Measuring the unmet needs of American military Veterans and their caregivers: Survey protocol of the HERO CARE survey.

BACKGROUND: Empowering Veterans to age in place is a Department of Veterans Affairs priority. Family or unpaid caregivers play an important role in supporting Veterans to achieve this goal. Effectively meeting the needs of Veterans and caregivers requires identifying unmet needs and relevant gaps in resources to address those needs. METHODS: Using a modified Socio-Ecological Model, we developed a prospective longitudinal panel design survey. We randomly selected 20,000 community-dwelling Veterans enrolled in the Veterans Health Administration (VHA), across five VHA sites. We oversampled Veterans with a higher predicted 2-year long-term institutional care (LTIC) risk. Veterans were mailed a packet containing a Veteran survey and a caregiver survey, to be answered by their caregiver if they had one. The Veteran survey assessed the following health-related domains: physical, mental, social determinants of health, and caregiver assistance. Caregivers completed questions regarding their demographic factors, caregiving activities, impact of caregiving, use of VA and non-VA services, and caregiver support resources. Follow-up surveys will be repeated twice at 12-month intervals for the same respondents. This article describes the HERO CARE survey protocol, content, and response rates. RESULTS: We received responses from 8,056 Veterans and 3,579 caregivers between July 2021 and January 2022, with 95.6% being received via mail. Veteran respondents were mostly males (96.5%), over 65 years of age (94.9%), married (55.0%), Non-Hispanic White (75.2%), and residing in urban areas (80.7%). CONCLUSIONS: This longitudinal survey is unique in its comprehensive assessment of domains relevant to older Veterans stratified by LTIC risk and their caregivers, focusing on social determinants, caregiver support, and the use of caregiver support resources. Survey data will be linked to Centers for Medicare & Medicaid Services and VA data. The results of this study will inform better planning of non-institutional care services and policy for Veterans and their caregivers.

Interdisciplinary Team Meetings in Practice: an Observational Study of IDTs, Sensemaking Around Care Transitions, and Readmission Rates.

BACKGROUND: Interdisciplinary teams (IDTs) have been implemented to improve collaboration in hospital care, but their impact on patient outcomes, including readmissions, has been mixed. These mixed results might be rooted in differences in organization of IDT meetings between hospitals, as well as variation in IDT characteristics and function. We hypothesize that relationships between IDT members are an important team characteristic, influencing IDT function in terms of how members make sense of what is happening with patients, a process called sensemaking OBJECTIVE: (1) To describe how IDT meetings are organized in practice, (2) assess differences in IDT member relationships and sensemaking during patient discussions, and (3) explore their potential association with risk-stratified readmission rates (RSRRs). DESIGN: Observational, explanatory convergent mixed-methods case-comparison study of IDT meetings in 10 Veterans Affairs hospitals. PARTICIPANTS: Clinicians participating in IDTs and facility leadership. APPROACH: Three-person teams observed and recorded IDT meetings during week-long visits. We used observational data to characterize relationships and sensemaking during IDT patient discussions. To assess sensemaking, we used 2 frameworks that reflected sensemaking around each patient's situation generally, and around care transitions specifically. We examined the association between IDT relationships and sensemaking, and RSRRs. KEY RESULTS: We observed variability in IDT organization, characteristics, and function across 10 hospitals. This variability was greater between hospitals than between teams at the same hospital. Relationship characteristics and both types of sensemaking were all significantly, positively correlated. General sensemaking regarding each patient was significantly negatively associated with RSRR (- 0.65, p = 0.044). CONCLUSIONS: IDTs vary not only in how they are organized, but also in team relationships and sensemaking. Though our design does not allow for inferences of causation, these differences may be associated with hospital readmission rates.

Engaging Veterans, caregivers, and system stakeholders to improve VA home and community-based services.

OBJECTIVE: To understand Veterans', caregivers', and stakeholders' perceptions of home-based and caregiver support services and their suggestions for improvement to better align services with needs. DATA SOURCES: We identified Veterans and caregivers at four EDCoE sites using the VA high-need, high-risk list, representing Veterans who qualify for home-based primary care. We randomly selected Veterans and their caregivers, stratifying by age. We also identified leaders and clinicians involved in clinical service delivery. STUDY DESIGN: Between February and November 2019, we conducted in-person and telephone interviews and focus groups using semi-structured questions tailored to each group, analyzing them through a rapid qualitative analysis approach and providing real-time feedback to operational partners. DATA COLLECTION: Thirty-four Veterans, 24 caregivers, and 39 leaders and clinicians participated. PRINCIPAL FINDINGS: Respondents identified key categories of experience that could be monitored and improved, including navigating an increasingly complex system, coordinating and communicating across services, and unmet household and financial needs. Veterans and caregivers described quality in terms of reliability, timeliness, standardization, and accountability. Summaries were created to contextualize results and to highlight gaps and opportunities for new measures and policy development. CONCLUSIONS: Collaborating with Veterans, caregivers, and stakeholders enables us to understand their daily experiences and to develop meaningful approaches to evaluating services that incorporate their perspectives. Providing regular, actionable feedback to operational partners informs policy and operational initiatives, such as the scope of services and infrastructure for system navigation.

