Tackling Guideline Non-concordance: Primary Care Barriers to Incorporating Life Expectancy into Lung Cancer Screening Decision-Making-A Qualitative Study.

BACKGROUND: Primary care providers (PCPs) are often the first point of contact for discussing lung cancer screening (LCS) with patients. While guidelines recommend against screening people with limited life expectancy (LLE) who are less likely to benefit, these patients are regularly referred for LCS. OBJECTIVE: We sought to understand barriers PCPs face to incorporating life expectancy into LCS decision-making for patients who otherwise meet eligibility criteria, and how a hypothetical point-of-care tool could support patient selection. DESIGN: Qualitative study based on semi-structured telephone interviews. PARTICIPANTS: Thirty-one PCPs who refer patients for LCS, from six Veterans Health Administration facilities. APPROACH: We thematically analyzed interviews to understand how PCPs incorporated life expectancy into LCS decision-making and PCPs' receptivity to a point-of-care tool to support patient selection. Final themes were organized according to the Cabana et al. framework Why Don't Physicians Follow Clinical Practice Guidelines, capturing the influence of clinician knowledge, attitudes, and behavior on LCS appropriateness determinations. KEY RESULTS: PCP referrals to LCS for patients with LLE were influenced by limited knowledge of the life expectancy threshold at which patients are less likely to benefit from LCS, discomfort estimating life expectancy, fear of missing cancer at the point of early detection, and prioritization of factors such as quality of life, patient values, clinician-patient relationship, and family support. PCPs were receptive to a decision support tool to inform and communicate LCS appropriateness decisions if easy to use and integrated into clinical workflows. CONCLUSIONS: Our study suggests knowledge gaps and attitudes may drive decisions to offer screening despite LLE, a behavior counter to guideline recommendations. Integrating a LCS decision support tool that incorporates life expectancy within the electronic medical record and existing clinical workflows may be one acceptable solution to improve guideline concordance and increase confidence in selecting high benefit patients for LCS.

"It Can't Hurt!": Why Many Patients With Limited Life Expectancy Decide to Accept Lung Cancer Screening.

PURPOSE: Lung cancer screening (LCS) has less benefit and greater potential for iatrogenic harm among people with multiple comorbidities and limited life expectancy. Yet, such individuals are more likely to undergo screening than healthier LCS-eligible people. We sought to understand how patients with marginal LCS benefit conceptualize their health and make decisions regarding LCS. METHODS: We interviewed 40 people with multimorbidity and limited life expectancy, as determined by high Care Assessment Need scores, which predict 1-year risk of hospitalization or death. Patients were recruited from 6 Veterans Health Administration facilities after discussing LCS with their clinician. We conducted a thematic analysis using constant comparison to explore factors that influence LCS decision making. RESULTS: Patients commonly held positive beliefs about screening and perceived LCS to be noninvasive. When posed with hypothetical scenarios of limited benefit, patients emphasized the nonlongevity benefits of LCS (eg, peace of mind, planning for the future) and generally did not consider their health status or life expectancy when making decisions regarding LCS. Most patients were unaware of possible additional evaluations or treatment of screen-detected findings, but when probed further, many expressed concerns about the potential need for multiple evaluations, referrals, or invasive procedures. CONCLUSIONS: Patients in this study with multimorbidity and limited life expectancy were unaware of their greater risk of potential harm when accepting LCS. Given patient trust in clinician recommendations, it is important that clinicians engage patients with marginal LCS benefit in shared decision making, ensuring that their values of desiring more information about their health are weighed against potential harms from further evaluations.

Using a Whole Health Approach to Build Biopsychosocial-Spiritual Personal Health Plans for Veterans with Chronic Pain.

Chronic pain affects over 50 million Americans per year and costs society billions of dollars annually. It is widely accepted that the biomedical model is outdated and research on the biopsychosocial model of chronic pain has increased in recent years, concurrent with investigations into self-management of chronic pain. The Veterans Health Administration (VHA) has incorporated both of these approaches into their Whole Health System. This work describes the VHA Whole Health System, reviews the literature on alignment between the Whole Health System's Circle of Health and chronic pain, and explains how the VHA Whole Health model may be used as a method for organizing self-management strategies within a personal health plan in the context of chronic pain. Given the infusion of nurses throughout the healthcare system, nurses are in a unique position to champion this biopsychosocial-spiritual approach to care.

