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BACKGROUND: Care coordination is critical for patients with multiple chronic conditions, but fragmentation of care persists. Providers’ perspectives of facilitators and barriers to coordination are needed to improve care. OBJECTIVES: We sought to understand providers’ perspectives on care coordination for patients having multiple chronic diseases served by multiple providers. RESEARCH DESIGN: Based upon our earlier survey of patients with multiple chronic conditions, we selected 8 medical centers having high and low coordination. We interviewed providers to identify facilitators and barriers to coordination and compare them between patient-rated high sites and low sites and between primary care – mental health and primary care - medical/surgical specialty care. SUBJECTS: Physicians, nurses and other clinicians in primary care, cardiology and mental health (N=102) in 8 Veterans Affairs medical centers. RESULTS: We identified warm handoffs, professional relationships, and physical proximity as facilitators, and service agreements, reporting relationships and staffing as barriers. Primary care – mental health coordination was reported as better than primary care – medical/surgical specialty coordination. Facilitators were more prevalent and barriers less prevalent in sites rated high by patients than sites rated low, and between primary care - mental health than between primary care - specialty care. DISCUSSION: We noted that professional relationships were highly related to coordination and both affected other facilitators and barriers and were affected by them. We suggested actions to improve relationships directly, and to address other facilitators and barriers that affect relationships and coordination. Among these is the use of the Primary Care Mental Health Integration model.

Background The experience of sexual assault and harassment during military service (military sexual trauma [MST]) is associated with increased risk for perinatal and reproductive health problems among women veterans. The objective of this study was to examine the associations between mothers' MST exposure and mother-infant bonding, as well as to examine whether there are any salient sociodemographic or military service characteristics among women veterans with greater impairment to mother-infant bonding, including stress during pregnancy and posttraumatic stress disorder (PTSD) diagnosis. Methods This study was a secondary analysis of data collected from prospective, longitudinal study of women veterans using VHA maternity care benefits at 15 VHA medical centers across the US between January 2016 and February 2020. Participants were 697 pregnant veterans using VHA maternity care benefits. Results MST was associated with higher maternal depression, and higher maternal depression was associated with poorer mother-infant bonding. The effect of MST on bonding was indirect through depression. PTSD diagnosis and life stressors during pregnancy also had significant indirect pathways with bonding through maternal depression. Conclusions Results underscore the need for access to high quality and trauma-informed perinatal mental health treatment for women veterans, for education on the unique risks conveyed by MST provided to civilian providers treating this population outside VA, and for further research to understand how to ameliorate the harmful effects of MST on perinatal women veterans and their children.

ImportanceIntimate partner violence (IPV) is a serious and prevalent public health issue that is interconnected with experiences of trauma, mental and physical health difficulties, and health disparities. Strength at Home (SAH) is a group intervention for persons using IPV in their relationships. Although previous studies have provided evidence of SAH’s effectiveness in reducing IPV, its patient outcomes as implemented within organized health care have not been examined.ObjectiveTo evaluate patient outcomes from implementation of SAH in the Department of Veterans Affairs (VA) health system.Design, Setting, and ParticipantsThis quality improvement study evaluated patient outcomes from a national implementation and training program conducted between December 11, 2015, and September 24, 2021. Data were collected as part of treatment and submitted by clinicians at 73 VA health care facilities. Patients were 1754 veterans seeking care aimed at addressing and/or preventing their use of aggression in intimate relationships. They completed 1 pretreatment assessment and 1 follow-up assessment in the immediate weeks after group completion.InterventionStrength at Home is a 12-week trauma-informed and cognitive behavioral group intervention to address and prevent the use of IPV in relationships.Main Outcomes and MeasuresChanges in IPV were measured with the Centers for Disease Control and Prevention 2010 National Intimate Partner and Sexual Violence Survey. Changes in posttraumatic stress disorder (PTSD) symptoms were measured with the PTSD Checklist for DSM-5, and alcohol misuse was measured with the Alcohol Use Disorders Identification Test.ResultsThe study included 1754 participants (mean [SD] age, 44.3 [13.0] years; 1421 men [81%]), of whom 1088 (62%) were involved with the criminal legal system for IPV charges. Analyses indicate that SAH was associated with reductions in use of physical IPV (odds ratio, 3.28; percentage difference from before to after treatment, –0.17 [95% CI, −0.21 to −0.13]) and psychological IPV (odds ratio, 2.73; percentage difference from before to after treatment, –0.23 [95% CI, −0.27 to −0.19]), coercive control behaviors (odds ratio, 3.19; percentage difference from before to after treatment, –0.18 [95% CI, –0.22 to –0.14), PTSD symptoms (mean change, −4.00; 95% CI, 0.90-7.09; Hedges g = 0.10), and alcohol misuse (mean change, 2.70; 95% CI, 1.54-3.86; Hedges g = 0.24).Conclusions and RelevanceIn this quality improvement study of the patient outcomes after implementation of SAH, results suggested that the program was associated with reductions in IPV behaviors, PTSD symptoms, and alcohol misuse. Results also suggest that IPV intervention in routine health care at VA health care facilities was successful; extension to other organized health care systems could be warranted.

