Virtual mental health care in the Veterans Health Administration's immediate response to coronavirus disease-19.

The coronavirus disease 2019 (COVID-19) pandemic has increased the need for psychological care in the global population and has created new barriers to accessing services. Hospitals, mental health facilities, and other clinics face the challenge of providing continued care to a population that is under severe stress, while minimizing in-person visits that risk spreading the virus. The Veterans Health Administration (VHA) is the largest integrated health care system in the United States, providing care at 1,286 sites. VHA ensured the continuity of mental health services after the COVID-19 outbreak by rapidly expanding its use of telemental health methods in the first weeks after the U.S. pandemic outbreak. VHA provided nearly 1.2 million telephone and video encounters to veterans in April 2020 and reduced in-person visits by approximately 80% when compared with the October 2019 to February 2020 period before the pandemic. By June 2020, VHA had an 11-fold increase in encounters using direct-to-home video and a fivefold increase in telephone contacts relative to before the pandemic. This article discusses research on the effectiveness of telemental health, VHA policies before COVID-19 that facilitated the use of telemental health systemwide, and VHA's actions that rapidly scaled use of telemental health during the first months of the outbreak. Key challenges and lessons learned from VHA's experience and implications for providers and health care systems regarding the use of telemental health to meet patients' mental health care needs during the pandemic are also discussed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Tailored to Fit: How an Implementation Framework Can Support Pragmatic Pain Care Trial Adaptation for Diverse Veterans Affairs Clinical Settings.

BACKGROUND: Veterans Affairs (VA) has rolled out a holistic, multicomponent Whole Health care model nationwide, yet no pragmatic trials have been conducted in real-world clinical settings to compare its effectiveness against other evidence-based approaches for chronic pain management in veterans. OBJECTIVES: We describe the adaptation of the first large pragmatic randomized controlled trial of the Whole Health model for chronic pain care for diverse VA clinical settings. RESEARCH DESIGN: Informed by the Promoting Action on Research Implementation in Health Systems implementation framework, we conducted qualitative semistructured interviews to obtain feedback on trial design from VA leadership, frontline clinicians, and veterans with chronic pain at 5 VA enrollment sites. Next, we convened in-person evidence-based quality improvement (EBQI) meetings with study stakeholders (including frontline clinicians and administrators) at each site to discuss study design; review interview themes; and identify site-specific barriers, facilitators, and approaches to implementation. Ethnographic observations from EBQI meetings provided additional insight into implementation strategies. SUBJECTS: Seventy-four veteran and VA staff stakeholders were interviewed; 71 stakeholders participated in EBQI meetings. RESULTS: At each site, unique clinical contexts and varying resources for Whole Health and pain care delivery affected plans for trial implementation. We present examples of local adaptations that emerged through the formative evaluation process to facilitate implementation and yield a more pragmatic trial design. CONCLUSIONS: A systematic formative evaluation can facilitate engagement and buy-in of study stakeholders. Locally tailored pragmatic implementation strategies may improve the likelihood of successful trial execution as well as future implementation of evidence-based pain care approaches in real-world clinical settings.

Patient Feedback on the Effectiveness of Auricular Acupuncture on Pain in Routine Clinical Care: The Experience of 11,406 Veterans.

OBJECTIVES: Veterans Health Administration (VHA) launched a national initiative to train providers in a specific, protocolized auricular acupuncture treatment (also called Battlefield Acupuncture or BFA) as a nonpharmacological approach to pain management. This evaluation assessed the real-world effectiveness of BFA on immediate pain relief and identified subgroups of patients for whom BFA is most effective. RESEARCH DESIGN: In a cross-sectional cohort study, electronic medical record data for 11,406 Veterans treated with BFA at 57 VHA medical centers between October 2016 and September 2018 was analyzed. The multivariate analysis incorporated data on pain history, change in pain level on an 11-point scale, complications, and demographic information. METHODS: A total of 11,406 Veterans were treated with BFA at 57 VHA medical centers between October 2016 and September 2018 and had effectiveness data recorded in their electronic medical record. RESULTS: More than 3 quarters experienced immediate decreases in pain following administration of BFA, with nearly 60% reported experiencing a minimal clinically important difference in pain intensity. The average decrease in pain intensity was -2.5 points (SD=2.2) at the initial BFA treatment, and -2.2 points (SD=2.0) at subsequent treatments. BFA was effective across a wide range of Veterans with many having preexisting chronic pain, or physical, or psychological comorbid conditions. Veterans with opioid use in the year before BFA experienced less improvement, with pain intensity scores improving more among Veterans who had not recently used opioids. CONCLUSION: VHA's rapid expansion of training providers to offer BFA as a nonpharmacological approach to pain management has benefited many Veterans.

