The Potential of an Embedded Mental Health Services Program Toward Increasing Health Care-Seeking Behaviors Among U.S. Air Force Aircrew: A Mixed-Methods Study.

INTRODUCTION: The U.S. Air Force implemented the Integrated Operational Support model, which involves embedding health care professionals within operational units to meet the health needs of the airmen. This study assessed the extent to which airmen sought out both traditional and embedded mental health services, as well as perceptions of factors that hinder or encourage health care-seeking behaviors. MATERIALS AND METHODS: A mixed-methods approach including a web-based occupational psychological health assessment and semi-structured interviews was used to assess airmen's experiences with seeking mental health care services. RESULTS: A total of 447 Remotely Piloted Aircraft operators participated in an occupational psychological health assessment (42% response rate) in 2018, and 15 airmen across five high operational tempo, restricted-access installations completed a semi-structured interview (60% participation rate) in 2021. From the occupational assessment, females (33%) sought care from the traditional mental health clinic significantly more than males (21%; χ2 = 5.10, P = .02). However, there were no significant gender differences in seeking embedded mental health services. Respondents who had not sought out help from either the traditional clinic or embedded services were significantly more likely to seek assistance from embedded mental health services (M = 4.29, SD = 2.09) over the traditional clinic (M = 3.92, SD = 1.90), t(205) = 4.94, P < .001. A resounding interview theme was the deep appreciation that airmen expressed for the availability of embedded mental health professionals. Airmen also discussed factors that hinder health care-seeking behaviors with the top-reported factor being the stigma associated with seeking mental health. The top three reported factors that encourage health care-seeking behaviors included leadership and mental health professionals normalizing care, trust in embedded mental health professionals, and ease of access to care. CONCLUSIONS: Findings suggest that having mental health professionals integrated within the unit brings the care straight to the airmen and may reduce the stigma associated with airmen asking for help.

The self-reported impacts of the COVID-19 pandemic on psychological health of U.S. Air Force cyber personnel.

U.S. Air Force cyber personnel were faced with changes in their workplace, fitness routines, and personal lives during the COVID19 pandemic. Adjusting to COVID-19-related requirements likely increased the stress of already stressful jobs for military members and their families, which could have resounding impacts on emotional, social, and physical well-being. Therefore, it is important to evaluate psychological health outcomes and self-perceived impacts of the changes presented to cyber personnel because of the COVID-19 pandemic. An online occupational health assessment that included demographics, standardized measures of burnout, psychological distress, and work role strain; health behaviors; and perceived impacts of the COVID-19 pandemic was administered to 1488 cyber personnel. Thirty-two negative themes and 13 positive themes were created from qualitative coding for "How has the COVID-19 pandemic impacted you as an individual?" Of the themes created, 966 (68.5%) reported at least one negative impact and 440 (31.2%) reported at least one positive impact. Top-reported negative impacts were limited face-to-face interactions and loss of personal activities. Negative impacts were associated with negative psychological health outcomes (e.g., psychological distress, exhaustion, cynicism) and work role strain. Action-oriented recommendations are given in the event of another pandemic.

Perspectives of mental health professionals on the delivery of embedded mental health services for U.S. Air Force airmen.

United States Air Force (USAF) leadership implemented the integrated operational support care model, which involves embedding mental health professionals directly within operational units to meet the mental health needs of airmen. The present study evaluated perspectives of embedded mental health professionals on the delivery of embedded care services for airmen assigned to various units and installations. We conducted semistructured interviews with 26 embedded mental health professionals. Interviews were audio-recorded and transcribed verbatim for qualitative analysis, involving thematic content analysis to identify and tabulate key themes emergent from the data. The most commonly reported barriers to delivering embedded mental health services were overcoming stigma associated with seeking mental health care, low staffing, insufficient training, and disconnected relationships between medical treatment facility and other support agencies. Interviewees described numerous strategies for effectively delivering embedded mental health services to include fully understanding and being able to communicate levels of mental health care services, reducing stigma, facilitating coordination of care/resources, and developing initiatives to target population needs. This is the first in-depth, systematic exploration of provider perspectives on embedded mental health services in the USAF. Future research should focus on how best to support embedded care programs to sustain this invaluable service for airmen and other military communities over time. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Assessing work role strain, burnout, and job satisfaction among remotely piloted aircraft operators: the moderating role of unit social support.

