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Introduction: Innovative healthcare delivery strategies are needed to address the healthcare needs of the 3.5 million older veterans living in US rural areas who face unique healthcare delivery challenges, including transportation barriers, poverty, and limited access to health professions and community-based programs. The care coordination home telehealth (CCHT) rural demonstration project was developed to address the mismatch between the timely identification of patient needs and the care delivered by the traditional disease-oriented institutionally-based healthcare delivery system for older rural veterans. The specific objectives were to: (1) serve as a facilitator of primary care; and (2) provide a portfolio of geriatric care management options to increase early detection of symptoms and to encourage adherence to care plans. Methods: Participants were recruited based on patterns of high outpatient, inpatient, and emergency care visits; 132 rural older veterans were enrolled. The CCHT applied care management principles to the delivery of healthcare services and used health informatics to facilitate access to evidence-based care. The CCHT's essential components, which were tailored to optimize remote access, included a face-to-face orientation, telephone contact with a designated care coordinator, and daily monitoring sessions using an in-home telehealth device to assess participants' medication usage, compliance, and symptoms, and to provide patient education. Results: One hundred eleven participants successfully installed and connected the telehealth monitoring device in their homes without hands-on assistance, monitored complex medical and psychiatric symptoms, and reported medication compliance remotely. Of the 93 participants who used the device for more than 10 sessions, 88 reported they did not have any difficulty using the device, 86 reported they were satisfied or very satisfied with the device, 73 reported they were likely to continue using the device, and 46 reported improved communication between themselves and their primary healthcare provider. Conclusion: Initial utilization and satisfaction evaluation data from this project supports the feasibility of employing a CCHT approach to serve medically-complicated older veterans in rural settings. This approach could also serve as a template for addressing a greater range of healthcare needs among other populations in hard-to-reach settings. [ABSTRACT FROM AUTHOR]

The article summarizes the results of the assessment of the interest of Alamance and Orange counties in North Carolina in August 2009 to receive H1N1 vaccine and seasonal influenza vaccines. The most commonly reported reasons for not aiming to receive H1N1 vaccine are noted, including the belief in a low likelihood infection and concern over the side effects of the vaccine. According to the article, influenza vaccination is the most effective way to prevent influenza and complications associated with influenza.

The article reports on two girls in a summer camp in North Carolina contacting influenza A(H1N1) virus resistant to oseltamivir, a neurominidase inhibitor commonly used for medication and chemoprophylaxis. In this case, the occurrence of an oseltamivir resistant A(H1N1) virus cannot be established but observed that receiving oseltamivir chemoprophylaxis is no guarantee preventing the A(H1N1) virus. Thus, guidelines for handling antiviral medications in the remedy and deterrent of influenza were issued by the U.S. Centers for Disease Control (CDC).

The article discusses fatalities from acute hepatitis B virus (HBV) infection linked with assisted blood glucose monitoring in an assisted-living facility in North Carolina between August and October 2010. The North Carolina Division of Public Health (NCDPH) investigated the HBV outbreak and found unsafe practices which include sharing of reusable fingerstick lancing devices and of blood glucose meters. The facility offered HBV vaccine to susceptible residents as recommended by NCDPH.

