Your browser doesn't support javascript.
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 24
Filtrar
Mais filtros










Base de dados
Intervalo de ano de publicação
1.
Am Psychol ; 2019 Aug 08.
Artigo em Inglês | MEDLINE | ID: mdl-31393143

RESUMO

The integration of behavioral health in primary care is critical for addressing worldwide concerns for access to, and quality of, health care services for physical and mental health promotion, prevention, and disease management. Clearly, promoting knowledge exchange internationally is critical to progress. In late 2015, the American Psychological Association convened an interdisciplinary summit on global approaches to integrated health care, bringing together 82 health care professionals (nurses, primary care physicians, psychologists, psychiatrists, and social workers) and scholars from diverse disciplines in medicine, psychology, economics, health policy, public health, and demography; participants came from 10 countries. The Global Summit provided an opportunity to share best practices and innovation in patient-centered integrated health care internationally. In this article, Global Summit participants from different countries reflect on the recommendations for future interprofessional endeavors across the following themes: build international interprofessional communities for change; advocate for, and promote social equity with, a population health and patient focus; advance research and program evaluation in integrated care; advance interprofessional training and education in integrated care; and develop financially sustainable models for integrated primary care. Building upon these recommendations and reflecting on current advancement in health care policy and integrated care research, new directions are suggested for clinicians, researchers, administrators, and policymakers working toward the advancement of integrated care to improve health care services globally. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

2.
Clin J Pain ; 35(10): 809-817, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31318726

RESUMO

OBJECTIVES: Although cognitive behavioral therapy is an effective intervention for chronic pain, it is a lengthy treatment typically applied only in specialty care settings. The aim of this project was to collect preliminary effectiveness data for Brief Cognitive Behavioral Therapy for Chronic Pain (Brief CBT-CP), an abbreviated, modular form of treatment designed for use in primary care. METHODS: A clinical demonstration project was conducted in which Brief CBT-CP was delivered to primary care patients by 22 integrated care providers practicing in the Primary Care Behavioral Health model of Veterans Health Administration primary care clinics. Brief measures were used at each appointment to collect patient-reported clinical outcomes. RESULTS: One hundred eighteen patients provided sufficient data for analysis (male, 75%; mean age, 51.4 y). Multilevel modeling suggested that a composite measure of pain intensity and functional limitations showed statistically significant improvements by the third appointment (Cohen's d=0.65). Pain-related self-efficacy outcomes showed a similar pattern of results but of smaller effect size (Cohen's d=0.22). The exploratory analysis identified that Brief CBT-CP modules addressing psychoeducation and goal setting, pacing, and relaxation training were associated with the most significant gains in treatment outcomes. DISCUSSION: These findings provide early support for the effectiveness of Brief CBT-CP when delivered by providers in every day Primary Care Behavioral Health settings. Results are discussed in relation to the need for additional research regarding the potential value of employing safe, population-based, nonpharmacological approaches to pain management in primary care.

3.
Fam Syst Health ; 37(1): 84-86, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30920264

RESUMO

Reviews the book, Integrating Behavioral Health into the Medical Home: A Rapid Implementation Guide by Kent A. Corso, Christopher L. Hunter, Owen Dahl, Gene A. Kallenberg, and Lesley Manson (see record 2016-51034-000). This practical how-to book is written specifically for an audience working to implement integrated primary care (IPC) from the ground up, moving beyond the clinical competencies required for success in these settings to the business operational requirements to facilitate implementation. The book is divided into three sections, beginning with an introduction to key concepts and tools for successfully IPC practices. Section II is focused on the business practices needed for success, including strategic plan development, return on investment analyses, business cases analyses, hiring, billing, personnel training, and outcome monitoring. The last section is a series of case studies of successful programs from Cherokee Health Systems to Intermountain Health. This is particularly priceless because it provides evidence that IPC can thrive in a multitude of diverse settings, describing practical guidance of what to do and what to avoid. The authors, with more than 84 years of combined IPC experience, offer the reader sage advice, which can be applied readily. Each chapter begins with a Bottom Line, Up Front section, offering bulleted points of specific direction for the lay reader hoping to advance their journey into integration. A nice bonus surprise to the book is the wittiness of this esteemed group, offering refreshing pieces of humor, which is welcomed when thinking through the specific demands of IPC implementation. The book is also an excellent resource manual to delve more deeply into the IPC literature, with each chapter providing a host of references for further study. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

