Quantifying relational change in community organisations participating in a Veteran suicide prevention learning collaborative: a social network analysis.

BACKGROUND: Veteran suicide remains a significant issue, as 17.5 Veterans die by suicide each day. The US Department of Veteran Affairs (VA) has implemented a robust suicide prevention program within its integrated behavioural health system. Further, the VA has increasingly contributed to suicide prevention in community settings, where a large proportion of Veterans receive health care and social services. One component integral to preventing suicide among Veterans receiving community services is ensuring that organisations are equipped with the latest evidence-based Veteran-specific suicide prevention strategies. METHODS: The Patient Safety Center of Inquiry-Suicide Prevention Collaborative piloted a Veteran suicide prevention learning collaborative in the Denver/Colorado Springs, CO region, spanning 16 months as a multimodal initiative to integrate community organisations and assist them in implementing Veteran suicide prevention strategies used within VA. Agencies completed social network analysis surveys at baseline (T1), year 1 (T2) and 16 months (T3) to examine social networks, partnerships and collaborations among community organisations and the VA over time. RESULTS: The quantity of learning collaborative relationships increased from 30 at T1 to 41 at T3 while the quality of relationships deepened over time from awareness and cooperative to more coordinated and integrated. CONCLUSION: Improvement in relationship quantity and quality facilitates community organisation engagement in collaborating to strengthen their Veteran suicide prevention programming. Learning collaboratives work with the individual organisation for intraorganisational facilitation of implementing suicide prevention strategies and engage and enhance interorganisational partnerships. This multimodal intervention can engage community organisations and provide a stronger safety net for Veterans at risk for suicide.

Evaluating the persuasiveness of messages promoting mobile mammography among uninsured women.

Mobile mammography units (MMUs) can enhance access to breast cancer screening by providing convenient, cost-effective service, particularly for uninsured and underinsured women. However, prior studies indicate that acceptability concerns about quality and privacy, among other issues, may prevent women from utilizing MMUs. The current study employs a within-participant experimental design exposing participants to messages about different MMU characteristics to determine which characteristics are most effective in persuading them to use an MMU. The study also examined how messaging interacts with participants' ethnic identity to influence outcomes. Data were collected from a diverse sample of uninsured and underinsured women as part of a formative study to promote the utilization of a mobile mammography facility in Central Texas. Results of mixed-effect linear models show that messages about equity, appointment convenience, privacy and comfort, and quality of equipment and staff were rated as more persuasive than messages about convenience of location and language accessibility. However, Hispanic women rated language accessibility higher than other participants did. The results can guide MMU organizers and promotion managers as they determine the best approach to promote mobile mammography services in different communities.

A Multi-site Case Study of Care Coordination Between Primary Care and Specialty Care.

BACKGROUND: Care coordination is critical for patients with multiple chronic conditions, but fragmentation of care persists. Providers' perspectives of facilitators and barriers to coordination are needed to improve care. OBJECTIVES: We sought to understand providers' perspectives on care coordination for patients having multiple chronic diseases served by multiple providers. RESEARCH DESIGN: Based upon our earlier survey of patients with multiple chronic conditions, we selected 8 medical centers having high and low coordination. We interviewed providers to identify facilitators and barriers to coordination and compare them between patient-rated high sites and low sites and between primary care (PC)-mental health (MH) and PC-medical/surgical specialty care. SUBJECTS: Physicians, nurses and other clinicians in PC, cardiology, and MH (N=102) in 8 Veterans Affairs medical centers. RESULTS: We identified warm handoffs, professional relationships, and physical proximity as facilitators, and service agreements, reporting relationships and staffing as barriers. PC-MH coordination was reported as better than PC-medical/surgical specialty coordination. Facilitators were more prevalent and barriers less prevalent in sites rated high by patients than sites rated low, and between PC-MH than between PC-specialty care. DISCUSSION: We noted that professional relationships were highly related to coordination and both affected other facilitators and barriers and were affected by them. We suggested actions to improve relationships directly, and to address other facilitators and barriers that affect relationships and coordination. Among these is the use of the Primary Care Mental Health Integration model.

