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Patzel M, Barnes C, Ramalingam N, Gunn R, Kenzie ES, Ono SS, Davis MM. Jumping Through Hoops: Community Care Clinician and Staff Experiences Providing Primary Care to Rural Veterans. J Gen Intern Med 2023:10.1007/s11606-023-08126-2. [PMID: 37340259 DOI: 10.1007/s11606-023-08126-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 02/24/2023] [Indexed: 06/22/2023]
Abstract
BACKGROUND The 2019 VA Maintaining Systems and Strengthening Integrated Outside Networks Act, or MISSION Act, aimed to improve rural veteran access to care by expanding coverage for services in the community. Increased access to clinicians outside the US Department of Veterans Affairs (VA) could benefit rural veterans, who often face obstacles obtaining VA care. This solution, however, relies on clinics willing to navigate VA administrative processes. OBJECTIVE To investigate the experiences rural, non-VA clinicians and staff have while providing care to rural veterans and inform challenges and opportunities for high-quality, equitable care access and delivery. DESIGN Phenomenological qualitative study. PARTICIPANTS Non-VA-affiliated primary care clinicians and staff in the Pacific Northwest. APPROACH Semi-structured interviews with a purposive sample of eligible clinicians and staff between May and August 2020; data analyzed using thematic analysis. KEY RESULTS We interviewed 13 clinicians and staff and identified four themes and multiple challenges related to providing care for rural veterans: (1) Confusion, variability and delays for VA administrative processes, (2) clarifying responsibility for dual-user veteran care, (3) accessing and sharing medical records outside the VA, and (4) negotiating communication pathways between systems and clinicians. Informants reported using workarounds to combat challenges, including using trial and error to gain expertise in VA system navigation, relying on veterans to act as intermediaries to coordinate their care, and depending on individual VA employees to support provider-to-provider communication and share system knowledge. Informants expressed concerns that dual-user veterans were more likely to have duplication or gaps in services. CONCLUSIONS Findings highlight the need to reduce the bureaucratic burden of interacting with the VA. Further work is needed to tailor structures to address challenges rural community providers experience and to identify strategies to reduce care fragmentation across VA and non-VA providers and encourage long-term commitment to care for veterans.
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Affiliation(s)
- Mary Patzel
- Oregon Rural Practice-Based Research Network, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Mail Code: L222, Portland, OR, 97239, USA.
| | - Chrystal Barnes
- Oregon Rural Practice-Based Research Network, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Mail Code: L222, Portland, OR, 97239, USA
| | - NithyaPriya Ramalingam
- Oregon Rural Practice-Based Research Network, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Mail Code: L222, Portland, OR, 97239, USA
| | | | - Erin S Kenzie
- Oregon Rural Practice-Based Research Network, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Mail Code: L222, Portland, OR, 97239, USA
| | - Sarah S Ono
- Department of Veterans Affairs Office of Rural Health, Veteran Rural Health Resources Center, Portland, OR, USA
- Department of Psychiatry, Oregon Health & Science University, Portland, OR, USA
| | - Melinda M Davis
- Oregon Rural Practice-Based Research Network, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Mail Code: L222, Portland, OR, 97239, USA
- Department of Family Medicine and OHSU-PSU School of Public Health, Oregon Health & Science University, Portland, OR, USA
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Phelps A, Lawrence-Wood E, Couineau AL, Hinton M, Dolan P, Smith P, Notarianni M, Forbes D, Hosseiny F. Mental Health Reform: Design and Implementation of a System to Optimize Outcomes for Veterans and Their Families. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:12681. [PMID: 36231981 PMCID: PMC9565186 DOI: 10.3390/ijerph191912681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 09/23/2022] [Accepted: 09/30/2022] [Indexed: 06/16/2023]
Abstract
The social, health, and economic burden of mental health problems in the veteran community is heavy. Internationally, the array of services and support available to veterans and their families are extensive but vary in quality, are often disconnected, complex to navigate, and lack clear coordination. This paper describes a conceptual framework to guide the design and implementation of a system of services and supports to optimize the mental health and wellbeing of all veterans and their families. The framework recognizes the diversity of veterans across intersecting identities that uniquely shape experiences of posttraumatic mental health and wellbeing. It brings together several strands of research: the values and principles that should underpin the system; the needs of diverse veterans and their families; challenges in the current services and supports; evidence-based interventions; and principles of effective implementation. Central to the future system design is a next generation stepped model of care that organizes best and next practice interventions in a coherent system, matches service provision to level of need and addresses access and navigation. Practical guidance on implementation provides an aspirational and flexible structure for system evolution, and a template for all stakeholders-individuals, groups, agencies and organizations-to effect system change.
