Impact of moral injury and posttraumatic stress disorder on health care utilization and suicidality in rural and urban veterans.

This study explored the impact of moral injury (MI) and posttraumatic stress disorder (PTSD) on health care utilization, mental health complexity, and suicidality in rural and urban veterans. Analyses combined data from the Salt Lake City PTSD Clinic Intake Database and the Department of Veterans Affairs Corporate Data Warehouse. Participants (N = 1,545; Mage = 45.9 years) were predominately male (88.3%) and White (87.8%). Adjusted analyses indicated associations between a 1-unit increase in Moral Injury Events Scale (MIES) score and increased mental health complexity, RR = 1.01, 95% CI [1.01, 1.02], p < .001; psychotropic medication utilization, RR = 1.01, 95% CI [1.01, 1.03], p < .001; VA drug class count, RR = 1.01, 95% CI [1.00, 1.01], p = .030; outpatient utilization, RR = 1.01, 95% CI [1.01, 1.02], p < .001; and mental health outpatient utilization, RR = 1.01, 95% CI [1.00, 1.03], p < .001. For the MIES x PTSD interaction, all associations remained statistically significant with similar estimated effects. However, for rural veterans, this interaction did not significantly affect utilization. Among those with PTSD, a 1-unit MIES increase was associated with an increased risk of suicidality, OR = 1.02, 95% CI [1.01, 1.04], and psychiatric admission, OR = 1.02, 95% CI [1.00, 1.04]. Findings suggest that higher MIES scores predict increased health care utilization and mental health complexity. Further, PTSD combined with higher MIES scores may increase the risk of suicidality and psychiatric admission. Rural veterans with PTSD and higher MIES scores may require additional outreach and intervention.

The graying of integrated health: the specialized role of psychology in geriatric primary care.

OBJECTIVES: Integrating behavioral health services into primary care is an important global initiative to improve access to mental health services. Within the Veterans Health Administration (VHA), Geriatric Patient Aligned Care Teams (GeriPACTs) are one model of integrated care for frail older adults to serve older Veterans with geriatric syndromes and increased probability of cognitive impairment. Understanding of the role of psychology in GeriPACT is limited. This study examines this role, describes the practice of these psychologists, and evaluates the integration of psychology into geriatric primary care. METHODS: A mixed-methods design was used. Recruitment occurred through two VHA listservs for GeriPACT and Primary Care Mental Health Integration (PC-MHI) psychologists. Surveys examined referral processes, service access, clinical services provision, and use of psychotherapy modalities. Twenty psychologists participated. Structured follow-up interviews were conducted with five participants. RESULTS: A large minority of psychologists did not have FTE allotted for GeriPACT work they provided (40%). Sixty percent were assigned to one GeriPACT team. Twenty percent served four to seven GeriPACT teams. Eighty percent provided same-day services. Cognitive assessment was provided weekly by over sixty percent of providers who had FTE allotment to this role. Qualitative data provided a rich description of psychologists' perceptions of their role, team functioning, referral processes, visit structure, and other factors. CONCLUSION: Findings are discussed in the context of the World Health Organization's guidelines for integrating mental health into primary care. Data suggest a need for an integrated model that adapts to the special needs of older adults in primary care.

Mental Health Integration in Geriatric Patient-Aligned Care Teams in the Department of Veterans Affairs.

OBJECTIVES: To inform geriatric mental health policy by describing the role of behavioral healthcare providers within a geriatric patient-aligned care team (GeriPACT), a patient-centered medical home model of care within the Veterans Health Administration (VHA), serving older veterans with chronic disease, functional dependency, cognitive decline, and psychosocial challenges, and/or those who have elder abuse, risk of long-term care placement, or impending disability. METHODS: The authors used mixed methods, consisting of a national survey and site visits between July 2016 and February 2017, at VHA outpatient clinics. The participants, 101 GeriPACTs at 44 sites, completed surveys, and 24 medical providers were interviewed. A standardized survey and semi-structured interview guide were developed based on the program handbook, with input from experts in the VHA Office of Geriatrics and Extended Care Services, guided by the Consolidated Framework for Implementation Science Research. RESULTS: Of surveyed GeriPACTs, 42.6% had a mental health provider on the team-a psychiatrist (28.7%) and/or psychologist (23.8%). Of these, the mean was 0.27 full-time equivalent psychiatrists and 0.44 full-time equivalent psychologists per team (suggested panel = 800 patients). In surveys, teams with behavioral health providers were more likely to manage psychosocial χ2 = 8.87, cognitive χ2 = 8.68, and depressive χ2 = 11.85 conditions in their panel than those without behavioral health providers. CONCLUSION: GeriPACT mental health integration is less than 50%. Population differences between general primary care and geriatric primary care may require different care approaches and provider competencies and need further study.

