Project Agency ID	PI Last Name	PI First Name	Co-PI Name (If applicable)	Email Contact	Project Title	Project Start Date	Project End Date	VA Site	Project Funds	Webpage	Abstract	Project Description	Project Methods	Project Objectives	Project Impact	Details
C19 20-207	Giannitrapani	Karleen		karleen.giannitrapani@va.gov	A Needs Assessment for Facilitating the Role of VA Occupational Health Providers during COVID-19	08/01/2020	06/30/2024	VA Palo Alto Health Care System, Palo Alto, CA	$138,535			Care of Complex Chronic Conditions	NEEDS ASSESSMENT AIM1a: In order to minimize contact time with frontline clinicians we will first use rapid qualitative analytic techniques to synthesize content posted by OH providers on their national internal VA forum. We will specifically identify current pain points (informed by Design Thinking) and challenges as well as shared learnings and local successes. We will synthesize this content within 6 weeks and supply operational partners with a "Lightning Report" (a rapid qualitative methodology published by Co-I Dr. Brown-Johnson of Stanford University). AIM1b: In partnership with occupational health leadership we will conduct ~20 semi-structed interviews with occupational health providers nationally through a rapid quality improvement exempted IRB approval. Given the time-sensitive nature of getting to the field, we are classifying the interviews as QI which is appropriate in part because there is no/low risk to participating providers. Interviews cover occupational health roles in implementing COVID-19 guidance, changes they are making at their sites, process gaps and failures, the facilitators/barriers to their expanded role or to change at the site if they instituted or changed a process, role of site leadership and middle managers in providing support, learnings for other sites, role readiness and provider self-efficacy to take on expanded roles listed under COVID-19 guidance, and how to produce cross-disciplinary role agreement (clear role definition and role negotiation mechanisms). We are adapting interview guides from Drs. Giannitrapani, Yano, and Rubenstein's previous work on evidence-based quality improvement. REAL TIME DISSEMINATION AIM2: We will present learnings from rapid synthesis to all sites via SharePoint in partnership with national occupational health leadership. This allows for real-time shared learning across facilities. Occupational health advisor S. Giannitrapani APRN will lead a field call to disseminate findings to frontline providers. We will record this field call and use it as a focus group. Methodologically this will also serve as a member check to validate rapid synthesis results. We will partner with OH leadership on any other dissemination strategies they would find most helpful. SURVEY DEVELOPMENT AIM3: We will develop a brief survey to capture occupational health provider role and site readiness. We will capture measures routinely used in VA research for age, time in clinic, position, tenure or years in VA, gender and race/ethnicity. Other items capturing provider perceptions of organizational readiness for the intervention (new COVID-19 guidance) will be adapted from ORCA, the organization readiness for change assessment. On its own, ORCA is a 74 item survey that divides into 3 domains: evidence, context and facilitation. This is too long to be feasible and we are often acting in advance of strong evidence. The consolidated framework for implementation research (CFIR) framework has sub-components that have been mapped to the items ORCA. When mapped to CFIR constructs it offers a briefer list of sub scales. We will use 20 ORCA items to capture readiness for implementation concepts such as "leadership engagement" and "available resources". We will explore additional items to capture role self-efficacy and role-readiness and cross-disciplinary role agreement. We will undertake cognitive interviewing to inform tailoring of items and explore hosting a virtual expert panel (led by Dr. Singer) to review findings from AIMS 1&2 prior to survey finalization.	AIM1. NEEDS ASSESSMENT: Understand challenges and opportunities facing occupational health providers assuming new roles in their facility following distribution of COVID-19 guidance. Aim 1a: produce lightning report. Aim 1b: Use rapid content analysis techniques to synthesize comments posted by OH providers on their actively-used national internal VA forum. AIM2. REAL TIME DISSEMINATION: Partner with national OH leadership to facilitate real-time dissemination of findings and shared learnings across sites (e.g. post on SharePoint, share results on national calls etc.). AIM3. SURVEY DEVELOPMENT: Develop and pilot a survey to capture OH provider role and site readiness for implementing COVID-19 Guidance (critical preparation for future COVID-19 waves).	Local EOH providers have had a role to play in navigating trade-offs between staff shortages and potential spread, staff mental health burdens, and the fact that all frontline clinicians fall into the high-risk category simultaneously. In this needs assessment we have identified how to support occupational health's role to site success. Facilitating shared learnings may help sites in preparation phase learn from EOH experience at sites with active COVID-19 Cases. Conducting a needs assessment has also helped understand EOH needs in the case of multiple COVID-19 waves or in advance of future infectious pandemics.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
C19 20-395	Hunt	Kelly		kelly.hunt@va.gov	Impact of the COVID-19 pandemic on chronic disease care within the VA	08/01/2020	09/30/2024	Ralph H. Johnson VA Medical Center, Charleston, SC	$96,301			Care of Complex Chronic Conditions	We plan to replicate our comprehensive spatio-temporal database that we have built for our ongoing merit (Neelon/Hunt, IIR HX002299-01A2) from 2017 through 2020. For Aim 1, we will use Bayesian hierarchical models to identify hotspots where diabetes outcomes and care are impacted most significantly by the pandemic. For Aim 2, we will use spatial propensity score methods to compare VAMCs with and without extensive telemedicine capabilities before the pandemic to determine to what extent this impacts care during the pandemic12-14. For Aim 3, we will examine interactions between pandemic hotspots, community social deprivation indices, race-ethnic group and diabetes outcomes and quality care metrics.	Our primary objective is to build capacity for a robust evaluation of the impacts of the pandemic on chronic medical conditions using diabetes as a template. Specifically, using diabetes as a template we will (1) examine the pre-post impact of the pandemic, (2) the extent to which telemedicine use prior to the pandemic impacts the ability of VAMCs to provide care during the pandemic and finally (3) the extent to which neighborhood deprivation as well as racial- ethnic disparities impact the ability of VAMCs to provide care during the pandemic.	Using diabetes as a template and leveraging our expertise in GIS analysis and advanced spatio-temporal statistics, we have provided an in-depth analysis of the impact of the pandemic on chronic disease care within the VA.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
C19 20-399	Yong	Celina		Celina.Yong@va.gov	Delaying Cardiovascular Procedures to Curb the Spread of COVID-19 among Veterans: Variation in VHA Practice Patterns and Outcomes	08/01/2020	09/30/2024	VA Palo Alto Health Care System, Palo Alto, CA	$100,000			Access	We will assess the total number of procedures performed from Dec 2018 to present, across the spectrum of cardiovascular disease treatments (e.g. PCI, TAVR, pacemaker, atrial fibrillation ablation, etc). We will compare Mar-July 2019 to Mar-July 2020 to see differences in volumes impacted by COVID 19. We will compare across the following demographic and disease categories: race, gender, geography (less than or farther than 200 miles from tertiary care center), socioeconomic status (income quartile by zip code), education (by zip code) and age (less than or older than 65), COVID-19 positive status. We will assess inpatient mortality and LOS, with comparison over time. We will also assess complexity of procedure by MS-DRG codes.	Specific Aim 1. To describe the impact of the COVID-19 pandemic on cardiovascular procedural volumes across the VHA nationally. Specific Aim 2. To assess whether there were differences in procedural treatment among vulnerable populations within the VHA comparing the pre to post-COVID-19 period. Specific Aim 3. To compare downstream outcomes in Veterans hospitalized with incident STEMI, NSTEMI, severe aortic stenosis, and AV block before and after the COVID-19 pandemic and to determine if inpatient procedure use mediates those outcomes.	This study, recently published in the Journal of the American Heart Association, provides important understanding about heart attack care in the VA and outside the VA over the course of the many pandemic phases. It demonstrates how the VA adapted to meet the pandemic needs, with appropriate triage of procedural care (revealing a potential delay to implementation of adapted systems). Importantly, it also suggests that Veterans treated in the VA had better mortality outcomes after heart attack compared to those treated outside the VA. Additionally, we found that the COVID-19 pandemic appears to have had a lasting impact on health-seeking behaviors among NSTEMI patients, with unclear long-term effects of this increased threshold to obtain cardiovascular care.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
C19 21-287	Davies	Louise	Amy Justice, Anita Vashi	Louise.Davies@va.gov	The Disrupted Care National Project	06/01/2021	05/31/2025	White River Junction VA Medical Center, White River Junction, VT	$2,646,900			Access	The main goal of this study is hypothesis generation. We will identify areas of greatest findings and then pursue more in-depth analyses. We will begin by examining broad trends in all-cause mortality overall, within demographic and diagnostic subgroups, and by calendar month, and identify associations between mortality trends and changes in healthcare utilization. US Mortality data. Data from the 5 years prior to the pandemic, as well as during 2020-21 for US deaths due to all causes and due to specific categories (defined by ICD10 codes) will be obtained from the National Center for Health Statistics mortality surveillance system. Data will be stratified by state, week, and age category. Medicare Data. Medicare data will be obtained from VIReC (The VA Information Resource Center). These "denominator" files will be used for overall mortality assessment, and the inpatient and outpatient files will provide comparative data for characterizing hospitalizations and procedure-based care (Medicare Part A and B), prescription drug utilization (Part D), and skilled nursing facility use and durable medical equipment files. Medicare claims provide widely generalizable, yet highly granular insights into healthcare utilization across the United States as a whole in the 65 and older population and will provide valuable context and benchmarks for regional and national comparisons to the healthcare of Veterans. VA Electronic Health Record Data. The Corporate Data Warehouse will provide access to all VA electronic medical record data, including hospital and outpatient diagnoses (recorded using ICD-9 and ICD-10 codes), pharmacy data, laboratory results, clinical notes, and vital signs. Veteran deaths will be ascertained from the VA Vital Status file and the Master Patient Index, which is updated daily. Once available, these VA data will be merged as indicated with Medicare and Community Care data at a patient level to consider outside healthcare utilization. VA Community Care Data. Over half of VA enrollees are eligible for community care through the MISSION (Maintaining Internal Systems and Strengthening Integrated Outside Networks) Act. In the first year after the start of the pandemic, community care encounters accounted for nearly 40% of all VA provided and paid for care. In comparison, from 2014-18, VA funds obligated for Community Care comprised about 20% of its healthcare budget. The Non-VA Care Program Integrity Tools (PIT) system, a comprehensive set of tools that aggregates many sources of data to check for fraud, waste, and abuse in the VA Community Care program, is the primary data source for VA Community Care. Whenever possible, for all study aims, PIT data will be analyzed in combination with Purchased Care/Fee data for a complete understanding of VA Community Care utilization and costs. During the course of the project outside VA healthcare services including dates, procedures, location, and diagnoses will be utilized.	The goal of this initial effort is to create a research roadmap to characterize conditions associated with excess mortality during the COVID-19 pandemic in Veterans. The VA experience will be placed in the larger US context by conducting parallel ecologic analyses of VA, Centers for Disease Control and Prevention (CDC), and Centers for Medicare and Medicaid (CMS) data. Changes in healthcare utilization that may be associated with both lowered and excess mortality in VA and Medicare populations will be examined. Available patient-level electronic health record (EHR) data within the VA will then be used to study in depth how much of the excess mortality is likely attributable to COVID-19. We will do this by using a risk index to identify probable undiagnosed cases and examine how these cases are distributed across specific demographic and diagnostic subgroups. Investigators will use the insights gained in this project to determine where further research and public health intervention efforts are most needed.	The work in this area has direct application to everyday care. This experiment is an opportunity to reveal the effects, both positive and negative, of the variations in care that occurred during the early and later stages on the COVID-19 pandemic. The findings have the potential to support broader efforts in US healthcare to further elucidate unmet needs while finding opportunities to safely de-escalate care when appropriate, freeing people from unneeded connections to the healthcare system.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CDA 13-023	Winchester	David		David.Winchester@va.gov	Strategies to Reduce Unnecessary Noninvasive Imaging	10/01/2017	09/30/2022	North Florida/South Georgia Veterans Health System, Gainesville, FL	$877,541		Background: Patients undergo millions of noninvasive diagnostic imaging tests, including computed tomography, magnetic resonance imaging, and nuclear medicine, in the United States annually. Based on Appropriate Use Criteria (AUC) developed by professional medical societies, 20-30% of these tests may be inappropriate, i.e., the potential benefit-to-risk ratio is not maximized. Limited data on appropriateness of imaging within the Veterans Health Administration (VHA) suggests that inappropriate use is similar to that outside the VHA. A variety of methods have been employed to encourage more appropriate use of noninvasive imaging. One of the most popular is an electronic decision support tool (DST). These software products are added to patient care workflows to capture meaningful AUC data and reduce unnecessary testing. A recent VHA Evidence Synthesis Program (ESP) report concluded that little is known about the implementation of DSTs and possible negative ramifications of their use. Further, the cost to the VHA of noninvasive imaging testing, which has not been calculated, is needed to determine the burden of inappropriate tests. Specific Aims: In the course of this award, we will achieve the following specific aims: (1) assess potential barriers and facilitators to successful adoption of a DST, (2) determine the effectiveness of a DST using a stepped implementation process, and (3) estimate the fiscal effectiveness of a DST in the VA health system by developing a micro-costing model for delivery of noninvasive imaging tests. Significance: Through these investigations, we will glean valuable insight into how to adjust processes to improve the ordering of millions of costly tests. If effective at reducing unnecessary tests, the results from this proposal will ultimately improve Veterans' access to care and reduce radiation risks. Innovation: Study of DSTs has focused primarily on effectiveness, with little attention paid to the implementation process and possible adverse effects such as provider dissatisfaction and inefficiency. Our investigations will break new ground in studying these aspects of DSTs. The use of qualitative and micro- costing methods as we propose is innovative given their underuse for clinically oriented research. Methods: We will apply the Practical Robust Implementation and Sustainability Model (PRISM) and Theoretical Domains Framework (TDF) to the specific aims for this award. In Specific Aim 1, we will use qualitative and quantitative methods to identify possible barriers and facilitators to DST implementation through interviews and surveys of providers who order noninvasive tests. In Specific Aim 2, implementation of a DST for noninvasive imaging will be assessed from the rate of testing, the proportion of testing that is inappropriate, and feedback from providers in three discrete steps. First, providers blinded to AUC for imaging tests will order tests as usual. Second, at the point of ordering, they will receive immediate feedback on appropriateness of the test and be given the option to change the order. Third, if the provider's decision is not consistent with AUC, the provider will be required to give a justification for the test order. These steps will help us understand the implementation process for DSTs and to address gaps in the literature raised by the recent ESP. In Specific Aim 3, the cost of noninvasive imaging tests will be calculated using information from administrative databases, time-and-motion observation of care delivery, and cost diaries from Veterans. Expected Results: We anticipate that through these investigations, we will learn and be able to share important lessons about implementation of a DST for noninvasive imaging. The results will be the basis for investigator initiated research grants on further spread of DSTs within the VA system and adaptation to other imaging/testing modalities such as echocardiography.	Care of Complex Chronic Conditions	Based on the Practical Robust Implementation and Sustainability Model (PRISM) and Theoretical Domains Framework (TDF), this project examines the implementation of a DST and its effect on ordering of noninvasive imaging tests as follows: In Specific Aim 1, we will use qualitative methods to identify barriers and facilitators to DST implementation through interviews with physicians and other providers who order noninvasive tests. In Specific Aim 2, implementation of a DST for noninvasive imaging will be assessed from the rate of testing, the proportion of testing that is inappropriate, and feedback from providers on the use of the DST. In Specific Aim 3, the cost of noninvasive imaging tests will be calculated using information from administrative databases, time-and-motion observation of care delivery, and cost diaries from Veterans.	For Specific Aim 1, we will assess potential barriers and facilitators to successful adoption of a DST. In Specific Aim 2, we will determine the effectiveness of a DST using a stepped implementation process. In Specific Aim 3, we will estimate the fiscal effectiveness of a DST in the VA health system by developing a micro-costing model for delivery of noninvasive imaging tests.	Thus far, data have provided insight as to how DST's might interfere with patient care. We have learned novel issues that may contribute to low value imaging. Further research will test concerns about DST's and estimate potential for avoided costs.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CDA 15-072	Yong	Celina		Celina.Yong@va.gov	Optimizing Access, Appropriateness, and Quality of Minimally Invasive Procedures for Veterans	02/01/2019	09/30/2023	VA Palo Alto Health Care System, Palo Alto, CA	$1,714,634		The last five years have seen a paradigm shift in healthcare: new minimally invasive treatments are now available that can effectively replace surgery for elderly, comorbid patients. The most striking example is Transcatheter Aortic Valve Replacement (TAVR), the first major minimally invasive structural heart disease treatment to be disseminated nationally. TAVR is a life-saving option for the approximately 87,000 Veterans nationwide who suffer from severe aortic stenosis, and thereby face a 50% mortality rate within two years if left untreated. Preliminary data suggest that the novel complexities associated with TAVR diffusion significantly impact vulnerable patient populations. Based on prior data, one key mechanism for these disparities may be that vulnerable patient populations are less equipped to make informed decisions about treatment. Driven by the hypothesis that vulnerable Veteran populations experience unequal treatment with TAVR, but that decision support to routinely assess appropriateness and reduce barriers to care for Veterans can reduce these differences, the aims of this proposal are to: (1) Identify patient level factors that influence cardiovascular procedural treatment on the spectrum from minimally invasive (newer: TAVR and older: PCI) to invasive (older: CABG, SAVR) within the VA, categorizing high and low access groups, with non- VA data comparison. Multivariate, hierarchical logistic regression will be used to determine the association of patient level factors, including demographic and VA-specific contextual factors (e.g., percent service connection, proximity to VA procedure site, use of Veterans Choice or Medicare) with procedural use, identifying “low” and “high” access profile groups. I hypothesize that older, established cardiovascular procedures will show fewer inequities in care compared to the newest paradigm of care, TAVR. (2) Identify decisional needs and barriers to achieving appropriate TAVR treatment from the perspectives of Veterans (stratified into low and high access groups as defined by Aim 1) and their healthcare providers. I will use an explanatory mixed methods design to conduct semi-structured interviews with a stratified sample of low and high access profile Veterans referred for TAVR from multiple states and their providers to inform development of a pilot intervention in Aim 3. I hypothesize that poor understanding of individualized risks and benefits are a major limitation to appropriate TAVR referrals, with geographic barriers and difficulty using Veterans Choice options particularly identified among low access profile Veterans. (3) Build and pilot a novel individualized decision-making tool and patient facing website to improve both appropriateness and access to care, along with a strategy for implementation into routine VA care. Using TAVR as a model, I will develop and validate the feasibility of a prototype physician-facing decision aid for incorporation into routine VA care that predicts individualized risks and benefits of TAVR, as well as a patient-facing website that addresses barriers to care, such as mapping proximity and quality of the nearest TAVR sites for geographically remote Veterans who may require use of Veterans Choice. Through the successful execution of this work, for the first time, potential inequities in access to TAVR among vulnerable Veterans will be identified, and insights will be revealed into the gaps in decision making support for Veterans and their physicians that may contribute to these differences. Additionally, this work will advance the field by piloting the first evidence-based intervention to systematically improve the appropriateness of care for Veterans receiving minimally invasive procedures by generating individualized risk-benefit profiles for treatment, with further online innovative decisional support resources. This will serve as a model for a host of novel minimally invasive treatments now becoming available across multiple therapeutic disciplines.	Quality Measurement Development				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CDA 15-259	Vanneman	Megan		Megan.Vanneman@va.gov	Access to and Choice of VA or Non-VA Health Care by Veterans of Recent Conflicts	04/01/2020	03/31/2025	VA Salt Lake City Health Care System, Salt Lake City, UT	$807,431		Background: This CDA will provide me, Megan E. Vanneman, PhD, MPH, with the training and experience to become an independent health services researcher who applies decision science and informatics to improve Veterans’ access to and engagement in high-quality care. To help achieve this goal, I will work with my mentors, consultants, and operational partners to develop and evaluate an information and decision support tool to improve VA leaders’ understanding and decision-making about VA enrollment and reliance (proportion of care received at VA) on primary and mental health care. Significance/Impact: This research will have a positive impact on VA leaders, Veterans interested in enrolling in VA health care, and Veterans needing primary and mental health care, by increasing understanding of how access, quality, enrollment, and reliance can be optimized to better meet Veterans’ needs. As the VA moves from a more closed, integrated healthcare system to providing care through networks that include community partners, VA leaders need to better understand enrollment, reliance, access, and quality at their local facilities and VISNs, particularly for “foundational services,” such as primary and mental health care. The CDA strongly aligns with top VA priorities – increasing choice for Veterans, modernizing the VA system, using VA resources more efficiently, and improving timeliness of services. Innovation: While we know that about 50% of Veterans enroll in VA and that about 50% of care for these enrollees is provided in the VA, we have little understanding of what drives these decisions for recently separated Servicemembers – those who participated in conflicts in Iraq and Afghanistan. Preliminary studies show that there is wide variation in VA facility enrollment rates, but we do not have data on variation in VA facility reliance rates. Furthermore, we do not understand what drives these differences. Although there is some understanding of individual (e.g., age) and community-level (e.g., non-VA provider supply) factors that influence VA enrollment and utilization, we lack understanding of facility factors that can be modified to appropriately connect Veterans to VA and needed services thereafter. Specific Aims: The research plan has three primary goals: 1) Learn what information and resources VA facility and VISN leaders need to better understand and manage enrollment rates and reliance rates for primary and mental health care; 2) Derive insights on facility factors by evaluating relationships among enrollment rates, reliance rates, access to care, and quality of care for primary and mental health care; and 3) Develop or modify existing information tool(s) to assist facility and VISN leaders to manage enrollment and reliance rates for primary and mental health care. Methodology: This CDA seeks to fill the gap in understanding on enrollment and reliance for primary and mental health care through a mixed-methods approach by: producing descriptive data on facility enrollment and reliance rates (Aim 1.1); qualitatively studying Veterans’ insights on their decisions regarding enrollment and reliance in interviews involving VA enrollees and non-enrollees (Aim 1.2); interviewing VA leaders about their information needs regarding enrollment and reliance (Aim 1.3); using hierarchical modeling to understand what modifiable facility factors on access and quality are associated with enrollment and reliance rates (Aim 2); and developing, testing, and implementing a tool to assist VA leaders to improve enrollment and reliance rates (Aim 3). Next Steps/Implementation: Study results will help VA healthcare leadership target changes that they can make to manage enrollment and retention of Veterans in the VA healthcare system and deliver needed foundational services. Results will also inform my future work on information and resource allocation tools to support Veterans’ and leaders’ decision making.	Access				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CDA 16-152	Edwards	Samuel		Samuel.Edwards@va.gov	Optimizing Outcomes in Home-Based Primary Care	07/01/2018	03/31/2023	VA Portland Health Care System, Portland, OR	$1,199,690		Objective: This proposal is for a CDA-2 mentored training program that will transition Samuel Edwards, MD, MPH into an independent VA health services researcher who has special expertise in the design, function and evaluation of care models for medically and socially complex Veterans. The overarching objective of the research plan is explore what features of VA Home Based Primary Care (HBPC) drive its success in reducing hospitalizations for ambulatory care sensitive conditions, and use these insights to develop an intervention to promote best practices in HBPC. Research Plan: Dr. Edwards will conduct three studies using mixed methods. The research approach will draw upon the literature on patient complexity, core features of primary care, and the chronic care model. The Specific Aims of the proposed research are to: 1) Characterize patterns of enrollment and care delivery within HBPC, and determine clinical and systems correlates of preventable hospitalizations, 2) Assess HBPC providers perceptions of appropriate patient selection and care delivery patterns, core functions of HBPC, and barriers and facilitators to HBPC performance, and 3) Develop and test a pilot intervention to promote best practices in HBPC. Methods: Aims 1 and 2 will consist of an explanatory sequential mixed methods study exploring HBPC patient selection, care delivery patterns, core functions of HBPC. Aim 1, is a quantitative study consisting of four secondary analyses of national VHA data to (1) determine predictors of enrollment in HBPC, (2) define clinical subgroups of HBPC patients, (3) describe care delivery patterns within HBPC, and (4) determine association of patient subgroups and care delivery patterns with ambulatory care sensitive hospitalizations. Aim 2 is a two phase qualitative study. In the first phase, we will perform an in depth study of our local HBPC program using interviews, focus groups and structured observation. Second, we will perform interviews with program directors at other HBPC programs to gain a broader understanding of differences between sites. In both phases we will explore perceptions of the patient selection process, appropriate care delivery patterns, and the importance of core HBPC functions focusing on 5 proposed domains: 1) strong provider-patient relationships, 2) medication management 3) addressing social determinants of health, 4) integration of palliative care, and 5) coordination of care. We also plan to explore provider perspectives on barriers and facilitators on HBPC performance. Finally, Aim 3 will be the development of a pilot intervention to promote best practices in HBPC learned from Aims 1 and 2, which will be tested locally in a trial. We will perform a formative evaluation concurrently focused on acceptability and feasibility, with a preliminary look at efficacy. The expected outcome will be preliminary data to support a multicenter trial of a refined intervention to be tested at multiple HBPC sites. Career Plan: Dr. Edwards is a physician-investigator with training in health services research methods and expertise in primary care redesign, team based care, and HBPC. This proposal will deepen his theoretical understanding, content expertise, and research skills. Specific areas for training are: 1) Qualitative and advanced quantitative skills that can be applied to mixed methods approaches in health services research; 2) Content expertise in patient complexity and home based primary care; and 3) Implementation science and intervention development. The training plan will consist of coursework, seminars, and readings guided by the mentorship team. Ultimately, these efforts will assist in Dr. Edwards reaching his goal of becoming a national leader in conducting research and testing care models directed at medically and socially complex Veterans.	Access	Aim 1 is a quantitative study consisting of four secondary analyses of national VHA data to (1) determine predictors of enrollment in HBPC, (2) define clinical subgroups of HBPC patients, (3) describe care delivery patterns within HBPC, and (4) determine association of patient subgroups and care delivery patterns with ambulatory care sensitive hospitalizations. Aim 2 is a two phase qualitative study. The first phase is an in depth study of the Portland HBPC program using interviews, focus groups and structured observation. In the second phase, program directors at other HBPC sites will be to gain an understanding of differences across sites. Finally, Aim 3 will be the development of a pilot intervention to promote best practices in HBPC learned from Aims 1 and 2, which will be tested locally in a trial.	The purpose of this research is to explore what features of HBPC drive its success in reducing hospitalizations for ambulatory care sensitive conditions, and use these insights to develop an intervention to promote best practices in HBPC. The aims of this proposal are 1) Characterize patterns of enrollment and care delivery within HBPC, and determine clinical and systems correlates of preventable hospitalizations, 2) Assess HBPC provider perceptions of appropriate patient selection and care delivery patterns, core functions of HBPC, and barriers and facilitators to HBPC performance, and 3) Develop and test a pilot intervention to promote best practices in HBPC	The research has the potential to improve the quality and efficiency of the HBPC program nationally, leading to improved care for older medically complex Veterans, and reduced rates of hospitalization and long term institutionalization.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CDA 16-204	Livorsi	Daniel		Daniel.Livorsi@va.gov	Improving antimicrobial use at hospitals that lack infectious disease specialists	10/01/2017	09/30/2022	Iowa City VA Health Care System, Iowa City, IA	$1,115,533		The primary goal of this application is to foster the development of Dr. Daniel Livorsi as an independent VHA investigator devoted to improving antimicrobial-prescribing across the continuum of healthcare. This application specifically focuses on optimizing the performance of antimicrobial stewardship programs (ASPs) in resource-limited settings. ASPs are hospital-based programs that ensure patients receive the right antimicrobial at the right dose and for the right duration. These programs have proven benefits, such as improving patient safety and reducing antimicrobial resistance. ASPs are now mandated in every VHA facility and will soon be required in non-VHA hospitals as well. The widespread implementation of robust ASPs is essential for addressing the crisis of antimicrobial resistance. Though necessary, widespread ASP implementation will be challenging. Many ASPs lack access to Infectious Disease (ID) specialists—including 23% of VHA-ASPs—and it is unclear how ASPs can be effective in such resource-limited settings. This application will begin to address this problem through an ambitious but achievable Research Plan. Project 1 will analyze antimicrobial use data from across the VHA. Multivariable analysis will be used to identify structural and process factors associated with optimal facility-level ASP performance, as measured by facility antimicrobial usage (primary outcome) and 7 secondary metrics. The goal is to identify processes that work for ASPs even in the absence of ID pharmacists and ID physicians. Facilities will also be ranked on the risk-adjusted primary outcome; high and low performers will be identified. Project 2 will use qualitative research methods to determine provider attitudes and organizational factors that impede or foster antimicrobial stewardship at 8 VHA hospitals with ASPs lacking ID support. For this project, the team will conduct research at 4 low-performing and 4 high-performing facilities, as determined by performance on the primary outcome. Project 3 will synthesize the findings from Projects 1 and 2 to develop pilot improvement strategies for low-performing ASPs that lack ID support. The model of Physician Mentored Implementation will guide this intervention, and a pretest-posttest design will be used to assess the effect of the intervention at the 2 intervention hospitals compared to 2 control hospitals. In addition to the above Research Plan, this application proposes integrated Career Development activities that build on Dr. Livorsi’s expertise in leading ASPs and his prior experience with qualitative assessments and secondary data analysis. These career development activities have the following objectives: 1) gaining fluency in the analysis of national VHA databases and the use of multilevel regression models; 2) building expertise in implementation science with a focus on qualitative assessments; and 3) developing proficiency in the conduct and analysis of multicenter interventions. These Research and Career Development plans will prepare Dr. Livorsi for submitting an Investigator-Initiated Research proposal focused on refining existing stewardship metrics. In addition, this work will set the stage for future investigations into evaluating and implementing stewardship processes in other healthcare settings, including ambulatory clinics, emergency rooms, and Community Living Centers.	Career Development	This study will use multilevel regression techniques to evaluate antimicrobial-prescribing across a large cohort of VHA inpatients. Qualitative assessments will also be conducted to understand local barriers and facilitators to antimicrobial stewardship. Finally, a pilot intervention will be implemented at 2 sites to augment local stewardship efforts. The model of Physician Mentored Implementation will guide this intervention, and a pretest-posttest design will be used to assess the effect of the intervention at the 2 intervention hospitals compared to 2 control hospitals.	The objective of the proposal is to evaluate and improve antimicrobial stewardship processes at VHA hospitals lacking local ID support. The specific aims are to: 1) identify structural factors and processes associated with facility-level ASP performance; 2) determine provider attitudes and organizational factors that impede or foster antimicrobial stewardship at VHA hospitals lacking ID support, and 3) conduct a pilot intervention to bolster antimicrobial stewardship at VHA hospitals that have low-performing ASPs and lack local ID support. The design of this pilot intervention will be informed by the findings of Aims 1 and 2.	Due to the crisis of AMR, there will be an ongoing need to improve antimicrobial use. For this reason, all VHA medical facilities are now mandated to have an active ASP. However, it's unclear how VHA-ASPs without ID support have implemented stewardship processes and whether these processes are effective. The findings from Aim 1 and Aim 2 should address this critical gap in the literature. Our work in Aim 3 will trial novel strategies for improving antimicrobial use in these settings.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CDA 16-206	Becker	Daniel		Daniel.Becker2@va.gov	Improving the Use of Tumor Genetic Testing with Decision Science	03/01/2020	05/31/2024	VA NY Harbor Healthcare System, New York, NY	$1,496,656		Background: Recent advances in cancer care have come from identifying the genetic mutations in an individual’s cancer, and focusing on those abnormalities with “targeted therapy,” i.e. precision medicine. Available genetic information is expanding rapidly and initial research suggests that oncologists struggle to order the correct tests at the correct times and use the results effectively to choose medication. We sought to study the scope of variation in the use of molecular testing and targeted therapy (MT/TT), the barriers to guideline concordant care, and to create an intervention to improve the use of guideline concordant MT/TT. Significance/Impact: More than 10,000 VA patients were diagnosed with lung and colorectal cancers in 2010, creating a pressing need to ensure that guideline concordant MT/TT are implemented rapidly and effectively. The Cancer Moonshot Initiative funded the Precision Oncology Program (POP) to increase access to MT/TT throughout the VA, but recent reports indicate that only 1/3 of VA medical centers (VAMC) are participating, and benefits are inconsistent among those hospitals. Research is needed to ensure that all veterans with cancer receive state of the art MT/TT via POP or other mechanisms. Innovation: This is among the first studies to use a mixed methods approach, combining both quantitative and qualitative research methods to address the complicated problem of implementing cancer MT/TT. The qualitative portion includes interviews of patients to understand their frequently neglected perspective. Specific Aims: Specific aim 1 uses national VA data from the VA Corporate Data Warehouse (CDW), and molecular testing data from contracted vendors and the VA POP to understand the patterns and predictors of guideline concordant care. Specific aim 2 seeks to conduct semi structured interviews with both patients and providers at centers with low guideline concordant MT/TT, high guideline concordant MT/TT, and centers implementing the POP program. The interviews are designed to elicit the barriers to guideline concordant care. Specific aim 3 is designed to use the data gathered in the quantitative and qualitative studies, along with behavior change theory, to design a behavior change strategy that empowers both patients and providers to improve care. Methodology: The quantitative portion of the mixed methods approach will study the national database of approximately 70,000 veterans diagnosed with either lung or colorectal cancer between 2010 and 2017, to identify patients at high risk for not receiving guideline concordant MT/TT. The qualitative phase of the study will interview 18 providers and 18 patients representing VAMC’s with high guideline concordant care, low guideline concordant care, and sites participating in the POP. The data from the quantitative and qualitative phases will form the basis for a multifaceted intervention to improve the use of guideline concordant MT/TT. The intervention will be further refined by a panel of patients, clinicians, behavior change experts, and operations stakeholders prior to testing it in VAMC’s. Next Steps/Implementation: The behavior change strategy will be tested in first a single site, and then multi- site clinical trials to examine effectiveness. The rapidly expanding knowledge about molecular drivers of cancer presents not only great promise for cancer patients, but also significant challenges for oncologists and patients trying to ensure that these advances are rapidly incorporated into care. The proposed research is designed to help VAMC’s implement effective evidence based strategies to incorporate cancer MT/TT, positioning the VA as a leader in precision medicine.	Genomics				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CDA 17-005	Wilson	Sarah		sarah.m.wilson@va.gov	A Personalized mHealth Approach to Smoking Cessation for Veterans Living with HIV	04/01/2018	09/30/2022	Durham VA Medical Center, Durham, NC	$713,559		Although smoking is a significant cause of damage to health and quality of life specifically for Veterans with human immunodeficiency virus (HIV), smoking cessation interventions for this population are lacking. Dr. Wilson’s proposed CDA-2 projects will develop and test a mobile health (mHealth) intervention called Mobile Contingency Management plus Evidence-Based Smoking Cessation for HIV-positive Veterans (MESH). The MESH intervention uses mHealth and telehealth technology to a) individually personalize smoking cessation counseling and pharmacotherapy, b) deliver reinforcement for smoking abstinence, and c) provide relapse- prevention messaging support. It is a personalized, tailored, multi-component intervention for smoking cessation specifically designed for Veteran smokers living with HIV. Specific aims are as follows: Aim 1: To qualitatively explore smoking cessation treatment preferences among Veteran smokers living with HIV, and to quantitively evaluate perspectives on relapse-prevention messages among Veterans and smokers living with HIV. We will complete N = 20 semi-structured interviews with VHA HIV patients (initial treatment tailoring phase) and subsequently complete N = 400 quantitative rapid online surveys (secondary user satisfaction data). Results will be used to refine design/content of the proposed intervention. Aim 2: To use a successive cohort design to develop and obtain patient feedback on an mHealth smoking cessation intervention that uses computerized algorithms to personalize treatment. We will collect qualitative data on 3 cohorts of n = 5 Veteran smokers with HIV. Results from each cohort will be iteratively used to modify the MESH treatment design/content/user experience. Aim 3: To determine the feasibility and acceptability of MESH. After finalizing design of the mHealth app, we will conduct a trial in which N = 30 Veteran smokers with HIV will be randomized to either MESH or to a comparison condition (VA Quitline and SmokefreeVET). Outcomes include feasibility of the overall approach and acceptability of the intervention. Tests of efficacy are not appropriate given power considerations and the overall focus on treatment development. Results will be used in an IIR application in Year 3 of the timeline. While the IIR design may change, I plan to propose a Hybrid Type 1 implementation-effectiveness design to test effectiveness of the MESH intervention while collecting preliminary clinic-level implementation data. Aim 4: To quantitatively examine trends and determine health disparities in use of smoking cessation aids among patients living with HIV and receiving VHA clinical care. I will leverage two large national VA cohorts to compare smoking cessation pharmacotherapy prescriptions by demographic group and medical comorbidity. I expect to detect disparities in pharmacotherapy prescription rates by medical comorbidity (e.g., pain, Hepatitis C coinfection) and demographic group (e.g., ethnicity). Results will enable future examination of whether MESH may help overcome existing disparities. This CDA-2 application is highly significant given that: 1) Smoking is prevalent among and particularly harmful for HIV-positive Veterans; 2) There is a dearth of research on smoking cessation for Veterans with HIV; 3) Current approaches to smoking cessation in this population are not efficacious; 4) As the largest U.S. provider of HIV health services, VHA is an ideal setting; and 5) The proposed intervention follows the VA Blueprint for Excellence, which prioritizes mHealth and treatment personalization to increase reach/efficacy. This CDA-2 application is innovative and unique in the following ways: 1) It is the first multi-component mHealth intervention for HIV-positive Veteran smokers that individually personalizes treatment; 2) Previous interventions have not attempted to maintain abstinence effects of behavioral reinforcement by offering relapse-prevention messaging; and 3) There is currently little knowledge of health disparities in VHA prescriptions for smoking cessation pharmacotherapy among Veterans with HIV.	Mental and Behavioral Health	The study has multiple components: (1) Qualitative feedback will be elicited from 20 Veteran smokers living with HIV to tailor the intervention, and subsequent quantitative feedback (N=400 rapid online surveys) will gauge satisfaction with a library of support and relapse-prevention messages. Aim 1 results will be mixed to inform the preliminary intervention design. (2) Three successive cohorts (each n = 5) of patients will complete the intervention and provide feedback. Qualitative data from each cohort will be used to refine treatment components including the user experience. (3) A feasibility trial will include N = 30 Veteran smokers with HIV, randomized to MESH or to a comparison condition (best practice telehealth). Outcomes include measures of feasibility and acceptability, as well as preliminary implementation feasibility data (i.e., intervention cost and key stakeholder perspectives). (4) Two large national VA cohorts (Veterans Aging Cohort Study, Women Veterans Cohort Study) will be leveraged to examine systemic trends and potential disparities in smoking cessation pharmacotherapy prescriptions. Utilization rates will be compared by demographic group as well as medical comorbidity.	The overall goal of this award is to develop a personalized, multi-component mHealth/telehealth smoking cessation intervention that targets the individualized needs of Veterans living with HIV. Aim 1: To qualitatively explore smoking cessation treatment preferences among Veteran smokers living with HIV, and to quantitatively evaluate perspectives on relapse-prevention messages among Veterans and smokers living with HIV Aim 2: To use a successive cohort design to develop and obtain patient feedback on the intervention. Aim 3: To determine the feasibility and acceptability of the tailored smoking cessation intervention for Veterans living with HIV. Aim 4: To quantitatively examine trends and determine health disparities in use of smoking cessation aids among VHA patients living with HIV.	Findings are not yet available. The study is anticipated to yield a new and potentially efficacious tailored intervention for smoking cessation among people living with HIV. This would have tremendous value in terms of reducing health risk and healthcare cost among this population of VHA high-utilizers.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CDA 17-006	Shepherd-Banigan	Megan		megan.shepherd-banigan@va.gov	Increasing mental health services use through enabling resources & family support	04/01/2019	09/30/2023	Durham VA Medical Center, Durham, NC	$827,982		Megan Shepherd-Banigan, Ph.D., obtained her doctorate in Health Services Research from the University of Washington in 2014 and her M.P.H from the University of Miami in 2006. From July 2015-November 2017, Dr. Shepherd-Banigan was a post-doctoral research fellow at the Durham VA Health Services Research & Development (HSR&D) Center of Innovation (COIN) and is now a VA Health Research Scientist in the COIN. Her long-term professional goal is to grow her career as an independent VA health services researcher who applies a diverse array of methods to evaluate and improve the effectiveness of mental health and family service delivery systems. The short-term objective of this application is to describe and strengthen Veteran and family determinants of mental health service utilization. The proposed CDA research seeks to address scientific gaps related to the low use of psychotherapy among Veterans with PTSD: Aim 1a— Identify Veteran and family determinants that predict initiation and completion of psycho-therapy for PTSD; Aim 1b— Explore mechanisms linking enabling resources, [treatment preparedness], and initiation and completion of PTSD psychotherapy; Aim 2— Refine and test the feasibility of a family-involved treatment preparedness intervention to increase initiation and completion of EBP psychotherapy for PTSD; Aim 3— Analyze whether use of VA supportive services predicts initiation and completion of PTSD psychotherapy by strengthening economic enabling resources. This application is highly innovative and will advance clinical practice by contributing evidence about 1) the role of complex Veteran and family risk factors that inhibit PTSD treatment use and 2) promising, strategies to strengthen these factors, including a family-involved treatment preparedness intervention and VA education and vocational rehabilitation services to increase uptake of PTSD evidenced-based practices (EBPs).21 This project is consistent with VA priorities, such as increased access to care and uptake of EBPs. The research proposed in Aim 1 will employ novel machine learning causal forest methods93 to Caregiver Support Program survey data and VA administrative data to identify Veteran and family predisposing, enabling, and need factors and elucidate how enabling resources (i.e. perceived financial strain, income, education level, family strain) moderate the association between need for treatment and use/completion of psychotherapy. Subsequent qualitative interviews with Veterans and family members will seek to identify the underlying mechanisms between Veteran/family determinants and service use. The goal of Aim 2 is to refine and test the feasibility and acceptability of an existing family engagement strategy74 using a successive cohort design (SCD) among Veterans who were referred to EBP psychotherapy for PTSD. For Aim 3, VHSC, Veteran Benefits Administration, and Caregiver Support Program data will be combined to examine the effect of VA supportive service use on time to use/completion of psychotherapy treatment using Cox proportional hazard models; sequential stratified matching will be applied to minimize baseline differences between treatment groups. By the end of the 3rd year of CDA funding, a merit award application will be submitted to fund a randomized trial of the Aim 2 intervention. To complete the proposed research, the applicant requires additional skills and content expertise in four areas: [1) intervention and implementation science; 2) advanced methods in qualitative and quantitative research; 3) mental health clinical research and context; and 4) professional development and networking.] Specific topics and activities will include courses in machine learning and qualitative research; workshops about randomized clinical trials and implementation methods; clinical shadowing; and academic conferences and workshops.	Mental and Behavioral Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CDA 17-007	Boucher	Nathan		nathan.boucher@va.gov	Navigating Advanced Illness for Informal Caregivers of Ill Veterans	08/01/2018	05/31/2023	Durham VA Medical Center, Durham, NC	$766,881		Of the 65 million Americans who serve as informal caregivers of persons with chronic disability or illness, about 5.5 million are caring for Veterans. These caregivers play a significant role in helping to maintain the health and well-being of Veterans and often experience significant burden related to their caregiving role, including poor physical health, financial difficulties, and low confidence in the care they provide. Current VA programs aim to improve caregivers' knowledge and ability to provide direct care at home to patients with dementia, TBI, cancer, and stroke. However, these programs have a number of limitations. First, they are not always able to respond to caregivers' social and practical needs adequately. Second, caregivers of seriously ill Veterans age 65 and older living in the community, an age group with high risk for unmet needs secondary to chronic illness and impairment, may not always get needed services due to an emphasis on post 9/11 Veterans and their caregivers. Third, they do not focus specifically on helping caregivers to navigate existing resources to meet their social and practical needs. Based on evidence of their effectiveness in other settings, health navigator programs may help address unmet social and practical needs of caregivers and reduce caregiver burden by providing direct linkages to services and other resources. This CDA proposes to develop a novel, effective navigator intervention targeting caregivers of older, community-dwelling Veterans with advanced illness. In prior work, patient navigation programs have facilitated cancer screening, clinical follow-up, advance care planning, psychosocial support, and care coordination. The central hypothesis is that a novel adaptation of established models of navigation can improve the ability of caregivers to care for older Veterans with advanced illness (cancer, COPD, or CHF) if it is: 1) informed by caregivers and patients themselves along with other VA and community stakeholders; and 2) focused on identifying and supporting social support and practical needs using both VA and community resources. To evaluate this hypothesis, three complementary, but distinct specific aims are proposed: (Aim 1) Assess social and practical needs of caregivers of older (age 65 and older) community-dwelling Veterans with advanced illness and their preferences for intervention. This aim will include prospectively conducted key-informant interviews with seriously ill Veterans and caregivers coupled with input from a Stakeholder Advisory Board which includes Veterans, caregivers, VA providers, and community organization membership (e.g., Area Agency on Aging); (Aim 2) Using data from Aim 1, develop a curriculum to train navigators to identify caregiver needs and link them to resources within VA and their community to address those needs; and (Aim 3) In a pilot study, assess feasibility and acceptability of a caregiver navigator intervention in meeting the social and practical needs of caregivers of community-dwelling older veterans with advanced illness by increasing knowledge of and access to services and resources. The findings of this study will lead to a novel intervention which may significantly reduce caregiver burden and, in so doing, improve the care of community dwelling veterans with advanced illness. This is consistent with VA's Health Services Research and Development priority of improving caregiving and long- term care in service to Veterans. The effectiveness of the intervention developed in this CDA can be further tested in a large, RCT supported by an IIR Merit Award.	Mental and Behavioral Health	To evaluate this hypothesis, three complementary, but distinct specific aims are proposed: (Aim 1) Assess social and practical needs of caregivers of older (age 65 and older) community-dwelling Veterans with advanced illness and their preferences for intervention. This aim will include prospectively conducted key-informant interviews with seriously ill Veterans and caregivers coupled with input from a Stakeholder Advisory Board which includes Veterans, caregivers, VA providers, and community organization membership (e.g., Area Agency on Aging); (Aim 2) Using data from Aim 1, develop a curriculum to train navigators to identify caregiver needs and link them to resources within VA and their community to address those needs; and (Aim 3). In a pilot study, assess feasibility and acceptability of a caregiver navigator intervention in meeting the social and practical needs of caregivers of community-dwelling older veterans with advanced illness by increasing knowledge of and access to services and resources.	Based on evidence of their effectiveness in other settings, health navigator programs may help address unmet social and practical needs of caregivers and reduce caregiver burden by providing direct linkages to services and other resources. This CDA proposes to develop a novel, effective navigator intervention targeting caregivers of older, community-dwelling Veterans with advanced illness. In prior work, patient navigation programs have facilitated cancer screening, clinical follow-up, advance care planning, psychosocial support, and care coordination. The central hypothesis is that a novel adaptation of established models of navigation can improve the ability of caregivers to care for older Veterans with advanced illness (cancer, COPD, or CHF) if it is: 1) informed by caregivers and patients themselves along with other VA and community stakeholders; and 2) focused on identifying and supporting social support and practical needs using both VA and community resources.	The findings of this study will lead to a novel intervention which may significantly reduce caregiver burden and, in so doing, improve the care of community dwelling veterans with advanced illness. This is consistent with VA's Health Services Research and Development priority of improving caregiving and long- term care in service to Veterans.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CDA 17-018	Gibson	Carolyn		Carolyn.Gibson2@va.gov	Improving Health Care for Women Veterans: Addressing Menopause and Mental Health	06/01/2018	03/31/2023	San Francisco VA Medical Center, San Francisco, CA	$798,003		Background. Women in midlife face increasing health risks related to menopause, a period of biological, hormonal, and social change characterized by often disruptive menopausal symptoms. Relevance and significance to Veterans’ Health. Almost half of women Veteran VA users are in midlife, with prevalent risk factors for burdensome menopausal symptoms. Unaddressed menopausal symptoms contribute to significant health care burden, impacting health risk behaviors, chronic health conditions, and mental health. Specific Aims. Aim 1: To describe midlife women Veterans’ experience of menopausal symptoms, and associations between menopausal symptom burden and mental health. H1a. High rates of hormone therapy (HT) use and menopausal symptom prevalence and burden will be observed. H1b. Self-reported menopausal symptoms will be more prevalent than suggested by VA clinical record categorization. H1c. Mental health diagnoses and symptoms will be associated with more prevalent and burdensome menopausal symptoms, and H1d. more prevalent HT use. Aim 2: To examine patient and provider preferences, experiences, and current practices seeking and receiving care related to menopause in the VA. Information gathered through patient and provider interviews will inform Aim 3, a Merit submission, and future intervention efforts focused on improving menopause-related care. Aim 3: To develop a user-ready tool to increase access to gender- sensitive menopause-related care in VA settings, and to activate self-management of menopausal symptoms. A menopause-focused psychoeducation and symptom tracking mobile application tailored to the menopausal Veteran population is planned, providing an evidence-based, low-resource intensive, high-yield intervention. Methods. Aim 1: I will use an analytic dataset from the National Cohort Study (PI: Seal) to examine mental health and menopause-related diagnoses in a national sample of women Veteran VA users aged 45-64 (current n=151,546). A sample (target n=200) of San Francisco VA Health Care System (SFVAHCS) enrollees from the national cohort will be recruited to complete structured surveys to thoroughly assess menopause status, menopausal symptoms, and current depression, anxiety, and posttraumatic stress disorder (PTSD) symptoms, and briefly assess menopause-related care practices. I will link survey data to medical record data, and use regression models to examine associations between self-reported and diagnosed menopausal symptoms, mental health concerns, medical comorbidities, and HT use. Insights from Aim 1 will inform Aim 2 interviews and Aim 3, Merit, and future projects. Aim 2: I will use semi-structured phone interviews with VA primary care providers and midlife women Veterans recruited from gender-specific and general primary care settings in Women’s Health Practice-Based Research Network (WH-PBRN) sites across the country to examine preferences, experiences, and current practices in menopause-related care. Interviews will provide context to Aim 1 findings, and inform Aim 3, Merit, and future projects. Aim 3: I will use Aims 1 and 2 findings and a participatory research process to inform the development of a menopause-focused psychoeducation and symptom tracking tool tailored to menopausal Veterans, to be further evaluated in a Merit submission. Unique features and innovation. These projects will serve as a novel evaluation of menopause-related symptoms, comorbidities, practices, and needs in the VA setting. These projects will also add to a body of literature on menopausal depression, addressing gaps in knowledge related to anxiety and PTSD. Finally, the development of a menopause-focused tool will provide an innovative model for promoting collaborative self- management and increasing access to gender-sensitive, patient-centered care. Implications for other areas. This research will add to reproductive mental health research relevant to VA and community settings, and may broadly inform integrated women’s health care. It will also inform health- related technology research, adding to the limited literature examining use and needs in aging populations.	Women's Health	Aim 1: I will use VA administrative data to examine menopause-related diagnoses, treatments, and comorbidities in a national sample of women Veteran VA users aged 45-64 (n=151,546). A sample (n=200) of women Veterans aged 45-64 enrolled in the San Francisco VA Health Care System will then be recruited to complete structured surveys to thoroughly assess menopause status, menopause symptoms, and current depression, anxiety, and PTSD symptoms, with survey data linked to electronic health records. Associations between self-reported and diagnosed menopause symptoms and treatments, mental health concerns, and medical comorbidities will be examined. Aim 2: I will use semi-structured phone interviews with VA primary care providers and midlife women Veterans recruited from gender-specific and general primary care settings in the national Women's Health Practice-Based Research Network to examine preferences, experiences, and practices in menopause-related care. Aim 3: Findings from Aims 1 and 2 and a participatory research process will inform the development of a VA-tailored, menopause-focused psychoeducation and symptom tracking tool.	Aim 1: To describe midlife women Veterans' experience of menopause symptoms, and associations between menopause symptom burden and mental health. Aim 2: To examine patient and provider preferences, experiences, and practices seeking and receiving menopause-related care in the VA. Aim 3: To develop a Veteran-focused tool to activate self-management of menopause symptoms in the VA setting.	This research will provide novel evaluation of menopause-related symptoms, comorbidities, practices, and needs among midlife women Veterans, and will address gaps in knowledge related to anxiety and PTSD. It will also provide an innovative model for promoting collaborative self-management and increasing access to gender-sensitive, patient-centered care in the VA and other health care settings.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CDA 17-169	Sears	Erika		Erika.Sears@va.gov	Assessing Treatment Delay and Resource Use to Improve Value of Pre-Surgical Care	04/01/2018	10/31/2022	VA Ann Arbor Healthcare System, Ann Arbor, MI	$1,610,696		Episode-based (“bundled”) approaches have been promoted for performance measurement to encourage shared accountability for the quality and efficiency of healthcare delivery among all of the providers involved in a patient's care. Most episode-based pilot programs use relatively narrow episode definitions, with the typical episode trigger starting at the time of a hospitalization or surgery. However, little attention has been paid to measuring quality and value of pre-surgical care. Although inpatient and postoperative care are costly, outpatient care accounts for the greatest utilization of health care resources in terms of visits and expenditures. This pre-surgical period, during which patients often have multiple touches with the healthcare system, is an important time to identify opportunities to improve coordination and quality of care for Veterans. The studies proposed as part of this CDA will facilitate development of innovative strategies to improve coordination, access, and value of care for Veterans with carpal tunnel syndrome (CTS), particularly in the pre- surgical period. Treatment for CTS is an ideal context to develop measurement models of care quality and utilization between primary care and specialty providers, given that approximately 40,000 Veterans per year are newly diagnosed with CTS and often receive care from one or more providers from primary care, occupational therapy, orthopedic surgery, plastic surgery, neurosurgery, physical medicine and rehabilitation, or pain management. Although a variety of nonoperative treatments can be appropriate under certain clinical circumstances, these same treatments can be low value if they lead to delays for patients who would benefit from surgery. This series of studies to evaluate and improve quality and utilization of CTS pre-surgical care will advance an understanding of how to optimize coordination of patient-centered surgical care more broadly. This project will have 3 aims: Aim 1: Using VHA national data, facility-level variation in CTS pre-surgical value will be assessed by examining both quality/access (inappropriate delay of surgery) and resource utilization (number of pre-surgical encounters), while evaluating the impact of key structural and process variables, including referral to community providers. Aim 2: Semi-structured interviews with patients and clinicians will be conducted to further identify and better understand factors associated with pre-surgical episode quality and utilization. Clinicians and patients will be recruited from 2 facilities with the highest and 2 facilities with the lowest performance on both pre-surgical measures (quality and utilization) to evaluate perspectives, preferences, organizational factors, and care goals of key stakeholders (patients and providers) who impact decision-making across phases of pre-surgical CTS care. Aim 3: Findings from Aim 1 and Aim 2 will be used to design and pilot a multi-disciplinary CTS clinical care pathway that addresses systemic barriers and processes impacting pre-surgical episode quality/access and utilization of CTS-related care provided across primary care and specialty clinics. Pilot testing will assess the intervention's feasibility, acceptability, and potential to improve facility-level pre-surgical episode value in preparation for an anticipated randomized trial. These methods, refined for CTS, will be applied in future work to examine variation in quality and utilization of pre-surgical care for other conditions, with the goal of optimizing use of health care services and maximizing outcomes for Veterans who receive surgical care. In anticipation of greater Veteran access to community- based care, this initiative will also be beneficial for monitoring and better coordinating the quality and value of care across diverse healthcare settings.	Quality Measurement Development	This research program will assess the quality and utilization of pre-surgical CTS care delivered over time among multiple providers using a model based on the National Quality Forum (NQF) patient-centered episodes of care theoretical construct coupled with Donabedian's structure-process-outcomes framework. In Aim 1, using VHA administrative data, I will construct facility-level measures of pre-surgical episode quality/access (inappropriate delay of surgery) and utilization (number of pre-surgical encounters) and examine the impact of structural and process considerations on facility variation in these performance measures. Structural considerations will focus on care organization that influences timely access to care, including specialist availability, proximity, and use of community care for referrals. Process considerations will focus on the mode of actual healthcare delivery, like use and timing of diagnostic tests, nonoperative treatments, and specialist referrals. In Aim 2, I will conduct semi-structured interviews with patients and providers to understand key factors associated with pre-surgical episode quality and utilization. The interviews will capture organizational factors (referral protocols and mechanisms of provider communication), perspectives, preferences, and care goals of key stakeholders (patients and clinicians) involved in pre-surgical CTS care to determine facilitators and barriers that impact pre-surgical episode value. For Aim 3, I will use findings from Aim 1 and Aim 2 to design and pilot a multidisciplinary CTS clinical care pathway to improve care coordination, prompt access, and appropriate use of resources for Veterans with CTS.	The studies proposed for this CDA will facilitate development of innovative strategies to improve coordination, access, and value of care for Veterans with CTS, particularly in the pre-surgical period. Aim 1: to assess facility-level variation in pre-surgical value for CTS-related care. Aim 2: to understand factors associated with pre-surgical episode quality and utilization from the patient and provider perspectives. Aim 3: to design and pilot a multi-disciplinary CTS clinical care pathway to improve pre-surgical episode value.	This series of studies will develop innovative strategies to improve coordination, access and value of care for CTS, particularly in the pre-surgical period. Through future work, I will use the model developed for CTS to examine variation in quality and utilization during pre-surgical care for other conditions, with the goal of optimizing the value of health care services across all treatment phases and maximizing outcomes for Veterans receiving surgical care. This approach will also be beneficial for quality measurement efforts across healthcare settings as the VHA provides more care through the community-based healthcare networks recommended by the Commission on Care.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CDA 18-005	Driscoll	Mary		Mary.Driscoll3@va.gov	Targeting Barriers to Pain Self-Management in Women Veterans: Refinement and Feasibility of a Novel Peer Support Intervention (Project CONNECT)	05/01/2020	06/30/2024	VA Connecticut Healthcare System West Haven Campus, West Haven, CT	$603,888		Background. Women are the fastest-growing segment of Veterans Healthcare Administration (VA) utilizers. Although men and women Veterans both report high rates of chronic pain, rates are higher in women. Addressing their unique needs is a priority. VA has placed renewed emphasis on promoting self-management for pain. Despite having a widely supported program for doing so, cognitive behavioral therapy for chronic pain (CBT-CP), several barriers to accessing this care and engaging optimally with its recommendations are noted and these may be particularly salient for women. These include logistical, healthcare delivery, and psychosocial barriers. Patient-centered efforts to address these in the context of evidence-based pain interventions, like CBT-CP, may translate to improved treatment access, engagement, adherence, and more optimal outcomes for women Veterans. Accordingly, a home-based, intervention integrating an evidence- based CBT-CP program with reciprocal peer support (RPS) has been developed (CONNECT) and is currently being pre-piloted. Results are promising but substantial refinement and feasibility testing is warranted before a full-scale trial is warranted. This proposal will optimize the feasibility and acceptability of CONNECT and examine the potential feasibility of candidate control conditions for a future randomized trial. Significance/Impact: Because CONNECT is less resource-intensive than CBT-CP and because it is home based, it may reduce costs and improve access to behavioral pain care, and its success may have implications for male Veterans with pain. It targets previously unaddressed and potentially modifiable factors (e.g. social support) thought to be relevant for adjustment and uptake of pain self-management among women Veterans. Innovation: CONNECT examines an alternate method for promoting CBT-CP that is potentially scalable, cost- effective and transportable. Specific Aims: Aim 1a. Solicit Veteran feedback on the refined recruitment strategies, treatment components and materials, duration/content, engagement strategies peer-matching and data collection methods. Aim 1b. Evaluate the feasibility (retention, adherence, assessment methods, recruitment rate) and acceptability (credibility, satisfaction) of a refined 8-week RPS pain self-management intervention (CONNECT) in a sample of 30 women Veterans with chronic musculoskeletal pain. Aim 1c: Conduct a responder analysis to classify the percentage of women Veterans that evidence clinically meaningful improvements in pain intensity/interference and depressive symptoms. Aim 2: Use qualitative methodology to a) examine participant perceptions regarding satisfaction/acceptability of CONNECT, and of specific components, and b) examine participant perceptions of underlying mechanisms. Aim 3: In preparation for a future randomized-controlled trial (RCT), conduct a feasibility analysis to determine preferences for treatment using the prospective preference assessment, which includes a) qualitative interviews to query motivations for, concerns about and factors influencing participation in a future RCT as well as survey measures to assess b) willingness to be randomized to candidate control conditions, and c) factors influencing their willingness. Methodology: A single arm pilot design and an analogue study to examine the feasibility of randomization to candidate control conditions. Next Steps/Implementation. If CONNECT is feasible a Hybrid Type 1 trial will be warranted to determine whether providers may confidently recommend CONNECT to women Veterans and to examine implementation factors.	Women's Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CDA 18-006	Gass	Julie		Julie.Gass@va.gov	Developing a Team-Delivered Intervention for Smoking and Hazardous Drinking for Primary Care Veterans with Cardiovascular Diseases	07/01/2019	09/30/2023	VA Western New York Healthcare System, Buffalo, NY	$641,982		Many Veterans (30.4%) with cardiovascular diseases (CVDs) continue to engage in behaviors that increase risk of cardiovascular events and early mortality, such as smoking or hazardous drinking. While the VA has several programs designed to help Veterans quit smoking or quit/reduce drinking, there is a gap in service for Veterans who are not ready for change-based treatments but continue to smoke or drink hazardously. VA Patient Aligned Care Teams (PACTs) screen all patients annually for alcohol and tobacco use, and thus the PACT platform is an ideal way to reach Veterans with CVDs who smoke and/or drink hazardously. Through the Primary Care Mental Health Integration (PCMHI) initiative, mental and behavioral health providers are embedded to provide effective, evidence-based, Veteran-centered, behavioral health interventions for a variety of co-occurring behavioral health concerns and medical problems. Educational and self-monitoring interventions are evidence-based and increase substance users' intentions to make a behavior change, and additionally improve patient factors including engagement, willingness to accept behavioral health referrals, and self-management strategies. This research proposal focuses on adapting elements of these evidence- based interventions specifically for a PACT-based VA setting to appeal to Veterans not yet ready to change smoking and/or drinking. This intervention aims to increase intention to change and may improve rates of cessation and engagement with change-based programs. The intervention will fill a gap in care and potentially improve the health and longevity of Veterans seen in PACT. Dr. Julie Gass is a clinical psychologist and postdoctoral fellow at the Center for Integrated Healthcare (CIH), a VA Mental Health Center of Excellence charged with improving Veteran healthcare through PCMHI. The purpose of this Career Development Award-2 (CDA-2) is to facilitate Dr. Gass's transition into an independent HSR&D investigator with a long-term objective of improving Veterans' health by studying the effectiveness of evidence-based, Veteran-centered interventions for commonly co-occurring behavioral and medical concerns within PACT patients. The short-term objective of this CDA-2 is to obtain formal training, expert mentorship, and research experience to facilitate a VA HSR&D career focused on improving interventions and PACT processes for Veterans who smoke and/or drink hazardously while diagnosed with CVDs. The CDA-2 will provide Dr. Gass (who has experience in tobacco treatment/research) with needed training in (1) RCT design, implementation, and data analysis; (2) team-based care in PC; (3) brief alcohol treatments; (4) qualitative analysis for intervention development; and (5) grantsmanship, which will allow her to conduct the three projects comprising the CDA-2 research plan. As it is important that any new intervention be accessible and feasible for the PACT and the patient, this research will use the extant literature, stakeholder feedback, and careful piloting to develop the most feasible and patient-centered intervention. The intervention will be piloted in this project in two modes: PACT team- delivered and PCMHI-delivered. Specific Aims of this CDA-2 are as follows. Aim 1, informed by pilot data and systematic literature review, is a qualitative study both of local and national stakeholders and experts to understand the preferences, barriers, and facilitators to engaging in conjoint appointments, and to refine the intervention; Aim 2 is designed to test this intervention in a small sample and make any necessary modifications; and Aim 3 is a pilot test of the manual in PACT to obtain feedback on the acceptability and feasibility of using evidence-based substance use intervention techniques in real-world clinical practice. Results of the CDA-2 will inform submission of an HSR&D merit proposal for a larger RCT to be submitted by the end of Year 3.	Mental and Behavioral Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CDA 18-008	Lin	Lewei		lewei.lin@va.gov	Using telehealth to expand treatment access for Veterans with opioid use disorder	04/01/2019	09/30/2023	VA Ann Arbor Healthcare System, Ann Arbor, MI	$1,099,507		Impacts: The proposed research addresses a critical VHA and HSR&D priority to improve access to opioid use disorder (OUD) treatment by developing and pilot testing a novel telehealth treatment delivery intervention. Background: With the national opioid epidemic, OUD prevalence in Veterans has increased and many Veterans with OUD experience serious and preventable harms including overdose and suicide. Increasing access to treatment, especially with the medication buprenorphine, can help prevent these harms. However, only a third of Veterans with OUD receive evidence-based treatment. The biggest access barrier is lack of trained buprenorphine providers on-site across VHA facilities, contributing to particularly low treatment for Veterans receiving care in Community-Based Outpatient Clinics (CBOCs). Telehealth interventions have been developed in the VA to allow specialists in VA Medical Centers to deliver treatment to Veterans in CBOCs, but minimal research has been done on telehealth for substance use disorders. A few VA facilities, including the VA Ann Arbor Healthcare System have begun to use telehealth to deliver OUD treatment, but research is needed to inform a telehealth model that can be scalable across facilities, examine impact on treatment use, and determine where telehealth should be targeted to maximize impact. The methods and sequence have been designed to address these pressing questions in the following 3 aims: Aim 1: Semi-structured interviews will be conducted with patients and clinicians in four facilities, including the VA Ann Arbor Healthcare System, that have begun to use telehealth delivery of OUD treatment to Veterans in CBOCs, to understand components of their interventions, perceptions of treatment and barriers and facilitators to use. Informed by these qualitative findings, a Delphi panel of OUD experts, including frontline providers, will help refine a telehealth intervention that can be feasible across facilities and will be pilot tested in Aim 2. Aim 2: In a pilot trial, CBOC Veterans with OUD will be randomized to the telehealth OUD intervention refined in Aim 1 (n=20) or in-person OUD treatment as usual (n=20). The study will examine feasibility and acceptability incorporating survey data and qualitative interviews with participants and study clinicians and characterize treatment engagement, retention and substance-use outcomes over 3 month followup. Aim 3: Using national VHA data of CBOC Veterans with OUD, analyses will examine factors associated with patient and facility-level variation in OUD treatment to understand areas where treatment is need. Analyses will also examine facility level variation in buprenorphine provider capacity and telehealth use. These findings will identify key patient and facility-level factors associated with treatment need and indicate which patients and CBOCs should be prioritized for telehealth. Candidate: The PI's long-term goal is to build on her addiction clinical and research background to become a leading VA health services researcher developing and evaluating interventions to improve treatment and outcomes for Veterans with OUD and other substance use disorders. The PI will gain training in: 1) mixed methods, 2) randomized intervention trials, 3) implementation science and 4) multi-level modeling. With a stellar mentorship team and key operational partners, the research and training in this CDA will allow her to launch a long trajectory of research developing and evaluating effective and accessible interventions to improve outcomes for Veterans with OUD and other substance use disorders.	Equity				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CDA 18-186	Chen	Jessica		Jessica.Chen663@va.gov	Patient Readiness for Improvement through Motivation, Engagement, and Decision-making for PTSD (PRIMED-PTSD)	09/01/2020	09/30/2024	VA Puget Sound Health Care System Seattle Division, Seattle, WA	$578,202		Background: Over 1 million Veterans have PTSD and most (80% or more) do not receive first-line treatments, evidence-based psychotherapies, despite significant VA investment to increase access to these treatments. Clinicians often struggle to engage Veterans in evidence-based psychotherapies because they can be emotionally challenging treatments. Engagement could be catalyzed by mental health providers integrated into primary care (i.e., VA’s Primary Care-Mental Health Integration, or PC-MHI) to maximize the reach of engagement efforts beyond specialty PTSD settings. Shared decision making, a process by which the patient and provider discuss treatment options, weigh benefits and risks, and select a treatment that meets the patient’s needs, addresses known patient and provider barriers to evidence-based psychotherapies, including knowledge, self-efficacy, and trust. However, no study has examined shared decision making for PTSD in primary care. The proposal will address this knowledge gap by developing and refining a shared decision making intervention for PTSD, Patient Readiness for Improvement through Motivation, Engagement, and Decision-making (PRIMED), using input from Veterans with diverse perspectives, PC-MHI providers, and VA operational partners to optimize integration of shared decision making into clinical care. We will collect acceptability and feasibility data to support an application for a future effectiveness-implementation trial. Significance/Impact: Dr. Chen’s proposed research addresses three HSR&D and VA priorities: 1) increase engagement and retention of Veterans in evidence-based PTSD treatments, 2) advance health services research methods, specifically implementation science and user-centered design, which focuses on thorough integration of Veteran and frontline provider input, and 3) support suicide prevention efforts through effective treatment of PTSD, a major risk factor for suicide. Innovation: The proposed project will promote significant change in current VA clinical practice. PC-MHI providers typically refer out patients with PTSD and defer discussions about treatment options to specialty providers. This proposal will help PC-MHI providers use a formal engagement strategy, shared decision making, to improve patients’ knowledge of first-line PTSD treatments and to build motivation for care. Specific Aims: 1) Refine PRIMED using user-centered design methods and diverse Veterans’ perspectives, 2) Beta test PRIMED in one rural and one urban PC-MHI clinic to optimize integration into clinical workflow and achieve satisfactory acceptability and feasibility across a range of settings, 3) Conduct a small, randomized pilot trial (N=40) of PRIMED vs. usual care in two VA PC-MHI clinics to assess the feasibility of study procedures, which will inform a future larger trial. Methodology: In Aim 1, Dr. Chen will conduct qualitative interviews using user-centered design methods with 25 VA PC-MHI patients with PTSD, oversampling women veterans and racial/ethnic minority veterans, to refine the PRIMED intervention protocol. In Aim 2, Dr. Chen will use rapid, iterative beta-testing with approximately 20 patients to optimize the acceptability and feasibility of delivering PRIMED in the clinical setting and its integration into clinical workflow across varied settings (small rural clinics and large urban clinics). In Aim 3, Dr. Chen will conduct a pilot randomized feasibility trial (N=40) to assess the feasibility of recruiting and randomizing Veterans and measuring treatment engagement and clinical outcomes. Next Steps/Implementation: The research and training activities will prepare the nominee to conduct a multi- site, hybrid type 1 effectiveness-implementation trial to test the effectiveness of PRIMED for increasing receipt of first-line PTSD treatments and to begin to assess implementation barriers and facilitators. Future work to move this research into practice would involve collaborating with operational partners to improve VA SAIL performance measures in mental health, which are weighted to encourage evidence-based psychotherapies.	Mental and Behavioral Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CDA 18-187	Donovan	Lucas		lucas.donovan@va.gov	Redesigning Medical specialty Outpatient DELivery through virtual SLEEP care (REMODEL-SLEEP)	01/01/2020	03/29/2024	VA Puget Sound Health Care System Seattle Division, Seattle, WA	$1,261,007		Background: The VA is tasked with providing specialty care services for ~4 million Veterans annually, and specialty care for obstructive sleep apnea (OSA) provides representative challenges and opportunities to improve access to high-quality care. Almost 50% of Veterans are at high risk for OSA, and care to diagnose and treat OSA can improve quality of life and health outcomes. However, the VA has limited capacity to meet demands for OSA care with just over 300 sleep providers nationwide, and these specialists are concentrated in VA medical centers (VAMCs), far from many Veterans. Referrals to community care providers represent one strategy to meet demands for OSA testing, but these community referrals often lead to delayed and more expensive care than necessary. As an alternative, a virtual approach incorporating E-consultation is used at some VA medical centers to improve the reach and capacity of VA sleep providers. However, the effect of virtual consults on important OSA treatment outcomes is unknown. Furthermore, virtual consults themselves do not address the need for on-site services to train Veterans to use necessary testing and treatment equipment. The nominee plans to address these gaps by refining and testing the feasibility and effectiveness of a virtual consult pathway to provide care to Veterans at rural community based outpatient clinics (CBOCs). His intervention will consist of virtual sleep consults supplemented with embedded respiratory therapists to provide services on-site. The nominee also seeks to understand the cost implications of current approaches to meet Veterans' OSA testing needs, and estimate the budget impact of expanding VA based services. Significance/Impact: Dr. Donovan's research addresses three key VA priorities. (1) Provide greater choice for Veterans: The virtual consult intervention will allow more Veterans to choose VA services rather than rely solely on community care. (2) Focus resources more efficiently: His research pilots an intervention intended to provide more affordable and effective OSA care. (3) Improve timeliness of care: The proposed work seeks to improve access to proximal and timely sleep care for Veterans otherwise referred to the community. Innovation: The virtual care intervention challenges the current medical center focused model of VA specialty care. Dr. Donovan's intervention would redeploy respiratory therapists to provide necessary on-site services for OSA care at CBOCs, obtain specialist input through E-consultations, and use VA ECHO telementorship sessions to support the ongoing engagement and training of remote providers. In addition, Dr. Donovan plans novel budget impact analyses to inform where it is more advantageous for the VA to expand existing sleep services or purchase them from the community (i.e “make vs. buy”). Specific Aims: (1) Assess Veteran and provider perspectives regarding initial OSA care. (2) Test the feasibility and acceptability of a virtual consult pathway for initial OSA care. (3) Assess the nationwide impact of community care referrals for OSA testing on diagnostic costs, timeliness to care, and treatment adherence. Methodology: In Aim 1, Dr. Donovan will conduct qualitative interviews among 20 Veterans referred to sleep care in the community, and 12 VA care providers. In Aim 2, Dr. Donovan will enroll 70 Veterans in a pilot randomized trial of a virtual consult pathway versus community care referrals, and this pilot will address the feasibility of procedures and data collection necessary for a definitive trial. In Aim 3, Dr. Donovan will assess nationwide costs of OSA care for VA relative to Community Care. Dr. Donovan will use these costs to perform budget impact analyses of expanding VA-based care relative to community care referrals. Next Steps/Implementation: The research and training activities in this award will enable the nominee to conduct a type I hybrid effectiveness-implementation trial. This multi-site trial will test the effectiveness of virtual sleep care relative to community care referrals to improve patient reported OSA symptoms, experience, and costs, while simultaneously engaging in a process evaluation to identify barriers to implementation.	Care of Complex Chronic Conditions				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CDA 18-189	Panaite	Vanessa		vanessa.panaite2@va.gov	An eHealth intervention to increase depression treatment initiation and adherence among veterans referred for mental health services	04/01/2021	01/31/2025	James A. Haley Veterans' Hospital, Tampa, FL	$620,285		Background: Depression is the most prevalent mental health disorder in VHA and is strongly associated with disability and suicide mortality, especially when untreated. Understanding the profiles of patients that disengage from care will help develop support systems to improve care utilization and outcomes. According to Levesque’s framework, relevant patient characteristics that lead to care access map onto a process that incorporates identifying health care needs and desire for care, healthcare seeking, reaching, and utilization, all leading to health care outcomes. Using this framework, the proposed CDA takes a two-prong approach in response to underutilization of care among those with depression by: developing risk predictive models through analytics methodology and leveraging the role of mood and symptom self-monitoring as key components in depression management. Significance/Impact: The knowledge developed through this CDA has long term implications for OEF/OIF Veterans who are at highest risk for depression and suicide. Depression has a significant impact on Veterans, providers, and the VA. It is a disorder that is linked to substantial medical and economic burden in the VA. Depression is a risk factor for the development and maintenance of medical and psychiatric conditions (i.e., PTSD, TBI). Despite persistent efforts to increase care for depression, treatment guidelines are exclusively focused on those engaging in care. Pre-treatment interventions have the potential to increase mental health care utilization and reduce depression related burden on patients and the VA. Such interventions can minimize provider burden by reducing no shows and by increasing adherence. Innovation: Research shows that the VA has the potential to foster the development of tools to enhance mental health care for Veterans. To fill gaps in the use of analytics and technology in enhancing care for mental health concerns, the proposed work is innovative in two ways: 1) we propose the use of big data and analytics tools to identify patient profiles associated with mental health treatment engagement and increased risk for drop out of care; 2) develop a technology driven intervention to increase self-efficacy and active engagement in mental health care. Specific Aims: RA1: Identify risk profiles (scores) associated with depression treatment use. Test prediction models using VHA electronic health records (EHR). Risk scores computed in Aim 1 will be used in selection of patients at risk and eligible for the proposed intervention.TA1: Gain proficiency in methods and analysis of EHR/big data. RA2: Design an eHealth intervention using technology driven self-monitoring. TA2: Develop skills and knowledge about intervention development. RA3: Formatively evaluate and pilot the eHealth intervention. TA3: Gain proficiency in formative evaluation. Methodology: RA1 will use a retrospective cohort design. Leveraging the strengths of EHR data and analytics tools, we will investigate risk models to identify patient profiles associated with treatment initiation and adherence. Predictors will be extracted from structured data. RA2 is a development aim. We propose to design and formatively develop an eHealth intervention primarily using technology driven self-monitoring of depressed mood and symptoms. RA3 is a formative evaluation and pilot aim focused on the use of the intervention among OEF/OIF Veterans with probable depression (N= 15). Next Steps/Implementation: This CDA will help to establish a foundation for future efficacy/effectiveness research on interventions to increase treatment utilization among Veterans with depression. Results will be used to inform the submission of a RCT IIR in year 3 of the CDA to evaluate the efficacy/effectiveness of this intervention. Tools developed in this CDA will contribute to VA innovation goals.	