Cultural challenges for adapting behavioral intervention frameworks: A critical examination from a cultural psychology perspective.

We introduce the bias and equivalence framework to highlight how concepts, methods, and tools from cultural psychology can contribute to successful cultural adaptation and implementation of behavioral interventions. To situate our contribution, we provide a review of recent cultural adaptation research and existing frameworks. We identified 68 different frameworks that have been cited when reporting cultural adaptations and highlight three major adaptation dimensions that can be used to differentiate adaptations. Regarding effectiveness, we found an average effect size of zr = 0.24 (95%CI 0.20, 0.29) in 24 meta-analyses published since 2014, but also substantive differences across domains and unclear effects of the extent of cultural adaptations. To advance cultural adaptation efforts, we outline a framework that integrates key steps from previous cultural adaptation frameworks and highlight how cultural bias and equivalence considerations in conjunction with community engagement help a) in the diagnosis of behavioral or psychological problems, b) identification of possible interventions, c) the selection of specific mechanisms of behavior change, d) the specification and documentation of dose effects and thresholds for diagnosis, e) entry and exit points within intervention programs, and f) cost-benefit-sustainability discussions. We provide guiding questions that may help researchers when adapting interventions to novel cultural contexts.

Gender Differences in Adoption and Frequency of Virtual Primary Care Among Men and Women Veterans.

Background: Women Veterans have unique health care utilization patterns; however, video-based primary care utilization among and between women and men has not been well examined. Methods: In a retrospective cohort study, we calculated gender-stratified video visit adoption (i.e., likelihood) and frequency (i.e., rate of use among users) between April 1, 2020, and March 31, 2022, by demographic and clinical characteristics known to impact health care utilization. Results: Among 5,389,139 Veterans (9.2% women), 32% of women and 18.6% of men had a video-based primary care visit over the 2-year study period. Gender interacted with Veteran characteristics and the likelihood of any video care. Men often had associations stronger in magnitude (both positive and negative) than women, including by age, rurality, history of housing instability, mental health conditions, and marital status. The direction of effect never diverged by gender. A positive association among women always coincided with a positive association among men, and vice versa, across all characteristics assessed. Only the risk ratio for video care use comparing Veterans of Black race with White race was stronger among women. In contrast to the video care adoption differences by gender, we found few differences in the frequency of video-based care by gender. Conclusions: The findings suggest there are fewer disparities by demographic and clinical characteristics in any video care use among women compared with men and little to no disparities in the frequency of video care use by gender. Understanding the variation in video care utilization by gender could help improve acceptance, appropriate utilization, and uptake of video-based visits for all.

Development and Validation of a Measure to Assess Patient Experiences With Video Care Encounters.

Importance: As video-based care expands in many clinical settings, assessing patient experiences with this care modality will help optimize health care quality, safety, and communication. Objective: To develop and assess the psychometric properties of the video visit user experience (VVUE) measure, a patient-reported measure of experiences with video-based technology. Design, Setting, and Participants: In this survey study, veterans completed a web-based, mail, or telephone survey about their use of Veterans Healthcare Administration (VHA) virtual care between September 2021 and January 2022. The survey was completed by patients who reported having a VHA video visit on their own device or a VHA-issued device and linked to VHA utilization data for the 6 months following the survey. Data analysis was performed from March 2022 to February 2023. Main Outcomes and Measures: The survey included 19 items about experiences with video visits that were rated using a 4-point Likert-type scale (strongly disagree to strongly agree). First, an exploratory factor analysis was conducted to determine the factor structure and parsimonious set of items, using the McDonald Omega test to assess internal consistency reliability. Then, a confirmatory factor analysis was conducted to test structural validity, and bivariate correlations between VVUE and VHA health care engagement were calculated to test concurrent validity. Finally, predictive validity was assessed using logistic regression to determine whether VVUE was associated with future VHA video visit use. Results: Among 1887 respondents included in the analyses, 83.2% (95% CI, 81.5%-84.8%) were male, 41.0% (95% CI, 38.8%-43.1%) were aged 65 years or older, and the majority had multiple chronic medical and mental health conditions. The exploratory factor analysis identified a 10-item single-factor VVUE measure (including questions about satisfaction, user-centeredness, technical quality, usefulness, and appropriateness), explaining 96% of the total variance, with acceptable internal consistency reliability (ω = 0.95). The confirmatory factor analysis results confirmed a single-factor solution (standardized root mean squared residual = 0.04). VVUE was positively associated with VHA health care engagement (ρ = 0.47; P < .001). Predictive validity models demonstrated that higher VVUE measure scores were associated with future use of video visits, where each 1-point increase on VVUE was associated with greater likelihood of having a video visit in subsequent 6 months (adjusted odds ratio, 1.04; 95% CI, 1.02-1.06). Conclusions and Relevance: The findings of this study of veterans using video visits suggest that a brief measure is valid to capture veterans' experiences receiving VHA virtual care.

