WORKING AT THE TOP OF THEIR CAPABILITIES: HOW TEAMWORK SUPPORT ATTENUATES LEADER ROLE CONFLICT.

Objective: To understand whether team member support reduces team leader stress. Method: In Phase 1, we used hierarchical linear modeling with survey data and administrative records from 45 Veterans Health Administration teams (73 providers and 228 associated members) to investigate how teamwork support mitigates leader stress. In Phase 2, we adopted a parallel/simultaneous mixed methods design, utilizing open- and closed-ended responses from 267 additional Veterans Health Administration providers. With the mixed methods design we first analyzed open-ended responses using directed content analysis and hypothesis coding. Next, we transformed our codes into counts and compared them with closed-ended responses to understand whether teamwork support allows leaders to engage in work aligned with their qualifications. Results: As predicted, providers' role conflict corresponded with decreased performance under low teamwork support, but this negative relationship was attenuated with high teamwork support as such support allows leaders to focus on tasks they are uniquely qualified to perform. Conclusions: These findings emphasize the facilitative nature of teams in supporting leaders: followers provide teamwork support that helps leaders navigate role conflict by allowing leaders to work on tasks consistent with their qualifications.

National Survey of the Bone Densitometry Evaluation Process Within an Integrated Healthcare System.

BACKGROUND: To assess the current state of bone mineral density evaluation services via dual energy x-ray absorptiometry (DXA) provided to Veterans with fracture risk through the development and administration of a nationwide survey of facilities in the Veterans Health Administration. METHODOLOGY: The Bone Densitometry Survey was developed by convening a Work Group of individuals with expertise in bone densitometry and engaging the Work Group in an iterative drafting and revision process. Once completed, the survey was beta tested, administered through REDCap, and sent via e-mail to points of contact at 178 VHA facilities. RESULTS: Facility response rate was 31 % (56/178). Most DXA centers reported positively to markers of readiness for their bone densitometers: less than 10 years old (n=35; 63 %); in "excellent" or "good" condition (n=44; 78 %, 32 % and 46 %, respectively); and perform phantom calibration (n=43; 77 %). Forty-one DXA centers (73 %) use intake processes that have been shown to reduce errors. Thirty-seven DXA centers (66 %) reported their technologists receive specialized training in DXA, while 14 (25 %) indicated they receive accredited training. Seventeen DXA centers (30 %) reported performing routine precision assessment. CONCLUSIONS: Many DXA centers reported using practices that meet minimal standards for DXA reporting and preparation; however, the lack of standardization, even within an integrated healthcare system, indicates an opportunity for quality improvement to ensure consistent high quality bone mineral density evaluation of Veterans.

Identification of Implementation Strategies Using the CFIR-ERIC Matching Tool to Mitigate Barriers in a Primary Care Model for Older Veterans.

BACKGROUND AND OBJECTIVES: As the proportion of the U.S. population over 65 and living with complex chronic conditions grows, understanding how to strengthen the implementation of age-sensitive primary care models for older adults, such as the Veterans Health Administration's Geriatric Patient-Aligned Care Teams (GeriPACT), is critical. However, little is known about which implementation strategies can best help to mitigate barriers to adopting these models. We aimed to identify barriers to GeriPACT implementation and strategies to address these barriers using the Consolidated Framework for Implementation Research-Expert Recommendations for Implementing Change (CFIR-ERIC) Matching Tool. RESEARCH DESIGN AND METHODS: We conducted a content analysis of qualitative responses obtained from a web-based survey sent to GeriPACT members. Using a matrix approach, we grouped similar responses into key barrier categories. After mapping barriers to CFIR, we used the Tool to identify recommended strategies. RESULTS: Across 53 Veterans Health Administration hospitals, 32% of team members (n = 197) responded to our open-ended question about barriers to GeriPACT care. Barriers identified include Available Resources, Networks & Communication, Design Quality & Packaging, Knowledge & Beliefs, Leadership Engagement, and Relative Priority. The Tool recommended 12 Level 1 (e.g., conduct educational meetings) and 24 Level 2 ERIC strategies (e.g., facilitation). Several strategies (e.g., conduct local consensus discussions) cut across multiple barriers. DISCUSSION AND IMPLICATIONS: Strategies identified by the Tool can inform on-going development of the GeriPACT model's effective implementation and sustainment. Incorporating cross-cutting implementation strategies that mitigate multiple barriers at once may further support these next steps.

