Urban Veterans Affairs Medical Center Research Articles

1859. Median Income by Location of Residence and Clinical Outcomes of Hospitalized Persons with COVID-19 in an Urban Veterans Affairs Medical Center

Abstract Background The COVID-19 pandemic has disproportionately affected racial and ethnic minorities and those of low socioeconomic status, including higher rates of illness severity and death. This has been attributed in part to decreased healthcare access. We sought to determine whether place of residence as a marker of socioeconomic status, healthcare access, and median income were predictive of disease severity in a large integrated healthcare system. Methods We conducted a prospective observational cohort study of ­348 patients admitted to the hospital with a diagnosis of COVID-19 between March 1, 2020 through June 30, 2021. Using univariate and multivariable logistic regression, we evaluated associations of disease severity outcomes with demographic characteristics of veterans, age-adjusted Charlson Comorbidity Index (CCI), and median income by place of residence. Results < The mean age of our cohort was 68 and 90% were male. The racial and ethnic makeup was 83% black, 14% white, 5% Hispanic or Latino, and 3% other. In unadjusted models, only median income and the CCI predicted need for high-flow oxygen (p = 0.009 and p < 0.0001, respectfully) and death (p = 0.04 and p = 0.0005, respectively), while the CCI also predicted the need for intubation (p = 0.02). In multivariable models, CCI was strongly associated with the need for high-flow oxygen, intubation, and death (p = 0.0001, 0.01, and 0.02, respectively); age alone remained the most powerful predictor of death. Race and ethnicity were not associated with the need for high-flow oxygen, intubation, or death. Place of residence was not associated with worse outcomes. Conclusion This cohort study of hospitalized patients in an urban Veterans Affairs Medical Center found that race, ethnicity, and location of residence were not associated with COVID-19 disease severity and death, but median income and higher scores on the CCI predicted worse outcomes. Disclosures Pratish C. Patel, PharmD, BCIDP, AAHIVP, VBI Vaccines: Stocks/Bonds

A retrospective comparison of pharmacist and psychiatrist‐led medication management clinics in an outpatient setting

AbstractIntroductionThe need for mental health care continues to outpace available providers in the United States. Clinical pharmacists trained in mental health are an available resource for mental health care delivery. To our knowledge, studies have not compared patient outcomes between pharmacist and psychiatrist medication management clinics. The aim of this study is to assess if a significant difference exists between pharmacist and psychiatrist medication management clinics with regard to escalation of care, evidence‐based medication prescribing, and medication adherence.MethodsThis study was a retrospective chart review of patients who received an outpatient prescription from a mental health provider between January 1, 2017 to July 1, 2018 at an urban Veterans Affairs (VA) medical center. The primary outcome was a composite of hospital admissions and emergency department visits due to a psychiatric or substance use condition. Secondary outcomes assessed in this study included treatment aspects related to escalation of care, medication prescribing, and adherence to treatment.ResultsIn this study, 111 patients were included in the pharmacist group and 110 patients in the psychiatrist group with patients matched based on diagnoses. The primary outcome was similar between groups (p = 0.646). The pharmacist clinic had a significantly higher medication possession ratio (p < 0.00001) and laboratory monitoring (p = 0.0015). The psychiatrist clinic had a significantly higher ratio of clinic appointments attended (p = 0.0025).DiscussionPsychiatric pharmacists may serve as an additional resource to provide evidence‐based medication management and improve medication adherence without the need for escalation of care. Increased utilization of psychiatric pharmacists can help improve access to quality care with the psychiatrist shortage.

Abstract 15287: Optimizing Guideline Directed Medical Therapy in Recently Hospitalized Patients With Heart Failure in a Large Urban Veterans Affairs Medical Center

