A Narrative Review of NICU Implementation of Evidence-Based Early Relational Health Interventions.

BACKGROUND: Early relational health (ERH) interventions in the neonatal intensive care unit (NICU) buffer infants from toxic stress effects. Implementation science (IS) can guide successful uptake of evidence-based practice (EBP) ERH interventions. It is unknown if implementors of ERH interventions currently use the resources of IS to improve implementation. PURPOSE: A narrative review of recent literature on implementation of ERH EBPs was completed to understand (a) which ERH interventions are currently being implemented in NICUs globally, (b) whether clinical implementors of ERH interventions have adopted the resources of IS, (c) existence of implementation gaps, and (d) implementation outcomes of ERH interventions in contemporary literature. DATA SOURCES: Scopus, PubMed, and CINHAL were searched for original research regarding implementation of dyadic ERH interventions using key words related to IS and ERH. STUDY SELECTION: For inclusion, ERH EBPs had to have been implemented exclusively in NICU settings, contained data addressing an IS domain, printed in English within the last 5 years. Twenty-four studies met inclusion criteria. DATA EXTRACTION: Studies were distilled for intervention, IS domains addressed, location, aims, design, sample, and outcomes. RESULTS: Eleven ERH interventions were described in the literature. Few studies utilized the resources of IS, indicating variable degrees of success in implementation. Discussions of implementation cost were notably missing. IMPLICATIONS FOR PRACTICE AND RESEARCH: Implementors of ERH interventions appear to be largely unfamiliar with IS resources. More work is needed to reach clinicians with the tools and resources of IS to improve implementation outcomes.

Evidence-Based Intervention Adaptations Within the Veterans Health Administration: a Scoping Review.

BACKGROUND: Veterans receiving care within the Veterans Health Administration (VA) are a unique population with distinctive cultural traits and healthcare needs compared to the civilian population. Modifications to evidence-based interventions (EBIs) developed outside of the VA may be useful to adapt care to the VA healthcare system context or to specific cultural norms among veterans. We sought to understand how EBIs have been modified for veterans and whether adaptations were feasible and acceptable to veteran populations. METHODS: We conducted a scoping review of EBI adaptations occurring within the VA at any time prior to June 2021. Eligible articles were those where study populations included veterans in VA care, EBIs were clearly defined, and there was a comprehensive description of the EBI adaptation from its original context. Data was summarized by the components of the Framework for Reporting Adaptations and Modifications to Evidence-based interventions (FRAME). FINDINGS: We retrieved 922 abstracts based on our search terms. Following review of titles and abstracts, 49 articles remained for full-text review; eleven of these articles (22%) met all inclusion criteria. EBIs were adapted for mental health (n = 4), access to care and/or care delivery (n = 3), diabetes prevention (n = 2), substance use (n = 2), weight management (n = 1), care specific to cancer survivors (n = 1), and/or to reduce criminal recidivism among veterans (n = 1). All articles used qualitative feedback (e.g., interviews or focus groups) with participants to inform adaptations. The majority of studies (55%) were modified in the pre-implementation, planning, or pilot phases, and all were planned proactive adaptations to EBIs. IMPLICATIONS FOR D&I RESEARCH: The reviewed articles used a variety of methods and frameworks to guide EBI adaptations for veterans receiving VA care. There is an opportunity to continue to expand the use of EBI adaptations to meet the specific needs of veteran populations.

Interdisciplinary Team Meetings in Practice: an Observational Study of IDTs, Sensemaking Around Care Transitions, and Readmission Rates.