The impact of military sexual trauma on parent-infant bonding in a sample of perinatal women veterans.

BACKGROUND: The experience of sexual assault and harassment during military service (military sexual trauma [MST]) is associated with increased risk for perinatal and reproductive health problems among women veterans. The objective of this study was to examine the associations between mothers' MST exposure and mother-infant bonding, as well as to examine whether there are any salient sociodemographic or military service characteristics among women veterans with greater impairment to mother-infant bonding, including stress during pregnancy and posttraumatic stress disorder (PTSD) diagnosis. METHODS: This study was a secondary analysis of data collected from prospective, longitudinal study of women veterans using VHA maternity care benefits at 15 VHA medical centers across the US between January 2016 and February 2020. Participants were 697 pregnant veterans using VHA maternity care benefits. RESULTS: MST was associated with higher maternal depression, and higher maternal depression was associated with poorer mother-infant bonding. The effect of MST on bonding was indirect through depression. PTSD diagnosis and life stressors during pregnancy also had significant indirect pathways with bonding through maternal depression. CONCLUSIONS: Results underscore the need for access to high quality and trauma-informed perinatal mental health treatment for women veterans, for education on the unique risks conveyed by MST provided to civilian providers treating this population outside VA, and for further research to understand how to ameliorate the harmful effects of MST on perinatal women veterans and their children.

Development of a digital platform to improve community response to overdose and prevention among harm reduction organizations.

The overdose crisis in the USA remains a growing and urgent public health concern. Over 108,000 people died due to overdose during 2021. Fatal and non-fatal overdoses are under-reported in the USA due to current surveillance methods. Systemic gaps in overdose data limit the opportunity for data-driven prevention efforts and resource allocation. This study aims to improve overdose surveillance and community response through developing a digital platform for overdose reporting and response among harm reduction organizations. We used a community-engaged, user-center design research approach. We conducted qualitative interviews with N = 44 overdose stakeholders including people who use drugs and harm reductionists. Results highlighted the need for a unified, multilingual reporting system uniquely tailored for harm reduction organizations. Anonymity, data transparency, protection from legal repercussions, data accuracy, and community-branded marketing emerged as key themes for the overdose platform. Emergent themes included the need for real-time data in a dashboard designed for community response and tailored to first responders and harm reduction organizations. This formative study provides the groundwork for improving overdose surveillance and data-driven response through the development of an innovative overdose digital platform.

A Mixed Methods Study of the Association of Non-Veterans Affairs Care With Veterans' and Clinicians' Experiences of Care Coordination.

BACKGROUND: Poor coordination between the Department of Veterans Affairs (VA) and non-VA care may negatively impact health care quality. Recent legislation is intended to increase Veterans' access to care, in part through increased use of non-VA care. However, a possible consequence may be diminished patient experiences of coordination. OBJECTIVE: The objective of this study was to determine VA patients' and clinicians' experiences of coordination across VA and non-VA settings. DESIGN: Observational mixed methods using patient surveys and clinician interviews. Sampled patients were diagnosed with type 2 diabetes mellitus and either cardiovascular or mental health comorbidities. PARTICIPANTS AND MEASURES: Patient perspectives on coordination were elicited between April and September 2016 through a national survey supplemented with VA administrative records (N=5372). Coordination was measured with the 8-dimension Patient Perceptions of Integrated Care survey. Receipt of non-VA care was measured through patient self-report. Clinician perspectives were elicited through individual interviews (N=100) between May and October 2017. RESULTS: Veterans who received both VA and non-VA care reported significantly worse care coordination experiences than Veterans who only receive care in VA. Clinicians report limited information exchange capabilities, which, combined with bureaucratic and opaque procedures, adversely impact clinical decision-making. CONCLUSIONS: VA is working through a shift in how Veterans receive health care by increasing access to care from non-VA providers. Study findings suggest that VA should prioritize coordination of care in addition to access. This could include requiring monitoring of patient-experienced care coordination, surveys of referring and consulting clinicians, and pilot testing and evaluation of interventions to improve coordination.

