A phenomenological inquiry into the costs and consequences of insomnia for veterans with serious mental illness.

Many individuals with serious mental illness (i.e. schizophrenia spectrum, bipolar or major depressive disorders, with serious functional impairments) have insomnia symptoms. Insomnia is a common reason for mental health referrals in the Veterans Health Administration. The primary aim of this study was to explore the costs (what participants lose or what trade-offs they make due to insomnia) and consequences (how insomnia impacts functioning) of insomnia for veterans with serious mental illness. Semi-structured interviews of 20 veterans with insomnia and serious mental illness were collected as data using an inductive phenomenological approach. Two main themes were identified: Sleep Affects Mental Health and Functioning; and Compromising to Cope. Results illuminate pathways by which sleep effort destabilizes functional recovery, and illustrate how sleep has multiplicative positive impacts on functioning and mood. Researchers and clinicians alike must explore supporting people with serious mental illness in replacing sleep effort with the recovery of meaningful identity-driven, values-based experiences formerly conceded due to serious mental illness, insomnia or both.

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

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

Supporting Veterans, Caregivers, and Providers in Rural Regions With Tele-Geriatric Psychiatry Consultation: A Mixed Methods Pilot Study.

OBJECTIVES: Cross-facility tele-geriatric psychiatry consultation is a promising model for providing specialty services to regions lacking sufficient geriatric psychiatry expertise. This evaluation focused on assessing the feasibility and acceptability of a consultation program developed by a geriatric psychiatrist in a Veterans Health Administration regional telehealth hub. DESIGN: Concurrent, mixed methods program evaluation. SETTING: A region served by a VA health care system telehealth hub. PARTICIPANTS: Patients with at least 1 geriatric mental health encounter with a geriatric psychiatrist consultant during a 1 year-period; referring providers. INTERVENTION: Virtual psychiatric evaluation of Veterans with time-limited follow-up and e-consultation with providers. MEASUREMENTS: Interviews with consultant, medical record data, and referring provider surveys. RESULTS: Three hundred fifteen Veterans (M = 76.0 ± 9.64 years; 40% rural-dwelling) had 666 encounters (M = 2.11 ± 1.78) with most occurring via clinical video telehealth (n = 443; 67.6%), e-consultation (n = 99; 15.1%), or video to home (n = 95; 14.5%). Most encounters were related to neurocognitive disorders, depressive disorders, trauma-related disorders, or serious mental illness. Referring providers (N = 58) highly recommended the program, reported high satisfaction, followed through with recommendations, and believed that this program increased access to geriatric psychiatry. CONCLUSIONS: This single program was shown to be feasible, acceptable, and valued by the referring providers. The findings highlighted the complex presentations of Veterans referred, and the current unmet need of providers of such Veterans, providing impetus for wider implementation.

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

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

Health Behavior Change Processes Among Adults With Serious Mental Illness Engaged in Illness Self-Management.

Self-management interventions promote illness management among adults with chronic health conditions. Little is known regarding the processes by which these interventions have their effects. The present study examined how Living Well, an effective self-management intervention for adults with serious mental illness, led to health behavior change in a randomized controlled trial. A convenience subset (N = 15) of participants completed qualitative interviews regarding the feasibility/acceptability of Living Well. An inductive secondary qualitative analysis, using a combination of interpretive phenomenological and social constructivist approaches, was conducted to examine processes of change. Results indicate that Living Well provided information and knowledge, opportunities for learning from others and real-world practice, and an interpersonally supportive environment. These active ingredients led to enhanced self-awareness, confidence, sense of control, and behavior and health status changes among participants. These findings are considered in the context of prominent behavior change theories such as social cognitive theory and self-regulation.

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

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

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

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

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

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

Evaluation of smoking cessation interventions for veterans in HIV clinics in the United States: a theory-informed concurrent mixed-method study.

OBJECTIVE: Although veterans living with HIV infection are burdened with smoking-related morbidities, few studies have explored theory-informed, evidence-based smoking cessation interventions in the Veterans Affairs (VA) Health System. METHOD: In this concurrent mixed-method study, we sought to better understand factors influencing the adoption of existing evidence-based smoking cessation interventions (reminders, telephone quit lines, pharmacological) for veterans in VA HIV clinics. We explored the alignment of the revised Promoting Action on Research Implementation in Health Services Framework (i-PARIHS) with study results. RESULTS: Nineteen clinicians working at eight HIV clinics in the VA System participated in the study. Seven themes were identified with relative quantitative and qualitative data convergence of clinicians' perceptions of the importance of integrating evidence-based smoking cessation interventions for veterans with HIV infection. CONCLUSION: Identified themes underscore the need for clinicians to provide smoking cessation training, supportive care, and motivate veterans living with HIV infection to quit smoking. Integrating smoking cessation programs into HIV treatment plans in the veteran patient population is critical. Dedicated time to fully implement these efforts will maximize smoking cessation intervention efforts and will yield successful utilization and subsequent patient compliance. Importantly, combination strategies will ensure cessation program impact and sustainability.Trial registration:Netherlands National Trial Register identifier: ntr050..

