Administration Primary Care Clinics Research Articles

"The Only Reason I Am Willing to Do It at All": Evaluation of VA's SUpporting Primary care Providers in Opioid Risk reduction and Treatment (SUPPORT) Center.

Medication treatment for opioid use disorder (MOUD) is effective and recommended for outpatient settings. We implemented and evaluated the SUpporting Primary care Providers in Opioid Risk reduction and Treatment (SUPPORT) Center-a quality improvement partnership to implement stepped care for MOUD in 2 Veterans Health Administration (VA) primary care (PC) clinics. SUPPORT provided a dedicated clinical team (nurse practitioner prescriber and social worker) and stepped care ([1] identification, assessment, referral; [2] MOUD induction; [3] stabilization; and [4] maintenance supporting PC providers [PCPs] to initiate and/or sustain treatment) coupled with ongoing internal facilitation (consultation, trainings, informatics support). Qualitative interviews with stakeholders (PCPs and patients) and meeting notes identified barriers and facilitators to implementation. Electronic health record and patient tracking data measured reach, adoption, and implementation outcomes descriptively. SUPPORT's implementation barriers included the need for an X-waiver, VA's opioid tapering policies, patient and PCP knowledge gaps and PCP discomfort, and logistical compatibility and sustainability challenges for clinics. SUPPORT's dedicated clinical staff, ongoing internal facilitation, and high patient and PCP satisfaction were key facilitators. SUPPORT (January 2019 to September 2021) trained 218 providers; 63 received X-waivers, and 23 provided MOUD (10.5% of those trained). SUPPORT provided care to 167 patients, initiated MOUD for 33, and provided education and naloxone to 72 (all = 0 in year before launch). SUPPORT reached many PCPs and patients and resulted in small increases in MOUD prescribing and high levels of stakeholder satisfaction. Dedicated clinical staff was key to observed successes. Although resource-intensive, SUPPORT offers a potential model for outpatient MOUD provision.

Depression care quality among patients with solid tumor cancers detected to have depression in Veterans Health Administration primary care clinics.

Patients with cancer, especially advanced cancer, experience depression at high rates. We aimed to evaluate the quality of depression care received by patients with solid tumor cancer and advanced solid tumor cancer in Veterans Affairs (VA) primary care clinics. This is a retrospective cohort study of patients seen in 82 VA primary care clinics who newly screened positive for depression on the Patient Health Questionnaire (PHQ-2). Outcomes included timely follow-up within 84 or 180 days (3+ mental health specialty, 3+ psychotherapy, or 3+ primary care visits with depression diagnosis codes) and minimum treatment within 1 year (60+ days antidepressants prescribed, 4+ mental health specialty visits, or 3+ psychotherapy visits). 608,042 individuals were seen in VA primary care clinics during this period; 49,839 patients (8.2%) had solid tumor cancer and 9,278 (1.5%) had advanced or poor-prognosis solid tumor cancer. For 686 observations of patients with cancer and new depression, rates of appropriate follow-up were 22.3% within 84 days and 38.2% within 180 days. For 73 observations of patients with advanced or poor-prognosis cancer and new depression, rates of appropriate follow-up were 21.9% within 84 days and 34.3% within 180 days. Rates of minimum treatment within 1 year were 68.4% and 64.4% for patients with cancer and patients with advanced or poor-prognosis cancer, respectively. Quality of timely depression management is low in patients with solid tumor cancers. Even in health systems with well-integrated mental health services, care gaps remain for patients with cancer and depression. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Supplemental Material for Depression Care Quality Among Patients With Solid Tumor Cancers Detected to Have Depression in Veterans Health Administration Primary Care Clinics

Supplemental Material for Depression Care Quality Among Patients With Solid Tumor Cancers Detected to Have Depression in Veterans Health Administration Primary Care Clinics

Promoting benzodiazepine cessation through an electronically-delivered patient self-management intervention (EMPOWER-ED): Randomized controlled trial protocol