Utilizing the Job Demands-Resources (JD-R) theory as a guiding framework, the current study examined the relationships between job demands (work role strain) and occupational outcomes (burnout and job satisfaction) and assessed how job resources (team member social support and leader social support) mitigated the impact of high job demands for U.S. Air Force remotely piloted aircraft (RPA) operators. A total of 905 active duty U.S. Air Force RPA operators participated in a web-based occupational health assessment. Study findings confirmed that work role strain proved to be strongly related to negative occupational outcomes - increased burnout and reduced job satisfaction. Compelling evidence emerged suggesting that boosting job resources (i.e., team member and leader social support) may be a promising point of intervention to mitigate negative occupational outcomes. By investigating ongoing job demands that result in a higher incidence of burnout and job dissatisfaction, as well as job resources that protect against burnout and job dissatisfaction, researchers and practitioners can continue to introduce supportive resources at crucial points to alleviate the adverse consequences of occupational stress and burnout. Applying the JD-R theory to these findings highlights the importance of job resources for RPA operators and other employees working in high-risk, high-demand career fields. Implications and future directions are discussed.

Implementation of the VA Intensive Dysphagia Treatment Program: A Mixed-Methods Evaluation.

The Department of Veterans Affairs (VA) Intensive Dysphagia Treatment program serves a critical role in facilitating improvements to quality of care, standardization of outcomes, and increased access to structured therapy for Veterans with dysphagia. It has been implemented at 26 sites nationally and continues expanding. An explanatory sequential mixed-methods design was utilized for program evaluation to identify barriers and facilitators to implementation as reported by speech-language pathologists (SLPs) participating in the program. All 23 IDT program SLPs were invited to participate in an online survey. SLPs were asked to describe etiologies referred for SLP evaluation, most and least clinically useful program aspects, and characteristics of patients recommended for therapy. Qualitative interviews/focus groups were then conducted with 9 SLPs at 3 facilities with varying levels of program experience. Transcripts underwent systems engineering framework informed deductive thematic analysis. Interview/focus groups revealed overall positive feedback. Barriers included data entry challenges and provider understanding of long-term program goals, while facilitators included program structure enabling increased patient follow-up, outcomes tracking, and training in new treatment modalities. Through this evaluation process, program leadership garnered actionable feedback to improve further implementation of the IDT program. Ongoing efforts will further improve data entry, site onboarding procedures, and program communication.

Effect of the Affordable Care Act on healthcare utilization for Veterans with spinal cord injuries and disorders.

Context/Objective: Provisions of the Affordable Care Act (ACA) potentially increase insurance options for Veterans with disabilities. We examined Veterans with spinal cord injuries and disorders (SCI/D) to assess whether the ACA was associated with changes in healthcare utilization from Department of Veterans Affairs (VA) healthcare facilities.Design: Using national VA data, we investigated impacts on VA healthcare utilization pre- (2012/13) and post-ACA (2014/15) implementation with negative binomial regression models.Setting: VA healthcare facilities.Participants: 8,591 VA users with SCI/D. Veterans with acute myelitis, Guillain-Barré syndrome, multiple sclerosis, or amyotrophic lateral sclerosis were excluded as were patients who died during the study period.Interventions: We assessed VA healthcare utilization before and after ACA implementation.Outcome Measures: Total numbers of VA visits for SCI/D care, diagnostic care, primary care, specialty care, and mental health care, and VA admissions.Results: The number of VA admissions was 7% higher in the post than pre-ACA implementation period (P < 0.01). The number of VA visits post-implementation increased for SCI/D care (8%; P < 0.01) and specialty care (12%; P < 0.001). Conversely, the number of mental health visits was 17% lower in the post-ACA period (P < 0.001). Veterans with SCI/D who live <5 miles from their nearest VA facility received VA care more frequently than those ≥40 miles from VA (P < 0.001).Conclusion: Counter to expectations, results suggest that Veterans with SCI/D sought more frequent VA care after ACA implementation, indicating Veterans with SCI/D continue to utilize the lifelong, comprehensive care provided at VA.

