A partnered research initiative to accelerate implementation of comprehensive care for women veterans: the VA women's health CREATE.

Abstract

POTENTIAL AND PROMISE OF PARTNERED RESEARCH Translation of research evidence into routine practice continues to take decades, undermining the potential promise of new evidence-based treatments and care models for improving population health.1 Yet research traditions often reward “ivory towers” of academic research excellence in the absence of demonstrated impacts on health and health care beyond those achieved in pristine, controlled settings, unlike those where most Americans receive their health care.2,3 As a result, our research enterprises frequently yield research evidence of uncertain applicability to routine care, making knowledge transfer and implementation difficult at best for successful translation of published research into evidence-based policy or practice improvement.4,5 Partnered research has been proposed as a promising alternative to the status quo, with the potential to produce more directly actionable findings more quickly in more diverse contexts amenable to implementation and adaptation.6 In a partnered research paradigm, researchers engage nonresearch partners in the definition of the research questions, approaches to study design and methods, and interpretation and application of study results.7 Depending on the targets of the research intervention, partners may include patients, their families, providers, practices, managers, and/or policymakers in local, regional, and/or national contexts.8 Although such multilevel engagement is considered a novel approach by some, involving people in decision making has long been found to increase their willingness to implement those decisions.9 There is no foundation for thinking that decision making around the many actions required for adoption, implementation, and spread of research evidence would be tangibly different.10 As a result, lack of embedded partnerships likely undermines meaningful research impacts on the health and health care of the population.11 FOSTERING PARTNERED RESEARCH IN THE VETERANS HEALTH ADMINISTRATION (VA) The VA, the largest integrated health care delivery system in the United States, established an intramural health services research and development (HSR&D) program over 40 years ago. This embedded research program of clinician investigators and social scientists, with academic ties to many of the country’s top research universities, is focused on addressing VA health care priorities that ultimately help to improve health care for Veterans and the nation. Given this mission in the context of operating within the VA health care system, VA HSR&D is uniquely positioned—like similarly embedded research programs, for example, at Kaiser and Group Health—to study the potential and promise of partnered research on patient, provider, and system outcomes.12 In their editorial, “Partner or Perish,” Kilbourne and Atkins13 argue for breaking down research “silos” through early involvement with clinical and operations decision makers, demonstration of value-added research, mutually beneficial bidirectional engagement, and input from different stakeholders. The VA Quality Enhancement Research Initiative (QUERI) is characteristic of early efforts to build effective research-clinical partnerships in service of implementation science and increased research impacts.14 Although QUERI has nearly 15 years’ experience in implementation science, VA HSR&D Service, which represents a much larger portfolio, had not yet begun to systematically encourage researchers to adopt more partnered approaches to research. To make this change in emphasis, HSR&D leaders launched a new initiative incentivizing partnered research: the Collaborative Research to Advance Transformation and Excellence (CREATE) Initiative.15 CREATEs were designed to fundamentally change the partnership equation by making local, regional, and/or national policy or operations leaders a requirement of the research development process around topical areas of high-value to the VA system. Partners also had to demonstrate active participation, leverage research funds where appropriate, and commit to implementation of research findings. In turn, researchers worked collaboratively with partners to develop 3–5 projects linked to an overarching impact goal, designed to be achievable within 5 years. Multisite collaborations were encouraged among midlevel to senior investigators to increase potential for success given the experimental nature of the initiative. After 2 years of proposal and partnership development, VA HSR&D funded 10 CREATEs, including one focused on women Veterans’ (WVs) health, which are now in varying stages of progress on their 4–5-year trajectories.16 VA WOMEN’S HEALTH CREATE AS AN EXEMPLAR OF PARTNERED RESEARCH Why WVs’ Health as a Focus? Historically an extreme numerical minority in VA settings, WVs are now the fastest growing segment