Clinical pharmacy practitioners' semi-visible labor: building referral relationships in interprofessional collaborative care.

Clinical pharmacy practitioners (CPP) in the Veterans Health Administration (VHA) prescribe medications and help manage chronic conditions such as diabetes, and they are increasingly working as part of interprofessional clinical teams. The challenges of integrating a new role in a clinical team are documented, but we know less about strategies new healthcare providers use to overcome these challenges. We studied how clinical pharmacy practitioners integrated into clinical teams. We conducted telephone interviews with clinical pharmacy practitioners (n = 53) and members of their clinical teams (n = 74), which were recorded, transcribed, and coded for concepts and themes. We identified four major themes. We found CPP perceived VHA as a "safe haven" for interprofessional care but found it necessary to build other prescribers' trust and confidence in their clinical skills to establish the referral relationships they needed for full integration. To facilitate their integration, CPP engaged in relational, untracked labor, which we characterize as semi-visible labor. While both CPP and clinical team members perceived CPPs' semi-visible labor as vital for implementing and maintaining strong interprofessional collaborations, such labor may be unsustainable as a long-term strategy for integrating CPP in clinical teams.

Impact of Patient-Clinical Team Secure Messaging on Communication Patterns and Patient Experience: Randomized Encouragement Design Trial.

BACKGROUND: Although secure messaging (SM) between patients and clinical team members is a recommended component of continuous care, uptake by patients remains relatively low. We designed a multicomponent Supported Adoption Program (SAP) to increase SM adoption among patients using the Veterans Health Administration (VHA) for primary care. OBJECTIVE: Our goals were to (1) conduct a multisite, randomized, encouragement design trial to test the effectiveness of an SAP designed to increase patient engagement with SM through VHA's online patient portal (My HealtheVet [MHV]) and (2) evaluate the impact of the SAP and patient-level SM adoption on perceived provider autonomy support and communication. Patient-reported barriers to SM adoption were also assessed. METHODS: We randomized 1195 patients at 3 VHA facilities who had MHV portal accounts but had never used SM. Half were randomized to receive the SAP, and half served as controls receiving usual care. The SAP consisted of encouragement to adopt SM via mailed educational materials, proactive SM sent to patients, and telephone-based motivational interviews. We examined differences in SM adoption rates between SAP recipients and controls at 9 months and 21 months. Follow-up telephone surveys were conducted to assess perceived provider autonomy support and self-report of telephone communication with clinical teams. RESULTS: Patients randomized to the SAP had significantly higher rates of SM adoption than the control group (101/595, 17.0% vs 40/600, 6.7%; P<.001). Most adopters in the SAP sent their first message without a motivational interview (71/101, 70.3%). The 10-percentage point difference in adoption persisted a full year after the encouragement ended (23.7%, 142/600 in the SAP group vs 13.5%, 80/595 in the control group, P<.001). We obtained follow-up survey data from 49.54% (592/1195) of the participants. SAP participants reported higher perceived provider autonomy support (5.7 vs 5.4, P=.007) and less telephone use to communicate with their provider (68.8% vs 76.0%, P=.05), compared to patients in the control group. Patient-reported barriers to SM adoption included self-efficacy (eg, not comfortable using a computer, 24%), no perceived need for SM (22%), and difficulties with portal password or login (17%). CONCLUSIONS: The multicomponent SAP was successful in increasing use of SM 10 percentage points above standard care; new SM adopters reported improved perceptions of provider autonomy support and less use of the telephone to communicate with their providers. Still, despite the encouragement and technical assistance provided through the SAP, adoption rates were lower than anticipated, reaching only 24% at 21 months (10% above controls). Common barriers to adoption such as limited perceived need for SM may be more challenging to address and require different interventions than barriers related to patient self-efficacy or technical difficulties. TRIAL REGISTRATION: ClinicalTrials.gov NCT02665468; https://clinicaltrials.gov/ct2/show/NCT02665468.

Individual differences in children's and parents' generic language.