BackgroundLong-term benzodiazepine dependence carries significant health risks which might be reduced with low-cost patient self-management interventions. A booklet version of one such intervention (Eliminating Medications Through Patient Ownership of End Results; EMPOWER) proved effective in a Canadian clinical trial with older adults. Digitizing such an intervention for electronic delivery and tailoring it to different populations could expand its reach. Accordingly, this article describes the protocol for a randomized controlled trial to test the effectiveness of an electronically-delivered, direct-to-patient benzodiazepine cessation intervention tailored to U.S. military veterans. MethodsDesign: Two-arm individually randomized controlled trial. SettingUS Veterans Health Administration primary care clinics. ParticipantsPrimary care patients taking benzodiazepines for three or more months and having access to a smartphone, tablet or desktop computer. Intervention and comparatorParticipants will be randomized to receive either the electronically-delivered EMPOWER (EMPOWER-ED) protocol or asked to continue to follow provider recommendations regarding their benzodiazepine use (treatment-as-usual). MeasurementsThe primary outcomes are complete benzodiazepine cessation and 25% dose reduction, assessed using administrative and self-report data, between baseline and six-month follow-up. Secondary outcomes are self-reported anxiety symptoms, sleep quality, and overall health and quality of life, measured at baseline and 6-month follow-up, and benzodiazepine cessation at 12-month follow-up. CommentsThis randomized controlled trial will evaluate whether the accessibility and effectiveness of a promising intervention for benzodiazepine cessation can be improved through digitization and population tailoring.

Factors Associated With Low-Value Cancer Screenings in the Veterans Health Administration

Most clinical practice guidelines recommend stopping cancer screenings when risks exceed benefits, yet low-value screenings persist. The Veterans Health Administration focuses on improving the value and quality of care, using a patient-centered medical home model that may affect cancer screening behavior. To understand rates and factors associated with outpatient low-value cancer screenings. This cohort study assessed the receipt of low-value cancer screening and associated factors among 5 993 010 veterans. Four measures of low-value cancer screening defined by validated recommendations of practices to avoid were constructed using administrative data. Patients with cancer screenings in 2017 at Veterans Health Administration primary care clinics were included. Excluded patients had recent symptoms or historic high-risk diagnoses that may affect test appropriateness (eg, melena preceding colonoscopy). Data were analyzed from December 23, 2019, to June 21, 2021. Receipt of cancer screening test. Low-value screenings were defined as occurring for average-risk patients outside of guideline-recommended ages or if the 1-year mortality risk estimated using a previously validated score was at least 50%. Factors evaluated in multivariable regression models included patient, clinician, and clinic characteristics and patient-centered medical home domain performance for team-based care, access, and continuity previously developed from administrative and survey data. Of 5 993 010 veterans (mean [SD] age, 63.1 [16.8] years; 5 496 976 men [91.7%]; 1 027 836 non-Hispanic Black [17.2%] and 4 539 341 non-Hispanic White [75.7%] race and ethnicity) enrolled in primary care, 903 612 of 4 647 479 men of average risk (19.4%) underwent prostate cancer screening; 299 765 of 5 770 622 patients of average risk (5.2%) underwent colorectal cancer screening; 21 930 of 469 045 women of average risk (4.7%) underwent breast cancer screening; and 65 511 of 458 086 women of average risk (14.3%) underwent cervical cancer screening. Of patients screened, low-value testing was rare for 3 cancers, with receipt of a low-value test in 633 of 21 930 of women screened for breast cancer (2.9%), 630 of 65 511 of women screened for cervical cancer (1.0%), and 6790 of 299 765 of patients screened for colorectal cancer (2.3%). However, 350 705 of 4 647 479 of screened men (7.5%) received a low-value prostate cancer test. Patient race and ethnicity, sociodemographic factors, and illness burden were significantly associated with likelihood of receipt of low-value tests among screened patients. No single patient-, clinician-, or clinic-level factor explained the receipt of a low-value test across cancer screening cohorts. This large cohort study found that low-value breast, cervical, and colorectal cancer screenings were rare in the Veterans Health Administration, but more than one-third of patients screened for prostate cancer were tested outside of clinical practice guidelines. Guideline-discordant care has quality implications and is not consistently explained by associated multilevel factors.

