Veterans Health Administration Staff Research Articles

Promoting Health and Wellbeing Through Non-Clinical Arts Programming: Multi-Stakeholder Perspectives From the Veterans Health Administration.

While the value of art therapy is well-established and arts are increasingly leveraged to promote health and wellbeing more broadly, little is known about the impacts of non-clinical arts programs. In this preliminary investigation, we sought to fill this gap by exploring diverse stakeholders' perspectives on the impacts of non-clinical arts programming on Veterans receiving care at the Veterans Health Administration (VA). Semi-structured qualitative interviews with Veterans, VA staff, and community partners. Interviewees were recruited from 7 VA medical centers that have recently implemented non-clinical arts programming to promote Veterans' health and wellbeing, some of them in partnership with community organizations. 33 individuals were interviewed, including 9 Veterans, 14 VA staff, and 10 community partners involved in non-clinical arts program implementation. Interview transcripts were analyzed using iterative rounds of qualitative content analysis. The following impacts on Veterans were described: (1) mental health improvements, (2) renewed sense of purpose; (3) increased social connectedness, (4) improved self-esteem, and (5) self-driven engagement in art activities. Non-clinical arts programming was perceived by diverse stakeholders to offer important benefits for Veterans' health and well-being. Offering non-clinical arts programming inside and outside healthcare facilities' walls is a promising direction for the field of public health undergoing a shift towards holistic approaches to improving individual and population health outcomes.

“It Feels Like Health Care with the Patient in Mind”: VA Patient and Staff Perspectives on Self-Collected HPV Testing

PurposeSelf-collected testing for human papillomavirus (HPV) is poised to transform cervical cancer screening. Self-tests demonstrate similar accuracy to clinician-collected tests, but for the half a million women served by the Veterans Health Administration (VA) and their clinicians, self-collected cervical cancer screening would be a new practice. We examined VA patient and staff perspectives to inform future implementation. MethodsSemi-structured telephone interviews were conducted between 2021 and 2022 with female veterans receiving VA care (n = 22) and VA women's health nurses, clinicians, and administrators (n = 27). Interviews were audio-recorded and transcribed. Interview questions addressed knowledge and interest, potential advantages or disadvantages, and any questions participants had about self-collected screening. Responses were analyzed using rapid qualitative methods. Main findingsFive overarching themes were identified. Both patients and staff indicated high interest and enthusiasm for self-collected HPV testing, tempered by questions about test accuracy and logistical considerations. Familiarity with self-testing for other conditions such as colon-cancer screening or COVID made self-collection seem like a simple, convenient option. However, self-testing was not viewed as a good fit for all patients, and concerns about lost opportunities or missed incidental lesions were raised. Patients and staff described challenges with pelvic examinations for patients with past sexual trauma, particularly in the male-dominated VA environment. Pelvic exams can leave patients feeling vulnerable and exposed; self-collected testing was seen as a mechanism for patient empowerment. Principal conclusionsVeteran patients and VA staff shared common perspectives about potential advantages and disadvantages of self-collected HPV testing. Self-collected HPV testing has the potential to improve trauma-informed preventive health care for veterans.

Early Scaling of Immersive Technology Within the Veterans Health Administration

Over the past several years, accelerated by the Covid-19 pandemic, immersive technologies — including virtual reality and augmented or mixed reality, also known collectively as extended reality — have shown mounting promise in their ability to enhance clinical care delivery and support clinical staff. These immersive systems can be used alongside standard of care in several areas and, at minimum, be used as additional ways to augment evidence-based therapies. These noninvasive and easy-to-use tools have demonstrated the ability to effectively channel patient experience into therapeutic activities, facilitate home-based care, provide valuable longitudinal patient data, and enhance treatment adherence. Given this promise, immersive health care applications have spread across the U.S. Veterans Health Administration (VA), building additional evidence for efficacy and laying implementation groundwork. To date, VA has documented more than 40 indications for immersive technology utilization within the organization, with more in the pipeline. Early exploration of immersive technology in VA began with 5 sites and 10 staff engaged in a Community of Practice and has now grown to 172 sites and more than 2,400 engaged VA staff. The most uptake and impact have been seen in pain management, physical rehabilitation, and mental health care, including anxiety, depression, and posttraumatic stress disorder. Crucial to further scaling the use of immersive technology, VA has developed standardized resources, such as knowledge networks, implementation guides, electronic health record templates, and standard operating procedures. VA continues to offer opportunities for more heads in headsets, because this is an effective way to demonstrate to veterans and staff how immersive technology can enhance care. Key to future success in VA will entail increasing equitable access, growing the scope of content, standardizing training for staff and patients, and improving processes for synthesizing and analyzing relevant data to optimize these tools. Through these activities and continued planning, VA is poised to define the landscape of immersive technology in health care and inform adoption beyond VA.