Health Insurance Coverage Among Veterans Receiving Care From VA Health Care Facilities.

Reasons for acquiring insurance outside Department of Veterans Affairs (VA) health care coverage among VA enrollees are incompletely understood. To assess Veterans' decision-making and acquisition of non-VA health care insurance in the Affordable Care Act era, we used mailed questionnaires and semistructured interviews in a stratified random sample of VA enrollees <65 years in the Midwest. Of the 3,666 survey participants, 32.1% reported non-VA insurance. Frequently reported reasons included wanting coverage for emergency situations or family members. Those without non-VA insurance cited unaffordability as the main obstacle. Analysis of the semistructured interview data revealed similar findings. In multivariable logistic regression analyses, characteristics associated with non-VA insurance included higher income (>$50,000 vs. <$10,000, odds ratio [OR] = 5.95, 95% confidence interval [CI]: 3.45-10.3, p < .001). As financial barriers exist for acquisition of non-VA insurance and hence community care, it is critically important that VA enrollees' health care needs are met through VA or community providers financed through VA.

Web-based patient portal use and medication overlap from VA and private-sector pharmacies among older veterans.

BACKGROUND: The availability of Medicare Part D pharmacy coverage may increase veterans' options for obtaining medications outside of the Department of Veterans Affairs (VA) pharmacies. However, availability of Part D coverage raises the potential that veterans may be receiving similar medications from VA and non-VA pharmacies. The VA's personal health record portal, My HealtheVet, allows veterans to self-enter the non-VA medications that they obtained from community-based pharmacies, including those reimbursed by Medicare Part D. The Blue Button medication view feature of My HealtheVet allows veterans to view and download their VA and self-entered non-VA medication history. OBJECTIVE: To examine whether the use by veterans of the Blue Button feature of My HealtheVet was associated with less acquisition of similar medications from VA and community-based pharmacies reimbursed by Medicare Part D. METHODS: This study included a national sample of veterans who were new My HealtheVet users during fiscal year 2013 (October 1, 2012-September 30, 2013) and who used the Blue Button medication view feature of My HealtheVet at least once (users). We compared these veterans with a random sample of veterans who were not registered to use My HealtheVet (nonusers). From these groups, we identified veterans who were enrolled in Part D. We used multiple logistic regression analysis to assess the association of Blue Button medication view use with obtaining medications from the same drug classes (with overlap of 7 or more days) from VA and Part D-reimbursed pharmacies. RESULTS: There were 7,973 My HealtheVet medication view users and 65,985 nonusers. During a 12-month period, medication view users received more 30-day supplies of medications (one 90-day supply equals three 30-day supplies) than nonusers, on average (152.1 vs 71.3, P < 0.001). A larger percentage of users than nonusers obtained medications from VA and Part D-reimbursed pharmacies with overlapping days supply from the same drug classes (30% vs 23%, P < 0.001). However, for veterans who obtained greater numbers of 30-day supplies (82 or more), a significantly smaller percentage of users than nonusers obtained overlapping medications from VA and Part D-reimbursed pharmacies. Moreover, controlling for the total number of 30-day supplies that veterans received, the odds of obtaining medications from VA and Part D-reimbursed pharmacies with days supply that overlapped by at least 7 days for the same drug classes was 18% lower for users than nonusers (P=0.002). CONCLUSIONS: Veterans who used the Blue Button medication view feature of My HealtheVet obtained a larger number of 30-day supplies of medications from VA pharmacies than nonusers. For veterans who obtained a larger number of 30-day supplies of medications, use of the Blue Button medication view feature of My HealtheVet was associated with less overlap in days supply of medication from the same drug class from VA and Part D-reimbursed pharmacies. DISCLOSURES: This study was funded by the Department of Veterans Affairs, Office of Research and Development, Health Services Research and Development Service project IIR 14-041-2. The sponsor provided funding but was not involved in the development of the manuscript. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or the Health Services Research and Development Service. All authors are employed in some capacity with the Department of Veterans Affairs and have no conflicts of interest to disclose.

