Abstract
Implementation strategies are activities to support integration of evidence-based programs (EBPs) into routine care. Comprised of 170+ facilities, the Veterans Affairs Healthcare System is ...conducive to evaluating feasibility and scalability of implementation strategies on a national level. In previous work evaluating implementation of three EBPs for older Veterans (hospital-based walking, caregiver skills training, group physical therapy), we found facilities varied in their need for implementation support, with some needing minimal guidance and others requiring intensive support. Committed to national scalability, our team developed an implementation intensification model consisting of foundational (low-touch) and enhanced (high-touch) implementation support. This Forum article describes our multilevel and multistep process to develop and evaluate implementation intensification. Steps included (a) review completed trial data; (b) conduct listening sessions; (c) review literature; (d) draft foundational and enhanced implementation support packages; (e) iteratively refine packages; and (7) devise an evaluation plan. Our model of implementation intensification may be relevant to other health care systems seeking strategies that can adapt to diverse delivery settings, optimize resources, help build capacity, and ultimately enhance implementation outcomes. As more health care systems focus on spread of EBPs into routine care, identifying scalable and effective implementation strategies will be critical.
Low back pain (LBP) continues to be a challenging condition to manage effectively. Recent guideline recommendations stress providing non-pharmacological care early, limiting diagnostic testing, and ...reducing exposure to opioid pain medications. However, there has been little uptake of these guideline recommendations by providers, patients or health systems, resulting in care that is neither effective nor safe. This paper describes the framework for an evidence-based pathway that would transform service delivery for LBP in the United States by creating changes that facilitate the delivery of guideline adherent care. An evidence informed clinical service pathway would be intentionally structured to include; a) direct linkages to community and population based resources that facilitate self-management, b) foundational LBP care that is appropriate for all seeking care, c) individualized LBP care for those who have persistent symptoms, and d) specialized LBP care for instances when advanced diagnostics and intensive treatments are indicated. There is an urgent need to transform LBP care by optimizing clinical care pathways focused on multiple opportunities for non-pharmacological treatments, carefully considering escalation of care, and facilitating self-management. Such approaches have the potential to increase patient access to guideline adherent LBP care as an alternative to opioids, unwarranted diagnostic tests, and unnecessary surgery.
Alzheimer's Disease and Other Related Dementias (AD/ADRD) leads to frequent emergency department (ED) and inpatient use. Mental health symptoms among persons with AD/ADRD increases cognitive and ...functional disabilities and could contribute to these high rates of intensive health care use. The objective of this paper is to assess the relationship of mental illness on 12-month patterns in hospitalization and ED use among Veterans aged 65 and over with a new AD/ADRD diagnosis.
We used an existing dataset of administrative electronic health record data of Veterans with AD/ADRD from the US Veterans Health Administration linked with Medicare claims data from 2011-2015. We use multivariable logistic regression to examine the association between no pre-existing mental illness, pre-existing mental illness (e.g., major depressive disorder, generalized anxiety disorder, or post-traumatic stress disorder), and pre-existing severe mental illness-or SMI-(e.g., bipolar disorder, major depressive disorder with psychosis, or schizophrenia) and 12- month ED and hospitalization use and readmissions among Veterans who had an initial hospitalization visit. We estimated predicted probabilities, differential effect, and associated 95% confidence intervals.
In our sample, 1.4% had SMI and 11% had non-SMI mental illness. The unadjusted percentage with inpatient and ED use was higher among Veterans with SMI (34% and 26%, respectively) and Veterans with non-SMI mental illness (20%, 16%) compared with Veterans without pre-existing mental illness (12%, 9%). Compared to individuals with no pre-existing mental illness, having a pre-existing mental illness (1.27 percentage points, 95% CI: 0.76, 1.78) and a pre-existing SMI (7.17 percentage points, 95% CI: 5.66, 8.69) were both associated with an increased likelihood of ED use. The same pattern was observed for any inpatient use (mental illness 2.18, 95% CI: 1.59, 2.77; SMI 9.91, 95% CI: 8.21, 11.61). Only pre-existing SMI was associated higher hospitalization readmission.
Pre-existing mental illness increases use of high cost, intensive health care and this association is higher of more severe mental health conditions. We also show that pre-existing mental illness exerts a unique influence, above and beyond other comorbidities, such as diabetes, on ED and inpatient visits. More needs to be done to increase recognition of the unique risks of this combination of health conditions and encourage strategies to address them. Developing, testing, and implementing comprehensive strategies that address the intersection of ADRD and mental illness is promising approach that requires more focused attention.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Abstract
Objective
The purpose of this study was to describe the referrals and use of a hybrid care model for low back pain that includes on-site care by physical therapists, physical activity ...training, and psychologically informed practice (PiP) delivered by telehealth in the Improving Veteran Access to Integrated Management of Low Back Pain (AIM-Back) trial.
Methods
Data were collected from November 2020 through February 2023 from 5 Veteran Health Administration clinics participating in AIM-Back, a multisite, cluster-randomized embedded pragmatic trial. The authors extracted data from the Veteran Health Administration Corporate Data Warehouse to describe referral and enrollment metrics, telehealth use (eg, distribution of physical activity and PiP calls), and treatments used by physical therapists and telehealth providers.