Engagement in Primary Prevention Program among Rural Veterans With Osteoporosis Risk.

A primary osteoporosis prevention program using a virtual bone health team (BHT) was implemented to comanage the care of rural veterans in the Mountain West region of the United States. The BHT identified, screened, and treated rural veterans at risk for osteoporosis using telephone and United States Postal Service communications. Eligibility was determined by regular use of Veterans Health Administration primary care, age 50 or older, and evidence of fracture risk. This study was conducted to identify demographic and clinical factors associated with the acceptance of osteoporosis screening and the initiation of medication where indicated. A cross-sectional cohort design (N = 6985) was utilized with a generalized estimating equation and logit link function to account for facility-level clustering. Fully saturated and reduced models were fitted using backward selection. Less than a quarter of eligible veterans enrolled in BHT's program and completed screening. Factors associated with a lower likelihood of clinic enrollment included being of older age, unmarried, greater distance from VHA services, having a copayment, prior fracture, or history of rheumatoid arthritis. A majority of veterans with treatment indication started medication therapy (N = 453). In this subpopulation, Fisher's exact test showed a significant association between osteoporosis treatment uptake and a history of two or more falls in the prior year, self-reported parental history of fracture, current smoking, and weight-bearing exercise. The BHT was designed to reduce barriers to screening; however, for this population cost and travel continue to limit engagement. The remarkable rate of medication initiation notwithstanding, low enrollment reduces the impact of this primary prevention program, and findings pertaining to fracture, smoking, and exercise imply that health beliefs are an important contributing factor. Efforts to identify and address barriers to osteoporosis screening and treatment, such as clinical factors, social determinants of health, and health beliefs, may pave the way for effective implementation of population bone health care delivery systems. Published 2022. This article is a U.S. Government work and is in the public domain in the USA. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Cultivating across "pockets of excellence": challenges to sustaining efforts to improve osteoporosis care.

We conducted in-depth, semi-structured interviews with clinicians involved in bone health care to understand the challenges of implementing and sustaining bone health care interventions. Participants identified individual- and system-level challenges to care delivery, implementation, and sustainment. We discuss opportunities to address challenges through a commitment to relationship- and infrastructure-building support. PURPOSE: Osteoporosis and fracture-related sequalae exact significant individual and societal costs; however, identification and treatment of at-risk patients are troublingly low, especially among men. The purpose of this study was to identify challenges to implementing and sustaining bone health care delivery interventions in the Veterans Health Administration. METHODS: We conducted interviews with endocrinologists, pharmacists, primary care physicians, rheumatologists, and orthopedic surgeons involved in bone health care (n = 20). Interviews were audio-recorded and transcribed verbatim. To determine thematic domains, we engaged in an iterative, qualitative content analysis of the transcripts. RESULTS: Participants reported multiple barriers to delivering bone health care and to sustaining the initiatives designed to address delivery challenges. Challenges of bone health care delivery existed at both the individual level-a lack of patient and clinician awareness and competing clinical demands-and the system level-multiple points of entry to bone health care, a dispersion of patient management, and guideline variability. To address the challenges, participants developed initiatives targeting the identification of at-risk patients, clinician education, increasing communication, and care coordination. Sustaining initiatives, however, was challenged by staff turnover and the inability to achieve and maintain priority status for bone health care. CONCLUSION: The multiple, multi-level barriers to bone health care affect both care delivery processes and sustainment of initiatives to improve those processes. Barriers to care delivery, while tempered by intervention, are entangled and persist alongside sustainment challenges. These challenges require relationship- and infrastructure-building support.

Attitudes toward bone health among rural-dwelling veterans identified as at risk of fracture: a qualitative analysis.