of new VA users, doubling in number since 2000, projected to be 10% of all Veteran users by 2018, and already 20% of new military recruits.17 These changing demographics have hastened VA’s need to address a wide spectrum of services to meet WVs’ complex needs, including gender-specific care.18 The predominance of men in VA settings has also created unintended consequences for the VA workforce, limiting exposure to female patients, increasing need for clinical retraining to ensure proficiencies in conditions common to women (eg, breast and routine gynecologic care) and highlighting the need for VA culture change.18 WVs’ high rates of military sexual trauma have underscored the importance of gender-sensitive care environments.19 Achieving gender-sensitive comprehensive care for WVs has, therefore, been a top VA priority.19 Establishing a VA Policy Anchor for Research Development In response to a growing body of evidence demonstrating WVs’ access barriers, service gaps, and care fragmentation, VA released Handbook 1330.01 on “Health Care Services for Women Veterans” in 2010 (Fig. 1). The Handbook codified organizational responsibilities at all VA operational levels, defining VA’s expectations that “each VA facility must ensure that eligible WVs have access to comprehensive medical care, including care for gender-specific conditions and mental health conditions … comparable to care provided for male Veterans.” Further, “all enrolled WVs need to receive comprehensive primary care (PC) from a designated women’s health PC provider who is interested and proficient in the delivery of comprehensive PC to women, irrespective of where they are seen … and regardless of the number of WVs utilizing a particular facility.” Such care must address fragmentation by including complete PC and care coordination by 1 PC provider in a single site (ie, “one-stop shopping”) in environments sensitive to women’s needs, safety, and dignity.FIGURE 1: Overview of the key elements of VA policy on delivering comprehensive health care to women Veterans.Although research provided evidence for the need for change, implementation and achievement of the Handbook’s tenets would be difficult to accomplish. The Women’s Health CREATE team worked in partnership with VA Women’s Health Services (WHS), the national office responsible for the breadth of WVs’ care (eg, PC, specialty care, mental health care), to develop 5 core studies designed to generate the evidence base for accelerating implementation of comprehensive care for WVs. Component CREATE Projects Component projects were developed among collaborating investigators in partnership with WHS and other partners with oversight over the policy and operational areas that individual projects involved. For example, leaders of the VA Primary Care Program Office were involved as advisors for a project planning to tailor PC to WVs’ needs. Leaders of VA women’s mental health services collaborated with PIs to ensure incorporation of measures related to mental health care across all studies, creating a thematic emphasis capable of leveraging the CREATE to answer key questions for VA Mental Health Services. Table 1 provides a summary of the 5 component projects’ aims and study approaches.TABLE 1: Overview of the Women’s Health CREATE’s Component ProjectsThese projects tackle issues underlying achievement of comprehensive care organically, individually complete but with marked cross-project leveraging of resources and synergy. The first project examines patient, provider, organizational, and area determinants of WVs’ attrition from VA care, exploring the degree to which access to comprehensive care is driving experience and behavior. The second project measures comprehensive care implementation nationwide, examining how attributes of comprehensiveness may influence WVs’ access and care quality. The third project tests evidence-based quality improvement approaches to adapting VA’s medical home model (PACT) to WVs’ comprehensive care needs. The fourth project seeks to increase comprehensive care for WVs seen at community-based clinics through virtual consultation and education. And the fifth project examines implications of achieving comprehensive care through use of VA-paid care in the community, evaluating quality, and coordination of outsourced care. CREATE Oversight and Management: Achieving a Sum Greater Than its Parts The Women’s Health CREATE is overseen by a national Executive Steering Committee (ESC), a national Women Veterans Council and VA HSR&D Service through intermittent in-person meetings and calls. The ESC reviews progress, provides critical feedback, and actively identifies policy and practice implications of study findings, while keeping researchers apprised of new initiatives and recommending potential spin-off projects, including those funded by VA operations. The ESC has requested more frequent interactions with CREATE investigators, including project-specific “deep dives” to enhance