Experiences of Veterans, Caregivers, and VA Home-Based Care Providers before, during, and Post-Hurricane Ian.

On 28 September 2022, Hurricane Ian pummeled parts of south Florida. Disaster and climate change research has shown that disasters exacerbate inequalities, especially amongst older and physically vulnerable people. Florida has a large population of Veterans managing multiple chronic health conditions and receiving long-term care in-home from Veterans Health Administration (VA) programs, including Home Based Primary Care and Medical Foster Home. To describe how VA staff provided high quality care during and after the hurricane, and how Veterans and caregivers accessed needed healthcare and supports post-hurricane, we conducted a site visit to Lee County, Florida area in May 2023, conducting N = 25 interviews with VA staff, Veterans, and caregivers. Findings from qualitative thematic analysis showed that while some Veterans and caregivers experienced significant challenges during and after the hurricane, including displacement and difficulty accessing oxygen, they felt highly supported by VA care teams. Staff efforts post-hurricane focused on improving care coordination in anticipation of future disasters, especially around communicating with Veterans and their caregivers, and a VA workgroup formed to implement changes. As climate change causes more severe hazard events, lessons learned from this project can better support healthcare staff, older adults, and their caregivers before and after major disasters.

Conducting health services research during the COVID-19 pandemic: experiences from the veterans health administration

BackgroundHealth services researchers within the Veterans Health Administration (VA) seek to improve the delivery of care to the Veteran population, whose medical needs often differ from the general population. The COVID-19 pandemic and restricted access to medical centers and offices forced VA researchers and staff to transition to remote work. This study aimed to characterize the work experience of health service researchers during the COVID-19 pandemic.MethodsA REDCap survey developed from the management literature was distributed in July 2020 to 800 HSR&D researchers and staff affiliated with VA Centers of Innovation. We requested recipients to forward the survey to VA colleagues. Descriptive analyses and logistic regression modeling were conducted on multiple choice and Likert scaled items. Manifest content analysis was conducted on open-text responses.ResultsResponses were received from 473 researchers and staff from 37 VA Medical Centers. About half (48%; n = 228) of VA HSR&D researchers and staff who responded to the survey experienced some interference with their research due to the COVID-19 pandemic, yet 55% (n = 260) reported their programs of research did not slow or stop. Clinician investigators reported significantly greater odds of interference than non-clinician investigators and support staff. The most common barriers to working remotely were loss of face-to-face interactions with colleagues (56%; n = 263) and absence of daily routines (25%; n = 118). Strategies teams used to address COVID-19 related remote work challenges included videoconferencing (79%; n = 375), virtual get-togethers (48%; n = 225), altered timelines (42%; n = 199), daily email updates (30%; n = 143) and virtual team huddles (16%; n = 74). Pre-pandemic VA information technology structures along with systems created to support multidisciplinary research teams working across a national healthcare system maintained and enhanced staff engagement and well-being.ConclusionsThis study identifies how the VA structures and systems put in place prior to the COVID-19 pandemic to support a dispersed workforce enabled the continuation of vital scientific research, staff engagement and well-being during a global pandemic. These findings can inform remote work policies and practices for researchers during the current and future crises.