Research Priorities to Expand Virtual Care Access for Patients in the Veterans Affairs Health Care System.

The rapid expansion of virtual care is driving demand for equitable, high-quality access to technologies that are required to utilize these services. While the Department of Veterans Affairs (VA) is seen as a national leader in the implementation of telehealth, there remain gaps in evidence about the most promising strategies to expand access to virtual care. To address these gaps, in 2022, the VA's Health Services Research and Development service and Office of Connected Care held a "state-of-the-art" (SOTA) conference to develop research priorities for advancing the science, clinical practice, and implementation of virtual care. One workgroup within the SOTA focused on access to virtual care and addressed three questions: (1) Based on the existing evidence about barriers that impede virtual care access in digitally vulnerable populations, what additional research is needed to understand these factors? (2) Based on the existing evidence about digital inclusion strategies, what additional research is needed to identify the most promising strategies? and (3) What additional research beyond barriers and strategies is needed to address disparities in virtual care access? Here, we report on the workgroup's discussions and recommendations for future research to improve and optimize access to virtual care. Effective implementation of these recommendations will require collaboration among VA operational leadership, researchers, Human Factors Engineering experts and front-line clinicians as they develop, implement, and evaluate the spread of virtual care access strategies.

Building Authentic Connection in the Patient-Physician Relationship.

INTRODUCTION/OBJECTIVES: Delivering optimal patient care is impacted by a physician's ability to build trusting relationships with patients. Identifying techniques for rapport building is important for promoting patient-physician collaboration and improved patient outcomes. This study sought to characterize the approaches highly skilled primary care physicians (PCPs) use to effectively connect with diverse patients. METHODS: Using an inductive thematic analysis approach, we analyzed semi-structured interview transcripts with 10 PCPs identified by leadership and/or colleagues for having exceptional patient communication skills. PCPs practiced in 3 diverse clinic settings: (1) academic medical center, (2) Veterans Affairs clinic, and (3) safety-net community clinic. RESULTS AND CONCLUSIONS: The thematic analysis yielded 5 themes that enable physicians to establish connections with patients: Respect for the Patient, Engaged Curiosity, Focused Listening, Mutual Participation, and Self-Awareness. Underlying all of these themes was a quality of authenticity, or a state of symmetry between one's internal experience and external words and actions. Adopting these communication techniques while allowing for adaptability in order to remain authentic in one's interactions with patients may facilitate improved connection and trust with patients. Encouraging physician authenticity in the patient-physician relationship supports a shift toward relationship-centered care. Additional medical education training is needed to facilitate authentic connection between physicians and patients.

Meeting high-risk patient pain care needs through intensive primary care: a secondary analysis.