Although much is known about system-level barriers to prevention and treatment of bone health problems, little is known about patient-level barriers. The objective of this study was to identify factors limiting engagement in bone health care from the perspective of rural-dwelling patients with known untreated risk. Over 6 months, 39 patients completed a qualitative interview. Interview questions focused on the patient's experience of care, their decision to not accept care, as well as their knowledge of osteoporosis and the impact it has had on their lives. Participants were well-informed and could adequately describe osteoporosis and its deleterious effects, and their decision making around accepting or declining a dual-energy x-ray absorptiometry (DXA) scan and treatment was both cautious and intentional. Decisions about how to engage in treatment were tempered by expectations for quality of life. Our findings suggest that people hold beliefs about bone health treatment that we can build on. Work to improve care of this population needs to recognize that bone health providers are not adding a behavior of medication taking to patients, they are changing a behavior or belief. Published 2021. This article is a U.S. Government work and is in the public domain in the USA. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

The importance of soft skills development in a hard data world: learning from interviews with healthcare leaders.

BACKGROUND: Learning healthcare systems have invested heavily in training primary care staff to provide care using patient-centered medical home models, but less is known about how to effectively lead such teams to deliver high quality care. Research is needed to better understand which healthcare leadership skills are most utilized or in need of development through additional training. METHOD: Semi-structured telephone interviews with healthcare leaders familiar with Patient-Aligned Care Teams (PACT) implementation in the U.S. Department of Veterans Affairs (VA). We interviewed sixteen (N = 16) physician, nursing, and administrative leaders at VA facilities located in the upper Midwestern United States. Content analysis of interviews transcripts using template techniques. RESULTS: Participants described instrumental challenges that they perceived hindered leadership effectiveness, including the supervisory structure; pace of change; complexity of the clinical data infrastructure; an over-reliance on technology for communication; and gaps in available leadership training. Factors perceived as facilitating effective leadership included training in soft skills, face-to-face communication, and opportunities for formal training and mentorship. A cross-cutting theme was the importance of developing "soft skills" for effective PACT leadership. CONCLUSIONS: Although formal leadership training and development were perceived as beneficial, healthcare leaders familiar with PACT implementation in the VA described a mismatch between the skills and knowledge PACT leaders need to succeed and the training available to them. Closing this gap could improve retention of skilled and knowledgeable healthcare leaders, thereby reducing the costs associated with training and leading to improvements in healthcare delivery.

Delivering fracture prevention services to rural US veterans through telemedicine: a process evaluation.

An informatics-driven population bone health clinic was implemented to identify, screen, and treat rural US Veterans at risk for osteoporosis. We report the results of our implementation process evaluation which demonstrated BHT to be a feasible telehealth model for delivering preventative osteoporosis services in this setting. PURPOSE: An established and growing quality gap in osteoporosis evaluation and treatment of at-risk patients has yet to be met with corresponding clinical care models addressing osteoporosis primary prevention. The rural bone health tea m (BHT) was implemented to identify, screen, and treat rural Veterans lacking evidence of bone health care and we conducted a process evaluation to understand BHT implementation feasibility. METHODS: For this evaluation, we defined the primary outcome as the number of Veterans evaluated with DXA and a secondary outcome as the number of Veterans who initiated prescription therapy to reduce fracture risk. Outcomes were measured over a 15-month period and analyzed descriptively. Qualitative data to understand successful implementation were collected concurrently by conducting interviews with clinical personnel interacting with BHT and BHT staff and observations of BHT implementation processes at three site visits using the Promoting Action on Research Implementation in Health Services (PARIHS) framework. RESULTS: Of 4500 at-risk, rural Veterans offered osteoporosis screening, 1081 (24%) completed screening, and of these, 37% had normal bone density, 48% osteopenia, and 15% osteoporosis. Among Veterans with pharmacotherapy indications, 90% initiated therapy. Qualitative analyses identified barriers of rural geography, rural population characteristics, and the infrastructural resource requirement. Data infrastructure, evidence base for care delivery, stakeholder buy-in, formal and informal facilitator engagement, and focus on teamwork were identified as facilitators of implementation success. CONCLUSION: The BHT is a feasible population telehealth model for delivering preventative osteoporosis care to rural Veterans.

Patient Aligned Care Team (PACT) Performance in Urban and Rural VHA Primary Care Clinics: A Mixed Methods Study.