Rolling out PRIDE in All Who Served: Barriers and Facilitators for Sites Implementing an LGBTQ+ Health Education Group for Military Veterans

Background/ObjectiveThe Veterans Health Administration (VHA) PRIDE in All Who Served health education group (PRIDE) was developed to improve health equity and access to care for military veterans who are lesbian, gay, bisexual, transgender, queer, and/or other sexual/gender-diverse identities (LGBTQ+). This 10-week program rapidly spread to over 30 VHA facilities in 4 years. Veterans receiving PRIDE experience improved LGBTQ+ identity-related resilience and reductions in suicide attempt likelihood. Despite PRIDE’s rapid spread across facilities, information is lacking on implementation determinants. The current study’s goal was to clarify determinants of PRIDE group implementation and sustainment.MethodsA purposive sample of VHA staff (N = 19) with experience delivering or implementing PRIDE completed teleconference interviews January–April 2021. The interview guide was informed by the Consolidated Framework for Implementation Research. Rapid qualitative matrix analysis was completed with methods to ensure rigor (e.g., triangulation and investigator reflexivity).ResultsKey barriers and facilitators of PRIDE implementation were heavily related to facility inner setting (what is happening inside the facility), including implementation readiness (e.g., leadership support for LGBTQ+-affirming programming, access to LGBTQ+-affirming care training) and facility culture (e.g., systemic anti-LGBTQ+ stigma). Several implementation process facilitators enhanced engagement at sites, such as a centrally facilitated PRIDE learning collaborative and a formal process of contracting/training for new PRIDE sites.Discussion/ConclusionAlthough aspects of the outer setting and larger societal influences were mentioned, the majority of factors impacting implementation success were at the VHA facility level and therefore may be more readily addressable through tailored implementation support. The importance of LGBTQ+ equity at the facility level indicates that implementation facilitation should ideally address institutional equity in addition to implementation logistics. Combining effective interventions with attention to local implementation needs will be required before LGBTQ+ veterans in all areas will benefit from PRIDE and other health equity-focused interventions.

VA Outreach Is an Essential Area for Improving Veterans' Health Care Accessibility.

The Veterans Health Administration (VHA) is tasked with providing access to health care to veterans of military service. However, many eligible veterans have either not yet enrolled or underutilized VHA services. Further study of barriers to access before veterans enroll in VHA care is necessary to understand how to address this issue. The ChooseVA (née MyVA Access) initiative aims to achieve this mission to improve veterans' health care access. Although veteran outreach was not specifically addressed by the initiative, it is a critical component of improving veterans' access to health care. Findings from this multisite evaluation of ChooseVA implementation describe sites' efforts to improve VHA outreach and veterans' experiences with access. This quality improvement evaluation employed a multi-method qualitative methodology, including 127 semi-structured interviews and 81 focus groups with VHA providers and staff ("VHA staff") completed during 21 VHA medical center facility site visits between July and November 2017 and 48 telephone interviews with veterans completed between May and October 2018. Interviews and focus groups were transcribed and analyzed using deductive and inductive analysis to capture challenges and strategies to improve VHA health care access (VHA staff data), experiences with access to care (veteran data), barriers and facilitators to care (staff and veteran data), contextual factors, and emerging categories and themes. We developed focused themes describing perceived challenges, descriptions of VHA staff efforts to improve veteran outreach, and veterans' experiences with accessing VHA health care. VHA staff and veteran respondents reported a lack of veteran awareness of eligibility for VHA services. Veterans reported limited understanding of the range of services offered. This awareness gap served as a barrier to veterans' ability to successfully access VHA health care services. Veterans described this awareness gap as contributing to delayed VHA enrollment and delayed or underutilized health care benefits and services. Staff focused on community outreach and engaging veterans for VHA enrollment as part of their efforts to implement the ChooseVA access initiative. Staff and veteran respondents agreed that outreach efforts were helpful for engaging veterans and facilitating access. Although efforts across VHA programs informed veterans about VHA services, our results suggest that both VHA staff and veterans agreed that missed opportunities exist. Gaps include veterans' lack of awareness or understanding of VHA benefits for which they qualify for. This can result in delayed access to care which may negatively impact veterans, including those separating from the military and vulnerable populations such as veterans who experience pregnancy or homelessness.

Veteran knowledge, perceptions, and receipt of care following visits to VA emergency departments for ambulatory care sensitive conditions.