OBJECTIVE: Chronic pain disproportionately affects medically and psychosocially complex patients, many of whom are at high risk of hospitalisation. Pain prevalence among high-risk patients, however, is unknown, and pain is seldom a focus for improving high-risk patient outcomes. Our objective is to (1) evaluate pain frequency in a high-risk patient population and (2) identify intensive management (IM) programme features that patients and providers perceive as important for promoting patient-centred pain care within primary care (PC)-based IM. DESIGN: Secondary observational analysis of quantitative and qualitative evaluation data from a multisite randomised PC-based IM programme for high-risk patients. SETTING: Five integrated local Veterans Affairs (VA) healthcare systems within distinct VA administrative regions. PARTICIPANTS: Staff and high-risk PC patients in the VA. INTERVENTION: A multisite randomised PC-based IM programme for high-risk patients. OUTCOME MEASURES: (a) Pain prevalence based on VA electronic administrative data and (b) transcripts of interviews with IM staff and patients that mentioned pain. RESULTS: Most (70%, 2593/3723) high-risk patients had at least moderate pain. Over one-third (38%, 40/104) of the interviewees mentioned pain or pain care. There were 89 pain-related comments addressing IM impacts on pain care within the 40 interview transcripts. Patient-identified themes were that IM improved communication and responsiveness to pain. PC provider-identified themes were that IM improved workload and access to expertise. IM team member-identified themes were that IM improved pain care coordination, facilitated non-opioid pain management options and mitigated provider compassion fatigue. No negative IM impacts on pain care were mentioned. CONCLUSIONS: Pain is common among high-risk patients. Future IM evaluations should consider including a focus on pain and pain care, with attention to impacts on patients, PC providers and IM teams.

Disparities in Video-Based Primary Care Use Among Veterans with Cardiovascular Disease.

BACKGROUND: Cardiovascular disease (CVD) is prevalent among Veterans, and video care enhances access to CVD care. However, it is unknown which patients with CVD conditions receive video care in primary care clinics, where a large proportion of CVD services is delivered. OBJECTIVE: Characterize use of VA video primary care for Veterans with two common CVDs, heart failure and hypertension. DESIGN: Retrospective cohort study. PATIENTS: Veterans seen in VA primary care with diagnoses of heart failure and/or hypertension in the year prior to the COVID-19 pandemic and for the first two pandemic-years. MAIN MEASURES: The primary outcome was use of any video-based primary care visits. Using multilevel regressions, we examined the association between video care use and patient sociodemographic and clinical characteristics, controlling for time and adjusting for patient- and site-level clustering. KEY RESULTS: Of 3.8M Veterans with 51.9M primary care visits, 456,901 Veterans had heart failure and hypertension, 50,753 had heart failure only, and 3,300,166 had hypertension only. Veterans with heart failure and hypertension had an average age of 71.6 years. 2.9% were female, and 34.8% lived in rural settings. Patients who were male, aged 75 or older, or rural-dwelling had lower odds of using video care than female patients, 18-44-year-olds, and urban-dwellers, respectively (male patients' adjusted odds ratio [AOR] 0.73, 95% confidence interval [CI] 0.72-0.74; 75 years or older, AOR 0.38, 95% CI 0.37-0.38; rural-dwellers, AOR 0.71, 95% CI 0.70-0.71). Veterans with heart failure had higher odds of video care use than those with hypertension only (AOR 1.05, 95% CI 1.04-1.06). CONCLUSIONS: Given lower odds of video primary care use among some patient groups, continued expansion of video care could make CVD services increasingly inequitable. These insights can inform equitable triage of patients, for example by identifying patients who may benefit from additional support to use virtual care.

Adoption and Sustained Use of Primary Care Video Visits Among Veterans with VA Video-Enabled Tablets.