Introduction: A quarter of patients hospitalized for heart failure either die or are re-hospitalized within 30 days. Optimization of guideline directed medical therapy (GDMT) has been shown to decrease both mortality and hospital readmissions. Methods: We used an existing heart failure clinical dashboard registry at our Veterans Affairs (VA) hospital to determine the rates of hospitalization from any medical cause and GDMT prescription rates from November to December 2022. We performed a retrospective chart review to validate dashboard results. Results: Twenty-nine patients in the registry were hospitalized within the last 30 days, with 5 patients excluded due to ongoing hospitalization; 19 were classified as heart failure with reduced ejection fraction (HFrEF, LVEF ≤ 40%), 4 as heart failure with preserved ejection fraction (LVEF ≥ 50%), and 2 unknown (no EF in 3 years). The rates of quadruple GDMT was 16% in all heart failure patients and 21% in patients with HFrEF (table 1). We performed a root cause analysis of low GDMT rates (figure 1). We used this data to secure buy-in from hospitalist medicine and cardiology to support a full-time cardiology pharmacist to screen all currently admitted patients with HFrEF. We created a standardized note template that gives recommendations for GDMT optimization prior to discharge. Conclusions: Although there is strong evidence that GDMT improves patient outcomes, many recently hospitalized patients are not optimized even after accounting for relative contraindications. We demonstrate that using tools such as a clinical dashboard and problem visualization with quality improvement methodology can both make GDMT optimization more tangible and also create buy-in from the health system to implement change.

Abstract 11693: Improving Angiotensin Receptor-Neprilysin Inhibitor Utilization for Veterans Admitted With Acute Decompensated Heart Failure: A Single-Center Experience

Objective: Improve angiotensin receptor-neprilysin inhibitor (ARNI) utilization among patients admitted with acute decompensated heart failure (HF) through a multidisciplinary quality improvement (QI) intervention. Background: ARNIs reduce mortality and hospitalizations for patients with HF and abnormal systolic function; current guidelines recommend them as first-line agents for Stage C HF. Inpatient initiation of ARNIs during an acute exacerbation is cost-effective and safe. Despite this, ARNI utilization remains low nationally and at our center. Methods: We implemented a multidisciplinary QI intervention at a large urban Veterans Affairs (VA) medical center. The intervention included electronic health record system redesign to provide clinical decision support, a new pharmacy-led screening process and recommendation system to the primary inpatient team, and an educational campaign. Our primary outcome metric was monthly ARNI initiation rate, defined as the number of new ARNI initiations divided by the number of eligible patients admitted for an acute HF exacerbation. We used a statistical process control (XmR) chart to measure change. Results: We observed a statistically significant, non-random improvement in mean monthly ARNI initiation rate from 8.4% pre-intervention to 35.7% post-intervention. An XmR chart is shown in Figure 1. Split limits analysis showed variation post-intervention was within statistical control, suggesting sustainable change. Conclusions: Our outcomes demonstrate successful implementation of a multidisciplinary intervention to improve ARNI utilization among patients admitted with acute decompensated HF at a large VA medical center. ARNI initiation rate increased significantly post-intervention, and the split limits analysis suggests that our results represent sustainable change. A longer period of data collection will be useful to assess HF readmission and mortality rates in response to this intervention.

Association of a geriatric emergency department program with healthcare outcomes among veterans.

We aim to describe the outcomes of Geriatric Emergency Room Innovations for Veterans (GERI-VET), the first comprehensive Veterans Affairs Geriatric ED program. In this prospective observational cohort study at an urban Veterans Affairs Medical Center ED, participants included Veterans aged 65 years and older treated in the ED from January 7, 2017 to February 29, 2020. Veterans with an Identification of Seniors At Risk (ISAR) score >2 were considered eligible for GERI-VET, receiving geriatric screens and care coordination in addition to standard ED treatment. The control group included GERI-VET eligible Veterans who did not receive GERI-VET care. Propensity score matching was used to compare outcomes in the GERI-VET group (N= 725) and a matched control group (n= 725). Key measures included ED resource utilization, outpatient referrals, ED admission, and 30-day admission. In the ED, the GERI-VET group received more consults to pharmacy (315 [43.4%] vs. 195 [26.9%], p< 0.001) and social work (399 [55.0%] vs. 132 [18.2%], p< 0.001). The GERI-VET group had higher referral rates to Geriatrics (64 [17.7%] vs. 18 [5.8%], p< 0.001) and Home Based Primary Care (110 [30.4%] vs. 24 [7.8%], p< 0.001). Key outcome measures included lower rates of ED admission (363 [50.1%] vs. 417 [n= 57.5%], p= 0.003) and 30-day hospital admission (412 [56.8%] vs. 464 [64.0%], p= 0.004) without increasing ED length of stay (5.4± 2.2 vs. 5.4± 2.6h, p= 0.85) or 72-h ED revisits (23 [3.2%] vs. 16 [2.2%], p= 0.25) in the GERI-VET group. A program designed to screen for geriatric syndromes and coordinate care among at-risk older Veterans was associated with increased multidisciplinary resource utilization and reduced ED and 30-day admissions without increasing ED length of stay or re-visitation.