BACKGROUND: Interdisciplinary teams (IDTs) have been implemented to improve collaboration in hospital care, but their impact on patient outcomes, including readmissions, has been mixed. These mixed results might be rooted in differences in organization of IDT meetings between hospitals, as well as variation in IDT characteristics and function. We hypothesize that relationships between IDT members are an important team characteristic, influencing IDT function in terms of how members make sense of what is happening with patients, a process called sensemaking OBJECTIVE: (1) To describe how IDT meetings are organized in practice, (2) assess differences in IDT member relationships and sensemaking during patient discussions, and (3) explore their potential association with risk-stratified readmission rates (RSRRs). DESIGN: Observational, explanatory convergent mixed-methods case-comparison study of IDT meetings in 10 Veterans Affairs hospitals. PARTICIPANTS: Clinicians participating in IDTs and facility leadership. APPROACH: Three-person teams observed and recorded IDT meetings during week-long visits. We used observational data to characterize relationships and sensemaking during IDT patient discussions. To assess sensemaking, we used 2 frameworks that reflected sensemaking around each patient's situation generally, and around care transitions specifically. We examined the association between IDT relationships and sensemaking, and RSRRs. KEY RESULTS: We observed variability in IDT organization, characteristics, and function across 10 hospitals. This variability was greater between hospitals than between teams at the same hospital. Relationship characteristics and both types of sensemaking were all significantly, positively correlated. General sensemaking regarding each patient was significantly negatively associated with RSRR (- 0.65, p = 0.044). CONCLUSIONS: IDTs vary not only in how they are organized, but also in team relationships and sensemaking. Though our design does not allow for inferences of causation, these differences may be associated with hospital readmission rates.

A practical risk calculator for suicidal behavior among transitioning U.S. Army soldiers: results from the Study to Assess Risk and Resilience in Servicemembers-Longitudinal Study (STARRS-LS).

BACKGROUND: Risk of suicide-related behaviors is elevated among military personnel transitioning to civilian life. An earlier report showed that high-risk U.S. Army soldiers could be identified shortly before this transition with a machine learning model that included predictors from administrative systems, self-report surveys, and geospatial data. Based on this result, a Veterans Affairs and Army initiative was launched to evaluate a suicide-prevention intervention for high-risk transitioning soldiers. To make targeting practical, though, a streamlined model and risk calculator were needed that used only a short series of self-report survey questions. METHODS: We revised the original model in a sample of n = 8335 observations from the Study to Assess Risk and Resilience in Servicemembers-Longitudinal Study (STARRS-LS) who participated in one of three Army STARRS 2011-2014 baseline surveys while in service and in one or more subsequent panel surveys (LS1: 2016-2018, LS2: 2018-2019) after leaving service. We trained ensemble machine learning models with constrained numbers of item-level survey predictors in a 70% training sample. The outcome was self-reported post-transition suicide attempts (SA). The models were validated in the 30% test sample. RESULTS: Twelve-month post-transition SA prevalence was 1.0% (s.e. = 0.1). The best constrained model, with only 17 predictors, had a test sample ROC-AUC of 0.85 (s.e. = 0.03). The 10-30% of respondents with the highest predicted risk included 44.9-92.5% of 12-month SAs. CONCLUSIONS: An accurate SA risk calculator based on a short self-report survey can target transitioning soldiers shortly before leaving service for intervention to prevent post-transition SA.

Initiating Cognitive Processing Therapy (CPT) in Community Settings: A Qualitative Investigation of Therapist Decision-Making.

Various organizations have provided treatment guidelines intended to aid therapists in deciding how to treat posttraumatic stress disorder (PTSD). Yet evidence-based psychotherapies (EBPs) for PTSD in the community may be difficult to obtain. Although strides have been made to implement EBPs for PTSD in institutional settings such as the United States Veterans Affairs, community uptake remains low. Factors surrounding clients' decisions to enroll in EBPs have been identified in some settings; however less is known regarding trained therapists' decisions related to offering trauma-focused therapies or alternative treatment options. Thus, the aim of the current study was to examine therapist motivations to initiate CPT in community settings. The present study utilizes data from a larger investigation aiming to support the sustained implementation of Cognitive Processing Therapy (CPT) in community mental health treatment settings. Enrolled therapists participated in phone interviews discussing their opinions of CPT, preferred treatments for PTSD, and process in assessing appropriate PTSD treatments for clients. Semi-structured interviews (N = 29) were transcribed and analyzed using a directed content analysis approach. Several themes emerged regarding therapists' decision-making in selecting PTSD treatments. Therapist motivations to use EBPs for PTSD, primarily CPT, were identified at the client (e.g., perceived compatibility with client-level characteristics), therapist (e.g., time limitations), and clinic levels (e.g., leadership support). The results provide insight into the complex array of factors that affect sustainability of EBPs for PTSD in community settings and inform future dissemination of EBPs, including training efforts in community settings.