The Impact of a Change in the Price of VA Health Care on Utilization of VA and Medicare Services.

INTRODUCTION: The passage of the Veterans Access, Choice, and Accountability Act of 2014 has expanded the non-Veteran Affairs (VA) care options for eligible US Veterans. In order for these new arrangements to provide the best care possible for Veterans, it is important to understand the relationship between VA and non-VA care options. The purpose of this study was to use another recent VA policy change, one that increased the reimbursement rate that eligible Veterans receive for travel for health care to VA, to understand the use of VA and Medicare services among Medicare-enrolled Veterans. METHODS: We used a difference-in-difference technique to compare inpatient and outpatient utilization and cost in VA and Medicare between Veterans who were eligible for travel reimbursement and those who were not eligible following 2 increases in the travel reimbursement rate. We used generalized estimating equation models and 2-part models when cost outcomes were rare. RESULTS: Our cohort consisted of 110,007 Medicare-enrolled Veterans, including 25,076 under 65 and 84,931 over 65 years old. Following the travel reimbursement rate increases, the number of VA outpatient encounters increased for Veterans in our cohort regardless of age group or whether living in an urban or rural area. The number of non-VA outpatient encounters decreased significantly for Veterans in both age groups living in rural areas following these policy changes. CONCLUSIONS: Our estimates suggest that VA outpatient care may be a substitute for Medicare outpatient care for Medicare-enrolled Veterans living in rural areas. These results are important because they indicate how Veteran health care utilization might be affected by future policy changes designed to increase access to VA services. They also indicate the ripple effects that may occur in other health systems due to changes in the VA system.

Variability in spousal perceptions of caregiving and its relationship to older caregiver health outcomes.

BACKGROUND: The transition to later-life caregiving roles, especially for couples caring for each other, can be rife with ambiguity. The incident discordance in spousal perceptions of one another's role and its relationship to mental health outcomes have not been well-described. OBJECTIVES: (1) To describe the range of daily agreement between older adult spouses' perceptions of care given and care received; (2) to explore associations between caregiving agreement and daily caregiver depression, anxiety, and marital satisfaction; and (3) to evaluate differential effects for male and female caregivers. DESIGN: Cross-sectional, ecological assessment (daily diary). PARTICIPANTS: Sample of 191 couples aged 60-64 (total 5196 daily surveys) drawn from the longitudinal Life and Family Legacies study. MAIN MEASURES: During 2011-2012, spouses independently completed 14 consecutive daily surveys about their mood, marital interactions, and support exchanges. Caregiving agreement was defined as the daily ratio of spouse-reported care received to self-reported care given. Using generalized linear mixed effect modeling, we examined associations between spousal care agreement and outcomes of depression, anxiety, and marital satisfaction. KEY RESULTS: Sample data demonstrated broad variability in spousal agreement, with couples exhibiting substantial disagreement on nearly one-third of couple days (780/2598 days). On days where care was exchanged, higher caregiving agreement was associated with lower caregiver depression (p < 0.01) and anxiety (p < 0.01) in male caregivers, and higher marital satisfaction (p = 0.03) in female caregivers. When care recipients reported receiving more support than their spouse reported giving, these associations did not persist. CONCLUSIONS: Findings suggest that spousal agreement about the amount of care given and received varies broadly and is an important consideration for primary care providers who counsel these patients day-to-day. Furthermore, agreement appears to predict mental health and relationship outcomes and should be further evaluated in this growing population of mid-to-late life adults emerging into caregiving.

Attitudes Toward Telemedicine in Urban, Rural, and Highly Rural Communities.

