Factors Contributing to Patient Satisfaction Among VA Medical Center and Non-VA Medical Center Hospitals.

INTRODUCTION: Veteran satisfaction of care within the Veterans Affairs is typically very high. Yet recommendation ratings of VA medical center (VA) hospitals as measured by Hospital Consumer Assessment of Healthcare Providers and Systems are generally lower than non-VA hospitals.Therefore, it was our objective to assess Veteran satisfaction and recommendation scores and then examine whether satisfaction correlates to recommendation. METHODS: We identified all acute care VAs as our primary analytic cohort. As a comparator group, we also included all acute care academic hospitals (non-VAs), as designated by the Centers for Medicare Services. Using data from Hospital Consumer Assessment of Healthcare Providers and Systems and Strategic Analytics for Improvement and Learning (SAIL) Value Model, we collated patient satisfaction scores, as well as markers of surgical safety from Hospital Compare. We then analyzed the correlation within VAs and non-VAs, primarily focusing the relationship between the "would you recommend Hospital Rating" and subdomains of the "Overall Hospital Rating," as well as a composite score of patient safety. RESULTS: A total of 133 VAs and 1116 non-VAs were identified. Among VAs, the "Would you Recommend" hospital rating was significantly and positively correlated with markers of patient satisfaction including care transitions (Pearson's r = 0.59, P = 0.03), Nursing communication (Pearson's R 0.79, P = 0.001), and percent of primary care provider wait times less than 30 min (Pearson's r = 0.25, P = 0.01). VA-recommended scores were negatively correlated with factors such as time to emergency department discharge, and the "leaving the emergency department before being evaluated." When looking at non-VAs, correlation directions were similar, albeit with stronger associations at almost every metric. While recommended scores correlated strongly to overall hospital ratings for both groups, VAs had no significant correlation between "would you recommend" and patient safety. However, there was a slight negative correlation between patient safety and "recommend" among non-VAs. CONCLUSIONS: Although satisfiers and dissatisfiers of care appear similar between VAs and non-VAs, "would you recommend" is a far weaker marker of patient perceptions of safety and quality. These seemingly empathetic markers such as "would you recommend" should be used with caution as they may not address the fundamental question being asked.

The Effectiveness of a Specialized Primary Care Medical Home for Patients with Serious Mental Illness.

BACKGROUND: There are unmet primary care needs among people with serious mental illness that might be improved with integrated care and medical care management. Many healthcare organizations have attempted to address this problem, but few interventions have been rigorously studied and found to be effective. OBJECTIVE: Study the implementation and effectiveness of a novel, specialized primary care medical home designed to improve the healthcare of patients with serious mental illness. DESIGN, SETTING, AND PARTICIPANTS: Clustered controlled trial for a median of 401 days. One Veterans Health Administration medical center was assigned to intervention and two were assigned to usual care (control). Thirty-nine clinicians and managers were included in the study, as well as 331 patients who met eligibility criteria. INTERVENTION: A specialized medical home with systematic patient engagement, proactive nurse panel management, a collaborative care psychiatrist, and a primary care physician providing care that included psychiatric treatment. MAIN MEASURES: Quality of care, chronic illness care and care experience, symptoms, and quality of life. KEY RESULTS: Sixty-five intervention patients (40%) moved all psychiatric care to the primary care team. No adverse events were attributable to the intervention. Compared with control, intervention patients had greater improvement over time in appropriate screening for body mass index, lipids, and glucose (χ2 = 6.9, 14.3, and 3.9; P's < .05); greater improvement in all domains of chronic illness care (activation, decision support, goal-setting, counseling, coordination) and care experience (doctor-patient interaction, shared decision-making, care coordination, access; F for each 10-24, P's < .05); and greater improvement in mental health-related quality of life (F = 3.9, P = .05) and psychotic symptoms (F = 3.9, P = .05). CONCLUSION: A primary care medical home for serious mental illness can be feasible to implement, safe, and more effective than usual care. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01668355.

Provider Perspectives on Implementing Shared Decision Making for PTSD Treatment in VA Primary Care.

Shared decision making is an important implementation "pull" strategy for increasing uptake of evidence-based mental health practices. In this qualitative study, we explored provider perspectives on implementing shared decision making at the point of mental health treatment initiation using a publicly available, patient-facing decision support tool for post-traumatic stress disorder (PTSD). We conducted semi-structured interviews with 22 mental health providers (psychiatrists, nurses, psychologists, and social workers) working in one of five VA primary care clinics. Interviewed were analyzed using thematic analysis. Provider were enthusiastic about using decision aids as a source of high quality information that could improve patient experience and confidence in treatment. However, providers had concerns about decision aid accessibility, time constraints to conduct shared decision making in-session, and patient motivation to engage in shared decision making. Providers stated they would prefer to use shared decision making with patients that they felt were most likely to follow through with treatment. While providers believed that shared decision making could improve PTSD treatment planning, they thought it most appropriate for patients with the highest levels of motivation and fewest barriers to care. These beliefs may limit widespread adoption and reflect missed opportunities to reach difficult-to-engage patients.