Generics ("Dogs bark") convey important information about categories and facilitate children's learning. Two studies with parents and their 2- or 4-year-old children (N = 104 dyads) examined whether individual differences in generic language use are as follows: (a) stable over time, contexts, and domains, and (b) linked to conceptual factors. For both children and parents, individual differences in rate of generic production were stable across time, contexts, and domains, and parents' generic usage significantly correlated with that of their own children. Furthermore, parents' essentialist beliefs correlated with their own and their children's rates of generic frequency. These results indicate that generic language use exhibits substantial stability and may reflect individual differences in speakers' conceptual attitudes toward categories.

Clinical pharmacist practitioners on primary care teams play an important role in caring for complex patients with diabetes.

PURPOSE: To evaluate whether clinical pharmacist practitioners (CPPs) are being utilized to care for patients with complex medication regimens and multiple chronic illnesses, we compared the clinical complexity of diabetes patients referred to CPPs in team primary care and those in care by other team providers (OTPs). METHODS: In this cross-sectional comparison of patients with diabetes in the US Department of Veterans Affairs (VA) healthcare system in the 2017-2019 period, patient complexity was based on clinical factors likely to indicate need for more time and resources in medication and disease state management. These factors include insulin prescriptions; use of 3 or more other diabetes medication classes; use of 6 or more other medication classes; 5 or more vascular complications; metabolic complications; 8 or more other complex chronic conditions; chronic kidney disease stage 3b or higher; glycated hemoglobin level of ≥10%; and medication regime nonadherence. RESULTS: Patients with diabetes referred to one of 110 CPPs for care (n = 12,728) scored substantially higher (P < 0.001) than patients with diabetes in care with one of 544 OTPs (n = 81,183) on every complexity measure, even after adjustment for age, sex, race, and marital status. Based on composite summary scores, the likelihood of complexity was 3.42 (interquartile range, 3.25-3.60) times higher for those in ongoing CPP care (ie, those with 2 or more visits) versus OTP care. Patients in CPP care also were, on average, younger, more obese, and had more prior outpatient visits and hospital stays. CONCLUSION: The greater complexity of patients with diabetes seen by CPPs in primary care suggests that CPPs are providing valuable services in comprehensive medication and disease management of complex patients.

Perceptions of clinical pharmacy specialists' contributions in mental health clinical teams.

INTRODUCTION: Mental health (MH) clinical pharmacy specialists (CPS) are increasingly functioning as integral providers in MH care teams. MH providers may delegate many medication management tasks to the CPS. As there is a shortage of primary care and specialist MH providers, CPS are increasingly being utilized in MH care clinics. We assess provider and CPS perceptions of the contributions of CPS to MH clinical teams in the Veterans Health Administration. METHODS: We examined the roles and functions of CPS in MH clinics through surveys (n = 374) and semistructured interviews (n = 16) with MH CPS and other members of MH clinical teams (psychiatrists, nurse practitioners, registered nurses, social workers) to gain insight into how CPS were integrated in these settings. We assessed perceptions of CPS contributions to MH teams, interactions between CPS and other providers, and challenges of integrating CPS into MH clinical teams. RESULTS: Contributions of CPS in MH were received positively by clinical team members. Clinical pharmacy specialists providing comprehensive medication management were especially valuable in the management of clozapine. The knowledge and training of CPS reassured providers who frequently referred to them with questions about medication and medication therapy management. MH CPS were also perceived to be received well by patients. DISCUSSION: The integration of MH CPS into MH teams was well received by team members and patients alike. The MH CPS have become important members of the MH team and are widely viewed as being able to improve access, quality, and workflow.

Introducing clinical pharmacy specialists into interprofessional primary care teams: Assessing pharmacists' team integration and access to care for rural patients.

