VA Provider Perspectives on Coordinating COPD Care Across Health Systems.

BACKGROUND: More and more Veterans are receiving care from community providers, increasing the need for effective coordination across health systems. For Veterans with chronic obstructive pulmonary disease (COPD), this need is intensified by complex comorbidity patterns that often include multiple providers co-managing patient care. OBJECTIVES: We sought to understand how VA providers perceive coordination with community providers for Veterans with COPD. DESIGN: Qualitative study of VA providers. METHODS: We selected six geographically diverse VA sites and conducted semi-structured telephone interviews with providers practicing in inpatient and/or outpatient settings who care for Veterans with COPD. MAIN MEASURES: Interviews focused on communication with community providers about discharge information and clinic management. We analyzed responses according to the principles of conventional content analysis, allowing inductive themes to emerge. KEY RESULTS: We interviewed 25 providers during the period of June to October 2017. Qualitative data analysis yielded five themes: (1) VA providers perceive communication challenges between VA and community providers, including difficult, inadequate, and delayed communication; (2) communication is facilitated by personal relationships across health systems; (3) the lack of electronic health record (EHR) interoperability impairs communication, resulting in transmission of unstructured data; (4) poor communication leads to duplicative efforts and wasted resources; and (5) providers frequently rely on patients to communicate about care taking place in the community. CONCLUSIONS: VA providers described major challenges in coordinating with community providers, leading to perceptions of delayed, missed, or duplicative care and jeopardizing the overall quality, safety, and efficiency of Veteran care. Our study highlights the need for system-level solutions to support coordination across health systems for Veterans with COPD and may have implications for other conditions that lead to recurrent hospitalization and/or care in the community.

Listening to Their Words: A Qualitative Analysis of Integrative Medicine Group Visits in an Urban Underserved Medical Setting.

OBJECTIVE: Integrative Medicine Group Visits (IMGVs) are an 8-week outpatient medical group visit program for chronic pain patients combining mindfulness-based stress reduction (MBSR), integrative medicine, and patient education. The authors conducted a qualitative study with IMGV participants to better understand the effects of IMGVs on patients' health. DESIGN: This qualitative study enrolled a convenience sample of 19 participants from the parent prospective observational cohort study of IMGVs (n = 65). All participants in the parent study were invited to participate. SETTING: Boston Medical Center (BMC) is a private, not-for-profit, 496-bed, academic medical center and the largest safety net hospital in New England. SUBJECTS: Individuals in this study had a diagnosis of chronic pain and/or one or more chronic conditions (e.g., diabetes, depression, or metabolic syndrome), had attended ≥1 group visit, and their 8-week session had ended before completing the interview. METHODS: The authors conducted individual semi-structured interviews. Interviews were audio-taped, transcribed, and analyzed. RESULTS: Participants cite gains from IMGVs including improved self-monitoring, self-regulation, and increased mindfulness. The group setting leads patients to feel "not alone" in their health conditions, gain a sense of perspective on their health, and share coping strategies in a supportive network. These improvements in physical and mental health improved clinical outcomes for participants including reductions in pain. CONCLUSIONS: Group visits and integrative medicine both offer some potential solutions in the treatment of chronic pain. Models such as IMGVs can help individuals living with chronic conditions, addressing their emotional and physical health needs.

Care coordination for veterans with COPD: a positive deviance study.