4.
JMIR Ment Health ; 5(3): e10277, 2018 Aug 22.
Artigo em Inglês | MEDLINE | ID: mdl-30135051

RESUMO

BACKGROUND: A national priority at the US Department of Veterans Affairs (VA) is to increase the availability and accessibility of evidence-based psychotherapies (EBPs) across all VA medical facilities. Yet many veterans, particularly those who use remote outpatient VA clinics, still do not receive much needed evidence-based treatment. Strategies are needed for supporting mental health providers at rural VA community-based outpatient clinics (CBOCs) as they translate their clinical training to routine practice. The Coordinated Anxiety Learning Management (CALM) program is a computer-delivered program that supports the delivery of cognitive behavioral therapy (CBT) by providers in outpatient settings to patients with depression and anxiety, including posttraumatic stress disorder. OBJECTIVE: The objectives of our study were to (1) adapt an existing computer-based program to rural VA CBOCs through feedback from key stakeholder focus groups; (2) develop a prototype of the adapted program; and (3) determine the adapted program's acceptability and feasibility. Mental health stakeholders included VA leaders (n=4) in the implementation of EBPs, VA experts (n=4) in CBT, VA CBOC mental health providers (n=8), and veterans (n=8) diagnosed with a mental health condition treated using the CALM program and receiving treatment in a VA CBOC. METHODS: An iterative approach comprising 3 waves of focus group discussions was used to develop a modified prototype of CALM. Following each wave of focus group discussions, template analysis was used to rapidly communicate stakeholder recommendations and feedback to the design team. The original program was first adapted through a process of data collection, design modification, and product development. Next, a prototype was developed. Finally, the redesigned program was tested for acceptability and feasibility through a live demonstration. RESULTS: Key stakeholders suggested modifications to the original CALM program that altered its modules' appearance by incorporating veteran-centric content. These modifications likely have no impact on the integrity of the original CALM program, but have altered its content to reflect better the demographic characteristics and experiences of rural veterans. Feedback from stakeholder groups indicates that changes will help VA patients identify with the program content, potentially enhancing their treatment engagement. CONCLUSIONS: The development model was effective for economically gathering actionable recommendations from stakeholders to adapt a computer-based program, and it can result in the development of an acceptable and feasible computer-delivered intervention. Results have implications for developing computer-based programs targeting behavior change more broadly and enhancing engagement in EBP.

5.
Arch Clin Neuropsychol ; 33(3): 280-289, 2018 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-29718079

RESUMO

Historically, integrated mental and behavioral healthcare in the Department of Veterans Affairs (VA) commenced with initiatives in geriatrics. Innovation and system-wide expansion has occurred over decades and culminated in a unified vision for training and practice in the VA medical home model: Patient Aligned Care Team or PACT approach. In one VA hospital, the integration of neuropsychological services in geriatric primary care is pivotal and increases access for patients, as well as contributing to timely and effective care on an interprofessional team. The development and innovative use of an algorithm to identify problems with cognition, health literacy, and mental and behavioral health has been pragmatic and provides useful information for collaborative treatment planning in GeriPACT, VA geriatric primary care. Use of the algorithm also assists with decision-making regarding brief versus comprehensive neuropsychological assessment in the primary care setting. The model presented here was developed by supervising neuropsychologists as part of a postdoctoral residency program in geropsychology. However, postdoctoral residency programs in neuropsychology, as well as neuropsychological clinics, can also use this model to integrate neuropsychological assessment and interventions in geriatric primary care settings.