In 2020, the U.S. Department of Veterans Affairs (VA) expanded an initiative to distribute video-enabled tablets to Veterans with limited virtual care access. We examined patient characteristics associated with adoption and sustained use of video-based primary care among Veterans. We conducted a retrospective cohort study of Veterans who received VA-issued tablets between 3/11/2020-9/10/2020. We used generalized linear models to evaluate the sociodemographic and clinical factors associated with video-based primary care adoption (i.e., likelihood of having a primary care video visit) and sustained use (i.e., rate of video care) in the six months after a Veteran received a VA-issued tablet. Of the 36,077 Veterans who received a tablet, 69% had at least one video-based visit within six months, and 24% had a video-based visit in primary care. Veterans with a history of housing instability or a mental health condition, and those meeting VA enrollment criteria for low-income were significantly less likely to adopt video-based primary care. However, among Veterans who had a video visit in primary care (e.g., those with at least one video visit), older Veterans, and Veterans with a mental health condition had more sustained use (higher rate) than younger Veterans or those without a mental health condition. We found no differences in adoption of video-based primary care by rurality, age, race, ethnicity, or low/moderate disability and high disability priority groups compared to Veterans with no special enrollment category. VA's tablet initiative has supported many Veterans with complex needs in accessing primary care by video. While Veterans with certain social and clinical challenges were less likely to have a video visit, those who adopted video telehealth generally had similar or higher rates of sustained use. These patterns suggest opportunities for tailored interventions that focus on needs specific to initial uptake vs. sustained use of video care.

Building Trust and Partnership with Black Pediatric Patients and their Caregivers.

Systemic racism embedded within the US health care system results in disproportionately worse health outcomes for Black pediatric patients and their caregivers. One meaningful mechanism through which these health disparities persist is through discriminatory treatment and anti-Black bias from clinicians. Strengthening care provided to Black pediatric patients and their caregivers requires that clinicians adopt culturally tailored communication strategies that promote health equity and counter racism. We conducted a scoping review of evidence-based communication practices in the medical literature that improve care for Black pediatric patients. We mapped the specific practices to the Presence 5 for Racial Justice framework and identified cross-cutting themes to describe practices across the five domains. There are three cross-cutting themes that underlie the recommended practices: 1) promote unbiased implementation of clinician communication strategies (eg, providing equitable recommendations for preventive care), 2) tailor care to Black pediatric patients (eg, explore the importance of the family unit), and 3) address racism experienced by Black pediatric patients and their caregivers (eg, acknowledge any previous negative experiences with the health care system). This review highlights communication practices that clinicians can adopt to build trusting relationships, empower Black families, and promote racial justice in clinical care. Future opportunities include expanding to system level change and validating these practices with patients and clinicians.

Patterns and predictors of mental health service use among older veterans with alcohol use disorder who received a video-enabled tablet.

Objectives: Video-based telehealth may expand access to mental health services among older veterans with alcohol use disorder (AUD). We examined the modalities through which mental health services were rendered, and predictors of video visits before and after video-enabled tablet receipt from the Veterans Health Administration. Method: 11,210 veterans aged 60 or older with a diagnosis of AUD who received a tablet between 1 April 2020 and 25 October 2021 were identified. The electronic health record was used to characterized encounters by modality of mental health care delivery in the six months pre/post tablet receipt. Logistic regression examined predictors of a video visit for mental health. Results: Phone was the most common modality; however, the proportion of video encounters increased from 8.7% to 26.2% after tablet receipt. Individuals who were older, male, and had more physical health conditions, were less likely to have a video visit. Individuals who were married, resided in urban areas, had a history of housing instability, and had more mental health conditions, were more likely to have a video visit. Conclusion: Video-enabled tablets may help older adults with AUD overcome access barriers to mental health services, although targeted support for certain groups may be necessary.

Overcoming Obstacles: Barriers to Virtual Care Use Among Video-Enabled Tablet Recipients in the Veterans Health Administration.

