Community Benefit Spending Among North Carolina's Tax-Exempt Hospitals After Performing Community Health Needs Assessments.

CONTEXT: As of March 23, 2012, the Internal Revenue Service (IRS) requires tax-exempt hospitals to conduct Community Health Needs Assessment (CHNA) every 3 years to incentivize hospitals to provide programs responsive to the health needs of their communities. OBJECTIVE: To examine the distribution and variation in community benefit spending among North Carolina's tax-exempt hospitals 2 years after completing their first IRS-mandated CHNA. DESIGN: Cross-sectional study using secondary analysis of published community benefit reports. Community benefit was categorized on the basis of North Carolina Hospital Association's community benefit reporting guidelines. Multiple regression analysis using generalized linear model was used to examine the variation in community benefit spending among study hospitals considering differences in hospital-level and community characteristics. SETTING: Fifty-three private, nonprofit hospitals across North Carolina. MAIN OUTCOME MEASURE: Dollar expenditures as a percentage of operating expenses of the 2 categories of community benefit spending: patient care financial assistance and community health programs. RESULTS: Study hospitals' aggregate community benefit spending was $2.6 billion, 85% of which was in the form of patient care financial assistance, with only 0.7% of total spending allocated to community-building activities such as affordable housing, economic development, and environmental improvements. On average, the study hospitals' community benefit spending was equivalent to 14.6% of operating expenses. Hospitals with 300 or more beds provided significantly higher investments in community health programs as a percentage of their operating expenses than hospitals with 101 to 299 beds (P = .03) or hospitals with 100 or fewer beds (P = .04). Access to care was not associated with patient care financial assistance (P = .81) or community health programs expenditures (P = .94). CONCLUSIONS: The study hospitals direct most of their community benefit expenditures to patient care financial assistance (individual welfare) rather than population health improvement initiatives, with virtually no investments in community-building activities that address socioeconomic determinants of health.

Did Performing Community Health Needs Assessments Increase Community Health Program Spending by North Carolina's Tax-Exempt Hospitals?

As of March 23, 2012, the Internal Revenue Service (IRS) requires tax-exempt hospitals to conduct a Community Health Needs Assessment (CHNA) every 3 years. This study assessed whether the IRS CHNA mandate incentivized North Carolina's tax-exempt hospitals to increase investments in community health programs. The authors gathered the 2012-2016 community benefit reports of 53 North Carolina private, nonprofit hospitals from the North Carolina Hospital Association. Community benefit spending data from the year of the first CHNA were compared to that 2 years later using paired t tests among matched subjects. No significant increases were found in hospitals' community health programs spending (P = 0.6920) or in providing patient care financial assistance (charity or discounted care) (P = 0.0934). In fact, aggregate community health programs spending effectively decreased by 4%, from $393.3 million to $377.5 million. Among all community benefit items, only the unreimbursed cost for treating Medicare patients increased significantly (P = 0.0297). The proportion of spending on community health programs relative to patient care financial assistance decreased significantly (P = 0.0338). Performing CHNAs did not incentivize North Carolina's tax-exempt hospitals to progressively invest in community health programs. The hospitals continue to spend heavily on patient care financial assistance and little on disease prevention and community health improvement activities. These findings suggest that tax-exempt hospitals continue to function as a safety net for the poor and the uninsured rather than as active partners in population health management initiatives. At present, performing CHNAs may be more a demonstration of compliance than a tool to improve population health.

Student Veterans Reintegrating From the Military to the University With Traumatic Injuries: How Does Service Use Relate to Health Status?

OBJECTIVE: To examine the effects of campus services on the health of veterans with traumatic injuries and comorbidities as they return from military service and enter college. DESIGN: Cross-sectional Internet survey using a mixed-methods analysis approach. SETTING: Four-year urban research university. PARTICIPANTS: Veterans returning from active military duty (N=127). INTERVENTIONS: None. MAIN OUTCOME MEASURES: Surveys included standardized measures of health status, traumatic injuries, and functional impairment (PTSD Checklist, Civilian version; Veterans Health Administration traumatic brain injury [TBI] screen; and Veterans RAND-12 item Health Survey); use of campus services and perceived effectiveness of these services in supporting reintegration to the university; and recommendations for additional services. RESULTS: Quantitative and qualitative data revealed that student veterans experience high rates of chronic pain that interfere with their daily functioning (92.7%), symptoms of posttraumatic stress disorder (PTSD) (77.9%), symptoms of TBI (26.0%), and comorbidities as the polytrauma clinical triad (14.2%). Despite the high prevalence of pain, PTSD, and TBI, few students used disability services (5.2%), counseling services (18.8%), or student health services (36.5%). Students experienced challenges accessing needed health services when reintegrating from the military to the university, including mutable university service factors. CONCLUSIONS: Findings indicate the need for campus services to address the particular needs of student veterans and the need for determining what particular services should be offered to help this population cope with injuries and succeed in college.