PURPOSE: To assess differences in Patient Aligned Care Team (PACT) performance between rural and urban primary care clinics within the Veterans Health Administration (VHA). METHODS: An Explanatory Sequential Mixed Methods design was conducted using VHA administrative data to assess performance of a national sample of 891 VHA primary care clinics. Generalized Estimating Equations with repeated measures were used to estimate associations between rurality and process-oriented endpoints including: chronic disease management through telehealth; use of telephone visits, group visits or secured messaging; same-day access; continuity with primary care provider; and postdischarge follow-up. Qualitative data collected during on-site visits with 5 clinics were used to provide insights into PACT processes from the perspectives of staff in rural and urban clinics. FINDINGS: After adjusting for patient- and practice-level characteristics, clinics located in large rural or small/isolated rural areas demonstrated difficulty enhancing access through use of telephone visits, group visits, or secured messaging and completing postdischarge follow-up calls, compared to urban clinics. Qualitative analysis indicated that staff from both rural and urban clinics reported similar barriers implementing these PACT processes. Both patient and staff behaviors and preferences impact implementation of these processes. Distance to care and access to high-speed Internet were also reported as barriers. CONCLUSIONS: This study contributes to the understanding of PACT performance in rural settings by highlighting ways contextual and behavioral factors relate to performance. Increasing implementation of patient-centered medical home (PCMH) models, such as PACT, will require additional attention to the complex relationships between the practice and surrounding context.

Using the PACT Resources Framework to Understand the Needs of Geriatric Primary Care Teams.

OBJECTIVES: To identify the perceived organizational resources required by healthcare workers to deliver geriatric primary care in a geriatric patient aligned care team (GeriPACT). DESIGN: Cross-sectional observational study using deductive analyses of qualitative interviews conducted with GeriPACT team members. SETTING: GeriPACTs practicing at eight geographically dispersed Department of Veterans Affairs (VA) healthcare systems. PARTICIPANTS: GeriPACT clinicians, nurses, clerical associates, clinical pharmacists, and social workers (n = 67). MEASUREMENTS: Semistructured qualitative interviews conducted in person, transcribed, and then analyzed using the PACT Resources Framework. RESULTS: Using the PACT Resources Framework, we identified facility-, clinic-, and team-level resources critical for GeriPACT implementation. Resources within each level reflect how the needs of older adults with complex comorbidity intersect with general population primary care medical home practice. GeriPACT implementation is facilitated by attention to patient characteristics such as cognitive impairment, ambulatory limitations, or social support services in staffing and resourcing teams. CONCLUSION: Models of geriatric primary care such as GeriPACT must be implemented with an eye toward the most effective use of our most limited resource-trained geriatricians. In contrast to much of the literature on medical home teams serving a general adult population, interviews with GeriPACT members emphasize how patient needs inform all aspects of practice design including universal accessibility, near real-time response to patient needs, and ongoing interdisciplinary care coordination. Examination of GeriPACT implementation resources through the lens of traditional primary care teams illustrates the importance of tailoring primary care design to the needs of older adults with complex comorbidity.

Environmental service workers as potential designers of infection control policy in long-term care settings.

BACKGROUND: Long-term care facility residents are at higher risk of methicillin-resistant Staphylococcus aureus infection and colonization than the general population. In 2009, the Department of Veterans Affairs (VA) implemented the "methicillin-resistant S. aureus prevention initiative" in long-term care facilities (ie, Community Living Centers or "CLCs"). METHODS: Over 4 months, 40 semistructured interviews were conducted with staff in medicine, nursing, and environmental services at 5 geographically dispersed CLCs. Interviews addressed knowledge, attitudes, and beliefs concerning infection prevention and resident-centered care. A modified constant comparative approach was used for data analysis. RESULTS: In CLCs, staff work to prevent and control infections in spaces where residents live. Nurses and Environmental Service Workers daily balance infection prevention conventions with the CLC setting. Infection control team members, who are accustomed to working in acute care settings, struggle to reconcile the CLC context with infection prevention. DISCUSSION: The focus on the resident's room as the locus of care, and thus the main target of infection control, misses opportunities for addressing infection prevention in the spaces beyond the residents' rooms. CONCLUSIONS: Environmental Service Workers' daily work inside the rooms and within the wider facility produces a unique perspective that might help in the design of workable infection control policies in CLCs.

Factors Associated With Osteoporosis Care of Men Hospitalized for Hip Fracture: A Retrospective Cohort Study.