INTRODUCTION: The rate of telemedicine adoption using interactive video between patient and provider has not met expectations. Technology, regulations, and physician buy-in are cited reasons, but patient acceptance has not received much consideration. We examine attitudes regarding telemedicine to better understand the subjective definitions of its acceptability and utility that shape patients' willingness to use telemedicine. MATERIALS AND METHODS: Using the Montana Health Matters study (a random, statewide survey [n=3,512]), we use latent class analysis to identify groups with similar patterns of attitudes toward telemedicine followed by multinomial logistic regression to estimate predictors of group membership. RESULTS: Although only 5% are amenable to telemedicine regardless of circumstance, 23% would be comfortable if it could be convenient, whereas 29% would be situationally amenable but uncomfortable using telemedicine. Still, a substantial percentage (43%) is unequivocally averse to telemedicine despite the inconvenience of in-person visits. Educational attainment, prior Internet use, and rural residence are main predictors that increase the likelihood of being in an amenable group. CONCLUSIONS: From the patient's perspective, the advantages of reduced travel and convenience are recognized, but questions remain about the equivalence to physician visits. Many people are averse to telemedicine, indicating a perceived incompatibility with patient needs. Only 1.7% of the respondents reported using telemedicine in the previous year; about half were veterans. Hence, few have used telemedicine, and key innovation adoption criteria-trialability and observability-are low. Increased attention to public awareness in the adoption process is needed to increase willingness to embrace telemedicine as a convenient way to obtain quality healthcare services.

The VA Caregiver Support Line: A Gateway of Support for Caregivers of Veterans.

In passing the Caregivers and Veterans Omnibus Health Services Act of 2010, Congress created a legislative mandate for the Veterans Administration (VA) to strengthen its program of support services for caregivers of veterans. As part of this expansion, the VA implemented a nationwide toll-free telephone Caregiver Support Line (CSL). The CSL is a single point of entry system to link caregivers to national and local services to support care of a veteran. This article describes the CSL and its role in supporting aging veterans and their caregivers, discusses social workers' contributions to its development and implementation, and reports utilization data.

Inflammatory Biomarkers Differ among Hospitalized Veterans Infected with Alpha, Delta, and Omicron SARS-CoV-2 Variants.

Mortality due to COVID-19 has been correlated with laboratory markers of inflammation, such as C-reactive protein (CRP). The lower mortality during Omicron variant infections could be explained by variant-specific immune responses or host factors, such as vaccination status. We hypothesized that infections due to Omicron variant cause less inflammation compared to Alpha and Delta, correlating with lower mortality. This was a retrospective cohort study of veterans hospitalized for COVID-19 at the Veterans Health Administration. We compared inflammatory markers among patients hospitalized during Omicron infection with those of Alpha and Delta. We reported the adjusted odds ratio (aOR) of the first laboratory results during hospitalization and in-hospital mortality, stratified by vaccination status. Of 2,075,564 Veterans tested for COVID-19, 29,075 Veterans met the criteria: Alpha (45.1%), Delta (23.9%), Omicron (31.0%). Odds of abnormal CRP in Delta (aOR = 1.85, 95% CI:1.64-2.09) and Alpha (aOR = 1.94, 95% CI:1.75-2.15) were significantly higher compared to Omicron. The same trend was observed for Ferritin, Alanine aminotransferase, Aspartate aminotransferase, Lactate dehydrogenase, and Albumin. The mortality in Delta (aOR = 1.92, 95% CI:1.73-2.12) and Alpha (aOR = 1.68, 95% CI:1.47-1.91) were higher than Omicron. The results remained significant after stratifying the outcomes based on vaccination status. Veterans infected with Omicron showed milder inflammatory responses and lower mortality than other variants.

Predictors of attrition in older users of a home-based monitoring and health information delivery system.

OBJECTIVE: This retrospective study evaluated predictors of attrition in data from veterans with chronic medical conditions who were enrolled in a Veterans Administration Care Coordination Home Telehealth program. SUBJECTS AND METHODS: Data were collected over a 4-year period. The enrolled sample was 73 veterans, 55.3% of whom discontinued enrollment during this period. RESULTS: Among the selected variables examined, program discontinuation was assessed within the first 30 days of enrollment by response frequency to the home telehealth device. Intermittent device response was associated with earlier dropout. Enrollment in the program via telephone (rather than in person) was the largest predictor of premature dropout. CONCLUSIONS: To ensure sustained home telehealth utilization, it is essential to engage patients through encouraging active and regular responding to the provider through the home telehealth device within the first 30 days of program initiation.

