Exploring expanded interdisciplinary roles in goals of care conversations in a national goals of care initiative: A qualitative approach

Background: The United States Veterans Health Administration National Center for Ethics in Health Care implemented the Life-Sustaining Treatment Decisions Initiative throughout the Veterans Health Administration health care system in 2017. This policy encourages goals of care conversations, referring to conversations about patient’s treatment and end-of-life wishes for life-sustaining treatments, among Veterans with serious illnesses. A key component of the initiative is expanding interdisciplinary provider roles in having goals of care conversations. Aim: Use organizational role theory to explore medical center experiences with expanding interdisciplinary roles in the implementation of a goals of care initiative. Design: A qualitative thematic analysis of semi-structured interviews. Setting/participants: Initial participants were recruited using purposive sampling of local medical center champions. Snowball sampling identified additional participants. Participants included thirty-one interdisciplinary providers from 12 geographically diverse initiative pilot and spread medical centers. Results: Five themes were identified. Expanding provider roles in goals of care conversations (1) involves organizational culture change; (2) is influenced by medical center leadership; (3) is supported by provider role readiness; (4) benefits from cross-disciplinary role agreement; and (5) can “overwhelm” providers. Conclusions: Organizational role theory is a helpful framework for exploring interdisciplinary roles in a goals of care initiative. Support and recognition of provider role expansion in goals of care conversations was important for the adoption of a goals of care initiative. Actionable strategies, including multi-level leadership support and the use of interdisciplinary champions, facilitate role change and have potential to strengthen uptake of a goals of care initiative.

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Transformation of the US Veterans Health Administration

Health Economics Policy and Law ◽

10.1017/s1744133105001222 ◽

2006 ◽

Vol 1 (2) ◽

pp. 99-105 ◽

Cited By ~ 12

Author(s):

Jonathan B. Perlin

Keyword(s):

United States ◽

Health Care ◽

Veterans Health Administration ◽

The United States ◽

Veterans Affairs ◽

United States Department ◽

Veterans Health ◽

Department Of Veterans Affairs ◽

Health Administration ◽

The Us

Ten years ago, it would have been hard to imagine the publication of an issue of a scholarly journal dedicated to applying lessons from the transformation of the United States Department of Veterans Affairs Health System to the renewal of other countries' national health systems. Yet, with the recent publication of a dedicated edition of the Canadian journal Healthcare Papers (2005), this actually happened. Veterans Affairs health care also has been similarly lauded this past year in the lay press, being described as ‘the best care anywhere’ in the Washington Monthly, and described as ‘top-notch healthcare’ in US News and World Report's annual health care issue enumerating the ‘Top 100 Hospitals’ in the United States (Longman, 2005; Gearon, 2005).

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Adoption and Appropriateness of mHealth for Weight Management in the Real World: A Qualitative Investigation of Patient Perspectives

JMIR Formative Research ◽

10.2196/29916 ◽

2021 ◽

Vol 5 (12) ◽

pp. e29916

Author(s):

Jessica Y Breland ◽

Khizran Agha ◽

Rakshitha Mohankumar

Keyword(s):