Developing a template matching algorithm for benchmarking hospital performance in a diverse, integrated healthcare system.

Template matching is a proposed approach for hospital benchmarking, which measures performance based on matching a subset of comparable patient hospitalizations from each hospital. We assessed the ability to create the required matched samples and thus the feasibility of template matching to benchmark hospital performance in a diverse healthcare system.Nationwide Veterans Affairs (VA) hospitals, 2017.Observational cohort study.We used administrative and clinical data from 668,592 hospitalizations at 134 VA hospitals in 2017. A standardized template of 300 hospitalizations was selected, and then 300 hospitalizations were matched to the template from each hospital.There was substantial case-mix variation across VA hospitals, which persisted after excluding small hospitals, hospitals with primarily psychiatric admissions, and hospitalizations for rare diagnoses. Median age ranged from 57 to 75 years across hospitals; percent surgical admissions ranged from 0.0% to 21.0%; percent of admissions through the emergency department, 0.1% to 98.7%; and percent Hispanic patients, 0.2% to 93.3%. Characteristics for which there was substantial variation across hospitals could not be balanced with any matching algorithm tested. Although most other variables could be balanced, we were unable to identify a matching algorithm that balanced more than ∼20 variables simultaneously.We were unable to identify a template matching approach that could balance hospitals on all measured characteristics potentially important to benchmarking. Given the magnitude of case-mix variation across VA hospitals, a single template is likely not feasible for general hospital benchmarking.

Team communication within integrated primary care in the context of suicide prevention: A mixed methods preliminary examination.

Direct and indirect communication through the electronic medical record play a vital role in helping medical home primary care teams implement suicide prevention efforts. The purpose of this study is to examine how communication related to suicide prevention occurs among primary care team members working within a group of clinics in the Veterans Health Administration that has embedded integrated behavioral health providers (BHPs) and uses a shared electronic medical record. Using sequential exploratory mixed methods design, eight focus groups and 11 in-depth interviews with primary care providers (PCPs), nurses, and BHPs comprised the qualitative portion of the study, which was used to help develop an online questionnaire distributed to all primary care teams. Participants (n = 86) of the online survey included 15 BHPs, 32 PCPs, and 39 registered nurses. Qualitative data included asking a series of questions concerning how suicide prevention is accomplished in primary care. Themes concerning how providers communicate both directly and indirectly arose from the data and were used to develop questions for the survey to help further understand the data. Overall, the data suggested good team communication was occurring. However, there were opportunities to enhance communication through the use of huddles and enhancing communication from PCPs to other team members when the patient's medical status changed. Direct communication was preferred, and finding ways to increase communication may be important to help decrease potential errors that may occur via diffusion of responsibility. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Measurement-based care implementation in a Veterans Affairs primary care-mental health integration program.

Measurement-based care (MBC) in behavioral health is the systematic use of validated measurement tools to guide clinical decision making and collaborative treatment planning. Although benefits of MBC for clinicians and patients have been supported by research, it appears to be underutilized in clinical settings. This study examined the effectiveness of a MBC implementation plan informed by the theory of planned behavior in a large, integrated primary care program at a Veterans Affairs hospital over 18 months. Multiple methods, including self-report clinician data and aggregated clinic data, were used to examine change in clinician MBC-related behaviors over time. Results demonstrated both an increase in symptom measures administered per clinical encounter and per individual patient treated. Additionally, the ratio of individuals receiving at least one symptom rating measure to total number of patients treated decreased over time, demonstrating increased use of MBC by integrated primary care clinicians. Survey data demonstrated upward trends in administering measures at initial assessment and at treatment termination, and clinician attitudes toward MBC were generally positive. Results corroborate the theory of planned behavior as a model in which to guide systematic MBC implementation. MBC implementation challenges and recommendations are discussed. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Analyzing free-text survey responses: An accessible strategy for developing patient-centered programs and program evaluation.

