Coping with disruptive patients: Perspectives of primary care employees.

BACKGROUND: The impact of patient aggression on primary health care employees is underexplored, yet imperative to address, given high rates of burnout. OBJECTIVE: We qualitatively explore perceptions of patient aggression among staff in women's health primary care at the Veterans Health Administration (VA). Our objective is to identify coping strategies that staf devised in response to aggressive behavior. METHODS: We conducted semi-structured interviews with 60 VA women's health primary care employees in 2021 and 2022. Informed by the Job Demands-Resources theoretical model, we used rapid qualitative analysis to identify themes related to patient aggression and employee coping strategies. RESULTS: Disruptive behaviors reported by participants included verbal and physical aggression. Staff cited disruptive patient behavior as emotionally draining and perceived a lack of consequences for low-level aggression. Respondents used coping strategies in response to patient aggression at three time points: before, during, and after a negative interaction. At each point, support from team members emerged as a dominant coping mechanism, as well as rapport-building with patients. CONCLUSION: Patient aggression can negatively impact the work experiences of primary care employees. At VA, women's health primary care staff have devised multiple strategies to cope with these interactions. However, the ability to effectively prevent and manage patient aggression is limited by the lack of meaningful repercussions for aggression at the organizational level, which has important implications for employee well-being and retention. Retention of women's health employees in VA is critical given the need for a highly specialized workforce to address the complex health needs of women veterans.

Veteran Caretaker Perspectives of the Need for Childcare Assistance During Health Care Appointments.

PURPOSE: In 2020, Congress passed legislation to establish the national Veterans Child Care Assistance Program (VCAP) targeting eligible veterans receiving care through the Veterans Health Administration (VA). This needs assessment describes the childcare needs of veteran caretakers of young children and explores the implications of inadequate childcare on health care engagement. METHODS: Survey data were collected from 2,000 VA users with dependent children; data were analyzed using standard descriptive statistics. Qualitative data were collected from 19 veterans through focus groups and analyzed using rapid thematic analysis. FINDINGS: More than 75% of veterans surveyed indicated that they required childcare assistance during health care appointments and 73% reported barriers to finding childcare. Prominent barriers included the high cost of childcare and not having a trusted source of childcare. Nearly 58% of survey respondents reported missed or canceled VA health care appointments due to childcare challenges. Furthermore, 35% of surveyed veterans reported that their children had accompanied them to an appointment in the past year. Among these veterans, 59% brought their children into the exam room. Focus group participants discussed how having children present during their health care appointments hampered communication with health care providers. CONCLUSIONS: Veterans report that lack of childcare keeps them from attending and remaining focused on the provider during their health care visits, which could compromise quality of care. As one of the only health systems in the United States that will offer childcare assistance, VCAP presents an opportunity to improve health care access and quality by reducing missed appointments and suboptimal care.

Clinician and Patient Perspectives on the Use of Passive Mobile Monitoring and Self-Tracking for Patients With Serious Mental Illness: User-Centered Approach.

BACKGROUND: Early intervention in mental health crises can prevent negative outcomes. A promising new direction is remote mental health monitoring using smartphone technology to passively collect data from individuals to rapidly detect the worsening of serious mental illness (SMI). This technology may benefit patients with SMI, but little is known about health IT acceptability among this population or their mental health clinicians. OBJECTIVE: We used the Health Information Technology Acceptability Model to analyze the acceptability and usability of passive mobile monitoring and self-tracking among patients with serious mental illness and their mental health clinicians. METHODS: Data collection took place between December 2020 and June 2021 in 1 Veterans Administration health care system. Interviews with mental health clinicians (n=16) assessed the acceptability of mobile sensing, its usefulness as a tool to improve clinical assessment and care, and recommendations for program refinements. Focus groups with patients with SMI (n=3 groups) and individual usability tests (n=8) elucidated patient attitudes about engaging in health IT and perceptions of its usefulness as a tool for self-tracking and improving mental health assessments. RESULTS: Clinicians discussed the utility of web-based data dashboards to monitor patients with SMI health behaviors and receiving alerts about their worsening health. Potential benefits included improving clinical care, capturing behaviors patients do not self-report, watching trends, and receiving alerts. Clinicians' concerns included increased workloads tied to dashboard data review, lack of experience using health IT in clinical care, and how SMI patients' associated paranoia and financial instability would impact patient uptake. Despite concerns, all mental health clinicians stated that they would recommend it. Almost all patients with SMI were receptive to using smartphone dashboards for self-monitoring and having behavioral change alerts sent to their mental health clinicians. They found the mobile app easy to navigate and dashboards easy to find and understand. Patient concerns centered on privacy and "government tracking," and their phone's battery life and data plans. Despite concerns, most reported that they would use it. CONCLUSIONS: Many people with SMI would like to have mobile informatics tools that can support their illness and recovery. Similar to other populations (eg, older adults, people experiencing homelessness) this population presents challenges to adoption and implementation. Health care organizations will need to provide resources to address these and support successful illness management. Clinicians are supportive of technological approaches, with adapting informatics data into their workflow as the primary challenge. Despite clear challenges, technological developments are increasingly designed to be acceptable to patients. The research development-clinical deployment gap must be addressed by health care systems, similar to computerized cognitive training. It will ensure clinicians operate at the top of their skill set and are not overwhelmed by administrative tasks, data summarization, or reviewing data that do not indicate a need for intervention. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/39010.