Endocrinologists' Experiences With Telehealth: A Qualitative Study With Implications for Promoting Sustained Use.

OBJECTIVE: Endocrinology is well-suited to telehealth, with high rates of use and known benefits. Clinician attitudes toward telehealth will be critical to ensuring sustained use after the pandemic. We examined endocrinologists' experiences with synchronous telehealth to identify factors affecting experiences with and acceptance of the technology. METHODS: We conducted qualitative interviews and directed-content analysis with a purposive sample of 26 U.S. endocrinologists. Factors affecting clinicians' experiences were mapped to the human-organization-technology fit (HOT-fit) framework. RESULTS: We found that clinicians' experiences with synchronous telehealth were influenced by: (1) Clinician factors: Clinicians welcomed telehealth but expressed concerns about patient interest, rapport building, and clinical appropriateness, desiring more data to support its use. Many clinicians feared missing clinical findings on virtual examination, despite no such personal experiences. Effects on professional and personal life contributed to satisfaction, through increased flexibility but also increased workload. (2) Organizational factors: Departmental meetings and trainings supported clinicians' technical, logistical, and clinical needs, reducing resistance to telehealth use. Shifting staff responsibilities in clinical workflows improved clinicians' experiences and supported telehealth use, while mixed telehealth and in-person schedules impeded workflow. (3) Technology factors: Most clinicians preferred video visits to telephone. Usability and reliability of telehealth platforms, integration of patient self-monitoring data, and availability of IT support were crucial to a positive experience. CONCLUSION: Clinician acceptance of telehealth is influenced by clinician, organizational, and technology factors that can be leveraged to improve buy-in. Organizational leaders' attention to addressing these factors will be critical to support endocrinologists' continued provision of telehealth for their patients.

The relationship between capacity and utilization of nonpharmacologic therapies in the US Military Health System.

BACKGROUND: Nonpharmacologic therapies (NPTs) are recommended as first-line treatments for pain, however the impact of expanding professional capacity to deliver these therapies on use has not been extensively studied. We sought to examine whether an effort by the US Military Health System (MHS) to improve access to NPTs by expanding professional capacity increased NPT utilization in a cohort at higher risk for pain - Army soldiers returning from deployment. METHODS: Our study involved secondary analysis of MHS workforce data derived from the Defense Medical Human Resources System Internet (DMHRSi), and healthcare utilization data obtained from two ambulatory record systems of the Military Health System (MHS) for a sample of 863,855 Army soldiers previously deployed to Iraq or Afghanistan over a 10-year period (2008-2017). We measured clinical provider capacity in three occupational groups responsible for pain management at 130 military treatment facilities (MTFs): physical therapy, chiropractic, and behavioral health, measured annually as full-time equivalence per 100,000 patients served at each MTF. Utilization in both direct and purchased care settings was measured as annual mean NPT users per 1000 sample members and mean encounters per NPT user. Generalized estimating equation models estimated the associations of facility-level occupational capacity measures and facility-level utilization NPT measures. RESULTS: In 2008, nearly all MTFs had some physical therapist and behavioral health provider capacity, but less than half had any chiropractor capacity. The largest increase in capacity from 2008 to 2017 was for chiropractors (89%) followed by behavioral health providers (77%) and physical therapists (37%). Models indicated that increased capacity of physical therapists and chiropractors were associated with significantly increased utilization of six out of seven NPTs. Acupuncture initiation was associated with capacity increases in each occupation. Increased professional capacity in MTFs was associated with limited but positive effects on NPT utilization in purchased care. CONCLUSIONS: Increasing occupational capacity in three professions responsible for delivering NPTs at MTFs were associated with growing utilization of seven NPTs in this Army sample. Despite increasing capacity in MTFs, some positive associations between MTF capacity and purchased care utilization suggest an unmet need for NPTs. Future research should examine if these changes lead to greater receipt of guideline-concordant pain management.