The Coordination Toolkit and Coaching Project: Cluster-Randomized Quality Improvement Initiative to Improve Patient Experience of Care Coordination.

BACKGROUND: Given persistent gaps in coordination of care for medically complex primary care patients, efficient strategies are needed to promote better care coordination. OBJECTIVE: The Coordination Toolkit and Coaching project compared two toolkit-based strategies of differing intensity to improve care coordination at VA primary care clinics. DESIGN: Multi-site, cluster-randomized QI initiative. PARTICIPANTS: Twelve VA primary care clinics matched in 6 pairs. INTERVENTIONS: We used a computer-generated allocation sequence to randomize clinics within each pair to two implementation strategies. Active control clinics received an online toolkit with evidence-based tools and QI coaching manual. Intervention clinics received the online toolkit plus weekly assistance from a distance coach for 12 months. MAIN MEASURES: We quantified patient experience of general care coordination using the Health Care System Hassles Scale (primary outcome) mailed at baseline and 12-month follow-up to serial cross-sectional patient samples. We measured the difference-in-difference (DiD) in clinic-level-predicted mean counts of hassles between coached and non-coached clinics, adjusting for clustering and patient characteristics using zero-inflated negative binomial regression and bootstrapping to obtain 95% confidence intervals. Other measures included care coordination QI projects attempted, tools adopted, and patient-reported exposure to projects. KEY RESULTS: N = 2,484 (49%) patients completed baseline surveys and 2,481 (48%) completed follow-ups. Six coached clinics versus five non-coached clinics attempted QI projects. All coached clinics versus two non-coached clinics attempted more than one project or projects that were multifaceted (i.e., involving multiple components addressing a common goal). Five coached versus three non-coached clinics used 1-2 toolkit tools. Both the coached and non-coached clinics experienced pre-post reductions in hassle counts over the study period (- 0.42 (- 0.76, - 0.08) non-coached; - 0.40 (- 0.75, - 0.06) coached). However, the DiD (0.02 (- 0.47, 0.50)) was not statistically significant; coaching did not improve patient experience of care coordination relative to the toolkit alone. CONCLUSION: Although coached clinics attempted more or more complex QI projects and used more tools than non-coached clinics, coaching provided no additional benefit versus the online toolkit alone in patient-reported outcomes. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03063294.

Evidence based processes to prevent readmissions: more is better, a ten-site observational study.

BACKGROUND: 30-day hospital readmissions are an indicator of quality of care; hospitals are financially penalized by Medicare for high rates. Numerous care transition processes reduce readmissions in clinical trials. The objective of this study was to examine the relationship between the number of evidence-based transitional care processes used and the risk standardized readmission rate (RSRR). METHODS: Design: Mixed method, multi-stepped observational study. Data collection occurred 2014-2018 with data analyses completed in 2021. SETTING: Ten VA hospitals, chosen for 5-year trend of improving or worsening RSRR prior to study start plus documented efforts to reduce readmissions. PARTICIPANTS: During five-day site visits, three observers conducted semi-structured interviews (n = 314) with staff responsible for care transition processes and observations of care transitions work (n = 105) in inpatient medicine, geriatrics, and primary care. EXPOSURE: Frequency of use of twenty recommended care transition processes, scored 0-3. Sites' individual process scores and cumulative total scores were tested for correlation with RSRR. OUTCOME: best fit predicted RSRR for quarter of site visit based on the 21 months surrounding the site visits. RESULTS: Total scores: Mean 38.3 (range 24-47). No site performed all 20 processes. Two processes (pre-discharge patient education, medication reconciliation prior to discharge) were performed at all facilities. Five processes were performed at most facilities but inconsistently and the other 13 processes were more varied across facilities. Total care transition process score was correlated with RSRR (R2 = 0..61, p < 0.007). CONCLUSIONS: Sites making use of more recommended care transition processes had lower RSRR. Given the variability in implementation and barriers noted by clinicians to consistently perform processes, further reduction of readmissions will likely require new strategies to facilitate implementation of these evidence-based processes, should include consideration of how to better incorporate activities into workflow, and may benefit from more consistent use of some of the more underutilized processes including patient inclusion in discharge planning and increased utilization of community supports. Although all facilities had inpatient social workers and/or dedicated case managers working on transitions, many had none or limited true bridging personnel (following the patient from inpatient to home and even providing home visits). More investment in these roles may also be needed.