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Affiliation(s)
- Andrea Phelps
- Phoenix Australia—Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Melbourne 3053, Australia
| | - Ellie Lawrence-Wood
- Phoenix Australia—Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Melbourne 3053, Australia
| | - Anne-Laure Couineau
- Phoenix Australia—Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Melbourne 3053, Australia
| | - Mark Hinton
- Phoenix Australia—Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Melbourne 3053, Australia
| | - Paul Dolan
- Phoenix Australia—Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Melbourne 3053, Australia
| | - Patrick Smith
- Atlas Institute for Veterans and Families, Ottawa, ON K1Z 7K4, Canada
| | | | - David Forbes
- Phoenix Australia—Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Melbourne 3053, Australia
| | - Fardous Hosseiny
- Atlas Institute for Veterans and Families, Ottawa, ON K1Z 7K4, Canada
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Gilmartin HM, Warsavage T, Hines A, Leonard C, Kelley L, Wills A, Gaskin D, Ujano-De Motta L, Connelly B, Plomondon ME, Yang F, Kaboli P, Burke RE, Jones CD. Effectiveness of the rural transitions nurse program for Veterans: A multicenter implementation study. J Hosp Med 2022; 17:149-157. [PMID: 35504490 DOI: 10.1002/jhm.12802] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 01/27/2022] [Accepted: 02/01/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Veterans are often transferred from rural areas to urban VA Medical Centers for care. The transition from hospital to home is vulnerable to postdischarge adverse events. OBJECTIVE To evaluate the effectiveness of the rural Transitions Nurse Program (TNP). DESIGN, SETTING, AND PARTICIPANTS National hybrid-effectiveness-implementation study, within site propensity-matched cohort in 11 urban VA hospitals. 3001 Veterans were enrolled in TNP from April 2017 to September 2019, and 6002 matched controls. INTERVENTION AND OUTCOMES The intervention was led by a transitions nurse who assessed discharge readiness, provided postdischarge communication with primary care providers (PCPs), and called the Veteran within 72 h of discharge home to assess needs, and encourage follow-up appointment attendance. Controls received usual care. The primary outcomes were PCP visits within 14 days of discharge and all-cause 30-day readmissions. Secondary outcomes were 30-day emergency department (ED) visits and 30-day mortality. Patients were matched by length of stay, prior hospitalizations and PCP visits, urban/rural status, and 32 Elixhauser comorbidities. RESULTS The 3001 Veterans enrolled in TNP were more likely to see their PCP within 14 days of discharge than 6002 matched controls (odds ratio = 2.24, 95% confidence interval [CI] = 2.05-2.45). TNP enrollment was not associated with reduced 30-day ED visits or readmissions but was associated with reduced 30-day mortality (hazard ratio = 0.33, 95% CI = 0.21-0.53). PCP and ED visits did not have a significant mediating effect on outcomes. The observational design, potential selection bias, and unmeasurable confounders limit causal inference. CONCLUSIONS TNP was associated with increased postdischarge follow-up and a mortality reduction. Further investigation to understand the reduction in mortality is needed.
