Staff-perceived Conflict between Resident-centered Care and Quality in the Skilled Nursing Facility: Are Both Possible?

OBJECTIVES: The purpose of this study was to understand if and how Veterans Affairs (VA) nursing home (CLC) staff experience difficulty in providing care that is both resident-centered (RCC) and concordant with quality standards. METHODS: Twelve VA CLCs were selected for site visits, stratified based on rankings on a composite quality measure (calculated from various indicators) and resident-centered care (RCC) progress (based on a culture change tool). Staff were interviewed about efforts and barriers to achieving goals in RCC and quality, and the interview transcripts systematically analyzed for themes. RESULTS: We interviewed 141 participants, including senior leaders, middle managers, and front-line staff. An emergent theme was conflict between RCC and quality, although participants varied in their perceptions of its impact. Participants perceived three conflict types: 1) between resident preferences and medically indicated actions; 2) between resident preferences and the needs or safety of others; and 3) limits of staff time or authority. CONCLUSIONS: CLC staff perceive conflicts between RCC and care consistent with quality imperatives. CLINICAL IMPLICATIONS: Variation in perceived RCC-quality conflicts suggests that policy clarifications and additional training may provide guidance in dealing with such dilemmas. It may be prudent to clearly communicate to what boundaries exist to RCC in the evolving CLC environment.

Is Variation in Resident-Centered Care and Quality Performance Related to Health System Factors in Veterans Health Administration Nursing Homes?

The purpose of this research was to explore and compare common health system factors for 5 Community Living Centers (ie Veterans Health Administration nursing homes) with high performance on both resident-centered care and clinical quality and for 5 Community Living Centers (CLC) with low performance on both resident-centered care and quality. In particular, we were interested in "how" and "why" some Community Living Centers were able to deliver high levels of resident-centered care and high quality of care, whereas others did not demonstrate this ability. Sites were identified based on their rankings on a composite quality measure calculated from 28 Minimum Data Set version 2.0 quality indicators and a resident-centered care summary score calculated from 6 domains of the Artifacts of Culture Change Tool. Data were from fiscal years 2009-2012. We selected high- and low-performing sites on quality and resident-centered care and conducted 12 in-person site visits in 2014-2015. We used systematic content analysis to code interview transcripts for a priori and emergent health system factor domains. We then assessed variations in these domains across high and low performers using cross-site summaries and matrixes. Our final sample included 108 staff members at 10 Veterans Health Administration CLCs. Staff members included senior leaders, middle managers, and frontline employees. Of the health system factors identified, high and low performers varied in 5 domains, including leadership support, organizational culture, teamwork and communication, resident-centered care recognition and awards, and resident-centered care training. Organizations must recognize that making improvements in the factors identified in this article will require dedicated resources from leaders and support from staff throughout the organization.

Identifying and overcoming implementation challenges: Experience of 59 noninstitutional long-term services and support pilot programs in the Veterans Health Administration.

BACKGROUND: From 2010 to 2013, the Department of Veterans Affairs (VA) funded a large pilot initiative to implement noninstitutional long-term services and supports (LTSS) programs to support aging Veterans. Our team evaluated implementation of 59 VA noninstitutional LTSS programs. PURPOSE: The specific objectives of this study are to (a) examine the challenges influencing program implementation comparing active sites that remained open and inactive sites that closed during the funding period and (b) identify ways that active sites overcame the challenges they experienced. METHODOLOGY: Key informant semistructured interviews occurred between 2011 and 2013. We conducted 217 telephone interviews over four time points. Content analysis was used to identify emergent themes. The study team met regularly to define each challenge, review all codes, and discuss discrepancies. For each follow-up interview with the sites, the list of established challenges was used as a priori themes. Emergent data were also coded. RESULTS: The challenges affecting implementation included human resources and staffing issues, infrastructure, resources allocation and geography, referrals and marketing, leadership support, and team dynamics and processes. Programs were able to overcome challenges by communicating with team members and other areas in the organization, utilizing information technology solutions, creative use of staff and flexible schedules, and obtaining additional resources. DISCUSSION: This study highlights several common challenges programs can address during the program implementation. The most often mentioned strategy was effective communication. Strategies also targeted several components of the organization including organizational functions and processes (e.g., importance of coordination within a team and across disciplines to provide good care), infrastructure (e.g., information technology and human resources), and program fit with priorities in the organization (e.g., leadership support). IMPLICATIONS: Anticipating potential pitfalls of program implementation for future noninstitutional LTSS programs can improve implementation efficiency and program sustainability. Staff at multiple levels in the organization must fully support noninstitutional LTSS programs to address these challenges.

