Veterans Health Administration Leadership Research Articles

What Should Healthcare Systems Consider When Modernizing Call Centers? Early Considerations From the Veterans Health Administration.

Growing numbers of hospitals and payers are using call centers to answer patients' clinical and administrative questions, schedule appointments, address billing issues, and offer supplementary care during public health emergencies and national disasters. In 2020, the Veterans Health Administration (VA) implemented VA Health Connect, an enterprise-wide initiative to modernize call centers. VA Health Connect is designed to improve the care experience with the convenience, flexibility, and simplicity of a single toll-free number connected to a range of 24/7 virtual services. The services are organized into four areas: administrative guidance for scheduling and general inquiries; pharmacy support for medication matters; clinical triage for evaluation of symptoms and recommended care; and virtual visits with providers for urgent and episodic care. Through a qualitative evaluation of VA Health Connect, we sought to identify the factors that affected the development of this program and to compile considerations to support the implementation of other enterprise-wide initiatives. The evaluation team interviewed 29 clinical and administrative leads from across the VA. These leads were responsible for the modernization of their local service networks. PhD-level qualitative methodologists conducted the interviews, asking participants to reflect on barriers and facilitators to modernization and implementation. The team employed a rapid qualitative analytic approach commonly used in healthcare research to distill robust results. A review of the early implementation of VA Health Connect found: (1) deadlines proved challenging but provided momentum for the initiative; (2) a balance between standardized processes and local adaptations facilitated implementation; (3) attention to staffing, hiring, and training of call center staff before implementation expedited workflows; (4) establishing national and local leadership commitment to the innovation from the onset increased team cohesion and efficacy; and (5) anticipating information technology infrastructure needs prevented delays to modernization and implementation. Our findings suggest that healthcare systems would benefit from anticipating likely obstacles (e.g., delays in software implementations and negotiations with unions), thus providing ample time to secure leadership buy-in and identify local champions, communicating early and often, and supporting flexible implementation to meet local needs. VA leadership can use this evaluation to refine implementation, and it could also have important implications for regulators, federal health exchanges, insurers, and other healthcare systems when determining resource levels for call centers.

Changes in Homelessness Among US Veterans After Implementation of the Ending Veteran Homelessness Initiative

Homelessness is a persistent and growing problem. What role health systems should play and how that role is incorporated into larger strategic efforts are not well-defined. To compare homelessness among veterans with that in the general population during a 16-year study period before and after implementation of the Ending Veteran Homelessness Initiative, a program to rehouse veterans experiencing homelessness. This national retrospective cohort study using a mixed-methods approach examined annualized administrative (January 1, 2007, to December 31, 2022) and population data prior to (2007-2009) and during (2010-2022) the Ending Veteran Homelessness initiative. Participants included unhoused adults in the US between 2007 and 2022. Enrollment in Veterans Health Administration (VHA) Homeless Program Office components providing housing, case management, and wrap-around clinical and supportive services. Point-in-time (PIT) count data for unhoused veterans and nonveterans during the study period, number of Section 8 housing vouchers provided by Housing and Urban Development-Veterans Administration Supportive Housing, number of community grants awarded by Supportive Services for Veterans and Families, and total number of veterans housed each year. Semistructured interviews with VHA leadership were performed to gain insight into the strategy. In 2022, 33 129 veterans were identified in the PIT count. They were predominantly male (88.7%), and 40.9% were unsheltered. During the active years of the Ending Veteran Homelessness initiative, veteran homelessness decreased 55.3% compared with 8.6% for the general population. The proportion of veterans in this cohort also declined from 11.6% to 5.3%. This change occurred during a shift to "housing first" as agency policy to create low-barrier housing availability. It was also coupled with substantial growth in housing vouchers, grants to community partner agencies, and growth in VHA clinical and social programming to provide homeless-tailored wrap-around services and support once participants were housed. Key respondent interviews consistently cited the shift to housing first, the engagement with community partners, and use of real-time data as critical. In this cohort study of the federal Ending Veteran Homelessness initiative, after program implementation, there was a substantially greater decrease in homelessness among veterans than in the general population. These findings suggest an important role for health systems in addressing complex social determinants of health. While some conditions unique to the VHA facilitated the change in homelessness, lessons learned here are applicable to other health systems.