Organizational Coordination and Patient Experiences of Specialty Care Integration.

BACKGROUND: Delivering care to patients with complex healthcare needs benefits from coordination among healthcare providers. Greater levels of care coordination have been associated with more favorable patient experiences, cost management, and lower utilization of services. Organizational approaches consider how systems, practices, and relationships influence coordination and associated outcomes. OBJECTIVE: Examine measures of organizational coordination and their association with patient experiences of care coordination involving specialists. DESIGN: Cross-sectional surveys of patients and primary care providers (PCPs). PARTICIPANTS: Final sample included 3183 patients matched to 233 PCPs from the Veterans Health Administration. All patients had a diagnosis of type 2 diabetes mellitus and one of four other conditions: hypertension; congestive heart failure; depression/anxiety; or severe mental illness/posttraumatic stress disorder. MAIN MEASURES: Patients completed a survey assessing perceptions of coordinated care. We examined ratings on three domains: specialist knowledge management; knowledge integration across settings and time; and knowledge fragmentation across settings and time. We created care coordination measures involving the PCP and three specialty provider types. PCPs provided ratings on relational coordination for specialists, feedback coordination, and team coordination. We aligned patient's specialty services used with corresponding PCP ratings of that specialty. KEY RESULTS: Patient ratings were significantly lower on specialist knowledge management and knowledge integration when either PCPs did not use feedback coordination (b = - .20; b = - .17, respectively) or rated feedback coordination lower (b = - .08 for both). Teamwork was significantly related to specialist knowledge management (b = .06), knowledge integration (b = .04); and knowledge fragmentation (b = - .04). Relational coordination was related to coordination between the primary care provider and (i) diabetes specialist (b = .09) and (ii) mental health provider (b = .12). CONCLUSIONS: Practices to improve provider coordination within and across primary care and specialty care services may improve patient experiences of care coordination. Improvements in these areas may improve care efficiency and effectiveness.

Survey of Patient-Centered Coordination of Care for Diabetes with Cardiovascular and Mental Health Comorbidities in the Department of Veterans Affairs.

BACKGROUND: Multiple comorbidities thought to be associated with poor coordination due to the need for shared treatment plans and active involvement of patients, among other factors. Cardiovascular and mental health comorbidities present potential coordination challenges relative to diabetes. OBJECTIVE: To determine how cardiovascular and mental health comorbidities relate to patient-centered coordinated care in the Department of Veterans Affairs. DESIGN: This observational study used a 2 × 2 factorial design to determine how cardiovascular and mental health comorbidities are associated with patient perceptions of coordinated care among patients with type 2 diabetes mellitus as a focal condition. PARTICIPANTS: Five thousand eight hundred six patients attributed to 262 primary care providers, from a national sample of 29 medical centers, who had completed an online survey of patient-centered coordinated care in the Department of Veterans Affairs (VA). MAIN MEASURES: Eight dimensions from the Patient Perceptions of Integrated Care (PPIC) survey, a state-of-the-art measure of patients' perspective on coordinated and patient-centered care. KEY RESULTS: Mental health conditions were associated with significantly lower patient experiences of coordinated care. Hypotheses for disease severity were not supported, with associations in the hypothesized direction for only one dimension. CONCLUSIONS: Results suggest that VA may be adequately addressing coordination needs related to cardiovascular conditions, but more attention could be placed on coordination for mental health conditions. While specialized programs for more severe conditions (e.g., heart failure and serious mental illness) are important, coordination is also needed for more common, less severe conditions (e.g., hypertension, depression, anxiety). Strengthening coordination for common, less severe conditions is particularly important as VA develops alternative models (e.g., community care) that may negatively impact the degree to which care is coordinated.