Electronic Consultations (E-consults): Advancing Infectious Disease Care in a Large Veterans Affairs Healthcare System.

The impact of e-consults on total consultative services was evaluated. After implementing infectious diseases e-consults within an electronically integrated healthcare system, consultation volume increased. As compared with face-to-face consultations, e-consults were more often related to antimicrobial guidance and were requested by off-site providers. E-consults increased the breadth and volume of total consults.

Explaining differences in hepatitis C between U.S. veterans and nonveterans in treatment for substance abuse: results from a regression decomposition.

Hepatitis C virus (HCV) infection is common among people with substance abuse histories and a burden for U.S. veterans in particular. This study compares self-reported HCV between 1,652 veterans and 48,013 nonveterans who received public-sector substance abuse treatment in Los Angeles between 2006 and 2010. A higher percentage of veterans than nonveterans reported HCV (6.5% vs. 3.8%, p < .0001). Homelessness and mental illness explained, respectively, 8.6% and 7.1% of the difference in HCV between the two groups, adjusting for other variables. Reducing homelessness and mental illness among veterans may also help reduce the excess burden of HCV in this population.

Personal medication preparedness among veteran and nonveteran men and women in the California population.

INTRODUCTION: The health of people with chronic medical conditions is particularly vulnerable to the disruptions caused by public health disasters, especially when there is massive damage to the medical infrastructure. Government agencies and national organizations recommend that people with chronic illness prepare for disasters by stockpiling extra supplies of medications. PROBLEM: A wide range of chronic illnesses has long been documented among veterans of the US armed forces. Veterans with chronic illness could be at great risk of complications due to disaster-related medication disruptions; however, the prevalence of personal medication preparedness among chronically ill veterans is not currently known. METHODS: Data was used from the 2009 California Health Interview Survey on 28,167 respondents who reported taking daily medications. After adjusting for differences in age, health status, and other characteristics, calculations were made of the percentage of respondents who had a two-week supply of emergency medications and, among respondents without a supply, the percentage who said they could obtain one. Veteran men, veteran women, nonveteran men, and nonveteran women were compared. RESULTS: Medication supplies among veteran men (81.9%) were higher than among nonveteran women (74.8%; P < .0001) and veteran women (81.1%; P = 0.014). Among respondents without medication supplies, 67.2% of nonveteran men said that they could obtain a two-week supply, compared with 60.1% of nonveteran women (P = .012). Discussion Among adults in California with chronic illness, veteran men are more likely to have personal emergency medication supplies than are veteran and nonveteran women. Veteran men may be more likely to be prepared because of their training to work in combat zones and other emergency situations, which perhaps engenders in them a culture of preparedness or self-reliance. It is also possible that people who choose to enlist in the military are different from the general population in ways that make them more likely to be better prepared for emergencies. CONCLUSION: Veterans in California have a relatively high level of emergency medication preparedness. Given the health complications that can result from disaster-related medication disruptions, this is a promising finding. Disasters are a national concern, however, and the personal preparedness of veterans in all parts of the nation should be assessed; these findings could serve as a useful reference point for such work in the future.

Using exercises to identify Veterans Health Administration priorities for disaster response: findings from the New Madrid Earthquake training exercise.