Despite widespread availability of yoga in the Veterans Health Administration (VA), it remains unclear how to best evaluate yoga programs. This is particularly problematic for programs aimed at veterans with mental health concerns, as evaluation typically focuses narrowly upon mental health symptom severity, even though program participants may have other health-related priorities. We analyzed responses to free-text questions on 237 surveys completed by veterans with mental health concerns enrolled in a yoga program at six VA clinics in Louisiana to characterize veteran participants' experiences with yoga. Qualitative analysis resulted in 15 domains reflecting veterans' individual health-related values and priorities. We use results to illustrate the potential for analysis of free-text responses to reveal valuable insights into patient experiences, demonstrating how these data can inform patient-centered program evaluation. The approach we present is more accessible to those responsible for decision-making about local programs than conventional methods of analyzing qualitive evaluation data.

Creating World-Class Care and Service for Our Nation's Finest: How Veterans Health Administration Diffusion of Excellence Initiative Is Innovating and Transforming Veterans Affairs Health Care.

As the largest integrated health care system in the US, the Veterans Health Administration is dedicated to continually innovating its systems, technology, and practices to provide high-quality care to US veterans. In this article, I describe the Veterans Health Administration's Diffusion of Excellence Initiative, which involves an annual, systemwide competition to recognize Department of Veterans Affairs employees and identify promising practices for implementation in other Department of Veterans Affairs facilities or Veterans Integrated Service Networks. To demonstrate the reach and impact of the initiative, I highlight practices that are being implemented in 4 areas: 1) direct scheduling, 2) access to health care in rural areas, 3) access to mental health care, and 4) interactive and patient-centered care. In addition, I outline the primary components of the current transition plan to elevate lessons learned and transform the initiative from a nascent start-up to a sustainable part of the Veterans Health Administration's culture.

Access to Comprehensive Services for Advanced Liver Disease in the Veterans Health Administration.

BACKGROUND: The Veterans Health Administration (VHA) provides care to the one of the largest cohorts of patients with advanced liver disease (ALD) in the USA. AIMS: We performed a national survey to assess system-wide strengths and barriers to care for Veterans with ALD in this national integrated healthcare setting. METHODS: A 52-item survey was developed to assess access and barriers to care in Veterans with ALD. The survey was distributed to all VHA medical centers in 2015. Results were analyzed using descriptive statistics. RESULTS: One hundred and fifty-three sites responded to this survey. Multidisciplinary services were available on-site at > 80% of sites. Ninety-five percent of sites had mental health and addictions treatment available, with 14% co-locating these services within the liver clinic. Few sites (< 25%) provided pharmacologic treatment for alcohol use disorder in primary care or hepatology settings. Seventy-two percent of sites reported at least one barrier to liver-related care. Of the sites reporting at least one barrier, 53% reported barriers to liver transplant referral, citing complex processes and lack of staff/resources to coordinate referrals. Palliative care was widely available, but 61% of sites reported referring < 25% of their patients with ALD for palliative services. CONCLUSION: Multidisciplinary services for Veterans with ALD are widely available at VHA sites, though barriers to optimal care remain. Opportunities for improvement include the expansion of providers with hepatology expertise, integrating pharmacotherapy for alcohol use disorder into hepatology and primary care, streamlining the transplant referral process, and expanding palliative care referrals for patients with ALD.

High Quality of Care Persists With Shifting Depression Services From VA Specialty to Integrated Primary Care.

