Women Veterans with co-morbid medical and mental health conditions face persistent barriers accessing high-quality health care. Evidence-based quality improvement (EBQI) offers a systematic approach ...to implementing new care models that can address care gaps for women Veterans.
This study examines factors associated with the successful deployment of EBQI within integrated health systems to improve primary care for women Veterans with complex mental health needs.
Following a 12-site (8 EBQI, 4 control) cluster randomized study to evaluate EBQI effectiveness, we conducted an in-depth case study analysis of one women's health clinic that used EBQI to improve integrated primary care-mental health services for women Veterans.
Our study sample included providers, program managers, and clinic staff at a women Veteran's health clinic that, at the time of the study, had one Primary Care and Mental Health Integration team and one women's health primary care provider serving 800 women. We analyzed interviews conducted 12 months, 24 months, and 4 years post-implementation and call summaries between the clinic and support team.
We conducted qualitative thematic analysis of interview and call summary data to identify EBQI elements, clinic characteristics, and reported challenges and successes within project development and execution.
The clinic harnessed core EBQI elements (multi-level stakeholder engagement, data-driven progress-monitoring, PDSA cycles, sharing results) to accomplish pre-defined project goals, strengthen inter-disciplinary partnerships, and bolster team confidence. Clinic characteristics that facilitated implementation success included prior QI experience and an organizational culture responsive to innovation, while lack of pre-existing guidelines and limited access to centralized databases posed implementation challenges.
Successful practice transformation emerges through the interaction of evidence-based methods and site-specific characteristics. Examining how clinic characteristics support or impede EBQI adaptation can facilitate efforts to improve care within integrated health systems.
Abstract
The Telephone Lifestyle Coaching (TLC) program provided telephone-based coaching for six lifestyle behaviors to 5321 Veterans at 24 Veterans Health Administration (VHA) medical facilities. ...The purpose of the study was to conduct an evaluation of the TLC program to identify factors associated with successful implementation. A mixed-methods study design was used. Quantitative measures of organizational readiness for implementation and facility complexity were used to purposively select a subset of facilities for in-depth evaluation. Context assessments were conducted using interview transcripts. The Consolidated Framework for Implementation Research (CFIR) was used to guide qualitative data collection and analysis. Factors most strongly correlated with referral rates included having a skilled implementation leader who used effective multi-component strategies to engage primary care clinicians as well as general clinic structures that supported implementation. Evaluation findings pointed to recommendations for local and national leaders to help anticipate and mitigate potential barriers to successful implementation.
Background Translating promising research findings into routine clinical care has proven difficult to achieve; even highly efficacious programmes remain unadopted. Critical to changing care is an ...understanding of the context within which the improvement effort occurs, including the climate or culture. Health care systems are multicultural due to the wide variety of professionals, subgroups, divisions and teams within them. Yet, little work describes and compares different stakeholders' views on their and others' roles in promoting successful quality improvement implementation.
Objective To identify manager and frontline staff perspectives about which organizational stakeholders should play a role in implementation efforts as well as what implementation roles these stakeholders should perform.
Methods We conducted qualitative semi‐structured interviews of a purposive sample of stakeholders at the clinic, medical centre and regional network levels. Participants included stakeholders across five clinics (n = 49), their four affiliated medical centres (n = 12) and three regional networks (n = 7). Working in coding teams, we conducted a content analysis utilizing Atlas.ti Version 5.
Results According to informants, individuals at each organizational level have unique and critical roles to play in implementing and sustaining quality improvement efforts. Informants advocated for participation of a wide range of organizational members, described distinct roles for each group, and articulated the need for and defined the characteristics of frontline programme champions.
Conclusions Involvement of multiple types of stakeholders is likely to be costly for health care organizations. Yet, if such organizations are to achieve the highest quality care, it is also likely that such involvement is essential.
Abstract Despite problematic evacuation and sheltering of nursing home residents during Hurricanes Katrina and Rita, an exploration of the experiences of Veterans Health Administration (VHA) nursing ...homes (VANHs) is necessary for a comprehensive examination of the healthcare community's response to these disasters. VANH evacuations during these hurricanes have not been widely studied. This exploratory project aimed to provide information about the evacuation experiences and characteristics of vulnerable nursing home residents. Interviews with key informants from VHA facilities with nursing home staff and representatives revealed that physical harm, psychological distress, cognitive decline and increased social isolation were areas that deserved special attention for this vulnerable population. Moreover, physical, psychological and social needs were interconnected in that each influenced the others. Findings contribute to the general conversation about meeting the biopsychosocial needs of nursing home residents in an integrated healthcare delivery system and more broadly, the role of long-term care facilities in general in planning for future disasters.
Although the patient-centered medical home endorses quality improvement principles, methods for supporting ongoing, systematic primary care quality improvement have not been evaluated. We introduced ...primary care quality councils at six Veterans Health Administration sites as an organizational intervention with three key design elements: (a) fostering interdisciplinary quality improvement leadership, (b) establishing a structured quality improvement process, and (c) facilitating organizationally aligned frontline quality improvement innovation.