Engaging Operational Partners Is Critical for Successful Implementation of Research Products: a Coincidence Analysis of Access-Related Projects in the Veterans Affairs Healthcare System

Background/ObjectiveThe Veterans Health Administration (VHA) has prioritized timely access to care and has invested substantially in research aimed at optimizing veteran access. However, implementing research into practice remains challenging. Here, we assessed the implementation status of recent VHA access-related research projects and explored factors associated with successful implementation.DesignWe conducted a portfolio review of recent VHA-funded or supported projects (1/2015–7/2020) focused on healthcare access (“Access Portfolio”). We then identified projects with implementable research deliverables by excluding those that (1) were non-research/operational projects; (2) were only recently completed (i.e., completed on or after 1/1/2020, meaning that they were unlikely to have had time to be implemented); and (3) did not propose an implementable deliverable. An electronic survey assessed each project’s implementation status and elicited barriers/facilitators to implementing deliverables. Results were analyzed using novel Coincidence Analysis (CNA) methods.Participants/Key ResultsAmong 286 Access Portfolio projects, 36 projects led by 32 investigators across 20 VHA facilities were included. Twenty-nine respondents completed the survey for 32 projects (response rate = 88.9%). Twenty-eight percent of projects reported fully implementing project deliverables, 34% reported partially implementing deliverables, and 37% reported not implementing any deliverables (i.e., resulting tool/intervention not implemented into practice). Of 14 possible barriers/facilitators assessed in the survey, two were identified through CNA as “difference-makers” to partial or full implementation of project deliverables: (1) engagement with national VHA operational leadership; (2) support and commitment from local site operational leadership.ConclusionsThese findings empirically highlight the importance of operational leadership engagement for successful implementation of research deliverables. Efforts to strengthen communication and engagement between the research community and VHA local/national operational leaders should be expanded to ensure VHA’s investment in research leads to meaningful improvements in veterans’ care.Lay SummaryThe Veterans Health Administration (VHA) has prioritized timely access to care and has invested substantially in research aimed at optimizing veteran access. However, implementing research findings into clinical practice remains challenging, both within and outside VHA. Here, we assessed the implementation status of recent VHA access-related research projects and explored factors associated with successful implementation. Only two factors were identified as “difference-makers” to adoption of project findings into practice: (1) engagement with national VHA leadership or (2) support and commitment from local site leadership. These findings highlight the importance of leadership engagement for successful implementation of research findings. Efforts to strengthen communication and engagement between the research community and VHA local/national leaders should be expanded to ensure VHA’s investment in research leads to meaningful improvements in veterans’ care.

Research Priorities to Support Women Veterans' Reproductive Health and Health Care Within a Learning Health Care System.

Research Priorities to Support Women Veterans' Reproductive Health and Health Care Within a Learning Health Care System.

Lessons Learned Using Rapid Human Factors Methods: Condensed Timeline with Effective and Impactful Results

Contextual inquiry and discount usability represent a powerful combination of human factors methods as a responsive and rapid approach to better understand end users’ interactions with a new electronic health record (EHR) system as an enterprise capability. Contextual inquiry is an approach to conducting ethnographic field studies and discount usability is a simplified and efficient technique to identify usability issues. This paper describes how the Veterans Health Administration (VHA) Office of Health Informatics Human Factors Engineering (OHI HFE) responded to a request from VHA leadership to provide rapid support to assess EHR post-implementation system performance to discover if there are barriers or shortcomings. The team utilized contextual inquiry methods and principles of discount usability to assess system usability and effectiveness in meeting end-user needs. OHI and the Electronic Health Record Modernization Integration Office (OEHRM IO) formed a team to conduct semi-structured interviews and observations with health care providers at a VHA facility to gather qualitative data showcasing representative users’ experiences with the EHR. The team analyzed the data collected to identify themes and created an affinity map and two service blueprints. It then used this information to produce a report of findings and recommendations. The study identified areas that required remediation, actions that would facilitate success, and opportunities for improvement. Key contributors to the success of this rapid and important effort included the team’s ability to accommodate a compressed schedule by carefully targeting scope; focusing on a smaller number of participants than originally planned; asking direct, targeted questions developed in advance; and capturing data during short interview and observation windows. The data collected also highlights opportunities to continue the use of discount usability methods, when necessary, to continuously improve OHI HFE data collection and achieve targeted quality improvement in a condensed timeframe.