Receipt of follow-up care after emergency department (ED) visits for chronic ambulatory care sensitive conditions (ACSCs)-asthma, chronic obstructive pulmonary disease, heart failure, diabetes, and/or hypertension-is crucial. We assessed Veterans' follow-up care knowledge, perceptions, and receipt of care after visits to Veterans Health Administration (VA) EDs for chronic ACSCs. Using explanatory sequential mixed methods, we interviewed Veterans with follow-up care needs after ACSC-related ED visits, and manually reviewed ED notes, abstracting interviewees' documented follow-up needs and care received. We interviewed and reviewed ED notes of 35 Veterans, 12-27 (mean 19) days after ED visits. Follow-up care was completely received/scheduled in 20, partially received/scheduled in eight, and not received in seven Veterans. Among those who received care, it was received within specified time frames half the time. However, interviewees often did not recall these time frames or reported them to be longer than specified in the ED notes. Veterans who had not yet received or scheduled follow-up care commonly did not recall follow-up care instructions, believed that they did not need this care since they were not currently having symptoms, or thought that such care would be difficult to obtain due to appointment unavailability and/or difficulties communicating with follow-up care providers. Among the 28 Veterans in whom all or some follow-up care had been received/scheduled, for 25 cases VA staff reached out to the Veteran or the appointment was scheduled prior to or during the ED visit. VA should prioritize implementing processes for EDs to efficiently communicate Veterans' needs to follow-up care providers and systems for reaching out to Veterans and/or arranging for care prior to Veterans leaving the ED. VA should also enhance practices using multimodal approaches for educating Veterans about recommended ED follow-up care and improve mechanisms for Veterans to communicate with follow-up care providers.

Veteran Postpartum Health: VA Care Team Perspectives on Care Coordination, Health Equity, and Trauma-Informed Care.

A growing number of veterans are having children, and pregnancy is an opportunity to engage with health care. Within the Veterans Health Administration (VA), the VA maternity care coordination program supports veterans before, during, and after pregnancy, which are periods that inherently involve transitions between clinicians and risk care fragmentation. Postpartum transitions in care are known to be especially tenuous, with low rates of primary care reengagement. The objective of this study is to better understand this transition from the perspectives of the VA care teams. Eight semi-structured qualitative interviews with VA team members who work in maternity care were conducted at a single VA center's regional network. Interviews explored the transition from maternity care to primary care to understand the care team's perspective at three levels: patient, clinician, and systems. Rapid qualitative analysis was used to identify emergent themes. Participants identified facilitators and opportunities for improvement in the postpartum transition of care. Patient-clinician trust is a key facilitator in the transition from maternity to primary care for veterans, and the breadth of VA services emerged as a key system-level facilitator to success. Interviewees also highlighted opportunities for improvement, including more trauma-informed practices for nonbinary veterans, increased care coordination between VA and community staff, and the need for training in postpartum health with an emphasis on health equity for primary care clinicians. The Department of Veterans Affairs Healthcare System care team perspectives may inform practice changes to support the transition from maternity to primary care for veterans. To move toward health equity, a system-level approach to policy and programming is necessary to reduce barriers to primary care reengagement. This study was limited in terms of sample size, and future research should explore veteran perspectives on VA postpartum care transitions.

Using electronic health records to streamline provider recruitment for implementation science studies.

Healthcare providers are often targeted as research participants, especially for implementation science studies evaluating provider- or system-level issues. Frequently, provider eligibility is based on both provider and patient factors. Manual chart review and self-report are common provider screening strategies but require substantial time, effort, and resources. The automated use of electronic health record (EHR) data may streamline provider identification for implementation science research. Here, we describe an approach to provider screening for a Veterans Health Administration (VHA)-funded study focused on implementing risk-aligned surveillance for bladder cancer patients. Our goal was to identify providers at 6 pre-specified facilities who performed ≥10 surveillance cystoscopy procedures among bladder cancer patients in the 12 months prior to recruitment start on January 16, 2020, and who were currently practicing at 1 of 6 pre-specified facilities. Using VHA EHR data (using CPT, ICD10 procedure, and ICD10 diagnosis codes), we identified cystoscopy procedures performed after an initial bladder cancer diagnosis (i.e., surveillance procedures). Procedures were linked to VHA staff data to determine the provider of record, the number of cystoscopies they performed, and their current location of practice. To validate this approach, we performed a chart review of 105 procedures performed by a random sample of identified providers. The proportion of correctly identified procedures was calculated (Positive Predictive Value (PPV)), along with binomial 95% confidence intervals (CI). We identified 1,917,856 cystoscopies performed on 703,324 patients from October 1, 1999-January 16, 2020, across the nationwide VHA. Of those procedures, 40% were done on patients who had a prior record of bladder cancer and were completed by 15,065 distinct providers. Of those, 61 performed ≥ 10 procedures and were currently practicing at 1 of the 6 facilities of interest in the 1 year prior to study recruitment. The random chart review of 7 providers found 101 of 105 procedures (PPV: 96%; 95% CI: 91% to 99%) were surveillance procedures and were performed by the selected provider on the recorded date. These results show that EHR data can be used for accurate identification of healthcare providers as research participants when inclusion criteria consist of both patient- (temporal relationship between diagnosis and procedure) and provider-level (frequency of procedure and location of current practice) factors. As administrative codes and provider identifiers are collected in most, if not all, EHRs for billing purposes this approach can be translated from provider recruitment in VHA to other healthcare systems. Implementation studies should consider this method of screening providers.