Pilot study of the Collaborative Assessment and Management of Suicidality-Group.

Few evidence-based options exist for outpatient treatment of patients at risk of suicide, and to-date almost all research has focused on individually delivered psychotherapy. Group therapy for veterans at risk of suicide is a promising alternative. Thirty veterans receiving care at an urban Veterans Affairs Medical Center in the southern United States were randomized to either care as usual (CAU) or to CAU plus the Collaborative Assessment and Management of Suicide-Group (CAMS-G). Veterans were assessed prior to randomization to condition and at 1, 3, and 6months post-randomization on a range of suicide-specific measures, burdensomeness, belonging, treatment satisfaction, and group cohesion. Across measures and follow-up assessments, veterans in CAMS-G reported good satisfaction with the intervention, a sense of cohesion with other members of the group, and reduced symptom distress. Veterans in both conditions reported decreases in suicidal ideation and behavior, with CAMS-G participants potentially improving slightly faster. This description of CAMS-G for veterans adds to the growing literature on suicide-specific interventions and supports the need for additional research to determine if wide-spread rollout is justifiable.

A pilot trial of collaborative care with motivational interviewing to reduce opioid risk and improve chronic pain management.

Opioid use and chronic pain are prevalent in the veteran population. Collaborative care enhances coordination between patients and their care teams, and motivational interviewing (MI) is a communication style designed to facilitate behavior change. This study evaluated the use of collaborative care with MI (CCMI) with patients with chronic pain and high-risk prescription opioid use. Small pilot study of a randomized controlled trial. An urban Veterans Affairs (VA) Medical Center in the United States. One hundredadult veterans with chronic pain currently enrolled into primary care and receiving long-term opioid therapy. During an initial 1-hour visit with a study primary-care physician (PCP), all veterans (n=100) developed a personalized pain care plan, after which they were randomized to receive four sessions (at 4, 6, 8 and 12weeks) of either CCMI (n=51) or attention control psychoeducation (ACP; n=49). Subsequently, participants had 30-minute follow-up visits with study PCPs and post-treatment assessment at 12weeks. Co-primary outcomes measures assessed opioid risk and pain interference; secondary measures assessed pain severity, PCP rating of opioid risk and pain management goals. At 12weeks, intent-to-treat (ITT) analyses using multivariate mixed-effects linear regression were inconclusive regarding the between-group differences in primary and secondary outcomes at post-intervention (12weeks). Bayes factors for opioid risk, pain interference, pain severity and PCP ratings were 1.96, 1.36, 0.45 and 0.82, respectively. Veterans in the CCMI group reported implementing more complementary integrative health (CIH) goals (e.g. yoga) than did those in the ACP group (d=0.54). US veterans with chronic pain who received collaborative care with motivational interviewing reduced their high-risk opioid use and showed improved pain interference and severity after an intake with a primary-care provider involving shared decision-making and the creation of a personalized pain care plan.

"Eyes in the Home": Addressing Social Complexity in Veterans Affairs Home-Based Primary Care.