OBJECTIVES: Improving chronic obstructive pulmonary disease (COPD) care and reducing hospital readmissions is an urgent healthcare system priority. However, little is known about the organizational factors that underlie intersite variation in readmission rates. Evidence from other chronic diseases points to care coordination as one such factor. STUDY DESIGN: To understand whether intersite differences in care coordination may be one of the organizational factors contributing to the variation in readmission rates, we examined provider perspectives on COPD care at Veterans Affairs (VA) sites. METHODS: In this mixed-methods positive deviance study, we selected 3 VA sites in the lowest quartile and 3 in the highest quartile for 2016 risk-adjusted COPD readmission rates. During June to October 2017, we conducted semistructured interviews with primary and specialty care providers involved in COPD care at VA sites with low (n = 14) and high (n = 11) readmission rates. RESULTS: Although providers at all sites referenced ongoing readmission reduction initiatives, only providers at low-readmission sites described practice environments characterized by high relational coordination (ie, high-quality work relationships and high-quality communication). They also reported fewer significant structural barriers to collaboration in areas like patient volume. CONCLUSIONS: The most notable differences between high- and low-readmission sites were related to the quality of relational coordination and the presence of structural barriers to coordination, rather than specific readmission reduction initiatives. Implementing organizational reforms aimed at enhancing relational coordination and removing structural barriers would enhance care for COPD and may improve quality of care for other chronic conditions.

Pregnancy and Childbirth After Sexual Trauma: Patient Perspectives and Care Preferences.

OBJECTIVE: To explore the pregnancy and childbirth experiences and preferences of women with a history of sexual trauma in order to identify trauma-informed care practices that health care providers may use to improve obstetric care. METHODS: We conducted a qualitative study consisting of semistructured interviews with women who either self-identified as having a history of sexual trauma or did not. Participants were recruited from a tertiary care ambulatory clinic and had at least one birth experience within the past 3 years. Interviews were audio-recorded and transcribed verbatim. Grounded theory was used to derive themes using the participants' own words. RESULTS: From 2015 to 2017, we interviewed 20 women with a history of sexual trauma and 10 without. Women with a history of sexual trauma desired clear communication about their history between prenatal care providers and the labor and delivery team. In the intrapartum period, they desired control over who was present in the labor room at the time of cervical examinations and for health care providers to avoid language that served as a stressing reminder of prior sexual trauma. They wanted control over the exposure of their bodies during labor and to be asked about their preference for a male health care provider. In the postpartum period, some women with a history of sexual trauma found breastfeeding healing and empowering. CONCLUSION: Women with a history of sexual trauma have clear needs, preferences, and recommendations for obstetric care providers regarding disclosure, cervical examinations, health care provider language, body exposure, and male health care providers. They offer insight into unique breastfeeding challenges and benefits.

Inpatient Massage Therapy Versus Music Therapy Versus Usual Care: A Mixed-methods Feasibility Randomized Controlled Trial.

BACKGROUND: Little is known about the feasibility of providing massage or music therapy to medical inpatients at urban safety-net hospitals or the impact these treatments may have on patient experience. OBJECTIVE: To determine the feasibility of providing massage and music therapy to medical inpatients and to assess the impact of these interventions on patient experience. DESIGN: Single-center 3-arm feasibility randomized controlled trial. SETTING: Urban academic safety-net hospital. PATIENTS: Adult inpatients on the Family Medicine ward. INTERVENTIONS: Massage therapy consisted of a standardized protocol adapted from a previous perioperative study. Music therapy involved a preference assessment, personalized compact disc, music-facilitated coping, singing/playing music, and/or songwriting. Credentialed therapists provided the interventions. MEASUREMENTS: Patient experience was measured with the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) within 7 days of discharge. We compared the proportion of patients in each study arm reporting "top box" scores for the following a priori HCAHPS domains: pain management, recommendation of hospital, and overall hospital rating. Responses to additional open-ended postdischarge questions were transcribed, coded independently, and analyzed for common themes. RESULTS: From July to December 2014, 90 medical inpatients were enrolled; postdischarge data were collected on 68 (76%) medical inpatients. Participants were 70% females, 43% non-Hispanic black, and 23% Hispanic. No differences between groups were observed on HCAHPS. The qualitative analysis found that massage and music therapy were associated with improved overall hospital experience, pain management, and connectedness to the massage or music therapist. CONCLUSIONS: Providing music and massage therapy in an urban safety-net inpatient setting was feasible. There was no quantitative impact on HCAHPS. Qualitative findings suggest benefits related to an improved hospital experience, pain management, and connectedness to the massage or music therapist.