Health-Related Goal Setting and Achievement Among Veterans with High Technology Adoption.

BACKGROUND: There is increasing recognition of the importance of supporting patients in their health-related goals. Patient-provider discussions and health-related mobile applications (apps) can support patients to pursue health goals; however, their impact on patient goal setting and achievement is not well understood. OBJECTIVE: To examine the relationships between the following: (1) patient demographics, patient-provider discussions, and health-related goal setting and achievement, and (2) patient mobile health app use and goal achievement. DESIGN: Cross-sectional survey. PARTICIPANTS: Veterans who receive Veterans Health Administration (VA) healthcare and are users of VA patient-facing technology. MAIN MEASURES: Veteran demographics, goal-related behaviors, and goal achievement. METHODS: Veterans were invited to participate in a telephone survey. VA administrative data were linked to survey data for additional health and demographic information. Logistic regression models were run to identify factors that predict health-related goal setting and achievement. KEY RESULTS: Among respondents (n=2552), 75% of patients indicated having set health goals in the preceding 6 months and approximately 42% reported achieving their goal. Men (vs. women) had lower odds of setting goals (OR: 0.71; CI95: 0.53-0.97), as did individuals with worse (vs. better) health (OR: 0.18; CI95: 0.04-0.88). Individuals with advanced education-some college/college degrees, and post-college degrees (vs. no college education)-demonstrated higher odds of setting goals (OR: 1.35; CI95: 1.01-1.79; OR: 1.71; CI95: 1.28-2.28, respectively). Those who reported having discussed their goals with their providers were more likely to set goals (OR: 3.60; CI95: 2.97-4.35). Patient mobile health app use was not statistically associated with goal achievement. CONCLUSIONS: Efforts to further promote patient-led goal setting should leverage the influence of patient-provider conversations. Use of patient-facing technologies, specifically mobile health apps, may facilitate goal-oriented care, but further work is needed to examine the potential benefits of apps to support patient goals, particularly if providers discuss and endorse use of those apps with patients.

Personality Traits That Distinguish Special Operations Female Aircrew.

INTRODUCTION: U.S. Air Force Special Operations Command (AFSOC) female aircrew represent a small group of military personnel in challenging high-risk, high-demand professions. Personality characteristics may play a key role in distinguishing those women who pursue a career as a special operations aircrew member and succeed in this pursuit. Having access to normative personality data can potentially support psychologists in assessing AFSOC female aircrew and subsequently making informed recommendations to leadership.METHODS: A total of 586 AFSOC aircrew trainees58 (9.9%) women and 528 (90.1%) mencompleted a series of computer-based psychological tests to assess cognitive ability and personality traits.RESULTS: Results indicated significant differences between female AFSOC aircrew and female civilians on four of the five NEO Personality Inventory domains: Neuroticism (M 74.9 vs. M 87.1), Extraversion (M 123.7 vs. M 112.8), Openness to Experience (M 122.6 vs. M 111.0), and Conscientiousness (M 136.0 vs. M 120.6), respectively. The comparison between female AFSOC aircrew and male AFSOC aircrew revealed significant differences across three of the five domains: Neuroticism (M 74.9 vs. M 65.1), Openness to Experience (M 122.6 vs. M 115.0), and Agreeableness (M 119.6 vs. M 112.7), respectively.DISCUSSION: Implications for assessment and interpretation of psychological testing are discussed. This paper provides a unique perspective and insight into those who pursue and excel in this career field. Identifying specific personality traits in our AFSOC female aircrew allows for tailored care and support when evaluating readiness in special operations aircrew for optimizing performance.Chappelle W, Shadle AH, Martinez RN, Reardon LE, Goodman T, Spencer H, Thompson W. Personality traits that distinguish special operations female aircrew. Aerosp Med Hum Perform. 2021; 92(4):240247.