A scoping review of veteran suicide prevention programs in Native American communities and in the general population.

Suicide is a major public health problem that disproportionately impacts veterans in the general U.S. population. Recent analyses indicate that American Indian and Alaska Native (AI/AN) veterans may be two to three times as likely as non-Hispanic White veterans to experience suicidal ideation. Although suicide prevention programs have been successfully implemented for many at-risk populations, to our knowledge, none have been designed or implemented for AI/AN veterans. To address this gap, we conducted a scoping review of suicide prevention programs with the objective of identifying promising strategies and lessons learned to identify promising practices for preventing suicide among AI/AN veterans. We conducted two parallel literature searches-a review of suicide prevention programs for the general U.S. adult population and AI/AN communities. We rated programs on 16 criteria, covering five domains-best practices in suicide prevention, U.S. Department of Veterans Affairs (VA) Office of Rural Health Promising Practice criteria, cultural fit, care coordination, and outcomes. Our findings indicate that many of the VA evidence-based or best practice programs are available system-wide, but none have been tailored for AI/AN veterans or the communities in which they live. Conversely, we found that many culturally specific programs implemented in AI/AN communities were rarely disseminated beyond tribal land and none were specifically developed for veterans. Based upon these findings, and to advance suicide prevention programs for AI/AN veterans, we propose a suicide prevention model that builds upon existing VA infrastructure to disseminate best practices to AI/AN communities and integrate tribal-specific cultural approaches to suicide prevention. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

American Indian and Alaska Native veterans in the Indian Health Service: Health status, utilization, and cost.

PURPOSE: Many rural American Indian and Alaska Native (AIAN) veterans receive care from the Indian Health Service (IHS). United States Department of Veterans Affairs (VA) has reimbursement agreements with some IHS facilities and tribal programs and seeks to expand community partnerships in tribal areas, but details of how AIAN veterans use IHS are unknown. We aimed to assess the health status, service utilization patterns, and cost of care of veterans who use IHS. METHODS: We used comprehensive and integrated IHS data to compare health status, health service utilization and treatment cost of veterans (n = 12,242) to a matched sample of non-veterans (n = 12,242). We employed logistic, linear, or negative binomial regressions as appropriate, by sex and overall. FINDINGS: Compared to non-veterans, veterans had lower odds of having hypertension, renal disease, all-cause dementia, and alcohol or drug use disorders, but had similar burden of other conditions. In service utilization, veterans had lower hospital inpatient days; patterns were mixed across outpatient services. Unadjusted treatment costs for veterans and non-veterans were $3,923 and $4,145, respectively; veteran adjusted treatment costs were statistically lower. Differences in significance by sex were found for health conditions and service use. CONCLUSIONS: AIAN veterans, compared to AIAN non-veterans, were not less healthy, nor did they require more intensive or more costly care under IHS. Our results indicate the viability and importance of expanding IHS-VA partnerships in community care.

"We Got an Invite into the Fortress": VA-Community Partnerships for Meeting Veterans' Healthcare Needs.

Responding to identified needs for increased veterans' access to healthcare, in 2010 the United States Department of Veterans Affairs (VA) launched the Veteran Community Partnership (VCP) initiative to "foster seamless access to, and transitions among, the full continuum of non-institutional extended care and support services in VA and the community". This initiative represents an important effort by VA to promote collaboration with a broad range of community organizations as equal partners in the service of veteran needs. The purpose of the study is an initial assessment of the VCP program. Focus group interviews conducted in six sites in 2015 included 53 representatives of the local VA and community organizations involved with rural and urban VCPs across the US. Interview topics included the experiences and practices of VCP members, perceived benefits and challenges, and the characteristics and dynamics of rural and urban areas served by VCPs. Using a community-oriented conceptual framework, the analyses address VCP processes and preliminary outcomes, including VCP goals and activities, and VCP members' perceptions of their efforts, benefits, challenges, and achievements. The results indicate largely positive perceptions of the VCP initiative and its early outcomes by both community and VA participants. Benefits and challenges vary by rural-urban community context and include resource limitations and the potential for VA dominance of other VCP partners. Although all VCPs identified significant benefits and challenges, time and resource constraints and local organizational dynamics varied by rural and urban context. Significant investments in VCPs will be required to increase their impacts.