Software is Policy: Electronic Health Record Governance and the Implications of Clinical Standardization.

BACKGROUND: Electronic health record (EHR) implementations, whether replacing paper or electronic systems, are major social and organizational transformations. Yet studies of EHR-to-EHR transitions have largely neglected to elucidate accompanying social and organizational changes. One such underexplored change is the standardization of clinical practice in the context of EHR transitions. The Department of Veterans Affairs (VA) has begun a decade-long process of replacing the approximately 130 separate versions of its homegrown EHR with a single commercial EHR system. This provides an opportunity to explore the standardization of clinical practice amidst an EHR transition. OBJECTIVE: To identify, in the context of a large-scale EHR transition, (1) the scope and content of clinical standardization and (2) the anticipated implications of such standardization. DESIGN: Qualitative study. PARTICIPANTS: Twenty-nine members of VA councils established for the EHR transition. APPROACH: We conducted semi-structured interviews, which were professionally transcribed, and analyzed first using rapid analysis methods, followed by coding and content analysis. KEY RESULTS: Clinical standardization across facilities was a central goal of the EHR transition, encompassing computerized recommendations, order sets, professional roles/permissions, and clinical documentation. The anticipated implications of this standardization include (i) potential efficiency gains, with less duplicated effort across facilities; (ii) expanded bureaucracy; and (iii) increased uniformity, reducing both wanted and unwanted variation in care. CONCLUSIONS: EHR systems shape a wide range of clinical processes, particularly in a large organization like VA with a long history of EHR use. This makes standardization of EHR content a powerful mechanism for standardizing clinical practice itself, which can bring dramatic collateral consequences. Organizations undergoing EHR transitions need to recognize the important role that clinical standardization plays by treating EHR transitions as major organizational transformations in the governance of clinical practice.

Primary Care Team Perspectives on the Suitability of Telehealth Modality (Phone vs Video) at the Veterans Health Administration.

INTRODUCTION: Telehealth has the potential to improve access and timeliness of care, enabling primary care teams to deliver hybrid (virtual/in-person) services that will likely extend beyond the COVID-19 pandemic. To optimize its use and sustainability, it is imperative to understand how primary care teams perceive the suitability of telehealth services, including appropriate choice of mode (telephone or video). However, there is limited research on providers' decision-making processes surrounding telehealth use in primary care, including whether to use telephone or video, which this VA-focused study addresses. We examined how primary care (PC) team members determine whether to use telehealth and the mode of delivery, in the care of patients. METHODS: Qualitative case study that included 15 semi-structured interviews with employees who provided or supported telehealth care at primary care clinics at the Veterans Health Administration. We used a team-based rapid analysis approach to identify experiences using telehealth soon after COVID-19's emergence, consisting of the creation of structured summaries of each transcribed interview. The lead author then identified and compiled themes and sub-themes related to the suitability of telehealth in primary care, as well as associated quotes from transcripts. Resulting themes and quotes were reviewed and validated by 2 members of the project team. RESULTS: Primary care team members considered several factors when assessing both the suitability of telehealth for appointments, and mode of use. They were largely guided by patient-related factors including patient preferences, specific health issues, and access to technology. Additional considerations centered on team members' personal preferences and factors that supported the wellbeing of the team, such as the flexibility to work from home (work-life balance) and protection from infection. Generally, participants viewed the option of both telephone and video telehealth modalities as useful tools in the care of patients although a few respondents emphasized its inferiority to in-person care. CONCLUSIONS: Determining the suitability of telehealth services, including appropriate choice of mode is complex. Its suitability is tied to a variety of factors related to multilevel resources, preferences, and timing. When appropriate, telehealth should be considered a useful tool in the care of patients and for employee well-being.

Passive Mobile Self-tracking of Mental Health by Veterans With Serious Mental Illness: Protocol for a User-Centered Design and Prospective Cohort Study.

