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Context As of March 23, 2012, the Internal Revenue Service (IRS) requires tax-exempt hospitals to conduct Community Health Needs Assessment (CHNA) every 3 years to incentivize hospitals to provide programs responsive to the health needs of their communities. Objective To examine the distribution and variation in community benefit spending among North Carolina's tax-exempt hospitals 2 years after completing their first IRS-mandated CHNA. Design Cross-sectional study using secondary analysis of published community benefit reports. Community benefit was categorized on the basis of North Carolina Hospital Association's community benefit reporting guidelines. Multiple regression analysis using generalized linear model was used to examine the variation in community benefit spending among study hospitals considering differences in hospital-level and community characteristics. Setting Fifty-three private, nonprofit hospitals across North Carolina. Main outcome measure Dollar expenditures as a percentage of operating expenses of the 2 categories of community benefit spending: patient care financial assistance and community health programs. Results Study hospitals' aggregate community benefit spending was $2.6 billion, 85% of which was in the form of patient care financial assistance, with only 0.7% of total spending allocated to community-building activities such as affordable housing, economic development, and environmental improvements. On average, the study hospitals' community benefit spending was equivalent to 14.6% of operating expenses. Hospitals with 300 or more beds provided significantly higher investments in community health programs as a percentage of their operating expenses than hospitals with 101 to 299 beds (P = .03) or hospitals with 100 or fewer beds (P = .04). Access to care was not associated with patient care financial assistance (P = .81) or community health programs expenditures (P = .94). Conclusions The study hospitals direct most of their community benefit expenditures to patient care financial assistance (individual welfare) rather than population health improvement initiatives, with virtually no investments in community-building activities that address socioeconomic determinants of health.

BACKGROUND Numerous studies of community reintegration (CR) in traumatic brain injury (TBI) have been conducted in civilian populations, but research is limited in veteran and military service member populations. Little is known about how knowledge from civilian studies translates into veterans’ experiences and needs. The US Department of Veterans Health Administration (VHA) recognizes the distinctive health care needs of post-9/11 veteran and military service members, particularly with TBI, including the need to bridge health and rehabilitation-related services from acute care and inpatient settings to veteran and military service members’ homes and communities to facilitate CR. OBJECTIVE The goal of this study is to better understand the experiences of veterans with complicated mild, moderate, or severe TBI; their families; and CR workers as veterans and servicemembers transition to and sustain living in communities. This paper describes the rationale, design, and methods used to reach this goal. METHODS This five-year longitudinal mixed methods study uses both a community-engaged research (CEnR) approach and an ethnographic approach. The sample includes 30 veterans and service members with TBI, 13 family caregivers, 11 CR specialists, 16 key stakeholders, and 82 community events. Interviews and observations are coded and analyzed using hierarchical coding schemes and thematic analysis. Analyses include data from surveys, interviews, and participant observations. Content analysis is used to highlight the complex social context of reintegration and to triangulate quantitative data. Egocentric (personal) social network analysis is used to examine the support system a veteran or service member has in place to facilitate reintegration. RESULTS Study enrollment and data collection are completed. Data analyses are underway. CONCLUSIONS The results of this study may provide a heightened understanding of environmental factors affecting CR in complicated mild, moderate, or severe TBI. Veteran, servicemember and family voices and insights provide VHA clinicians and policy makers with an ecological view of CR that is grounded in the life experiences of veterans, military service members, and families. The results of this study provide a roadmap for designing and testing interventions to maximize CR in a variety of domains. The longitudinal ethnographic approach allows for capturing detailed experiences within the naturalistic context. CEnR allows collaborative assessment of the social context of reintegration with community members. INTERNATIONAL REGISTERED REPORT DERR1-10.2196/14170

Returning military service members and veterans (MSMVs) experience a wide range of stress-related disorders in addition to social and occupational difficulties when reintegrating to the community. Facilitating reintegration of MSMVs following deployment is a societal priority. With an objective of identifying challenges and facilitators for reintegration of MSMVs of the current war era, we critically review and identify gaps in the literature. We searched 8 electronic databases and identified 1,764 articles. Screening of abstracts and full-text review based on our inclusion/exclusion criteria, yielded 186 articles for review. Two investigators evaluating relevant articles independently found a lack of clear definition or comprehensive theorizing about MSMV reintegration. To address these gaps, we linked the findings from the literature to provide a unified definition of reintegration and adapted the social ecological systems theory to guide research and practice aimed at MSMV reintegration. Furthermore, we identified individual, interpersonal, community, and societal challenges related to reintegration. The 186 studies published from 2001 (the start of the current war era) to 2015 included 6 experimental studies or clinical trials. Most studies do not adequately account for context or more than a narrow set of potential influences on MSMV reintegration. Little evidence was found that evaluated interventions for health conditions, rehabilitation, and employment, or effective models of integrated delivery systems. We recommend an ecological model of MSMV reintegration to advance research and practice processes and outcomes at 4 levels (individual, interpersonal, organizational, and societal). (PsycINFO Database Record