Toolkit and distance coaching strategies: a mixed methods evaluation of a trial to implement care coordination quality improvement projects in primary care

BackgroundCare coordination tools and toolkits can be challenging to implement. Practice facilitation, an active but expensive strategy, may facilitate toolkit implementation. We evaluated the comparative effectiveness of distance coaching, a form of practice facilitation, for improving the implementation of care coordination quality improvement (QI) projects.MethodsWe conducted a mixed methods evaluation of the Coordination Toolkit and Coaching (CTAC) initiative. Twelve matched US Veterans Health Administration primary care clinics were randomized to receive coaching and an online care coordination toolkit (“coached”; n = 6) or access to the toolkit only (“non-coached”; n = 6). We did interviews at six, 12, and 18 months. For coached sites, we‘ly collected site visit fieldnotes, prospective coach logs, retrospective coach team debriefs, and project reports. We employed matrix analysis using constructs from the Consolidated Framework for Implementation Research and a taxonomy of outcomes. We assessed each site’s project(s) using an adapted Complexity Assessment Tool for Systematic Reviews.ResultsEleven sites implemented a local CTAC project. Eight sites (5 coached, 3 non-coached) used at least one tool from the toolkit. Coached sites implemented significantly more complex projects than non-coached sites (11.5 vs 7.5, 95% confidence interval 1.75–6.25, p < 0.001); engaged in more formal implementation processes (planning, engaging, reflecting and evaluating); and generally had larger, more multidisciplinary QI teams. Regardless of coaching status, sites focused on internal organizational improvement and low-intensity educational projects rather than the full suite of care coordination tools. At 12 months, half the coached and non-coached sites had clinic-wide project implementation; the remaining coached sites had implemented most of their project(s), while the remaining non-coached sites had either not implemented anything or conducted limited pilots. At 18 months, coached sites reported ongoing effort to monitor, adapt, and spread their CTAC projects, while non-coached sites did not report much continuing work. Coached sites accrued benefits like improved clinic relationships and team QI skill building that non-coached sites did not describe.ConclusionsCoaching had a positive influence on QI skills of (and relationships among) coached sites’ team members, and the scope and rigor of projects. However, a 12-month project period was potentially too short to ensure full project implementation or to address cross-setting or patient-partnered initiatives.Trial registrationNCT03063294.

A pilot study of a brief group adaptation of the Unified Protocol in integrated primary care.

Primary care clinics are a common treatment venue for a broad range of mental health conditions, including anxiety and depressive disorders, which are experienced by up to a fifth of primary care patients. Integrated primary care is a treatment model in which behavioral health providers are integrated into primary care clinics to treat mental health disorders and help improve the psychosocial functioning of patients. The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders' (UP) focus on functional outcomes is consistent with the goals of integrated primary care. However, its 12-18 session length is not feasible for implementation in primary care. A 5-session group adaptation was developed for primary care. This pilot project examines changes in veterans' (n = 48) self-reported anxiety, depression, and psychosocial adjustment following completion of the 5-week group adaptation. Participants were enrolled in a Veterans' Health Administration (VHA) primary care clinic and were diagnosed with mild to moderate mood and stressor disorders. Treatment completers experienced improvements on all outcome measures with significant increases in the proportion of participants scoring in the subclinical range upon treatment completion (anxiety [50.0%]: t = 6.67, df = 45, p = .000; Cohen's d = .86; depression [62.5%]: t = 5.60, df = 45, p = .000; Cohen's d = .55; psychosocial functioning [35.4%]: t = 4.89, df = 36, p = .000; Cohen's d = .66). This pilot project demonstrates that a 5-session group adaptation of the UP may be a promising transdiagnostic treatment appropriate for the primary care setting. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Teaching Baccalaureate Nursing Students to Practice in Primary Care Settings.

The Affordable Care Act of 2010 emphasized the importance of primary care and preventative services as core components to promote the health of the U.S. A unique program was created for baccalaureate nursing students to provide learning and practice experiences in primary practice sites that emphasized chronic disease prevention and management, including mental health and substance abuse services. Students were selected using a holistic approach. Students were selected to participate in the project. A community leadership advisory board was created. Students were assigned to the Veteran Administration's primary care clinics for their clinical experiences. This project is well-developed to increase the knowledge of present and future RNs, interprofessional providers and educators, researchers, and policy makers in community-oriented primary care. [J Nurs Educ. 2021;60(3):129-135.].

