Suicide-related behaviors among American Indian and Alaska Native Veterans: A population-based analysis.

American Indian and Alaska Native (AI/AN) Veterans are at elevated risk for suicide, but currently, no population-based research exists on precursors, including ideation, plans, or attempts. We employed two large national surveys to investigate the occurrence of suicide-related behaviors among AI/AN Veterans. Using cross-sectional data from the Behavioral Risk Factor Surveillance System (BRFSS, 2010-2012) and National Survey on Drug Use and Health (NSDUH, 2010-2015), we compared weighted frequencies of suicide ideation in AI/AN Veterans and non-Hispanic White (NHW) Veterans. Suicide ideation among AI/AN Veterans was 9.1% (95%CI = 3.6%, 21.5%) and 8.9% (95%CI = 1.9%, 15.9%) in BRFSS and NSDUH, respectively, compared to 3.5% (95%CI = 3.0%, 4.1%) and 3.7% (95%CI = 3.0%, 4.4%) for NHW Veterans. Logit analysis suggested higher odds of ideation among AI/AN Veterans in both samples (NDSUH: OR = 2.68, 95%CI = 1.14-6.31; BRFSS: OR = 2.66, 95% CI 0.96-7.38), although sample sizes were small and confidence intervals were wide. Consistent findings from two national samples suggest AI/AN Veterans have more than twice the risk of suicide ideation relative to NHW Veterans. Ongoing efforts include weighing these results together with data on suicide deaths from medical and death records to develop effective suicide prevention approaches in collaboration with AI/AN Veterans and their communities.

Rural and Urban American Indian and Alaska Native Veteran Health Disparities: a Population-Based Study.

The health service ecology varies considerably across urban-rural divides for American Indian and Alaska Native (AIAN) veterans, which may place rural AIAN veterans at high risk for poor health outcomes. Using the Behavioral Risk Factor Surveillance System 2011 and 2012 data for its detailed race information, we employed adjusted multinomial logistical regression analyses to estimate differences in health outcomes among rural AIAN veterans (n = 1500) and urban AIAN veterans (n = 1567). We used rural White (n = 32,316) and urban White (n = 59,849) veteran samples as comparators. No statistically significant differences between urban and rural AIAN veterans' health outcomes were found. Urban AIAN veterans were 72% more likely to report financial barriers to care compared with urban White veterans (P = .002); no other healthcare access differences were found. Compared with their White veteran counterparts, both urban and rural AIAN veterans were significantly more likely to report poorer physical and mental health across an array of outcomes. Overall, rural and urban AIAN veterans' health outcomes were similar, but both groups suffered compromised health compared with that of both rural and urban White veterans. The findings identified key areas for improving and innovating care for both rural and urban AIAN veterans.

Methodology for Evaluating Models of Telemental Health Delivery Against Population and Healthcare System Needs: Application to Telemental Healthcare for Rural Native Veterans.

Background: Rural American Indian and Alaska Native (AI/AN) Veterans face exceptional barriers to receiving quality mental healthcare. We aimed to identify models of in-person and telemental health service delivery with promise for adaptation and wide dissemination to rural AI/AN Veterans. Methods: Our method for matching specific populations with models of care includes (1) selecting frameworks that represent the healthcare organization's goals, (2) identifying relevant service delivery models for the target population(s), (3) assessing models against the selected frameworks, and (4) summarizing findings across models. We applied this approach to rural AI/AN Veteran populations. Results: Searches identified 13 current models of service delivery for rural AI/AN Veteran, rural AI/AN, and general rural Veteran populations. These models were assessed against four frameworks-the U.S. Department of Veterans Affairs' Office of Rural Health's Promising Practices, Veterans Health Administration's Guide to Mental Health Services, the Institute for Healthcare Improvement's Triple Aim Framework, and the American Indian Telemental Health Clinic framework. Discussion: The one model used for service delivery for rural AI/AN Veterans increases access and is patient-centered but lacks operational feasibility. Models for rural AI/ANs also increase access and are patient-centered but generally lack effectiveness evaluations. Models for rural Veterans demonstrate beneficial effects on mental health outcomes but do not emphasize cultural adaptations to diverse populations. Conclusions: Our approach to selecting models of service delivery considers the needs of operational partners as well as target populations and emphasizes large-scale implementation alongside effectiveness. Pending further testing, this approach holds promise for wider application.

