Clinical pharmacist practitioners on primary care teams play an important role in caring for complex patients with diabetes.

PURPOSE: To evaluate whether clinical pharmacist practitioners (CPPs) are being utilized to care for patients with complex medication regimens and multiple chronic illnesses, we compared the clinical complexity of diabetes patients referred to CPPs in team primary care and those in care by other team providers (OTPs). METHODS: In this cross-sectional comparison of patients with diabetes in the US Department of Veterans Affairs (VA) healthcare system in the 2017-2019 period, patient complexity was based on clinical factors likely to indicate need for more time and resources in medication and disease state management. These factors include insulin prescriptions; use of 3 or more other diabetes medication classes; use of 6 or more other medication classes; 5 or more vascular complications; metabolic complications; 8 or more other complex chronic conditions; chronic kidney disease stage 3b or higher; glycated hemoglobin level of ≥10%; and medication regime nonadherence. RESULTS: Patients with diabetes referred to one of 110 CPPs for care (n = 12,728) scored substantially higher (P < 0.001) than patients with diabetes in care with one of 544 OTPs (n = 81,183) on every complexity measure, even after adjustment for age, sex, race, and marital status. Based on composite summary scores, the likelihood of complexity was 3.42 (interquartile range, 3.25-3.60) times higher for those in ongoing CPP care (ie, those with 2 or more visits) versus OTP care. Patients in CPP care also were, on average, younger, more obese, and had more prior outpatient visits and hospital stays. CONCLUSION: The greater complexity of patients with diabetes seen by CPPs in primary care suggests that CPPs are providing valuable services in comprehensive medication and disease management of complex patients.

Factors Differentiating Nursing Homes With Strong Resident Safety Climate: A Qualitative Study of Leadership and Staff Perspectives.

The current qualitative study assessed leadership and staff perceptions related to resident safety at Department of Veterans Affairs (VA) nursing homes with a range of safety climates. We recruited a purposive sample of six VA nursing homes from geographically diverse regions of the United States and with diverse overall safety climate ratings. We conducted semi-structured phone interviews with 43 senior and middle level nursing home leaders and frontline providers (medical and nursing). We performed a thematic analysis of interview data to assess participant perceptions of factors that influence resident safety at higher and lower safety climate sites. Analyses identified two factors that differentiated VA nursing homes with high safety climate ratings from those with medium or low ratings: (1) communication about resident safety, particularly the important role of accessibility of physicians and managers; and (2) leadership support for and responsiveness to resident safety issues raised by frontline staff. Findings from high safety climate nursing homes underscore the importance of leadership accessibility, communication, support, and follow through regarding resident safety concerns. These results may provide a basis for designing safety climate interventions, such as those designed to improve communication, teamwork, and quality improvement structures and processes. [Journal of Gerontological Nursing, 49(2), 13-17.].

Incorporating African American Veterans' Success Stories for Hypertension Management: Developing a Behavioral Support Texting Protocol.

BACKGROUND: Peer narratives engage listeners through personally relevant content and have been shown to promote lifestyle change and effective self-management among patients with hypertension. Incorporating key quotations from these stories into follow-up text messages is a novel way to continue the conversation, providing reinforcement of health behaviors in the patients' daily lives. OBJECTIVE: In our previous work, we developed and tested videos in which African American Veterans shared stories of challenges and success strategies related to hypertension self-management. This study aims to describe our process for developing a text-messaging protocol intended for use after viewing videos that incorporate the voices of these Veterans. METHODS: We used a multistep process, transforming video-recorded story excerpts from 5 Veterans into 160-character texts. We then integrated these into comprehensive 6-month texting protocols. We began with an iterative review of story transcripts to identify vernacular features and key self-management concepts emphasized by each storyteller. We worked with 2 Veteran consultants who guided our narrative text message development in substantive ways, as we sought to craft culturally sensitive content for texts. Informed by Veteran input on timing and integration, supplementary educational and 2-way interactive assessment text messages were also developed. RESULTS: Within the Veterans Affairs texting system Annie, we programmed five 6-month text-messaging protocols that included cycles of 3 text message types: narrative messages, nonnarrative educational messages, and 2-way interactive messages assessing self-efficacy and behavior related to hypertension self-management. Each protocol corresponds to a single Veteran storyteller, allowing Veterans to choose the story that most resonates with their own life experiences. CONCLUSIONS: We crafted a culturally sensitive text-messaging protocol using narrative content referenced in Veteran stories to support effective hypertension self-management. Integrating narrative content into a mobile health texting intervention provides a low-cost way to support longitudinal behavior change. A randomized trial is underway to test its impact on the lifestyle changes and blood pressure of African American Veterans. TRIAL REGISTRATION: ClinicalTrials.gov NCT03970590; https://clinicaltrials.gov/ct2/show/NCT03970590. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/29423.