Patient experience of health care system hassles: Dual-system vs single-system users.

OBJECTIVE: To compare health care system problems or "hassles" experienced by Veterans receiving VA health care only versus those receiving dual care from both VA and non-VA community providers. DATA SOURCES: We collected survey data in 2017-2018 from 2444 randomly selected Veterans with four or more primary care visits in the prior year at one of 12 VA primary care clinics located in four geographically diverse regions of the United States. STUDY DESIGN: We used baseline surveys from the Coordination Toolkit and Coaching quality improvement project to explore Veterans' experience of hassles (dependent variable), source of health care, self-rated physical and mental health, and sociodemographics. DATA COLLECTION: Participants responded to mailed surveys by mail, telephone, or online. PRINCIPAL FINDINGS: The number of reported hassles ranged from 0 to 16; 79 percent of Veterans reported experiencing one or more hassles. Controlling for sociodemographic characteristics and self-rated physical and mental health, zero-inflated negative binominal regression indicated that dual care users experienced more hassles than VA-only users (adjusted predicted average 5.5 [CI: 5.2, 5.8] vs 4.3 [CI: 4.1, 4.6] hassles [P < .0001]). CONCLUSIONS: Anticipated increases in Veterans accessing community-based care may require new strategies to help VA primary care teams optimize care coordination for dual care users.

Cardiovascular Risk Assessment Varies Widely by Calculator and Race/Ethnicity in a Majority Latinx Cohort Living with HIV.

Comparison of cardiovascular disease (CVD) risk calculators in Latinx majority populations living with HIV can assist clinicians in selecting a calculator and interpreting results. 10-year CVD risks were estimated for 652 patients seen ≥ 2 times over 12 months in a public clinic using three risk calculators: Atherosclerotic CVD risk Calculator (ASCVD), Framingham Risk Calculator (FRC), and Data Collection on Adverse Effects of Anti-HIV Drugs Study (D:A:D) Calculator. Median estimated 10-year CVD risk in this population was highest using FRC (11%), followed by D:A:D (10%), and lowest with ASCVD (5%; p < 0.001). However, D:A:D classified 44.3% in a high/very high risk category compared to FRC (20.7%) and ASCVD (33.4%) (all p < 0.001). ASCVD risk estimates differed significantly by race/ethnicity (p < 0.001). Risk varied widely across three risk calculators and by race/ethnicity, and providers should be aware of these differences when choosing a calculator for use in majority minority populations.

Staff Perspectives on Primary Care Teams as De Facto "Hubs" for Care Coordination in VA: a Qualitative Study.

BACKGROUND: Improving care coordination is a key priority for many healthcare systems. However, initiatives to improve care coordination are complex to implement and have produced mixed results. A better understanding of how to craft and support implementation of effective care coordination strategies is needed. OBJECTIVE: To identify and understand the challenges and factors encountered by Patient-Aligned Care Team (PACT) staff in performing care coordination tasks in outpatient clinics in the Veterans Health Administration (VA). DESIGN: Qualitative study using semi-structured formative evaluation interviews. PARTICIPANTS: Fourteen interviews with 18 clinical frontline managers and staff from 12 clinic sites across five VA health systems. INTERVENTIONS: This paper reports on baseline data collected for the Coordination Toolkit and Coaching (CTAC) project. CTAC aims to improve patients' experience of care coordination within VA primary care and between PACT and other outpatient and community settings. APPROACH: We conducted pre-implementation telephone interviews with frontline managers and staff, primarily nurse managers. KEY RESULTS: PACT staff described challenges in aligning care coordination priorities across different levels of the VA system, including staff, patients, and leadership. Additionally, PACT staff noted challenges coordinating care both within and outside the VA, and identified resource barriers impeding their care coordination efforts. To address these challenges, staff made several recommendations for improvement, including (1) contingency staffing to address staff burnout; (2) additional PACT training for new staff; (3) clarification of care coordination roles and responsibilities; and (4) and care coordination initiatives that align both with centrally initiated care coordination programs and frontline needs. CONCLUSION: In the VA and similarly complex healthcare systems, our findings suggest the need for care coordination strategies that are buttressed by a system-level vision for care coordination, backed up by clear roles and responsibilities for information exchange between primary care staff and other settings, and multidimensional accountability metrics that encompass patient-, staff-, and system-level goals.