Rates of postfracture DXA and pharmacotherapy appear to be declining despite their known benefits in fracture reduction. We sought to identify factors associated with osteoporosis care among male veterans aged 50 years and older after hip fracture and to evaluate trends in rates of care with an observational cohort design using US Department of Veterans Affairs' (VA) inpatient, pharmacy, and outpatient encounters and Centers for Medicare and Medicaid Services outpatient pharmacy claims (2007 to 2014) from men aged 50 years and older treated for hip fracture (N = 7317). We used the Cox proportional hazards model with random effects for the admitting facility. A sensitivity analysis was performed for a subset of patients aged 65 to 99 dually enrolled in Medicare ( N = 5821). Overall, approximately 13% of patients had evidence of osteoporosis care within one year of fracture. In the adjusted model, rural residence was associated with lower likelihood of care, and several comorbidities were associated with higher likelihood of receiving care. In sensitivity analyses of patients dually enrolled in Medicare, rural residence remained associated with lower likelihood of osteoporosis care. Overall rates of care decreased over time, but rates of DXA in the VA remained stable. These findings highlight the ongoing problem of low rates of postfracture care among a population with the highest risk of future fracture and its associated morbidity and mortality. The rural disparity in care and differences in rates of care across healthcare delivery systems illustrates the importance of healthcare delivery systems in promoting pharmacotherapy and DXA after sentinel events. Because the VA removes a majority of cost barriers to care, this integrated healthcare system may outperform the private sector in access to care. However, declining rates of pharmacotherapy imply knowledge gaps that undermine quality care. © 2019 The Authors. JBMR Plus is published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

Metasynthesis of Patient Attitudes Toward Bone Densitometry.

BACKGROUND: Bone densitometry (e.g., dual-energy X-ray absorptiometry or "DXA") is strongly associated with osteoporosis treatment; however, rates of DXA are low. While studies have demonstrated a continued need for primary care provider education on the role of DXA in preventive care, little is known about the role of patient attitudes toward DXA. This review's purpose is to synthesize the evidence about the effects of patient perceptions and experiences of DXA on osteoporosis prevention. METHODS: A metasynthesis was conducted of English language, peer-reviewed publications, searching relevant databases: MEDLINE, CINAHL, Web of Science Social Science Citation Index, PsycINFO, and Sociological Abstracts. Identified articles' quality was appraised using the Critical Appraisal Skills Programme (CASP) Qualitative Checklist, and an iterative process of data evaluation, integration, and synthesis was used to develop the findings. RESULTS: Thirteen articles from ten studies were identified, composing an aggregated sample of 265 people (231 women). Participant attitudes toward screening ranged from receptive to ambivalent to concerned about results. Participants' understandings of DXA and its role in clinical care were limited. Knowledge of osteoporosis was also partial and influenced by lay sources, the media, and health care providers. Primary care providers strongly influenced participant behavior, especially if participants had a more passive approach to health care. Participants reported less concern about expected barriers of health care access and cost. CONCLUSION: Minimal knowledge exists of patient perceptions and experiences of DXA among those who are fracture naïve: Prior research has focused primarily on secondary fracture prevention contexts. Our metasynthesis reveals patients' significant reliance, given their limited risk appraisal and knowledge, upon primary care providers in decision-making. We urge colleagues to conduct qualitative research on DXA barriers among general primary care population in order to facilitate health care delivery systems better equipped to diagnose and treat patients before their first fracture.

Understanding Preferences for Osteoporosis Information to Develop an Osteoporosis Patient Education Brochure.

CONTEXT: Patient education materials can provide important information related to osteoporosis prevention and treatment. However, available osteoporosis education materials fail to follow best-practice guidelines for patient education. OBJECTIVE: To develop an educational brochure on bone health for adults aged 50 years and older using mixed-method, semistructured interviews. DESIGN: This project consisted of 3 phases. In Phase 1, we developed written content that included information about osteoporosis. Additionally, we designed 2 graphic-rich brochures, Brochure A (photographs) and Brochure B (illustrations). In Phase 2, interviewers presented the text-only document and both brochure designs to 53 participants from an academic Medical Center in the Midwest and an outpatient clinic in the Southeastern region of the US. Interviewers used open- and closed-ended questions to elicit opinions regarding the brochures. In Phase 3, using feedback from Phase 2, we revised the brochure and presented it to 11 participants at a third site in the Southeastern US. MAIN OUTCOME MEASURES: Participants' comprehension of brochure text and acceptability of brochure design. RESULTS: We enrolled 64 participants. Most were women, white, and college-educated, with an average age of 66.1 years. Participants were able to restate the basic content of the brochure and preferred Brochure A's use of photographs. CONCLUSIONS: Using feedback from older adults, we developed and refined a brochure for communicating bone health information to older adults at risk of osteoporosis and fragility fractures. The methods outlined in this article may serve to guide others in developing health educational brochures for chronic medical conditions.