Background: Cortical hyperarousal and ruminative thinking are common aspects of insomnia that have been linked with greater connectivity in the default mode network (DMN). Therefore, disrupting network activity within the DMN may reduce cortical and cognitive hyperarousal and facilitate better sleep., Objective: This trial aims to establish a novel, noninvasive method for treating insomnia through disruption of the DMN with repetitive transcranial magnetic stimulation, specifically with continuous theta burst stimulation (cTBS). This double-blind, pilot randomized controlled trial will assess the efficacy of repetitive transcranial magnetic stimulation as a novel, nonpharmacological approach to improve sleep through disruption of the DMN prior to sleep onset for individuals with insomnia. Primary outcome measures will include assessing changes in DMN functional connectivity before and after stimulation., Methods: A total of 20 participants between the ages of 18 to 50 years with reported sleep disturbances will be recruited as a part of the study. Participants will then conduct an in-person screening and follow-on enrollment visit. Eligible participants then conduct at-home actigraphic collection until their first in-residence overnight study visit. In a double-blind, counterbalanced, crossover study design, participants will receive a 40-second stimulation to the left inferior parietal lobule of the DMN during 2 separate overnight in-residence visits. Participants are randomized to the order in which they receive the active stimulation and sham stimulation. Study participants will undergo a prestimulation functional magnetic resonance imaging scan and a poststimulation functional magnetic resonance imaging scan prior to sleep for each overnight study visit. Sleep outcomes will be measured using clinical polysomnography. After their first in-residence study visit, participants conduct another at-home actigraphic collection before returning for their second in-residence overnight study visit., Results: Our study was funded in September 2020 by the Department of Defense (W81XWH2010173). We completed the enrollment of our target study population in the October 2022 and are currently working on neuroimaging processing and analysis. We aim to publish the results of our study by 2024. Primary neuroimaging outcome measures will be tested using independent components analysis, seed-to-voxel analyses, and region of interest to region of interest analyses. A repeated measures analysis of covariance (ANCOVA) will be used to assess the effects of active and sham stimulation on sleep variables. Additionally, we will correlate changes in functional connectivity to polysomnography-graded sleep., Conclusions: The presently proposed cTBS protocol is aimed at establishing the initial research outcomes of the effects of a single burst of cTBS on disrupting the network connectivity of the DMN to improve sleep. If effective, future work could determine the most effective stimulation sites and administration schedules to optimize this potential intervention for sleep problems., Trial Registration: ClinicalTrials.gov NCT04953559; https://clinicaltrials.gov/ct2/show/NCT04953559., International Registered Report Identifier (irrid): DERR1-10.2196/51212., (©Lindsey Hildebrand, Alisa Huskey, Natalie Dailey, Samantha Jankowski, Kymberly Henderson-Arredondo, Christopher Trapani, Salma Imran Patel, Allison Yu-Chin Chen, Ying-Hui Chou, William D S Killgore. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 26.01.2024.)

Background: The National Institute for Health and Care Excellence (NICE) recommends that cognitive behaviour therapy (CBT) is offered to all patients with a psychosis diagnosis. However, only a minority of psychosis patients in England and Wales are offered CBT. This is attributable, in part, to the resource-intensive nature of CBT. One response to this problem has been the development of CBT in brief formats that are targeted at a single symptom and are deliverable by briefly trained therapists. We have developed Guided self-help CBT (the GiVE intervention) as a brief form of CBT for distressing voices and reported evidence for the feasibility of a randomised controlled trial (RCT) when the intervention was delivered by briefly trained therapists (assistant psychologists). This study will investigate the clinical and cost-effectiveness of the GiVE intervention when delivered by assistant psychologists following a brief training., Methods: This study is a pragmatic, two-arm, parallel group, superiority RCT comparing the GiVE intervention (delivered by assistant psychologists) and treatment as usual to treatment as usual alone, recruiting across three sites, using 1:1 allocation and blind post-treatment and follow-up assessments. A nested qualitative study will develop a model for implementation., Discussion: If the GiVE intervention is found to be effective when delivered by assistant psychologists, this intervention could significantly contribute to increasing access to evidence-based psychological interventions for psychosis patients. Furthermore, implementation across secondary care services within the UK's National Health Service may pave the way for other symptom-specific and less resource-intensive CBT-informed interventions for psychosis patients to be developed and evaluated., Trial Registration: Current Controlled Trials ISRCTN registration number: 12748453. Registered on 28 September 2022., (© 2023. BioMed Central Ltd., part of Springer Nature.)

The health service ecology varies considerably across urban-rural divides for American Indian and Alaska Native (AIAN) veterans, which may place rural AIAN veterans at high risk for poor health outcomes. Using the Behavioral Risk Factor Surveillance System 2011 and 2012 data for its detailed race information, we employed adjusted multinomial logistical regression analyses to estimate differences in health outcomes among rural AIAN veterans (n = 1500) and urban AIAN veterans (n = 1567). We used rural White (n = 32,316) and urban White (n = 59,849) veteran samples as comparators. No statistically significant differences between urban and rural AIAN veterans' health outcomes were found. Urban AIAN veterans were 72% more likely to report financial barriers to care compared with urban White veterans (P = .002); no other healthcare access differences were found. Compared with their White veteran counterparts, both urban and rural AIAN veterans were significantly more likely to report poorer physical and mental health across an array of outcomes. Overall, rural and urban AIAN veterans' health outcomes were similar, but both groups suffered compromised health compared with that of both rural and urban White veterans. The findings identified key areas for improving and innovating care for both rural and urban AIAN veterans.