Emergency managers are often charged with prioritizing the relative importance of key issues and tasks associated with disaster response. However, little work has been done to identify specific ways that the decision-making process can be improved. This exercise was conducted with 220 employees of the US Department of Veterans Affairs, who were asked to assign priority rankings to a list of possible options of the most important issues to address after a hypothetical disaster scenario impacting a Veterans Affairs Medical Center. We found that groups that were assigned to represent perspectives farther from the impacted site had less agreement in their identification of the top priorities than those assigned to the impacted facility. These findings suggest that greater geographic and administrative proximity to the impacted site may generate greater clarity and certainty about priority setting. Given the complex structure of many organizations, and the multiple levels of group decision making and coordination likely to be needed during disasters, research to better understand training needs with respect to decision making is essential to improve preparedness. Relatively simple modifications to exercises, as outlined here, could provide valuable information to better understand emergency management decision making across multiple organizational levels.

Care transitions from the specialty to the primary care setting: A scoping literature review of potential barriers and facilitators with implications for mental health care.

BACKGROUND, AIMS AND OBJECTIVES: This scoping review aimed to understand potential barriers and facilitators in transitioning patients from specialty to primary care settings, to inform the implementation of an intervention to promote active consideration of psychiatrically stable patients for transition from the specialty mental health setting back to primary care. METHODS: Guided by Levac and colleagues' six-stage methodological framework for conducting scoping studies, we systematically searched electronic article databases for peer-reviewed literature from January 2000 to May 2016. We included identified articles that discuss findings related to potential barriers and facilitators in transitioning patients from specialty to primary care settings. We performed descriptive and thematic analyses of results to generate emergent codes and their categorizations. RESULTS: Our database search yielded 906 unique articles, 23 of which we included in our scoping review. All but one of the included studies were conducted in North America. Identified potential barriers and facilitators spanned eight emergent themes-(i) primary care accessibility, especially in terms of timely availability of appointments, (ii) clarity in respective roles of specialty care and primary care in managing a patient, (iii) timely exchange of information, (iv) transition process management, (v) perceived ability of primary care providers to manage specialty conditions, (vi) perceived ability of patients to self-manage, (vii) leadership support and (viii) support for implementing initiatives to promote transitions. CONCLUSIONS: Findings from this scoping review enable an increased understanding of current practices and considerations regarding care transitions from specialty to primary care settings. The importance of role clarification, shared clinical information systems, confidence in care competency, and adequate organizational support to promote appropriate transitions were themes most widely reported across the reviewed studies. Few studies specifically examined the transition from specialty mental health to primary care. Future studies should account for mental health-specific symptomatic patterns and recovery trajectories, such as prevalent chronicity and frequency of relapse, in planning and conducting transitions from specialty mental health back to primary care.

Electronic consultations (E-consults) and their outcomes: a systematic review.

OBJECTIVE: Electronic consultations (e-consults) are clinician-to-clinician communications that may obviate face-to-face specialist visits. E-consult programs have spread within the US and internationally despite limited data on outcomes. We conducted a systematic review of the recent peer-reviewed literature on the effect of e-consults on access, cost, quality, and patient and clinician experience and identified the gaps in existing research on these outcomes. MATERIALS AND METHODS: We searched 4 databases for empirical studies published between 1/1/2015 and 2/28/2019 that reported on one or more outcomes of interest. Two investigators reviewed titles and abstracts. One investigator abstracted information from each relevant article, and another confirmed the abstraction. We applied the GRADE criteria for the strength of evidence for each outcome. RESULTS: We found only modest empirical evidence for effectiveness of e-consults on important outcomes. Most studies are observational and within a single health care system, and comprehensive assessments are lacking. For those outcomes that have been reported, findings are generally positive, with mixed results for clinician experience. These findings reassure but also raise concern for publication bias. CONCLUSION: Despite stakeholder enthusiasm and encouraging results in the literature to date, more rigorous study designs applied across all outcomes are needed. Policy makers need to know what benefits may be expected in what contexts, so they can define appropriate measures of success and determine how to achieve them.