INTRODUCTION: The Veterans Health Administration (VHA) distributes video-enabled tablets to individuals with barriers to accessing care. Data suggests that many tablets are under-used. We surveyed Veterans who received a tablet to identify barriers that are associated with lower use, and evaluated the impact of a telephone-based orientation call on reported barriers and future video use. METHODS: We used a national survey to assess for the presence of 13 barriers to accessing video-based care, and then calculated the prevalence of the barriers stratified by video care utilization in the 6 months after survey administration. We used multivariable modeling to examine the association between each barrier and video-based care use and evaluated whether a telephone-based orientation modified this association. RESULTS: The most prevalent patient-reported barriers to video-based care were not knowing how to schedule a visit, prior video care being rescheduled/canceled, and past problems using video care. Following adjustment, individuals who reported vision or hearing difficulties and those who reported that video care does not provide high-quality care had a 19% and 12% lower probability of future video care use, respectively. Individuals who reported no interest in video care, or did not know how to schedule a video care visit, had an 11% and 10% lower probability of being a video care user, respectively. A telephone-based orientation following device receipt did not improve the probability of being a video care user. DISCUSSION: Barriers to engaging in virtual care persist despite access to video-enabled devices. Targeted interventions beyond telephone-based orientation are needed to facilitate adoption and engagement in video visits.

Association between patient-reported social and behavioral risks and health care costs in high-risk Veterans health administration patients.

OBJECTIVE: Social risks complicate patients' ability to manage their conditions and access healthcare, but their association with health expenditures is not well established. To identify patient-reported social risk, behavioral, and health factors associated with health expenditures in Veterans Affairs (VA) patients at high risk for hospitalization or death. DATA SOURCES, STUDY SETTING, AND STUDY DESIGN: Prospective cohort study among high-risk Veterans obtaining VA care. Patient-reported social risk, function, and other measures derived from a 2018 survey sent to 10,000 VA patients were linked to clinical and demographic characteristics extracted from VA data. Response-weighted generalized linear and marginalized two-part models were used to examine VA expenditures (total, outpatient, medication, inpatient) 1 year after survey completion in adjusted models. PRINCIPAL FINDINGS: Among 4680 survey respondents, the average age was 70.9 years, 6.3% were female, 16.7% were African American, 20% had body mass index ≥35, 42.4% had difficulty with two or more basic or instrumental activities of daily living, 19.3% reported transportation barriers, 12.5% reported medication insecurity and 21.8% reported food insecurity. Medication insecurity was associated with lower outpatient expenditures (-$1859.51 per patient per year, 95% confidence interval [CI]: -3200.77 to -518.25) and lower total expenditures (-$4304.99 per patient per year, 95% CI: -7564.87 to -1045.10). Transportation barriers were negatively associated with medication expenditures (-$558.42, 95% CI: -1087.93 to -31.91). Patients with one functional impairment had higher outpatient expenditures ($2997.59 per patient year, 95% CI: 1185.81-4809.36) than patients without functional impairments. No social risks were associated with inpatient expenditures. CONCLUSIONS: In this study of VA patients at high risk for hospitalization and mortality, few social and functional measures were independently associated with the costs of VA care. Individuals with functional limitations and those with barriers to accessing medications and transportation may benefit from targeted interventions to ensure that they are receiving the services that they need.

Sociodemographic Differences in the Impacts of Video-Enabled Tablets on Psychotherapy Usage Among Veterans.

OBJECTIVE: To examine potential health disparities due to a broad reliance on telehealth during the COVID-19 pandemic, the authors studied the impact of video-enabled tablets provided by the U.S. Department of Veterans Affairs (VA) on psychotherapy usage among rural versus urban, Black versus White, and female versus male veterans. METHODS: Psychotherapy usage trends before and after onset of the COVID-19 pandemic were examined among veterans with at least one mental health visit in 2019 (63,764 tablet recipients and 1,414,636 nonrecipients). Adjusted difference-in-differences and event study analyses were conducted to compare psychotherapy usage among tablet recipients and nonrecipients (March 15, 2020-December 31, 2021) 10 months before and after tablet issuance. Analyses were stratified by rurality, sex, and race. RESULTS: Adjusted analyses demonstrated that tablet receipt was associated with increases in psychotherapy visit frequency in every patient group studied (rural, 27.4%; urban, 24.6%; women, 30.5%; men, 24.4%; Black, 20.8%; White, 28.1%), compared with visits before tablet receipt. Compared with men, women had statistically significant tablet-associated psychotherapy visit increases (video visits, 1.2 per year; all modalities, 1.0 per year). CONCLUSIONS: VA-issued tablets led to increased psychotherapy usage for all groups examined, with similar increases found for rural versus urban and Black versus White veterans and higher increases for women versus men. Eliminating barriers to Internet access or device ownership may improve mental health care access among underserved or historically disadvantaged populations. VA's tablet program offers insights to inform policy makers' and health systems' efforts to bridge the digital divide.