Characterization of Telehealth Use in Veterans With Spinal Cord Injuries and Disorders.

BACKGROUND: Individuals with spinal cord injuries and disorders (SCI/D) require frequent interdisciplinary health care to address impairments in mobility, autonomic function, and secondary complications. Telehealth has the capacity to substantially transform health care delivery and improve care by increasing access and communication. However, relatively little is known about telehealth use in this specific population. Here we attempt to fill part of this gap. OBJECTIVE: To investigate the frequency and characteristics associated with telehealth use in Veterans with SCI/D. DESIGN: Cross-sectional, descriptive project. SETTING: Veterans Health Administration (VHA) facilities. PARTICIPANTS: A total of 15 028 Veterans living with SCI/D who received services from the VHA SCI/D System of Care. INTERVENTION: Not applicable. OUTCOME MEASURES: Frequency and characteristics associated with VHA telehealth utilization. RESULTS: Of the 15 028 Veterans with SCI/D included in the evaluation, 17% used some form of telehealth in VHA Fiscal Year (FY)2017. Veterans older than 65 years of age had lower odds (odds ratio [OR] = 0.88, P < .05, confidence interval [CI] 0.80-0.98) of using telehealth. Being Caucasian (OR = 1.29, P < .01, CI 1.09-1.52), living in rural areas (OR = 1.16, P < .01, CI 1.05-1.28), living greater distances away from the VHA (P < .01 for all distances), and being in priority group 8, meaning that Veterans have higher copayment requirements (OR = 1.46, P < .001, CI 1.19-1.81), were all significantly associated with greater odds of telehealth use. The most frequent types of telehealth used were real-time clinical video and store-and-forward between a provider and patient within the same hub network. CONCLUSION: There are opportunities to increase telehealth adoption in the SCI/D arena. The findings from this project highlight which Veterans are currently using telehealth services, as well as gaps regarding telehealth adoption in this population.

Predictors and protective factors for suicide ideation across remotely piloted aircraft career fields.

The US Air Force remote warrior community comprises several career fields including remotely piloted aircraft pilots and intelligence, cyber, and sensor operators. The crews are responsible for working seamlessly together to provide 24/7 real-time intelligence, surveillance, and reconnaissance and precision-strike weapons capabilities for a wide range of global combat operations. Due to the rapid increase in global demands and operational tempo, there is growing concern from military leadership about the impact of operational stress on the health and psychological well-being of remote warriors. Previous assessments from 2011 and 2015 have demonstrated a significant increase in the reported rates of operators experiencing suicide ideation. The current study examined two protective factors expected to reduce the risk of suicide ideation - team member social support and leader social support. A total of 905 active duty remote warriors participated in occupational health assessments conducted in 2018. Risk factors for suicide ideation included being unmarried, worsening relationship problems, occupational burnout, and increased operational stress. Results indicated that team member and leader social support were significant protective factors for shift workers and those who reported being less likely to seek mental healthcare. Implications of the findings, intervention recommendations, and directions for future research are discussed.

Leptin Receptor Signaling Regulates Protein Synthesis Pathways and Neuronal Differentiation in Pluripotent Stem Cells.

The role of leptin receptor (OB-R) signaling in linking pluripotency with growth and development and the consequences of dysfunctional leptin signaling on progression of metabolic disease is poorly understood. Using a global unbiased proteomics approach we report that embryonic fibroblasts (MEFs) carrying the db/db mutation exhibit metabolic abnormalities, while their reprogrammed induced pluripotent stem cells (iPSCs) show altered expression of proteins involved in embryonic development. An upregulation in expression of eukaryotic translation initiation factor 4e (Eif4e) and Stat3 binding to the Eif4e promoter was supported by enhanced protein synthesis in mutant iPSCs. Directed differentiation of db/db iPSCs toward the neuronal lineage showed defects. Gene editing to correct the point mutation in db/db iPSCs using CRISPR-Cas9, restored expression of neuronal markers and protein synthesis while reversing the metabolic defects. These data imply a direct role for OB-R in regulating metabolism in embryonic fibroblasts and key developmental pathways in iPSCs.

