Rural Veterans' Experiences with Social Risk Factors: Impacts, Challenges, and Care System Recommendations.

BACKGROUND: Social risk factors, such as food insecurity and financial needs, are associated with increased risk of cardiovascular diseases, health conditions that are highly prevalent in rural populations. A better understanding of rural Veterans' experiences with social risk factors can inform expansion of Veterans Health Administration (VHA) efforts to address social needs. OBJECTIVE: To examine social risk and need from rural Veterans' lived experiences and develop recommendations for VHA to address social needs. DESIGN: We conducted semi-structured interviews with participants purposively sampled for racial diversity. The interview guide was informed by Andersen's Behavioral Model of Health Services Use and the Outcomes from Addressing Social Determinants of Health in Systems framework. PARTICIPANTS: Rural Veterans with or at risk of cardiovascular disease who participated in a parent survey and agreed to be recontacted. APPROACH: Interviews were recorded and transcribed. We analyzed transcripts using directed qualitative content analysis to identify themes. KEY RESULTS: Interviews (n = 29) took place from March to June 2022. We identified four themes: (1) Social needs can impact access to healthcare, (2) Structural factors can make it difficult to get help for social needs, (3) Some Veterans are reluctant to seek help, and (4) Veterans recommended enhancing resource dissemination and navigation support. CONCLUSIONS: VHA interventions should include active dissemination of information on social needs resources and navigation support to help Veterans access resources. Community-based organizations (e.g., Veteran Service Organizations) could be key partners in the design and implementation of future social need interventions.

Prevalence and Determinants of Unmet Social Needs Among Rural and Urban Veterans.

PURPOSE: To examine the prevalence and determinants of nine unmet social needs among rural compared with urban Veterans. METHODS: Retrospective study using survey data collected in 2020 merged with Veterans Health Administration (VA) administrative data. For each unmet need, separate logistic regression modes were run predicting the odds of rural compared with urban Veterans endorsing the need adjusting for sociodemographic characteristics and comorbidities. FINDINGS: 2,801 Veterans responded to the survey (53.7% response rate). Veterans experienced high rates of need (e.g., 22% reported food insecurity). Unmet need prevalence varied minimally between rural and urban Veterans and where they did, rural Veterans were less likely to endorse the need (e.g., loneliness). For many unmet needs, Black compared with White Veterans were at higher risk. Regional unmet need disparities were also observed. CONCLUSIONS: As VA considers expanding unmet need interventions, tailoring interventions to the sub-populations most at risk may be warranted.

Relationship Between Unmet Social Needs and Care Access in a Veteran Cohort.

BACKGROUND: The association between unmet social needs (e.g., food insecurity) and adverse health outcomes is well-established, especially for patients with and at risk for cardiovascular disease (CVD). This has motivated healthcare systems to focus on unmet social needs. Yet, little is known about the mechanisms by which unmet social needs impact health, which limits healthcare-based intervention design and evaluation. One conceptual framework posits that unmet social needs may impact health by limiting care access, but this remains understudied. OBJECTIVE: Examine the relationship between unmet social needs and care access. DESIGN: Cross-sectional study design using survey data on unmet needs merged with administrative data from the Veterans Health Administration (VA) Corporate Data Warehouse (September 2019-March 2021) and multivariable models to predict care access outcomes. Pooled and separate rural and urban logistic regression models were utilized with adjustments from sociodemographics, region, and comorbidity. SUBJECTS: A national stratified random sample of VA-enrolled Veterans with and at risk for CVD who responded to the survey. MAIN MEASURES: No-show appointments were defined dichotomously as patients with one or more missed outpatient visits. Medication non-adherence was measured as proportion of days covered and defined dichotomously as adherence less than 80%. KEY RESULTS: Greater burden of unmet social needs was associated with significantly higher odds of no-show appointments (OR = 3.27, 95% CI = 2.43, 4.39) and medication non-adherence (OR = 1.59, 95% CI = 1.19, 2.13), with similar associations observed for rural and urban Veterans. Social disconnection and legal needs were especially strong predictors of care access measures. CONCLUSIONS: Findings suggest that unmet social needs may adversely impact care access. Findings also point to specific unmet social needs that may be especially impactful and thus might be prioritized for interventions, in particular social disconnection and legal needs.

Utilization of Whole Health and Longitudinal Outcomes After Screening Positive for Possible Depression Documented in Veterans Health Administration's Electronic Health Record.