Types of Engagement Strategies to Engage High-Risk Patients in VA.

BACKGROUND: Many healthcare systems seek to improve care for complex high-risk patients, but engaging such patients to actively participate in their healthcare can be challenging. OBJECTIVE: To identify and describe types of patient engagement strategies reported as successfully deployed by providers/teams and experienced by patients in a Veterans Health Administration (VA) intensive primary care (IPC) pilot program. METHODS: We conducted semi-structured qualitative telephone interviews with 29 VA IPC staff (e.g., physicians, nurses, psychologists) and 51 patients who had at least four IPC team encounters. Interviews were recorded, transcribed, and analyzed thematically using a combination a priori/inductive approach. RESULTS: The engagement strategies successfully deployed by the IPC providers/teams could be considered either more "facilitative," i.e., facilitated by and dependent on staff actions, or more "self-sustaining," i.e., taught to patients, thus cultivating their ongoing patient self-care. Facilitative strategies revolved around enhancing patient access and coordination of care, trust-building, and addressing social determinants of health. Self-sustaining strategies were oriented around patient empowerment and education, caregiver and/or community support, and boundaries and responsibilities. When patients described their experiences with the "facilitative" strategies, many discussed positive proximal outcomes (e.g., increased access to healthcare providers). Self-sustaining strategies led to positive (self-reported) longer-term clinical outcomes, such as behavior change. CONCLUSION: We identified two categories of strategies for successfully engaging complex, high-risk patients: facilitative and self-sustaining. Intensive primary care program leaders may consider thoughtfully building "self-sustaining" engagement strategies into program development. Future research can confirm their effectiveness in improving health outcomes.

Adapting a Telephone-Based, Dyadic Self-management Program to Be Delivered Over the Web: Methodology and Usability Testing.

BACKGROUND: The COVID-19 pandemic has amplified the need for web-based behavioral interventions to support individuals who are diagnosed with chronic conditions and their informal caregivers. However, most interventions focus on patient outcomes. Dyadic technology-enabled interventions that simultaneously improve outcomes for patients and caregivers are needed. OBJECTIVE: This study aimed to describe the methodology used to adapt a telephone-based, facilitated, and dyadic self-management program called Self-care Using Collaborative Coping Enhancement in Diseases (SUCCEED) into a self-guided, web-based version (web-SUCCEED) and to conduct usability testing for web-SUCCEED. METHODS: We developed web-SUCCEED in 6 steps: ideation-determine the intervention content areas; prototyping-develop the wireframes, illustrating the look and feel of the website; prototype refinement via feedback from focus groups; finalizing the module content; programming web-SUCCEED; and usability testing. A diverse team of stakeholders including content experts, web designers, patients, and caregivers provided input at various stages of development. Costs, including full-time equivalent employee, were summarized. RESULTS: At the ideation stage, we determined the content of web-SUCCEED based on feedback from the program's original pilot study. At the prototyping stage, the principal investigator and web designers iteratively developed prototypes that included inclusive design elements (eg, large font size). Feedback about these prototypes was elicited through 2 focus groups of veterans with chronic conditions (n=13). Rapid thematic analysis identified two themes: (1) web-based interventions can be useful for many but should include ways to connect with other users and (2) prototypes were sufficient to elicit feedback about the esthetics, but a live website allowing for continual feedback and updating would be better. Focus group feedback was incorporated into building a functional website. In parallel, the content experts worked in small groups to adapt SUCCEED's content, so that it could be delivered in a didactic, self-guided format. Usability testing was completed by veterans (8/16, 50%) and caregivers (8/16, 50%). Veterans and caregivers gave web-SUCCEED high usability scores, noting that it was easy to understand, easy to use, and not overly burdensome. Notable negative feedback included "slightly agreeing" that the site was confusing and awkward. All veterans (8/8, 100%) agreed that they would choose this type of program in the future to access an intervention that aims to improve their health. Developing and maintaining the software and hosting together cost approximately US $100,000, excluding salary and fringe benefits for project personnel (steps 1-3: US $25,000; steps 4-6: US $75,000). CONCLUSIONS: Adapting an existing, facilitated self-management support program for delivery via the web is feasible, and such programs can remotely deliver content. Input from a multidisciplinary team of experts and stakeholders can ensure the program's success. Those interested in adapting programs should have a realistic estimate of the budget and staffing requirements.