Let's be civil: Elaborating the link between civility climate and hospital performance.

BACKGROUND: The importance of interpersonal behavior at the workplace is increasingly recognized in the health care industry and related literature. An unresolved issue in the existing health care research is how a climate of courteous interpersonal behavior may form the foundation for strong hospital care performance. PURPOSE: The aim of this study was to test the link between a climate of courteous interpersonal behavior, termed "civility climate," and hospital care performance. We conceptualize a multidimensional model of care performance by contrasting two dimensions: performance as perceived by employees and performance as perceived by patients. Furthermore, for both performance perspectives, we test an intermediate variable (error orientation climate) that may explain the relationship between civility climate and hospital care performance. METHODOLOGY: The 2011 study sample comprised responses from 6,094 nurses and 38,627 patients at 123 Veterans Health Administration acute care inpatient hospitals in the United States. We developed and empirically tested a theoretical model using regression modeling, and we used a bootstrap method to test for mediation. RESULTS: The results indicate a direct effect of civility climate on employee perceptions of care performance and an indirect effect mediated by error orientation climate. With regard to patient perceptions of care performance, the analyses reveal a direct effect of civility climate. The indirect effect mediated by error orientation climate was not supported. PRACTICE IMPLICATIONS: Our findings point to the importance of strengthening interpersonal interactions for ensuring and improving both employees' and patients' perceptions of care, which constitute key success factors in the increasingly competitive hospital market. The insights may further stimulate discussion regarding interventions to foster a strong civility climate in hospitals.

National implementation of a trauma-informed intervention for intimate partner violence in the Department of Veterans Affairs: first year outcomes.

BACKGROUND: The U.S. Department of Veterans Affairs (VA) has recently implemented a comprehensive national program to help veterans who use or experience intimate partner violence (IPV). One important component of this plan is to implement Strength at Home (SAH), a 12-week cognitive-behavioral and trauma-informed group treatment designed to reduce and end IPV use among military and veteran populations. METHOD: The present study describes initial patient and clinician findings from the first year of a training program tasked with implementing SAH at 10 VA medical centers. RESULTS: Results from 51 veterans who completed both pre- and post-treatment assessments indicate SAH was associated with significant pre- to post-treatment reductions in the proportion of veterans who reported using physical and psychological IPV toward a partner, the types of IPV used, and posttraumatic stress disorder symptoms. Overall, veterans reported high satisfaction with the quality and nature of services received, and with the program materials. In addition, 70% of sites and 34% of the 79 clinicians trained were successful in launching the program in the first year. The mean number of days between site training and initiation of the first group session was 135.86 (SD = 63.16, range 72-252). CONCLUSIONS: Results suggest that the training and implementation program was successful overall. However, average length of time between in-person training and initiation of group services was longer than desired and there were three sites that did not successfully implement the program within the first year, suggesting a need to reduce implementation barriers and enhance institutional support.

Management of Medicare Part D Prescription Drug Plans and Medication Adherence: A Conceptual Framework and Empirical Analysis.

BACKGROUND: Although contractors that offer prescription drug plans through the Medicare Part D program are evaluated in part on enrollees' medication adherence scores, little evidence addresses contractors' ability to influence these scores. OBJECTIVE: We used data from the Centers for Medicare and Medicaid Services and US Census to investigate contractors' ability to influence their medication adherence scores. In accordance with a conceptual model, we hypothesized that contractors can directly and indirectly influence their medication adherence scores based on how effectively they manage prescription drug benefits for enrollees. We focused on 4 plan management variables: service reliability, stability/accuracy of drug prices, accessibility of prescription drugs, and availability of drug information. We examined indirect effects via enrollees' satisfaction with the plan. RESEARCH DESIGN: We conducted a cross-sectional study based on 2012 data for which the contractor was the unit of analysis. We conducted path regression models that accounted for plan type (ie, Medicare Advantage vs. stand alone) and enrollee characteristics. RESULTS: Among contractors, enrollee satisfaction scores were positively and significantly associated with medication adherence scores. Two of the 4 plan management variables were observed to have both direct and indirect effects on medication adherence scores: accessibility of prescription drugs and service reliability. CONCLUSIONS: Our study indicates that Part D contractors do appear to have some level of influence over their medication adherence scores based on how effectively they manage prescription drug benefits for enrollees. Accessibility to prescriptions and better service delivery appear important in this regard and should be explored further in future research.