Objectives: Depression is common among Veterans. Veterans Health Administration (VHA) is transforming into a Whole Health system of care that includes holistic treatment planning, well-being programs, and health coaching. This evaluation explores the impact of Whole Health on improving symptoms of depression among Veterans who screen positive for possible depression diagnosis. Materials and Methods: We examined a cohort of Veterans who started using Whole Health after screening positive for possible depression (having a PHQ-2 score ≥3) at 18 VA Whole Health sites. We compared Whole Health users with non-Whole Health users on their follow-up PHQ-2 scores (9-36 months after baseline), using propensity score matching with multivariable regression to adjust for baseline differences. Results: Of the 13,559 Veterans screening positive for possible depression on the PHQ-2 and having a follow-up PHQ-2, 902 (7%) began using Whole Health after their initial positive PHQ-2. Whole Health users at baseline were more likely than non-Whole Health users to have posttraumatic stress disorder or acute stress (43% vs. 29%), anxiety (22% vs. 12%), ongoing opioid use (14% vs. 8%), recent severe pain scores (15% vs. 8%), or obesity (51% vs. 40%). Both groups improved at follow-up, with mean PHQ-2 scores decreasing from 4.49 to 1.77 in the Whole Health group and 4.46 to 1.46 in the conventional care group, with the Whole Health group significantly higher at follow-up. Also, the proportion continuing to screen positive at follow-up trended higher in the Whole Health group (26% and 21%, respectively). Conclusions: After screening positive for depression, Veterans with more mental and physical health conditions were more likely to subsequently use Whole Health services, suggesting that Whole Health is becoming a tool used in VHA to address the needs of complex patients. Nevertheless, the Whole Health group did not improve compared to the Conventional Care group. Results add to the growing body of literature that Whole Health services may play an important role among patients with complex symptom presentations by promoting self-management of symptoms and targeting "what matters most" to Veterans.

Developing Relational Coordination: A Qualitative Study of Outpatient Mental Health Teams.

Previous studies have shown Relational Coordination improves team functioning in healthcare settings. The aim of this study was to examine the relational factors needed to support team functioning in outpatient mental health care teams with low staffing ratios. We interviewed interdisciplinary mental health teams that had achieved high team functioning despite low staffing ratios in U.S. Department of Veterans Affairs medical centers. We conducted qualitative interviews with 21 interdisciplinary team members across three teams within two medical centers. We used directed content analysis to code the transcripts with a priori codes based on the Relational Coordination dimensions, while also being attentive to emergent themes. We found that all seven dimensions of Relational Coordination were relevant to improved team functioning: frequent communication, timely communication, accurate communication, problem-solving communication, shared goals, shared knowledge, and mutual respect. Participants also described these dimensions as reciprocal processes that influenced each other. In conclusion, relational Coordination dimensions can play pivotal roles in improving team functioning both individually and in combination. Communication dimensions were a catalyst for developing relationship dimensions; once relationships were developed, there was a mutually reinforcing cycle between communication and relationship dimensions. Our results suggest that establishing high-functioning mental health care teams, even in low-staffed settings, requires encouraging frequent communication within teams. Moreover, attention should be given to ensuring appropriate representation of disciplines among leadership and defining roles of team members when teams are formed.

Identification of Implementation Strategies Using the CFIR-ERIC Matching Tool to Mitigate Barriers in a Primary Care Model for Older Veterans.

BACKGROUND AND OBJECTIVES: As the proportion of the U.S. population over 65 and living with complex chronic conditions grows, understanding how to strengthen the implementation of age-sensitive primary care models for older adults, such as the Veterans Health Administration's Geriatric Patient-Aligned Care Teams (GeriPACT), is critical. However, little is known about which implementation strategies can best help to mitigate barriers to adopting these models. We aimed to identify barriers to GeriPACT implementation and strategies to address these barriers using the Consolidated Framework for Implementation Research-Expert Recommendations for Implementing Change (CFIR-ERIC) Matching Tool. RESEARCH DESIGN AND METHODS: We conducted a content analysis of qualitative responses obtained from a web-based survey sent to GeriPACT members. Using a matrix approach, we grouped similar responses into key barrier categories. After mapping barriers to CFIR, we used the Tool to identify recommended strategies. RESULTS: Across 53 Veterans Health Administration hospitals, 32% of team members (n = 197) responded to our open-ended question about barriers to GeriPACT care. Barriers identified include Available Resources, Networks & Communication, Design Quality & Packaging, Knowledge & Beliefs, Leadership Engagement, and Relative Priority. The Tool recommended 12 Level 1 (e.g., conduct educational meetings) and 24 Level 2 ERIC strategies (e.g., facilitation). Several strategies (e.g., conduct local consensus discussions) cut across multiple barriers. DISCUSSION AND IMPLICATIONS: Strategies identified by the Tool can inform on-going development of the GeriPACT model's effective implementation and sustainment. Incorporating cross-cutting implementation strategies that mitigate multiple barriers at once may further support these next steps.

