Interdisciplinary Team Perspectives on Mental Health Care in VA Home-Based Primary Care: A Qualitative Study.

OBJECTIVES: This qualitative study describes the structure and processes of providing care to U.S. Department of Veterans Affairs (VA) Home-Based Primary Care (HBPC) enrollees with mental health care needs; explains the role of the HBPC psychologist; and describes how mental health treatment is integrated into care from the perspective of HBPC team members. DESIGN: HBPC programs were selected for in-person site visits based on initial surveys and low hospitalization rates. SETTING: Programs varied in setting, geographic locations, and primary care model. PARTICIPANTS: Eight site visits were completed. During visits, key informants including HBPC program directors, medical directors, team members, and other key staff involved with the HBPC program participated in semi-structured individual and group interviews. MEASUREMENTS: Recorded interviews, focus groups, and field observation notes. RESULTS: Qualitative thematic content analysis revealed four themes: 1) HBPC Veterans have not only complex physical needs but also co-occurring mental health needs; 2) the multi-faceted role of psychologists on HBPC teams, that includes providing care for Veterans and support for colleagues; 3) collaboration between medical and mental health providers as a means of caring for HBPC Veterans with mental health needs; and 4) gaps in providing mental health care on HBPC teams, primarily related to a lack of team psychiatrists and/or need for specialized medication management for psychiatric illness. CONCLUSIONS: Mental health providers are essential to HBPC teams. Given the significant mental health care needs of HBPC enrollees and the roles of HBPC mental health providers, HBPC teams should integrate both psychologists and consulting psychiatrists.

A qualitative exploration of veteran and family perspectives on medical foster homes.

Since 2008, the Veterans Health Administration Medical Foster Home (MFH) program has served as an alternative to nursing home care for Veterans. As part of a larger national research study, 55 in-person interviews with 62 Veterans and/or their families were conducted to identify reasons for selecting or declining MFH placement. Enrollment was attributed to: a need for increased care and a preference for highly individualized care oversight and family-oriented settings. Reasons for declining placement included: costs, location of MFHs, lack of readiness of family or Veteran to move, and level of confidence that MFHs would meet care needs. Experiences and perspectives regarding advantages and challenges of the MFH program are also described.

The Veterans Health Administration's Medical Foster Home Program: Where Heroes Meet (Older) Angels.

The Veterans Health Administration's Medical Foster Home (MFH) program is a long-term-care model in which veterans requiring personalized nursing home-level care live in the homes of private caregivers, who are recruited and screened by a VA MFH program coordinator. Often, these caregivers are older adults who are nearer to or older than retirement age. Seven years of research into the program has shown benefits in building community and improving quality of life for veterans, caregivers, and family members of veterans living in MFHs across the United States.

Caregivers Create a Veteran-Centric Community in VHA Medical Foster Homes.

The Veteran's Health Administration's Medical Foster Home program offers a unique long-term care option for veterans who require nursing-home- or assisted-living-level care. Veterans in a medical foster home reside with community-based caregivers who provide 24-hr-a-day care and monitoring. The veterans often remain in the medical foster home until end of life. Support and oversight is provided to the caregiver from the Veteran's Health Administration's community-based medical team. This qualitative descriptive study is based on secondary analysis of interviews with 20 medical foster home caregivers from 7 programs across the United States. The study's research aims are to describe and explain (a) the type of care backgrounds and skills these caregivers possess, (b) caregivers' primary motivations to open their homes to veterans who often have complex medical and social needs, and (c) how caregivers function in their role as primary caregiver for veterans. Findings indicated that caregivers interviewed had worked in long-term care settings and/or cared for family members. A strong desire to serve veterans was a primary motivation for caregivers, rather than financial gain. The caregivers' long-term care skills aided them in building and sustaining the unique medical foster home family-like community.

Implementation of VA's Life-Sustaining Treatment Decisions Initiative: Facilitators and Barriers to Early Implementation Across Seven VA Medical Centers.

CONTEXT: In 2017, Veterans Health Administration (VHA) National Center for Ethics in Health Care began system-wide implementation of the Life-Sustaining Treatment Decisions Initiative (LSTDI). The LSTDI is a national VHA policy and practice to promote conducting goals of care conversations and documenting veterans' preferences for life-sustaining treatments (LSTs). OBJECTIVES: The aim of this article is to describe facilitators and barriers to early implementation of the LSTDI within one VHA Veterans Integrated Service Network. METHODS: From September 2016 to December 2018, we conducted site visits and semistructured phone interviews with implementation coordinators who championed the LSTDI rollout at seven VHA medical centers. We applied the Consolidated Framework for Implementation Research (CFIR) to assess facilitators and barriers to implementing the LSTDI and assigning interview data to specific CFIR constructs and CFIR valence ratings. We simultaneously benchmarked VHA medical centers' implementation progress as outlined by the National Center for Ethics in Health Care implementation guidebook. RESULTS: We divided sites into three descriptive groups based on implementation progress: successfully implemented (n = 2); moving forward, but delayed (n = 3); and implementation stalled (n = 2). Five CFIR constructs emerged as facilitators or barriers to implementation of the LSTDI: 1) self-efficacy of implementation coordinators; 2) leadership engagement; 3) compatibility with pre-existing workflows; 4) available resources; and 5) overall implementation climate. CONCLUSION: Although self-efficacy proved key to overcoming obstacles, degree of perceived workflow compatibility of the LSTDI policy, available resources, and leadership engagement must be adequate for successful implementation within the implementation time line. Without these components, successful implementation was hindered or delayed.

Dedicated to the Mission: Strategies US Department of Veterans Affairs Home-Based Primary Care Teams Apply to Keep Veterans at Home.

BACKGROUND/OBJECTIVES: The US Department of Veterans Affairs (VA) Home-Based Primary Care (HBPC) Program provides interdisciplinary, long-term primary care for frail, disabled, or chronically ill veterans. This research identifies strategies used by HBPC teams to support veterans in their homes, rather than in institutionalized care. DESIGN: Focus groups and semistructured interviews were conducted with HBPC interdisciplinary team (IDT) members, including program directors, medical directors, and key staff, from September 2017 to March 2018. Field observations were gathered during visits to veterans' homes and IDT meetings. SETTING: In-person site visits were conducted at eight HBPC Programs across the United States. Sites varied in location, setting, and primary care model. PARTICIPANTS: A total of 105 HBPC professionals. MEASUREMENT: Qualitative thematic content analysis. RESULTS: Four main strategies drive and support the shared mission of IDTs to support veterans at home: fostering frequent communication among IDT members, veterans, caregivers, and outside agencies; development of longitudinal, trusting, reliable relationships within IDTs and with veterans and caregivers; ongoing, consistent education for IDT members and veterans and caregivers; and collaboration within and outside IDTs. Adhering to this mission meant providing timely and efficient care that kept veterans in their homes and minimized the need for acute hospitalizations and nursing home placement. CONCLUSION: HBPC IDTs studied worked together across disciplines to effectively create a dedicated culture of caring for veterans, caregivers, and themselves, leading to keeping veterans at home. Focusing on the strategies identified in this research may be useful to achieve similar positive outcomes when caring for medically complex, homebound patients within and outside the VA. J Am Geriatr Soc 67:2511-2518, 2019.