BACKGROUND/OBJECTIVE: Offering depression collaborative care services in primary care (PC) settings can reduce use of nonintegrated mental health care resources and improve mental health care access, particularly for vulnerable PC patients. Tests of effects on depression care quality, however, are needed. We examined overall quality of depression care and tested whether increasing clinic engagement in Veterans Affairs (VA)'s Primary Care-Mental Health Integration (PC-MHI) services was associated with differences in depression care quality over time. METHODS: We conducted a retrospective longitudinal cohort study of 80,136 Veterans seen in 26 Southern California VA PC clinics (October 1, 2008-September 30, 2013). Using multilevel regression models adjusting for year, clinic, and patient characteristics, we predicted effects of clinic PC-MHI engagement (ie, percent of PC patients receiving PC-MHI services) on 3 VA-developed longitudinal electronic population-based depression quality measures among Veterans newly diagnosed with depression (n=12,533). RESULTS: Clinic PC-MHI engagement rates were not associated with significant depression care quality differences. Across all clinics, average rates of follow-up within 84 or 180 days were, 66.4% and 74.5%, respectively. Receipt of minimally appropriate treatment was 80.5%. Treatment probabilities were significantly higher for vulnerable PC patients (homeless: 4.5%, P=0.03; serious mental illness: 15.2%, P<0.001), than for otherwise similar patients without these characteristics. CONCLUSIONS/POLICY IMPLICATIONS: Study patients treated in PC clinics with greater PC-MHI engagement received similarly high quality depression care, and even higher quality for vulnerable patients. Findings support increasing use of PC-MHI models to the extent that they confer some advantage over existing services (eg, access, patient satisfaction) other than quality of care.

Coordinating Care Across VA Providers and Settings: Policy and Research Recommendations from VA's State of the Art Conference.

Delivering well-coordinated care is essential for optimizing clinical outcomes, enhancing patient care experiences, minimizing costs, and increasing provider satisfaction. The Veterans Health Administration (VA) has built a strong foundation for internally coordinating care. However, VA faces mounting internal care coordination challenges due to growth in the number of Veterans using VA care, high complexity in Veterans' care needs, the breadth and depth of VA services, and increasing use of virtual care. VA's Health Services Research and Development service with the Office of Research and Development held a conference assessing the state-of-the-art (SOTA) on care coordination. One workgroup within the SOTA focused on coordination between VA providers for high-need Veterans, including (1) Veterans with multiple chronic conditions; (2) Veterans with high-intensity, focused, specialty care needs; (3) Veterans experiencing care transitions; (4) Veterans with severe mental illness; (5) and Veterans with homelessness and/or substance use disorders. We report on this workgroup's recommendations for policy and organizational initiatives and identify questions for further research. Recommendations from a separate workgroup on coordinating VA and non-VA care are contained in a companion paper. Leaders from research, clinical services, and VA policy will need to partner closely as they develop, implement, assess, and spread effective practices if VA is to fully realize its potential for delivering highly coordinated care to every Veteran.

Recommendations for the Evaluation of Cross-System Care Coordination from the VA State-of-the-art Working Group on VA/Non-VA Care.

In response to widespread concerns regarding Veterans' access to VA care, Congress enacted the Veterans Access, Choice and Accountability Act of 2014, which required VA to establish the Veterans Choice Program (VCP). Since the inception of VCP, more than two million Veterans have received care from community providers, representing approximately 25% of Veterans enrolled in VA care. However, expanded access to non-VA care has created challenges in care coordination between VA and community health systems. In March 2018, the VA Health Services Research & Development Service hosted a VA State of the Art conference (SOTA) focused on care coordination. The SOTA convened VA researchers, program directors, clinicians, and policy makers to identify knowledge gaps regarding care coordination within the VA and between VA and community systems of care. This article provides a summary and synthesis of relevant literature and provides recommendations generated from the SOTA about how to evaluate cross-system care coordination. Care coordination is typically evaluated using health outcomes including hospital readmissions and death; however, in cross-system evaluations of care coordination, measures such as access, cost, Veteran/patient and provider satisfaction (including with cross-system communication), comparable quality metrics, context (urban vs. rural), and patient complexity (medical and mental health conditions) need to be included to fully evaluate care coordination effectiveness. Future research should examine the role of multiple individuals coordinating VA and non-VA care, and how these coordinators work together to optimize coordination.

Organizational Coordination and Patient Experiences of Specialty Care Integration.