Results
Seven hundred one veterans were referred to the AIM-Back trial with 422 enrolling in the program (consult-to-enrollment rate = 60.2%). After travel restrictions were lifted, site visits resulted in a significant increase in referrals and a number of new referring providers. At initial evaluation by on-site physical therapists, 92.2% of veterans received pain modulation (eg, transcutaneous electrical nerve stimulation, manual therapy). Over 81% of enrollees completed at least 1 telehealth physical activity call, with a mean of 2.8 (SD = 2.0) calls out of 6. Of the 167 veterans who screened as medium to high risk of persistent disability, 74.9% completed at least 1 PiP call, with a mean of 2.5 (SD = 2.0) calls out of 6. Of those who completed at least 1 PiP call (n = 125), 100% received communication strategies, 97.6% received pain coping skills training, 89.6% received activity-based treatments, and 99.2% received education in a home program.
Conclusion
In implementing a hybrid care pathway for low back pain, the authors observed consistency in the delivery of core components (ie, pain modulation, use of physical activity training, and risk stratification to PiP), notable variability in telehealth calls, high use of PiP components, and increased referrals with tailored provider engagement.
Impact
These findings describe variability occurring within a hybrid care pathway and can inform future implementation efforts.
Marked by difficulty falling or staying asleep and/or poor sleep leading to daytime dysfunction, insomnia contributes to functional impairment, poor health, and increased healthcare utilization when ...left untreated. As many as two-thirds of Iraq and Afghanistan military veterans complain of insomnia. Older veterans of prior conflicts report insomnia occurring since initial service, suggesting a chronic nature to insomnia in this population. Despite insomnia's high prevalence and severe consequences, there is no theoretical model to explain either the onset or chronicity of insomnia in this growing patient population. Existing theories view insomnia as an acute, unidirectional phenomenon and do little to elucidate long-term consequences of such problems. Existing theories also fail to address mechanisms by which acute insomnia becomes chronic. This paper presents an original, integrated theoretical model that draws upon constructs from several prominent behavioral medicine theories to reconceptualize insomnia as a chronic, cyclical problem that is both a consequence and predictor of stress. Additional research examining the relationships between stress, sleep, resilience, and outcomes of interest could inform clinical and research practices. Addressing sleep problems early could potentially enhance adaptive capacity, thereby reducing the risk for subsequent negative outcomes.
•Chronic insomnia problems are highly prevalent among US military Veterans.•Existing theoretical models view insomnia as a unidirectional phenomenon.•An integrated model is proposed that explains insomnia as a chronic, cyclical problem.•Insomnia should be viewed as a both a consequence and predictor of stress.
Although most care for people with serious illness is delivered by multiple providers and agencies, there is no gold standard for how to assemble, train, unify, and sustain strong teams. Using ...lessons from complexity science, a way of studying complex systems, we propose improving team connections; the quality, quantity, and timeliness of information flow; and the purposeful seeking of diverse perspectives to interpret information and make decisions as a means of driving effective self-organization of teams and leading to high-quality outcomes. We highlight an adaptable intervention that helped improve connections, information flow, and cognitive diversity and resulted in effective self-organization in the Department of Veterans Affairs health care system. Finally, we describe challenges to building teams across systems and sectors, and we present research priorities for spreading a complexity science-based approach to optimize teams that care for people with serious illness.
An important contributor to hospital‐associated disability is immobility during hospitalization. Preliminary results from STRIDE, a clinical demonstration program of supervised walking for older ...adults admitted to the hospital with medical illness, are reported. The STRIDE program consisted of a targeted gait and balance assessment by a physical therapist, followed by daily walks supervised by a recreation therapy assistant for the duration of the hospital stay. To examine program effectiveness, STRIDE participants (n = 92) were compared with individuals referred but not enrolled (because of refusal or because program was at capacity, n = 35). Median length of stay was 4.7 days for STRIDE participants and 5.7 days for individuals receiving usual care (P = .31). There was one inpatient fall in each group (not associated with a STRIDE walk). Overall, 92% of STRIDE participants were discharged to home (rather than a skilled nursing facility (SNF)) compared to 74% of individuals receiving usual care (P = .007). Thirty‐day emergency department visit rates and readmission rates were not significantly different between the two groups. STRIDE, a supervised walking program for hospitalized older adults, was feasible and safe, and program participants were less likely to be discharged to a SNF than a demographically similar comparison group. STRIDE is a promising interdisciplinary approach to promoting mobility and improving outcomes in hospitalized older adults.
OBJECTIVES
To evaluate the effect of emergency department (ED) interventions on clinical, utilization, and care experience outcomes for older adults.
DESIGN
A conceptual model informed, ...protocol‐based systematic review.
SETTING
Emergency Department (ED).
PARTICIPANTS
Older adults 65 years of age and older.
METHODS AND MEASUREMENT
Medline, Embase, CINAHL, and PsycINFO were searched for English‐language studies published through December 2017. Studies evaluating the use of one or more eligible intervention strategies (discharge planning, case management, medication safety or management, and geriatric EDs including those that cited the 2014 Geriatric ED Guidelines) with adults 65 years of age and older were included. Studies were classified by the number of intervention strategies used (ie, single strategy or multi‐strategy) and key intervention components present (ie, assessment, referral plus follow‐up, and contact both before and after ED discharge “bridge”). The effect of ED interventions on clinical (functional status, quality of life QOL), patient experience, and utilization (hospitalization, ED return visit) outcomes was evaluated.
RESULTS
A total of 2000 citations were identified; 17 articles describing 15 unique studies (9 randomized and 6 nonrandomized) met eligibility criteria and were included in analyses. ED interventions showed a mixed pattern of effects. Overall, there was a small positive effect of ED interventions on functional status but no effects on QOL, patient experience, hospitalization at or after the initial ED index visit, or ED return visit.
CONCLUSION
Studies using two or more intervention strategies may be associated with the greatest effects on clinical and utilization outcomes. More comprehensive interventions, defined as those with all three key intervention components present, may be associated with some positive outcomes.
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