ABSTRACT: Clinical pharmacy specialists (CPS) were deployed nationally to improve care access and relieve provider burden in primary care.The aim of this study was to assess CPS integration in primary care and the Clinical Pharmacy Specialist Rural Veteran Access (CRVA) initiative's effectiveness in improving access.Concurrent embedded mixed-methods evaluation of participating CRVA CPS and their clinical team members (primary care providers, others).Health care providers on primary care teams in Veterans Health Administration (VHA).Perceived CPS integration in comprehensive medication management assessed using the MUPM and semi-structured interviews, and access measured with patient encounter data.There were 496,323 medical encounters with CPS in primary care over a 3-year period. One hundred twenty-four CPS and 1177 other clinical team members responded to a self-administered web-based questionnaire, with semi-structured interviews completed by 22 CPS and clinicians. Survey results indicated that all clinical provider groups rank CPS as making major contributions to CMM. CPS ranked themselves as contributing more to CMM than did their physician team members. CPS reported higher job satisfaction, less burn out, and better role fit; but CPS gave lower scores for communication and decision making as clinic organizational attributes. Themes in provider interviews focused on value of CPS in teams, relieving provider burden, facilitators to integration, and team communication issues.This evaluation indicates good integration of CPS on primary care teams as perceived by other team members despite some communication and role clarification challenges. CPS may play an important role in improving access to primary care.

Clinical Pharmacist Integration Into Veterans' Primary Care: Team Members Perspectives.

BACKGROUND: With the restructuring of primary care into patient-centered medical homes (PCMH), researchers have described role transformations that accompany the formation of core primary care teamlets (eg, primary care provider, registered nurse care manager, licensed practical nurse, medical support assistant). However, few studies offer insight into how primary care teamlets, once established, integrate additional extended team members, and the factors that influence the quality of their integration. METHODS: We examine the process of integrating Clinical Pharmacy Specialists (CPS) into primary care teams in the Veterans Health Administration (VHA). We conducted semi-structured interviews with CPS (n = 6) and clinical team members (n = 16) and performed a thematic analysis of interview transcripts. RESULTS: We characterize 2 ways CPS are integrated into primary care teamlets: in consultative roles and collaborative roles. CPS may be limited to consultative roles by team members' misconceptions about their competencies (ie, if CPS are perceived to handle only medication-related issues like refills) and by primary care providers' opinions about distributing responsibilities for patient care. Over time, teams may correct misconceptions and integrate the CPS in a more collaborative role (ie, CPS helps manage disease states with comprehensive medication management). CONCLUSIONS: CPS integrated into collaborative roles may have more opportunities to optimize their contributions to primary care, underscoring the importance of clarifying roles as part of adequately integrating advanced practitioners in interprofessional teams.

Effects of generic language on category content and structure.

We hypothesized that generic noun phrases ("Bears climb trees") would provide important input to children's developing concepts. In three experiments, four-year-olds and adults learned a series of facts about a novel animal category, in one of three wording conditions: generic (e.g., "Zarpies hate ice cream"), specific-label (e.g., "This zarpie hates ice cream"), or no-label (e.g., "This hates ice cream"). Participants completed a battery of tasks assessing the extent to which they linked the category to the properties expressed, and the extent to which they treated the category as constituting an essentialized kind. As predicted, for adults, generics training resulted in tighter category-property links and more category essentialism than both the specific-label and no-label training. Children also showed effects of generic wording, though the effects were weaker and required more extensive input. We discuss the implications for language-thought relations, and for the acquisition of essentialized categories.

The Role of Representational Status and Item Complexity in Parent-Child Conversations about Pictures and Objects.

Mother-child conversations about pictures systematically differ from mother-child conversations about objects: Pictures are more likely than objects to elicit talk about kinds, whereas objects are more likely than pictures to elicit talk about individuals. The purpose of the current study is to examine whether this difference between pictures and objects is explained by differences in item complexity. Mothers and their 4-year-old children were randomly assigned to one of two conditions: Simple or Complex. In each condition, participants viewed 12 toy objects and 12 pictures, matched for content. The items were either highly detailed (complex condition) or very plain (simple condition). Replicating previous research, mothers and children provided relatively more focus on kinds when talking about pictures, and relatively more focus on individuals when talking about objects. The current results go further, however, to demonstrate that this effect is independent of the items' complexity. We therefore propose that the picture-object difference is not due to low-level differences in amount of perceptual detail provided, but rather is due to the greater ease with which pictures serve as representations (DeLoache, 1991). These data indicate the ways in which a fundamental conceptual distinction between kinds and individuals arises in different linguistic expressions and in different contexts.