American Indian and Alaska Native (AI/AN) veterans living in rural areas have unique health care needs and face numerous barriers to accessing health care services. Among these needs is a disproportionate prevalence of posttraumatic stress disorder and other mental illnesses. Since 2001, 14 rural communities have partnered with the U.S. Department of Veterans Affairs and the Centers for American Indian and Alaska Native Health at the University of Colorado Anschutz Medical Campus to extend telemental health clinics to American Indian veterans. Administrative and, to some extent, clinical considerations of these clinics have been reviewed previously. This paper describes a model of care, evolved over a 14-year period, that weaves together evidence-based Western treatment, traditional Native healing, and rural Native communities into 4 main components: mental health care, technology, care coordination, and cultural facilitation. We delineate improvements to care made by addressing barriers such as system transference, provider-patient trust, and videoconferencing. Similarly, the discussion notes ways that the care model leverages strengths within Native communities, such as social cohesion and spirituality. Future steps include selection of appropriate performance indicators for systematic evaluation. The identification of key constructs of this care model will facilitate comparisons with other models of care in underserved populations with chronic and complex health conditions, and eventually advance the state of care for our warriors. (PsycINFO Database Record, ((c) 2017 APA, all rights reserved).)

While pasture-raised poultry comprises a small portion of the commercial poultry industry in North America, these alternative rearing systems have become increasingly popular. As such, it is critical to improve our understanding of husbandry practices and prevalence of zoonotic and epizoonotic diseases in these systems. This research reviews the results of a survey sent to 82 commercial pastured poultry farms in California. While the survey response was low (13.4%), it was enhanced by detailed in-person interviews and farm visits. In addition, we conducted drag swabs for Salmonella Enteritidis. On average, farms utilized 12.3% of their total farmland for pastured poultry operations, which often coexisted with other livestock (45%), touch crops (27%), and non-touch crops (45%). While the mean (44.6 sq. ft./hen) and median (22.2 sq. ft./hen) pasture stocking densities were within auditing guidelines, the mean (1.2 sq. ft./hen) and median (0.5 sq. ft./hen) coop stocking densities were below the pending USDA (2016) guidelines recommended in 7 CFR Part 205. Drag swab results showed the presence of Salmonella Enteritidis (SE) in the environment of one of the 11 farms (9.1%). In addition, Salmonella Pullorum (SP) whole blood agglutination tests were used to understand the prevalence of Salmonella spp. in laying hens within the studied farms. Results showed the presence of antibodies in flocks at six of the seven non-SE vaccinated farms, with a mean on-farm prevalence of 25.6% in laying hens. Logistic regression was used to determine risk factors for Group D Salmonella exposure in non-vaccinated flocks, using the SP blood agglutination data as the dependent variable and the survey questions as the independent variables. Statistically significant (P < 0.05) risk factors included exposed wire floors and flock size. These results improve our understanding of Salmonella prevalence and husbandry practices on commercial pastured poultry farms in California., (© 2016 Poultry Science Association Inc.)

The purpose of this project was to describe experiences of reservation-based American Indian (AI) veterans with the Department of Veterans Affairs (VA), and to identify opportunities for improving care and services. Focus group discussions and individual interviews were conducted with AI veterans, family members, and community members in three diverse tribes. Results showed that many veterans in tribal communities experienced challenges receiving services and benefits from the VA, including lack of culturally competent care, transportation problems, and difficulties navigating the system. Family members, often main caregivers for AI veterans, lacked necessary resources, including sources for information, support services, and financial means to procure adequate care. A number of strengths also were identified, including local leadership and a strong community commitment to improve care for veterans.