feedback detail and potential impacts. The Women Veterans Council currently focuses on strategic planning around patient engagement and dissemination. VA HSR&D Service participates in the ESC in ex-officio roles, requests evaluative information, and helps troubleshoot fiscal and regulatory issues (eg, union notification to facilitate VA staff participation). Additional monthly calls with WHS leadership and other partners ensure attention to their respective policy/operations priorities and information needs. Individual studies have additional approaches to partner engagement. For example, one study has a project-specific advisory board that engages leaders from the VA Office of Specialty Care Services and the VA network in which the majority of the designated women’s health providers participate, in addition to experts in virtual strategies for educating and supporting providers at a distance. Component projects also benefit from synergistic management, including routine cross-project monitoring; generation of cross-project briefing summaries for VA HSR&D Service and partners; systematic cross-project sharing of techniques, methodological advances, and data, where appropriate; and continuous review of planned products. This centralized management is funded by WHS as primary CREATE partner, adding another layer of “skin in the game,” in addition to supporting development of CREATE-level theoretical, methodological, and impact-related products. Anchoring component projects in a unified conceptual and theoretical framework applying diffusion of innovation theory will enhance the ability to synthesize lessons across projects in meaningful ways (Fig. 2).FIGURE 2: VA Women’s Health CREATE Conceptual Model: using research to accelerate implementation of comprehensive care for women Veterans through diffusion of innovation.Research-Clinical Partnerships: “Not a Shotgun Wedding” Although the Women’s Health CREATE has just completed its second year of operation, the extent and quality of the research-clinical partnerships underlying its development and management are particularly strong. For example, research engagement with WHS—present and past—has been active for 15+ years, including invitations to partners to serve in project advisory roles and dissemination of manuscripts/reports to them as research findings become available. WHS has also funded just-in-time projects over the years, engaging researchers in program evaluation of new initiatives (eg, telegynecology), often seeding new areas of work that ultimately lead to new research funding and creating incentives for researchers to pay heightened attention to VA policy priorities. The Women’s Health CREATE also benefits from a 10-year history of collaborative research development, beginning with establishment of the first VA women’s health research agenda and first systematic review of WVs’ research in 2004, which outlined knowledge gaps and made recommendations for enhancing VA women’s health research capacity and focus.20,21 Recommendations were acted on by VA HSR&D through WVs’ research solicitations, integration of women’s health expertise in scientific review panels, and eventual funding of the VA Women’s Health Research Network (WHRN) in 2010. WHRN comprised 2 capacity-building arms. The first reflected Consortium development, arming VA investigators with the knowledge, methods, and means to support inclusion of women in VA research and/or to focus on high-priority WVs’ topics. The second reflected development of a multisite practice-based research network to foster inclusion of WVs by creating a network of VA facilities prepared to enroll women and involve VA providers and staff in practice-based research.22 Both arms were central to mounting a meaningful, partnered approach to CREATE development among teams of researchers across the country with a decade of collaborative experience under their belts. USING PARTNERED RESEARCH TO TRANSFORM VA CARE To achieve the vision for personalized, proactive, patient-driven health care for Veterans, the VA will require ongoing clinical innovation, research, and education.23 Practicing partnered research through new approaches to multilevel engagement, like the CREATE, holds significant promise for forming robust, sustainable strategies for more rapidly integrating rigorous science into quality improvement and transforming the VA into a next generation learning organization.24,25 ACKNOWLEDGMENTS The author thanks Angela Cohen, MPH, for her superlative cross-CREATE management and Linda Lipson, MA, VA HSR&D Service Scientific Program Manager for the Women’s Health CREATE and the larger women’s health research portfolio, among other key topical areas. On behalf of all of the CREATE principal investigators, the author would like to particularly acknowledge Patricia Hayes, PhD, Chief Consultant, VHA Women's Health Services, primary partner for the Women's Health CREATE, without whom the work described here would have occurred.