Supporting the Implementation of Connected Care Technologies in the Veterans Health Administration: Cross-Sectional Survey Findings from the Veterans Engagement with Technology Collaborative (VET-C) Cohort.

BACKGROUND: Widespread adoption, use, and integration of patient-facing technologies into the workflow of health care systems has been slow, thus limiting the realization of their potential. A growing body of work has focused on how best to promote adoption and use of these technologies and measure their impacts on processes of care and outcomes. This body of work currently suffers from limitations (eg, cross-sectional analyses, limited patient-generated data linked with clinical records) and would benefit from institutional infrastructure to enhance available data and integrate the voice of the patient into implementation and evaluation efforts. OBJECTIVE: The Veterans Health Administration (VHA) has launched an initiative called the Veterans Engagement with Technology Collaborative cohort to directly address these challenges. This paper reports the process by which the cohort was developed and describes the baseline data being collected from cohort members. The overarching goal of the Veterans Engagement with Technology Collaborative cohort is to directly engage veterans in the evaluation of new VHA patient-facing technologies and in so doing, to create new infrastructure to support related quality improvement and evaluation activities. METHODS: Inclusion criteria for veterans to be eligible for membership in the cohort included being an active user of VHA health care services, having a mobile phone, and being an established user of existing VHA patient-facing technologies as represented by use of the secure messaging feature of VHA's patient portal. Between 2017 and 2018, we recruited veterans who met these criteria and administered a survey to them over the telephone. RESULTS: The majority of participants (N=2727) were male (2268/2727, 83.2%), White (2226/2727, 81.6%), living in their own apartment or house (2519/2696, 93.4%), and had completed some college (1176/2701, 43.5%) or an advanced degree (1178/2701, 43.6%). Cohort members were 59.9 years old, on average. The majority self-reported their health status as being good (1055/2725, 38.7%) or very good (524/2725, 19.2%). Most cohort members owned a personal computer (2609/2725, 95.7%), tablet computer (1616/2716, 59.5%), and/or smartphone (2438/2722, 89.6%). CONCLUSIONS: The Veterans Engagement with Technology Collaborative cohort is an example of a VHA learning health care system initiative designed to support the data-driven implementation of patient-facing technologies into practice and measurement of their impacts. With this initiative, VHA is building capacity for future, rapid, rigorous evaluation and quality improvement efforts to enhance understanding of the adoption, use, and impact of patient-facing technologies.

Developing an animal-assisted support program for healthcare employees.

BACKGROUND: Employee burnout and its associated consequences is a significant problem in the healthcare workforce. Workplace animal therapy programs offer a potential strategy for improving employee well-being; however, research on animal therapy programs for healthcare workers is lacking. This study aimed to evaluate the feasibility, acceptability and preliminary impact of an animal-assisted support program to improve healthcare employee well-being. METHODS: In this mixed-methods pilot intervention study, we implemented an animal-assisted support program in a multidisciplinary healthcare clinic at a large VA hospital. The program included 20 sessions over 3 months, each approximately 1-h long. Real-time mood data were collected from participants immediately before and after each session. Participation rates were tracked in real time and self-reported at follow-up. Data on burnout and employee perceptions of the program were collected upon completion via a survey and semi-structured interviews. Differences in mood and burnout pre/post program participation were assessed with t-tests. RESULTS: Participation was high; about 51% of clinic employees (n = 39) participated in any given session, averaging participation in 9/20 sessions. Mood (on a scale of 1 = worst to 5 = best mood) significantly improved from immediately before employees interacted with therapy dogs (M = 2.9) to immediately after (M = 4.5) (p = 0.000). Employees reported significantly lower levels of patient-related burnout (e.g., how much exhaustion at work relates to interaction with patients) after (M = 18.0 vs. before, M = 40.0) participating (p = 0.002). Qualitative findings suggested that employees were highly satisfied with the program, noticed an improved clinic atmosphere, and experienced a reduction in stress and boost in mood. CONCLUSIONS: Establishing an animal-assisted support program for employees in a busy healthcare clinic is feasible and acceptable. Our pilot data suggest that animal-assisted programs could be a means to boost mood and decrease facets of burnout among healthcare employees.

