A Triangulated Qualitative Study of Veteran Decision-Making to Seek Care During Heart Failure Exacerbation: Implications of Dual Health System Use.

Among Veterans, heart failure (HF) contributes to frequent emergency department visits and hospitalization. Dual health care system use (dual use) occurs when Veterans Health Administration (VA) enrollees also receive care from non-VA sources. Mounting evidence suggests that dual use decreases efficiency and patient safety. This qualitative study used constructivist grounded theory and content analysis to examine decision making among 25 Veterans with HF, for similarities and differences between all-VA users and dual users. In general, all-VA users praised specific VA providers, called services helpful, and expressed positive capacity for managing HF. In addition, several Veterans who described inadvertent one-time non-VA health care utilization in emergent situations more closely mirrored all-VA users. By contrast, committed dual users more often reported unmet needs, nonresponse to VA requests, and faster services in non-VA facilities. However, a primary trigger for dual use was VA telephone referral for escalating symptoms, instead of care coordination or primary/specialty care problem-solving.

Perceptions of U.S. Veterans Affairs and community healthcare providers regarding cross-system care for heart failure.

OBJECTIVES: This study explores perceptions of US Veterans Affairs (VA) and non-VA healthcare providers caring for Veterans with heart failure (HF) regarding Veteran knowledge and motivations for dual use, provider roles in recommending and coordinating dual use, systems barriers and facilitators, and suggestions for improving cross-system care. METHODS: Twenty VA and 11 non-VA providers participated in semi-structured interviews, which were analyzed using parallel qualitative content and discourse analysis. RESULTS: VA and non-VA providers described variable HF knowledge and self-management among Veterans, and both groups described the need for improved education addressing medication adherence, self-care, and management of acute symptoms. Both groups described highly limited roles for providers in shaping choices surrounding dual use. VA and non-VA providers had significantly different perceptions regarding the availability, quality, and effectiveness of VA HF services. Multiple non-VA providers expressed frustration with and difficulty in contacting VA providers, accessing records, and making referrals into the VA system. Suggestions for improved care focused on patient education and care coordination. DISCUSSION: Dual healthcare system use for Veterans is increasingly common. Similarities and contrasts in perceptions of VA and non-VA providers are instructive and should be incorporated into future policy and program initiatives.

Contested Ownership of Disease and Ambulatory-Sensitive Emergency Department Visits for Type 2 Diabetes.

BACKGROUND: Approximately 21 million persons have diabetes and account for 11.9% of all emergency department (ED) visits for a total cost of $14.1 billion. Nonemergent visits for ambulatory-sensitive conditions that could be managed by the primary care provider make up almost one-third of the ED visits. African Americans comprise approximately 30% of South Carolina's population but make up approximately 50% of the ED visits for diabetes. The purpose of the research was to explore the experiences of 20 African-American adults with diabetes with ambulatory-sensitive ED use. RESEARCH DESIGN AND METHODS: The research design for this study is grounded theory with dimensional analysis methods. Following ethics approval and informed consent, interviews were conducted, recorded and transcribed verbatim, and themes were analyzed to form the explanatory framework or matrix for ED use. The framework of context, conditions, processes and consequences provides a key for understanding the themes of the story embedded in the descriptive narratives. RESULTS: The contested ownership of diabetes was the overarching perspective--"doing what I got to do," "it's always on mind… wishing not to be a diabetic" and "it's a constant burden." And handling diabetes involved taking decisions "into your hands." The context of perceived urgency of symptoms included all the reasons that precipitated ED visit--personal experience, primary care access and services and social network support for decisions--influenced ownership of these decisions.

Veteran-specific suicide prevention.

Suicide rates have been increasing in some subgroups of Veteran populations, such as those who have experienced combat. Several initiatives are addressing this critical need and the Department of Veterans Affairs (VA) has been recognized for its leadership. This integrative review adopts the Research Impact Framework (RIM) to address suicide-specific prevention activities targeting Veterans. The RIM is a standardized approach for developing issue narratives using four broad areas: societal-related impacts, research-related impacts, policy-related impacts, and service-related impacts. The questions addressed in this review are: (1) What are the major initiatives in Veteran-specific suicide prevention in four areas of impact-society, research, policy, and services? (2) Are there gaps related in each impact area? and (3) What are the implications of this narrative for other strategies to address suicide prevention targeting Veterans? Systematic application of the RIM identifies exemplars, milestones, gaps, and health disparity issues.