As of March 23, 2012, the Internal Revenue Service (IRS) requires tax-exempt hospitals to conduct a Community Health Needs Assessment (CHNA) every 3 years. This study assessed whether the IRS CHNA mandate incentivized North Carolina's tax-exempt hospitals to increase investments in community health programs. The authors gathered the 2012-2016 community benefit reports of 53 North Carolina private, nonprofit hospitals from the North Carolina Hospital Association. Community benefit spending data from the year of the first CHNA were compared to that 2 years later using paired

Background Although the literature has noted the positive effects of facilitation in implementation research, little is known about what facilitators do or how they increase adoption of a program. The purpose of this study was to understand internal facilitation activities in implementing a national safe patient handling program from the perspective of facility coordinators who implemented the program. Methods Using a qualitative descriptive design, data were collected in five focus groups at two international Safe Patient Handling and Mobility Conferences. Participants were 38 facility coordinators implementing a safe patient handling program in the Department of Veterans Affairs medical centers throughout the United States. Data were analyzed using direct content analysis to gather descriptions of internal facilitation. Results The internal facilitation process involved engaging multiple disciplines and levels of leadership for implementation. Fifty-four facilitation activities were identified, including five activities not currently listed in an existing taxonomy. Key characteristics and skills of facilitators included persistence, credibility and clinical experience, and leadership and project management experience. Themes were mapped onto an existing framework and taxonomy of facilitation activities. Linking Evidence to Action Internal facilitation is both an implementation intervention and a process involving a wide range of activities. The findings provide an understanding of what internal facilitators are doing to support practice changes and the characteristics and skills of internal facilitators that are likely to result in long-term organizational change. Five recommendations for action address organizations, senior leaders, and internal facilitators.

Objective To examine the effects of campus services on the health of veterans with traumatic injuries and comorbidities as they return from military service and enter college. Design Cross-sectional Internet survey using a mixed-methods analysis approach. Setting Four-year urban research university. Participants Veterans returning from active military duty (N=127). Interventions None. Main Outcome Measures Surveys included standardized measures of health status, traumatic injuries, and functional impairment (PTSD Checklist, Civilian version; Veterans Health Administration traumatic brain injury [TBI] screen; and Veterans RAND-12 item Health Survey); use of campus services and perceived effectiveness of these services in supporting reintegration to the university; and recommendations for additional services. Results Quantitative and qualitative data revealed that student veterans experience high rates of chronic pain that interfere with their daily functioning (92.7%), symptoms of posttraumatic stress disorder (PTSD) (77.9%), symptoms of TBI (26.0%), and comorbidities as the polytrauma clinical triad (14.2%). Despite the high prevalence of pain, PTSD, and TBI, few students used disability services (5.2%), counseling services (18.8%), or student health services (36.5%). Students experienced challenges accessing needed health services when reintegrating from the military to the university, including mutable university service factors. Conclusions Findings indicate the need for campus services to address the particular needs of student veterans and the need for determining what particular services should be offered to help this population cope with injuries and succeed in college.

Returning military service members and veterans (MSMVs) may experience a variety of stress-related disorders and challenges when reintegrating from the military to the community. Facilitating the reintegration, transition, readjustment and coping, and community integration, of MSMVs is a societal priority. To date, research addressing MSMV reintegration has not identified a comprehensive definition of the term or defined the broader context within which the process of reintegration occurs although both are needed to promote valid and reliable measurement of reintegration and clarify related challenges, processes, and their impact on outcomes. Therefore, this principle-based concept analysis sought to review existing empirical reintegration measurement instruments and identify the problems and needs of MSMV reintegration to provide a unified definition of reintegration to guide future research, clinical practice, and related services. We identified 1,459 articles in the health and social sciences literature, published between 1990 and 2015, by searching multiple electronic databases. Screening of abstracts and full text review based on our inclusion/exclusion criteria, yielded 117 articles for review. Two investigators used constant conceptual comparison to evaluate relevant articles independently. We examined the term reintegration and related terms (i.e., transition, readjustment, community integration) identifying trends in their use over time, analyzed the eight reintegration survey instruments, and synthesized service member and veteran self-reported challenges and needs for reintegration. More reintegration research was published during the last 5 years (n = 373) than in the previous 10 years combined (n = 130). The research suggests coping with life stresses plays an integral role in military service member and veteran post-deployment reintegration. Key domains of reintegration include individual, interpersonal, community organizations, and societal factors that may facilitate or challenge successful reintegration, and results suggest that successful coping with life stressors plays an integral role in post-deployment reintegration. Overall, the literature does not provide a comprehensive representation of reintegration among MSMVs. Although, previous research describes military service member and veteran reintegration challenges, this concept analysis provides a unified definition of the phenomenon and identifies key domains of reintegration that may broaden our understanding and guide reintegration research and practice.