Understanding collaborative care implementation in the Department of Veterans Affairs: core functions and implementation challenges.

BACKGROUND: The collaborative care model is an evidence-based practice for treatment of depression in which designated care managers provide clinical services, often by telephone. However, the collaborative care model is infrequently adopted in the Department of Veterans Affairs (VA). Almost all VA medical centers have adopted a co-located or embedded approach to integrating mental health care for primary care patients. Some VA medical centers have also adopted a telephone-based collaborative care model where depression care managers support patient education, patient activation, and monitoring of adherence and progress over time. This study evaluated two research questions: (1) What does a dedicated care manager offer in addition to an embedded-only model? (2) What are the barriers to implementing a dedicated depression care manager? METHODS: This study involved 15 qualitative, multi-disciplinary, key informant interviews at two VA medical centers where reimbursement options were the same- both with embedded mental health staff, but one with a depression care manager. Participant interviews were recorded and transcribed. Thematic analysis was used to identify descriptive and analytical themes. RESULTS: Findings suggested that some of the core functions of depression care management are provided as part of embedded-only mental health care. However, formal structural attention to care management may improve the reliability of care management functions, in particular monitoring of progress over time. Barriers to optimal implementation were identified at both sites. Themes from the care management site included finding assertive care managers to hire, cross-discipline integration and collaboration, and primary care provider burden. Themes from interviews at the embedded site included difficulty getting care management on leaders' agendas amidst competing priorities and logistics (staffing and space). CONCLUSIONS: Providers and administrators see depression care management as a valuable healthcare service that improves patient care. Barriers to implementation may be addressed by team-building interventions to improve cross-discipline integration and communication. Findings from this study are limited in scope to the VA healthcare system. Future investigation of whether alternative barriers exist in implementation of depression care management programs in non-VA hospital systems, where reimbursement rates may be a more prominent concern, would be valuable.

How personal and standardized coordination impact implementation of integrated care.

BACKGROUND: Integrating health care across specialized work units has the potential to lower costs and increase quality and access to mental health care. However, a key challenge for healthcare managers is how to develop policies, procedures, and practices that coordinate care across specialized units. The purpose of this study was to identify how organizational factors impacted coordination, and how to facilitate implementation of integrated care. METHODS: Semi-structured interviews were conducted in August 2009 with 30 clinic leaders and 35 frontline staff who were recruited from a convenience sample of 16 primary care and mental health clinics across eight medical centers. Data were drawn from a management evaluation of primary care-mental health integration in the US Department of Veterans Affairs. To protect informant confidentiality, the institutional review board did not allow quotations. RESULTS: Interviews identified antecedents of organizational coordination processes, and highlighted how these antecedents can impact the implementation of integrated care. Overall, implementing new workflow practices were reported to create conflicts with pre-existing standardized coordination processes. Personal coordination (i.e., interpersonal communication processes) between primary care leaders and staff was reported to be effective in overcoming these barriers both by working around standardized coordination barriers and modifying standardized procedures. DISCUSSION: This study identifies challenges to integrated care that might be solved with attention to personal and standardized coordination. A key finding was that personal coordination both between primary care and mental health leaders and between frontline staff is important for resolving barriers related to integrated care implementation. CONCLUSION: Integrated care interventions can involve both new standardized procedures and adjustments to existing procedures. Aligning and integrating procedures between primary care and specialty care requires personal coordination amongst leaders. Interpersonal relationships should be strengthened between staff when personal connections are important for coordinating patient care across clinical settings.