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Affiliation(s)
- Heather M Gilmartin
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
- Department of Health Systems, Management and Policy, School of Public Health, University of Colorado, Aurora, Colorado, USA
| | - Theodore Warsavage
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
| | - Anne Hines
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
| | - Chelsea Leonard
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
| | - Lynette Kelley
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
| | - Ashlea Wills
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
| | - David Gaskin
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
| | - Lexus Ujano-De Motta
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
| | - Brigid Connelly
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
| | - Mary E Plomondon
- Clinical Assessment Reporting and Tracking Program, Office of Quality and Patient Safety, Veterans' Health Administration, Washington, District of Columbia, USA
| | - Fan Yang
- Department of Biostatistics and Informatics, School of Public Health, University of Colorado, Aurora, Colorado, USA
| | - Peter Kaboli
- Research Department, Veterans Rural Health Resource Center-Iowa City, VA Office of Rural Health, and Center for Access and Delivery Research and Evaluation (CADRE) at the Iowa City VA Healthcare System, Iowa City, Iowa, USA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Robert E Burke
- Research Department, Center for Health Equity Research and Promotion, Corporal Crescenz Veterans Health Administration Medical Center, Philadelphia, Pennsylvania, USA
- Hospital Medicine Section - Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Christine D Jones
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
- Division of Hospital Medicine, Department of Medicine, Anschutz Medical Campus, University of Colorado, Aurora, Colorado, USA
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Giannitrapani KF, Silveira MJ, Azarfar A, Glassman PA, Singer SJ, Asch SM, Midboe AM, Zenoni MA, Gamboa RC, Becker WC, Lorenz KA. Cross Disciplinary Role Agreement is Needed When Coordinating Long-Term Opioid Prescribing for Cancer: a Qualitative Study. J Gen Intern Med 2021; 36:1867-1874. [PMID: 33948790 PMCID: PMC8298631 DOI: 10.1007/s11606-021-06747-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 03/18/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Cancer pain is highly prevalent and often managed in primary care or by oncology providers in combination with primary care providers. OBJECTIVES To understand interdisciplinary provider experiences coordinating opioid pain management for patients with chronic cancer-related pain in a large integrated healthcare system. DESIGN Qualitative research. PARTICIPANTS We conducted 20 semi-structured interviews with interdisciplinary providers in two large academically affiliated VA Medical Centers and their associated community-based outpatient clinics. Participants included primary care providers (PCPs) and oncology-based personnel (OBPs). APPROACH We deductively identified 94 examples of care coordination for cancer pain in the 20 interviews. We secondarily used an inductive open coding approach and identified themes through constant comparison coming to research team consensus. RESULTS Theme 1: PCPs and OBPs generally believed one provider should handle all opioid prescribing for a specific patient, but did not always agree on who that prescriber should be in the context of cancer pain. Theme 2: There are special circumstances where having multiple prescribers is appropriate (e.g., a pain crisis). Theme 3: A collaborative process to opioid cancer pain management would include real-time communication and negotiation between PCPs and oncology around who will handle opioid prescribing. Theme 4: Providers identified multiple barriers in coordinating cancer pain management across disciplines. CONCLUSIONS Our findings highlight how real-time negotiation about roles in opioid pain management is needed between interdisciplinary clinicians. Lack of cross-disciplinary role agreement may result in delays in clinically appropriate cancer pain management.
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Affiliation(s)
- K F Giannitrapani
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA. .,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA.