How Should We Organize Care for Patients With Human Immunodeficiency Virus and Comorbidities? A Multisite Qualitative Study of Human Immunodeficiency Virus Care in the United States Department of Veterans Affairs.

BACKGROUND: With human immunodeficiency virus (HIV) now managed as a chronic disease, health care has had to change and expand to include management of other critical comorbidities. We sought to understand how variation in the organization, structure and processes of HIV and comorbidity care, based on patient-centered medical home (PCMH) principles, was related to care quality for Veterans with HIV. RESEARCH DESIGN: Qualitative site visits were conducted at a purposive sample of 8 Department of Veterans Affairs Medical Centers, varying in care quality and outcomes for HIV and common comorbidities. Site visits entailed conduct of patient interviews (n=60); HIV care team interviews (n=60); direct observation of clinic processes and team interactions (n=22); and direct observations of patient-provider clinical encounters (n=45). Data were analyzed using a priori and emergent codes, construction of site syntheses and comparing sites with varying levels of quality. RESULTS: Sites highest and lowest in both HIV and comorbidity care quality demonstrated clear differences in provision of PCMH-principled care. The highest site provided greater team-based, comprehensive, patient-centered, and data-driven care and engaged in continuous improvement. Sites with higher HIV care quality attended more to psychosocial needs. Sites that had consistent processes for comorbidity care, whether in HIV or primary care clinics, had higher quality of comorbidity care. CONCLUSIONS: Provision of high-quality HIV care and high-quality co-morbidity care require different care structures and processes. Provision of both requires a focus on providing care aligned with PCMH principles, integrating psychosocial needs into care, and establishing explicit consistent approaches to comorbidity management.

Integrating Personalized Care Planning into Primary Care: a Multiple-Case Study of Early Adopting Patient-Centered Medical Homes.

BACKGROUND: Personalized care planning is a patient-centered, whole-person approach to treatment planning. Personalized care plans improve patient outcomes and are now mandated for chronic care management reimbursement. Yet guidance on how to best implement personalized care planning in practice is limited. OBJECTIVE: We examined the adoption of personalized care planning in patient-centered medical home (PCMH) clinics to identify processes and organizational characteristics that facilitated or hindered use in routine practice. DESIGN: Qualitative multiple-case study design. We conducted site visits at PCMH clinics in four US Veterans Health Administration (VHA) medical centers. Data included 10 general clinic observations, 34 direct observations of patient-provider clinical encounters, 60 key informant interviews, and a document review. Data were analyzed via qualitative content analysis using a priori and emergent coding. PARTICIPANTS: Employees and patients participating in clinical encounters in PCMH clinics at four VHA medical centers. KEY RESULTS: Each clinic used a distinct approach to personalized care planning: (1) distributed tasks approach; (2) two-tiered approach; (3) health coaching approach; and (4) leveraging a village approach. Each varied in workflow, healthcare team utilization, and degree of integration into clinical care. Across sites, critical components for implementation included expanding planning beyond initial assessment of patient priorities; framing the initiative for patients; using a team-based approach to care plan development and updates; using communication mechanisms beyond the electronic health record; and engaging stakeholders in implementation planning. CONCLUSIONS: Personalized care planning is a novel patient-centered practice, but complicated to implement. We found variation in effective implementation and identified critical components to structuring this practice in a manner that engages patients in treatment aligned with personal priorities. Primary care practices seeking to implement personalized care planning must go beyond simply asking patients a series of questions to establish a plan. They must also engage team members in plan development, communication, and dissemination.

Primary care provider perceptions and experiences of implementing hepatitis C virus birth cohort testing: a qualitative formative evaluation.