Age-friendly care in the Veterans Health Administration: Past, present, and future.

The Veterans Health Administration (VHA) has long recognized the need for age-friendly care. VHA leadership anticipated the impact of aging World War II veterans on VA healthcare systems and in 1975 developed Geriatric Research, Education, and Clinical Centers (GRECCs) to meet this need. GRECCs catalyzed a series of innovations in geriatric models of care that span the continuum of care, most of which endure. These innovative care models also contributed to the evidence base supporting the present-day Age-Friendly Health Systems movement, with which VHA is inherently aligned. As both a provider of and payor for care, VHA is strongly incentivized to promote coordination across the continuum of care, with resultant cost savings. VHA is also a major contributor to developing the workforce that is essential for the provision of age-friendly care. As VHA continues to develop and refine innovative geriatric models of care, policymakers and non-VHA health care systems should look to VHA programs as exemplars for the development and implementation of age-friendly care.

Veterans Health Administration's Whole Health System of Care: Supporting the Health, Well-Being, and Resiliency of Employees.

The Veterans Health Administration (VHA) is implementing a Whole Health System (WHS) of care that empowers and equips Veterans to take charge of their health and well-being and live their lives to the fullest, and increasingly leaders recognize the need and value in implementing a similar approach to support the health and well-being of employees. The purpose of this paper is to do the following: 1) provide an overview of the WHS of care in VHA and applicability in addressing employee resiliency; 2) provide a brief history of employee well-being efforts in VHA to date; 3) share new priorities from VHA leadership as they relate to Employee Whole Health strategy and implementation; and 4) provide a summary of the impacts of WHS of care delivery on employees. The WHS of care utilizes all therapeutic, evidence-based approaches to support self-care goals and personal health planning. Extending these approaches to employees builds upon 10 years of foundational work supporting employee health and well-being in VHA. In 2017, one facility in each of the 18 Veterans Integrated Service Networks (VISNs) in VHA was selected to participate in piloting the WHS of care with subsequent evaluation by VA’s Center for Evaluating Patient-Centered Care (EPCC). Early outcomes, from an employee perspective, suggest involvement in the delivery of the WHS of care and personal use of the whole health approach have a meaningful impact on the well-being of employees and how they experience the workplace. During the COVID-19 pandemic, VHA has continued to support employees through virtual resources to support well-being and resiliency. VHA's shift to this patient-centered model is supporting not only Veteran care but also employee health and well-being at a time when increased support is needed.

Innovations in Care: Complementary and Integrative Health in the Veterans Health Administration Whole Health System.

Innovations in Care: Complementary and Integrative Health in the Veterans Health Administration Whole Health System.

"It Would've Been Nice if They Interpreted the Data a Little Bit. It Didn't Really Say Much, and It Didn't Really Help Us.": A Qualitative Study of VA Health System Evidence Needs.

Patient health outcomes improve when learning health care systems use evidence to implement promising services and allocate resources effectively. Here, we examine the unique environment in which Veterans Health Administration (VHA) leadership use evidence and the facilitators and barriers to using evidence synthesis products in decision-making. We end by describing the steps researchers can take to better support the needs of health system leadership. We conducted 20 semistructured phone interviews with individuals in VHA leadership positions. We used an inductive approach to identify themes observed across key informant interviews. Key informants identified several factors that fostered the use of evidence including, timeliness, lack of bias, flexible approaches, and concise reports with a clear bottom line. Barriers included lack of relevant evidence and lack of information on how to translate evidence into practice, resistance to change among providers and within the larger health system, and political pressures to implement therapies or technologies with little evidence or uncertainty. Researchers can foster evidence uptake by developing a review scope and key questions that are important to multiple stakeholders, including frontline clinicians and health system leadership. The VHA's evidence needs resemble other health systems, but evidence synthesis products should include a translational component to enhance implementation. Resistance to change and political pressures can further hinder the uptake of evidence within VHA.