Sustainability of quality improvement following removal of pay-for-performance incentives.

BACKGROUND: Although pay-for-performance (P4P) has become a central strategy for improving quality in US healthcare, questions persist about the effectiveness of these programs. A key question is whether quality improvement that occurs as a result of P4P programs is sustainable, particularly if incentives are removed. OBJECTIVE: To investigate sustainability of performance levels following removal of performance-based incentives. DESIGN, SETTING, AND PARTICIPANTS: Observational cohort study that capitalized on a P4P program within the Veterans Health Administration (VA) that included adoption and subsequent removal of performance-based incentives for selected inpatient quality measures. The study sample comprised 128 acute care VA hospitals where performance was assessed between 2004 and 2010. INTERVENTION: VA system managers set annual performance goals in consultation with clinical leaders, and report performance scores to medical centers on a quarterly basis. These scores inform performance-based incentives for facilities and their managers. Bonuses are distributed based on the attainment of these performance goals. MEASUREMENTS: Seven quality of care measures for acute coronary syndrome, heart failure, and pneumonia linked to performance-based incentives. RESULTS: Significant improvements in performance were observed for six of seven quality of care measures following adoption of performance-based incentives and were maintained up to the removal of the incentive; subsequently, the observed performance levels were sustained. LIMITATIONS: This is a quasi-experimental study without a comparison group; causal conclusions are limited. CONCLUSION: The maintenance of performance levels after removal of a performance-based incentive has implications for the implementation of Medicare's value-based purchasing initiative and other P4P programs. Additional research is needed to better understand human and system-level factors that mediate sustainability of performance-based incentives.

Organizational Capacity for Sexual Assault Prevention Within a U.S. Army Installation.

INTRODUCTION: Preventing military sexual assault (SA) is a DoD priority. Building prevention capacity could strengthen the impact of prevention programs and improve outcomes. Capacity was conceptualized as implementation knowledge and skills using the Getting To Outcomes (GTO) process and organizational-level capacities using the Prevention Evaluation Framework, a framework that applies best practices in prevention and implementation science to prevention at the program and organizational level. The present study assesses implementation knowledge and skills currently possessed by SA prevention personnel in one U.S. Army installation with the goal of identifying preexisting proficiencies and potential gaps. The study uses the Prevention Evaluation Framework organizational-level domains to identify organizational capacities that could be improved. MATERIALS AND METHODS: Fifteen SA prevention program personnel were recruited for individual 1-hour interviews from one U.S. Army installation. A semi-structured interview guide was developed by the study team to assess knowledge and skills within the GTO framework. Applied thematic analysis guided data coding and analysis. RESULTS: Participants reported a range of proficiencies and gaps in capacity for SA prevention. Within the prevention workforce capacity, proficiencies were skill in tailoring training, and an existing train-the-trainer model. Gaps were training to facilitate difficult conversations, and an inability to tailor trainings to audience needs. Two proficiencies related to the comprehensive approach were having a victim advocate present during trainings, and providing training across leadership levels. The final proficiency involved data. Existing data sources were viewed as useful for identifying the nature and extent of local problems. However, participants reported a lack of confidence and skill in selecting appropriate outcome measures and collecting and using primary data. Gaps in leadership capacity were cultural norms, lack of trust, leader investment, logistical difficulty working with leaders, and comfort engaging with leaders. Gaps in collaborative relationships were the lack of informal networking within the SA prevention area to include civilians. CONCLUSIONS: The GTO-specific knowledge and skills of SA prevention personnel at one U.S. Army installation revealed proficiencies and gaps in organizational capacities influencing the prevention mission. Findings indicate that GTO support could be useful for improving the quality of program activities. However, results also indicate that GTO support would be more effective if they were paired with sufficient prevention infrastructure at the organizational level.

Suicide Prevention Programming: Comparing Four Prominent Frameworks.