Gatekeepers as Care Providers: The Care Work of Patient-centered Medical Home Clerical Staff.

International implementation of the patient-centered medical home (PCMH) model for delivering primary care has dramatically increased in the last decade. A majority of research on PCMH's impact has emphasized the care provided by clinically trained staff. In this article, we report our ethnographic analysis of data collected from Department of Veterans Affairs staff implementing PACT, the VA version of PCMH. Teams were trained to use within-team delegation, largely accomplished through attention to clinical licensure, to differentiate staff in providing efficient, patient-centered care. In doing so, PACT may reinforce a clinically defined culture of care that countermands PCMH ideals. Such competing rubrics for care are brought into relief through a focus on the care work performed by clerks. Ethnographic analysis identifies clerks' care as a kind of emotional dirty work, signaling important areas for future anthropological study of the relationships among patient-centered care, stigma, and clinical authority.

The Critical Role of Clerks in the Patient-Centered Medical Home.

Research evaluating the effectiveness, function, and implementation of patient-centered medical homes (PCMHs) has found major socioprofessional transformations and contributions of primary care physicians and, to a lesser degree, nurses. Our longitudinal ethnographic research with teams implementing PCMH in Veterans Health Administration (VHA) primary care identifies the important but largely underutilized contributions of clerks to PCMH outcomes. Although the relationship of high-performing clerical staff to patient satisfaction is widely acknowledged, PCMH can be further enhanced by enabling clerks to use administrative tasks as conduits for investing in long-term personalized relationships with patients that foster trust in the PCMH and the broader health care organization. Such relationships are engendered through the care-coordination activities clerks perform, which may be bolstered by organizational investment in clerks as skilled health care team members.

Implications of the Patient-Centered Medical Home for Nursing Practice.

OBJECTIVE: The experiences of RNs and licensed practical nurses (LPNs) implementing a patient-centered medical home (PCMH) in the Department of Veterans Affairs (VA) primary care clinics were examined to understand model implications for nursing practice and professional identity. BACKGROUND: National implementation of the PCMH model, called patient-aligned care teams (PACTs) in VA, emphasizes areas of nursing expertise, yet little is known about the effect of medical homes on the day-to-day work of nurses. METHODS: As part of a formative evaluation to identify barriers and facilitators to PACT implementation, we interviewed 18 nurses implementing PACT. RESULTS: Challenges to nurse's organizational and professional roles were experienced differently by RNs and LPNs in the following areas: (1) diversified modes of care and expanded clinical duties, (2) division of labor among PACT nurses, and (3) interprofessional status in the team. CONCLUSIONS: Healthcare managers implementing PCMH should consider its inherent cultural and practice transformations.

The empowerment paradox as a central challenge to patient centered medical home implementation in the veteran's health administration.

In this paper we present results of a mixed methods study conducted to identify barriers to team function among staff implementing patient aligned care teams - the Department of Veterans Affairs' patient centered medical home (PCMH) model. Using a convergent mixed methods design, we administered a standardized survey measure (Team and Individual Role Perception Survey) to assess work role challenge and engagement; and conducted discussion groups to gather context pertaining to role change. We found that the role of primary care providers is highly challenging and did not become less difficult over the initial year of implementation. Unexpectedly over the course of the first year nurse care managers reported a decrease in their perceptions of empowerment and clerical associates reported less skill variety. Qualitative data suggest that more skilled team members fail to delegate and share tasks within their teams. We characterize this interprofessional knowledge factor as an empowerment paradox where team members find it difficult to share tasks in ways that are counter to traditionally structured hierarchical roles. Health care systems seeking to implement PCMH should dedicate resources to facilitating within-team role knowledge and negotiation.