BACKGROUND: Serious mental illnesses (SMI) are common, disabling, and challenging to treat, requiring years of monitoring and treatment adjustments. Stress or reduced medication adherence can lead to rapid worsening of symptoms and behaviors. Illness exacerbations and relapses generally occur with little or no clinician awareness in real time, leaving limited opportunity to modify treatments. Previous research suggests that passive mobile sensing may be beneficial for individuals with SMI by helping them monitor mental health status and behaviors, and quickly detect worsening mental health for prompt assessment and intervention. However, there is too little research on its feasibility and acceptability and the extent to which passive data can predict changes in behaviors or symptoms. OBJECTIVE: The aim of this research is to study the feasibility, acceptability, and safety of passive mobile sensing for tracking behaviors and symptoms of patients in treatment for SMI, as well as developing analytics that use passive data to predict changes in behaviors and symptoms. METHODS: A mobile app monitors and transmits passive mobile sensor and phone utilization data, which is used to track activity, sociability, and sleep in patients with SMI. The study consists of a user-centered design phase and a mobile sensing phase. In the design phase, focus groups, interviews, and usability testing inform further app development. In the mobile sensing phase, passive mobile sensing occurs with participants engaging in weekly assessments for 9 months. Three- and nine-month interviews study the perceptions of passive mobile sensing and ease of app use. Clinician interviews before and after the mobile sensing phase study the usefulness and feasibility of app utilization in clinical care. Predictive analytic models are built, trained, and selected, and make use of machine learning methods. Models use sensor and phone utilization data to predict behavioral changes and symptoms. RESULTS: The study started in October 2020. It has received institutional review board approval. The user-centered design phase, consisting of focus groups, usability testing, and preintervention clinician interviews, was completed in June 2021. Recruitment and enrollment for the mobile sensing phase began in October 2021. CONCLUSIONS: Findings may inform the development of passive sensing apps and self-tracking in patients with SMI, and integration into care to improve assessment, treatment, and patient outcomes. TRIAL REGISTRATION: ClinicalTrials.gov NCT05023252; https://clinicaltrials.gov/ct2/show/NCT05023252. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/39010.

Managers' and Leaders' Perceptions of Sexual and Gender-Based Public Harassment in the Veterans Health Administration.

PURPOSE: Managers and leaders have a critical role to play in sexual and gender-based harassment prevention within organizations. Although the Veterans Health Administration has committed to eliminating harassment through national directives and training programs, it is unclear how aware local-level managers and leaders are about public harassment at their facilities and how they perceive sexual and gender-based harassment. We examined middle managers' and leaders' views about whether harassment is perceived as a problem locally, and what policies and procedures (if any) are in place to address public harassment. METHODS: We conducted 69 semistructured telephone interviews with middle managers and facility leaders before implementation of an evidence-based quality improvement project designed to improve delivery of comprehensive women's health care. Transcripts were coded using the constant comparative method and analyzed for overarching themes. RESULTS: Perceptions of the prevalence of sexual and gender-based public harassment varied among middle managers and leaders. A little more than one-half of respondents were unaware of facility-level policies and procedures to address public harassment between patients. To decrease patient-to-patient harassment, both groups generally supported the creation of separate clinical spaces for women. However, middle managers also stated that education was needed to change patient harassing behavior, which they tied to male military culture. CONCLUSIONS: Aligning divergent perspectives of what constitutes sexual and gender-based harassment and how to address it is a necessary step towards tackling harassment at the local level. Managers and leaders should continue to assess environments of care and share findings widely among employees and leadership to improve awareness and inform a unified response.

Health System Resiliency and the COVID-19 Pandemic: A Case Study of a New Nationwide Contingency Staffing Program.

When COVID-19 emerged, the U.S. Veterans Health Administration (VA) was in the process of implementing a national contingency staffing program called Clinical Resource Hubs (CRHs). CRHs were intended to provide regional contingency staffing for primary and mental health clinics experiencing staffing shortages primarily through telehealth. Long-term plans (year 2) included emergency management support. Early in the implementation, we conducted semi-structured interviews with CRH directors and national program leaders (n = 26) and used a rapid analysis approach to identify actions taken by CRHs to support the resiliency of the VA healthcare system during the pandemic. We found that the CRH program was flexible and nimble enough to allow VA to leverage providers at hubs to better respond to the demands of COVID-19. Actions taken at hubs to sustain patient access and staff resiliency during the pandemic included supporting call centers and training VA providers on virtual care delivery. Factors that facilitated CRH's emergency response included hub staff expertise in telehealth and the increased acceptability of virtual care among key stakeholders. We conclude that hub providers serving as contingency staff, as well as specialization in delivering virtual outpatient and inpatient care, enabled VA health system resiliency and recovery during the COVID-19 pandemic.