Gail Powell-Cope, PhD, ARNP, FAANPeter Toyinbo, PhDNitin Patel, MPHDeborah Rugs, PhDChristine Elnitsky, PhD, RNBridget Hahm, MA, MPHBryce Sutton, PhDRobert Campbell, PhDKaren Besterman-Dahan, PhDMary Matz, MSPH, CPE, CSPHPMichael Hodgson, MD, MPHOBJECTIVE: Theobjectiveofthestudywastoidentifywhichcomponentsof asystem-wide safepatienthand-ling(SPH)programreducedmusculoskeletalinjury(MSI) due to patient handling among nurses.METHODS: The3-yearlongitudinalstudyfrom2008to2011usedapretest-posttestdesign.ThestudywasconductedintheVeteransHealthAdministration,andallmedicalcentersparticipated.Theoutcomewas2011MSI incidence rates due to patient-related handlingfor nurses, expressed as injuries per 10000 full-timeemployees.RESULTS: Threeorganizationalriskfactors,beddaysof care, facility complexity level, and baseline MSIincidence rate, were significantly associated with MSIincidencerateandexplained21%ofitsvariation.FiveSPHcomponents,includingdeploymentofceilingliftsand other new technologies, peer leader effectiveness,competencyinSPHequipmentuse,facilitycoordinatorlink with safety committee, and peer leader training,uniquelyaccountedforanadditional23%ofthetotalvariation.CONCLUSIONS: Findings provide evidence to sup-port the effectiveness of a multicomponent approachto SPH programs given contextual considerations.Healthcare workers responsible for manual patienthandling,particularlynursesandnursingassistants(NAs), have among the highest rates of nonfatal occu-pational injuries requiring days away from work.

U.S. Army Combat Medic serves as both Soldier and provider of combat casualty care, often in the heat of battle and with limited resources. Yet little is known about their help-seeking behavior and perceived stigma and barriers to care. Participants were three groups of U.S. Army Combat Medics surveyed at 3- and 12-months postdeployment from assignment with line units vs. those Medics who had never deployed to combat. The primary data source was surveys of mental health service utilization, perceived stigma and barriers to care, and depression and post-traumatic stress disorder screens. Medics who received help in the past year from a mental health professional ranged from 18% to 30%, with 18% to 30% seeking mental health assistance from other sources. Previously deployed Medics were more likely to obtain assistance than those who never deployed. Those meeting a mental health screening criteria were more likely to report associated stigma and barriers to care. Findings indicate that Medics in need of assistance report greater perceived barriers to mental health care, as well as stigma from seeking treatment, and that depression may be a salient issue for Medics. The longitudinal nature of the ongoing study will help determine the actual trajectory and onset of depression and post-traumatic stress disorder.

The U.S. Army Combat Medic faces enormous stress as both soldier and trauma care provider. This study provides an initial assessment of the mental health attitudes and behaviors of these soldiers. To date, there is no known research assessing Combat Medic behavioral health or their help seeking behavior following deployment. Medics who were 12 months post-deployment from a yearlong deployment to combat were compared with a baseline group of Medics who had never been deployed to war. Participants completed a survey containing measures of mental health service utilization, perceived stigma and barriers to care, depression and posttraumatic stress disorder (PTSD) symptoms. Medics screening positive for a mental health issue were more likely to report concerns about stigma and barriers to care compared to those who screened negative. Medics who had deployed to the combat were more likely to screen positive for major depression, and have sought care for mental health issues compared to the baseline group. There were no differences in PTSD screenings between the deployed group and the baseline group. FINDINGS indicate that depression may be a salient issue for previously deployed Combat Medics. Language: en

