Implementing evidence-based patient self-management programs in the Veterans Health Administration: perspectives on delivery system design considerations.

While many patient self-management (PSM) programs have been developed and evaluated for effectiveness, less effort has been devoted to translating and systematically delivering PSM in primary and specialty care. Therefore, the purpose of this paper is to review delivery system design considerations for implementing self-management programs in practice. As lessons are learned about implementing PSM programs in Veterans Health Administration (VHA), resource allocation by healthcare organization for formatting PSM programs, providing patient access, facilitating PSM, and incorporating support tools to foster PSM among its consumers can be refined and tailored. Redesigning the system to deliver and support PSM will be important as implementation researchers translate evidence based PSM practices into routine care and evaluate its impact on the health-related quality of life of veterans living with chronic disease.

Department of Veterans Affairs Quality Enhancement Research Initiative for spinal cord injury.

Spinal cord injury (SCI) is a lifelong condition, requiring ongoing efforts by multiple disciplines to stabilize, diminish, or prevent impairments; avoid or limit secondary complications; and improve or maintain social role functioning and quality of life for the individual throughout his or her life. There are approximately 200,000 persons with SCI in the United States, of whom roughly 22% are veterans. The estimated national economic impact of SCI is approximately $9.73 billion per year. These figures illustrate why SCI is an important topic for the Department of Veterans Affairs Quality Enhancement Research Initiative (QUERI). The SCI QUERI will identify gaps in knowledge of SCI treatment and management, develop research efforts to address these gaps, identify best practices for care and management of SCI, and assess whether best practices lead to improved outcomes, including health-related quality of life.

Using Department of Veterans Affairs Administrative databases to examine long-term care utilization for men and women veterans.

We examined long-term care (LTC) utilization by male and female veterans using administrative databases maintained by VA. Research questions included: (1) Which LTC services are utilized? (2) Do utilization patterns of older veterans differ from those of elderly persons in the general U.S. population? (3) Do LTC needs of veterans vary by gender? We were unable to track LTC utilization of individuals across administrative databases. Some databases could only provide information at the national level, or alternatively, were available only at local facilities, or only at the patient or program-level data--making it impossible to get a clear picture of all the services received by an individual. Those planning to use administrative databases to conduct research must: (1) take more time than expected; (2) be flexible/willing to compromise, (3) "ferret out" information, and (4) recognize that because of dynamism inherent in information systems, results may change over time.

Nursing facilities and managed care.

OBJECTIVE: To examine the extent to which Illinois nursing facilities have developed relationships with other healthcare providers, particularly managed care organizations (MCOs). STUDY DESIGN: A cross-sectional survey of nursing facilities designed to determine: 1) relationship objectives; 2) obstacles to developing relationships; 3) currently available services; 4) staffing for these services and; 5) nursing facility approaches to networking. The survey was sent to a census sample of 867 nursing facilities serving the elderly in Illinois. Descriptive and multivariate logistic regression analyses of relationships determined to be formal/risk-sharing were performed. STUDY POPULATION: The sample included 523 Illinois nursing facilities. A total response rate of 60% was achieved (523/867). RESULTS: Higher strategic goals, urban location, nonprofit ownership status, higher percentages of private pay and/or Medicare clients (vs Medicaid), and provision of home care and subacute services were all significant predictors of formal or risk-sharing relationships with MCOs. CONCLUSIONS: Facilities with more relationships and higher goals have more formal/risk-sharing relationships with MCOs. Facilities in urban areas have more relationships, likely due to the fact that rural facilities have fewer options and operate in different markets. In addition, nursing facilities rely on Medicare referrals from hospitals, and these Medicare patients, especially those in urban areas, are increasingly controlled by MCOs.

Development and sensitivity to visual impairment of the Low Vision Functional Status Evaluation (LVFSE).

BACKGROUND: Functional limitation because of visual impairment is one of the most important measures of low vision rehabilitation outcome because it represents the true impact of visual impairment upon the daily lives of individuals. The Low Vision Functional Status Evaluation (LVFSE) was designed to evaluate functional limitation because of visual impairment using both observed and self-reported performance on daily activities. METHODS: Performance on 27 daily activities was evaluated for 155 visually impaired subjects. Subjects also provided ratings of task difficulty. RESULTS: Correlations between observed performance and visual acuity, contrast sensitivity, and visual field loss severity were moderate, r = -0.60 to r = 0.34. Correlations between self-reported task performance difficulty and measures of visual clinical state were weaker, r = -0.44 to r = 0.21. CONCLUSIONS: The LVFSE shows promise as a sensitive measure of low vision-related functional status but more work is needed to refine the measure.