Access to mental health (MH) care is of paramount concern to U.S. health care delivery systems, including the Veterans Health Administration. To improve access, there is a need to better focus existing MH resources toward care for those most in need of specialty-level MH treatment. This article provides early results of Project FLOW's (not an acronym) approach to developing and evaluating electronic medical record (EMR)-based criteria to identify clinically stable patients and promote their effective transition from specialty MH back to primary care (PC). Implementation utilized a blended facilitation approach consistent with Integrated Promoting Action on Research Implementation in Health Services (iPARIHS). The Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework guided measurement of implementation outcomes. During FLOW, 424 unique MH patients transitioned from MH to PC; of those, only 9 (2.1%) returned to MH after that transition. Most of those patients (n = 335; 79.0%) were first identified on the MH FLOW report, but 89 (21.0%) were other MH patients. The total number of patients discharged due to recovery or stabilization was 411. The 335 patients represent 21.3% of all unique patients (n = 1,566) who met the EMR criteria during the project. The 411 recovered/stabilized patients are 16.4% of all unique MH patients (n = 2,504) treated at the site. These early results suggest that this EMR-based system, combined with sound clinical practices, can be used to identify MH patients who are candidates for transition and foster their effective transition to care management in PC. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Background Poor coordination between the Department of Veterans Affairs (VA) and non-VA care may negatively impact health care quality. Recent legislation is intended to increase Veterans' access to care, in part through increased use of non-VA care. However, a possible consequence may be diminished patient experiences of coordination. Objective The objective of this study was to determine VA patients' and clinicians' experiences of coordination across VA and non-VA settings. Design Observational mixed methods using patient surveys and clinician interviews. Sampled patients were diagnosed with type 2 diabetes mellitus and either cardiovascular or mental health comorbidities. Participants and measures Patient perspectives on coordination were elicited between April and September 2016 through a national survey supplemented with VA administrative records (N=5372). Coordination was measured with the 8-dimension Patient Perceptions of Integrated Care survey. Receipt of non-VA care was measured through patient self-report. Clinician perspectives were elicited through individual interviews (N=100) between May and October 2017. Results Veterans who received both VA and non-VA care reported significantly worse care coordination experiences than Veterans who only receive care in VA. Clinicians report limited information exchange capabilities, which, combined with bureaucratic and opaque procedures, adversely impact clinical decision-making. Conclusions VA is working through a shift in how Veterans receive health care by increasing access to care from non-VA providers. Study findings suggest that VA should prioritize coordination of care in addition to access. This could include requiring monitoring of patient-experienced care coordination, surveys of referring and consulting clinicians, and pilot testing and evaluation of interventions to improve coordination.

BACKGROUND: Multiple comorbidities thought to be associated with poor coordination due to the need for shared treatment plans and active involvement of patients, among other factors. Cardiovascular and mental health comorbidities present potential coordination challenges relative to diabetes. OBJECTIVE: To determine how cardiovascular and mental health comorbidities relate to patient-centered coordinated care in the Department of Veterans Affairs. DESIGN: This observational study used a 2 × 2 factorial design to determine how cardiovascular and mental health comorbidities are associated with patient perceptions of coordinated care among patients with type 2 diabetes mellitus as a focal condition. PARTICIPANTS: Five thousand eight hundred six patients attributed to 262 primary care providers, from a national sample of 29 medical centers, who had completed an online survey of patient-centered coordinated care in the Department of Veterans Affairs (VA). MAIN MEASURES: Eight dimensions from the Patient Perceptions of Integrated Care (PPIC) survey, a state-of-the-art measure of patients’ perspective on coordinated and patient-centered care. KEY RESULTS: Mental health conditions were associated with significantly lower patient experiences of coordinated care. Hypotheses for disease severity were not supported, with associations in the hypothesized direction for only one dimension. CONCLUSIONS: Results suggest that VA may be adequately addressing coordination needs related to cardiovascular conditions, but more attention could be placed on coordination for mental health conditions. While specialized programs for more severe conditions (e.g., heart failure and serious mental illness) are important, coordination is also needed for more common, less severe conditions (e.g., hypertension, depression, anxiety). Strengthening coordination for common, less severe conditions is particularly important as VA develops alternative models (e.g., community care) that may negatively impact the degree to which care is coordinated. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-019-04979-8) contains supplementary material, which is available to authorized users.

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

Background While the US Department of Veterans Affairs has made significant strides to prevent veteran suicide, efforts have largely targeted veterans actively engaged in and eligible for Veterans Health Administration (VHA) care, which is consistent with the VHA mission. The majority of veterans are not enrolled in VHA care, and many are ineligible for services. Veterans not connected to VHA have experienced an increase in suicides in recent years. Observations Since 2018, VHA National Center for Patient Safety has funded the Patient Safety Center of Inquiry-Suicide Prevention Collaborative (PSCI-SPC), which has worked to develop, implement, and evaluate practical solutions aimed at curbing the rising suicide rate among veterans not receiving VHA care. PSCI-SPC has 3 guiding objectives: (1) Develop and test a collaborative, organizational structure to connect VHA and community organizations, such as national, local, public, private, nonprofit, and academic partners who provide high-quality and timely health care; (2) Build and test a learning collaborative to facilitate sharing of VHA suicide prevention best practices with community partners to increase availability, consistency, and quality of mental health services for all veterans; and (3) Implement, test, and refine a novel program to provide affordable suicide prevention interventions to veterans with mental health needs, regardless of their use of, or eligibility for, VHA services. This paper details the current progress for this demonstration project. As these objectives are met, PSCI-SPC will create and disseminate products to support broad implementation of these practices to other VA medical centers and the communities they are embedded in. Conclusions PSCI-SPC seeks to fill an important gap in veteran health care by serving as a national clinical innovation and dissemination center for best practices in suicide prevention for veterans who receive care in their communities.