The VA and Non-VA Experience of Tracking Good Care.

The VA Mission Act of 2018 allows for choice of health care for 9 million veterans in their community, but deciding where the best care is requires transparency. Recent reports questioning the transparency of reporting health care outcomes in the Department of Veterans Affairs (VA), the largest US health care organization, pointed to flaws in how VA tracks and improves performance, and posed questions about the validity and transparency of using popular hospital ratings systems to define good care. To explore this further, the authors examined 3 widely referenced public health care ranking models - U.S. News America's Best Hospitals, Truven Health Analytics, and Hospital Compare - and the VA model. Upon examination, the authors find that metrics used across the 4 models are neither comparable nor transparent. Between 6%-46% reporting deficiencies were found in reporting of hospital metrics in non-VA hospitals, which reduces transparency for the public. In contrast, VA reporting is 100%. Comparing VA health care and Hospital Compare quality outcomes showed similar or better outcomes for VA for the same metrics of quality and for comparable health care costs. VA inpatient satisfaction falls significantly short of the private sector, but no individual VA outcome measure was found to contribute significantly to inpatient satisfaction. However, overall inpatient satisfaction increased over time with higher global hospital ranking in both VA and non-VA health care. Encouraging use of uniform rating models and reporting of metrics from all hospitals would improve transparency of current health care reporting to the consumer.

Courage to care for our United States veterans: A constructivist way of teaching and learning for future nurses.

The knowledge and skills in providing veteran centered care is essential. The purpose of this retrospective evaluation is to examine a faculty's reflections on a BSN psychiatric mental health curriculum initiative that provides knowledge and skills regarding veterans care through several avenues to senior nursing students. This qualitative study use self-reflections through a constructivist view of teaching and learning as the framework. Open discussions in didactic about the unique psychological health issues of veterans formed a foundational knowledge for the students. The seminar time was used to discuss real veteran case situations. Simulation provided opportunities to address veteran resources. Problem based projects use available evidence to solve veteran health issues. The educators show their commitment to the compassionate and caring ideals of our profession by fostering an educational environment where future nurses can truly learn about veteran centered care.

Baccalaureate Nursing Faculty Competencies and Teaching Strategies to Enhance the Care of the Veteran Population: Perspectives of Veteran Affairs Nursing Academy (VANA) Faculty.

It is critical that faculty competencies, teaching strategies, and the essential knowledge relating to the care of our veterans be delineated and taught to health care professionals in order for our Veterans to receive optimal care. The purpose of this qualitative study was to ascertain from nursing faculty members who have worked extensively with veterans, the necessary faculty competencies, essential knowledge, and teaching strategies needed to prepare baccalaureate level nurses to provide individualized, quality, and holistic care to veterans. Six Veteran Affairs Nursing Academy faculty members participated in two 2-hour focus group sessions. There were a total of 12 multidimensional major concepts identified: 5 faculty competencies, 4 essential knowledge areas, and 3 teaching strategies specifically related to veteran care. The information generated can be used for faculty, staff, and or nurse development. Having a comprehensive understanding of veteran health care needs enable effective patient-centered care delivery to veterans, which is the gold standard in health care our veterans deserve.

Hazardous drinking and its association with homelessness among veterans in care.

BACKGROUND: While scholarship on alcohol use and homelessness has focused on the impact of alcohol abuse and dependence, little is known about the effects of lower levels of misuse such as hazardous use. Veterans receiving care in the Department of Veterans Affairs Health Care System (VA) constitute a population that is vulnerable to alcohol misuse and homelessness. This research examines the effects of hazardous drinking on homelessness in the Veterans Aging Cohort Study, a sample of 2898 older veterans (mean age=50.2), receiving care in 8 VAs across the country. METHODS: Logistic regression models examined the associations between (1) hazardous drinking at baseline and homelessness at 1-year follow-up, (2) transitions into and out of hazardous drinking from baseline to follow-up and homelessness at follow-up, and (3) transitioning to hazardous drinking and transitioning to homelessness from baseline to follow-up during that same time-period. RESULTS: After controlling for other correlates including alcohol dependence, hazardous drinking at baseline increased the risk of homelessness at follow-up (adjusted odds ratio [AOR]=1.39, 95% confidence interval [CI]=1.02, 1.88). Transitioning to hazardous drinking more than doubled the risk of homelessness at follow-up (AOR=2.42, 95% CI=1.41, 4.15), while more than doubling the risk of transitioning from being housed at baseline to being homeless at follow-up (AOR=2.49, 95% CI=1.30, 4.79). CONCLUSIONS: Early intervention that seeks to prevent transitioning into hazardous drinking could increase housing stability among veterans. Brief interventions which have been shown to be effective at lower levels of alcohol use should be implemented with veterans in VA care.