Health Care ◽

Weight Management ◽

Real World ◽

Health Care Policy ◽

Veterans Health Administration ◽

The United States ◽

Free Access ◽

Veterans Health ◽

Perceived Fit ◽

Health Administration

Background Mobile health (mHealth) interventions for weight management can result in weight loss outcomes comparable to in-person treatments. However, there is little information on implementing these treatments in real-world settings. Objective This work aimed to answer two implementation research questions related to mHealth for weight management: (1) what are barriers and facilitators to mHealth adoption (initial use) and engagement (continued use)? and (2) what are patient beliefs about the appropriateness (ie, perceived fit, relevance, or compatibility) of mHealth for weight management? Methods We conducted semistructured interviews with patients with obesity at a single facility in an integrated health care system (the Veterans Health Administration). All participants had been referred to a new mHealth program, which included access to a live coach. We performed a rapid qualitative analysis of interviews to identify themes related to the adoption of, engagement with, and appropriateness of mHealth for weight management. Results We interviewed 24 veterans, seven of whom used the mHealth program. Almost all participants were ≥45 years of age and two-thirds were White. Rapid analysis identified three themes: (1) coaching both facilitates and prevents mHealth adoption and engagement by promoting accountability but leading to guilt among those not meeting goals; (2) preferences regarding the mode of treatment delivery, usability, and treatment content were barriers to mHealth appropriateness and adoption, including preferences for in-person care and a dislike of self-monitoring; and (3) a single invitation was not sufficient to facilitate adoption of a new mHealth program. Themes were unrelated to participants’ age, race, or ethnicity. Conclusions In a study assessing real-world use of mHealth in a group of middle-aged and older adults, we found that—despite free access to mHealth with a live coach—most did not complete the registration process. Our findings suggest that implementing mHealth for weight management requires more than one information session. Findings also suggest that focusing on the coaching relationship and how users’ lives and goals change over time may be an important way to facilitate engagement and improved health. Most participants thought mHealth was appropriate for weight management, with some nevertheless preferring in-person care. Therefore, the best way to guarantee equitable care will be to ensure multiple routes to achieving the same behavioral health goals. Veterans Health Administration patients have the option of using mHealth for weight management, but can also attend group weight management programs or single-session nutrition classes or access fitness facilities. Health care policy does not allow such access for most people in the United States; however, expanded access to behavioral weight management is an important long-term goal to ensure health for all.

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Social Context and Value-Based Care

Policy Politics & Nursing Practice ◽

10.1177/1527154417698145 ◽

2017 ◽

Vol 18 (1) ◽

pp. 26-35 ◽

Cited By ~ 3

Author(s):

Whitney A. Thurman ◽

Tracie Harrison

Keyword(s):

United States ◽

Health Care ◽

Health Disparities ◽

Social Context ◽

Veterans Health Administration ◽

The United States ◽

Capabilities Approach ◽

System Level ◽

Veterans Health ◽

Health Administration

Racial disparities in health are persistent and pervasive in the United States. Researchers and policymakers have known for decades that access to health care is not sufficient for addressing health disparities because of the socially situated roots of the disparities. We argue that the lack of progress in alleviating health disparities is the result of a lack of overarching framework to guide both policymakers and researchers in their efforts. We propose Amartya Sen’s capabilities approach as a theoretical framework that is expansive enough to address both the social context in which health occurs as well as the quality of health care provided. In this article, we use a subset of veterans receiving care from the Veterans Health Administration to review the theoretical concepts that link social inequalities with health disparities. Next, we provide empirical evidence of disparities in health based on race within the Veterans Health Administration, and we then provide a theoretical explanation for those disparities that exist at a system level. We close with a detailed examination of the applicability of the capabilities approach in addressing health disparities in the United States.

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Implementation of Evidence-Based Psychological Treatments in the Veterans Health Administration

10.1093/med:psych/9780195389050.003.0005 ◽

2015 ◽

Author(s):

Josef I. Ruzek ◽

Bradley E. Karlin ◽

Antonette Zeiss

Keyword(s):

Health Care ◽

Best Practices ◽

Veterans Health Administration ◽

The United States ◽

Evidence Based ◽

Veterans Health ◽

Health Administration ◽

Psychological Treatments ◽

Integrated Health Care System ◽

Anxiety Depression

Chapter 5 describes the innovative approaches taken to facilitate implementation and maintenance of best practices for anxiety, depression, and severe mental illness in the Veterans Health Administration, the largest integrated health care system in the United States.

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Adaptive Control of Modular Ankle Exoskeletons in Neurologically Disabled Populations#This material is based upon work supported by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, VA Maryland Health Care System, Baltimore VA Medical Center.