Author(s): Fernandez, William G.; Benzer, Justin K.; Charns, Martin P.; Burgess, James F. | Abstract: Introduction: Effective teamwork has been shown to optimize patient safety. However, researchcentered on the critical inputs, processes, and outcomes of team effectiveness in emergency medicalservices (EMS) has only recently begun to emerge. We conducted a theory-driven qualitative studyof teamwork processes—the interdependent actions that convert inputs to outputs—by frontline EMSpersonnel in order to provide a model for use in EMS education and research.Methods: We purposively sampled participants from an EMS agency in Houston, TX. Full-timeemployees with a valid emergency medical technician license were eligible. Using semi-structuredformat, we queried respondents on task/team functions and enablers/obstacles of teamwork in EMS.Phone interviews were recorded and transcribed. Using a thematic analytic approach, we combinedcodes into candidate themes through an iterative process. Analytic memos during coding and analysisidentified potential themes, which were reviewed/refined and then compared against a model ofteamwork processes in emergency medicine.Results: We reached saturation once 32 respondents completed interviews. Among participants, 30(94%) were male; the median experience was 15 years. The data demonstrated general support forthe framework. Teamwork processes were clustered into four domains: planning; action; reflection;and interpersonal processes. Additionally, we identified six emergent concepts during open coding:leadership; crew familiarity; team cohesion; interpersonal trust; shared mental models; and proceduralknowledge.Conclusion: In this thematic analysis, we outlined a new framework of EMS teamwork processes todescribe the procedures that EMS operators employ to convert individual inputs into team performanceoutputs. The revised framework may be useful in both EMS education and research to empiricallyevaluate the key planning, action, reflection, and interpersonal processes that are critical to teamworkeffectiveness in EMS.

Research to improve access to mental healthcare often focuses on increasing timely referrals from primary care (PC) to specialty mental health (SMH). However, timely and appropriate transitions back to PC are indispensable for increasing access to SMH for new patients. We developed and implemented a formalized process to identify patients eligible for transition from SMH to PC. The FLOW intervention was piloted at a Veterans Health Administration community-based outpatient clinic. Qualitatively examine provider perspectives regarding patient transitions at initiation and termination of the FLOW project. Sixteen mental health providers and three PC staff completed qualitative interviews about the benefits and drawbacks of FLOW at initiation. Ten mental health providers and one PC staff completed interviews at 12-month follow-up. Primary benefits anticipated at initiation were that FLOW would increase access to SMH, provide acknowledgment of veterans’ recovery, and differentiate between higher and lower intensity mental health services. SMH providers reported additional perceived benefits at 12-month follow-up, including decreased stress over their caseloads and increased ability to deliver efficient, effective treatment. Anticipated drawbacks at initiation were that veterans would get inconsistent care, PC could not offer the same level of care as SMH, and veterans might view transition as a rejection by their SMH provider. Perceived drawbacks were similar at 12-month follow-up, but there was less frequent endorsement. Findings highlight need for sustained and frequent provider education regarding (i) the appropriate characteristics of individuals eligible for transition and (ii) established procedures to ensure care coordination during and after transition.

OBJECTIVE: This study sought to extend findings from a randomized controlled trial of the Strength at Home Men's Program (SAH-M) for intimate partner aggression (IPA) in military veterans by examining the impact of pretreatment posttraumatic stress disorder (PTSD) symptoms on treatment efficacy, and by examining new data on postintervention follow-up for individuals who received SAH-M after completing the enhanced treatment as usual (ETAU) wait-list control condition. METHOD: Using data from 125 male veterans who attended the SAH-M program immediately after an intake assessment or after waiting 6-month in the ETAU condition, this study used generalized linear modeling to examine predictors of physical and psychological IPA over a 9-month period of time. RESULTS: PTSD symptoms at intake significantly predicted both physical and psychological IPA use, even after accounting for the effects of treatment condition, time, and number of sessions attended. PTSD had a strong association with both physical and psychological IPA. An interaction between PTSD and SAH-M was observed for psychological IPA but not physical IPA, and the magnitude of the effect was not clinically significant. There was a significant effect of SAH-M in reducing IPA in the full sample, including previously unanalyzed outcome data from the ETAU condition. CONCLUSION: The study results suggest that while SAH-M does not need to be modified to address the interaction between PTSD and treatment, outcomes could be enhanced through additional direct treatment of PTSD symptoms. RESULTS extend prior analyses by demonstrating the effectiveness of SAH-M in reducing use of IPA in both the treatment and ETAU conditions. (PsycINFO Database Record(c) 2017 APA, all rights reserved). Language: en

With the relatively recent emphasis on providing family-centered care at the Veterans Health Administration (VHA), there is growing interest in understanding how mental health disorders such as posttraumatic stress disorder (PTSD) may impact and be impacted by parent-child functioning in veteran families. However, basic and intervention research on the impact of PTSD and parenting behaviors on parent-child functioning among recent veterans is lacking. Utilizing the responses of 111 veterans with children ages 3–18 to a Web-based survey, the current study used hierarchical linear regression to examine whether it is PTSD symptoms, parenting behaviors, or both that best explain two components of parent-child functioning: parenting satisfaction and parent-reported child psychosocial problems. Results indicated that parenting behaviors uniquely and significantly explained variance in parenting satisfaction and child psychosocial problems above and beyond the contributions of PTSD symptoms and demograph...