Dual use of Department of Veterans Affairs and community healthcare: Homeless veterans' experiences, perspectives, and perceptions.

BACKGROUND: Veteran homelessness is a pervasive problem and a high-priority, mission-oriented area of investigation in the United States (US). Most veterans enrolled in healthcare with the Department of Veterans Affairs (VA) carry additional health coverage, which may increase their access to care. For veterans, dual use of VA and non-VA healthcare has potentially positive and negative consequences. PURPOSE: To explore homeless veterans' experiences seeking and obtaining healthcare within and outside the VA. METHODOLOGY: US homeless veterans were recruited from a large, urban Northeast Healthcare for the Homeless program from two sites. This was a descriptive phenomenological study. Three semistructured focus group interviews were conducted (total n = 21 distinct participants). We used inductive content analysis procedures to identify main themes in the data. RESULTS: We found four main themes: dual use decision making, access to care, preferences and perceptions of care, and suggestions for improving VA care. Although veterans in our sample had mixed positive and negative experiences with both systems, positive responses were more common regarding community care than VA. Veterans provided more verbose responses when describing negative VA experiences and more succinct responses for positive experiences. CONCLUSIONS: We found mixed positive and negative experiences for both healthcare systems, although reports were more positive for non-VA care than VA. IMPLICATIONS: Veterans' healthcare concerns and needs appeared difficult to meet. Future research is warranted to improve veteran-centered care access and care experiences.

Organizational readiness to change as a leverage point for improving safety: a national nursing home survey.

BACKGROUND: A stronger safety climate in nursing homes may reduce avoidable adverse events. Yet efforts to strengthen safety climate may fail if nursing homes are not ready to change. To inform improvement efforts, we examined the link between organizational readiness to change and safety climate. METHODS: Seven safety climate domains and organizational readiness to change were measured with validated Community Living Center/CLC Employee Survey of Attitudes about Resident Safety and Organizational Readiness to Change Assessment. Safety climate domains comprised of safety priorities, supervisor commitment to safety, senior management commitment to safety, safety attitudes, environmental safety, coworker interactions around safety, and global rating of CLC. We specified models with and without readiness to change to explain CLC- and person-level variance in safety climate domains. RESULTS: One thousand three hundred ninety seven workers (frontline staff and managers) responded from 56 US Veterans Health Administration CLCs located throughout the US. Adding readiness to change reduced baseline CLC-level variance of outcomes (2.3-9.3%) by > 70% for interpersonal domains (co-workers, supervisors, and senior management). Readiness to change explained person-level variance of every safety climate domain (P < 0.05), especially for interpersonal domains. CONCLUSIONS: Organizational readiness to change predicted safety climate. Safety climate initiatives that address readiness to change among frontline staff and managers may be more likely to succeed and eventually increase resident safety.

Safety Climate Associated With Adverse Events in Nursing Homes: A National VA Study.

OBJECTIVES: Adverse events in nursing homes are leading causes of morbidity and mortality, prompting facilities to investigate their antecedents. This study examined the contribution of safety climate-how frontline staff typically think about safety and act on safety issues-to adverse events in Veterans Affairs (VA) nursing homes or Community Living Centers (CLCs). DESIGN: Cross-sectional study. SETTING AND PARTICIPANTS: A total of 56 CLCs nationwide, 1397 and 1645 CLC staff (including nurses, nursing assistants, and clinicians/specialists), respectively, responded to the CLC Employee Survey of Attitudes about Resident Safety (CESARS) in 2017 and 2018. METHODS: Adverse events (pressure ulcers, falls, major injuries from falls, and catheter use) were measured using the FY2017-FY2018 Minimum Data Set (MDS). Safety climate was defined as 7 CESARS domains (safety priorities, supervisor commitment to safety, senior management commitment to safety, personal attitudes toward safety, environmental safety, coworker interactions around safety, and global rating of CLC). The associations between safety climate domains and each adverse event were determined separately for each frontline group, using beta-logistic regression with random effects. RESULTS: Better ratings of supervisor commitment to safety were associated with lower rates of major injuries from falls [odds ratio (OR) 0.33, 95% confidence interval (CI) 0.11-0.97, clinicians] and catheter use (OR 0.42, 95% CI 0.21-0.85, nurses), and better ratings of environmental safety were associated with lower rates of pressure ulcers (OR 0.23, 95% CI 0.09-0.61, clinicians), major injuries from falls (OR 0.48, 95% CI 0.24-0.93, nurses), and catheter use (OR 0.55, 95% CI 0.32-0.93, nursing assistants). Better global CLC ratings were associated with higher rates of catheter use. No other safety climate domains had significant associations. CONCLUSIONS AND IMPLICATIONS: Nursing homes may reduce adverse events by fostering supportive supervision of frontline staff and a safer physical environment.