Assuntos
Prestação Integrada de Cuidados de Saúde/organização & administração , Avaliação Geriátrica , Serviços de Saúde para Idosos/organização & administração , Neuropsicologia , Veteranos , Idoso , Idoso de 80 Anos ou mais , Prestação Integrada de Cuidados de Saúde/história , Geriatria , História do Século XX , Humanos , Neuropsicologia/métodos , Neuropsicologia/organização & administração , Neuropsicologia/tendências , Estados Unidos , United States Department of Veterans Affairs
6.
Psychol Serv ; 15(2): 129-134, 2018 May.
Artigo em Inglês | MEDLINE | ID: mdl-29723014

RESUMO

This special issue of Psychological Services provides a glimpse of some of the most recent work in the arena of psychosocial interventions for military service members who are reintegrating into civilian society and becoming veterans. The psychological effects that can occur as members go through the military-to-civilian transition as they leave the military have been extensively recorded and treated. While psychosocial interventions have been utilized throughout history, we are seeing a new interest and recent renaissance in their use. These psychosocial interventions will help our veterans reintegrate into civilian society not just by focusing on reducing the symptoms from their visible and invisible wounds but by taking a more holistic and integrative perspective that works to improve the veterans' functioning in their surrounding social environments through community reengagement, treatment of the individual and their social environment, and functional improvement. The articles in this special issue illustrate how clinicians and researchers are validating new techniques to improve functioning among those learning to change careers as warriors in their new civilian occupations. (PsycINFO Database Record


Assuntos
Adaptação Psicológica , Militares/psicologia , Apoio Social , Veteranos/psicologia , Humanos , Serviços de Saúde Mental , Estados Unidos , United States Department of Veterans Affairs
7.
Psychiatr Serv ; 69(7): 744-747, 2018 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-29656709

RESUMO

This column reviews the unique contributions of multiple partners in establishing a standardized site visit process to promote quality improvement in mental health care at the Veterans Health Administration. Working as a team, leaders in policy and operations, staff of research centers, and regional- and facility-level mental health leaders developed a standardized protocol for evaluating mental health services at each site and using the data to help implement policy goals. The authors discuss the challenges experienced and lessons learned in this systemwide process and how this information can be part of a framework for improving mental health services on a national level.


Assuntos
Tomada de Decisões Gerenciais , Assistência à Saúde/organização & administração , Transtornos Mentais/terapia , Serviços de Saúde Mental/normas , Veteranos/psicologia , Hospitais de Veteranos , Humanos , Inovação Organizacional , Melhoria de Qualidade/organização & administração , Estados Unidos
8.
Fam Syst Health ; 36(1): 32-44, 2018 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-29369648

RESUMO

Same-day access to behavioral health services is a critical feature of integrated primary care. Despite the benefits of same-day access, implementing and sustaining this key feature has been a challenge for multiple health care settings. Further, there is relatively little practical guidance on how to implement this practice management feature. Diverse program design solutions for same-day access are implemented in clinics across the Veterans Health Administration. The authors identified innovative approaches, developed in local facilities, with demonstrated success in same-day access that can be implemented in any setting. The purpose of this article is to describe five approaches for providing same-day access within integrated care. The authors discuss key considerations (staffing, space, program maturity), potential challenges and facilitators, and provide practical recommendations for implementation. (PsycINFO Database Record


Assuntos
Prestação Integrada de Cuidados de Saúde/métodos , Acesso aos Serviços de Saúde/normas , Atenção Primária à Saúde/métodos , Fatores de Tempo , Prestação Integrada de Cuidados de Saúde/normas , Humanos , Atenção Primária à Saúde/organização & administração , Atenção Primária à Saúde/normas , Desenvolvimento de Programas/métodos , Estados Unidos , United States Department of Veterans Affairs/organização & administração
9.
Psychol Serv ; 15(4): 486-495, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-28714721

RESUMO

Achieving quality outcomes and cost efficiency within mental health are overarching objectives of the Veterans Health Administration (VHA). The mental health care workforce has long been oriented toward the goal of high quality outcomes; however, cost efficiency has only recently been elevated into this important value equation. With increased demand for access to mental health services within the VHA, leadership sought to advance methods of determining and improving mental health provider productivity. Monitoring of productivity data may also provide data signaling the potential need for additional staffing to keep up with demand for services. This article outlines VHA's development and specification of mental health productivity policy, implementation strategies, and a discussion of challenges and lessons learned for other systems to consider in implementing productivity monitoring. (PsycINFO Database Record (c) 2018 APA, all rights reserved).