Military Service Member and Veteran Reintegration: A Conceptual Analysis, Unified Definition, and Key Domains.

Returning military service members and veterans (MSMVs) may experience a variety of stress-related disorders and challenges when reintegrating from the military to the community. Facilitating the reintegration, transition, readjustment and coping, and community integration, of MSMVs is a societal priority. To date, research addressing MSMV reintegration has not identified a comprehensive definition of the term or defined the broader context within which the process of reintegration occurs although both are needed to promote valid and reliable measurement of reintegration and clarify related challenges, processes, and their impact on outcomes. Therefore, this principle-based concept analysis sought to review existing empirical reintegration measurement instruments and identify the problems and needs of MSMV reintegration to provide a unified definition of reintegration to guide future research, clinical practice, and related services. We identified 1,459 articles in the health and social sciences literature, published between 1990 and 2015, by searching multiple electronic databases. Screening of abstracts and full text review based on our inclusion/exclusion criteria, yielded 117 articles for review. Two investigators used constant conceptual comparison to evaluate relevant articles independently. We examined the term reintegration and related terms (i.e., transition, readjustment, community integration) identifying trends in their use over time, analyzed the eight reintegration survey instruments, and synthesized service member and veteran self-reported challenges and needs for reintegration. More reintegration research was published during the last 5 years (n = 373) than in the previous 10 years combined (n = 130). The research suggests coping with life stresses plays an integral role in military service member and veteran post-deployment reintegration. Key domains of reintegration include individual, interpersonal, community organizations, and societal factors that may facilitate or challenge successful reintegration, and results suggest that successful coping with life stressors plays an integral role in post-deployment reintegration. Overall, the literature does not provide a comprehensive representation of reintegration among MSMVs. Although, previous research describes military service member and veteran reintegration challenges, this concept analysis provides a unified definition of the phenomenon and identifies key domains of reintegration that may broaden our understanding and guide reintegration research and practice.

Facilitating reintegration for military service personnel, veterans, and their families: An introduction to the special issue.

As service members return from active duty and, in some cases, exit the military, they face a process of reintegration (also referred to as community reintegration) as they seek to resume participation in their life roles as civilians. Facilitating this dynamic process of reintegration for service members, veterans, and their families-including outlining potential strategies for supporting this return to civilian life and its demands, roles, and responsibilities-is the focus of this Special Issue. Reintegration has been framed as a national priority (U.S. Department of Veterans Affairs, 2015) and has been a point of emphasis of efforts at federal, state, and local levels. As the articles in this issue suggest, multiple public, private, and voluntary systems and the communities to which service members, veterans, and their families return can help influence their health outcomes and, ultimately, their reintegration. (PsycINFO Database Record

Military service member and veteran reintegration: A critical review and adapted ecological model.

Returning military service members and veterans (MSMVs) experience a wide range of stress-related disorders in addition to social and occupational difficulties when reintegrating to the community. Facilitating reintegration of MSMVs following deployment is a societal priority. With an objective of identifying challenges and facilitators for reintegration of MSMVs of the current war era, we critically review and identify gaps in the literature. We searched 8 electronic databases and identified 1,764 articles. Screening of abstracts and full-text review based on our inclusion/exclusion criteria, yielded 186 articles for review. Two investigators evaluating relevant articles independently found a lack of clear definition or comprehensive theorizing about MSMV reintegration. To address these gaps, we linked the findings from the literature to provide a unified definition of reintegration and adapted the social ecological systems theory to guide research and practice aimed at MSMV reintegration. Furthermore, we identified individual, interpersonal, community, and societal challenges related to reintegration. The 186 studies published from 2001 (the start of the current war era) to 2015 included 6 experimental studies or clinical trials. Most studies do not adequately account for context or more than a narrow set of potential influences on MSMV reintegration. Little evidence was found that evaluated interventions for health conditions, rehabilitation, and employment, or effective models of integrated delivery systems. We recommend an ecological model of MSMV reintegration to advance research and practice processes and outcomes at 4 levels (individual, interpersonal, organizational, and societal). (PsycINFO Database Record

A retrospective cohort study of comorbidity trajectories associated with traumatic brain injury in veterans of the Iraq and Afghanistan wars.