OBJECTIVE: To assess the influence of relational climate on quality of diabetes care. DATA SOURCES/STUDY SETTING: The study was conducted at the Department of Veterans Affairs (VA). The VA All Employee Survey (AES) was used to measure relational climate. Patient and facility characteristics were gathered from VA administrative datasets. STUDY DESIGN: Multilevel panel data (2008–2012) with patients nested into clinics. DATA COLLECTION/EXTRACTION METHODS: Diabetic patients were identified using ICD‐9 codes and assigned to the clinic with the highest frequency of primary care visits. Multiple quality indicators were used, including an all‐or‐none process measure capturing guideline compliance, the actual number of tests and procedures, and three intermediate continuous outcomes (cholesterol, glycated hemoglobin, and blood pressure). PRINCIPAL FINDINGS: The study sample included 327,805 patients, 212 primary care clinics, and 101 parent facilities in 2010. Across all study years, there were 1,568,180 observations. Clinics with the highest relational climate were 25 percent more likely to provide guideline‐compliant care than those with the lowest relational climate (OR for a 1‐unit increase: 1.02, p‐value

BACKGROUND: Delivering care to patients with complex healthcare needs benefits from coordination among healthcare providers. Greater levels of care coordination have been associated with more favorable patient experiences, cost management, and lower utilization of services. Organizational approaches consider how systems, practices, and relationships influence coordination and associated outcomes. OBJECTIVE: Examine measures of organizational coordination and their association with patient experiences of care coordination involving specialists. DESIGN: Cross-sectional surveys of patients and primary care providers (PCPs). PARTICIPANTS: Final sample included 3183 patients matched to 233 PCPs from the Veterans Health Administration. All patients had a diagnosis of type 2 diabetes mellitus and one of four other conditions: hypertension; congestive heart failure; depression/anxiety; or severe mental illness/posttraumatic stress disorder. MAIN MEASURES: Patients completed a survey assessing perceptions of coordinated care. We examined ratings on three domains: specialist knowledge management; knowledge integration across settings and time; and knowledge fragmentation across settings and time. We created care coordination measures involving the PCP and three specialty provider types. PCPs provided ratings on relational coordination for specialists, feedback coordination, and team coordination. We aligned patient’s specialty services used with corresponding PCP ratings of that specialty. KEY RESULTS: Patient ratings were significantly lower on specialist knowledge management and knowledge integration when either PCPs did not use feedback coordination (b = − .20; b = − .17, respectively) or rated feedback coordination lower (b = − .08 for both). Teamwork was significantly related to specialist knowledge management (b = .06), knowledge integration (b = .04); and knowledge fragmentation (b = − .04). Relational coordination was related to coordination between the primary care provider and (i) diabetes specialist (b = .09) and (ii) mental health provider (b = .12). CONCLUSIONS: Practices to improve provider coordination within and across primary care and specialty care services may improve patient experiences of care coordination. Improvements in these areas may improve care efficiency and effectiveness. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-019-04973-0) contains supplementary material, which is available to authorized users.

Posttraumatic stress disorder (PTSD) is prevalent among combat veterans and is associated with intimate relationship difficulties. Few studies have examined the prospective longitudinal course of associations between PTSD and relationship difficulties and whether there are gender differences. In a sample comprised of 202 male and female post 9/11 veterans, this study examined gender differences in the association between PTSD symptoms measured 4 times over the course of 1 year and romantic relationship role impairment measured at the beginning and end of that year, accounting for the association of combat stress and noncombat stressful life events. Increases in PTSD symptoms over time were positively associated with increased relationship impairment; however, relationship impairment was not associated with changes in PTSD over time. Gender did not significantly moderate this relationship. However, allowing model parameters to vary between genders revealed that noncombat life stress was associated with changes in PTSD over time for women, but not men. Conversely, only men exhibited associations of baseline levels of combat stress and noncombat stress with baseline relationship functioning, and between baseline relationship functioning and baseline PTSD symptoms. Findings suggest women veterans in particular may benefit from clinical attention to the influence of general stress on PTSD symptoms, while clinical work to improve couple impairment in the context of PTSD symptoms may be beneficial for veterans of both genders. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Background Primary care clinics present challenges to implementing evidence-based psychotherapies (EBPs) for depression and anxiety, and frontline providers infrequently adopt these treatments. The current study explored providers’ perspectives on fidelity to a manualized brief cognitive behavioral therapy (CBT) as delivered in primary care clinics as part of a pragmatic randomized trial. Data from the primary study demonstrated the clinical effectiveness of the treatment and indicated that providers delivered brief CBT with high fidelity, as evaluated by experts using a standardized rating form. Data presented here explore challenges providers faced during implementation and how they adapted nonessential intervention components to make the protocol “fit” into their clinical practice. Methods A multiprofessional group of providers (n = 18) completed a one-time semi-structured interview documenting their experiences using brief CBT in the primary care setting. Data were analyzed via directed content analysis, followed by inductive sorting of interview excerpts to identify key themes agreed upon by consensus. The Dynamic Adaptation Process model provided an overarching framework to allow better understanding and contextualization of emergent themes. Results Providers described a variety of adaptations to the brief CBT to better enable its implementation. Adaptations were driven by provider skills and abilities (i.e., using flexible content and delivery options to promote treatment engagement), patient-emergent issues (i.e., addressing patients’ broader life and clinical concerns), and system-level resources (i.e., maximizing the time available to provide treatment). Conclusions The therapeutic relationship, individual patient factors, and system-level factors were critical drivers guiding how providers adapted EBP delivery to improve the “fit” into their clinical practice. Adaptations were generally informed by tensions between the EBP protocol and patient and system needs and were largely not addressed in the EBP protocol itself. Adaptations were generally viewed as acceptable by study fidelity experts and helped to more clearly define delivery procedures to improve future implementation efforts. It is recommended that future EBP implementation efforts examine the concept of fidelity on a continuum rather than dichotomized as adherent/not adherent with focused efforts to understand the context of EBP delivery. Trial registration ClinicalTrials.gov, NCT01149772 Electronic supplementary material The online version of this article (10.1186/s13012-018-0768-z) contains supplementary material, which is available to authorized users.