Veterans Health Administration Staff Perceptions of Overseeing Care in Community Nursing Homes During COVID-19.

IntroductionThe Veterans Health Administration (VA) contracts with non-VA owned and operated community nursing homes (CNHs) to provide Veterans nursing home care. This study explored VA staffs’ experiences coordinating care with CNH staff during the COVID-19 pandemic.MethodsQualitative study interviewing VA staff overseeing and coordinating care for CNH Veterans. Interviews were recorded, transcribed, and analyzed using inductive and deductive thematic analysis.ResultsThree themes influenced care coordination. (1) Pre-established working relationships strengthened trust in CNH staff and remote access to CNH electronic medical records (EMRs). (2) Remote oversight proved challenging as virtual visits did not fully capture Veterans’ needs and Veterans experienced challenges due to cognitive status, hearing impairment, and discomfort with technology. (3) Partnerships strengthened as VA staff provided CNHs personal protective equipment, COVID-19 testing, infection control education, and emotional support.DiscussionDespite pre-existing relationships and improved partnerships, most VA staff felt uncertain about the quality of oversight provided through remote monitoring and preferred in-person interactions. However, they found benefit in remote access to CNH EMRs and shared optimism with expanding virtual care.ConclusionsFostering strong partnerships between VAs and CNHs improve care coordination during crises like the COVID-19 pandemic and for daily care.

Evaluation of a Veterans Health Administration Whole Health for Mental Health Course for Clinicians.

Objectives: Veterans experience mental health disorders at higher rates than their civilian counterparts and also experience multiple barriers to mental health services. The Veterans Health Administration (VA) has implemented a Whole Health approach to make health care more person-focused and oriented toward promotion of health-sustaining behavior. We conducted an evaluation to investigate the effects of a Whole Health for Mental Health (WHMH) course for clinicians that focuses on shifting the perspective to a system of care in which mental health is incorporated as a core part of whole-person care. Design: We collected surveys before the course, immediately after the course, and at a 2-month follow-up. Settings/Location: The course was implemented in non-clinical settings in two VA medical centers (one in the Northeast and one in the Mountain West). Subjects: Our sample consisted of VA staff who enrolled in WHMH and completed a pre- and post-survey (n = 100) and follow-up survey (n = 99). Intervention: The WHMH is a 2-day face-to-face course that covers multiple aspects of mental health through a Whole Health lens. The course includes evidence-based practices within each aspect of mental health. The course also emphasizes implementation of Whole Health in clinicians' lives, their practice, and the health care system. Outcome measures: Attitudes were measured at pre-, post-, and follow-up assessments. The WHMH behaviors were measured at pre- and follow-up assessments. Results: There were statistically significant, large changes toward improvement from pre-test to post-test for all attitudes examined. These changes remained significant at follow-up, and the magnitude of change remained at least medium to large. Statistically significant, medium magnitude or larger improvements were found at follow-up for four of the five WHMH behavior outcomes examined. Conclusions: Our results suggest that clinicians can increase their attitudes and use of Whole Health concepts and both conventional and complementary approaches related to mental health issues.

Exploring Research Engagement and Priorities of Transgender and Gender Diverse Veterans.