| | - M J Silveira
- Geriatric Research Education Clinical Center (GRECC), Ann Arbor VA Health Care System, University of Michigan, Ann Arbor, MI, USA.,Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - A Azarfar
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA.,University of Central Florida, Orlando, FL, USA
| | - P A Glassman
- Pharmacy Benefits Management Services, Department of Veterans Affairs, Washington, DC, USA.,Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - S J Singer
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - S M Asch
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - A M Midboe
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - M A Zenoni
- Pain Research Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Health Care System, West Haven, CT, USA.,Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - R C Gamboa
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - W C Becker
- Pain Research Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Health Care System, West Haven, CT, USA.,Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - K A Lorenz
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
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Wagner TH, Lo J, Beilstein-Wedel E, Vanneman ME, Shwartz M, Rosen AK. Estimating the Cost of Surgical Care Purchased in the Community by the Veterans Health Administration. MDM Policy Pract 2021; 6:23814683211057902. [PMID: 34820527 PMCID: PMC8606928 DOI: 10.1177/23814683211057902] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 10/18/2021] [Indexed: 11/29/2022] Open
Abstract
Background. Veterans' access to Veterans Affairs (VA)-purchased community care expanded due to large increases in funding provided in the 2014 Veterans Choice Act. Objectives. To compare costs between VA-delivered care and VA payments for purchased care for two commonly performed surgeries: total knee arthroplasties (TKAs) and cataract surgeries. Research Design. Descriptive statistics and regressions examining costs in VA-delivered and VA-purchased care (fiscal year [FY] 2018 [October 2017 to September 2018]). Subjects. A total of 13,718 TKAs, of which 6,293 (46%) were performed in VA. A total of 91,659 cataract surgeries, of which 65,799 (72%) were performed in VA. Measures. Costs of VA-delivered care based on activity-based cost estimates; costs of VA-purchased care based on approved and paid claims. Results. Ninety-eight percent of VA-delivered TKAs occurred in inpatient hospitals, with an average cost of $28,969 (SD $10,778). The majority (86%) of VA-purchased TKAs were also performed at inpatient hospitals, with an average payment of $13,339 (SD $23,698). VA-delivered cataract surgeries were performed at hospitals as outpatient procedures, with an average cost of $4,301 (SD $2,835). VA-purchased cataract surgeries performed at hospitals averaged $1,585 (SD $629); those performed at ambulatory surgical centers cost an average of $1,346 (SD $463). We also found significantly higher Nosos risk scores for patients who used VA-delivered versus VA-purchased care. Conclusions. Costs of VA-delivered care were higher than payments for VA-purchased care, but this partly reflects legislative caps limiting VA payments to community providers to Medicare amounts. Higher patient risk scores in the VA could indicate that community providers are reluctant to accept high-risk patients because of Medicare reimbursements, or that VA providers prefer to keep the more complex patients in VA.
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Affiliation(s)
- Todd H. Wagner
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California
- Department of Surgery, Stanford University, Stanford, California
| | - Jeanie Lo
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California
| | - Erin Beilstein-Wedel
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts
| | - Megan E. Vanneman
- Informatics, Decision-Enhancement and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
- Division of Health System Innovation and Research, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah
| | - Michael Shwartz
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts
| | - Amy K. Rosen
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts
- Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
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Penney LS, Moreau JL, Miake-Lye I, Lewis D, D'Amico A, Lee K, Scott B, Kirsh S, Cordasco KM. Spreading the Veterans Health Administration's emergency department rapid access clinics (ED-RAC) innovation: Role of champions and local contexts. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2021; 9:100516. [PMID: 33384257 DOI: 10.1016/j.hjdsi.2020.100516] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Revised: 09/11/2020] [Accepted: 12/21/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Champions frequently facilitate change in healthcare, but the literature lacks specificity regarding champion activities and interactions with local contexts. The Veterans' Health Administration (VA) Emergency Department (ED) Rapid Access Clinic (ED-RAC) initiative used champions to spread an innovation aimed at achieving timely specialty follow-up care for ED patients. We assessed the roles champions and local contexts played in successful ED-RAC spread in the initiative's first year. METHODS Our mixed method formative evaluation included serial questionnaires, fieldnotes from meetings, and champion interviews. We analyzed qualitative data from spread site rapid and non-rapid implementers, assessing champion and contextual factors. RESULTS Among 24 participating VA sites, 11 were rapid implementers (i.e., implemented ED-RAC in first year), 13 were not. Site champions at rapid sites described crossing multiple organizational units to get tasks accomplished (e.g., gaining buy-in, requesting resources); champions at non-rapid sites experienced inter-departmental communication challenges and competing demands. Champions at rapid and non-rapid sites encountered similar context-related barriers (e.g. scheduling complexities) and facilitators (e.g. enthusiastic buy-in), but differed in leadership and resource barriers. CONCLUSIONS Identifying site champions was not enough to assure rapid innovation spread. Interdependencies between ED-RAC implementation requirements (e.g., boundary spanning, resources) and champion and contextual factors helped explain variations in progress. IMPLICATIONS Tailoring spread support to champion and contextual factors may facilitate more rapid spread of innovations.