Mental and Behavioral Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CDA 18-192	Woodward	Eva		Eva.Woodward2@va.gov	Veteran Engagement Implementation Strategies to Prevent Rural Veteran Suicide	07/01/2020	09/30/2024	Central Arkansas Veterans Healthcare System , Little Rock, AR	$585,218		Background. As a psychologist with strong beginner implementation science competencies, Dr. Woodward’s goal is to become an independent investigator and advanced implementation scientist to improve health equity in VA by engaging vulnerable Veterans in implementing healthcare services. In this CDA, she will acquire skills to identify, manualize, pilot, and rigorously evaluate effective methods to engage vulnerable Veterans (those who experience health disparities) throughout the implementation process. Health care disparities persist in VA. In community-based participatory research (CBPR), engaging consumers in research helps vulnerable populations improve health behaviors and outcomes. Thus, implementation researchers could also engage consumers in selecting and tailoring implementation strategies. Implementation strategies are techniques to enhance uptake of an intervention (e.g., quality monitoring, sustainability planning). There is little consumer involvement in this process likely because no formal guidance exists. Dr. Woodward will manualize methods to engage vulnerable Veteran consumers (including families, caregivers, community members) in selecting and tailoring implementation strategies. This manual (called Consumer Voice) will provide concrete guidance on what, when, where, how, and why an implementer might engage consumers in implementing or redesigning healthcare services. Dr. Woodward will pilot this manual in the context of implementing Safety Planning Intervention (SPI) for suicide prevention, focused on rural Veterans, a population particularly vulnerable to suicide. Suicide is VA’s top clinical priority. SPI is an effective intervention that reduces suicidal ideation and behaviors. Dr. Woodward needs training in CBPR, mixed methods in implementation research, and implementation strategy design. Significance/Impact. By adding Veterans’ voices throughout the implementation process, VA can increase access to and quality of healthcare for vulnerable Veterans and improve health equity. Dr. Woodward’s training will ensure her expertise in implementation science and health disparities to meet VA’s needs. Innovation. Consumer Voice is timely given critical needs for innovative implementation science to reduce health disparities and VA’s increasing emphasis on Veteran engagement. Consumer Voice is novel as the first manual to guide a process for consumer engagement throughout implementation; [although it will be piloted on SPI, it will be generalizable to other vulnerable groups and interventions.] Specific Aims. 1) Identify and manualize methods to engage consumers in selecting and tailoring implementation strategies (Consumer Voice). 2) Use Consumer Voice and pilot its acceptability, feasibility, and preliminary effect on implementation and Veteran outcomes. 3) Evaluate SPI sustainment [as a metric of Consumer Voice’s impact.] Methodology. In Aim 1, Dr. Woodward will use a CBPR approach to develop Consumer Voice. During the Aim 2 pilot, Dr. Woodward will implement SPI in two community-based outpatient clinics serving rural Veterans. The comparison site will receive Implementation Facilitation (IF) and the implementation site will receive IF+Consumer Voice. Dr. Woodward will use mixed methods to assess feasibility and acceptability of Consumer Voice. Dr. Woodward will use a pilot hybrid implementation- effectiveness Type 3 design and compare IF to IF+Consumer Voice on: 1) implementation (reach, adoption, fidelity); and 2) Veteran outcomes (depression severity, suicidal ideation, suicidal behavior). In Aim 3, Dr. Woodward will use mixed methods to re-evaluate Aim 2 outcomes at 12-month follow up to assess SPI sustainment. Dr. Woodward will also gather qualitative data from stakeholders to understand what hinders or promotes SPI sustainment and [compare the degree to which consumers were involved in each site’s Sustainability Action Plan]. Next Steps/Implementation. Dr. Woodward will conduct a full evaluation of Consumer Voice on implementation outcomes and suicide disparities between urban and rural Veterans. Full dissemination will include VA cyberseminars and meetings with policy and program partners.	Mental and Behavioral Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CDA 18-193	Wyse	Jessica		Jessica.Wyse@va.gov	Expanding access to opioid use disorder treatment with buprenorphine in rural primary care settings	07/01/2020	08/31/2024	VA Portland Health Care System, Portland, OR	$677,657		Background: Opioid use disorder (OUD) affects a significant number of VA patients, and has serious consequences, including overdose and death. While medication is recognized as the most effective treatment for OUD, it remains under-utilized within VA. This is particularly true for rural patients, who are 37% less likely to receive a medication for OUD than Veterans residing in urban areas. Addressing the rural disparity in access to medication has become increasingly important as rural areas have been disproportionately impacted by the consequences of the opioid crisis, including opioid-related mortality. Significance/Impact: Enhancing access to medication for OUD for all Veterans is a major priority within VA. The research proposed will address a substantial disparity in health care access for rural Veterans, and has the potential to positively impact thousands of rural Veterans with OUD who currently lack access to evidence- based OUD treatment. Innovation: The proposed research leverages the knowledge and experience of rural facilities that have been successful in integrating buprenorphine into primary care to inform the design of an implementation strategy to support rural, primary care buprenorphine treatment. Specific Aims: Aim 1: Characterize a) VA facilities’ rates of primary care buprenorphine prescribing over time and b) differences in primary care-based buprenorphine prescribing for rural versus urban Veterans. Aim 2) Among rural facilities with improved primary care based buprenorphine prescribing, qualitatively explore implementation strategies utilized, facilitators to success, and methods to overcome implementation barriers. Aim 3) Develop and pilot test an implementation strategy to facilitate the initiation and scale-up of buprenorphine prescribing in rural CBOCs within one VA facility. Methodology: This study utilizes a mixed methods sequential explanatory design, in which findings from each Aim inform the design and conduct of subsequent Aims, which themselves contextualize and elaborate upon initial findings. Aim 1 is a retrospective cohort study utilizing national VA data. Aim 2 utilizes qualitative interviews with a sample of clinical administrators and direct care providers embedded within rural facilities that have improved their rate of primary care-based buprenorphine prescribing over time. Aim 3 is a pilot trial of the implementation strategy that will be evaluated via formative evaluation methods. Next Steps/Implementation: The Aim 3 pilot will inform IIR #2 in year 5 of the CDA, which will be a multi- center trial of the implementation strategy within rural CBOCs of VISN 20, comprising Alaska, Washington, Oregon, and Idaho—states with a considerable number of rural primary care locations.	Care of Complex Chronic Conditions				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CDA 18-327	Mohanty	April		April.Mohanty@va.gov	Race/ethnic differences in guideline recommended hypertension medications in VHA	04/01/2018	04/30/2023	VA Salt Lake City Health Care System, Salt Lake City, UT	$816,060		Among Veterans, hypertension is the most common chronic condition with a prevalence of 37% and can lead to stroke, myocardial infarction, chronic kidney disease, and heart failure. Among blacks, hypertension occurs earlier in life, is more prevalent and severe, and is less likely to be controlled. While control of hypertension has significantly improved over recent years in the Veterans Affairs (VA), from 46% in 2000 to 76% in 2010, disparities persist among blacks, and reasons are not well understood. The Joint National Committee (JNC) publishes guidelines on evidence-based medications for hypertension treatment. However, controversy remains regarding the target blood pressure (BP) to achieve with therapy. The recently published Systolic Blood Pressure Intervention Trial (SPRINT), a landmark clinical trial, is anticipated to lead to changes in hypertension practices for patients with increased cardiovascular disease risk and without a history of diabetes. Investigators reported a reduction of systolic BP to <120 mm Hg (vs < 140 mm Hg) was associated with a lower incidence of cardiovascular-events, - mortality, and all-cause mortality for both black and nonblack patients. The extent to which systolic BP control of <120 mm Hg is achieved in VA is unknown. Special focus is needed for the VA group at highest risk for uncontrolled BP, black Veterans. This group is expected to grow at least 3% from 11% of Veterans in 2014 to 14% by 2034. The goals of this project are: Aim 1. To examine, one year following Veterans’ incident hypertension diagnosis, patient level predictors of (1) use of guideline-recommended medications and (2) BP control among Veterans and to describe how the effect of these predictors varies by race; Aim 2. To identify provider and facility level predictors of use of guideline-recommended medications and BP control among Veterans with incident hypertension and to describe how the effect of these predictors varies by race using mixed-methods; and Aim 3. To develop and pilot test a provider/team focused informatics strategy to facilitate hypertension control with enhanced features for racial minority Veterans. Aims 1-2 involve a longitudinal retrospective cohort study of black and white Veterans from VA facilities nationwide with incident hypertension 2007-2012 and examining outcomes of (1) prescriptions for JNC7 guideline-recommended medications and (2) controlled hypertension 1-year after incident hypertension diagnosis. Using regression models, patient- (Aim 1), provider- and facility-level (Aim 2) variables will be identified that are predictors for not receiving of guideline-recommended medications for hypertension and/or lack of BP control at 1-year of follow-up. Aims 1-2 further examine how these predictors vary by race. The qualitative analysis for Aim 2 will include chart review using natural language processing methods and a total of 36 telephone interviews with Patient Aligned Care Team (PACT) providers from 4 VA facilities (identified from Aim 1 and Aim 2) to ascertain reasons for not prescribing guideline-recommended hypertension medications among patients identified from Aims 1-2.The Consolidated Framework of Implementation Research will be used to conduct these interviews. Aim 3 includes the development of a trained and tested algorithm (from retrospective data) that incorporates SPRINT and Aim 1-2 findings and enhanced features for racial minorities based. A scenario based mockup with 20 Salt Lake City VA Medical Center (SLCVAMC) PACT providers will be used to determine initial tool feasibility, usability, acceptance, provider interest, safety, and satisfaction.	Career Development	Aim 1: We are conducting a national longitudinal cohort study of Veterans who accessed primary care within the Veterans Health Administration (VHA) and who received a new hypertension diagnosis between 2007 and 2012. Our study includes 21,125 black and 162,800 white Veterans with a new hypertension diagnosis over the 5-year period. We are assessing patient predictors (e.g. demographic, clinical, military characteristics) for achieving blood pressure control at 1-year follow-up by race using regression analyses. Aim 2: Among the Veterans included in Aim 1, we are using quantitative analysis methods similar to Aim 1 to identify provider- (e.g. number of visits with provider) and facility (e.g. urban/rural)-level predictors. We are also reviewing 300 charts and conducting semi-structured interviews with 36 Patient Aligned Care Team (PACT) providers to identify reasons for lack of guideline-concordant blood pressure management/prescribing. Aim 3: Aims 1-2 will inform the clinical decision support strategy which will align with current blood pressure management guidelines and will be developed to support the PACT workflow.	To identify patient-level (Aim 1), provider- and facility-level (Aim 2) predictors of use of guideline-recommended medications and blood pressure control among Veterans with newly diagnosed hypertension and to describe how the effect of these predictors vary by race; to develop and pilot test a provider/team focused informatics strategy to facilitate hypertension control tailored to reduce minority race disparities (Aim 3).	In 2014 11% of Veterans were black and this group is expected to grow by at least 3% over the next 20 years. My research aims to identify the causes of blood pressure related disparities and ultimately to develop an informatics strategy to support high quality, equitable healthcare for all Veterans. This research is consistent with the VA Blueprint for Excellence Transformational Actions: "to understand and eliminate health inequalities" and the VHA's Strategic Objective on Quality & Equity to ensure that Veterans receive "timely, high quality, personalized, safe effective and equitable health care."	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CDA 19-035	Blalock	Daniel		daniel.blalock@va.gov	Telehealth Treatment of Veterans with Alcohol Misuse at Risk for Cardiovascular Disease	05/01/2021	01/31/2025	Durham VA Medical Center, Durham, NC	$485,361		Background: Cardiovascular disease (CVD) is the most common cause of death in Veterans. CVD-related deaths are over twice as likely in patients with comorbid alcohol misuse, due in part to alcohol misuse directly exacerbating several modifiable factors that lead to CVD. No interventions exist targeting both these comorbidities, and current VA/DoD treatment guidelines for comorbid alcohol misuse in primary care are ineffective. Because alcohol misuse is often a recurrent problem, and the dominant driver of treatment recommendations, timely treatment of these Veterans’ CVD risk in conjunction with alcohol misuse treatment in may be critical for developing clinical traction with CVD risk. Dr. Blalock seeks to refine a telehealth intervention and acquire necessary training throughout this CDA-2 proposal to begin his career as an independent VA health services researcher who seeks to improve the effectiveness and reach of behavioral health treatments for Veterans with comorbid behavioral health problems. Significance/Impact: 9-32% of the entire Veteran population has comorbid alcohol misuse and modifiable elevated CVD risk. This high-risk population is entirely preventable, but is undertreated and understudied. The proposed CDA research would be the first to directly target this high-risk population. This research is highly relevant to Veteran health, VHA priorities, and HSR&D priorities because the combined intervention targets and telehealth approaches address critical gaps in treatment timeliness and access. Specific Aims: Aim 1 –Characterize a national cohort of Veterans with alcohol misuse and modifiable CVD risk, their alcohol services utilization, and clinical outcomes. Aim 2 – Qualitatively assess barriers to treatment for Veterans with alcohol misuse and CVD risk across multiple stakeholders. Aim 3 – Use a successive cohort design to iteratively develop an intervention based on patient feedback. Aim 4 – Test the acceptability and feasibility of an intervention to reduce alcohol misuse and CVD risk in Veterans. Innovation: This application is highly innovative in its attempt to address for the first time: 1) perceptions of barriers to treatment in this population, 2) the utility of a combined intervention for alcohol misuse and CVD risk, 3) multimorbid patient preferences for timing of treatments for multiple different targets, and 4) the sustainability of health behavior habits in VA formed by an intervention using “implementation intentions.” Methodology: Aim 1 will use electronic health records to examine the status of key health criteria and services utilization among Veterans with alcohol misuse, both with and without comorbid CVD risk. Aim 2 will use qualitative interviews of both Veterans with comorbid alcohol misuse and elevated modifiable CVD risk, their providers across different settings, and systems-level stakeholders to assess current treatment barriers. Aim 3 will employ a successive cohort design to iteratively test the proposed intervention with rapid and early feedback from multiple Veteran cohorts. Aim 4 will test a refined intervention based on feedback from Aims 2 and 3 to determine the acceptability to Veteran patients, as well as the feasibility of recruitment, randomization, and intervention. Next Steps/Implementation: Beginning in Aim 1, a systems-level advisory board will be convened semi- annually with the goal of eliciting feedback throughout intervention development to aid implementation. By the end of the 3rd year of the CDA-2, an IIR application will be submitted to fund a randomized comparative effectiveness trial of the Aim 3 intervention. Results will also be presented to local Veterans engagement panels associated with “VetREP.” Additional feedback from OCC and OMHSP operations partners, and implementation considerations gleaned from utilization patterns and care settings in Aim 4, will allow rapid development of a post-IIR implementation plan. Additional training in cost effectiveness and implementation science will also give Dr. Blalock the skills to follow through with additional research and implementation.	Health Care Organization and Implementation				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CDA 19-076	Simonetti	Joseph		Joseph.Simonetti@va.gov	Development and Testing of a Veteran-Centered Lethal Means Safety Suicide Prevention Intervention	07/01/2021	12/31/2024	Rocky Mountain Regional VA Medical Center, Aurora, CO	$859,498		Background: Seventeen Veterans die by suicide on a daily basis, and Veterans often seek care in Emergency Departments (EDs) prior to a suicide attempt. Lethal means safety (LMS) interventions, which aim to reduce access to common methods of suicide such as firearms or toxic medications, are considered important components of suicide prevention programs and are recommended for Veterans with elevated suicide risk. Significance/Impact: The Veterans Health Administration (VHA) considers suicide prevention a clinical and research priority. In 2019, VHA began screening all Veterans seeking ED care for elevated suicide risk. The VA’s National Strategy for Preventing Veteran Suicide highlights “efforts to reduce access to lethal means of suicide among Veterans with identified suicide risk.” However, no LMS intervention has been developed to accompany this initiative and prior LMS interventions have not been developed for US Veterans or VHA settings. The proposed work will address this critical gap in VHA suicide prevention efforts by developing and testing a Veteran-centered, ED-based LMS intervention for multiple methods of suicide. Innovation: Several evidence gaps must be addressed in developing such an intervention. No prior LMS intervention has been shown to be efficacious in promoting medication and firearm safety, and prior interventions have not accounted for the various, person-specific mechanisms by which individuals change behaviors. The proposed intervention will incorporate multiple evidence-informed elements specifically chosen to target different but complimentary behavioral mechanisms highlighted within the Health Belief Model (e.g., self-efficacy) as critical to behavior change. Elements include those that equip staff with evidence-based communication strategies, and provide Veterans with practical, patient-centered support to facilitate LMS behaviors. To ensure that this intervention meets the needs of at-risk ED patients and is sustainable long-term if shown to be efficacious, we will engage Veteran and clinical stakeholders to develop the intervention. Engaging stakeholders in intervention development, an emerging VHA priority, is critical for ensuring feasibility, acceptability, and credibility. As one Veteran remarked during a focus group, “I appreciate you all askin’ us what we’re thinkin’, rather than just sayin’, ya know, here’s what it is and here’s what it’s gonna be.” Specific Aims and Methodology: Aim 1: Identify contextual factors that may inform development of the intervention. I will conduct semi- structured qualitative interviews with up to 30 at-risk Veterans who recently received VHA ED care to identify intrapersonal, interpersonal, and institutional factors that should be considered during intervention refinement and adaptation in Aim 2. Aim 2: Leverage the expertise of a diverse sample of stakeholders to refine intervention elements, adapt them for use among Veterans and within VHA EDs, and develop a final intervention protocol and related materials. Building on prior studies and knowledge gained from Aim 1, I will employ a stakeholder-engaged process to refine, adapt, and finalize the LMS intervention protocol and materials. I will use two evidence-based methods to engage stakeholders and build consensus (Nominal Group Technique, online modified-Delphi process). Aim 3: Pilot the ED-based LMS intervention among 40 Veterans to assess feasibility and acceptability. I will assess feasibility of recruitment, staff fidelity to the intervention, and Veteran engagement, including after ED discharge, and acceptability of the intervention among participants, intervention staff, and ED staff. Next Steps/Implementation: Results from this pilot study will support an IIR application to test the efficacy of this intervention in promoting LMS behaviors among at-risk Veterans. If found to be efficacious, consistent with VHA’s public health approach to suicide prevention and my long-term career goals, my future work will aim to adapt and disseminate the intervention across various VHA (e.g., primary care) and community settings.	Mental and Behavioral Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CDA 19-081	Melzer	Anne		Anne.Melzer2@va.gov	Electronic Proactive Outreach for Smokers with COPD: Engaging patients to quit	08/01/2020	08/31/2024	Minneapolis VA Health Care System, Minneapolis, MN	$1,232,380		Overview: I am applying for a 5-year Career Development Award (CDA) to support my overarching goal of increasing smoking cessation among patients with respiratory diseases. This will be accomplished through the completion of mentored research activities and formal training designed to provide the skills necessary to become an independent investigator. During the course of my award, I will develop and test a program of proactive tobacco treatment for smokers with chronic obstructive pulmonary disease (COPD), delivered electronically and designed to increase participation in evidence-based tobacco treatments. Significance: COPD is one of the most common conditions cared for by the Veterans Health Administration and 90% of cases are directly attributable to smoking. Though the VA has made great strides in tobacco control, patients with COPD continue to smoke at rates double the overall VA average. Treatment for tobacco use disorder is the most impactful intervention for smokers with COPD. Unfortunately, smokers with COPD remain undertreated for tobacco use. Proactive tobacco treatment programs, where smokers are systematically identified outside of a routine visit, engaged in a cessation attempt, and connected to evidence- based treatment, have been found to be effective for increasing smoking cessation and use of quit support, and may be particularly beneficial for smokers with COPD. Proactive programs are rarely implemented, possibly due to high associated workload. Using electronic communication such as secure messaging to deliver this care may be effective without the cost and workload associated with previously tested telephone outreach programs. The intervention developed in this CDA proposal has the potential for wide-reaching impact, leveraging existing VA resources more efficiently to increase cessation in this high-risk population. Career Plan: My primary area of research has focused on identifying gaps in care quality for patients with COPD, particularly in tobacco cessation treatment. To successfully achieve my goals of improving utilization of tobacco treatment for smokers with COPD, I need further mentored training in implementation science including: qualitative and mixed methods, design and testing of behavioral tobacco interventions with a focus on mobile health, and cost analysis. I will achieve these objectives through formal coursework, seminars, and mentored research activities under the guidance of Steven Fu, MD MSCE (primary mentor, Minneapolis VA Health Care System [MVAHCS]), Hildi Hagedorn, PhD (MVAHCS) and David Au, MD MS (VA Puget Sound). Research Plan: My primary research objective is to develop and test an electronic proactive tobacco treatment program for smokers with COPD. To execute this goal, I will complete the following projects: 1) a mixed methods (survey and interview) assessment of current use of health information technology among smokers with COPD to (A) inform the creation of a proactive tobacco treatment program tailored to the target population (B) assess the association between the chronic disease state and intention to engage with the proactive program 2) a qualitative assessment of barriers and facilitators to implementation of proactive tobacco treatment programs for patients with COPD among staff and leadership to (A) understand the slow adoption of proactive tobacco treatment interventions and (B) inform future implementation efforts, 3) a randomized pilot of a proactive tobacco treatment program for smokers with COPD delivered through secure messaging and compared to usual care to (A) assess feasibility and (B) quantify the cost of the program. The proposed training and research projects will generate preliminary data necessary for development of a future Investigator-Initiated Research (IIR) proposal submitted in Year 3. I plan to propose a randomized comparative effectiveness trial comparing the intervention developed in this proposal to a previously tested telephone method for increasing tobacco abstinence, launching my career as an independent VA HSR&D investigator committed to improving Veterans’ health through enhanced access to tobacco cessation treatment.	Care of Complex Chronic Conditions				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CDA 19-108	Leung	Lucinda		Lucinda.Leung@va.gov	Improving Depression Management in Primary Care	07/01/2020	09/30/2024	VA Greater Los Angeles Healthcare System, West Los Angeles, CA	$1,052,385		Background: VA’s Primary Care–Mental Health Integration (PC-MHI) is rooted in evidence-based collaborative care models, where care managers, mental health specialists, and primary care providers jointly treat depression in primary care. While PC-MHI enabled specialists to support medication treatment in primary care, timely and sufficient access to psychotherapy is unattainable. Alternative therapy modalities are needed. Significance/Impact: Depression is disabling and affects one in five Veterans. Psychotherapy is preferred by Veterans, but fraught with multilevel barriers (e.g., staff availability, patient travel to clinic, limited clinic hours). Without enhancing existing PC-MHI models to enable better primary care patient access to effective psychotherapies, Veteran engagement in depression treatment is unlikely to improve. Innovation: This CDA aims to close the gap in psychotherapy access for VA primary care patients with depression by adapting PC-MHI collaborative care models to improve uptake of computerized cognitive behavioral therapy (cCBT). cCBT is accessible 24/7 via the internet and has effectively treated depression in more than 30 trials. With modest specialist support, it is non-inferior to face-to-face psychotherapy. PC-MHI can facilitate Veteran uptake of cCBT, using an evidence-based collaborative care model to provide the follow- up care management and mental health specialist back-up that characterizes the most effective cCBT trials. Specific Aims: This CDA will enable me to be a VA implementation scientist who designs, tests, implements, and disseminates effective collaborative care model improvements to treat depression in primary care. My Specific Aims are: (1) to adapt PC-MHI collaborative care to improve uptake of cCBT among VA primary care patients with depression, based on input from multilevel stakeholders; (2) to pilot test the feasibility, acceptability, and potential effects of cCBT-enhanced collaborative care on Veterans’ depression symptoms and related outcomes in one primary care clinic, in preparation for a larger, multi-site hybrid effectiveness- implementation trial; and (3) to establish expert consensus on the translation of pilot findings into a design for cCBT-enhanced collaborative care that is feasible locally, regionally and nationally in VA. Methodology: In Aim 1, I will use qualitative methods and elicit feedback from Veterans, VA providers, and other key stakeholders of national experts and operations leaders (CDA advisory group) to adapt the PC-MHI collaborative care model to improve cCBT uptake. In Aim 2, I will conduct a pilot randomized controlled trial (RCT) to examine feasibility, acceptability, and potential effects on depression, patient activation, and health- related quality of life in VA primary care patients with depression receiving either (1) cCBT-enhanced collaborative care (n=32) or (2) usual care (n=32) in West Los Angeles VA, from baseline to 2-months (post- intervention). This pilot will position me to conduct a multi-site hybrid type I effectiveness-implementation RCT. In Aim 3, I will conduct a virtual expert panel using modified Delphi methods to examine critical barriers and facilitators in the cCBT-enhanced collaborative care model for closing the gap in psychotherapy access for Veterans with depression and other illnesses in routine VA primary care, which will be informed by existing literature and VA-based pilot data. The CDA training and mentorship will facilitate my transition into an independent VA HSR&D investigator by filling explicit training gaps in implementation science (and qualitative methods), clinical trial design (for depression care), and health informatics. Next Steps/Implementation: Adapting PC-MHI’s collaborative care model to incorporate cCBT can improve access to psychotherapy and engage the ~400,000 untreated Veterans with depression who prefer psychotherapy, especially OIF/OEF/OND Veterans seeking care that is convenient. The CDA will provide mentorship and training to begin my career as an implementation scientist who leads collaborative care model improvements using novel technology to address unmet needs and preferences of Veterans in primary care.	Mental and Behavioral Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CDA 19-120	Jacobs	Josephine		josephine.jacobs@va.gov	Helping VA optimize its long-term care services	07/01/2020	09/30/2024	VA Palo Alto Health Care System, Palo Alto, CA	$770,080		By 2023, it is expected that the number of VHA enrollees aged 65 and over will increase from 4.1 million to 4.7 million. To meet the growing demand for long-term care services, VA has attempted to expand its home and community-based services (HCBS) through measures such as the 1999 Millennium Health Care and Benefits Act (the Millennium Act). These expansion efforts were based on the premise that HCBS provide care in Veterans’ setting of choice for a lower cost than in institutional settings and with comparable outcomes. Since passing the Millennium Act, however, VA still lags significantly behind other health systems with respect to rebalancing its long-term care expenditures away from institutional care and towards HCBS. VA’s 21 percentage point increase in the proportion of its long-term care expenditures spent on HCBS between 1999 and 2016 (from 5% to 26%) can be compared to Medicaid’s 42 percentage point increase over the same period (from 15% o 57%). VA needs to examine the empirical evidence to understand why this transformation remains elusive. A health system’s ability to rebalance towards HCBS is determined by a combination of patient, system, and family level factors. Precise patient targeting, local home health market conditions, and adequate supply of and support for informal caregivers all contribute to how successful health systems will be in rebalancing towards HCBS. However, these factors remain under-explored in the VA context – in part due to gaps in VA’s structured data and in part due to the limited application of methods that enable these types of analyses. My long-term goal is to become an independent investigator focused on leading research initiatives that help VA to achieve its long-term care rebalancing aims and to fill these gaps in the existing evidence base. The proposed research will strengthen VA’s knowledge of how patient, system, and family level factors are affecting its rebalancing efforts. Specifically, the research aims of this CDA-2 are to: 1) use natural language processing to extract patient functional status from free-text notes and use the constructed measures to improve prediction of Veterans’ one-year risk of institutionalization; 2) build a geospatial database of VA and VA-contracted home health providers and conduct analyses evaluating the association between distance to and market supply of home health agencies and long-term care utilization patterns; and 3) quantify the impact of informal care receipt on VA health care utilization and costs. I will achieve these aims by receiving mentorship and training in natural language processing, risk adjustment, geospatial econometrics, and causal modeling. These new skills will contribute to my overall career development and, in collaboration with my mentors and operational partners, enable me to submit two merit review proposals focused on developing enhanced HCBS patient targeting tools and improved caregivers supports. They will also enable me to submit an application for a partnered evaluation initiative with the Office of Connected Care aimed at developing a geospatial tool to help regional offices efficiently identify prospective partners for new home health service contracts. Overall, this CDA will help me to become an independent investigator focused on leading research initiatives that help VA achieve its long-term care rebalancing aims. The results of this CDA project will be relevant to Veterans, their caregivers, and VA policy makers involved in allocating long-term care funding and will be an innovative contribution to the broader literature on the determinants of successful HCBS expansion strategies.	Long Term Care and Aging				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CDA 19-233	Jones	Audrey		Audrey.Jones3@va.gov	Quality of Mental Health Services for Homeless Veterans in Primary Care Settings	04/01/2021	02/28/2025	VA Salt Lake City Health Care System, Salt Lake City, UT	$621,248		Background: My long-term goal is to become an independent VA health services researcher focused on designing and testing integrated care solutions to improve mental health and substance abuse (MHSA) services access, quality, and outcomes for vulnerable Veteran populations. This CDA-2 will provide me with the necessary mentorship, skills, and experiences to evaluate, modify and implement organizational changes that improve MHSA outcomes for vulnerable Veterans in primary care settings. Significance/Impact: Veterans who have been homeless have high rates of depression and opioid use disorder and barriers to accessing traditional primary care services. It is important to determine effective models of MHSA services integration at this time when Veterans have more options for care in VA and community settings. VA’s homeless patient aligned care team (H-PACT) program, implemented in over 60 VA facilities, offers a natural laboratory to determine optimal approaches of MHSA services integration to advance Veteran health. My research will impact Veteran health by determining the effectiveness of H-PACT for providing high quality MHSA care and mitigating adverse MHSA outcomes among homeless-experienced Veterans; and by determining the unique and potentially modifiable aspects of H-PACT and other patient aligned care teams (PACTs) that could be scaled to achieve superior MHSA outcomes for homeless-experienced Veterans in specialized and non-specialized PACT settings. This research strongly aligns with VA research priorities of mental health and primary care, and legislative priorities related to addiction recovery and community care. Innovation: While prior studies suggest H-PACT improves primary care utilization and Veteran experiences with care, there is less research focused on determining what features of H-PACT are successful. We lack data on clinical process measures and outcomes for Veterans empaneled in H-PACTs, information on aspects of MHSA services integration that exists within H-PACTs and traditional PACTs caring for homeless-experienced Veterans, and the barriers and facilitators that contribute to MHSA quality for homeless-experienced Veterans. Specific Aims: My CDA-2 has three primary aims: 1) Compare MHSA services quality of care (e.g., clinical performance measures for depression, opioid use disorder) and outcomes (e.g., psychiatric hospitalization, opioid-related overdose, suicide) for homeless-experienced Veterans empaneled in H-PACTs versus other PACTs in the same facilities; 2) Measure levels and features of MHSA services integration (e.g., coordination with community services, co-location of providers, full integration) for homeless-experienced Veterans in H- PACTs and other PACTs; and 3) Evaluate MHSA service practices and barriers in 4 facilities ranked low and 4 ranked high on measures of MHSA services quality for homeless-experienced Veterans. I will work with my mentors to develop the expertise to study MHSA services quality in primary care settings, and to augment my foundational training with new skills in survey design, qualitative methods and implementation science. Methodology: I aim to 1) use VA administrative data to operationalize MHSA services quality of care based on VA performance measures and established definitions; 2) adapt an organizational survey of H-PACT structures to survey providers from H-PACTs and PACTs about how MHSA services integration is achieved for homeless-experienced Veterans, and; 3) conduct stakeholder interviews in low and high performing facilities to identify barriers to delivering high quality MHSA services for homeless-experienced Veterans. Next Steps/Implementation: Findings will provide information to VA providers, operational partners, and leadership about the effectiveness of the H-PACT initiative, and targets for intervention to bolster lower performing H-PACTs. My pre-implementation research findings and training experiences will inform my future work focused on MHSA outcomes in specialized PACT settings, including an HSR&D effectiveness- implementation study (IIR) application to improve MHSA services quality for homeless Veterans in PACTs.	Mental and Behavioral Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CDA 19-349	Wray	Charlie		charles.wray@va.gov	Improving Access Through Targeted Delivery of Telemedicine	02/01/2021	09/30/2024	San Francisco VA Medical Center, San Francisco, CA	$1,091,868		Background: Improving access to care is a high priority within the VA. While improvements to access have been made in recent years, gaps and inefficiencies still exist, particularly around missed clinic visits, or `no- shows'. The VA reports that approximately 15-18% of scheduled outpatient primary care appointments are not completed and that 9.2 million appointments were lost because of no-shows in FY2017. In preliminary work, we demonstrated the importance of social risk factors on VA no-show rates. These findings suggest that a no- show prediction model that incorporates patient-level factors could predict missed clinic rates and provide clinical phenotypes (i.e. an aggregate description of a Veterns' social vulnerabilities) of Veterans at greatest risk of no-showing. VA Video Connect (VVC) is a newly developed telemedicine application that provides video conferencing services as a means to connect Veterans with their VA medical providers. With VVC, Veterans can access their VA provider from any mobile or web-based device (e.g. smartphone, tablet, or computer) and do not need to be located at a satelite clinic. Previous work supports the idea that VVC could be targeted to those at elevated risk of no-showing clinic appointments. This CDA proposes a risk-based, targeted use of VVC in patients with social vulnerabilities as a means of decreasing clinic no-shows. Significance: This proposal aims to improve access to care by identifying, describing and engaging Veterans who would most benefit from alternative methods of primary care, specifically VA Video Connect. Innovation: This research has several innovative aspects to it. First, we will utilize machine-learning predictive techniques to identify and describe Veterans who are at highest risk of no-showing based on their social risk. This methodology has never been utilized in addressing no-shows. Second, we will actively engage Veterans in a formative assessment of how to optimize the use of VVC as an alternative method to obtaining primary care. Engaging Veterans throughout this proposal will ensure that Veterans' voices are properly integrated into the final product. Finally, this proposal utilizes novel telemedicine technologies (i.e. VVC) as a means of improving access for Veterans who are at high risk of missing clinic visits. Specific Aims & Methodology: (1) Use regression tree analysis to phenotype Veterans based on their estimated risk of no-showing clinic appointments. Hypothesis: Social risk factors are associated with no- shows in the ambulatory VA population and certain phenotypes will have higher no-show rates compared to others. (2) Use a sequential exploratory mixed methods design to engage phenotyped Veterans at high risk for no-showing and assess Veteran suitability and capability of using VVC. Hypothesis: Certain phenotypes of Veterans will be optimally served by VVC, while other phenotypes will require higher intensity primary care programs or continued in-person care. (3) Pilot the targeted use of VVC among 50 Veterans at-risk of no-showing primary care clinic appointments at the SFVA using a Type I hybrid effectiveness-implementation design. We will collect formative implementation data about local adaptability, acceptability, and fidelity. Hypothesis: VVC will be an acceptable alternative modality of primary care for both Veterans and providers. Next Steps: Following the effective implementation of this CDA, we will work with operational partners (Office of Connected Care and Telehealth) and perform a multisite assessment of the focused use of VVC on Veterans at high risk of missing clinic appointment.	Access				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CDA 19-391	Bachmann	Justin		justin.bachmann2@va.gov	Development of a Tailored Intervention to Increase Veteran Enrollment in Cardiac Rehabilitation	01/01/2021	09/30/2024	Tennessee Valley Healthcare System Nashville Campus, Nashville, TN	$1,250,602		Background: This Veterans Affairs (VA) Health Services Research & Development Career Development Award resubmission is a five-year plan that will enable the candidate, a staff cardiologist and specialist in cardiac rehabilitation (CR) at the VA Tennessee Valley Healthcare System, to develop and implement interventions to increase CR enrollment in Veterans. CR is an outpatient program including prescriptive exercise and cardiac risk factor education that is an essential therapy for patients with cardiovascular disease. This proposal will develop a tailored intervention to increase Veteran enrollment in CR. Significance/Impact: CR is widely underutilized, with less than 20% of eligible patients enrolling in CR programs nationally. CR utilization is particularly low among Veterans, with only 10% of eligible Veterans enrolling in CR programs. Though CR referral rates have risen substantially over the past decade, CR enrollment has remained static. It is imperative to study barriers to CR enrollment among Veterans that have already been referred to CR and develop interventions tailored to these individual barriers. Innovation: The applicant will develop a tailored intervention for increasing CR enrollment using the Obesity- Related Behavioral Intervention Trials model, a conceptual model for intervention development, as well as the information-motivation-behavioral skills model, a theory of behavior change that allows individual tailoring. Linking these models will produce new knowledge regarding behavioral intervention methodology as well as an innovative clinical intervention that can be delivered by nurses and other clinical staff at VA facilities. The proposed intervention aligns with current VA initiatives by supporting CR enrollment wherever is most convenient for Veterans (including VA CR programs, non-VA CR programs, and home-based CR programs). Specific Aims: Aims 1 and 2 comprise a sequential explanatory mixed methods study to evaluate barriers to CR enrollment among Veterans. The purpose of Aim 1 is to quantify barriers to CR in 100 Veterans hospitalized with ischemic heart disease using the previously validated Beliefs About Cardiac Rehabilitation Scale (BACRS). The purpose of Aim 2 is to reveal additional barriers to outpatient CR enrollment through qualitative interviews in 30 Veterans from Aim 1 who did not enroll in CR. Aim 3 focuses on the iterative development of a tailored intervention to increase outpatient CR enrollment in 3 groups of 5 hospitalized Veterans, characterizing the intervention’s feasibility and acceptability. In Aim 4, the tailored intervention will undergo proof-of-concept testing in a non-randomized group of 25 Veterans hospitalized with ischemic heart disease. The applicant hypothesizes that these Veterans will have a clinically significant improvement in BACRS summary scores after the intervention, representing a decrease in perceived barriers to CR. Methodology: Aim 1 will quantitate the burden of CR barriers among Veterans by evaluating distributions of BACRS summary scores and subscales. In Aim 2, the applicant will use intensity sampling to purposefully select Veterans with the lowest individual BACRS subscale scores (and highest perceived barriers to CR) from the Aim 1 cohort for semi-structured qualitative interviews. Aim 3 will use mixed data from Aims 1 and 2 and serial formative evaluations to inform the iterative development of a tailored intervention. In Aim 4, the BACRS will be administered before and after the intervention, characterizing the intervention’s effect on perceived barriers to CR enrollment as measured by the BACRS summary score. Implementation/Next Steps: The applicant will align the study activities with the QUERI Implementation Roadmap and convene a Stakeholder Engagement Panel to ensure that the tailored intervention is developed with maximum generalizability to other VA facilities. Findings from the proposed study will inform a wide range of initiatives related to CR enrollment among Veterans and will be used to conduct a randomized clinical trial of the tailored intervention within the context of an Investigator Initiated Research application.	Access				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CDA 20-037	Cohen	Alicia		Alicia.Cohen@va.gov	Implementing a Clinical-Community Partnered Intervention to Address Food Insecurity Among High-Risk Veterans	10/01/2020	09/30/2024	Providence VA Medical Center, Providence, RI	$1,026,389		Background: Nearly 25% of Veterans are estimated to be food insecure (FI), experiencing limited or uncertain access to nutritionally adequate and safe foods. FI has been associated with a wide range of adverse health outcomes as well as increased healthcare costs and utilization. Concerningly, FI is frequently under- recognized in clinical settings including VHA. Prior research has shown that clinicians and other care team members often feel ill equipped to address FI even once identified. As such, there is a critical need to determine how to most effectively connect FI Veterans with relevant services and community resources in order to address Veteran FI and its downstream consequences. Gaps Addressed (Knowledge and Practice): In October 2017 the VA launched a national FI clinical reminder intended to screen all Veterans receiving care in the VHA. In the first 24 months of screening, the reminder identified over 77,000 Veterans across the country that reported FI. Little is known, however, about the variation in screening across VA sites; how sites respond when a Veteran screens positive for FI; or what VHA practices following a positive screen best improve Veteran food security status, Veteran experiences of care, and health outcomes. This proposed application would address these knowledge gaps. Innovativeness: Although VHA has begun to address social determinants of health more broadly, efforts to address FI are still in their nascency. This proposal, and the future area of research it will foster, is innovative because it seeks to develop novel VA-community partnerships that address key social determinants of health contributing to adverse health outcomes. This proposal further innovates through its emphasis on multi-level stakeholder engagement including strong Veteran engagement, and seeking Veteran-centered approaches to addressing food insecurity. Specific Aims: My long-term career goal is to become national leader in developing, evaluating, and implementing effective interventions to address Veteran FI and other social determinants of health. Through this CDA-2 application, I will build upon my prior training in family medicine and health services research to acquire advanced skills in implementation science, intervention design, and mixed methods evaluation. I propose the following research aims: Aim 1: Examine variation across VA sites nationally in implementation of the FI clinical reminder and characterize implementation experiences and community referral processes; Aim 2: Understand Veteran experiences of FI and their interactions with VA and community resources following a positive FI screen; Aim 3: Develop and pilot test an intervention model to optimize screening and referral processes for connecting FI Veterans to relevant VA and community resources. Methodology: This proposal employs a multistage mixed methods framework with integrated analyses across aims. Next Steps: When completed, this proposed work will evaluate current approaches to Veteran FI and identify and pilot strategies to integrate VHA-community partnered interventions to address FI into clinical practice. Findings will lay the foundation for a future IIR to conduct a multi-site trial of an intervention model. Further, the proposed research and training will help launch my career as an independent physician-investigator committed to providing a rigorous, scientific basis for reducing Veteran FI and related social determinants of health in a way that is Veteran-centered, maximizes patient autonomy, and optimizes health outcomes.	Equity				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CDA 20-049	Essien	Utibe		Utibe.Essien@va.gov	Access, Quality and Equity of Anticoagulants in Veterans with Atrial Fibrillation	02/01/2021	09/30/2024	VA Greater Los Angeles Healthcare System, West Los Angeles, CA	$913,990		Background. Atrial fibrillation (AF) is a common cardiac arrhythmia, affecting up to 1 million Veterans. AF increases the risk of stroke by 5-fold and is associated with higher rates of death. Oral anticoagulation reduces the risk of stroke in AF by 60%, yet such therapy is underutilized. Further, racial and ethnic disparities in anticoagulation for AF exist, despite a 2-fold higher risk of stroke among racial and ethnic minorities with this condition. In pilot work conducted in >40,000 Veterans with newly diagnosed AF in FY 2017, black Veterans were significantly less likely than white Veterans to receive any form of anticoagulant, particularly safer, more effective therapy with direct-acting oral anticoagulants. In these analyses there was up to 2.5-fold facility-level variation in the frequency of anticoagulation and in racial and ethnic disparities in such therapy. With the detection of these treatment disparities documented in VA, this CDA-2 will quantitatively assess the multilevel determinants of these disparities, qualitatively identify barriers to and facilitators of equitable anticoagulation for AF, and use these findings to develop and pilot test implementation strategies to eliminate these disparities. Significance / Impact. Ensuring access to high-quality, equitable care for all Veterans are VA and VA HSR&D priority areas. This CDA-2 addresses underuse of an evidence-based therapy for racial and ethnic minority Veterans with AF—a common and costly condition. The significance of this problem is likely to increase with the aging of the Veteran population and the steadily increasing proportion of minority Veterans receiving health care within VA. Innovation. This CDA-2 is framed using blended health equity and implementation science conceptual models to understand and reduce racial and ethnic disparities in health care. This CDA-2 uses novel data sources to assess the association of underexamined determinants of racial and ethnic disparities in Veterans with AF and is among the first to qualitatively examine Veteran experiences with AF and anticoagulation. Finally, this research will be the first to develop and test implementation strategies to reduce disparities in anticoagulation for AF. Specific Aims. Aim 1 is a quantitative study to characterize the association between race, ethnicity, and oral anticoagulant initiation in Veterans with AF. Aim 2 is a qualitative study to examine stakeholder perceptions of the barriers to and facilitators of equitable oral anticoagulant initiation in Veterans with AF. Aim 3 proposes to design and pilot test an empirically-developed implementation strategy bundle to improve equitable oral anticoagulant initiation in Veterans with AF. Methodology. Aim 1 uses a national cohort of ~130,000 Veterans with incident AF in FYs 2010-2019 to assess the patient, provider, and facility-level determinants of the association of race, ethnicity and anticoagulation. Aim 2 will recruit and interview providers, administrators, and Veterans with AF about barriers to and facilitators of equitable anticoagulant initiation for AF in VA. Aim 3 uses the findings from Aims 1 and 2 to develop and pilot-test the feasibility of a set of implementation strategies to promote equitable anticoagulant initiation within a local VA primary care practice. Implementation / Next steps. Findings from research Aims 1-3 will set the stage for a hybrid type 3 trial to broadly test the effectiveness of the pilot-tested implementation strategies on equitable anticoagulant initiation in Veterans with AF. Candidate. Dr. Utibe Essien is a general internist and Core Investigator in the VA Center for Health Equity Research and Promotion. The short-term goal of this CDA-2 is to gain training and research experience in understanding and implementing strategies to reduce treatment disparities in Veterans with AF. This will be achieved through in-depth training in: (1) advanced quantitative research; (2) qualitative research; (3) implementation science; and (4) professional leadership. This CDA-2 will support his long-term goal of becoming an independent VA health services investigator focused on developing implementation strategies to reduce racial and ethnic disparities in the use of evidence-based medical therapies for Veterans with chronic cardiovascular diseases.	Care of Complex Chronic Conditions				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CDA 20-057	Bachrach	Rachel	Emily Williams	Rachel.Bachrach2@va.gov	Implementation Intervention to Improve Care for Unhealthy Alcohol Use	10/01/2020	09/30/2024	VA Ann Arbor Healthcare System, Ann Arbor, MI	$537,731		Background. Alcohol use is a significant risk factor of disability and death for U.S. adults and one out of every six Veteran seen in primary care (PC) report unhealthy alcohol use. Unhealthy drinking is associated with increased risk for poor medical outcomes, substantial societal costs, and death, including suicide. Based on substantial evidence from randomized controlled trials and the U.S. Preventive Services Task Force, VA/DoD clinical guidelines stipulate that all Veterans screening positive for unhealthy alcohol use should receive evidence-based alcohol care in PC, including brief counseling interventions (BI) and additional treatment (e.g., pharmacotherapy) for those with alcohol use disorders (AUD). The VA was a pioneer in implementing alcohol screening and BI in PC, yet substantial implementation gaps remain. Approximately 25% of Veterans with unhealthy alcohol use still do not receive BIs and evidence suggests that the quality of BIs is lacking. For those with AUD, BI implementation has not appeared to increase access to recommended services (e.g., referrals) nor reduced barriers to pharmacotherapy. In order to improve the quality and fidelity of alcohol-related care, the current research proposes to use an evidence-based implementation strategy, practice facilitation, at one VA to pilot test whether practice facilitation has the potential to improve quality of PC-based alcohol-related care. Significance/Impact. This research directly addresses one of the largest public health crises of our time, as alcohol kills more people than opioids and is associated with increased risk of suicide. Thus, this work may have far-reaching effects on adverse outcomes experienced by Veterans and is aligned with top HSRD and VA priorities, including increased access to care and suicide prevention. Innovation. The project will use innovative implementation techniques not previously used to improve VA alcohol-related care. Specific Aims. Aim 1 is a qualitative study assessing Veteran and PC stakeholders to understand barriers and facilitators to high-quality alcohol care and use results to refine and hone the practice facilitation intervention. Aim 2 will deliver the practice facilitation intervention in a small PC sample to examine its acceptability and feasibility. Aim 3 is a pilot test of the practice facilitation intervention in the full PC clinic to understand whether practice facilitation improves quality of PC-based alcohol-related care. Methodology. Aim 1 will recruit and interview Veterans with unhealthy alcohol use (n=20-25) and PC stakeholders (N=10-15) to help refine the practice facilitation. Aim 2 will deliver the practice facilitation among a small sample of PC providers and staff (n=5-7) to assess acceptability/feasibility. In Aim 3, PC providers/staff from the full clinic will be invited to participate in the practice facilitation in order to assess implementation (e.g., reach) and effectiveness (reduced drinking) outcomes. Implementation/Next Steps. Findings will be presented to local and national operational partners and used to improve evidence-based alcohol-related care nationally across VA PC. Candidate. Dr. Rachel Bachrach is a clinical psychologist and postdoctoral research fellow in the Interprofessional Advanced Fellowship in Addiction Treatment based within the Center for Health Equity Research and Promotion (CHERP), a VA HSR&D Research Center of Excellence. The purpose of this CDA-2 is to facilitate Dr. Bachrach’s transition to an independent HSR&D investigator with a long-term objective of improving evidence-based care for addictive disorders. The short-term objective is to obtain formal training, expert mentorship, and research experience to facilitate a VA HSR&D career focused on improving prevention and intervention efforts within PC for Veterans who screen positive for unhealthy alcohol use. Mentorship will provide focused training on goals relevant for both the current CDA-2 research project and for Dr. Bachrach’s career as an independent scientist, including in-depth training in (1) implementation science; (2) alcohol-related care; (3) qualitative methods for intervention development; and (4) intervention design and evaluation.	Mental and Behavioral Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CDA 20-073	Gutierrez	Jorge		jorgeantonio.gutierrez@va.gov	Telehealth to Improve Functional Status and Quality of Life in Veterans with PAD	05/01/2021	01/31/2025	Durham VA Medical Center, Durham, NC	$1,194,298		The present study aims to increase Veteran access to supervised exercise therapy and expand its role in improving functional status, quality of life, and cardiovascular risk profile of Veterans with PAD. To accomplish these goals, we will use the VA Telehealth service to deploy a remotely accessible supervised exercise training program and evaluate whether a telehealth-based intervention can improve walking performance, quality of life, and ultimately cardiac risk in Veterans with PAD. The impetus for the current proposal stems from the following: 1) over 50% of VA-enrolled Veterans live in rural communities; 2) Veterans with PAD are older (mean age, 70 years), further increasing their risk for functional decline; and 3) there is a significant lack of access to facility- based supervised exercise training for Veterans with PAD. The training goals of the present proposal are the following: 1) To obtain practical research study management experience as primary investigator; 2) To develop skills required for scalable intervention development and implementation; and 3) To improve stakeholder engagement skills. By completing the following aims, the applicant will undergo invaluable training in regard to the development, implementation, and dissemination of a newly proposed Veteran model of care for local and national adoption. The central hypothesis of this proposed research is that a telehealth-based intervention can improve physical function, health-related quality of life, and reduce coronary artery disease risk among Veterans with PAD. Two prospective pilot studies will accomplish our initial steps and include the following: Aim 1. To develop a telehealth-facilitated exercise intervention for Veterans with PAD that serves as a Veteran centric new model of care. We will evaluate the feasibility, acceptability, and implementation of a telehealth-facilitated supervised exercise program. Using a prospective pre-post pilot study design, Veterans with PAD (n=54) will be enrolled in a 12-week, 3 day a week, aerobic training program in a self- selected location. Nine exercise cohorts of 6 patients are planned. Data on participation, satisfaction, technical errors, and adherence will be collected. Walking performance, quality of life, and PAD risk factor metrics at baseline and completion of intervention (3 months) will also be evaluated. Aim 2. To integrate Veteran preferences into the development of a telehealth-facilitated supervised exercise program. We will collect and evaluate patient, provider, and stakeholder feedback with each exercise cohort. These data will be used to actively modify the intervention to improve feasibility, acceptability, and potential scalability for future broad based implementation. Aim 3. To assess the long term patterns of functional impairment and quality of life among Veterans with PAD not undergoing supervised exercise training. We will conduct a prospective longitudinal study contemporaneous to the pilot study described above. Using a prospective cohort study design, we will measure the natural course of overall physical performance and its impact on PAD risk factors and quality of life of Veterans with PAD (n=100) in the absence of supervised exercise therapy. This cohort will not include Veterans participating in Aims 1 and 2. Data on walking performance, functional status, perception of walking ability, quality of life, PAD risk factors, and cardiovascular risk will be collected at baseline and 12 months. The pilot data collected through this proposal will guide the development of a novel Veteran centric model of care. Telehealth is highlighted as a research priority by the VA Office of Research and Development/Health Services Research and Development Service to improve access to care for underserved populations. Furthermore, this work serves as a foundation for a [subsequent Merit Award application during year 3 of the proposal focusing on a multi-site implementation trial and outcomes assessing reach, adoption, fidelity, and sustainability.]	Mobility, Activity, and Function				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CDA 20-104	Wyman	Mary		Mary.Wyman@va.gov	Improving Mental Health for Veterans with Dementia: Provider Training in Caregiver Engagement	07/01/2021	05/31/2025	William S. Middleton Memorial Veterans Hospital, Madison, WI	$520,957		Background: This career development proposal is designed to prepare Mary Wyman, PhD for a VA career conducting health services research focused on improving mental health care delivery and access for aging Veterans. Dr. Wyman will accomplish this goal by completing training activities, obtaining expert mentorship, and completing a series of research studies on family caregiver engagement in mental health services for Veterans with dementia. Comorbid mental health conditions (e.g., depression and anxiety) are common in dementia and are associated with worse outcomes if left untreated. To improve care quality and access, it is critical to effectively involve family caregivers in mental health services; however, providers lack the confidence and skills to do so. The primary objectives in this CDA application are 1) to use a qualitative research approach to identify facilitators and barriers to caregiver engagement; 2) develop and test a provider training curriculum to increase skills in engaging caregivers; and 3) use an existing dataset combining longitudinal survey data and VA health care records to explore how caregiving associates to use of mental health services among Veterans with dementia. Significance/Impact: This work has the potential to have significant and meaningful impact on the delivery of mental health care to aging Veterans. Our methodology will support rapid dissemination and implementation of the final, effectiveness-tested intervention, and our findings can inform development of future interventions to address modifiable factors associated with mental health care access and outcomes. This work aligns strongly with VHA and HSR&D priorities, including increased access to care, mental health and suicide prevention, caregiver support, and employee engagement. Innovation: While there are several effective interventions aimed at caregivers, we propose an innovative approach to increasing caregiver involvement in mental health care by training providers in knowledge and skills for effective caregiver engagement. As such, our proposal offers new directions for improving mental health care quality and access for aging Veterans. The resultant systems intervention may be applicable across VHA care settings and could positively impact employee engagement through increased provider self-efficacy. Specific Aims: Objectives will be achieved through three specific aims: 1) Identify patient-, provider-, and system-level factors that support or impede caregiver engagement in mental health care for aging Veterans with dementia; 2) Develop and pilot-test a provider training curriculum and implementation strategy to improve mental health provider engagement of caregivers of Veterans with dementia; 3) Examine associations of intensity of informal caregiving received and cognitive status with MH care utilization by aging Veterans. Methodology: Aim 1 involves semi-structured interviews with Veterans with dementia, their caregivers, and mental health providers and leadership. Aim 2 will use established methodology to develop, refine, and pilot-test a provider training and implementation strategy for the mental health setting. In Aim 3, data from the VA-Health & Retirement Study Aging Veterans Cohort will be analyzed to explore associations between caregiving, cognitive status, and mental health care utilization. Next Steps/Implementation: During the CDA period, a proposal will be submitted to fund an adequately powered “real-world” efficacy trial of the training curriculum. Dr. Wyman will work with local and national VHA dissemination partners to disseminate study results and the final, effectiveness-tested intervention. Embedded in the Madison VA GRECC and the rich environment of the University of Wisconsin, which offers extensive infrastructure to support early stage investigators, Dr. Wyman is in an ideal environment to complete the proposed research and training, allowing her to successfully launch as an independent investigator in VHA.	Mental and Behavioral Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CDA 20-231	Hayes	Corey		corey.hayes@va.gov	Data to Clinical Action: Using Predictive Analytics to Improve Care of Veterans with Opioid Use Disorder	04/01/2022	09/30/2025	Central Arkansas Veterans Healthcare System , Little Rock, AR	$510,151		Background. Medication for opioid use disorder (MOUD) prevents overdoses and improves mortality in Veterans with OUD, but retention on MOUD is critical for achieving those clinical endpoints. Only 50% of Veterans are retained on MOUD at 6-months post-MOUD initiation. Poor engagement in additional needed care services is an important risk factor for early MOUD discontinuation. Consequently, providers’ ability to identify Veterans in need of additional care or support while on MOUD may increase the likelihood of Veterans’ continued use of MOUD. Valid predictive models can provide an accurate probability of an individual Veteran experiencing the outcome being modeled (e.g., MOUD discontinuation). Prediction of future MOUD discontinuation risk could provide an innovative and real-time method for identifying Veterans in need of additional care (e.g., peer support). Significance/Impact. Predictive models could be used to lower MOUD attrition risk and improve outcomes for this Veteran population by continuously monitoring their risk of MOUD discontinuation in real-time during active MOUD treatment and identifying those Veterans in need of additional care (e.g., if increasing risk between visits, providers might add peer support services to a treatment plan). Innovation. This CDA-2 encompasses three HSR&D research priority areas (opioid/pain, health care informatics, and access to care) while crosscutting HSR methods of “big” data and implementation science, all in an effort to improve care and outcomes for Veterans with OUD. This study will also be the first to develop and pilot test a clinical decision support tool (CDST), based on a predictive model, to improve Veterans’ MOUD retention. Specific Aims. (1) To develop and validate PREMMOUD, a PREdictive Model for MOUD discontinuation. Hypotheses: (H1) I will develop a predictive model with good discrimination (e.g., c-statistic, a measure of goodness-of-fit, ≥0.8) for identifying Veterans likely to discontinue MOUD within the initial 6 months of treatment; (H2) the model generated using neural network techniques will have better discrimination than the models generated using random forest and logistic regression techniques. (2) To adapt PREMMOUD into a CDST to continuously monitor risk of MOUD discontinuation and provide clinical guidelines for addressing the primary risk factors driving the PREMMOUD score. (3) To assess (a) the feasibility of conducting a large scale, randomized controlled trial (RCT) to test PREMMOUD CDST’s (P-CDST) effectiveness as well as (b) P- CDST’s acceptability among waivered providers. Hypotheses: (H3) The feasibility of conducting a large-scale RCT to evaluate P-CDST’s effectiveness will be supported; (H4) P-CDST will be acceptable among VHA waivered providers. Methodology. Using machine-learning methods and data from the VHA Corporate Data Warehouse (2006-2019), I will train and validate PREMMOUD in a national sample of Veterans initiating MOUD (Aim 1). For Aim 2, I will conduct two rounds of focus groups with key stakeholders (VHA providers, Veterans receiving MOUD, VHA operations partners) to inform the creation of a beta-version of P-CDST to be integrated into CPRS/Cerner. To build P-CDST, I will use VHA CDW data, PREMMOUD, SQL Server Reporting Services (SSRS) and the Business Intelligence Service Line (BISL) platform. P-CDST will contain the patient’s real-time PREMMOUD score as well as clinical guidelines to support the provider in addressing the Veteran’s specific risk factors driving the PREMMOUD score. For Aim 3, I will conduct a single-arm, two- site pilot trial to assess study feasibility (provider enrollment, frequency of P-CDST use, and follow-up rates) and P-CDST’s acceptability (clinical usability of P-CDST). Implementation/Next Steps. Aim 1 will support an HSR&D IIR submission in Year 3 to assess whether PREMMOUD can be used to identify which Veterans, receiving MOUD, can effectively be treated in specialty care versus non-specialty care and which Veterans benefit from additional supportive services. A second IIR proposal will be submitted post CDA-2 to conduct an RCT, using a hybrid design, to evaluate the effectiveness and implementation potential of P-CDST in VHA.	Quality Measurement Development				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CDA 20-261	Boykin	Derrecka		Derrecka.Boykin@va.gov	Understanding Community-based Mental Healthcare for Rural Veterans with Military Sexual Trauma	04/01/2022	09/30/2025	Michael E. DeBakey VA Medical Center, Houston, TX	$419,401		Background/Significance: The 2018 MISSION Act allows Veterans to seek healthcare from non-VHA providers through the Veterans Community Care Program (VCCP). However, shortages of mental health providers in over 50% of U.S. rural counties jeopardize access to psychological services in these areas. These shortages indicate a growing need to bridge gaps in the provision of mental healthcare in rural communities. The VCCP presents a distinct opportunity for VHA to leverage its relationships with community stakeholders to develop innovative strategies to improve access to high-quality care for rural Veterans. Guided by the VHA state-of-the-art access model, this project seeks to understand the current state of VCCP mental healthcare and build a program that uses community engagement strategies to support community providers in delivering high-quality care to rural Veterans. This work will initially focus on rural Veterans who have experienced military sexual trauma (MST). These Veterans represent a high priority, understudied rural Veteran population. MST exposure is common among Veterans (25-33% of females, 1-3% of males) and associated with high rates of psychiatric distress and suicide risk. Preliminary data show that, despite equivalent rates of MST exposure, rural Veterans are less likely to receive psychotherapy than urban Veterans. Research on specific access barriers and gaps in mental healthcare for rural Veterans with MST is greatly needed. Innovation: Project innovations include: (1) targeting a high priority rural Veteran population with a history of MST, (2) obtaining input from Veterans and frontline community providers, and (3) novel use of community engagement and planning (CEP) to address gaps in rural mental healthcare. CEP is a community-based participatory research strategy designed to increase the capacity of community providers in delivering evidence-based care and building a community network of services. Specific Aims/Methods: Guided by the VHA access model, Aim 1 will use qualitative interviews and secondary data analysis to examine VCCP mental healthcare for MST. Qualitative interviews with Veterans will explore perceived accessibility, quality, and satisfaction with this care. A secondary analysis of VHA administrative and community care data will assess VCCP delivery and access outcomes (e.g., appointment wait time, session length and duration). Aim 1 data will support an HSR&D IIR proposal by year 3 to conduct an in-depth evaluation of VCCP delivery of MST-related mental healthcare. These data will also inform development of the Enhancing Community Care for MST Program in Aims 2 and 3. The proposed program aims to support VCCP and other community providers in aligning VHA and community resources to increase delivery of MST-related mental healthcare to rural Veterans. The program will educate community providers about evidence-based MST-related clinical practices and provide group consultation to facilitate their use of these practices. Group consultation will also include structured activities to assist providers in developing a collaborative community network of MST-related services. Aim 3 will pilot the feasibility and acceptability of the proposed program. Depending on Aim 3 findings, the PI will submit either an HSR&D pilot to refine the program or a larger research project (e.g., HSR&D IIR, VHA Office of Rural Health demonstration project). Next Steps: To achieve research aims and facilitate the PI’s transition to an independent VHA health services researcher, the CDA will provide advanced training in qualitative data analysis, community-engaged research methods, and program development and evaluation. These training goals will be accomplished through formal coursework, mentorship, and participation in training workshops, seminars, and conferences. The expertise gained from training and research activities will allow the PI to execute a line of research that aligns with VHA’s priorities of access to care/rural access and MISSION Act.	Women's Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CDA 20-273	Hung	Anna		anna.hung@va.gov	Helping Veterans Navigate Dual Pharmacy Benefits	07/01/2022	09/30/2025	Durham VA Medical Center, Durham, NC	$347,672		Background: Nearly 30% of Veterans with diabetes dually use Medicare Part D and VA to fill their antidiabetic medications, and dual users have poorer glycemic control and poorer medication adherence than Veterans who fill only through VA. Yet few resources exist to help Veterans understand and navigate between these dual pharmacy benefits. Significance/Impact: The goal of this research is to understand how Veterans are choosing between VA and Part D, identify knowledge gaps, and rigorously develop and test an intervention that will educate and optimize Veteran choice on prescription coverage. Innovation: This research is innovative because it: i) uses a stated-preference research method, called a discrete choice experiment, to quantify Veteran preferences when choosing which pharmacy benefit through which to fill their antidiabetic medications and ii) rigorously develops the first Veteran-facing decision aid that helps improve Veteran decision-making about where to fill their medication. By applying a Veteran-centered intervention focused on access to care and health care value to an aging population with a costly and prevalent condition, this proposal aligns with strategic goals for HSR&D, PBM, and VA in general. Specific Aims: The specific aims of the CDA-2 proposal are: 1) Identify medication acquisition challenges and informational needs that Part D-enrolled Veterans have when filling antidiabetic medications through VA or Medicare Part D; 2) Estimate how Veteran preferences around aspects such as prescription coverage, travel time, wait time, medication copay, and chance of adverse events influence where Part D-enrolled Veterans choose to fill antidiabetic medications; 3) Develop and assess feasibility and acceptability of a decision aid that helps Part D-enrolled Veterans comprehend VA and Medicare Part D prescription benefits to optimize choice on where to fill medications; and 4) Evaluate how dual use of VA and Part D to fill antidiabetic medications affects medication expenditures for Veterans, Medicare, and VA. Methodology: The proposed research consists of four projects, all focused on Part D-enrolled Veterans using antidiabetic medications. Project 1 is a qualitative study to identify knowledge gaps and other medication acquisition barriers that Veterans experience when filling medications through Part D versus VA. Project 1 will comprise of 24 interviews with Part D- enrolled Veterans with type 2 diabetes, and 12 interviews with caregivers. Project 2 consists of a discrete choice experiment study that estimates how Veterans trade off between different aspects such as prescription coverage, travel time, wait time, medication copay, and chance of adverse events when they decide where to fill their medications. Project 3 will involve the development and assessment of feasibility and acceptability of a decision aid based on findings from Aims 1 and 2. Project 4 will encompass a retrospective cohort study, using VA Corporate Data Warehouse medical records linked to Medicare claims data, to study the impact of dual use of pharmacy benefit on costs to Veterans, Medicare, and VA. Implementation/Next Steps: Two IIRs will be submitted to support: i) an expanded secondary data analysis that informs future implementation of the decision aid and ii) a hybrid type I effectiveness-implementation trial assessing the impact of the decision aid on Veteran satisfaction; medication supply, switching, and adherence; glycemic control; and costs to the Veteran and VA.	Care of Complex Chronic Conditions				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CDA 21-032	Kamdar	Nipa		Nipa.Kamdar@va.gov	Designing veteran-centered strategies to reduce and prevent food insecurity: A veteran and community-partnered approach	10/01/2022	07/31/2026	Michael E. DeBakey VA Medical Center, Houston, TX	$368,126		Background: Food insecurity is defined as limited or uncertain access to food due to household economic restrictions and affects 1 in 4 post-9/11 Veterans. Food insecure Veterans have increased risk for mental health conditions like depression and suicidal ideation. Current methods to reduce food insecurity focus on immediate food access but do little to address underlying contributors such as such as unemployment, poor access to healthcare, and social isolation. Fortunately, the VA has services that address these underlying contributors. Unfortunately, more than half of post-9/11 Veterans have yet to enroll in, or use, VA programs because they lack awareness of, and/or access to, services. Community-based VSOs are critical entry points for Veterans with unmet social needs who have yet to connect with VA services. However, we know little about their screening practices. Like in healthcare settings, robust screening and referral processes in community settings are imperative; otherwise, a large portion of Veterans may continue to go without food. Significance: The proposed CDA directly responds to the VHA HSR&D’s call for research to mitigate unmet social needs of Veterans. Mounting evidence indicates that food provision alone does not improve food security. We need a comprehensive approach that considers underlying contributors to food insecurity. Many of the 53% of post- 9/11 Veterans not enrolled in VA services separated with low enlistment ranks and/or are women. These characteristics place them at increased risk for food insecurity. Thus, we also need to integrate robust screening processes to identify Veterans who are food insecure where they are—in the community; otherwise, a significant portion of Veterans may continue to go with unmet social needs. Innovation: The need to partner with community-based organizations, VHA, and VBA to design an intervention that will address underlying contributors through peer-support to reduce isolation and navigate existing resources is the basis for the research proposed in this CDA. Our study will also, to my knowledge, be the first attempt to examine how VSOs are screening for food insecurity and other health-related social needs. Specific Aims: My long-term career goal is to be a VA-based independent investigator recognized for implementing innovative, community- engaged solutions that tackle food insecurity and other social determinants of health. With guidance from my mentorship team, I aim to increase proficiency with participatory research, expand knowledge on intervention design and evaluation, and build implementation skills to translate evidence to practice. To support these career objectives, during the CDA I propose to: Aim 1. Design a stakeholder-informed, wrap-around intervention to help post-9/11 Veterans who are food insecure. Aim 2. Conduct a feasibility trial of a stakeholder-informed, wrap-around intervention designed to provide Veterans who are food insecure with peer support and connect to existing services that address underlying contributors to food insecurity. Aim 3. Examine community-based screening practices for food insecurity and other health-related social needs in Veterans. Methodology: We will use the human-centered design framework to design a wrap-around intervention with key stakeholders (e.g., Veterans, community partner, VHA social work, and VBA outreach specialists). We will then conduct a 12-week feasibility and acceptability trial of the intervention. In Year 4 and 5, we will conduct a landscape survey of screening practices among VSOs in Texas and 1:1 in-depth interviews with select VSOs to further explore factors that facilitate and prevent screening in VSOs. Findings will include stakeholder-informed process maps for screening. Next steps: The research generated from this CDA will support an IIR submission to conduct a hybrid type 1 study of the stakeholder-informed, wrap-around intervention and a proposal to initiate and/or expand screening of social needs in community settings. As a VA- based nurse scientist, I will use the skills, mentorship, and experience gained from my CDA to generate research that will inform practice and policy to address complex social needs affecting Veterans.	Equity				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CDA 21-158	Apaydin	Eric		eric.apaydin@va.gov	Reducing Burnout among VA PCPs Using Evidence-Based Quality Improvement	10/01/2023	09/30/2027	VA Greater Los Angeles Healthcare System, West Los Angeles, CA	$188,955		Background: Burnout, a long-term psychological response to chronic workplace stress, is highly prevalent among providers and staff in VA primary care. Healthcare worker (HCW) burnout is not only detrimental to affected individuals, but also to the organizations that they work in. High rates of HCW burnout are linked to increased medical errors, worse quality of care, and worse patient experience. Burned out HCWs also work fewer hours and are more likely to leave their organization. Organizational interventions to reduce burnout are more effective than individual interventions, but no single organizational intervention is applicable to all settings. We propose to use evidence-based quality improvement (EBQI) to utilize collaborative leadership and PACT teamlet input to develop and pilot test a burnout reduction intervention, informed by evidence and facilitated by experts, that is tailored to the specific needs of participating primary care clinics. Findings from this work will inform strategies for implementing burnout interventions in other VA facilities, adapted to local organizational contexts. Significance/Impact: In VA, 31-55% of providers, nurses, clinical associates, and administrative associates in patient-aligned care team (PACT) teamlets consistently report burnout. Strong primary care models are essential to the VA’s integrated delivery system. High burnout, and subsequent turnover, could erode that strength by decreasing primary care staffing, team function and PACT fidelity, thereby impairing Veteran access and shifting more care to the community. Addressing burnout in primary care before it leads to larger downstream effects is essential to preserving Veteran health and the integrity of the VA healthcare system. In addition, addressing burnout in primary care meets the HSR&D and ORD research priorities of primary care practice and complex chronic disease management, and of increasing substantial real-world impact of VA research. Innovation: EBQI is an effective and well-evaluated strategy that aided in the implementation of PACT, Women’s Health PACT, depression collaborative care, and smoking cessation guidelines. The strategy also reduced provider and staff burnout during PACT implementation, but has never been used in tandem with burnout interventions to optimize impacts. This CDA is the first endeavor to combine EBQI as an implementation strategy with evidence-based burnout interventions, adapted for local organizational contexts. Through EBQI, a multi-level, collaborative approach that empowers frontline HCWs, we may increase the feasibility and impact of burnout reduction interventions. Specific Aims: In this CDA, I aim to: Aim 1: Understand facility- and clinic-level drivers of burnout in VA primary care; Aim 2: Develop burnout reduction interventions using an EBQI approach; and Aim 3: Evaluate feasibility, acceptability, and effectiveness of the pilot EBQI-facilitated burnout reduction interventions. Methodology: For Aim 1, I will measure burnout and identify burnout drivers using surveys and interviews, which will serve as the foundation for stakeholder-engaged priority setting processes using EBQI to design locally-tailored evidence-based burnout reduction interventions. Aim 2 will involve integrating the key drivers of burnout and intervention activities identified in Aim 1, and developing EBQI-facilitated burnout interventions (using stakeholder panels, quality improvement training, formative feedback, and practice facilitation). Aim 3 will entail evaluation of the feasibility, acceptability, and effectiveness of the EBQI-facilitated burnout interventions in a pilot stepped wedge design among five VA medical centers and community-based outpatient clinics in VISN 22. During Aim 3, I will also use interviews to identify intervention barriers and facilitators. Next Steps / Implementation: In Years 3 and 5 of this CDA, respectively, I will prepare and submit IIRs to conduct a national organizational survey to identify and study the impact of burnout drivers in VA primary care, and a larger multi-site cluster randomized controlled trial to fully evaluate the effectiveness and impacts of EBQI-facilitated burnout reduction. Findings will also be shared with national and local stakeholders to inform future implementation.	Career Development				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CDA 21-161	Blok	Amanda		amanda.blok@va.gov	Family-Centered Co-Design of a Technology-Facilitated Intervention for Family Caregivers of Critical Care Survivors	05/01/2023	04/30/2027	VA Ann Arbor Healthcare System, Ann Arbor, MI	$232,460		Background: Family caregivers play a central role during a Veteran’s critical care (medical care for a life- threatening illness or injury) hospitalization and survivorship. Yet, up to 73% of caregivers experience anxiety and 97% experience depression during a critically ill patient’s hospital stay, compromising their engagement with the clinical team, their readiness for the survivor journey and can impair patient recovery. Addressing family caregiver needs, including informational and emotional processing, social support and self-care, during key moments early in a family’s crisis may moderate the development of caregiver psychological distress. Significance/Impact: Supporting family caregivers is important for promoting caregiver well-being, engagement with the clinical team and Veteran outcomes during hospitalization and survivorship. This work addresses several VA priorities. Specifically, VA HRO values support family-centered approaches to care and the MISSION Act has increased supportive resources for Veteran family caregivers. While formal (paid) caregivers are commonly aware of and access these resources, informal caregivers—such as family caregivers of critically ill Veterans—are a missed yet vulnerable population. VA virtual care technologies (an HSR&D priority) may be an effective way to provide these caregivers with psychosocial resources to mitigate psychological distress and link them to VA programs that support caregivers and Veterans after hospitalization. In addition to helping family caregivers, this work supports Dr. Blok’s career goal of becoming a leading nurse researcher and implementation scientist in the VA, with a program of research in Veteran and family-facing intervention and implementation program design. Innovation: This research will create an intervention for family caregivers, with family caregivers, by using visual participatory methods, such as PhotoVoice, to understand support needs, and user-centered design principles to co-design an intervention with Veteran family caregivers to meet these needs. Drawing on Crisis Theory principles, this work extends beyond providing medical information, to address ‘crisis-solving’ needs, including information processing, emotional processing, social support and self-care, essential elements for reducing anxiety and distress. Finally, available VA virtual care technologies will be used to deliver intervention components to caregivers in crisis, which is a new application of these resources. Specific Aims: Aim 1. Identify how family caregiver experiences and needs evolve while their critically ill Veteran is hospitalized. Aim 2. Design a psychosocial support intervention with family caregivers, for family caregivers. Aim 3. Test the feasibility of a psychosocial support intervention for family caregivers. Methodology: In years 1-3, advanced qualitative and participatory research methods will be used to examine common key moments in the caregiver experience that can lead to distress and engage family caregivers and clinical team members in user-centered design to build psychosocial intervention components to meet caregiver needs during these key moments. In years 4 and 5, a single-arm pilot study of 30 family caregivers of hospitalized critically ill Veterans will be conducted to test the feasibility and acceptability of the intervention, as well as the tools used to collect quantitative and qualitative outcome measures. Implementation/Next Steps: Dr. Blok will receive mentorship and formal training in (1) advanced qualitative methods, (2) user-centered design, (3) development and adaptation of surveys, and (4) conducting clinical trials in complex settings. Additionally, she will build upon her work by submitting research proposals to (1) understand the persistence of factors impacting psychological distress after critical care hospitalization and (2) test the intervention piloted in Aim 3 through an effectiveness-implementation trial. National partners will be engaged throughout the award to provide opportunities to disseminate and utilize her findings.	Complementary and Integrative Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CDA 21-187	Robinson	Stephanie		stephanie.robinson5@va.gov	Developing an Intervention to Optimize Virtual Care Adoption for COPD Management	09/01/2023	09/30/2027	VA Bedford HealthCare System, Bedford, MA	$219,000		Background: VA is a leader in virtual care (VC), a term that covers over 60 patient- and team-facing mobile applications, an online patient portal, and numerous telehealth services. There is incredible potential for VC to support chronic disease management, such as that for chronic obstructive pulmonary disease (COPD). COPD is a leading cause of mortality and substantially more prevalent in Veterans than civilians. Use of VC in COPD has shown significant improvements in morbidity and hospitalizations. However, VC services can only support COPD management if they are adopted. Veterans are not currently taking full advantage of the power of VC, largely because neither patients nor the healthcare team are aware of the available options. My CDA will develop a strategy to address this gap. This CDA will equip me with the necessary training to tackle this and other barriers as I develop into an independent health services researcher with expertise in the development and implementation of VC services to support chronic disease management. Significance/Impact: As part of the MISSION Act, VA prioritizes providing “any care anywhere” and emphasizes the value of VC in achieving this goal. This prioritization is echoed in the VA Office of Connected Care’s 2021-2025 Strategic Plan which aims to enhance Veteran engagement with VC and empower the workforce to deliver VC. Aligned with these priorities, the proposed study will develop and pilot an innovative, patient-centered implementation strategy aimed at addressing patient- and healthcare team-facing barriers to adopting VC for COPD. The proposed work will yield knowledge as to whether this strategy is feasible and effective for engaging patients, encouraging patient-team decision making, and expanding access to VC services for patients who want to use them. This knowledge will be transferable across other chronic conditions by adapting the educational content pertaining to the VC services for other chronic conditions. An effective strategy to support VC adoption has potential for enormous impact on the lives and health of Veterans. Innovation: This is the first study to leverage VA’s Annie, a free and easily accessible short message service (SMS) texting platform, to deliver empowering educational content to support Veterans in navigating the multitude of VA VC services. Specific Aims: We will generate information about barriers and facilitators healthcare team members (Aim 1) and Veterans with COPD (Aim 2a) face regarding adoption of VC. Aim 2b will develop a multicomponent implementation strategy, referred to as VC-OPTIONS (Virtual Care for Chronic Obstructive Pulmonary Disease Adoption Support) to support adoption of VC for COPD management. Aim 3 will pilot the VC-OPTIONS implementation strategy to assess feasibility and acceptability and gather preliminary effectiveness data to inform a larger hybrid effectiveness-implementation trial. Methodology: In Aim 1a I will administer a survey to clinical team members to understand current awareness and use of VC and identify persons to interview in Aim 1b, which will use qualitative interviews to identify barriers and facilitators to supporting Veteran adoption of VC. Aim 2a will identify patient-facing barriers to VC adoption. This aim will also use a participatory design process to develop and refine educational content to be delivered via Annie as the core component of VC-OPTIONS. Aim 2b will develop and refine the components of VC-OPTIONS. Aim 3 will pilot the implementation strategy for feasibility and acceptability and gather preliminary effectiveness data on VC awareness and adoption. Next Steps/Implementation: The implementation strategy will be evaluated in a hybrid type 2 effectiveness- implementation trial in a subsequent IIR. Findings will be communicated to VA operational partners to inform the future of VC adoption initiatives. Knowledge from this CDA will prepare me to develop studies focused on supporting uptake of VC in other prevalent chronic conditions and overcoming other barriers to VC adoption.	