Home-Based Primary Care (HBPC) has demonstrated success in decreasing risk of hospitalization and improving patient satisfaction through patient targeting and integrating long-term services and supports. Less is known about how HBPC teams approach social factors. Describe HBPC providers' knowledge of social complexity among HBPC patients and how this knowledge impacts care delivery. Between 2018 and 2019, we conducted in-person semi-structured interviews with 14 HBPC providers representing nursing, medicine, physical therapy, pharmacy, and psychology, at an urban Veterans Affairs (VA) medical center. We also conducted field observations of 6 HBPC team meetings and 2 home visits. We employed an exploratory, content-driven approach to qualitative data analysis. Four thematic categories were identified: (1) HBPC patients are socially isolated and have multiple layers of medical and social complexity that compromise their ability to use clinic-based care; (2) providers having "eyes in the home" yields essential information not accessible in outpatient clinics; (3) HBPC fills gaps in instrumental support, many of which are not medical; and (4) addressing social complexity requires a flexible care design that HBPC provides. HBPC providers emphasized the importance of having "eyes in the home" to observe and address the care needs of homebound Veterans who are older, socially isolated, and have functional limitations. Patient selection criteria and discharge recommendations for a resource-intensive program like VA HBPC should include considerations for the compounding effects of medical and social complexity. Additionally, staffing that provides resources for these effects should be integrated into HBPC programming.

Yoga for warriors: An intervention for veterans with comorbid chronic pain and PTSD.

Comorbid chronic pain and posttraumatic stress disorder (PTSD) is common in veterans; this comorbidity is associated with increased severity and poorer prognosis when compared to each outcome alone. Yoga has been shown to be effective for chronic pain and promising for PTSD, but yoga for comorbid pain and PTSD has not been examined. This article offers empirical support for a yoga intervention for comorbid chronic pain and PTSD in a veteran population. Results are presented from a 4-year pilot yoga intervention for comorbid chronic pain and PTSD at a large, urban Veterans Affairs Medical Center. Based on the fear avoidance model of pain, the intervention used a cross-sectional, open-trial design with pre- and postmeasures. T test analyses were conducted on program completers (N = 49; out of 87 initially enrolled, 44% attrition rate), who were primarily African American (69%) and male (61%) and had a mean age of 51.41 years (SD = 11.32). Results indicated trend-level reductions in overall PTSD symptoms, as measured by the PTSD Checklist for DSM-5 (p = .02, d = 0.38) and in symptom cluster scores of negative alterations of cognitions and mood (p = .03, d = 0.36) and arousal and reactivity (p = .03, d = 0.35). Veterans reported significant improvement in ability to participate in social activities (p < .001, d = 0.44) and significant reductions in kinesiophobia (fear of movement or physical activity; p < .001, d = 0.85). On a satisfaction measure with a range of 1 (quite dissatisfied) to 4 (extremely satisfied), the mean rating was 3.74 (SD = 0.33). Yoga is a feasible and effective intervention for veterans with comorbid chronic pain and PTSD. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Coordinated-Transitional Care for Veterans with Heart Failure and Chronic Lung Disease.

Patients with congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) account for most 30-day hospital readmissions nationwide. The Coordinated-Transitional Care (C-TraC) program is a telephone-based, nurse-driven intervention shown to decrease readmissions in Veterans Affairs (VA) and non-VA hospitals. The goal of this project was to assess the feasibility and efficacy of adapting C-TraC to meet the needs of complex patients with CHF and COPD in a large urban tertiary care VA medical center. We used the Replicating Effective Programs model to guide the implementation. The C-TraC nurse received intensive training in cardiology and pulmonology and worked closely with both inpatient and outpatient providers to coordinate care. Eligible patients were admitted with CHF or COPD and had at least one additional risk for readmission. The nurse met patients in the hospital, participated in their discharge planning, and then provided intensive case management for up to 4 weeks. Over its initial 14 months, the program successfully enrolled 299 veterans with good fidelity to the protocol. A total of 43 (15.8%) C-TraC participants were rehospitalized within 30 days compared with 172 (21.0%) of historical controls matched 3:1 on age, risk of 90-day hospital admission, and discharge diagnosis. Participants were 54% less likely to be rehospitalized (odds ratio = .46; 95% CI = .24-.89). The program was financially sustainable. The total cost of care in the 30-day postdischarge period was $1842.52 less per C-TraC patient than per controls, leading the medical center to sustain and expand the program.

Vocational rehabilitation for veterans with felony histories and mental illness: 12-month outcomes.