BACKGROUND: In 2014, the Department of Veterans Affairs (VA) adopted a screening test policy for hepatitis C virus (HCV) in all "Baby Boomers" - those born between 1945 and 1965. About 1 in 12 Veterans were estimated to be infected with HCV yet approximately 34% of the birth cohort remained untested. Early HCV diagnosis and successful antiviral treatment decrease the risk of onward transmission, cirrhosis, hepatocellular carcinoma, liver transplant, and death. Implementing evidence-based HCV screening in primary care has great potential to reduce morbidity and mortality. To inform design and implementation of a quality improvement intervention, we studied primary care provider (PCP) perceptions of and experiences with HCV birth cohort testing. METHODS: We conducted a formative evaluation using qualitative semi-structured interviews guided by the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework. Twenty-two PCPs in six states across a large integrated US healthcare system were interviewed. Content analysis with a priori and emergent codes was performed on verbatim interview transcripts. RESULTS: We identified three themes related to primary care provider HCV testing and linkage practices, as mapped to i-PARIHS constructs: 1) evaluating cues to HCV testing (innovation/evidence), 2) framing HCV testing decisions (recipients), and 3) HCV testing and linkage to care in the new treatment era (context). The most frequently reported HCV testing cue was an electronic clinical reminder alert, followed by clinical markers and the presence of behavioral risk factors. Most PCPs saw testing as routine, but less urgent, leading to some reluctance. Providers largely saw themselves as performing guideline-concordant testing, yet no performance data were available to assess performance. Given the recent availability of new HCV medications, many PCPs were highly motivated to test and link patients to specialty care for treatment. CONCLUSIONS: Our results suggest a multi-component intervention around awareness and education, feedback of performance data, clinical reminder updates, and leadership support, would address both a significant need, and be deemed acceptable and feasible to primary care providers.

Patient and Clinician Perspectives on Shared Decision-making in Early Adopting Lung Cancer Screening Programs: a Qualitative Study.

BACKGROUND: Guidelines recommend, and Medicare requires, shared decision-making between patients and clinicians before referring individuals at high risk of lung cancer for chest CT screening. However, little is known about the extent to which shared decision-making about lung cancer screening is achieved in real-world settings. OBJECTIVE: To characterize patient and clinician impressions of early experiences with communication and decision-making about lung cancer screening and perceived barriers to achieving shared decision-making. DESIGN: Qualitative study entailing semi-structured interviews and focus groups. PARTICIPANTS: We enrolled 36 clinicians who refer patients for lung cancer screening and 49 patients who had undergone lung cancer screening in the prior year. Participants were recruited from lung cancer screening programs at four hospitals (three Veterans Health Administration, one urban safety net). APPROACH: Using content analysis, we analyzed transcripts to characterize communication and decision-making about lung cancer screening. Our analysis focused on the recommended components of shared decision-making (information sharing, deliberation, and decision aid use) and barriers to achieving shared decision-making. KEY RESULTS: Clinicians varied in the information shared with patients, and did not consistently incorporate decision aids. Clinicians believed they explained the rationale and gave some (often purposely limited) information about the trade-offs of lung cancer screening. By contrast, some patients reported receiving little information about screening or its trade-offs and did not realize the CT was intended as a screening test for lung cancer. Clinicians and patients alike did not perceive that significant deliberation typically occurred. Clinicians perceived insufficient time, competing priorities, difficulty accessing decision aids, limited patient comprehension, and anticipated patient emotions as barriers to realizing shared decision-making. CONCLUSIONS: Due to multiple perceived barriers, patient-clinician conversations about lung cancer screening may fall short of guideline-recommended shared decision-making supported by a decision aid. Consequently, patients may be left uncertain about lung cancer screening's rationale, trade-offs, and process.

Patient-centred care is a way of doing things: How healthcare employees conceptualize patient-centred care.