Reasoning in the capacity to make medical decisions: the consideration of values.

PURPOSE: To examine the contribution of "values-based reasoning" in evaluating older adults' capacity to make medical decisions. DESIGN AND METHODS: Older men with schizophrenia (n=20) or dementia (n=20), and a primary care comparison group (n=19), completed cognitive and psychiatric screening and an interview to determine their capacity to make medical decisions, which included a component on values. All of the participants were receiving treatment at Veterans Administration (VA) outpatient clinics. RESULTS: Participants varied widely in the activities and relationships they most valued, the extent to which religious beliefs would influence healthcare decisions, and in ratings of the importance of preserving quality versus length of life. Most participants preferred shared decision making with doctor, family, or both. Individuals with schizophrenia or dementia performed worse than a primary care comparison group in reasoning measured by the ability to list risks and benefits and compare choices. Individuals with dementia performed comparably to the primary care group in reasoning measured by the ability to justify choices in terms of valued abilities or activities, whereas individuals with schizophrenia performed relatively worse compared to the other two groups. Compared to primary care patients, participants with schizophrenia and with dementia were impaired on the ability to explain treatment choices in terms of valued relationships. CONCLUSION: Medical decision making may be influenced by strongly held values and beliefs, emotions, and long life experience. To date, these issues have not been explicitly included in structured evaluations of medical decision-making capacity. This study demonstrated that it is possible to inquire of and elicit a range of healthcare related values and preferences from older adults with dementia or schizophrenia, and individuals with mild to moderate dementia may be able to discuss healthcare options in relation to their values. However, how best to incorporate a values assessment into a structured capacity evaluation deserves further research attention.

The Care Coordination Home Telehealth (CCHT) rural demonstration project: a symptom-based approach for serving older veterans in remote geographical settings.

INTRODUCTION: Innovative healthcare delivery strategies are needed to address the healthcare needs of the 3.5 million older veterans living in US rural areas who face unique healthcare delivery challenges, including transportation barriers, poverty, and limited access to health professions and community-based programs. The care coordination home telehealth (CCHT) rural demonstration project was developed to address the mismatch between the timely identification of patient needs and the care delivered by the traditional disease-oriented institutionally-based healthcare delivery system for older rural veterans. The specific objectives were to: (1) serve as a facilitator of primary care; and (2) provide a portfolio of geriatric care management options to increase early detection of symptoms and to encourage adherence to care plans. METHODS: Participants were recruited based on patterns of high outpatient, inpatient, and emergency care visits; 132 rural older veterans were enrolled. The CCHT applied care management principles to the delivery of healthcare services and used health informatics to facilitate access to evidence-based care. The CCHT's essential components, which were tailored to optimize remote access, included a face-to-face orientation, telephone contact with a designated care coordinator, and daily monitoring sessions using an in-home telehealth device to assess participants' medication usage, compliance, and symptoms, and to provide patient education. RESULTS: One hundred eleven participants successfully installed and connected the telehealth monitoring device in their homes without hands-on assistance, monitored complex medical and psychiatric symptoms, and reported medication compliance remotely. Of the 93 participants who used the device for more than 10 sessions, 88 reported they did not have any difficulty using the device, 86 reported they were satisfied or very satisfied with the device, 73 reported they were likely to continue using the device, and 46 reported improved communication between themselves and their primary healthcare provider. CONCLUSION: Initial utilization and satisfaction evaluation data from this project supports the feasibility of employing a CCHT approach to serve medically-complicated older veterans in rural settings. This approach could also serve as a template for addressing a greater range of healthcare needs among other populations in hard-to-reach settings.

Predicting Psychiatric Hospitalizations among Elderly Veterans with a History of Mental Health Disease.