In recent years, the U.S. Veterans Health Administration (VHA) has seen an increasing population of transgender and gender diverse (TGD) veterans accessing care. Approximately 139 per 100,000 VHA users had a gender identity disorder diagnosis documented in 2018 compared to 32.9 per 100,000 in 2013. Despite TGD patients being overrepresented within VHA, TGD veterans may distrust or face unique barriers with various aspects of the VHA, including health services research. Existing VHA health research focused on TGD populations is largely limited to secondary analyses of electronic health record data. Identifying strategies to enhance primary data collection is crucial for more deeply investigating health care challenges experienced by TGD veterans using VHA care. Additionally, describing health topics of importance for TGD veterans is important for making the research agenda more patient-centered. In this study, we offer veterans' recommendations for researchers working with underrepresented populations based on our findings. From September through October 2019, 30 TGD veterans were recruited through VHA lesbian, gay, bisexual, transgender, and queer/questioning Veteran Care Coordinators (LGBTQ+ VCC) located nationwide. Semi-structured interviews were used to explore barriers and facilitators to research participation, recommendations for improving outreach and engagement, and overall perspectives about priorities in health services research. Transcripts were independently and jointly reviewed and coded by two TGD research analysts, including a veteran using VHA care. Codes were derived inductively. Themes were identified using conventional content analysis. The VA Pittsburgh Healthcare System institutional review board approved this study. Participants cited privacy concerns of being "outed" and potentially having VHA benefits revoked, in addition to a level of distrust in researchers' intentions as barriers to participating in studies. Facilitators for participating included feeling a sense of serving the TGD community and accessibility to study locations, especially VHA-affiliated sites. Suggestions for recruitment included tailored messaging and using other TGD peers or affirming VHA staff (e.g., LGBTQ+ VCCs) for study outreach. Mental health and gender-affirming hormone therapy were the most understudied topics identified by participants. Additionally, participants prioritized the inclusion and study of underrepresented subpopulations, such as transgender women of color, transgender men, and non-binary/gender diverse veterans, in future research. By harnessing the VHA LGBTQ+ VCC network, this study recruited a national sample of TGD veterans to provide insight on methods for more effectively engaging TGD veterans in research and elicited their suggestions for health services research topics. The findings provide numerous suggestions for medicine and public health that are ripe for future research endeavors. Despite the study's lack of gender, racial, and ethnic diversity, findings highlight the need for engagement and study of underrepresented veteran populations. These suggested areas of focus for research in combination with valuable insight on research participation provide researchers with guidance for developing research agendas and designing recruitment and data collection methods that can facilitate future primary research advancing health services research involving TGD patients. Similarly, VHA and non-VHA researchers conducting research involving other underrepresented populations can also gain insight from these findings.

A dissemination strategy to promote relational coordination in the veterans health administration: a case study

BackgroundLarge healthcare institutions like the Veterans Health Administration (VA) continually seek best practices to improve clinical care. Relational coordination is an evidence-based organizational theory of communicating and relating to coordinate work and drive performance outcomes. Implementing relational coordination-guided practices can be difficult due to challenges with spreading information across large systems. Using social marketing theory and evidence-based dissemination strategies, we developed an evidence-based dissemination plan to educate and motivate researchers and operational staff to study and implement relational coordination in the VA.MethodsIn this case study, we used the four Ps (product, price, place, promotion) of social marketing theory to develop a 2-phase dissemination strategy. In phase one, we created and distributed relational coordination information and invited VA staff to join the Relational Coordination Research Collaborative. In phase two, dissemination efforts targeted researchers ready to implement relational coordination within existing programs of research. Process and outcome measures included dissemination, engagement and adoption data and a post-project survey. Quantitative results were calculated using descriptive statistics. Survey text responses were analyzed using deductive content analysis and a structured categorization matrix.ResultsPhase one included social media dissemination, virtual and in-person presentations, as well as phone and email communication between project staff and the target audience. In total, 47 VA staff became members of the Relational Coordination Research Collaborative and 27 routinely participated in online research seminars. In phase 2, 13 researchers expressed interest in studying relational coordination and 5 projects were selected to participate. Multiple relational coordination-related trainings and publications originated from this program.ConclusionsDissemination approaches that involved personalized, one-on-one efforts (e.g., phone or email) seemed to be more effective at disseminating relational coordination compared to social media or online presentations. Participants in phase 2 agreed that relational coordination should be adopted in the VA but indicated that cost would be a barrier. Results support the importance of evidence-based dissemination planning that address the unique costs and benefits of programs.