Assuntos
Esgotamento Profissional , Eficiência , Pessoal de Saúde , Serviços de Saúde Mental , Moral , United States Department of Veterans Affairs , Adulto , Humanos , Estados Unidos
10.
Am Psychol ; 72(8): 822-836, 2017 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-29172583

RESUMO

Powerful forces have shaped professional psychology over the past 25 years, including significant changes in health policy and health care delivery systems. Examples include managed care cost containment, rapid growth of nondoctoral mental health providers, federal mental health parity legislation, and passage of the Affordable Care Act of 2010, with its emphasis on primary care-behavioral health integration and alternatives to fee-for-service reimbursement. This article considers these factors for psychology as a mental health profession and as a health profession more broadly defined, and describes the American Psychological Association's advocacy about the value of psychology in each domain. While challenging to psychology's traditional models of care, these changes offer significant promise for the future of psychology in health care. (PsycINFO Database Record


Assuntos
Assistência à Saúde/história , Saúde Mental/história , Psicologia/história , História do Século XX , História do Século XXI , Humanos , Serviços de Saúde Mental/história , Patient Protection and Affordable Care Act/história , Sociedades Científicas/história
11.
Psychol Serv ; 14(2): 113-117, 2017 05.
Artigo em Inglês | MEDLINE | ID: mdl-28481596

RESUMO

Homelessness is a major public health problem that has received considerable attention from clinicians, researchers, administrators, and policymakers in recent years. In 2016, 550,000 individuals were homeless in the United States (U.S. Department of Housing and Urban Development, 2016) with 4.2% of individuals in the United States experiencing homelessness for over 1 month sometime in their lives and 1.5% experiencing homelessness in the last year (Tsai, 2017). Homelessness remains a recalcitrant problem and a ripe area for study, particularly in addressing needs of individuals at high risk for homelessness and those from understudied populations. New and innovative measurement approaches, interventions, and study methodologies are presented in this special issue to shed light on how psychology can help benefit and improve homeless services. (PsycINFO Database Record


Assuntos
Pessoas em Situação de Rua/psicologia , Saúde Mental , Saúde Pública , Problemas Sociais , Habitação , Humanos , Estados Unidos
12.
Psychol Serv ; 14(1): 1-12, 2017 02.
Artigo em Inglês | MEDLINE | ID: mdl-28134552

RESUMO

We outline the development of a Mental Health Domain to track accessibility and quality of mental health care in the United States Veterans Health Administration (VHA) as part of a broad-based performance measurement system. This domain adds an important element to national performance improvement efforts by targeting regional and facility leadership and providing them a concise yet comprehensive measure to identify facilities facing challenges in their mental health programs. We present the conceptual framework and rationale behind measure selection and development. The Mental Health Domain covers three important aspects of mental health treatment: Population Coverage, Continuity of Care, and Experience of Care. Each component is a composite of existing and newly adapted measures with moderate to high internal consistency; components are statistically independent or moderately related. Development and dissemination of the Mental Health Domain involved a variety of approaches and benefited from close collaboration between local, regional, and national leadership and from coordination with existing quality-improvement initiatives. During the first year of use, facilities varied in the direction and extent of change. These patterns of change were generally consistent with qualitative information, providing support for the validity of the domain and its component measures. Measure maintenance remains an iterative process as the VHA mental health system and potential data resources continue to evolve. Lessons learned may be helpful to the broader mental health-provider community as mental health care consolidates and becomes increasingly integrated within healthcare systems. (PsycINFO Database Record


Assuntos
Continuidade da Assistência ao Paciente/normas , Acesso aos Serviços de Saúde/normas , Serviços de Saúde Mental/normas , Aceitação pelo Paciente de Cuidados de Saúde , Qualidade da Assistência à Saúde/normas , United States Department of Veterans Affairs/normas , Humanos , Melhoria de Qualidade/normas , Estados Unidos
13.
J Clin Psychol Med Settings ; 22(4): 232-42, 2015 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-26645090