OBJECTIVE: Suicide is a significant public health concern. About 48,000 individuals died by suicide in 2021 in the United States, and approximately one in 100 deaths globally are due to suicide. Continuing efforts in program development and evaluation are vital to preventing suicide. Multiple frameworks have been developed to reduce suicide rates, but they have not been compared to assess their comprehensiveness, nor have their components been classified. METHODS: In 2019, the authors conducted a narrative review of the literature and identified four major frameworks for suicide prevention: the U.S. Department of Veterans Affairs (VA) Suicide Prevention Program, the Defense Suicide Prevention Program of the U.S. Department of Defense, Zero Suicide in Health and Behavioral Health Care, and the technical package developed by the Centers for Disease Control and Prevention. Program components for these frameworks were identified and classified by using two prevention strategy classification systems: the National Academy of Medicine's (NAM's) continuum-of-care model and the Substance Abuse and Mental Health Services Administration's (SAMHSA's) prevention model. RESULTS: The cross-program comparison revealed that no single program included all components of suicide prevention programs. However, the VA program was the most comprehensive in terms of the number of components and their spread across prevention strategy classifications. The programs used few components categorized under NAM's promotion or selective prevention strategy classifications. The SAMHSA prevention strategy classifications of information dissemination, community-based processes, and positive alternatives were also used infrequently. CONCLUSIONS: Organizations, health care systems, and policy makers may use these findings as they develop, improve, and implement suicide prevention programs.

Provider workload and quality of care in primary care settings: moderating role of relational climate.

Primary care providers are increasingly under pressure to do more with fewer resources. We examined the effect of workload on patients' experiences of quality of care, measured through approximately 44,000 patient experience surveys in a sample of 222 primary care clinics in the Veterans Health Administration. We tested the extent to which relational climate, a measure of teamwork, moderated the relationship between workload and patient ratings of quality of care. Our outcome measures included patient complaints, time spent with provider, and overall visit quality. Workload was negatively associated with patients' quality of care ratings and relational climate moderated the relation between workload and quality of care ratings. Patients seen in clinics with higher workload and greater relational climate reported better care compared with patients in clinics with higher workload but lower relational climate. Findings highlight the importance of relational climate as an important teamwork factor when managing and developing clinic policies, practices, and procedures in resource-constrained settings.

Impact of coping style and PTSD on family functioning after deployment in Operation Desert Shield/Storm returnees.

The relationship between military combat and postdeployment family functioning difficulties has been frequently investigated in the literature, as has the relationship between types of coping and posttraumatic stress disorder (PTSD). Few studies, however, have examined these variables together, and no studies of which we are aware have examined the effect of coping on family functioning after combat exposure. This study examined coping style measured immediately after return from deployment, and PTSD symptoms and family functioning 18-24 months after return from deployment in a sample of Operation Desert Shield/Storm veterans (N = 2,949). Structural equation models suggested that the relationships between distinct coping styles on family functioning were differentially mediated by postdeployment PTSD symptoms. Results are consistent with full mediation for avoidant coping (ßdirect = -.09, p = .07; ßindirect = -.17, p < .001) and partial mediation for approach coping (ßdirect = .16, p < .001; ßindirect = .09, p < .001). Results suggest that the strategies used to cope with a combat stress event may impact both PTSD and family functioning outcomes, and highlight the potential utility of pre- and postdeployment coping skills training.

Evaluation of the Strength at Home Group Intervention for Intimate Partner Violence in the Veterans Affairs Health System.