OBJECTIVES: To identify and validate trajectories of comorbidity associated with traumatic brain injury in male and female Iraq and Afghanistan war Veterans (IAV). METHODS: Derivation and validation cohorts were compiled of IAV who entered the Department of Veterans Affairs (VA) care and received 3 years of VA care between 2002-2011. Chronic disease and comorbidities associated with deployment including TBI were identified using diagnosis codes. A latent class analysis (LCA) of longitudinal comorbidity data was used to identify trajectories of comorbidity. RESULTS: LCA revealed five trajectories that were similar for women and men: (1) Healthy, (2) Chronic Disease, (3) Mental Health, (4) Pain and (5) Polytrauma Clinical Triad (PCT: pain, mental health and TBI). Two additional classes found in men were 6) Minor Chronic and 7) PCT with chronic disease. Among these gender-stratified trajectories, it was found that women were more likely to experience headache (Pain trajectory) and depression (Mental Health trajectory), while men were more likely to experience lower back pain (Pain trajectory) and substance use disorder (Mental Health trajectory). The probability of TBI was highest in the PCT-related trajectories, with significantly lower probabilities in other trajectories. CONCLUSIONS: It was found that TBI was most common in PCT-related trajectories, indicating that TBI is commonly comorbid with pain and mental health conditions for both men and women. The relatively young age of this cohort raises important questions regarding how disease burden, including the possibility of neurodegenerative sequelae, will accrue alongside normal age-related decline in individuals with TBI. Additional 'big data' methods and a longer observation period may allow the development of predictive models to identify individuals with TBI that are at-risk for adverse outcomes.

Pain and psychiatric comorbidities among two groups of Iraq and Afghanistan era Veterans.

This study aimed to (1) identify the prevalence and severity of pain and psychiatric comorbidities among personnel who had been deployed during Operation Iraqi Freedom (OIF), Operation Enduring Freedom (OEF), and Operation New Dawn (OND) and (2) assess whether the Department of Veterans Affairs (VA) Polytrauma System of Care and an OIF/OEF/OND registry reflect real differences among patients. Participants (N = 359) were recruited from two VA hospitals. They completed a clinical interview, structured diagnostic interview, and self-report measures. Results indicated pain was the most common complaint, with 87 percent experiencing pain during the prior week and 56 percent reporting moderate or severe pain. Eighty percent of participants met criteria for at least one of seven assessed comorbid problems (moderate or severe pain, postconcussional disorder, posttraumatic stress disorder [PTSD], anxiety disorder, mood disorder, substance use disorder, psychosis), and 59 percent met criteria for two or more problems. PTSD and postconcussional disorder rarely occurred in the absence of pain or other comorbidities (0.3% and 0%, respectively). The Polytrauma group had more comorbid psychiatric conditions (χ(2) = 48.67, p < 0.05) and reported greater severity of symptoms (p < 0.05) than the Registry group. This study confirmed the high prevalence of pain and concurrent mental health problems among personnel returning from military deployment.

Implications for patient safety in the use of safe patient handling equipment: a national survey.

BACKGROUND: The prevalence of musculoskeletal injuries among nursing staff has been high due to patient handling and movement. Internationally, healthcare organizations are integrating technological equipment into patient handling and movement to improve safety. Although evidence shows that safe patient handling programs reduce work-related musculoskeletal injuries in nursing staff, it is not clear how safe these new programs are for patients. OBJECTIVES: The objective of this study was to explore adverse patient events associated with safe patient handling programs and preventive approaches in US Veterans Affairs medical centers. METHODS: The study surveyed a convenience sample of safe patient handling program managers from 51 US Department of Veterans Affairs medical centers to collect data on skin-related and fall-related adverse patient events. RESULTS: Both skin- and fall-related adverse patient events associated with safe patient handling occurred at VA Medical centers. Skin-related events included abrasions, contusions, pressure ulcers and lacerations. Fall-related events included sprains and strains, fractures, concussions and bleeding. Program managers described contextual factors in these adverse events and ways of preventing the events. CONCLUSIONS: The use of safe patient handling equipment can pose risks for patients. This study found that organizational factors, human factors and technology factors were associated with patient adverse events. The findings have implications for how nursing professionals can implement safe patient handling programs in ways that are safe for both staff and patients.