Lack of employment is an important barrier to successful reintegration encountered by those released from prison with mental illnesses and/or substance use disorders. This study compares 3 different vocational reintegration modalities for a veteran population: (a) basic services; (b) self-study using the About Face Vocational Manual; and (c) the About Face Vocational Program, a standardized group program focused on the About Face Vocational Manual. One-hundred eleven veterans with a history of at least one felony conviction and a mental illness and/or substance use disorder were recruited from a large urban Veterans Affairs (VA) medical center. Veterans were assigned to 1 of the 3 conditions and followed for 12 months. At the end of the 1-year follow-up period, veterans in the group condition had superior competitive and stable employment rates, as well as faster times to employment compared with both the basic and self-study conditions. The self-study condition was generally indistinguishable from the basic services condition. Overall, new employment during the last 6 months of the follow-up period was relatively low. The findings support the use of standardized group vocational reintegration programs such as the About Face Vocational Program. Limitations and implications are discussed. (PsycINFO Database Record

Blister Packaging Medication Increases Treatment Adherence in Psychiatric Patients.

To evaluate whether blister packing medications would improve prescription medication adherence in psychiatric patients. It was hypothesized that patients in the blister pack (BP) condition would be more adherent to their daily medications than those in the dispense as usual condition. This was a randomized trial involving up to 1 year of monthly follow-up assessments. Participants were recruited from an urban Veterans Affairs (VA) Medical Center in the Western United States. Inclusion criteria for participants included being diagnosed with a major affective disorder, posttraumatic stress disorder, schizophrenia, or a combination of these disorders; being 18 to 89 years of age; receiving prescription medications from the VA pharmacy; and being considered competent to manage their own medications. Of the 303 patients who consented to participate, 277 were randomized to 1 of the 2 study conditions, and 243 were retained in the study. The sample was 87% male, 47% white, with a mean age of 54.4 years. All medications prescribed and dispensed by the VA were either repackaged in monthly BPs or dispensed in standard pill vials. The primary hypothesis was supported. Patients in the BPs condition showed evidence of better adherence at 12-month follow-up, as well as larger increases in adherence from 1 month to 12 months. Psychiatric patients adhere better to prescription medication regimens when receiving their medications in BP.

“I Got to Voice What’s in My Heart”: Participation in the Cultural Formulation Interview—Perspectives of Consumers with Psychotic Disorders

Consumers with serious mental illness (SMI) frequently disengage from treatment; tools to enhance rapport and therapeutic alliance with these consumers are needed. The Cultural Formulation Interview (CFI), published in the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5), assesses social and cultural context as it relates to mental health and has potential as a rapport-building tool. The present study aimed to examine the perspectives of consumers with psychotic spectrum disorders on participating in the CFI. Consumers (N = 14) with psychotic disorders were recruited from mental health programs at an urban Veterans Affairs Medical Center. They participated in the CFI followed by a debriefing interview, during which they were queried about their experiences with the CFI. Debriefing interviews were audio recorded and transcribed. Thematic analysis was used to collate the data and identify themes. Participants reported that the CFI was validating, therapeutic, and led to deeper realizations about themselves and their recovery. The CFI may be used to simultaneously enhance rapport and obtain meaningful health narrative data with consumers with psychotic disorders. The CFI may be a valuable tool to promote treatment engagement among individuals with SMI.

Applying Lean Six Sigma to improve medication management.

A significant proportion of veterans use dual care or health care services within and outside the Veterans Health Administration (VHA). In this study conducted at a VHA medical center in the USA, the authors used Lean Six Sigma principles to develop recommendations to eliminate wasteful processes and implement a more efficient and effective process to manage medications for dual care veteran patients. The purpose of this study is to: assess compliance with the VHA's dual care policy; collect data and describe the current process for co-management of dual care veterans' medications; and draft recommendations to improve the current process for dual care medications co-management. Input was obtained from the VHA patient care team members to draw a process map to describe the current process for filling a non-VHA prescription at a VHA facility. Data were collected through surveys and direct observation to measure the current process and to develop recommendations to redesign and improve the process. A key bottleneck in the process that was identified was the receipt of the non-VHA medical record which resulted in delays in filling prescriptions. The recommendations of this project focus on the four domains of: documentation of dual care; veteran education; process redesign; and outreach to community providers. This case study describes the application of Lean Six Sigma principles in one urban Veterans Affairs Medical Center (VAMC) in the Mid-Western USA to solve a specific organizational quality problem. Therefore, the findings may not be generalizable to other organizations. The Lean Six Sigma general principles applied in this project to develop recommendations to improve medication management for dual care veterans are applicable to any process improvement or redesign project and has valuable lessons for other VAMCs seeking to improve care for their dual care veteran patients. The findings of this project will be of value to VA providers and policy makers and health care managers who plan to apply Lean Six Sigma techniques in their organizations to improve the quality of care for their patients.