Importance: Intimate partner violence (IPV) is a serious and prevalent public health issue that is interconnected with experiences of trauma, mental and physical health difficulties, and health disparities. Strength at Home (SAH) is a group intervention for persons using IPV in their relationships. Although previous studies have provided evidence of SAH's effectiveness in reducing IPV, its patient outcomes as implemented within organized health care have not been examined. Objective: To evaluate patient outcomes from implementation of SAH in the Department of Veterans Affairs (VA) health system. Design, Setting, and Participants: This quality improvement study evaluated patient outcomes from a national implementation and training program conducted between December 11, 2015, and September 24, 2021. Data were collected as part of treatment and submitted by clinicians at 73 VA health care facilities. Patients were 1754 veterans seeking care aimed at addressing and/or preventing their use of aggression in intimate relationships. They completed 1 pretreatment assessment and 1 follow-up assessment in the immediate weeks after group completion. Intervention: Strength at Home is a 12-week trauma-informed and cognitive behavioral group intervention to address and prevent the use of IPV in relationships. Main Outcomes and Measures: Changes in IPV were measured with the Centers for Disease Control and Prevention 2010 National Intimate Partner and Sexual Violence Survey. Changes in posttraumatic stress disorder (PTSD) symptoms were measured with the PTSD Checklist for DSM-5, and alcohol misuse was measured with the Alcohol Use Disorders Identification Test. Results: The study included 1754 participants (mean [SD] age, 44.3 [13.0] years; 1421 men [81%]), of whom 1088 (62%) were involved with the criminal legal system for IPV charges. Analyses indicate that SAH was associated with reductions in use of physical IPV (odds ratio, 3.28; percentage difference from before to after treatment, -0.17 [95% CI, -0.21 to -0.13]) and psychological IPV (odds ratio, 2.73; percentage difference from before to after treatment, -0.23 [95% CI, -0.27 to -0.19]), coercive control behaviors (odds ratio, 3.19; percentage difference from before to after treatment, -0.18 [95% CI, -0.22 to -0.14), PTSD symptoms (mean change, -4.00; 95% CI, 0.90-7.09; Hedges g = 0.10), and alcohol misuse (mean change, 2.70; 95% CI, 1.54-3.86; Hedges g = 0.24). Conclusions and Relevance: In this quality improvement study of the patient outcomes after implementation of SAH, results suggested that the program was associated with reductions in IPV behaviors, PTSD symptoms, and alcohol misuse. Results also suggest that IPV intervention in routine health care at VA health care facilities was successful; extension to other organized health care systems could be warranted.

Care transitions from the specialty to the primary care setting: A scoping literature review of potential barriers and facilitators with implications for mental health care.

BACKGROUND, AIMS AND OBJECTIVES: This scoping review aimed to understand potential barriers and facilitators in transitioning patients from specialty to primary care settings, to inform the implementation of an intervention to promote active consideration of psychiatrically stable patients for transition from the specialty mental health setting back to primary care. METHODS: Guided by Levac and colleagues' six-stage methodological framework for conducting scoping studies, we systematically searched electronic article databases for peer-reviewed literature from January 2000 to May 2016. We included identified articles that discuss findings related to potential barriers and facilitators in transitioning patients from specialty to primary care settings. We performed descriptive and thematic analyses of results to generate emergent codes and their categorizations. RESULTS: Our database search yielded 906 unique articles, 23 of which we included in our scoping review. All but one of the included studies were conducted in North America. Identified potential barriers and facilitators spanned eight emergent themes-(i) primary care accessibility, especially in terms of timely availability of appointments, (ii) clarity in respective roles of specialty care and primary care in managing a patient, (iii) timely exchange of information, (iv) transition process management, (v) perceived ability of primary care providers to manage specialty conditions, (vi) perceived ability of patients to self-manage, (vii) leadership support and (viii) support for implementing initiatives to promote transitions. CONCLUSIONS: Findings from this scoping review enable an increased understanding of current practices and considerations regarding care transitions from specialty to primary care settings. The importance of role clarification, shared clinical information systems, confidence in care competency, and adequate organizational support to promote appropriate transitions were themes most widely reported across the reviewed studies. Few studies specifically examined the transition from specialty mental health to primary care. Future studies should account for mental health-specific symptomatic patterns and recovery trajectories, such as prevalent chronicity and frequency of relapse, in planning and conducting transitions from specialty mental health back to primary care.