Prevalence of subacute patients in acute care: results of a study of VA hospitals.

Subacute care is a transitional level of care for medically stable patients who no longer require daily diagnostic/invasive care but require more intensive care than is typical in a skilled care facility. A Congressionally mandated study was undertaken to determine the number of VA patients with subacute needs being cared for in acute care. InterQual, Inc. subacute care criteria were retrospectively applied to 858 medical and surgical admissions from 43 VA hospitals. Over one-third contained at least one subacute day; with an average length of stay (LOS) of 12.7 days (SD = 12.4); of which 6.8 days were subacute. Patients with these admissions had significantly longer LOSs, were older, and were more likely to die or to be discharged to a nursing home. Diagnoses with subacute days included COPD, pneumonia, joint replacement, and cellulitis. Future studies should develop clinical pathways to prospectively manage admissions with subacute needs and then evaluate their effectiveness.

Evaluation of a prospective payment system for VA contract nursing homes.

An evaluation of a pilot program for community nursing home care reimbursement by Department of Veterans Affairs Medical Centers (VAMCs) was undertaken. Eight VAMCs began using the Enhanced Prospective Payment System (EPPS) in 1992. These sites were compared to eight customary payment sites in a pretest/posttest quasi-experimental design. Outcomes included access to care, administrative workload, quality of care, and cost. As expected, per diem costs were significantly higher for EPPS than customary reimbursement patients ($106 vs. $87). However, EPPS sites placed veterans more quickly (81 days vs. 113 days; p < .01) than comparison sites and reduced administrative workload associated with placement. EPPS sites also increased the number of Medicare-certified homes under contract (76% vs. 54%) and placed significantly more veterans who received therapy (20% vs. < 1%). Savings in hospital days more than offset the increased cost of nursing home placement. Because the findings were attributed largely to a few veterans with long lengths of hospital stay, the early success of EPPS may diminish as the backlog of these long-stay patients decreases.

Organizational characteristics, client characteristics, and the delivery of home care services.

This research examines the extent to which organizational professional orientation, client perceived needs, and client characteristics jointly determine long-term care service delivery to a frail elderly population. The study uses primary data collected from 16 community networks that were part of a national demonstration of the Living at Home Program, conducted from 1986 to 1989. Data include baseline assessments of individuals enrolled at each site, subsequent utilization data, and data on community network characteristics. Site professional orientation has a significant role in determining services provided to clients, with social service agencies more likely to provide nonmedical services and less likely to provide skilled-care services. Despite systematic site variation in the services provided to individuals, sites appear to reasonably allocate resources among individuals with differing levels of functional disability.

Predicting agency participation in interorganizational networks providing community care.

In response to health care reform, health care providers have begun to develop interorganizational networks. At present, however, relatively little is known about factors facilitating participation in networks. To this end, organizational characteristics and views were obtained from key informants from both "Lead" and "Affiliate" Agencies participating in the networks for the Living-at-Home Program (LAHP) Demonstration (N = 131) using an Organizational Change Survey. Logistic regression analysis was used to examine factors related to network member agencies' participation. Significant relationships were found between decreased participation and lack of agreement between network agencies regarding expectations (P = 0.02), membership in a network with a Medical Lead Agency (P < 0.01), and Lead Agency inexperience (P < 0.01). Agencies with lower ratings of the impact that LAHP had on their community were more likely to decrease their participation (P = 0.01). The number of unoccupied nursing home beds in the community was positively and significantly related to decreased participation (P < 0.001). These results suggest that leadership skills of the Lead Agency, and in particular, experience, may be among the chief requirements for the creation and development of successful networks, and confirm that inexperienced Lead Agencies may face an uphill battle in terms of recruiting and maintaining network members.

Effect of altering handle position of a rolling walker on gait in children with cerebral palsy.

The purpose of this study was to determine whether altering the handle position on a rolling walker would affect the gait pattern of children with spastic cerebral palsy (CP). Sixteen children with CP (2-10 years old) performed six gait trials, three with the handle on the rolling walker positioned horizontally and three with the handle positioned vertically. Using the footprint-on-paper method, gait characteristics of right and left step width, step length, and stride length; cadence; and velocity were determined. A two-way analysis of variance for two repeated measures indicated no significant differences in the measured gait characteristics between handle positions. Significant differences between the first trial and subsequent trials for both horizontal and vertical handle positions were found using Duncan's multiple comparison test. This study suggests that in this sample of children, altering the handle position did not lead to any immediate statistically significant changes in the gait characteristics measured. Results suggest that walkers with vertical handles should not be prescribed under the assumption that the gait characteristics of the child using the walker will be changed. This study does not rule out other changes that might occur with the use of vertical-handled walkers.