Care of Complex Chronic Conditions				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CDA 21-194	Holder	Nicholas		nicholas.holder@va.gov	Improving Care for Veterans by Understanding and Facilitating Transition to Recommended PTSD Treatment	05/01/2022	08/31/2025	San Francisco VA Medical Center, San Francisco, CA	$522,497		Background: Posttraumatic stress disorder (PTSD) is one of the most common mental health diagnoses among Veterans. Cognitive processing therapy (CPT) and prolonged exposure therapy (PE) were widely disseminated in the Veterans Health Administration (VHA) as recommended PTSD treatments. Despite these efforts, few post-9/11 Veterans diagnosed with PTSD initiate CPT or PE. In the small percentage of Veterans who receive these therapies, CPT and PE are rarely the first treatment a Veteran receives. A common treatment sequence identified in implementation research, begins with “stabilization treatment,” combinations of psychosocial and medication treatments that prepare Veterans for CPT or PE. A gap in existing research is how treatment sequences, particularly stabilization treatment, influence initiation of CPT or PE. Significance/Impact: PTSD is an HSR&D priority condition due to its substantial negative biopsychosocial impact on Veterans lives. Novel strategies are needed to increase engagement, retention, and improve outcomes from recommended PTSD treatments, and to reduce disparities in access to this care. Understanding how to most effectively combine and sequence PTSD treatment is an HSR&D identified area of interest, and a research gap identified in the VHA PTSD clinical practice guideline. Innovation: Despite consistently identifying stabilization treatment as a common VHA practice, little research has investigated this treatment sequence. A novel approach to solving existing limitations in PTSD treatment delivery involves developing an intervention that both acknowledges the ubiquitous presence and benefits of stabilization treatment, while facilitating timely transition from stabilization treatment to CPT or PE. Specific Aims: This CDA-2 aims to improve delivery of PTSD services in the VHA, while simultaneously providing me with training in health services research methods to support my development into an independent VHA researcher. The proposed research aims are: (1) To qualitatively understand Veterans’ and clinicians’ perspectives on selecting stabilization treatments and how stabilization treatment serves as a barrier or facilitator of transition to CPT or PE; (2) To develop and conduct a randomized, pragmatic pilot trial of a brief, Veteran-centered intervention to support transition from stabilization treatment to CPT or PE; and (3) To identify sociodemographic disparities in treatment sequences and to determine how treatment sequences influence time to CPT or PE initiation across the VHA. Methodology: I will then conduct qualitative interviews with a national sample of Veterans (n=30) and clinicians (n=20; Aim 1). Using rapid qualitative analysis procedures, I will evaluate how treatment sequences, particularly stabilization treatment, are chosen and how they serve as a barrier or facilitator of transition to CPT and PE. I will then use knowledge gained from Aim 1 to develop a health services intervention that facilitates timely transition to CPT or PE. I will test this intervention in a randomized, pragmatic, pilot trial comparing the intervention (n=20) to treatment as usual (n=20; Aim 2). I will assess the proportion of Veterans who initiate CPT or PE within a year after beginning the intervention as a primary outcome and feasibility as a secondary outcome. Using electronic health record data from a national, longitudinal cohort of post-9/11 Veterans who received VHA PTSD treatment (anticipated n=400,000) from 10/05-12/23, I will identify treatment sequences; understand how treatment sequence impacts time to CPT or PE initiation using Cox proportional hazard regression; and identify disparities in treatment sequences based on sociodemographic characteristics (Aim 3). Implementation/Next Steps: I will apply the knowledge and training gained through this proposal to an HSR&D Merit application to test the benefits of the developed intervention on a large scale through a multisite hybrid type-II pragmatic trial. I will collaborate with organizational partners at the Office of Mental Health and Suicide Prevention to ensure that work supports efforts to promote clinical practice guideline-consistent care.	Mental and Behavioral Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CDA 22-008	Franzosa	Emily		emily.franzosa@va.gov	Maximizing the Value of VA Homemaker/Home Health Aide (H/HHA) Services to Veterans, Caregivers and VA: Supporting Older Veterans'' Pathways to Stable H/HHA Care	07/01/2023	09/30/2027	James J. Peters VA Medical Center, Bronx, NY	$263,301		Background: Home health aides (HHAs) advance VA’s priority to honor Veterans’ desire to age in place by improving health outcomes, reducing family caregiver burden and strain, and delaying or avoiding costly institutional placement. Lack of adequate, stable HHA support for older Veterans is associated with loneliness, depression and mortality. Improving access to HHA services is an urgent VA and legislative priority, and VA’s HHA benefit is the health system’s most widely used and fastest growing home and community-based service (HCBS). But because HHA care is purchased from community providers, navigating care can be complex and fragmented. Ensuring stable, continuous HHA care thus demands a stakeholder-engaged systems approach to better understand how Veterans navigate roadblocks and to identify potential interventions at the individual, organizational and policy levels. My extensive research and professional experience with HHAs and my qualitative training prepares me for this work. With mentorship and additional training in process improvement, intervention development, implementation science, and trial design, I will leverage this CDA’s findings into a bundle of actionable, multi-level interventions and advance my VA career. Specific Aims: This proposed CDA simultaneously fills the gaps in my training and provides VA with rigorous research on which to ground future interventions to strengthen Veterans’ caregiving teams in the home. This work is guided by a theory-driven framework and supported by operational partners in GEC, Caregiver Support, and Primary Care. Aims will: (1) Systematically describe the process of receiving and maintaining VA- paid HHA services by identifying steps; individual, organizational and policy-level roadblocks; and promising points of intervention. (2) Collaboratively adapt VA’s established Caregivers FIRST family caregiver curriculum for VA-paid HHAs. (3) Conduct a pilot and formative evaluation of the intervention at the Bronx VA. Methods: Aim 1: At 4 VAMCs diverse in geography, size, and HHA benefit structure, I will create process maps using participatory methods with Veterans, caregivers, VA primary care teams, VA HCBS coordinators, home health agencies and HHAs to prioritize potentially modifiable organizational factors to improve HHA access. Aim 2: Through a stakeholder-engaged co-design process informed by previous pilot data and the needs and barriers identified in Aim 1, I will develop an intervention to better prepare HHAs to provide Veteran- centered care. Aim 3: I will use mixed methods to assess implementation outcomes (feasibility, acceptability, usefulness) and HHA outcomes (preparedness). I will also examine potential downstream measures (caregiver burden, Veteran days at home). Expected Results and Next Steps: Throughout this study, I will provide my operational partners with key deliverables, including HHA process maps and priorities for organizational-level interventions, and a scalable, stakeholder-designed training program for VA-paid HHAs. Knowledge and skills developed through this CDA will help me develop multi-site studies to more rigorously evaluate the effectiveness of this intervention and address individual and organizational-level interventions through two proposed multi-site IIRs. Findings will inform future research and action to improve the delivery and stability of HHA services and leverage the skills of this critical workforce. Significance and Relevance to Veterans’ Health: My study is innovative, timely, and responsive to VA and legislative priorities. It addresses multiple HSR&D priority areas in Long-term Care/Aging and Disability, with a focus on health systems issues and cross-cutting HSR methods, and shines light on a critical yet understudied anchor of VA HCBS. This work comes at a critical juncture for VA as long-term care shifts to the community. This study seizes these opportunities, systematically identifying needed improvements and launching a promising intervention as a first step toward leveraging VA resources to support Veterans’ caregiving teams.	Health Care Organization and Implementation				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CDA 22-012	Connolly	Samantha		Samantha.Connolly@va.gov	Provision of high quality telemental health care during COVID-19 and beyond	10/01/2022	08/31/2026	VA Boston Healthcare System Jamaica Plain Campus, Jamaica Plain, MA	$319,170		Background: Telemental health (TMH) via videoconferencing or phone can increase Veterans’ access to mental health (MH) care. TMH can eliminate barriers including travel distance and cost, as well as physical limitations, caregiving responsibilities, and MH symptoms that can make leaving home difficult. Prior to COVID- 19, rates of TMH in VA were low (~9%). There was a dramatic shift towards TMH during COVID-19 to prevent infection, with ~50% of care delivered by phone, ~25% by video, and ~25% in-person. Benefits and drawbacks of phone, video, and in-person care must be considered when choosing a MH care modality. If patients, providers, and/or leadership believe that phone care is equivalent in quality to video and/or in-person, they may be more likely to choose this modality as it often has the fewest barriers to use; however, based on limited evidence, phone care may be lower quality than video and in-person. We need more nuanced analyses regarding: 1) the relative quality of phone, video, and in-person care (e.g., for more complex patients, for psychotherapy sessions versus shorter medication management appointments), and 2) patient preferences. As a clinical psychologist and HSR&D investigator with TMH experience, I am well-positioned to conduct this research. This proposal will provide key methodological training and advance me toward my goal of becoming a leading health services researcher and implementation scientist with expertise in telehealth. Significance/Impact: MH, telehealth, access, and quality of care are all major HSR&D research priorities. The increased use of TMH during COVID-19 has led to a wealth of untapped data through which we can examine the relative quality of TMH care as well as patient preferences across modalities, in order to improve care modality decision-making processes. Results, which will incorporate data from millions of patients and thousands of providers, have the potential to impact delivery of high-quality MH care on a national scale. Innovation: To our knowledge, there has been no published research that: 1) compares the quality and patient preference of phone, video, and in-person MH care, and 2) uses this information to develop and implement evidenced-based strategies to increase video use when clinically effective and preferred by patients. Specific Aims: Aim 1: Examine quality outcomes of phone, video, and in-person MH care (e.g., differences in MH hospitalization rates). Hypothesis: Video care will be equivalent to in-person care and superior to phone care for more complex patients (e.g., history of MH hospitalization, 3+ MH diagnoses) and for psychotherapy appointments. Aim 2: Qualitative interviews with MH patients, providers, and leadership. Research question: What are facilitators/barriers to video use based on stakeholder attitudes, preferences, and decision-making processes, and how do these factors vary between sites with high levels of phone, video, and in-person care? Aim 3: Develop/pilot implementation strategies to increase video use in circumstances where it is clinically effective and preferred by patients. Hypothesis: Implementation strategies will increase video use. Methodology: In Aim 1, I will test for differences in quality outcomes between modalities via a sample of ~2 million Veterans who received MH care between 3/2020-3/2021 using comparative effectiveness research strategies. In Aim 2, I will conduct interviews with key stakeholders to understand facilitators and barriers to video use based on attitudes, preferences and current decision-making processes. In Aim 3, I will synthesize Aim 1 and 2 findings to develop and pilot implementation strategies at one VISN 1 MH site to increase video use in circumstances where it is clinically effective and preferred by patients. Strategies will be targeted at the patient, provider, and/or system levels based on Aim 1 and 2 findings. Next Steps/Implementation: The piloted strategies will be spread to additional MH sites, and ultimately other clinical services, via hybrid implementation-effectiveness trials in subsequent IIRs. Findings will be communicated to MH and Connected Care operational partners to inform the future of VA MH care delivery.	Health Care Organization and Implementation				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CDA 22-054	Schwartz	Aaron		Aaron.Schwartz2@va.gov	Understanding Low-Value Veteran Care with Natural Experiments	10/01/2023	10/31/2027	Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA	$187,419		Background: Low-value medical services are common and costly. Veterans often receive services that offer little or no clinical benefit while generating costs and unnecessary risks. Gaps in research have hindered effective policies to address low-value Veteran care. First, the causes of low-value service use are uncertain. For example, through the VA Community Care program (VACC), Veterans are treated by non-VA clinicians who face few incentives to avoid unnecessary tests and procedures. However, it is unclear whether VACC has increased Veterans’ risk of receiving low-value services. Our research has shown an association between greater use of VACC and increased rates of low-value care. Rigorous quasi-experimental research could confirm whether this association is causal, guiding appropriate policy responses. Second, policies addressing low-value care have been hindered by a lack of evidence on what constitutes low-value care and how to translate evidence into effective clinical decision-making. To address these research gaps, first, I will test whether VACC under Choice/MISSION has increased low-value care. Second, I will study strategies to address low-value care via evidence development and evidence translation. Significance/Impact: Addressing low-value health care use is of crucial importance to Veterans, aligning with multiple dimensions of HSR&D priority domains including priority research areas (health care value, quality and safety of health care), priority HSR methods (advancing HSR methods in areas that cut across conditions or care settings), and priority policy/legislative areas (MISSION Act). Innovation: This research applies innovative methods to novel research questions. The quantitative methods have wide potential applications across VA HSR, though they have been rarely applied in this setting. Specific Aims: This Career Development Award (CDA) would support the following research aims: Aim 1 Quantify the effect of VACC under Choice/MISSION on Veterans’ low-value service use and spending. Aim 2a Convene an expert panel to identify and prioritize “gray zone” services ideal for evidence development. Aim 2b Conduct focus groups to identify barriers and facilitators to translating new evidence on service value into high-value practices Methodology: Aim 1: Using 33 measures of low-value services applied to national clinical data, we will test the effect of outpatient VACC on low-value service use and spending. A regression discontinuity (RD) analysis will examine a natural experiment that arose because VACC eligibility can differ for otherwise similar Veterans who live slightly different distances from VA facilities. Machine learning covariate selection techniques will optimize statistical power. Aim 2a: Via an expert consensus building process, clinicians, researchers and Veterans will prioritize “gray zone” services, which have unclear value, for evidence development. Services will be prioritized based on incidence among Veterans, expected costs/harms, and analytical tractability for RD analysis in VA data. Aim 2b: We will conduct focus groups with clinical and health system leaders as well as Veterans; drawing on a conceptual model of health care value, we will identify barriers and facilitators to translating new evidence on low-value services into high-value practices. Complementary training aims in qualitative methods, machine learning, and learning health system competencies will support the research aims. Next Steps/Implementation: This work has the support of the VA Office of Analytics and Performance Integration and VA Office of Community Care, operational partners whose efforts to detect and address low- value care will be enhanced by this research. I will collaborate with the VA Office of Community Care to assess how Aim 1 results will inform their efforts to discourage low-value care in VACC. I will submit one IIR proposal evaluating VA efforts to employ utilization management strategies in VACC. I will submit a second IIR proposal to quantify the value of high-priority gray zone services identified in Aim 2.	Career Development				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CDA 22-066	Abbate	Lauren		Lauren.Abbate@va.gov	Expanding Exercise Programming for Veterans Through Telehealth	04/01/2023	03/31/2027	Rocky Mountain Regional VA Medical Center, Aurora, CO	$535,067		Background: Exercise is an evidence-based intervention for the management of chronic conditions, yet the majority of Veterans are inactive. Group telehealth (GT) delivered exercise can potentially improve access to and participation in exercise. GT exercise sessions may increase exercise participation by providing social support, but a better understanding of the feasibility and acceptability of this format is needed. Telehealth delivered exercise programs should be designed with initiation and maintenance phases, but there is not consensus regarding the strategies for delivering exercise maintenance interventions. Skills for exercise initiation and maintenance differ, and interventions that focus on one or the other are not likely to result in sustained exercise participation. Significance/Impact: As the Veterans Health Administration is the largest integrated health care system in the US, implementing successful exercise programs could have a profound impact of public health. National priorities including telehealth and access to care as well as management of chronic conditions will be addressed by the development of this GT exercise initiation and maintenance intervention. Innovation: GT exercise combines the benefits of group exercise sessions, such as social support, and telehealth technology. There have been no studies comparing GT exercise booster sessions plus text messaging to text messaging alone to support exercise maintenance. These two strategies will be used as a multi-faceted approach to improving exercise maintenance. Specific Aims: Aim 1: Adapt evidenced-based exercise components for a group telehealth (GT) exercise intervention, guided by stakeholder input. Using qualitative methods, I will explore the perspectives of stakeholders through focus groups and interviews. Intervention development will include an iterative approach and formative evaluation. Aim 2: Conduct a randomized pilot trial to assess the feasibility and acceptability of the GT exercise initiation and maintenance program. I will use lower extremity osteoarthritis (OA) as a model to conduct this work because: 1) lower extremity osteoarthritis (OA) is a prevalent condition among Veterans, 2) exercise is a first line recommendation for the management of lower extremity OA, and 3) I have previous experience in OA. Veterans with lower extremity OA (n=50) will be randomized to the intervention. I will assess feasibility (i.e. referral, retention, data collection) and acceptability (i.e. number of sessions attended, number of text message responses, participant and provider feedback). Aim 3: Determine contextual factors related to successful implementation and sustainability of telehealth- delivered exercise programs within VA. Gerofit, an existing telehealth-delivered VA exercise program implemented at multiple sites, will be used as a model. An explanatory sequential mixed methods design will be used to describe site characteristics and simultaneously explore the perspectives of the site personnel, using survey and interview data. Methodology: The Practical Robust Implementation and Sustainability Model (PRISM), a conceptual framework for translating health interventions into practice, will be used with Dissemination and Implementation Science methods. Specifically, qualitative methods will be used to obtain stakeholder perspectives to design a GT delivered exercise program. A randomized pilot trial design will be used to pilot the GT exercise intervention to evaluate feasibility and acceptability. Mixed methods will be used to identify contextual factors related to successful implementation and sustainment. Next Steps/Implementation: This formative work will be used in a future larger, single site trial to test the effectiveness and evaluate the implementation of the GT exercise initiation and maintenance intervention.	Complementary and Integrative Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CDA 22-092	Ayele	Roman		roman.ayele@va.gov	Optimizing Transitions for Dual-Use Veterans Living with Dementia followingHospitalization in the Community	01/01/2023	08/31/2026	Rocky Mountain Regional VA Medical Center, Aurora, CO	$345,127		Background: The Veterans Health Administration (VA) mandated expanded community care services for Veterans with the VA Maintaining Systems & Strengthening Integrated outside Networks (MISSION) Act of 2018. As a result, the VA has increasingly partnered with community-based facilities and growing number of Veterans Living with Dementia (VLWD) will receive community and VA care (dual-users). However, there are gaps in care for dual-use Veterans, including increased hospitalization and fragmented care. Significance/Impact: Understanding community care for dual-use Veteran health outcomes, care quality, and safety is crucial and provides objective measures of MISSION Act. My CDA is significant for its potential to uncover current transitional care gaps, while creating an adaptable, pragmatic intervention aimed at reducing adverse outcomes for VLWD. Innovation: My CDA uses mixed methods to inform the identification of adverse transitional outcomes among VLWD and the adaptation of a pilot intervention. The VA is undergoing a major transformation due to the MISSION Act. My CDA research is innovative in assessing community care for VLWD, is the first to assess outcomes for VLWD in the MISSION Act era and inform adapted pilot intervention. The methods developed and applied in this CDA will provide a roadmap for evaluating and comparing outcomes across care settings while also identifying barriers and facilitators to transitions in care. Specific Aims Aim 1: Understand health care utilization patterns and associated outcomes of dual-use VLWD. Aim 2: Understand preferences and transitional care needs of dual-use VLWD, their care partners, and clinicians through qualitative interviews. Aim 3: Adapt and pilot test an evidence-based transitional care model to improve transitional care outcomes for VLWD following ED visit and/or hospitalization. This work has the support of the VA offices of Geriatrics and Extended Care, community care and emergency medicine and aligns with VA priority-- research focused on national legislative priorities affecting Veteran care, notably the MISSION Act. Methodology: We will use a mixed methods sequential quantitative-to-qualitative design. First, we will perform a quantitative study of dual-use VLWD to understand factors that contribute to adverse outcomes (30-day re- hospitalizations, 30-day ED readmissions and mortality within 30 days of hospital discharge). Second, we will perform a qualitative study of dual-use VLWD (n = 25), their family caregivers (n = 25) and their clinicians (n = 25) to identify transitional care priorities and needs. Third, we will use findings from Aims 1 and 2 to adapt and pilot an intervention aimed at reducing adverse outcomes of VLWD. Using mixed-methods, we will test the feasibility and acceptability of the intervention. Next steps: This CDA findings will be the basis for future work to study the effectiveness and impact on Veteran outcomes.	Long Term Care and Aging				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CDA 22-140	Gillmeyer	Kari		kari.gillmeyer@va.gov	Veteran-Centered Transformation of Pulmonary Hypertension Organization into a Regional Model of Care in VA (TRANSPHORM-VA)	01/01/2024	11/30/2027	VA Boston Healthcare System Jamaica Plain Campus, Jamaica Plain, MA	$207,208		Background: VA is tasked with providing timely, high-quality specialty care for nearly 3 million Veterans, yet faces unique challenges in doing so, including a large rural Veteran population and specialty provider shortages. These challenges are particularly evident for pulmonary hypertension (PH), a devastating and prevalent disease among Veterans with a median survival of only 3.9 years. Patients with PH require frequent access to PH experts and careful coordination across multidisciplinary teams and facilities to ensure high- quality care. Yet, VA has not taken a coordinated approach to PH care, and as a result there are wide gaps in PH care access and quality across VA. The redesign of VA PH care into a hub-and-spoke model is a guideline- recommended, evidence-based solution to improve PH care quality. The integration of telehealth technologies into this model, a “telehealth-enhanced hub-and-spoke model,” can advance this model to ensure every Veteran has equal access to state-of-the-art PH care. Yet, before this innovative solution can be implemented, several critical research and implementation questions must be addressed, including how to adapt other hub- and-spoke models to unique PH challenges, and which model components are key to improve outcomes. To address these knowledge gaps, this proposal will leverage survey data paired with in-depth qualitative analyses to understand provider and organizational characteristics of high-quality PH care within potential hub sites. This knowledge will inform the co-design of an implementation blueprint with stakeholder input that will be used to pilot test the telehealth-enhanced hub-and-spoke model in VISN 1. Significance/Impact: This research has the potential to improve the organization, access, quality, equity, and coordination of care for the more than 250,000 Veterans living with PH. Furthermore, by developing a process to design a telehealth-enhanced hub-and-spoke model that is driven by scientific hypotheses, grounded in theory, and integrates key stakeholder perspectives, this work will provide VA with key guidance to redesign specialty care for other specialty conditions. Innovation: The union of telehealth technologies with the organizational redesign of PH care into hub and spoke sites represents an innovative model of excellence for PH care to comprehensively address current gaps in PH care delivery across VA. Additionally, the integration of co-design with health services research and implementation science to develop a scalable solution to PH care delivery is an innovative approach that will ensure the solution is relevant and acceptable to key stakeholder groups while being rigorously evaluated for effectiveness and broader application to other complex redesign and implementation questions. Specific Aims: Aim 1: Characterize stakeholder perspectives on PH hub site care delivery through mixed methods. Aim 2: Co-design a blueprint for the reorganization of PH care into a telehealth-enhanced hub-and- spoke model. Aim 3: Assess feasibility and acceptability of core components of the hub-and-spoke model. Methodology: In Aim 1a, I will conduct a survey of Veterans and providers within the 22 VA sites that have existing PH expert clinics (potential future hub sites) to identify provider and organizational characteristics of high-quality care. In Aim 1b, I will conduct qualitative interviews of Veterans, providers, and clinical leaders at these potential hub sites to explore their perspectives on current VA PH care and the redesign of care into a hub-and-spoke model. In Aim 2, I will partner with stakeholders to co-design an implementation blueprint that comprehensively describes 1) the components of a telehealth-enhanced hub-and-spoke model, 2) evaluation metrics, and 3) implementation strategies. In Aim 3, I will use the implementation blueprint to pilot test the model across 2 VISN 1 sites and will assess its feasibility and acceptability. Next Steps/Implementation: This work will lead to the submission of two IIR proposals, including a hybrid implementation-effectiveness stepped wedge study across all 8 VISN 1 sites.	Career Development				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CDA 22-194	Dawson	Darius		darius.dawson@va.gov	Addressing Health Equity in Tobacco Cessation Treatment for Historically Underrepresented Veterans	01/01/2024	12/31/2027	Michael E. DeBakey VA Medical Center, Houston, TX	$133,865		Background: Tobacco inflicts a tremendous health burden on its users. Veterans use tobacco products at a higher rate than seen in the US adult population. Nearly 16% of African American Veterans and 11% of Hispanic Veterans smoke, compared to 12% of White Veterans. Risk of developing tobacco-related disease is highest for African American Veterans, with higher use of menthol cigarettes than other Veterans increasing burden. Hispanic Veterans are also at elevated risk for developing tobacco-related disease. However, both African American and Hispanic Veterans’ use of evidence-based tobacco cessation treatment in the Veterans Health Administration (VHA) is low, despite the 2019 VHA Directive 1056 updated requirements for increasing access to evidence-based tobacco cessation to Veterans. African American and Hispanic Veterans who use tobacco report greater readiness to quit and are more motivated to quit than White Veterans. High levels of motivation, desire to quit, and acceptability of treatment options should result in high levels of treatment initiation. However, low initiation of treatment may reflect cultural barriers to treatment and the need for tailored strategies to increase use. Significance/Impact: The project aims to improve the health of African American and Hispanic Veterans by addressing health equity and evaluating social determinants of health associated with accessing tobacco cessation treatment use, combining two important HSR&D research priorities. Increasing the proportion of African American and Hispanic Veterans that use tobacco cessation treatment in the VHA would greatly diminish disease burden, prevent mortality, and increase functioning in this underserved population. That, in turn, would decrease the healthcare burden on VHA, as well as the $2.7 billion dollars spent annually on tobacco-related care. Lastly, the project aligns with ORD-wide research priorities to expand historically underrepresented Veterans’ access to quality clinical trials and promotion of equity. Innovation: Project innovations include: 1) focusing on vulnerable and underrepresented African American Veteran and Hispanic population, 2) addressing under-researched health equity in tobacco cessation treatment in VHA, 3) novel use of the population-specific, health communication research methods, and 4) obtaining input from both Veterans and national stakeholders. Specific Aims: The project has 3 aims. Aim 1: Identify barriers and facilitators impacting delivery of tobacco cessation treatment to African American and Hispanic Veterans across facilities within VISN 16. Aim 2: Develop the Engagement, Navigation, and Transmission Intervention for Cessation Efficiency (ENTICE) intervention to increase African American and Hispanic Veteran initiation of tobacco cessation treatment. Aim 3: Conduct a pilot trial of ENTICE for African American and Hispanic Veterans at the Houston VAMC. Methodology: For Aim 1, a mixed-methods evaluation (interviews and VA administrative data) will identify barriers and facilitators of delivery of tobacco cessation treatment to African American and Hispanic Veterans across VISN 16. For Aim 2, the Boot Camp Translation process will integrate patient recommendations to develop two population-specific ENTICE interventions with 8 African American and 8 Hispanic Veterans who use tobacco and 4 African American and 4 Hispanic community members during a full-day retreat followed by 3, 1–3-hour sessions. For Aim 3, a pilot randomized controlled trial will assess the feasibility and acceptability of ENTICE compared to Enhanced Usual Care for 32 African American and Hispanic Veterans tobacco users. Next Steps/Implementation: Strategies and information generated during this project will highlight potential gaps in care that affect African American and Hispanic Veteran health and overall strength of the VHA system by addressing under-researched gaps in health equity. Activities in this project will foster the PI’s growth as an independent VA researcher and allow execution of a line of research that advances health equity in VHA.	Career Development				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CIN 13-401	Frayne	Susan		susan.frayne@va.gov	Center for Innovation to Implementation (Ci2i): Fostering High Value Health Care	10/01/2013	03/31/2022	VA Palo Alto Health Care System, Palo Alto, CA	$28,484,710		The U.S. health care system faces dual challenges: a continuing quality chasm and costs that are growing faster than the economy. The unifying concept of value, or health outcomes achieved per dollar spent, simultaneously addresses these challenges. The mission of the Center for Innovation to Implementation (Ci2i) will be to produce health services research in pursuit of high-value health care through better access, quality and wiser use of resources. Ci2i will have three thematic research goals (focus areas): " Fostering high-value mental health care (e.g., substance use disorder) where suboptimal access and underuse are common, " Fostering high-value medical specialty care for chronic disease (e.g., heart, liver, and renal disease), where costly hospitalizations, procedures and drugs demand better management, and " Advancing methods to assess and improve value through better modeling and informatics. Together, these clinical areas provide a generalizable portfolio of diverse domains in which value opportunities lie. The methodological innovations produced will support Ci2i's work and advance this field of inquiry. Though we concentrate on specialty care, our purview is not confined to specialists' offices; improving value may mean transforming some care now delivered in specialty settings to lower cost, more accessible venues, such as primary care or even self-care. The concept of the "Value Frontier," or the optimal allocation of resources- given current technology-to produce health, guides our research agenda. We will examine where the Veterans Health Administration (VHA) currently operates below the Value Frontier, to identify opportunities for innovation. We will then evaluate clinical and organizational innovations that either move care towards the frontier or transform care more fundamentally by expanding the frontier, particularly through the use of provider-facing informatics. In so doing, Ci2i will take advantage of the exceptionally fertile local environment at our academic affiliates of Stanford University and the University of California San Francisco for enhancing cost-effectiveness modeling, implementation science and structured health systems redesign. In addition to value-oriented research, Ci2i will advance health services research more generally, with particular support for research into the special populations of women and older Veterans. It will continue Palo Alto's tradition as a leader in career development of junior investigators locally and nationally through innovative use of distance mentoring and collaboration. Promoting their career development will be central to Ci2i's commitment to growing the next generation of high value health care investigators. Core investigators' extensive, deep and longstanding network of connections to implementation research centers and delivery system partners will ensure that the innovations we test are relevant to health system needs. The local presence of three Quality Enhancement Research Initiatives (QUERI's) will facilitate hand-off of proven innovations for study of their implementation and for wider dissemination. Ci2i will provide infrastructure support to these and other health services researchers nationwide committed to having a role in VHA's continued journey toward being a learning organization that delivers high-value care. In all of its endeavors, Ci2i is designed to be a model for the new breed of health services research built for both rigor and relevance in support of Veterans' health.					View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CIN 13-408	Saini	Sameer		Sameer.Saini@va.gov	Center for Clinical Management Research (CCMR)	10/01/2013	03/31/2022	VA Ann Arbor Healthcare System, Ann Arbor, MI	$21,915,194		For the second time in two decades, the Veterans Health Administration (VHA) is undergoing a major transformation. The VA Strategic Plan directs VHA to become more Veteran-centric, to use technology to better support health care delivery, and to improve appropriateness, safety, and efficiency of care for the 8.1 million Veterans it serves. Achieving these goals is clearly necessary for the VHA to retain its status as a premier healthcare system in the era of rising healthcare costs and rapid technology advancement. As health care reform broadens choices for citizens, VHA must become a healthcare system where well-informed Veterans choose to obtain their care. The Ann Arbor Center for Clinical Management Research (CCMR) has the expertise, experience, infrastructure, collaborations, and partnerships necessary to help VHA meet these goals. Our vision is to improve the quality, effectiveness, safety, and efficiency of Veteran's healthcare through research and partnerships that are driven by important challenges in clinical management. CCMR, an HSR&D Center of Excellence since 1996, has built the infrastructure necessary to recruit, mentor and support exceptional investigators, promote highly impactful research, ensure safe research practices, and develop enduring collaborations and partnerships. We have brought together 39 superb, multidisciplinary core investigators, many of whom are nationally recognized experts in a broad spectrum of disciplines, including performance measurement, decision-making psychology, behavioral change, systems design, measurement theory, health technology, and implementation science. Our research seeks to result in sustainable clinical and policy impacts in VHA. Thus, whenever possible, we work closely with our clinical, policy, and operations partners as we first develop research ideas and plans, and continue to work with them throughout the project to help ensure a clear path to implementation and impact. Our partners include leaders in our VISN and in VHA Central Office, several of whom have funded CCMR investigators to perform investigations and evaluations that advance their operational priorities. We plan to improve clinical management in VHA through three focused areas (FA) of research: FA1: To incorporate individual patient clinical data and preferences in predictive modeling, decision support tools, and performance measures that increase appropriateness and Veteran-centeredness of care. In the next five years, this work will develop the methods and tools to help VHA develop and implement a state-of-the-art performance management system that allows patients and providers to make individualized decisions about optimal care for common, important clinical situations. FA2: To develop, implement, and evaluate systems-based approaches to improve safety and outcomes for our most vulnerable, high-risk, and complex patients. In the next five years, our investigations will yield the tools necessary to systematically identify patients at high risk for poor outcomes, identify and monitor high-risk clinical practices, and develop and implement system-based interventions to mitigate risk and improve Veterans' outcomes. FA3: To use innovative approaches to improve the effectiveness and efficiency of patient self-management and treatment engagement. In the next five years, our research will produce resources designed to increase the efficiency of support for self-management and behavior change, increase the accessibility and effectiveness of these supports for Veterans, and decrease the adverse impacts of chronic disease on Veterans and their caregivers. In sum, CCMR has brought together an exceptionally strong group of investigators and staff notable for their expertise, productivity and synergistic mix of disciplines. Together, we will conduct innovative research that seeks solutions to common and costly clinical management challenges facing our nation's Veterans.					View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CIN 13-411	Owen	Richard		Richard.Owen2@va.gov	Center for Mental Healthcare and Outcomes Research (CeMHOR)	10/01/2013	03/31/2022	Central Arkansas Veterans Healthcare System , Little Rock, AR	$6,265,130		CeMHOR's mission as a Center of Innovation (COIN) will be to optimize outcomes for Veterans by conducting innovative research to improve access to and engagement in evidence-based mental health and substance use care. CeMHOR's vision is that this COIN will be the premier Center in HSR&D and the nation for mental healthcare research, producing measurable improvements in access to and engagement in evidence-based mental healthcare by conducting cutting-edge, high-impact health services research, in close and continuous partnership with Veterans, clinicians, managers, and policy makers. VHA has implemented new policies and programs to increase the availability of evidence-based practices and to enhance access to care. Despite this health care transformation, there are gaps in scientific knowledge regarding how to improve access and engagement. Mental Health (MH) services research is desperately needed to inform efficient and effective allocation of resources as VHA strives to provide patient-centered, cost-effective, evidence-based MH services. CeMHOR's research goals and proposed projects were developed by working closely with Mental Health Services (MHS), Office of Mental Health Operations (OMHO), the VISN 16 Mental Health Product Line (MHPL), and several other partners: the Primary Care-Mental Health Integration Initiative (PC-MHI), the Office of Rural Health (ORH), and the Office of Informatics and Analytics (OIA). CeMHOR also has close relationships with research centers that promote dissemination and implementation including the South Central MIRECC, other MIRECCs, and Mental Health QUERI. As its high-impact, partnered-focused area of research, CeMHOR proposes research to advance knowledge and address gaps in access to and engagement in evidence-based MH care (Goal 1). Within Goal 1 are three objectives that aim to improve access and engagement for a) rural Veterans in primary care settings (as proposed in CeMHOR's approved CREATE); b) Veterans receiving care in specialty MH settings; and c) Veterans in the community who face challenges in accessing and engaging in mental healthcare. CeMHOR will also continue to support and advance innovative research outside the focused area (Goal 2). Because CeMHOR investigators have been major contributors to scientific advances in the rapidly developing field of implementation science, and have led the field in moving mental health services research along the "implementation pipeline," the primary objective for this goal includes plans for ongoing contributions in this area. A secondary objective of this goal will be to support high impact research that, although it is outside CeMHOR's focus areas, will make significant contributions to improving care for Veterans. Goal 3 is to support mentoring and career development of MH services researchers. CeMHOR recruits talented investigators and fellows; provides formal mentoring and training programs, as well as a rich academic environment to develop their careers; and retains successful investigators. CeMHOR's advanced post- doctoral training program will emphasize methods to study and improve access and engagement; partnered research approaches; and implementation science methods, including hybrid effectiveness-implementation study designs. Goal 4 is to encourage and support clinical-research partnerships and cross-medical center research collaboration. CeMHOR will sustain existing and develop new partnerships with program offices, operations, frontline providers and Veterans, and promote collaboration with other VA investigators and Centers. At a time of dramatic change in VA mental healthcare, we propose a Center of Innovation (COIN) that will create new knowledge and have major impact on VHA mental healthcare and health policy.					View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CIN 13-412	Perencevich	Eli		eli.perencevich@va.gov	Center for Comprehensive Access & Delivery Research and Evaluation (CADRE)	10/01/2013	04/30/2022	Iowa City VA Health Care System, Iowa City, IA	$7,168,433		While Secretary of Veterans Affairs Eric Shinseki has made expanding access to care one of his three major themes, VA has had a continuous focus on expanding access to care for decades. Given the influx of new veterans and the growing needs of special populations (e.g., rural, homeless, women), the study and improvement of healthcare access needs to be a key focus of HSR&D. Further, as healthcare shifts from a primarily face-to-face episodic care paradigm to expanded communication and access, there remains a need for continued focus on measuring access as well as expanding access with innovative care models to all veterans. The CREATE focus for the Center will be hospital-associated infections (HAI), a major threat to patient safety. The most significant HAI, methicillin-resistant Staphylococcus aureus (MRSA), is the focus of a VA-wide MRSA Initiative and yet is still found on 13% of admitted Veterans, twice the national average. Three key factors may explain high levels of HAI in VA: 1) hand-hygiene compliance is suboptimal, 2) frequent movement of colonized/infected patients between acute-care and community-living center settings, and 3) current efforts to prevent transmission do not address endogenous infections (i.e., infections that arise in patients already colonized on admission) It is in this context that CADRE seeks COIN funding to advance its missions for understanding and expanding access to care (Goal 1, Focused Area) and preventing HAIs (Goal 2, Focused Area - CREATE). Goal 1 will focus on access to care with a particular focus on rural veterans, specialty care, and women's health services. Areas of innovative expertise include tele-health, tele-ICU, and understanding the impact of dual-use with non- VA care. Key operational partners include the Office of Rural Health and the e-Health QUERI. Goal 2 will focus on evaluating interventions targeting the prevention of HAI through the use of vertical (i.e., pathogen specific) and horizontal (i.e., pathogen non-specific) interventions. These efforts will be supported through partnerships with the VA Office of Public Health including the Center for Occupation Health and Infection Control along with VA's National Infectious Diseases Service. CADRE will also expand and support innovative health services research in several additional areas including women's health, substance abuse, mental health, and comparative effectiveness research (Goal 3). CADRE will continue its success in supporting mentored, career- development opportunities (Goal 4) and promoting cross-medical center collaborations in VA (Goal 5). CADRE will be led by two accomplished scientists, Eli Perencevich and Peter Kaboli, whose leadership in HAI prevention and rural access provide experience and the necessary connections with VA operations to undertake important partner-oriented health services research in the proposed Focused Areas.					View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CIN 13-415	Stroupe	Kevin		kevin.stroupe@va.gov	Center of INovation for Complex Chronic Healthcare (CINCCH)	10/01/2013	04/30/2022	Edward Hines Jr. VA Hospital, Hines, IL	$7,997,595		The mission of the Center for INnovation in Complex Chronic Healthcare (CINCCH) is to improve health care and outcomes for Veterans with complex chronic illnesses. We will accomplish this through research, mentorship and career development with the collaboration of operational and clinical partners. Veterans with complex chronic healthcare needs include those with multiple chronic illnesses (e.g., patients with neurological conditions and secondary conditions) or those with one or more condition who have complicated social situations and/or use multiple healthcare systems (e.g., dual Medicare and VA users). To improve care and outcomes for Veterans with complex chronic healthcare needs, CINCCH investigators will engage in activities to enhance the provision of patient-centered and evidence-based care and to identify new effective models of healthcare delivery. The Focused Areas for Research for CINCCH are to: 1) Improve patient-centeredness of care through new models of care and 2) Improve delivery of care for patients with neurological conditions. The first focused area of research directly addresses key VA transformational initiatives: provision of patient-centered care and use of new healthcare models for care delivery such as through technology. To achieve this goal, CINCCH investigators will conduct research to i) test new ways to deliver patient- centered care (e.g., through telehealth) and ii) enhance patient-centeredness of patient-provider communication (such as innovative patient and provider training). These projects are designed to develop and evaluate strategies, innovations and tools that ensure care is patient-centered and that have a measurable impact on patient outcomes. The second focused area of research will target Veterans with neurological conditions such as spinal cord injury and disorder (SCI/D), traumatic brain injury, and Parkinson's disease. These Veterans often have complex chronic care needs because they experience conditions secondary to their neurological condition (such as SCI/D-related pressure ulcers) and/or issues of coordination of care across providers and settings. To achieve this goal, we will conduct research to i) characterize, prevent, and improve management of secondary conditions associated with neurological conditions, ii) improve access to and coordination of care, and iii) improve healthcare practice in prevention and control of healthcare associated infections. To achieve these goals, CINCCH will partner with the Office of Patient Centered Care and Cultural Transformation (OPCC&CT) and with SCI/D Services. The partnership with the OPCC&CT will be key in ensuring that the COIN's research advances the VA's transformational initiatives. The partnership with SCI/D Services represents a long-standing and fruitful relationship with CINCCH investigators that has developed over the past 14 years in conjunction with the SCI QUERI, which is also based at Hines VA and includes many of the investigators who will participate in the COIN. This partnership will ensure implementation of key findings in this vulnerable population of Veterans. Overall, through innovative research and key partnerships, CINCCH will build on almost 30 years of experience and accomplishments by investigators from our VA HSR&D program to conduct research that will remain at the forefront of efforts to improve health care for our Veterans.					View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CIN 13-418	Axon	Robert		Robert.Axon@va.gov	Charleston Health Equity and Rural Outreach Innovation Center (HEROIC)	10/01/2013	04/30/2022	Ralph H. Johnson VA Medical Center, Charleston, SC	$6,519,353		The mission of the Charleston Health Equity and Rural Outreach Innovation Center (HEROIC) is to improve access and equity in health care for all Veterans by eliminating geographic, racial/ethnic, and gender-based disparities. Our strong, growing and talented group of VA health services researchers has been continuously funded by the VHA HSR&D Program for more than 8 years, as a TREP (2004-2008) and as a REAP (2008-current) under the leadership of Dr. Leonard Egede. Over the past 8 years, the Charleston TREP and REAP have achieved many major milestones, including (a) assembling a multidisciplinary MD and PhD faculty (19 core investigators and 15 affiliate investigators) who have effectively used both quantitative and qualitative research methodology to advance VA health services research and develop Veteran-centric interventions; (b) engaging clinical and operations partners, such as the VA Office of Rural Health, the VA Center for Minority Veterans, the VA Office of Health Equity and the VA Office of Informatics and Analytics; (c) obtaining funding for over 20 investigator-initiated Merit, QUERI and CDA proposals; (d) disseminating research findings via over 60 publications and 25 presentations, the majority of which were directly in line with the mission of HSR&D; (e) fostering an increase in VA HSR&D funding between 2004 and 2012; and (f) providing extensive mentorship opportunities to undergraduate and graduate research students, general internal medicine fellows, interns, and post-doctoral fellows. Our multi-disciplinary team has demonstrated scientific leadership in health services research; has led development and rigorous testing of innovative interventions for Veterans; has led implementation research as well as systems-oriented research; and has been consistently dedicated to research on health equity and access for rural and minority Veterans. We are smaller than many other programs, but our consistency in research focus, multidisciplinary make-up, and scientific leadership have enabled us to achieve national and international recognition in the areas of equity and access in a relatively short period of time. The three focused areas of research for the proposed COIN fall directly in line with our areas of expertise and HSR&D priorities: health equity, access, and rural health. The VHA is an "equal access" healthcare system for over 5 million U.S. Veterans. Yet, disparities in health continue to be significant despite success in addressing many barriers to care. Recent reviews continue to document disparities across all clinical content areas and our investigative team also has documented racial/ethnic, gender, and geographic disparities in health outcomes among Veterans. Our COIN, consistent with over 8 years of research, will develop and test interventions to eliminate health disparities in clinical outcomes for Veterans and improve access for rural Veterans. We define health disparities as racial/ethnic, gender, and geographic (urban-rural) differences in health outcomes for chronic medical and mental illnesses among Veterans. The CREATE for our COIN was conceptualized in collaboration with our partners: the VA Office of Rural Health, VA Office of Health Equity, VA Center for Minority Veterans, and VA Office of Informatics and Analytics and includes 5 closely linked CREATE projects that will advance the field in our focused area of research. Our CREATE is entitled, "Access to Evidence-Based Interventions for Rural and Minority Veterans." The CREATE projects will be conducted in partnership with investigators from CHERP, VISN 7, and National Center for PTSD/Pacific Islands VA. In addition to support from our host medical center, we have very strong institutional support for the COIN from our academic affiliate, the Medical University of South Carolina (MUSC), which has made a commitment of faculty FTEs, space and institutional resources to ensure the success of the COIN.					View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CIN 13-419	Rudolph	James		James.Rudolph@va.gov	Center of Innovation in Long-Term Services and Supports for Vulnerable Veterans	10/01/2013	04/30/2022	Providence VA Medical Center, Providence, RI	$7,231,583		Background: The VA Geriatrics and Extended Care (GEC) envisions a dynamic long term services and supports (LTSS) system that emphasizes community living, with provision of needed care enhanced by community-based LTSS. Facility-based LTSS is viewed as a choice of last resort when community-based LTSS cannot support function. This Veteran-centric approach toward the least restrictive environment and enabling community living is supported by a suite of community-based LTSS programs administered by GEC Accomplishments: Since funding in FY2014, the LTSS COIN has significant accomplishments including a HSR&D funded CREATE, 5 funded HSR&D Merit Proposals, two VISN-1 Career Development Awards (CDA), an HSR&D Office of Academic Affairs (OAA) advanced fellowship, and a partnered QUERI. Additionally, the LTSS COIN investment in the Geriatrics and Extended Care Data Analysis Center (GEC DAC) is beginning to pay dividends with three QUERIs (one program and two partnered) using the Residential History File (RHF) as the backbone of operations data. Partners: The LTSS COIN has a close partnership with VHA GEC where the GEC Chief Consultant and Executive Director of GEC Operations lead the LTSS COIN steering committee. The LTSS COIN has research programs involving multiple VHA partners regionally and nationally; new research will be similarly partnered to increase benefit to GEC, HSR&D Research, VA policy and the care delivered to Veterans. Goal: The LTSS COIN proposes 4 goals for this renewal: 1. To improve access, quality, and value of LTSS for vulnerable Veterans; 2. To advance HSR&D research at the Providence VAMC in areas and populations that are relevant to, but outside of the focused area of LTSS policies and service delivery models; 3. To support mentoring and career development of clinician- and non-clinician-investigators interested in LTSS locally, regionally, and across VHA; 4. To expand the network of LTSS researchers, clinicians, leaders, and policy-makers within VA and outside-VA with vested interest in LTSS and the work of the LTSS COIN Plans for Accomplishing these Goals: In the 5 years of funding sought for this proposal, we will work closely with VHA GEC to enhance the value of LTSS COIN through program evaluation, quality improvement, and implementation research. To accomplish this, the LTSS COIN is focused on delivering results of our ongoing partnered research with the LTC-CREATE, CNH QUERI, and Providence VAMC HSR&D. At the same time, the LTSS COIN has several investigators submitting new HSR&D investigator initiated research and CDA applications. We will leverage GEC DAC as a resource for HSR&D research, partnered QUERI LTSS evaluations, and implementation by sharing scientific expertise, resources, and personnel. The LTSS COIN was awarded an OAA Advanced HSR&D fellowship and will leverage close connections with Brown University's Center for Gerontology and the University of Rhode Island to train junior investigators in LTSS research and implementation. Each of these steps broadens our network of invested LTSS researchers, clinicians, and policy-makers and will lead to the development of the LTSS COIN Research Resource Center. This center will enable HSR&D and other researchers to collaborate on national protocols, implementation, disseminations, and value assessments to meet the mission of the LTSS COIN. As a result, the LTSS COIN will become the hub of HSR&D LTSS research, aligning investigators across disciplines, including through pilot funded locally initiated projects.					View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
COR 20-186	Ho	P. Michael	Peter Kaboli, Sameer Saini, Stephanie Shimada	michael.ho@va.gov	Access Consortium of Research (CORE)	01/01/2020	02/29/2024	Rocky Mountain Regional VA Medical Center, Aurora, CO	$1,065,902	https://www.hsrd.research.va.gov/centers/core/						View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
COR 23-190	Mattocks	Kristin	Denise Hynes, Megan Vanneman, Michelle Mengeling, Amy Rosen	kristin.mattocks@va.gov	Access and Community Care Engagement Network Team (ACCENT) CORE	12/01/2023	12/31/2027	VA Central Western Massachusetts Healthcare System, Leeds, MA	$363,998	https://www.hsrd.research.va.gov/centers/core/accent/						View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
CYS 04-253	O'Keefe	Gerald		Gerald.Okeefe@va.gov	VA HSR&D Cyber Seminar Series	07/01/2004	12/31/2021	VA Boston Healthcare System Jamaica Plain Campus, Jamaica Plain, MA	$4,840,478	https://www.hsrd.research.va.gov/cyberseminars/			HSR&D Cyber Seminars employ state-of-the-art web conferencing technologies to enable users at remote locations to engage in interactive sessions. Sessions are also recorded for on-demand access thereby expanding the reach of the sessions even further.	To enable HSR&D resource centers to continue current training offerings and expand offerings available to their target audiences without the investment of time and the expense of travel to a centralized location.	The cyber seminars have leveraged existing HSR&D Resource Center training and education resources to provide key training sessions and seminars without expending additional resources for travel. Interest in the cyber seminars beyond the HSR&D Resource Centers has extended these cost savings to other HSR&D programs and initiatives. The cyber seminar technology provides HSR&D with a powerful state-of-the-art tool for communication, collaboration, dissemination and education.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 14-080	Mavandadi	Shahrzad		Shahrzad.Mavandadi@va.gov	Comparative Effectiveness of Delivery Methods for Caregiver Support and Education	10/01/2015	06/30/2022	Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA	$1,053,679		 DESCRIPTION (provided by applicant): Background Existing interventions for informal caregivers (CGs) of care recipients (CRs) with dementia vary on multiple dimensions (e.g., content, administration time, mode of delivery), and findings indicate that these programs are effective in improving CG and CR outcomes. Our team has developed and evaluated two CG programs that are unique in that they are relatively brief (i.e., 3 months) and rely solely on telephone administration. The original program, the Telehealth Education Program (TEP), provides CG support, psychoeducation, and skills training in a group format. The second program adapted the original TEP to be delivered to individual CGs and includes collaborative care management services. Key components of this CR/CG-centered program include direct collaboration among teams of care managers, primary care providers (PCPs), and CGs. The decision to develop an individually-tailored, collaborative care program was partly in response to the success of collaborative care models with other patient populations and the fact that the majority of individuals with dementia receive their healthcare from their PCPs. Nonetheless, an individually-delivered program lacks the benefits derived from the mutual peer support and feedback provided by group-based interventions. What remains to be determined, therefore, is whether modifying the individually-delivered care management program to deliver TEP in a group format is more effective than the individually-delivered program alone. Objectives The objectives of the project include: a) testing the comparative effectiveness of 2 delivery models (individual TEP + individual care management vs. group TEP + individual care management) of a telephone-based, collaborative dementia care intervention for CGs, and b) exploring whether the individual or individual + group intervention is more effective/acceptable among spousal vs. adult children CGs. Methods To meet these objectives, we will use a prospective, randomized control group, repeated measures (i.e., baseline, 3, 6, and 12 month follow-up) design. Participants will include 405 CGs (spouses and children 18 years of age and older) of Veterans diagnosed with dementia and receiving routine clinical care at two VA sites. CGs will be recruited for participation if they live with and/or provide 4+ hours f care/day. CGs will be randomly assigned to usual care, the individual intervention, or the individual + group intervention. The main objectives of both interventions are to facilitate resource connection and provide education, psychosocial support, and care management for individuals caring for Veterans with dementia, thereby improving access to and use of non-institutional services, rates of guideline adherent care, and CG/CR outcomes. In both interventions, CGs will receive education, continuous support, skills training, and monitoring of Veterans' medication adherence, symptoms, and service needs. CGs will be asked to complete an assessment battery of standardized measures of CR- and CG-characteristics. Veterans' clinical medical records (including cost data) also will be evaluated for screening and clinical data collection purposes. Generalized estimating equations (GEE) will be the primary method used to analyze the nested, longitudinal data. Anticipated Impact on Veteran's Healthcare Approximately 1/2 million Veterans have dementia and approximately 80% of these individuals receive care at home from informal CGs. Patient/CG-centered, integrated care management programs that also include CG education, psychosocial support, and skills training have the capacity to significantly facilitate use of services and to improve outcomes, including quality of life, for Veterans with dementia and their families. CRITIQUE 1 1. Significance. This proposal addresses dementia caregiver support, a high priority in VA care particularly given the aging veteran population. The sub-hypotheses are interesting as they compare individual to group administration that will inform both understanding the mechanism of action and the optimal mode of delivery. This can inform future implementation studies. 2. Approach (including Feasibility). The investigators addressed most if not all of reviewers' initial concerns. They have focused on the first two specific aims and have removed the third exploratory aim. The investigators' discussion of expected effect size remains separate from the effect size derived from the pilot data and does not take into account the possible diminution of effect by including collaborative care in both treatment arms -which they have retained in this resubmission. The proposal adequately outlines the feasibility of caseload and the number of required FTE care managers. The investigators report success in administering assessments with administration time of 60 to 90 minutes in caregiver samples. 90 minutes still seems overly burdensome for this sample. The low drop-out rates in the pilot study are reassuring. 3. Impact and Innovation. More evidence-based caregiver interventions are needed for both dementia and other chronic disease groups. The results of this study will be informative for both groups. The intervention is moderately innovative, but the analysis and planned comparisons are more innovative. Conducting the intervention in primary care and the use of collaborative care are strong aspects of the intervention that bode well for both its effectiveness and its eventual uptake by the VA. 4. Investigator Qualifications, and Facilities and Resources. Both sites are well suited to conduct the study with a long history of geriatric research and specialty clinics. The investigators have strong ties to primary care and have demonstrated buy-in from both local and national-level operational partners. Any concerns about staffing was addressed in this revised protocol. 5. Multiple PI Leadership Plan. (if applicable) No concerns. 6. Adequacy of Response to Previous Feedback Provided by HSR&D Regarding the Proposed Study. The investigators responded well to concerns about the original proposal. They have simplified the hypotheses and aims. They retained some aspects of the study such as extensive assessment, which remains a concern. They continue to base power calculations on standard effect sizes rather than what they observed in the pilot study. Otherwise, investigators adequately addressed all prior reviewer concerns. 7. Responsiveness to Research Priorities or Special Solicitations. 8. Protection of Human Subjects from Research Risk. The investigators are now proposing to assess capacity to consent to in care receivers and then obtaining consent when appropriate. The investigators have added more detail about managing any potential for risk or psychological distress should this become evident during the course of the intervention. Both sites have expertise in managing mental health issues and risk in late-life. 9. Inclusion of Women and Minorities in Research. Inclusion of women and minorities is adequately addressed. 10. Budget. The investigators have included more extensive discussion justifying staffing and effort needed for recruitment. This reviewer has no remaining concerns about the budget. 11. Overall Impression. 12. Key Strengths. 1. Interesting sub-hypotheses examining optimal strategy for administration 2. Caregiver support interventions delivered within primary care are needed 3. Investigative team with sophisticated research experience 13. Key Weaknesses. 1. Concerns about adequate power given pilot data remain. 2. Caregiver interviews that can last up to 90 minutes may be overly burdensome, though the proposal does counter the concern that there will be attrition because of this. CRITIQUE 2 1. Significance. Development of interventions to support dementia caregivers is a high priority for VA as the population of Veterans served continues to age. This proposal is responsive to national VA priority areas (Long-term Care and Caregiving; Access/Rural Health) and will obviously be of benefit to VA transformations now and in the future. The interventions to be tested in this study are short in duration compared to other caregiver interventions and are delivered by telephone. Veterans and their caregivers are likely to benefit from this unique intervention in measurable as well as immeasurable ways. 2. Approach. The investigators are proposing a longitudinal RCT to evaluate the comparative efficacy of individual TEP+individual care management to group TEP+individual care management. Both will be compared to usual care. The investigators hypothesize that the group TEP will confer even greater benefit for caregivers than individual TEP, but that these effects may be moderated by caregiver type. As such, sampling and randomization will be stratified so that any moderating effects of caregiver type (adult child vs. spouse/partner) can be evaluated. Assessments will occur at baseline, 3, 6, and 12 months. There is some residual concern that assessments that are 60-90 minutes in length will be burdensome to otherwise very busy individuals (caregivers). However, the investigators seem assured that this is reasonable and, like in their past studies, retention of participants will be high. Otherwise, the approach is reasonable and well justified based on past work. 3. Impact and Innovation. The proposed work could have relatively quick impact on VA support for dementia caregivers. The project has high likelihood of ultimately helping improve VA's support of caregivers, which is a quickly growing need in many domains. 4. Investigator Qualifications, and Facilities and Resources. This is a strong research team situated in maximally supportive environments, with an HSR&D COIN, MIRECC, and Center for Integrated Healthcare. Both PIs have ample experience with the research, including RCTs, that lead up to the proposed work. Their respective sites are also familiar with the intervention and associated research. 5. Multiple PI Leadership Plan. The multiple PI plan seems reasonable given the contributions of each PI to the project, its history, and its implementation. 6. Adequacy of Response to Previous Feedback Provided by HSR&D Regarding the Proposed Study. The investigators were very thoughtful in their responses to reviewers' critiques. They removed the exploratory aim of the study, thereby tightening up the focus on the evaluative Aims 1 and 2. Power considerations were clarified and justified based on prior work. The potential for dissemination of the resulting product/service was clarified, as was the role of the Case Managers and their ability to provide services to the large number of participants. Human subjects risks and protections were more carefully considered. While the investigators clarified the suspected length of time for assessments and assured reviewers that this amount of time would be ok, they might have instead looked more critically at their measures and cut out any that weren't entirely necessary to the aims or exchange them for shorter measures. 7. Responsiveness to Research Priorities or Special Solicitations. 8. Protection of Human Subjects from Research Risk. The researchers and their respective sites are well prepared to conduct this research while maximally protecting the human subject participants. The investigators added details about responses and actions should care recipients or caregivers are found to be at risk. 9. Inclusion of Women and Minorities in Research. The study participants will directly reflect the demographics of caregivers and care recipients in the regions in which the study will take place. As such, the vast majority of caregivers are likely to be women. There are no concerns about inclusion of women or minorities in this research. 10. Budget. Budget seems adequate for the proposed activities - no concerns. 11. Overall Impression. This proposal is well written and the investigators did an outstanding job of addressing most of the reviewers' previous concerns. The topic is of critical importance to VA and the potential impact of this research is great. It has a strong theoretical basis bolstered by preliminary data and established methods for recruitment/enrollment. The research approach is strong and very likely to meet the proposed aims. 12. Key Strengths. 1. This project will disentangle differential needs of spouse/partners vs. adult children caregivers, directly informing educational methods and delivery in VA according to specific caregiver needs. 2. Strong significance and likely impact 3. Strong investigative team, at low cost to R&D, and with proven track record of research and established connections with stakeholders. 13. Key Weaknesses. 1. Some residual concern about the length of the assessments (60-90 minutes) for aging (spouses/partners) and otherwise busy (adult children) caregivers. 2. No additional weaknesses identified.	Long Term Care and Aging	To meet these objectives, we will use a prospective, randomized control group, repeated measures (i.e., baseline, 3, 6, and 12 month follow-up) design. Participants will include 405 CGs (spouses and children 18 years of age and older) of Veterans diagnosed with dementia and receiving routine clinical care at two VA sites. CGs will be recruited for participation if they live with and/or provide 4+ hours of care/day. CGs will be randomly assigned to usual care, the individual intervention, or the individual + group intervention. The main objectives of both interventions are to facilitate resource connection and provide education, psychosocial support, and care management for individuals caring for Veterans with dementia, thereby improving access to and use of non-institutional services, rates of guideline adherent care, and CG/CR outcomes. In both interventions, CGs will receive education, continuous support, skills training, and monitoring of Veterans' medication adherence, symptoms, and service needs. In the usual care arm, participants will be sent general material about VA and community resources for patients with dementia and their CGs, as well as brochures for caregivers. With the exception of that material, individuals will receive UC and will be free to seek medical, psychological, social support, and social services that are available through VAMCs or any other non-VA/community source. CGs will be asked to complete an assessment battery of standardized measures of CR- and CG-characteristics. Veterans' clinical medical records (including cost data) also will be evaluated for screening and clinical data collection purposes. Generalized estimating equations (GEE) will be the primary method used to analyze the nested, longitudinal data.	The objectives of the project include: a) testing the comparative effectiveness of 2 delivery models (individual care management + individual TEP vs. individual care management + group TEP) of a telephone-based, collaborative dementia care intervention for CGs vs. usual care, b) examining whether the individual or individual + group intervention is more effective/acceptable in spousal vs. adult children CGs, and c) exploring whether the effectiveness of the CG interventions is mediated by changes in the social networks of CGs.	Approximately 0.5 million Veterans have dementia and approximately 80% of these individuals receive care at home from informal CGs. Patient/CG-centered, integrated care management programs that also include CG education, psychosocial support, and skills training have the capacity to significantly facilitate use of services and to improve outcomes, including quality of life, for Veterans with dementia and their families.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 15-092	Bastian	Lori		Lori.Bastian@va.gov	Pain-related Anxiety Intervention for Smokers with Chronic Pain: A Comparative Effectiveness Trial of Smoking Cessation Counseling for Veterans	02/01/2017	09/30/2022	VA Connecticut Healthcare System West Haven Campus, West Haven, CT	$1,168,783		 DESCRIPTION (provided by applicant): Impacts: Cigarette smoking is the single greatest cause of preventable deaths in the U.S. Military service is a risk factor for smoking and approximately 20% of US Veterans are smokers. Pain is frequently reported by Veterans and research suggests smoking is associated with concurrent pain intensity. Veterans with chronic pain represent an important population in which to focus smoking cessation efforts. Background: Smoking cessation among patients with chronic medical illnesses substantially decreases morbidity and mortality; yet, many patients (>50%) with chronic pain continue to smoke. Recently, Hooten et al tested a standard smoking cessation protocol augmented with a cognitive behavioral intervention (CBI) targeting coping strategies for emotional distress to address smoking among hospitalized patients with chronic pain. Results revealed that 20% of the patients in the CBI condition were abstinent from smoking compared to none in the control group at the 6 month follow-up. Concomitant efforts to address smoking cessation and pain-related anxiety, via established CBIs, have the potential to provide smokers with pain the requisite skills to navigate the smoking cessation process and manage the associated anxiety-related cues that interfere with efforts to quit. Given the widespread prevalence of smoking and its staggering impact on Veteran health, VHA has highlighted the need for adopting a public health approach to smoking cessation. From a public health perspective, the impact is defined as Reach (i.e., number of Veterans who access/receive an intervention) multiplied by Efficacy (effect size of an intervention). Efforts to improve the reach of smoking cessation efforts while simultaneously removing barriers that limit access to and participation in effective interventions is critical to improving cessation rates at he population level. The current investigation combines the established efficacy of a CBI and the reach of a proactive telephone-delivered intervention. This study aims to test the telephone delivery of a CBI, for smoking cessation among Veteran smokers with chronic pain. Objectives: AIM 1: Evaluate the impact of smoking cessation plus CBI (SMK-CBI) on cigarette abstinence rates among Veterans with chronic pain at 6 and 12-months. Hypotheses 1.1 & 1.2: Prolonged abstinence rates (H 1.1) and 7-day point prevalence abstinence rates (H 1.2) will be significantly higher among Veterans with chronic pain who receive SMK-CBI compared with those in 2) smoking cessation telephone counseling control (SMK Control). AIM 2: Evaluate the impact of SMK-CBI on pain intensity and pain interference among Veterans at 6- and12- months. Hypothesis 2.1: Veterans in SMK-CBI will report significantly lower usual pain intensity and pain interference relative to SMK Control. AIM 3: Assess whether change in self-efficacy and pain-related anxiety mediate the impact of SMK-CBI on smoking cessation in Veterans with pain at 6- and 12-months. Hypothesis 3.1: The relationship between SMK-CBI and reported smoking cessation will be mediated by self- efficacy and pain-related anxiety.In addition, teaching these skills will improve pain-related anxiety. Methods: Proposed is a randomized comparative effectiveness trial with a two-group design in which 350 Veteran smokers with chronic pain will be randomized to either: 1) SMK-CBI, an intervention that includes a proactive tele-health intervention combining evidence-based smoking cessation counseling augmented with behavioral approaches for coping with pain and a tele-medicine clinic for accessing nicotine replacement therapy (NRT), or 2) SMK Control, a contact-equivalent control that provides standard smoking cessation telephone counseling and a tele-medicine clinic for accessing NRT.	Complementary and Integrative Health	Proposed is a randomized comparative effectiveness trial with a two-group design in which 370 Veteran smokers with moderate to severe pain will be randomized to either: 1) SMK-CBI, an intervention that includes a proactive tele-health intervention combining evidence-based smoking cessation counseling augmented with behavioral approaches for coping with pain or 2) SMK-STD, a contact-equivalent intervention that provides standard smoking cessation telephone counseling. Subjects with pain intensity > 4, current tobacco use, and receiving care at VACHS will be identified by administrative data. An introductory opt-out letter will be sent to prospective patients informing them of the study. Subjects who have not opted out will receive a phone call from a research assistant to further assess inclusion criteria. Enrolled subjects will be randomized into the SMK-CBI or SMK-STD arm. Each participant will complete 5 telephone-based sessions within 12 weeks. Subjects will be surveyed three times: enrollment, 6-months post-intervention and 12-months post-intervention for pain intensity, self-efficacy to quit, demographics, smoking history/habits, depression, smoking status, nicotine withdrawal symptoms, use of intervention materials, and intervention acceptability. Based on follow-up surveys, self-reported non-smokers will be asked to provide a saliva sample at their next clinic visit following the follow-up surveys.	This study will compare the effectiveness of a telephone-based smoking cessation intervention including CBI for pain to a standard telephone-based smoking cessation intervention among Veteran smokers with moderate to severe pain, a pain intensity >4. AIM 1: Evaluate the impact of smoking cessation plus CBI (SMK-CBI) on cigarette abstinence rates among Veterans with chronic pain at 6 and 12-months compared to standard smoking cessation counseling (SMK-STD). AIM 2: Evaluate the impact of SMK-CBI on pain intensity and pain interference among Veterans at 6- and12-months compared to SMK-STD. AIM 3: Assess whether change in self-efficacy and pain-related anxiety mediate the impact of SMK-CBI on smoking cessation in Veterans with pain at 6- and 12-months compared to SMK-STD.	Cigarette smoking is the single greatest cause of preventable deaths in the U.S. Military service is a risk factor for smoking and approximately 20% of US Veterans are smokers. Pain is frequently reported by Veterans and research suggests smoking is associated with concurrent pain intensity. Veterans with chronic pain represent an important population in which to focus smoking cessation efforts.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 15-095	Kertesz	Stefan		stefan.kertesz@va.gov	Primary Care Quality and Homeless Service Tailoring	07/01/2016	09/30/2022	Birmingham VA Medical Center, Birmingham, AL	$1,534,262		 DESCRIPTION (provided by applicant): The Department of Veterans Affairs has embraced the patient-centered medical home, termed the Patient-Aligned Care Team (PACT) in VA, an approach that promises care that is comprehensive, patient- centered, team-based, focused on coordination and communication, and able to sustain a relationship that continues over time. For patients who are homeless or exiting homelessness, these ideals are often not met. Despite significant efforts to develop patient-centered medical homes for people who are homeless, little is known about the particular aspects service design delivery that create valuable, enduring primary care experiences for patients. Since 2012, VA has ambitiously piloted homeless-tailored primary care service design through Homeless PACTs (HPACTs, n=60). This has created a natural experiment that invites two questions important not just to VA but to non-VA agencies seeking to promote viable medical homes for socially-vulnerable populations. First, do VA's homeless-tailored primary care programs offer a substantively superior patient experience? Second, what particular organizational features actually matter? This proposal prioritizes homeless patients' experience of primary care as the proximal indicator of successful engagement in primary care. Patient experience surveys seek an experiential report of how well aspects of care delivery (access, coordination, etc.) map to what patients and experts consider ideal. In prior VA-funded research, we asked patients and providers about their aspirations for primary care of the homeless. From this we developed a psychometrically valid patient experience survey (Primary Care Quality-Homeless, PCQ-H), which has been used in homeless health care programs across the country. This study will combine patient surveys from homeless-experienced (currently and previously homeless) veterans (n=6,181) and organizational assessment among a sample of HPACTs to advance two aims: Aim 1: Compare the primary care experience (i.e. PCQ-H scores) for homeless-experienced patients obtaining primary care in HPACTs to patients receiving primary care in mainstream PACT clinics operated by the same VA Medical Center. Aim 2: Characterize those features of HPACT service design that are most strongly associated with a superior patient experience (i.e. better PCQ-H scores). This Aim will be advanced sequentially through (a) adaptation of an organizational assessment tool specific to homeless-tailored primary care for use in this project; (b) conducting that assessment through surveys of HPACT directors to identify the presence or absence of potentially relevant HPACT service features; (c) analysis to compare PCQ-H scores for HPACTs that have versus those that lack each potentially relevant HPACT service feature. Evidence from this study will help to guide the future of primary care delivery for homeless and formerly homeless patients within VA, and in non-VA Federally Qualified Health Centers. Additionally, it may help to foster a primary care culture that holds itself accountable, first and foremost, to the unique contextual needs of patients as they leave homelessness behind.	Mental and Behavioral Health	Aim 1 is a mailed survey (with telephone follow-up) of homeless-experienced Veterans (n = ~15,000) at 29 VAMCs who receive care in either an HPACT or non-HPACT setting to assess patient experience. We anticipate a final sample size of ~6,000 veterans. Methods for Aim 2 are sequential. First, the team will gather qualitative insights through semi-structured interviews at 5 primary care sites. This will help us to refine an organizational assessment survey focusing on service design features likely to impact patient experience and other utilization indicators. This optimized survey will be given to the HPACTs lead nurse and/or prescribing provider at the same 29 HPACTS from which our Veteran cohort is drawn. We will then perform analysis to compare satisfaction scores for HPACTs on the presences or absence of each potentially relevant HPACT service feature.	This proposal prioritizes homeless patients' experience of care as the proximal indicator of successful engagement, and includes other indicators, i.e. health care utilization. Aim 1: Compare primary care experience and utilization indicators for homeless-experienced patients obtaining primary care in HPACTs to patients receiving primary care in mainstream-PACT clinics operating at the same VA Medical Centers. Aim 2: Identify features of HPACT service design that are most associated with a superior patient experience.	The study team has presented qualitative findings and preliminary quantitative results at several regional and national scientific conferences. Evidence from this study will help to guide the future of primary care delivery for homeless-experienced patients within VA, and in non-VA Federally Qualified Health Centers.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 15-117	Freytes	Ivette		Ivette.Freytes@va.gov	Spanish Online & Telephone Intervention for Caregivers of Veterans with Stroke	10/01/2017	09/30/2022	North Florida/South Georgia Veterans Health System, Gainesville, FL	$1,331,656		 DESCRIPTION (provided by applicant): Stroke is a major cause of disability and a leading cause of healthcare utilization within the Veterans Health Administration (VHA). Family caregivers are the major sources of support for stroke survivors. Unlike other chronic diseases, strokes occur suddenly and family members have little time to prepare and adjust to their new, caregiving roles. Previous research has found that family members, particularly Hispanics, have high rates of depression and burden when their stroke survivors return home. Providing caregivers with culturally-appropriate information, support, and skills has the potential to reduce negative caregiver outcomes and increase the likelihood that stroke survivors remain in the community. Unfortunately, no studies have focused on support interventions specifically for Hispanic caregivers. The proposed study will test the effect of a brief, online and telephone skills-building intervention, using the Spanish version of the VA's Resources and Education for Stroke Caregivers' Understanding and Empowerment (RESCUE) website. The objectives are: 1) reduce caregiver depressive symptoms (primary objective), 2) improve caregivers' perceptions of the positive aspects of caregiving, self-efficacy and quality of life and reduce burden, 3) improve Veterans' functional abilities and determine the intervention's impact on Veterans' healthcare utilization, 4) determine budgetary impact, and 5) determine caregivers' perception of the intervention. The long-term goal is to partner with VHA Program Offices and stakeholders to implement a culturally relevant, accessible, and cost-effective intervention for caregivers of Veterans post-stroke. The project is guided by the relational/problem solving COPE model of stress. A two-arm (8-session intervention vs. standard care), randomized controlled clinical trial with three assessment points (baseline and 10 and 22 weeks after baseline) will be conducted. A sample of 290 stroke caregivers will be randomly assigned to either an intervention or a standard care group. Study participants will be recruited from the VA Caribbean Healthcare System (VA CHS) in San Juan, Puerto Rico (PR). The intervention consists of information and tools on the previously developed, evidenced-based Spanish-version of the RESCUE stroke caregiver website and a problem-solving intervention that has been previously pilot-tested to improve stroke caregiver outcomes. The intervention will be conducted via telephone by trained rehabilitation counselors. We adapted the intervention to reflect specific characteristics of the target population such as language, cultural values and norms, and degree of acculturation. The intervention consists of four components: 1. Introduction to the RESCUE website and the problem-solving method; 2. Illustrative example on how to use the problem-solving approach and the RESCUE website to address caregiving problems; 3. Individualized practice exercise to develop a personalized problem-solving plan; and 4. Summary of the problem-solving method. Baseline and post-test assessments will be conducted using validated instruments in Spanish. We will obtain pre- and post-test measures of Veteran-related variables via CPRS electronic health records. Qualitative interviews will be conducted with a subsample of 8-12 caregivers to assess caregivers' perceptions of the intervention. A general linear mixed model for repeated measures will be used to examine the relationship between treatment assignment and each outcome over time. The budgetary impact of the intervention will consist of (1) the incremental cost of the intervention itself over and above usual care, and (2) the impact of the intervention of healthcare utilization. Qualitative data will be analyzed using the constant comparative method. The Advisory Consortium will collaborate in all aspects of the project. If proven effective, this intervention could serve as a novel strategy to reduce cultural disparities for caregivers of Veterans with other disabilities.	Long Term Care and Aging	The project is guided by the relational/problem solving model of stress. A two-arm (8-session intervention vs. standard care), randomized controlled clinical trial with three assessment points will be conducted. A sample of 290 Hispanic stroke caregivers will be randomly assigned to either an intervention or a standard care group. The intervention consists of a problem-solving intervention and information/tools on the previously developed, evidenced-based Spanish-version of the RESCUE stroke caregiver website. The intervention will be conducted via telephone by a trained healthcare professional and consists of four components: 1. Introduction to the RESCUE website and the problem-solving method; 2. Illustrative example on how to use the problem-solving approach and the RESCUE website to address caregiving problems; 3. Individualized practice exercise to develop a personalized problem-solving plan; and 4. Summary of the problem-solving method. Baseline measurements will be conducted with the caregivers prior to the intervention. Post-test assessments will be collected at 1 and 12 weeks post-intervention. In addition, we will obtain pre- and post-test measures of Veteran-related variables via CPRS electronic health records. Qualitative interviews will be conducted to assess caregivers' perceptions of the intervention. A general linear mixed model for repeated measures will be used to examine the relationship between treatment assignment and each outcome over time. We will also measure the budgetary impact of providing intervention by comparing the costs of the intervention group to the costs of the control group.	