VA Sunshine Healthcare Network

Chronic illnesses account for approximately 75% of all healthcare costs in the United States today, resulting in functional limitations and loss of independence, as well as increased medical expenditures. The elderly population is at a higher risk for developing chronic conditions, increasing their risk for disabilities. Given the rapid growth of the aging population, and the chronic illnesses, disabilities, and loss of functional independence endemic to elders, novel methods of rehabilitation and care management are urgently needed. Telehealth models that combine care coordination with communications technology offer a means for managing chronic illnesses, thereby decreasing healthcare costs. We examined the effects of a Veterans Administration (VA) telerehabilitation program (Low Activities of Daily Living [ADL] Monitoring Program-LAMP) on healthcare costs. LAMP is based on a rehabilitative model of care. LAMP patients received adaptive equipment and environmental modifications, which focused on self-care and safety within the home. LAMP Care Coordinators remotely monitored their patient's vital signs and provided education and self-management strategies for decreasing the effects of chronic illnesses and functional decline. The matched comparison group (MCG) received standard VA care. Healthcare costs 12 months preenrollment and 12 months post-enrollment were examined through a difference-in-differences multivariable model. Using actual costs totaled for these analyses, no significant differences were detected in post-enrollment costs between LAMP and the MCG. For LAMP patients, the provision of adaptive equipment and environmental modifications, plus intensive in-home monitoring of patients, led to increases in clinic visits post-intervention with decreases in hospital and nursing home stays.

BACKGROUND: Contextual elements have significant impact on uptake of health care innovations. While existing conceptual frameworks in implementation science suggest contextual elements interact with each other, little research has described how this might look in practice. To bridge this gap, this study identifies the interconnected patterns among contextual elements that influence uptake of an anticoagulation clinic improvement initiative. METHODS: We completed 51 semi-structured interviews and ethnographic observations across five case study sites involved in an evidence-based practice (EBP) quality improvement initiative. We analyzed data in NVivo 10 using an a priori approach based on the Promoting Action on Research Implementation in Health Services (PARIHS) model and an emergent thematic analysis. RESULTS: Key contextual elements, such as leadership, teamwork, and communication, interacted with each other in contributing to site-level uptake of the EBP, often yielding results that could not be predicted by looking at just one of these elements alone. Sites with context conducive to change in these areas predictably had high uptake, while sites with uniformly weak contextual elements had low uptake. Most sites presented a mixed picture, with contextual elements being strongly supportive of change in some areas and weak or moderate in others. In some cases, we found that sites with strong context in at least one area only needed to have adequate context in other areas to yield high uptake. At other sites, weak context in just one area had the potential to contribute to low uptake, despite countervailing strengths. Even a site with positive views of EBPs could not succeed when context was weak. CONCLUSION: Interrelationships among different contextual elements can act as barriers to uptake at some sites and as facilitators at others. Accounting for interconnections among elements enables PARIHS to more fully describe the determinants of successful implementation as they operate in real-world settings.

Although technology has sometimes been the cause of rising healthcare costs, telemedicine technology has been proposed as a means to increase productivity in the workplace and reduce resource utilization for high-risk populations. The Veterans Health Administration (VHA) in April of 2000, implemented an expansive telemedicine technology initiative in its Sunshine Network, covering veterans in south Georgia, Florida, Puerto Rico, and the Virgin Islands through the Community Care Coordination Service (CCCS). The initiative uses home telehealth technology to support veteran healthcare. Choosing appropriate tools to enhance care coordination and matching technology to specific patient needs was vital to the success of the CCCS model. A technology algorithm was developed across the Network initiative and grew out of a need to identify and benchmark best practices. An evaluation methodology developed by a health economist and his research team at the University of Maryland was used to determine patient satisfaction with technology and functional status through a validated instrument. Outcomes were for 791 chronic medical and 120 mental health patients. Patient satisfaction was extremely high, patients used technology without difficulty and acceptance was greater than expected. Patients' perception of health as surveyed with the functional status instrument showed improved perception in many factors including pain, physical, and social functioning.