BACKGROUND: Delivering care to patients with complex healthcare needs benefits from coordination among healthcare providers. Greater levels of care coordination have been associated with more favorable patient experiences, cost management, and lower utilization of services. Organizational approaches consider how systems, practices, and relationships influence coordination and associated outcomes. OBJECTIVE: Examine measures of organizational coordination and their association with patient experiences of care coordination involving specialists. DESIGN: Cross-sectional surveys of patients and primary care providers (PCPs). PARTICIPANTS: Final sample included 3183 patients matched to 233 PCPs from the Veterans Health Administration. All patients had a diagnosis of type 2 diabetes mellitus and one of four other conditions: hypertension; congestive heart failure; depression/anxiety; or severe mental illness/posttraumatic stress disorder. MAIN MEASURES: Patients completed a survey assessing perceptions of coordinated care. We examined ratings on three domains: specialist knowledge management; knowledge integration across settings and time; and knowledge fragmentation across settings and time. We created care coordination measures involving the PCP and three specialty provider types. PCPs provided ratings on relational coordination for specialists, feedback coordination, and team coordination. We aligned patient's specialty services used with corresponding PCP ratings of that specialty. KEY RESULTS: Patient ratings were significantly lower on specialist knowledge management and knowledge integration when either PCPs did not use feedback coordination (b = - .20; b = - .17, respectively) or rated feedback coordination lower (b = - .08 for both). Teamwork was significantly related to specialist knowledge management (b = .06), knowledge integration (b = .04); and knowledge fragmentation (b = - .04). Relational coordination was related to coordination between the primary care provider and (i) diabetes specialist (b = .09) and (ii) mental health provider (b = .12). CONCLUSIONS: Practices to improve provider coordination within and across primary care and specialty care services may improve patient experiences of care coordination. Improvements in these areas may improve care efficiency and effectiveness.

What Should Health Care Systems Consider When Implementing Complementary and Integrative Health: Lessons from Veterans Health Administration.

OBJECTIVES: Health care systems are increasingly interested in becoming whole health systems that include complementary and integrative health (CIH) approaches. The nation's largest health care system, the Veterans Health Administration (VA), has been transforming to such a system. However, anecdotal evidence suggested that many VA medical centers have faced challenges in implementing CIH approaches, whereas others have flourished. We report on a large-scale, research-operations partnered effort to understand the challenges faced by VA sites and the strategies used to address these to better support VAs implementation of CIH nationally. DESIGN: We conducted semi-structured, in-person qualitative interviews with 149 key stakeholders at 8 VA medical centers, with content based on Greenhalgh's implementation framework. For analysis, we identified a priori categories of content aligned with Greenhalgh's framework and then generated additional categories developed inductively, capturing additional implementation experiences. These categories formed a template to aid in coding data. RESULTS: VA sites commonly reported that nine key factors facilitated CIH implementation: (1) organizing individual CIH approaches into one program instead of spreading across several departments; (2) having CIH strategic plans and steering committees; (3) strong, professional, and enthusiastic CIH program leads and practitioners; (4) leadership support; (5) providers' positive attitudes toward CIH; (6) perceptions of patients' attitudes; (7) demonstrating evidence of CIH effectiveness; (8) champions; and (9) effectively marketing. Common challenges included are: (1) difficulties in hiring; (2) insufficient/inconsistent CIH funding; (3) appropriate patient access to CIH approaches; (4) difficulties in coding/documenting CIH use; (5) insufficient/inappropriate space; (6) insufficient staff's and provider's time; and (7) the health care cultural and geographic environments. Sites also reported several successful strategies supporting CIH implementation. CONCLUSIONS: VA sites experience both success and challenges with implementing CIH approaches and have developed a wide range of strategies to support their implementation efforts. This information is potentially useful to other health care organizations considering how best to support CIH provision.

Improvements in Gulf War Illness Symptoms After Near-Infrared Transcranial and Intranasal Photobiomodulation: Two Case Reports.

At least one-fourth of US veterans who served in the 1990-1991 Gulf War (GW) are affected by the chronic symptomatic illness known as Gulf War illness (GWI). This condition typically includes some combination of fatigue, headaches, cognitive dysfunction, musculoskeletal pain, and respiratory, gastrointestinal and dermatologic complaints. To date, effective treatments for GWI have been elusive. Photobiomodulation (PBM) describes the non-pharmacological, non-thermal use of light to stimulate, heal, and protect tissue that has either been injured, is degenerating, or else is at risk of dying. Significant benefits have been reported following application of transcranial PBM to humans with acute stoke, traumatic brain injury (TBI), and dementia. This report describes the first documentation of improved GWI symptoms in two GW veterans following 12 weeks of PBM treatments.