Our main goal is to test the efficacy of a brief, telephone and online problem-solving intervention using the Spanish version of the VA RESCUE stroke caregiver website. The objectives are: 1) reduce caregiver burden and depression; 2) improve caregivers' problem-solving abilities, self-efficacy, and quality of life; 3) improve Veterans' functional abilities and determine the intervention's impact on Veterans' healthcare utilization; 4) determine budgetary impact; and 5) determine caregivers' perceptions of the intervention. The long-term goal is to partner with leaders to implement a culturally relevant, accessible, and cost-effective intervention for caregivers of Veterans post-stroke throughout the VHA.	This study is the first known randomized control trial to test a Spanish-language telephone and online intervention for caregivers in the VA and addresses the need for culturally appropriate health information for an understudied population. If found effective, this intervention can serve as a model for caregivers of Veterans with other conditions by providing education and support and helping reduce caregiver depression and burden.	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IIR 15-316	Zulman	Donna		Donna.Zulman@va.gov	Care Coordination for High-Risk Patients with Multiple Chronic Conditions	01/01/2018	09/30/2022	VA Palo Alto Health Care System, Palo Alto, CA	$684,269		Background. Care fragmentation is a mounting challenge for Veterans, many of whom face multiple chronic conditions requiring care from different providers and clinics. This issue is likely to intensify in light of a policy environment that increasingly encourages Veterans’ dual use of VA and community care. When patient care is dispersed across providers, clinics, and health systems, it increases risks of information loss, medication interactions, and unwieldy treatment regimens, leading to health deterioration. Veterans in poor health and those with functional limitations or resource constraints may be especially vulnerable, yet little is known about fragmentation patterns and care coordination needs in these high-risk patients. Project Objectives. The objective of this study is to advance understanding of care fragmentation and care coordination’s potential among high-risk Veterans with multiple chronic conditions. Project Methods. To achieve the study goals, we will first describe care fragmentation prevalence and variation in a national cohort of high-risk patients (Aim 1). We will then examine the relationships between care fragmentation and outcomes, including acute care utilization (Aim 2.1) and patient-reported care experience (Aim 3.1). Finally we will evaluate whether randomization to comprehensive care coordination mitigates the effects of fragmentation (Aims 2.2 and 3.2).  Aim 1. We will use 2014-2015 VA, VA purchased care (including Veterans Access, Choice, and Accountability Act), and Medicare data from a national sample of high-risk patients (Care Assessment Needs hospitalization risk score ≥ 90th percentile). In Aim 1.1, we will describe primary care, outpatient care, and health system fragmentation, using validated and adapted measures of care fragmentation and discontinuity. Using a theoretical approach to compare measures, we will select a primary fragmentation measure within each domain for use in subsequent aims. In Aim 1.2, we will use these select measures to examine variation in care fragmentation by patient characteristics (e.g., age, sex, chronic conditions, housing instability, distance from VA, and enrollment in care coordination programs).  Aim 2. Using select fragmentation measures identified in Aim 1.1, we will evaluate the relationship between care fragmentation and acute care utilization among high-risk Veterans. In Aim 2.1, we will determine whether care fragmentation is independently associated with higher rates of acute care utilization (including emergency department visits and hospitalizations). In Aim 2.2, we will take advantage of an ongoing randomized evaluation of an Office of Primary Care PACT-Intensive Management (PIM) Demonstration Program to test whether comprehensive care coordination influences the relationship between fragmentation and acute care outcomes.  Aim 3. In Aim 3, we will analyze findings from an operations-supported survey administered to high-risk patients in the PIM Demonstration Program to examine the relationship between care fragmentation and patient experiences with care. In Aim 3.1, we will assess whether greater fragmentation is associated with low satisfaction, poor perceived care coordination, and patient-reported challenges with access, communication, and self-management. In Aim 3.2, we will examine whether comprehensive care coordination offered through PIM influences the relationship between fragmentation and patient experience. Study findings will advance understanding of high-risk Veterans’ care fragmentation, associated outcomes, and their potential benefit from intensive care coordination. The study will also inform program development and generate care fragmentation measures for our operations partners in VA’s Offices of Primary Care, Access to Care, Community Care, Geriatrics and Extended Care, and Women’s Health Services.	Care of Complex Chronic Conditions	This project will first identify a cohort of Veterans with Care Assessment Needs hospitalization risk scores >= 90th percentile in FY14, and examine their primary care, outpatient care, and health system fragmentation, using validated and adapted measures of care fragmentation and discontinuity (Aim 1.1). After using a theoretical approach to compare and refine the measure list, we will examine variation in care fragmentation by patient characteristics (e.g., age, sex, chronic conditions, housing instability, distance from VA, and enrollment in care coordination programs) (Aim 1.2). In Aim 2, we will use select fragmentation measures identified in Aim 1 to evaluate the relationship between care fragmentation and acute care utilization among high-risk Veterans. We will first determine whether care fragmentation is independently associated with higher rates of acute care utilization (including emergency department visits and hospitalizations) (Aim 2.1). Then we will take advantage of an ongoing randomized evaluation of an Office of Primary Care PACT-Intensive Management (PIM) Demonstration Program to test whether comprehensive care coordination influences the relationship between fragmentation and acute care outcomes (Aim 2.2). In Aim 3, we will analyze findings from a patient survey that was conducted for the PIM Demonstration Program to examine the relationship between care fragmentation and patient experiences with care. We will assess whether greater fragmentation is associated with low satisfaction, poor perceived care coordination, and patient-reported challenges with access, communication, and self-management (Aim 3.1), and determine whether comprehensive care coordination offered through PIM influenced the relationship between fragmentation and patient experience (Aim 3.2).	The objective of this study is to advance the understanding of care fragmentation and care coordination's potential among Veterans who are at high-risk for hospitalization. To achieve the study goals, we will first describe care fragmentation prevalence and variation in a national cohort of high-risk patients (Aim 1). We will then examine the relationships between care fragmentation and outcomes, including acute care utilization (Aim 2.1) and patient-reported care experience (Aim 3.1). Finally, we will evaluate whether randomization to comprehensive care coordination mitigates the effects of fragmentation (Aims 2.2 and 3.2).	Veterans are increasingly facing care fragmentation, a challenge that will likely intensify in a policy environment that encourages Veterans to use both VA and community care. Veterans who are at high-risk for hospitalization and individuals with functional limitations or resource constraints may be especially vulnerable to negative consequences from fragmented care. Our findings will inform both current and future efforts to improve and streamline care for high-risk Veterans with multiple chronic conditions.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 15-333	Bair	Matthew		mbair@iupui.edu	Trial Outcomes for Massage: Caregiver-Assisted vs. Therapist-Treated (TOMCATT)	02/01/2017	09/30/2022	Richard L. Roudebush VA Medical Center, Indianapolis, IN	$1,328,917		Background: Neck pain is the fourth leading cause of disability in the US, after back pain, depression, and joint pain, and accounts for more than 10 million medical visits per year. Conventional treatments (medications, physical therapy) are widely used for chronic neck pain, yet have modest effectiveness and may carry risks, such as the toxicities associated with non-steroidal anti-inflammatory drugs (NSAIDs) and opioids. As a result many patients live with chronic, often debilitating, pain. Patients unable to find relief frequently turn to complementary health approaches. Complementary therapies are exceptionally popular among Veterans; 82% reported use of at least one complementary therapy and nearly all (99%) were willing to try massage for pain relief. Neck pain is the second most common reason for using a complementary therapy, with massage used for neck pain more commonly than all other complementary therapies except chiropractic care. Of all complementary approaches, massage was the most preferred by Veterans. In a national survey, almost two-thirds (61%) of individuals with neck pain who used both complementary and conventional treatments perceived complementary to be more helpful, whereas only 6% perceived conventional treatments to be better. Objectives: The Trial Outcomes for Massage: Caregiver-Assisted vs. Therapist-Treated (TOMCATT) Study is a 3-arm, parallel group, randomized clinical trial that will last 6 months. The TOMCATT Study will target 468 Veterans with chronic neck pain and will compare caregiver-assisted massage and therapist-treated massage to a waitlist control arm on primary, secondary, and exploratory outcomes. Methods: Our study sample will include 468 veterans with chronic neck pain. Patients from the 5 primary care clinics at the Roudebush VA Medical Center (RVAMC) and 3 community based outpatient clinics (Terre Haute, Martinsville, and Bloomington) will be recruited to participate. The Trial Outcomes for Massage: Caregiver-Assisted vs. Therapist-Treated (TOMCATT) Study will be a 3-arm, parallel group, randomized clinical trial. Eligible participants will be randomized to one of three study arms: 1) The caregiver-assisted (CA-M) arm will involve a standardized 3-month, massage routine; and 2) Patients in the therapist-treated arm will receive 3 months of twice weekly massage delivered by certified massage therapists. The third and comparator arm will be a waitlist control. The trial will last 6 months and compare caregiver-assisted and therapist-delivered massage to control on neck pain outcomes. We will compare changes in pain-related disability (primary outcome) between the three groups (Aim 1) and examine secondary outcomes: pain severity, quality of life, depression, anxiety, and stress (Aim 2) as well as exploratory outcomes. To examine the implementation potential of both interventions, including facilitators and barriers, we will conduct post-study, in-depth qualitative interviews of a subsample of study participants (Veteran patients and caregivers) from both massage groups (Aim 3). Lastly, we will assess treatment fidelity and compare the relative intervention costs and budget impact for both interventions. The intervention period will last for 3 months, after which time Veterans will be followed for an additional 3 months. Innovation: The TOMCATT Study is a novel extension of our prior work, has strong implementation potential, and innovates by placing caregivers in a treatment delivery role that has the potential to reach a greater number of Veterans with chronic neck pain while also producing substantial cost-savings. Although studies have shown that massage is effective for pain, caregiver-delivered strategies have not been tested or implemented in any systematic way across VA.	Complementary and Integrative Health	Eligible participants will be those with chronic neck pain for 6 or more months that averages 5 or greater on a 0 to 10 scale. Participants must also have a caregiver (spouse, partner, family member, or friend) willing to learn and provide massage therapy during the study period. Once enrolled, participants will be randomized to one of three study groups: 1) Care ally-assisted massage (CA-M) 2) Therapist-treated massage (TT-M); 3) Waitlist control (WL-C) The intervention period will last 3 months and outcomes assessments will be completed at baseline, 1, 3, and 6 months. Outcomes will be collected on care allies at baseline and 3 months. The care ally-assisted massage (CA-M) intervention will consist of 3 treatment components: 1) An in-person training workshop 2) An instructional DVD recording to reinforce concepts taught during the in- person training session 3) A written treatment manual with illustrations and images to serve as a reference for participants. Participants will be asked to engage in at least 3 care ally -assisted massage sessions (30 minutes each) every week at home for the 3-month intervention period. To standardize delivery and facilitate reproducibility of CA-M, the content and general structure of the care ally-delivered massage routine is established and will be taught during the training workshop. The DVD includes a real-time demonstration of the routine for participants to play during applications if desired. The care ally-assisted massage routine is included in the treatment manual. Participants will be asked to record their massage study activity in a provided study log and return log sheets on a monthly basis. Therapist-treated massage. Participants randomized to the therapist-treated massage (TT-M) arm will receive a standardized Swedish massage protocol tailored to chronic neck pain. Massage therapists will deliver the massage protocol to participants. The massage therapists will use the standard massage techniques applied to the neck region and associated trigger points. Massage sessions will involve a maximum of 60 minutes of hands-on, table time and occur twice a week for 3 months. During the first massage session, the massage therapist will provide an introduction and overview of massage. Thereafter, therapist-treated massage will involve a standardized sequence: 1) hands-on assessment; 2) Swedish massage techniques (e.g. effleurage, p trissage, compression) applied directly to the neck and associated trigger points; and 3) identification and treatment of compensatory patterns. While massage therapists will be permitted to use the range of Swedish massage techniques in the protocol, we will discourage them from providing self-care recommendations about postures, behavioral changes, and sleep. Waitlist Control Arm. Participants in the control arm will receive check-in calls at months 2 and 4 from study staff and undergo outcome assessments on the same schedule (baseline, 1, 3, and 6 months) as the treatment groups. Participants in the waitlist control will be instructed to continue their medical care as normal and to not begin any massage treatment during the 6 months of the study. At the completion of the final 6 month outcome, participants in the control arm will be eligible to attend a care-ally training session and receive a complementary massage session from a TOMCATT study therapist.	This study has three objectives: 1)To compare the effects of two massage interventions (care ally-assisted massage and therapist-treated massage) vs. control on pain-related disability 2)To compare the effects of two massage interventions vs. control on secondary outcomes, including pain severity, health-related quality of life, depression, anxiety, and stress 3)To examine the implementation potential of both massage interventions, including facilitators and barriers, treatment and adherence, and intervention costs.	This study tests an innovative approach (care ally -delivered massage) to improve access to a high-demand and promising treatment for chronic neck pain and its associated comorbidities (depression, anxiety, and PTSD). Furthermore, this study tests the capacity of informal caregivers to deliver massage and supports individuals in a novel caregiving role. Despite the prevalence and disability related to chronic neck pain, research has largely neglected this condition in Veterans. This is of particular concern for VA, given that studies show that chronic pain is associated with lower satisfaction with VA care. Only 28% of Veterans report very good or excellent pain treatment effectiveness. Furthermore, massage is strongly preferred by Veterans and VA facilities are being mandated to reduce reliance on opioids and increase access to complementary approaches since introduction of the Opioid Safety Initiative. It is in this context that the TOMCATT Study is proposed. This project addresses an important VA priority area, pain, consistent with current VA objectives and recommendations, using a novel care delivery approach with strong implementation potential. This study has strong implementation potential, and innovates by placing caregivers in a treatment delivery role that has the potential to reach a greater number of Veterans with chronic neck pain while also producing substantial cost-savings. Although small studies have shown the effectiveness of massage for pain, massage has not been tested in a large trial or implemented in a systematic in the VA. The study began recruitment in May 1, 2018.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 15-339	Sarmiento	Kathleen		Kathleen.Sarmiento@va.gov	Improving Access to Sleep Apnea Care: A Pragmatic Study of New Consultation Models	08/01/2020	09/30/2024	San Francisco VA Medical Center, San Francisco, CA	$709,904		Project Background: Obstructive sleep apnea (OSA) is one of the most common sleep disorders among U.S. military Veterans. Unfortunately, most VA sleep programs have not been able to keep up with Veterans’ ever-increasing demand for OSA assessment and treatment. Project Objectives: The objective of this proposal is to compare a health care delivery model, Direct Referral for Apnea Monitoring (DREAM), with initial in-person (IP) encounters for Veterans at risk for OSA. The central hypothesis of the proposed research is that the DREAM clinical pathway can improve Veterans’ access to sleep services by reducing wait times for home sleep apnea testing (HSAT) and OSA treatment while maintaining prognostic accuracy that is comparable to IP assessments. We will test our central hypothesis and accomplish the objective of this proposal by pursuing the following specific aims: Aim 1. Compare the time from referral to sleep testing and treatment of OSA in Veterans in the DREAM vs. the traditional clinical pathway, which includes an initial encounter with a care provider. Aim 2. Compare positive airway pressure (PAP) adherence and patient-reported clinical outcomes in Veterans with and without an initial sleep provider encounter. Aim 3. Determine the negative predictive value of home sleep apnea testing Significance of the Proposed Research and Relevance to Veterans’ Health: OSA is associated with increased risk for hypertension, stroke, cardiovascular disease, diabetes mellitus, and premature death. Improving Veterans’ access to OSA assessment and treatment will improve the quality of their sleep and the quality of their lives. HSR&D Priority Areas: 1) Improving Veterans’ healthcare access via telehealth implementation; 2) Testing new models of care to improve access, cost, and/or outcomes; 3) Design and testing of implementation strategies to improve uptake of effective practices and quality of care. Innovation: This approach is innovative because, (a) the use of the DREAM clinical model in lieu of initial IP consultation for OSA evaluations is novel; (b) using electronic medical record data to triage Veterans directly to sleep studies is a new application of this technology. Project Methods: This study is a pragmatic, prospective, observational study that compares a health care delivery model (DREAM) which is based on data stored in patients’ electronic medical records (EMRs), with initial in-person (IP) clinic encounters for Veterans at risk for obstructive sleep apnea (OSA). Patients referred to the participating sleep medicine clinics for OSA will undergo HSAT as appropriate, with subsequent in-lab sleep testing if the home study is negative. Patient-reported outcomes will be measured at baseline and 3- months. Adherence with treatment and utilization data will be collected at 3-months. Expected Results: Compared to the initial IP pathway, DREAM will result in significantly shorter wait times for Veterans to receive assessment and treatment for OSA. Also, rates of positive diagnostic sleep apnea studies will be statistically equivalent in Veterans assigned to DREAM compared to those who attend initial in-person appointments. Adherence to OSA treatment in the DREAM condition will not be inferior to initial in-person consultation; patient outcomes and satisfaction will not be inferior in the DREAM versus the in-person arm. Next Steps: If the DREAM model demonstrates efficacy for reducing Veterans’ wait times for OSA diagnosis and treatment, steps will be taken to implement the procedure in medical centers and clinics throughout the VHA system.	Systems Modeling, Design, and Delivery				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 15-362	Helfrich	Christian		christian.helfrich@va.gov	Implementation trial of a coaching intervention to increase the use of transradial PCI	02/01/2018	09/30/2022	VA Puget Sound Health Care System Seattle Division, Seattle, WA	$1,188,785		Background: Of the two approaches to performing cardiac catheterization, cardiologists in the VA and US overwhelmingly choose the approach that is known to be less comfortable and more dangerous to patients and more costly to the health care system. The trans-radial approach (TRA), which is accessed via the wrist, is more comfortable for patients; is much safer with half the rate of bleeding complications; and has lower overall costs per episode of care than the trans-femoral approach (TFA), which is accessed via the groin. Yet, today in the US TRA is used in only 25%-30% of cardiac catheterizations, and in the VA is used for just over 40% of catheterizations. The reasons are that TFA predominates in the fellowships where cardiologists train to perform catherizations; certain aspects of TRA, such as the anatomy of the radial artery, make it initially more challenging than TFA; and there is a lack of training resources that address the needs for hands-on training, feedback from an expert, and training of the team. This challenge is common to many medical and surgical specialties where new, superior procedures emerge regularly. We previously developed and piloted a coaching intervention to help cath labs become “TRA-dominant.” The coaching intervention was team-based, included hands-on instruction with multiple opportunities for corrective feedback, and included a period of support and accountability beyond a training session. The pilot test garnered positive reports from participating teams; however, we do not know if it successfully increases use of TRA. Nor do we know if the coaching intervention works the way we believe it does, through creating a non-punitive atmosphere where participants develop self- efficacy with TRA, overcome the steep learning curve and become proficient. Finally, we do not know the budget impact of the coaching intervention, and whether the costs may be offset by the savings from reduced complications and associated costs. Objectives: Our objective is to improve the VA’s ability to systematically implement new technically challenging, evidence-based clinical procedures. We have 3 aims. Aim 1: Test the effectiveness of a successfully-piloted, team-based coaching intervention in increasing implementation of radial-artery access cardiac catheterization. Aim 2: Adapt, test and refine a conceptual model of team-based coaching for implementation of new procedures based on the Promoting Action on Research Implementation in Health Services framework. Aim 3: Perform a cost analysis of the coaching intervention and effects on costs per episode of care. Methods: We will use a stepped wedge design (i.e., graduated participation) to maximize validity and permit formative evaluation of the coaching intervention to improve it in real time. The primary outcome will be change in number of TRAs as a function of all catheterizations. Secondary outcomes will include improvements in complications, and cost per catheterization. We will conduct qualitative interviews and structured surveys at baseline, again just after the coaching intervention and a third time at 6 months follow-up to adapt, test and refine a conceptual model of team-based implementation that can inform modifying the coaching intervention to other clinical procedures and settings by understanding how the coaching intervention affects factors such as different types of perceived evidence related to TRA, contextual factors related to psychological safety, and team self-efficacy and outcome expectancy. Aim 3 will include two components: 1) estimate the costs of the organizational efforts needed to implement the coaching intervention, and 2) assess the effect of the coaching intervention aimed to increase adoption of TRA on healthcare costs. This will help establish the business case for the coaching intervention cost. Trial data suggests TRA leads to substantial cost savings. By developing a VA business case for the coaching intervention, we will help foster support for dissemination of the proctoring intervention.	Care of Complex Chronic Conditions	We will conduct a stepped wedge trial design, with a mixed-methods formative evaluation. In the stepped wedge trial, all participating sites ultimately receive the intervention, but are randomized to receive it at different time points or "steps." Sites serve as internal controls to account for site-specific confounders before and after the intervention. Because they are randomized to receive the intervention at different times, they also serve as controls for each other to account for secular time trends. Some might also characterize this study as a hybrid implementation trial because we are assessing both implementation (i.e., practice) outcomes and clinical outcomes. The primary outcome is implementation of TRA, assessed as the proportion of radial catheterization performed at the cath lab; and secondary outcomes include bleeding complications, employee job satisfaction and organizational commitment.	Our primary goal is to improve the VA's ability to implement new technically-challenging, evidence-based clinical procedures, such as TRA. We will test a previously-piloted, team-based coaching intervention to support adoption and implementation of TRA that is designed to help shorten the learning curve and sustain teams until they become proficient. Toward that goal, we want to build on, and contribute to conceptual models of innovation implementation and the cognition of development of expert skills that can help us understand why clinical procedures that have so many apparent advantages are implemented so slowly. Our specific aims are: Aim 1: Test the effectiveness of a successfully-piloted, team-based coaching intervention in increasing implementation of radial-artery access cardiac catheterization Aim 2: Adapt and refine a conceptual model of team-based coaching for implementation of new clinical procedures based on the Promoting Action on Research Implementation in Health Services framework. Aim 3: Perform a cost analysis of the coaching intervention and effects on costs per episode of care.	VA seeks to become a learning organization, and one of the central tenants of learning organization theory is that the organization invests in how to learn better (i.e., learns to learn better). That means identifying ways to more systematically integrate new practices or knowledge.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 15-363	Wong	Edwin		Edwin.Wong@va.gov	Identifying Value-Driven Approaches to Strengthening the VA Physician Workforce	03/01/2018	12/31/2022	VA Puget Sound Health Care System Seattle Division, Seattle, WA	$1,082,567		Background: Primary care physician (PCP) shortages are a significant and growing problem confronting the US healthcare system. An overall shortage of up to 53,000 PCPs is projected in the US by 2025, due in part to increased demand for primary care services because of an aging population, growing disease burden and a declining interest in primary care careers among medical residents. A shortage of PCPs in VA has recently come under increased focus due to the emphasis on improving Veterans’ access to high quality and timely healthcare. Providing timely access to primary care requires a sufficiently large PCP workforce. However, as of May 2016, VA was reported to have been trying to fill up to 500 PCP positions, reflecting roughly 12% of the current VA PCP workforce. Prior research has not examined several important individual, economic, job and system-level factors associated with the recruitment and retention of PCPs by health systems. These understudied factors include components of pay and compensation, academic affiliation, elements of the patient-centered medical home model and workplace climate, which represent areas where VA data offer unique contributions. In addition, no prior research has examined the relative importance of factors in explaining PCP recruitment and retention. Identifying and prioritizing key factors associated with PCPs’ employment choices will help VA and other health systems with the strategic recruitment of PCPs and the development of evidence-based strategies to retain high quality PCPs. Objectives: The objectives of this study are to: 1) identify and prioritize individual, job, economic and system- level factors associated with the choice of VA for employment and selection of rural practice (i.e. recruitment) using existing VA data as well as new qualitative and survey data collected for this study and 2) identify and prioritize individual, job, economic and system-level factors associated with long-run retention of PCPs within VA and in rural VA clinics using administrative data and existing survey data. Methods: This mixed methods study will examine VA administrative data, existing VA employee survey data, public health resource data and new qualitative and survey data collected for this project. To measure factors associated with VA recruitment and choice of rural practice setting (Aim 1), we will conduct structured interviews with current internal medicine residents exposed to VA settings during their training and new PCPs with a permanent VA position. We will then develop and administer a new survey instrument using key factors identified in qualitative interviews and factors of particular interest in this study. Triangulation will then be used to assess whether key factors and themes established in qualitative analyses generalize to the larger population of internal medicine residents and new VA PCPs. We will perform descriptive analyses to compare influential factors identified in interviews and surveys between residents and new PCPs. Multivariable analyses will be used to identify factors that are significantly associated with consideration of VA employment and rural practice among internal medicine residents. For Aim 2, we will use VA administrative databases to track the employment status of VA PCPs longitudinally. We will identify all PCPs assigned to a panel of primary care patients who met a minimum clinical full-time equivalent (FTE) threshold and were employed by VA at any time during the period 2003-2016. We will link administrative data with VA and public survey data to examine key factors of interest. Statistical methods for survival data analysis will be applied to assess the influence of hypothesized factors on quarterly retention probabilities and PCPs’ expected duration of VA employment. Parallel analyses will assess PCP retention in rural VA facilities. Secondary analyses will examine the longitudinal profile of clinical FTE using an extended two-part model. In both aims, we will apply econometric methods including Shapley value decompositions to partition the variation in PCP recruitment and retention explained by key explanatory factors and factor combinations.	Systems Modeling, Design, and Delivery	To measure factors associated with VA recruitment and choice of rural practice setting (Aim 1), we will conduct structured interviews with current internal medicine residents exposed to VA settings during their training and new PCPs with a permanent VA position. We will then develop and administer a new survey instrument using key factors identified in qualitative interviews and factors of particular interest in this study. We will perform descriptive analyses to compare influential factors identified in interviews and surveys between residents and new PCPs. Multivariable analyses will be used to identify factors that are significantly associated with consideration of VA employment and rural practice among internal medicine residents. For Aim 2, we will use VA administrative databases to track the employment status of VA PCPs longitudinally. We will identify all full-time equivalent PCPs assigned to a panel of primary care patients at any time during the period 2003-2016. We will link administrative data with VA and public survey data to examine key factors of interest. Statistical methods for survival data analysis will be applied to assess the influence of hypothesized factors on quarterly retention probabilities and PCPs' expected duration of VA employment. Parallel analyses will assess PCP retention in rural VA facilities. We estimate examining approximately 10,000 PCPs in retrospective analyses of retention, 3,000-6,000 survey responses and 30-60 interviews.	The objectives of this study are to: 1) identify and prioritize individual, job, economic and system-level factors associated with the choice of VA for employment and selection of rural practice (i.e. recruitment) using existing VA data as well as new qualitative and survey data collected for this study; and 2) identify and prioritize individual, job, economic, and system-level factors associated with long-run retention of PCPs within VA and in rural VA clinics using administrative data and existing survey data.	This study is of current policy relevance given the shortage of VA PCPs and the emphasis on providing Veterans timely access to care in the VA FY 2018-2024 Strategic Plan. Findings from this study will inform strategic physician workforce planning in VA to ensure appropriate capacity to meet the health care needs of Veterans.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 16-070	Cloitre	Marylene		marylene.cloitre@va.gov	Connecting Women to Care: Home-based Psychotherapy for Women with MST Living in Rural Areas	04/01/2018	09/30/2022	VA Palo Alto Health Care System, Palo Alto, CA	$1,086,584		Background – Military Sexual Trauma (MST) among women Veterans is a problem of epidemic proportion associated with significant mental health and functional impairment and substantial access to care barriers. Surveillance data indicate that one in four women Veterans reports MST when screened. Compared to women Veterans with other service-related stressors, those experiencing MST have greater mental health problems, are more likely to report difficulty in functioning in social, family and intimate relationships and are more likely to be unemployed and to report difficulties in finding a job. Nevertheless, women with MST engage less frequently in VA health care than other women Veterans. Barriers to care include distance from specialty services, financial difficulties, childcare and family responsibilities, and gender-related discomfort in male- dominated VA facilities. Research over the past decade has identified the problems and concerns of women Veterans with MST but programs addressing their mental health needs and responsive to identified barriers are lacking. The proposed study addresses this gap by evaluating a gender-sensitive, evidence-based skills training program delivered via home-based video technology. Specific Aims – The study will conduct a Hybrid Type 1 effectiveness-implementation study to accomplish two aims. The first is to determine the effectiveness of the HBVT-delivered, Skills Training in Affective Regulation (STAIR) relative to a HBVT-delivered nonspecific active comparator, Present Centered Therapy (PCT) among women Veterans with MST. It is hypothesized that STAIR will be superior to PCT in regards to improvement in CAPS PTSD symptoms (primary outcome) as well as in perceived social support and social engagement (secondary outcomes). The second aim is to conduct a multi-stakeholder, mixed method evaluation to inform future potential implementation plans by identify barriers and facilitators of implementing STAIR via HBVT and to contextualize and interpret the quantitative data on treatment processes and clinical effectiveness. Methodology – This is a four-year, two-site Hybrid Type 1 effectiveness-implementation study design. A total of 200 women Veterans with MST and PTSD symptoms (with DSM-5 PTSD Screen cut-off > 3) will be enrolled into the study. Participants will be stratified by rurality status in a proportion representative of the national population (34% rural vs. 66% nonrural). Stratification will ensure that resources are dedicated to recruit the identified number of rural women. Within each level of stratification, participants will be randomized into one of two treatments conditions, STAIR or PCT, each of which is comprised of 10 weekly sessions. Assessments will be conducted at five time-points: baseline (week 0), midtreatment (week 5), immediately posttreatment (week 10), 2-month follow-up (week 18) and 4-month follow-up (week 26). Rurality will be included as a covariate and assessed for variations in aspects such as retention and outcome, which will help inform future implementation plans. Multi-stakeholder mixed-method process evaluation concerning STAIR and the use of in-home delivery of services will include administrator, clinician and patient stakeholders. Expected Results and Anticipated Impacts on Veterans Healthcare – It is expected that the proposed study has the potential to improve the quality of VA healthcare by establishing the effectiveness of a social skills intervention, Skills Training in Affective and Interpersonal Regulation (STAIR) delivered via home-based video technology (HBVT) to women Veterans with MST, particularly those living in rural areas. The treatment simultaneously addresses social concerns and PTSD symptoms, both of which are identified needs of women Veterans who have experienced MST. STAIR has been demonstrated as efficacious in community populations and pilot data with women Veterans with MST indicate similar outcomes regarding improvements in perceived social support, social engagement and PTSD symptoms. The use of HBVT has the potential of increasing access to care to this geographically dispersed and underserved population.	Women's Health	The current study proposes to conduct a Hybrid Type 1 effectiveness-implementation design to assess the effectiveness of STAIR relative to a nonspecific active comparator, Present Centered Therapy (PCT) among women Veterans with MST, with dedicated resources to ensure engagement of those living in rural areas. We will also evaluate remote delivery of the treatment to the home rather than a VA clinic. 1. A randomized controlled trial will be conducted to assess the relative effectiveness of STAIR vs. PCT. 2. Qualitative assessment will be conducted via a multi-stakeholder mixed-methods evaluation of the delivery of STAIR via HBVT, based on two integrated frameworks: the Consolidated Framework for Implementation Research (CFIR) and the Replicating Effective Programs (REP).	The objectives of the current proposal are: 1. To evaluate the effectiveness of a skills training treatment, Skills Training in Affective and Interpersonal Regulation (STAIR) compared to an active nonspecific treatment, Present Centered Therapy (PCT), both delivered via home-based video. It is hypothesized that STAIR will be superior to PCT in reducing PTSD and related symptoms and in improving perceived social support, community engagement and social functioning. Assessments will occur five times: baseline (week 0), mid-treatment (week 5), post-treatment (week 10), 2 month follow-up (week 18) and 4 month follow-up (week 26). 2. To elucidate facilitators and barriers of implementing STAIR via home- based video treatment (HBVT) and (b) contextualize the quantitative findings of the clinical trial to enhance our understanding of both treatment processes and effectiveness.	STAIR provided superior outcomes to PCT across several outcomes. These results could have a major impact on the treatment of women veterans with MST where interventions addressing social support and multiple types of mental health problems are needed. The substantial effect sizes in PTSD symptoms in both treatments suggest the viability of treatments that do not focus on trauma as an alternative intervention among individuals who do not wish to engage in trauma-focused CBT. Availability of these types of treatment may increase engagement in mental health services.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 16-075	Kanwal	Fasiha	Aanand Naik	Fasiha.Kanwal@va.gov	Patient Centered Care for Individuals with Advanced Liver Disease	05/01/2018	02/11/2023	Michael E. DeBakey VA Medical Center, Houston, TX	$990,889		Background: Ensuring that Veterans with serious illness receive patient-centered care is a fundamental goal of VA. Advanced liver disease (AdvLD) is a serious illness that disproportionately affects Veterans and is characterized by declining health, increasing symptoms and frequent hospitalizations. Recent patient-centered models of care in other conditions, like cancer, have promoted early integration of supportive and palliative with curative care. These models can improve quality and even length of life. Integrated care in AdvLD is essential because it can reduce complications, maintain both function and well-being, and may even prolong life. Objectives: Patient-centered models of integrated AdvLD care have been slow to develop due to specific knowledge gaps. First, precise and complete understanding of disease severity and progression is lacking. Second, no studies exist that characterize Veterans' experiences and understanding of their AdvLD severity, or goals of care across the spectrum of disease severity. Third, little is known about clinicians' experiences, expectations, and perceived barriers to delivering AdvLD care. Our proposed study, conducted in close collaboration with AdvLD patients, caregivers, clinicians and clinical operations partners, will use a multi- method approach to fill these gaps so crucial to developing integrated care for AdvLD. Our specific aims are: (1) to develop risk prediction models to stratify patients into groups at different risks for key AdvLD outcomes; (2) to describe patient and caregiver experiences and goals of AdvLD care, including perceptions of illness severity, preferences for the amount and type of risk information desired, and expected health outcome goals; and (3) to identify clinicians' perceptions of opportunities and barriers to patient-centered AdvLD care. Methods: For Aim 1, we will conduct a national retrospective cohort study of Veterans with AdvLD seen in the VA between 2011 and 2015. We will use pre-existing administrative and clinical data in VA Corporate Data Warehouse to combine liver severity indices with sociodemographic (age, gender, homelessness), clinical (physical and mental health comorbidity, alcohol use), and healthcare resource use (hospitalization, emergency room visits) factors to provide risk category estimates for three patient-centered outcomes: risk of developing AdvLD complications, requiring AdvLD related hospitalizations, and overall mortality. To achieve Aim 2, we will conduct in-depth qualitative interviews with 60 patients who have AdvLD, and 30 caregivers, at 3 diverse VA facilities. Participants will be stratified by risk strata (e.g., low, intermediate or high risk of mortality from AdvLD-specific complications). To achieve Aim 3, we will conduct in-depth qualitative interviews with 30 clinicians involved in direct care of patients with AdvLD. Interviews will examine their experiences in communicating risk and making treatment plans; perceptions of their and their patients' roles in treatment planning; and barriers to and facilitators of providing care aligned with patients' health outcome goals. Significance: Together, these aims will yield products that have direct impact on current clinical care of advanced liver disease as well as provide the foundation for developing a patient-centered, integrated approach to AdvLD care that ensures timely supportive and palliative care consistent with patients' preferences and health outcome goals within the context of contemporary AdvLD care as provided in the VA.	Care of Complex Chronic Conditions	Aim 1: To develop risk stratification models of AdvLD prognosis. We will develop models that combine liver severity indices (e.g., MELD, Child Pugh) with psychosocial (e.g., age, race, homelessness), clinical (e.g., physical and mental health comorbidity, alcohol use), and healthcare resource use (e.g., emergency room visits) factors to estimate the risk of developing AdvLD complications, requiring AdvLD related hospitalizations, and overall mortality. We will use existing automated data from a national cohort of Veterans with AdvLD (n~45,000) enrolled in the VA between 2011 and 2015. Aim 1 will provide estimates of AdvLD Veterans' risk (e.g., low, intermediate or high) of developing AdvLD-specific outcomes. These data will allow patients, caregivers and clinicians to understand patients' illness severity and future risks. Aim 2: To describe patients' experiences and goals of AdvLD care. We will conduct in-depth interviews with a representative sample of AdvLD patients (and their caregivers) from three VA centers to understand patients' experiences with care; perceptions of illness severity including preferences for the amount and type of risk information needed; and desired health outcome goals. Aim 2 will identify the range of goals that patients in different risk strata perceive as important. Data from Aims 1 and 2 will allow clinicians to place their patients' perspectives in context and deliver clinical care consistent with patients' prognosis and goals. Aim 3: To identify clinicians' perceptions of opportunities and barriers to patient-centered AdvLD care. We will conduct in-depth interviews with clinicians involved with AdvLD treatment planning at three VA centers to examine their experiences in communicating risk and making treatment plans; perceptions of their and patients' roles in treatment planning; and barriers to and facilitators of providing care aligned with patients' goals. Aim 3 will complement the first two by identifying problems that clinicians face delivering patient-centered AdvLD care as well as possible solutions to these problems. Combined with Aim 2, data from Aim 3 will provide design elements for intervention strategies to improve patient-centered AdvLD care.	To use a multi-method approach to fill knowledge gaps in the care of advanced liver disease (AdvLD) patients that are crucial to integrated care for AdvLD. Aim 1: To develop risk stratification models of advanced liver disease prognosis. Aim 2: To describe Veteran patients' experiences and goals of advanced liver disease care. Aim 3:To identify clinicians' perceptions of opportunities and barriers to patient-centered advanced liver disease care.	This study will develop a patient-centered model of collaborative care for AdvLD that may be applicable to other serious illness conditions. It will develop Veteran-specific risk stratification models for AdvLD care that will provide clinicians with a practical method for predicting risks of major clinical outcomes in AdvLD. Interviews with Veterans and their caregivers will reveal how patients with AdvLD experience care and to what extent such care meets their needs and preferences.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 16-089	Pogoda	Terri		terri.pogoda@va.gov	Improving Access to Supported Employment for Veterans with Polytrauma/Traumatic Brain Injury	05/01/2018	03/31/2023	VA Boston Healthcare System Jamaica Plain Campus, Jamaica Plain, MA	$1,496,071		Anticipated impacts on Veteran healthcare: Supported Employment (SE) is an effective evidence- based practice that focuses on competitive employment through job coaching and unlimited support. This research aims to increase access to SE for Veterans with polytrauma/traumatic brain injury (PT/TBI) so that more of these Veterans can reach their vocational potential. Ensuring that Veterans with PT/TBI can access effective vocational rehabilitation services may help prevent numerous downstream health and functional problems. Project background: Many OEF/OIF/OND Veterans have experienced PT/TBI, which can result in functional limitations and challenges to employment. Pogoda et al. found that among Veterans evaluated in VHA PT/TBI clinics, approximately 20% reported that they were unemployed and looking for work, and of these, 71.6% had a TBI diagnosis and were in their prime working years. Carlson et al. reported that Veterans with PT/TBI have an interest in receiving SE services, yet are not routinely informed of vocational rehabilitation programs. Though SE is targeted to Veterans with serious mental illness (SMI), up to 25% of the SE caseload may be used for non-SMI clinical populations. However a recent review found that more than one-half of VA SE programs were working below their caseload capacity and were able to serve more Veterans. Moreover, very few PT/TBI clinics were referring Veterans to SE. Project Objectives: The purpose of this study is to increase access to SE for Veterans with PT/TBI. This will be achieved by (1) identifying actionable barriers and facilitators to referring Veterans to SE, providing SE services to and retaining these clients, and integrating the SE and PT/TBI clinic teams, (2) developing and refining an intervention package/toolkit for an SE-TBI program, and (3) implementing the intervention and conducting qualitative and quantitative assessment of its effectiveness at local VA Medical Centers (VAMCs) that are below SE caseload capacity. Project Methods: Guided by the integrated-Promoting Action Research on Implementation in Health Services (i-PARIHS) framework, for Aim 1, we will identify barriers and facilitators to SE-TBI by interviewing SE vocational rehabilitation specialists and PT/TBI providers at (a) 4 VAMCs that have a successful SE-TBI program, and (b) 12 VAMCs that are below SE caseload capacity. Based on findings from Aim 1, we will adapt and refine current toolkit materials to develop a customizable intervention package that includes menu-based choices (e.g., educational materials, marketing practices to facilitate integration between the SE and PT/TBI clinic teams) to maximize success in SE referral and implementation. Finally, for Aim 3, at the 12 VAMCs from Aim 1 that are below SE caseload capacity, through external and internal facilitation, we will implement an intervention package to enhance PT/TBI participation in SE and document: (a) its effectiveness for change in number of Veterans with PT/TBI referrals and SE caseload size from pre- to post-intervention, (b) stakeholder (SE vocational rehabilitation specialists, PT/TBI providers, Veterans with PT/TBI) perceptions of implementation and SE program progress, (c) Veteran vocational and nonvocational outcomes, and (d) SE program fidelity. We will follow each site's progress over an 18-month implementation and evaluation period.	Traumatic Brain Injury	This longitudinal mixed methods study will be guided by the integrated-Promoting Action Research on Implementation in Health Services (i-PARIHS) framework. For Aim 1, we will identify barriers and facilitators to SE-TBI by interviewing SE vocational rehabilitation specialists and polytrauma/TBI providers at (a) 4 VAMCs that have a successful SE-TBI program, and (b) 12 VAMCs that are below SE caseload capacity. Based on findings from Aim 1, for Aim 2 we will adapt and refine current toolkit materials to develop a customizable intervention package that includes menu-based choices (e.g., educational materials, marketing practices to facilitate integration between the SE and polytrauma/TBI clinic teams) to maximize success in SE referral and implementation. Finally, for Aim 3, at the 12 VAMCs from Aim 1 that are below SE caseload capacity, through external and internal facilitation, we will implement an intervention package to enhance polytrauma/TBI participation in SE and document: (a) its effectiveness for change in number of Veterans with polytrauma/TBI referrals and SE caseload size from pre- to post-intervention, (b) stakeholder (SE vocational rehabilitation specialists, polytrauma/TBI providers, Veterans with polytrauma/TBI) perceptions of implementation and SE program progress, (c) Veteran vocational and nonvocational outcomes, and (d) SE program fidelity. We will follow each site's progress over an 18-month implementation and evaluation period.	This research aims to increase access to SE for Veterans with polytrauma/TBI. This will be achieved by (1) identifying actionable barriers and facilitators to referring Veterans to SE, providing SE services to and retaining these clients, and integrating the SE and polytrauma/TBI clinic teams, (2) developing and refining an intervention package/toolkit for an SE-TBI program, and (3) implementing the intervention and conducting qualitative and quantitative assessment of its effectiveness at local VA Medical Centers (VAMCs) that are below SE caseload capacity.	Ensuring that Veterans with polytrauma/TBI can access effective vocational rehabilitation services may help prevent numerous downstream health and functional problems.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 16-096	Sadler	Anne		Anne.Sadler@va.gov	Online and Shared Decision-Making Interventions to Engage Service Men and Women in Post-Deployment Mental Health Care	06/01/2018	01/31/2023	Iowa City VA Health Care System, Iowa City, IA	$1,140,500		OEF/OIF/OND war Veterans have unique post-deployment care needs that the VA is striving to understand and address. Unfortunately, there is a significant disparity in utilization of mental health (MH) care and VA access as most war Veterans don’t seek needed care. New interventions are urgently needed to address disparities in post-deployment MH treatment engagement for our war Veterans and to support VA’s efforts to provide them with optimal access and care. Online health interventions have been shown to be preferred by OEF/OIF combat Veterans and have the potential to promote access to VA MH care. Our research team has developed a web-based interface (WEB-ED) evolved by feedback from Veterans that screens for common post-deployment MH and readjustment concerns, provides tailored education about positive screens, and facilitates linkage to VA resources. Data from our prior studies demonstrate WEB-ED can be successfully implemented within VA and activate Veterans to seek needed care. Furthermore, emerging evidence indicates that when patients are educated about their health conditions and treatment alternatives using shared decision- making (SDM), increased treatment participation and adherence, and better health outcomes result. Next steps include: linking Veteran WEB-ED screening results to a VA secure network so that a provider can access the results; and integrating a SDM interface to promote Veteran- Provider partnerships in patient-centered care. We propose a three phase study to address our aims. Aim 1 (phase 1) we will gather qualitative information from key VA and Veteran informants to create an enhanced version (WEB-ED+) of our Current WEB-ED that includes an eHealth and SDM interface. Aim 2 (phase 2) will use a randomized controlled trial (RCT) to test WEB- ED+ vs. Current WEB-ED in promoting VA MH care engagement. Aim 3 (phase 3) we will employ a process evaluation to determine the feasibility and acceptability of WEB-ED+ for both Veterans and VA practitioner and to document the VA processes Veterans use to enroll and engage in VA MH care. This study will improve our understanding of the most effective methods to reduce barriers to enrollment in VA/MHV and transferring important medical information using My HealtheVet (MHV). Furthermore, it will provide important information regarding how WEB- ED results can enhance the capability of VA providers and transition patient advocates to use Veterans’ screening results to triage and engage Veterans in patient-centered MH care and promote VA provider adoption of WEB-ED+ to facilitate patient engagement. Online screening, tailored education, and links to geographically accessible VA resources has been shown to be preferred by Veterans, providing recognition of treatable post-deployment MH concerns, and education that reduces stigma. This study builds upon and augments this prior work with research to understand and evaluate the processes needed to integrate WEB-ED+ into current VHA systems to support efficient care delivery, facilitate patient-centered care, and address unmet need for MH care while also resolving disparities in VA and VA MH care access and engagement for war Veterans. WEB-ED+’s use of shared decision making is a key component for promoting these benefits. WEB-ED+ represents a readily implementable and cost-effective intervention that, with partner collaboration, can be integrated into VA systems through MHV. Findings have important policy implications for several operational partners heavily invested in the improved access and delivery of evidence-based mental health care for war Veterans.	Mental and Behavioral Health	Participants will be recruited from a community sample of male and female Veterans returning from Iraq/Afghanistan deployment(s) in the preceding 4 years. In phase one, key Veteran, provider, and other VA informants at five VA sites (one in each MyVA geographic region) will be engaged and interviewed with on-site semi-structured interviews. Clinical workflow process mapping will also be completed with regard to how to integrate WEB-ED+ into existing care delivery. In phase two, a RCT will be performed to compare MH care engagement differences between WEB-ED and WEB-ED+ study groups at the 5 phase one sites and at 5 additional sites within the MyVA regions. Sites were selected from Women's Practice-Based Research Network (PBRN) sites and in consideration of rural/urban differences and war Veteran density. A VA chart review will be performed 6 months following initial WEB-ED screening. Phase 3 will consist of a telephone interview assessing the post-intervention process evaluation of Veterans and their providers who participated in the RCT. The Consolidated Framework of Implementation Research will guide phases 1 and 3 interviews.	The objectives of this study are: Objective 1 (phase 1) to gather qualitative information from key VA and Veteran informants to create an enhanced version (WEB-ED+) of the investigators' Current WEB-ED that includes an eHealth (MyHealtheVet (MHV) and enhanced shared decision-making interface (SDM). Objective 2 (phase 2) to test WEB-ED+ vs. Current WEB-ED in promoting VA MH care engagement in Veterans with positive MH screens through a randomized clinical trial (RCT). Objective 3 (phase 3) elicit feedback from key stakeholders in both arms of the RCT to: a) assess the usefulness of an eHealth interface and the perceptions of how the interventions influenced patient access to and efficiency of VA patient-centered care delivery; b) assess Veteran and provider satisfaction with SDM educational materials, chart template and clinical interface; and c) document the processes study Veterans used to enroll in VA and engage in MH care.	This research will provide vital information to evaluate the processes needed to integrate WEB-ED+ into current VHA systems to support efficient care delivery, facilitate patient-centered care, and address unmet need for MH care while also resolving disparities in VA and VA MH care access and engagement for war Veterans. WEB-ED+'s use of shared decision making by both Veterans and providers is a key component for promoting these benefits. WEB-ED+ represents a readily implementable and cost-effective intervention that, with partner collaboration, can be integrated into VA systems through MHV.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 16-214	Chinman	Matthew		matthew.chinman@va.gov	Evaluating the Use of Peer Specialists to Deliver Cognitive Behavioral Social Skills Training	05/01/2018	09/30/2022	VA Pittsburgh Healthcare System University Drive Division, Pittsburgh, PA	$1,441,341		Background: The Veterans Health Administration (VHA) is advocating that Veterans with serious mental ill- ness (SMI) receive recovery-oriented, rehabilitation approaches that target real-world functioning. One such approach is Cognitive-Behavioral Social Skills Training (CBSST). Unlike traditional cognitive-behavioral thera- py, CBSST is a more recovery-oriented psychosocial rehabilitation intervention that teaches Veterans with SMI to correct errors in thinking and build social skills. While effective, CBSST has only been tested when facilitated by masters- or doctoral-level therapists, which limits its use in VHA. However, our pilot data shows that Peer Specialists—individuals with SMI who are hired and trained to use their own recovery experience to assist oth- ers with SMI—can also provide CBSST (called CBSST-Peer). Stand-alone social skills training (SST) is also a recovery-oriented program that VHA is attempting to rollout nationwide for Veterans with SMI. A few Peer Spe- cialists have been trained to co-lead SST with professionals. However, SST is not widely implemented be- cause professionals are busy and Peer Specialist delivered SST has not been tested. This study will evaluate the effectiveness of Peer Specialist-delivered CBSST and SST, which would increase access Veterans with SMI have to effective treatment. Our aims are: Aim 1 (Effectiveness): To compare the impact of CBSST-Peer on outcomes in Veterans with SMI to Veterans receiving Peer Specialist-delivered SST and Peer Specialist-led manualized, goal-focused groups of equal duration. We will also assess fidelity of SST and CBSST. Aim 2: (Helpfulness of CBSST/SST--Peer and implementation barriers and facilitators): To use focus groups with patients and interviews with Peer Specialists and other staff to assess perceptions of SST- and CBSST- Peer and identify potential barriers and facilitators to future implementation. Methods: This is a randomized, Hybrid 1 trial involving 252 Veterans with SMI (n=126 each from Pittsburgh, San Diego) comparing 3 treatment arms: CBSST-Peer vs. SST-Peer vs. a manualized, goal-focused group of equal duration. Hybrid 1 trials test the effectiveness of an intervention and collect implementation data that could inform its future adoption. At each site, across 6 waves (a wave = 1 CBSST-Peer, 1 SST-Peer, 1 goal focused group), 2 Peer Specialists will co-lead 18, 20-week groups. Like in the pilot, Peer Specialists will be trained and receive an hour of super- vision weekly by the CBSST developers. Master trainers from the SST rollout will train and supervise Peer Specialists in each site. All three arms' sessions will be taped and 25% rated for fidelity on standardized measures. A survey battery that assesses functioning, quality of life, recovery, and symptoms will be adminis- tered to the Veterans in each wave at: baseline, mid-intervention (10 weeks), end-of-intervention (20 weeks), and follow-up (32 weeks, 3 months post intervention). We will examine all outcomes using HLM, with treatment condition included as a time-invariant covariate, and random intercepts for person and random slopes for time. Relevant covariates will include site, treatment attendance, symptom severity, service use, and demographic variables. We will evaluate the effect for treatment conditions (CBSST-Peer vs. SST-Peer vs. goal focused group) in the expected direction and the time X group effect. Qualitative data on SST- and CBSST-Peer help- fulness and implementation factors will be audio-recorded from a random sample of Veterans who participated in SST- and CBSST-Peer (4 focus groups per site), participating Peer Specialists (interviews with n=6-8 per site), and mental health administrators (interviews with about n=3-4 per site). Using a modified grounded theo- ry approach, verbatim text will be coded to develop categories of responses regarding the helpfulness of, and barriers and facilitators to, future implementation of SST- and CBSST-Peer in VHA. Innovation: No study has tested peer-delivered SST or CBSST, or compared the two, in a rigorous trial. Significance/Expected Re- sults: CBSST and SST are not widely available. If SST- or CBSST-Peer is effective, it could greatly increase the delivery of evidence-based services Veterans receive and enhance the services by VHA Peer Specialists.	Mental and Behavioral Health	This is a randomized, Hybrid 1 trial involving 252 Veterans with SMI (n=126 each from Pittsburgh, San Diego) comparing 3 treatment arms: CBSST-Peer vs. SST-Peer vs. a manualized, goal-focused group of equal duration. Hybrid 1 trials test the effectiveness of an intervention and collect implementation data that could inform its future adoption. At each site, across 6 waves (a wave = 1 CBSST-Peer, 1 SST-Peer, 1 goal focused group), 2 Peer Specialists will co-lead 18, 20-week groups. Like in the pilot, Peer Specialists will be trained and receive an hour of supervision weekly by the CBSST developers. Master trainers from the SST rollout will train and supervise Peer Specialists in each site. All three arms' sessions will be taped and 25% rated for fidelity on standardized measures. A survey battery that assesses functioning, quality of life, recovery, and symptoms will be administered to the Veterans in each wave at: baseline, mid-intervention (10 weeks), end-of-intervention (20 weeks), and follow-up (32 weeks, 3 months post intervention). We will examine all outcomes using HLM, with treatment condition included as a time-invariant covariate, and random intercepts for person and random slopes for time. Relevant covariates will include site, treatment attendance, symptom severity, service use, and demographic variables. We will evaluate the effect for treatment conditions (CBSST-Peer vs. SST-Peer vs. goal focused group) in the expected direction and the time X group effect. Qualitative data on SST- and CBSST-Peer helpfulness and implementation factors will be audio-recorded from a random sample of Veterans who participated in SST- and CBSST-Peer (4 focus groups per site), participating Peer Specialists (interviews with n=6-8 per site), and mental health administrators (interviews with about n=3-4 per site). Using a modified grounded theory approach, verbatim text will be coded to develop categories of responses regarding the helpfulness of, and barriers and facilitators to, future implementation of SST- and CBSST-Peer in VHA.	Objective 1 (Effectiveness): To compare the impact of CBSST-Peer on outcomes in Veterans with SMI to Veterans receiving Peer Specialist-delivered SST and Peer Specialist-led manualized, goal-focused groups of equal duration. We will also assess fidelity of SST and CBSST. Objective 2: (Helpfulness of CBSST/SST--Peer and implementation barriers and facilitators): To use focus groups with patients and interviews with Peer Specialists and other staff to assess perceptions of SST- and CBSST-Peer and identify potential barriers and facilitators to future implementation.	This trial has not had any impacts to date.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 16-230	Scott	Steven	Sandra Winkler	steven.scott@va.gov	Recommendations and Interventions for and Changes in the Ocular Health and visual Function of Veterans with Traumatic Brain Injury	04/01/2018	09/30/2022	James A. Haley Veterans' Hospital, Tampa, FL	$1,007,921		More than 65% of patients with blast-related and non-blast-related traumatic brain injuries report vision problems. Traumatic brain injury (TBI) related visual impairment can damage not only the eye, but the visual (sensory and ocular-motor) pathways and/or cortical processing areas. Thus, the traditional objectives and treatment plans for eye-related blindness or low-vision may not be appropriate for combat and TBI related vision injuries. In 2008, the Veteran Health Administration (VHA) published Directive 2008-065 titled “Performance of Traumatic Brain Injury Specific Ocular Health and Visual Functioning Examinations for Polytrauma Rehabilitation Center Patients” specifying that all patients with a diagnosis of TBI who are admitted to VHA Polytrauma Rehabilitation Centers (PRCs) have a TBI-specific ocular health and visual functioning examination performed by an optometrist or ophthalmologist. Several studies have identified the prevalence and symptomology of this cohort; however, the service delivery data generated by this mandated exam have not been analyzed. The purposed study will evaluate how a selected attempt to organize the structure of care (Directive 2008-065) affects access to and utilization of vision health care services. The Specific Aims are to (1) Determine the pattern of access to and utilization of services among Veterans with TBI with visual and ocular deficits; (2) Describe rehabilitation service delivery; and (3) Explore clinical recovery as measured by visual and ocular outcomes. This population-based study will use a retrospective cohort design with a prospective survey component to identify access barriers to follow up appointments. The population is defined as all Veterans and active duty service persons with TBI admitted to one of the five VHA PRCs (approximate n=2,500). Patient identifiers (both Veteran and active duty) are provided by the Physical Medicine and Rehabilitation National Program Office. Using the VA Informatics and Computing Infrastructure workspace, both structured and unstructured data will be used to create an analytic data set. Structured data will be extracted from relevant data tables from the Corporate Data Warehouse. Unstructured data will be extracted from text documents stored in the electronic health record, also housed in the Corporate Data Warehouse, using an Information Extraction system. Extraction methods include manual chart review by experts, natural language processing, named entity recognition, machine learning and ad-hoc methods like handcrafted rules or regular expressions. Extracted data will be validated by an Expert Panel composed of oculomotor and vision experts from each of the five PRCs, the Polytrauma System of Care, and pre-911 vision and blind services clinics. Geographic Information System tools will be used to determine geographic access (both drive distance and drive time) to health services. The final dataset will consist of diverse variables including patient characteristics, treatment recommendations, access factors, facility locations, clinic visits, treatments/assistive devices, and patient-level outcomes with substantial inter- dependencies among the variables, all of which are interrelated in a complex non-linear fashion. Frequentist and Bayesian Network methods will be used to analyze data. The impact of this study on Veterans and the VHA system of care will be the development of recommendations to improve community reintegration by improving access to and utilization of quality TBI-related vision services. This will be accomplished by translating PRC specialized knowledge to non-specialized VHA facilities closer to the patients' residences.	Long Term Care and Aging	This is a population-based study of all patients with TBI admitted to VHA Polytrauma Rehabilitation Centers since 2008. Both retrospective large data and prospective survey designs will be used. Retrospective data will be extracted from the Corporate Data Warehouse. Natural language processing will be used to extract data from clinical notes. An expert panel will validate extracted data. Geographic Information System tools will be used to evaluate geographic barriers. The final dataset will consist of patient characteristics, treatment recommendations, access factors, facility locations, clinic visits, treatments/assistive devices, and patient-level outcomes. Frequentist and Bayesian Network methods will be used to analyze data.	Aim I: Determine the pattern of access to and utilization of services among Veterans with TBI with visual and ocular deficits. Q 1.1: What recommendations were made to Veterans by the Optometrist/Ophthalmologist performing the exam? Q 1.2: What proportion of Veterans attended recommendations had follow up visits at 6, 12, and 24 months? Q 1.3: How is the type of recommendation made to Veterans dependent on demographic variables, comorbidity, severity of TBI injury, specific visual and ocular deficits, access, and evaluating facility? H 1: The type of recommendation made to Veterans is associated with demographic factors, severity of TBI injury, specific visual and ocular deficits, access, and evaluating facility. Q 1.4: How is follow up rate dependent on type of recommendation, demographic factors, severity of TBI injury, specific visual and ocular deficits, access, and evaluating facility? H 2: The probability that Veterans return for follow up is influenced by the type of recommendation, demographic factors, severity of TBI injury, specific visual and ocular deficits access, and evaluating facility. Aim II: Describe rehabilitation service delivery. Q 2.1 What proportion of rehabilitation follow up visits are attended per specialty clinic? Q 2.2 What types of interventions are provided in follow up visits per specialty clinic? Q 2.3 What visual aids and assistive devices are provided per specialty clinic? Q 2.4 How is type of specialty clinic attended associated with demographic variables, comorbidity, severity of TBI injury, specific visual and ocular deficits, access, and evaluating facility? H 3: The type of specialty clinic attended is associated with demographic factors, severity of TBI injury, specific visual and ocular deficits, access, and evaluating facility. Aim III: Explore clinical recovery as measured by visual and ocular outcomes. Q 3.1: For patients who have follow up data, how do outcomes change over time? Q 3.2: To what extent are demographic variables, comorbidity, severity of TBI injury, presenting visual and ocular deficits, access, and evaluating facility associated with outcomes? H 4: Visual and ocular outcomes are associated with demographic factors, severity of TBI injury, presenting visual and ocular deficits, access, and evaluating facility.	The impact of this study on Veterans and the VHA system of care will be the development of recommendations to improve access to and utilization of quality TBI-related vision services. This will be accomplished by translating PRC specialized knowledge to non-specialized VHA facilities closer to the patients' residences. 1. Polytrauma and Blind Rehabilitation Services have implemented telerehabilitation to increase access to vision therapy for Veterans with TBI-related visual dysfunction. 2. Polytrauma and Blind Rehabilitation Services have implemented cross training (Optometry + TBI). The initial OD fellowship program was at the Tampa PRC. A second training OD fellowship has been added at the San Antonio VA. Individual PRC have initiated their own cross-training. 3. The dialogue between DoD and the VA has begun on how standardize vision therapy across DoD and the VA including theDoD to VA transition. The dialogue includes the planning of follow up studies. Leadership and clinician researchers who served on the expert panel have realized that research is hindered by the lack of standardization of content of the clinical notes which has also affected publication of findings. Even the Defense & Veterans Eye Injury and Vision Registry (DVEIVR) database is riddled with error in incorrectly annotated units of measurement. The result is that this research topic will be limited to smaller samples and prospective or retrospective chart review designs.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 16-254	Kimerling	Rachel		Rachel.Kimerling@va.gov	Development of a Patient-Reported Measure to Assess Healthcare Engagement	04/01/2018	11/30/2022	VA Palo Alto Health Care System, Palo Alto, CA	$959,545		Enhancing engagement with health care is the foundation for VHA's transformation to personalized, proactive, patient-driven care that optimizes health and well-being. Patient engagement is linked to better care experiences and better clinical outcomes at reduced costs: the “triple aim” of healthcare systems. The science devoted to measurement must keep pace with new models of care. The ability to measure Veteran engagement is a critical component of patient-centered care. A self-report measure could be incorporated into patient-facing applications, inform personalized care plans and risk stratification, and facilitate research efforts. Extant measures do not meet VHA needs with respect to literacy levels, measurement sensitivity, or feasibility. Our goal is to develop a Veteran-centered, precise, and predictive patient-report measure that quantifies the propensity to engage with health care. Our approach builds on a Veteran-centered construct definition and item pool derived through extensive pilot work. A multi-level stakeholder engagement strategy will optimize Veteran usability and correspondence with VHA strategic priorities. The use of calibrated item banks will enable flexible implementation for a range of treatment settings and Veteran populations. The proposed aims of this project are to: 1) establish an item bank and corresponding short form that measures a Veteran's propensity to engage with health care; 2) assess concurrent validity and test-retest reliability of the measure; and 3) evaluate the predictive validity of the new measure against objective indicators of patient engagement. The item pool will be evaluated using a national survey of VHA primary care users who have been diagnosed with a mental health condition (depression and PTSD) or chronic medical condition (hypertension and diabetes), oversampling for women and racial minorities. Item Response Theory models will be used to calibrate items. Convergent validity with self-report correlates of patient engagement will provide preliminary validation. Predictive validity will be examined using global and condition-specific indicators of engagement from VA administrative data aggregated over the year following the survey. The VHA population has a high burden of chronic illness. The treatment demands of complex chronic conditions can be overwhelming to patients and account for a disproportionate amount of health care costs. High value care is determined by how well services fit with Veteran needs, preferences, and opportunities to benefit from care. A measure of engagement can help tailor care to Veteran needs and identify individuals who require adjunctive intervention to achieve the most benefit from their care. This research will fill an important gap in population health management, not only by enhancing risk prediction, but by integrating Veteran perspectives through patient-report measures. This work will catalyze efforts to promote engagement with care by providing flexible and practical assessment tools.	Access	The item pool will be evaluated using a national survey of VHA primary care users who have been diagnosed with a mental health condition (depression or PTSD) or chronic medical condition (hypertension or diabetes), oversampling for women and racial minorities. Item Response Theory models will be used to calibrate items. Convergent validity with self-report correlates of patient engagement will provide preliminary validation. Predictive validity will be examined using global and condition-specific indicators of engagement from VA administrative data aggregated over the year following the survey.	Our goal is to develop a Veteran-centered, precise, and predictive patient-reported measure that quantifies the propensity to engage with health care. The aims of this project are to: 1) establish an item bank and corresponding short form that measures a Veteran's propensity to engage with health care; 2) assess concurrent validity and test-retest reliability of the measure; 3) evaluate the predictive validity of the new measure against objective indicators of patient engagement.	High value care is determined by how well services fit with Veteran needs, preferences, and opportunities to benefit from care. A measure of engagement can help tailor care to Veteran needs and identify individuals who require adjunctive intervention to achieve the most benefit from their care. This research will fill an important gap in population health management, not only by enhancing risk prediction, but by integrating Veteran perspectives through patient-reported measures.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 16-266	Vashi	Anita		Anita.Vashi@va.gov	Veteran Access to Emergency Care	05/01/2018	02/28/2023	VA Palo Alto Health Care System, Palo Alto, CA	$1,237,712		Significance: This project evaluates access to emergency care for Veterans with particular emphasis on: assessing resources and capabilities of VA EDs to care for Veterans during times of crisis, determining where care is provided (VA vs. non-VA EDs), and understanding how and why Veterans make decisions regarding where to seek emergency care. The objectives of this proposal are directly responsive to HSRD priority areas (Access and Health systems change) and three of the VA Breakthrough priority areas (Improve Access to Health Care, Improve Community Care, and Improve the Veteran Experience). We also address Secretary Shulkin's priority areas (Choice Act, improve infrastructure). Dr. Vashi and her team have strong ties to VA and non-VA operational and policy partners, including the VA National Director of Emergency Medicine, which will be instrumental in translating research findings into meaningful improvements in policy. Background and Innovation: Emergency care is a critical but understudied part of the continuum of health care services offered to Veterans by the VA. While the VA is committed to providing timely and high- quality emergency care, surprisingly little is known about Veteran access to acute care or about the quality of care provided. Variations in VA emergency care resources are not well understood and prevent Veterans from making informed choices. Moreover, eligibility for non-VA ED care is confusing, complex and can translate to delays in treatment and poor outcomes. VA estimates that current VA users get, on average, only about 38% of their ED visits from VA, yet no study to date has examined emergency care Veterans receive in non-VA settings. While use of non-VA EDs may sometimes be appropriate, there are other times when the ED care could have been provided at the VA and use of the non-VA ED may result in duplicative care and delays. This dual use matters to the VA because, like an Accountable Care Organization, the VA is still responsible for the overall health of the Veteran and often the expenses even when Veterans receive care outside of the VA. Aims: Objectives of this proposal are: (1) To create survey items that facilitate a comprehensive inventory of VA ED resources and capabilities; (2) to calculate VA and non-VA ED utilization rates and identify the patient, facility, and community-level predictors of VA ED use and VA reliance; and (3) to characterize Veterans' preferences, resources and contextual factors that influence ED setting choice (i.e. VA, non-VA). Methods: We will build on pilot work and convene an advisory panel to create and add survey items to the next ED survey to assess VA ED resources and capabilities and determine how they vary (e.g. region, rurality, complexity). Using an innovative linkage method, we will use VA, Medicare, and California data to examine ED use across groups. Further, we will assess the patient, facility, and community level predictors of Veterans' choice of delivery system and VA reliance. All analyses will be conducted for three cohorts: a national accountable veteran population (Veterans 65+), residents of California (Veterans 65+), and residents of California (Veterans 18-64). Finally, we will conduct semi-structured interviews with Veterans to better understand why Veterans choose to receive their ED care inside or outside the VA. As underscored by the Secretary, our methods rely on “what Veterans actually tell us” and lay the groundwork for future comparisons of VA and non-VA ED quality metrics. Expected results: We will determine capabilities of VA EDs nationwide and examine the impact of these factors on VA ED use and reliance. Further by analyzing data and speaking with Veterans, we will better understand where and why Veterans access the acute care system (in both VA and non-VA settings) and will identify barriers in access amendable to future intervention and policy changes. Once we can identify patients receiving care outside the VA and determine why they made that decision, we can then develop interventions to keep Veterans “in-network” when appropriate.	Access	We will build on pilot work and convene an advisory panel to create and add survey items to the next ED survey to assess VA ED resources and capabilities and determine how they vary (e.g. region, rurality, complexity). Using an innovative linkage method, we will use VA, Medicare, and California data to examine ED use across groups. Further, we will assess the patient, facility, and community level predictors of Veterans' choice of delivery system and VA reliance. All analyses will be conducted for three cohorts: a national accountable veteran population (Veterans 65+), residents of California (Veterans 65+), and residents of California (Veterans 18-64). Finally, we will conduct semi-structured interviews with Veterans to better understand why Veterans choose to receive their ED care inside or outside the VA.	Objectives of this proposal are: (1) To create survey items that facilitate a comprehensive inventory of VA ED resources and capabilities; (2) to calculate VA and non-VA ED utilization rates and identify the patient, facility, and community-level predictors of VA ED use and VA reliance; and (3) to characterize Veterans' preferences, resources and contextual factors that influence ED setting choice (i.e. VA, non-VA).	Access to ED care for Veterans is poorly understood, fragmented, costly and confusing to Veterans. New VA EM leadership is committed to using our results to make impactful changes in emergency care organization, care provision and resource allocation. Using novel data sources and linkages, and Veteran perspectives, for the first time we can study the complexities of VA and non-VA use of acute care services.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 16-274	Neelon	Brian	Kelly Hunt	neelon@musc.edu	Impact of neighborhood and workforce deprivation on diabetes outcomes in Veterans: a spatio-temporal analysis	05/01/2018	12/31/2022	Ralph H. Johnson VA Medical Center, Charleston, SC	$797,724		Anticipated Impacts on Veterans Health Care: This project will put forth a comprehensive geospatial framework to address the VA Blueprint for Excellence Strategy 3: Leverage information technologies, analytics, and models of healthcare to optimize individual well-being and population health outcomes. By creating a spatially referenced dataset incorporating health information, workforce productivity, neighborhood deprivation, we will develop a comprehensive database to examine multiple dimensions of diabetes care. Through the use of advanced GIS and spatiotemporal statistics, we will identify hotspots of high disease risk, poor neighborhood resources, and low VA workforce capacity. This information will improve access to care by helping VA policy makers better match resources to areas with poor outcomes. Finally, by pinpointing areas with excessive health expenditures, the VA can develop cost-reduction measures to improve Veterans’ health while containing costs. Background: Diabetes is the seventh leading cause of death in the United States, can lead to serious complications, and is associated with increased healthcare costs. Prevalence estimates for Veterans show a disproportionate burden of disease, with estimates close to 25%, as compared to 8% of the general US population. Evidence consistently shows racial minorities have a higher prevalence of diabetes, worse outcomes, higher risk of complications, and higher mortality rate compared to non-Hispanic whites. This disparity persists after controlling for patient-level factors such as education, income, knowledge, health literacy, and self-efficacy; provider-level factors, such as bias, communication, and trust; and system-level factors, such as access to care. Little attention has been given to differences that may be explained by regional variation in patient-level resources, community-level resources, and health workforce resources. Objectives: This study seeks to identify and explain spatial and temporal variation in health outcomes, community resources, VA workforce capacity, and health disparities among patients with type 2 diabetes. Aim 1 will examine spatiotemporal trends in diabetes outcomes, including metabolic control, cost, and mortality. Aim 2 will develop a new spatiotemporal neighborhood deprivation index and examine its association with diabetes outcomes and racial disparities. Aim 3 will develop and validate a novel geographic workforce deprivation index to examine its association with diabetes outcomes and racial disparities. Methods: We will construct a cohort of veterans with type 2 diabetes receiving either inpatient or outpatient care at the VA during the years 2000 through 2015 by linking multiple patient and administrative files from the VHA National Patient Care and Pharmacy Benefits Management databases, using a previously validated VA algorithm. Using advanced GIS and spatial statistical methods, we will examine spatiotemporal trends in diabetes outcomes among Veterans with type 2 diabetes. In Aim 1, we will develop a flexible Bayesian spatiotemporal model to identify hotspots of high prevalence of diabetes-related outcomes. In Aims 2 and 3, we will use spatiotemporal latent factor models to develop novel neighborhood and workforce deprivation indices, allowing us to investigate evolving patterns in community resource availability and VA workforce capacity. Completion of these aims will enable the VA to identify individual, community, and institutional factors associated with poor diabetes outcomes and to target community and system-level efforts to improve health in low-resource areas.	Access	We will construct a cohort of veterans with type 2 diabetes receiving either inpatient or outpatient care at the VA during the years 2000 through 2015 by linking multiple patient and administrative files from the VHA National Patient Care and Pharmacy Benefits Management databases, using a previously validated VA algorithm. Using advanced GIS and spatial statistical methods, we will examine spatiotemporal trends in diabetes outcomes among Veterans with type 2 diabetes. In Aim 1, we will develop a flexible Bayesian spatiotemporal model to identify hotspots of high prevalence of diabetes-related outcomes. In Aims 2 and 3, we will use spatiotemporal latent factor models to develop novel neighborhood and workforce deprivation indices, allowing us to investigate evolving patterns in community resource availability and VA workforce capacity. Completion of these aims will enable the VA to identify individual, community, and institutional factors associated with poor diabetes outcomes and to target community and system-level efforts to improve health in low-resource areas.	This study seeks to identify and explain spatial and temporal variation in health outcomes, community resources, VA workforce capacity, and health disparities among patients with type 2 diabetes. Aim 1 will examine spatiotemporal trends in diabetes outcomes, including metabolic control, cost, and mortality. Aim 2 will develop a new spatiotemporal neighborhood deprivation index and examine its association with diabetes outcomes and racial disparities. Aim 3 will develop and validate a novel geographic workforce deprivation index to examine its association with diabetes outcomes and racial disparities.	This project will put forth a comprehensive geospatial framework to address the VA Blueprint for Excellence Strategy 3: Leverage information technologies, analytics, and models of healthcare to optimize individual well-being and population health outcomes. By creating a spatially referenced dataset incorporating health information, workforce productivity, neighborhood deprivation, we will develop a comprehensive database to examine multiple dimensions of diabetes care. Through the use of advanced GIS and spatiotemporal statistics, we will identify hotspots of high disease risk, poor neighborhood resources, and low VA workforce capacity. This information will improve access to care by helping VA policy makers better match resources to areas with poor outcomes. Finally, by pinpointing areas with excessive health expenditures, the VA can develop cost-reduction measures to improve Veterans' health while containing costs.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 16-277	Stepnowsky, Jr.	Carl		Carl.Stepnowsky@va.gov	Self-Management of Continuous Positive Airway Pressure Settings for Veterans with Sleep Apnea	05/01/2018	12/31/2022	VA San Diego Healthcare System, San Diego, CA	$1,198,806		Background: Because of clinical demands, patients are often under-educated and under-supported about the features of their positive airway pressure (PAP) devices. The most engaged patients are ones who understand the details of their device and change the feature settings so that they can maximize the benefits of therapy. Features settings include humidification level, expiratory pressure relief, pressure ramping, mask alert, auto pressure start, among other important comfort features. Historically, patients have not been provided with access to alter or modify therapy pressure settings, which requires physician prescription. Allied medical staff can carry out subsequent pressure setting changes. It is clear that it is difficult for the healthcare system to engage in optimal chronic disease management, and accommodate the needs of sleep apnea patients early in the treatment initialization process, which requires multiple visits/contacts to ensure that patients are maximizing the use of therapy. Objectives and Aims: The overarching aim of the proposed project is to examine the effect of providing patients with the ability to adjust their PAP pressure levels on therapy adherence and outcomes. To answer these research questions, the proposed randomized, controlled two-group trial of Sleep Apnea Self- Management Program (SM) and SM plus Individualized Pressure Adjustment (IPA) has the following specific aims related to APAP adherence and efficacy, patient-reported outcomes, and utilization: (1) To examine the effect of Individualized Pressure Adjustment (IPA) of settings on treatment adherence and efficacy (i.e., mask leak and residual apnea-hypopnea index); (2) To examine the effect of SM+IPA versus SM on patient self- reported treatment outcomes; and (3) To describe the effects of SM-IPA and SM groups on utilization. Significance: Sleep apnea is one of the most common chronic conditions in the VA. Positive airway pressure (PAP) therapy is the gold-standard therapy for sleep apnea, but adherence with PAP is suboptimal. VA sleep programs are understaffed relative to clinical demand for education and support. While adaption to PAP therapy has traditionally been achieved through sequential visits and pressure changes initiated by providers during office-based care, self-monitoring and individualized pressure adjustment is an important strategy that would empower Veterans to achieve better control of their OSA. The key impacts of this project are significant for both patients (improved outcomes) and the VA (improved staff efficiencies). Innovation: While patients have control over a wide range of comfort features on their PAP devices, historically they have not been formally educated and supported to adjust pressure settings. The unique aspect of this study is the focus on individualizing pressure settings to allow for the maximizing therapeutic benefit, including increased PAP adherence. Importantly, this is done within the context of provider oversight. Methods: The proposed study is a 6-month randomized, controlled, non-blinded, single-center study comparing the Sleep Apnea Self-Management Program (SM) to SM plus Individualized Pressure Adjustment (IPA). Both groups will receive the SM protocol to ensure that they receive identical OSA and PAP education and support. Participants in the intervention arm will be provided with additional education and support that will allow them to adjust their PAP pressures. Expected Results: Positive findings from this study will result in a Toolkit that can be distributed through the VA Sleep Network and the American Sleep Apnea Association to provide patients and providers with the knowledge necessary to improve the clinical management of OSA.	Care of Complex Chronic Conditions	The proposed study is a 6-month randomized, controlled, non-blinded, single-center study comparing the Sleep Apnea Self-Management Program (SM) to SM plus Individualized Pressure Adjustment (IPA). Both groups will receive the SM protocol to ensure that they receive identical OSA and PAP education and support. Participants in the intervention arm will be provided with additional education and support that will allow them to adjust their PAP pressures.	