The Impact of Trust, Satisfaction, and Perceived Quality on Preference for Setting of Future Care Among Veterans With PTSD.

INTRODUCTION: Among US veterans, posttraumatic stress disorder (PTSD) is a high-prevalence condition; more than a million veterans of all combat eras are service-connected for this condition. Research on factors driving veterans' decision-making regarding preferred setting for PTSD care has been limited. The purpose of this study was to understand factors associated with preferences for setting of future PTSD care among veterans service-connected for PTSD. MATERIALS AND METHODS: We conducted a cross-sectional mailed survey among veterans with service connection for PTSD in Texas and Vermont identified from the Veterans Services Network Corporate Mini Master File (VETSNET). Survey items were intended to elucidate PTSD healthcare decision-making and queried utilization, perceived need for care, and satisfaction and preferences for VA, community, and/or military setting for receipt of future PTSD care. Logistic regression was used to identify factors associated with preference for care setting. UT Health San Antonio's Institutional Review Board determined this quality improvement project to be non-research. RESULTS: Veterans (n = 2,327) were surveyed with an overall response rate of 37.1%. Most veterans (72.4%) identified VA as a preferred site for their future PTSD care; a substantial, but smaller, number of veterans identified being interested in receiving care in community (39.9%) and military (12.7%) settings. Factors associated with preferences for future care setting included demographics (e.g., ethnicity, income), availability of healthcare coverage, prior experiences of care, and attitudes related to perceived quality of care and trust in VA. CONCLUSIONS: These findings suggest that it is important to retain foundational mental health services within VA, as well as to continue to invest in building provider and network capacity in community settings, to ensure alignment with veteran preferences for care setting.

Use of Guideline-Recommended Treatments for PTSD Among Community-Based Providers in Texas and Vermont: Implications for the Veterans Choice Program.

Implementation of the Veterans Choice Program (VCP) allows Veterans to receive care paid for by the Department of Veterans Affairs (VA) in community settings. However, the quality of that care is unknown, particularly for complex conditions such as posttraumatic stress disorder (PTSD). A cross-sectional survey was conducted of 668 community primary care and mental health providers in Texas and Vermont to describe use of guideline-recommended treatments (GRTs) for PTSD. Relatively, few providers reported using guideline-recommended psychotherapy or prescribing practices. More than half of psychotherapists reported the use of at least one guideline-recommended psychotherapy for PTSD, but fewer reported the use of core treatment components, prior training in the GRT(s) they use, or adherence to a treatment manual. Suboptimal prescribing for PTSD patients was reported more commonly than optimal prescribing. Findings raise critical questions regarding how to ensure veterans seeking PTSD care in community settings receive psychotherapy and/or prescribing consistent with clinical practice guidelines.

Interventions to reduce readmissions: can complex adaptive system theory explain the heterogeneity in effectiveness? A systematic review.

BACKGROUND: Successfully transitioning patients from hospital to home is a complex, often uncertain task. Despite significant efforts to improve the effectiveness of care transitions, they remain a challenge across health care systems. The lens of complex adaptive systems (CAS) provides a theoretical approach for studying care transition interventions, with potential implications for intervention effectiveness. The aim of this study is to examine whether care transition interventions that are congruent with the complexity of the processes and conditions they are trying to improve will have better outcomes. METHODS: We identified a convenience sample of high-quality care transition intervention studies included in a care transition synthesis report by Kansagara and colleagues. After excluding studies that did not meet our criteria, we scored each study based on (1) the presence or absence of 5 CAS characteristics (learning, interconnections, self-organization, co-evolution, and emergence), as well as system-level interdependencies (resources and processes) in the intervention design, and (2) scored study readmission-related outcomes for effectiveness. RESULTS: Forty-four of the 154 reviewed articles met our inclusion criteria; these studies reported on 46 interventions. Nearly all the interventions involved a change in interconnections between people compared with care as usual (96% of interventions), and added resources (98%) and processes (98%). Most contained elements impacting learning (67%) and self-organization (69%). No intervention reflected either co-evolution or emergence. Almost 40% of interventions were rated as effective in terms of impact on hospital readmissions. Chi square testing for an association between outcomes and CAS characteristics was not significant for learning or self-organization, however interventions rated as effective were significantly more likely to have both of these characteristics (78%) than interventions rated as having no effect (32%, p = 0.005). CONCLUSIONS: Interventions with components that influenced learning and self-organization were associated with a significant improvement in hospital readmissions-related outcomes. Learning alone might be necessary but not be sufficient for improving transitions. However, building self-organization into the intervention might help people effectively respond to problems and adapt in uncertain situations to reduce the likelihood of readmission.

