Objectives
Care transition interventions (CTIs) are used to improve outcomes after an emergency department (ED) visit. A recent randomized controlled trial of a Veterans Health Administration (VHA) ...CTI titled Discharge Information and Support for Patients receiving Outpatient care in the ED (DISPO ED) demonstrated no difference in repeat ED visits. However, changes in health care utilization are not the only measures of a CTI worth evaluation, and there is interest in using patient‐centered outcomes to assess CTIs as well. To inform future CTI design and outcome measure selection, the study aims were to understand how patients experienced the CTI and what elements they valued.
Methods
This was a qualitative study of participants randomized to the intervention arm of the DISPO ED trial using semistructured interviews. The interview guide included questions about clinical health and other issues addressed by the study nurse, the most and least helpful aspects of the intervention, and impacts of the intervention on their perceptions of self‐management. Interviews were analyzed using directed content analysis.
Results
Our sample comprised 24 participants, with average age of 61 years, 58% male, and 50% Black or African American. We identified six major themes related to (1) experiences during the intervention and (2) elements they valued. Patients reported clinical health coaching recommendations covering a wide range of topics as well as care coordination actions such as appointment scheduling. Valuable elements of the intervention highlighted personal characteristics of the study nurse that promoted a sense of interpersonal connection and empathy in their interactions.
Conclusions
Intervention users described assistance with care coordination as well as clinical concerns. We identified aspects that were highly valued by the participants, such as interpersonal support and empathy from the interventionist. These findings suggest the need for more comprehensive nonutilization outcome measures for CTIs to capture the patient's perspective.
Family caregivers often serve as unpaid members of the home and community-based care workforce for people with serious illness; as key partners in the home-clinic continuum, they should be included ...in health care teams. The campaign for Inclusive care is an initiative within the Veterans Affairs health care system to improve provider practices for including caregivers of military members in treatment planning and decisions. We defined inclusive care using a literature review, provider interviews, and a caregiver survey. We found that inclusive care involves clear definition of the caregiver role, system policies for inclusion, assessment of caregivers' capacity, explicit involvement of caregivers, and mutuality in caregiver-provider communication. We recommend solutions based on this definition that can inform development of a national caregiver strategy, required of the Department of Health and Human services by the Recognize, Assist, Include, support, and Engage Family Caregivers Act of 2018.
•Health care system employee vaccination is important to avoid COVID-19 outbreaks.•Most health care system employees want the vaccine but some are unsure or refuse.•More employees identifying with ...Black or multiple race are vaccine hesitant.•Employees who are vaccine believers need little to no intervention for vaccination.•Addressing specific concerns of cautious acceptors or fence sitters may spur vaccination.
Achieving high COVID-19 vaccination rates among employees is necessary to prevent outbreaks in health care settings. The goal of the study was to produce actionable and timely evidence about factors underlying the intention and decisions to obtain the COVID-19 vaccine by employees.
The study was conducted from December 2020 – May 2021 with employees from a VA health care system in Southeastern US. The study used a convergent mixed methods design comprising two main activities: a cross-sectional survey conducted prior to COVID-19 vaccine distribution, and semi-structured interviews conducted 4–6 months after vaccine distribution. Data were collected about participant characteristics, vaccination intention prior to distribution, vaccination decision post-distribution, determinants of vaccination intention and decision, activating factors, sources of information and intervention needs. Data from the survey and interviews were analyzed separately and integrated narratively in the discussion.
Prior to vaccine distribution, 77% of employees wanted to be vaccinated. Post vaccine distribution, we identified 5 distinct decision-making groups: 1) vaccine believers who actively sought vaccination and included those sometimes described as “immunization advocates”, 2) go along to get along (GATGA) individuals who got vaccinated but did not actively seek it, 3) cautious acceptors who got the COVID-19 vaccine after some delay, 4) fence sitters who remained uncertain about getting vaccinated, and 5) vaccine refusers who actively rejected the COVID-19 vaccine. Participants identifying with Black or multiple races were more likely to express hesitancy in their vaccination intention.
The findings of our study highlight distinct decision-making profiles associated with COVID-19 vaccination among employees of a VA health care system, and provide tailored recommendations to reduce vaccine hesitancy in this population.