Associations Between Social Risks and Primary Care Utilization Among Medically Complex Veterans.

BACKGROUND: Social risks contribute to poor health outcomes, especially for patients with complex medical needs. These same risks may impact access to primary care services. OBJECTIVE: To study associations between social risks and primary care utilization among patients with medical complexity. DESIGN: Prospective cohort study of respondents to a 2018 mailed survey, followed up to 2 years after survey completion. PARTICIPANTS: Nationally representative sample of 10,000 primary care patients in the Veterans Affairs (VA) health care system, with high (≥ 75th percentile) 1-year risk of hospitalization or death. MAIN MEASURES: Survey-based exposures were low social support, no family member/friend involved in health care, unemployment, transportation problem, food insecurity, medication insecurity, financial strain, low medical literacy, and less than high school graduate. Electronic health record-based outcomes were number of primary care provider (PCP) encounters, number of primary care team encounters (PCP, nurse, clinical pharmacist, and social worker), and having ≥ 1 social work encounter. KEY RESULTS: Among 4680 respondents, mean age was 70.3, 93.7% were male, 71.8% White non-Hispanic, and 15.8% Black non-Hispanic. Unemployment was associated with fewer PCP and primary care team encounters (incident rate ratio 0.77, 95% CI 0.65-0.91; p = 0.002 and 0.75, 0.59-0.95; p = 0.02, respectively), and low medical literacy was associated with more primary care team encounters (1.17, 1.05-1.32; p = 0.006). Among those with one or more social risks, 18.4% had ≥ 1 social work encounter. Low medical literacy (OR 1.95, 95% CI 1.45-2.61; p < 0.001), transportation problem (1.42, 1.10-1.83; p = 0.007), and low social support (1.31, 1.06-1.63; p = 0.01) were associated with higher odds of  ≥ 1 social work encounter. CONCLUSIONS: We found few differences in PCP and primary care team utilization among medically complex VA patients by social risk. However, social work use was low, despite its central role in addressing social risks. More work is needed to understand barriers to social work utilization.

Impact of VA's video telehealth tablets on substance use disorder care during the COVID-19 pandemic.