Background Numerous studies of community reintegration (CR) in traumatic brain injury (TBI) have been conducted in civilian populations, but research is limited in veteran and military service member populations. Little is known about how knowledge from civilian studies translates into veterans’ experiences and needs. The US Department of Veterans Health Administration (VHA) recognizes the distinctive health care needs of post-9/11 veteran and military service members, particularly with TBI, including the need to bridge health and rehabilitation-related services from acute care and inpatient settings to veteran and military service members’ homes and communities to facilitate CR. Objective The goal of this study is to better understand the experiences of veterans with complicated mild, moderate, or severe TBI; their families; and CR workers as veterans and servicemembers transition to and sustain living in communities. This paper describes the rationale, design, and methods used to reach this goal. Methods This five-year longitudinal mixed methods study uses both a community-engaged research (CEnR) approach and an ethnographic approach. The sample includes 30 veterans and service members with TBI, 13 family caregivers, 11 CR specialists, 16 key stakeholders, and 82 community events. Interviews and observations are coded and analyzed using hierarchical coding schemes and thematic analysis. Analyses include data from surveys, interviews, and participant observations. Content analysis is used to highlight the complex social context of reintegration and to triangulate quantitative data. Egocentric (personal) social network analysis is used to examine the support system a veteran or service member has in place to facilitate reintegration. Results Study enrollment and data collection are completed. Data analyses are underway. Conclusions The results of this study may provide a heightened understanding of environmental factors affecting CR in complicated mild, moderate, or severe TBI. Veteran, servicemember and family voices and insights provide VHA clinicians and policy makers with an ecological view of CR that is grounded in the life experiences of veterans, military service members, and families. The results of this study provide a roadmap for designing and testing interventions to maximize CR in a variety of domains. The longitudinal ethnographic approach allows for capturing detailed experiences within the naturalistic context. CEnR allows collaborative assessment of the social context of reintegration with community members. International Registered Report Identifier (IRRID) DERR1-10.2196/14170

While combat-related loss is likely to result in the development of lingering stress responses, little is known about its impact on behavioral health. The purpose of this study was to present preliminary results on war-related losses and behavioral health among Operations Enduring Freedom/Iraqi Freedomveterans. Veterans who suffered losses, to include noncombat losses (relationships back home) that occurred while the combatant was in the combat theater, reported more stress, depressive symptoms, and combat experiences. Outcomes were worse for veterans reporting two losses. Most notable was the decline in social support as losses increased. Also of note, avoidance and arousal symptom clusters were the most endorsed. While the pattern was more pronounced for those experiencing loss, results were consistent regardless of number of losses. Language: en

Purpose We present five cases of adult females with major limb amputations, their concerns and preferences for services across the life span. Design A convenience sample of five veteran and nonveteran women aged 19–58 with major limb amputations participating in a regional VA Prosthetics Conference in 2010 took part in a panel interview. Findings The concerns identified by these women as high priorities included independence and participation in a full range of life activities, limitations in access, patient decision-making and body image concerns, and preferences for selected services. Maximizing function and quality of life for women amputees requires identifying patient preferences for rehabilitation and prosthetic services. Lessons learned could inform development of clinic-based rehabilitation care, prosthetic services, and studies of women with major limb amputations. Conclusions As the current conflicts in Iraq and Afghanistan wind down, the number of women veterans seeking rehabilitation and prosthetic services will increase. With this information, rehabilitation and prosthetic service providers and organizations will be uniquely positioned to provide prevention and treatment of amputations for this growing population of women veterans in national care delivery systems and in communities. Clinical Relevance An open-ended facilitated discussion among a panel of women with major limb amputations provided insights for providers and organizations with respect to needs, concerns, and preferences for rehabilitation and prosthetic services.

To identify and validate trajectories of comorbidity associated with traumatic brain injury in male and female Iraq and Afghanistan war Veterans (IAV).Derivation and validation cohorts were compiled of IAV who entered the Department of Veterans Affairs (VA) care and received 3 years of VA care between 2002-2011. Chronic disease and comorbidities associated with deployment including TBI were identified using diagnosis codes. A latent class analysis (LCA) of longitudinal comorbidity data was used to identify trajectories of comorbidity.LCA revealed five trajectories that were similar for women and men: (1) Healthy, (2) Chronic Disease, (3) Mental Health, (4) Pain and (5) Polytrauma Clinical Triad (PCT: pain, mental health and TBI). Two additional classes found in men were 6) Minor Chronic and 7) PCT with chronic disease. Among these gender-stratified trajectories, it was found that women were more likely to experience headache (Pain trajectory) and depression (Mental Health trajectory), while men were more likely to experience lower back pain (Pain trajectory) and substance use disorder (Mental Health trajectory). The probability of TBI was highest in the PCT-related trajectories, with significantly lower probabilities in other trajectories.It was found that TBI was most common in PCT-related trajectories, indicating that TBI is commonly comorbid with pain and mental health conditions for both men and women. The relatively young age of this cohort raises important questions regarding how disease burden, including the possibility of neurodegenerative sequelae, will accrue alongside normal age-related decline in individuals with TBI. Additional 'big data' methods and a longer observation period may allow the development of predictive models to identify individuals with TBI that are at-risk for adverse outcomes.