The Coordination Toolkit and Coaching Project: Cluster-Randomized Quality Improvement Initiative to Improve Patient Experience of Care Coordination.

BACKGROUND: Given persistent gaps in coordination of care for medically complex primary care patients, efficient strategies are needed to promote better care coordination. OBJECTIVE: The Coordination Toolkit and Coaching project compared two toolkit-based strategies of differing intensity to improve care coordination at VA primary care clinics. DESIGN: Multi-site, cluster-randomized QI initiative. PARTICIPANTS: Twelve VA primary care clinics matched in 6 pairs. INTERVENTIONS: We used a computer-generated allocation sequence to randomize clinics within each pair to two implementation strategies. Active control clinics received an online toolkit with evidence-based tools and QI coaching manual. Intervention clinics received the online toolkit plus weekly assistance from a distance coach for 12 months. MAIN MEASURES: We quantified patient experience of general care coordination using the Health Care System Hassles Scale (primary outcome) mailed at baseline and 12-month follow-up to serial cross-sectional patient samples. We measured the difference-in-difference (DiD) in clinic-level-predicted mean counts of hassles between coached and non-coached clinics, adjusting for clustering and patient characteristics using zero-inflated negative binomial regression and bootstrapping to obtain 95% confidence intervals. Other measures included care coordination QI projects attempted, tools adopted, and patient-reported exposure to projects. KEY RESULTS: N = 2,484 (49%) patients completed baseline surveys and 2,481 (48%) completed follow-ups. Six coached clinics versus five non-coached clinics attempted QI projects. All coached clinics versus two non-coached clinics attempted more than one project or projects that were multifaceted (i.e., involving multiple components addressing a common goal). Five coached versus three non-coached clinics used 1-2 toolkit tools. Both the coached and non-coached clinics experienced pre-post reductions in hassle counts over the study period (- 0.42 (- 0.76, - 0.08) non-coached; - 0.40 (- 0.75, - 0.06) coached). However, the DiD (0.02 (- 0.47, 0.50)) was not statistically significant; coaching did not improve patient experience of care coordination relative to the toolkit alone. CONCLUSION: Although coached clinics attempted more or more complex QI projects and used more tools than non-coached clinics, coaching provided no additional benefit versus the online toolkit alone in patient-reported outcomes. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03063294.

Trajectories of functioning in a population-based sample of veterans: contributions of moral injury, PTSD, and depression.

BACKGROUND: Although research has shown that exposure to potentially traumatic and morally injurious events is associated with psychological symptoms among veterans, knowledge regarding functioning impacts remains limited. METHODS: A population-based sample of post-9/11 veterans completed measures of intimate relationship, health, and work functioning at approximately 9, 15, 21, and 27 months after leaving service. Moral injury, posttraumatic stress, and depression were assessed at ~9 months post-separation. We used Latent Growth Mixture Models to identify discrete classes characterized by unique trajectories of change in functioning over time and to examine predictors of class membership. RESULTS: Veterans were assigned to one of four functioning trajectories: high and stable, high and decreasing, moderate and increasing, and moderate and stable. Whereas posttraumatic stress, depression, and moral injury associated with perpetration and betrayal predicted worse outcomes at baseline across multiple functioning domains, moral injury associated with perpetration and depression most reliably predicted assignment to trajectories characterized by relatively poor or declining functioning. CONCLUSIONS: Moral injury contributes to functional problems beyond what is explained by posttraumatic stress and depression, and moral injury due to perpetration and depression most reliably predicted assignment to trajectories characterized by functional impairment over time.