The overarching aim of the proposed project is to examine the effect of providing patients with the ability to adjust their PAP pressure levels on therapy adherence and outcomes. To answer these research questions, the proposed randomized, controlled two-group trial of Sleep Apnea Self-Management Program (SM) and SM plus Individualized Pressure Adjustment (IPA) has the following specific aims related to APAP (automatic positive airway pressure) adherence and efficacy, patient-reported outcomes, and utilization: (1) To examine the effect of Individualized Pressure Adjustment (IPA) of settings on treatment adherence and efficacy (i.e., mask leak and residual apnea-hypopnea index); (2) To examine the effect of SM+IPA versus SM on patient self-reported treatment outcomes; and (3) To describe the effects of SM-IPA and SM groups on utilization.	Positive findings from this study will result in a Toolkit that can be distributed through the VA Sleep Network and the American Sleep Apnea Association to provide patients and providers with the knowledge necessary to improve the clinical management of OSA.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 16-281	Ulmer	Christi		christi.ulmer@va.gov	Provider Supported Self-Help Cognitive Behavioral Therapy for Insomnia (Tele-Self-CBTI)	11/01/2018	05/31/2023	Durham VA Medical Center, Durham, NC	$1,149,214		Anticipated Impacts on Veteran’s Healthcare: Insomnia is pervasive among Veterans and is a risk factor for the most common mental health problems treated in the VA healthcare system, including depression, PTSD, and suicidality. A provider-supported Self-management strategy for insomnia can bridge the gap between unavailable resources and high demand for services, and has the potential to improve outcomes across multiple life domains. Project Background/Rationale: Cognitive Behavioral Therapy for Insomnia (CBTI) is a multi-component insomnia intervention that is recommended as the first-line insomnia treatment. Yet, Veteran access to CBTI is limited by a number of factors, including an inadequate number of trained providers for the high prevalence of insomnia among Veterans, the inconvenience of weekly treatment offered exclusively in a clinical setting, and the distance to VA facilities among rural Veterans. Self-management CBTI is effective in treating insomnia among those without significant medical and mental health co-morbidities, and requires fewer provider resources. As such, Self-management CBTI is a viable option for increasing Veteran access to CBTI. Project Objectives: The proposed study will examine two primary research questions, and one exploratory research question: 1. Does Tele-Self CBTI result in reduced insomnia severity among Veterans with Insomnia Disorder? Primary Hypothesis: (H1) Relative to Health Education, participants randomized to receive Tele-Self CBTI will have greater improvements in insomnia severity, as measured by the Insomnia Severity Index (ISI) at 6 weeks. 2. Does Tele-Self CBTI result in improvements in subjectively and objectively assessed sleep, fatigue, depression symptoms, and quality of life (QOL)? Secondary Hypotheses: (H2) Relative to Health Education, participants randomized to receive Tele-Self CBTI will have greater improvements in subjective sleep (per diary sleep onset latency, wake after sleep onset, and sleep efficiency), objective sleep (per actigraphy wake after sleep onset, total sleep time, and sleep efficiency), fatigue, depression symptoms, and QOL at 6 weeks. 3. How do nurses and administrators perceive Tele-Self CBTI in terms of the feasibility and acceptability of implementing this intervention in the primary care setting? No hypotheses are proposed for this exploratory research question. Project Methods: Study participants (200) will be randomly assigned in equal proportions to either the Tele- Self CBTI intervention, or to Health Education. A multi-modal assessment strategy will be used to assess insomnia severity, sleep parameters, fatigue, depression symptoms, and quality of life across 3 time points: baseline, 6 weeks (primary endpoint), and 6 months. In addition, we will interview nurses and clinic administrators about Tele-Self CBTI to inform future efforts to implement and disseminate the intervention in the primary care clinical setting, if Tele-Self CBTI is found to be effective.	Care of Complex Chronic Conditions				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 16-297	Weiner	Michael		Michael.Weiner4@va.gov	A Human Factors Investigation of Health Information Exchange: Tools to Support Providers' Coordination of Medications	03/01/2018	09/30/2022	Richard L. Roudebush VA Medical Center, Indianapolis, IN	$1,082,904		Background/Rationale: Millions of Veterans receive care from both VA and non-VA healthcare providers. Health information exchange (HIE) technologies are relatively new and are implemented across VA. HIE allows VA providers to send and receive medication data from non-VA medical institutions. This data exchange is important to coordinate patients’ medications, reconcile medications to reflect what the patient is actually taking, and reduce the risk of adverse drug events. With the recent Veterans Access, Choice, and Accountability Act of 2014, it is even more critical to foster effective HIE that improves provider decision-making. Reports indicate, however, that VA’s HIE technologies are inadequately supporting medication reconciliation tasks and are underutilized by providers. In addition, HIE medication data and VA medication orders are shown in separate displays, limiting the utility of HIE data and impeding providers’ ability to coordinate medications. Objectives: The objective of this research is to identify the cognitive needs of providers and develop a novel interface that integrates HIE and VA medication data. We hypothesize that, compared to VA technologies, the innovative medication interface will significantly improve providers’ efficiency and accuracy of medication reconciliation. Specific aims are as follows: Aim 1: Assess the strengths and weaknesses of VA’s HIE interfaces for supporting providers’ workflow and decision-making processes for medication reconciliation in the context of care. Aim 2: Identify the fundamental, cognitive strategies that providers use for medication reconciliation tasks and develop a novel VA-HIE interface that supports cognition and integrates HIE and VA medication data. Aim 3: Evaluate whether the novel, integrated VA-HIE interface significantly improves providers’ performance, including medication reconciliation process and outcome measures. Project Methods: For Aim 1, field observations, interviews, and remote usability tests will be conducted with inpatient and outpatient providers (physicians, nurses, and pharmacists) to generate a baseline, exploratory assessment of how well HIE interfaces support medication reconciliation. Qualitative data will be collected across four geographically dispersed VA Medical Centers. For Aim 2, established techniques, including card sorts and simulation interviews, will be conducted with inpatient and outpatient providers, to identify the underlying cognitive processes involved in medication reconciliation tasks. Results from Aims 1 and 2 will be used to develop a novel VA-HIE interface. For Aim 3, we will conduct a randomized controlled trial with providers in a simulated environment and collect qualitative and quantitative data in order to evaluate whether the novel VA-HIE interface improves the efficiency and accuracy of medication reconciliation. Significance: This research will provide foundational knowledge on provider’ cognition, which is necessary to ensure that VA and Veterans maximally benefit from VA’s investment in HIE technologies. Study findings can be used to increase providers’ adoption of HIE technologies and enhance medication coordination for Veterans.	Healthcare Informatics	Methods: For Aim 1, field observations, interviews, and remote usability tests will be conducted with inpatient and outpatient providers (prescribers and pharmacists) to generate a baseline, exploratory assessment of how well HIE interfaces support provider workflow. Qualitative data will be collected across four geographically dispersed VA Medical Centers. In Aim 2, card sorts and simulation interviews will be conducted with inpatient and outpatient providers to identify the underlying cognitive processes involved in medication reconciliation tasks. For Aim 3, we will conduct a randomized controlled trial with providers in a simulated environment and collect qualitative and quantitative data in order to evaluate whether the design guidelines significantly improves providers' efficiency and accuracy of medication reconciliation.	The study objective is to identify providers' underlying cognitive needs in order to develop a set of technology design guidelines for presenting VA and HIE medication data. We hypothesize that, compared to current VA technologies, design guidelines from this research can significantly improve the quality and safety of providers' decision-making, including the efficiency and accuracy of medication reconciliation. Specific aims are as follows: Aim 1: Assess the strengths and weaknesses of VA's HIE interfaces for supporting providers' workflow and decision-making processes for medication reconciliation in the context of care. Aim 1 will yield an initial set of HIE design guidelines to support providers' workflow. Aim 2: Identify the cognitive strategies that providers use for medication reconciliation tasks. Aim 2 will yield an initial set of HIE design guidelines to support providers' cognition. Guidelines from Aims 1, 2 will be translated into a novel prototype for the VA-HIE interface. Aim 3: Evaluate the novel VA-HIE interface to assess whether the design guidelines significantly improve the quality and safety of providers' performance.	This research will provide foundational knowledge on provider' cognition, which is necessary to ensure that VA and Veterans maximally benefit from VA's investment in HIE technologies. Study findings can be used to increase providers' adoption of HIE technologies and enhance the quality and safety of medication coordination for Veterans.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 17-030	Mitchell	Karen		karen.mitchell5@va.gov	Eating disorders in Veterans: Risk, resilience, and service use	05/01/2019	09/30/2023	VA Boston Healthcare System Jamaica Plain Campus, Jamaica Plain, MA	$543,819		Background Eating disorders (EDs) likely affect a significant proportion of female and male Veterans; however, they remain understudied and under-treated in VA. Individuals with EDs are likely to be high users of medical care, which is at least partly due to the physical complications of EDs. Nonetheless, EDs often go undetected in general medical settings, unless providers screen for them. Currently, the VA does not routinely screen for EDs; thus, enhancing VA's capacity nationally to provide comprehensive care for Veterans with EDs is a priority area of focus. This proposal will address four major gaps: the lack of prevalence estimates of EDs in nationally representative samples of Veterans, the lack of knowledge of healthcare needs and preferences of Veterans with EDs, the paucity of findings regarding military/Veteran-specific risk factors for EDs, the lack of a validated screening measure for EDs in Veterans, and the lack of knowledge regarding Veteran preferences for ED screening. These gaps are barriers to screening for and treating Veterans with EDs in VA healthcare. Objectives The specific aims are to establish a nationally representative cohort of male and female Veterans in order to: 1) a) examine the prevalence of male and female Veterans reporting full and subthreshold EDs and b) to examine the potential prevalence of EDs among vulnerable subgroups of Veterans; 2) to identify service use and needs among male and female Veterans with full and subthreshold EDs; 3) to estimate models of risk and protective factors for EDs, including military sexual trauma, combat trauma, and unit and family deployment support; and 4) to validate an existing screening measure of EDs in a Veteran sample and assess screening preferences. Methods In order to achieve these aims, we will recruit a nationally representative sample of 1500 male and female Veterans. We will request that the VA/DoD Identity Repository (VADIR), a VA office with access to Department of Defense records, assist in randomly selecting 3750 individuals from the national Veteran population. We will stratify the sample based on race/ethnicity and oversample women to achieve a 1:1 ratio. We will mail a comprehensive survey to potential participants using a multi-pronged, six-stage mailing strategy. Participants will complete survey measures of ED symptoms, risk and protective factors, and VA and non-VA healthcare service and needs. Aim 1: sample weighting procedures will be used in order to calculate nationally representative prevalence estimates of EDs among male and female Veterans. Aim 2: Poisson regression will be used to compare healthcare service use for Veterans with EDs to Veterans without EDs. In addition, we will use descriptive statistics to report service use among male and female Veterans with full and subthreshold EDs and which services, if available, they would like to use. Aim 3: structural equation modeling will be used to estimate models of risk and protective factors for EDs. Aim 4: Receiver Operating Characteristic curves will be used to estimate sensitivity and specificity of the ED screening measure, regression models will be used to investigate criterion validity, and descriptive statistics will be used to describe Veteran screening preferences. Dissemination Plan We will share our findings with our Operational Partners on monthly workgroup calls and make recommendations based on these results. Our findings regarding the scope of EDs among Veterans and their healthcare use and preferences will be used to inform ongoing provider trainings in EDs. We also will disseminate findings during Women's Health Cyberseminars and via newsletters such as the Women's Health Roundup. We will develop clinician and executive briefs in order to disseminate findings to both clinicians and policy-makers. Thus, our results will be summarized and disseminated to VA leadership in a timely manner. !	Mental and Behavioral Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 17-051	Miles	Shannon		Shannon.Miles@va.gov	Health Outcomes Associated with TBI Screening	05/01/2019	09/30/2023	James A. Haley Veterans' Hospital, Tampa, FL	$747,871		Background: The purpose of this study is to inform strategies to improve screening and treatment processes for Veterans returning from deployment. For almost a decade the Veterans' Health Administration (VHA) has been screening post 9-11 Veterans for traumatic brain injury (TBI) and other deployment-related invisible injuries. Despite the time and resources invested, little is known about outcomes of these screening programs. This project will provide crucial information for improving the current screening program and implementing a new program in the event of future wars. This study will be the first to systematically evaluate outcomes associated with the VHA's TBI post-deployment screening processes and integrate findings from TBI screening with findings from mental health (MH) screening. Project Objectives: (1) Describe specialty care treatment patterns following TBI screening; (2) Determine if the TBI screening process results in different patterns of specialty care utilization compared to just MH screening; and (3) Determine whether post deployment TBI screening enhances clinical outcomes and quality of life. Project Methods: This study will involve: (1) a retrospective analysis of VHA national post deployment screening and utilization data as well as (2) a survey of a subset of those individuals identified in the national data as having been screened for TBI. VHA national data will be utilized to examine the screening and evaluation results (both TBI and MH), as well as subsequent treatments received, by category. DSS identifiers will be used to create categories of outpatient services: MH, Neurology, and Physical Medicine and Rehabilitation (PMR). Data from Corporate Data Warehouse inpatient and outpatient data domains will be used to obtain diagnoses, categorize the inpatient and outpatient health services utilization (including medications) based on the category of care (i.e., Neurology, MH, PMR). In addition to VA national data, we will survey a random sample of the individuals identified as having been screened for TBI during the study period. We will mail questionnaires to this sample to evaluate outcomes and potential moderators/mediators of outcome, controlling for relevant variables. Priority Area: This project is relevant to HSR&D's priority on healthcare system change, as factors associated with efficiency and outcome with be investigated. This project also aligns with HSR&D's focus on postdeployment health (Atkins et al., 2017); existing data will be leveraged to evaluate services and outcomes associated with postdeployment screening. Expected Results/Significance: This study will be the first to systematically evaluate outcomes associated with the VHA's TBI post-deployment screening processes and integrate findings from TBI screening with findings from MH screening. VHA has invested heavily in post deployment screening. Despite increasing identification of possible TBI, it is unknown if the TBI screen and subsequent treatments improve outcomes over and above the MH screening process in place before the TBI screening. The significant overlap between TBI and MH symptoms may create inefficiencies, redundancies, and “silo” approaches to treatment following positive screens. As such, data on the `value added' of the TBI screen will be important for enhanced efficiency, greater access to care via reduction of waste, scientific evidence on long-term outcomes of post deployment screening.	Traumatic Brain Injury				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 17-063	Puri	Varun		Varun.Puri@va.gov	Defining Quality of Care in Lung Cancer	10/01/2019	03/30/2024	St. Louis VA Medical Center John Cochran Division, St. Louis, MO	$876,330		Background: Non-small cell lung cancer (NSCLC) is the leading cause of cancer-related mortality in Veterans. With the implementation of computed tomography screening, the incidence of Stage I lung cancer (tumors less than 5 cm with no metastases) is increasing exponentially in Veterans. Stage I NSCLC is potentially curable with surgery as the recognized gold standard of therapy. Wide variations exist in the care of Veterans with lung cancer. These inconsistencies in care are directly linked to suboptimal short- and long-term outcomes. Lack of clear guidelines is an important determinant of variable care. A number of national organizations have proposed quality measures (QMs) for surgery in lung cancer. However, these measures have largely been developed based upon retrospective institutional studies or expert opinion. A lack of evidence-based, validated QMs remains a critical unmet need. To address this crucial gap in knowledge, we will use the large, prospectively maintained Veterans Health Administration (VHA) database. The goal of this proposal is to develop a model to define high-quality surgical care for lung cancer and understand factors impacting quality of surgery. Significance: By creating a model of high-quality surgery for lung cancer, relevant to Veterans and the general population, our proposal directly addresses the Department of Veterans Affairs (VA) priorities of quality of care and transforming VA data into a national treasure. The recently launched VA-Partnership to increase Access to Lung Screening aims to detect 80% of all lung cancers at a curable stage. Our study focuses on optimal therapy for early-stage lung cancer, a current and, even more importantly, future imperative for the Veteran population. Innovation: Our proposal is innovative both conceptually and technically. The conceptual innovation relates to the holistic consideration of modifiable variables to define and impact high quality healthcare. The technical innovation relates to the implementation of a unique approach utilizing a prospectively maintained dataset for model development and validation. Specific Aims: Aim 1. To identify model-based quality measures for surgery in lung cancer and determine which have the greatest impact on short, and long-term outcomes. We hypothesize that among the candidate QMs, our models will identify key measures that are associated with improved short-term outcomes (operative morbidity and mortality) and long-term survival. Aim 2. To evaluate adherence to quality measures for surgery and understand the contribution of geographic, patient-, disease-, and treatment-related factors in adherence to quality measures for surgery in lung cancer. We hypothesize that younger, white patients, with smaller tumors, treated at urban facilities will be associated with meeting QMs for surgery in lung cancer. Methodology: In Aim 1, utilizing the VHA database, we will examine the relationship between adherence to previously proposed (e.g. type of operation, extent of nodal sampling) as well as novel (e.g. delay in surgery) QMs for surgery and short-term outcomes (postoperative complications, 30-day mortality) and long-term survival using regression models. The relative importance of the QMs will be assessed by rank ordering. In Aim 2, we will develop a weighted, validated QM adherence score ranging from 0 (no adherence to QMs) to 100 (complete adherence to QMs) for lung cancer operations. We will evaluate geographic (e.g. urban versus rural), patient (race, comorbidities), disease (e.g. tumor size), and treatment (e.g. facility size) factors associated with adherence to QMs. Next Steps/Implementation: Our study will define “what constitutes a high-quality lung cancer operation”. For the next logical step of “how to optimize the likelihood of a high-quality operation”, we will propose interventions addressing important QMs with input from the results of our study and the advisory board, which represents expertise in lung cancer, health policy, and implementation science. These interventions will be refined and pilot- tested in our VISN 15 in a future study before being nominated for policy change at the national level.	Quality Measurement Development				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 17-065	Depp	Colin		Colin.Depp@va.gov	Rapid Referral to Suicide Specific Intervention in Psychiatric Emergency Care	10/01/2018	07/31/2023	VA San Diego Healthcare System, San Diego, CA	$675,910		This revised proposal responds to HSR&D's Targeted Solicitation for Health Services Research on Suicide Prevention. Same-day psychiatric emergency clinics are increasingly implemented and are a best practice in increasing access to mental health care and in suicide prevention. Our preliminary data indicate a high frequency of suicidal ideation and recent suicidal behavior among Veterans accessing same-day mental health evaluation, and yet fewer than half of Veterans with these risk factors engage in outpatient mental health appointments that are set following their initial acute evaluation. To reduce risk of suicide during the transition from acute to outpatient care, it is unclear if models that “bridge” the transition should emphasize telephone outreach, as delivered by Suicide Prevention Coordination teams, or suicide-specific psychotherapy, such as Collaborative Assessment and Management of Suicidality (CAMS). CAMS is a brief transdiagnostic evidence-based psychotherapy that is recognized by the Joint Commission and Zero Suicide Framework as indicated for Veterans experiencing active suicidal ideation and/or recent suicidal behavior. This single-site 4- year randomized clinical trial addresses pragmatic questions regarding the relative impact of rapid referral to CAMS versus compared to outreach delivered by Suicide Prevention Coordinators for Veterans who are accessing same day mental health evaluation and who are gauged to be at elevated risk for suicide. In a Hybrid Type 1 research design, we propose to recruit Veterans from the same-day clinic setting who report recent or current active suicidal ideation and/or suicide attempt within the past 3 months. Veterans will be randomized to timely initiation of CAMS or to telephone outreach from Suicide Prevention Coordinators. The primary outcome (Aim 1) is the 12-month rate of suicide-related behavior or psychiatric hospitalization. Aim 2 contrasts indicators of operational efficiency between randomized conditions, including Veterans' rate of missed appointments at referred ongoing mental health care and urgent care re-presentation. We will also evaluate secondary outcomes (e.g., suicidal ideation severity). Aim 3 will examine the mediating impact of outpatient mental health treatment engagement on primary outcomes. Aim 4 evaluates fidelity to CAMS and its association with outcomes. Fidelity and in-person outcomes are measured by use of information technology, called eScreening, that is integrated with the electronic medical record and is used coordinate rapid referral and measurement-based care. This project builds on our preliminary data which indicate that research recruitment and rapid referral to CAMS therapy in same-day setting is highly feasible, acceptable and potentially impactful. This project is innovative in its focus on transitional care interventions in the same day clinic setting and its integration of health information technology to facilitate rapid referral, extensible to the dissemination of other evidence-based treatments. This research directly responds to the National Prioritized Research Agenda for Suicide Prevention, which emphasizes a need for care models that deliver “suicide-specific intervention as soon as risk is identified” and addresses important gaps on the impact of timely suicide prevention strategies identified the White House report. The study also responds to the HSR&D Mental and Behavioral Health, Access, and Care Coordination Priority Areas. We expect that these data will inform best practices in suicide prevention in same day mental health services where many at-risk Veterans are seen.	Mental and Behavioral Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 17-087	Shimada	Stephanie		Stephanie.Shimada@va.gov	Diabetes Disparities: Texting to Extend Treatment (DD-TXT)	05/01/2020	09/30/2023	VA Bedford HealthCare System, Bedford, MA	$1,356,665		Background: Type 2 Diabetes, a common, complex condition with high comorbidity, affects 24% of Veterans. Vulnerable Veterans (e.g., African-American, rural, comorbid mental health diagnosis, low-income) are less likely to have controlled diabetes, and have higher mortality and morbidity compared to other Veterans. Significance/Impact: Health Care Informatics interventions to support chronic disease self-management through technology can improve access, health equity, and health outcomes for vulnerable Veterans. Customizable, interactive self-management support through Annie addresses the VA's priority of improving access, including via virtual modalities, and providing a tailored experience that incorporates Veteran needs and preferences (VA Strategic Imperative 2). Research priority areas of access to care, women's health, mental health, primary care practice, informatics, virtual care, health equity, and patient-centered care are all addressed. Innovation: By incorporating the needs and preferences of vulnerable Veterans with diabetes in a self- management texting intervention and testing its effectiveness against a more traditional education-only intervention, lessons learned can improve the development of text-based support for other complex chronic conditions. It can also improve future implementation of Annie-based self-management support throughout VA. Specific Aims: AIM 1: Refine and beta test components of an interactive, tailored self-management texting protocol (DD-TXT) using a participatory design process incorporating vulnerable Veterans' preferences, VA clinician input, and evidence on effective texting-enabled self-management programs. The DD-TXT protocol will consist of: Core Messaging: Customizable core modules on medication management, blood sugar and blood pressure monitoring, preventive care, problem solving, appointment reminders, administrative messages; and Optional Messaging: A library of patient-selected modules (e.g. nutrition, physical activity, weight management, emotional coping, goal setting) designed to motivate and educate. AIM 2: Conduct a randomized controlled comparative effectiveness trial with 400 Veterans whose diabetes was uncontrolled (defined as HbA1c over 8.0% for at least 50% of the most recent 6 months) in 2018 in Gainesville, FL or Chicago, IL. The primary aim will be to assess the comparative effectiveness of DD-TXT compared to DSE, a diabetes skills education-only texting protocol based on a skills workbook that is currently given to VA patients with diabetes. The primary outcome will be HbA1c percent time in control. Secondary outcomes include self-reported adherence to diabetes self-care recommendations (SCI-R), diabetes self- efficacy, diabetes distress, LDL, and blood pressure control. We hypothesize that DD-TXT will result in better proximal health outcomes and diabetes self-management behaviors vs an education-only protocol (DSE). AIM 3: Obtain information to guide future implementation of diabetes self-management support through texting by (a) gathering and analyzing qualitative feedback from patients engaged in the comparative effectiveness trial, overall and by subgroup (b) collecting qualitative feedback from providers and key stakeholders on the barriers/facilitators of future RCT evaluation and implementation of DD-TXT vs DSE, (c) conducting a cost- identification analysis and safety analysis to identify resources required for larger-scale implementation. Methodology: We will refine the DD-TXT protocol through a participatory design process, conduct a randomized controlled comparative effectiveness trial with 400 Veterans with uncontrolled diabetes, and collect qualitative feedback from patients, providers, and other stakeholders and conduct a cost-identification analysis to guide future implementation. Next Steps/Implementation: This project will inform future processes for incorporating Veteran input into Annie protocol development and lead to a future Type 2 hybrid implementation trial of DD-TXT or DSE (based on our findings) to determine best implementation strategies for Annie-based self-management support.	Healthcare Informatics				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 17-113	Gebregziabher	Mulugeta	Christine Melillo	Mulugeta.gebregziabher@va.gov	Evaluating Care Coordination for Community Hospitalized Veterans to Improve Outcomes in Dual Use (ECHOeD)	03/01/2019	07/31/2023	Ralph H. Johnson VA Medical Center, Charleston, SC	$1,318,769		Anticipated Impacts on Veterans Health Care: Hospitalization and Emergency Department (ED) visits in community hospitals represent a vulnerable time for Veterans, since dual VA-Community healthcare can be associated with adverse health outcomes. The rigorous evaluation of VA Office of Community Care (VAOCC) Acute Hospital Care Coordination Program that we propose will yield valuable formative and summative information to our operations partner. A systematic program evaluation has the potential to: expand knowledge of best practices for hospital care transitions, better understand factors associated with program effectiveness, and enable comparisons of differential impacts among rural vs. urban Veterans. Background: While current VA access initiatives should have net-positive impacts for Veterans, there may be negative unintended consequences. To address these concerns, the VAOCC is currently developing a multicomponent, evidence-based care coordination program to help Veterans receiving acute (ED and hospital) care at non-VA facilities navigate back to the VA system. Our Ralph H. Johnson VAMC team has partnered with VAOCC in developing this program, and when implemented nationally, the VAOCC Acute program will be the first in VA to address cross-system hospital care and the first national rollout in or outside VA of a post-discharge care coordination intervention. Objectives Specific Aim 1: Evaluate the implementation of the VAOCC Acute Community Hospital Care Coordination Program across multiple implementation domains including adoption of key program components, fidelity of implementation, reach to community partners and eligible Veterans, and maintenance of program activities in 3 VISNs (7, 8, 19). Evaluation will be guided by the RE-AIM model collecting formative information using VA operations data to be shared with VAOCC during program roll-out. Specific Aim2: Determine overall program effectiveness (summative evaluation) in coordinating care for Veterans through a) reducing subsequent acute healthcare utilization, b) fidelity to key intervention components, and c) reducing/neutralizing costs. H1: Veterans with acute community care events after program implementation will experience lower rates of a) 7-day, 30-day ED revisit, b) 7-day, 30-day hospital readmission, c) fewer total hospital days per episode of acute illness as compared to Veterans from the pre-implementation period. H2: Facilities implementing program components with higher measures of fidelity and higher satisfaction with/perception of care transition quality will demonstrate larger relative improvements in healthcare utilization and as compared to facilities with lower levels of implementation success. H3: In a formal cost benefit analysis considering program costs and estimated savings including avoided acute care visits, the program will be deemed budget neutral or cost saving based on cost-benefit ratios. Methods. Patient-reported data will be collected using interactive voice response (IVR) and telephone interviews. Qualitative interviews and questionnaire methods will be used for VA providers. For utilization outcomes, we will create a research database of merged VA (CDW) and state level all-payer claims data from 3 states (FL, SC, CO). As part of our summative evaluation, we will use a qualitative case study approach in analyzing qualitative interviews, and we will integrate findings from various data sources.	Care of Complex Chronic Conditions				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 17-120	Williams	Emily		emily.williams3@va.gov	Evaluating Practice Facilitation to Optimize Alcohol-Related Care and HCV Treatment Outcomes in HCV Treatment Settings	10/01/2018	06/30/2023	VA Puget Sound Health Care System Seattle Division, Seattle, WA	$1,085,850		Background. Hepatitis C virus (HCV) is among the most common chronic viral infections in the U.S. and has surpassed all other infectious diseases as a cause of death. With the arrival of highly efficacious directly-acting anti-viral agents, treatment for HCV is now curative for the vast majority of patients. The VA is the largest provider of HCV care in the world and has scaled up efforts to identify and treat HCV. Unhealthy alcohol use is very risky for patients with HCV and influences HCV treatment adherence and outcomes. Despite the risks associated, many patients with HCV drink alcohol at unhealthy levels. While alcohol use was previously a contraindication to treatment, VA guidelines now recommend consideration of treatment for all patients with HCV, including those with unhealthy alcohol use, creating a prime opportunity for co-interventions focused on addressing unhealthy alcohol use during HCV treatment. HCV treatment-typically delivered over multiple visits- may provide time-limited opportunities for delivery of evidence-based alcohol-related interventions, but, due to previous contraindications, clinicians in HCV treatment settings are likely unprepared to offer evidence-based alcohol-related care. Practice facilitation is an effective multilevel implementation strategy that has promise for facilitating provision of alcohol-related care and ultimately improving alcohol use and HCV outcomes among patients with HCV and unhealthy alcohol use. Objective. The proposed study—conducted by a unique team of experts in implementation science and HCV and alcohol-related care—will use practice facilitation to increase provision of evidence-based alcohol-related care in HCV treatment settings and improve alcohol use and HCV treatment outcomes among Veterans with HCV and unhealthy alcohol use. Methods. The study will be guided by the Consolidated Framework for Implementation Research (CFIR) model. In Aim 1, we will use semi-structured qualitative interviewers with key clinical and patient stakeholders and rapid analytic methods to tailor the practice facilitation intervention. In Aims 2 and 3 we will disseminate the tailored intervention to 4 VA clinics in the western U.S. and then apply a Hybrid Type III implementation/ effectiveness design to evaluate the influence of the tailored practice facilitation intervention on implementation (primary) and clinical effectiveness (secondary) outcomes. Five implementation outcomes (acceptability, feasibility, adoption, penetration, and fidelity of alcohol-related care) and three clinical outcomes (alcohol use, HCV treatment completion, and sustained virologic response) will be evaluated using mixed methods. The primary implementation outcome (penetration) and clinical outcomes, will be evaluated using an interrupted time series design in which the implementation intervention is rolled-out in a stepped wedge fashion and clinics serve as their own controls (pre-post). Order in which the clinics receive the intervention will be randomized. Impact. The study is aligned with VA’s cross-cutting research priorities focused on mental and behavioral health, healthcare access, implementation science, and health disparities and with VA’s commitment to providing patient-centered care for unhealthy alcohol use. If effective, the implementation intervention could be scaled throughout VA HCV treatment settings, which could improve health among the vulnerable population of Veterans with HCV and unhealthy alcohol use and may optimize return on VA’s large investment in HCV treatment via reductions in treatment discontinuation and increased cure rates. Moreover, the intervention will help clinicians in VA liver clinics offer alcohol-related care to patients with chronic liver conditions influenced by alcohol use even as the demand for HCV treatment decreases.	Mental and Behavioral Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 17-123	Grubaugh	Anouk		Anouk.Grubaugh@va.gov	Randomized Controlled Trial of AboutFace: A Novel Video Storytelling Resource to Improve Access, Engagement, and Utilization of Mental Health Treatment among Veterans with PTSD	05/01/2018	12/30/2022	Ralph H. Johnson VA Medical Center, Charleston, SC	$855,400		Anticipated Impacts on Veterans Health Care: Behavioral health problems among Veterans have raised awareness of the critical need for more reliable, effective, and accessible means to recognize those in need, direct them to help, and ensure that they receive the best treatment available. Research has suggested that people are most responsive to advice and education when it comes from someone to whom they can relate. AboutFace is a peer education resource for Veterans that was developed, launched, and recently updated by the National Center for PTSD (NCPTSD) based on HSR&D funded pilot data. AboutFace features personal stories of Veterans and is designed to improve mental health treatment engagement among Veterans with PTSD and related comorbidities. The study team, which includes the NCPTSD, recently completed a usability assessment and pilot feasibility trial of AboutFace under HSR&D grant #PPO 14-360- 1. Data from this study (1) guided improvements to AboutFace for increasing PTSD treatment initiation and engagement; and (2) demonstrated the feasibility of the methodology for the proposed study. If AboutFace is found to increase Veterans’ initiation and engagement in PTSD treatment, study data will have broad implications for overcoming barriers to care for Veterans with PTSD and other stigmatized conditions. Background: At least 1 in 10 Veterans meet criteria for PTSD related to their military experience. Treatment for PTSD is widely available, and national dissemination initiatives have increased Veterans’ access to best- practice interventions. However, treatment-seeking remains strikingly low; most Veterans with PTSD do not seek mental health services due to perceived stigma and other barriers. NCPTSD developed and launched AboutFace, a public awareness campaign to help Veterans recognize PTSD and motivate them to seek evidence-based care. Since its development, AboutFace has earned three major awards and has had tens of thousands of visits. Despite the tremendous potential for AboutFace to reduce stigma, improve attitudes toward mental health treatment seeking, and to increase PTSD treatment initiation and engagement, it has yet to be formally evaluated or effectively implemented within VHA practice settings. In addition to providing needed data on the efficacy of AboutFace and identifying strategies for effective implementation within VHA, this study will provide a greater understanding of the role and value of digital storytelling interventions to improve access to care for a wide range of stigmatized conditions. Objectives: The primary objectives of the study are to examine the impact of AboutFace on a) increasing PTSD treatment initiation and engagement; and b) decreasing stigma and negative attitudes toward mental health services. It is anticipated that Veterans in the AboutFace condition will be more likely to access and complete treatment than those receiving enhanced Usual Care (eUC) for PTSD. Finally, qualitative interviews with key stakeholders across the nation will be conducted to inform best practices for future implementation of AboutFace. Methods: A total of 376 Veterans referred for a PTSD assessment and recommended for treatment in the Charleston PTSD clinic will be enrolled in the study. Veterans will be randomized to receive AboutFace versus eUC. All Veterans will receive standard PTSD educational materials, and half will also be randomly assigned to receive AboutFace. Comparisons will be made across indices of treatment engagement [i.e., initiated treatment (yes/no), total number of sessions completed;]; changes in stigma and attitudes toward seeking mental health treatment; and changes in PTSD symptoms and quality of life. Veterans will be assessed on these indices at baseline, 1-month, 3-month, and 6-months. Thematic interviews will be conducted with 20-30 VA PTSD Clinical Team Directors from a diverse range of PTSD clinics (i.e., ranging in size, location, and practice) to inform future implementation and dissemination initiatives.	Mental and Behavioral Health	A total of 376 Veterans referred for a PTSD assessment and recommended for treatment in the Charleston PTSD clinic will be enrolled in the study. Veterans will be randomized to receive AboutFace versus enhanced Usual Care (eUC). All Veterans will receive standard PTSD educational materials, and half will also be randomly assigned to receive AboutFace. Comparisons will be made across indices of treatment engagement [i.e., initiated treatment (yes/no), total number of sessions completed;]; changes in stigma and attitudes toward seeking mental health treatment; and changes in PTSD symptoms and quality of life. Veterans will be assessed on these indices at baseline, 1-month, 3-months, and 6-months. Thematic interviews will be conducted with 20-30 VA PTSD Clinical Team Directors from a diverse range of PTSD clinics (i.e., ranging in size, location, and practice) to inform future implementation and dissemination initiatives.	The primary objectives of the study are to examine the impact of AboutFace on a) increasing PTSD treatment initiation and engagement; and b) decreasing stigma and negative attitudes toward mental health services. It is anticipated that Veterans in the AboutFace condition will be more likely to access and complete treatment than those receiving enhanced Usual Care (eUC) for PTSD. Finally, qualitative interviews with key stakeholders across the nation will be conducted to inform best practices for future implementation of AboutFace.	Behavioral health problems among Veterans have raised awareness of the critical need for more reliable, effective, and accessible means to recognize those in need, direct them to help, and ensure that they receive the best treatment available. Research has suggested that people are most responsive to advice and education when it comes from someone to whom they can relate. AboutFace is a peer education resource for Veterans that was developed, launched, and recently updated by the National Center for PTSD (NCPTSD) based on HSR&D funded pilot data. AboutFace features personal stories of Veterans and is designed to improve mental health treatment engagement among Veterans with PTSD and related comorbidities. The study team, which includes the NCPTSD, recently completed a usability assessment and pilot feasibility trial of AboutFace under HSR&D grant #PPO 14-360-1. Data from this study (1) guided improvements to AboutFace for increasing PTSD treatment initiation and engagement; and (2) demonstrated the feasibility of the methodology for the proposed study. If AboutFace is found to increase Veterans' initiation and engagement in PTSD treatment, study data will have broad implications for overcoming barriers to care for Veterans with PTSD and other stigmatized conditions.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 17-134	Teo	Alan		Alan.Teo@va.gov	Using Behavioral Economics to Enhance Appointment Reminders and Reduce Missed Visits	11/01/2018	05/31/2023	VA Portland Health Care System, Portland, OR	$1,063,094		“No-shows,” or missed visits are a persistent problem in all health care systems. They compromise patient access, lengthen wait times, increase health care inefficiencies, and worsen clinical care. The VA’s no-show rate has shown no improvement in years, resulting in a staggering nine million ambulatory no-shows in 2015 and perhaps over $1 billion in additional annual costs. Appointment reminders are an essential element to addressing no-shows but major research gaps exist. Behavioral economics (BE) suggests that “nudges” can be designed to make it easier for people to do the “right” thing while retaining individual autonomy. We draw from BE, psychology and related fields to identify concepts that can be applied to innovating the field of appointment reminders. One concept is social norms, which suggests that Veterans are likely to attend appointments if they sense that it is the norm for Veterans to do so. Another concept is based on the idea that providing clear instructions and an implementation plan increases the target behavior. A third approach is to highlight potential harms or losses to the Veteran from missing an appointment, while a fourth approach instead highlights potential negative consequences of no- showing to other Veterans. Each of these concepts can be transformed into messages that can be incorporated into appointment reminders. We will design and evaluate four intervention groups varying in type of nudge included in appointment reminder letters. We will address the following Specific Aims: 1) Develop and iteratively refine BE-informed messages based on Veterans’ perceptions, and incorporate them into enhanced appointment reminders; 2) Determine the effect of four versions of enhanced appointment reminders on measures relevant to treatment access, compared with usual reminders; 3) Evaluate differences in treatment effect associated with four versions of enhanced appointment reminders; 4) Characterize potential barriers and facilitators to widespread implementation of enhanced appointment reminder messages. Applying insights from BE to enhance appointment attendance in VA is highly significant and innovative. VA leaders describe reducing no-shows as critical to efforts to improve access, the top priority in VA. Appointment reminders are especially important in mental health (where no-show rates are high) and primary care (where appointments are scheduled far in advance). With the exception of a few studies in the U.K.’s National Health Service, BE has not been incorporated and evaluated in the design and content of appointment reminders. After iterative refinement of nudges to include in enhanced appointment reminders, we will conduct a cluster randomized controlled trial to test four interventions. Intervention arms will vary by what type of nudge and messages are added to appointment reminders. Appointments will be randomly allocated at the provider-level to one of the four interventions or a control group of usual appointment reminders. The study will be conducted at VA Portland Health Care System in primary care and mental health clinics. We will evaluate effect on a variety of access-related metrics, including appointment no-show, attendance, and cancelation rates. We will also explore impact on wait times. Finally, we will also conduct a qualitative assessment consisting of semi- structured interviews with key informants (Veterans and VA leaders) to inform future implementation of the intervention. Together, we believe this will result in a reduction in no-show rates, increased attendance and access by Veterans, decreased wait times for scheduled appointments, and information to prepare to extend the results to other VA facilities. Study results will have direct implications for VA at local and national levels. Individual VA facilities interested in reducing their no-show rates could benefit from implementation of the most effective study intervention, and VA leaders nationally, including our operational partners working on access and no- show issues, could utilize our results for future changes to appointment reminder systems.	Care of Complex Chronic Conditions				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 17-178	Sayer	Nina		nina.sayer@va.gov	Shared Contributions to Outcomes and Retention in EBPs for PTSD (SCORE PTSD)	08/01/2018	04/30/2023	Minneapolis VA Health Care System, Minneapolis, MN	$1,051,595		Anticipated Impacts on Veterans Healthcare: This research will inform provider- and system-level interventions to optimize the effectiveness of evidence-based psychotherapies (EBPs) for Posttraumatic Stress Disorder (PTSD) in routine clinical practice. Project Background: VHA has committed considerable resources to ensuring that all veterans with PTSD have access to EBPs. These efforts have focused primarily on two EBPs for PTSD – Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE). Over the past decade more than 6,300 VHA clinicians have received VHA competency based training in CPT or PE. Therapists providing CPT and PE are required to use templated CPT and PE chart notes for session documentation, providing detailed information on the prescribed elements of CPT and PE delivered in each session. Prior research on CPT and PE has focused primarily on treatment outcomes, uptake among providers and reasons for drop-out among patients. Understudied are systematic differences between therapists in their effectiveness, indicators of the quality of CPT and PE delivery, and the work conditions conducive to positive outcomes. By addressing these evidence-gaps, we will identify modifiable factors affecting CPT and PE delivery that we can target for intervention and thereby improve treatment retention and clinical outcomes among Veterans with PTSD. Project Objectives: Specific aims are to: (a) Examine systematic differences between therapists in CPT and PE outcomes, and whether certain therapists are more effective with vulnerable patient subgroups, and (b) Determine whether the therapeutic relationship and therapist adherence predict CPT and PE outcomes and whether these indicators of therapy quality explain systematic differences between therapists in patient outcomes. Exploratory aims are to: (a) Determine whether the intensity and consistency of time between sessions contribute to patient outcomes and at least partially account for systematic differences between therapists in patient outcomes; (b) Examine whether therapist caseload, clinic setting and resources for therapy delivery in therapists' work environment contribute to patient outcomes and at least partially account for systematic differences between therapists in patient outcomes; and (c) Elucidate quantitative findings on therapist effects, therapy quality and aspects of therapist work context associated with patient outcomes through qualitative interviews. Project Methods: This is an explanatory sequential mixed-method study of 200 therapists who deliver CPT or PE to approximately 2,000 patients with PTSD. Therapists will be enrolled if they use the chart note templates VHA requires for documentation of CPT and PE and treat at least three patients with CPT or PE over one year. Patients of these therapists will be included if they have a diagnosis of PTSD and receive at least two sessions of CPT or PE. After enrollment, therapists will complete a brief online CPT and PE template refresher tutorial to ensure high quality CPT and PE documentation and a survey to assess training history and resources for EBPs in their work environment. Patient retention in treatment and clinical improvement in PTSD are the primary outcomes. To partition the total variance in patient outcomes between patient and therapist levels, we will use multilevel modeling of therapist and patient data from VHA administrative datasets and chart notes, supplemented with survey data. Qualitative interviews with a purposive sample of 32 therapists after quantitative data collection will contextualize, explain and illustrate quantitative findings. 1	Mental and Behavioral Health	This explanatory sequential mixed-method study will enroll 250 therapists who deliver CPT or PE to between 2,000 and 3,000 patients with PTSD. Therapists will be enrolled if they use the chart note templates VHA requires for documentation of CPT and PE and treat at least three patients with CPT or PE over one year. Patients of these therapists will be included if they have a diagnosis of PTSD and receive at least two sessions of CPT or PE. After enrollment, therapists will complete a brief online CPT and PE template refresher tutorial to ensure high quality CPT and PE documentation and a survey to assess training history and resources for EBPs in their work environment. Patient retention in treatment and clinical improvement in PTSD are the primary outcomes. To partition the total variance in patient outcomes between patient and therapist levels, we will use multilevel modeling of therapist and patient data from VHA administrative datasets and chart notes, supplemented with survey data. Qualitative interviews with a purposive sample of 32 therapists after quantitative data collection will contextualize, explain and illustrate quantitative findings.	Specific aims are to: (a) Examine systematic differences between therapists in CPT and PE outcomes, and whether certain therapists are more effective with vulnerable patient subgroups, and (b) Determine whether the therapeutic relationship and therapist adherence predict CPT and PE outcomes and whether these indicators of therapy quality explain systematic differences between therapists in patient outcomes. Exploratory aims are to: (a) Determine whether the intensity and consistency of time between sessions contribute to patient outcomes and at least partially account for systematic differences between therapists in patient outcomes; (b) Examine whether therapist caseload, clinic setting and resources for therapy delivery in therapists' work environment contribute to patient outcomes and at least partially account for systematic differences between therapists in patient outcomes; and (c) Elucidate quantitative findings on therapist effects, therapy quality and aspects of therapist work context associated with patient outcomes through qualitative interviews.	This research will inform provider- and system-level interventions to optimize the effectiveness of evidence-based psychotherapies (EBPs) for Posttraumatic Stress Disorder (PTSD) in routine clinical practice.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 17-221	Kunik	Mark		kunik.marke@va.gov	Using Peer Navigators to increase access to VA and community resources for Veterans with diabetes-related distress	05/01/2019	09/30/2023	Michael E. DeBakey VA Medical Center, Houston, TX	$1,438,510		Diabetes-related distress, the negative emotional impact of living with diabetes (DM), is a powerful predictor of psychosocial functioning, treatment adherence, and glycemic control. Practice guidelines and consensus statements call for innovative approaches to address DM-related distress. Despite availability of self- management and psychosocial interventions to reduce DM related distress, these interventions are underutilized due to constraints in time, finances, motivation, and resource-awareness. Interventions that leverage traditional medical care and community-based health promotion programs (e.g., DM self- management education (DSME) programs) may enhance the ability of Veterans with DM to engage with a broad and accessible range of resources. Ensuring that Veterans with DM receive adequate self-care support requires interventions that (1) attend to both medical care and diabetes-related distress and (2) improve Veterans' access and engagement with DSME and traditional medical/mental care. Integrating VA and community health services and DSME resources is innovative and affords great opportunities to enhance Veteran outcomes and build VA community partnerships. Engagement of Veterans and community organizations in developing and delivering care responds to the 2016 HSR&D high-priority domain of Health Care Systems Change and aligns with the 2017 VA Under Secretary's priorities of Greater Choice (offering community and VA resources), Efficiency (community and VA coordination), and Timeliness (telephone delivery). This community-VA partnership and three-month Veteran peer coaching intervention (iNSPiRED) aims to enhance psychological well-being and diabetes self-management behavior in Veterans with DM by facilitating access to and use of healthcare and health promotion resources. The intervention focuses on reducing cognitive and practical barriers to use of services by engaging Veteran peers as coaches and navigators, and by encouraging engagement in health promotion and healthcare services in the VA and the greater community. A secondary goal, integral to the main goal, is to strengthen and integrate VHA partnerships with community- based organizations and Veteran Support Organizations (VSO's). This is a single-blind, parallel group randomized trial of a 3-month peer navigation intervention for Veterans with DM and elevated levels of DM-related distress. We will recruit Veterans with DM-related distress through existing help-seeking channels within and outside of the VA in partnership with community agencies, VSO's, and the Houston VAMC. Eligible Veterans will be assigned at random to the iNSPiRED intervention (peer navigation and coaching) versus usual care (written resource materials and encouragement to continue follow- up with healthcare providers). Consistent with the focus on the overall emotional impact of DM, the PRIMARY OUTCOME is DM-related distress (DM Distress Scale). In previous studies the DDS has shown strong relationships with psychological symptoms, self-management behaviors, and objective measures of glycemic control. SECONDARY OUTCOMES include anxiety symptoms (Generalized Anxiety Disorder Scale), depression symptoms (Patient Health Questionnaire-8), DM self-management behaviors (DM Self- Management Scale), and self-reported use and new use of VA or community resources. In addition to participant-level outcomes, we will also assess STAKEHOLDER OUTCOMES through a mixed methods process evaluation. Our objective will be to measure the impact of stakeholder engagement activities on development and sustainability of VA-community partnerships, trust and communication, and capacity building. Assessment of primary and secondary endpoints will occur at baseline, post-intervention, and at 6 months. If this project meets intended goals, we will partner with VHA Office of Community Engagement and VHA Specialty Care to implement the intervention for DM and other chronic diseases..	Care of Complex Chronic Conditions				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 17-222	Wong	Edwin		Edwin.Wong@va.gov	Measuring the Value of Improving Access to Community Care	06/01/2019	09/30/2023	VA Puget Sound Health Care System Seattle Division, Seattle, WA	$993,260		Background: Providing timely access to health care has been a long-standing VA goal that has been re- emphasized by the Commission on Care. To improve access to care, VA implemented the Veterans Choice Program in August 2014, which provides eligible Veterans the option of receiving care from community providers paid for by VA. Currently, there is a substantial gap in scientific evidence on the effect of the Choice Program and other VA community care programs, particularly in regards to the degree the program has improved access to care. More generally, non-VA literature examining the effect of greater provider options has focused on changes in utilization, but has not assessed the value of improved patient choice. The development of measures that capture the value of greater provider options is methodologically challenging because patients’ preferences are not directly observed and value encompasses many dimensions of access (e.g., travel distance, appointment wait times, provider quality, etc.). To address these evidence gaps, we propose the development and examination of new measures capturing the value of provider options to Veterans using state-of-the art econometric methods. Greater scientific evidence to help VA provide enhanced choice for Veterans through the Choice Program and future VA community care programs is consistent with the VHA FY 2018-2019 Operational Plan. This study addresses the ORD-wide Learning Health Care System priority area and HSR&D’s Access and Health Care Systems Change major priority domains. Objectives: The objectives of this study are to: 1) develop new econometric method applications to quantitatively measure the value of greater access to providers from the perspective of Veterans and 2) examine the relative importance of local area and provider characteristics in determining Veterans’ value of having improved access to providers. Methods: This observational study will examine VA administrative data and existing public data characterizing outpatient providers. In Aim 1, we will use VA administrative data to identify: 1) Veterans eligible for the VA Choice Program in 2016, 2) VA and Choice outpatient providers and 3) utilization of outpatient services from VA facilities and through the Choice Program. We will analyze Veterans’ revealed preference for providers using econometric random utility models. These models assume patients select the provider that yields the greatest benefit, given all available options. We will empirically estimate Veterans’ choice of provider within the random utility framework using a nested multinomial logit model (NMNL). We will then use parameter estimates and predictive margins from the NMNL model to calculate the value of greater provider options through the Choice Program. Specifically, econometric models will calculate Veterans’ willingness to pay (WTP), which represents the maximum dollar amount an individual would theoretically pay for greater provider options. In Aim 2, we will apply econometric decomposition methods to models developed in Aim 1 to assess the influence of key provider and local area characteristics in determining value. Notably, we will leverage novel data linkages between VA administrative data and public use data capturing an extensive set of provider characteristics. Statement on Next Steps: We will develop a simulation tool designed for non-researchers that incorporates study results to estimate the value to Veterans of a specified set of provider options (i.e. a community care network). This tool will provide the ability for operational partners to assess the adequacy of community care networks and establish the business case of “what-if” scenarios. Stakeholders will be able to adapt to changing conditions through simulating the hypothetical addition and subtraction of providers within a community care network. This simulation feature will facilitate future analyses to ensure community care networks include high quality providers that best match Veterans’ preferences.	Systems Modeling, Design, and Delivery				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 17-231	Levy	Cari		cari.levy@va.gov	Are Veterans' Outcomes Better when VHA Purchases High-Quality Nursing Home Care?	01/01/2019	06/30/2023	Rocky Mountain Regional VA Medical Center, Aurora, CO	$1,099,999		Background: Over the last decade, the Veterans' Health Administration (VHA) has shifted from providing long-term and post-acute care in facilities owned and operated by states or the VHA, toward contracted care in privately-owned facilities, known as community nursing homes (CNHs). From fiscal years 2000 to 2015, expenditures for CNH care in the VHA expanded from $227 million to $861 million—nearly a fourfold increase. Meanwhile, the Office of Inspector General and General Accountability Office have raised concerns that the VHA contracts with low-quality providers. Through a Quality Enhancement Research Initiative (QUERI)-funded CNH Dashboard, Veteran Affairs Medical Centers (VAMCs) now have ready access to real-time information that displays data on the quality ratings of facilities caring for their Veterans relative to other, non-contracted facilities in the same local market and nationally. However, those data have not been analyzed to reveal trends or patterns across VAMCs that could inform VHA's purchasing policy and operations. Furthermore, the publicly-reported quality star ratings from the Centers for Medicare and Medicaid Services (CMS) have not been validated for their relevance to important Veterans' outcomes. The objective of the proposed research is to characterize variation in CNH quality as it relates to VAMC characteristics, Veteran outcomes, and contracting practices. Our central hypothesis is that a significant portion of VAMCs have opportunities to improve practices related to the purchase of high-quality care for Veterans that will lead to improved outcomes by optimizing identifiable contracting policies and practices. The significance that motivates the proposed project is that identifying variation in quality, quantifying potential gains, and understanding the policies associated with success within an integrated health care system will also contribute to our general understanding of the use of quality information in purchasing policies and practices, an HSR&D priority area of long-term care which is of broad concern to health services research in this era of value based purchasing. The Specific Aims of this proposal are to: Aim 1. Characterize utilization, cost, and quality of care that Veterans receive from VHA-contracted compared to non-contracted community nursing homes (CNHs) available in the same market area. Aim 2. Determine whether utilization of highly-rated CNHs improves outcomes for Veterans. Aim 3. Identify incentive characteristics and contextual factors that contribute to purchase of high-quality CNH care by VAMCs. Methods: Aim 1 will use descriptive analysis to compare Veterans' utilization of nursing home care, including length of stay, concentration of Veteran population within individual nursing homes, and allocation of care to CNH compared to other VHA long-term care and post-acute settings in each study year 2013-2017. Risk- adjusted total direct CNH payments per Veteran will be calculated and the relationship between price and quality rating will be modeled. For Aim 2 we will estimate the effect of increases in quality ratings on Veterans' outcomes. We will test the hypothesis that increasing the availability of highly-rated facilities among Veterans' CNH options results in fewer hospitalizations and an increased likelihood of successful discharge to the community. Using highly-innovative analytic technique, potential cost offsets available from reduced hospitalization in highly-rated nursing homes will be quantified. Aim 3 will use the analyses in Aim 1 to identify a sample of VAMCs with variation in relative quality. Two in-person site visits and subsequent semi-structured telephone interviews with key VHA and community stakeholders will be conducted and analyzed using a general inductive qualitative approach to identify how incentive characteristics and contextual factors support or thwart purchase of care from high quality CNHs. Results will be used to create a web-based toolkit to inform program revisions and VHA purchased care policy in general to purchase of high-quality CNH Veteran care.	Long Term Care and Aging				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 17-238	Jasuja	Guneet		Guneet.Jasuja@va.gov	Understanding Hormone Therapy Care Received by Transgender Veterans in VHA	04/01/2019	09/30/2023	VA Bedford HealthCare System, Bedford, MA	$328,800		Background: The prevalence of transgender Veterans (“trans vets”) is on the rise. Transgender individuals experience discord between their self-identified gender and biological sex, defined as gender dysphoria (GD). Untreated and/or undertreated GD is associated with increased mortality and morbidity including depression, anxiety, and suicidality. Hormone therapy is generally the first, and often the only, medical intervention accessed by trans persons with GD who seek to masculinize or feminize their body to be consistent with their gender identity. In 2012, Pharmacy Benefits Management (PBM) issued Criteria for Use (CFU) for trans vet hormone therapy care. In our pilot work, we identified that out of 7,944 trans vets with GD from FY 2005-17, 4,977 were on hormone therapy, with 7-fold variation on one quality of measure recommended by CFU across sites. In order to identify more such gaps in delivery of this care, we need to understand the current patterns of care, determine the degree of concordance with recommendations, and factors driving trans vet hormone care. Objectives: We propose a quantitative study with the following 3 specific aims: 1: Refine methods for identifying trans vets on hormone therapy using VHA data and validate by chart reviews. 2: Examine the hormone therapy care provided to trans vets in VHA. 2a: Describe the current state of hormone care for trans vets in VHA. 2b: Determine the degree that hormone care is concordant with PBM CFU and non-VHA guidelines. 3: Identify patient-, clinician-, and site-level predictors of trans vet guideline-concordant hormone care. Methods: Aim 1: After having identified a population of GD documented trans vets on hormone therapy using national VHA data, we will also consider alternative approaches of identification, including receipt of hormones by opposite sex, and change in coded gender over time, which will be further validated by chart reviews. Aim 2: We will then describe the study cohort in terms of demographics, proportion of those receiving each type of hormone therapy (estrogen vs. testosterone vs. none), route of administration (oral, transdermal, injectable), dosage and titration schedule, and duration of therapy. We will also proceed with the work of identifying key aspects of care recommended by PBM CFU and non-VHA guidelines (e.g. adequacy of laboratory monitoring) against which the current care can be measured. Aim 3: We will apply Generalized Linear Mixed Models to examine factors associated with guideline-concordant hormone therapy care at the patient- (e.g. housing instability), provider- (e.g. availability of trans electronic consultations) and site-level (e.g. trans specialty training offered at site). Anticipated Impacts on Veterans’ Healthcare: VHA has an imperative to provide high-quality care to trans vets, which is also a primary goal of our operational partners in the Lesbian, Gay, Bisexual, and Transgender (LGBT) Health Program in the Office of Patient Care Services. This study will be the first to provide an assessment of the quality of hormone therapy care received by trans vets served by VHA, as well as to refine methods to identify trans persons on hormones in VHA data. In addition, this proposal will lay the groundwork for a follow-up qualitative study to identify best practices associated with the delivery of guideline-concordant hormone therapy care in trans vets. This work is firmly in line with the call to provide high-quality care irrespective of gender and sexual orientation, as outlined in the VHA Strategic Plan, and Blueprint for Excellence, and addresses the 2017 HSR&D priority area of healthcare equity and health disparities.	Equity				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 17-241	Fletcher	Terri		Terri.Fletcher@va.gov	Anxiety diagnostic accuracy in VA primary care mental health integration settings: Identifying barriers and facilitators to inform a learning health care system	05/01/2019	09/30/2023	Michael E. DeBakey VA Medical Center, Houston, TX	$804,666		Anticipated Impacts on Veteran's Healthcare: The provision of high quality healthcare requires accurate and timely diagnosis. The National Academy of Medicine asserts that “Improving the diagnostic process is not only possible, but also represents a moral, professional, and public health imperative.” Identifying factors influencing diagnostic accuracy is essential to improving the diagnostic process. The proposed study will identify factors associated with anxiety diagnostic errors in VHA primary care mental health integration (PCMHI) and specialty mental health (MH) settings, and addresses HSR&D priority areas "Mental and Behavioral Health” and “Health Care Systems Change” and the ORD-wide priority area “Learning Health Care System” Project Background: VHA has little information about specific determinants of current anxiety diagnostic practices and the sociotechnical context in which diagnoses are made. Unspecified anxiety disorder is the most common anxiety-related diagnosis in VHA but is often a diagnostic error. In FY2017, 408,250 Veterans enrolled in the VHA carried an unspecified anxiety disorder diagnosis, and unspecified anxiety accounted for 70% of anxiety diagnoses in PCMHI that year. However, the majority of these diagnoses are erroneous as fewer than 3% of Veterans diagnosed with unspecified anxiety meet DSM-5 criteria for this disorder. Accurate diagnosis is foundational to evidence-based healthcare, and 77% of Veterans diagnosed with unspecified anxiety meet diagnostic criteria for a specific anxiety or trauma-related disorder (generalized anxiety disorder [GAD, 44%]; posttraumatic stress disorder [PTSD, 38%]; panic disorder, 20%; social anxiety disorder 20%). Diagnostic accuracy is critical to accessing appropriate services. Only 32% of Veterans with unspecified anxiety disorder received mental health services in the year following diagnosis, compared to Veterans diagnosed with GAD (60%), panic disorder (67%), and social anxiety disorder (88%). Thus, an erroneous diagnosis of unspecified anxiety disorder is a barrier to receipt of appropriate evidence-based care for specific disorders such as PTSD, GAD, and panic disorder. Project Objectives: The proposed, 3-year, multisite study will use mixed quantitative and qualitative methods, informed by the Safer Dx framework, to identify system-, provider-, and patient-level factors associated with anxiety diagnostic specificity in VHA PCMHI and specialty MH settings. Understanding how these factors interact in the anxiety diagnostic process is crucial to identifying point(s) in the diagnostic process at which to intervene. Project Methods: The aims of the proposed project will be achieved through three major activities that will be carried out using mixed, qualitative and quantitative, methods. Aim 1 will use administrative data from the Corporate Data Warehouse (CDW) to identify system-, provider-, and patient-level factors associated with anxiety diagnostic specificity in PCMHI and specialty MH settings. Aim 2 will consist of qualitative interviews with PCMHI and specialty MH providers to understand their perspectives on barriers and facilitators to anxiety diagnostic specificity. Aim 3 will identify barriers to anxiety diagnostic specificity in each phase of the diagnostic process outlined by the Safer Dx framework. This aim will be achieved through chart reviews and diagnostic interviews of patients diagnosed with unspecified anxiety disorder, as well as critical incident interviews with PCMHI and specialty MH providers. Next Steps: Findings from this study will position the research team to design and test a tailored intervention to facilitate mental health providers' accurate and timely diagnosis of anxiety- and trauma-related disorders for Veterans.	Mental and Behavioral Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 17-262	Zivin	Kara		Kara.Zivin@va.gov	Caring for the caregiver: predictors and consequences of VA mental health provider burnout	12/01/2019	03/31/2024	VA Ann Arbor Healthcare System, Ann Arbor, MI	$1,032,781		Background: Mental health providers (MHPs), who are "mission critical" for the VHA, report the second highest level of burnout after primary care physicians. MHP burnout may be associated with negative system- level factors (organizational climate, workgroup perceptions, and supervisory behaviors), provider experiences (engagement, satisfaction, and turnover) and patient outcomes (access to, continuity of, experience of care). VHA has yet to conduct a systematic facility-level study identifying predictors and consequences of MHP burnout. This study will address HSR&D priorities focused on health care systems change, the impact of organizational and provider factors associated with quality of care for Veterans, and improving employee engagement. Objectives: This pre-implementation study aims to characterize variation in MHP burnout by facility over time, identifying workplace characteristics and practices of high performing facilities that can be translated for potential implementation at facilities with room for improvement. Aim 1: to examine facility- level predictors and consequences of VHA MHP burnout; Aim 2: to understand VHA MHP leadership and front-line provider perspectives regarding factors that protect against or exacerbate burnout in facilities with differing levels of burnout; and Aim 3: to identify context-sensitive strategies for facilities to successfully reduce VHA MHP burnout. Methods: Using a sequential explanatory mixed methods study, a two-phase design with quantitative data collection and analysis followed by qualitative data collection and analysis, and subsequent integration, we will evaluate factors that influence MHP burnout and their effects on patient outcomes. We will compile annual survey data on workplace conditions and annual staffing and productivity data between FY2014 and FY2018 to assess same and subsequent year provider and patient outcomes reflecting provider and patient experiences. The All Employee Survey (AES) is an annual organizational census of workplace perceptions and satisfaction. The Mental Health Provider Survey (MHPS) is an annual survey to assess MHP perceptions about access to and quality of mental health care, and job satisfaction. The Mental Health Outpatient Clinical method tracks MHP inpatient and outpatient clinical hours and productivity. We will examine MHP job satisfaction and patient experience metrics using the Strategic Analytics for Improvement and Learning (SAIL) Mental Health domain, the VHA's quality monitoring system. Facility complexity level is measured using a five level indicator based on patient risk, number of specialists, volume, and level of teaching and research, including mental health program characteristics. By linking these data sources, we will quantify predictors of burnout and the impact of burnout on patient outcomes. We will conduct interviews with mental health facility leadership and front-line MHPs, intentionally sampled using facility-level MHP burnout. We will create a joint display to interpret quantitative and qualitative findings on predictors and patient outcomes associated with burnout in light of facility context and any strategies used to address burnout. We will present our findings to an expert panel of operational partners, VA clinicians, administrators, policy leaders, and experts. The panel will select context-sensitive best practices to share with facilities to address MHP burnout and recommend potential interventions. Finally, we will reengage facilities that participated in Aim 2 and conduct focus groups and share results presented in feedback reports. We will broadly disseminate findings, which will support the development of actionable policies and approaches to addressing MHP burnout. Anticipated impacts on Veterans' health and next steps: This study will assist in future developing and testing interventions with VHA partners to improve MHP burnout and employee engagement. Decreased MHP burnout could improve quality of care, wait times, and lost revenues due to staff attrition. Our findings could be of clinical and financial value to VHA, its providers, and patients. Our work will contribute to broad VHA care improvements, and will generate new insights for care delivery.	Systems Modeling, Design, and Delivery				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 17-263	Feemster	Laura		laura.feemster@va.gov	post-REcovery LIbEration From Oxygen in Exacerbated COPD (RELIEF)	07/01/2018	03/31/2023	VA Puget Sound Health Care System Seattle Division, Seattle, WA	$1,436,969		Projects such as the American Board of Internal Medicine’s “Choosing Wisely” campaign emphasize the importance of identifying and de-implementing ineffective, harmful and/or wasteful practices to improve the quality and safety of delivered care. Among patients with chronic obstructive pulmonary disease (COPD), oxygen has been shown to improve survival among a specific subset of patients with severe resting hypoxemia. The provision of oxygen therapy has been extrapolated to other populations leading to the prescription of oxygen to patients with COPD who do not have an evidence-based indication for its use. For example, oxygen is frequently prescribed upon discharge from hospital after an exacerbation of COPD, then continued indefinitely, resulting in patients who become habituated to having oxygen readily accessible. Published in 2016, the Long-Term Oxygen Treatment Trial (LOTT) demonstrated that the use of supplemental oxygen conferred no benefit to patients with COPD who have moderate resting or ambulatory hypoxemia. In addition to being ineffective in this patient population, supplemental oxygen can pose risks of harm, such as the potential for fire or injury due to falls caused by entanglement in oxygen tubing. It is in this setting that we now have an opportunity, as well as a challenge, to learn how best to improve care quality by de-implementing a therapy that has no demonstrable benefit, is not without risk, but is deeply entrenched in clinical practice. To address this knowledge gap, our proposed study aims to use a mixed-methods approach to inform VA about their current practices for prescribing oxygen therapy to patients with COPD, as well as to identify anticipated barriers and facilitators to its de-implementation among patients in whom it has been shown to be ineffective. To achieve these goals, we will first identify a nationwide cohort of Veterans discharged with supplemental oxygen after hospitalization for a COPD exacerbation and identify patient-, clinician- and system level factors associated with appropriate reassessment of oxygen need within 90 days of discharge. We will then identify a range of high- to low-performing sites in regards to timeliness of oxygen need reassessment. Using a sequential mixed methods approach incorporating quantitative survey collection and in-depth qualitative interviews, we will elicit patient and clinician perspectives on the discontinuation of supplemental oxygen across a range of the high- and low-performing sites as well as at the sites of our planned intervention. Using these initial results, we will develop, refine, and test a patient-, organizational-, and operational partner- informed pilot intervention to increase value-based care by decreasing inappropriate oxygen use. We will randomize 50 patients at two VA sites (VA Puget Sound and Bedford VA) to receive usual care or our de- implementation intervention. In addition to assessing feasibility and acceptability of the intervention, we will assess secondary outcomes, including changes in functional status and symptoms over 12 weeks. If successful, this study has the potential to lead to a larger randomized control trial of our de-implementation intervention throughout VA. In addition, the results of this study could be extended to other clinical contexts to inform interventions designed to de-implement therapies that are pervasive in clinical practice but of low-value.	Care of Complex Chronic Conditions	Aim 1: Using combined VA-Medicare data, we will first identify a nationwide cohort of patients 40 years and older discharged from hospital with supplemental oxygen after an exacerbation of COPD between Fiscal Year (FY) 2011-2016. We will perform analysis using a hierarchical (logistic mixed random effects) model to identify patient-, clinician-, and system-level factors associated with reassessment of oxygen need within 90 days of discharge. Aim 2: Using a sequential mixed methods approach incorporating quantitative survey collection and in-depth qualitative interviews, we will elicit patient and clinician views on the discontinuation of supplemental oxygen across a range of the high- and low-performing sites as well as at the sites of our planned intervention. Aim 3: We will use these initial results to refine a patient level-intervention designed to decrease inappropriate oxygen use after discharge from hospital for an exacerbation of COPD. We will randomize 50 patients at two VA sites (VA Puget Sound and Bedford VA) to receive usual care or our de-implementation intervention. In addition to assessing feasibility and acceptability of the intervention, we will assess secondary outcomes, including changes in functional status and symptoms over 12 weeks.	The overarching goal of this study is to inform VA about their current practices for the provision of oxygen therapy among patients with COPD (Aim 1), as well as identify anticipated barriers and facilitators to its de-implementation among patients in whom it has been shown to be ineffective (Aim 2). We will use our results to develop and test a patient-, organizational-, and operational partner-informed pilot intervention to increase value-based care among patients with COPD (Aim 3).	Our proposal will provide valuable insights into challenges faced when de-implementing widespread accepted practice, even when data refutes benefit and demonstrates possible harm. The results of this study have the potential to improve our understanding of how to best deliver high-value care to Veterans with COPD. The novel scientific knowledge that will result from this study could be extended to other clinical contexts to inform interventions designed to de-implement low-value but entrenched practice.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 17-294	Zimmerman	Lindsey		lindsey.zimmerman@va.gov	Participatory system dynamics vs usual quality improvement: Is staff use of simulation an effective, scalable and affordable way to improve timely Veteran access to high-quality mental health care?	09/01/2020	09/30/2023	VA Palo Alto Health Care System, Palo Alto, CA	$856,675		Background: Evidence-based practices (EBPs) are the most high value treatments to meet Veterans’ addiction and mental health needs, reduce chronic impairment, and prevent suicide or overdose. Over 10 years, VA invested in dissemination of evidence-based psychotherapies and pharmacotherapies based on substantial evidence of effectiveness as compared to usual care. Quality metrics also track progress. Despite these investments, patients with prevalent needs, such as depression, PTSD and opioid use disorder often don’t receive EBPs. Systems theory explains limited EBP reach as a system behavior emerging dynamically from local components (e.g., patient demand/health service supply). Participatory research and engagement principles guide participatory system dynamics (PSD), a mixed-methods approach used in business and engineering, shown to be effective for improving quality with existing resources. Significance/Impact: We propose our study in the high priority area of VA addiction and mental health care to improve Veteran access to VA’s highest quality care. Our PSD program, Modeling to Learn (MTL), improves frontline management of dynamic complexity through simulations of staffing, scheduling and service referrals common in healthcare, across generalist and specialty programs, patient populations, and provider disciplines/treatments. Innovation: Recent synthesis of VA data in the enterprise-wide SQL Corporate Data Warehouse (CDW) makes it feasible to scale participatory simulation learning activities with VA frontline addiction and mental health staff. MTL is an advanced quality improvement (QI) infrastructure that helps VA take a major step toward becoming a learning health care system, by empowering local multidisciplinary staff to develop change strategies that fit to local capacities and constraints. Model parameters are from one VA source and generic across health services. If findings show that MTL is superior to usual VA quality improvement activities of data review with facilitators from VA program offices, this paradigm could prove useful across VA services. The PSD approach also advances implementation science. Systems theory explains how dynamic system behaviors (EBP reach) are defined by general scientific laws, yet arise from idiographic local conditions. Empowering staff with systems science simulation encourages the safe prototyping of ideas necessary for learning, increasing ongoing quality improvement capacities, and saving time and money as compared to trial-and-error approaches. Specific Aims: 1. Effectiveness: Test for superiority of MTL over usual QI for increasing the proportion of patients (1a) initiating, and (1b) completing a course of evidence-based psychotherapy (EBPsy) and evidence-based pharmacotherapy (EBPharm). 2. Scalable: (2a) Evaluate usual QI and MTL fidelity. (2b) Test MTL fidelity for convergent validity with participatory measures. (2c) Test the participatory theory of change: Evaluate whether 12 month period EBP reach is mediated by team scores on participatory measures. 3. Affordable: (3a) Determine the budget impact of MTL. (3b). Calculate the average marginal costs per 1% increase in EBP reach. Methodology: We propose a two-arm, 24-clinic (12 per arm) cluster randomized trial to test for superiority of MTL over usual QI for increasing EBP reach. Clinics will be from 24 regional health care systems (HCS) below the SAIL mental health median, and low on 3 of 8 SAIL measures associated with EBPs. Computer-assisted stratified block randomization will balance MTL and usual QI arms at baseline using Corporate Data Warehouse (CDW) data. Participants will be the multidisciplinary frontline teams of addiction and mental health providers. Next Steps/Implementation: MTL was developed in partnership with the VA Office of Mental Health and Suicide Prevention (OMHSP) and if shown to be effective, scalable, and affordable for improving timely Veteran access to EBPs, MTL will be scaled nationally to more clinics by expanding MTL online resources, and training more VA staff to facilitate MTL activities instead of usual QI.	Systems Modeling, Design, and Delivery				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 18-032	O'Hare	Ann		Ann.OHare@va.gov	Optimizing the value of community care for Veterans with advanced kidney disease	12/01/2019	04/30/2024	VA Puget Sound Health Care System Seattle Division, Seattle, WA	$1,119,896		The Veterans Health Administration has a long history of providing maintenance dialysis treatment for Veterans with end-stage renal disease (ESRD) in the community under the VA Fee Basis program. Starting Fiscal Year 2015, access to specialized nephrology care in the community became available to the much larger population of Veterans with advanced kidney disease not yet on dialysis under the Veterans Choice Program (VCP) and is expected to continue under a consolidated Community Care program. Like their counterparts on dialysis, Veterans with advanced kidney disease not on dialysis are a high-cost high-needs population for whom access to care, continuity of care and coordination of care are all vitally important in optimizing quality and outcomes. All three metrics are important in building strong relationships between patients and providers, and supporting the kind of iterative cycle of evaluation and re-evaluation and care coordination needed to properly care for these patients Objective: We will use mixed methods to study the impact of the VA’s evolving community care policy on outcomes and costs for Veterans with advanced kidney disease and identify opportunities for program improvement. Because many of the outcomes and care processes relevant to this population are sensitive to continuity and coordination of care, we hypothesize that receipt of VA-financed nephrology care in the community will negatively impact a range of clinical outcomes and care processes relevant to this population and will be more costly than nephrology care provided within the VA. We anticipate that for some groups, the potential harms of care fragmentation and discontinuity may be outweighed by the benefits of more timely receipt of needed care in the community. Because some VA medical centers may be more effective in coordinating care with community providers to mitigate the effects of care fragmentation, we hypothesize that there will be heterogeneity in the effect of VA-financed community care within the population and across VA medical centers that could be informative in improving the process of community referral for this population. Methods: We will use national VA administrative and clinical data to track the impact of VA-financed community care on clinical outcomes, care processes and costs to the VA system among Veterans with advanced kidney disease using an instrumental variable approach (Aim 1). To identify opportunities for improving the value of community referral for this population, we will elicit the perspectives and experiences of Veterans with advanced kidney disease eligible for, or receiving VA-financed community care and their VA and community care providers (Aim 2). Impact: This proposal will directly address three VA HSR&D priority areas (Health Care Systems Change, Healthcare Access and Patient-centered Care, Care Management, and Health Promotion). The work proposed here is extraordinarily timely and policy-relevant given that the VA MISSION Act of 2018 recently passed both the House and the Senate with strong bipartisan support. We anticipate that our work to measure the impact of VA-financed community nephrology care on Veterans with advanced kidney disease will help to identify opportunities for more effective use of agency resources to optimize access, continuity and coordination of care for a high-cost high-needs segment of the Veteran population. To ensure that our work is poised to shape evolving VA policy around provision of community care, the investigators are partnering with the VHA National Program for Kidney Disease and the Office of Community Care	Health Care Organization and Implementation				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 18-037	Kovesdy	Csaba		csaba.kovesdy@va.gov	Therapeutic Interventions to Access Outcomes and Disparities in Chronic Kidney Disease Among Veterans	01/01/2020	03/31/2024	Memphis VA Medical Center, Memphis, TN	$1,891,234		Chronic kidney disease (CKD) affects approximately 10% of the general population and is especially common among US veterans, affecting up to 36% of all VA users during FY2006-2014. All-cause and cardiovascular (CV) morbidity and mortality are extremely high in veterans with CKD and ESRD, and African American veterans have substantially higher rates of CKD and CV disease than whites. Traditional risk factors of cardiovascular disease such as hypercholesterolemia, hypertension and obesity often show seemingly anomalous, inverse associations with adverse outcomes among individuals with CKD and ESRD. To date there are few therapeutic interventions proven to prevent the development of CKD, delay its progression, or decrease morbidity/mortality in patients with CKD. There is also a lack of race-specific application of clinical interventions, in spite of evidence suggesting that African-Americans may respond differently to various therapies. The lack of clinical end point driven randomized controlled trials in this population necessitates robust epidemiologic studies to provide preliminary results in support of future clinical trials, and to offer large- scale, widely applicable evidence to inform clinical practice in cases when clinical trials are not feasible. Our proposal will expand on our previous work using data obtained from the national VA research database, which offers uniquely detailed sociodemographic and clinical information on millions of individuals across all parts of the US. The Specific Aims of our proposal are: Aim 1: Examine the effect of interventions on clinical outcomes in veterans with non-dialysis dependent CKD (NDD-CKD) overall and by race-ethnicity. Aim 2: Examine the effect of interventions on incident CKD and on all-cause and cause-specific mortality, CHD, incident stroke and incident CHF in veterans with normal baseline estimated GFR, overall and by race- ethnicity. Aim 3: Employ powerful graph theoretical algorithms and scalable supercomputer implementations to test and extend the validity of the findings from Aims 1 and 2, and to help elucidate hidden factors and highlight previously unknown relationships between condition, risk, treatment and outcome. Next steps: This four-year project will generate a wealth of information to examine the above outcomes of patients with all levels of kidney function, and could have significant implications for the care of US veterans and also for patients with kidney diseases in general. Clinicians and guideline committees could use information generated from our research to determine the most likely benefits for interventions without clinical trial evidence, and this could help prioritization of healthcare expenditures and drug formularies. Clinical trialists could also use information generated from our research to determine likely effect sizes for various interventions and various subgroups that may be most prone to benefit from interventions. Furthermore,	Healthcare Informatics				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 18-040	Smelson	David	Daniel Blonigen	david.smelson@va.gov	A Randomized Controlled Trial of MISSION-CJ for Justice-Involved Homeless Veterans with Co-Occurring Substance Use and Mental Health Disorders	09/01/2020	07/31/2024	VA Bedford HealthCare System, Bedford, MA	$1,110,678		Background: Among the 146,000 Veterans released from correctional settings annually, approximately 60% have a co-occurring mental health and substance use disorder (COD). These individuals often access treatment inconsistently, resulting in increased antisocial activities and acceleration into unemployment and homelessness – strong predictors of reoffending. VHA Mental Health Residential Rehabilitation Treatment Programs (MH RRTPs) commonly serve justice-involved Veterans (JIVs) with an estimated 50% annually. JIVs receive assistance with their addiction and behavioral health needs, but MH RRTP programs do not directly address their antisocial behaviors and cognitions. Furthermore, MH RRTP discharge is a vulnerable transition and no national transitional approach facilitates Veteran engagement in prosocial community behaviors that maintain MH RRTP gains, and ultimately reducing revolving door service use. Maintaining Independence and Sobriety through Systems Integration, Outreach, and Networking-Criminal Justice version (MISSION-CJ) is a new case manager and peer delivered team-based treatment for JIVs with a COD. Three recent open pilots of MISSION-CJ showed reduced criminal recidivism, improved behavioral health outcomes and increased access and engagement in care. A randomized controlled trial (RCT) is a critical next step prior to dissemination. Significance/Impact: This application is responsive to the VHA MISSION Act, Veteran Care Priorities of Access to Care, Mental Health, and Health Equity. The project aims to (a) increase access and engagement in VHA and community-based care, (b) offer timely Veteran-centered care, and (c) improve the health and well- being of JIVs while reducing disparities. It also includes an implementation aim to support VHA learning. Innovation: While MISSION-CJ derives in part from an evidence-based treatment for homeless individuals (MISSION), it includes a new conceptual framework and numerous new and differentiating features for a CJ population including: (1) a treatment planning tool focused on criminogenic needs that monitors progress and tunes service delivery elements, (2) a prosocial treatment curriculum, and (3) tools/resources to address Veteran legal issues. With MISSION-CJ, this study attempts to change the practice paradigm and transform care for JIVs by moving beyond the current model of linking Veterans to VA care and tracking behavioral health outcomes, to a hybrid treatment/linkage approach that addresses criminogenic needs, supports engagement in VA and non-VA care, and targets recidivism as an outcome–the gold standard for CJ research. Specific Aims: Aim 1: An RCT will compare MISSION-CJ to EUC. We predict that those in MISSION-CJ will have (1a) lower criminal recidivism; (1b) lower overall risk for criminal recidivism; (1c) better health-related outcomes (substance use, mental health, housing, employment); and (1d) the effects of MISSION-CJ on 1a, 1b and 1c, will be mediated by (i) reductions antisocial attitudes, (ii) reductions in affiliations with antisocial peers and increases in affiliations with prosocial peers, (iii) greater treatment engagement (i.e., MH RRTP completion; substance use/mental health continuing care; 12-step group attendance), and (iv) increased community reintegration. Aim 2: A formative evaluation will identify barriers and facilitators to future implementation of MISSION-CJ in other MH RRTPs nationally. Methodology: This project will use a Hybrid Type 1 design. First, we will test the effectiveness of MISSION- CJ in a two-site RCT (Bedford and Palo Alto VAs) with 226 Veterans with a COD, admitted to an MH RRTP, and previously arrested and charged and/or released from incarceration in the past 12 months. Next, we will use the Reach, Effectiveness, Adoption, Implementation & Maintenance framework to conduct a formative evaluation with 7 providers and 12 Veterans at each site to inform future MISSION-CJ implementation. Next Steps/Implementation: Depending on the results of this study, we will work with our VACO operational partners and two HSR&D Centers of Innovation to conduct a large multisite implementation trial.	Mental and Behavioral Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 18-077	Lindsay	Jan		Jan.Lindsay2@va.gov	VA Video Connect to Improve Access to Multi-disciplinary Specialty Care	01/01/2020	09/30/2023	Michael E. DeBakey VA Medical Center, Houston, TX	$1,183,908		Background: Improving retention in human immunodeficiency virus (HIV) care and increasing the proportion of Veterans with persistent HIV suppression is one of the 4 national priorities outlined in the VHA HIV, Hepatitis and Related Conditions Program’s 2016 Annual Report. Treatment of complex conditions like HIV requires multidisciplinary care and monitoring at regular clinic visits with multiple providers. In VHA that care is located and delivered primarily in VA medical centers, posing logistic and stigma related barriers to Veterans’ access to multidisciplinary HIV care. VA Video Connect (VVC), a VA-supported mobile health video technology that allows Veterans and providers to complete clinical visits from any remote location including the home, has the potential to transform delivery of multidisciplinary care for HIV and other chronic conditions by increasing access to care. VA leadership wants 5% of Veterans to receive care via VVC in FY2018, but less than 0.1% of Veterans with HIV have used VVC. VVC could help fill these gaps in care. Specific Aims: The aims are: Aim 1-Clinical Effectiveness: To determine the effectiveness of VVC-delivered, multidisciplinary HIV care compared to routine care on retention in care. Aim 2-Implementation: To conduct a mixed-methods formative evaluation to refine and evaluate our implementation facilitation (IF) strategy to improve the reach of VVC-delivered HIV care, increase provider and Veteran adoption, and determine potential for sustainability. Exploratory Aim: To assess the implementation potential of VVC- delivered HIV care across 6 diverse VHA settings and identify contextually specific barriers and facilitators to adoption. Significance to Veterans’ Health: The VA is one of the largest providers of HIV care in the US and improving retention in care and HIV suppression is associated with improved survival with HIV. Priority areas: Improving access to care, modernization of VA, healthcare equity and health disparities. Innovation: While VVC is gaining a foothold in mental health care, it has not been widely used in specialty medical care. We will determine if multidisciplinary care delivered by VVC can improve retention in care and clinical outcomes for vulnerable Veterans in need of specialty medical care. The research will provide models and evidence for a transformative solution to increase Veterans' access to multidisciplinary care. Methodology: Aim 1 will be achieved with a pragmatic, Hybrid Type II effectiveness-implementation study within the Michael E. DeBakey VA Medical Center infectious diseases clinic, which cares for nearly 1000 Veterans with HIV. We will deploy an IF strategy to facilitate uptake of VVC and randomize Veterans to either be offered or not offered VVC. The study will enroll 360 Veterans and is powered to detect a 12% absolute improvement in retention in care, the primary outcome. Secondary outcomes include adherence to antiretroviral therapy, HIV suppression, and safety measures. Guided by the RE-AIM QuEST framework, Aim 2 layers a mixed-method evaluation on top of the effectiveness trial, enrolling 40 Veteran participants and numerous staff in in-depth interviews at all phases of the trial. The Exploratory Aim will be conducted working with 6 diverse VA HIV clinics and includes assessing organizational readiness, deploying the IF strategy, conducting in-depth interviews, and assessing reach and adoption of VVC in these clinics. Expected Results: We hypothesize that VVC will improve engagement and clinical outcomes and be acceptable to patients and providers. We will generate extremely valuable data and experience on implementation of VVC outside mental health care, regardless of impact on HIV care, and identify IF strategies that could be used in later implementation of VVC. Next Steps: If successful, we will work with partners to disseminate and implement VVC for multi-disciplinary HIV care throughout VA. We will also foster work in other chronic medical conditions. Our results could lead to accelerated uptake of VVC, improved access to care, and improved health for many Veterans.	Care of Complex Chronic Conditions				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 18-092	Yoon	Jean		Jean.Yoon@va.gov	Veterans' Choice in Hospital Care	06/01/2019	09/30/2023	VA Palo Alto Health Care System, Palo Alto, CA	$1,212,248		The mission of the Department of Veterans Affairs has been, since its inception, “To care for him who shall have borne the battle,” yet the mode of providing that care has recently undergone sweeping transformation. With passage of the Veterans Access, Choice and Accountability Act of 2014 (Public Law 113- 146) (“Choice Act”), Veterans' options for VA-sponsored health care have increased. Veterans can now access care in VA hospitals or in non-VA settings through traditional VA community care and the recent Veterans Choice Program (VCP). Ultimately, expanding non-VA options may lead to greater choices for patients to potentially obtain care that is more accessible, timely, higher quality, and that may lead to better outcomes. Sicker veterans who use hospital care for inpatient stays are some of the sickest and most vulnerable VA patients, so planning for their care is paramount to ensuring access to high-quality care. A comprehensive examination of the use of VA and non-VA care, total VA spending, and outcomes is needed to guide the development and expansion of community care programs like the VCP. Therefore, we will estimate the change in utilization and spending on VA-provided and VA-sponsored care in the context of other non-VA care (primarily Medicaid expansion). We will also study which patient characteristics and VA hospital characteristics influenced Veterans' choice of VA or community care providers. Finally, we will examine the impact of the VCP on hospital mortality for hospitalized patients. We will use innovative methods to link non- VA hospital discharge data with VA data for 11 geographically diverse states to answer these questions. To obtain a comprehensive picture of veterans' utilization, we will obtain hospital and other provider data from 11 state agencies (AZ, CA, CT, FL, IL, LA, MA, MO, NY, PA, SC). State patient discharge data includes data from all non-federal hospitals in the state including inpatient care. We will measure all VA-sponsored community care from state discharge data because these data report more comprehensive and standardized information, such as the type of care and provider, than that available in Fee Basis claims data. We will link state data to VA data and use quantitative methods to examine overall changes in VA-provided hospital care, VA-sponsored hospital care, and hospital care covered by other payers before and after VCP implementation. Utilization and spending of inpatient stays provided/sponsored by VA and non-VA providers will be estimated from Calendar Year (CY) 2011 to CY2017. We will estimate the impact of the VCP on total hospital spending after adjusting for patient and VA hospital factors. We will also look at factors influencing choice of hospitals and hospital mortality among hospitalized patients and whether it decreased after implementation of the VCP. Next steps involve sharing findings with operational partners to guide VA strategic planning, budget and reimbursement models, and programs to improve access to patient-centered care by the VA Office of Community Care, the VA Office of the Assistant Deputy Under Secretary for Health for Policy and Planning, and the VA Allocation Resource Center. New data like these are urgently needed by VAMCs and VA policy makers to help long-term planning for hospital services through integrated systems of VA and community care providers and maintaining access to high-quality care for Veterans.	Systems Modeling, Design, and Delivery				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 18-093	Yano	Elizabeth	Katherine Hoggatt	Elizabeth.Yano@va.gov	Quantifying the Burden of Disease and Healthcare Need in Veterans and Civilians	10/01/2020	09/30/2024	VA Greater Los Angeles Healthcare System, Sepulveda, CA	$708,356		Background: With rapid acceleration of Veterans’ use of care in the community, limited data exist to prepare community providers and others in the broader VA integrated care network. Many community providers and health plans may assume Veteran patients are similar to their routine practice populations, composed primarily of civilians, although prior research would suggest otherwise. Significance/Impact: The proposed study will use detailed, current, and comprehensive data from the Behavioral Risk Factor Surveillance System (BRFSS), National Health Interview Survey (NHIS), the National Surveys on Drug Use and Health (NSDUH), and VA Corporate Data Warehouse (CDW) to quantify broadly the distribution of health and healthcare factors for Veterans, VA users, and VA non-users and to evaluate in-depth the factors that differ between Veterans and civilians. This information will not only substantially update our knowledge of how Veterans are similar to or different from civilians but will also be used by VA policymakers to improve the design and readiness of community care partners as VA referrals increase. Innovation: In contrast to previous studies and reports using national survey data, the proposed project will include VA data to provide a richer description of VA patients than is possible using only publicly-available data on VA users, and examine in depth the patterns in Veterans’ health and healthcare across subgroups and over time. The proposed research has no corollary or antecedent study in VA HSR&D’s or QUERI’s portfolio, and of the studies funded outside the VA that use one or more of these sources and is underway or recently completed, none proposed to use VA data or to combine the breadth and depth of the proposed project Specific Aims: This project aims to 1. Quantify the distribution of population characteristics, health behaviors, health conditions, health status, access to care, and healthcare utilization among Veterans overall and among VA users and non-users; 2. Evaluate the extent to which patterns in population-, health-, and healthcare- related factors differ between Veterans and civilians; 3. Determine whether the patterns identified under Aims 1 and 2 vary for subgroups defined by age, gender, and race-ethnicity; and, 4. Conduct an expert panel to review results from Aims 1-3 to come to consensus on evidence-based recommendations for improved community care (e.g., community provider readiness) and health equity. Methodology: We will conduct a secondary analysis using multiple years of data from BRFSS, NHIS, NSDUH, and VA CDW. Our analyses will include measures for Veteran and VA user status, geographic region, population characteristics, health behaviors and conditions, and healthcare outcomes, such as access, utilization, and unmet need for care. We will quantify the distribution of population-, health-, and healthcare- related factors among Veterans, VA users, and VA non-users, evaluate how these factors differ between Veterans and civilians, assess the extent to which VA use moderates differences between Veterans and civilians, and assess how patterns for Veterans differ across population subgroups. We will use modified Delphi panel methods to critically appraise findings, rate their importance, feasibility, and potential for Veteran impacts, and come to consensus on evidence-based recommendations for community care and health equity. Next Steps/Implementation: We will engage diverse stakeholders as advisors/panelists (e.g., national program office, VISN, VAMC and Veteran representatives) in design of dissemination products (e.g., fact sheets, visual abstracts) for different venues that meet end user needs in addition to traditional scientific products. Integrated into the panel process will be explicit planning for products capable of informing and supporting potential practice and policy changes and their subsequent implementation.	Access				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 18-114	Rose	Danielle		Danielle.Rose@va.gov	Impacts of Organizational Variations on Access Management	01/01/2020	03/31/2024	VA Greater Los Angeles Healthcare System, Sepulveda, CA	$803,911		Background: Delays in care (i.e., poor access to timely care) are associated with adverse impacts on morbidity, mortality and quality of life, as well as poor outcomes from physical and mental health conditions. The VHA healthcare system has long struggled with access issues, however, VHA's “access crisis” in 2014, where systemic access problems were identified after whistleblowers revealed intentional cover-ups of long delays, drew particular outrage as evidence emerged that Veterans had died waiting to see their VHA doctors. Improving Veterans' access to care continues to be among VHA's top priorities, and while expansion of access to community providers has been among the most visible approaches to reducing waits and delays, VHA has implemented numerous initiatives to improve Veterans' timely access to care within VHA as well. These include development of a group practice manager role to facilitate face-to-face and virtual appointment-making through call centers and access management tools (e.g., grid validation). Improving access management— effectively deploying clinic personnel, resources, and processes to achieve timely access—remains a major challenge nonetheless, especially across widely varying organizational and geographic contexts. Despite their importance, remarkably little is known about which of these strategies have been implemented, the factors that support or hinder their use, or their relationship to access metrics. Specific Aims: To address these gaps, we propose the following specific aims: Aim 1: To assess national variations in how local VA facilities manage primary care access. Aim 2: To evaluate how different access management strategies relate to access metrics. Aim 3: Building on results from Aims 1 and 2, to conduct a national expert panel to come to consensus on evidence-based practice and policy recommendations to improve access to care. Methods: For Aim 1, we propose to use key informant-based organizational surveys to assess implementation of access management strategies on a national basis. We will examine area and organizational determinants of their uptake, use and implementation by linking resulting survey data with Area Resource File measures (e.g., urban/rural, primary care shortage area), facility characteristics (e.g., complexity, academic affiliation), and other organizational measures (e.g., PACT Implementation Index). For Aim 2, we will then link data from Aim 1 to VHA access metrics, including both administrative (e.g., appointment wait times) and patient-reported access measures (e.g., obtained care when needed). For Aim 3, we will use modified Delphi panel techniques to bring together VA and non-VA experts in access management, primary care, care coordination and other areas to generate evidence-based recommendations based on data from Aims 1 and 2. Anticipated Impacts on Veterans' Healthcare: The proposed study will provide critical information for VA leadership to better understand which access management strategies have been implemented, what has driven uptake and implementation, the barriers and facilitators to their use, and which of them are in fact associated with better performance on access metrics. No other data sources are available to lay the groundwork for evidence-based approaches to solving VHA's access crisis on this scale despite the resources being applied. This study will yield multilevel targets for intervention and implementation in partnership with senior leaders and other stakeholders. Next Steps: We will work with leaders in Primary Care and Office of Veterans' Access to Care to disseminate findings to the field. During the Expert Panel, we will confer with panelists to identify optimal means of communication, including but not limited to issues briefs, toolkits, field guides, workgroups or other methods.	Systems Modeling, Design, and Delivery				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 18-116	Frayne	Susan	Alison Hamilton	susan.frayne@va.gov	Attrition of Women Veterans New to VHA in the Community Care Era	05/01/2019	09/30/2023	VA Palo Alto Health Care System, Palo Alto, CA	$1,194,058		Project Background: The Veterans Health Administration (VA) outsources care through its Community Care (CC) program, a top VA priority. With the 2014 passage of the Veterans Choice Act came rapid expansion of CC. While expanded CC is meant to enhance choice and access, emerging evidence raises concerns about how VA patients experience it. Early CC implementation has been challenging, e.g., with limited availability of CC providers and fragmented care coordination between VA and CC providers. Patient experiences of CC may have special relevance for women, who use far more CC than men. Furthermore, nearly one in five new women Veteran VA patients stops using, or “attrits” from, VA care, which is three-fold higher odds of attrition than other women in VA. Our team has learned through our current CREATE study that patient experiences of care can impact attrition: in preliminary analyses, odds of attrition in a fiscal year (FY) 2011 cohort were lower for women who received CC care. However, in this post-expansion era of CC, it is not known whether CC will continue to protect against attrition, whether the attrition rate among women will improve or worsen, how specific types of CC may influence women's decisions to continue in versus leave VA care, or what patient subgroups are at particular risk for CC-related attrition. Project Objectives: The Specific Aims are to (1) model CC and other factors expected to predict attrition from VA; (2) examine the longitudinal attrition trajectory pre/post expansion of CC; (3) characterize the facility-level context of CC, to triangulate with Aims 1 & 2 results and inform Aim 4; and (4) examine women's experiences of care and their perspectives on the relationship between CC and plans for future VA use. Project Methods: Guided by a conceptual model that combines the Andersen Behavioral Model and Consumer Choice Theory, we will conduct a mixed methods study designed to achieve integration at all levels: design, methods, interpretation, and reporting. For Aim 1, we will analyze existing data sources in an FY17 national cohort of new women (N~23,000) and new men (N~200,000) VA primary care patients. For Aim 2, we will model the attrition trajectory in sequential national cohorts (FY07-FY19Q2) of all women Veterans new to VA, and separately, men. For Aim 3, we will conduct semi-structured interviews at two timepoints with clinician/staff key stakeholders (n=30) involved in CC at ten purposively selected sites. For Aim 4, we will conduct semi-structured interviews at two timepoints with new women Veteran primary care patients (n=70) at Aim 3 sites who received a CC referral in FY20. Key stakeholders and women Veterans will be asked to provide recommendations for organizational/policy changes that would improve CC and retention of Veterans in VA care. Significance and Relevance to Veterans' Health: Understanding the potential association between CC experiences and attrition among women Veterans represents a critical topic, not only because women are far more likely than men to be referred to CC and often receive gender-specific services that require heavy care coordination, but also because the number of women Veteran VA patients has nearly tripled over the past 15 years. This study addresses the VA priority area of focusing resources more efficiently, by yielding results relevant to system-level and policy changes: it will point to specific types of CC that are associated with greater attrition risk, specific subgroups who are at more risk, and specific elements of VA delivery systems that interact with CC to increase risk of attrition. Next Steps: If this project meets the intended goals, the next step will be to work with our policy partners to identify targets for change and intervention, to minimize attrition and maximize patient-centered care.	Women's Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 18-146	Chan	David		David.ChanJr@va.gov	Evaluating the VA Make-or-Buy Decision in Emergency Care	01/01/2020	03/31/2024	VA Palo Alto Health Care System, Palo Alto, CA	$1,181,571		Background: In response to concerns about access to and quality of care at VA facilities, the VA has begun to redirect resources toward financing care for Veterans outside of the VA. However, the quality and cost of care for Veterans that will result from this ?make-or-buy? decision remain a scientific unknown, with significant policy implications for how the VA can optimize Veteran health. Quality and cost of care are particularly influenced by emergency services, with 13% of care and more than $800 million in yearly costs directed outside the VA. Objective: Our objective is to identify how quality and cost of care for Veterans are affected by its provision inside or outside the VA. Studying the quality and costs of VA vs. non-VA care faces the fundamental concern that patients who receive care at VA facilities may have different levels of underlying health than do those who receive care outside the VA. Without understanding the consequences of VA vs. non-VA emergency care on quality and cost, VA policymakers will be unable to direct Veterans to the best care location, nor will they understand mechanisms behind quality and cost differences between VA vs. non-VA care. Finally, a lack of knowledge about the effects of VA vs. non-VA care, and about how Veterans access care, prevents policymakers from predicting quality and cost outcomes for Veterans from policy interventions redirecting Veterans to non-VA care. Methods: In Aim 1, we will adopt a quasi-experimental approach, based on instrumental variables (IVs), to study the effect of the care source on health, utilization, and spending. In preliminary results, we find that VA EDs reduce elderly Veteran mortality by 50%, or five percentage points. In Aim 2, we will assess the factors altering the effect of VA vs. non-VA care, evaluating mechanisms behind the effect. For example, we will investigate whether the VA performs better for Veterans with certain conditions or demographics, such as a mental health diagnosis or low socioeconomic status. We will assess whether the capacity of local VA options plays a key role in determining outcomes, and whether coordination of care mediates improved VA outcomes. In Aim 3, we will evaluate how Veteran use VA and non-VA ED alternatives, and we will use these results and those in Aims 1 and 2 to simulate quality and cost outcomes under policies for expanding VA capacity, contracting with non-VA options, and redirecting Veterans to care depending on their characteristics and on local options. Expected Outcome: Based on our preliminary results, we expect there to be important differences in health outcomes and spending between VA and non-VA emergency care. We therefore expect that policymakers can save thousands of Veteran lives and can improve health outcomes by making decisions based on this research. The effect of VA care likely differs across Veterans and local conditions. Accordingly, we expect there to be large additional gains in health and spending outcomes that result from tailoring policies related to this important make-or-buy decision. Finally, by understanding how outcomes differ across settings and Veteran types, we expect to contribute to a general understanding about which components of health care delivery are most critical to achieving excellence. In partnership with the Offices of Policy and Planning, Community Care, and Emergency Medicine, we anticipate that our findings will be disseminated widely and will be applied directly to VA decisions and guidelines.	Health Care Organization and Implementation				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 18-230	Hoerster	Katherine		Katherine.Hoerster@va.gov	MOVE!+UP: Testing a Tailored Weight Management Program for Veterans with PTSD	10/01/2020	07/31/2024	VA Puget Sound Health Care System Seattle Division, Seattle, WA	$1,156,206		Project Summary Background: Post-traumatic stress disorder (PTSD), prevalent among Veterans, puts Veterans at increased risk for obesity and related conditions. Veterans with PTSD lose less weight in VA’s MOVE! weight management program, due to PTSD symptoms that interfere with activity and healthy diet. In addition, many Veterans who receive evidence-based PTSD treatment remain symptomatic. A behavioral weight loss program that augments standard PTSD care and targets PTSD-related weight loss barriers called MOVE!+UP was piloted and iteratively refined among 44 overweight Veterans with PTSD. The fully developed MOVE!+UP is led by a psychologist and a Veteran peer support counselor, who provide complementary expertise. It includes 16 in-person group sessions with 90 minutes of general weight loss support, coupled with Cognitive Behavior Therapy skills to address PTSD-specific barriers. Each session also includes a 30-minute community walk to address hypervigilance-based activity barriers and enhance classroom-based learning. Veterans receive two individual dietician visits, and counseling calls as needed. The cohort receiving the final MOVE!+UP package reported high satisfaction and had better weight loss outcomes than Veterans with PTSD in the general MOVE! program. They also reported substantial PTSD symptom reduction. Treatment targets like eating behaviors, activity, and insomnia also improved. MOVE!+UP effectiveness must be tested in a randomized trial. Significance/Impact: MOVE!+UP is timely and efficient, simultaneously addressing physical and mental health of a priority Veteran group. MOVE!+UP is positioned to address HSR&D priorities by promoting mental health and improving PTSD symptoms, access to care, and whole health. This study is aligned with HSR&D and ORD methodological priorities by using a hybrid type 1 trial. This study’s cost and utilization analyses, and systematic identification of implementation barriers and facilitators, would place effectiveness findings in context and facilitate rapid translation to the field if MOVE!+UP is effective. This study will also provide insights about ways that general MOVE! and PTSD care can be enhanced to improve reach and effectiveness. Innovation: MOVE!+UP is the first weight loss program designed to address obesity in Veterans with PTSD. Specific Aims: This study proposes to randomize overweight/obese Veterans with PTSD enrolled in PTSD care to usual care enhanced with enrollment in MOVE! (control) or usual care enhanced with MOVE!+UP (intervention), and is guided by three aims: 1) Test whether intervention participants have greater 6-month weight loss (primary outcome), and 6-month PTSD symptom reduction and 12-month weight loss (secondary exploratory outcomes), relative to controls; 2) Assess whether compared to control, intervention participants have greater improvements on 6-month treatment targets: physical activity, eating behavior, insomnia, depression, and social support; 3) Estimate intervention and control condition costs and utilization, and identify MOVE!+UP implementation barriers and facilitators, to contextualize Aim 1 and inform future implementation. Methodology: Hybrid type 1 trial with 164 overweight/obese Veterans with PTSD enrolled in PTSD care. Implementation/Next Steps: This hybrid type 1 trial will provide data needed to prepare a MOVE!+UP implementation package for broader VA implementation if MOVE!+UP is effective. If it is not effective, Aims 2 and 3 will help understand how overweight Veterans with PTSD could be better supported in the future. Implementation activities would be coordinated with existing local, VISN, and national operational partners.	Complementary and Integrative Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 18-233	Fletcher	Terri		Terri.Fletcher@va.gov	A pragmatic trial of brief CBT for anxiety in VA primary care	10/01/2020	07/31/2024	Michael E. DeBakey VA Medical Center, Houston, TX	$1,288,945		Anticipated Impacts on Veteran's Healthcare VA has established strategic goals related to “Access” and "Timely and Integrated Care". The proposed pragmatic trial targets these goals by addressing a significant gap in VA mental health care - namely the treatment of anxiety in the primary care setting using innovative delivery options. Using a partnership approach, the project will examine the effectiveness and implementation potential of a brief psychotherapy program for Veterans with anxiety in primary care. Psychotherapy services will be delivered either in-person or through VA Video Connect-Home (VVC-H). Clinical and implementation outcomes will inform future dissemination efforts to improve access and delivery of high quality anxiety care in VA primary care settings. Background Anxiety disorders are common in VA primary care settings and are associated with substantial functional impairment, poor health-related quality of life, suicide, and high rates of comorbid psychiatric and medical disorders. No brief psychotherapy interventions for anxiety currently exist for VA primary care settings - where many Veterans seek care. Cognitive Behavioral Therapy (CBT) is a first line treatment for anxiety but Primary Care Mental Health Integration (PCMHI) providers need an intervention approach for anxiety disorders that is brief, problem-focused, and fits into their system of care. Objectives The proposed 4-year, multisite trial will use a pragmatic randomized trial design to examine the effectiveness and implementation potential of a brief CBT intervention for anxiety delivered either in-person or via VVC-H, according to patient preference. CBT will be delivered by existing PCMHI providers at three large VAMCs. Aim 1 will examine the clinical effectiveness of the bCBT intervention vs. EUC for anxiety and quality of life at 4-, 8-, and 12-month follow-ups. Aim 2 will determine factors associated with bCBT response and explore Veteran demographic and clinical factors associated with VVC-H engagement. An exploratory aim will use mixed, qualitative and quantitative methods to better understand implementation successes and challenges related to delivery and impact of bCBT anxiety and VVC-H use in the PCMHI setting. Methods The proposed project seeks to embed bCBT into PCMHI programs using existing VHA providers. A total of 225 Veterans diagnosed with an anxiety disorder will be recruited from three VAMCs. Eligible Veteran participants will be randomized to a bCBT or to an Enhanced Usual Care (EUC) condition. A professionally diverse set of PCMHI providers will be invited to deliver bCBT. Providers will receive bCBT training and support to embed treatment into their existing practice setting. Veterans randomized to bCBT will receive 4 – 9 sessions based upon treatment response (50% reduction in GAD-7) by session 4. Veterans will also be offered the choice of receiving bCBT in-person or through VVC-H. EUC participants will receive 4 brief monthly check- in calls from study staff and a note placed in their medical record alerting their provider to the presence of significant anxiety symptoms. BCBT treatment and EUC check-in calls will end at 4 months. Next Steps The proposed project leverages VA stakeholders at all levels to improve alignment of the work with VA and Veteran initiatives. Clinical outcomes will provide justifications or cautions to inform future evidence- based psychotherapy (EBP) programs. If positive, data will be used to assist VA leadership in the expansion of EBPs and VVC-H in PCMHI. For example, should the project produce robust clinical outcomes - next steps would involve a non-research / demonstration project in one or two VISNs where the project team will train and support a wider group of providers in the delivery of brief CBT for anxiety. The project team will use the web- based training program and clinical intervention materials as well as lessons learned from the proposed HSR&D IIR to support and enhance brief CBT delivery in a non-research context.	Mental and Behavioral Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 18-239	Kullgren	Jeffrey	Angela Fagerlin	Jeffrey.Kullgren@va.gov	Optimizing Veteran Decision-Making About Use of VA and Non-VA Health Care	02/01/2020	03/31/2024	VA Ann Arbor Healthcare System, Ann Arbor, MI	$1,199,628		Background: Major health care transformations within and outside of VA are now providing Veterans with unprecedented health care choices. Within VA, under recent federal legislation integrated networks of community providers and public reporting of access and quality at VA facilities are aiming to expand health care choices for Veterans and improve the timeliness of services. Outside of VA, many lower-income Veterans in states that expanded Medicaid now have a public insurance option, while privately-insured Veterans are increasingly facing high deductibles in their health plans. Significance/Impact: Major shifts in health care financing and delivery present Veterans with opportunities to make decisions about their use of VA and non-VA health care that optimize the timeliness, affordability, quality, and patient-centeredness of their care. However, these decisions also carry great potential for unintended consequences if they are not well-informed. Despite such high stakes, little is known about how Veterans are making decisions about using VA and non-VA care, what information they want to use in this decision-making, and how provision of information to Veterans about their health care options could be improved. Understanding these issues is critical to the success of national efforts to expand health care choices for Veterans under the VA MISSION Act and to achieve a VA health care system that is maximally responsive to Veterans’ needs. Innovation: This study is the first to assess the views, experiences, and information needs of Veterans who are users and non-users of VA health care. Specific Aims: Aim 1: Examine how Veterans are making decisions about VA and non-VA care and what information they want to use when making these decisions. Aim 2: Identify correlates of Veterans’ decisions to use and experiences with using VA and non-VA health care. Aim 3: Engage Veterans and VA leaders to identify opportunities to optimize Veterans’ decisions about use of VA and non-VA care and VA’s responsiveness to Veterans’ health care preferences. Methodology: We will partner with Veterans organizations to conduct focus groups and semi-structured interviews that will examine decision-making experiences of Veterans who use VA care, non-VA care, or both; the sources of information Veterans have used and would want to use in this decision-making; and Veterans’ experiences with the timeliness, affordability, quality, and patient-centeredness of VA and non-VA care. We will use these findings to develop and field a national survey of Veterans’ use of and decision-making about VA and non-VA care; factors related to their decision-making and health needs; and perceptions of the timeliness, affordability, quality, and patient-centeredness of their health care. The nationally representative sample of 3,000 Veterans will include both users and non-users of VA health care. We will identify Veteran characteristics associated with use of VA and non-VA health care services and with their health care experiences in VA and community health care settings. Finally, we will conduct deliberative forums with Veterans and VA operational leaders to develop actionable strategies that can be used to support Veterans’ decisions about VA and non-VA health care. Using a combination of deliberation and design methods, we will share key findings from the first 2 Aims and then guide participants through a collaborative process in which they will identify and prioritize programs and policies that could support Veteran decision-making about use of VA and non-VA care. Next Steps/Implementation: Products will include a compendium of the types of information Veterans use and need for decision-making about VA and non-VA care, new survey measures to assess Veterans’ decisions about VA and non-VA care, and a prioritized list of programs and policies that could be implemented to help Veterans make decisions about VA and non-VA care. We will use these products to work with our VA and non- VA partners to develop new strategies to optimize Veteran decision-making about VA and non-VA care.	Access				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 18-244	McInnes	Donald		Keith.McInnes@va.gov	Capturing the Dynamics of Homelessness through Ethnography and Mobile Technology	08/01/2020	09/30/2024	VA Bedford HealthCare System, Bedford, MA	$1,452,551		Background: On a given night around 40,000 Veterans are homeless and another 300,000 are at risk. Many of these Veterans have complex health and social needs, and they experience frequent residential transitions which can disrupt access to healthcare and treatment adherence. Many persons who are housing unstable experience frequent residential transitions, such as from transitional housing to shelter, or from doubled up with family/friend to living out of a car. Disruptions caused by such transitions likely contribute to this population's poor health by interfering with access to care and treatment adherence. Despite the potential harm, there is a major gap in detailed, contextual knowledge of these transitions, especially from the perspective of the individuals experiencing them – such as their in-the-moment emotions, behaviors, geographic movements, and social support. Filling this gap would improve knowledge of Veterans' trajectories into and out of homelessness and their day-to-day barriers to health care and other services. New approaches are needed. Research has shown that most persons experiencing homelessness have mobile phones, and increasingly they are smartphones. This provides an opportunity to gather near real-time information, at relatively low cost, that would help improve understanding of Veterans' changes in housing, health, mood, and use of services. Significance/Impact: Homelessness among Veterans represents one of the worst failures of our national and VA health care and social service systems. Health is poor, and life expectancy for homeless persons is 10 to 20 years shorter than for housed populations. The work proposed here will contribute to VA priorities of improving access to care, increasing virtual care/telehealth, and improving the health of homeless Veterans. Innovation: We propose the first significant test of passive and active mobile phone data collection among homeless Veterans, including the use of global positioning system (GPS) location and ecological momentary assessment (EMA) to improve understanding of context, mobility, and distance to services. These methods can change how health services researchers think about collecting data from marginalized and hidden populations. These techniques can identify sequences of micro-temporal events, for example teasing apart the events and experiences that immediately precede (and follow) the transition from one housing type to the next, or the events that led to a missed healthcare opportunity (e.g. a missed appointment). Specific Aims: This study assesses the feasibility of smartphone data collection from homeless Veterans. Aim 1: Characterize the real-time lived experience of homeless Veterans, including day-to-day activities, interactions with services, and residential transitions using a formative ethnographic approach; Aim 2: Refine and tailor smartphone data collection methods; Aim 3: Conduct a 4-week demonstration of smartphone data collection to evaluate its acceptability and feasibility with Veterans experiencing homelessness. Integrate quantitative (GPS, EMA, mobile survey, medical records) and qualitative data; identify distinct patterns (or typologies) of residential transitions; and, assess associations among residential transitions, mobility, mood, health services, and adherence. Methodology: Ethnographic interview methods are used in Aim 1; focus groups and usability assessments in Aim 2; and smartphone data collection in Aim 3. Next Steps/Implementation: Using the methods and findings from this study, next steps will be to develop interventions to identify and intervene at timepoints when there is rapid deterioration in Veterans' housing stability or health to prevent major housing disruptions and health crises. Interventions will also contribute to enhancing access to care and adherence to treatments.	Equity				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 18-246	Tamura	Manjula		manjula.tamura@va.gov	Developing Tools for Dialysis Decision Support in Older Adults	07/01/2020	09/30/2024	VA Palo Alto Health Care System, Palo Alto, CA	$1,055,007		Background: Each year, more than 25,000 patients over the age of 75 start maintenance dialysis treatment in the United States. Although dialysis may prolong life, it entails profound and sometimes burdensome changes in lifestyle, substantial risks for complications, and for older adults, a high likelihood of permanent disability. The quality of dialysis decision making is often poor; few patients receive prognostic information or discuss the option to receive medical management without dialysis. Rather, patients perceive these decisions as a choice between dialysis or death. Significance/Impact: Our overarching goal is to support informed, goal-concordant dialysis decisions by developing decision support tools, addressing HSRD Priority Domain `Healthcare Informatics'. This project will address the information needs of patients and clinicians by generating new tools to support informed decision- making and goal-concordant care for Veterans with advanced chronic kidney disease and end-stage renal disease. Innovation: The project is innovative in several ways. First, it applies causal inference models to estimate treatment effects of dialysis to address an important clinical question for which a clinical trial is not feasible. Second, it incorporates patient-centered outcomes to evaluate the effectiveness of dialysis. Third, it uses novel scenario planning frameworks to address uncertainty with decision support. Specific Aims and Methods: To accomplish this goal, we will (1) compare survival, hospital-free survival, time to nursing home placement and number of dialysis access procedures using causal inference models to illustrate trade-offs from dialysis versus medical management among older Veterans with end-stage renal disease; (2) develop a web-based risk benefit calculator and decision aid based on the framework of scenario planning that incorporates estimates of survival and treatment complications with dialysis initiation compared to medical management; and (3) using mixed methods, evaluate the tools' usability, acceptability and effects on patient knowledge and decisional conflict. Implementation/Next Steps: We will work with operational partners to ensure the tools meet the needs of the end-users, and develop plans for broader testing and dissemination. By the end of the project period, we expect to submit a proposal to test a dialysis decision support intervention incorporating these tools in older Veterans.	Healthcare Informatics				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 18-266	Markland	Alayne	Susan Hastings, Elizabeth Vaughan	alayne.markland@va.gov	Optimizing Remote Access to Urinary Incontinence Treatment for Women Veterans	01/01/2020	12/31/2023	Birmingham VA Medical Center, Birmingham, AL	$1,199,962		Background: Primary care and prevention research among women Veterans across the life cycle is an area of increasing focus within VA Health Administration (VHA). Increasing numbers of women Veterans are using the VA for their general and gender-specific health care, representing a doubling in the past decade with 7% of all Veterans seen in the VHA being women. Up to 20 percent of women Veterans experience urinary incontinence (UI) and may be at increased risk due to exposures during military service, such as restricted toilet access and the impact of heavy protective gear and equipment on the pelvic floor. These factors, along with known risk factors such as pregnancy, childbirth, and menopausal transitions increase UI risk among women Veterans. Significance/Impact: This proposed clinical trial focuses on improving access to first-line treatments for women Veterans with UI. Several evidence-based treatments are available for UI including behavioral, medical, and surgical therapies. Behavioral self-management treatments including pelvic floor muscle training, bladder control strategies, and fluid management are widely recommended by guidelines as first-line treatment options because of their demonstrated effectiveness and low risk of side effects. Women who receive behavioral therapy for UI report greater confidence in self-management when provided with input from a clinician with specific training in UI management. To identify gaps in UI treatment modalities within VHA, we surveyed VA gynecologists, urologists, and behavioral and physical therapy providers for first-line treatment options at VA Medical Centers across the nation. We found that only 55% of facilities reported offering pelvic floor muscle training (PFMT), while 14% referred to another VA, and 44% referred to non-VA care. Sixteen percent of facilities did not provide PFMT. Our data demonstrated that women Veterans have limited access to clinicians who can provide these safe and effective treatments. Innovation: Given the identified need to improve access to UI treatments, we developed and tested two remote delivery models: an interactive mobile-health or mHealth UI smart phone/computer application and a clinical video telehealth (CVT) visit. This proposed study will incorporate an innovative sequential, multiple assignment, randomized trial (SMART) design to determine the optimal method for remote delivery. Specific Aims: Our specific aims are to: (1) compare the effectiveness among women Veterans of two remote delivery models for evidenced-based behavioral UI treatment, an interactive mHealth smart phone/computer application versus a remote CVT visit; (2) use a SMART design to optimize UI symptom improvement for women who do not respond to either type of remote delivery; (3) explore key factors that could influence future remote UI treatment dissemination. Our overarching hypothesis is that women Veterans who receive the interactive mHealth application will achieve greater reduction in UI symptoms compared to the training provided in a remote CVT visit. The broad goal is to improve access to evidenced-based UI treatments. Methodology: Including expertise from the Women’s Health Practice-Based Research Network, the Birmingham VAMC, the Atlanta VAHCS, and the Durham VAMC, we will randomize 260 women Veterans (86 per site). We will compare the effectiveness of our mHealth UI application to a CVT session by evaluating the sequential addition of an additional 1:1 CVT visit for non-responders in both randomization groups. This SMART design includes two randomization stages and compares 1 optimization factor over a 3-month intervention period with validated UI symptom outcomes assessed at baseline, 8-weeks, 12-weeks (primary outcome), and 6-months for durabiltiy. Additionally, we will use qualitative methods to identify key factors influencing participation and dissemination from women Veterans and providers. Next Steps/Implementation: Our next steps will be to test the ability to implement the most effective modality for improving access to UI care for women Veterans across a wider array of VHA facilities.	Women's Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 18-273	Benzer	Justin		justin.benzer@va.gov	Validating a data science methodology for patterns of mental health services use: The patient record of clinical experience sequence study (PROCESS)	08/01/2020	09/30/2024	Central Texas Veterans Health Care System, Temple, TX	$445,181		Background: An effective learning healthcare system needs measures that help managers identify how to promote system-level improvements. One opportunity to influence system level improvements is to directly measure the care sequences provided to patients that may reflect decreased efficiency and increased care fragmentation. We propose to determine whether a VA administrative data can be used to construct reliable measures of care sequences. Significance/Impact: Our innovation is in adapting a data science sequence analysis methodology to VA administrative records. This methodology has the potential to highlight care fragmentation and integration. Fragmentation is arguably the most important underemphasized goal in VA. Performance goals exist for quality of care and access, and there is a strong infrastructure for managing cost. However, there is limited focus on reducing fragmentation and improving integration, in part due to the lack of adequate measures. VA priorities include more efficient resource use. Two VHA strategies to increase efficiency are to diligently find areas of waste and correct to generate savings, and to improve the delivery of health care services by ensuring care coordination across all care settings. Sequence-based fragmentation and integration measures have the potential to directly inform these strategies. Specific Aim: The specific aim of this two-year proposal is to determine whether VA administrative data can be used to reliably measure mental health sequences of care. As an exploratory aim, we will determine whether sequences may represent care fragmentation. Methodology: We will use the VA Corporate Data Warehouse to collect evidence for internal consistency and test-retest reliability. Approximately 46,000 Veterans will be sampled in each of 6 annual cohorts (FY2013-FY2018) across 54 medical centers. We will use sequence analysis to identify clusters of similar sequences that are characterized by a common consensus sequential pattern. Internal consistency will be determined by comparing random patient samples to determine if patient sequences are more similar within consensus sequential patterns than between patterns. Test-retest reliability will compare patterns over time. We expect a step function where sequences will be similar over time, with periodic changes as capabilities improve. Generally, proximal sequences will be more similar than distal sequences. For the exploratory aim, we will calculate patient-level correlations with administrative database measures of care fragmentation and facility-level correlations with VA performance measures. A Delphi process with an expert panel will the degree to which each sequence generated by the methodology may measure fragmentation. This will provide preliminary data for the next study. Next Steps/Implementation: This two-year study will determine whether the sequence analysis method can be applied to VA administrative data to identify reliable care sequences. The output of the Delphi process and the convergent and discriminant validity tests will allow the team to develop specific hypotheses about VA depression care sequences that will be tested in a follow- up study. The next step will be to determine the association of depression care sequences with mental health symptoms, functioning, satisfaction, and cost. Our long-term goal is to develop a method for measuring care sequences in near-real time and provide feedback to managers and clinicians to identify patients regarding care sequences that may require intervention.	Research Methods Development				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 18-273	Benzer	Justin		justin.benzer@va.gov	Validating a data science methodology for patterns of mental health services use: The patient record of clinical experience sequence study (PROCESS)	08/01/2020	09/30/2024	Central Texas Veterans Health Care System, Temple, TX	$445,181		Background: An effective learning healthcare system needs measures that help managers identify how to promote system-level improvements. One opportunity to influence system level improvements is to directly measure the care sequences provided to patients that may reflect decreased efficiency and increased care fragmentation. We propose to determine whether a VA administrative data can be used to construct reliable measures of care sequences. Significance/Impact: Our innovation is in adapting a data science sequence analysis methodology to VA administrative records. This methodology has the potential to highlight care fragmentation and integration. Fragmentation is arguably the most important underemphasized goal in VA. Performance goals exist for quality of care and access, and there is a strong infrastructure for managing cost. However, there is limited focus on reducing fragmentation and improving integration, in part due to the lack of adequate measures. VA priorities include more efficient resource use. Two VHA strategies to increase efficiency are to diligently find areas of waste and correct to generate savings, and to improve the delivery of health care services by ensuring care coordination across all care settings. Sequence-based fragmentation and integration measures have the potential to directly inform these strategies. Specific Aim: The specific aim of this two-year proposal is to determine whether VA administrative data can be used to reliably measure mental health sequences of care. As an exploratory aim, we will determine whether sequences may represent care fragmentation. Methodology: We will use the VA Corporate Data Warehouse to collect evidence for internal consistency and test-retest reliability. Approximately 46,000 Veterans will be sampled in each of 6 annual cohorts (FY2013-FY2018) across 54 medical centers. We will use sequence analysis to identify clusters of similar sequences that are characterized by a common consensus sequential pattern. Internal consistency will be determined by comparing random patient samples to determine if patient sequences are more similar within consensus sequential patterns than between patterns. Test-retest reliability will compare patterns over time. We expect a step function where sequences will be similar over time, with periodic changes as capabilities improve. Generally, proximal sequences will be more similar than distal sequences. For the exploratory aim, we will calculate patient-level correlations with administrative database measures of care fragmentation and facility-level correlations with VA performance measures. A Delphi process with an expert panel will the degree to which each sequence generated by the methodology may measure fragmentation. This will provide preliminary data for the next study. Next Steps/Implementation: This two-year study will determine whether the sequence analysis method can be applied to VA administrative data to identify reliable care sequences. The output of the Delphi process and the convergent and discriminant validity tests will allow the team to develop specific hypotheses about VA depression care sequences that will be tested in a follow- up study. The next step will be to determine the association of depression care sequences with mental health symptoms, functioning, satisfaction, and cost. Our long-term goal is to develop a method for measuring care sequences in near-real time and provide feedback to managers and clinicians to identify patients regarding care sequences that may require intervention.	Research Methods Development				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 18-286	Hung	William	Lauren Moo	william.hung@va.gov	Effect of Medication Management at Home Via Pharmacy Home Televisits	05/01/2020	02/29/2024	James J. Peters VA Medical Center, Bronx, NY	$1,206,582		Older adults are more likely to suffer from multiple chronic conditions, to be prescribed multiple medications, and are more susceptible to adverse effects of medications. In addition, older adults often use over-the-counter medications and supplements, further complicating their medication regimen. Complex medication regimens are potentially harmful to older adults due to potential drug interactions, potentially inappropriate prescribing or over-the-counter drug use, and medication non-adherence that may lead to poor control of chronic disease. Interventions aimed at reducing medication discrepancy in the ambulatory clinic setting, such as the review of written medication lists, and implementation of “brown bag” reconciliation (asking patients to bring in all medication bottles for review in the clinic) continues to be challenging and have limited success. Clinical pharmacist led interventions to improve appropriate medication use in older adults, including the application of the START/STOPP criteria, have demonstrated effectiveness in reducing adverse drug events. With the increased capability of VA telemedicine to reach Veteran in their homes, delivering medication management via televisit by clinical pharmacists has the potential to yield similar benefits for a larger number of older Veterans. Telemedicine is an increasingly vital component within VHA to increase access and improve quality of care. By extending care beyond brick-and-mortar clinics, telemedicine increases the reach of care teams and is more convenient for patients, resulting in improved patient satisfaction. Using the capability of telemedicine to reach patients' homes, we propose to examine the effect of medication management by clinical pharmacists via home video televisits, as home video visits have the potential to provide direct visualization of medications in older adults' homes, thereby reducing medication discrepancy and increasing medication adherence. Pharmacist management for older adult medication regimen may also improve appropriate medication use in older adults through direct pharmacist-patient interview and education. In support of this application, preliminary data from our team of investigators demonstrate acceptability of video televisits by older adults, that there is good uptake by patients and VA providers, and that video televisits into the home are feasible. In this study, we aim to develop a protocol for pharmacy home televisits for medication management in older adults who have multiple chronic conditions and are on multiple medications. We will then conduct a randomized trial with hybrid effectiveness Type I design to examine the effect of these televisits on appropriate medication use, medication discrepancies, adherence and adverse drug events and observe and gather information on implementation. We anticipate that a pharmacist led medication management home televisit intervention will lead to reduction in potentially inappropriate use of medication, reduction in medication discrepancies, increased medication adherence and reduced adverse drug events in older adults compared to older adults receiving usual care. We will also examine the barriers and facilitators in implementing the intervention so that the study findings may inform future implementation.	Access				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 18-287	Dichter	Melissa		Melissa.Dichter@va.gov	Strengthening Suicide Prevention Efforts for Women Veterans through the Veterans Crisis Line	07/01/2020	09/30/2024	Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA	$1,235,613		Background. The suicide rate among women Veterans has increased substantially in recent years, particularly among younger women and those with limited or no engagement in Veterans Health Administration (VHA) care. The U.S. Department of Veterans Affairs (VA) has invested extensive resources toward preventing suicide among Veterans, including through the Veterans Crisis Line (VCL). Prior research on Veteran suicide prevention and VCL use has focused largely on male Veterans. However, research has identified potentially unique characteristics associated with suicide risk among women Veterans and a need for further investigation into how to best meet the suicide prevention needs of this population. Significance/Impact. The objective of this research is to understand and develop recommendations to better address the suicide prevention needs of women Veterans who utilize the Veterans Crisis Line (VCL). Findings from this study will inform recommendations for strengthening crisis intervention services to prevent suicide among women Veterans. Innovation. The proposed multi-method study will focus on the understudied and vulnerable population of women Veterans who contact the VCL. We will analyze the rich yet largely unexamined data collected by the VCL on user and call characteristics, merge VCL data with VHA medical record data for callers who also access VHA services, and conduct in-depth interviews with women Veteran VCL users to obtain more detailed understanding of their experiences and perspectives. Findings will inform efforts to better tailor VCL services to, and increase engagement of, high-risk women Veterans. Specific Aims. The specific aims are to: (1) describe and compare the demographic and VCL contact characteristics (reason for call, call outcome, and VCL risk rating) among female and male Veteran VCL users; (2) examine the relationship between VCL contact characteristics (risk rating, referral, identified needs) and subsequent fatal and non-fatal suicidal self-directed violence (S-SDV), assessing for variation by Veteran gender, among female and male Veteran VCL users who use VHA services; (3) understand women Veterans’ experiences with and recommendations regarding VCL services, including the use of VCL as a resource for both acute and more upstream suicide prevention. Methodology. This mixed-methods study will utilize (a) administrative data from the VCL, VHA, and Suicide Data Repository (SDR); and (b) semi-structured interviews with women Veterans who have utilized the VCL. To address Aim 1, we will conduct statistical analysis of VCL data for prior-year Veteran users with identified gender (approximately 330,000 contacts per year), comparing demographic and VCL contact characteristics (reason for contact, severity rating, and contact resolution/referral) by gender. For Aim 2, we will merge VCL data with VHA health records and SDR data to assess relationships between VCL risk rating and suicidal ideation, suicide attempts, and suicide, with consideration of other health and service utilization characteristics. For Aim 3, we will conduct semi-structured telephone interviews with a sample (n = 40) of women Veteran VHA patients who have used the VCL, and assess: their reasons for contacting the VCL, expectations of VCL, experience with VCL service and connection with follow-up services, and recommendations for improvements in suicide prevention services. We will integrate our findings with input from a study-specific stakeholder advisory board composed of Veterans and clinical and operations partners, to develop recommendations for enhancing VA’s crisis intervention and broader suicide prevention efforts for women Veterans. Implementation/Next Steps. In collaboration with partners and Veteran stakeholders, findings will be used to develop a set of recommendations for clinical enhancement that operations partners can then implement into policy and practice. Future research will examine the impact of these clinical innovations.	Mental and Behavioral Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 18-290	Helstrom	Amy	Laura Wray	amy.helstrom@va.gov	Caregiver SOS: An Intervention for Employed Caregivers	04/01/2020	12/31/2023	Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA	$1,197,816		Background: Research has shown that unpaid, informal caregivers (CGs), such as family and friends, who are also employed may be at significant risk of experiencing burden and stress. A recent national survey found that approximately 60% of employed CGs had significant problems balancing work and caregiving. Stress not only increases the CG’s risk of illness and diminishes their quality of life; it also impacts the CG’s ability to provide care for the care recipient (CR) and overall relationship quality. Moreover, while work frequently adds to the CG’s stress, relinquishing work can create new stress for both the CG and CR, particularly when it involves losses in resources such as income, benefits, social contacts and/or respite from caregiving duties. Significance/Impact: Approximately 5.5 million Veterans rely on CGs to help them with their daily care. CGs often cope with stress and strain from CG/work roles. This may be particularly true of CGs of Veterans coping with behavioral health issues related to conditions such as depression, posttraumatic stress disorder (PTSD), anxiety, and traumatic brain injury (TBI). Programs that specifically address caregiving-work role stress may be especially effective in improving CGs’ wellbeing and work/financial stability and the quality of Veterans’ care. Given this project’s focus, it is responsive to multiple ORD and HSR&D priority areas, including long- term care/aging, access to care, mental health/PTSD, and health equity, expanded Veteran/CG access to high quality clinical trials, and legislative priorities such as the MISSION Act, which emphasizes research on new models that support and benefit both Veterans and CGs and maximize the ability of Veterans to age in place. Innovation: The evidence for CG stress interventions is limited mainly to studies of psychoeducational and support programs, many of which are targeted to specific groups of CGs (e.g., CGs of individuals with dementia). Few studies address CGs in the context of their work and CG roles, and even fewer focus on CGs of Veterans with behavioral health conditions, who often provide care to CRs with complex symptom profiles. To our knowledge, no program specifically targets work functioning and productivity among employed CGs. Specific Aims: The aims of this study are to, 1) determine the extent to which, relative to usual care, a novel intervention providing evidence-based, telephonic CG/work stress self-management counseling is related to changes in CG psychological distress and ability to function effectively in work and CG roles, and 2) evaluate whether participation in the intervention is related to CGs’ overall wellbeing and CRs’ health care utilization. Methodology: We will conduct a randomized controlled trial and compare pre/post changes among 300 CGs allocated to the Caregiver SOS (for Self-Management of Stress) program or usual care. CGs who, 1) care for Veterans diagnosed with depression, anxiety, PTSD, and/or TBI and, 2) screen positive for clinically significant distress and CG/work role difficulty will be recruited to participate from two VA Medical Centers and their affiliated outpatient clinics. A novel intervention, Caregiver SOS includes 6, 1-hour telephonic sessions with a care manager. Usual care will consist of 1 telephonic session with a care manager. Primary and secondary outcomes will be pre-post change in CG distress and work functioning, respectively. Additional CG and CR outcomes (i.e., physical mental and interpersonal functioning) also will be measured and analyzed. CRs’ VA health utilization data will be extracted from clinical patient records and non-VA health utilization data will be collected via CG self-report. Intent to treat analysis using mixed effects models will be used to test the study hypotheses. We anticipate that CGs in the intervention arm will show significantly greater improvements in outcomes compared to those in usual care. Next Steps/Implementation: We will work with our local and national partners (e.g., Caregiver Support Program; Office of Mental Health and Suicide Prevention) to evaluate findings and devise a strategy for ultimately testing effectiveness and implementation of the intervention both locally and across multiple sites.	Long Term Care and Aging				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 18-314	Monteith	Lindsey		lindsey.monteith@va.gov	Preventing Suicide Among Female and Male Veterans Not Receiving VHA Services	06/01/2020	07/31/2024	Rocky Mountain Regional VA Medical Center, Aurora, CO	$1,195,604		BACKGROUND: Veterans are at elevated and increasing risk for suicide, relative to civilians. In particular, female Veterans are nearly twice as likely to die by suicide, compared to female civilians. In addition, 70% of Veterans who died by suicide did not use any Veterans Health Administration (VHA) care in the year before death. Consequently, female and non-VHA Veterans have been identified as two target populations in the VA National Strategy for Veteran Suicide Prevention. Yet most suicide prevention research has focused on VHA users and male Veterans. Knowledge is thus limited regarding whether VHA and non-VHA users differ with respect to who dies by suicide, precipitating circumstances of death, and regarding gender differences within these domains. Moreover, while mental health (MH) care offers an important opportunity to recognize and intervene upon suicide risk, knowledge is limited regarding barriers to accessing MH or suicide-specific care, particularly in relation to whether these differ by gender or VHA use. These gaps preclude determining the most effective and patient-centered means of preventing suicide among both female and male Veterans, particularly those who not using VHA care. SIGNIFICANCE/IMPACT: The present study has strong implications for understanding and preventing suicide among non-VHA users and female Veterans, both of whom have been vastly understudied. This is particularly crucial considering: (1) the 2016 Female Veteran Suicide Prevention Act, which directs VA to determine the most satisfactory and effective MH and suicide prevention programing for female Veterans; and (2) the 2019 Executive Order on a National Roadmap to Empower Veterans and End Suicide, which directs VA to work side-by-side with communities to reduce suicide among all Veterans, not only those using VHA services. This study will increase knowledge of female and male Veterans who died by suicide, including circumstances surrounding death, and the extent to which suicide decedents accessed MH care prior to death. Such knowledge can be garnered to tailor prevention efforts across Veteran groups. Moreover, by engaging with living Veterans, this study will improve understanding of Veterans’ experiences and willingness to seek MH care in general and when suicidal, while also informing the extent to which their experiences, barriers, and preferences differ by gender and VHA use. This knowledge is timely and critical as VA seeks to engage more Veterans in care. INNOVATION: This study will be the first to identify factors differentiating VHA and non- VHA suicide decedents and to explore female and male Veterans’ experiences and preferences for seeking help when suicidal. This study is also innovative in conceptualizing non-VHA users as comprising Veterans who were lost-to-care and who never used any VHA care. SPECIFIC AIMS: This study uses mixed-methods to compare three groups of Veterans (VHA users, never users, and lost-to-care) across three aims: (1) Identify factors that differentiate Veteran suicide decedents (e.g., circumstances of death, MH care use); (2) Examine differences in willingness to seek MH care, barriers to using MH care, and MH care experiences; and (3) Describe and compare Veterans’ experiences, preferences, and barriers to help-seeking when suicidal. Gender differences will be examined across aims. METHODOLOGY: For Aim 1, probabilistic linkage of data from national sources will be combined for Veteran suicide decedents to evaluate circumstances of death (e.g., interpersonal and socioeconomic stressors, MH problems), as well as VHA MH care use (for VHA and lost-to-care decedents). For Aim 2, Veterans will be surveyed about their willingness to seek MH care, barriers to doing so, and MH care experiences. For Aim 3, qualitative interviews will explore Veterans’ experiences, barriers, and preferences for seeking help when suicidal. Female Veterans will be oversampled. IMPLEMENTATION/NEXT STEPS: Intended impacts include greatly enhancing knowledge and facilitating new opportunities for implementing patient- centered, gender-sensitive suicide prevention strategies for all Veterans. Findings will be consolidated, and key stakeholder input obtained to propose actionable clinical and policy changes.	Mental and Behavioral Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 19-023	Sox-Harris	Alexander		Alexander.Harris2@va.gov	Addressing the Gap in Feasible, Valid, and Important Quality Measures for the Treatment of Carpal Tunnel Syndrome	10/01/2020	09/30/2024	VA Palo Alto Health Care System, Palo Alto, CA	$1,181,379		PROJECT SUMMARY/ABSTRACT Background: Efforts to measure, report, and incentivize the quality of healthcare are now widespread within the Veterans Health Administration (VA), Medicare, and private healthcare settings—but common musculoskeletal disorders including carpal tunnel syndrome (CTS) have been omitted from these efforts due to a lack of valid, feasible quality measures. Although clinical practice guidelines for the diagnosis and management of CTS have recently been published, no valid and feasible measures of these guidelines currently exist. Also, great interest exists across healthcare specialties in developing and implementing patient reported outcome measure-based quality measures (PRO-QMs). Before implementing process or outcome- based quality measures, it is essential to determine if they are valid and produce actionable information. Significance/Impact: VA is increasingly becoming a purchaser of community-based healthcare, making it essential to evaluate if healthcare quality measures are valid for both VA and cross-system comparisons. This proposal is aligned with VA ORD and HSR&D priorities including quality and safety, supporting the development of value-based payment models, methods for monitoring quality and safety of non-VA purchased care, and evaluating measures and methods to compare the quality of VA and non-VA care. The continued absence of valid CTS quality measures leaves all stakeholders without any means to identify quality gaps, evaluate the impacts of quality improvement initiatives, or to enact performance-based reimbursement or purchasing initiatives. Innovation: Enthusiasm for implementing PRO-QMs has outpaced careful consideration of issues related to logistics, statistics, measurement, and unintended consequences. Currently, methods are under-developed to evaluate if sufficient variability in outcomes exist to justify implementation of PRO-QMs. The work proposed in Aim 2 will significantly advance the conceptual and statistical basis of methods to examine outcome variance for quality measurement applications. In Aim 3, we propose to examine associations between fully operationalized and pilot tested process quality measures (Aim 1) with PROMs collected for Aim 2. Information about each process measure's predictive validity is essential for future prioritization and implementation. Specific Aims: Aim 1 – Complete development and validity testing of process-oriented quality measures for the treatment of CTS using diverse administrative datasets. Aim 2 – Evaluate the measurement characteristics of PRO-QMs for CTS. Aim 3 – Test the predictive validity of promising process measures from Aim 1 Methodology: Existing healthcare data from VA, Medicare, and 3 university and community systems will be used to examine the measurement characteristics of four currently proposed, but inadequately tested, CTS process quality measures (Aim 1). Patient reported outcome measures will be collected from 2000 patients in 5 diverse health care settings representing 24 hand surgeons to examine if meaningful between-facility and - surgeon variation exists in changes in outcome among patients receiving initial consultation with a hand surgeon (Aim 2). The predictive validity of the process measures in Aim 1 will be evaluated using the outcome data collected in Aim 2 (Aim 3). Next Steps/Implementation: Study results that support the validity of specific quality measures will facilitate planned efforts to pursue National Quality Forum endorsement, and provide VA hand surgeons, quality managers, and community care purchasers a means to judge CTS treatment quality. Study results that do not support the validity of specific quality measures will be used to resist their implementation.	Quality Measurement Development				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 19-027	Burke	Robert		Robert.Burke5@va.gov	Improving Post-Acute Care Value for Veterans	10/01/2021	09/30/2025	Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA	$769,647		Background: The transition to a skilled nursing facility (SNF) after an acute hospitalization is one of the most perilous times in the life of an older Veteran. Veterans undergo more than 250,000 transitions between hospitals and SNFs annually, but more than 1 in 4 is readmitted to the hospital from SNF and less than half have returned to the community by 100 days following hospital discharge. Although the intent of SNF care is to allow recuperation and rehabilitation, Veterans who do not successfully recover are commonly placed in institutional long-term care at significant cost to themselves and to the VA, which spends more than $7 billion annually on this care. However, SNFs vary widely in their rates of community discharge and costs of care delivered. It is unclear how to identify “high-value” SNFs (those that deliver the best community discharge rates at lowest cost) for Veterans since existing public quality metrics do not include VA SNFs, do not list Veteran- specific outcomes, and do not include costs. Similarly, it is unclear how much matching individual Veteran needs with particular SNF characteristics might improve value. The VA as both payer and provider of SNF care has the unique opportunity to develop an optimal SNF network to drive high-value care. Significance/Impact: This work aligns with VA priorities to develop an integrated, high-performing network for Veterans as part of the MISSION Act and positions the VA as a leader in delivery of post-acute care. There are more than 4 million Veterans currently over age 65, making it imperative to improve outcomes and lower costs in SNFs as more Veterans transition out of the hospital to this care setting. Innovation: The approach uses novel data sets and methods drawn from health economics, big data, and systems engineering to provide new insights. To our knowledge, there are no published studies describing the outcomes of Veterans in post-acute care, identifying characteristics of high-performing facilities, nor establishing how matching patient to post-acute care provider characteristics affects outcomes. Specific Aims: Our Specific Aims are to: 1) Compare outcomes (successful discharge to the community) and costs (Federal dollars) across the population of Veterans discharged from a VA hospital to the three most common post-acute care settings where Veterans receive SNF care: CLCs, CNHs, and non-VA SNFs. 2) Evaluate the effect of matching individual subpopulations of Veterans (e.g., by risk for adverse outcome) to SNF type (CLCs, CNHs, or non-VA SNFs) and SNF star rating on outcomes and costs. 3) Compare the effects of consolidating SNF referrals to the SNF type with best outcomes and lowest costs (Aim 1) or matching individual Veteran characteristics to different SNFs (Aim 2) on Veteran outcomes, overall costs of care, and SNF capacity. Methodology: This proposal uses advanced statistical techniques (such as instrumental variable and machine learning methods) and a unique dataset (the 2014-18 Residential History File, which concatenates VA, fee- basis, Medicare, and Medicaid data into longitudinal episodes of care for individual Veterans) to accomplish our Aims. Implementation/Next Steps: The results of this work will be disseminated to VA Geriatrics and Extended Care and Office of Community Care leadership, who have been involved in the development of the proposal, as well as VISN and VA facility leadership through two tools that can be used 1) at the bedside to optimize SNF choice and 2) at a leadership level to help shape the SNF network to maximize value.	Long Term Care and Aging				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 19-031	Kuhn	Eric	Steven Sayers	Eric.Kuhn@va.gov	A Randomized Controlled Trial of Coaching into Care with VA-CRAFT to Promote Veteran Engagement in PTSD Care	09/01/2020	07/31/2024	VA Palo Alto Health Care System, Palo Alto, CA	$1,071,542		Impact: Family members are primary sources of support for Veterans struggling with PTSD. While family support and encouragement are powerful facilitators of Veterans’ mental health care engagement, few interventions have been developed that capitalize on this support. To address this gap, VA created Coaching Into Care (CIC) – a national telephone-based coaching service intended to educate, support, and empower family members and friends who are seeking services for a Veteran. While program evaluation data show that CIC is highly valued by callers, only about 25% of callers with Veterans not already in care, report that their Veteran sought care over the next six months. The proposed study tests an innovative approach to improve the effectiveness of CIC by integrating a web program called VA Community Reinforcement and Family Training (VA-CRAFT), which is based on an empirically-validated intervention. The long-term goal is to establish an efficacious, efficient, scalable, and satisfying family outreach intervention that will significantly increase mental health service initiation among a high priority Veteran population while addressing the needs of their primary supporters, their family members. Background: PTSD is a highly prevalent psychiatric disorder among combat Veterans that often results in significant individual impairment and distress for family members. Although evidence-based treatments are available, most Veterans with PTSD do not receive any mental health care. Preliminary work suggests that VA’s Coaching Into Care services could be improved by integrating VA-CRAFT. In a prior HSR&D-funded pilot, our team found that family members who completed the relatively brief VA-CRAFT course alone (without coaching) had greater decreases in caregiver burden than wait-list controls. However, qualitative interviews also suggested that participants often did not raise the issue of treatment with their Veteran due to not believing such a conversation would be successful. Therefore, we developed CIC+VA-CRAFT to leverage the strengths of both approaches to increase family members’ motivation, perceived ability to have treatment-seeking conversations with their Veteran, and success at engaging their Veterans in care. Initial findings from an NC- PTSD-funded pilot of CIC+VA-CRAFT suggest that this brief, blended intervention is feasible, acceptable, and potentially more effective than CIC alone in enhancing Veteran mental health treatment initiation. Objectives: This project will employ a two-group randomized controlled trial (RCT) to compare CIC+VA- CRAFT to CIC only (treatment as usual). Specific aims are to: 1) Determine the effectiveness of CIC+VA- CRAFT in enhancing Veterans’ mental health service initiation compared to CIC only; 2) Determine if CIC+VA- CRAFT is non-inferior to CIC only on caller satisfaction, and 3) Conduct a process evaluation to inform potential future implementation of CIC+VA-CRAFT. The project will also explore potential 1) treatment effects on other important family-related outcomes, and 2) mediators and moderators of treatment. This proposal was developed as a collaboration between the VA CIC and VA-CRAFT programs and their leadership, which will facilitate the intervention’s rapid dissemination should the trial prove successful. Methods: This is a four-year RCT that will recruit spouses or intimate partners of Veterans with PTSD using social media advertisements and referrals from CIC. Participating partners will be randomized to the CIC+VA- CRAFT (n = 115) or CIC only (n = 115) condition for up to three months. CIC+VA-CRAFT will include four manualized CIC phone-coaching calls and access to the VA-CRAFT website. CIC participants will receive only CIC services as usual. Assessments will be at baseline, post-intervention (3 months after randomization), and six-month follow-up and will include partner reports of Veteran service utilization, caregiver burden, wellbeing, and relationship functioning. The feasibility and acceptability of implementing CIC+VA-CRAFT will be assessed with interviews of CIC+VA-CRAFT participants, Veterans of participants, and study and CIC phone coaches.	Mental and Behavioral Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 19-057	Petersen	Laura		laura.petersen@va.gov	Medicaid Expansion and Quality, Utilization and Coordination of Health Care for Veterans with Chronic Kidney Disease	04/01/2021	02/28/2025	Michael E. DeBakey VA Medical Center, Houston, TX	$1,025,790		Background: [The 2019 US Department of Health and Human Services Advancing American Kidney Health Initiative aims to “improve care coordination…for people living with kidney disease.” Accessing care from multiple systems and insurers can result in lapses in care coordination, and] patients with serious conditions, such as chronic kidney disease (CKD), are especially vulnerable to poorer outcomes from fragmented care. [While Medicaid expansion, as occurred with the Affordable Care Act (ACA),] is effective in improving access to health care and health outcomes for the uninsured, the significant number of Veterans enrolled in VA (who already have access to comprehensive care) who gained access to Medicaid with expansion face increased risk of care fragmentation. Increased use of non-VA care as a result of the MISSION Act poses similar risks.] Significance/Impact: As more Veterans access care from a mixture of VA and non-VA sources, VA needs to adopt strategies for cross-system care coordination to ensure effective and efficient care for Veterans. This requires understanding how Veterans utilize care when multiple options are available. Patients with advanced CKD have highly complex care needs. Lack of well-coordinated care may increase unnecessary care and worsen outcomes for such patients. Examining use and outcomes data will illustrate multiple aspects of access and care coordination for Veterans with chronic conditions and anticipates implementation of the MISSION Act. Innovation: [That some states opted out of ACA Medicaid expansion allows for a natural experiment where changes in quality of care and utilization over time can be compared between states that did and did not expand Medicaid. The team will use VA, Medicare, and recently-released post-expansion Medicaid claims data to evaluate how Medicaid expansion influences Veteran choices of health system use and CKD treatment.] Specific Aims: Aim 1: To determine the characteristics of Veterans and Veterans with CKD who are most likely to enroll in both Medicaid and VA. Aim 2: To determine the impact of dual enrollment on the utilization of health care services for Veterans with advanced CKD and to create a reference tool to enhance coordination for these patients. Aim 3: To evaluate differences in quality of health care and costs among Veterans with advanced CKD in states that have expanded Medicaid and those that have not. Methodology: Claims data [from 17 states (7 that expanded Medicaid in 2014 and 10 that did not) in the Medicaid Analytic eXtract (MAX) file for 2011-2014] are included. A difference-in-difference model will estimate the association of state Medicaid expansion with [changes in Veterans’ dual-enrollment status (VA and Medicaid) and in utilization and outcomes for Veterans with CKD. Utilization analyses will consider outpatient visits, emergency department visits and hospital admissions recorded in VA and Medicaid data. Outcomes to be considered are time-to-mortality, emergent vs. elective initiation of dialysis, and costs to the health care system.] Each analysis contains demographics, comorbidity and illness severity. For all aims, separate models for low-income (Priority 5) Veterans are estimated as a sensitivity check. [In addition, strategies to support enhanced care coordination will be gathered from interviews with renal care teams and organizational leaders then developed into a care coordination reference tool for those who provide care for patients with kidney disease. Input from Veterans and patients will be incorporated at each stage of the interview and reference tool development process. Next Steps/Implementation: Veteran/patient and VA operational (National Kidney Program; Office of Veterans Access to Care) partners will be provided with interim and final findings to guide strategic planning and to inform programs that support optimal care for Veterans with access to multiple sources of care. Results from this project will be of great importance as stakeholders plan for Veteran needs in the form of direct health care services and effective care coordination, and as they make state and national policy recommendations.]	Access				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 19-068	Weiner	Saul		saul.weiner@va.gov	An Assessment of Open Access Audio of the Clinical Encounter on Veterans and their Care	08/01/2021	06/30/2024	Jesse Brown VA Medical Center, Chicago, IL	$1,194,911		Background: The medical encounter can be overwhelming in term of the amount of information discussed, its technical nature, and the anxiety it can generate. Easy access to a secure audio recording from any internet enabled device is an available low cost technology that allows patients to “revisit the visit” either alone or sharing with caretakers and family. It has been introduced and tested outside the VA with evidence that it increases patient recall and understanding and may even improve physician performance. Little is known, however, about whether and to what extent these effects lead to better outcomes, such as improved treatment plan adherence and chronic disease self-management. Significance/Impact: This study will assess a new resource for enhancing Veterans capacity to understand their care plan, and share information from their visit with caregivers. The study design is intended to yield information to guide decision makers about the value of bringing “open access audio” (OAA) to VHA. Innovation: The Open Chart movement, in which patients can freely access their written medical information was a major innovation first introduced through the patient portal in 2010, and is rapidly disseminating-- including within VHA. OAA extends the same principles of full transparency and easy access to medical information and, if successful, could also be incorporated into the patient portal. The VHA Office of Connected Care, which manages MyHealtheVet has indicated interest in this project because of its potential to transform the next generation portal. Specific Aims: This study will access, using a randomized controlled trial design, whether the known benefits of OAA (better patient recall and understanding) lead to several desired service utilization and health care outcomes. It will also measure the effect of OAA on provider behaviors that may mediate those outcomes. Throughout, data will be collected on participant and other stakeholder perceptions of the program that, based on prior research on audio- recording in the clinical setting, reflect a readiness to adopt the new technology. Aim 1: Assess the impact of an open access audio program on two behaviors (patient activation, treatment plan adherence), and two chronic condition measures (glycosylated hemoglobin, blood pressure). Secondary analysis will descriptively measure effect size on ED visits and hospital admissions. Aim 2: Assess the impact of open access audio on provider communication and on their attention to patient contextual factors (i.e. individual Veterans needs and circumstances relevant to planning effective care). Aim 3: Assess patient, provider, and leadership perceptions of the extent to which the program is safe, not burdensome, and worthwhile at both the start and at two years into the program. Methodology: The setting will be primary care and diabetes clinics, at two facilities for generalizability. To achieve aims 1 and 2, we propose a randomized controlled three arm design: (1) the encounter is recorded, with provider and patient aware, and uploaded to a server the Veteran, provider, and research team can access post visit; (2) the encounter is recorded, with both parties aware, and uploaded to a server only the research team can access; and (3) the encounter is recorded, with only the patient aware, and uploaded to a server only the research team can access. Resource utilization and disease measures indicated in aims 1 and 2 will be collected in all arms. Comparisons of Arms “1” and “2” enable assessing the impact of the availability of audio on patients (for aim 1). Comparisons of Arm “2” with “3” enables isolating the effect of providers knowing they are being recorded (for aim 2). Data for aim 3 will come from survey tools, focus groups and semi-structured leadership interviews to elicit perceptions of project safety, burden, and value. Next Steps/Implementation: We will work with the Office of Connected Health to identify opportunities, based on the findings for incorporating Open Audio Access into the next generation patient portal.	