Rural American Indian and Alaska Native veterans' telemental health: A model of culturally centered care.

American Indian and Alaska Native (AI/AN) veterans living in rural areas have unique health care needs and face numerous barriers to accessing health care services. Among these needs is a disproportionate prevalence of posttraumatic stress disorder and other mental illnesses. Since 2001, 14 rural communities have partnered with the U.S. Department of Veterans Affairs and the Centers for American Indian and Alaska Native Health at the University of Colorado Anschutz Medical Campus to extend telemental health clinics to American Indian veterans. Administrative and, to some extent, clinical considerations of these clinics have been reviewed previously. This paper describes a model of care, evolved over a 14-year period, that weaves together evidence-based Western treatment, traditional Native healing, and rural Native communities into 4 main components: mental health care, technology, care coordination, and cultural facilitation. We delineate improvements to care made by addressing barriers such as system transference, provider-patient trust, and videoconferencing. Similarly, the discussion notes ways that the care model leverages strengths within Native communities, such as social cohesion and spirituality. Future steps include selection of appropriate performance indicators for systematic evaluation. The identification of key constructs of this care model will facilitate comparisons with other models of care in underserved populations with chronic and complex health conditions, and eventually advance the state of care for our warriors. (PsycINFO Database Record

Listening to the Patient: Women Veterans' Insights About Health Care Needs, Access, and Quality in Rural Areas.

OBJECTIVES: Many work to ensure that women veterans receive appropriate and timely health care, yet the needs of those living in rural areas are often ignored. This is a critical oversight given the multitude of reports documenting rural access problems and health disparities. Lacking this, we are unable to plan for and evaluate appropriate care for this specific group. In this project, we spoke with rural women veterans to document service needs and quality of care from their perspective. METHODS: Rural women veterans' views about health care access and quality were ascertained in a series of five, semistructured focus groups (n = 35) and completion of a demographic questionnaire. Content analysis documented focus-group themes. RESULTS: Participants said that local dental, mental health, and gender-specific care options were needed, as well as alternative healing options. Community-based support for women veterans and interaction with female peers were absent. Participants' support for telehealth was mixed, as were requests for gender-specific care. Personal experiences in the military impacted participants' current service utilization. CONCLUSIONS: Action by both Veterans Affairs and the local community is vital to improving the health of women veterans. Service planning should consider additional Veterans Affairs contracts, mobile health vans, peer support, and enhanced outreach.

American Indian veterans and VA services in three tribes.

The purpose of this project was to describe experiences of reservation-based American Indian (AI) veterans with the Department of Veterans Affairs (VA), and to identify opportunities for improving care and services. Focus group discussions and individual interviews were conducted with AI veterans, family members, and community members in three diverse tribes. Results showed that many veterans in tribal communities experienced challenges receiving services and benefits from the VA, including lack of culturally competent care, transportation problems, and difficulties navigating the system. Family members, often main caregivers for AI veterans, lacked necessary resources, including sources for information, support services, and financial means to procure adequate care. A number of strengths also were identified, including local leadership and a strong community commitment to improve care for veterans.

The impact of demographic differences on native veterans' outpatient service utilization.