The interaction of exposure to adverse childhood and combat experiences on the current mental health of new post-9/11 veterans.

Military veterans have greater exposure to adverse childhood experiences (ACEs) than civilians and many also encounter warfare exposures, which can increase the likelihood of mental health problems. The purpose of this study was to test an interaction between childhood traumas and warfare exposures on the mental health of a sample of nearly 10,000 new post-9/11 veterans. Results revealed that male veterans exposed to one or two ACEs, but no warfare, were more likely to experience anxiety, depression, suicidal thinking, and angry outbursts than the reference group (i.e., no ACEs and no warfare exposure). Female veterans exposed to one or two ACEs, but no warfare, were only more likely to experience suicidal thinking. Male and female veterans exposed to three or more ACEs and no warfare were more likely to experience probable posttraumatic stress disorder (PTSD), anxiety, depression, suicidality, and angry outbursts. Among those veterans who experienced corollaries of combat only (e.g., seeing someone killed or seriously wounded), male, but not female veterans were more likely to have probable PTSD, anxiety, and depression. Veterans exposed to warfare (i.e., combat and the corollaries of combat), irrespective of ACEs exposure, were the most likely to report mental health symptoms. Implications for community-based mental health services are discussed.

Evidence based processes to prevent readmissions: more is better, a ten-site observational study.

BACKGROUND: 30-day hospital readmissions are an indicator of quality of care; hospitals are financially penalized by Medicare for high rates. Numerous care transition processes reduce readmissions in clinical trials. The objective of this study was to examine the relationship between the number of evidence-based transitional care processes used and the risk standardized readmission rate (RSRR). METHODS: Design: Mixed method, multi-stepped observational study. Data collection occurred 2014-2018 with data analyses completed in 2021. SETTING: Ten VA hospitals, chosen for 5-year trend of improving or worsening RSRR prior to study start plus documented efforts to reduce readmissions. PARTICIPANTS: During five-day site visits, three observers conducted semi-structured interviews (n = 314) with staff responsible for care transition processes and observations of care transitions work (n = 105) in inpatient medicine, geriatrics, and primary care. EXPOSURE: Frequency of use of twenty recommended care transition processes, scored 0-3. Sites' individual process scores and cumulative total scores were tested for correlation with RSRR. OUTCOME: best fit predicted RSRR for quarter of site visit based on the 21 months surrounding the site visits. RESULTS: Total scores: Mean 38.3 (range 24-47). No site performed all 20 processes. Two processes (pre-discharge patient education, medication reconciliation prior to discharge) were performed at all facilities. Five processes were performed at most facilities but inconsistently and the other 13 processes were more varied across facilities. Total care transition process score was correlated with RSRR (R2 = 0..61, p < 0.007). CONCLUSIONS: Sites making use of more recommended care transition processes had lower RSRR. Given the variability in implementation and barriers noted by clinicians to consistently perform processes, further reduction of readmissions will likely require new strategies to facilitate implementation of these evidence-based processes, should include consideration of how to better incorporate activities into workflow, and may benefit from more consistent use of some of the more underutilized processes including patient inclusion in discharge planning and increased utilization of community supports. Although all facilities had inpatient social workers and/or dedicated case managers working on transitions, many had none or limited true bridging personnel (following the patient from inpatient to home and even providing home visits). More investment in these roles may also be needed.

Toolkit and distance coaching strategies: a mixed methods evaluation of a trial to implement care coordination quality improvement projects in primary care.