The Veterans Health Administration (VHA) has recognized Traumatic Brain Injury (TBI) as a priority condition for healthcare services. However, diagnosis rates of TBI in the VA TBI screening tool (VATBIST) vary quite widely across the Veterans Affairs (VA) facilities. Factors that make this diagnostic decision difficult include the reliance on patient self-report, the symptom overlap of mild TBI with other conditions (especially behavioral health and pain), and the need for nuanced diagnostic understanding by the clinician. With the objective of standardizing the TBI screening process, a Virtual Standardized Patient (VSP) portraying an OEF (Operation Enduring Freedom) veteran with mild TBI was proposed as a training tool. This paper presents the design and development of the VSP and describes the results from the preliminary study conducted to validate the usability of a VSP for training within this context.

Objectives: Optimal depression screening necessitates measurement tools that are valid across varied populations and in the presence of comorbidities. Methods: This study assessed the test properties of two versions of the Center for Epidemiologic Studies Depression scale against psychiatric diagnoses established by the Mini International Neuropsychiatric Interview among a clinical sample of US Veterans deployed during Operations Enduring Freedom, Iraqi Freedom, and New Dawn. Participants (N = 359) recruited from two Department of Veterans Affairs hospitals completed a clinical interview, structured diagnostic interview, and self-reported measures. Results: Based on diagnostic interview and the Diagnostic and Statistical Manual of Mental Disorders 4th Edition criteria, 29.5% of the sample met diagnostic criteria for major depressive disorder and 26.5% met diagnostic criteria for post-traumatic stress disorder. Both Center for Epidemiologic Studies Depression-20 and Center for Epidemiologic Studies Depression-10 scales performed well and almost identically against the Mini International Neuropsychiatric Interview-major depressive disorder in identifying Veterans with major depressive disorder (Center for Epidemiologic Studies Depression-20 area under the Receiver Operating Characteristic curve 91%; Center for Epidemiologic Studies Depression-10 area under the ROC curve 90%). Overall, higher cut points for the Center for Epidemiologic Studies Depression scales performed better in correctly identifying true positives and true negatives for major depressive disorder (Center for Epidemiologic Studies Depression-20 cut point 18+ sensitivity 92% specificity 72%; Center for Epidemiologic Studies Depression-10 cut point 10+ sensitivity 92% specificity 69%). Conclusions: The specificity of the Center for Epidemiologic Studies Depression scales was poor among Veterans with co-occurring post-traumatic stress disorder (13% and 16%). Veterans with post-traumatic stress disorder who have a positive depression screen should have a more thorough assessment of mental health symptoms and comorbidities, rather than immediate diagnosis of and treatment for depression.

This study aimed to (1) identify the prevalence and severity of pain and psychiatric comorbidities among personnel who had been deployed during Operation Iraqi Freedom (OIF), Operation Enduring Freedom (OEF), and Operation New Dawn (OND) and (2) assess whether the Department of Veterans Affairs (VA) Polytrauma System of Care and an OIF/OEF/OND registry reflect real differences among patients. Participants (N = 359) were recruited from two VA hospitals. They completed a clinical interview, structured diagnostic interview, and self-report measures. Results indicated pain was the most common complaint, with 87 percent experiencing pain during the prior week and 56 percent reporting moderate or severe pain. Eighty percent of participants met criteria for at least one of seven assessed comorbid problems (moderate or severe pain, postconcussional disorder, posttraumatic stress disorder [PTSD], anxiety disorder, mood disorder, substance use disorder, psychosis), and 59 percent met criteria for two or more problems. PTSD and postconcussional disorder rarely occurred in the absence of pain or other comorbidities (0.3% and 0%, respectively). The Polytrauma group had more comorbid psychiatric conditions (χ(2) = 48.67, p < 0.05) and reported greater severity of symptoms (p < 0.05) than the Registry group. This study confirmed the high prevalence of pain and concurrent mental health problems among personnel returning from military deployment.

Revolutionary changes in the health care system necessitate subsequent changes in emergency medical services (EMS). The development and dissemination of the EMS Agenda for the Future focus attention on awareness and attitudes of field providers. This study attempted to measure awareness of and agreement with concepts set forth in the agenda.Through a unique cooperative partnership between state government and two health services research students, researchers were able to describe and explore the attitudes of EMS providers about the future direction of the profession. A representative sample of participants, chosen from the Commonwealth of Virginia in fall 1997, responded to a mailed researcher-developed questionnaire based on the EMS Agenda for the Future.A cover letter written by the state EMS director and the enclosure of self-addressed, stamped envelopes yielded a 47% response rate. Paramedic-level providers and paid personnel were more likely to agree with the concepts of the EMS Agenda for the Future than were other-level providers and volunteers. The attribute with which the respondents agreed most was "legislation and regulation." The respondents agreed the least with "integration of health services." Providers were most concerned with the issue of liability protection, one aspect of the "legislation and regulation" attribute. Only 10% of the respondents reported having read the agenda.EMS providers' awareness, perspectives, and attitudes are essential to the forward progression of the EMS Agenda for the Future. Successful implementation of the agenda will depend on these professionals' participation and support. Providers tended to agree most with traditional concepts discussed in the EMS Agenda for the Future. Awareness levels and attitudes toward the vision suggest implications for future education, planning, and research activities.