Care of Complex Chronic Conditions				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 19-089	Thorpe	Carolyn		Carolyn.Thorpe@va.gov	Use and costs of low-value health services by Veterans in VA and non-VA settings	03/01/2020	03/31/2024	VA Pittsburgh Healthcare System University Drive Division, Pittsburgh, PA	$1,198,320		Background: Overuse of health services whose immediate or downstream costs or harms exceed their benefits (i.e., low-value health services) is a major driver of healthcare costs in the United States. Comprehensive measures of low-value service use have been applied to identify low-value services with the highest utilization and costs in non-VA populations, but less is known about which low-value services are most frequently used and costly in Veterans managed in the Veterans Health Administration (VHA). Also, all Veterans aged 65+ are eligible to use non-VA care via Medicare, and Veterans of all ages increasingly receive care outside VA through VA Community Care (VACC). Past research suggests that dual use of VA and non- VA care places Veterans at risk for overuse of health services, but information on Veterans’ use of low-value services in non-VA settings is lacking. Significance/Impact: Our objective is to determine the extent of utilization, costs, and determinants of Veterans' low-value service use within and outside VA. Our study will identify the low-value services most commonly used by Veterans through VA Medical Centers (VAMCs), VACC, and dual Medicare benefits, and those that are most costly. This study will inform policies and interventions, including possible new quality metrics, to reduce low-value care provided to Veterans. Results will be valuable to our VA partners (Office of Reporting, Analysis, Performance Improvement and Deployment, and Office of Community Care) who are committed to ensuring that Veterans receive high-value services regardless of where they receive care. It will also empower Veterans to consider value of care when choosing between a VA vs non-VA setting. This study addresses two Veteran Care Priorities (health care value; quality/ safety of care) and the VA legislation priority to understand impact of non-VA care on value of care received by Veterans in light of the MISSION Act. Innovation: Current VA performance metrics capture key dimensions of access, quality, safety, and efficiency, but do not address Veterans' receipt of low-value care or quality of care received in non-VA settings. Our project will use novel methods to quantify use and determinants of an array of low-value services that Veterans may receive both within and outside of VA. Specific Aims: Aim 1: Quantify utilization and costs of low-value services provided to VHA enrollees in VAMCs and VACC, and characterize variation across VA facilities in low-value services provided in each setting. Aim 2: Quantify utilization and costs of low-value services used by dual VHA-Medicare enrollees in VAMCs and non-VA settings through Medicare, and characterize VA facility-level variation in low-value services provided in each setting. Aim 3: Identify barriers and facilitators of de-implementing low-value services in each setting. Methodology: In Aim 1, we will apply a claims-based measure of low-value care to VA utilization data and VACC data for a national cohort of VHA enrollees. We will identify frequency of use of 26 low-value services in 6 categories: cancer screening, diagnostic/preventive testing, preoperative testing, imaging, cardiovascular testing/procedures, and surgery. We will apply average HERC cost estimates to calculate total costs of each service and category in VAMCs and in VACC. We will use multilevel modeling to examine facility variation in rates of VAMC and VACC low-value service use and extent to which Veteran and VAMC factors explain this variation. Aim 2 will involve similar analyses involving VA utilization data and Medicare claims for dual VA-Medicare enrollees. Aim 3 will apply latent profile analysis to facility-level estimates of low-value service categories to identify clusters of VAMCs with similar patterns of low-value service use in VA and non-VA settings. We will conduct interviews with VA providers who practice at VAMCs in different clusters to examine barriers and facilitators to de- implementing low-value services for Veterans. Next Steps & Implementation: We will use results to work with operations partners to develop performance measures, policies, and interventions to mitigate Veterans’ receipt of low-value care in VA and non-VA settings, as VA evolves as a provider and payer of Veteran care.	Systems Modeling, Design, and Delivery				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 19-106	Thorpe	Joshua		Joshua.Thorpe@va.gov	Outpatient Palliative Care and Prescribing Safety and Quality at End-of-Life	08/01/2020	09/30/2024	VA Pittsburgh Healthcare System University Drive Division, Pittsburgh, PA	$1,188,556		Background: The long-term goal of this research is to support the ability of Veterans with life-limiting conditions (LLCs) to remain living their communities by ensuring access to the highest possible quality of care; including long-term care support services like palliative care. Given their complex healthcare needs, Veterans with LLCs often manage many different medications, each carrying their own risk/benefit profile. Unfortunately, complex medication regimens are a significant risk factor for receiving potentially unsafe medications or being over- treated for chronic conditions such as high cholesterol and diabetes. Significance/Impact: A key component of palliative care that can assist Veterans is ensuring that medication therapy is aligned with patients’ and families’ goals of care. Palliative care, therefore, provides a critical opportunity to deprescribe or de-intensity potentially harmful or unnecessary medications. Outpatient palliative care (OPC) is a growing community-based medical service known to improve access to palliative care for patients living in the community. OPC is also underutilized, and little is known about potential barriers to receiving OPC services. Innovation: Our study is highly innovative 4 key ways: (1) outpatient palliative care is a relatively new, community-based, long-term care service offered to Veterans, and OPC is still underutilized across the VA; (2) It is the first study to evaluate the comparative effectiveness of OPC versus usual care in the VA; (3) Veterans with LLCs prefer to remain in non-institutional settings. However, community-based care is not covered by the regulations that monitor the quality of care in their nursing home counterparts. This research is therefore essential for developing community-based performance metrics to monitor the quality of care in community-dwelling Veterans with LLCs; and (4) VA policy directives state that VA palliative care teams are necessarily multidisciplinary. This mixed-methods study is novel in its use of semi-structured interviews that will include different provider-types comprising a palliative care team. Specific Aims: The specific aims are to: (1) determine the extent to which variation in OPC use exists across VA facilities, and identify patient- and facility-level factors that contribute to this variation; (2) evaluating the comparative effectiveness of OPC (versus traditional outpatient care use) on deprescribing of potentially unsafe medications (PUMs), and deintensification of unnecessary chronic disease medications in Veterans with LLC; and (3) explore VA palliative care provider perspectives about barriers and facilitators to using OPC and to effectively addressing the deprescribing unsafe or unnecessary medications in Veterans with LLCs. Methodology: The quantitative phase of this mixed-method study will involve analyses of VA and Medicare data in over 2,000,000 Veterans with LLC. Pooling data from 2010-2017, we will link inpatient, outpatient, nursing home, vital status, and medication data from VA and Medicare to develop a national cohort of Veterans with LLCs. Our analytic approach involves propensity score weighting and instrumental variables to address potential selection bias associated with OPC use. The qualitative phase will involve semi-structured interviews of VA outpatient palliative care providers to assist in interpreting quantitative results and gain additional insights about barriers to OPC use and challenges with managing medications. Next Steps/Implementation: Together, these aims will assist both VA and non-VA healthcare systems in making evidence-based decisions about improvements and expansions to OPC services, and to better design policies and interventions to ensure safe and effective medication use at end-of-life.	Long Term Care and Aging				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 19-118	Ioannou	George		George.Ioannou@va.gov	Development and Validation of a Cirrhosis-specific Surgical Risk Calculator (C-SuRC)	08/01/2020	09/30/2024	VA Puget Sound Health Care System Seattle Division, Seattle, WA	$897,398		Background: Perioperative mortality is 2-4 times higher in patients with cirrhosis compared to patients without cirrhosis due to cirrhosis-related factors such as portal hypertension and impaired hepatic synthetic function. Currently no models exist that accurately estimate peri-operative mortality and morbidity in patients with cirrhosis. Our overarching aim is to develop and validate a Cirrhosis-specific Surgical Risk Calculator (C- SuRC) that accurately estimates perioperative mortality and complications in patients with cirrhosis. Significance/Impact: Use of C-SuRC in routine pre-operative assessment of cirrhotic patients will optimize the selection of patients with cirrhosis for surgical procedures, improve access to elective surgery for patients with cirrhosis with low operative mortality, prevent surgeries in patients with prohibitively high operative mortality, and reduce emergency surgical presentations in patients who can safely undergo surgery electively. Innovation: • C-SuRC will be the first surgical risk calculator specifically designed for patients with cirrhosis that incorporates all three major classes of predictors that contribute to operative mortality in patients with cirrhosis, that is cirrhosis-related, surgery-related and comorbidity-related predictors. • C-SuRC will be developed using a unique dataset that we developed by merging VASQIP and CDW data. This is a nationally representative VA dataset of cirrhotic patients undergoing surgical procedures with prospectively collected baseline characteristics and surgical outcomes. • We will develop both traditional logistic regression models as well as novel machine learning (ML) models for C-SuRC and compare their discrimination, calibration and overall accuracy. • We will apply user-centered design to develop a web-based tool that executes C-SuRC. Specific Aims: SA1. Develop and internally validate a predictive model (the Cirrhosis-specific Surgical Risk Calculator or C-SuRC) that accurately estimates 30-day postoperative mortality in patients with cirrhosis using routinely available cirrhosis-related, comorbidity-related and surgery-related predictors. SA2. a. Compare the performance characteristics of C-SuRC to those of the existing VASQIP, NSQIP and Mayo Clinic surgical risk calculators, and b. Externally validate C-SuRC using a dataset of cirrhotic patients at the Mayo clinic. SA3. a. Develop a web-based tool that executes C-SuRC to estimate 30-day mortality in cirrhotic patients undergoing surgery, and b. Apply best practices in user-centered design to improve the user interface. Methodology: We will use conventional logistic regression models as well as novel machine learning models for C-SuRC development. We will formally test the discrimination, calibration and accuracy of C-SuRC, externally validate it and compare it to existing surgical risk calculators. We will use best practices in user- centered design to develop a web-based tool that executes C-SuRC for use in routine clinical practice. Next Steps/Implementation: We will solicit support from all important VA stakeholders, many of whom have already endorsed this proposal, and disseminate our findings and the web-based C-SuRC tool in the VA nationally as a routine instrument in the pre-operative assessment of patients with cirrhosis.	Healthcare Informatics				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 19-137	Trivedi	Ranak		ranak.trivedi@va.gov	A web-based program to improve chronic illness self-management by engaging patients and informal caregivers	10/01/2022	03/31/2025	VA Palo Alto Health Care System, Palo Alto, CA	$477,190		Background: For the 80% of older Americans who have at least one chronic condition, sharing self- management responsibilities with caregivers (relatives or friends) predicts longevity, better health, better quality of life, and fewer hospitalizations. Caregivers often support patients in their self-management efforts. This can bring patients and caregivers closer but can also generate stress for both that can interfere with self- management. Yet, self-management programs rarely support the coping needs of patient-caregiver dyads. Significance: There are more than 5 million caregivers of Veterans; 75% of older Veterans receive some caregiver support. Caregivers incur individual financial and emotional costs even as they provide unpaid care. Having an effective self-management strategy that addresses the needs of both can improve outcomes and quality of life for millions of Veterans who suffer from chronic illnesses and their caregivers. This project addresses the priorities “Long-term care and Caregiving,” “Virtual Care/Telehealth,” and “Access to Care” and is consistent with the legislative goals of the MISSION Act. Innovation and Impact: This highly innovative proposal uses the novel concept that strengthening the interpersonal relationships between Veterans and caregivers can improve the self-management of chronic conditions. It challenges current clinical paradigms by addressing the collective stress coping needs of dyads. It is methodologically innovative because unlike many behavioral intervention trials, it assesses barriers and facilitators to plan for future implementation. Our focus on technology-enabled tools is timely given how COVID19 has transformed care delivery. This project takes advantage of the unique capabilities of the VA health system to explore questions including robust caregiver support and virtual care programs. Specific Aims: With investments from VA HSR&D, we have developed and successfully pilot tested a new theoretically-derived technology called Web-based Self-care Using Collaborative Coping EnhancEment in Diseases (web-SUCCEED). We propose to conduct a randomized clinical trial comparing web-SUCCEED to an enhanced usual care (EUC) control. We will conduct a formative evaluation guided by the Consolidated Framework of Implementation Research (CFIR) to accelerate future implementation. 1. Assess whether web-SUCCEED improves Veteran outcomes of self-management compared to EUC, 4 weeks and 6 months following randomization. 2a. Assess whether web-SUCCEED improves patient stress and quality of life. 2b. Assess whether web-SUCCEED improves caregiver stress, quality of life and caregiver burden. 2c. Examine communication, dyadic coping, mutuality, and relationship quality as mediators of primary and secondary outcomes (Aims 1, 2a, 2b). 3. Guided by CFIR, conduct a formative evaluation involving key stakeholder interviews to understand barriers and facilitators of future implementation. Methodology: We will recruit 280 cognitively intact Veterans from VA Palo Alto Health Care System who are managing at least one common chronic condition, and their caregivers. Veteran-caregiver dyads will be randomized 1:1 to web-SUCCEED or EUC. Veteran and caregiver assessments will take place at baseline, then again at 4 weeks and 6 months. The formative evaluation will be guided by CFIR and involve semi- structured interviews with clinical staff, providers, and facility leaders in Year 4. Next Steps: Our formative evaluation will set us up for implementation studies to evaluate web-SUCCEED in a wider array of clinical settings and facilities. Existing operational partnerships will facilitate wider clinical implementation and moving research into practice. Our innovative project, strong investigative team and operational partnerships will ensure a successful study that has the potential to shift clinical paradigms.	Long Term Care and Aging				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 19-153	Chinman	Matthew		matthew.chinman@va.gov	CoachToFit: Adapted Weight Loss Intervention for Individuals with Serious Mental Illness	10/01/2020	09/30/2024	VA Pittsburgh Healthcare System University Drive Division, Pittsburgh, PA	$1,203,365		Background: Between 40% to 60% of individuals with serious mental illness (SMI) are obese. Obesity and physical inactivity result in increased rates of chronic diseases, increased risk of death, and substantial health care costs. Treatment guidelines recommend that individuals with SMI who are overweight should be offered evidence-based weight loss interventions, including psychosocial interventions. The VA’s weight management program, MOVE!, is attended by less than 5% of the overweight population and is not adapted to the cognitive needs and patient preferences for the population with SMI. Effective adapted weight management programs are not offered in VA because they are time-intensive and require the skills of trained providers who are often in short-supply. CoachToFit can address this gap in care. CoachToFit is a weight management program, adapted for the population with SMI, that includes a smartphone app delivering evidence-based weight management services with weekly telephonic support from a VA peer specialist who acts as a wellness coach. Peer specialists are individuals who draw upon lived experiences with SMI to provide services to others with SMI in clinical settings. CoachToFit was shown to have high rates of acceptability and usability and was efficacious for weight loss in a small sample. VA has an opportunity to address obesity in the population with serious mental illness, currently a substantial gap in care. Significance/Impact: This project addresses obesity in the population with SMI by evaluating a weight management program that is not only evidence-based, it is sustainable, transportable, appealing to patients, easy to use, and minimally burdensome to the healthcare system. This effort addresses two HSR&D priority areas: 1) Mental Health: Testing new models of care to improve access, cost, and/or outcomes, and 2) Health Care Informatics: Building the evidence base for ehealth/mhealth tools. Innovation: CoachToFit’s use of mobile technology is an important innovation in VA service delivery and its user-centered design involving individuals with SMI was the first of its kind. CoachToFit is enhanced by data visualization in real-time via a web-based dashboard used by VA peer specialists and their supervisor. We are aware of no other evidence-based mobile platforms to help people with SMI reduce their weight. Specific Aims: The project aims to 1) Test the efficacy of CoachToFit, compared to usual care, in decreasing weight among Veterans with SMI who are obese; 2) Assess the hypothesized mechanisms of action for CoachToFit, including self-efficacy, motivation, and readiness to change; and 3) Characterize factors that will inform future implementation and maintenance of CoachToFit using a multi-stakeholder qualitative post- intervention evaluation guided by the RE-AIM framework. Methodology: The study design includes a randomized controlled trial to test the efficacy of CoachToFit and assess the hypothesized mechanisms of action. This will include enrollment of obese Veterans with SMI from the mental health clinics at one VA medical center (n=256). Individuals will be randomized to CoachToFit or usual care. Those in CoachToFit will have access to the app and coaching for 6 months. Outcomes are assessed at 6- and 12-months. Efficacy outcomes utilize objective measures. The design also includes a multi- stakeholder qualitative post-intervention evaluation guided by the RE-AIM framework to characterize factors that will inform future implementation and maintenance of CoachToFit. This will include interviews with Veterans randomized to CoachToFit (n=30); interviews with staff stakeholders (n=18); a discussion with Veterans in local Veteran groups (n=2 groups; n=11 Veterans), and interviews with national leadership (n=3). Next Steps/Implementation: If CoachToFit is found to be efficacious, the VA National Center for Health Promotion and Disease Prevention, along with input from national leadership in Peer Support Services and Mental Health Informatics, will assist in integration into the VA context.	Complementary and Integrative Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 19-154	Katon	Jodie	Lisa Callegari	jodie.katon@va.gov	Understanding Racial/Ethnic Disparities in Uterine Fibroid Outcomes among Women Veterans: A mixed-methods study	02/01/2020	09/30/2024	VA Greater Los Angeles Healthcare System, West Los Angeles, CA	$935,301		Background: Uterine fibroids (UF) are a common and costly gynecologic condition that disproportionately affect Black women with regard to incidence, severity, treatment, and outcomes. UF result in debilitating symptoms including pelvic pressure and pain, problems with reproduction, heavy menstrual bleeding, and severe anemia, and are the leading cause of hysterectomy among women Veterans in VA. Although VA is a model healthcare system regarding health equity in many areas, recent data suggest that substantial Black/White disparities in UF treatment and outcomes exist within VA. As one-third of women Veterans using VA health care are Black and this proportion is increasing, understanding the underlying drivers of these disparities within VA is of critical importance. Limited research has examined these mechanisms either outside or within VA. Building a comprehensive understanding of UF disparities and potential opportunities to address them will require examining the role of race and racism in women Veterans’ pathways to diagnosis and treatment of UF and their UF treatment patterns and experiences. Objectives: Our objective is to investigate the mechanisms underlying Black/White disparities in UF-related outcomes among women Veterans receiving VA care. Guided by the Public Health Critical Race Praxis, which asserts that race is a social construct and that ubiquitous patterns and structures of contemporary racism shape racial disparities in health, we propose: (1) To examine Black/White differences in treatment patterns for women Veterans with UF and identify modifiable determinants; (2) To examine Black/White differences in clinical and post-surgical outcomes among women Veterans receiving treatment for UF in VA and identify modifiable determinants; and (3) To understand and contextualize differences identified in Aims 1 and 2 using qualitative exploration of Black women Veterans’ experiences with UF symptoms, care seeking behaviors, and treatment and how they differ from those of White women Veterans. Methods: We will use a mixed methods approach to address our study objectives. All three aims, will draw from a single cohort of Black and White women Veteran users of VA healthcare with newly diagnosed symptomatic UF between Fiscal Year 2010 (FY10) and FY12, identified through the Corporate Data Warehouse (CDW). Aims 1 and 2 are retrospective cohort analyses. We will examine administrative data and chart-abstracted medical record data through FY18 to compare Black/White differences in treatment and outcomes. Aim 1 will compare time from diagnosis to initial treatment and surgical treatments; type of initial treatment (medical, non-definitive procedure, hysterectomy); and mode of surgery (minimally invasive vs abdominal). Aim 2 will examine Black/White differences in clinical (emergency room visits, hospitalization for anemia, blood transfusion) and surgical outcomes (surgical complications, 30-day readmission) for UF. Aim 3 is a qualitative study with a purposively selected sample of up to 30 Black and 30 White women Veterans to inform and contextualize our quantitative findings from Aims 1 and 2. Content analysis will be used to understand and identify how the constructs of race and gender may interact to impact women Veterans’ experiences with UF, pathways to treatment, treatment decision making, and treatment patterns. Our dissemination plan includes a stakeholder engagement process which will engage Veterans, providers, and operational partners in translating our findings into actionable practice and policy recommendations to reduce disparities. Innovation and Next Steps: This proposal addresses key HSR&D priorities of women’s health, health equity, and healthcare access. The innovative approach ensures substantial impact by moving beyond documenting racial/ethnic disparities to building understanding of underlying and potentially modifiable causes. Next steps following completion of the research and stakeholder engagement process will include partnering with VA Women’s Health Services and VA Office of Health Equity to develop targeted interventions, programs, and policies to address UF disparities. Ultimately, this research has the potential to accelerate progress towards quality and equity in gynecology and reproductive healthcare both within and beyond VA.	Equity				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 19-187	Blonigen	Daniel	David Smelson	Daniel.Blonigen@va.gov	Using Data Analytics and Targeted Whole Health Coaching to Reduce Frequent Utilization of Acute Care among Homeless Veterans	01/01/2022	03/31/2025	VA Palo Alto Health Care System, Palo Alto, CA	$994,824		Background: Ten percent of patients account for up to 70% of acute care costs. Among these “super-utilizer” patients, homelessness is a robust social determinant of acute care utilization. Through a field-based dashboard and clinical aids, the Hot Spotter Analytic program assists Patient Aligned Care Teams (PACT) with targeting and tailoring care for the highest-need homeless Veterans. However, many Veterans identified by the Analytics do not engage in supportive services that reduce risk for acute care utilization. Peer Specialists (PS) are a high-value workforce that can facilitate Veterans’ engagement in care. Yet, there is a need to enhance the PS role with a structured approach that can capitalize on known facilitators of care engagement among homeless Veterans. Whole Health Coaching (WHC) is one such approach. By focusing on patients’ values and goals rather than treatment of specific conditions, WHC reduces patients’ stigma regarding their care needs and increases patient activation and well-being, which can increase engagement in supportive services. Significance: By training a high-value workforce in a patient-centered approach to care that facilitates engagement in supportive services, our proposed research can reduce homeless Veterans’ reliance on acute care services, thereby minimizing the financial burden these patients exert on the care system. This proposal responds to several VA HSR&D Research Priorities including Mental Health, Healthcare Value, Primary Care Practice, Healthcare Informatics, and Whole Health, as well as VA-related Legislative Priorities (MISSION Act). Innovation and Impact: A critical innovation of this research is use of data-driven processes (Hot Spotter Analytics) to better target and tailor care for high-need, homeless Veterans in VHA. Our proposed research is also innovative in that it seeks to integrate the Analytics with a workforce (PS) and approach to care (WHC) that are rapidly expanding in primary care services VA-wide. These features of our target intervention are consistent with the National Academy of Medicine’s recommendations for high-quality care for high-need patients. Finally, by focusing on the development of personal health goals that are aligned with patients’ priorities and values, WHC is a key innovation to be added to existing VHA services for homeless Veterans. Specific Aims: The goal of this project is to integrate use of Hot Spotter Analytics with Peer Specialists trained in Whole Health Coaching (PS-WHC) and evaluate whether this approach reduces homeless Veterans’ frequent use of acute care. Aim 1: Conduct an RCT to test whether receipt of PS-WHC (vs. Enhanced Usual Care; EUC) predicts (1a) lower acute care utilization, (1b) better health-related outcomes, and whether (1c) the effects of PS-WHC on 1a and 1b are mediated by increased (i) patient activation and well-being, and (ii) access to supportive services. Aim 2: Conduct a process evaluation to inform VA's potential widespread implementation of Hot Spotter Analytics + PS-WHC on PACTs. Aim 3: Conduct a Budget Impact Analysis (BIA) to determine the impact on total costs of VA care due to implementing PS-WHC. Methodology: Using a Hybrid Type 1 design at the Palo Alto and Bedford VAs, 220 Veterans on PACT panels who are (i) on the VA Homeless Registry, and (ii) persistent super-utilizers of acute care will complete a baseline interview, be randomized to either EUC (usual PACT care + Hot Spotter Analytics and text reminders of appointments) or EUC plus 12 sessions of PS-WHC over 12 weeks, and be re-interviewed at 3, 6, and 9 months. For Aim 2, the CFIR framework will guide key informant interviews with 7 PACT staff/leaders and 12 patients from each site. For the BIA, we will include only VA costs from VA, Fee Basis care, and Choice care. Costs will be estimated per patient for all treatment beginning with randomization and continuing for 9 months. Next Steps/Implementation: Depending on the results, we will work with our VACO partners in the National Center for Homelessness Among Veterans, the Office of Patient Centered Care & Cultural Transformation, and the Office of Mental Health & Suicide Prevention to conduct a large multisite implementation trial.	Equity				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 19-202	Shukla	Ashutosh		ashutosh.shukla@va.gov	A Patient-centered, System-based Approach to Improve Informed Dialysis Choice and Outcomes in Veterans with CKD	03/01/2020	09/30/2023	North Florida/South Georgia Veterans Health System, Gainesville, FL	$775,192		Background: CKD is the 4th most common diagnosis among Veterans. Each year 13,000 Veterans transition to ESRD. VHA supports over 52,000 ESRD Veterans on dialysis. The care of CKD costs VHA over $18 billion dollars annually. Transition care of these Veterans is uncoordinated and suboptimal as most receive their pre- ESRD care within VHA but over 90% are outsourced for their dialysis, on fee-basis. Thus, the majority of Veterans progressing to ESRD have limited awareness of CKD and its management options including the dialysis modalities. This leads to gross underuse (7%) of home dialysis (HoD). Professional renal societies and VHA national CKD program advocate informed dialysis choice, and greater use of HoD for all patients transitioning to ESRD. European and Canadian reports show that CPE empowers informed choice of dialysis, increases HoD use, and improves the quality of CKD care. However, availability of CPE within VHA is limited and HoD utilization is low. To address these issues, we have developed and pilot-tested a concise CPE model in two different universities and affiliated VA in Florida and Arkansas. Our preliminary findings show that CPE improves patient informed dialysis choice, and increases HoD selection to 74% and HoD use to 61%. In a separate pilot study, we found that tele-CPE is as efficacious as F2F-CPE. Objectives: The overall goal of this RCT is to investigate the impact of CPE on patient knowledge and confidence, HoD selection and use, and patient-reported, health services and clinical outcomes in a cohort of Veterans who were diagnosed with CKD and receive CKD treatment from the North Florida/South Georgia Veterans Health System (NF/SG VHS). The study aligns with HSR&D major research priorities including “patient-centered care, care management, and health promotion” and “health care systems change.” The 4 Specific Aims are: Aim 1: Compare the impact of CPE on Veterans’ knowledge of CKD, their confidence in dialysis decision making, and their selection of dialysis modality, between the CPE and usual care groups. Aim 2: Compare Veterans’ actual use of HoD (Primary Outcome) between the CPE and usual care groups. Aim 3: Examine Veterans’ perceived satisfaction with CPE, explore their preferences for F2F- or Tele-CPE, and investigate barriers and facilitators in the selection and use of their preferred dialysis modality. (Qualitative) Aim 4: Compare the following post-ESRD secondary outcomes between the CPE and usual care groups. Patient reported outcomes: 1) health-related quality of life and 2) satisfaction with dialysis; clinical outcomes: 3) time to ESRD, 4) estimated glomerular filtration rate at ESRD, 5) need for inpatient initiation of dialysis, and 6) vascular access status at ESRD; and health services utilization outcomes: 7) number of inpatient stays, and 8) number of outpatient visits, from enrollment to 90-day post ESRD period. Methods: In this mixed method RCT, we will enroll 800 Veterans with stage 4 or 5 CKD, ≥18 years of age, English speaking, and not yet on dialysis who receive CKD care from NF/SG VHS. In 1:1 ratio, all the consented Veterans will be randomly allocated into intervention (CPE) or control (enhanced usual care or EUC) group. For Aim 1, multiple regression analysis will be applied to model the risk-adjusted post-intervention CKD knowledge and confidence in Veteran dialysis decision making; For Aim 2, logistic regression will be used to compare the HoD selection and use between the CPE and EUC groups. Aim 3 will be a qualitative study using semi-structured interviews to obtain in-depth data on Veterans’ satisfaction with CPE, preference for CPE delivery, and barriers and facilitators to HoD selection and use as a dialysis. For Aim 4, multiple regression analysis will be applied to model the risk-adjusted effects of CPE, HoD, and the group-modality interaction on outcomes. Expected Results: We anticipate that CPE will enhance Veterans’ CKD knowledge and confidence for informed dialysis selection, and increase HoD use, leading to improved Veterans’ and health services outcomes. Next Step: If successful, this study may deliver a ready to roll-out strategy to meet the CKD care needs of the Veterans and reduce VHA healthcare costs.	Care of Complex Chronic Conditions				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 19-340	Bramoweth	Adam	Christi Ulmer	Adam.Bramoweth@va.gov	Enhancing Access to Insomnia Care (EASI Care): Implementing Brief Behavioral Treatment for Insomnia in Primary Care Mental Health Integration Clinics	09/01/2020	06/30/2024	VA Pittsburgh Healthcare System University Drive Division, Pittsburgh, PA	$1,188,536		Background: Chronic insomnia, one of the most common health problems among Veterans, significantly impacts health, function, and quality of life. Cognitive Behavioral Therapy for Insomnia (CBTI) is the first line treatment; however, despite efforts to train hundreds of VA clinicians to deliver CBTI, there are still significant barriers to providing adequate access to insomnia care. Up to 44% of Veterans seen in Primary Care report insomnia, making it an optimal clinical setting for improving access to insomnia care. Furthermore, Brief Behavioral Treatment for Insomnia (BBTI), adapted from CBTI as a briefer, more flexible treatment, is easily delivered by Primary Care Mental Health Integration (PCMHI) clinicians and can greatly improve access to care for Veterans with insomnia. Yet, simply training PCMHI clinicians to deliver BBTI is not enough. Implementation strategies are needed for successful uptake, adoption, and sustainable delivery of care. Significance/Impact: BBTI is effective, developed for non-specialty care settings, and easier to deliver than CBTI. If delivered sustainably within Primary Care, BBTI can help increase access to evidence-based insomnia care and overcome barriers related to accessing CBTI. The proposed study has potential to significantly impact, and improve, how insomnia care is delivered in VA. It is responsive to VA ORD priorities of expanding access to high quality clinical trials and increasing the real-world impact of VA research. Also, it targets HSR&D research, and ORD clinical, priority areas (access to care, mental health, primary care practice, virtual care/telehealth) using a cross-cutting health services research methodology, implementation science. Innovativeness: The study design is rigorous, pragmatic, and features innovative methods, notably a stepped- wedge, hybrid implementation-effectiveness design. This study is unique—a search of VA ORD and NIH funded studies found there are no studies testing implementation strategies to improve the delivery of BBTI in Primary Care. Focusing on implementation outcomes and treatment effectiveness will help produce results that can improve access to care for a prevalent disorder and more rapidly translate results into practice and policy. Specific Aims: Aim 1 will compare the impact of PCMHI clinicians trained to deliver BBTI vs. the impact of BBTI training plus 12-months of access to an implementation strategy bundle (BBTI+IS). BBTI+IS vs. BBTI training alone is expected to result in more Veterans with access to insomnia care in the Primary Care setting. Aim 2 will identify specific strategies that promote successful implementation of BBTI in PCMHI through the use of qualitative interviews and surveys with clinical stakeholders at each study site. Methodology: This stepped-wedge, hybrid III implementation-effectiveness trial involves four VA Medical Centers/Health Care Systems: Baltimore, Durham, Minneapolis, and Philadelphia. The stepped-wedge design allows for fewer sites to achieve adequate power as all sites are exposed to BBTI training and BBTI+IS. The hybrid design allows for testing of implementation and treatment effectiveness, guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. The target sample are PCMHI clinicians and the impact of a bundle of strategies on the success of sustainably delivering BBTI in Primary Care. Retrospective data collected from VA electronic health records will be used to obtain variables of interest related to Veteran treatment outcomes and data related to how PCMHI clinicians deliver BBTI. Implementation/Next Steps: Findings will be used to better understand specific implementation strategies that can help increase uptake and sustainable delivery of BBTI in PCMHI through research and quality improvement efforts on a larger scale. Through collaborations with operations partners in the Office of Mental Health and Suicide Prevention, the study team will work towards the development of products to educate VA stakeholders (local, VISN, VACO) and methods to widely disseminate BBTI training for PCMHI clinicians, efforts that will further contribute towards the improvement of insomnia care and Veteran health overall.	Mental and Behavioral Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 19-355	Montgomery	Ann	Jennifer True	ann.montgomery2@va.gov	Can services to address Veterans social determinants of health reduce their suicide risk?	10/01/2020	09/30/2024	Birmingham VA Medical Center, Birmingham, AL	$1,332,818		Background: Despite accessible and effective suicide prevention strategies offered by the Veterans Health Administration (VHA), Veteran suicide remains elevated compared to the general US population, indicating a continued need to identify Veterans at risk for suicide and provide interventions to prevent suicide. Suicide prevention can be enhanced when health care systems integrate dynamic social determinants of health (SDH), such as housing instability, justice involvement, and unemployment. Significance/Impact: The goal of this HSR&D Veteran Suicide Prevention project is to address prevention activities that occur “upstream” by examining how services addressing SDH may also prevent suicide among Veterans, key objectives in the VA’s National Strategy for Preventing Veteran Suicide 2018–2028. Innovation: This study will integrate a public health perspective to suicide prevention through a lens of SDH. Rather than focusing specifically on medical intervention, this study will explore—based both on a natural experimental design using existing administrative data and on gathering the perspectives of key informants and Veterans—how addressing SDH can decrease suicide risk, taking into account the complex needs of Veterans who may be at risk for suicide. Specific Aims: This study aims to determine whether VHA services tailored to address SDH may also have an added benefit of preventing suicide mortality; identify organizational assets and opportunities to improve how SDH-focused services address suicide risk among Veterans; and engage Veterans in identifying ways to integrate suicide prevention into VHA programs that respond to SDH. Methodology: The proposed research is a concurrent mixed methods design. Retrospective quantitative analyses will examine how VHA services tailored to Veterans’ SDH (i.e., housing instability, justice involvement, unemployment) may protect against suicide mortality and morbidity. A mixed methods environmental scan will include a questionnaire of staff/key informants and qualitative interviews. Qualitative interviews with Veterans with a history of suicide risk will explore how services to address SDH respond to those needs. Implementation/Next Steps: This project will lead to actionable implementation projects: increased linkages to services for SDH among Veterans with histories of suicidal crisis as well as enhanced training for providers to integrate suicide prevention into services addressing SDH, and vice versa. We have convened an array of VA operations partners—Social Work, VHA Homeless and Justice Programs, employment programs, and VA Office of Mental Health and Suicide Prevention—to facilitate removing siloes around SDH and suicide prevention in VA, amplifying VA’s current infrastructure to bolster suicide prevention.	Mental and Behavioral Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 19-378	Zeng	Qing		Qing.Zeng@va.gov	Assessing and Reducing Opioid Misuse Among Veterans in VA and Non-VA Systems: Coordination of Fragmented Care	05/01/2021	02/28/2025	Washington DC VA Medical Center, Washington, DC	$1,162,100		Project Summary The US opioid epidemic has put a significant burden on Veterans and the VA. Veterans often suffer from chronic pain syndromes due to war injuries, toxic exposures, and deployment-related psychiatric comorbidities and are vulnerable to opioid use/misuse. Chronic pain syndromes occur in 65.4% of U.S. veterans, 9.1% of it severe, as against 56 and 6.4% in non-veterans respectively. Both opioid misuse and unrelieved pain have been linked to a higher risk of suicide among Veterans, greater among women. To address the opioid epidemic in the VA, in August 2013, the VA deployed the Opioid Safety Initiative (OSI) to ensure that opioids are used in a safe, effective, and judicious manner and the Stratification Tool for Opioid Risk Management (STORM). Although the implementation of OSI has substantially reduced risky and other opioid prescriptions in VHA and increased use of non-opioid treatments for pain, there remain major gaps in evidence to formulate comprehensive policy as current data is almost exclusively derived from Veterans receiving care within the VHA. This is important as ~80% of the Veterans have private health insurance. It has been reported that Veterans who receive dual VHA and non-VHA care received more opioid prescriptions and more risky prescriptions, that mono VHA users. Also, while opioid overdose rates have been increasing in VHA enrollees VHA Opioid prescriptions in these veterans declined. To address the prescription drug misuse problem, states use Prescription Drug Monitoring Programs (PDMPs), which are electronic databases that collect and track prescription data on controlled substances to reduce their abuse and diversion. However, despite access to these data via Health Information Exchanges (HIE), the guideline-discordant unsafe and concurrent prescriptions and fillings of opioids continue. Also, PDMP data alone are not suitable for policy decisions and practice recommendations as they lack the detailed clinical information necessary to make a comprehensive evaluation of underlying factors associated with non-guideline-concordant prescriptions. Our preliminary data show a decline in Opioid prescriptions with less decline in the diagnosis of Opioid Use Disorder. The absence of community data is also mentioned as a major deficiency in the study and analyses of the opioid misuse crisis in a 2017 VA Office of Inspector General Report. In this VHA HSR&D Merit Review Application we propose to examine factors associated with prescription opioid misuse, specifically the guideline-discordant use of opioids, in 3 Veterans groups, (1) VHA mono-users, (2) VHA paid dual users of both VHA and non-VHA care, and (3) non-VHA paid dual users. We also propose to conduct an interview/focus group study of VA and non-VA community health providers perspectives on: a) barriers and facilitators in providing guideline- concordant care to the dual users, and b) coordination strategies to reduce opioid misuse in the dual user groups. These aims will be achieved by analyzing the complex data using novel deep learning and natural language processing methods in addition to the state-of-the-art statistical methods. The data involved will include the VHA and MedStar Health (largest healthcare system in the Mid-Atlantic region) electronic health record (EHR), the Chesapeake Regional Information System for Patients (CRISP) and Medicare databases. We will also bring together VA and non-VA community health providers, including clinicians, administrators, policy makers, and patients. We have conducted preliminary studies and collected preliminary data to demonstrate the feasibility of the proposed deep learning and natural language processing methods as well as our access to VA and non-VA EHR data. The results of the proposed study will be shared with our VHA and community operational partners. Our ultimate goal is to evaluate and improve care coordination and reduce opioid misuse in Veterans who are dual users of VA and community care.	Systems Modeling, Design, and Delivery				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 19-384	Chao	Linda		Linda.Chao@va.gov	Preventing Loss of Independence through Exercise in Community Living Centers (PLIE-CLC)	06/01/2020	06/30/2024	San Francisco VA Medical Center, San Francisco, CA	$1,076,040		Background: Dementia is a neurodegenerative disorder that is associated with a progressive decline in cognitive function that slowly robs people of the ability to function independently. Community Living Centers (CLCs) provide care for approximately 20,000 Veterans with dementia annually, many of whom have comorbid conditions such as posttraumatic stress disorder and traumatic brain injury that can complicate their care. CLC staff receive limited training in strategies for engaging residents with dementia in meaningful activities and managing dementia-related behaviors, and this training gap can result in low quality of life for residents and suboptimal care. We have developed an innovative group movement program for Veterans with dementia called Preventing Loss of Independence through Exercise (PLIÉ). The goal of this study is to refine PLIÉ for CLCs and develop and pilot-test remote staff training procedures so that PLIÉ can be widely implemented. Significance/Impact. Our proposal is directly responsive to the following 2019 HSR&D Priority Areas: Long-Term Care/Aging and Population Health/Whole Health. In addition, it employs rigorous implementation science methods and is designed to address the ORD-wide research priority of increasing the real-world impact of VA research. Innovation. PLIÉ capitalizes on recent discoveries in neuroscience, behavioral psychology and integrative health and shifts the paradigm of care by targeting abilities and neural mechanisms that are maintained, rather than lost, in the setting of dementia. This includes the ability to learn new movement sequences through procedural or ‘muscle’ memory; the ability to calm the mind and increase attention through mindful body awareness and breathing; and the ability to connect in meaningful ways with others. PLIÉ was originally designed for and tested in adult day programs that contract with VHA, and results to date suggest that participants are experiencing clinically meaningful improvements in quality of life and mobility (standardized effect sizes >0.4) and high levels of caregiver satisfaction. In 2017, we received a VA Innovators Award that enabled us to pilot PLIÉ at the San Francisco VA CLC (PLIÉ-CLC). Participants gave the program high satisfaction ratings (mean: 4.75 on 5-point Likert scale) and reported noticeable physical and emotional benefits in themselves and others. SFVA CLC staff are continuing to implement the program with positive results. Dr. Barnes was nominated for a Federal Executive Board Employee of the Year Award in 2018 for her ground-breaking work on the PLIÉ program. Specific Aims. 1) To identify barriers and facilitators to implementation of PLIÉ-CLC by conducting semi-structured interviews with VHA leaders, CLC directors and CLC staff. 2) To refine PLIÉ-CLC to maximize its scalability and potential for implementation and develop remote training procedures through iterative Plan- Do-Study-Act (PDSA) cycles at two local CLCs. 3) To assess feasibility and provide proof-of-concept for PLIÉ- CLC implementation by piloting remote training procedures at 4 CLCs sequentially. Methodology and Expected Results. This mixed-methods pre-implementation study will include key informants (Aim 1) and CLC residents, clinical champions and instructor trainees (Aims 2 and 3). The expected result is that PLIÉ will be successfully adapted for CLCs, that remote training materials and procedures will be fully developed by the end of the 3-year study, and that pilot data will support the feasibility and potential clinical benefits of implementation. Next steps/Implementation: We will seek funding to perform a type II hybrid effectiveness- implementation study and will work with VHA operational partners (see letter of support from Office of Geriatrics and Extended Care) to disseminate PLIÉ-CLC nationally, including working with community-based organizations that provide care to Veterans with dementia and caregivers as part of the MISSION Act.	Long Term Care and Aging				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 19-387	Callegari	Lisa		lisa.callegari@va.gov	MyPath: A Patient-Centered Web-Based Intervention to Improve Reproductive Planning for Women Veterans	10/01/2020	01/31/2024	VA Puget Sound Health Care System Seattle Division, Seattle, WA	$1,348,833		Background: High rates of medical and mental health comorbidities result in elevated risks of poor maternal and neonatal outcomes among women Veterans compared to their civilian counterparts. Proactive planning and optimization of physical and mental health prior to pregnancy can mitigate these risks; however, nearly 40% of pregnancies among Veterans are unintended. National guidelines recommend routine delivery of patient-centered reproductive planning services in primary care, including assessment of reproductive goals followed by tailored contraceptive and/or preconception counseling, to reduce unintended pregnancy and improve pregnancy outcomes. Only 38% of women Veterans at risk of pregnancy, however, report having contraceptive or preconception health discussions with their primary care provider in the past year. We developed “MyPath,” a novel patient-facing web-based decision support tool, to address gaps in reproductive planning services in VA primary care. MyPath’s objectives are to help women Veterans consider their reproductive goals, increase their knowledge, align contraceptive and pregnancy timing decisions with their goals and health needs, and engage in shared decision making with providers. In pilot testing among 58 Veterans, use of MyPath prior to clinic visits was highly acceptable to Veterans and increased reproductive planning discussions compared to usual care without increasing providers’ perceived workload. MyPath use was also associated with increased decision quality and effective contraceptive use. Additional evaluation of MyPath in a pragmatic randomized trial is needed to assess effectiveness and collect implementation data. Significance/Impact: Patient-centered, scalable interventions that can enhance delivery of VA reproductive planning services without creating burden on primary care providers are urgently needed. The MyPath intervention leverages interactive patient-facing technology to empower women to make high-quality informed decisions and engage with providers about their reproductive health needs. If found to be successful, MyPath will lead to increased access to patient-centered reproductive planning services in VA primary care, addressing key HSR&D priorities, including access, primary care practice, women’s health, and whole health. Innovation: MyPath is the first online decision support tool designed to promote patient-centered reproductive planning services in primary care settings and to facilitate high-quality decisions aligned with reproductive goals. We will deliver the tool using the innovative strategy of partnering with the national VEText program to send the MyPath link to Veterans before appointments in an automated text message appointment reminder. Specific Aims: 1) Aim 1 will test the effect of the MyPath tool used before primary care visits on occurrence of reproductive planning discussions with shared decision making (primary outcome), patient-provider communication self-efficacy, and contraceptive decision quality, compared to usual care; 2) Aim 2 will test the longer-term effect of MyPath on contraceptive utilization, unintended pregnancy, and preconception health behaviors, compared to usual care; 3) Aim 3 is an implementation process evaluation, including quantitative and qualitative data collection to identify implementation barriers and facilitators and intervention costs. Methodology: This study is a 3-site hybrid type 1 pragmatic randomized controlled trial clustered at the provider level among 24 women’s health primary care providers and their reproductive-aged Veteran patients. We will assess outcomes among a minimum of 342 women Veterans by telephone surveys post-visit and at 3- and 6-month follow up. We will collect information on barriers and facilitators to implementation using quantitative and qualitative methods, including interviews with Veterans, providers, and clinic leaders. Next Steps/Implementation: The pragmatic design, in combination with strong operational partnerships, will enable rapid translation of research findings into practice if MyPath is found to be effective, with the ultimate objective of improving reproductive health outcomes and well-being among women Veterans nationally.	Women's Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 19-395	Santa Ana	Elizabeth		Elizabeth.SantaAna2@va.gov	Impact of Combined Recovery Program and Home Telehealth Among Veterans with substance use disorders in the VA Inpatient Setting	10/01/2021	06/30/2025	Ralph H. Johnson VA Medical Center, Charleston, SC	$701,962		Justification: High inpatient readmissions among Veterans with SUDs constitutes a costly and persistent healthcare problem. VHA Handbook 1160.06 guides the development and implementation of recovery-oriented mental health (MH) services, although significant service gaps remain on VA inpatient settings. ‘Combined Recovery Program (CRP)’ is designed to address these gaps by enhancing stabilization of Veterans with SUDs beyond hospital discharge and consists of ‘Group Motivational Interviewing’, an adaptation of motivational interviewing; and ‘Life Skills for Housing Maintenance’, involving skills training for enhancing housing stability. To be added to CRP, Stable & Able (S&A) is a VA Home Telehealth (HT) nurse-monitored program providing assessment and self-management skills in the post-hospitalization phase. Gaps Addressed: This proposal addresses VA research priorities: access to care and MH, benefitting Veterans with SUDs. A significant proportion of these Veterans exhibit homelessness and suicidality. Study objectives address SAIL MH Composite measures ‘PDE1’ to increase Post-Discharge Treatment Engagement in MH care; and ‘HRF7’ to increase care processes for Veterans at high risk for suicide. During the COVID-19 pandemic, telehealth solutions offer safe treatment options as well as reduce isolation. Innovativeness: This proposal is consistent with 2018 MISSION Act in priority areas: mental illness, SUD, and housing instability via a technology-enabled format and through addressing gaps in the current inpatient recovery model involving limited availability of staff training in and availability of recovery-oriented services. CRP and S&A present innovative/novel interventions ready for deployment. Both CRP and S&A were designed specifically to assist high risk Veterans with SUDs to remain stably housed. S&A is conveniently provided via App using an iPad, cell phone, or the Medtronic Commander Flex and allows 3 mos. of daily monitoring by trained HT staff. Specific Aim I: Assess the relative effects of Treatment Engagement and Substance Use [and SUD-related problems] between CRP+S&A vs. CRP and CRP+S&A vs. TAU by 3-mos follow-up. Primary Hypothesis 1a: Treatment Engagement: Participants in CRP + S&A will attend more outpatient SUD treatment sessions and general MH treatment sessions compared to participants in CRP and to TAU. Primary Hypothesis 1b: Substance Use: Participants in CRP + S&A will lower quantity and frequency of substance use and SUD-related problems compared to participants in CRP and to TAU. Secondary Hypothesis 1c: Preventable Services: Participants in CRP + S&A will reduce Preventable Healthcare Services (hospital readmissions and ED visits) compared to participants in CRP and to TAU. Secondary Hypothesis 1d: Participants in CRP + S&A will report Greater QoL; # of Days Living in Stable Housing; and # of Days Engaging in Community Events and/or Activities compared to CRP and to TAU. Specific Aim II: Conduct Veteran participant thematic interviews and Staff ‘focus’ interviews to assess qualitative facilitators and barriers to implementation. Project Methods: 195 Veterans with SUDs in the Charleston VAMC inpatient setting will be recruited. Participants will be randomly assigned to: (1) CRP + S&A; (2) CRP; and (3) TAU. Participants will be followed- up at 1 and 3-months and data analyzed using mixed methods. Investigators of this project plan to evaluate implementation of the interventions proposed in other VA inpatient programs within the VISN through future implementation projects and will utilize study findings in partnership for improving SAIL performance measures. Description of Primary Outcomes: A. Treatment Engagement (measured in SUD and general MH treatment sessions attended); B. Substance Use (measured in quantity and frequency) and SUD-related problems. Secondary outcomes: C. Preventable Services (measured in hospital readmissions and ED visits) and D. Quality of Life, #Days Living in Stable Housing, and # Days Engaging in Community Events and/or Activities.	Mental and Behavioral Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 19-408	Halford	Jonathan		Jonathan.Halford@va.gov	Testing a Novel Dry Electrode Headset for Electroencephalography Telehealth	03/01/2022	09/30/2025	Ralph H. Johnson VA Medical Center, Charleston, SC	$684,548		Background: Many Veterans live far away from a VAMC with substantial electroencephalography (EEG) expertise. Travel is difficult for epilepsy patients since they often cannot drive. We propose to study a novel dry electrode system (DES) which does not require EEG technologists to operate and can be operated by a nurse assistant. This DES integrates the electrodes and EEG amplifier into a compact headset which is easily placed on the head (without skin preparation) and could be used in an epilepsy telemedicine outreach program along with clinical interviews. We have performed three preliminary studies with DES headsets. In our first two studies in 33 Veterans performed at a VAMC, we found that the DES was quick to apply, taking only 5-6 minutes to put on by a research subject with the assistance of a neurologist. Subjects preferred the DES headset over the standard EEG system (SES). In our third study a nurse performed 30 DES recordings in a VA community based outpatient clinic (CBOC). Rating of the EEG recordings on a five point scale by three board certified clinical EEG experts (after automated EEG artifact reduction was applied to the recordings) showed that all 30 recordings were of acceptable quality (rated 3 out of 5 or higher with some artifact present) and 18 of 30 recordings were of good quality (rate 4 or above with only minor artifacts present). Significant Impact: This study will improve access of Veterans with epilepsy living in rural areas to the most important diagnostic procedure for the care of patients with epilepsy: the routine EEG. Being able to perform routine EEG in CBOCs can decrease cost to the VA system since DES EEG systems are less expensive and because Veterans will not have to travel to VAMCs for EEG. This study will also test the DES system to make sure it can record epileptiform transients (ETs), the pattern in EEG which indicates that patients have epilepsy. Innovation: This study is innovative because it will use a new recording system for EEG that just got FDA approval. This new DES EEG recording system provides a method for recording EEG which is cheaper and much easier to perform than conventional EEG. This study is also innovative because it will test for the first time if a DES can reliably record ETs. (The FDA approval for the DES system was based on EEG signal quality only and not whether it could reliably detect ETs.) The study will also use a new FDA-approved method for automatically removing artifactual signals which can obscure DES EEG recordings. Specific Aims: The first aim of the project is to test the ability of the DES to record ETs versus the SES. The second aim is to collect data on appointment wait time, appointment cancellation rate, and procedure cost of DES versus SES to project the improvement in Veteran access and potential cost-benefit of DES EEG performed in CBOCs versus SES EEG performed in VAMCs. Methodology: This is a randomized controlled trial which will be performed at three sites: the Charleston VAMC, Durham VAMC, and Miami VAMC. For Specific Aim 1, 400 Veterans (200 with a history of an abnormal EEGs in which ETs were recorded and 200 prospective Veterans scheduled for an outpatient EEG) will be recruited to have a DES EEG procedure and a SES EEG procedure performed during a single study visit in a VAMC by an EEG technologist. Each EEG recording will be interpreted and rated for technical quality by three study investigators, who will also annotate the location of ETs in each EEG recording. The fraction of EEGs which demonstrate ETs and the technical quality ratings will be compared. For Specific Aim 2, data will be collected on 300 prospective Veterans scheduled for an outpatient routine EEG, including appointment cancellation rate, travel cost, and other patient factors. Costs for EEG equipment/supplies as well as technician effort/salary and nurse and nurse assistant effort/salary will also be collected. This will be used to project the potential improvement in patient access and potential cost savings of a nurse or nurse technician performing outpatient DES EEG in a CBOC versus an EEG technician performing outpatient SES EEG in a VAMC.	Care of Complex Chronic Conditions				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 19-410	Pao	Alan		Alan.Pao@va.gov	Defining Optimal Care for Urinary Stone Disease in the Veterans Health Administration	10/01/2020	09/30/2024	VA Palo Alto Health Care System, Palo Alto, CA	$925,684		Background: Urinary stone disease (USD) imposes a major economic and health burden on the United States and the Veterans Health Administration (VHA). The current barriers to delivering optimal health care to patients with USD is the dearth of evidence-based process measures and treatments and the complexity of secondary prevention measures for USD. Significance/Impact: Current guidelines for best practice management of USD are largely based on clinical principles or expert opinion. The VHA/DoD has not developed clinical practice guidelines for USD because there remains a critical need to determine what are the most effective prevention and treatment strategies to reduce USD risk. The relative lack of evidence-based guidelines may lead to suboptimal care and drive unwanted practice pattern variability of quality of care for USD. The proposed research will address the following VHA/ORD priorities: Primary care practice and management of complex chronic diseases (such as recurrent USD) and quality measurement of USD prevention. Innovation: As a first step to address uncertainty in the best practice management of USD, we aim to test whether multidisciplinary specialty care structure is associated with guideline- concordant care and improved outcomes for USD. The findings from proposed research may inform efforts to include more specialty care options in the management of patients with USD, such as implementation of e-consult or telehealth modalities as a way to expand access of Veterans to quality care for USD. Specific Aims: The main objectives are the following: 1) Identify unwanted variation in USD care in the VHA; and 2) Test whether multidisciplinary specialty care structure is associated with guideline-concordant care and improved outcomes for Veterans with USD. We hypothesize that multidisciplinary specialty care is associated with guideline-concordant care and improved outcomes for Veterans with USD. We propose the following specific aims: 1) Evaluate facility- level variation of guideline-concordant care for patients with USD in the VHA; 2) Determine whether multidisciplinary care is associated with guideline-concordant USD care; and 3) Test whether multidisciplinary care is associated with improved USD outcomes. Methodology: Aim 1 will calculate a composite guideline-concordance score for each patient with USD and summarize variation in guideline-concordant care for USD by VHA facility. Aim 2 will use mixed effects multivariable models to determine relationships among outpatient care with primary care, specialty care, and guideline-concordant care. Aim 3 will develop a mixed effects time-to-event model, incorporating provider care structure and composite guideline- concordant score, to test whether multidisciplinary care is associated with improved outcomes. Next Steps/Implementation: The VHA is ideally positioned to support comparative effectiveness studies to determine which USD treatment paradigms are most effective at reducing USD recurrence. Findings from the proposed will define more clearly best practice management of USD, reduce unwanted variation in USD care, and inform future quality improvement efforts in both the VA and civilian health care systems.	Quality Measurement Development				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 19-414	Hall	Daniel	Mary Vaughan-Sarrazin	daniel.hall2@va.gov	Understanding the effect of rurality and social risk factors on barriers to care and surgical outcomes	10/01/2021	09/30/2025	VA Pittsburgh Healthcare System University Drive Division, Pittsburgh, PA	$827,696		Background: The Mission Act provides improved Veteran access to care both within the Veterans Administration (VA) and community systems. An underlying assumption is that faster care with more choices results in better care. However, care fragmentation is associated with increased length of stay, readmissions, and mortality. Postoperative complications and readmissions are higher in minority and low socioeconomic status (SES) patients. Low SES is also associated with frailty, one of the best predictors of 30-day postoperative complications and hospital readmissions. Despite having a profound influence on health outcomes, social risk factors are absent from risk adjustment for VA quality measures, further exacerbating disparities in minority and low SES populations. This strategy may further constrain resources to care for vulnerable populations, as many Veterans are economically disadvantaged and potentially adding avoidable costs to care delivery. Another major issue is care fragmentation. Nevertheless, the impact of non-VA care and care fragmentation is absent in performance metrics. Our goal is to identify social risk factors and levels of care fragmentation that affect surgical outcomes to inform VA quality metric policy and institutional resource allocation. We improve upon current practice by joining surgical outcomes data with 1) VA/Centers for Medicare & Medicaid Services (CMS) claims data, 2) VA fee-basis files to identify encounters outside of the VA health system and 3) using more granular proxy social risk factors and neighborhood disadvantage. Significance/Impact: Our significance is modeling surgical outcomes using social risk factors, rurality, living in a disadvantaged neighborhood and care fragmentation to identify factors contributing to health care disparities and to inform VA policy. The impact is to develop quality metrics using social risk factors and care fragmentation. HSR&D priority areas: Rural Health, Health Equity, Health Care Value and Health Care Informatics. Innovation: Joining diverse data sources to develop predictive models using both traditional parametric methods and exploratory machine learning techniques to provide clinicians and administrators with outcomes and economic analyses necessary to change institutional practices to benefit our most vulnerable Veterans. Specific Aims: Aim 1: Identify factors affecting surgical outcomes by assessing the contributions of ethnicity, race, SES, place of residence and care fragmentation to surgical complications, readmissions and mortality Hypothesis: Using ethnic/racial minority status, SES, place of residence and care fragmentation will identify important risk factors for postoperative complications, readmissions, and mortality Aim 2: Assess the impact of social risk factors and care fragmentation on hospital performance metrics for readmissions and mortality Hypothesis: Including social risk factors and care fragmentation in risk adjustment models significantly changes VA hospital performance rankings with respect to readmissions and mortality Aim 3: Determine the relationship of place of residence, care fragmentation, SES and minority status to acute and long-term VA surgical health care utilization to inform VA resource allocation Hypothesis: Low SES, rurality, care fragmentation and minority status are associated with higher VA resource utilization Methodology: Quantitative analyses using traditional parametric and exploratory machine learning techniques performed on diverse datasets to develop predictive models of surgical outcomes using care fragmentation, rurality and social risk factors risk adjusted for medical comorbidities and applied to VA quality metrics. Implementation/Next Steps: Deployment of quality metric models using social risk factors and care fragmentation within the VA system. Adjusting resource allocation to account for social risk factors.	Equity				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 19-418	Bosworth	Hayden	Puja Van Epps, Eleanor Wilson	hayden.bosworth@va.gov	A nurse-led intervention to extend the Veteran HIV treatment cascade for cardiovascular disease prevention (V-EXTRA-CVD)	09/01/2020	06/30/2024	Durham VA Medical Center, Durham, NC	$1,488,759		Background: The VA is the largest provider of HIV care in the United States. The ~31,000 Veterans with HIV use significantly more healthcare and have up to 2x higher risk of atherosclerotic cardiovascular disease (ASCVD) compared to uninfected Veterans. The HIV treatment cascade model includes care steps; once people obtain remission, providers should focus on preventing ASCVD. We will extend the HIV treatment cascade and focus on reducing ASCVD risk among people with HIV. Veterans with HIV have low perceived risk for ASCVD and uptake of guideline-based treatment for BP is low. Significance/Impact: The proposed intervention has the potential to reduce ASCVD events in this population by more than a quarter and meet VA strategic priorities of: 1) improve timeliness of services; 2) focus resources more efficiently as well as address HSR&D research priorities: 1) patient centered care, care management, and health promotion; 2) healthcare access; 3) aging; 4) virtual care. Innovation: The study is innovative: Cascade Model. By leveraging the HIV treatment cascade model, we will create a pathway for ASCVD risk reduction to be added into widespread quality improvement initiatives. Stakeholder-engaged design process. We will employ stakeholder-engaged research methods to ensure the intervention meets the needs of patients and healthcare providers. Multi-component nurse-led intervention. While each of the components of our intervention have an evidence base, they have not been tested together in an HIV context. Telehealth. We will use VA Video Connect (VVC) to monitor CVD risk factors. Specific Aims: Aim 1a: Conduct qualitative interviews with Veterans and healthcare providers to ascertain perceptions regarding HIV and CVD risk reductions to inform intervention adaptation. Aim 1b: Adapt the intervention to the VA HIV clinic context with key stakeholder input. Aim 2: Evaluate the 12-month efficacy of a nurse intervention to improve systolic blood pressure in Veterans with HIV. Hypothesis: We hypothesize that our intervention will result in a clinically significant 6mmHg reduction in SBP over 12 months compared to those receiving [enhanced education + usual care] only. Aim 3: Conduct an evaluation of the prevention nurse intervention. Exploratory aim: If effective, [we will conduct a budget impact analysis] and simulate 10-year cost-effectiveness of the nurse intervention. Methodology: We will conduct qualitative interviews with care team and Veterans to adapt the intervention in an iterative design process. We will then conduct a RCT to evaluate an intervention to reduce ASCVD risk. The study will be conducted in 3 clinics among HIV+ veterans (n=300) on suppressive ART with confirmed SBP >140 mmHg, stratified by clinic site and randomized 1:1 to intervention vs. education control. The intervention will involve 4 evidence-based components based on our prior studies and adapted to veterans with HIV: (1) nurse-led care coordination, (2) nurse-managed medication and adherence support (3) home BP monitoring, and (4) administered VA Video Connect (VVC). The education control will receive enhanced education and usual care. Primary outcome: difference in 12-month systolic BP in the intervention arm vs control. Secondary outcome: 12-month difference in non-HDL cholesterol. We will use a mixed-methods design to evaluate fidelity, dose delivered/received, reach, recruitment, and context of the intervention. Implementation/Next Steps: We designed the intervention with downstream implementation in view. This includes: a fully remote delivery of the intervention to facilitate access and widespread implementation, and guidance for selection of nurses with education / experience levels that match those of health coaches delivering interventions within the VA. We will work with operational partners from the Office of Connected Care and Office of HIV/AIDS care regarding implementation plans. We will disseminate a clinical program, including scripts, and description of all intervention processes, to facilitate implementation within the VA.	Care of Complex Chronic Conditions				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 19-421	Wagner	Todd		todd.wagner@va.gov	Utilization and Health Outcomes for Veterans with Expanded Health Care Access	07/01/2020	09/30/2024	VA Palo Alto Health Care System, Palo Alto, CA	$1,163,880		Background: Improving access to high-quality care is a top priority for VHA. However, access is difficult to measure, especially in the ever-changing U.S. health care landscape. VHA currently focuses on perceived satisfaction measured from survey questions, or wait times measured with administrative data. The wait time metric has received considerable focus in both the Choice and MISSION Acts, yet experts recognize that wait times are imperfect; they are not only challenging to interpret, but they are rarely available from community providers, hindering any VHA to non-VA comparisons. VHA leaders tasked with implementing the Choice and MISSION Acts desire better evidence-based access measures so they can evaluate their program’s impact. Our inability to measure access threatens the future of VHA as a health care provider. Without new metrics that track gaps or improvements in access, VHA is likely to invest in the wrong initiatives, fueling critics who will argue that privatization will fix the programs Significance/Impact: Our objective is to develop new measures of access. These new measures will provide causal information on gaps in VHA services, while also showing the potential impact that expanded access would have on Veterans’ health. Our study leverages natural experiments in the form of arbitrary administrative rules that enable Veterans to access care outside VHA in the forms of Medicare and VA Community Care (VACC). Veterans close to the rule thresholds are similar, yet some gain access based on the rule, while the others do not. We can leverage this information to understand how this added access changes health care utilization and health outcomes. Our results will be useful to national and local VHA leaders as they grapple with how to best improve access with a limited budget. Innovation: It is not feasible to perform a large-scale randomized clinical trial to find the effect of access on utilization and health outcomes. Correlational studies will miss important confounders, and as everyone knows correlation does not equal causation, which is what VHA leaders need most. Instead, we apply novel econometric techniques to take advantage of natural experiments and find the causal effects of increasing access. The results from this approach can then be used as a measure of access for both VHA and non-VA care. This is directly aligned with HSR&D's priorities on access to care, research related to the MISSION Act, and advancing health services research methods across conditions or care settings. Specific Aims: Aim 1: Find the causal impact of Medicare eligibility on Veteran utilization and health, and identify procedures and diagnosis groups that are most affected. Aim 2: Find the causal impact of VACC on Veteran utilization and health, and find the procedures and diagnoses most affected. Aim 3: Identify subgroup analyses that would give crucial information to VHA leaders. Methodology: In Aims 1 and 2, we will apply an econometric technique called regression discontinuity design. We will gather a near complete census of VHA and non-VA records for all recent Veteran VHA users, allowing for precise claims-based measures of utilization, health, and mortality. In Aim 1, this approach leverages the sharp change in Medicare eligibility that occurs at age 65 to find the effect of Medicare on utilization and health. Aim 2 uses the same approach, but instead of age 65, we use the driving distance rules to find the effect of VA Community Care on utilization and health. For these aims we will examine both overall effects and procedure and diagnosis specific effects. In Aim 3, we take a combined approach of working with operational partners and applying machine learning techniques for heterogenous treatment effects to identify and examine metrics and measures that can be used for policy formation. Next Steps and Implementation: By working with operational partners through Aim 3, we will identify opportunities and barriers to implementing measures and metrics derived from our results. This information will be key to setting policy related to VHA’s evolution into a provider and payer of Veteran care while ensuring that Veterans receive high-quality care in both VHA and non-VA settings.	Access				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 19-422	Breland	Jessica		Jessica.Breland@va.gov	The EMBER Trial for Weight Management Engagement	02/01/2022	03/31/2025	VA Palo Alto Health Care System, Palo Alto, CA	$862,385		Background: Almost 40% of Veterans using the Veterans Health Administration (VA) have obesity, putting millions at risk for costly and debilitating conditions, including diabetes, cancer, and severe COVID-19. VA weight management programs effectively reduce weight, morbidity, and mortality. For example, MOVE!, VA’s flagship program for weight management is associated with reductions in cardiovascular disease and diabetes. However, while 94% of eligible Veterans are offered weight management programs, less than 8% use them. Motivational interviewing improves treatment engagement, but clinicians have limited time to apply it. Therefore, we developed EMBER, a self-directed tool with the goal of Enhancing Motivation for Better Engagement and Reach for weight management. It is available in paper and digital formats. EMBER is not a weight management program, instead it engages Veterans in existing programs by informing and guiding choices about weight management. EMBER is the product of an HSR&D Career Development Award (15-257). Significance: If EMBER increases engagement in effective weight management programs, it has the potential to help Veterans lose weight, thereby improving health and quality of life for thousands of patients. As a result, we address many HSR&D priorities, e.g., access to care, virtual care, healthy equity, & primary care. Innovation & Impact: EMBER is the first self-directed, motivational interviewing-based intervention designed to increase Veteran engagement in weight management programs. As opposed to a “one-off” study in a specific population, the proposed work takes a novel, low-touch population health approach that could be translated to other programs (e.g., behavioral pain management). EMBER also includes vignettes relevant to populations at high risk for obesity (e.g., women, people of color). Further, t he Hybrid Type 1 design will ensure results can be scaled and sustained while also advancing implementation science. As such, the proposed work will: 1) advance the science of engagement in behavioral health programs and 2) facilitate future research on the implementation of EMBER and similar interventions. Specific Aims: 1. Assess whether Veterans randomized to EMBER are more likely to have any weight management engagement at 2-month follow-up (per administrative data supplemented with self-report) compared to those randomized to the control arm (information sheet listing available programs). (Primary Outcome) 2. Assess whether Veterans randomized to EMBER have greater weight management program retention, weight management behaviors (e.g., physical activity), weight loss, and quality of life gains at 6-month follow-up compared to those randomized to the control arm. (Secondary Outcomes) 3. Assess factors likely to affect EMBER’s implementation. Preliminary implementation outcomes will be assessed via RE-AIM4 (Reach, Effectiveness, Implementation) and the Proctor et al.5 implementation outcomes framework (Acceptability, Appropriateness, Costs, Fidelity). (Implementation Outcomes) Randomized two site Hybrid Type 1 Effectiveness-Implementation Trial among Veteran primary care patients with obesity in VA (N=470). Participants will be randomized to EMBER or a control condition consisting of a list of available weight management programs. The primary outcome is any weight management engagement 2-months after baseline. Aims 1 and 2 will use self-report and administrative data to assess intervention outcomes. Aim 3 will use patient data and information from research staff. Methodology: Implementation/Next Steps: If effective, we will use implementation strategies suggested by Aim 3 to ensure Veterans receive EMBER. We will test these strategies in a Hybrid Type 2 trial to understand EMBER’s effectiveness in real world contexts and best practices for dissemination and implementation of EMBER and similar interventions.	Mobility, Activity, and Function				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 19-425	Slatore	Christopher		Christopher.Slatore@va.gov	Teachable Moment to Opt-out of Tobacco (TeaM OUT): A Stepped Wedge Cluster Randomized Intervention	10/01/2020	06/30/2024	VA Portland Health Care System, Portland, OR	$901,959		Background: Cigarette smoking is the leading cause of preventable disease in the U.S. Despite decades of slowly declining cigarette use, many older adults still actively smoke. Among Veterans, 22% overall and 17% of those over 50 years old actively smoked in 2015. It is notoriously difficult to quit, despite widespread knowledge among adults about the health hazards of persistent smoking and a frequent desire to quit. Given the prevalence and persistence of tobacco addiction, the U.S. Preventive Services Task Force (USPSTF) recommends that health care professionals offer cessation interventions at every health care encounter. Significance/Impact: The TeaM OUT intervention is specifically designed to increase motivation to quit, reduce roadblocks, and increase access to smoking cessation resources. It is especially focused connecting older active smokers not yet ready to quit to smoking cessation services. TeaM OUT has the potential to result in more frequent and longer periods of abstinence from smoking in this hard-to-reach population. Innovation: TeaM OUT combines a teachable moment with an opt-out, proactive approach to connect patients to existing cessation services using interactive voice response (IVR) technology. IVR is a proactive and affordable way to reach more older active smokers more frequently. Specific Aims: Aim 1: Among patients recently diagnosed with a pulmonary nodule, evaluate the effect of a proactive, teachable moment-based, smoking cessation outreach intervention (TeaM OUT) on increasing engagement with smoking cessation resources compared to Enhanced Usual Care. Aim 2: Evaluate the association of receipt of TeaM OUT with patient-reported seven-day point prevalence nicotine abstinence and quit motivation compared to Enhanced Usual Care. Aim 3: Qualitatively elicit perspectives from key stakeholders to inform acceptability and utility, implementation barriers and facilitators, and scalability of TeaM OUT. Methodology: In aim 1, we use pulmonary nodule registries to identify participants from three VA facilities (VA Portland, Minneapolis VA, Charleston VA). Patients with pulmonary nodules will be contacted after a stepped- wedged randomization at the clinical level. Participants in the intervention arm are called by the IVR Quitline, whereas participants the control arm must proactively choose to call the quitline. Options selected on the quitline will be recorded and analyzed using logistic regression to test if the quitline increases engagement with smoking cessation services. For aim 2, a subsample of participants in aim 1 will be contacted to complete additional surveys for 12 months after exposure to either arm of the study. We will measure nicotine abstinence, quit motivation, and communication and analyze the measures using multivariable, multi-level hierarchical logistic regression. In aim 3, we will qualitatively assess TeaM OUT by interviewing patient participants twice during the study – first at the time of the initial Proactive IVR contact and second at 13 months after enrollment. Clinical stakeholders will also be interviewed, with a focus on current and desired smoking cessations and experiences with the TeaM OUT intervention. Codes will be derived without preconceived categories. Next Steps/Implementation: We have purposely designed the intervention and overall study to maximize generalizability, feasibility, adoption, and sustainability of the intervention. We plan multiple scientific presentations and publications. Investigators will attend annual American Thoracic Society and HSRD conferences to present the research findings. We will place all de-identified data in our IRB-approved Health Services Research Repository (IRB #3535) at the conclusion of the study. We are creating a detailed toolkit as part of the study’s implementation process so that the IVR system can be easily replicated in multiple settings.	Complementary and Integrative Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 19-431	Wachterman	Melissa		melissa.wachterman@va.gov	Optimizing Pain Management in End-Stage Renal Disease Among Veterans (OPERA-Vets):Balancing Benefits and Harms of Opioids	07/01/2021	05/31/2025	VA Boston Healthcare System Jamaica Plain Campus, Jamaica Plain, MA	$972,062		Background: Over the past decade, VA has implemented opioid policies, most notably the 2013 Opioid Safety Initiative, designed to address the burgeoning opioid crisis. As the pendulum has swung away from opioid prescribing, it is possible that some patients with serious illness may have experienced unintended consequences, including uncontrolled pain, even while others may have avoided potential complications of opioid use. This project examines the potential impact of these policies on Veterans with end-stage renal disease (ESRD), a population of approximately 35,000 Veterans for whom balancing the benefits and harms of opioids may be particularly challenging. These Veterans have very limited life expectancy and a substantial pain burden, comparable to Veterans with metastatic cancer, but often under-appreciated. They are at increased risk of opioid-related serious adverse events (SAE; e.g. opioid overdose). Yet compared with other seriously-ill populations, they have fewer non-opioid analgesic alternatives to fall back on and may face barriers to non-pharmacologic pain management strategies. Moreover, most Veterans with ESRD receive dialysis in the community either under VA Community Care or Medicare, exposing them to the potential adverse impact of care fragmentation on opioid safety and pain control. Significance/Impact: Understanding the impact of VA initiatives to improve opioid safety at the population level on Veterans with serious illness is critical to the VA’s commitment to ensure that these vulnerable Veterans are provided care that relieves distressing symptoms. The work proposed here is responsive to the VA Under Secretary for Health’s priority to improve pain management and the safety of pain medications. Innovation: The proposed study is the first to examine the impact of opioid safety initiatives and prescribing guidelines on a group of seriously-ill Veterans. It leverages VA data that include rich measures of pain control unavailable from any other national data source. The use of a sequential explanatory mixed-methods study design to triangulate quantitative and qualitative findings on pain management in the context of contemporary opioid policy is a novel contribution to the field of opioid research. Specific Aims: 1) Examine changes in pain management strategies, opioid-related SAE, and pain control among Veterans with ESRD from 2010-2018; 2) Compare changes in opioid-related SAE by setting of dialysis (VA, VA-Community Care, Medicare) from 2010-2018; 3) Elicit the perspectives and experiences of Veterans with ESRD and the clinicians who care for them related to pain management in the context of VA opioid safety initiatives in order to inform policy and practice. Methodology: The study employs a sequential explanatory mixed-methods design. The quantitative portion of the study (Aims 1 and 2) includes Veterans on dialysis across all VAs between 2010 and 2018. We will conduct an interrupted time series analysis of linked VA, Medicare, and USRDS data to examine whether Veterans with ESRD have had changes in pain therapies (opioids, non-opioids, non-pharmacologic), opioid- related serious adverse, and pain, overall and by setting of dialysis, over time since the 2013 OSI. We will then conduct semi-structured interviews with Veterans with ESRD and VA clinicians who care for ESRD patients to identify opportunities for improvement in VA pain management policy and practice (Aim 3). Implementation/Next Steps: We will work with our Advisory Board of operational partners, to ensure that our research will inform policy about how to optimally align opioid safety initiatives and pain management guidelines to meet the needs of Veterans with ESRD and those with other serious illnesses. We will collaborate with the Board to develop a ‘roadmap” that will summarize our key findings, identify implications for policy and clinical care, and identify priorities for future clinical and policy intervention intended to optimize pain control for Veterans with ESRD. This roadmap can likely be adapted for other groups of seriously-ill Veterans.	Care of Complex Chronic Conditions				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 19-445	Carlson	Kathleen		Kathleen.Carlson@va.gov	Community Care Utilization among Post-9/11 Veterans with Traumatic Brain Injury	01/01/2021	09/30/2024	VA Portland Health Care System, Portland, OR	$1,111,087		Background: Estimates suggest that 20% or more of Post-9/11 Veterans have experienced at least one military-related traumatic brain injury (TBI); the majority are categorized as mild (mTBI). TBI of all levels of severity, including mTBI, can lead to chronic physical, cognitive, and emotional symptoms that, for many, interfere with daily functioning. It is also associated with comorbid diagnoses such as posttraumatic stress disorder, depression, pain, dementia, and suicidal ideation. As such, early detection and coordinated treatment are critical for preventing chronic dysfunction, disability, and early mortality among Veterans with TBI history. The VA Polytrauma/TBI System of Care (PSC), through a regional, integrated structure, serves this function by overseeing and providing screening, evaluation, education, and evidence-based treatment for those in need of TBI-related care. The PSC will care for this substantial patient population for decades to come. Since the 2014 passage of the Veterans Choice Act and, more recently, the VA MISSION Act, the VA has been outsourcing larger amounts of healthcare to non-VA providers (“Community Care”). VA Community Care may improve Veterans’ access to care; however, dual use of healthcare systems and providers can lead to poor outcomes due to fragmentation of care. Preliminary work has suggested that higher proportions of Veterans with TBI diagnoses, relative to those without TBI, are receiving VA Community Care services, and that this may be leading to the receipt of therapies that are not recommended for patients with TBI. Significance/Impact: This study will inform the development and implementation of strategies to enhance the care received by Veterans with TBI who use VA Community Care services. This work will identify gaps in the provision of evidence-based TBI care in a timely manner, as VA Community Care services continue to expand under the new MISSION Act. Our results will help ensure that Veterans with TBI receive care that is coordinated, interdisciplinary, and evidence-based, and that promotes their optimal health and functioning. Innovation: This project will develop new knowledge about Community Care utilization and outcomes among Veterans receiving care for TBI, a high-priority, clinically-complex patient population. It will be the first, to our knowledge, to measure patient-reported health and functional outcomes among Veterans who receive Community Care. Additionally, we will link to multiple VA and Department of Defense (DoD) databases to objectively account for differences in characteristics between those who do and do not use Community Care. Specific Aims: Our aims are to: (1) Describe utilization of VA Community Care (rates and types of; reliance on) among Post-9/11 Veterans with TBI; (2) Estimate associations between Veterans’ reliance on Community Care and their health and functional outcomes; and (3) Understand Veterans’ need for, perceptions of, and experiences with VA Community Care. Methodology: This 4-year, mixed-methods project will link data identifying Post-9/11 Veterans with TBI to administrative data identifying VA healthcare use including Community Care. For Aim 1, we will examine patterns of Community Care use (rates and types of; reliance on) over time and by Veterans’ sociodemographics, military history, TBI severity, medical complexity, and PSC utilization history. For Aim 2, we will survey a stratified, random sample of 1,800 Veterans with TBI to estimate associations between their reliance on Community Care and their health and functional outcomes, while accounting for potential confounders and sources of bias. For Aim 3, we will interview 100 Veterans to examine factors related to their access to, satisfaction with, trust of, and actual and perceived quality of Community Care. Implementation/Next Steps: This work may identify subgroups of Veterans whose healthcare needs are not being met and who are at risk of poor outcomes. Results will inform strategies to ensure continued delivery of coordinated, high-quality care across the entire spectrum in which Veterans with TBI are receiving VA care.	