BACKGROUND: Care coordination tools and toolkits can be challenging to implement. Practice facilitation, an active but expensive strategy, may facilitate toolkit implementation. We evaluated the comparative effectiveness of distance coaching, a form of practice facilitation, for improving the implementation of care coordination quality improvement (QI) projects. METHODS: We conducted a mixed methods evaluation of the Coordination Toolkit and Coaching (CTAC) initiative. Twelve matched US Veterans Health Administration primary care clinics were randomized to receive coaching and an online care coordination toolkit ("coached"; n = 6) or access to the toolkit only ("non-coached"; n = 6). We did interviews at six, 12, and 18 months. For coached sites, we'ly collected site visit fieldnotes, prospective coach logs, retrospective coach team debriefs, and project reports. We employed matrix analysis using constructs from the Consolidated Framework for Implementation Research and a taxonomy of outcomes. We assessed each site's project(s) using an adapted Complexity Assessment Tool for Systematic Reviews. RESULTS: Eleven sites implemented a local CTAC project. Eight sites (5 coached, 3 non-coached) used at least one tool from the toolkit. Coached sites implemented significantly more complex projects than non-coached sites (11.5 vs 7.5, 95% confidence interval 1.75-6.25, p < 0.001); engaged in more formal implementation processes (planning, engaging, reflecting and evaluating); and generally had larger, more multidisciplinary QI teams. Regardless of coaching status, sites focused on internal organizational improvement and low-intensity educational projects rather than the full suite of care coordination tools. At 12 months, half the coached and non-coached sites had clinic-wide project implementation; the remaining coached sites had implemented most of their project(s), while the remaining non-coached sites had either not implemented anything or conducted limited pilots. At 18 months, coached sites reported ongoing effort to monitor, adapt, and spread their CTAC projects, while non-coached sites did not report much continuing work. Coached sites accrued benefits like improved clinic relationships and team QI skill building that non-coached sites did not describe. CONCLUSIONS: Coaching had a positive influence on QI skills of (and relationships among) coached sites' team members, and the scope and rigor of projects. However, a 12-month project period was potentially too short to ensure full project implementation or to address cross-setting or patient-partnered initiatives. TRIAL REGISTRATION: NCT03063294 .

Launching a Competency-Based Training Program in Evidence-Based Treatments for PTSD: Supporting Veteran-Serving Mental Health Providers in Texas.

Community mental health providers play an essential role in delivering services to veterans who either have limited access to U.S. Department of Veterans Affairs (VA) facilities or who prefer to seek care outside of the VA. However, there are limited training opportunities in evidence-based treatments for posttraumatic stress disorder (PTSD) outside of the VA. In 2017, the STRONG STAR Training Initiative was established to develop competency-based training in two evidence-based therapies for PTSD and to provide that training for mental health providers serving veterans and their families in community settings in Texas. This article describes the program's development and implementation, baseline characteristics of participating clinicians, and lessons learned toward the scale-up and extension of this competency-based training effort to include other interventions and locations.

The Impact of Discriminatory Stress on Changes in Posttraumatic Stress Severity at the Intersection of Race/Ethnicity and Gender.

Given the diversity of military veterans and growing evidence of ethnoracial disparities in posttraumatic stress disorder (PTSD) within this population, elucidating the role of discrimination-related stress in contributing to these disparities is crucial. We examined the relative impact of discriminatory stress (i.e., due to race/ethnicity, religion, nationality, gender, sexual orientation, or physical appearance) on 6-month changes in PTSD symptom severity among trauma-exposed White (74%), Black (11%) and Hispanic/Latino/a/x (15%) veterans (17% female). PTSD symptoms were measured with the 8-item PTSD Checklist for DSM-5. A measure of the extent to which discrimination has caused stress for the respondent assessed discriminatory stress. Hierarchical regression analyses examined interactions among race/ethnicity, gender and discriminatory stress in predicting six-month changes in PTSD severity. Black and Hispanic/Latino/a/x veterans reported higher baseline PTSD severity and discriminatory stress than White veterans, with some variation by gender. Three-way interactions of race/ethnicity by discriminatory stress by gender were significant, controlling for income, education and age. The relationship between discriminatory stress and increases in PTSD severity was significantly stronger for Black women compared with Black men and did not differ between White men and women. There was also a stronger relationship between discriminatory stress and increases in PTSD severity for Hispanic/Latino/x men as compared to Black men. These findings suggest that discriminatory stress impacts PTSD severity differentially for various ethnoracial/gender groups and highlight the value of applying an intersectional framework that accounts for the synergistic connections among multiple identities to future screening, intervention, and research efforts.