Evaluating Bystander Intervention Training to Address Patient Harassment at the Veterans Health Administration.

One in four women veteran patients report experiencing sexual and gender harassment when attending the Veterans Health Administration (VA) for health care. Bystander intervention-training community members how to intervene when witnessing inappropriate behaviors-is a common approach for addressing harassment in school and military settings. We evaluated implementation of a VA harassment awareness and bystander intervention training that teaches health care staff how to identify and intervene in the harassment of women veteran patients. Participants included 180 VA staff, including both providers and administrative staff from one VA state health care system, who participated in harassment training during the first year of implementation. Pretest and post-test evaluation surveys included questions on acceptability of training length and relevance, staff experiences with harassment, perceptions of the training, and four short-term attitudinal outcomes: awareness of harassment, barriers to intervening, self-efficacy for intervening, and intentions to intervene. At pretest, most staff reported witnessing harassment, yet fewer than one-half had intervened. By post-test, staff reported significantly decreased barriers to intervening and increased awareness, self-efficacy, and intentions to intervene. Belief that harassment is a problem increased from 42.4% to 75.0%. The majority of staff found the training relevant and appropriate in length. Staff felt the most useful aspects of the training were learning how to intervene, group discussion, effective facilitation, and information on harassment. We found that a bystander approach was acceptable to health care staff and efficacious on short-term outcomes. Bystander intervention may be a promising strategy to address harassment among patients in medical facilities.

Access to Pain Care From Compensation Clinics: A Relational Coordination Perspective

The Compensation and Pension (C&P) determination process is a potential gateway to accessing pain treatment in the Veterans Health Administration (VHA). However, attitudes about C&P as a gateway and about collaboration with C&P clinics among VHA staff are unknown. In preparation for an initiative to link veterans seeking compensation for musculoskeletal disorders to treatment, clinical and administrative staff from the 8 VHA medical centers in New England were invited to complete a relational coordination survey that examined how different workgroups collaborate (communication and relationships) to provide pain care to veterans. A subset of those staff also participated in a semistructured interview about pain treatment referral practices within their medical centers. VHA staff were from primary care, administration, pain management, and C&P teams. Eighty-three VHA staff were invited to complete the relational coordination survey; 66 completed the survey and 39 participated in the semistructured interview. Most C&P staff interviewed thought of the compensation examination as a forensic process and that C&P-based efforts to engage veterans might interfere with the examination or were not their responsibility. However, some examiners described their efforts to determine new veterans' eligibility for VHA care and to connect them to specific treatments. VHA staff reported that there was little communication between the C&P team and other teams. The survey results supported this finding. The C&P group's relational coordination composite scores were lower than any other workgroup. Outreach to veterans at New England C&P clinics was inconsistent, and C&P teams rated low on a measure of coordination with workgroups involved in pain treatment. Compensation examinations appear to be underused opportunities to help veterans access treatment. C&P-based treatment engagement is feasible; it is being done by some Compensation teams.

Diffusion of Excellence: Accelerating the Spread of Clinical Innovation and Best Practices across the Nation's Largest Health System.

The time it takes for clinical innovation and evidence-based practices to reach patients remains a major challenge for the health care sector. In 2015, the Veterans Health Administration (VHA) launched the Diffusion of Excellence Initiative aimed at aligning organizational resources with early-stage to midstage promising practices and innovations to replicate, scale, and eventually spread those with greatest potential for impact and positive outcomes. Using a 5-step systematic approach refined over time, frontline VHA staff have submitted more than 1676 practices since the initiative's inception, 47 of which have been selected as high-impact, Gold Status practices. These Gold Status practices have been replicated more than 412 times in Veterans Affairs hospitals across the country, improving care for more than 100,000 veterans and approximately $22.6 million in cost avoidance for the VHA. More importantly, practices such as Project HAPPEN (Hospital-Acquired Pneumonia Prevention by Engaging Nurses to complete oral care) and rapid availability of intranasal naloxone have saved veterans' lives. Several practices are now being implemented across the country, and the Diffusion of Excellence Initiative is playing a pivotal role as the VHA works to modernize its health care system. This initiative serves as a promising model for other health care systems seeking to accelerate the spread and adoption of clinical innovation and evidence-based practices.