Despite decades of effort to improve quality and safety in health care, this goal feels increasingly elusive. Successful examples of improvement are infrequently replicated. This scoping review synthesizes 76 empirical or conceptual studies (out of 1208 originally screened) addressing learning in quality or safety improvement, that were published in selected health care and management journals between January 2000 and December 2014 to deepen understanding of the role that collective learning plays in quality and safety improvement. We categorize learning activities using a theoretical model that shows how leadership and environmental factors support collective learning processes and practices, and in turn team and organizational improvement outcomes. By focusing on quality and safety improvement, our review elaborates the premise of learning theory that leadership, environment, and processes combine to create conditions that promote learning. Specifically, we found that learning for quality and safety improvement includes experimentation (including deliberate experimentation, improvisation, learning from failures, exploration, and exploitation), internal and external knowledge acquisition, performance monitoring and comparison, and training. Supportive learning environments are characterized by team characteristics like psychological safety, appreciation of differences, openness to new ideas social motivation, and team autonomy; team contextual factors including learning resources like time for reflection, access to knowledge, organizational capabilities; incentives; and organizational culture, strategy, and structure; and external environmental factors including institutional pressures, environmental dynamism and competitiveness and learning collaboratives. Lastly learning in the context of quality and safety improvement requires leadership that reinforces learning through actions and behaviors that affect people, such as coaching and trust building, and through influencing contextual factors, including providing resources, developing culture, and taking strategic actions that support improvement. Our review highlights the importance of leadership in both promoting a supportive learning environment and implementing learning processes.

Quality of care worries and rising costs have resulted in a widespread interest in enhancing the efficiency of health care delivery. One area of increasing interest is in promoting teamwork as a way of coordinating efforts to reduce costs and improve quality, and identifying the characteristics of the work environment that support teamwork. Relational climate is a measure of the work environment that captures shared employee perceptions of teamwork, conflict resolution, and diversity acceptance. Previous research has found a positive association between relational climate and quality of care, yet its relationship with costs remains unexplored. We examined the influence of primary care relational climate on health care costs incurred by diabetic patients at the U.S. Department of Veterans Affairs between 2008 and 2012. We found that better relational climate is significantly related to lower costs. Clinics with the strongest relational climate saved $334 in outpatient costs per patient compared with facilities with the weakest score in 2010. The total outpatient cost saving if all clinics achieved the top 5% relational climate score was $20 million. Relational climate may contribute to lower costs by enhancing diabetic treatment work processes, especially in outpatient settings.

Sustaining ongoing relationships with patients is a strategic, clinically relevant goal of health care systems. This study develops and tests a conceptual model that aims to account for the influence of organization design, perceptions of quality of patient care, and other patient-level factors on the extent to which patients sustain reliance on a health care system. We use a longitudinal survey design and structural equation modeling to predict increases or decreases in patient reliance on the Department of Veterans Affairs health care system across a 4-year period for Veterans with Parkinson’s Disease. Our findings show that specialized and integrated clinical practices have a positive association with the quality of patient care. Health care systems may be able to foster long-term relations with patients and improve service quality by allocating resources to form integrated, specialized, disease-specific centers of care designed for patients with chronic illnesses.

There is no consensus as to what constructs should be considered to be psychological climate. Further, there is no clear taxonomy of psychological climate, although the climate literature suggests that psychological climate perceptions should form higher-order (i.e., abstract, broad) dimensions. Two meta-analyses have been conducted to evaluate higher-order frameworks, but neither study tested the psychometric structure of their hypothesized models. The current meta-analysis estimated the intercorrelations and criterion-related validity of 23 psychological climate constructs in order to test the theoretical frameworks proposed by prior meta-analyses. Confirmatory factor analyses supplemented by a method analogous to item-to-scale correlations indicated little empirical support for the a priori frameworks. Results suggest that that psychological climate may be parsimoniously represented by two dimensions. Task climate was most strongly indicated by supervisor goal setting, innovation, and organizational responsiveness. Relational climate was most strongly indicated by work group warmth and social rewards. A path analysis was estimated to test whether job satisfaction partially mediated the association between psychological climate and the outcomes of job performance, turnover intentions, and psychological well-being. Results provide guidance to researchers and practitioners interested in measuring perceptions of the work environment.

Background The collaborative care model is an evidence-based practice for treatment of depression in which designated care managers provide clinical services, often by telephone. However, the collaborative care model is infrequently adopted in the Department of Veterans Affairs (VA). Almost all VA medical centers have adopted a co-located or embedded approach to integrating mental health care for primary care patients. Some VA medical centers have also adopted a telephone-based collaborative care model where depression care managers support patient education, patient activation, and monitoring of adherence and progress over time. This study evaluated two research questions: (1) What does a dedicated care manager offer in addition to an embedded-only model? (2) What are the barriers to implementing a dedicated depression care manager? Methods This study involved 15 qualitative, multi-disciplinary, key informant interviews at two VA medical centers where reimbursement options were the same— both with embedded mental health staff, but one with a depression care manager. Participant interviews were recorded and transcribed. Thematic analysis was used to identify descriptive and analytical themes. Results Findings suggested that some of the core functions of depression care management are provided as part of embedded-only mental health care. However, formal structural attention to care management may improve the reliability of care management functions, in particular monitoring of progress over time. Barriers to optimal implementation were identified at both sites. Themes from the care management site included finding assertive care managers to hire, cross-discipline integration and collaboration, and primary care provider burden. Themes from interviews at the embedded site included difficulty getting care management on leaders’ agendas amidst competing priorities and logistics (staffing and space). Conclusions Providers and administrators see depression care management as a valuable healthcare service that improves patient care. Barriers to implementation may be addressed by team-building interventions to improve cross-discipline integration and communication. Findings from this study are limited in scope to the VA healthcare system. Future investigation of whether alternative barriers exist in implementation of depression care management programs in non-VA hospital systems, where reimbursement rates may be a more prominent concern, would be valuable.