Purpose: While many women choose to live in rural areas after retiring from active military duty, a paucity of studies examine rural women veterans' health care needs. This report is the first of its kind to describe the population demographics and health care utilization of rural female veteran patients enrolled in the Department of Veterans Affairs (VA)., Methods: Using the National Patient Care Datasets (n = 327,785), we ran adjusted regression analyses to examine service utilization between (1) urban and rural and (2) urban and highly rural women veterans., Findings: Rural and highly rural women veterans were older and more likely to be married than their urban counterparts. Diagnostic rates were generally similar between groups for several mental health disorders, hypertension, and diabetes, with the exception of nonposttraumatic stress anxiety that was significantly lower for highly rural women veterans. Rural and highly rural women veterans were less likely to present to the VA for women's specific care than urban women veterans; highly rural women veterans were less likely to present for mental health care compared to urban women veterans. Among the users of primary care, mental health, women's specific, and all outpatient services, patients' annual utilization rates were similar., Conclusions: Improved service options for women's specific care and mental health visits may help rural women veterans access care. Telehealth technologies and increased outreach, perhaps peer-based, should be considered. Other recommendations for VA policy and planning include increasing caregiver support options, providing consistency for mental health services, and revising medical encounter coding procedures., (© 2013 National Rural Health Association.)

Purpose: The Department of Veterans Affairs (VA) and the Indian Health Service (IHS) signed a Memo of Understanding in 2010 to strengthen their partnership in improving health care services for Native veterans, who are disproportionately rural. This paper describes the demographic and service use profile of rural Native veterans who access VA health care., Methods: Data were abstracted from the 2008 Veteran Health Administration (VHA) medical dataset, and the characteristics of rural Native veterans were compared to rural non-Native veterans., Findings: Rural Native veterans were more rural (41% vs 35%) and more highly rural (8% vs 2%) compared to non-Native veterans. Rural Native veterans were younger, more likely to be female, and earned about the same median income compared to rural non-Native veterans. Although rural Native veterans had fewer diagnoses on average, they were more likely to have served in combat areas and to have higher levels of service-connected disability compared to other rural veterans., Conclusions: Demographic and service-related characteristics of rural Native veterans who accessed VA care differ from those of rural non-Native veterans. Identifying specific health care and service use characteristics will assist in the development of appropriate policy and programs to serve rural Native veterans., (© 2013 National Rural Health Association.)

Objective: Providing specialized healthcare to rural communities can be extremely difficult, and consequently many health organizations are turning to the use of telehealth technologies for care delivery. One such technology, remote monitoring, has been successfully implemented with patients suffering from chronic and other medical conditions. A drawback, however, is that remote monitoring devices are programmed to reach a broad audience, and consequently the content may not be suitable for all patients-especially those who are not a part of the dominant culture., Subjects and Methods: This report provides a model for adapting remote monitoring to specific populations who are undergoing care for posttraumatic stress disorder. Adaptation changes focus on (1) information gathering, (2) process and dialogue changes, (3) testing, and (4) patient and administrative feedback. Data for such modifications were gathered through a series of community meetings, patient interviews, and provider feedback. A case example highlights the successful implementation of the adaptation model for a rural American Indian Veteran population., Results: Patients showed high acceptability of both the programmatic and cultural adaptations. Feasibility of the program also appeared positive, with most patients reporting that the readability of the program was appropriate, the dialogue duration was not burdensome, and technical problems were rare., Conclusions: Remote monitoring provides the ability to be modified for use with certain subpopulations. Procedural recommendations in this report highlight special considerations for working with American Indians living on or near reservation areas, although the model can be broadly adapted to several groups.

Objective: Posttraumatic stress disorder (PTSD) is widespread among veterans, but many veterans with PTSD use few health services. This study examined how individual characteristics influenced use of outpatient visits by veterans with PTSD., Methods: The study assessed number of annual visits by 414,748 veterans with PTSD who sought care from October 2007 through September 2008 at U.S. Department of Veteran Affairs (VA) facilities. Negative binomial regression and adjusted risk ratios assessed the relationship of number of visits and demographic characteristics as well as place of residence, era of service, extent to which disability was connected to service history, and having comorbid illnesses., Results: Veterans from rural or highly rural areas had 19% (confidence interval [CI]=.80-.82) and 25% (CI=.72-.79), respectively, fewer visits than urban-dwelling veterans. Iraq and Afghanistan veterans had 21% fewer visits than veterans of prior eras (CI=.78-.81). Veterans with comorbid conditions had 64% more visits than veterans with only PTSD (CI=1.62-1.66). Veterans from rural or highly rural areas had 22% (CI=.87-.89) and 33% (CI=.64-.71), respectively, fewer visits to PTSD specialty clinics than veterans from urban areas., Conclusions: Service use by veterans is lower in rural areas. The VA should build on existing efforts to provide more outreach and care opportunities, including telemental health and specialized PTSD services, in rural areas and for veterans of the current service era. Future research should investigate the impact of fewer visits on aspects of functioning, such as interpersonal factors, and the impact of system-level variables on service utilization.