Building Sustainable Models of Veteran-Engaged Health Services Research

Engaging veterans in research has gained momentum in the Veterans Health Administration (VHA) in recent years. Engagement ensures that health services research is more relevant and tailored to the unique needs of veteran populations. VHA research centers promote engagement through the development of veteran engagement groups (VEGs). Members engage with researchers in organized meetings to review research proposals or projects, and provide individual feedback to improve veteran-centricity. This article shares important lessons learned in implementing VEGs locally from the liaisons who serve as a bridge between researchers and the veterans involved in these groups. Five steps in the VEG formation process are discussed: (1) regulatory considerations (e.g., compliance issues, ethics); (2) recruitment of VEG members (e.g., group size, demographic characteristics); (3) structure and governance (e.g., meeting logistics, participation, and privacy/confidentiality); (4) orientation and training (e.g., orienting veterans and researchers to the engagement process); and (5) evaluation and feedback (e.g., the effectiveness of engagement and tracking the incorporation of veteran feedback in the research). While all VEGs go through identical steps in the formation process, local implementation varies contextually by research center location. To illustrate the diversity in the formation methods, we present a series of case studies throughout this article: Denver, Colorado; Portland, Oregon; Hines, Illinois; West Haven, Connecticut; Iowa City, Iowa; and Houston, Texas. Normalization of veteran engagement in VHA health services research will require a cultural shift to one that embraces veterans’ perspectives and results in a more collaborative partnership between VHA leadership, researchers, and veterans.

Occupational burnout among PTSD specialty clinic providers in the Veterans Health Administration: Perceptions of bureaucratic and political oversight

Background and objectivesPrior research suggests a link between occupational burnout and perceived vulnerability to organizational oversight. The purpose of this exploratory study was to examine the relationship between perceptions of political and bureaucratic oversight (e.g., by Congress, media, or policies, rules, and performance metrics) and occupational burnout among mental health providers working in Veterans Health Administration (VHA) PTSD specialty clinical teams (PCTs). DesignThis cross-sectional study included 481 prescribing and non-prescribing PCT providers throughout the VHA system. The sample was mostly female (70%), Caucasian (84%), and psychologists (48%). MethodParticipants completed an online survey that assessed demographics, perceptions of political and bureaucratic oversight, and burnout. Burnout was evaluated using the Maslach Burnout Inventory-General Survey. ResultsHigh levels of emotional exhaustion (55%), cynicism (55%), and professional efficacy (53%) were found. Results indicate that burnout in PCT providers was associated with: feeling vulnerable to complaints to media, Congress, and VHA leadership; reporting “political influence” on PTSD diagnoses or treatment offerings; and feeling care delivery is hindered by the large volume of VHA policies, rules, and performance metrics. ConclusionResults suggest increasing providers’ sense of psychological safety and reducing metric overload may support burnout prevention in VHA's complex environment of care.

An operations-partnered evaluation of care redesign for high-risk patients in the Veterans Health Administration (VHA): Study protocol for the PACT Intensive Management (PIM) randomized quality improvement evaluation