Interaction between Legal and Social Needs in Their Association with Self-rated Health in a National Sample of Veterans.

Many health-related social needs, such as financial insecurity, are interconnected with legal needs. However, little is known about which social needs are more likely to be associated with legal needs, or whether legal and other needs interact to affect health. Using data from a 2020 national mailed survey assessing social needs among Veterans who had or were at risk for cardiovascular disease (N=2,801) and linked administrative data, linear regression models tested interactions between legal and other social needs, and their associations with self-rated health. In a model examining the interaction of financial and legal needs, experiencing financial but not legal needs was as strongly associated with worse health (b=-0.58, 95% CI -0.69, -0.46) as experiencing both financial and legal needs (b= -0.55, 95% CI -0.70, -0.40). Financial needs are important to Veterans' health and further research is needed to determine how financial and legal needs should be triaged by providers.

Promoting high-functioning mental health treatment teams in the context of low staffing ratios.

BACKGROUND: Many previous studies of health care teamwork have taken place in clinical teams with high staffing ratios (i.e., high ratios of staff to patients). PURPOSE: The aim of this study was to identify clinicians' viewpoints of foundational resources necessary to support good team functioning in the context of low staffing ratios. METHODOLOGY: We used administrative data, validated with local mental health chiefs, to identify mental health teams that had achieved high team functioning despite low staffing ratios in U.S. Department of Veterans Affairs medical centers. Guided by a recently developed model of team effectiveness, the Team Effectiveness Pyramid, we conducted qualitative interviews with 21 team members across three teams within two medical centers. Interview questions focused on the resources needed to support good team functioning despite low staffing ratios. We used directed content analysis to analyze results. RESULTS: We found there were several domains of relevant resources: material, staffing, temporal, organizational, and psychological. These represent an expansion of the domains originally included in the Team Effectiveness Pyramid. CONCLUSIONS: Within the five domains, we identified key tensions to be addressed when forming teams, including the balances between providing care for new versus established patients, emphasizing shared caseloads within the team versus matching patients to clinicians based on individual expertise, and establishing reporting structures by clinical discipline versus team membership. PRACTICE IMPLICATIONS: Establishing high-functioning health care teams in the context of low staffing ratios requires attention to key resource domains and fundamental trade-offs in how teams are structured.

Development and Validation of an Instrument to Measure Staff Perceptions of Recovery Climate and Culture in Mental Health Programs.

OBJECTIVE: Few existing instruments measure recovery-oriented organizational climate and culture. This study developed, psychometrically assessed, and validated an instrument to measure recovery climate and culture. METHODS: Organizational theory and an evidence-based conceptualization of mental health recovery guided instrument development. Items from existing instruments were reviewed and adapted, and new items were developed as needed. All items were rated by recovery experts. A 35-item instrument was pilot-tested and administered to a national sample of mental health staff in U.S. Department of Veterans Affairs Psychosocial Rehabilitation and Recovery Centers (PRRCs). Analysis entailed an exploratory factor analysis (EFA) and inter-item reliability and scale correlation assessment. Blinded site visits to four PRRCs were performed to validate the instrument. RESULTS: The EFA determined a seven-factor solution for the data. The factors identified were staff expectations, values, leadership, rewards, policies, education and training, and quality improvement. Seven items did not meet retention criteria and were dropped from the final instrument. The instrument exhibited good internal consistency (Cronbach's α=0.81; subscales, α=0.84-0.88). Scale correlations were between 0.16 and 0.61, well below the threshold (α=0.9) for indicating overlapping constructs. Site visitors validated the instrument by correctly identifying high-scoring and low-scoring centers. CONCLUSIONS: These findings provide a psychometrically tested and validated instrument for measuring recovery climate and culture in mental health programs. This instrument can be used in evaluation of mental health services to determine the extent to which programs possess the organizational precursors that drive recovery-oriented service delivery.

Organizational Coordination and Patient Experiences of Specialty Care Integration.