Positive posttraumatic stress disorder screens among first-time medical cannabis patients: prevalence and association with other substance use.

Twenty-one states and the District of Columbia have passed legislation allowing for the use of medical cannabis for those individuals with qualifying medical conditions, which include posttraumatic stress disorder (PTSD) for a growing number of states. Little information is available regarding PTSD among medical cannabis patients. This study seeks to provide initial data on this topic by examining the prevalence and correlates of positive PTSD screens among a sample of patients seeking medical cannabis certification for the first time (n=186). Twenty-three percent (42/186; 95% confidence interval [CI] =17%-29%) of the patients in the study sample screened positive for PTSD. Moreover, the group that screened positive for PTSD had higher percentages of lifetime prescription opioid, cocaine, prescription sedative, and street opioid use, as well as a higher percentage of recent prescription sedative use, than the group that screened negative for PTSD. These findings highlight the relatively common use of other substances among medical cannabis patients with significant PTSD symptoms, even when compared with other patients seeking medical cannabis for the first time. As a growing number of states include PTSD among the list of qualifying medical conditions for medical cannabis, additional research is needed to better characterize the longitudinal relationship between medical cannabis use and PTSD symptoms.

Self-efficacy to avoid suicidal action: factor structure and convergent validity among adults in substance use disorder treatment.

Individuals with substance use disorders (SUDs) are at high risk of suicidal behaviors, highlighting the need for an improved understanding of potentially influential factors. One such domain is self-efficacy to manage suicidal thoughts and impulses. Psychometric data about the Self-Efficacy to Avoid Suicidal Action (SEASA) Scale within a sample of adults seeking SUD treatment (N = 464) is provided. Exploratory factor analysis supported a single self-efficacy construct. Lower SEASA scores, or lower self-efficacy, were reported in those with more severe suicidal ideation and those with more suicide attempts, providing evidence for convergent validity. Implications of measuring self-efficacy in the context of suicide risk assessment are discussed.

The Medium is the Message: Pictures and Objects Evoke Distinct Conceptual Relations in Parent-Child Conversations.

An important developmental task is learning to organize experience by forming conceptual relations among entities (e.g., a lion and a snake can be linked because both are animals; a lion and a cage can be linked because the lion lives in the cage). We propose that representational medium (i.e., pictures vs. objects) plays an important role in influencing which relations children consider. Prior work has demonstrated that pictures more readily evoke broader categories, whereas objects more readily call attention to specific individuals. We therefore predicted that pictures would encourage taxonomic and shared-property relations, whereas objects would encourage thematic and slot-filler relations. We observed 32 mother-child dyads (M child ages = 2.9 and 4.3) playing with pictures and objects, and identified utterances in which they made taxonomic, thematic, shared-property, or slot-filler links between items. The results confirmed our predictions and thus support representational medium as an important factor that influences the conceptual relations expressed during dyadic conversations.

Noncancer pain conditions and risk of suicide.

IMPORTANCE: There are limited data on the extent to which suicide mortality is associated with specific pain conditions. OBJECTIVE: To examine the associations between clinical diagnoses of noncancer pain conditions and suicide among individuals receiving services in the Department of Veterans Affairs Healthcare System. DESIGN: Retrospective data analysis. SETTING: Data were extracted from National Death Index and treatment records from the Department of Veterans Healthcare System. PARTICIPANTS: Individuals receiving services in fiscal year 2005 who remained alive at the start of fiscal year 2006 (N = 4 863 086). MAIN OUTCOMES AND MEASURES: Analyses examined the association between baseline clinical diagnoses of pain-related conditions (arthritis, back pain, migraine, neuropathy, headache or tension headache, fibromyalgia, and psychogenic pain) and subsequent suicide death (assessed in fiscal years 2006-2008). RESULTS: Controlling for demographic and contextual factors (age, sex, and Charlson score), elevated suicide risks were observed for each pain condition except arthritis and neuropathy (hazard ratios ranging from 1.33 [99% CI, 1.22-1.45] for back pain to 2.61 [1.82-3.74] for psychogenic pain). When analyses controlled for concomitant psychiatric conditions, the associations between pain conditions and suicide death were reduced; however, significant associations remained for back pain (hazard ratio, 1.13 [99% CI, 1.03-1.24]), migraine (1.34 [1.02-1.77]), and psychogenic pain (1.58 [1.11-2.26]). CONCLUSIONS AND RELEVANCE: There is a need for increased awareness of suicide risk in individuals with certain noncancer pain diagnoses, in particular back pain, migraine, and psychogenic pain.