The Impact of Posttraumatic Stress Disorder and Moral Injury on Women Veterans' Perinatal Outcomes Following Separation From Military Service.

Posttraumatic stress disorder (PTSD) has been found to lead to several adverse perinatal outcomes in the general population. Preliminary research has found that women veterans with PTSD have an increased prevalence of preterm birth, gestational diabetes, and preeclampsia. Less research has examined the role of moral injury (MI) in perinatal outcomes. This longitudinal survey study examined the impact of PTSD symptoms and MI on prospectively assessed adverse perinatal outcomes among women who became pregnant in the first 3 years after separating from U.S. military service (N = 318). The Moral Injury Events Scale was used to assess the degree to which individuals experienced distress related to transgressions of deeply held moral beliefs, and the Primary Care PTSD Screen for DSM-5 (PC-PTSD) was used to assess PTSD symptoms. Perinatal outcomes included experiencing an adverse pregnancy outcome (e.g., preterm birth, gestational diabetes), postpartum depression and/or anxiety, and perceived difficult pregnancy. Although both PTSD symptoms, adjusted odds ratio (aOR) = 1.16, 95% CI [1.00, 1.35]; and MI, aOR = 1.27, 95% CI [1.06, 1.41], emerged as significant predictors of adverse pregnancy outcomes, only PTSD symptoms were a significant predictor of postpartum depression and/or anxiety, aOR = 1.43, 95% CI [1.22, 1.68], and perception of a difficult pregnancy, ß = .31, when controlling for lifetime trauma exposure, age, socioeconomic status, and ethnic/racial minority status. The results indicate that both PTSD symptoms and MI are associated with adverse perinatal outcomes, supporting the potential need to screen for both PTSD and MI during the perinatal period.

Moral Injury and Social Well-Being: A Growth Curve Analysis.

Moral injury (MI) may occur in the context of committing transgressions (i.e., self-directed MI reactions), witnessing transgressions, or being the victims of others' transgressions (i.e., other-directed MI reactions) that violate an individual's moral principles. Veterans with MI may experience impaired social well-being (SWB). Studies on MI and veterans' SWB have focused almost exclusively on social support and used cross-sectional data. The present study used growth curve analyses to examine the associations between self- and other-directed MI reactions and veterans' levels of social support, social functioning, social activities, and social satisfaction over the first 18 to 21 months of their transition to civilian life (N = 9,566). The results demonstrated declines in all SWB outcomes, with self- and other-directed MI reactions having differential effects. Higher versus lower levels of other-directed MI reactions were related to lower baseline scores on all SWB outcomes, ßs = -.06 to -.20, and steeper declines over time in social functioning, ß = -.09, and social satisfaction, ß = -.10. Higher versus lower levels of self-directed MI reactions were related to lower baseline levels of social functioning, ß = -.07, but higher baseline levels of social activity, ß = .04. Higher versus lower levels of self-directed MI reactions were related to a steeper decline in social activity over time, ß = -.10. These findings present a more nuanced picture than that depicted by current MI theoretical frameworks and support further research to uncover moderators of the associations between self- and other-directed MI reactions and SWB outcomes.

Unpacking organizational readiness for change: an updated systematic review and content analysis of assessments.