RESUMO

With the expansion of integrated primary care and the increased focus on fiscal sustainability, it is critical for clinical managers of these innovative systems to have practical methods for measuring administrative outcomes. Administrative outcomes will assist leadership in the development of efficient, streamlined clinics to provide services to the primary care population. Additionally, administrative measures can be utilized to provide information to assist in guiding resource utilization and management decisions. Several administrative outcomes are suggested for integrated primary care managers to consider for application, including: clinic utilization measures, integrated care administrative measures, wait time and access metrics, and productivity monitors. Effective utilization of these measures can help office managers and clinic leadership not only to maximize patient care, but also to enhance essential business operations, which increase the long-term sustainability of integrated primary care programs.


Assuntos
Prestação Integrada de Cuidados de Saúde/organização & administração , Psicologia Clínica/organização & administração , Humanos , Atenção Primária à Saúde/organização & administração
14.
J Clin Psychol Med Settings ; 22(4): 213-27, 2015 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-26645091

RESUMO

Full implementation of the patient-centered medical home requires the identification and treatment of patients with behavioral health concerns, leading to improved patient outcomes and reduced health care costs. Measurement-based care (MBC) for mental health conditions is an essential step in achieving these goals. Integrated primary care (IPC) administrators and providers are key leaders in MBC that spans initial screening for conditions to monitoring clinical outcomes over time. The purpose of this article is to assist IPC leaders, in partnership with their primary care team, in developing standard operating procedures for screening and follow up evaluations in order to lay a foundation for assessing program outcomes and improving quality of care in their unique settings.


Assuntos
Transtornos Mentais/terapia , Avaliação de Resultados em Cuidados de Saúde , Assistência Centrada no Paciente , Atenção Primária à Saúde , Humanos , Equipe de Assistência ao Paciente , Melhoria de Qualidade
15.
Psychol Serv ; 11(3): 243-53, 2014 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-24841512

RESUMO

Since the early 1990s, primary care has been described as the de facto mental health care system in the United States. Most individuals with mental health concerns present in primary care, but the majority are either not identified or do not receive evidence-based services or guideline concordant care. Despite 20 years of research supporting the integration of mental health services into primary care, the translation of this evidence into real-world settings remains limited. The growing impetus to build comprehensive health care systems that provide care for a defined population has recently spurred interest in providing mental health care within primary care. The Department of Veterans Affairs (VA) began to systematically incorporate psychological and other mental health services into primary care in 2007. National evaluation and local program data reviewed here have demonstrated that the initiative has already improved the identification and treatment of mental health disorders in the primary care population, increased the likelihood of receiving guideline concordant care, and enhanced treatment engagement for patients referred into specialty mental health services. These results provide support for expectations that integrated care enhances access to high-quality mental health care. This article summarizes critical factors for success identified in the VA integrated care rollout. These factors are applicable for other health care organizations that seek to improve mental health services delivery.


Assuntos
Prestação Integrada de Cuidados de Saúde/organização & administração , Serviços de Saúde Mental/organização & administração , United States Department of Veterans Affairs/organização & administração , Veteranos/psicologia , Humanos , Assistência Centrada no Paciente/organização & administração , Estados Unidos
16.
Am Psychol ; 69(4): 399-408, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-24820689

RESUMO

The Veterans Health Administration (VHA) is the largest integrated health care system in the United States, serving more than 8 million veterans. VHA is currently undergoing extensive changes to its health care delivery model, moving toward the full implementation of the patient-centered medical home. Mental health providers, including psychologists working in primary care, are playing key roles in this transformation to interprofessional teams and systems-as clinicians, researchers, program evaluators, and educators. Moreover, VHA mental health staff serves critical leadership functions supporting primary care in the broad transformation that is required to implement the medical home. In this article, we review the implementation of mental health integration into this new model of care.