Characteristics of adults seeking medical marijuana certification.

BACKGROUND: Very little is known about medical marijuana users. The present study provides descriptive information on adults seeking medical marijuana and compares individuals seeking medical marijuana for the first time with those renewing their medical marijuana card on measures of substance use, pain and functioning. METHODS: Research staff approached patients (n=348) in the waiting area of a medical marijuana certification clinic. Chi-square and Wilcoxon signed rank tests were used to compare participants who reported that they were seeking medical marijuana for the first time (n=195) and those who were seeking to renew their access to medical marijuana (n=153). RESULTS: Returning medical marijuana patients reported a higher prevalence of lifetime cocaine, amphetamine, inhalant and hallucinogen use than first time patients. Rates of recent alcohol misuse and drug use were relatively similar between first time patients and returning patients with the exception of nonmedical use of prescription sedatives and marijuana use. Nonmedical prescription sedative use was more common among first time visitors compared to those seeking renewal (p<0.05). The frequency of recent marijuana use was higher in returning patients than first time patients (p<0.0001). Compared to first time patients, returning patients reported somewhat lower current pain level and slightly higher mental health and physical functioning. CONCLUSIONS: Study results indicate that differences exist between first time and returning medical marijuana patients. Longitudinal data are needed to characterize trajectories of substance use and functioning in these two groups.

Qualitative evaluation of suicide and overdose risk assessment procedures among veterans in substance use disorder treatment clinics.

The objective of this study was to examine risk assessment practices for suicide and unintentional overdose to inform ongoing care in substance use disorder clinics. Focus groups were conducted via telephone among a random sample of treatment providers (N = 19) from Veterans Health Administration substance use disorder clinics across the nation. Themes were coded by research staff. Treatment providers reported consistent and clear guidelines for risk assessment of suicide among patients. Unintentional overdose questions elicited dissimilar responses which indicated a lack of cohesion and uniformity in risk assessment practices across clinics. Suicide risk assessment protocols are cohesively implemented by treatment providers. Unintentional overdose risk, however, may be less consistently assessed in clinics.

The prevalence of substance use among patients at a dental school clinic in Michigan.

BACKGROUND: Problematic alcohol use and illicit drug use are associated with a number of physical health consequences, including poor oral health. The authors evaluate the prevalence of problematic alcohol use and illicit drug use in adults who visited a dental school clinic. METHODS: The authors recruited patients from the waiting area of the clinic. During recruitment, 85.9 percent of patients (n = 384) who the authors approached consented to participate in the study. RESULTS: Overall, 20.6 percent of the participants reported either recent problematic alcohol use or illicit drug use; 7.4 percent of reported problematic alcohol use and 18.6 percent reported illicit drug use. The most common illicit drugs participants reported that they used were marijuana (16.8 percent), amphetamines (2.6 percent) and cocaine (1.1 percent). Participants who reported recent problematic alcohol use or illicit drug use were more likely to identify as white, were younger and did not have a spouse or partner. CONCLUSIONS: There was a high prevalence of illicit drug use and problematic alcohol use among the patients seen at dental school clinic. These rates were higher than those in the general population. CLINICAL IMPLICATIONS: The findings suggest that dental clinics are appropriate settings in which to identify and provide interventions for adults at risk of experiencing problems due to alcohol or drug use.