BACKGROUND: Patient-centred care is now ubiquitous in health services research, and healthcare systems are moving ahead with patient-centred care implementation. Yet, little is known about how healthcare employees, charged with implementing patient-centred care, conceptualize what they are implementing. OBJECTIVE: To examine how hospital employees conceptualize patient-centred care. RESEARCH DESIGN: We conducted qualitative interviews about patient-centred care during site four visits, from January to April 2013. SUBJECTS: We interviewed 107 employees, including leadership, middle managers, front line providers and staff at four US Veteran Health Administration (VHA) medical centres leading VHA's patient-centred care transformation. MEASURES: Data were analysed using grounded thematic analysis. Findings were then mapped to established patient-centred care constructs identified in the literature: taking a biopsychosocial perspective; viewing the patient-as-person; sharing power and responsibility; establishing a therapeutic alliance; and viewing the doctor-as-person. RESULTS: We identified three distinct conceptualizations: (i) those that were well aligned with established patient-centred care constructs surrounding the clinical encounter; (ii) others that extended conceptualizations of patient-centred care into the organizational culture, encompassing the entire patient-experience; and (iii) still others that were poorly aligned with patient-centred care constructs, reflecting more traditional patient care practices. CONCLUSIONS: Patient-centred care ideals have permeated into healthcare systems. Additionally, patient-centred care has been expanded to encompass a cultural shift in care delivery, beginning with patients' experiences entering a facility. However, some healthcare employees, namely leadership, see patient-centred care so broadly, it encompasses on-going hospital initiatives, while others consider patient-centred care as inherent to specific positions. These latter conceptualizations risk undermining patient-centred care implementation by limiting transformational initiatives to specific providers or simply repackaging existing programmes.

Organization of pulmonary hypertension care in non-expert care settings: Lessons learned from a multi-site study.

OBJECTIVE: To examine how select Veterans Health Administration (VA) sites organized care for patients with pulmonary hypertension (PH), with a focus on describing existing practices and identifying unmet needs within the sites. DATA SOURCES AND STUDY SETTING: Semi-structured interviews across seven diverse VA sites. STUDY DESIGN: Qualitative multiple-site study. DATA COLLECTION/EXTRACTION METHODS: We interviewed 54 key informants including pulmonologists, cardiologists, primary care providers, advanced care practitioners, pharmacists, and clinical leaders to assess the structures and processes of PH care delivery. We analyzed transcripts using directed content analysis and constructed site profiles for each site, comparing profiles to existing guidelines for PH expert centers. PRINCIPAL FINDINGS: Sites varied considerably in how they organized PH care, with wide variation in the availability of structures and processes recommended for expert centers, including availability of PH expertise and PH-specific resources, multidisciplinary approach to care, establishment of clear referral pathways, and presence of PH education. Further, participants identified three areas of unmet need not directly addressed within current guidelines, including better integration of pharmacists into multidisciplinary teams, early and routine involvement of palliative care, and improved care coordination efforts. CONCLUSIONS: The rising prevalence of PH and evolution of treatments for common PH subgroups underscore the need to standardize PH care delivery in non-expert care settings to improve care quality and patient outcomes. The insight gained from this study may inform the development of guidance appropriate for care settings outside of expert centers.

Creating Whole Person Health Care Systems: Understanding Employee Perceptions of VAs Whole Health Cultural Transformation.

Objective: Whole person health care, like that being implemented in the U.S. Veterans Health Administration (VHA), involves person-centered approaches that address what matters most to patients to achieve well-being beyond the biomedical absence of disease. As whole health (WH) approaches expand, their integration into clinical practice is predicated on health care employees reconceptualizing practice beyond find-it-fix-it medicine and embracing WH as a new philosophy of care. This study examined employee perspectives of WH and their integration of this approach into care. Design: We conducted a survey with responses from 1073 clinical and 800 nonclinical employees at 5 VHA WH Flagship sites about their perceptions and use of a WH approach. We used descriptive statistics to examine employees' support for WH and conducted thematic analysis to qualitatively explore their perceptions about this approach from free-text comments supplied by 475 respondents. Results: On structured survey items, employees largely agreed that WH was a valuable approach but were relatively less likely to have incorporated it into practice or report support within their organization for WH. Qualitative comments revealed varying conceptualizations of WH. While some respondents understood that WH represented a philosophical shift in care, many characterized WH narrowly as services. These conceptualizations contributed to lower perceived relevance, skepticism, and misgivings that WH diverted needed resources away from existing clinical services. Organizational context including leadership messaging, siloed structures, and limited educational opportunities reinforced these perceptions. Conclusions: Successfully transforming the culture of care requires a shift in mindset among employees and leadership alike. Employees' depictions didn't always reflect WH as a person-centered approach designed to engage patients to enhance their health and well-being. Without consistent leadership messaging and accessible training, opportunities to expand understandings of WH are likely to be missed. To promote WH transformation, additional attention is needed for employees to embrace this approach to care.