Background The importance of interpersonal behavior at the workplace is increasingly recognized in the health care industry and related literature. An unresolved issue in the existing health care research is how a climate of courteous interpersonal behavior may form the foundation for strong hospital care performance. Purpose The aim of this study was to test the link between a climate of courteous interpersonal behavior, termed "civility climate," and hospital care performance. We conceptualize a multidimensional model of care performance by contrasting two dimensions: performance as perceived by employees and performance as perceived by patients. Furthermore, for both performance perspectives, we test an intermediate variable (error orientation climate) that may explain the relationship between civility climate and hospital care performance. Methodology The 2011 study sample comprised responses from 6,094 nurses and 38,627 patients at 123 Veterans Health Administration acute care inpatient hospitals in the United States. We developed and empirically tested a theoretical model using regression modeling, and we used a bootstrap method to test for mediation. Results The results indicate a direct effect of civility climate on employee perceptions of care performance and an indirect effect mediated by error orientation climate. With regard to patient perceptions of care performance, the analyses reveal a direct effect of civility climate. The indirect effect mediated by error orientation climate was not supported. Practice implications Our findings point to the importance of strengthening interpersonal interactions for ensuring and improving both employees' and patients' perceptions of care, which constitute key success factors in the increasingly competitive hospital market. The insights may further stimulate discussion regarding interventions to foster a strong civility climate in hospitals.

Background The U.S. Department of Veterans Affairs (VA) has recently implemented a comprehensive national program to help veterans who use or experience intimate partner violence (IPV). One important component of this plan is to implement Strength at Home (SAH), a 12-week cognitive-behavioral and trauma-informed group treatment designed to reduce and end IPV use among military and veteran populations. Method The present study describes initial patient and clinician findings from the first year of a training program tasked with implementing SAH at 10 VA medical centers. Results Results from 51 veterans who completed both pre- and post-treatment assessments indicate SAH was associated with significant pre- to post-treatment reductions in the proportion of veterans who reported using physical and psychological IPV toward a partner, the types of IPV used, and posttraumatic stress disorder symptoms. Overall, veterans reported high satisfaction with the quality and nature of services received, and with the program materials. In addition, 70% of sites and 34% of the 79 clinicians trained were successful in launching the program in the first year. The mean number of days between site training and initiation of the first group session was 135.86 (SD = 63.16, range 72–252). Conclusions Results suggest that the training and implementation program was successful overall. However, average length of time between in-person training and initiation of group services was longer than desired and there were three sites that did not successfully implement the program within the first year, suggesting a need to reduce implementation barriers and enhance institutional support.

The purpose of this review is to extend extant conceptualizations of readiness for change as an individual-level phenomenon. This review-of-reviews focuses on existing conceptual frameworks from the dissemination, implementation, quality improvement, and organizational transformation literatures in order to integrate theoretical rationales for how organization structure, a key dimension of the organizational context, may impact readiness for change. We propose that the organization structure dimensions of differentiation and integration impact readiness for change at the individual level of analysis by influencing four key concepts of relevance, legitimacy, perceived need for change, and resource allocation. We identify future research directions that focus on these four key concepts.

Background Advanced practice providers (APPs), including nurse practitioners (NPs) and physician assistants (PAs) are cost-effective substitutes for physicians, with similar outcomes in primary care and surgery. However, little is understood about APP roles in inpatient medicine. Objective Describe APPs role in inpatient medicine. Design Observational cross-sectional cohort study. Setting One hundred twenty-four Veterans Health Administration (VHA) hospitals. Participants Chiefs of medicine (COMs) and nurse managers. Measurements Surveys included inpatient medicine scope of practice for APPs and perceived healthcare quality. We conducted bivariate unadjusted and multivariable adjusted analyses. Results One hundred eighteen COMs (95.2%) and 198 nurse managers (75.0%) completed surveys. Of 118 medicine services, 56 (47.5%) employed APPs; 27 (48.2%) used NPs only, 15 (26.8%) PAs only, and 14 (25.0%) used both. Full-time equivalents for NPs was 0.5 to 7 (mean = 2.22) and PAs was 1 to 9 (mean = 2.23). Daily caseload was similar at 4 to 10 patients (mean = 6.5 patients). There were few significant differences between tasks. The presence of APPs was not associated with patient or nurse manager satisfaction. Presence of NPs was associated with greater overall inpatient and discharge coordination ratings by COMs and nurse managers, respectively; the presence of PAs was associated with lower overall inpatient coordination ratings by nurse managers. Conclusions NPs and PAs work on half of VHA inpatient medicine services with broad, yet similar, scopes of practice. There were few differences between their roles and perceptions of care. Given their very different background, regulation, and reimbursement, this has implications for inpatient medicine services that plan to hire NPs or PAs.