Our evaluation objectives were to (a) assess design element implementation, (b) describe implementation barriers and facilitators, and (c) assess successful quality improvement project completion and spread.
We analyzed administrative records and conducted interviews with 85 organizational leaders. We developed and applied criteria for assessing design element implementation using hybrid deductive/inductive analytic techniques.
All quality councils implemented interdisciplinary leadership and a structured quality improvement process, and all but one completed at least one quality improvement project and a toolkit for spreading improvements. Quality councils were perceived as most effective when service line leaders had well-functioning interdisciplinary communication. Matching positions within leadership hierarchies with appropriate supportive roles facilitated frontline quality improvement efforts. Two key resources were (a) a dedicated internal facilitator with project management, data collection, and presentation skills and (b) support for preparing customized data reports for identifying and addressing practice level quality issues.
Overall, quality councils successfully cultivated interdisciplinary, multilevel primary care quality improvement leadership with accountability mechanisms and generated frontline innovations suitable for spread. Practice level performance data and quality improvement project management support were critical.
In order to successfully facilitate systematic, sustainable primary care quality improvement, regional and executive health care system leaders should engage interdisciplinary practice level leadership in a priority-setting process that encourages frontline innovation and establish local structures such as quality councils to coordinate quality improvement initiatives, ensure accountability, and promote spread of best practices.
Introduction: Collaborative care improves depression and anxiety outcomes. In this naturalistic, observational case study, we adapted an evidence-based depression collaborative care protocol for the ...assessment and treatment of posttraumatic stress disorder (PTSD) and sought to demonstrate that the protocol could be implemented in Veterans Affairs (VA) primary care. Method: Based on feedback from a content expert panel, clinical stakeholders, and a pilot study conducted in a postdeployment clinic, the original depression collaborative care protocol was modified to include PTSD assessment and support for PTSD medication adherence, self-management, and engagement in evidence-based PTSD care. Results: The modified program was implemented from November 2012 to March 2017, and 239 patients with PTSD were referred. Nearly two thirds (n = 185) enrolled, and they participated in the program for an average of 4 to 5 months and completed calls approximately once per month. Among patients with more than one assessment of clinical outcomes, 53.4% (n = 94) reported clinically significant improvement in depression on the Patient Health Questionnaire-9 (≥ 5-point decrease), and 42.2% (n = 35) reported clinically significant improvement on the PTSD Checklist (≥ 10-point decrease). Veterans and clinical staff described the modified collaborative care program positively in qualitative interviews. Discussion: Our findings suggest that a depression collaborative care program can be modified to support treatment of PTSD in primary care. The modified program was acceptable to both veterans and clinical staff and showed potential for positive clinical change in an uncontrolled quality improvement study.
Public Significance StatementIn this naturalistic, observational case study conducted at a major Veterans Affairs healthcare system, we adapted an evidence-based depression collaborative care protocol to assess and treat posttraumatic stress disorder (PTSD) in primary care. Both patients and clinical staff described the modified protocol in positive terms. Patients engaged in collaborative care at high levels and reported reductions in depression and PTSD symptoms.
ABSTRACT
BACKGROUND
The Veterans Health Administration (VA) has invested substantially in evidence-based mental health care. Yet no electronic performance measures for assessing the level at which ...the population of Veterans with depression receive appropriate care have proven robust enough to support rigorous evaluation of the VA’s depression initiatives.
OBJECTIVE
Our objectives were to develop prototype longitudinal electronic population-based measures of depression care quality, validate the measures using expert panel judgment by VA and non-VA experts, and examine detection, follow-up and treatment rates over a decade (2000–2010). We describe our development methodology and the challenges to creating measures that capture the longitudinal course of clinical care from detection to treatment.
DESIGN AND PARTICIPANTS
Data come from the National Patient Care Database and Pharmacy Benefits Management Database for primary care patients from 1999 to 2011, from nine Veteran Integrated Service Networks.
MEASURES
We developed four population-based quality metrics for depression care that incorporate a 6-month look back and 1-year follow-up: detection of a new episode of depression, 84 and 180 day follow-up, and minimum appropriate treatment 1-year post detection. Expert panel techniques were used to evaluate the measure development methodology and results. Key challenges to creating valid longitudinal measures are discussed.
KEY RESULTS
Over the decade, the rates for detection of new episodes of depression remained stable at 7–8 %. Follow-up at 84 and 180 days were 37 % and 45 % in 2000 and increased to 56 % and 63 % by 2010. Minimum appropriate treatment remained relatively stable over the decade (82–84 %).
CONCLUSIONS
The development of valid longitudinal, population-based quality measures for depression care is a complex process with numerous challenges. If the full spectrum of care from detection to follow-up and treatment is not captured, performance measures could actually mask the clinical areas in need of quality improvement efforts.