Modifying Whole Health Services for Successful Telehealth Delivery: Lessons from Veterans Health Administration's Rapid Transition During the COVID-19 Pandemic.

Introduction: The Veterans Health Administration (VHA) is shifting care from a disease-oriented to health-creating approach that aims to provide whole person care. This Whole Health (WH) system combines person-centered care with delivery of WH services (e.g., health coaching, well-being education and skill-building classes, and evidence-based complementary and integrative health therapies), alongside conventional medical services. During the COVID-19 pandemic, WH services were modified for delivery through telehealth (teleWH). This article characterizes modifications to WH services made to maintain continuity during the transition to telehealth formats. Materials and methods: We conducted semistructured qualitative interviews with a purposive sample of 51 providers delivering teleWH services at 10 VHA medical centers. We examined WH service modifications as well as facilitators and barriers to those modifications using rapid coding and directed content analysis. Results: Modifications were driven by (1) preparing for teleWH service delivery and (2) improving teleWH service delivery. To prepare for teleWH services, modifications were prompted by access, readiness, and setting and resources. Modifications to improve the delivery of teleWH services were motivated by engagement, community-building, safety, and content for a teleWH environment. One-on-one teleWH services required the fewest modifications, while more significant modifications were needed for well-being, skill-building, and movement-based groups, and reconfiguration of manual therapies. Discussion: Findings highlighted the need for modifications to ensure that teleWH services are accessible and safe and support interpersonal relationships between patients and providers, as well as in group-based classes. Successfully delivering teleWH services requires proactive preparation that considers access, readiness, and the availability of resources to engage in teleWH services. Tailoring strategies and considering the unique needs of different teleWH services are critical. Conclusions: The COVID-19 pandemic catalyzed teleWH service implementation, utilization, and sustainment. The challenges faced and modifications made during this transition provide lessons learned for other health care systems as they attempt to implement teleWH services.

'She thought the same way I that I thought:' a qualitative study of patient-provider concordance among Gulf War Veterans with Gulf War Illness.

Objective: Medically unexplained symptoms (MUS), such as chronic fatigue syndrome, irritable bowel syndrome, and Gulf War Illness (GWI), are difficult to treat. Concordance-shared understanding between patient and provider about illness causes, course, and treatment-is an essential component of high-quality care for people with MUS. This qualitative paper focuses on the experiences of United States military Veterans living with GWI who have endured unique healthcare challenges. Methods & Measures: Qualitative interviews were conducted with 31 Veterans with GWI to explore factors that contribute to and detract from concordance with their Veteran Affairs (VA) healthcare providers. In addition to being seen by VA primary care, over half of participants also sought care at a War Related Illness and Injury Study Center, which specializes in post-deployment health. Deductive and inductive codes were used to organize the data, and themes were identified through iterative review of coded data. Results: Major themes associated with patient-provider concordance included validation of illness experiences, perceived provider expertise in GWI/MUS, and trust in providers. Invalidation, low provider expertise, and distrust detracted from concordance. Conclusion: These findings suggest providers can foster concordance with MUS patients by legitimizing patients' experiences, communicating knowledge about MUS, and establishing trust.

Commentary on Burns, Nembhard and Shortell, "Integrating network theory into the study of integrated healthcare": Revisiting and extending research on structural and processual factors affecting coordination.