Adaptive Control for Robotic Manipulators ◽

10.1201/9781315166056-10 ◽

2016 ◽

pp. 172-207

Author(s):

Roy Anindo ◽

Larry Forrester ◽

Richard Macko

Keyword(s):

Health Care ◽

Adaptive Control ◽

Research And Development ◽

Health Care System ◽

Medical Center ◽

Veterans Health Administration ◽

Veterans Affairs ◽

Veterans Health ◽

Department Of Veterans Affairs ◽

Health Administration

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Adoption and Appropriateness of mHealth for Weight Management in the Real World: A Qualitative Investigation of Patient Perspectives (Preprint)

10.2196/preprints.29916 ◽

2021 ◽

Author(s):

Jessica Y Breland ◽

Khizran Agha ◽

Rakshitha Mohankumar

Keyword(s):

Health Care ◽

Weight Management ◽

Real World ◽

Health Care Policy ◽

Veterans Health Administration ◽

The United States ◽

Free Access ◽

Veterans Health ◽

Perceived Fit ◽

Health Administration

BACKGROUND Mobile health (mHealth) interventions for weight management can result in weight loss outcomes comparable to in-person treatments. However, there is little information on implementing these treatments in real-world settings. OBJECTIVE This work aimed to answer two implementation research questions related to mHealth for weight management: (1) what are barriers and facilitators to mHealth adoption (initial use) and engagement (continued use)? and (2) what are patient beliefs about the appropriateness (ie, perceived fit, relevance, or compatibility) of mHealth for weight management? METHODS We conducted semistructured interviews with patients with obesity at a single facility in an integrated health care system (the Veterans Health Administration). All participants had been referred to a new mHealth program, which included access to a live coach. We performed a rapid qualitative analysis of interviews to identify themes related to the adoption of, engagement with, and appropriateness of mHealth for weight management. RESULTS We interviewed 24 veterans, seven of whom used the mHealth program. Almost all participants were ≥45 years of age and two-thirds were White. Rapid analysis identified three themes: (1) coaching both facilitates and prevents mHealth adoption and engagement by promoting accountability but leading to guilt among those not meeting goals; (2) preferences regarding the mode of treatment delivery, usability, and treatment content were barriers to mHealth appropriateness and adoption, including preferences for in-person care and a dislike of self-monitoring; and (3) a single invitation was not sufficient to facilitate adoption of a new mHealth program. Themes were unrelated to participants’ age, race, or ethnicity. CONCLUSIONS In a study assessing real-world use of mHealth in a group of middle-aged and older adults, we found that—despite free access to mHealth with a live coach—most did not complete the registration process. Our findings suggest that implementing mHealth for weight management requires more than one information session. Findings also suggest that focusing on the coaching relationship and how users’ lives and goals change over time may be an important way to facilitate engagement and improved health. Most participants thought mHealth was appropriate for weight management, with some nevertheless preferring in-person care. Therefore, the best way to guarantee equitable care will be to ensure multiple routes to achieving the same behavioral health goals. Veterans Health Administration patients have the option of using mHealth for weight management, but can also attend group weight management programs or single-session nutrition classes or access fitness facilities. Health care policy does not allow such access for most people in the United States; however, expanded access to behavioral weight management is an important long-term goal to ensure health for all.

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Development of Predictive Informatics Tool Using Electronic Health Records to Inform Personalized Evidence-Based Pressure Injury Management for Veterans with Spinal Cord Injury

Military Medicine ◽

10.1093/milmed/usaa469 ◽

2021 ◽

Vol 186 (Supplement_1) ◽

pp. 651-658

Author(s):

Kath M Bogie ◽

Steven K Roggenkamp ◽

Ningzhou Zeng ◽

Jacinta M Seton ◽

Katelyn R Schwartz ◽

...

Keyword(s):