Communication skills curriculum for foreign medical graduates in an internal medicine residency program.

Effective communication is an important aspect of caring for the elderly, who are more likely to have multimorbidity, limited health literacy, and psychosocial barriers to care. About half of Internal Medicine (IM) trainees in the United States are foreign medical graduates, and may not have been exposed to prior communication skills education. This novel communication skills curriculum for IM interns aimed to increase trainees' confidence and use of specific communication tools with older adults, particularly in delivering bad news and conducting family meetings. The workshop consisted of two interactive sessions in a small group with two learners and one or two facilitators, during the 4-week geriatrics block in IM internship training year. Twenty-three IM interns at an urban Veterans Affairs Medical Center were surveyed at the beginning and at the end of the 4-week block and 3 months after completion of the workshop about their knowledge, confidence, and skill in communication and asked about challenges to effective communication with older adults. The primary outcome measure was change in self-reported confidence and behavior in communication at 4 weeks. On a 4-point Likert scale, there was average improvement of 0.70 in self-reported confidence in communication, which was sustained 3 months after completion of the workshop. Participants reported several patient, physician, and system barriers to effective communication. Communication skills education in a small-group setting and the opportunity for repeated practice and self-reflection resulted in a sustained increase in overall confidence in IM interns in communication with older adults and may help overcome certain patient- and physician-specific communication barriers.

HIV rapid testing in a Veterans Affairs hospital ED setting: a 5-year sustainability evaluation

Routine HIV testing in primary care settings is now recommended in the United States. The US Department of Veterans Affairs (VA) has increased the number of patients tested for HIV, but overall HIV testing rates in VA remain low. A proven strategy for increasing such testing involves nurse-initiated HIV rapid testing (HIV RT). The purpose of this work was to use a mixed methodology approach to evaluate the 5-year sustainability of an intervention that implemented HIV RT in a VA emergency department setting in a large, urban VA medical center to reduce missed diagnostic and treatment opportunities in this vulnerable patient population. In-person semistructured interviews were conducted with providers and stakeholders. Interview notes were qualitatively coded for emerging themes. Quarterly testing rates were evaluated for a 5-year time span starting from the launch in July 2008. Findings indicate that HIV RT was sustained by the enthusiasm of 2 clinical champions who oversaw the registered nurses responsible for conducting the testing. The departure of the clinical champions was correlated with a substantial drop-off in testing. Findings also indicate potential strategies for improving sustainability including engaging senior leadership in the project, engaging line staff in the implementation planning from the start to increase ownership over the innovation, incorporating information into initial training explaining the importance of the innovation to quality patient care, providing ongoing training to maintain skills, and providing routine progress reports to staff to demonstrate the ongoing impact of their efforts.

Outcomes of Prolonged Exposure Therapy for Veterans With Posttraumatic Stress Disorder

Prolonged Exposure (PE) is an evidenced-based psychotherapy for posttraumatic stress disorder (PTSD) that is being disseminated nationally within the U.S. Department of Veterans Affairs (VA) with promising initial results. Empirical evidence, however, regarding the effectiveness of PE for treatment of PTSD in military veterans is limited. Building on previous treatment outcome research, the current study investigated the effectiveness of PE in a diverse veteran sample. One-hundred fifteen veterans were enrolled in PE at an urban VA medical center and its surrounding outpatient clinics. PTSD and depression symptoms as well as quality of life were measured before and after treatment. Several baseline patient characteristics were examined as predictors of treatment response. Eighty-four participants completed treatment. Participants experienced a 42% reduction in PTSD symptoms, a 31% reduction in depression symptoms, and an increase in quality of life following PE. Veterans not prescribed psychotropic medication reported greater PTSD symptom reduction than veterans prescribed such medication. The implications of these results for treatment programs targeting PTSD in veterans are discussed.