Did the Affordable Care Act Decrease Veteran Enrollment in the Veterans Health Administration?

BACKGROUND: Provisions of the Affordable Care Act (ACA) provided nonelderly individuals, including Veterans, with additional health care coverage options. This may impact enrollment for health care through the Veterans Health Administration (VHA). National enrollment data was used to: (1) compare characteristics of enrollees at 3 time points in relation to the implementation of ACA insurance provisions (2012); and (2) examine enrollment trends. METHODS: The study population included a 10% sample of Veterans under age 65 who were VHA enrollees between January 2012 and September 2015. Demographic and baseline characteristics were compared between 3 enrollment groups: pre-2012, pre-ACA (2012-2013), and post-ACA (2014-2015). Using an interrupted time series approach, we employed pooled logistic regression to assess trends in new VHA enrollment, overall, and by select enrollee characteristics. RESULTS: A total of 429,833 enrollees were identified. Compared with pre-ACA enrollees, post-ACA enrollees were more likely to be older, have a service-connected disability, live further away from a VHA medical center, but less likely to use primary care within 6 months. The post-ACA quarterly trend in the odds of being a new enrollee was 3% lower (95% confidence interval: 0.96, 0.98) as compared with the pre-ACA trend. This decline was consistent across sex, geography, (all but 1) priority group, and state Medicaid-expansion subgroups. CONCLUSIONS: The ACA appears to have contributed to a decline in new VHA enrollment. In addition, the profile of newer enrollees differs from that of pre-ACA enrollees. The VHA must continue to monitor trends in demand in order to continue delivering high-quality, efficient care.

Impact of Patient Portal Use on Duplicate Laboratory Tests in Diabetes Management.

Background: Patients seek care across multiple health care settings. One coordination issue is the unnecessary duplication of laboratory across different health care settings. This analysis examined the association between patient portal use and duplication of laboratory testing among Veterans who are dual users of Veterans Affairs (VA) and non-VA providers. Materials and Methods: A national sample of Veterans who were newly authenticated users of the portal during fiscal year (FY) 2013 who used Blue Button at least once were compared with a random sample of Veterans who were not registered to use the portal. From these two groups, Veterans who were also Medicare-eligible users in FY2014 were identified. Duplicate testing was defined as receipt of more than five HbA1c (hemoglobin A1c) in 1 year. Results: Use of the Blue Button decreased the odds of duplicate HbA1c testing in VA and Medicare-covered facilities across three comparisons: (1) overall between users and nonusers: portal users were less likely to have duplicate testing; (2) pre-post comparison: there was a trend toward lower duplicate testing in both groups across time; and (3) pre-post comparisons accounting for use of the portal: the trend toward lower duplicate testing was greater in Blue Button users. Conclusion: Duplicate HbA1c testing was significantly lower in dual users of VA and Medicare services who used the Blue Button feature of their VA patient portal. Non-VA providers encounter barriers to access of complete information about Veterans who also use VA health care. Provider endorsement of consumer-mediated health information exchange could help further this model of sharing information.

An ecological perspective on implementing environmental control units for veterans with spinal cord injuries and disorders.