Hurricanes Katrina and Rita exposed significant flaws in US preparedness for catastrophic events and the nation's capacity to respond to them. These flaws were especially evident in the affected ...disaster areas' nursing homes, which house a particularly vulnerable population of frail older adults. Although evacuation of a healthcare facility is a key preparedness activity, there is limited research on factors that lead to effective evacuation.
Our review of the literature on evacuation is focused on developing a conceptual framework to study future evacuations rather than as a comprehensive assessment of prior work.
This paper summarizes what is known thus far about disaster response activities of nursing homes following natural and human-caused disasters, describes a conceptual model to guide future inquiry regarding this topic, and suggests future areas of research to further understand the decision-making process of nursing home facilitators regarding evacuating nursing home residents. To demonstrate the utility of the conceptual model and to provide guidance about effective practices and procedures, this paper focuses on the responses of Veterans Health Administration (VHA) nursing homes to the 2 hurricanes.
Quarantelli's conceptual framework, as modified by Perry and Mushkatel, is useful in guiding the development of central hypotheses related to the decision-making that occurred in VA nursing homes and other healthcare facilities following Hurricanes Katrina and Rita. However, we define evacuation somewhat differently to account for the fact that evacuation may, in some instances, be permanent. Thus, we propose modifying this framework to improve its applicability beyond preventive evacuation.
We need to better understand how disaster plans can be adapted to meet the needs of frail elders and other residents in nursing homes. Moreover, we must address identified gaps in the scientific literature with respect to health outcomes by tracking outcomes over time. Information on health outcomes would allow administrators and others to more appropriately weigh the balance of risks and benefits associated with evacuation. Without this understanding of the relationship between evacuation and health outcomes, it is not possible to develop effective response plans that are tailored to meet the needs of nursing home residents.
Background
The high prevalence of comorbid physical and mental illnesses among veterans is well known. Therefore, ensuring effective communication between primary care (PC) and mental health (MH) ...clinicians in the Veterans Affairs (VA) health care system is essential. The VA’s Patient Aligned Care Teams (PACT) initiative has further raised awareness of the need for communication between PC and MH. Improving such communication, however, has proven challenging.
Objective
To qualitatively understand barriers to PC-MH communication in an academic community-based clinic by using continuous quality improvement (CQI) tools and then initiate a change strategy.
Design, Participants, and Approach
An interdisciplinary quality improvement (QI) work group composed of 11 on-site PC and MH providers, administrators, and researchers identified communication barriers and facilitators using fishbone diagrams and process flow maps. The work group then verified and provided context for the diagram and flow maps through medical record review (32 patients who received both PC and MH care), interviews (6 stakeholders), and reports from four previously completed focus groups. Based on these findings and a previous systematic review of interventions to improve interspecialty communication, the team initiated plans for improvement.
Key Results
Key communication barriers included lack of effective standardized communication processes, practice style differences, and inadequate PC training in MH. Clinicians often accessed advice or formal consultation based on pre-existing across-discipline personal relationships. The work group identified collocated collaborative care, joint care planning, and joint case conferences as feasible, evidence-based interventions for improving communication.
Conclusions
CQI tools enabled providers to systematically assess local communication barriers and facilitators and engaged stakeholders in developing possible solutions. A locally tailored CQI process focusing on communication helped initiate change strategies and ongoing improvement efforts.
Collaborative care and care management are cornerstones of Primary Care-Mental Health Integration (PC-MHI) and have been shown to reduce depressive symptoms. Historically, the standard of Veterans ...Affairs (VA) collaborative care was referring patients with posttraumatic stress disorder (PTSD) to specialty care. Although referral to evidence-based specialty care is ideal, many veterans with PTSD do not receive such care. To address this issue and reduce barriers to care, VA currently recommends veterans with PTSD be offered treatment within PC-MHI as an alternative. The current project outlines a pilot implementation of an established telephone-based collaborative care model-Translating Initiatives for Depression into Effective Solutions (TIDES)-adapted for Iraq/Afghanistan War veterans with PTSD symptoms (TIDES/PTSD) seen in a postdeployment primary care clinic.
Structured medical record extraction and qualitative data collection procedures were used to evaluate acceptability, feasibility, and outcomes.
Most participants (n=17) were male (94.1%) and white (70.6%). Average age was 31.2 (standard deviation=6.4) years. TIDES/PTSD was successfully implemented within PC-MHI and was acceptable to patients and staff. Additionally, the total number of care manager calls was positively correlated with number of psychiatry visits (r=0.63, p<0.05) and amount of reduction in PTSD symptoms (r=0.66, p<0.05). Overall, participants in the pilot reported a significant reduction in PTSD symptoms over the course of the treatment (t=2.87, p=0.01).
TIDES can be successfully adapted and implemented for use among Iraq/Afghanistan veterans with PTSD. Further work is needed to test the effectiveness and implementation of this model in other sites and among veterans of other eras.
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