Documentation of Intimate Partner Violence in Women Veterans’ Medical Records: An In-Depth Analysis

National guidelines for identifying and addressing intimate partner violence (IPV) in the health care setting recommend that health care practitioners screen for IPV experiences and document disclosure and response in patients’ medical records. Women veterans are a growing population with particular risk of lifetime IPV victimization, yet we know little about how IPV presents and is addressed within the Veterans Health Administration (VHA). The purpose of this study was to examine documentation of women veterans’ disclosed experiences of IPV victimization in electronic medical records to identify how IPV presents in the VHA and to compare IPV screening, assessment, and response at a VHA medical center to nationally recognized best practices. We reviewed medical records for a five-year period (2005 to 2009) of 533 women veteran patients receiving care at an urban Veterans Affairs (VA) medical center and analyzed documentation of IPV disclosure and clinician response for patients with any documentation of IPV (N = 126). Women veterans presented with both acute and chronic IPV victimization experiences, as well as long-term effects of past IPV. Documentation of screening and response revealed opportunities for improvement to meet best practices.

A qualitative study of anticipated barriers and facilitators to the implementation of nurse-delivered alcohol screening, brief intervention, and referral to treatment for hospitalized patients in a Veterans Affairs medical center.

BackgroundUnhealthy alcohol use includes the spectrum of alcohol consumption from risky drinking to alcohol use disorders. Routine alcohol screening, brief intervention (BI) and referral to treatment (RT) are commonly endorsed for improving the identification and management of unhealthy alcohol use in outpatient settings. However, factors which might impact screening, BI, and RT implementation in inpatient settings, particularly if delivered by nurses, are unknown, and must be identified to effectively plan randomized controlled trials (RCTs) of nurse-delivered BI. The purpose of this study was to identify the potential barriers and facilitators associated with nurse-delivered alcohol screening, BI and RT for hospitalized patients.MethodsWe conducted audio-recorded focus groups with nurses from three medical-surgical units at a large urban Veterans Affairs Medical Center. Transcripts were analyzed using modified grounded theory techniques to identify key themes regarding anticipated barriers and facilitators to nurse-delivered screening, BI and RT in the inpatient setting.ResultsA total of 33 medical-surgical nurses (97% female, 83% white) participated in one of seven focus groups. Nurses consistently anticipated the following barriers to nurse-delivered screening, BI, and RT for hospitalized patients: (1) lack of alcohol-related knowledge and skills; (2) limited interdisciplinary collaboration and communication around alcohol-related care; (3) inadequate alcohol assessment protocols and poor integration with the electronic medical record; (4) concerns about negative patient reaction and limited patient motivation to address alcohol use; (5) questionable compatibility of screening, BI and RT with the acute care paradigm and nursing role; and (6) logistical issues (e.g., lack of time/privacy). Suggested facilitators of nurse-delivered screening, BI, and RT focused on provider- and system-level factors related to: (1) improved provider knowledge, skills, communication, and collaboration; (2) expanded processes of care and nursing roles; and (3) enhanced electronic medical record features.ConclusionsRCTs of nurse-delivered alcohol BI for hospitalized patients should include consideration of the following elements: comprehensive provider education on alcohol screening, BI and RT; record-keeping systems which efficiently document and plan alcohol-related care; a hybrid model of implementation featuring active roles for interdisciplinary generalists and specialists; and ongoing partnerships to facilitate generation of additional evidence for BI efficacy in hospitalized patients.

Adapting the Safety Planning Intervention for Use in a Veterans Psychiatric Inpatient Group Setting

The Department of Veterans Affairs (VA) recently has adopted the Safety Planning Intervention (SPI; Stanley &amp; Brown, 2011), a brief collaborative intervention, for use with veterans who are at high risk of suicide. The SPI is a hierarchical list of strategies for veterans to use in coping with a suicidal crisis. Its developers recommended that it be used with individual psychiatric inpatients working toward discharge, but its utility in a group format has not previously been addressed. This article describes the facilitation of a safety planning group with psychiatric inpatients at a large urban VA medical center. It depicts each step in the safety plan and offers case examples, anecdotal support, and specific considerations for its use in groups. Directions for further research are also discussed.