Care Practices to Promote Patient Engagement in VA Primary Care: Factors Associated With High Performance.

Patient engagement has been broadly defined as the process of actively involving and supporting patients in health care and treatment decision making. The aim of this study was to identify organizational factors that are associated with greater use of patient engagement care practices in Veterans Health Administration primary care clinics. We conducted a cross-sectional analysis of data from the 2016 Patient-Aligned Care Team (PACT) national survey of direct care clinicians (primary care clinicians, registered nurses, and clinical associates). Exploratory factor analysis was used to group conceptually related patient engagement survey items into 3 subscales: planning and goal setting; motivational interviewing; and organizational strategies to promote self-management. Our independent variables included literature-based factors reported to promote team-based care and interdisciplinary collaboration in primary care. We used generalized estimating equations with multivariate logistic regression analysis to identify independent correlates of high performance on each patient engagement domain (top 25th vs bottom 25th percentile). A total of 2,478 direct care clinicians from 609 clinics completed all patient engagement items in the PACT survey. For all patient engagement sub-scales, respondents at high-performing clinics were more likely to report having regular team meetings to discuss performance improvement and having leadership responsible for implementing PACT. For 2 of 3 patient engagement subscales, high performance was also associated with having fully staffed PACT teams (≥3 team members per primary care clinician) and role clarity. Several desirable organizational and contextual factors were associated with high performance of patient engagement care practices. Strategies to improve the organizational functioning of primary care teams may enhance patient engagement in care.

Connecting veterans with smoking cessation services in less than 3 minutes.

Veterans smoke disproportionately higher (nearly 1.3 times greater) than the general population and puts them at greater risk for tobacco-related illnesses. Annual screenings by the primary care providers are conducted at Veterans Health Administration (VHA) primary care clinics, but this practice may be inadequate to overcome the chronicity of smoking. The Ask, Advise, Refer strategy for smoking cessation was integrated in the workflow and implemented by the nursing staff at a VHA outpatient surgery clinic. Nurses established smoking status, advised smokers to quit, and for those interested, provided the smoker a list of resources Department of Veterans Affairs' approved smoking cessation options (telephone, text, and web-based interventions). All the smokers took a referral card containing a list of resources to help them quit smoking. During the follow-up phone calls after the clinic visit, 19% of patients reported using at least one of the resources listed on the card. Each clinical encounter should be viewed by health care providers as a window of opportunity to promote smoking cessation. The simplicity of the AAR strategy is effective in promoting smoking cessation especially in busy outpatient settings.

Brief Cognitive Behavioral Therapy For Chronic Pain: Results From a Clinical Demonstration Project in Primary Care Behavioral Health.

Although cognitive behavioral therapy is an effective intervention for chronic pain, it is a lengthy treatment typically applied only in specialty care settings. The aim of this project was to collect preliminary effectiveness data for Brief Cognitive Behavioral Therapy for Chronic Pain (Brief CBT-CP), an abbreviated, modular form of treatment designed for use in primary care. A clinical demonstration project was conducted in which Brief CBT-CP was delivered to primary care patients by 22 integrated care providers practicing in the Primary Care Behavioral Health model of Veterans Health Administration primary care clinics. Brief measures were used at each appointment to collect patient-reported clinical outcomes. One hundred eighteen patients provided sufficient data for analysis (male, 75%; mean age, 51.4 y). Multilevel modeling suggested that a composite measure of pain intensity and functional limitations showed statistically significant improvements by the third appointment (Cohen's d=0.65). Pain-related self-efficacy outcomes showed a similar pattern of results but of smaller effect size (Cohen's d=0.22). The exploratory analysis identified that Brief CBT-CP modules addressing psychoeducation and goal setting, pacing, and relaxation training were associated with the most significant gains in treatment outcomes. These findings provide early support for the effectiveness of Brief CBT-CP when delivered by providers in every day Primary Care Behavioral Health settings. Results are discussed in relation to the need for additional research regarding the potential value of employing safe, population-based, nonpharmacological approaches to pain management in primary care.