A Longitudinal Assessment of the Effect of Resident-Centered Care on Quality in Veterans Health Administration Community Living Centers.

OBJECTIVE: To examine whether changes in resident-centered care (RCC) over time were associated with changes in quality. DATA SOURCES/STUDY SETTING: Data sources were the Minimum Dataset quality indicators (which consist of measures of both prevalence and incidence of adverse events) and the Artifacts of Culture Change Tool (which measures RCC; FYs 2009-2012) from 130 Veterans Health Administration community living centers. STUDY DESIGN: A retrospective longitudinal study. DATA COLLECTION/EXTRACTION METHODS: Data were from VA secondary data sources. PRINCIPAL FINDINGS: The overall relationship between RCC and quality was not statistically significant (p = .22), although there was a weakly significant negative relationship (i.e., increased RCC was associated with poorer quality) in the seven quarters after implementation of an automated version of the Artifacts Tool (p = .08). In facility-specific analyses, there were 15 facilities with a weakly significant (p < .10) positive relationship between RCC and quality and 21 with a weakly significant negative relationship. Adjusted cost per patient day was over 50 percent higher in the 21 facilities with a negative relationship than in the 15 facilities with a positive relationship (p < .05). CONCLUSIONS: The Artifacts score is a formal performance metric in the VA, and thus, facilities were explicitly incentivized to increase RCC. Using qualitative methods to identify characteristics that distinguished those facilities able to increase both RCC and quality from those that suffered declines in quality as RCC was improved is an important follow-up to this study.

Innovative Use Of Electronic Consultations In Preoperative Anesthesiology Evaluation At VA Medical Centers In New England.

Electronic consultations (e-consults) improve access to specialty care without requiring face-to-face patient visits. We conducted a mixed-methods descriptive study to understand the variability in e-consult use across anesthesiology departments in the Veterans Affairs New England Healthcare System (VANEHS). In the period 2012-15, the system experienced a rapid increase in the use of anesthesiology e-consults: 5,023 were sent in 2015, compared with 103 in 2012. Uptake across sites varied from near-universal use of e-consults for preoperative assessment to use for only selected low-risk patients or no use. Interviews with stakeholders revealed considerable differences in the perceived impact of e-consults on workflow and patient-centeredness. Clinicians at sites with high use of e-consults noted that they improved workflow efficiency. In comparison, clinicians at sites with low use preferentially valued face-to-face visits for some or all patients. The adoption of a health information technology innovation can alter the process of care delivery, depending on perceptions of its value by key stakeholders.

Identifying barriers to culture change: A qualitative analysis of the obstacles to delivering resident-centered care.

A growing number of healthcare organizations have moved from traditional, institutional nursing home models to ones that emphasize culture change, or resident-centered care (RCC). In 2006, the Department of Veterans Affairs (VA) began implementing a number of changes to VA nursing homes, now called Community Living Centers (CLCs), to provide veterans with a more resident-centered and homelike environment. This study aimed to understand the barriers CLC staff face when delivering RCC. Ten CLCs were included on the basis of their performance levels on RCC and quality of care. Semistructured interviews that focused on facility efforts in RCC and quality were conducted with all levels of staff. Interviews were systematically content coded. We found similarities and differences in barriers reported at high- and low-performing sites. Staff across all performance levels cited 5 main categories of barriers to delivering RCC: staffing, resources, acuity of residents, RCC and quality of care conflicts, and regulations. Staff in high-performing sites reported fewer barriers to RCC, although 1 barrier cited was difficulty coordinating RCC across departments. Staff in low-performing sites reported additional categories of barriers related to administrator turnover/lack of guidance, CLC culture/staff morale, and difficulty working with residents and families. As RCC continues to spread, it is important to anticipate the barriers to implementing these practices. Particular focus on regulatory, leadership, organizational, workforce, and process factors may help organizations avoid or reduce barriers to RCC. Given their training and skill set, mental health providers may be uniquely situated to assist staff in overcoming these barriers. (PsycINFO Database Record