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BACKGROUND: The COVID-19 pandemic intersected with a housing crisis for unsheltered Veterans experiencing homelessness (VEHs); congregate settings became high risk for viral spread. The VA Greater Los Angeles responded by creating the Care, Treatment, and Rehabilitation Service (CTRS), an outdoor, low-barrier-to-entry transitional housing program on VA grounds. This novel emergency initiative offered a protected outdoor environment (sanctioned encampment) where VEHs lived in tents and had access to three meals a day, hygiene resources, and health and social services. OBJECTIVE: To identify contextual factors that supported and impeded CTRS participants access to healthcare and housing services. DESIGN: Multi-method, ethnographic data collection. PARTICIPANTS: VEHs residing at CTRS, CTRS staff. APPROACH: Over 150 hours of participant observation were conducted at CTRS and at eight town hall meetings; semi-structured interviews were conducted with 21 VEHs and 11 staff. Rapid turn-around qualitative analysis was used to synthesize data, engaging stakeholders in iterative participant validation. Content analysis techniques were used to identify key factors that impacted access to housing and health services among VEHs residing in CTRS. KEY RESULTS: Staff varied in their interpretation of CTRS mission. Some conceptualized access to health services as a central tenet, while others viewed CTRS as an emergency shelter only. Regardless, staff burnout was prevalent, which lead to low morale, high turnover, and worsened access to and quality of care. VEHs endorsed trusting, long-term relationships with CTRS staff as paramount for facilitating access to services. Though CTRS addressed basic priorities (food, shelter, etc.) that traditionally compete with access to healthcare, some VEHs needed on-site healthcare services, at their tents, to access care. CONCLUSIONS: CTRS provided VEHs access to basic needs and health and housing services. To improve access to healthcare services within encampments, our data suggest the value of longitudinal trusting relationships, adequate staff support, and on-site health services.

BACKGROUND: Veteran family homelessness is a significant issue, yet little is known about the needs and barriers to services of veteran families experiencing homelessness. This qualitative study examined the experiences, needs, and barriers to services among homeless-experienced veteran families to inform providers for this important population. METHODS: Twenty-five semi-structured interviews were conducted from February through September 2016 with 18 veteran parents with a recent history of homelessness (9 mothers, 9 fathers), and 7 homeless service providers throughout Los Angeles County. The Sector Wheel for Under-Resourced Populations data elicitation approach was used to conduct the interviews, which allowed the participant to guide the interview by discussing different sectors of a familys life affected by homelessness. The interviews were audio-recorded, transcribed, and themes were coded with Atlas.ti. RESULTS: Interviews revealed parenting stress and worsening family mental health during homelessness. Participants described barriers to navigating housing, social, and health services with children, including not knowing where to seek help, difficulty connecting to health and social services in the community, and a lack of family-focused services. Parents encountered discrimination by landlords and lack of access to permanent housing in safe neighborhoods. CONCLUSIONS: Findings demonstrate a need for delivering family-centered and comprehensive services to homeless-experienced veteran families that recognize the multifaceted needs of this population. Advocacy initiatives are needed to address discrimination against veterans experiencing family homelessness and increase access to affordable permanent housing in safe neighborhoods for families.

OBJECTIVES: Homeless adults have low primary care engagement and high emergency department (ED) utilization. Homeless-tailored, patient-centered medical homes (PCMH) decrease this populations acute care use. We studied the feasibility (focused on patient recruitment) and acceptability (conceptualized as clinicians attitudes/beliefs) of a pilot initiative to colocate a homeless-tailored PCMH with an ED. After ED triage, low-acuity patients appropriate for outpatient care were screened for homelessness; homeless patients chose between a colocated PCMH or ED visit. METHODS: To study feasibility, we captured (from May to September 2012) the number of patients screened for homelessness, positive screens, unique patients seen, and primary care visits. We focused on acceptability to ED clinicians (physicians, nurses, social workers); we sent a 32-item survey to ED clinicians (n = 57) who worked during clinic hours. Questions derived from an instrument measuring clinician attitudes toward homeless persons; acceptability of homelessness screening and the clinic itself were also explored. RESULTS: Over the 5 months of interest, 281 patients were screened; 172 (61.2%) screened positive for homelessness; 112 (65.1%) of these positive screens were seen over 215 visits. Acceptability data were obtained from 56% (n = 32) of surveyed clinicians. Attitudes toward homeless patients were similar to prior studies of primary care physicians. Most (54.6%) clinicians agreed with the homelessness screening procedures. Nearly all (90.3%) clinicians supported expansion of the homeless-tailored clinic; a minority (42.0%) agreed that ED colocation worked well. CONCLUSION: Our data suggest the feasibility of recruiting patients to a homeless-tailored primary care clinic colocated with the ED; however, the clinics acceptability was mixed. Future quality improvement work should focus on tailoring the clinic to increase its acceptability among ED clinicians, while assessing its impact on health, housing, and costs.