BACKGROUND: Telehealth has the potential to improve health care access for patients but it has been underused and understudied for examining patients with substance use disorders (SUD). VA began distributing video-enabled tablets to veterans with access barriers in 2016 to facilitate participation in home-based telehealth and expanded this program in 2020 due to the coronavirus COVID-19 pandemic. OBJECTIVE: Examine the impact of VA's video-enabled telehealth tablets on mental health services for patients diagnosed with SUD. METHODS: This study included VA patients who had ≥1 mental health visit in the calendar year 2019 and a documented diagnosis of SUD. Using difference-in-differences and event study designs, we compared outcomes for SUD-diagnosed patients who received a video-enabled tablet from VA between March 15th, 2020 and December 31st, 2021 and SUD-diagnosed patients who never received VA tablets, 10 months before and after tablet-issuance. Outcomes included monthly frequency of SUD psychotherapy visits, SUD specialty group therapy visits and SUD specialty individual outpatient visits. We examined changes in video visits and changes in visits across all modalities of care (video, phone, and in-person). Regression models adjusted for several covariates such as age, sex, rurality, race, ethnicity, physical and mental health chronic conditions, and broadband coverage in patients' residential zip-code. RESULTS: The cohort included 21,684 SUD-diagnosed tablet-recipients and 267,873 SUD-diagnosed non-recipients. VA's video-enabled tablets were associated with increases in video visits for SUD psychotherapy (+3.5 visits/year), SUD group therapy (+2.1 visits/year) and SUD individual outpatient visits (+1 visit/year), translating to increases in visits across all modalities (in-person, phone and video): increase of 18 % for SUD psychotherapy (+1.9 visits/year), 10 % for SUD specialty group therapy (+0.5 visit/year), and 4 % for SUD specialty individual outpatient treatment (+0.5 visit/year). CONCLUSIONS: VA's distribution of video-enabled tablets during the COVID-19 pandemic were associated with higher engagement with video-based services for SUD care among patients diagnosed with SUD, translating to modest increases in total visits across in-person, phone and video modalities. Distribution of video-enabled devices can offer patients critical continuity of SUD therapy, particularly in scenarios where they have heightened barriers to in-person care.

VA's implementation of universal screening and evaluation for the suicide risk identification program in November 2020 -Implications for Veterans with prior mental health needs.

IMPORTANCE: United States Veterans are at higher risk for suicide than non-Veterans. Veterans in rural areas are at higher risk than their urban counterparts. The coronavirus pandemic intensified risk factors for suicide, especially in rural areas. OBJECTIVE: To examine associations between Veterans Health Administration's (VA's) universal suicide risk screening, implemented November 2020, and likelihood of Veterans being screened, and receiving follow-up evaluations, as well as post-screening suicidal behavior among patients who used VA mental health services in 2019. METHODS: VA's Suicide Risk Identification Strategy (Risk ID), implemented October 2018, is a national, standardized process for suicide risk screening and evaluation. In November 2020, VA expanded Risk ID, requiring annual universal suicide screening. As such, we are evaluating outcomes of interest before and after the start of the policy among Veterans who had ≥1 VA mental health care visit in 2019 (n = 1,654,180; rural n = 485,592, urban n = 1,168,588). Regression-adjusted outcomes were compared 6 months pre-universal screening and 6, 12 and 13 months post-universal screening implementation. MEASURES: Item-9 on the Patient Health Questionnaire (I-9, VA's historic suicide screener), Columbia- Suicide Severity Risk Scale (C-SSRS) Screener, VA's Comprehensive Suicide Risk Evaluation (CSRE), and Suicide Behavior and Overdose Report (SBOR). RESULTS: 12 months post-universal screening implementation, 1.3 million Veterans (80% of the study cohort) were screened or evaluated for suicide risk, with 91% the sub-cohort who had at least one mental health visit in the 12 months post-universal screening implementation period were screened or evaluated. At least 20% of the study cohort was screened outside of mental health care settings. Among Veterans with positive screens, 80% received follow-up CSREs. Covariate-adjusted models indicated that an additional 89,160 Veterans were screened per month via the C-SSRS and an additional 30,106 Veterans/month screened via either C-SSRS or I-9 post-universal screening implementation. Compared to their urban counterparts, 7,720 additional rural Veterans/month were screened via the C-SSRS and 9,226 additional rural Veterans/month were screened via either the C-SSRS or I-9. CONCLUSION: VA's universal screening requirement via VA's Risk ID program increased screening for suicide risk among Veterans with mental health care needs. A universal approach to screening may be particularly advantageous for rural Veterans, who are typically at higher risk for suicide but have fewer interactions with the health care system, particularly within specialty care settings, due to higher barriers to accessing care. Insights from this program offer valuable insights for health systems nationwide.