BackgroundPatient-centered medical homes have made great strides providing comprehensive care for patients with chronic conditions, but may not provide sufficient support for patients at highest risk for acute care use. To address this, the Veterans Health Administration (VHA) initiated a five-site demonstration project to evaluate the effectiveness of augmenting the VA's Patient Aligned Care Team (PACT) medical home with PACT Intensive Management (PIM) teams for Veterans at highest risk for hospitalization. Methods/designResearchers partnered with VHA leadership to design a mixed-methods prospective multi-site evaluation that met leadership's desire for a rigorous evaluation conducted as quality improvement rather than research. We conducted a randomized QI evaluation and assigned high-risk patients to participate in PIM and compared them with high-risk Veterans receiving usual care through PACT. The summative evaluation examines whether PIM: 1) decreases VHA emergency department and hospital use; 2) increases satisfaction with VHA care; 3) decreases provider burnout; and 4) generates positive returns on investment. The formative evaluation aims to support improved care for high-risk patients at demonstration sites and to inform future initiatives for high-risk patients. The evaluation was reviewed by representatives from the VHA Office of Research and Development and the Office of Research Oversight and met criteria for quality improvement. DiscussionVHA aims to function as a learning organization by rapidly implementing and rigorously testing QI innovations prior to final program or policy development. We observed challenges and opportunities in designing an evaluation consistent with QI standards and operations priorities, while also maintaining scientific rigor.Trial registration: This trial was retrospectively registered at ClinicalTrials.gov on April 3, 2017: NCT03100526. Protocol v1, FY14-17.

Clinical Policy Recommendations from the VHA State-of-the-Art Conference on Non-Pharmacological Approaches to Chronic Musculoskeletal Pain.

As a large national healthcare system, Veterans Health Administration (VHA) is ideally suited to build on its work to date and develop a safe, evidence-based, and comprehensive approach to the care of chronic musculoskeletal pain conditions that de-emphasizes opioid use and emphasizes non-pharmacological strategies. The VHA Office of Health Services Research and Development (HSR&D) held a state-of-the-art (SOTA) conference titled "Non-pharmacological Approaches to Chronic Musculoskeletal Pain Management" in November 2016. Goals of the conference were (1) to establish consensus on the current state of evidence regarding non-pharmacological approaches to chronic musculoskeletal pain to inform VHA policy in this area and (2) to begin to identify priorities for the future VHA research agenda. Workgroups were established and asked to reach consensus recommendations on clinical and research priorities for the following treatment strategies: psychological/behavioral therapies, exercise/movement therapies, manual therapies, and models for delivering multimodal pain care. Participants in the SOTA identified nine non-pharmacological therapies with sufficient evidence to be implemented across the VHA system as part of pain care. Participants further recommended that effective integration of these non-pharmacological approaches across the VHA and especially into VHA primary care, pain care, and mental health settings should be a priority, and that these treatments should be offered early in the course of pain treatment and delivered in a team-based, multimodal treatment setting concurrently with active self-care and self-management approaches. In addition, we recommend that VHA leadership and policy makers systematically address the barriers to implementation of these approaches by expanding opportunities for clinician and veteran education on the effectiveness of these strategies; supporting and funding further research to determine optimal dosage, duration, sequencing, combination, and frequency of treatment; emphasizing multimodal care with rigorous evaluation grounded in team-based approaches to test integrated models of delivery and stepped-care approaches; and working to address socioeconomic and cultural barriers to veterans' access to non-pharmacological approaches.