Relationship Between Work Experience and Safety Climate in Veterans Affairs Nursing Homes Nationwide.

OBJECTIVES: Staff values and beliefs about resident safety (safety climate) represent one potential driver of nursing home safety. Staff with more work experience (length of service) may possess richer knowledge of resident safety for strengthening safety climate. We investigated the association of length of service with safety climate in the U.S. Department of Veterans Affairs nursing homes or Community Living Centers (CLCs). METHODS: Fifty-six of 134 CLCs participated in 2017 and then 2018 in the previously validated CLC Employee Survey of Attitudes about Resident Safety, which comprised 7 safety climate domains and employee characteristics. We conducted 2 cross-sectional analyses of length of service on each safety climate domain, controlling for occupation, shift, work hours, and clustering by VA hospital, service network, and geographic region, in mixed random-effect regression models. RESULTS: A total of 1397 and 1645 staff participated in the survey (26% and 28% response rates) at round 1 and 2, respectively. At each round participants working greater than 6 months were less positive than those working less than 6 months about supervisor commitment to safety, coworker interactions around safety, and CLC global ratings. CONCLUSIONS: Differences in work experience contributed to incongruence in perceptions about supervisors, coworkers, and the facility. Workers with more experience may have higher perceived job aptitude and thus higher expectations of supervisory recognition and more criticisms of coworkers. Pairing experienced workers with newer ones may narrow the knowledge gap and increase collaboration. Huddles, team meetings, and organizational initiatives represent opportunities to recognize and leverage experienced workers' accumulated safety knowledge.

Nursing Home Staff Perceptions of Barriers and Facilitators to Implementing a Quality Improvement Intervention.

OBJECTIVES: Quality improvement (QI) may be a promising approach for staff to improve the quality of care in nursing homes. However, little is known about the challenges and facilitators to implementing QI interventions in nursing homes. This study examines staff perspectives on the implementation process. DESIGN: We conducted semistructured interviews with staff involved in implementing an evidence-based QI intervention ("LOCK") to improve interactions between residents and staff through targeted staff behavior change. The LOCK intervention consists of 4 practices: (1) Learn from the bright spots, (2) Observe, (3) Collaborate in huddles, and (4) Keep it bite sized. SETTING AND PARTICIPANTS: We interviewed staff members in 6 Veterans Health Administration nursing homes [ie, Community Living Centers (CLCs)] via opportunistic and snowball sampling. MEASURES: The semistructured interviews were grounded in the Capability, Opportunity, Motivation, Behavior (COM-B) model of behavior change and covered staff experience, challenges, facilitators, and lessons learned during the implementation process. The interviews were analyzed using thematic content analysis. RESULTS: Overall, staff accepted the intervention and appreciated the focus on the positives. Challenges fell largely within the categories of capability and opportunity and included difficulty finding time to complete intervention activities, inability to interpret data reports, need for ongoing training, and misunderstanding of study goals. Facilitators were largely within the motivation category, including incentives for participation, reinforcement of desired behavior, feasibility of intervention activities, and use of data to quantify improvements. CONCLUSIONS/IMPLICATIONS: As QI programs become more common in nursing homes, it is critical that interventions are tailored for this unique setting. We identified barriers and facilitators of our intervention's implementation and learned that no challenge was insurmountable or derailed the implementation of LOCK. This ability of frontline staff to overcome implementation challenges may be attributed to LOCK's inherently motivational features. Future nursing home QI interventions should consider including built-in motivational components.

The relationship between gastrointestinal symptom attribution, bothersomeness, and antiretroviral adherence among adults with HIV.

Patients who attribute their symptoms to HIV medications, rather than disease, may be prone to switching antiretrovirals (ARVs) and experience poor retention/adherence to care. Gastrointestinal (GI) symptoms (e.g., nausea/vomiting) are often experienced as a side effect of ARVs, but little is known about the relationship of symptom attribution and bothersomeness to adherence. We hypothesized that attribution of a GI symptom to ARVs is associated with a reduction in adherence, and that this relationship is moderated by the bothersomeness of the symptom. Data for our analysis come from the pre-randomization enrollment period of a larger study testing an adherence improvement intervention. Analyses revealed that patients with diarrhea who attributed the symptom to ARVs (compared to those who did not) had significantly worse adherence. We did not find a significant moderating effect of bothersomeness on this relationship. Incorporating patient beliefs about causes of symptoms into clinical care may contribute to improved symptom and medication management, and better adherence.