Burns et al.'s innovative recommendation to use social network theory to study integration will contribute to our understanding of how healthcare systems can optimally deliver high quality, coordinated, person-centered care. We discuss three enhancements to this approach. (1) In increasing our attention to social network analysis and processual perspectives, we must not "throw out the baby with the bathwater" and abandon research that includes formal organizational structure. Structure remains an important focus for researchers and healthcare managers, who spend considerable resources on reorganizing. Since there is evidence that formal structure affects social processes and coordination, future research should build on that evidence and investigate how coordination is affected by the segmentation of organizations into units and the structures and processes designed to integrate interdependent work across those units. Conducting network analysis in the context of formal structure can help us better understand how formal structure affects both social networks and coordination. (2) Using multi-level, mixed methods, and qualitative research will be critically important to fully understand how and why formal organizational structure, social networks, and processual dynamics contribute to coordination or fragmentation of care. Because the relationships among these constructs occur not only within, but also across multiple levels, multi-level research is necessary to understand their effects on coordination. In considering the individual level, patients can be studied as a role embedded in networks. In addition, however, we must not lose a focus on patients as people at the center of multi-level networks, whose attitudes, values, preferences and goals may directly affect processual dynamics and coordination of care. (3) Finally, our field lacks precision in nomenclature, specification of levels, and the constructs within them, including ambiguity around even what is meant by "structure" and its variations. Furthermore, different authors use "macro", "meso", and "micro", differently, contributing to confusion in the discourse on organizational phenomena. Greater clarity and consistency in terminology is needed to facilitate research and improve communication across the field.

Clinical Appropriateness of Telehealth: A Qualitative Study of Endocrinologists' Perspectives.

Background: Outpatient endocrinology care delivered by telehealth is likely to remain common after the pandemic. There are few data to guide endocrinologists' judgments of clinical appropriateness (safety and effectiveness) for telehealth by synchronous video. We examined how, in the absence of guidelines, endocrinologists determine clinical appropriateness for telehealth, and we identified their strategies to navigate barriers to safe and effective use. Methods: We conducted qualitative, semi-structuredinterviews with 26 purposively selected US endocrinologists. We used a directed content analysis to characterize participant perceptions of which patients and situations were clinically appropriate for telehealth and to identify adaptations they made to accommodate telehealth visits. Results: Endocrinologists' perspectives about appropriateness for telehealth were influenced by clinical considerations, nonclinical patient factors, and the type and timing of the visit. These factors were weighed differently across individual participants according to their risk tolerance, values related to the physical examination and patient relationships, and impressions of patient capabilities and preferences. Some participants made practice adaptations that increased their comfort offering telehealth to a wider swath of patients. Conclusions: Endocrinologists' judgments about clinical appropriateness of telehealth for different patient situations varied widely across participants. The risk of such divergent approaches to determining appropriateness is unintended and clinically unwarranted variation in use of telehealth, compromising quality of care. Expert consensus is needed to guide endocrinologists now, along with studies to anchor future evidence-based guidelines for determining clinical appropriateness of telehealth in endocrinology.

"I've just never done that:" The influence of transitional anxiety on post-incarceration reentry and reintegration experiences among veterans.

Military veterans involved in the criminal justice system are a vulnerable subpopulation that has extensive physical and behavioural health treatment needs. Like non-veteran populations, safe and stable housing, employment and social support are critical for veterans returning to society after incarceration. The challenges of social reintegration are immense, and the risk of recidivism is high. The U.S. Department of Veteran Affairs (VA) has developed specific programmes to assist veterans plan for and assist with reentry. While there have been successes, recidivism and early mortality are persistent concerns. This study examined reentry experiences of veterans living in one northeastern state to gain a better understanding of factors that influence social reintegration. The study was conducted in 2017 to inform an enhancement of VA reentry services through the addition of peer support. Qualitative interviews were conducted with 16 veterans with recent incarceration experiences and 27 reentry specialists working in five correctional facilities, two VA hospitals, five community agencies and two state departments. Interview transcripts were reviewed and coded using a Framework Analysis approach. Narratives highlight high levels of anxiety and uncertainty experienced as participants went through physical and emotional transitions associated with reentry and reintegration. This 'transitional anxiety' was often rooted in the absence of prior positive experiences engaging in socially normative activities, like obtaining housing and employment. Embarrassment and shame regarding a lack of experience with expected responsibilities were commonly reported. Although salient in veterans' narratives, reentry specialists rarely talked about problems post-incarceration in terms of limited life experience and skills, focusing instead on substance use and mental health issues. Few resources were available to support the development of critical life skills. Findings call attention to the need for understanding pre-incarceration experiences that may influence social reintegration and the development of tailored interventions to build skills and experience when needed.