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Affiliation(s)
- Lauren S Penney
- Veterans Evidence-Based Research Dissemination Implementation Center, South Texas Veterans Health Care System, San Antonio, TX, USA; Department of Medicine, University of Texas Health San Antonio, San Antonio, TX, USA.
| | - Jessica L Moreau
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Isomi Miake-Lye
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Davis Lewis
- VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | | | - Kelli Lee
- VA Office of Healthcare Transformation, Pittsburgh, PA, USA
| | - Brianna Scott
- VA Pittsburgh Healthcare System, Pittsburgh, PA, USA; VA Office of Healthcare Transformation, Pittsburgh, PA, USA
| | - Susan Kirsh
- Office of Veterans Access to Care, Veterans Health Administration, Washington, DC, USA; Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA
| | - Kristina M Cordasco
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA; Department of Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA; Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
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Coughlin LN, Bonar EE, Bickel WK. Considerations for remote delivery of behavioral economic interventions for substance use disorder during COVID-19 and beyond. J Subst Abuse Treat 2020; 120:108150. [PMID: 33298296 PMCID: PMC7532990 DOI: 10.1016/j.jsat.2020.108150] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 08/10/2020] [Accepted: 09/22/2020] [Indexed: 12/24/2022]
Abstract
The response to the COVID-19 crisis has created direct pressure on health care providers to deliver virtual care, and has created the opportunity to develop innovations in remote treatment for people with substance use disorders. Remote treatments provide an intervention delivery framework that capitalizes on technological innovations in remote monitoring of behaviors and can efficiently use information collected from people and their environment to provide personalized treatments as needed. Interventions informed by behavioral economic theories can help to harness the largely untapped potential of virtual care in substance use treatment. Behavioral economic treatments, such as contingency management, the substance-free activity session, and episodic future thinking, are positioned to leverage remote monitoring of substance use and to use personalized medicine frameworks to deliver remote interventions in the COVID-19 era and beyond. With increased remote care, there is an opportunity for virtual treatment development. Treatments can capitalize on remote technology to increase effectiveness. Behavioral economic interventions are well positioned to fill this need. Remote behavioral economic interventions can add to current treatments.
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Affiliation(s)
- Lara N Coughlin
- Addiction Center, Department of Psychiatry, University of Michigan, United States of America.
| | - Erin E Bonar
- Addiction Center, Department of Psychiatry, University of Michigan, United States of America; Injury Prevention Center, University of Michigan, United States of America
| | - Warren K Bickel
- Fralin Biomedical Research Institute at Virginia Tech, United States of America
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Napolitano MA, Sparks AD, Randall JA, Brody FJ, Duncan JE. Elective surgery for diverticular disease in U.S. veterans: A VASQIP study of national trends and outcomes from 2004 to 2018. Am J Surg 2020; 221:1042-1049. [PMID: 32938529 DOI: 10.1016/j.amjsurg.2020.08.050] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/31/2020] [Accepted: 08/25/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND Treatment for diverticular disease has evolved over time. In the United States, there has been a trend towards minimally invasive surgical approaches and fewer postoperative complications, but no study has investigated this subject in the Veterans Health Administration. METHODS This retrospective review identified patients undergoing elective surgery for diverticular disease from 2004 to 2018. Demographics, comorbidities, operative approach, rates of ostomy creation, and 30-day outcomes were compared. The 15-year time period was divided into 3-year increments to assess changes over time. RESULTS 4198 patients were identified. Complication rate decreased significantly over time (28.1%-15.7%, p < 0.001), as did infectious complications (21.5-6.3%, p < 0.001). Median hospital length-of-stay decreased from 7 to 5 days (p < 0.001). Rates of laparoscopic surgery increased over time (17.7%-48.1%, p < 0.001). CONCLUSIONS Increased utilization of laparoscopy in veterans undergoing elective surgery for diverticular disease coincided with fewer complications and a shorter length-of-stay. These trends mirror outcomes reported in non-veterans.