Risk management and quality improvement measures assume that staff recognize and report individual hospital incidents. A survey of nurses working in acute care hospitals in 15 localities across a south-eastern state was conducted to explore nurses hospital incident reporting behaviors and supervisors beliefs about and use of incident reports. Nurse managers may have reason to be concerned about this quality measure: the number of incidents documented may represent only a portion of all incidents.

This column discusses patient preference measures and their application in cost utility analysis. A variety of methods of eliciting patient preferences by use of generic utility measures are described. Practical issues in the use of utility measures are discussed.

Background The U.S. Department of Veterans Affairs (VA) implemented the Polytrauma System of Care to meet the health care needs of military and veterans with multiple injuries returning from combat operations in Afghanistan and Iraq. Studies are needed to systematically assess barriers to use of comprehensive and exclusive VA healthcare services from the perspective of veterans with polytrauma and with other complex health outcomes following their service in Afghanistan and Iraq. These perspectives can inform policy with regard to the optimal delivery of care to returning veterans. Methods We studied combat veterans (n = 359) from two polytrauma rehabilitation centers using structured clinical interviews and qualitative open-ended questions, augmented with data collected from electronic health records. Our outcomes included several measures of exclusive utilization of VA care with our primary exposure as reported access barriers to care. Results Nearly two thirds of the veterans reported one or more barriers to their exclusive use of VA healthcare services. These barriers predicted differences in exclusive use of VA healthcare services. Experiencing any barriers doubled the returnees’ odds of not using VA exclusively, the geographic distance to VA barrier resulted in a 7 fold increase in the returnees odds of not using VA, and reporting a wait time barrier doubled the returnee’s odds of not using VA. There were no striking differences in access barriers for veterans with polytrauma compared to other returning veterans, suggesting the barriers may be uniform barriers that predict differences in using the VA exclusively for health care. Conclusions This study provides an initial description of utilization of VA polytrauma rehabilitation and other medical care for veteran returnees from all military services who were involved in combat operations in Afghanistan or Iraq. Our findings indicate that these veterans reported important stigmatization and barriers to receiving services exclusively from the VA, including mutable health delivery system factors.

Background The prevalence of musculoskeletal injuries among nursing staff has been high due to patient handling and movement. Internationally, healthcare organizations are integrating technological equipment into patient handling and movement to improve safety. Although evidence shows that safe patient handling programs reduce work-related musculoskeletal injuries in nursing staff, it is not clear how safe these new programs are for patients. Objectives The objective of this study was to explore adverse patient events associated with safe patient handling programs and preventive approaches in US Veterans Affairs medical centers. Methods The study surveyed a convenience sample of safe patient handling program managers from 51 US Department of Veterans Affairs medical centers to collect data on skin-related and fall-related adverse patient events. Results Both skin- and fall-related adverse patient events associated with safe patient handling occurred at VA Medical centers. Skin-related events included abrasions, contusions, pressure ulcers and lacerations. Fall-related events included sprains and strains, fractures, concussions and bleeding. Program managers described contextual factors in these adverse events and ways of preventing the events. Conclusions The use of safe patient handling equipment can pose risks for patients. This study found that organizational factors, human factors and technology factors were associated with patient adverse events. The findings have implications for how nursing professionals can implement safe patient handling programs in ways that are safe for both staff and patients.