Many Native veterans--including American Indian/Alaska Native (AIAN) and Native Hawaiian/Pacific Islanders (NHPI)--have served in the United States Armed Forces. Most of these veterans are eligible for medical care from the Department of Veterans Affairs (VA), but research examining the determinants of their service use is needed to inform policy and allocate appropriate resources for these unique groups. In a retrospective cohort study, we examined the impact of Native veterans' personal demographics on their outpatient utilization of VA-based primary care and mental health services. AIAN (n = 37,687) and NHPI (n = 46,582) veterans were compared with a non-Native reference (N = 262,212) using logistic and binomial regression. AIAN and NHPIs were more likely to be female, report military sexual trauma, and utilize the VA for posttraumatic stress disorder, traumatic brain injury, depression, addiction, anxiety, hypertension, and diabetes care. More AIAN and urban NHPI veterans served in Iraq and Afghanistan, and Native women reported more military sexual trauma than their non-Native counterparts. Primary care and mental health services were associated with race, number of diagnoses, and disability ratings. For mental health services, service era, military sexual trauma, and marital status were related to service utilization. Native veterans' medical need was elevated for primary and mental health care. Rural residence was associated with less mental health use. The findings underscore the need for additional specialized services in rural areas, more targeted outreach to Operation Enduring Freedom/Operation Iraqi Freedom Native veterans, and additional care directed toward Native women's health care needs.

Attitudes Toward Telemedicine in Urban, Rural, and Highly Rural Communities.

INTRODUCTION: The rate of telemedicine adoption using interactive video between patient and provider has not met expectations. Technology, regulations, and physician buy-in are cited reasons, but patient acceptance has not received much consideration. We examine attitudes regarding telemedicine to better understand the subjective definitions of its acceptability and utility that shape patients' willingness to use telemedicine. MATERIALS AND METHODS: Using the Montana Health Matters study (a random, statewide survey [n=3,512]), we use latent class analysis to identify groups with similar patterns of attitudes toward telemedicine followed by multinomial logistic regression to estimate predictors of group membership. RESULTS: Although only 5% are amenable to telemedicine regardless of circumstance, 23% would be comfortable if it could be convenient, whereas 29% would be situationally amenable but uncomfortable using telemedicine. Still, a substantial percentage (43%) is unequivocally averse to telemedicine despite the inconvenience of in-person visits. Educational attainment, prior Internet use, and rural residence are main predictors that increase the likelihood of being in an amenable group. CONCLUSIONS: From the patient's perspective, the advantages of reduced travel and convenience are recognized, but questions remain about the equivalence to physician visits. Many people are averse to telemedicine, indicating a perceived incompatibility with patient needs. Only 1.7% of the respondents reported using telemedicine in the previous year; about half were veterans. Hence, few have used telemedicine, and key innovation adoption criteria-trialability and observability-are low. Increased attention to public awareness in the adoption process is needed to increase willingness to embrace telemedicine as a convenient way to obtain quality healthcare services.

Rural women veterans demographic report: defining VA users' health and health care access in rural areas.

PURPOSE: While many women choose to live in rural areas after retiring from active military duty, a paucity of studies examine rural women veterans' health care needs. This report is the first of its kind to describe the population demographics and health care utilization of rural female veteran patients enrolled in the Department of Veterans Affairs (VA). METHODS: Using the National Patient Care Datasets (n = 327,785), we ran adjusted regression analyses to examine service utilization between (1) urban and rural and (2) urban and highly rural women veterans. FINDINGS: Rural and highly rural women veterans were older and more likely to be married than their urban counterparts. Diagnostic rates were generally similar between groups for several mental health disorders, hypertension, and diabetes, with the exception of nonposttraumatic stress anxiety that was significantly lower for highly rural women veterans. Rural and highly rural women veterans were less likely to present to the VA for women's specific care than urban women veterans; highly rural women veterans were less likely to present for mental health care compared to urban women veterans. Among the users of primary care, mental health, women's specific, and all outpatient services, patients' annual utilization rates were similar. CONCLUSIONS: Improved service options for women's specific care and mental health visits may help rural women veterans access care. Telehealth technologies and increased outreach, perhaps peer-based, should be considered. Other recommendations for VA policy and planning include increasing caregiver support options, providing consistency for mental health services, and revising medical encounter coding procedures.

Rural native veterans in the Veterans Health Administration: characteristics and service utilization patterns.