Rural American Indian veterans have unique healthcare needs and face numerous barriers to accessing healthcare services. Over the past decade, the Department of Veterans Affairs in conjunction with the University of Colorado Denver has turned to the promising field of telemental health to develop a series of videoconferencing-based clinics to reach this vulnerable population and improve mental healthcare services. The ongoing development, implementation, and expansion of these clinics have been assessed as part of a program improvement. The outcomes of these assessments have been documented in a series of published articles, controlled studies, program and case reports, and model descriptions. This article summarizes a decade of experience with the American Indian Telemental Health Clinics, the clinic model, and the literature arising from these clinics and presents lessons learned while establishing, maintaining, and evaluating these clinics. The ability to tailor the clinics to individual sites and cultures and to provide various services has been critical to the operation of the clinics. Culturally specific care through culturally knowledgeable providers, onsite tribal outreach workers, and collaboration with community services has proven essential in operating the clinics, as well as building rapport, trust, and engagement with the target patient population. It is hoped that the lessons learned and practices presented here can not only assist others working to improve the care for rural Native veterans but also serve as a model in the use of telemental health services for improving care and access to rural veteran and non-veteran populations.

Objective: This study examined use by American Indian and Alaska Native veterans of services provided by specialty telemental health clinics focused on posttraumatic stress disorder. These clinics offer services via videoconferencing to address challenges faced by rural veterans in accessing care., Methods: A retrospective chart and electronic medical record review was conducted for 85 male veterans who used services at two rural telemental health clinics from 2001 through 2006. Service use and other characteristics were documented before and after their initial telemental health intake., Results: After intake, patients' use of any health services (both general medical and mental health services) significantly increased (p<.01), as did the proportion receiving psychotropic medication (p<.01)., Conclusions: This first examination of service use by American Indian and Alaska Native veterans at specialty telemental health clinics will help inform research and clinical strategies for improving telemental health for this and other rural populations.

Objective: Mental health issues are a serious concern for many American Indian Veterans, especially for post-traumatic stress disorder and related psychiatric conditions. Yet, acquiring mental health treatment can be a challenge in Native communities where specialized services are largely unavailable. Consequently, telehealth is increasingly being suggested as a way to expand healthcare access on or near reservation lands. In this study, we wanted to understand the factors affecting the diffusion of telehealth clinics that provided mental health care to rural, American Indian Veterans., Materials and Methods: We surveyed 39 key personnel and stakeholders who were involved in the decision-making process, technological infrastructure, and implementation of three clinics. Using Roger Everett's Diffusion Theory as a framework, we gathered information about specific tasks, factors hindering progress, and personal reactions to telehealth both before and after implementation., Results: Many participants expressed initial concerns about using telehealth; however, most became positive over time. Factors that influenced participants' viewpoint largely included patient and staff feedback and witnessing the fulfillment of a community health need. The use of outside information to support the implementation of the clinics and personal champions also showed considerable influence in the clinics' success., Conclusion: The findings presented here address critical gaps in our understanding of telehealth diffusion and inform research strategies regarding the cultural issues and outcomes related to telemental health services. Information contained in this report serves as a long overdue guide for developing telemental health programs and policies among American Indians, specifically, and rural populations in general.

The Veterans Health Administration (VHA) is a leader in developing and implementing innovative healthcare technology. We review 19 exemplary peer-reviewed articles published between 2000 and 2009 of controlled, VHA-supported telemedicine intervention trials that focused on health outcomes. These trials underscore the role of telemedicine in large managed healthcare organizations in support of (1) chronic disease management, (2) mental health service delivery through in-home monitoring and treatment, and (3) interdisciplinary team functioning through electronic medical record information interchange. Telemedicine is advantageous when ongoing monitoring of patient symptoms is needed, as in chronic disease care (eg, for diabetes) or mental health treatment. Telemedicine appears to enhance patient access to healthcare professionals and provides quick access to patient medical information. The sustainability of telemedicine interventions for the broad spectrum of veteran patient issues and the ongoing technology training of patients and providers are challenges to telemedicine-delivered care.