The Impact of Social Determinants of Health on Hospitalization in the Veterans Health Administration

This study aims to assess the effect of individual and geographic-level social determinants of health on risk of hospitalization in the Veterans Health Administration primary care clinics known as the Patient Aligned Care Team. For a population of Veterans enrolled in the primary care clinics, the study team extracted patient-level characteristics and healthcare utilization records from 2015 Veterans Health Administration electronic health record data. They also collected census data on social determinants of health factors for all U.S. census tracts. They used generalized estimating equation modeling and a spatial-based GIS analysis to assess the role of key social determinants of health on hospitalization. Data analysis was completed in 2018. A total of 6.63% of the Veterans Health Administration population was hospitalized during 2015. Most of the hospitalized patients were male (93.40%) and white (68.80%); the mean age was 64.5 years. In the generalized estimating equation model, white Veterans had a 15% decreased odds of hospitalization compared with non-white Veterans. After controlling for patient-level characteristics, Veterans residing in census tracts with the higher neighborhood SES index experienced decreased odds of hospitalization. A spatial-based analysis presented variations in the hospitalization rate across the Veterans Health Administration primary care clinics and identified the clinic sites with an elevated risk of hospitalization (hotspots) compared with other clinics across the country. By linking patient and population-level data at a geographic level, social determinants of health assessments can help with designing population health interventions and identifying features leading to potentially unnecessary hospitalization in selected geographic areas that appear to be outliers.

Duration of opioid prescriptions predicts incident nonmedical use of prescription opioids among U.S. veterans receiving medical care

Background/AimsAlthough nonmedical use of prescription opioids (NMUPO) is a public health problem, few studies have examined the new-onset NMUPO in clinical populations. We estimated NMUPO incidence among veterans in medical care who had received prescription opioid medication and examined correlates of new-onset NMUPO. DesignProspective cohort study. SettingVeterans Health Administration primary care and infectious disease clinics in Atlanta, Baltimore, Bronx, Houston, Los Angeles, Manhattan, Pittsburgh, and Washington, DC. ParticipantsPatients enrolled in the Veterans Aging Cohort Study wave 3 (2005–2007) who received prescription opioids in the previous year and without lifetime NMUPO were followed at waves 4 and 5 (2008–2011). MeasurementsCox proportional hazards regression was used to examine the relationship between duration of prescription opioid receipt and incident NMUPO, adjusting for demographics, alcohol and tobacco use, substance use disorders, psychiatric and medical diagnoses, and medication-related characteristics. FindingsAmong eligible participants (n = 815), the median age was 52 (IQR = 47–58) and 498 (59.8%) were Black; 122 (15.0%) reported new-onset NMUPO, for an incidence rate of 5.0 per 100 person-years. In a multivariable Cox model, compared to <30 days, receipt of prescription opioids for 30–180 days (adjusted hazard ratio [AHR] = 1.65 95% CI: 1.06, 2.58) or >180 days (AHR = 1.99, 95% CI: 1.21, 3.29) was associated with incident NMUPO. ConclusionsDuration of prescription opioid receipt is a risk factor for incident NMUPO among veterans receiving medical care. Providers who prescribe opioids should monitor for NMUPO, especially among those with a longer duration of opioid therapy.

Patient-Centered Medical Home Implementation and Improved Chronic Disease Quality: A Longitudinal Observational Study.

To examine associations between clinics' extent of patient-centered medical home (PCMH) implementation and improvements in chronic illness care quality. Data from 808 Veterans Health Administration (VHA) primary care clinics nationwide implementing the Patient Aligned Care Teams (PACT) PCMH initiative, begun in 2010. Clinic-level longitudinal observational study of clinics that received training and resources to implement PACT. Clinics varied in the extent they had PACT components in place by 2012. Clinical care quality measures reflecting intermediate outcomes and care processes related to coronary artery disease (CAD), diabetes, and hypertension care were collected by manual chart review at each VHA facility from 2009 to 2013. In adjusted models containing 808 clinics, the 77 clinics with the most PACT components in place had significantly larger improvements in five of seven chronic disease intermediate outcome measures (e.g., BP<160/100 in diabetes), ranging from 1.3 percent to 5.2 percent of the patient population meeting measures, and two of eight process measures (HbA1c measurement, LDL measurement in CAD) than the 69 clinics with the least PACT components. Clinics with moderate levels of PACT components showed few significantly larger improvements than the lowest PACT clinics. Veterans Health Administration primary care clinics with the most PCMH components in place in 2012 had greater improvements in several chronic disease quality measures in 2009-2013 than the lowest PCMH clinics.