Assuntos
Prestação Integrada de Cuidados de Saúde/organização & administração , Serviços de Saúde Mental/organização & administração , Assistência Centrada no Paciente/organização & administração , United States Department of Veterans Affairs/organização & administração , Humanos , Relações Interprofissionais , Estados Unidos
17.
Am Psychol ; 69(4): 409-29, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-24820690

RESUMO

This article reports on the outcome of a presidential initiative of 2012 American Psychological Association President Suzanne Bennett Johnson to delineate competencies for primary care (PC) psychology in six broad domains: science, systems, professionalism, relationships, application, and education. Essential knowledge, skills, and attitudes are described for each PC psychology competency. Two behavioral examples are provided to illustrate each competency. Clinical vignettes demonstrate the competencies in action. Delineation of these competencies is intended to inform education, practice, and research in PC psychology and efforts to further develop team-based competencies in PC.


Assuntos
Competência Clínica/normas , Conhecimentos, Atitudes e Prática em Saúde , Atenção Primária à Saúde/normas , Psicologia Clínica/normas , Sociedades Científicas/normas , Humanos
18.
Psychiatr Serv ; 65(5): 577-9, 2014 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-24585229

RESUMO

This column describes lessons learned by U.S. Department of Veterans Affairs (VA) researchers and clinical operations managers while they were engaged in a unique partnership. In this partnership, researchers turned generalizable lessons from implementation research into actionable guidance for use by clinical managers in implementing health care system change. The lessons learned are reflections about the necessary foundations for partnering, the importance of relationships, the need for regular communication, and the need to recognize and adapt to partners' timelines and time constraints.


Assuntos
Comportamento Cooperativo , Administradores de Instituições de Saúde/organização & administração , Pesquisadores/organização & administração , Melhoria de Qualidade , Estados Unidos , United States Department of Veterans Affairs
19.
Psychiatr Serv ; 65(2): 141-3, 2014 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-24492898

RESUMO

This column describes a facilitation strategy that incorporates evidence-based implementation knowledge and practice-based wisdom. The authors also describe a partnership between research and clinical operations leaders in the U.S. Department of Veterans Affairs to bridge the gap between implementation knowledge and its use. The initial product of the partnership, the Implementation Facilitation Training Manual: Using External and Internal Facilitation to Improve Care in the Veterans Health Administration, is a resource that can be used by others to guide implementation efforts.


Assuntos
Pesquisa Biomédica/organização & administração , Prática Clínica Baseada em Evidências/organização & administração , Serviços de Saúde Mental/organização & administração , United States Department of Veterans Affairs/organização & administração , Pesquisa Biomédica/normas , Comportamento Cooperativo , Prática Clínica Baseada em Evidências/normas , Humanos , Serviços de Saúde Mental/normas , Estados Unidos , United States Department of Veterans Affairs/normas
20.
J Clin Psychol Med Settings ; 19(1): 105-16, 2012 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-22383016

RESUMO

This paper describes the status of the Veterans Health Administration (VHA) Primary Care-Mental Health Integration (PC-MHI) services implementation and presents an assessment of associations between receipt of PC-MHI services and likelihood of receiving a second specialty mental health (SMH) appointment following an initial SMH encounter. The total PC-MHI service recipients and encounters/month rose substantially between October 2007 and April 2011. Adjusting for important covariates, the likelihood of receiving a second SMH encounter within 3 months of an index SMH appointment was 1.37 times greater among individuals who had received a PC-MHI encounter within 3 months of the initial SMH appointment. Implementation of VHA PC-MHI services has substantially increased VHA capacity to deliver mental health services in primary care and findings indicate that PC-MHI services are associated with greater engagement in SMH treatment. Implementation of VHA PC-MHI services is progressing with new technical assistance strategies being deployed.


Assuntos
Prestação Integrada de Cuidados de Saúde/organização & administração , Transtornos Mentais/terapia , Serviços de Saúde Mental/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde , Atenção Primária à Saúde/organização & administração , Adolescente , Adulto , Idoso , Feminino , Implementação de Plano de Saúde , Humanos , Modelos Logísticos , Masculino , Serviços de Saúde Mental/organização & administração , Pessoa de Meia-Idade , Análise Multivariada , Estados Unidos , United States Department of Veterans Affairs
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA