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BACKGROUND Informal caregivers, or care partners, provide critical support to care recipients when managing health care. Veterans Health Administration (VHA) priorities identify care partners as vital in supporting veterans’ care management. The Veteran Delegation Tool (VDT) is VHA’s Health Insurance Portability and Accountability Act–compliant solution for care partners to comanage veterans’ care through VHA’s electronic health portal. Human-centered design approaches in VDT development are needed to inform enhancements aimed at promoting uptake and sustained use. OBJECTIVE The objective of this prospective descriptive quality improvement project was to use a human-centered design approach to examine VDT use perceptions and practical experiences. METHODS This project was conducted using a 4-phase approach: frame, discover, design, and deliver. The frame phase designed the protocol and prepared the VDT system for testing. This paper reports on the discover phase, which used semistructured and follow-up interviews and user testing to examine VDT’s benefits, facilitators, and barriers. The discover phase data informed the design and deliver phases, which are underway. RESULTS Veterans (24/54, 44%), care partners (21/54, 39%), and individuals who represented dual roles (9/54, 17%)—namely veteran care partner (4/54, 7%), veteran clinical provider (2/54, 4%), and care partner provider (3/54, 6%)—participated in semistructured interviews in the discover phase. A subsample of these participants (3/54, 6%) participated in the follow-up interviews and user testing. Analysis of the semistructured interviews indicated convergence on the respondents’ perceptions of VDT’s benefits, facilitators, and barriers and recommendations for improving VDT. The perceived benefits were authorized access, comanagement of care needs on the web, communication with the clinical team, access to resources, and ease of burden. Perceived barriers were nonrecognition of the benefits of VDT, technical literacy access issues, increased stress in or burden on care partners, and personal health information security. Participant experiences across 4 VDT activity domains were upgrade to My HealtheVet Premium account, registration, sign-in, and use. User testing demonstrated users’ challenges to register, navigate, and use VDT. Findings informed VDT development enhancements and recommendations. CONCLUSIONS Care partners need Health Insurance Portability and Accountability Act–compliant access to electronic health portals to assist with care management. VDT is VHA’s solution, allowing communication among delegates, veterans, and clinical care teams. Users value VDT’s potential use and benefits, while access and navigation improvements to ensure uptake and sustained use are needed. Future efforts need to iteratively evaluate the human-centered phases, design and deliver, of VDT to target audiences. Continued efforts to understand and respond to care partners’ needs are warranted.

BackgroundUrinary and fecal incontinence contribute to significant quality of life impairments for patients and caregivers. Preliminary research suggests that incontinence rates may be higher among Veterans. However, few studies have examined incontinence experiences among Veterans and their caregivers.ObjectivesWe aimed to demonstrate the feasibility of conducting a one-year, telephone survey with Veterans and their caregivers to help inform larger studies. By including both Veteran and caregiver perspectives, we explored how incontinence impacts Veterans’ self-management strategies, quality of life, and treatment experiences.DesignWe used a mixed methods design, employing quantitative (i.e., cross-sectional survey) and qualitative approaches (i.e., semi-structured interviews).ParticipantsOur sample included 64 Veterans with urinary incontinence, fecal incontinence, or mixed incontinence, and 36 caregivers. A subset of 18 Veterans and 8 caregivers completed semi-structured interviews.MethodsData were collected via telephone surveys over the course of 1-year from a small research team at the Veterans Health Administration (VHA). Participants completed measures about the Veteran’s incontinence severity, quality of life, and VHA treatment experiences. Interviews asked participants about their perceptions and satisfaction in receiving treatment for the Veterans’ incontinence. Qualitative themes were extracted using a Rapid Assessment Process model.ResultsVeterans’ self-reported physical quality of life correlated negatively and significantly with both urinary and fecal incontinence severity, as well as negatively and significantly with urinary continence bother (rs range: −.36 to −.47, ps < .01). Veterans’ mental quality of life correlated negatively and significantly with urinary incontinence bother (r = −.43, p < .001). About 67% Veterans experienced incontinence symptoms for 5-years or more, yet 44% waited at least 1-year to discuss incontinence with a VHA provider. Most Veterans (92%) reported speaking with a VHA provider about incontinence, while only 42% reported speaking with a non-VHA provider. Qualitative findings revealed that, upon speaking to a provider, Veterans felt comfortable but also desired more incontinence education from their providers, including obtaining more appropriate and tailored treatment options. While most Veterans followed their provider’s treatment recommendations, some felt unsatisfied with treatments that they perceived as embarrassing.ConclusionsRecruiting a substantial sample of Veterans with incontinence, and their caregivers, is feasible using our recruitment methods, which can inform larger studies. Our study revealed that incontinence symptoms interfere significantly with the quality of life of Veterans and their caregivers. Intervening at the healthcare level by educating providers and systematizing inquiry into incontinence for higher risk populations would be fruitful to explore.Contribution of the PaperWhat is already known about this topic?Urinary incontinence is more prevalent than fecal incontinence, and both are associated with significant impairments in physical, mental, and social functioning.Urinary and fecal incontinence become more prevalent with older age and additional chronic health conditions.There is a lack of incontinence diagnoses documented in Veteran’s medical records, even when incontinence is present. Few studies have reported on caregiver burden related to incontinence care.What this paper addsThis study is the first to report on the potential delay between Veteran’s experiencing symptoms of incontinence and informing their healthcare provider or caregiver about those symptoms (sometimes 5-years or more).Insights on Veteran and caregiver satisfaction with incontinence care can guide healthcare interventions to improve incontinence care.Both Veteran quality of life and caregiver burden correlated significantly and negatively with satisfaction with incontinence treatments tried and number of treatments tried. Only 21% of Veterans were satisfied with the treatment plan they were given, suggesting a potential knowledge gap or opportunity for improvement in healthcare provider approaches to incontinence management.

Background The majority of stroke survivors return to their homes and need assistance from family caregivers to perform activities of daily living. These increased demands coupled with the lack of preparedness for their new roles lead to a high risk for caregivers developing depressive symptoms and other negative outcomes. Follow-up home support and problem-solving interventions with caregivers are crucial for maintaining stroke survivors in their homes. Problem-solving interventions are effective but are underused in practice because they require large amounts of staff time to implement and are difficult for caregivers logistically. Objective The aim of this study is to test a problem-solving intervention for stroke caregivers that can be delivered over the telephone during the patient’s transitional care period (time when the stroke survivor is discharged to home) followed by 8 asynchronous online sessions. Methods The design is a two-arm parallel randomized clinical trial with repeated measures. We will enroll 240 caregivers from eight Veterans Affairs (VA) medical centers. Participants randomized into the intervention arm receive a modified problem-solving intervention that uses telephone and web-based support and training with interactive modules, fact sheets, and tools on the previously developed and nationally available Resources and Education for Stroke Caregivers’ Understanding and Empowerment Caregiver website. In the usual care group, no changes are made in the information, discharge planning, or care the patients who have had a stroke normally receive, and caregivers have access to existing VA resources (eg, caregiver support line, self-help materials). The primary outcome is a change in caregiver depressive symptoms at 11 and 19 weeks after baseline data collection. Secondary outcomes include changes in stroke caregivers’ burden, knowledge, positive aspects of caregiving, self-efficacy, perceived stress, health-related quality of life, and satisfaction with care and changes in stroke survivors’ functional abilities and health care use. The team will also determine the budgetary impact, facilitators, barriers, and best practices for implementing the intervention. Throughout all phases of the study, we will collaborate with members of an advisory panel. Results Study enrollment began in June 2015 and is ongoing. The first results are expected to be submitted for publication in 2021. Conclusions This is the first known study to test a transitional care and messaging center intervention combined with technology to decrease caregiver depressive symptoms and to improve the recovery of stroke survivors. If successful, findings will support an evidence-based model that can be transported into clinical practice to improve the quality of caregiving post stroke. Trial Registration ClinicalTrials.gov NCT01600131; https://www.clinicaltrials.gov/ct2/show/NCT01600131 International Registered Report Identifier (IRRID) DERR1-10.2196/21799

BACKGROUND The majority of stroke survivors return to their homes and need assistance from family caregivers to perform activities of daily living. These increased demands coupled with the lack of preparedness for their new roles lead to a high risk for caregivers developing depressive symptoms and other negative outcomes. Follow-up home support and problem-solving interventions with caregivers are crucial for maintaining stroke survivors in their homes. Problem-solving interventions are effective but are underused in practice because they require large amounts of staff time to implement and are difficult for caregivers logistically. OBJECTIVE The aim of this study is to test a problem-solving intervention for stroke caregivers that can be delivered over the telephone during the patient’s transitional care period (time when the stroke survivor is discharged to home) followed by 8 asynchronous online sessions. METHODS The design is a two-arm parallel randomized clinical trial with repeated measures. We will enroll 240 caregivers from eight Veterans Affairs (VA) medical centers. Participants randomized into the intervention arm receive a modified problem-solving intervention that uses telephone and web-based support and training with interactive modules, fact sheets, and tools on the previously developed and nationally available Resources and Education for Stroke Caregivers’ Understanding and Empowerment Caregiver website. In the usual care group, no changes are made in the information, discharge planning, or care the patients who have had a stroke normally receive, and caregivers have access to existing VA resources (eg, caregiver support line, self-help materials). The primary outcome is a change in caregiver depressive symptoms at 11 and 19 weeks after baseline data collection. Secondary outcomes include changes in stroke caregivers’ burden, knowledge, positive aspects of caregiving, self-efficacy, perceived stress, health-related quality of life, and satisfaction with care and changes in stroke survivors’ functional abilities and health care use. The team will also determine the budgetary impact, facilitators, barriers, and best practices for implementing the intervention. Throughout all phases of the study, we will collaborate with members of an advisory panel. RESULTS Study enrollment began in June 2015 and is ongoing. The first results are expected to be submitted for publication in 2021. CONCLUSIONS This is the first known study to test a transitional care and messaging center intervention combined with technology to decrease caregiver depressive symptoms and to improve the recovery of stroke survivors. If successful, findings will support an evidence-based model that can be transported into clinical practice to improve the quality of caregiving post stroke. CLINICALTRIAL ClinicalTrials.gov NCT01600131; https://www.clinicaltrials.gov/ct2/show/NCT01600131 INTERNATIONAL REGISTERED REPORT DERR1-10.2196/21799

Research Objectives There is a global trend in healthcare towards non-pharmacological and complementary and integrative approaches to health (CIH). The primary objective of this poster is to present the experience of veterans with chronic pain and PTSD and their partners with a remotely delivered CIH education program. Design A parent four year, mixed methods randomized control trial proposed to conduct telephone interviews with a subsample of veteran and partner intervention dyads. Transcripts were analyzed using a content analysis. Data in this poster represent preliminary findings from 13 dyads that have been interviewed to date. Setting Three Veterans Administration Medical Centers recruited participants from surrounding areas, resulting in recruitment from 12 states. Participants Veterans with chronic pain and PTSD, and their selected partners (e.g., spouse, child). Interventions The Mission Reconnect program is a partnered, self-directed intervention which teaches CIH skills (e.g., meditation, partnered massage) remotely using mobile and web-based mediums. Main Outcome Measure(s) Main outcomes are physical and mental, overall quality of life for veterans; and social relationship with partners. Results Participants reported improvements in physical, mental, overall quality of life for veterans; and social relationship with partners. Veterans reported improvements in sleep quality, pain management, and anxiety and PTSD symptoms. For veterans and partners, respondents reported improvements in quality of life, including feeling energized, refreshed, centered, and relaxed; and enhanced relationships, including increase in quality time spent together, and expression of affection. Conclusions Veterans and their partners reported Mission Reconnect is an effective approach to “reconnecting with life.” Online and mobile CIH approaches should be considered for other diverse patient populations and partners, who will benefit from ongoing self-care management. Future research should examine cost-effectiveness of such approaches and broadscale implementation. Author Disclosures None disclosed.

Stroke caregivers need education and support to care for suddenly disabled family members. To address this need, we are conducting a nurse-led intervention, called RESCUE CREST, to teach caregivers problem-solving skills using an educational website and an online messaging center. In our first, preliminary study, we pre-tested an investigator-created, senior-friendly website called RESCUE (Resources and Education for Stroke Caregivers’ Understanding and Empowerment) using focus groups and interviews with clinicians and caregivers. We refined the website based on additional surveys, a cognitive usability study, and Webtrends analysis. In the second study, we used a single-group pre- and post-test design to evaluate the content and outcomes of the problem-solving intervention. Third, we conducted a four-arm RCT (4-week intervention, 8-week intervention, attention control, standard care) to refine our methods. We will describe the lessons learned and results of our 10 years of stroke caregiver research that provide background for the RESCUE CREST study.

Lithium−water reaction experiments were conducted at 616.5 K in a thermoelectric calorimeter in an effort to characterize the reaction in a batch-type environment. The experimental system was configured to measure both heat of reaction and hydrogen generation as small fixed-volume doses of water were repeatedly admitted to a large quantity of lithium. Heat of reaction measurements slightly declined with each successive water dose, while hydrogen generation markedly increased. These heat and hydrogen quantities, along with material and energy balances, were used to quantify gradual changes in reaction chemistry as lithium was depleted. The trends evident with heat and hydrogen generation indicated the formation of lithium hydride and lithium oxide as intermediates. These products, in competition with unreacted lithium, reacted with additional water to yield hydrogen and lithium hydroxide. In conclusion, these experiments provided a quantitative understanding of how reaction chemistry changes when water is ...

The aim of this study is to describe the process of staff and patient adoption and compliance of a real-time locating system (RTLS) across two health care settings and present lessons learned. While previous work has examined the technological feasibility of tracking staff and patients in a health care setting in real-time, these studies have not described the critical adoption issues that must be overcome for deployment. The ability to track and monitor individual staff and patients presents new opportunities for improving workflow, patient health and reducing health care costs. A RTLS is introduced in both a long-term care and a polytrauma transitional rehabilitation program (PTRP) in a Veterans Hospital to track staff and patient locations and five lessons learned are presented from our experiences and responses to emergent technological, work-related and social barriers to adoption. We conclude that successful tracking in a health care environment requires time and careful consideration of existing work, policies and stakeholder needs which directly impact the efficacy of the technology.

The lithium hydride-water reaction was studied using a novel flow calorimeter to determine the mechanism and thermodynamics of lithium compound-water interactions at elevated temperatures. A concomitant consideration of heat and hydrogen evolution data led to a simple physical reaction model for temperatures of 505 and 588 K. Initially, water interacts directly with lithium hydride to form lithium oxide and hydrogen. However, the lithium oxide surface layer which forms via this reaction subsequently reacts with additional water to form lithium hydroxide. The net effect of this mechanism is that both heat and hydrogen evolution decline per amount of water injected in a batch-type reaction system.

The initial operation of a Calvet‐type calorimeter is reported. The instrument has been designed specifically to study lithium and lithium compound reactions with water at an elevated temperature. Additionally, the calorimeter test section incorporates an environment that resembles actual application conditions. Calibration procedures are explained for three important parts of the instrument, including (1) introduction of the water sample, (2) analysis of the effluent gas, and (3) measurement of the heat of reaction. Ten measurements of the heat of the lithium oxide‐water reaction yielded values from 110 to 140 kJ/mol H2O and averaged 124 kJ/mol H2O. The average is in perfect agreement with the theoretical heat value computed utilizing JANAF thermochemical data.

Objective The study sought to examine the functional health literacy in a sample of geriatric patients diagnosed with movement disorders. The hypothesis was that the study group would demonstrate marginal levels of health literacy scores on a standardized health literacy instrument. Design/Setting The study used a prospective analysis of patients referred to an outpatient movement disorders clinic in a Veterans Affairs Medical Center. Patients Fifty-four men with a movement disorder volunteered for the study, with data analysis conducted on 44 of these patients. Main Outcome Measurements The primary outcome measure was the Test of Functional Health Literacy in Adults (TOFHLA). Results Members of the current sample demonstrated adequate health literacy and scored significantly higher on the TOFHLA relative to the measure's normative sample. Younger age, more education, and higher Mini Mental Status Examination (MMSE) scores were predictive of health literacy. Conclusions The extant literature strongly suggests that limited health literacy is a frequent problem across the United States and represents a considerable obstacle to the effective delivery of health care. In a group of movement disorder subjects with a Folstein MMSE of at least 24, health literacy was generally well preserved. Years with movement disorder and severity of disorder did not impact health literacy. Thus, practitioners should not be prejudiced in a belief that individuals with movement disorders cannot manage their medications.

The purpose of this study was to determine the influence of radial motion of an arterial wall on the shear stress that flowing blood imposes on the wall (wall shear stress). Wall shear stress is known to influence endothelial cell function and may play a role in atherogenesis, but its magnitude and distribution in the circulation are not well understood. To simulate arterial wall motion, we used both straight and curved rubber tubing models in a mock circulatory system incorporating a variable impedance element distal to the model aorta. Wall shear rate was measured with a hot-film anemometer probe mounted flush on the tubing wall and free to move with the wall. Wall shear stress was determined as the product of wall shear rate and viscosity. By changing the distal impedance element, we determined the influence of the (temporal) phase angle between pressure and flow, or equivalently, tube diameter and flow, on wall shear stress. We observed a fivefold increase in peak wall shear stress and the onset of intense wall shear stress reversal sinusoidal flows as the phase angle between pressure and flow was reduced from -60 degrees to -80 degrees. Wall shear stresses were insensitive to this same phase angle when its value was between -10 degrees and -60 degrees. Theoretical predictions, also presented here, are in accord with these observations. The phenomena we have observed in elastic tubes may be important in the arterial system because the phase angle between the first harmonic of pressure and flow in the aorta of humans is usually near our sensitive range. This same phase angle becomes more negative in hypertensive patients and is influenced by vasoactive drugs.

A simple model of, water flow through deformable porous media has been developed with emphasis on application to arterial walls. The model incorporates a strain-dependent permeability function into Darcy's Law which is coupled, to the force balance for the bulk material. A simple analytical expression relating water flux (volume flux) to pressure differential is developed which shows how strain-dependent permeability can lead to a reduction in hydraulic conductivity with increasing differential pressure as observed in experiments with arteries. The variation of permeability with position in the wall, which may influence the convective diffusion of macromolecules, is determined for both cylindrical and planar segments and a marked influence of geometry is noted.

Pressure drop and flow rate measurements in a rigid cast of a human aortic bifurcation under both steady and physiological pulsatile flow conditions are reported. Integral momentum and mechanical energy balances are used to calculate impedance, spatially averaged wall shear stress and viscous dissipation rate from the data. In the daughter branches, steady flow impedance is within 30% of the Poiseuille flow prediction, while pulsatile flow impedance is within a factor of 2 of fully developed, oscillatory, straight tube flow theory (Womersley theory). Estimates of wall shear stress are in accord with measurements obtained from velocity profiles. Mean pressure drop and viscous dissipation rate are elevated in pulsatile flow relative to steady flow at the mean flow rate, and the exponents of their Reynolds number dependence are in accord with available theory.

A Simple model of water flow through deformable porous media has been developed with emphasis on application to arterial walls. The model incorporates a strain-depedent permeability function into Darcy's Law which is coupled to the force balance for the bulk material. A simple analytical expression relating water flux (volume flux) to pressure differential is developed which shows how strain-dependent permeability can lead to a reduction in hydraulic conductivity with increasing differential pressure as observed in experiments with arteries. The variation of permeability with position in the wall, which may influence the convective diffusion of macromolecules, is determined for both cylindrical and planar segments and a marked influence of geometry is noted.