Sources of Distress in Primary Care Opioid Management and the Role of a Controlled Substance Review Group: A Qualitative Study.

The objective of the study was to explore provider perspectives surrounding opioid prescribing in the context of the early implementation of a multidisciplinary group, called the Controlled Substance Review Group, that provided structured opioid case discussion and consultation to primary care providers. A Veterans Health Administration primary care clinic in Portland, Oregon. Participants: 12 members of primary care clinic staff representing multiple disciplines with recent participation in the Controlled Substance Review Group. Six semistructured interviews with primary care providers, one focus group discussion with six Nurse Care Managers, and 28 structured observations of CSRG meetings were conducted. In an iterative process using applied thematic analysis, a trained qualitative researcher reviewed textual data for themes. Four broad domains with associated themes emerged from the analysis: 1) challenges of pain management-objective pain measures, changing guidelines, lack of coordinated approach; 2) patient attachment to opioids-threats, entitlement, abandonment; 3) provider frustration-confrontation in clinic visits, lack of mental health engagement, complex social situation; and 4) role of the Controlled Substance Review Group-communication techniques, supporting mental health engagement, structured backing. Primary care providers experience stress associated with opioid prescribing, including the provision of appropriate pain management using opioid analgesics and difficult patient-provider communication. The Controlled Substance Review Group functions to support providers through assistance with decision-making and shared responsibility for decision outcomes.

Clinical experiences at veterans administration primary care clinics: An interprofessional education project for advanced practice nurses and health professions students

There is limited literature that specifically addresses how academic institutions and healthcare facilities effectively establish and manage clinical experiences for students. Since advanced practice nursing education (APRN) programs strive to provide appropriate clinical experiences as part of their students’ educational training, it is imperative that academic institutions and clinical facilities establish working relationships and protocols for productive collaboration. Barriers may exist in arranging student clinical placements, including scheduling conflicts and provider workload burden. Collaborative approaches for placing APRN students in primary care settings can be beneficial for student learning and the clinical care of patients. The purpose of this paper is to provide an initial roadmap for coordinating APRN and other health professional students’ placement in clinical rotations at a Veterans Health Administration Medical Center (VAMC) primary care clinic in the Midwest.

Elements of the Veterans Health Administration Patient-Centered Medical Home are Associated with Greater Adherence to Oral Hypoglycemic Agents in Patients with Diabetes.

In 2010, Veterans Health Administration (VHA) primary care clinics adopted a patient-centered medical home (PCMH) model. This study sought to examine the association between the organizational features related to adoption of PCMH and the level of adherence to oral hypoglycemic agents (OHAs) among patients with diabetes. This retrospective cohort study involved 757 VA clinics that provide primary care to 440,971 patients with diabetes who were taking OHAs in fiscal year 2012. One-year refill-based medication possession ratios (MPRs) were calculated at the patient level. Clinic-level adherence was defined as the proportion of clinics with MPR ≥80%. Risk adjustment of adherence was performed using logistic regression to account for differences in patient populations at clinics. Eight domains of the PCMH model (ie, access, continuity, coordination, teamwork, comprehensive care, self-management, communication, shared decision making) were assessed using items from a previously validated index. Multivariate linear regression was applied to identify PCMH components associated with clinic-level adherence. Patients with diabetes per clinic ranged from 100 to 5011. The average level of adherence to OHAs among clinics ranged from 52.8% to 61.9% (interquartile range = 57.9% to 59.4%). In multivariate analysis, organizational features associated with higher clinic-level adherence included access to routine care (standardized beta [Sβ] = .21, P = .004), having a respectful office staff (Sβ = 0.21, P = .002), and utilization of telephone encounters (Sβ = 0.23, P < .001). Among a national cohort of veterans with diabetes, overall PCMH implementation did not significantly increase adherence to oral hypoglycemic agents, although aspects of implementation were associated with increased adherence. Measures of access to care appear the most significant.