BACKGROUND: Healthcare systems and their primary care practices are redesigning to achieve goals identified in Patient-Centered Medical Home (PCMH) models such as Veterans Affairs (VA)s Patient Aligned Care Teams (PACT). Implementation of these models, however, requires major transformation. Evidence-Based Quality Improvement (EBQI) is a multi-level approach for supporting organizational change and innovation spread. OBJECTIVE: To describe EBQI as an approach for promoting VAs PACT and to assess initial implementation of planned EBQI elements. DESIGN: Descriptive. PARTICIPANTS: Regional and local interdisciplinary clinical leaders, patient representatives, Quality Council Coordinators, practicing primary care clinicians and staff, and researchers from six demonstration site practices in three local healthcare systems in one VA region. INTERVENTION: EBQI promotes bottom-up local innovation and spread within top-down organizational priorities. EBQI innovations are supported by a research-clinical partnership, use continuous quality improvement methods, and are developed in regional demonstration sites. APPROACH: We developed a logic model for EBQI for PACT (EBQI-PACT) with inputs, outputs, and expected outcomes. We describe implementation of logic model outputs over 18 months, using qualitative data from 84 key stakeholders (104 interviews from two waves) and review of study documents. RESULTS: Nearly all implementation elements of the EBQI-PACT logic model were fully or partially implemented. Elements not fully achieved included patient engagement in Quality Councils (4/6) and consistent local primary care practice interdisciplinary leadership (4/6). Fourteen of 15 regionally approved innovation projects have been completed, three have undergone initial spread, five are prepared to spread, and two have completed toolkits that have been pretested in two to three sites and are now ready for external spread. DISCUSSION: EBQI-PACT has been feasible to implement in three participating healthcare systems in one VA region. Further development of methods for engaging patients in care design and for promoting interdisciplinary leadership is needed.

A veteran-clinician-researcher partnership—the Care, Treatment, and Rehabilitation Service (CTRS)—enabled quality improvement within a U.S. Department of Veterans Affairs–sanctioned homeless encampment created in response to the COVID-19 pandemic. Although the differing concerns of clinicians and operational leaders led to challenges in defining CTRS's goals and quality metrics, partnering with frontline social work and peer staff (N=11) and veterans (N=21 of 381 CTRS participants) and considering their feedback resolved those differences. Multilevel partnerships improved care within the encampment, leading to the development of an encampment medicine team (providing onsite integrated health care) and a veteran engagement committee (providing feedback). [ABSTRACT FROM AUTHOR]

THE INNOVATION In response to the COVID-19 pandemic, the Veterans Administration (VA) Greater Los Angeles Healthcare System initiated an innovative approach to providing integrated primary care services (Supplemental Figure 1). [...]

Carotid artery disease may be visible on a dental X-ray of the mouth. Atherosclerosis in the carotid arteries is believed to be a risk factor for stroke. In a study of 52 asymptomatic postmenopausal women, 31% had visible carotid artery disease on the dental X-ray. Many also had other risk factors for cardiovascular disease, including hypertension, obesity, and type 2 diabetes.

Abstract Background Collaborative-care management is an evidence-based practice for improving depression outcomes in primary care. The Department of Veterans Affairs (VA) has mandated the implementation of collaborative-care management in its satellite clinics, known as Community Based Outpatient Clinics (CBOCs). However, the organizational characteristics of CBOCs present added challenges to implementation. The objective of this study was to evaluate the effectiveness of evidence-based quality improvement (EBQI) as a strategy to facilitate the adoption of collaborative-care management in CBOCs. Methods This nonrandomized, small-scale, multisite evaluation of EBQI was conducted at three VA Medical Centers and 11 of their affiliated CBOCs. The Plan phase of the EBQI process involved the localized tailoring of the collaborative-care management program to each CBOC. Researchers ensured that the adaptations were evidence based. Clinical and administrative staff were responsible for adapting the collaborative-care management program for local needs, priorities, preferences and resources. Plan-Do-Study-Act cycles were used to refine the program over time. The evaluation was based on the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) Framework and used data from multiple sources: administrative records, web-based decision-support systems, surveys, and key-informant interviews. Results Adoption: 69.0% (58/84) of primary care providers referred patients to the program. Reach: 9.0% (298/3,296) of primary care patients diagnosed with depression who were not already receiving specialty care were enrolled in the program. Fidelity: During baseline care manager encounters, education/activation was provided to 100% (298/298) of patients, barriers were assessed and addressed for 100% (298/298) of patients, and depression severity was monitored for 100% (298/298) of patients. Less than half (42.5%, 681/1603) of follow-up encounters during the acute stage were completed within the timeframe specified. During the acute phase of treatment for all trials, the Patient Health Questionnaire (PHQ9) symptom-monitoring tool was used at 100% (681/681) of completed follow-up encounters, and self-management goals were discussed during 15.3% (104/681) of completed follow-up encounters. During the acute phase of treatment for pharmacotherapy and combination trials, medication adherence was assessed at 99.1% (575/580) of completed follow-up encounters, and side effects were assessed at 92.4% (536/580) of completed follow-up encounters. During the acute phase of treatment for psychotherapy and combination trials, counseling session adherence was assessed at 83.3% (239/287) of completed follow-up encounters. Effectiveness: 18.8% (56/298) of enrolled patients remitted (symptom free) and another 22.1% (66/298) responded to treatment (50% reduction in symptom severity). Maintenance: 91.9% (10/11) of the CBOCs chose to sustain the program after research funds were withdrawn. Conclusions Provider adoption was good, although reach into the target population was relatively low. Fidelity and maintenance were excellent, and clinical outcomes were comparable to those in randomized controlled trials. Despite the organizational barriers, these findings suggest that EBQI is an effective facilitation strategy for CBOCs. Trial registration Clinical trial # NCT00317018.

The temporal coding assumption is that time of presentation is coded more accurately for auditory events than for visual events. This assumption has been used to explain the modality effect, in which recall of recent auditory events is superior to recall of recent visual events. We tested the temporal coding assumption by examining the coding and reproduction of quintessentially temporal stimuli--rhythms. The rhythms were produced by sequences of short and long auditory stimuli or short and long visual stimuli; in either case, the task was to reproduce the temporal sequence. The results from four experiments demonstrated reproduction of auditory rhythms superior to that of visual rhythms. We conclude that speech-based explanations of modality effects cannot accommodate these findings, whereas the findings are consistent with explanations based on the temporal coding assumption.