental waitlist control group (n = 156). Data sources included VHA administrative and electronic health records. RESULTS: Patients were roughly 51 years old, were typically White/Caucasian, and had a service priority level representing catastrophic disability. The adjusted post-THRIVE cost was $26,291 [95% confidence interval (CI): $23,014-29,015]; $1,720 higher than the previous year's cost but was not statistically significant (P = 0.289). However, a comparison between the THRIVE cohort and a group of waitlist THRIVE patients (n = 156) the intervention group on average was $8,108 more than the waitlist group (95% CI: $3,194-14,005; P < 0.01). CONCLUSIONS: In summary, data analysis of veterans' annual healthcare cost trajectories were inconclusive. This preliminary study produced mixed results requiring more research with larger samples and randomized control trial methodology. Evidence of whether the THRIVE intervention can maintain cost effectiveness while maintaining its supported evidence of healthcare quality is needed.

Transforming Health and Resiliency Through Integration of Values-based Experiences: Implementation of an Electronic Evidence-based Whole Health Clinical Program.

BACKGROUND: Complementary and integrative health (CIH) is the foundation of the Department of Veterans Affairs (VA) Whole Health System program (WH), including Transforming Health and Resiliency through Integration of Values-based Experiences (THRIVE). The global COVID-19 pandemic prompted an urgent need to provide services such as THRIVE while following guidelines for social distancing. OBJECTIVE: The objective of this paper was to describe the systematic implementation of THRIVE using an electronic delivery model. METHODS: The study involved an observational clinical program implementation project using the RE-AIM framework to contextualize the implementation strategies and results, and then the implementation of an electronically delivered CIH group medical appointment program (eTHRIVE). RESULTS: Clinical staff transitioned to 100% electronic delivery of the THRIVE curriculum using the new eTHRIVE delivery model. The current electronic delivery model, eTHRIVE, has effectively enrolled 10-12 veterans per cohort, with 8 cohorts, totaling 87 veterans to date. eTHRIVE attrition has been 6% (5/87) since initiation. CONCLUSIONS: The current climate of the VA WH programmatic initiative combined with the public health needs during a global pandemic prompted the move of THRIVE program into an electronic format to broaden scalability and reach.

A complementary and integrative health group-based program pilot demonstrates positive health outcomes with female Veterans.

INTRODUCTION: Transforming Health and Resiliency through Integration of Values-based Experiences (THRIVE) is an evidence-based 14-week curriculum-based group medical appointment clinical program. THRIVE is based on principles of integrative medicine, positive psychology, and acceptance and commitment therapy. The goal of this paper is to review findings from a local THRIVE program implementation piloted in the Women's Health outpatient clinics on mental and physical health indicators. MATERIALS AND METHODS: Pilot data were obtained for 14 THRIVE cohorts of female veterans enrolled from outpatient clinics at the James A. Haley veterans' Hospital in Tampa, FL between 2016 and 2018 (N = 201). THRIVE assessments were conducted as part of the THRIVE program, at the first visit (baseline), mid-way, and at the end of the program. Data were collected using self-administered paper-pencil method on standardized scales for physical and mental health (Patient Health Questionnaire, Generalized Anxiety Disorder Questionnaire, Acceptance and Action Questionnaire-II, Satisfaction With Life Scale, and the physical and mental function components of the Short Form Survey). Linear mixed effects models were used to examine change in physical and mental health scales over time while adjusting for age, race (white vs. other), and cohort. In addition, we examined whether the rate of change differed by age or race. RESULTS: Improvement was seen for most scales across the 3 assessments (p < 0.05) with the exception of physical composite score of the Short Form Survey (p = 0.487). Participants reported that pain interfering with work significantly decreased from "quite a bit" at baseline to "moderately" by assessment 3 (p = 0.042). Older ages had lower baseline scores on the Patient Health Questionnaire and Acceptance and Action Questionnaire than younger ages, but younger ages had a greater rate of improvement over the intervention (p for interaction 0.016 and 0.056, respectively). Whites reported greater improvement in life satisfaction than non-whites (p for interaction 0.043). For physical composite score, whites had higher baseline score, but did not report significant improvement in physical function over the assessment period, while non-whites had lower baseline score, but did report significant improvement in physical function (p for interaction 0.059). Non-white veterans reported more pain interfering with work relative to white veterans (OR 5.9, 95% CI 1.79-19.43, p = 0.004). CONCLUSIONS: We found significant improvement on self-reported mental health scales as well as improvement in how much pain interferes with work in a pilot sample of women veterans over the 14-week program.

Using Electronic Data Collection Platforms to Assess Complementary and Integrative Health Patient-Reported Outcomes: Feasibility Project.

BACKGROUND: The Veteran Administration (VA) Office of Patient-Centered Care and Cultural Transformation is invested in improving veteran health through a whole-person approach while taking advantage of the electronic resources suite available through the VA. Currently, there is no standardized process to collect and integrate electronic patient-reported outcomes (ePROs) of complementary and integrative health (CIH) into clinical care using a web-based survey platform. This quality improvement project enrolled veterans attending CIH appointments within a VA facility and used web-based technologies to collect ePROs. OBJECTIVE: This study aimed to (1) determine a practical process for collecting ePROs using patient email services and a web-based survey platform and (2) conduct analyses of survey data using repeated measures to estimate the effects of CIH on patient outcomes. METHODS: In total, 100 veterans from one VA facility, comprising 11 cohorts, agreed to participate. The VA patient email services (Secure Messaging) were used to manually send links to a 16-item web-based survey stored on a secure web-based survey storage platform (Qualtrics). Each survey included questions about patient outcomes from CIH programs. Each cohort was sent survey links via Secure Messaging (SM) at 6 time points: weeks 1 through 4, week 8, and week 12. Process evaluation interviews were conducted with five primary care providers to assess barriers and facilitators to using the patient-reported outcome survey in usual care. RESULTS: This quality improvement project demonstrated the usability of SM and Qualtrics for ePRO collection. However, SM for ePROs was labor intensive for providers. Descriptive statistics on health competence (2-item Perceived Health Competence Scale), physical and mental health (Patient-Reported Outcomes Measurement Information System Global-10), and stress (4-item Perceived Stress Scale) indicated that scores did not significantly change over time. Survey response rates varied (18/100, 18.0%-42/100, 42.0%) across each of the 12 weekly survey periods. In total, 74 of 100 participants provided ≥1 survey, and 90% (66/74) were female. The majority, 62% (33/53) of participants, who reported the use of any CIH modality, reported the use of two or more unique modalities. Primary care providers highlighted specific challenges with SM and offered solutions regarding staff involvement in survey implementation. CONCLUSIONS: This quality improvement project informs our understanding of the processes currently available for using SM and web-based data platforms to collect ePROs. The study results indicate that although it is possible to use SM and web-based survey platforms for ePROs, automating scheduled administration will be necessary to reduce provider burden. The lack of significant change in ePROs may be due to standard measures taking a biomedical approach to wellness. Future work should focus on identifying ideal ePRO processes that would include standardized, whole-person measures of wellness.