Development of a web-based toolkit to support improvement of care coordination in primary care.

Promising practices for the coordination of chronic care exist, but how to select and share these practices to support quality improvement within a healthcare system is uncertain. This study describes an approach for selecting high-quality tools for an online care coordination toolkit to be used in Veterans Health Administration (VA) primary care practices. We evaluated tools in three steps: (1) an initial screening to identify tools relevant to care coordination in VA primary care, (2) a two-clinician expert review process assessing tool characteristics (e.g. frequency of problem addressed, linkage to patients' experience of care, effect on practice workflow, and sustainability with existing resources) and assigning each tool a summary rating, and (3) semi-structured interviews with VA patients and frontline clinicians and staff. Of 300 potentially relevant tools identified by searching online resources, 65, 38, and 18 remained after steps one, two and three, respectively. The 18 tools cover five topics: managing referrals to specialty care, medication management, patient after-visit summary, patient activation materials, agenda setting, patient pre-visit packet, and provider contact information for patients. The final toolkit provides access to the 18 tools, as well as detailed information about tools' expected benefits, and resources required for tool implementation. Future care coordination efforts can benefit from systematically reviewing available tools to identify those that are high quality and relevant.

Psychotherapy practices for veterans with PTSD among community-based providers in Texas.

Significant changes in national health policy, like the Veterans Choice Act, have created growing opportunities for veterans to receive care outside of the Veterans Administration (VA), yet little is known about the attitudes and practices in PTSD care of community providers, particularly their use of evidence-based psychotherapies (EBPs). The authors assessed psychotherapy practices of community providers serving veterans with PTSD in Texas. They surveyed Texas mental health providers regarding their patient population, practice setting, and posttraumatic stress disorder (PTSD)-related screening, assessment, and treatment practices. They identified providers from state licensing board rosters and included a stratified sample of social workers, marriage and family therapists, and professional counselors (500 each), all psychologists with available email addresses (n = 3,986), and 106 providers known to have completed state-sponsored training for 1 of the EBPs for PTSD, cognitive processing therapy. Four hundred sixty-three eligible respondents returned surveys (15% response rate). Providers reported treating a mean of 7.9 veterans with PTSD in the past year (range = 0-200; SD = 20.5), using a variety of therapeutic approaches for PTSD. Only 15.0% of providers reported regularly conducting psychotherapy for PTSD following a treatment manual, and fewer than half reported any use of EBPs for PTSD with patients. Although many veterans are receiving treatment for PTSD in the community, many community-based mental health providers in Texas do not consistently use recommended treatments for PTSD. These findings may suggest an important opportunity for VA to engage and partner with community providers to achieve high-quality care for veterans. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Community Clinicians and the Veterans Choice Program for PTSD Care: Understanding Provider Interest During Early Implementation.

BACKGROUND: In 2014, the Department of Veterans Affairs (VA) implemented the Veterans Choice Program (VCP) to provide reimbursement for community-based care to eligible veterans. Inadequate networks of participating providers may impact the utility of VCP for veterans with posttraumatic stress disorder (PTSD), a complex condition occurring at lower frequency among civilians. OBJECTIVES: To compare characteristics and attitudes of community-based primary care and mental health providers reporting interest or no interest in VCP participation during early implementation; and to examine perceptions and experiences of VCP among "early adopters." RESEARCH DESIGN: Cross-sectional surveys with 2 samples: a stratified random sample of mental health and primary care prescribers and psychotherapists drawn from state licensing boards (Community Sample); and a stratified random sample of prescribers and psychotherapists identified as VCP-authorized providers (VCP-Authorized). SUBJECTS: Five hundred fifty-three respondents in the Community Sample and 115 in the VCP-Authorized (total, n=668; 21.1% response). MEASURES: Surveys assessed provider and practice characteristics, attitudes to VA and VCP, and experiences and satisfaction with the VCP; an open-ended survey item assessed providers' reasons for interest or lack of interest in VCP participation. RESULTS: Few providers reported VCP participation during this period. Interest in VCP participation was associated across provider groups with factors including being a veteran and receiving VA reimbursement; currently providing treatment for PTSD was associated with interest in VCP participation among psychotherapists, but not prescribers. CONCLUSIONS: Developing networks of VCP providers to serve Veterans with PTSD is likely to require targeting more receptive provider groups, reducing barriers to participation, and more effectively communicating the value of VCP participation to providers.