Implementation of peer specialist services in VA primary care: a cluster randomized trial on the impact of external facilitation.

BACKGROUND: Over 1100 veterans work in the Veterans Health Administration (VHA) as peer specialists (PSs)-those with formal training who support other veterans with similar diagnoses. A White House Executive Action mandated the pilot reassignment of VHA PSs from their usual placement in mental health to 25 primary care Patient Aligned Care Teams (PACTs) in order to broaden the provision of wellness services that can address many chronic illnesses. An evaluation of this initiative was undertaken to assess the impact of outside assistance on the deployment of PSs in PACTs, as implementation support is often needed to prevent challenges commonly experienced when first deploying PSs in new settings. METHODS: This study was a cluster-randomized hybrid II effectiveness-implementation trial to test the impact of minimal implementation support vs. facilitated implementation on the deployment of VHA PSs in PACT over 2 years. Twenty-five Veterans Affairs Medical Centers (VAMCs) were recruited to reassign mental health PSs to provide wellness-oriented care in PACT. Sites in three successive cohorts (n = 7, 10, 8) over 6-month blocks were matched and randomized to each study condition. In facilitated implementation, an outside expert worked with site stakeholders through a site visit and regular calls, and provided performance data to guide the planning and address challenges. Minimal implementation sites received a webinar and access to the VHA Office of Mental Health Services work group. The two conditions were compared on PS workload data and veteran measures of activation, satisfaction, and functioning. Qualitative interviews collected information on perceived usefulness of the PS services. RESULTS: In the first year, sites that received facilitation had higher numbers of unique veterans served and a higher number of PS visits, although the groups did not differ after the second year. Also, sites receiving external facilitation started delivering PS services more quickly than minimal support sites. All sites in the external facilitation condition continued in the pilot into the second year, whereas two of the sites in the minimal assistance condition dropped out after the first year. There were no differences between groups on veterans' outcomes-activation, satisfaction, and functioning. Most veterans were very positive about the help they received as evidenced in the qualitative interviews. DISCUSSION: These findings demonstrate that external facilitation can be effective in supporting the implementation of PSs in primary care settings. The lack of significant differences across conditions after the second year highlights the positive outcomes associated with active facilitation, while also raising the important question of whether longer-term success may require some level of ongoing facilitation and implementation support. TRIAL REGISTRATION: This project is registered at ClinicalTrials.gov with number NCT02732600 (URL: https://clinicaltrials.gov/ct2/show/NCT02732600 ).

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

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

Provision of peer specialist services in VA patient aligned care teams: protocol for testing a cluster randomized implementation trial.

BACKGROUND: Over 1100 Veterans work in the Veterans Health Administration (VHA) as peer specialists (PSs). PSs are Veterans with formal training who provide support to other Veterans with similar diagnoses, primarily in mental health settings. A White House Executive Action mandated the pilot reassignment of VHA PSs from mental health to 25 primary care Patient Aligned Care Teams (PACT) in order to broaden the provision of wellness services that can address many chronic illnesses. An evaluation of this initiative was undertaken to assess the impact of outside assistance on the deployment of PS in PACT, as implementation support is often needed to prevent challenges commonly experienced when first deploying PSs in VHA settings. We present the protocol for this cluster-randomized hybrid type II trial to test the impact of standard implementation (receive minimal assistance) vs. facilitated implementation (receive outside assistance) on the deployment of VHA PSs in PACT. METHODS: A VHA Office of Mental Health Services work group is recruiting 25 Veterans Affairs Medical Centers to reassign a mental health PSs to provide wellness-oriented care in PACT. Sites in three successive cohorts (n = 8, 8, 9) beginning over 6-month blocks will be matched and randomized to either standard or facilitated implementation. In facilitated implementation, an outside expert works with site stakeholders through a site visit, regular calls, and performance data to guide the planning and address challenges. Standard implementation sites will receive a webinar and access the Office of Mental Health Services work group. The two conditions will be compared on PS workload data, fidelity to the PS model of service delivery, team functioning, and Veteran measures of activation, satisfaction, and functioning. Qualitative interviews will collect information on implementation barriers and facilitators. DISCUSSION: This evaluation will provide critical data to guide administrators and VHA policy makers on future deployment of PSs, as their role has been expanding beyond mental health. In addition, development of novel implementation strategies (facilitation tailored to PSs) and the use of new tools (peer fidelity) can be models for monitoring and supporting deployment of PSs throughout VHA. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02732600 (URL: https://clinicaltrials.gov/ct2/show/NCT02732600 ).

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

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

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

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

The facade of stability in assisted living.

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

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

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