BackgroundHealth care workers, such as nurses, nursing aides, orderlies, and attendants, who manually move patients, are consistently listed in the top professions for musculoskeletal injuries (MSIs) by the Bureau of Labor Statistics. These MSIs are typically caused by high-risk patient caregiving activities. In 2008, a safe patient handling (SPH) program was implemented in all 153 Veterans Administration Medical Centers (VAMCs) throughout the United States to reduce patient handling injuries. ObjectiveThe goal of the present study is to evaluate the effects associated with the national implementation of a comprehensive SPH program. The primary objectives of the research were to determine the effectiveness of the SPH program in improving direct care nursing outcomes and to provide a context for understanding variations in program results across sites over time. Secondary objectives of the present research were to evaluate the effectiveness of the program in reducing direct and indirect costs associated with patient handling, to explore the potential mediating and moderating mechanisms, and to identify unintended consequences of implementing the program. MethodsThis 3-year longitudinal study used mixed methods of data collection at 6- to 9-month intervals. The analyses will include data from surveys, administrative databases, individual and focus group interviews, and nonparticipant observations. For this study, a 3-tiered measurement plan was used. For Tier 1, the unit of analysis was the facility, the data source was the facility coordinator or administrative data, and all 153 VAMCs participated. For Tier 2, frontline caregivers and program peer leaders at 17 facilities each completed different surveys. For Tier 3, six facilities completed qualitative site visits, which included individual interviews, focus groups, and nonparticipant observations. Multiple regression models were proposed to test the effects of SPH components on nursing outcomes related to patient handling. Content analysis and constant comparative analysis were proposed for qualitative data analysis to understand the context of implementation and to triangulate quantitative data. ResultsAll three tiers of data for this study have been collected. We are now in the analyses and writing phase of the project, with the possibility for extraction of additional administrative data. The focus of this paper is to describe the SPH program, its evaluation study design, and its data collection procedures. This study evaluates the effects associated with the national implementation of a comprehensive SPH program that was implemented in all 153 VAMCs throughout the United States to reduce patient handling injuries. ConclusionsTo our knowledge, this is the largest evaluation of an SPH program in the United States. A major strength of this observational study design is that all VAMCs implemented the program and were included in Tier 1 of the study; therefore, population sampling bias is not a concern. Although the design lacks a comparison group for testing program effects, this longitudinal field study design allows for capturing program dose-response effects within a naturalistic context. Implementation of the VA-wide SPH program afforded the opportunity for rigorous evaluation in a naturalistic context. Findings will guide VA operations for policy and decision making about resources, and will be useful for health care, in general, outside of the VA, in implementation and impact of an SPH program.

Military health care providers experience considerable stressors related to their exposure to death and traumatic injuries in others. This study used survey data from 799 active duty U.S. Army Combat Medics deployed to Operation Iraqi Freedom/Operation Enduring Freedom. Military experiences, combat exposures, and mental health care seeking of active duty Combat Medics were explored and compared across both genders. Barriers to care were also assessed. Male and female Combat Medics reported surprisingly similar experiences, exposures, and health issues. Overall, results indicate no striking differences in barriers for females compared to their male counterparts, suggesting the barriers to utilization of mental health services may be consistent across gender. Although medics endorsed barriers and stigma related to mental health counseling services, they still sought these health services. Female and male medics who endorsed barriers were more likely to report seeking services than those who did not endorse barriers. This study provides an initial description of utilization of mental health counseling services for U.S. Army Combat Medics, the majority of whom were involved in combat operations in Afghanistan or Iraq. Our findings indicate that comprehensive assessment of the military experiences and combat exposures is needed to appreciate their potential influence on military health care providers.

With the increased emphasis on cost containment, hospital administrators are investigating community outreach projects to remain economically viable. The authors describe the planning and implementation of a mobile health unit for rural elderly residents. This project represents an alternative model of healthcare delivery in a rural area with limited resources and healthcare providers.

The ill elderly are more at risk for recurrent hospitalizations than any other segment of the population. What is known about hospital admission readmission of chronically ill older adults and how can this information be used to develop cost-effective strategies? The authors found variation in percent reimbursement (43% to 93%) of overall average charges, which indicates that further examination of low reimbursement major diagnostic categories can be useful. Hospital readmission data should be used to improve quality of care while containing hospital costs.

Military Chaplains are a critical component of behavioral health and spiritual support in combat operations. Support of combat operations has taken a toll on these caregivers. The purpose of this study was to explore the impact of deployment on the psychosocial and health characteristics and reintegration of Army National Guard (ARNG) chaplains. Seventy-four ARNG chaplains participated in an anonymous, online survey. Results were categorized into two mutually exclusive groups, combat deployed and non-combat deployed. Although both groups tended to present similar results, Combat deployed group chaplains were significantly more likely to be of higher rank, have served in a pastoral role in the ARNG longer, and present with higher scores for combat exposure, resilience, and alcohol use. Further, five and seven participants, respectively, the majority of whom were from the combat deployed group, endorsed "frequently" or "a great deal" to negative religious coping. These endorsements of abandonment may relate back to Reserve component specific deployment concerns.

Health and social services integration is particularly relevant for populations whose needs span physical health, mental health, housing, and disability services, along with others. Veterans, homeless, chronically ill, and aging are among those populations. This review examines recent peer-reviewed literature about different approaches to services integration, rationales behind those approaches, and successes of those approaches, including factors that make them succeed or fail. The focus here is on services that cross disciplinary boundaries; that is, those that integrate health services with social services, health services with mental health services, or one social service with a categorically different social service.