Pharmacogenetic testing could reduce the time to identify a safe and effective medication for depression; however, it is underutilized in practice. Major depression constitutes the most common mental ...disorder in the US, and while antidepressant therapy can help, the current trial –and error approach can require patients to endure multiple medication trials before finding one that is effective. Tailoring the fit of pharmacogenetic testing with prescribers' needs across a variety of settings could help to establish a generalizable value proposition to improve likelihood of adoption. We conducted a study to explore the value proposition for health systems using pharmacogenetic testing for mental health medications through prescribers' real‐world experiences using implementation science concepts and systematic interviews with prescribers and administrators from four health care systems. To identify a value proposition, we organized the themes according to the Triple Aim framework, a leading framework for health care policy which asserts that high‐value care should focus on three key metrics: (1) better health care quality and (2) population‐level outcomes with (3) reduced per capita costs. Primary care providers whom we interviewed said that they value pharmacogenetic testing because it would provide more information about medications that they can prescribe, expanding their ability to identify medications that best‐fit patients and reducing their reliance on referrals to specialists; they said that this capacity would help meet patients' needs for access to mental health care through primary care. At the same time, prescribers expressed differing views about how pharmacogenetic testing can help with quality of care and whether their views about out‐of‐pocket cost would prevent them from offering it. Thus, implementation should focus on integrating pharmacogenetic testing into primary care and using strategies to support prescribers' interactions with patients.
Background
Almost 40 million family caregivers care for a loved one with severe physical or cognitive impairments. The purpose of this review is to summarize evidence about the benefits of ...interventions to support or involve family members/caregivers of patients with trauma-related injury on caregiver, patient, and household outcomes.
Methods
English-language peer-reviewed publications in MEDLINE, CINAHL, and PsycINFO from 1995 through December 2016 were identified. Eligible studies included RCT or quasi-experimental studies evaluating interventions designed to support or involve caregivers or family members of patients with TBI, PTSD, or polytrauma. Abstractions were completed by one reviewer and checked by a second; two reviewers independently assessed risk of bias using the Cochrane Effective Practice and Organization of Care Review Criteria.
Results
Thirteen studies (
n
= 9 TBI;
n
= 4 PTSD,
n
= 0 polytrauma) evaluated psychological or rehabilitation interventions involving caregivers. Interventions did not improve
TBI patients’
functional status (standardized mean difference SMD, 0.29 95% confidence interval CI, − 0.51 to 1.08) or psychological symptoms (SMD − 0.25, CI − 0.62 to 0.12). Qualitative analysis shows potential intervention benefit for TBI symptoms. Interventions did not improve
TBI caregiver
psychological symptoms (SMD − 0.26, CI − 0.57 to 0.05); however, qualitative analysis suggests mixed effects for caregiver burden and quality of life. Positive intervention effects on
patients’
PTSD symptoms, mental health service use, and
PTSD caregivers’
psychological symptoms were identified with certain interventions. Strength of evidence ranged from moderate to very low.
Discussion
Studies showed mixed patterns of intervention effects on caregiver and patient outcomes; evidence about intervention impact is inconclusive. This review is the first to identify caregiving interventions for patients with TBI and polytrauma and extends past reviews about patients with PTSD. Limitations include a small evidence base, low study quality, disparate methods, varied outcome measures, and high heterogeneity. PROSPERO Registration CRD42017053516.
Understanding barriers and facilitators to pharmacogenomics (PGx) implementation and how to structure a clinical program with the Veterans Health Administration (VA).
Healthcare provider (HCP) survey ...at 20 VA facilities assessing PGx knowledge/acceptance and qualitative interviews to understand how best to design and sustain a national program.
186 (12% response rate) surveyed believed PGx informs drug efficacy (74.7%) and adverse events (71.0%). Low confidence in knowledge (43.0%) and ability to implement (35.4-43.5%). 23 (60.5% response rate) interviewees supported a nationally program to oversee VA education, consultation and IT resources. Prescribing HCPs should be directing local activities.
HCPs recognize PGx value but are not prepared to implement. Healthcare systems should build system-wide programs for implementation education and support.
Background:
Home-based and community-based health care for individuals with complex medical conditions is often provided by family caregivers. Yet caregivers often are not meaningfully included in ...interactions with clinical health care teams. Inclusive care means inviting the caregiver to participate in shared decision-making and treatment planning. For aging or medically vulnerable adults, caregiver inclusion is an important facet of patient-centered care.
Methods:
We apply a mixed-methods approach using a survey (n=50) and semistructured interview data (n=13) from a national sample of caregivers of veterans and semistructured interview data from (n=24) providers from 3 Veterans Affairs regional networks. We elicited data from caregivers about their experiences with inclusive care and how providers communicate with them and assess their capacity. We juxtaposed these data with provider perspectives to see where there was alignment.
Findings:
We determined that caregivers play important roles in trust-building, communications management, implementation of care plans at home or in the community, and improving the care of care recipients—while maintaining a balance between competing tensions.
