"Something Has to Be Done to Make Women Feel Safe": Women Veterans' Recommendations for Strengthening the Veterans Crisis Line for Women Veterans.

OBJECTIVE: Women represent 15% of veteran callers to the Veterans Crisis Line (VCL); there has been little research identifying the experiences and needs of women veterans who use the VCL. The objective of this study was to identify women veterans' experiences with and recommendations for strengthening VCL services for women. METHOD: We conducted qualitative interviews with 26 women veterans across the United States who had contacted the VCL in the preceding year. Interviews were conducted by telephone in 2022 and were audio recorded and transcribed. A team-based content analysis approach was used to identify participants' concerns around contacting the VCL and recommendations for strengthening the service. RESULTS: Interviews revealed women veterans' concerns with regard to contacting the VCL related to responder gender, appropriateness of VCL services for veterans not at imminent risk for suicide, and potential consequences of contacting the VCL. Key recommendations included letting veterans select the gender of the responder who takes their call, providing more information to potential callers about what to expect from VCL calls, and raising awareness about and maintaining options for caller anonymity. CONCLUSIONS: This study uniquely focused on women veterans' experiences and perspectives, in their own voices. Findings point to trauma-informed approaches supporting women veteran callers to the VCL and may also hold implications for other similar crisis hotline services.

Relationship between Veterans Crisis Line risk rating and subsequent suicidal self-directed violence among veteran callers: A gender comparison.

BACKGROUND: Disparities in suicide rates by veteran status are particularly striking for women. Veterans Crisis Line (VCL) is a preventive strategy. OBJECTIVES: Examine the relationships and gender differences between VCL risk rating, and subsequent suicidal self-directed violence (SSDV) in the 12-months following VCL index call. METHODS: Cohort study of VCL callers in 2018. OUTCOMES: Dichotomized composite SSDV (non-fatal suicide event and/or suicide) in the 12 months following VCL call. RESULTS: Veterans with high/moderate VCL risk had significantly higher odds of SSDV (OR = 4.02, 95% CI: 3.75, 4.30). There were no gender/VCL risk interaction (p = 0.3605). We also examined the association of gender, combination of VCL risk and suicide attempt (SA) history, on SSDV. Differential odds of SSDV for gender and combined VCL risk and SA history combinations were observed (p = 0.0005). Compared to those with lower VCL risk without SA history, those with high/moderate VCL risk with SA history showed higher odds of SSDV. Magnitude was higher for men, than for women veterans. CONCLUSIONS AND RELEVANCE: Veterans Crisis Line risk assessment performs relatively stable across the gender binary and highlights potential gender differences when factoring in SA history. Combining risk assessment and attempt history may lead to effective suicide prevention strategies.

The Gears of Knowledge Translation: Process Evaluation of the Dissemination and Implementation of a Patient Engagement Toolkit.

BACKGROUND: Patient engagement is a key tenet of patient-centered care and is associated with many positive health outcomes. To improve resources for patient engagement, we created a web-based, interactive patient engagement toolkit to improve patient engagement in primary care across the Veterans Health Administration (VHA). OBJECTIVE: To use the knowledge translation (KT) framework to evaluate the dissemination and implementation of a patient engagement toolkit at facilities across one region in the VHA. DESIGN: Using a mixed-methods approach, this process evaluation involved phone monitoring via semi-structured interviews and group meetings, during which we explored barriers and facilitators to KT. Outcomes were assessed using a structured rubric and existing patient satisfaction measures. PARTICIPANTS: We enlisted implementers at 40 VHA facilities primarily serving Pennsylvania, New Jersey, and Delaware to implement patient engagement practices at their sites. Sites were randomly assigned into a high or low coaching group to assess whether external support influenced implementation. KEY RESULTS: Sites with high rubric scores employed and possessed several elements across the KT trajectory from identification of the problem to sustainment of knowledge use. Key factors for successful implementation and dissemination included implementer engagement, organizational support, and strong collaborators. The most frequently cited barriers included short staffing, time availability, lack of buy-in, and issues with leadership. Successful implementers experienced just as many barriers, but leveraged facilitators to overcome obstacles. While sites that received more coaching did not have different outcomes, they were more likely to revisit the toolkit and indicated that they felt more accountable to local personnel. CONCLUSIONS: Because leveraging available resources is a key component of successful implementation, future toolkits should highlight the type of facilitators necessary for successful implementation of toolkit content in healthcare settings. The ability to tailor interventions to local context is critical for overcoming barriers faced in most healthcare settings.

Improving Patient-centered Care: How Clinical Staff Overcome Barriers to Patient Engagement at the VHA.

BACKGROUND: While patient engagement can be beneficial for patient care, there are barriers to engaging patients. These barriers exist for health care organizations, for health care personnel, and for the patients themselves. Solutions to barriers are not well documented. OBJECTIVES: Our objective was to explore barriers to patient engagement efforts and their corresponding solutions. RESEARCH DESIGN: Qualitative interviews and site visits from a national sample of primary care facilities within the Veterans Health Administration were analyzed to understand patient engagement barriers and solutions. SAMPLING: We conducted a total of 155 phone and in-person semistructured interviews with primary care providers, mental health staff, social workers, pharmacists, patient advocates, health behavior coaches, and administrative staff at 27 Veterans Health Administration sites. Participants were asked to describe the obstacles they had to overcome in their efforts to improve patient engagement at their site. RESULTS: Barriers to patient engagement are overcome by strategically updating data analytics; enhancing organization-wide processes and procedures; being creative with space design, staff hiring, and time commitments; cultivating staff collaborations; and addressing patient care issues such as access, customer service, and patient education. A key component of successful implementation is to create a culture, supported by leadership that promotes patient engagement. CONCLUSIONS: Participants understood the patient centered approach, despite experiencing a lack of resources and training and could push through solutions to patient engagement barriers while working within the limits of their settings.

Creating a Toolkit to Reduce Disparities in Patient Engagement.

BACKGROUND: Patient engagement has become a major focus of health care improvement efforts nationally. Although evidence suggests patient engagement can be beneficial to patients, it has not been consistently defined, operationalized, or translated into practice. OBJECTIVES: Our objective was to develop a toolkit to help providers increase patient engagement and reduce disparities in patient engagement. RESEARCH DESIGN: We used qualitative interviews and observations with staff at primary care sites nationally to identify patient engagement practices and resources used to engage patients. We then used a modified Delphi process, that included a series of conference calls and surveys, where stakeholders reduced lists of engagement practices based on perceived feasibility and importance to develop a toolkit for patient engagement. SAMPLING: Sites were selected for interviews and site visits based on the concentration of minority patients served and performance on a measure of patient engagement, with the goal of highlighting practices at sites that successfully serve minority patients. RESULTS: We created a toolkit consisting of patient engagement practices and resources. No identified practice or resource specifically targeted patient engagement of minorities or addressed disparities. However, high-performing, high-minority-serving sites tended to describe more staff training opportunities and staff feedback mechanisms. In addition, low-performing and high-minority-serving sites more often reported barriers to implementation of patient engagement practices. CONCLUSIONS: Stakeholders agreed on feasible and important engagement practices. Implementation of this toolkit will be tracked to better understand patient engagement and its effect on patient-centered care and related disparities in care.