Risk Factors ◽

Health Care ◽

Spinal Cord ◽

Spinal Cord Injury ◽

User Interface ◽

Veterans Health Administration ◽

Study Cohort ◽

Veterans Health ◽

Health Administration ◽

Cord Injury

ABSTRACT Background Pressure injuries (PrI) are serious complications for many with spinal cord injury (SCI), significantly burdening health care systems, in particular the Veterans Health Administration. Clinical practice guidelines (CPG) provide recommendations. However, many risk factors span multiple domains. Effective prioritization of CPG recommendations has been identified as a need. Bioinformatics facilitates clinical decision support for complex challenges. The Veteran’s Administration Informatics and Computing Infrastructure provides access to electronic health record (EHR) data for all Veterans Health Administration health care encounters. The overall study objective was to expand our prototype structural model of environmental, social, and clinical factors and develop the foundation for resource which will provide weighted systemic insight into PrI risk in veterans with SCI. Methods The SCI PrI Resource (SCI-PIR) includes three integrated modules: (1) the SCIPUDSphere multidomain database of veterans’ EHR data extracted from October 2010 to September 2015 for ICD-9-CM coding consistency together with tissue health profiles, (2) the Spinal Cord Injury Pressure Ulcer and Deep Tissue Injury Ontology (SCIPUDO) developed from the cohort’s free text clinical note (Text Integration Utility) notes, and (3) the clinical user interface for direct SCI-PIR query. Results The SCI-PIR contains relevant EHR data for a study cohort of 36,626 veterans with SCI, representing 10% to 14% of the U.S. population with SCI. Extracted datasets include SCI diagnostics, demographics, comorbidities, rurality, medications, and laboratory tests. Many terminology variations for non-coded input data were found. SCIPUDO facilitates robust information extraction from over six million Text Integration Utility notes annually for the study cohort. Visual widgets in the clinical user interface can be directly populated with SCIPUDO terms, allowing patient-specific query construction. Conclusion The SCI-PIR contains valuable clinical data based on CPG-identified risk factors, providing a basis for personalized PrI risk management following SCI. Understanding the relative impact of risk factors supports PrI management for veterans with SCI. Personalized interactive programs can enhance best practices by decreasing both initial PrI formation and readmission rates due to PrI recurrence for veterans with SCI.

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Predictors of Veterans Health Administration utilization and pain persistence among soldiers treated for postdeployment chronic pain in the Military Health System

BMC Health Services Research ◽

10.1186/s12913-021-06536-8 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Rachel Sayko Adams ◽

Esther L. Meerwijk ◽

Mary Jo Larson ◽

Alex H. S. Harris

Keyword(s):

Mental Health ◽

Health Care ◽

Chronic Pain ◽

Veterans Health Administration ◽

First Year ◽

Veterans Health ◽

Health Administration ◽

Military Health System ◽

Military Health ◽

The Military

Abstract Background Chronic pain presents a significant burden for both federal health care systems designed to serve combat Veterans in the United States (i.e., the Military Health System [MHS] and Veterans Health Administration [VHA]), yet there have been few studies of Veterans with chronic pain that have integrated data from both systems of care. This study examined 1) health care utilization in VHA as an enrollee (i.e., linkage to VHA) after military separation among soldiers with postdeployment chronic pain identified in the MHS, and predictors of linkage, and 2) persistence of chronic pain among those utilizing the VHA. Methods Observational, longitudinal study of soldiers returning from a deployment in support of the Afghanistan/Iraq conflicts in fiscal years 2008–2014. The analytic sample included 138,206 active duty soldiers for whom linkage to VHA was determined through FY2019. A Cox proportional hazards model was estimated to examine the effects of demographic characteristics, military history, and MHS clinical characteristics on time to linkage to VHA after separation from the military. Among the subpopulation of soldiers who linked to VHA, we described whether they met criteria for chronic pain in the VHA and pain management treatments received during the first year in VHA. Results The majority (79%) of soldiers within the chronic pain cohort linked to VHA after military separation. Significant predictors of VHA linkage included: VHA utilization as a non-enrollee prior to military separation, separating for disability, mental health comorbidities, and being non-Hispanic Black or Hispanic. Soldiers that separated because of misconduct were less likely to link than other soldiers. Soldiers who received nonpharmacological treatments, opioids/tramadol, or mental health treatment in the MHS linked earlier to VHA than soldiers who did not receive these treatments. Among those who enrolled in VHA, during the first year after linking to the VHA, 49.7% of soldiers met criteria for persistent chronic pain in VHA. Conclusions The vast majority of soldiers identified with chronic pain in the MHS utilized care within VHA after military separation. Careful coordination of pain management approaches across the MHS and VHA is required to optimize care for soldiers with chronic pain.

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