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

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

Primary care-public health linkages: Older primary care patients with prediabetes & type 2 diabetes encouraged to attend community-based senior centers.

The Institute of Medicine (IOM) suggests that primary care-public health integration can improve health outcomes for vulnerable patients, but the extent to which formal linkages may enhance patients' use of community resources, or the factors that may influence providers to encourage their patients to use these resources, remain unclear. We conducted baseline assessments in 2014-2015 with 149 older adults with prediabetes or diabetes who had recently joined three senior centers linked to a network of primary care clinics in San Antonio, Texas. In addition to collecting sociodemographic and clinical characteristics, we asked members to identify their source of primary care and whether a health care provider had encouraged them to go to the senior center. We also asked members why they had joined the senior centers and which programs interested them the most. Members' source of primary care was not associated with being encouraged to attend the senior centers by a health care professional. Multivariable analysis indicated that participants with total annual household incomes of $20,000 or less [OR = 2.78; 95% CI = (1.05, 7.14)] and those reporting 12 years of education or less [OR = 3.57; 95% CI = (1.11, 11.11)] were significantly more likely to report being encouraged to attend the senior center by a health care provider. Providers who are aware of community-based resources to support patient self-management may be just as likely to encourage their socioeconomically vulnerable patients with prediabetes or diabetes to use them as providers who have a more formal partnership with the senior centers.

A national cohort study of the association between the polytrauma clinical triad and suicide-related behavior among US Veterans who served in Iraq and Afghanistan.

OBJECTIVES: We examined the association of posttraumatic stress disorder (PTSD), traumatic brain injury, and chronic pain-the polytrauma clinical triad (PCT)-independently and with other conditions, with suicide-related behavior (SRB) risk among Operation Enduring Freedom (OEF; Afghanistan) and Operation Iraqi Freedom (OIF) veterans. METHODS: We used Department of Veterans Affairs (VA) administrative data to identify OEF and OIF veterans receiving VA care in fiscal years 2009-2011; we used International Classification of Diseases, Ninth Revision, Clinical Modification codes to characterize 211652 cohort members. Descriptive statistics were followed by multinomial logistic regression analyses predicting SRB. RESULTS: Co-occurrence of PCT conditions was associated with significant increase in suicide ideation risk (odds ratio [OR] = 1.9; 95% confidence interval [CI]=1.5, 2.4) or attempt and ideation (OR=2.6; 95% CI=1.5, 4.6), but did not exceed increased risk with PTSD alone (ideation: OR=2.3; 95% CI=2.0, 2.6; attempt: OR=2.0; 95% CI=1.4, 2.9; ideation and attempt: OR=1.8; 95% CI=1.2, 2.8). Ideation risk was significantly elevated when PTSD was comorbid with depression (OR=4.2; 95% CI=3.6, 4.8) or substance abuse (OR=4.7; 95% CI = 3.9, 5.6). CONCLUSIONS: Although PCT was a moderate SRB predictor, interactions among PCT conditions, particularly PTSD, and depression or substance abuse had larger risk increases.

Providers' perspectives on treating psychogenic nonepileptic seizures: frustration and hope.

Recent diagnostic and treatment advances in psychogenic nonepileptic seizures (PNES) have the potential to improve care for patients, but little is known about the current state of PNES care delivery in the Veterans Health Administration (VA). We conducted semistructured interviews with 74 health-care clinicians and workers in the VA, eliciting provider perceptions of PNES care. Data were analyzed according to principles of Grounded Theory. The results revealed variation in care and two emergent domain themes of frustration and hope. Frustration was manifest in subthemes including Complexity, Patient Acceptance, Uncertainty About Treatment, Need for Evidence-based Treatment, and Failure of Cross-Disciplinary Collaboration between neurologists and mental health providers. Hope encompassed subthemes of Positive Attitudes, Developing Cross-Disciplinary Treatment, and Specific PNES Care. Increased resources for diagnosing, treating, and researching PNES have improved awareness of the disorder. More research is needed to understand patients' and caregivers' perceptions of PNES care.