PURPOSE: The Department of Veterans Affairs (VA) and the Indian Health Service (IHS) signed a Memo of Understanding in 2010 to strengthen their partnership in improving health care services for Native veterans, who are disproportionately rural. This paper describes the demographic and service use profile of rural Native veterans who access VA health care. METHODS: Data were abstracted from the 2008 Veteran Health Administration (VHA) medical dataset, and the characteristics of rural Native veterans were compared to rural non-Native veterans. FINDINGS: Rural Native veterans were more rural (41% vs 35%) and more highly rural (8% vs 2%) compared to non-Native veterans. Rural Native veterans were younger, more likely to be female, and earned about the same median income compared to rural non-Native veterans. Although rural Native veterans had fewer diagnoses on average, they were more likely to have served in combat areas and to have higher levels of service-connected disability compared to other rural veterans. CONCLUSIONS: Demographic and service-related characteristics of rural Native veterans who accessed VA care differ from those of rural non-Native veterans. Identifying specific health care and service use characteristics will assist in the development of appropriate policy and programs to serve rural Native veterans.

Reaching rural communities with culturally appropriate care: a model for adapting remote monitoring to American Indian veterans with posttraumatic stress disorder.

OBJECTIVE: Providing specialized healthcare to rural communities can be extremely difficult, and consequently many health organizations are turning to the use of telehealth technologies for care delivery. One such technology, remote monitoring, has been successfully implemented with patients suffering from chronic and other medical conditions. A drawback, however, is that remote monitoring devices are programmed to reach a broad audience, and consequently the content may not be suitable for all patients-especially those who are not a part of the dominant culture. SUBJECTS AND METHODS: This report provides a model for adapting remote monitoring to specific populations who are undergoing care for posttraumatic stress disorder. Adaptation changes focus on (1) information gathering, (2) process and dialogue changes, (3) testing, and (4) patient and administrative feedback. Data for such modifications were gathered through a series of community meetings, patient interviews, and provider feedback. A case example highlights the successful implementation of the adaptation model for a rural American Indian Veteran population. RESULTS: Patients showed high acceptability of both the programmatic and cultural adaptations. Feasibility of the program also appeared positive, with most patients reporting that the readability of the program was appropriate, the dialogue duration was not burdensome, and technical problems were rare. CONCLUSIONS: Remote monitoring provides the ability to be modified for use with certain subpopulations. Procedural recommendations in this report highlight special considerations for working with American Indians living on or near reservation areas, although the model can be broadly adapted to several groups.

Personal characteristics affecting veterans' use of services for posttraumatic stress disorder.

OBJECTIVE: Posttraumatic stress disorder (PTSD) is widespread among veterans, but many veterans with PTSD use few health services. This study examined how individual characteristics influenced use of outpatient visits by veterans with PTSD. METHODS: The study assessed number of annual visits by 414,748 veterans with PTSD who sought care from October 2007 through September 2008 at U.S. Department of Veteran Affairs (VA) facilities. Negative binomial regression and adjusted risk ratios assessed the relationship of number of visits and demographic characteristics as well as place of residence, era of service, extent to which disability was connected to service history, and having comorbid illnesses. RESULTS: Veterans from rural or highly rural areas had 19% (confidence interval [CI]=.80-.82) and 25% (CI=.72-.79), respectively, fewer visits than urban-dwelling veterans. Iraq and Afghanistan veterans had 21% fewer visits than veterans of prior eras (CI=.78-.81). Veterans with comorbid conditions had 64% more visits than veterans with only PTSD (CI=1.62-1.66). Veterans from rural or highly rural areas had 22% (CI=.87-.89) and 33% (CI=.64-.71), respectively, fewer visits to PTSD specialty clinics than veterans from urban areas. CONCLUSIONS: Service use by veterans is lower in rural areas. The VA should build on existing efforts to provide more outreach and care opportunities, including telemental health and specialized PTSD services, in rural areas and for veterans of the current service era. Future research should investigate the impact of fewer visits on aspects of functioning, such as interpersonal factors, and the impact of system-level variables on service utilization.