Conclusions:
Our findings suggest that expanding inclusive care could improve care quality and health outcomes of individuals with complex health care needs. Further, our findings bolster recent policy efforts at the federal and state levels to increase recognition of caregivers as key members of the health care team.
PurposeImplementation research provides a structure for evaluating the clinical integration of genomic medicine interventions. This paper describes the Implementing Genomics in Practice (IGNITE) ...Network's efforts to promote (i) a broader understanding of genomic medicine implementation research and (ii) the sharing of knowledge generated in the network.MethodsTo facilitate this goal, the IGNITE Network Common Measures Working Group (CMG) members adopted the Consolidated Framework for Implementation Research (CFIR) to guide its approach to identifying constructs and measures relevant to evaluating genomic medicine as a whole, standardizing data collection across projects, and combining data in a centralized resource for cross-network analyses.ResultsCMG identified 10 high-priority CFIR constructs as important for genomic medicine. Of those, eight did not have standardized measurement instruments. Therefore, we developed four survey tools to address this gap. In addition, we identified seven high-priority constructs related to patients, families, and communities that did not map to CFIR constructs. Both sets of constructs were combined to create a draft genomic medicine implementation model.ConclusionWe developed processes to identify constructs deemed valuable for genomic medicine implementation and codified them in a model. These resources are freely available to facilitate knowledge generation and sharing across the field.
Abstract Objective To examine the relationship between site‐level adaptation and early adoption of Caregivers Finding Important Resources, Support, and Training (FIRST) training during national ...implementation across diverse Veteran Health Administration (VA) medical centers. Data Sources and Study Setting We enrolled and evaluated 25 VA medical centers (VAMCs). Along with administrative data on site characteristics, we examined site‐reported data on adaptations and intervention adoption, defined as ≥4 training classes delivered to ≥5 caregivers at 6 months from April through October 2022. Study Design A type III hybrid implementation‐effectiveness cluster randomized controlled trial, randomized VAMCs 1:1 to receive foundational (low‐touch) implementation support ( n = 12) or the addition of enhanced (high‐touch) implementation support ( n = 13). Data Collection/Extraction Methods At key implementation phases, VAMCs were asked to report adaptations including content, contextual modifications (format, setting, personnel, and population), and training of providers. We describe site‐level adaptations by arm and by organizational characteristics that included VAMC complexity level, staffing, rurality, and organizational readiness to change. We used qualitative comparative analysis to identify unique adaptations that contributed to intervention adoption at 6 months. Principal Finding s VAMCs randomized to receive enhanced support reported slightly more adaptations than those randomized to foundational support. At 6 months, VAMCs with two or more adaptations adopted Caregivers FIRST at a higher rate than those with fewer adaptations (90% vs. 44%). Staffing adaptations (e.g., who delivered the intervention), format and content (e.g., modified delivery pace), and referring provider training were unique adaptations to adopting sites. Conclusions Site‐level adaptations were diverse and occurred more frequently in sites with early adoption of Caregivers FIRST. Future research should identify best practices of supporting and monitoring intervention adaptation. Understanding the role of adaptation in early adoption success could assist other healthcare systems in implementing interventions for caregivers.
Abstract
Background and Objectives
A minority of family caregivers receive training, with implications for their own and their recipient’s outcomes. Federal policy has supported the implementation ...and expansion of caregiver training and support. The Department of Veterans Affairs (VA) has developed a national Caregiver Support Program and collaborated with VA health services researchers to explore caregivers’ acceptance of an evidence-based training program in preparation for system-wide dissemination.
Research Design and Methods
This approach entailed a convergent mixed-methods design, which involved separate analyses of quantitative and qualitative data. Survey questions based on the Kirkpatrick model for training evaluation measured caregivers’ reaction and learning, and interview questions elicited caregivers’ reports about the value of the program for them.
Results
Most caregivers reported satisfaction with the training when responding to survey questions, although qualitative interviews revealed caveats suggesting need to hone the best timing and specific group of caregivers for maximal benefit.
Discussion and Implications
Our findings indicate that understanding program–user fit may be particularly critical when implementing training for caregivers as they come to the program at different points along their caregiving journey, needing differing types and intensities of support. While a general program may appeal to policymakers aiming to scale caregiver training within a large, heterogeneous system, there may be shortcomings in terms of end-user acceptance and subsequent downstream outcomes such as reach and ultimately program effectiveness. Good, iterative communication flow between program developers and policymakers facilitates this understanding and, in turn, decisions about scaling.
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