Access to the US Department of Veterans Affairs health system: self-reported barriers to care among returnees of Operations Enduring Freedom and Iraqi Freedom.

BACKGROUND: The U.S. Department of Veterans Affairs (VA) implemented the Polytrauma System of Care to meet the health care needs of military and veterans with multiple injuries returning from combat operations in Afghanistan and Iraq. Studies are needed to systematically assess barriers to use of comprehensive and exclusive VA healthcare services from the perspective of veterans with polytrauma and with other complex health outcomes following their service in Afghanistan and Iraq. These perspectives can inform policy with regard to the optimal delivery of care to returning veterans. METHODS: We studied combat veterans (n = 359) from two polytrauma rehabilitation centers using structured clinical interviews and qualitative open-ended questions, augmented with data collected from electronic health records. Our outcomes included several measures of exclusive utilization of VA care with our primary exposure as reported access barriers to care. RESULTS: Nearly two thirds of the veterans reported one or more barriers to their exclusive use of VA healthcare services. These barriers predicted differences in exclusive use of VA healthcare services. Experiencing any barriers doubled the returnees' odds of not using VA exclusively, the geographic distance to VA barrier resulted in a 7 fold increase in the returnees odds of not using VA, and reporting a wait time barrier doubled the returnee's odds of not using VA. There were no striking differences in access barriers for veterans with polytrauma compared to other returning veterans, suggesting the barriers may be uniform barriers that predict differences in using the VA exclusively for health care. CONCLUSIONS: This study provides an initial description of utilization of VA polytrauma rehabilitation and other medical care for veteran returnees from all military services who were involved in combat operations in Afghanistan or Iraq. Our findings indicate that these veterans reported important stigmatization and barriers to receiving services exclusively from the VA, including mutable health delivery system factors.

Gender differences in combat medic mental health services utilization, barriers, and stigma.

Military health care providers experience considerable stressors related to their exposure to death and traumatic injuries in others. This study used survey data from 799 active duty U.S. Army Combat Medics deployed to Operation Iraqi Freedom/Operation Enduring Freedom. Military experiences, combat exposures, and mental health care seeking of active duty Combat Medics were explored and compared across both genders. Barriers to care were also assessed. Male and female Combat Medics reported surprisingly similar experiences, exposures, and health issues. Overall, results indicate no striking differences in barriers for females compared to their male counterparts, suggesting the barriers to utilization of mental health services may be consistent across gender. Although medics endorsed barriers and stigma related to mental health counseling services, they still sought these health services. Female and male medics who endorsed barriers were more likely to report seeking services than those who did not endorse barriers. This study provides an initial description of utilization of mental health counseling services for U.S. Army Combat Medics, the majority of whom were involved in combat operations in Afghanistan or Iraq. Our findings indicate that comprehensive assessment of the military experiences and combat exposures is needed to appreciate their potential influence on military health care providers.

Preferences for rehabilitation services among women with major limb amputations.

PURPOSE: We present five cases of adult females with major limb amputations, their concerns and preferences for services across the life span. DESIGN: A convenience sample of five veteran and nonveteran women aged 19-58 with major limb amputations participating in a regional VA Prosthetics Conference in 2010 took part in a panel interview. FINDINGS: The concerns identified by these women as high priorities included independence and participation in a full range of life activities, limitations in access, patient decision-making and body image concerns, and preferences for selected services. Maximizing function and quality of life for women amputees requires identifying patient preferences for rehabilitation and prosthetic services. Lessons learned could inform development of clinic-based rehabilitation care, prosthetic services, and studies of women with major limb amputations. CONCLUSIONS: As the current conflicts in Iraq and Afghanistan wind down, the number of women veterans seeking rehabilitation and prosthetic services will increase. With this information, rehabilitation and prosthetic service providers and organizations will be uniquely positioned to provide prevention and treatment of amputations for this growing population of women veterans in national care delivery systems and in communities. CLINICAL RELEVANCE: An open-ended facilitated discussion among a panel of women with major limb amputations provided insights for providers and organizations with respect to needs, concerns, and preferences for rehabilitation and prosthetic services.

Patient preferences and cost-utility analysis.

This column discusses patient preference measures and their application in cost utility analysis. A variety of methods of eliciting patient preferences by use of generic utility measures are described. Practical issues in the use of utility measures are discussed.