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Affiliation(s)
- Michael A Napolitano
- Department of Surgery, Washington, D.C. Veterans Affairs Medical Center. 50 Irving St.NW, Suite 2B-100, Washington, DC, 20422, USA; Department of Surgery, George Washington University, 2150 Pennsylvania Ave Suite 6B. Washington, DC, 20037, USA.
| | - Andrew D Sparks
- Department of Surgery, George Washington University, 2150 Pennsylvania Ave Suite 6B. Washington, DC, 20037, USA.
| | - J Alex Randall
- Stritch School of Medicine, Loyola University Chicago, 2160 S 1st Ave, Maywood, IL, 60153, USA.
| | - Fred J Brody
- Department of Surgery, Washington, D.C. Veterans Affairs Medical Center. 50 Irving St.NW, Suite 2B-100, Washington, DC, 20422, USA.
| | - James E Duncan
- Department of Surgery, Washington, D.C. Veterans Affairs Medical Center. 50 Irving St.NW, Suite 2B-100, Washington, DC, 20422, USA.
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Schlosser J, Kollisch D, Johnson D, Perkins T, Olson A. VA-Community Dual Care: Veteran and Clinician Perspectives. J Community Health 2020; 45:795-802. [PMID: 32112237 PMCID: PMC7319870 DOI: 10.1007/s10900-020-00795-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Many veterans receive care in both community settings and the VA. Recent legislation has increased veteran access to community providers, raising concerns about safety and coordination. This project aimed to understand the benefits and challenges of dual care from the perceptions of both the Veterans their clinicians. We conducted surveys and focus groups of veterans who use both VA and community care in VT and NH. We also conducted a web-based survey and a focus group involving primary care clinicians from both settings. The main measures included (1) reasons that veterans seek care in both settings; (2) problems faced by veterans and clinicians; (3) association of health status and ease of managing care with sites of primary care; and (4) association of veteran rurality with dual care experiences. The primary reasons veterans reported for using both VA and community care were (1) for convenience, (2) to access needed services, and (3) to get a second opinion. Veterans reported that community and VA providers were informed about the others' care more than half the time. Veterans in isolated rural towns reported better overall health and ease of managing their care. VA and community primary care clinicians reported encountering systems problems with dual-care including communicating medication changes, sharing lab and imaging results, communicating with specialists, sharing discharge summaries and managing medication renewals. Both Veterans and their primary clinicians report substantial system issues in coordinating care between the VA and the community, raising the potential for significant patient safety and Veteran satisfaction concerns.
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Affiliation(s)
- James Schlosser
- VA New England Healthcare System, the Manchester VA Medical Center, Manchester, USA.
- , Concord, USA.
| | - Donald Kollisch
- VA New England Healthcare System, the White River Junction VA Medical Center, White River Junction, USA
- Geisel School of Medicine At Dartmouth, Hanover, USA
| | | | - Troi Perkins
- Nicholas School of the Environment, Duke University, Durham, USA
| | - Ardis Olson
- Geisel School of Medicine At Dartmouth, Hanover, USA
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10
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Cordasco KM, Hynes DM, Mattocks KM, Bastian LA, Bosworth HB, Atkins D. Improving Care Coordination for Veterans Within VA and Across Healthcare Systems. J Gen Intern Med 2019; 34:1-3. [PMID: 31098970 PMCID: PMC6542920 DOI: 10.1007/s11606-019-04999-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Kristina M Cordasco
- VA Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation and Policy, Los Angeles, CA, USA.
- Division of General Internal Medicine, Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
- Department of Medicine, University of California Los Angeles (UCLA) Geffen School of Medicine, Los Angeles, CA, USA.
| | - Denise M Hynes
- Center to Improve Veteran Involvement in Care, Portland VA Health Care System, Portland, OR, USA
- College of Public Health and Human Sciences, Oregon State University, Corvallis, OR, USA
| | - Kristin M Mattocks
- VA Central Western Massachusetts, Leeds, MA, USA
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Lori A Bastian
- Pain Research, Informatics, Multimorbidities and Education Center, VA Connecticut, West Haven, CT, USA
- Division of General Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Hayden B Bosworth
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Medical Center, Durham, NC, USA
- Departments of Population Health Sciences, Medicine, Psychiatry, and School of Nursing, Duke University, Durham, NC, USA
| | - David Atkins
- VA Health Services Research and Development Services, Office of Research and Development, Washington, DC, USA
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