Characteristics of telemental health service use by American Indian veterans.

OBJECTIVE: This study examined use by American Indian and Alaska Native veterans of services provided by specialty telemental health clinics focused on posttraumatic stress disorder. These clinics offer services via videoconferencing to address challenges faced by rural veterans in accessing care. METHODS: A retrospective chart and electronic medical record review was conducted for 85 male veterans who used services at two rural telemental health clinics from 2001 through 2006. Service use and other characteristics were documented before and after their initial telemental health intake. RESULTS: After intake, patients' use of any health services (both general medical and mental health services) significantly increased (p<.01), as did the proportion receiving psychotropic medication (p<.01). CONCLUSIONS: This first examination of service use by American Indian and Alaska Native veterans at specialty telemental health clinics will help inform research and clinical strategies for improving telemental health for this and other rural populations.

Review of American Indian veteran telemental health.

Rural American Indian veterans have unique healthcare needs and face numerous barriers to accessing healthcare services. Over the past decade, the Department of Veterans Affairs in conjunction with the University of Colorado Denver has turned to the promising field of telemental health to develop a series of videoconferencing-based clinics to reach this vulnerable population and improve mental healthcare services. The ongoing development, implementation, and expansion of these clinics have been assessed as part of a program improvement. The outcomes of these assessments have been documented in a series of published articles, controlled studies, program and case reports, and model descriptions. This article summarizes a decade of experience with the American Indian Telemental Health Clinics, the clinic model, and the literature arising from these clinics and presents lessons learned while establishing, maintaining, and evaluating these clinics. The ability to tailor the clinics to individual sites and cultures and to provide various services has been critical to the operation of the clinics. Culturally specific care through culturally knowledgeable providers, onsite tribal outreach workers, and collaboration with community services has proven essential in operating the clinics, as well as building rapport, trust, and engagement with the target patient population. It is hoped that the lessons learned and practices presented here can not only assist others working to improve the care for rural Native veterans but also serve as a model in the use of telemental health services for improving care and access to rural veteran and non-veteran populations.

The diffusion of telehealth in rural American Indian communities: a retrospective survey of key stakeholders.

OBJECTIVE: Mental health issues are a serious concern for many American Indian Veterans, especially for post-traumatic stress disorder and related psychiatric conditions. Yet, acquiring mental health treatment can be a challenge in Native communities where specialized services are largely unavailable. Consequently, telehealth is increasingly being suggested as a way to expand healthcare access on or near reservation lands. In this study, we wanted to understand the factors affecting the diffusion of telehealth clinics that provided mental health care to rural, American Indian Veterans. MATERIALS AND METHODS: We surveyed 39 key personnel and stakeholders who were involved in the decision-making process, technological infrastructure, and implementation of three clinics. Using Roger Everett's Diffusion Theory as a framework, we gathered information about specific tasks, factors hindering progress, and personal reactions to telehealth both before and after implementation. RESULTS: Many participants expressed initial concerns about using telehealth; however, most became positive over time. Factors that influenced participants' viewpoint largely included patient and staff feedback and witnessing the fulfillment of a community health need. The use of outside information to support the implementation of the clinics and personal champions also showed considerable influence in the clinics' success. CONCLUSION: The findings presented here address critical gaps in our understanding of telehealth diffusion and inform research strategies regarding the cultural issues and outcomes related to telemental health services. Information contained in this report serves as a long overdue guide for developing telemental health programs and policies among American Indians, specifically, and rural populations in general.

Reaching out to older veterans in need: the Elko clinic demonstration project.