BACKGROUND: Organizational readiness assessments have a history of being developed as important support tools for successful implementation. However, it remains unclear how best to operationalize readiness across varied projects or settings. We conducted a synthesis and content analysis of published readiness instruments to compare how investigators have operationalized the concept of organizational readiness for change. METHODS: We identified readiness assessments using a systematic review and update search. We mapped individual assessment items to the Consolidated Framework for Implementation Research (CFIR), which identifies five domains affecting implementation (outer setting, inner setting, intervention characteristics, characteristics of individuals, and implementation process) and multiple constructs within each domain. RESULTS: Of 1370 survey items, 897 (68%) mapped to the CFIR domain of inner setting, most commonly related to constructs of readiness for implementation (n = 220); networks and communication (n = 207); implementation climate (n = 204); structural characteristics (n = 139); and culture (n = 93). Two hundred forty-two items (18%) mapped to characteristics of individuals (mainly other personal attributes [n = 157] and self-efficacy [n = 52]); 80 (6%) mapped to outer setting; 51 (4%) mapped to implementation process; 40 (3%) mapped to intervention characteristics; and 60 (4%) did not map to CFIR constructs. Instruments were typically tailored to specific interventions or contexts. DISCUSSION: Available readiness instruments predominantly focus on contextual factors within the organization and characteristics of individuals, but the specificity of most assessment items suggests a need to tailor items to the specific scenario in which an assessment is fielded. Readiness assessments must bridge the gap between measuring a theoretical construct and factors of importance to a particular implementation.

Reducing barriers to post-9/11 veterans' use of programs and services as they transition to civilian life.

BACKGROUND: Numerous programs exist to support veterans in their transitions to civilian life. Programs are offered by a host of governmental and non-governmental stakeholders. Veterans report encountering many barriers to program participation. This study identified barrier reduction strategies offered by programs that new post-9/11 veterans reported using, determined which strategies veterans use and value, and examined veteran characteristics that impact their odds of using programs that offer barrier reduction strategies. METHOD: This study reflects findings from the first wave of data collection of The Veterans Metrics Initiative (TVMI), a longitudinal study examining the military-to-civilian reintegration of new post-9/11 veterans. The websites of programs used by respondents were coded for barrier reduction components. Veterans also indicated which barrier reduction components they found most helpful in meeting their reintegration goals. RESULTS: Of 9566 veterans who participated in Wave 1 data collection, 84% reported using a program that offered at least one barrier reduction component. Barrier reduction components included tangible supports (e.g., scholarships, cash), increased access to programs, decreased stigma, and encouraged motivation to change. Although only 4% of programs that were used by veterans focused on helping them obtain Veterans Administration benefits, nearly 60% of veterans reported that this component was helpful in reaching their goals. Access assistance to other resources and supports was also reported as a helpful barrier reduction component. For instance, approximately 20% of veterans nominated programs that offered transportation. The study also found evidence of a misalignment between the kinds of barrier reduction components veterans valued and those which programs offered. Veterans from the most junior enlisted ranks, who are at most risk, were less likely than those from other ranks to use barrier reduction components. Study limitations and ideas for future research are discussed. CONCLUSIONS: Despite the evidence that barrier reduction components enhance access to programs and contribute to program sustainability, many programs used by post-9/11 veterans do not offer them. There was also a misalignment between the barrier reduction strategies that veterans value and the strategies offered by programs. Veteran serving organizations should increasingly implement barrier reduction strategies valued by veterans.

Tailoring an evidence-based lifestyle intervention to meet the needs of women Veterans with prediabetes.

Prediabetes affects one-third of U.S. adults. Lifestyle change interventions, such as the Diabetes Prevention Program (DPP), can significantly lower type 2 diabetes risk, but little is known about how the DPP could be best adapted for women. This mixed-methods study assessed the impact of gender-tailoring and modality choice on DPP engagement among women Veterans with prediabetes. Participants were offered women-only groups and either in-person/peer-led or online modalities. Implementation outcomes were assessed using attendance logs, recruitment calls, and semi-structured interviews about patient preferences. Between June 2016 and March 2017, 119 women Veterans enrolled in the DPP (n = 51 in-person, n = 68 online). We conducted 22 interviews between August and September 2016 (n = 10 early-implementation) and March and July 2017 (n = 12 follow-up). Most interviewees preferred women-only groups, citing increased comfort, camaraderie, and mutual understanding of gender-specific barriers to lifestyle change. More women preferred online DPP, and those using this modality participated at higher rates. Most endorsed the importance of modality choice and were satisfied with their selection; however, selection was frequently based on participants' personal circumstances and access barriers and not on a "preferred choice" of two equally accessible options. Patient engagement and program reach can be expanded by tailoring the DPP for population-specific needs.