Gender Differences in Veterans' Perceptions of Harassment on Veterans Health Administration Grounds.

Stranger harassment at Veterans Health Administration (VA) facilities is prevalent, affecting one in four women veteran VA primary care users. Harassment interferes with health care quality and may result in veterans forgoing or delaying needed care. To better understand this phenomenon, gender-stratified discussion groups were held with men and women veterans. This article examines gender differences in veterans' perceptions and experiences of harassment on VA grounds. We conducted a total of 15 discussion groups at four VA medical centers, eight with men (n=57) and seven with women (n=38). Transcripts were coded using the constant comparative method and analyzed for overarching themes. Awareness of harassment was not uniformly high among participants. Although women voiced clear understandings and experiences of specific behaviors constituting harassment (e.g., cat-calls, sexual comments), many men expressed confusion about how to differentiate between harassment, "harmless flirting," and general friendliness; they were unsure which behaviors "cross a line." Furthermore, men placed the onus on women for setting boundaries, whereas women indicated it was not their responsibility to "train" men about acceptable behavior. Men and women agreed that VA staff hold primary responsibility for preventing and managing harassment. Substantive gender differences in understandings of harassment exist among veteran VA users. To minimize harassment, veterans recommend education of men veteran VA users, and staff-oriented trainings. Privacy, safety, dignity, and security are the cornerstones of women veterans' health care, per VA policy. Harassment undermines these standards, impeding women's access to VA care and compromising both their health outcomes and health care experiences. Understanding harassment through a gendered lens is a critical step in designing comprehensive initiatives that respond to diverse viewpoints and experiences.

Lesbian, gay, and transgender veterans' experiences in the Veterans Health Administration: Positive signs and room for improvement.

This study explored the characteristics of lesbian, gay, and transgender veteran users of Veterans Health Administration (VHA) services and nonusers, using a national convenience sample. Participants responded to an online, anonymous survey posted on LGBT websites and forwarded through personal contacts, using a snow-ball sampling strategy, resulting in a final sample of 218. Most participants were enrolled in VHA (n = 151). VHA users were older, more ethnically diverse, had less income, and were less public about their sexual or gender minority identity than nonusers. VHA users and nonusers did not differ on depression, anxiety, alcohol use, or tobacco use; although VHA users had more physical limitations and chronic medical conditions and lower health literacy than nonusers. Most lesbian, gay, and transgender VHA users felt welcome at their facility and comfortable disclosing their sexual orientation and gender identity with their provider. Compared with earlier studies, the positive experiences of lesbian, gay, and transgender VHA users in this study provide supportive evidence that VHA staff training efforts to raise awareness and competency have been successful. Additional efforts are needed to understand why transgender men feel less welcome and comfortable disclosing their gender identity. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Nursing Home Referral Within the Veterans Health Administration: Practice Variation by Payment Source and Facility Type.

Veterans enrolled within the Veterans Health Administration (VHA) of the U.S. Department of Veterans Affairs (VA) may receive nursing home (NH) care in VHA-operated Community Living Centers (CLCs), State Veterans Homes (SVHs), or community NHs, which may or may not be under contract with the VHA. This study examined VHA staff perceptions of how Veterans' eligibility for VA and other payment impacts NH referrals within VA Medical Centers (VAMCs). Thirty-five semistructured interviews were performed with discharge planning and contracting staff from 12 VAMCs from around the country. VA staff highlights the preeminent role that VA priority status played in determining placement in VA-paid NH care. VHA staff reported that Veterans' placement in a CLC, community NH, or SVH was contingent, in part, on potential payment source (VA, Medicare, Medicaid, and other) and anticipated length of stay. They also reported that variation in Veteran referral to VA-paid NH care across VAMCs derived, in part, from differences in local and regional policies and markets. Implications for NH referral within the VHA are drawn.