BACKGROUND: Delivering care to patients with complex healthcare needs benefits from coordination among healthcare providers. Greater levels of care coordination have been associated with more favorable patient experiences, cost management, and lower utilization of services. Organizational approaches consider how systems, practices, and relationships influence coordination and associated outcomes. OBJECTIVE: Examine measures of organizational coordination and their association with patient experiences of care coordination involving specialists. DESIGN: Cross-sectional surveys of patients and primary care providers (PCPs). PARTICIPANTS: Final sample included 3183 patients matched to 233 PCPs from the Veterans Health Administration. All patients had a diagnosis of type 2 diabetes mellitus and one of four other conditions: hypertension; congestive heart failure; depression/anxiety; or severe mental illness/posttraumatic stress disorder. MAIN MEASURES: Patients completed a survey assessing perceptions of coordinated care. We examined ratings on three domains: specialist knowledge management; knowledge integration across settings and time; and knowledge fragmentation across settings and time. We created care coordination measures involving the PCP and three specialty provider types. PCPs provided ratings on relational coordination for specialists, feedback coordination, and team coordination. We aligned patient's specialty services used with corresponding PCP ratings of that specialty. KEY RESULTS: Patient ratings were significantly lower on specialist knowledge management and knowledge integration when either PCPs did not use feedback coordination (b = - .20; b = - .17, respectively) or rated feedback coordination lower (b = - .08 for both). Teamwork was significantly related to specialist knowledge management (b = .06), knowledge integration (b = .04); and knowledge fragmentation (b = - .04). Relational coordination was related to coordination between the primary care provider and (i) diabetes specialist (b = .09) and (ii) mental health provider (b = .12). CONCLUSIONS: Practices to improve provider coordination within and across primary care and specialty care services may improve patient experiences of care coordination. Improvements in these areas may improve care efficiency and effectiveness.

Survey of Patient-Centered Coordination of Care for Diabetes with Cardiovascular and Mental Health Comorbidities in the Department of Veterans Affairs.

BACKGROUND: Multiple comorbidities thought to be associated with poor coordination due to the need for shared treatment plans and active involvement of patients, among other factors. Cardiovascular and mental health comorbidities present potential coordination challenges relative to diabetes. OBJECTIVE: To determine how cardiovascular and mental health comorbidities relate to patient-centered coordinated care in the Department of Veterans Affairs. DESIGN: This observational study used a 2 × 2 factorial design to determine how cardiovascular and mental health comorbidities are associated with patient perceptions of coordinated care among patients with type 2 diabetes mellitus as a focal condition. PARTICIPANTS: Five thousand eight hundred six patients attributed to 262 primary care providers, from a national sample of 29 medical centers, who had completed an online survey of patient-centered coordinated care in the Department of Veterans Affairs (VA). MAIN MEASURES: Eight dimensions from the Patient Perceptions of Integrated Care (PPIC) survey, a state-of-the-art measure of patients' perspective on coordinated and patient-centered care. KEY RESULTS: Mental health conditions were associated with significantly lower patient experiences of coordinated care. Hypotheses for disease severity were not supported, with associations in the hypothesized direction for only one dimension. CONCLUSIONS: Results suggest that VA may be adequately addressing coordination needs related to cardiovascular conditions, but more attention could be placed on coordination for mental health conditions. While specialized programs for more severe conditions (e.g., heart failure and serious mental illness) are important, coordination is also needed for more common, less severe conditions (e.g., hypertension, depression, anxiety). Strengthening coordination for common, less severe conditions is particularly important as VA develops alternative models (e.g., community care) that may negatively impact the degree to which care is coordinated.

Geriatric Patient-Aligned Care Teams in Department of Veterans Affairs: How Are They Structured?

Geriatric Patient-Aligned Care Teams (GeriPACT) were implemented in the Department of Veterans Affairs (VA) (i.e., Patient-Centered Medical Homes for older adults) to provide high quality coordinated care to older adults with more risk of negative health and psychosocial outcomes. The objectives of this paper are: (1) to present data on GeriPACT structural characteristics; and (2) to examine a composite measure of GeriPACT model consistency. We utilized a web survey targeting 71 physician leads resulting in a 62% response rate. We found GeriPACTs employed a range of staffing, empanelment, clinic space, and patient assignment practices. The mean value of the GeriPACT consistency measure was 2.03 (range: 1-4) and 6.3% of facilities were considered consistent to the GeriPACT model. We observed large variation in GeriPACT structure and in model consistency. More research is needed to understand how these variations are related to processes and outcomes of care.

Older Veteran Digital Disparities: Examining the Potential for Solutions Within Social Networks.

BACKGROUND: Older adults typically have less access to the Internet than other age groups, and older Veterans may use the Internet even less due to economic and geographic reasons. OBJECTIVE: To explore solutions to this problem, our study examined older Veterans' reported ability to access technology through their close social ties. METHODS: Data were collected via mail survey from a sample of Veterans aged 65 years and older (N=266). RESULTS: Nearly half (44.0%, 117/266) of the sample reported having no Internet access. Yet, among those without current access, older Veterans reported having a median of 5 (IQR 7) close social ties with home Internet access. These older Veterans also reported that they would feel comfortable asking a median of 2 (IQR 4) social ties for help to access the Internet, and that a median of 2 (IQR 4) social ties would directly access the Internet for the older Veteran to help with health management. CONCLUSIONS: Findings suggest that even older Veterans without current Internet access have at least two social ties with home Internet who could be called upon for technology support. Thus, older Veterans may be willing to call upon these "surrogate seekers" for technology assistance and support in health management. This has implications for the digital divide, technology design, and health care policy.