INTRODUCTION: Patient Aligned Care Team (PACT) care managers are tasked with identifying aging Veterans with psychiatric disease in attempt to prevent psychiatric crises. However, few resources exist that use real-time information on patient risk to prioritize coordinating appropriate care amongst a complex aging population. OBJECTIVE: To develop and validate a model to predict psychiatric hospital admission, during a 90-day risk window, in Veterans ages 65 or older with a history of mental health disease. METHODS: This study applied a cohort design to historical data available in the Veterans Affairs (VA) Corporate Data Warehouse (CDW). The Least Absolute Shrinkage and Selection Operator (LASSO) regularization regression technique was used for model development and variable selection. Individual predicted probabilities were estimated using logistic regression. A split-sample approach was used in performing external validation of the fitted model. The concordance statistic (C-statistic) was calculated to assess model performance. RESULTS: Prior to modeling, 61 potential candidate predictors were identified and 27 variables remained after applying the LASSO method. The final model's predictive accuracy is represented by a C-statistic of 0.903. The model's predictive accuracy during external validation is represented by a C-statistic of 0.935. Having a previous psychiatric hospitalization, psychosis, bipolar disorder, and the number of mental-health related social work encounters were strong predictors of a geriatric psychiatric hospitalization. CONCLUSION: This predictive model is capable of quantifying the risk of a geriatric psychiatric hospitalization with acceptable performance and allows for the development of interventions that could potentially reduce such risk.

A cognitive task analysis of information management strategies in a computerized provider order entry environment.

OBJECTIVE: Computerized Provider Order Entry (CPOE) with electronic documentation, and computerized decision support dramatically changes the information environment of the practicing clinician. Prior work patterns based on paper, verbal exchange, and manual methods are replaced with automated, computerized, and potentially less flexible systems. The objective of this study is to explore the information management strategies that clinicians use in the process of adapting to a CPOE system using cognitive task analysis techniques. DESIGN: Observation and semi-structured interviews were conducted with 88 primary-care clinicians at 10 Veterans Administration Medical Centers. MEASUREMENTS: Interviews were taped, transcribed, and extensively analyzed to identify key information management goals, strategies, and tasks. Tasks were aggregated into groups, common components across tasks were clarified, and underlying goals and strategies identified. RESULTS: Nearly half of the identified tasks were not fully supported by the available technology. Six core components of tasks were identified. Four meta-cognitive information management goals emerged: 1) Relevance Screening; 2) Ensuring Accuracy; 3) Minimizing memory load; and 4) Negotiating Responsibility. Strategies used to support these goals are presented. CONCLUSION: Users develop a wide array of information management strategies that allow them to successfully adapt to new technology. Supporting the ability of users to develop adaptive strategies to support meta-cognitive goals is a key component of a successful system.

Veterans as Caregivers: Those Who Continue to Serve.

Provider referrals are effective for connecting caregiving veterans to community-based resources, which can provide necessary support that reduces the caregiving burden.

COVER to COVER: Connecting Older Veterans (Especially Rural) to Community or Veteran-Eligible Resources.

A demonstration project trained community counselors to become veteran benefits specialists to improve access to benefits for veterans who are unaware of their eligibility.

Supporting Caregivers of Rural Veterans Electronically (SCORE).

BACKGROUND: The increasing prevalence of dementia, including among rural veterans, highlights the improved outcomes possible for caregivers who receive effective support. However, providing these complex interventions in rural areas presents challenges. Internet-based and telephone-based caregiver support can potentially expand access to effective support. METHODS: We designed a multisite intervention for caregivers of veterans with dementia. Caregivers were stratified into 2 cohorts based on their use or nonuse of the Internet. Each cohort was then randomized to either a technology or telephone-delivered support group within each cohort. All groups had a care manager who monitored the 4- to 6-month multicomponent program of assessments, educational content, and skills training. Caregiver outcome measures included burden, anticipatory grief, depression, family conflict, and a desire to institutionalize the care recipient. RESULTS: The majority of comparative effectiveness outcomes were not different between caregivers receiving technology interventions versus those receiving telephone-delivered support. This was true for the 68% of caregivers using home Internet and the 32% nonusers, as well as the 53% rural versus 47% urban caregivers. For experienced Internet users, a meaningful difference in the Marwit Grief Inventory was noted for caregivers receiving Internet versus telephone support, particularly for the Isolation Subscale. CONCLUSION: This study demonstrates the feasibility and acceptability of using a variety of modalities to deliver caregiver support to a group of largely older, rural, spousal caregivers of veterans with dementia. The potential for reducing isolation for caregivers capable of receiving this intervention through the Internet is a promising finding.