Purpose: Guided by an ecological perspective, the purpose of this study was to identify multilevel factors that influenced the implementation of environmental control units (ECUs) in Veterans Health Administration (VHA) Spinal Cord Injury/Disorders (SCI/D) Centres.Materials and methods: Mixed methods including an online survey and qualitative interviews of VHA healthcare employees.Results: VHA healthcare employees participated in the online survey (n = 153, 21% participation rate) and semi-structured interview (n = 28; 54% participation rate). About 58.2% of survey respondents indicated that patients admitted to a VHA SCI/D Centre received ECU training. Interview participants reported that patients might benefit from educational materials on using ECUs. About 53.7% of survey respondents indicated that they did not receive ECU training. Interview participants emphasized that more healthcare employees needed to be trained to distribute ECU-related tasks including patient training and troubleshooting problems. The most common challenge was the coordination involved in moving patients out of rooms that were being outfitted with an ECU.Conclusions: Application of an ecological framework highlighted a range of factors at multiple levels that dynamically influence ECU implementation while accounting for the SCI/D care context. Integrating this technology with the care experiences of patients, the workflow of healthcare employees, and the structure of the organization may improve the implementation of ECUs.IMPLICATIONS FOR REHABILITATIONAn environmental control unit (ECU) is an assistive technology device that provides persons with a physical disability (e.g., spinal cord injuries and disorders) increased independence in a home, hospital, or rehabilitation facility setting.An ECU allows a person to access and control appliances like their hospital bed, lights, television, doors, nurse call button, telephone, and computer, thus, decreasing workload on attendants and family members while increasing independence for the user.Application of an ecological framework in this study highlighted a range of factors at multiple levels that dynamically influence ECU implementation while accounting for the SCI/D care context.Integrating this technology with the care experiences of patients, the workflow of healthcare employees, and the structure of the organization may improve the implementation of ECUs in an inpatient setting.

Experiences with the Veterans' Choice Program.

BACKGROUND: To address concerns about Veterans' access to care at US Department of Veterans Affairs (VA) healthcare facilities, the Veterans Access, Choice, and Accountability Act was enacted to facilitate Veterans' access to care in non-VA settings, resulting in the "Veterans Choice Program" (VCP). OBJECTIVES: To assess the characteristics of Veterans who used or planned to use the VCP, reasons for using or planning to use the VCP, and experiences with the VCP. DESIGN: Mixed-methods. SUBJECTS: After sampling Veterans in the Midwest census region receiving care at VA healthcare facilities, we included 4521 Veterans in the analyses. Of these, 60 Veterans participated in semi-structured qualitative interviews. APPROACH: Quantitative data were derived from VA's administrative and clinical data and a survey of Veterans including Veteran characteristics and self-reported use of VCP. Associations between Veterans' characteristics and use or planned use of the VCP were assessed using logistic regression analysis. Interview data were analyzed using thematic analysis. KEY RESULTS: Veterans with a higher odds of reporting use or intended use of the VCP were women, lived further distances from VA facilities, or had worse health status than other Veterans (P ≤ 0.01). Key themes included positive experiences with the VCP (timeliness of care, location of care, access to services, scheduling improvements, and coverage of services), and negative experiences with the VCP (complicated scheduling processes, inconveniently located appointments, delays securing appointments, billing confusion, and communication breakdowns). DISCUSSION: Our findings suggest that Veterans value access to care close to their home and care that addresses the needs of women and Veterans with poor health status. The Mission Act was passed in June 2018 to restructure the VCP and consolidate community care into a single program, continuing VA's commitment to support access to community care into the future.

How Do Patients with Mental Health Diagnoses Use Online Patient Portals? An Observational Analysis from the Veterans Health Administration.

Online patient portals may be effective for engaging patients with mental health conditions in their own health care. This retrospective database analysis reports patient portal use among Veterans with mental health diagnoses. Unadjusted and adjusted odds of portal feature use was calculated using logistic regressions. Having experienced military sexual trauma or having an anxiety disorder, post-traumatic stress disorder, or depression were associated with increased odds of portal use; bipolar, substance use, psychotic and adjustment disorders were associated with decreased odds. Future research should examine factors that influence portal use to understand diagnosis-level differences and improve engagement with such tools.