This article reviews and summarizes the literature on patient safety issues in the rehabilitation of adults with an amputation. Safety issues in the following areas are discussed; the prosthesis, falls, wound care, pain, and treatment of complex patients. Specific recommendations for further research and implementation strategies to prevent injury and improve safety are also provided. Communication between interdisciplinary team members and patient and caregiver education are crucial to executing a safe treatment plan. The multidisciplinary rehabilitation team members should feel comfortable discussing safety issues with patients and be able to recommend preventive approaches to patients as appropriate.

To describe the perceptions of training and deployment preparation and combat experiences and exposures of U.S. Army combat medics.Data were from the first year of a 3-year longitudinal study designed to assess the impact of combat on the behavioral health and resilience of 347 combat medics surveyed 3 to 6 months after returning from a 12-month deployment to Operation Enduring Freedom/Operation Iraqi Freedom theatre and assigned to brigade combat teams.Analyses indicated that combat medics may benefit from better preparation in types of shifts required during deployment, type and intensity of combat likely to be seen and experienced, more adequate training in the area of stress and mental health care management, and easier access to behavioral mental health care.The military has shown considerable progress in addressing and understanding the mental health care needs of Soldiers. However, challenges remain. Additional emphasis should be placed on reducing the stigma and barriers related to mental health care both in theatre and garrison and on developing an evidence-based, validated program for medics and other Soldiers to recognize stress and mental health issues on the battlefield. For medics, this should be from two perspectives-that of a combat Soldier and that of a medical provider.

Older rural residents are vulnerable in both health status and access to health services. This descriptive study was designed to assess the general health status and risk factors of older rural residents age 65 and over. Cluster analysis methods were used to group older adults into unique clusters of individuals with similar health risks. Although strategies are generally targeted at those with limitations in two or more activities of daily living, community health nurses might need to initiate interventions much earlier. Findings of this study can help community health providers, policymakers, and administrators strategically plan to meet the health care needs of various groups of at-risk older rural populations.

The Mobile Health Unit was implemented to increase access to nursing services, to improve and/or maintain functional status and health status, and to increase health promotion behaviors of rural elderly residents experiencing difficulty obtaining health care due to illness, transportation problems, or financial factors. For 222 project participants 1,773 encounters were completed, with a mean number of visits per individual of 7.9. Participants in the project demonstrated increased breast and cervical cancer screenings, increased immunization rates for influenza, pneumonia and tetanus, and decreased utilization of the emergency room. This project represents an alternative model of health care delivery in a rural area with limited resources and health care providers.

INTRODUCTION The Veterans Health Administration (VHA) aims to honor America's veterans by providing exceptional healthcare that improves their health and well-being. To accomplish this mission, VHA will continuously improve the quality and safety of healthcare for veterans--particularly in health areas associated with their military service--and conduct research and development in clinical and system improvement areas. Approximately 5 million people received care in Department of Veterans Affairs (VA) healthcare facilities in 2006. The VA healthcare system includes settings across the healthcare continuum, including 156 hospitals, 877 outpatient clinics, 136 nursing homes, 43 residential rehabilitation facilities, and 207 readjustment counseling centers. The majority of patients, approximately 54 million, were treated in outpatient clinics. The VA Office of Research and Development (ORD) is dedicated to the discovery of new knowledge, the creation of innovations to advance healthcare for veterans and the nation, and the development of VA researchers and healthcare leaders. In 2006, funding for VA research from all sources was just over $1.5 billion. The VA currently conducts more than 10,000 research projects at more than 100 VA medical centers. VA research is organized into four services of research and development (RD studies on the mechanisms and mediators of pain treatments; efficacy studies of innovative treatment approaches, including psychological interventions and complementary and alternative medicine interventions; and studies of pain in the context of terminal illness and palliative care. Health Services RD the efficacy of innovative rehabilitation approaches to pain management; development and evaluation of pain outcome assessment methods, especially those involving technology; and pain and psychiatric comorbidities. Finally, Biomedical Laboratory R&D focuses on basic biological or physiological principles using laboratory and animal models. Funded studies include animal models and investigations of tissues, blood, or other biological specimens from humans. Pain-related priorities in the portfolio include studies with a neurological and cellular-level focus and basic research with potential to contribute to the development of innovative pain treatments. Initiatives established across all research service portfolios provide foci for a broad cross-section of pain dimensions. The recent and continuing focus on deployment health issues for veterans returning from Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) represents a particularly important area for targeted solicitations that emphasize pain management. …