Towards a framework for patient-centred care coordination: a scoping review protocol.

INTRODUCTION: Patient-centred care and care coordination are each key priority areas for delivering high quality healthcare. However, the intersection between these two concepts is poorly characterised. We theorise that greater advancements in healthcare quality could be realised when care is organised in a way that aligns with patients' preferences, needs and values across every level of the healthcare system. There is currently no published review that describes the intersection of patient-centred care and care coordination. We will undertake a scoping review that will be foundational to the development of a conceptual framework for patient-centred care coordination that integrates and synthesises the overlap between these two concepts and describe how it manifests across levels of the healthcare system. METHODS AND ANALYSIS: A multidisciplinary team of reviewers will conduct a scoping review of published and grey literature to identify and synthesise key concepts at the intersection of patient-centred care and care coordination, following Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews guidance for scoping reviews. Databases we will use in our search include PubMed, CINAHL, Embase, Social Sciences Abstracts, Nursing and Allied Health Premium, Health and Medical Collection, and PsycINFO. Articles will be included that are English-language; published during or after 2001; describe a theory, conceptual model, theoretical framework or definition that addresses both patient-centred care and care coordination. Articles will be excluded if they do not address the intersection of patient-centred care and care coordination; discuss a patient-centred medical home without discussion on patient-centred care concepts; or discuss a paediatric, inpatient or palliative care setting. A data extraction template will facilitate qualitative thematic analysis and findings will be synthesised into a conceptual framework. ETHICS AND DISSEMINATION: This work does not require ethics approval. A preliminary framework will be presented to a group of patient stakeholders for refinement before dissemination through a peer-reviewed journal and conference presentations.

Enhancing community integration after incarceration: findings from a prospective study of an intensive peer support intervention for veterans with an historical comparison group.

BACKGROUND: The transition to the community after incarceration presents challenges for returning citizens, including the immediate need to secure housing, employment, and income. Additionally, health care is essential for this population due to high rates of chronic physical health and mental health problems and substance use disorders. There is growing recognition of the need for interventions that support returning citizens as they navigate community reintegration while simultaneously tending to physical and behavioral health needs. We developed and pilot tested a peer support intervention designed to provide social, emotional, and logistic support and promote linkage and engagement in healthcare for returning citizens. We tested the intervention with US military veterans in Massachusetts who were being released from prison and jail. Outcomes related to linkage to and engagement in healthcare were evaluated using an historical comparison group. Engagement in peer support, housing status, and reincarceration rates were monitored for the intervention group. RESULTS: There were 43 veterans in the intervention group, and 36 in the historical comparison group. For linkage to primary care within 90 days of release, there were no statistically significant differences between the intervention and comparison groups (58% versus 67%). Intervention participants were significantly more likely to receive substance use treatment than the comparison group (86% versus 19%, p < .0001) and the mean monthly substance use visits was greater in the intervention group (0.96 versus 0.34, p < .007). Engagement in mental health services was greater for the intervention group than the comparison group (93% versus 64%, p < .003). There were no significant differences between groups for emergency department use and hospitalization. At the end of the study period, the majority of intervention participants who had been released for over a year were living in permanent housing (84%). Recidivism among the was low, with 7% re-arrested during the study period. CONCLUSIONS: Augmenting reentry support through intensive peer support appears to have substantial benefits for veterans in terms of engaging them in health care and contributing to their longer-term stability, including housing and recidivism. Flexible reentry support such as this intervention may be well suited to meet the widely varying needs of returning citizens.