Usual Care Among Providers Treating Women Veterans: Managing Complexity and Multimorbidity in the Era of Evidence-Based Practice.

To better understand VA providers' approaches to and perspectives on providing care to women Veterans, providers (n = 97) in primary care and mental health settings were interviewed about women's perceived treatment needs, types of care provided, and perceptions of evidence-based treatments (EBTs) for this population. Providers perceived that women Veteran VA users are often diagnostically complex and require a coordinated approach to treatment planning. They struggled with decisions about how to offer services such as EBTs and collaborative care in light of comorbidity and psychosocial stressors, and endorsed the belief that a tailored approach and consideration of these factors is essential in providing care.

Staff Perspectives on Primary Care Teams as De Facto "Hubs" for Care Coordination in VA: a Qualitative Study.

BACKGROUND: Improving care coordination is a key priority for many healthcare systems. However, initiatives to improve care coordination are complex to implement and have produced mixed results. A better understanding of how to craft and support implementation of effective care coordination strategies is needed. OBJECTIVE: To identify and understand the challenges and factors encountered by Patient-Aligned Care Team (PACT) staff in performing care coordination tasks in outpatient clinics in the Veterans Health Administration (VA). DESIGN: Qualitative study using semi-structured formative evaluation interviews. PARTICIPANTS: Fourteen interviews with 18 clinical frontline managers and staff from 12 clinic sites across five VA health systems. INTERVENTIONS: This paper reports on baseline data collected for the Coordination Toolkit and Coaching (CTAC) project. CTAC aims to improve patients' experience of care coordination within VA primary care and between PACT and other outpatient and community settings. APPROACH: We conducted pre-implementation telephone interviews with frontline managers and staff, primarily nurse managers. KEY RESULTS: PACT staff described challenges in aligning care coordination priorities across different levels of the VA system, including staff, patients, and leadership. Additionally, PACT staff noted challenges coordinating care both within and outside the VA, and identified resource barriers impeding their care coordination efforts. To address these challenges, staff made several recommendations for improvement, including (1) contingency staffing to address staff burnout; (2) additional PACT training for new staff; (3) clarification of care coordination roles and responsibilities; and (4) and care coordination initiatives that align both with centrally initiated care coordination programs and frontline needs. CONCLUSION: In the VA and similarly complex healthcare systems, our findings suggest the need for care coordination strategies that are buttressed by a system-level vision for care coordination, backed up by clear roles and responsibilities for information exchange between primary care staff and other settings, and multidimensional accountability metrics that encompass patient-, staff-, and system-level goals.

Recommendations for the Evaluation of Cross-System Care Coordination from the VA State-of-the-art Working Group on VA/Non-VA Care.

In response to widespread concerns regarding Veterans' access to VA care, Congress enacted the Veterans Access, Choice and Accountability Act of 2014, which required VA to establish the Veterans Choice Program (VCP). Since the inception of VCP, more than two million Veterans have received care from community providers, representing approximately 25% of Veterans enrolled in VA care. However, expanded access to non-VA care has created challenges in care coordination between VA and community health systems. In March 2018, the VA Health Services Research & Development Service hosted a VA State of the Art conference (SOTA) focused on care coordination. The SOTA convened VA researchers, program directors, clinicians, and policy makers to identify knowledge gaps regarding care coordination within the VA and between VA and community systems of care. This article provides a summary and synthesis of relevant literature and provides recommendations generated from the SOTA about how to evaluate cross-system care coordination. Care coordination is typically evaluated using health outcomes including hospital readmissions and death; however, in cross-system evaluations of care coordination, measures such as access, cost, Veteran/patient and provider satisfaction (including with cross-system communication), comparable quality metrics, context (urban vs. rural), and patient complexity (medical and mental health conditions) need to be included to fully evaluate care coordination effectiveness. Future research should examine the role of multiple individuals coordinating VA and non-VA care, and how these coordinators work together to optimize coordination.