CONTEXT: The challenge of providing meaningful health care services to veterans living in rural communities is a major public health concern that involves redefining the traditional facility-based model of care delivery employed in urban areas. PURPOSE: This paper describes the steps of a demonstration project, the Elko Telehealth Outreach Clinic. The clinic, located in Elko, Nevada, was created to meet the health care needs of veterans who expressed a desire for greater access to VA services. METHODS: The Elko Telehealth Outreach Clinic is a specific example of the real-life implementation of the community-as-partner model as an operational framework for coordinating local, regional, and VA resources. The Elko Clinic provides a limited set of health care services including medication management, health education, prescription refills, routine lab tests, and specialty services through telehealth. FINDINGS: From December 2006 to December 2007, a total of 84 unique veterans received health care services through the Elko Clinic. CONCLUSIONS: Our findings support the usefulness of an expanded community-as-partner model to guide a process for addressing the health care needs of veterans in Elko, Nevada, and they have implications for the development and maintenance of outreach clinics in other rural settings.

The Care Coordination Home Telehealth (CCHT) rural demonstration project: a symptom-based approach for serving older veterans in remote geographical settings.

INTRODUCTION: Innovative healthcare delivery strategies are needed to address the healthcare needs of the 3.5 million older veterans living in US rural areas who face unique healthcare delivery challenges, including transportation barriers, poverty, and limited access to health professions and community-based programs. The care coordination home telehealth (CCHT) rural demonstration project was developed to address the mismatch between the timely identification of patient needs and the care delivered by the traditional disease-oriented institutionally-based healthcare delivery system for older rural veterans. The specific objectives were to: (1) serve as a facilitator of primary care; and (2) provide a portfolio of geriatric care management options to increase early detection of symptoms and to encourage adherence to care plans. METHODS: Participants were recruited based on patterns of high outpatient, inpatient, and emergency care visits; 132 rural older veterans were enrolled. The CCHT applied care management principles to the delivery of healthcare services and used health informatics to facilitate access to evidence-based care. The CCHT's essential components, which were tailored to optimize remote access, included a face-to-face orientation, telephone contact with a designated care coordinator, and daily monitoring sessions using an in-home telehealth device to assess participants' medication usage, compliance, and symptoms, and to provide patient education. RESULTS: One hundred eleven participants successfully installed and connected the telehealth monitoring device in their homes without hands-on assistance, monitored complex medical and psychiatric symptoms, and reported medication compliance remotely. Of the 93 participants who used the device for more than 10 sessions, 88 reported they did not have any difficulty using the device, 86 reported they were satisfied or very satisfied with the device, 73 reported they were likely to continue using the device, and 46 reported improved communication between themselves and their primary healthcare provider. CONCLUSION: Initial utilization and satisfaction evaluation data from this project supports the feasibility of employing a CCHT approach to serve medically-complicated older veterans in rural settings. This approach could also serve as a template for addressing a greater range of healthcare needs among other populations in hard-to-reach settings.

Review of Veterans Health Administration telemedicine interventions.

The Veterans Health Administration (VHA) is a leader in developing and implementing innovative healthcare technology. We review 19 exemplary peer-reviewed articles published between 2000 and 2009 of controlled, VHA-supported telemedicine intervention trials that focused on health outcomes. These trials underscore the role of telemedicine in large managed healthcare organizations in support of (1) chronic disease management, (2) mental health service delivery through in-home monitoring and treatment, and (3) interdisciplinary team functioning through electronic medical record information interchange. Telemedicine is advantageous when ongoing monitoring of patient symptoms is needed, as in chronic disease care (eg, for diabetes) or mental health treatment. Telemedicine appears to enhance patient access to healthcare professionals and provides quick access to patient medical information. The sustainability of telemedicine interventions for the broad spectrum of veteran patient issues and the ongoing technology training of patients and providers are challenges to telemedicine-delivered care.

The role of grief in dementia caregiving.

The literature examining issues of caregiver stress, burden,or depression has focused on the stress-process model of caregiving, which posits that there are characteristics inherent in dementia and in the course of caregiving for a person with dementia that can cause stress in the caregiver's life. A more recent literature has emerged that argues that issues of loss and grief play a significant role ina caregiver's ability to cope with the stressors of caregiving. This article reviews the caregiver stress and grief literatures,and proposes a conceptual model of dementia caregiving that outlines pathways of stress and grief in dementia caregiving. Issues specific to caregiver grief are proposed for future research and intervention design.