Delivery of Brief Cognitive Behavioral Therapy for Medically Ill Patients in Primary Care: A Pragmatic Randomized Clinical Trial.

Few studies have examined the practical effectiveness and implementation potential of brief psychotherapies that integrate mental and physical health. To determine whether an integrated brief cognitive behavioral therapy (bCBT), delivered by mental health providers in primary care, would improve depression, anxiety and quality of life for medically ill veterans. Pragmatic patient-randomized trial comparing bCBT to enhanced usual care (EUC). A total of 302 participants with heart failure and/or chronic obstructive pulmonary disease (COPD) with elevated symptoms of depression and/or anxiety were enrolled from two Veterans Health Administration primary care clinics. bCBT was delivered to 180 participants by staff mental health providers (n=19). bCBT addressed physical and emotional health using a modular, skill-based approach. bCBT was delivered in person or by telephone over 4months. Participants randomized to EUC (n=122) received a mental health assessment documented in their medical record. Primary outcomes included depression (Patient Health Questionnaire) and anxiety (Beck Anxiety Inventory). Secondary outcomes included health-related quality of life. Assessments occurred at baseline, posttreatment (4months), and 8- and 12-month follow-up. Participants received, on average, 3.9 bCBT sessions with 63.3% completing treatment (4+ sessions). bCBT improved symptoms of depression (p=0.004; effect size, d=0.33) and anxiety (p<0.001; d=0.37) relative to EUC at posttreatment, with effects maintained at 8 and 12months. Health-related quality of life improved posttreatment for bCBT participants with COPD but not for heart failure. Health-related quality of life outcomes were not maintained at 12months. Integrated bCBT is acceptable to participants and providers, appears feasible for delivery in primary care settings and is effective for medically ill veterans with depression and anxiety. Improvements for both depression and anxiety were modest but persistent, and the impact on physical health outcomes was limited to shorter-term effects and COPD participants. Clinical trials.Gov identifier: NCT01149772.

Interprofessional education to foster communication and resilience among health professional students

Abstract An 8-week interprofessional education (IPE) immersion classroom experience was developed to prepare advanced practice nursing, pharmacy, social work and clinical psychology students for delivering care as interprofessional clinical practice (IPCP) teams at a Veterans Administration primary care clinic. The course was designed to assist students in building resilience for negotiating challenges in the healthcare environment, to transition from autonomous novices to interprofessional practitioners, and to fortify knowledge and attitudes around veteran healthcare. Using case studies and standardized patients, student teams learned to negotiate challenging patient and interprofessional conflicts that can arise around moral dilemmas, cultural differences, and the hierarchy within the healthcare system. Students learned to anticipate and manage challenging situations through increased problem-solving skills, effective coping strategies, and improved confidence in managing negative emotions.

Screening for Food Insecurity in Six Veterans Administration Clinics for the Homeless, June-December 2015.

ObjectiveWe assessed findings from a food-insecurity screening of a national sample of Veterans Administration clinics for homeless and formerly homeless veterans.MethodsWe reviewed results from initial screenings administered at 6 Veterans Administration primary care clinics for the homeless and responses from clinic staff members interviewed about the screening program.ResultsA total of 270 patients were screened. The average age was 53 years, and most were male (93.1%). Screening showed a high prevalence of food insecurity. Of the 270, 48.5% reported they experienced food insecurity in the previous 3 months, 55.0% reported averaging 2 meals a day, and 27.3% averaged 1 meal a day. Eighty-seven percent prepared their own meals, relying on food they bought (54.2%), help from friends and family (19.1%), and soup kitchens and food pantries (22%); 47.3% received Supplemental Nutrition Assistance Program benefits (food stamps). Additionally, of those who screened positive for food insecurity 19.8% had diabetes or prediabetes, and 43.5% reported hypoglycemia symptoms when without food. Clinic staff members responded positively to the screening program and described it as a good rapport builder with patients.ConclusionsIntegrating screening for food insecurity among patients in clinical settings was well received by both patients and health care providers. Addressing these positive findings of food insecurity requires a multidisciplinary health care approach.