Although pay-for-performance (P4P) has become a central strategy for improving quality in US healthcare, questions persist about the effectiveness of these programs. A key question is whether quality improvement that occurs as a result of P4P programs is sustainable, particularly if incentives are removed. To investigate sustainability of performance levels following removal of performance-based incentives. Observational cohort study that capitalized on a P4P program within the Veterans Health Administration (VA) that included adoption and subsequent removal of performance-based incentives for selected inpatient quality measures. The study sample comprised 128 acute care VA hospitals where performance was assessed between 2004 and 2010. VA system managers set annual performance goals in consultation with clinical leaders, and report performance scores to medical centers on a quarterly basis. These scores inform performance-based incentives for facilities and their managers. Bonuses are distributed based on the attainment of these performance goals. Seven quality of care measures for acute coronary syndrome, heart failure, and pneumonia linked to performance-based incentives. Significant improvements in performance were observed for six of seven quality of care measures following adoption of performance-based incentives and were maintained up to the removal of the incentive; subsequently, the observed performance levels were sustained. This is a quasi-experimental study without a comparison group; causal conclusions are limited. The maintenance of performance levels after removal of a performance-based incentive has implications for the implementation of Medicare’s value-based purchasing initiative and other P4P programs. Additional research is needed to better understand human and system-level factors that mediate sustainability of performance-based incentives.

This paper proposes a new perspective on the development of commitment. We propose that organizational events are evaluated relative to a person's values to determine whether the person fits or misfits the organization. The fit information is then organized into commitment elements, which reflect the extent to which workplace events fit (relative to misfit) a particular value across events over time. We propose that elements are organized around values, not events, such that values are the main effect and events are the moderators of said effect on elements. Elements are, in turn, formative indicators of the latent commitment construct. They are the proximal causes of commitment. Multiple elements contribute to a single commitment and they are weighted via the value hierarchy. Our perspective contributes to the literature by: (a) being developmental; (b) focusing on events; and, (c) having implications for both within-person and between-person questions about commitment development.

Background Although contractors that offer prescription drug plans through the Medicare Part D program are evaluated in part on enrollees' medication adherence scores, little evidence addresses contractors' ability to influence these scores. Objective We used data from the Centers for Medicare and Medicaid Services and US Census to investigate contractors' ability to influence their medication adherence scores. In accordance with a conceptual model, we hypothesized that contractors can directly and indirectly influence their medication adherence scores based on how effectively they manage prescription drug benefits for enrollees. We focused on 4 plan management variables: service reliability, stability/accuracy of drug prices, accessibility of prescription drugs, and availability of drug information. We examined indirect effects via enrollees' satisfaction with the plan. Research design We conducted a cross-sectional study based on 2012 data for which the contractor was the unit of analysis. We conducted path regression models that accounted for plan type (ie, Medicare Advantage vs. stand alone) and enrollee characteristics. Results Among contractors, enrollee satisfaction scores were positively and significantly associated with medication adherence scores. Two of the 4 plan management variables were observed to have both direct and indirect effects on medication adherence scores: accessibility of prescription drugs and service reliability. Conclusions Our study indicates that Part D contractors do appear to have some level of influence over their medication adherence scores based on how effectively they manage prescription drug benefits for enrollees. Accessibility to prescriptions and better service delivery appear important in this regard and should be explored further in future research.

Rationale, Aims, and Objectives Measures of safety climate are increasingly used to guide safety improvement initiatives. However, cost and respondent burden may limit the use of safety climate surveys. The purpose of this study was to develop a 15- to 20-item safety climate survey based on the Patient Safety Climate in Healthcare Organizations survey, a well-validated 38-item measure of safety climate. Methods The Patient Safety Climate in Healthcare Organizations was administered to all senior managers, all physicians, and a 10% random sample of all other hospital personnel in 69 private sector hospitals and 30 Veterans Health Administration hospitals. Both samples were randomly divided into a derivation sample to identify a short-form subset and a confirmation sample to assess the psychometric properties of the proposed short form. Results The short form consists of 15 items represented 3 overarching domains in the long-form scale—organization, work unit, and interpersonal. Conclusion The proposed short form efficiently captures 3 important sources of variance in safety climate: organizational, work-unit, and interpersonal. The short-form development process was a practical method that can be applied to other safety climate surveys. This safety climate short form may increase response rates in studies that involve busy clinicians or repeated measures.

Objective. To test the utility of a two-dimensional model of organizational climate for explaining variation in diabetes care between primary care clinics. Data Sources/Study Setting. Secondary data were obtained from 223 primary care clinics in the Department of Veterans Affairs health care system. Study Design. Organizational climate was defined using the dimensions of task and relational climate. The association between primary care organizational climate and diabetes processes and intermediate outcomes were estimated for 4,539 patients in a cross-sectional study. Data Collection/Extraction Methods. All data were collected from administrative datasets. The climate data were drawn from the 2007 VA All Employee Survey, and the outcomes data were collected as part of the VA External Peer Review Program. Climate data were aggregated to the facility level of analysis and merged with patient-level data. Principal Findings. Relational climate was related to an increased likelihood of diabetes care process adherence, with significant but small effects for adherence to intermediate outcomes. Task climate was generally not shown to be related to adherence. Conclusions. The role of relational climate in predicting the quality of chronic care was supported. Future research should examine the mediators and moderators of relational climate and further investigate task climate.

Background: The delivery of healthcare depends on individual providers, coordination within teams, and the structure of the work setting. We analyzed the amount of variation in technical quality and patient satisfaction accounted for at the patient, provider, team, and medical center level. Methods: Data abstracted from Veterans Health Administration patient medical records for 2007 were used to calculate measures of technical quality based on adherence to best practice guidelines in 5 domains. Outpatient satisfaction was obtained from a 2007 standardized national mail survey. Hierarchical linear models that accounted for the clustering of patients within providers, providers within teams, and teams within medical centers were used to partition the variation in technical quality and satisfaction across patients and components of the system (ie, providers, teams, and medical centers). Results: Providers accounted for the largest percent of system-level variance for all technical quality domains, ranging from 46.5% to 71.9%. For the single-item measure of patient satisfaction, medical centers, teams, and providers accounted for about the same percent of system-level variance (31%–34%). For the doctor/patient interaction scale providers explained 59.9% of system-level variance, more than double that of teams and medical centers. For all the measures, the residual variance (composed of patient-level and random error) explained the largest proportion of the total variance. Conclusions: Providers explained the greatest amount of systemlevel variation in technical quality and patient satisfaction. However, in both of these domains, differences between patients were the predominant source of nonrandom variance.