The National Cancer Institute's Health Information National Trends Survey [HINTS]: a national cross-sectional analysis of talking to your doctor and other healthcare providers for health information.

BACKGROUND: The need to understand preferred sources of health information remains important to providing patient-centered care. The Internet remains a popular resource for health information, but more traditional sources may still be valid for patients during a recent health need. This study sought to understand the characteristics of patients that turn to their doctor or healthcare provider first for a recent health or medical information need. METHODS: Using the national cross-sectional survey, Health Information National Trend Study [HINTS], characteristics of those who sought a doctor or healthcare provider for a recent health information need were compared to other sources. Weighted survey responses from Cycle 1 and Cycle 2 of the HINTS survey were used for multivariable logistic regression. RESULTS: A total 5,307 patient responses were analyzed. Overall, those who seek a doctor or healthcare provider first for a health need are female, 46-64 years, White non-Hispanic, educated, in good health and users of the Internet. Yet, adjusted logistic regressions showed that those who sought a doctor or healthcare provider first during a recent health information need compared to other sources were most likely to be 65+ years, in poor health, less educated and have health insurance. CONCLUSIONS: Patients who seek their doctor or healthcare provider first for health information rather than other sources of information represent a unique population. Doctors or healthcare providers remain an important resource for these patients during recent needs, despite the wide use of the Internet as a source of health information.

Developing critical thinking skills from clinical assignments: a pilot study on nursing students' self-reported perceptions.

AIM: Clinical assignments in nursing education provide opportunities for students to develop thinking skills vital to the effective delivery of patient care. The purpose of the present study was to examine students' perceived levels of confidence for using thinking skills when completing two types of clinical assignments. BACKGROUND: Clinical educators and managers are challenged to develop teaching and learning strategies that help students think critically and reflectively and transfer these skills into sound nursing practice. METHOD: This study is based on the theoretical framework of critical thinking within the nursing process framework. Undergraduate nursing students (n=51) completed surveys indicating their confidence in using seven thinking skills for nursing care. RESULTS: Students indicated significantly more confidence when implementing the journal format as compared with the care plan format when analysing information, determining relevance, making connections, selecting appropriate information, applying relevant knowledge and evaluating outcomes. CONCLUSIONS: The findings of the present study propose a new approach for enhancing students' thinking skills. Journaling is an effective strategy for enhancing students' thinking skills. IMPLICATIONS FOR NURSING MANAGEMENT: Nursing managers are in key organisational positions for supporting and promoting the use of the journal format and building supportive and collaborative learning environments for students to develop thinking skills for managing patient care.

Exploring and evaluating five paediatric falls assessment instruments and injury risk indicators: an ambispective study in a tertiary care setting.

AIM: To evaluate currently available paediatric falls assessments instruments and to build a predictive fall model while also evaluating injury risk as a predictor of fall likelihood within the paediatric inpatient population. BACKGROUND: There is lack of paediatric-specific fall assessment instruments and little information on the exploration of injury risk as related to falls in hospitalized children. METHOD: An ambispective, matched case-control design conducted in a sample of 100 inpatient paediatric patients. Results Two out of five instruments performed well to classify children at risk of falls. Longer length of stay, bleeding cautions/blood disorders and temperament/behaviour issues were significant predictors of fall likelihood. Cognitive impairment or neurological disease was not related to an increased likelihood of fall or injury risk for this sample. CONCLUSIONS: More research is required to institute and standardize paediatric fall and injury risk assessments for everyday use. The explicit approach of using predictive modelling is critical in creating a universal, baseline reference for the most reliable and valid measure of assessment in children. IMPLICATIONS FOR NURSING MANAGEMENT: Findings of the present study increase awareness of nursing managers and leaders as to the necessity for fall and injury risk assessment as a safety and quality measure for inpatient paediatric populations.

Regioselective palladium-catalyzed arylation of 3-carboalkoxy furan and thiophene.

[reaction: see text] The regioselective palladium(0)-catalyzed arylation of 3-furoate and 3-thiophenecarboxylate esters with aryl bromides is described. Conditions were developed that allow for the selective synthesis of either 2-aryl or 5-aryl products.