BACKGROUND: Emerging evidence suggests electronic health record (EHR)-related information overload is a risk to patient safety. In the US Department of Veterans Affairs (VA), EHR-based 'inbox' notifications originally intended for communicating important clinical information are now cited by 70% of primary care practitioners (PCPs) to be of unmanageable volume. We evaluated the impact of a national, multicomponent, quality improvement (QI) programme to reduce low-value EHR notifications. METHODS: The programme involved three steps: (1) accessing daily PCP notification load data at all 148 facilities operated nationally by the VA; (2) standardising and restricting mandatory notification types at all facilities to a recommended list; and (3) hands-on training for all PCPs on customising and processing notifications more effectively. Designated leaders at each of VA's 18 regional networks led programme implementation using a nationally developed toolkit. Each network supervised technical requirements and data collection, ensuring consistency. Coaching calls and emails allowed the national team to address implementation challenges and monitor effects. We analysed notification load and mandatory notifications preintervention (March 2017) and immediately postintervention (June-July 2017) to assess programme impact. RESULTS: Median number of mandatory notification types at each facility decreased significantly from 15 (IQR: 13-19) to 10 (IQR: 10-11) preintervention to postintervention, respectively (P<0.001). Mean daily notifications per PCP decreased significantly from 128 (SEM=4) to 116 (SEM=4; P<0.001). Heterogeneity in implementation across sites led to differences in observed programme impact, including potentially beneficial carryover effects. CONCLUSIONS: Based on prior estimates on time to process notifications, a national QI programme potentially saved 1.5 hours per week per PCP to enable higher value work. The number of daily notifications remained high, suggesting the need for additional multifaceted interventions and protected clinical time to help manage them. Nevertheless, our project suggests feasibility of using large-scale 'de-implementation' interventions to reduce unintended safety or efficiency consequences of well-intended electronic communication systems.

The COVID-19 pandemic is placing enormous stress on U.S. health care workers. Prior studies of infectious disease outbreaks and other catastrophic events have shown the damaging mental health impacts caused by these events. Implications for the policy and treatment of health care workers facing the COVID-19 crisis are discussed in this commentary. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

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

Patients are exposed to iatrogenic injury when hospitalized. In the Tech Care Coordination Program, older veterans with chronic diseases and high healthcare utilization were followed with an in-home technology device, the Health Buddy, and risk management software. Program staff could identify at-risk patients based on their responses to a series of questions about symptoms, behavior, and knowledge. Patients followed in the program for at least 6 months experienced a 45% decrease in hospital admissions, 67% decrease in nursing home admissions, 54% decrease in emergency room visits, and 38% decrease in pharmacy prescriptions. The patients also demonstrated improved compliance with treatment regimens and both patients and providers reported high levels of program satisfaction.

BACKGROUND: In response to increasing scientific evidence which indicates that ultraviolet radiation (UVR) is a potential threat to ocular health, Acuvue contact lenses (Vistakon, Johnson & Johnson Vision Products Inc., Jacksonville, Florida) have been developed which incorporate an ultraviolet (UV) blocker within the lens polymer. Data are presented for the first clinical evaluation of Acuvue lenses with UV blocking characteristics. METHOD: A double-masked, multicenter, prospective clinical trial involving 94 subjects was conducted. The study followed a randomized, parallel group design and consisted of 3 months of daily wear with two-weekly lens replacement. Two thirds of the subjects (61) wore the test lenses (Acuvue with UV blocker) and the remaining subjects (33) wore conventional Acuvue lenses (without UV blocker). RESULTS: Biomicroscopic evaluations indicated that the performance of the test and control lenses was clinically similar. No clinically relevant differences between the test and control lenses were noted in the subjective assessments of vision, comfort, or handling. In addition, no differences were shown for surface deposition, lens durability, visual acuity, and subjective symptoms. CONCLUSION: The study findings indicate that the addition of a UV blocker to Acuvue contact lenses has been achieved without affecting daily wear clinical performance. Because there is increasing evidence to suggest that the ocular tissues may be damaged by UVR, it is prudent for eye care practitioners to prescribe contact lenses that offer the benefits of both regular replacement and UV protection.

BACKGROUND: To compare the 90-day rates of select secondary procedures after cataract extraction in patients having fee-for-service surgery under Medicare to surgeries provided through the Veterans Health Administration (VHA) during the same calendar year. METHODS: Medicare, VHA, and VHA Fee Basis Program data for calendar year 2007 were merged to identify a cohort of veterans that had outpatient cataract surgery. Secondary surgeries were tracked using selected Current Procedural Terminology (CPT) codes as surrogate markers for complications. Primary surgery and corrective surgeries were linked through right and left eye CPT modifier codes. Risks of complications were adjusted for race, age, sex, and ocular and medical comorbidities. RESULTS: A total of 223,873 cataract extractions were performed on veterans during calendar year 2007, 88.4% of which were provided through Medicare. The 90-day overall rate of CPT-coded secondary procedures was greater for patients having cataract surgery through the VHA (37.2 per 1000 surgeries) than Medicare (18.2 per 1000 surgeries). The overall rate was influenced primarily by higher rates of vitrectomy and related procedures, after both routine and complex cataract extractions. The adjusted odds ratio of vitrectomy within 90 days of routine cataract surgery in the VHA with reference to Medicare was 3.77 (95% confidence interval, 3.44-4.14). CONCLUSIONS: In 2007, the pattern and rates of secondary surgeries after cataract extraction varied between the Medicare and the VHA programs. If these results are confirmed, further research to identify the sources of higher secondary procedure rates is warranted to enhance patient safety.

BACKGROUND: The Veterans Health Administration (VHA) is making system-wide efforts to increase integrated use of health information technology (HIT), including My HealtheVet (MHV), the Veterans Affairs (VA) electronic patient portal, Vet Link kiosks, telehealth, and mobile apps. Integrated use of HIT can increase individual and system efficiency, maximize resources, and enhance patient outcomes. Prior research indicates that provider endorsement and reinforcement are key determinants of patient adoption of HIT. HIT implementation strategies need to reflect providers' perspectives to promote adoption and endorsement of these tools; however, providers often lack awareness or are unmotivated to incorporate HIT into clinical care with their patients. When these modalities are used by patients, the approach is often fragmented rather than integrated within and across care settings. Research is needed to identify effective implementation strategies for increasing patient-aligned care team (PACT) member (ie, the VHA's Patient Centered Medical Home) awareness and motivation to use HIT in a proactive and integrated approach with patients. OBJECTIVE: This paper describes the rationale, design, and methods of the PACT protocol to promote proactive integrated use of HIT. METHODS: In Aim 1, focus groups (n=21) were conducted with PACT members (n=65) along with questionnaires and follow-up individual interviews (n=16). In Aim 2, the team collaborated with VA clinicians, electronic health researchers and operational partners to conduct individual expert interviews (n=13), and an environmental scan to collect current and emerging provider-focused implementation tools and resources. Based on Aim 1 findings, a gap analysis was conducted to determine what implementation strategies and content needed to be adapted or developed. Following the adaptation or development of resources, a PACT expert panel was convened to evaluate the resultant content. In Aim 3, a local implementation of PACT-focused strategies to promote integrated use of HIT was evaluated using pre- and postquestionnaire surveys, brief structured interviews, and secondary data analysis with PACT members (n=63). RESULTS: Study enrollment for Aim 1 has been completed. Aims 1 and 2 data collection and analysis are underway. Aim 3 activities are scheduled for year 3. CONCLUSIONS: This work highlights the practical, technological, and participatory factors involved in facilitating implementation research designed to engage PACT clinical members in the proactive integrated use of HIT. These efforts are designed to support the integrated and proactive use of VA HIT to support clinical care coordination in ways that are directly aligned with PACT member preferences. This study evaluated integrated VA HIT use employing mixed-methods and multiple data sources. Deliverables included PACT-focused strategies to support integrated use of HIT in the ambulatory care setting that will also inform strategy development in other systems of care and support subsequent implementation efforts at regional and national levels. REGISTERED REPORT IDENTIFIER: RR1-10.2196/11262.

BACKGROUND: Improved anticoagulation control with warfarin reduces adverse events and represents a target for quality improvement. No previous study has described an effort to improve anticoagulation control across a health system. OBJECTIVE: To describe the results of an effort to improve anticoagulation control in the New England region of the Veterans Health Administration (VA). METHODS: Our intervention encompassed 8 VA sites managing warfarin for more than 5000 patients in New England (Veterans Integrated Service Network 1 [VISN 1]). We provided sites with a system to measure processes of care, along with targeted audit and feedback. We focused on processes of care associated with site-level anticoagulation control, including prompt follow-up after out-of-range international normalized ratio (INR) values, minimizing loss to follow-up, and use of guideline-concordant INR target ranges. We used a difference-in-differences (DID) model to examine changes in anticoagulation control, measured as percentage time in therapeutic range (TTR), as well as process measures and compared VISN 1 sites with 116 VA sites located outside VISN 1. RESULTS: VISN 1 sites improved on TTR, our main indicator of quality, from 66.4% to 69.2%, whereas sites outside VISN 1 improved from 65.9% to 66.4% (DID 2.3%, P < 0.001). Improvement in TTR correlated strongly with the extent of improvement on process-of-care measures, which varied widely across VISN 1 sites. CONCLUSIONS: A regional quality improvement initiative, using performance measurement with audit and feedback, improved TTR by 2.3% more than control sites, which is a clinically important difference. Improving relevant processes of care can improve outcomes for patients receiving warfarin.

In June 1990, the American Diabetes Association approved a food labeling position statement (1) that emphasized the following four general points: 1) food labeling must be truthful, meaningful, understandable, and complete; 2) no food should be designated or promoted as nutritionally good, bad, healthful, or unhealthful for people with diabetes; 3) education, based on principles of good nutrition and use of food labels, is essential for people with diabetes; and 4) specific recommendations for label inclusions.

Rehabilitation nurses are in a critical position to lead interdisciplinary team fall prevention management, including injury risk reduction. This article provides an update for rehabilitation nurses on evidence-based strategies to reduce patients'risk of fall-related injuries. This content builds on existing literature by focusing on knowledge to promote patient responses that reduce the risk of falls and ultimately fall-related injuries. Although rehabilitation nurses understand the complex nature of falls, addressing the intrinsic and extrinsic risk factors that increase the risk of fall-related injuries requires both individually based treatment programs and a system-wide commitment. A plethora of literature discusses fall risks and falls, but this article profiles the at-risk patient and describes current and emerging evidence-based interventions to protect patients from fall-related injuries by reducing risk factors. This discussion is limited to exercise, environmental redesign, osteoporosis prevention, and hip protectors.

Background: Artificial intelligence (AI) has great potential to improve health care quality, safety, efficiency, and access. However, the widespread adoption of health care AI needs to catch up to other sectors. Challenges, including data limitations, misaligned incentives, and organizational obstacles, have hindered implementation. Strategic demonstrations, partnerships, aligned incentives, and continued investment are needed to enable responsible adoption of AI. High reliability health care organizations offer insights into safely implementing major initiatives through frameworks like the Patient Safety Adoption Framework, which provides practical guidance on leadership, culture, process, measurement, and person-centeredness to successfully adopt safety practices. High reliability health care organizations ensure consistently safe and high quality care through a culture focused on reliability, accountability, and learning from errors and near misses. Observations: The Veterans Health Administration applied a high reliability health care model to instill safety principles and improve outcomes. As the use of AI becomes more widespread, ensuring its ethical development is crucial to avoiding new risks and harm. The US Department of Veterans Affairs National AI Institute proposed a Trustworthy AI Framework tailored for federal health care with 6 principles: purposeful, effective and safe, secure and private, fair and equitable, transparent and explainable, and accountable and monitored. This aims to manage risks and build trust. Conclusions: Combining these AI principles with high reliability safety principles can enable successful, trustworthy AI that improves health care quality, safety, efficiency, and access. Overcoming AI adoption barriers will require strategic efforts, partnerships, and investment to implement AI responsibly, safely, and equitably based on the health care context.

Background: Limited staff, rising costs, and regulatory oversight, coupled with the need to achieve clinical endpoints and improve access to care, has made scaling health care operations challenging. This article explores the emerging paradigm of multiagent artificial intelligence (AI) systems in health care, which represent a significant leap beyond traditional large language models. Observations: This analysis reviews the potential of multiagent AI systems to revolutionize patient care, streamline administrative processes, and support complex clinical decision-making. It describes a hypothetical sepsis management system comprising 7 specialized AI agents, with each agent handling specific aspects of patient care from data collection and diagnosis to treatment recommendations and resource management. Additional applications in chronic disease management and hospital patient flow optimization are also examined. The technical implementation of these systems is discussed, including the use of advanced large language models, interagent quality control measures, guardrail implementation, self-reflection mechanisms, integration with electronic health records, and the importance of explainable AI in ensuring decision transparency. Potential benefits include enhanced diagnostic accuracy and personalized treatment plans. Challenges remain related to data quality assurance, workflow integration, and ethical considerations. Future directions for AI include the integration of internet-enabled devices and the development of more sophisticated natural language interfaces. Conclusions: This article underscores the transformative potential of multiagent AI systems in health care while emphasizing the importance of rigorous validation, ethical oversight, and a patient-centered approach in their development and implementation.

The authors used 2 national Veterans Health Administration databases to identify outpatient medications and all 30 Elixhauser comorbidities for 2579 unique patients, age 65+ years, hospitalized for syncope in fiscal year 2004. For comparison, we identified other elderly patients hospitalized with acute myocardial infarction (N = 4491), fracture (N = 2797), or pneumonia (N = 9473). The categories of medications included drugs that affect the cardiovascular, central nervous, or the muscular skeletal system. The most notable differences between syncope compared to acute myocardial infarction patients occurred in central nervous system drugs in anticonvulsants/barbiturates, antidepressants, antihistamine/antinauseants, antipsychotics, and cholinesterase inhibitors (P < .0018). Comparing syncope patients with fracture patients, the central nervous medication profile was similar, but the cardiovascular medication profile differed (P < .0018); their hypertension comorbidities also differed (60.45% vs 46.34%); (P < .0016). These findings indicate significant potential associations that warrant further study. Studies linking national outpatient medications to hospitalizations for specific conditions can foster the development of more proactive pharmacovigilance systems.

INTRODUCTION: Although telemedicine was predominantly adopted during the COVID-19 pandemic, its impact on healthcare outcomes in the veteran population in achieving first contact resolution, or the ability to safely manage patient care at home from an urgent care perspective, is yet to be determined. METHODS: This study included 13,090 veteran patient episodes who presented to the Department of Veteran's Affairs Veterans Integrated Services Network 8's Clinical Contact Center, a virtual urgent care organization covering South Georgia, Florida, and U.S. Virgin Islands in providing episodic care, between March 2020 and February 2021. Multivariate logistic regression estimated the probability that veterans with COVID-19-related symptoms stayed at home compared to presenting to the emergency department (ED) or their primary care provider. RESULTS: Patients with COVID-related symptoms were 33% less likely to present to the ED compared to patients who presented with non-COVID-related symptoms. DISCUSSION: The virtual urgent care center enabled veterans to receive timely care and avoid public places that could potentially lead to a COVID-19 infection or infecting others.

Abstract The Department of Veterans Affairs (VA) is shifting from institutional to Home and Community Based Services, such as the Veteran-Directed Care (VDC) program, a self-directed program in which Veterans choose services and employ their providers to avoid or delay long-term institutionalization. The VA plans to expand VDC to all VA facilities by FY2026, but factors affecting VDC expansion are poorly understood. We focused on facilitators and barriers in the seven Veterans Integrated Service Network (VISN) 8 VDC programs between May 2022 and January 2023 to inform program expansion. We used a mixed-methods approach, with surveys followed by semi-structured interviews with VA VDC staff, their partners at Aging and Disability Network Agencies (ADNAs) and VISN 8 leadership, such as lead program coordinators, using the Consolidated Framework for Implementation Research to guide the project rapid analysis techniques. We found substantial variability in the structure, size, and operations of the VDC programs reflecting challenges noted by respondents. VA staff were consistently enthusiastic about VDC’s quality benefits for Veterans, however, they recommended additional staff, a dedicated VDC coordinator, and a national guidebook or standard operating procedures to streamline processes. Respondents also noted the need for more program education targeting referring providers. Unique local challenges, like the lack of available caregivers or no local ADNA, and limited local leadership support were other factors noted that could limit expansion. Importantly, Veterans were often overwhelmed by the employer responsibilities they needed to fulfill. Addressing these concerns remains a challenge to VISN 8 and national leadership.

Introduction: Quality improvement (QI) competencies for health professions trainees were developed to address health care quality. Strategies to integrate QI into curricula exist, but methods for assessing interdisciplinary learners' competency are less developed. We refined the Knowledge section scoring rubric of the Systems Quality Improvement Training and Assessment Tool (SQI TAT) and examined its validity evidence. Methods: In 2017, the SQI TAT Knowledge section was expanded to cover seven core QI concepts, and the scoring rubric was refined. Three coders independently scored 35 SQI TAT Knowledge sections (18 pretests, 17 posttests). Interrater reliability was assessed by percent agreement and Cohen's kappa for individual variables and by Lin's concordance correlation for total scores for knowledge and application. Concurrent validity was assessed by comparing responses from two groups with different QI exposure and evaluating whether differences in exposure were measured. Results: < .001), with improvement in posttest knowledge scores. Discussion: The SQI TAT Knowledge section provides a comprehensive assessment of QI knowledge. The scoring rubric was able to discriminate QI knowledge along a continuum. The SQI TAT Knowledge section is not linked to a clinical context, making it useful for assessing interprofessional learners and varying education levels.

Key messageThis article highlights the benefits, challenges, and current significance of telemedicine.Future research is needed, primarily to address the challenges of optimizing the im plementation of telehealth.To use telemedicine effectively and efficiently for the timely diagnosis and management of patients, an evaluation of current telemedicine practice is needed.Analysis of shortcomings and advantages can help enhance healthcare delivery to pediatric patients, making it more accessible for future use.