Background: Posttraumatic stress disorder (PTSD) is a prevalent mental health issue among veterans. Access to PTSD treatment is influenced by geographic (ie, travel distance to facilities), temporal (ie, time delay between services), financial (ie, eligibility and cost of services), and cultural (ie, social stigma) barriers. Objective: The emergence of mobile health (mHealth) apps has the potential to bridge many of these access gaps by providing remote resources and monitoring that can offer discrete assistance to trauma survivors with PTSD and enhance patient-clinician relationships. In this study, we investigate the current mHealth capabilities relevant to PTSD. Methods: This study consists of two parts: (1) a review of publicly available PTSD apps designed to determine the availability of PTSD apps, which includes more detailed information about three dominant apps and (2) a scoping literature review performed using a systematic method to determine app usage and efforts toward validation of such mHealth apps. App usage relates to how the end users (eg, clinicians and patients) are interacting with the app, whereas validation is testing performed to ensure the app’s purpose and specifications are met. Results: The results suggest that though numerous apps have been developed to aid in the diagnosis and treatment of PTSD symptoms, few apps were designed to be integrated with clinical PTSD treatment, and minimal efforts have been made toward enhancing the usability and validation of PTSD apps. Conclusions: These findings expose the need for studies relating to the human factors evaluation of such tools, with the ultimate goal of increasing access to treatment and widening the app adoption rate for patients with PTSD. [JMIR Mhealth Uhealth 2017;5(10):e156]

A letter to the editor is presented in response to two articles in a previous issue that were concerned with problems in the U.S. Veterans Health Administration.

Conceptual frameworks in health care do not address mechanisms whereby teamwork processes affect quality of care. We seek to fill this gap by applying a framework of teamwork processes to compare different patterns of primary care performance over time. We thematically analyzed 114 primary care staff interviews across 17 primary care clinics. We purposefully selected clinics using diabetes quality of care over 3 years using four categories: consistently high, improving, worsening, and consistently low. Analyses compared participant responses within and between performance categories. Differences were observed among performance categories for action processes (monitoring progress and coordination), transition processes (goal specification and strategy formulation), and interpersonal processes (conflict management and affect management). Analyses also revealed emergent concepts related to psychological and organizational context that were reported to affect team processes. This study is a first step toward a comprehensive model of how teamwork processes might affect quality of care.

The relationship between military combat and postdeployment family functioning difficulties has been frequently investigated in the literature, as has the relationship between types of coping and posttraumatic stress disorder (PTSD). Few studies, however, have examined these variables together, and no studies of which we are aware have examined the effect of coping on family functioning after combat exposure. This study examined coping style measured immediately after return from deployment, and PTSD symptoms and family functioning 18-24 months after return from deployment in a sample of Operation Desert Shield/Storm veterans (N = 2,949). Structural equation models suggested that the relationships between distinct coping styles on family functioning were differentially mediated by postdeployment PTSD symptoms. Results are consistent with full mediation for avoidant coping (βdirect = -.09, p = .07; βindirect = -.17, p.001) and partial mediation for approach coping (βdirect = .16, p.001; βindirect = .09, p.001). Results suggest that the strategies used to cope with a combat stress event may impact both PTSD and family functioning outcomes, and highlight the potential utility of pre- and postdeployment coping skills training.

Primary care providers are increasingly under pressure to do more with fewer resources. We examined the effect of workload on patients' experiences of quality of care, measured through approximately 44,000 patient experience surveys in a sample of 222 primary care clinics in the Veterans Health Administration. We tested the extent to which relational climate, a measure of teamwork, moderated the relationship between workload and patient ratings of quality of care. Our outcome measures included patient complaints, time spent with provider, and overall visit quality. Workload was negatively associated with patients' quality of care ratings and relational climate moderated the relation between workload and quality of care ratings. Patients seen in clinics with higher workload and greater relational climate reported better care compared with patients in clinics with higher workload but lower relational climate. Findings highlight the importance of relational climate as an important teamwork factor when managing and developing clinic policies, practices, and procedures in resource-constrained settings.

In this paper we report results from an investigation of the relationship between a positive inter-personal work climate, termed civility climate, and hospital care performance. We extend the extan...

Although value-based purchasing has become a centerpiece of the Medicare program, a persistent concern among participating health care providers and health plans is whether influencing selected per...

Objective. There is limited theory regarding the real-world implementation of mental health care in the primary care setting: a type of organizational coordination intervention. The purpose of this study was to develop a theory to conceptualize the potential causes of barriers and facilitators to how local sites responded to this mandated intervention to achieve coordinated mental health care.Methods. Data from 65 primary care and mental health staff interviews across 16 sites were analyzed to identify how coordination was perceived one year after an organizational mandate to provide integrated mental health care in the primary care setting.Results. Standardized referral procedures and communication practices between primary care and mental health were influenced by the organizational factors of resources, training, and work design, as well as provider-experienced organizational boundaries between primary care and mental health, time pressures, and staff participation. Organizational factors and provider experiences were in turn influenced by leadership.Conclusions. Our emergent theory describes how leadership, organizational factors, and provider experiences affect the implementation of a mandated mental health coordination intervention. This framework provides a nuanced understanding of the potential barriers and facilitators to implementing interventions designed to improve coordination between professional groups.