Firearm Injury Encounters in the Veterans Health Administration (VHA), 2010-2015

IntroductionFirearm violence is an issue of public health concern leading tomore than 30,000 deaths and 80,000 nonfatal injuries in the UnitedStates annually.1To date, firearm-related studies among Veteranshave focused primarily on suicide and attempted suicide.2-5Herein,we examine firearm violence among VHA enrollees for all manners/intents, including assault, unintentional, self-inflicted, undeterminedand other firearm-related injury encounters in both the inpatient andoutpatient settings.MethodsInpatient and Outpatient encounters with one or more ICD-9-CM firearm external-cause-of-injury codes (E-codes) from1/1/2010-9/30/2015 were extracted from the VHA’s Praedico™Public Health Surveillance System, including demographics, era ofservice/eligibility, encounter type, and deaths. Firearm E-codes wereclassified for manner/intent based on the CDC’s Web-based InjuryStatistics Query and Reporting System (WISQARS™) matrix.6Outpatient/emergency department (ED) data were exclusively fromVHA facilities (a single pediatric patient seen as a humanitarianemergency was excluded from the dataset). Inpatient data includedVHA facilities and some records received from non-VHA facilities.VHA rate of hospitalization for firearm-related admissions wascalculated using the total VHA acute-care admissions for the sametime period as the denominator.ResultsDuring the time frame examined, 5,205 unique individuals wereseen with a firearm E-code. Of these, 4,221 were seen in the outpatient/ED setting only, 597 in the inpatient setting only, and the remaining387 had encounters in both the outpatient/ED and inpatient settings.VHA firearm admission rate was 1.63 per 10,000 VHA admissions,compared to a national rate of 1.96 per 10,000 in 2010.7Table 1 showsthe breakdown of encounters by manner/intent. Unintentional was themost common firearm injury manner/intent. Overall, the median age atinitial encounter was 54 (range 19-100 years), and 96% were male. Thehighest percentage served in the Persian Gulf War Era (2,136, 41%),followed by Vietnam Era (1,816, 35%) and Post-Vietnam Era (716,14%). The greatest number of patients with a firearm-coded encounterresided in Texas (453), California (349), Florida (326), Arizona (214)and Ohio (212).ConclusionsUnintentional injuries were the most common form of firearminjury among VHA enrollees, representing over half of alloutpatient/ED firearm encounters and more than twice the numberof firearm hospitalizations compared with any other manner/intent.Limitations include that not all U.S. Veterans are VHA enrollees;miscoding and misclassification of firearm-related injuries may haveoccurred; and data from non-VHA outpatient/ED encounters andsome non-VHA hospitalizations are not available to our surveillancesystem for analysis. Additional study is needed to further understandthe epidemiology of firearm-related injuries among Veterans andinform VHA leadership and providers

NEGOTIATING DOMAINS OF PATIENT DIGNITY IN VA SPINAL CORD INJURY UNITS: PERSPECTIVES FROM INTERDISCIPLINARY CARE TEAMS AND VETERANS

Patient dignity is a significant concern among inpatient Veterans with spinal cord injuries (SCIs) because they may lack physical control over their bodies and thus rely on others for a variety of specialized needs, including mobility, personal care, wound care, bowel and bladder care, and rehabilitation, among others. This study examines the complexities of providing and negotiating dignified care in the context of interdisciplinary care teams in SCI, and the challenges Veterans with SCI face maintaining dignity in the context of limited independence. Based on a mixed methods approach that included in‐depth interviews, observations, and pile sorting at six Veterans Health Administration (VA) SCI units, the goal of this study was to explore ways in which dignity was defined, negotiated, and conferred during patient and provider interactions. Study results have immediate value to VA leadership, VA providers, and Veterans by calling attention to the ways in which the concept of patient dignity can be integrated into clinical practice on SCI units. This study provides a methodological framework to capture complex interactions among interdisciplinary care teams and patients, and offers a significant contribution to our understanding of how patient and provider interactions are conferred and negotiated.

Health services research is translational: lessons learned from VHA-funded research on cancer screening in older adults

Health services research is translational: lessons learned from VHA-funded research on cancer screening in older adults

Civility, Respect, Engagement in the Workforce (CREW)

This article presents a description and preliminary evaluation of a nationwide initiative by the Veterans Health Administration (VHA) called Civility, Respect, and Engagement in the Workforce (CREW). The goal of CREW is to increase workplace civility as assessed by employee ratings of interpersonal climate in workgroups. Once endorsed by the VHA leadership and adopted by the leaders of particular VHA hospitals, CREW was conducted by local facility coordinators who were trained and supported by the VHA National Center for Organization Development. This article explains the conceptual and operational background of CREW and the approach used to implement the initiative, presents results from two CREW administrations with a total of 23 sites, and reports significant preintervention to postintervention changes in civility at intervention sites as compared to no significant changes at comparison sites within each administration. It discusses these findings in the conceptual (theoretical) and operational (intervention evaluation) context of interventions targeting civility.