Access				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 20-048	Adams	Megan	Liam Rose	megan.adams5@va.gov	Understanding the Effects of the MISSION Act on VA's Specialty Care Referral Networks	05/01/2022	09/30/2025	VA Ann Arbor Healthcare System, Ann Arbor, MI	$740,664		Background: Recently, VA underwent two unprecedented disruptive changes that fundamentally altered how care is delivered to Veterans. First, the VA MISSION Act was implemented in June 2019. Arguably the biggest policy change in VA care delivery since the "Kizer revolution,” MISSION’s purpose is to improve Veteran access to care, especially for services that have traditionally been resource-limited in VA due to geographic/ temporal barriers (e.g., specialty care). While VA healthcare systems were still in the early phases of adapting to MISSION, the COVID pandemic spread rapidly across the world, resulting in a sudden and prolonged ramp- down of elective outpatient care across the entire US healthcare system. VAMCs nationwide are independently adapting to these disruptive changes in ways that directly impact Veterans’ health and experience. Significance/Impact: Currently, we know little about MISSION’s early effects on where and how Veterans access specialty care (as moderated by COVID-related disruptions), or factors influencing community care referral. We also lack a clear understanding of how individual VAMCs are responding to these disruptive forces in realigning organizational strategy/structure to optimize performance. Addressing these knowledge gaps is critical to assessing the long-term impacts of MISSION and COVID on VA specialty care delivery and helping VAMCs to tailor adaptation approaches to their local setting to optimize the health and experience of Veterans. Innovation: Expansion of VA community care under the MISSION Act represents one of the largest natural experiments in delivery transformation in any U.S. healthcare system in modern times. Thus, VA community care expansion under MISSION offers an unparalleled opportunity to study the relationship between rapid environmental change, organizational adaptation, and long-term performance. The unanticipated system "reset" caused by COVID will only amplify and accelerate the adaptation process already underway. Specific Aims: Aim 1: Examine the relationship between VAMC organizational/environmental characteristics and longitudinal performance under MISSION/post-COVID, and the extent to which facility-level organizational adaptation measurably impacts performance. Aim 2: Characterize variation in organizational adaptation by high-performing tertiary VAMCs with different organizational/environmental characteristics. Aim 3: Explore how the experience of Veterans with specialty care needs differs at high-performing VAMCs with distinct organizational adaptation approaches. Methodology: In Aim 1a, using a longitudinal pre-/post- comparison analysis, we will examine the relationship between VAMC organizational/environmental characteristics and longitudinal performance under MISSION/post-COVID, including measures of access, care coordination, and community care referral. In Aim 1b, using a difference-in-differences approach, we will leverage differences in financial incentives between VAMCs to empirically assess the effect of VAMC organizational adaptation on longitudinal rates of VA community care referral and other outcomes. In Aim 2, we will interview leadership at 12 high-performing Level 1 VAMCs with varying organizational/environmental attributes to characterize variation in adaptation approaches under MISSION/post-COVID. In Aim 3, we will explore how VAMC organizational adaptation impacts Veterans’ specialty care experience through qualitative interviews of 48 Veterans at select Aim 2 sites. Implementation/Next Steps: This study will provide critical information about where and how Veterans access specialty care under MISSION/post-COVID, how high-performing tertiary VAMCs with different organizational/ environmental characteristics are adapting to enhance specialty care delivery under MISSION/post-COVID, and how variation in these adaptation approaches affects the Veteran experience of care. Grant products will provide vital information to VHA leaders about how tertiary VAMCs with unique facility-level characteristics can best adapt their organizational approaches to optimize performance and enhance the Veteran care experience.	Health Care Organization and Implementation				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 20-058	Cucciare	Michael	Keith Humphreys	Michael.Cucciare@va.gov	Multi-site Pilot Trial of Strengths-based Linkage to Alcohol Care (SLAC) for Hazardous Drinkers in Primary Care	01/01/2022	03/31/2025	Central Arkansas Veterans Healthcare System , Little Rock, AR	$890,726		Project Summary/Abstract Background: Relatively few Veterans screening positive for hazardous drinking in primary care (PC) receive alcohol care in the year following their alcohol screening. This suggests that existing VHA options for linking Veterans in need of alcohol care, including those with comorbid hazardous drinking and PTSD and/or depression (A-MH), are not effective. To that end, we have identified and propose to pilot test a promising evidence-based intervention, Strengths-based Linkage to Alcohol Care (SLAC). SLAC has the potential to increase linkage to alcohol care, as well as to improve drinking and mental health outcomes, among Veterans with A-MH in PC. Significance: Existing VHA options such as VHA-recommended brief alcohol counseling do not improve linkage to alcohol care, suggesting a critical need for more intensive but practical efforts to link Veterans with A-MH to care. This proposal directly addresses HSR&D priorities in the areas of Access to Care, Mental Health (PTSD), and Primary Care by testing a novel approach (SLAC) to linking Veterans with A-MH to VA and non- VA alcohol care and to improve their drinking and mental health outcomes. Innovation and Impact: The proposed project is highly innovative because it offers a solution to the critical gap in VHA care in which most Veterans in need of alcohol care do not receive it. It tests a strategy to increase linkage to alcohol care that is both intensive enough to produce change, yet feasible to use in busy clinical settings with too-high demand on too-few staff members. A highly innovative feature of SLAC is that it teaches PC providers how to link Veterans with A-MH to alcohol care, which may help normalize conversations about patients’ alcohol use and their care options in PC as part of the provider role. PC providers’ lack of knowledge on how to treat hazardous drinking is a substantial obstacle to Veterans receiving alcohol care. Additional unique and innovative features of SLAC are that it uses patients’ self-identified strengths, abilities, and skills to help them link to an alcohol care option. Specific Aims: Our two aims are (Aim 1): To adapt SLAC for use among Veterans with A-MH and for delivery by telephone in the VHA PC setting. We will conduct qualitative interviews with Veterans, PC staff, and our VACO operational partners to ensure that the content and format of SLAC are adapted so they are relevant and acceptable to these stakeholders. (Aim 2): To determine (a) the feasibility of conducting a larger scale randomized controlled trial (RCT) to test SLAC’s effectiveness and (b) SLAC’s acceptability among Veterans with A-MH in PC, and to explore (c) the efficacy of SLAC in this Veteran population. To achieve Aim 2, we will conduct a multi-site pilot RCT of SLAC at two VA medical facilities (Little Rock, AR and Palo Alto, CA). To achieve Aims 2a-b, we will measure the feasibility (e.g., rates of enrollment and follow-up, fidelity to the SLAC intervention) of conducting a subsequent larger RCT (to test SLAC’s effectiveness) and SLAC’s acceptability (SLAC completion rates, satisfaction with SLAC) among Veterans. To achieve Aim 2c, we will explore the efficacy of SLAC to improve Veterans’ linkage to and utilization of alcohol care, and their alcohol and mental health outcomes, at 3-month follow-up. Methodology: We will use (Aim 1) qualitative interviews to adapt SLAC for Veterans with A-MH and for PC, and (Aim 2) conduct a multi-site, pilot RCT. Debriefing interviews with Veterans will follow the pilot RCT. Next Steps/Implementation: Should our findings justify a subsequent project, we plan to propose a fully powered, multi-site study, using a Hybrid design, to test SLAC’s clinical effectiveness when delivered in VHA PC while observing and gathering information on the implementation potential of SLAC in this setting. Our operations partners are committed to implementing SLAC nationally should it be found to be effective.	Mental and Behavioral Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 20-079	Dindo	Lilian		lilian.dindo@va.gov	Effect of Patient Priorities Care Implementation in Older Veterans with Multiple Chronic Conditions	07/01/2021	09/30/2024	Michael E. DeBakey VA Medical Center, Houston, TX	$1,014,352		Background: As Veterans age, they face an increasing number of chronic conditions and functional limitations. Multiple chronic conditions (MCC) in this population are inadequately treated by current approaches to healthcare, based on single-disease guidelines. These guidelines do not provide optimum care for patients with MCC for three key reasons: 1) single disease treatments in cases of MCC can often be conflicting and lead to adverse events because they do not take into account disease or drug interactions; 2) they do not take into account the priorities of older adult patients (what matters most) when offering treatment recommendations; 3) Guideline in this older population often lead to care that is burdensome. Significance/Impact: Patient Priorities Care (PPC) was designed with input from patients, caregivers and clinicians to address these concerns by promoting a shift in decision-making for MCC which will result in less burdensome care, fewer adverse events, and care which is focused on what matters most for patients (including increased use of long-term home and community-based services and support) for Veterans with MCC and their families. Innovation: The PPC approach elaborates specific patient priorities (i.e., values-based patient outcome goals and care preferences) and trains clinicians to recommend care that aligns with patient priorities rather than single-disease guidelines alone. Specific Aim 1: Using our primary care-research partnership, we will conduct a formative assessment of PPC implementation for Veterans with MCC and develop implementation tools. Aim 1 Methods: We will perform stakeholder interviews with leadership, clinician, and staff partners structured by a formative evaluation framework. The assessment will identify barriers to implementation of PPC within VA primary care, and inform our enablers of implementation (e.g., recruitment of clinical champions, training of interested primary care providers, note templates, and processes for identifying care that aligns with patient priorities within routine care). Specific Aim 2: Evaluate the effectiveness of PPC in a randomized controlled study at two VA primary care centers. Aim 2 Methods: We will conduct a randomized clinical trial with 366 Veterans at Houston DeBakey VA and West Haven, Connecticut VA primary care practices to determine if PPC results in care that reduces treatment burden and unnecessary medications, increases use of home and community services, and aligns care with patient priorities compared with usual care. We will determine if Veterans randomized to PPC have lower ratings on the treatment burden questionnaire, and increased number of home and community based services used compared to usual care at six months post intervention. Specific Aim 3: Conduct a summative assessment of implementation outcomes of PPC in VA primary care. Aim 3 Methods: Evaluate PPC implementation in primary care using Proctor’s implementation outcomes framework (i.e., acceptability, adoption, appropriateness, feasibility, fidelity, penetration, and activity cost accounting). Participants will complete pre and post surveys and post-implementation interviews to assess these implementation outcomes of the PPC intervention. Cost analysis will be performed to determine costs associated with PPC. Implementation/Next Step: Working with the VA Whole Health program and VA Office of Geriatrics and Extended Care, we to evaluate our effectiveness and implementation outcomes and develop an implementation toolkit and strategies for dissemination across VA.	Long Term Care and Aging				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 20-093	Blonigen	Daniel		Daniel.Blonigen@va.gov	Stand Down-Think Before You Drink: An RCT of a Mobile App for Hazardous Drinking with Peer Phone Support	09/01/2022	07/31/2025	VA Palo Alto Health Care System, Palo Alto, CA	$649,844		Background: One in four Veterans presenting to VA primary care screen positive for hazardous drinking. However, due to barriers such as Veterans’ stigma about seeking alcohol use treatment and challenges with traveling to VA, most of these Veterans do not receive any alcohol-related care. Mobile applications (apps) are an innovative means of expanding access to alcohol use treatment. The evidence for mobile apps, such as “Step Away”, to improve drinking outcomes is emerging. Nevertheless, poor patient engagement remains the Achilles’ heel of these apps. Peer Specialists (“Peers”) can facilitate Veterans’ engagement with mobile apps intended for self-management of hazardous drinking by helping to orient patients to these apps and by providing technical support and accountability. In a VA HSR&D pilot study (PPO 16-305), we created a Veteran version of the Step Away app (“Stand Down: Think Before You Drink”) and conducted an open trial in which Veterans with hazardous drinking used the app while receiving Peer phone support. The intervention (“Peer- Supported [PS]-Stand Down”) was highly acceptable to patients, and patients reported significant improvements in drinking outcomes. These data provide a strong foundation for a larger pragmatic trial to test the effectiveness of the Stand Down app and PS-Stand Down to reduce hazardous drinking among Veterans seen in primary care, relative to the current standard of care that these patients receive. Significance: By capitalizing on a high-value workforce shown to improve Veterans engagement in care (i.e., Peers), this research can expand access to alcohol care for Veterans with low staff burden and, in turn, reduce the long-term health consequences associated with untreated hazardous drinking. Our proposed research responds to HSR&D priorities of Access to Care, Mental Health, and Virtual Care, and the VA MISSION Act. Innovation and Impact: Poor patient engagement severely limits the potential effectiveness of mobile apps for self-management of alcohol use problems. Use of Peers to enhance patients’ engagement with such apps is a novel approach to overcoming this problem. Peers are ideally suited to this role by virtue of their lived experience with addiction. This approach represents a novel application of the supportive accountability model of adherence to e-health interventions. Combined with VA’s expansion of Peers on Patient Aligned Care Teams (PACT), PS-Stand Down, if shown to be effective, can transform the delivery of care for Veterans in primary care who screen positive for hazardous drinking. Specific Aims: We propose to evaluate whether the Stand Down app reduces drinking among Veteran primary care patients who engage in hazardous drinking, and for whom PS-Stand Down is more effective than the app alone. Aim 1: Test whether Stand Down (vs. Usual Care; UC) and PS-Stand Down (vs. UC and vs. app only) predicts better drinking outcomes, and test mediators of these effects. Aim 2: Test for differences in satisfaction with care across conditions, and conduct qualitative interviews with patients and PACT staff to understand potential barriers/facilitators to implementing PS-Stand Down in primary care. Aim 3: Explore baseline moderators to elucidate for whom PS-Stand Down (vs. app only) is most beneficial. Methodology: In a 3-group RCT at the Palo Alto and Syracuse VAs, 274 Veteran primary patients who screen positive for hazardous drinking, received a brief intervention following a positive screen, and are not currently in alcohol use treatment will complete a baseline interview, be randomized to either (i) UC, (ii) UC plus Stand Down, or (iii) UC plus PS-Stand Down (four phone sessions with a Peer over 8 weeks to enhance app engagement), and be re-interviewed at 8, 20, and 32 weeks. For Aim 2, the CFIR framework will guide key informant interviews with 12 patients and 12 PACT providers from each site. Next Steps/Implementation: Depending on the results, we will work with our VACO partners in the Offices of Mental Health & Suicide Prevention and Connected Care to conduct a large multisite implementation trial.	Mental and Behavioral Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 20-102	Kehle-Forbes	Shannon		Shannon.Kehle-Forbes@va.gov	Empowering Veterans to Self-Manage PTSD Symptoms Following Completion of Trauma-Focused Therapy	06/01/2023	01/31/2027	Minneapolis VA Health Care System, Minneapolis, MN	$311,247		Background. Nearly 90% of Veterans who complete trauma-focused therapy (TFT) for PTSD have remaining treatment needs. In the six-months following TFT, successful completers remain some of the highest utilizers of VA mental health services despite clinically meaningful symptom improvement. Our prior work demonstrated that Veterans who benefitted from TFT's primary post-TFT treatment needs were the practice and application of skills learned during therapy, with the goal of maintaining or building upon treatment gains. Veterans expressed low self-efficacy for meeting these goals without the support of their therapists and feared stagnation or relapse without ongoing contact. As such, we developed and feasibility-tested a therapist- assisted self-management program for TFT completers (EMPOWER) designed as a step down from active psychotherapy. The feasibility open trial demonstrated that EMPOWER is feasible and highly acceptable to patients. Further, findings suggest that the intervention was successful in helping Veterans maintain or enhance PTSD-related gains while reducing their mental health service utilization. These promising findings warrant a randomized evaluation. Significance. Interventions that meet Veterans' post-TFT treatment needs are urgently needed. Mental health providers are delivering ongoing treatment to this high priority cohort of Veterans without evidence to guide their treatment plan. Further, higher than expected levels of post-TFT mental health care utilization threatens the continued implementation of these highly effective treatments. For all Veterans to have access to the most effective treatments for PTSD, we must evaluate and implement interventions that prepare and enable successful TFT completers to step down from active therapy. Innovation. The proposed study is the first large-scale study of post-TFT care and the first to rigorously evaluate a self-management program to step-down from active to maintenance mental health services following a course of active psychotherapy. More broadly, we believe it to be the first intervention to directly facilitate an episodic model of mental health care. Specific Aims: 1) Estimate posterior probability distributions of EMPOWER's effects and establish likely ranges for those effects as compared to post-TFT TAU for Veterans' MH service utilization and self-reported PTSD symptoms. The subsequent Hybrid RCT will be designed after assessing the likelihood of detecting an effect for EMPOWER across a range of sample sizes using Go/No Go and Overall Power methods. 2) Explore the impact of EMPOWER compared to post-TFT TAU on Veterans'(a) self-efficacy for managing PTSD symptoms, (b) satisfaction with post-TFT care, (c) well-being & functioning (d) depression, and (e) secondary utilization outcomes. 3) Conduct semi-structured interviews with Veterans and providers to contextualize quantitative findings and identify potential barriers, facilitators, and strategies to facilitate future implementation of EMPOWER. Methodology: We are proposing a pragmatic randomized control trial (RCT) in which 36 PE and CPT providers will be randomized to support Veterans as they participate in the EMPOWER self-management program or facilitate TAU. Participants will be patients of the study providers who recently completed a course of PE/CPT during which they experienced clinically meaningful reductions in PTSD symptoms (n=90). Primary outcomes will be mental health service utilization (overall and with PE/CPT providers) and self-reported PTSD symptoms measured four times over a 9-month period. Qualitative interviews with providers (n=18) and Veterans (n=24) focused on providers' impressions of treatment effectiveness, implementation challenges/potential strategies, and Veterans' perception of treatment effectiveness. Next Steps: With partners at the National Center for PTSD and the Office of Mental Health & Suicide Prevention, we will determine whether a subsequent Hybrid Type I or II RCT is warranted.	Mental and Behavioral Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 20-114	Zulman	Donna	Matthew Maciejewski	Donna.Zulman@va.gov	Social and Behavioral Determinants of Health in High-Risk Veterans	10/01/2021	09/30/2025	VA Palo Alto Health Care System, Palo Alto, CA	$953,920		Background. Social factors exert a substantially more potent impact on health than does health care, especially among disadvantaged populations such as VA users. Adverse social determinants of health (SDH)—factors such as housing instability, food insecurity, social isolation, and transportation barriers—are linked to problems with access, poorer clinical outcomes, and increased health care costs. Despite the clinical and business case for integrating SDHs into health care, these factors are not systematically assessed or addressed in clinical settings. Significance/Impact. This study will leverage a previous survey of Veterans at high-risk for hospitalization, and a new survey to be fielded to a nationally-representative sample of Veterans, to determine how SDHs influence clinical, health care utilization, and experience outcomes. Review of findings by key stakeholders will generate recommended SDH measures for universal screening within VA. These steps, coupled with qualitative interviews about implementation challenges, will inform the future integration of high-value patient-reported SDH measures into VA’s health record. Innovation. The proposed work is innovative in its evaluation of a broad array of SDHs in high-need Veterans to identify candidate measures for electronic health record (EHR) integration. The study will leverage a theoretically-driven survey of SDH measures with a data-driven approach to identifying the associations between these SDHs and a range of health, utilization, and patient experience outcomes. Results from these analyses will inform a facilitated deliberative process to prioritize high-value, validated, and actionable measures that are predictive of outcomes that are important to Veterans and the VA. Specific Aims. In Aim 1, we will use data from an Office of Primary Care-funded survey of Veterans at high-risk for hospitalization to examine relationships between patient-reported SDH measures and utilization, cost, and days in the community outcomes. In Aim 2, we will field a survey to a nationally-representative sample of VA patients to determine the association between SDH measures and key outcomes, and to examine the prevalence of SDHs in subpopulations of Veterans who are disproportionately affected by disparities (e.g., women, racial/ethnic minorities, and rural Veterans). Aims 1 and 2 will inform partner and stakeholder discussions in Aim 3 to identify measures that are associated with key outcomes and that are perceived by operations partners as actionable (i.e., addressable through VA or community services) and thereby good candidates for EHR integration. Methodology. In Aim 1, we will leverage data from an operations-funded survey that our team administered in 2018. Using survey data for 4,685 Veterans at high-risk for hospitalization, we will examine the association between patient-reported SDHs and utilization (i.e., VA and Medicare emergency department visits and hospitalizations), VA and Medicare costs, and days in the community. In Aim 2, we will field a similar survey to a nationally-representative sample of Veterans, evaluate the association between SDHs, patient experiences (e.g., perceived access and coordination), and 12-month VA emergency department visits, hospitalizations, and costs, and describe the prevalence of SDHs in the general VA population and Veterans who are at risk for health disparities. In Aim 3, we will use a facilitated deliberative process with key stakeholders to prioritize actionable SDH measures for EHR integration, and then conduct qualitative interviews with health system leaders, clinicians, staff, and patients to examine implementation barriers and facilitators to assessing select SDH measures at point of care. Implementation/Next Steps. This study addresses health equity, particularly relevant in light of COVID-19, and will be conducted with partners from VA’s Offices of Primary Care, Health Equity, Rural Health, and Women’s Health. The study is especially timely with VA’s transition to the new Cerner EHR as the proposed aims will identify SDH measures for potential EHR integration that are concise, actionable, and predictive of important outcomes.	Equity				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 20-117	Fu	Steven		steven.fu@va.gov	Veteran Social Support Intervention for Enhancing Smoking Treatment Utilization and Cessation	06/01/2023	09/30/2025	Minneapolis VA Health Care System, Minneapolis, MN	$513,065		Background: Enhancing access and use of evidence-based tobacco cessation treatments and eliminating tobacco-related health disparities are top national and VA health services priorities. The prevalence of tobacco use is greater among Veterans compared to non-Veterans. From 2010-2015, 29% of women and 21% of male Veterans reported current cigarette smoking. Evidence-based cessation treatments (EBCTs) such as, tobacco quitlines, behavioral counseling, and pharmacotherapy, are greatly underutilized by Veteran smokers. Gaps remain in reaching women Veterans and use of existing social support networks to enhance use of EBCTs and cessation among Veterans Innovation and Impact: This project is innovative for evaluating social support networks as a proactive outreach approach to enhance cessation treatment utilization among Veteran smokers. The role of social network influences and social support on successful smoking cessation is established. Based on Cohen’s theory of social support, our team developed a social support intervention for diverse family members, friends, and other adults who wanted to help a smoker quit. The intervention consists of written materials and a 1-call, 15-25 minute coaching session. It is expected to be especially beneficial for Veteran smokers who might not otherwise access cessation treatment. Because our prior VHA trials enrolled about 94% men and the higher smoking rates among women, we will oversample women to enroll an equal number of men and women smokers. Our study contributes to VA HSR&D’s priority initiatives for enhancing treatment access and women’s health and is significant because it will advance research on the role of partnering with Veterans’ families and/or important others to enhance access to VA healthcare and population-specific treatments, especially women Veterans. The potential reach and public health impact of an effective social support intervention for the Veteran tobacco user population is considerable. Specific Aims: (Aim 1) To evaluate the impact of the social support intervention on Veteran smokers’ use of EBCT, (Aim 2) To examine the effectiveness of the social support intervention on the biochemically confirmed 7-day point prevalence cigarette smoking abstinence, (Aim 3) To explore potential moderators (e.g., smoker gender, SP tobacco use status) of intervention effects on study outcomes, and (Aim 4) To conduct a process evaluation assessing implementation outcomes (reach, adoption, fidelity) of the social support intervention and multilevel factors that may influence implementation. Methodology: We will conduct a pragmatic randomized controlled trial (RCT) within the national VHA health system to evaluate the effectiveness of a social support intervention compared with a control condition on utilization of EBCT among VHA-enrolled smokers. Veteran smokers, regardless of level of readiness to quit, will be identified nationally using the VHA electronic health record and proactively recruited. Interested smokers will be asked to identify a support person (SP) who will enroll. Participants will be randomized as smoker-SP dyads to the intervention (n= 594 dyads) or control condition (n= 594 dyads). All smokers will receive written resources and information on EBCTs. All SP participants will receive written materials. SP participants assigned to the intervention group will additionally receive a 1-call coaching session. Assessments for dyads in both study groups will be conducted at baseline, 3-, and 6-months post-randomization. Implementation/Next Steps: Next steps depend on the actual results, but we expect findings to be important to VA leaders, the VA Women’s Health Research Consortium and the Veteran community. We will maintain communication throughout the project with VA program partners to share findings in a timely manner. We will collaborate with CCDOR’s Veteran Engagement Panel on development of patient-centered dissemination approaches and recommendations for future intervention adaptations and/or implementation.	Complementary and Integrative Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 20-122	Duan-Porter	Wei		wei.duanporter@va.gov	ECCO - Evaluation of Outcomes Associated with Community Care Prescribed Opioids	03/01/2023	09/30/2026	Minneapolis VA Health Care System, Minneapolis, MN	$394,037		Background: Starting in 2013, VA's Opioid Safety Initiative expanded resources for pain management and successfully reduced high-risk opioid prescriptions. MISSION Act expansion of VA Community Care (CC) includes authorization for CC providers to prescribe opioids for outpatient treatment of acute and chronic pain, but charges VA with ensuring that these are safely and appropriately dispensed from VA pharmacies. Veterans who use both VA and non-VA services may be particularly at risk for opioid-related harms, but past work was conducted before MISSION Act implementation and mainly addressed services paid by non-VA insurers. Although the main goal of MISSION Act is to improve Veterans' health care access, it remains unclear how CC expansion has impacted opioid safety and patient-reported outcomes for Veterans. Significance & Impact: Reducing opioid-related harms and improving treatment for chronic pain are high- priority goals for VA HSRD and clinical services. Given increasing numbers of Veterans now using CC, there is an urgent need to better understand Veteran, community, and VA facility factors associated with receipt of CC opioids, and explore potential differences in higher-risk CC prescriptions, compared with VA-prescribed opioids. Moreover, examination of Veteran-centered pain outcomes will address the ORD-wide priority of increasing real- world impact of VA research. Innovation: This study will be the first to evaluate Veteran-centered outcomes associated with CC opioids, including functioning and health-related quality of life. The proposed design also includes multiple elements to rigorously address multilevel confounders, including variation in community opioid prescribing patterns. We use innovative causal estimation methods in our predictive models, in order to understand the relative importance of a variety of factors in contributing to likelihood of receiving CC opioids. Specific Aims: 1) Identify key multilevel predictors of receiving any CC vs. only VA-prescribed opioids for outpatient pain treatment, and evaluate potential differences in higher-risk opioid prescriptions; and 2) for a national prospective cohort of Veterans receiving any CC vs. only VA-prescribed opioids, examine differences in patient-reported outcomes and acute care episodes over 1 year. Methodology: First, we will conduct a retrospective analysis using national VA data from January-December 2021 to determine key Veteran, community, and VA facility factors that predict receiving any CC-prescribed opioids. Then, we will use propensity score adjusted models to examine differences in higher-risk opioids prescriptions between Veterans receiving any CC vs. only VA-prescribed opioids. For Aim 2, we will enroll a prospective national cohort to evaluate outcomes associated with receiving any CC vs. only VA-prescribed opioids. We will use survey data (at baseline and 1-year follow-up) to assess patient-reported outcomes (pain- related functioning, pain severity, quality of life, and satisfaction with pain care) and acute care episodes (hospitalizations and emergency department visits). Implementation & Next Steps: We will disseminate study results to various stakeholders, including Veterans, VA staff, and VA leadership. The exact next steps will depend on the nature of findings and their immediate relevance to different stakeholders. We will work with our operational partners in the VA Program for Pain Management, Opioid Safety and PDMP, Office for Medication Safety, and Office of Community Care to develop the dissemination plan. We will also seek feedback from our Veteran Engagement Panel to inform dissemination efforts. We will communicate findings through presentations and publications, cyber-seminars, and involvement with groups or networks focused on improving CC services and pain treatment for Veterans.	Systems Modeling, Design, and Delivery				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 20-146	Shepardson	Robyn		Robyn.Shepardson@va.gov	Improving Anxiety Treatment Engagement and Effectiveness in Primary Care-Mental Health Integration: Multi-site Hybrid I RCT of a Brief Veteran-Centered Anxiety Intervention	05/01/2021	09/30/2024	Syracuse VA Medical Center, Syracuse, NY	$1,077,940		Background: Many Veterans experience impairing symptoms of anxiety and seek treatment in primary care, yet anxiety is highly undertreated in this setting. Primary Care-Mental Health Integration (PCMHI), in which mental health clinicians embedded in primary care provide brief treatment, affords an opportunity to address this treatment gap. However, behavioral interventions that are compatible with the brief PCMHI treatment format and able to accommodate a wide range of anxiety presentations are needed. Accordingly, Veterans Anxiety Skills Training (VAST) was designed to be evidence-based, transdiagnostic, feasible for PCMHI, and Veteran-centered. VAST comprises empirically-supported cognitive-behavioral therapy (CBT) techniques adapted into a manualized modular intervention specifically designed for delivery in PCMHI. As VAST is being piloted at a single site with study therapists, the next scientific step is a multi-site randomized controlled trial (RCT) to evaluate its effectiveness using PCMHI providers in routine care. Significance/Impact: This study addresses Veteran care priorities of mental health and suicide prevention, MISSION Act priorities of increasing access to care and improving patient satisfaction with Veterans Health Administration (VHA) care, and Health Services Research and Development (HSR&D) focus areas of quality, effectiveness, and efficiency as well as implementation science research methods. Improving anxiety treatment in PCMHI will address a major gap in VHA treatment options, given the high prevalence of anxiety in primary care, tendency for patients with anxiety to seek treatment in primary care rather than specialty mental health settings, and absence of Evidence-Based Psychotherapy (EBP) protocols addressing non-trauma related anxiety. Innovation: Modular (vs. standard) intervention designs offer advantages in efficiency, patient and provider satisfaction, efficacy, effectiveness, implementation, and sustainability. Other innovative aspects include the transdiagnostic approach and examination of fidelity to inform future implementation. Specific Aims: The specific aims are to: (1) Compare patient clinical outcomes for VAST vs. PCMHI usual care between baseline and 16 weeks (post) in a multi-site RCT in which PCMHI providers deliver VAST, and examine whether treatment gains are more likely to be maintained for VAST vs. PCMHI usual care at 28 weeks (follow-up); (2) For participants assigned to receive VAST, explore patient-level predictors of (a) early (8 weeks) and (b) overall (16 weeks) treatment response; and (3) Conduct a mixed-methods process evaluation of VAST implementation to examine rates of, barriers to, and facilitators of achieving and sustaining high-fidelity intervention delivery. Methodology: In this multi-site, hybrid type I effectiveness-implementation RCT, 178 adult Veterans with elevated anxiety symptoms will be recruited from primary care at two VHA sites. PCMHI providers will be randomized to deliver either VAST or usual care (routine PCMHI care, meaning whatever care the provider deems appropriate), and participants will be randomized to condition. VAST (up to six biweekly 30-minute sessions) consists of a standard initial and final session as well as up to 4 CBT skills-based modules. The primary outcome (Overall Anxiety Severity and Impairment Scale) and secondary outcomes (anxiety and depressive symptom severity, functioning, quality of life, suicidality) will be assessed at baseline, 4, 8, 12, 16 (post) and 28 weeks (follow-up). Multi-level modeling will be used to evaluate the hypothesis that patient clinical outcomes will improve more from baseline to 16 weeks for participants receiving VAST compared to PCMHI usual care. Multivariate logistic regression will be used to explore predictors of early (8 weeks) and overall (16 weeks) VAST treatment response. A mixed- methods process evaluation will examine the proportion of PCMHI providers who achieve and sustain high- fidelity VAST delivery as well as barriers to and facilitators of high-fidelity delivery. Implementation/Next Steps: VAST will be disseminated to VHA PCMHI leadership and providers nationwide using several strategies, and a follow-up hybrid III trial will facilitate formal implementation in VHA PCMHI.	Mental and Behavioral Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 20-154	Intrator	Orna	William Hung, Jennifer Sullivan	Orna.Intrator@va.gov	Hospital In Home: Evaluating Need and Readiness for Implementation (HENRI)	06/01/2022	09/30/2025	VA Finger Lakes Healthcare System, Canandaigua, NY	$699,758		Background: The Department of Veterans Affairs (VA's) Hospital In Home (HIH) program, designed from experiences of the Hospital At Home community program, is a model of care that delivers patient-centered, acute-level hospital care at home which has demonstrated safety, effectiveness and patient satisfaction beyond those observed in hospitals. Since 2010, the VHA Office of Geriatrics & Extended Care (GEC), through its transformational programs and mentored partnerships has spurred the development of [12] HIH program sites nationally, which have all been sustained by their parent station. Significance/Impact: [Hospital In Home is a mix of interventions and levels of implementations; understanding how to weave these successfully is the overarching aim of this project.] Continued spread of HIH across the VA requires evidence be established regarding the need for HIH and about the implementation of existing HIH programs. Understanding barriers and facilitators and processes of implementation of HIH programs will allow more facile adoption of HIH programs allowing for substantial cost savings of about $3,000 per inpatient event. Especially in the era of the Mission Act, having HIH available may incentivize Veterans to choose VA. [With the recent Covid-19 pandemic, HIH has been identified as a potential contributor to addressing the disease and sequelae.] Innovation: This project will generate generalizable knowledge regarding implementation of HIH models and will advance implementation science from its application of implementation science frameworks, Re-Aim- PRISM and novel methods such as Implementation Mapping. The project will curate knowledge garnered from the existing programs and develop tools to disseminate it. It will develop and conduct readiness for implementation surveys. Finally, it will “dry-run” implementations in sites with greater readiness for implementation. The results of the “dry runs” will provide feedback to the implementation planning thus increasing their probability of successful adoption of HIH and its sustainment and growth. Specific Aims: 1. Establish evidence regarding the implementation of the existing HIH sites using a mixed methods approach. Deliverables: An evaluation framework and report summarizing the experiences of the existing sites. 2. Develop operational implementation tools and a readiness for implementation survey to be conducted. Deliverables: A survey of readiness for implementation and prioritization of sites ready to implement; implementation tools. 3. Select ten new sites with the greatest evidence of readiness for implementation to conduct “dry-runs” and create blueprints for implementation; identify causal loop diagram(s); catalog the evidence. Deliverables: Report summarizing common and site specific implementation themes; Site-specific Implementation logic models; Searchable catalog of HIH implementation strategies. Methodology: This mixed-methods project will conduct quantitative analyses, interviews, focus groups and “dry runs” applying implementation science frameworks and methods (RE-AIM-PRISM, implementation mapping) and system science to understand the existing HIH programs and to create implementation tools, evaluation framework, readiness survey, causal loop diagrams and a searchable catalog of HIH implementation evidence. Implementation/Next Steps: Future work will develop simulation studies and conduct evaluations of newly implemented sites as well as a hybrid II implementation trial of the effectiveness and safety of the HIH model.	Long Term Care and Aging				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 20-165	Hynes	Denise		denise.hynes@va.gov	Care Coordination and Outcomes for High Risk Patients: Building the Evidence for Implementation	10/01/2021	09/30/2025	VA Portland Health Care System, Portland, OR	$856,764		Abstract Background: Care coordination is essential to improve patients’ access to healthcare, clinical outcomes, enhancing patients experience, increasing provider satisfaction, and decreasing or maintaining costs, yet appears to be most successful for those with complex care needs. While the VA’s established primary care model, the Patient Aligned Care Team (PACT) has proven effective in increasing Veterans’ experience and trust while decreasing costs, many high need, high risk Veterans lack support for their complex clinical and psychosocial needs that impacts their health care use, outcomes and costs. Two major VA initiatives led by the Offices of Nursing Service (ONS) and Care Management and Social Work (SW), and the Office of Community Care (OCC) intend to address this gap with initiation of new care coordination needs assessment (CCNA) tools to match Veterans with the right level of care coordination and services in 2019. Yet, the CCNA tools and organizational processes have not been evaluated. Significance: Evaluation and implementation of effective care coordination practices are a high priority for the VA and is the focus of two major national initiatives to address MISSION Act access to care goals. Innovation/Impact: We will leverage ongoing initiatives, using routinely collected CCNA data, supplemented with health care use data, and Veteran and provider perspectives to systematically evaluate care coordination needs assessment tools, practices, and impacts on Veterans’ services received, outcomes and costs. Specific Aims: We will build evidence about the CCNA, processes, and outcomes for high need, high risk Veterans seeking VA covered healthcare at VA facilities and community sites. Our aims are to: 1. Characterize and compare the relationship between Veteran needs assessment, services received, health outcomes and costs for Veterans exposed to CCNA with a matched comparison group. 2. Survey and compare Veterans about their experience with care coordination services, integration with other healthcare services, and perceived health impacts. 3. Conduct formative evaluation to assess provider perceptions at early adoption VA sites about CCNA tools and processes related to determinants of innovation diffusion, care integration, and to inform and conduct a broader survey of providers. Methodology: We will use an organizational theoretical approach including care coordination and innovation diffusion frameworks to guide our research and employ an observational design using quantitative and qualitative methods. Veterans treated at early adopter sites beginning in 2019 and categorized as needing complex care based on the CCNA will be compared to matched Veterans using multiple data sources. Data sources will include Veteran CCNA from the CC/ICM and OCC sites; CDW, VA Community Care, Consult Toolbox, Medicare, vital status, and cost data. Survey data will be collected from Veterans and providers. Quantitative analyses will describe and compare Veterans’ health services use, mortality and costs. Qualitative analyses will focus on understanding how perceived attributes of the CCNA tools, as well the perceived organizational context and implementation, influence uptake and adoption. The results of these analyses will inform ongoing CCNA adaptation, build the evidence for the utility of the innovation attributes for real-life implementation, and ensure evaluation of CCNA tools captures the most important elements. Next Steps/Implementation/Sustainability: Building the evidence for care coordination processes will inform best practices and implementation. With the VA’s electronic health record migration, this study may inform how to adapt new CCNA electronic tools to facilitate and sustain implementation of evidenced-based practices.	Health Care Organization and Implementation				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 20-222	Gravenstein	Stefan	Christine Jones	stefan.gravenstein@va.gov	Post-Acute Home Health Care for Veterans: Examining Payer Source, Quality, and Outcomes	07/01/2022	03/31/2026	Providence VA Medical Center, Providence, RI	$722,262		PROJECT SUMMARY/ABSTRACT Background. Veterans are at increased risk of adverse outcomes after hospital discharge, including rehospitalization, nursing home admission, and mortality. Post-acute skilled home health care (HHC) can provide critical support for Veterans following a hospitalization. The services provided through HHC, including nursing and therapies, can help Veterans meet their goals to improve function, well-being, and return to independent living in their homes. For Medicare-eligible Veterans, skilled HHC is provided through 1) VA purchased skilled HHC from a contracted HHC agency or 2) Medicare-funded HHC (i.e., Part A benefit, Medicare Advantage). Preliminary work suggests that the majority (66%) of Veterans discharged home from VA Medical Centers (VAMCs) with skilled HHC receive VA-contracted skilled HHC and the remainder receive Medicare-funded HHC. However, funding for skilled HHC varies substantially across VAMCs, with implications both for HHC service delivery and Veterans’ outcomes. In preliminary work, we found that 30-day readmissions are higher among Veterans who receive VA-financed HHC compared to Medicare-financed HHC, which could be related to HHC agency quality. Significance/Impact. A better understanding of HHC referrals and financing, which has always been purchased and delivered by community HHC agencies, could provide key insights for the VA given the growth in community care for Veterans. Because community home health agencies have always provided post-acute HHC, this context provides an ideal opportunity to examine interorganizational partnerships and Veterans’ outcomes. The proposed research will characterize post-acute HHC use, financing, and quality of care, and how these factors are associated with outcomes for Veterans discharged from VAMCs, as well as providers’ and Veterans’ experiences of delivering and receiving post-acute HHC. Findings will inform the development of a toolkit for VA and HHC leaders with resources to guide high-value HHC agency selection and collaboration. The contribution of this research is significant because the results will directly inform how operational partners choose HHC agencies to include in provider networks and develop policy for skilled HHC referrals, and will also provide practical tools for multiple stakeholders to provide optimal HHC for Veterans. Innovation. This is the first comprehensive study to examine VA contracting, referral practices, and financing - including both VA and Medicare - to understand their influence on Veterans’ outcomes. A stakeholder- engaged, complex mixed-methods study design is used to understand the mechanisms and processes that shape the use and outcomes of post-acute HHC from multiple perspectives. Specific Aims. 1) Identify determinants of VA vs Medicare-financed post-acute skilled HHC among community dwelling Medicare-enrolled Veterans; 2) Understand multiple stakeholders’ perspectives on older Veterans’ use of post-acute skilled HHC and factors that influence the delivery of HHC; 3) Determine the impact of home health agency quality and HHC payer source on differences in outcomes for older Veterans receiving post- acute HHC. Methodology. This proposal uses a complex mixed-methods study design with advanced statistical techniques and comprehensive VA and Medicare administrative data, as well as a robust qualitative approach to interview stakeholders from VAMCs, HHC agencies, Veterans, and caregivers to accomplish our aims. Implementation/Next Steps. The culmination of findings from this work will be incorporated into a toolkit to promote high-value HHC selection and collaboration. In addition, this work will form the foundation for a large- scale study to develop and test implementation and effectiveness of a shared decision-making model for Veterans and VAMC personnel to promote high-value HHC.	Long Term Care and Aging				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 20-240	Donovan	Lucas		lucas.donovan@va.gov	Pragmatic Obstructive Sleep Apnea Weight Loss Trial Assessing Effectiveness and Reach (POWER)	10/01/2021	03/31/2025	VA Puget Sound Health Care System Seattle Division, Seattle, WA	$1,101,317		Background: Prevalent obesity related conditions like obstructive sleep apnea (OSA) represent an important opportunity for the VA to improve population health. OSA markedly reduces quality of life and is associated with 3-fold greater risk for cardiovascular disease. Although obesity is the single greatest reversible risk factor for OSA, the 1 million Veterans with OSA and obesity rarely receive weight loss care to reverse OSA and other serious comorbidities. Efficacy trials reinforce that time and resource intensive lifestyle-based weight loss programs improve weight and physiologic measures of OSA severity (apnea hypopnea index, AHI). However, there are barriers to translating these findings into meaningful gains for population health. First, VA has limited capacity to counsel patients around lifestyle change. Less than one-third of Veterans with OSA and obesity are counseled about weight loss and even fewer are referred to weight loss services. Second, VA’s current weight loss offerings are difficult to access. Only 12% of Veterans with OSA and obesity utilize MOVE!, and those referred to MOVE! achieve minimal weight loss—1.2 kg at 1 year. Third, prior weight loss trials focused on intermediate measures (e.g. AHI), limiting understanding of effectiveness for meaningful outcomes. To meet these challenges, we propose a pragmatic trial of proactively offering a remote video-based and self-directed weight loss intervention with telephone-based coaching to Veterans with newly diagnosed OSA. Our weight loss intervention (D-ELITE) is adapted from a program known to be effective in a non-VA population, with 44% of participants achieving ≥5% weight loss at 24 months. Further optimizing reach, our remote intervention includes low-technology options (e.g. DVD videos) to accommodate those with low technology literacy. Significance: Our research tests a program of proactively providing Veterans with OSA the tools to manage weight loss in a way that is independent of local provider time and resources. Our research addresses a key gap in Veteran’s health in a way that aligns with important VA priorities including population health, virtual care, access, and health care value. We anticipate our intervention can efficiently achieve improvements in quality of life while reducing the burden and risk of serious comorbidities. Innovation and Impact: Our research directly challenges the traditional provider-driven model of healthcare delivery where providers direct care and provide necessary services aimed at managing a single disease. Instead, we propose to proactively deliver weight loss services to a high-risk group using a population health approach. In doing so, we will conduct the first trial of remote and self-directed weight loss care in OSA and will test whether weight loss care can improve meaningful outcomes such as quality of life and cardiovascular risk. Specific Aims: Our primary aim is to test the effectiveness of a proactively delivered and pragmatic weight loss intervention to improve co-primary endpoints of sleep-related quality of life and weight among Veterans with OSA and obesity. Secondarily, we will compare additional outcomes between groups: cardiovascular risk scores, sleep symptoms, and AHI. Finally, we will also conduct an implementation process evaluation informed by the RE-AIM framework to identify barriers and facilitators to widespread implementation. Methodology: We plan a hybrid type 1 pragmatic randomized controlled trial. We will proactively identify Veterans with OSA and obesity nationwide using data from the CDW (n=696), randomizing 1:1 to usual care plus the D-ELITE weight loss intervention or usual care alone. We will collect primary outcomes at 12 months, but we will also collect outcomes at 3 and 24 months to assess trends over time. We will use quantitative and qualitative methods to assess barriers to implementation, including a comprehensive budget impact analysis. Next Steps/Implementation: If effective, we will work with our operational partner, the National Center for Health Promotion and Prevention (NCP), to integrate D-ELITE into NCPs suite of weight loss offerings. The National Program Office for Pulmonary/Sleep also agrees to promote policies supporting nationwide adoption.	Complementary and Integrative Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 20-241	Vimalananda	Varsha		Varsha.Vimalananda@va.gov	Patient Experience of Specialty Care Coordination under the MISSION Act	06/01/2022	09/30/2025	VA Bedford HealthCare System, Bedford, MA	$999,686		Background. The MISSION Act incurs unprecedented challenges to care coordination due to greater use of community care (CC). Yet VA lacks data on patients' experience of coordination, which hinders improvement efforts. This prospective survey study focuses on VA primary care patients with common chronic medical conditions that require care coordination [diabetes, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD)]. It will compare patients' experience of specialty care coordination with VA vs. CC, examine how patients' and clinicians' experiences of coordination relate, and examine the association of patients' experience of coordination to important outcomes. Significance. This project addresses HSR&D priority: MISSION Act, coordination of VA and non-VA care. It will examine how coordination, as experienced by Veterans, relates to both antecedents and outcomes in VA and CC. These data are novel, important to VA's mission to ensure high quality care within VA and for CC, and will be actionable by operational partners while advancing the science of care coordination. Innovation. The surveys measure specialty care coordination directly, i.e. as experienced, by the three main stakeholders (“triad”) in specialty care coordination: patient, PCP and specialist. Direct assessment of coordination (rather than of satisfaction) provides specific, actionable information about what needs to improve. The triad approach permits comprehensive assessment by those who most directly experience the effects of efforts organize care. It also enables us to examine how stakeholder experiences inter-relate. Specific Aims. AIM 1. Compare patients' overall experience of coordination in VA vs. CC.  H1a. Scores for overall coordination will be better in VA vs CC.  H1b. The gap in coordination scores for high- vs. low-complexity patients will be less in VA vs. CC. AIM 2. Examine how patients' overall experience of coordination correlates with those of PCPs and specialists.  H2a. In VA, patients' scores for overall experience will correlate most strongly with scale scores for PCPs and specialists on clarity and agreement on roles and responsibilities.  H2b. In CC, patients' scores for overall experience will correlate most strongly with the scale scores for PCPs and specialists that measure adequacy of data transfer. AIM 3. Examine the association of patients' overall experience of coordination with selected outcomes: test duplication, medication problems, A1C control (in diabetes), self-efficacy, and patient satisfaction.  H3a. Each outcome is better in VA vs. CC.  H3b. Better coordination as experienced by patients is associated with fewer duplicated tests and medication problems, and better A1C control (in diabetes), self-efficacy, and patient satisfaction. Methodology. VA primary care patients with referrals to VA or CC specialty care for diabetes, CHF, or COPD will be included. Clinicians of patient survey respondents will be included. Surveys will be used to measure coordination, medication problems, self-efficacy, and satisfaction. Test duplication and A1C control will be from VA databases. Hierarchical regression models will control for the nesting of patients within facility complexity levels, and system-level comparisons will account for selection bias with propensity score weighting. Implementation/ Next Steps. Bi-annual reports for operational partners will include actionable and evidence- based recommendations about clinical or policy interventions that could address any shortcomings we find. We will apply for project funding to examine hypotheses generated by the proposed work. These may include studies to examine, for example, best practices to coordinate from the patient and/or clinician perspective, reasons for any observed facility effects, or prospective studies on coordination and other outcomes.	Health Care Organization and Implementation				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 20-242	Krein	Sarah		Sarah.Krein@va.gov	Self-Administered Acupressure for Veterans with Chronic Back Pain: A Multisite Evaluation of Effectiveness and Implementation	06/01/2022	08/31/2025	VA Ann Arbor Healthcare System, Ann Arbor, MI	$811,169		Background: It is estimated that about half of the 9 million Veterans who receive care at Veterans Health Administration (VHA) have chronic pain, of which chronic low back pain (CLBP) is a major type. Veterans with CLBP are high healthcare utilizers and are experiencing a dramatic shift in care – from a medical approach that relied on medications like opioids for pain management to a biopsychosocial approach in which evidence - based, lower risk non-pharmacological options are favored. Non-pharmacological interventions, which include complementary and integrative health (CIH) treatments, are now a first line of care. Consequently, Veterans need to be able to access these treatments, but they are complex to deliver and difficult to provide in real-world settings. Thus, non-pharmacological treatments for CLBP need to not only be effective, but also low cost, easy-to-administer, accessible, and acceptable to Veterans and to their providers. Significance: Our long-term goal is to improve chronic pain management for Veterans with CLBP by integrating an effective self-administered acupressure intervention into VHA using current structures that support Veteran-centered care. The proposed project is a crucial first step. It directly addresses priorities from VA, HSR&D, and CARA legislation that seek to provide greater access to non-opioid options for chronic pain, including CIH treatments like acupressure. Innovation and Impact: This project leverages the unique infrastructure within VHA to test and deliver interventions that could have system-wide uptake. Self-administered acupressure is an ideal intervention to test using the existing VHA support structure for CIH treatments, the Whole Health System. Self-administered acupressure is a promising candidate for uptake at VHA given its low risk and ability to be performed at home at any time. In addition to providing evidence that can inform VA clinical practice guidelines for low back pain on effectiveness of self-administered acupressure for CLBP, this project will also inform on how to begin to implement this treatment at VHA, which would support the recent CIH Directive that outlines processes for how to integrate CIH treatments for Veterans. Specific Aims: Aim 1: Determine effectiveness of a 6-week self-administered acupressure protocol on pain interference, disability, fatigue, and sleep post intervention, and [sustained effects at 10 weeks] and 2) Evaluate supports and barriers for implementation of self -administered acupressure to Veterans with CLBP. Methodology: A Type 1 effectiveness-implementation hybrid study will be conducted at three VA sites: Ann Arbor VA Medical Center, Toledo Community-Based Outpatient Clinic, and Flint Community-Based Outpatient Clinic. There will be 300 Veterans recruited from providers at these sites and through classes offered through the Whole Health System, an initiative designed to teach Veterans how to self-manage aspects of their health. Participants who are randomized into the stimulating acupressure arm will be compared to participants randomized into a wait list control group and implementation factors will be measured quantitatively and qualitatively. This work is guided by dissemination frameworks, engaging stakeholders, measuring fidelity, considering site characteristics, and assessing facilitators and barriers to implementation. Next Steps/Implementation: This study contributes to the knowledge base of self -administered acupressure as a treatment for symptoms in CLBP, extending the state of the research beyond efficacy studies. It fills a gap in knowledge about effectiveness and how to best implement self-administered acupressure. This project will provide critical information that can increase the ability to access a patient-preferred, non-opioid pain treatment. If self-administered acupressure is effective, next steps would be to test implementation across several VA sites in different regions and more comprehensively examine facilitators and barriers considering geographical and cultural differences in Veterans across the country.	Care of Complex Chronic Conditions				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 20-246	Jump	Robin	Charlesnika Evans	Robin.Jump@va.gov	Dissemination and Implementation of a Videoconference Antimicrobial Stewardship Team (VAST)	05/01/2022	03/31/2025	VA Pittsburgh Healthcare System University Drive Division, Pittsburgh, PA	$811,122		Background: Antimicrobial stewardship guidelines call for a multidisciplinary team with an infectious disease (ID) physician and ID-trained clinical pharmacist as core members. Unfortunately, there are insufficient ID- trained specialists to staff on-site antimicrobial stewardship programs throughout VA. Significance: This proposal is highly significant for Veterans and the goals of VA. Veterans experience many of the risk factors associated with development of antimicrobial resistant and healthcare-associated infections. The unprecedented effects of the novel Coronavirus disease 2019 (COVID-19) on the health of our Veterans and on our entire healthcare system makes the demand for ID expertise even more apparent, especially in long-term care. Also, this study directly addresses the VA MISSION ACT to improve access to care, timeliness and quality of care, using telehealth services. Finally, this project is aligned with the priorities of our operation partners: VA Antimicrobial Stewardship Taskforce (ASTF), the VA National Infectious Disease Service (NIDS), VA Pharmacy Benefits Management (PBM) Services, and the Office of Rural Health. Innovation and Impact: The design is innovative because we will systematically test and assess implementation barriers to telehealth for antimicrobial stewardship, a novel approach that has not been implemented in VA facilities, other than in our previous pilot study. Further, the Antibiotic Use Reports (AURs) are an innovative adaptation of peer-comparison, an antibiotic stewardship strategy successful in outpatient settings. This project will provide findings for a scalable model that could be deployed nationally to all applicable VAMCs, continuing the role of VHA as a leader in implementing large-scale interventions focused on prevention and management of ID and stewardship. Specific Aims: Our goal is to implement a multidisciplinary videoconference antimicrobial stewardship team (VAST) in VAMCs using SCAN-ECHO. Our central hypothesis is that feedback reports that quantify facility- level antibiotic use will enhance the efficacy of VASTs to support antimicrobial stewardship. We propose a Type 2 hybrid effectiveness-implementation design, comparing clinical effectiveness in sites that implement the VAST alone (VAST-) to sites that implement the VAST augmented by facility-level Antibiotic Use Reports (VAST+). Aims are: 1) Identify and test effective strategies for implementing the VAST; 2) Determine the influence of the VAST overall and VAST+ on the care of Veterans with suspected infections; 3) Determine the influence of the VAST overall and VAST+ on antibiotic use at each VAMC. Methodology: We will randomize rural VAMCs that do not have ID-trained professionals on staff to implement the VAST alone (VAST-) versus VAST + antibiotic use feedback (VAST+). Aim 1: We will assess modification and adaptations at the intervention sites and by the infectious disease experts. Methods will include process maps and semi-structured interviews to gather qualitative data about what key VAST members perceive as facilitators, barriers and burden to VAST implementation. We will also evaluate costs of implementation. Aim 2: We will evaluate the Veteran population served, clinical activities, and user perceptions of the VAST. We will assess the concordance of clinical care with recommendations from evidence-based clinical practice guidelines. VAST members’ perceptions of the quality and timeliness of care will be evaluated. Aim 3: The primary outcome measure will be overall rates of antibiotic use. Secondary outcomes will be changes in the rates of broad-spectrum antibiotic use, antibiotic starts, and length of antibiotic therapy. Next steps/Implementation: Testing effective implementation of the VAST at additional VAMCs is an important step toward augmenting antimicrobial stewardship in both acute- and long-term care settings. In collaboration with VA clinical operation partners, outcomes from this trial will be used to roll-out an implementation playbook to be used by other VAMCs, as well as non-VA settings.	Care of Complex Chronic Conditions				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 20-253	Hermes	Eric	Christi Ulmer	Eric.Hermes@va.gov	Path To Better Sleep + Virtual Coaching: The Effectiveness and Implementation of Internet-Based Self-Management Program for Insomnia in a Regional Healthcare System	10/01/2022	03/31/2025	VA Connecticut Healthcare System West Haven Campus, West Haven, CT	$629,556		Background: As many as 1.8 million individuals using VA services meet criteria for insomnia disorder, a condition associated with suicide, poor functioning, and medical and mental health disorders. Cognitive Behavioral Therapy for insomnia (CBTi) is the gold-standard treatment. However, only a small fraction of Veterans receive CBTi due to a host of barriers. A digital intervention delivering CBTi, Path to Better Sleep (PTBS), has been developed by VA specifically for Veterans. PTBS, enhanced by personal coaching, may mitigate barriers to CBTi by enabling self-management beyond clinic walls. Significance: Current PTBS dissemination practices consist of inadequate messaging, poor integration into clinical workflow, and no personal support. Preliminary data indicate that while PTBS has increased access to CBTi, only an estimated 0.8% of Veterans with insomnia disorder have visited the PTBS site. To address these gaps, (1) coaching must be integrated with PTBS (Coached PTBS) to increase engagement/adherence and (2) Coached PTBS must be embedded in current VA care practices using a scalable implementation strategy. The prevalence of insomnia far outweighs VA’s capacity to deliver gold-standard treatment through any single modality. An array of treatment options is needed. Moreover, PTBS coaching delivered through a hub-and- spoke model is a scalable approach to MISSION Act directives mandating evidence-based care in rural areas. Innovation and Impact: PTBS is the first digital CBTi designed for Veterans. PTBS is open access and meets stringent VA information security requirements. Coaching integrated into PTBS will increase engagement and adherence. A hub-and-spoke model of coaching limits reliance on local facility resources. A scalable implementation strategy for digital interventions, optimized in prior research, will be used. The VISN 1 clinical trials network allows access to a rural Veteran population and provides research coordination resources. Specific Aims: 1. [Establish effectiveness of Coached PTBS when implemented in rural-facing VISN 1 facilities] H1: Veterans randomized to Coached PTBS will report greater improvement in insomnia severity (primary) and sleep parameters (secondary) compared to [PTBS + Contact (enhanced treatment as usual control)] 2. Evaluate the quantitative outcomes of REP-DI, the strategy used to embed Coached PTBS in VA care. H2: REP-DI will result in adequate Reach among Veterans, Adoption among providers, and Maintenance. 3. Conduct a 3-part formative evaluation of implementation. Interviews with Veterans, providers, and staff will be informed by constructs from the Consolidated Framework for Implementation Research (CFIR). Data will optimize implementation in real time by tailoring implementation strategy elements to specific contexts. Methodology: A pragmatic hybrid type-2 effectiveness/implementation mixed-methods trial will be used. Outpatients with insomnia disorder will be referred by providers and randomized to Coached PTBS or PTBS + Contact. The implementation strategy will be REP-DI, a scalable and resource efficient strategy for implementing digital interventions. REP-DI will include provider training and augmentation of site referral processes to support PTBS implementation. Outcomes will be evaluated according to the RE-AIM framework. Outcomes include insomnia severity (primary), sleep parameters, fatigue, mood, sedative-hypnotic use, and other measures collected at baseline, 8 weeks, and 6 months. REP-DI quantitative implementation outcomes include Reach, Adoption, and Maintenance evaluated at patient and provider/staff levels. A 3-part formative evaluation employing qualitative methods will identify patient and provider/staff determinants. Next Steps/Implementation: Coached PTBS can be implemented across VA using REP-DI by the National Center for Health Promotion and Disease Prevention and secondary VA partners such as the Offices of Rural Health and Connected Care.	Care of Complex Chronic Conditions				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 20-256	Makris	Una		Una.Makris2@va.gov	MOTIVATE to Improve Outcomes for Older Veterans with Musculoskeletal Pain and Depression	10/01/2022	08/31/2025	VA North Texas Health Care System Dallas VA Medical Center, Dallas, TX	$619,699		Background: Musculoskeletal (MSK) pain is the leading cause of disability and reduced quality of life among older adults. We also know that depressive symptoms frequently co-exist with MSK pain and complicate management. Despite rising costs attributed to MSK pain and depressive symptoms, few behavioral interventions have been developed to address these comorbid conditions in this vulnerable aging population. Significance: The PI, during her VA HSR&D CDA2, developed and tested the feasibility of a novel behavioral intervention targeting older Veterans with chronic back pain and depressive symptoms. MOTIVATE (Moving to Improve Pain and Depression in Older Veterans) incorporates evidence-based components of motivational interviewing (MI), values elicitation, goal setting and patient activation to motivate older Veterans to become more physically active, thereby improving pain interference, function, and depressive symptoms. MOTIVATE is delivered by a health coach via telephone or video during eight sessions over 12-weeks. Preliminary findings from the PI’s ongoing pilot trial of MOTIVATE show it is feasible, improves step counts, pain interference, and depressive symptoms. In response to VA HSR&D research priority areas, this application focuses on improving access to care, augmenting resources for primary care practices – specifically in the areas of pain management and aging, and leveraging virtual care to deliver behavioral interventions to vulnerable Veterans. Innovation/Impact: This research is innovative because we 1) target both MSK pain and depressive symptoms and enhance generalizability of our findings, 2) incorporate older Veterans’ motivation to change as a key behavioral determinant, 3) use remote delivery to enhance reach of both pain and mental health services to older Veterans; and 4) involved older Veterans and other stakeholders at every stage of development. Specific Aims: We propose a hybrid type 1 implementation-effectiveness randomized controlled trial at two large VA sites to establish the effectiveness and scalability of MOTIVATE. The overall goals of this study are to 1) examine the effectiveness of MOTIVATE compared to a waitlist control arm on clinical and behavioral outcomes; 2) explore implementation processes for the MOTIVATE intervention, and 3) evaluate preliminary cost with a budget impact analysis for MOTIVATE in older Veterans with chronic MSK pain and depressive symptoms. We hypothesize that MOTIVATE will improve clinical and behavioral outcomes in this population. Methodology: We will recruit older Veterans with MSK pain and depressive symptoms (n=264) to determine effectiveness of MOTIVATE versus waitlist control arm to improve clinical and behavioral outcomes at 3 (primary endpoint) and 6 months post-enrollment. The primary outcome is pain interference (a subscale of the Brief Pain Inventory) and secondary outcomes include depressive symptoms (PHQ-9), pain intensity, arthritis self-efficacy, pain catastrophizing Scale, PROMIS scales (including sleep), resilience, frailty, and Global Impression of Change. Using intent-to treat analyses, we will compare MOTIVATE and waitlist groups in terms of primary and secondary outcomes by using a linear mixed-effects model which simultaneously models all available measurements including baseline. Concurrently we will examine implementation processes of delivering MOTIVATE (Aim 2). Using semi-structured interviews, we will explore the contextual factors, barriers and facilitators to implementation and uptake of MOTIVATE, among Veterans, frontline providers, health coaches, and facility leaders (n~50). We will use the i-PARIHS implementation framework to inform the discussion guide. Aim 3 will provide necessary cost evaluation of MOTIVATE along with budget impact analysis from the perspective of a VA facility to estimate the costs of implementing MOTIVATE. Implementation/Next Steps: Results will facilitate national implementation and dissemination of MOTIVATE, along with a hybrid type 3 trial, which can augment the care provided by primary care, mental health, and specialty services to improve outcomes in older Veterans with comorbid MSK pain and depressive symptoms.	Mobility, Activity, and Function				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 20-259	Weisbord	Steven		steven.weisbord@va.gov	Patterns, Processes, and Outcomes of Kidney and Liver Transplantation in an Era of Enhanced Community Care for Veterans	05/01/2021	03/31/2025	VA Pittsburgh Healthcare System University Drive Division, Pittsburgh, PA	$1,031,359		Background: While the VA has provided life-saving organ transplantation to Veterans for decades, critics of the VA Transplant Program claimed that its requirement for Veterans to travel to designated VA Transplant Centers across the nation reduced access to care. The passage of the MISSION Act by Congress in 2018 markedly expanded the number of Veterans eligible to pursue transplantation and post-transplant care in the community. We recently investigated where Veterans dually enrolled in VA and Medicare underwent kidney transplantation and received post-transplant care and the association of the site of transplant care with long-term mortality. The findings of this work suggest that the MISSION Act could substantially transform patterns and processes of VA transplant care and unintentionally lead to adverse health outcomes following transplantation. Significance/Impact: Characterizing the effects of the MISSION Act on VA transplantation and the factors that influence where Veterans receive transplant care is critical to refine policies governing the VA Transplant Program and allocation of resources to support the delivery of transplant-related care to Veterans with end-stage kidney and/or liver disease. Our study will provide novel insights into how the MISSION Act is affecting patterns and processes of transplant care, as well as outcomes of kidney and liver transplantation among Veterans. Findings from this study will enable Veterans and VA providers to make evidence-based decisions on the source of transplant care that optimizes long-term allograft function and overall survival. Innovation: Our study will be the first to assess the impact of the MISSION Act on processes and outcomes of kidney and liver transplant care and the only study to combine data from the Scientific Registry of Transplant Recipients (SRTR) and the VA Corporate Data Warehouse (CDW) to characterize the effect of this legislation on Veterans’ transplant care and outcomes. Specific Aims. Our specific aims are to: (1) describe temporal patterns of VA and community transplant care (i.e., activation on the wait list, receipt of transplant, and post-transplant management) among Veterans approved for kidney or liver transplantation before and after implementation of the MISSION Act; (2) identify patient and system factors associated with the site Veterans are wait listed for and undergo kidney or liver transplantation and receive post-transplant care (VA vs. community vs. dual); (3) examine the associations of site of: (a) wait listing; (b) transplant surgery; and (c) post-transplant care with key outcomes (i.e., time on the wait list, death on the wait list, receipt of transplant, allograft failure, and mortality) among Veterans approved for kidney or liver transplantation; and (4) qualitatively examine key stakeholders’ (i.e., Veterans, VA providers, VA operations leaders) perceptions of the facilitators of and barriers to Veterans’ use of VA for kidney and liver transplant care. Methodology: We will link SRTR and CDW data to construct a cohort of Veterans enrolled in VA who were activated on the UNOS wait list for kidney and/or liver transplantation between 7/1/2010 and 6/30/2022. Using this cohort, we will characterize secular trends in VA and community transplant care, quantitatively assess patient and system factors associated with the site that Veterans undergo transplant and receive post-transplant care, and examine the associations of site of transplant care with key transplant-related outcomes. We will also conduct semi-structured interviews with Veterans, VA providers, and VA operations leaders to qualitatively assess their perceptions of facilitators and barriers to Veterans’ use of VA for transplant care. Implementation/Next Steps: Our next steps will include: (1) continued partnership with operational leaders in VA’s Office of Community Care and National Surgery Office to design, deploy, and evaluate interventions informed by this research to improve the processes and outcomes of transplant care for Veterans; and (2) broad dissemination of our findings to key stakeholders including Veterans, nephrologists, hepatologists, and transplant surgeons to inform their decision-making regarding the optimal site of transplant and post-transplant care.	Systems Modeling, Design, and Delivery				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 20-270	Groeneveld	Peter		peter.groeneveld@va.gov	Impact of the MISSION Act on Quality and Outcomes of Interventional Cardiology and Cardiac Surgery among Veterans	06/01/2022	09/30/2025	Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA	$591,823		Background: The implementation of the VA’s Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act in June of 2019 greatly expanded opportunities for Veterans to be referred outside of the Veterans Health Administration (VHA) for complex cardiac procedures and surgeries. However, the VA has been a longstanding national leader in both interventional cardiology and cardiac surgical quality of care. Hence, increased referrals outside of the VHA may reduce the probability that Veterans undergoing cardiac procedures receive the highest care quality and the best procedural outcomes. Significance/Impact: With increasing numbers of Veterans now eligible under the MISSION Act to obtain major cardiac procedures outside VA, it is critically important for Veterans, their VA providers, and VA operational leaders to fully understand the consequences of Veterans' choices in terms of their access to care, quality of care, outcomes of care, and health care costs. The total costs of VA's Community Care program are substantial; it is therefore essential that VA maximizes the value from funds expended on Community Care. Innovation: The proposed research will extend prior studies comparing VA and Community Care provision of major cardiac procedures with a specific focus on the impact of the MISSION Act, which has the potential to vastly expand the number of Veterans receiving care outside VA. Our research will provide novel insight into how Veterans’ choices between VA and non-VA providers could be better informed by information about health care quality and outcomes of care, thus enhancing the decision-making process. Our cost analysis will identify potential opportunities where better care coordination between VA and non-VA providers could improve both the value of care delivered by eliminating gaps in, and reducing duplication of, services. Specific Aims: The primary objectives of this study are to: (a) quantify the changes in use of VA and non-VA cardiac surgery and interventional cardiology services resulting from the MISSION Act, with a focus on how access to care was affected; (b) measure the effects of MISSION Act implementation on the rates Veterans obtain cardiac surgery and interventional cardiology care from high-quality hospitals, and compare the risk- adjusted post-procedure outcomes among Veterans obtaining cardiac procedures in VA hospitals or via Community Care after the MISSION Act was implemented; (c) assess the effect of MISSION Act imple- mentation on the cost of interventional cardiology and cardiac surgical care to both the VA and to Veterans. Methodology: This study will leverage our research team’s substantial expertise with both VA and non-VA clinical, administrative, and cost datasets. We will combine data from VA’s cardiac surgery and interventional cardiology national registries with health care utilization, cost, and outcomes data housed in the VA’s Corporate Data Warehouse, as well as VA’s Community Care datasets such as the Program Integrity Tool database. We will focus on Veterans undergoing (1) percutaneous coronary intervention, (2) coronary artery bypass grafting, (3) surgical valvular replacement, or (4) transcatheter aortic valve replacement. These are among the most common major cardiac procedures performed among veterans, with substantial risk of mortality and morbidity as well as high associated health care costs. We will assess the impact of the MISSION Act on Veterans’ access to these procedures, the quality of cardiovascular care delivered by the hospitals performing these procedures, the outcomes of care, and the costs to both VA and to Veterans. Implementation/Next Steps: The project's overarching goals are to demonstrate the importance of quality and outcomes information in making choices between health systems, and to identify opportunities for VA leadership to improve care coordination, optimize clinical outcomes, and reduce costs in the Community Care program. Our research team will work closely with our Operational Partners in the VA's Office of Community Care and the VA's National Surgery Office to shape the VA Community Care Program’s future operations.	Access				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 20-288	Oh	Dennis		Dennis.Oh@va.gov	Clinical outcomes for asynchronous teledermatology	06/01/2022	09/30/2025	San Francisco VA Medical Center, San Francisco, CA	$728,833		Background: Store-and-forward teledermatology is a significant part of Department of Veterans Affairs’ telehealth portfolio. While considerable evidence supports teledermatology’s potential to provide timely access to expert dermatologic care, its effectiveness in achieving clinical outcomes that are equivalent to usual in- person care has not been as well documented due to the lack of objective outcome measures for many skin diseases. Clinicians typically document skin diseases using non-standardized qualitative language. Manual review to extract meaningful outcomes data from relatively unstructured text is typically prohibitive. Significance/Impact: Natural language processing (NLP) offers a previously unexplored approach to objectively and systematically identify relevant text in the electronic medical record to gauge patients’ clinical responses following either in-person dermatology and asynchronous teledermatology consultation. This project will leverage NLP to follow clinical courses of important skin conditions in the medical record and to compare the outcomes and effectiveness of teledermatology relative to usual office-based dermatology consultation. It will also serve as a test for other outcome measures such as access times that are often assumed to be proxies for quality of care for Veterans. The results may help influence VA telehealth strategy and policies to enhance access of patients to high quality skin care and to improve patient safety. Innovation: This project represents a novel application of NLP methods to understand how key clinicians document skin conditions and to provide a large-scale, systematic and rigorous assessment of teledermatology’s effectiveness in caring for Veterans with a variety of skin diseases. The project will also result in NLP systems which may be translatable to create practical operational quality management tools for monitoring the quality of follow-up care of both dermatology and teledermatology patients in VA. Specific Aims: Aim 1 will survey expert and non-expert clinicians to learn how each group evaluates and documents clinical change in five common skin diagnostic categories. We will test novel annotation methods, and identify differences between clinician groups in annotated survey responses. Aim 2 will use our annotated data sets to train and validate NLP models to extract concepts and relationships for our five diagnostic categories from actual VA clinical notes. This information will be used to create a document classifier capable of assigning a clinical change status to follow-up notes. Aim 3 will integrate output from our NLP tools to assign an overall clinical outcome to dermatology and teledermatology referrals. Other important clinical events and activities available as structured data will be correlated with NLP outcomes to further interpret their significance. Commonly used access outcome measures will also be compared as a test of their validity. Methodology: Aim 1 will survey dermatologists and primary care providers to annotate and compare their responses. Aims 2 and 3 will create trained and validated NLP tools to assign condition and outcome status to actual clinical notes. Aim 3 will use our tools to compare clinical outcomes following teledermatology and dermatology consultation and will will utilize the VA Corporate Data Warehouse to obtain structured data on other key clinical events and access measures. Implementation/Next Steps: The NLP models that result from this project may be extendable beyond routine in-person and teledermatology care to generally track clinical course outcomes related to other forms of telehealth such as dermatology e-consults and video telehealth. In addition, the models may be adaptable to create a practical dashboard tool to allow providers and quality management staff to monitor the effectiveness and quality of teledermatology delivered to Veteran patients.	Healthcare Informatics				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 20-299	Bovin	Michelle		michelle.bovin@va.gov	Understanding Pathways to Care for Veterans who Screen Positive for PTSD: The PTSD Access To Healthcare (PATH) Study	10/01/2021	09/30/2025	VA Boston Healthcare System Jamaica Plain Campus, Jamaica Plain, MA	$913,578		Background: Nearly half of Veterans who screen positive for PTSD in VA primary care clinics do not receive VA mental health treatment. To increase timely access to VA care, we must understand Veterans’ access pathways (the series of options offered to, and choices made by, Veterans after a positive PTSD screen that may lead them to VA care). Mapping these pathways is key to understanding who is being lost to VA care and where they are being lost. Further, by examining contextual and individual factors that predict who and where Veterans are falling off these pathways, we will be able to ascertain why these Veterans are being lost. Significance: The proposed IIR is responsive to the HSR&D priorities of both mental health and access to care and will provide insight into the impact of the MISSION Act on mental health access. At the completion of this project, we will provide three distinct deliverables: 1) guidance on where and to whom access interventions should be targeted; 2) policy and practice guidance to aid providers in linking Veterans who screen positive to effective VA care; and 3) a method for classifying Veterans from screening to VA mental health care, which could be extended to other conditions (e.g. suicidality). Innovation and Impact: Past research designed to provide information to improve access to PTSD care has been limited by focusing on the end goal (whether these Veterans do or do not access care) rather than the process by which Veterans arrive at this goal (the access pathways). The proposed project is not only one of the first to consider access to care as a process rather than an end point, it is the only study to propose examining the process of access comprehensively using a method that will generalize to the VA system as a whole, and will be applicable to other healthcare conditions identified by VA-based screening. Specific Aims: The proposed mixed methods study has the following aims: 1. Aim 1: Identify contextual- and individual-level variables that differentiate Veterans classified into a VA initial access step (an immediate response to a positive PTSD screen in primary care likely to lead to VA care; e.g., referral to PC-MHI) from those who were not, including those referred to community care via the MISSION Act. 2. Aim 2: Understand VA providers’ and patients’ experiences with, and perspectives on, why Veterans are lost to VA follow-up care immediately after screening positive for PTSD, including the role of the MISSION Act. 3. Aim 3: Map the access pathway steps hypothesized to follow each of the six initial VA access steps, as well as the step hypothesized to lead to community care provided via the MISSION Act, by leveraging the methods developed in our pilot work. Methodology: Aim 1 will include all Veterans with new PTSD screens in primary care between FY 2017-2019. Data from the VA Corporate Data Warehouse (CDW) will be used to determine Veteran access step classification and to identify contextual and individual variables that significantly predict classification. Aim 2 will use the data from Aim 1 to identify high- and low-performing sites, and qualitative interviews will be conducted with site stakeholders to understand access barriers and facilitators. Aim 3 will use quantitative data extracted from the VA CDW to map the remaining steps in the access pathways to identify which Veterans are lost to follow-up, and where. Predictive models using relevant access variables identified in Aims 1 and 2 will be run. Next Steps/Implementation: Results from the proposed IIR will inform the best ways to deploy and tailor existing access interventions (e.g. PC-MHI, direct-to-Veteran media campaigns). We will work with the Office of Primary Care to develop policy and practice guidance, and work with both the Office of Primary Care and NCPTSD leadership to disseminate guidelines and our methodology to VA primary care and PC-MHI leadership at the national level. We will begin testing implementation strategies in a subsequent IIR.	Mental and Behavioral Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 20-314	Phibbs	Ciaran		Ciaran.Phibbs@va.gov	A comprehensive assessment of maternal health and pregnancy outcomes among women veterans	04/01/2022	09/30/2025	VA Palo Alto Health Care System, Palo Alto, CA	$1,007,175		Background: Women are a growing share of the VA population, especially among younger Veterans. To date there hasn’t been a comprehensive assessment of pregnancy outcomes among women Veterans, which is needed, especially given that Veterans have higher pregnancy risk profiles than the general population. Significance: Given the growing share of women Veterans, their increased pregnancy risk, and known U.S. racial and geographic maternal health disparities, VA needs to better understand the provision and outcomes of pregnancy care to implement policies to optimize pregnancy outcomes for Veterans. Findings will facilitate the VA Office of Women’s Health Services (WHS) efforts to improve pregnancy care and outcomes. Innovation and Impact: Existing state of the art methods will be innovatively applied to examine national VA and state Medicaid records in parallel to comprehensively assess VA maternity care. This project is the first to rigorously compare VA pregnancy outcomes with those in the general population at a national level. Specific Aims: Aim 1. This aim has two parts, of which the first is purely descriptive: We will describe a wide range of key maternal outcomes, examining trends and changes over time (with respect to key VA policy changes) for all pregnancies where the VA provided pregnancy care (purchased). Key maternal outcomes will include cesarean deliveries, pregnancy complications and severe maternal morbidity (SMM), a CDC defined set of serious life-threatening maternal complications. We will also describe a broad range of maternal risk factors (individual health factors, and systemic factors of race and geography) and process outcomes including use of prenatal care, VA mental healthcare, and post-partum reintegration to VA care. We will also examine if Veterans with known risk-factors deliver at settings appropriate for their risk levels, as outcomes are demonstrably worse when high-risk deliveries occur in sub-optimal settings. Concurrently we will assess key infant outcomes (e.g., mortality, prematurity, and unexpected NICU admission—i.e. in non-preterm infants). The final part of Aim 1 will use regression analyses to examine the impacts of VA policy changes on key outcomes, while also analyzing the extent of racial/ethnic and urban/rural disparities in outcomes. Aim 2: Repeat, in parallel, the Aim 1 descriptive analyses, for deliveries to VA-enrolled Veterans who do NOT use VA maternity benefits, but instead use Medicaid. We will assess how these Veterans differ in characteristics and maternal outcomes. Since they have chosen not to have VA cover their delivery, we will also assess their use of VA care in the years prior to and after delivery to determine if opting for non-VA pregnancy care was a temporary or lasting healthcare shift away from VA. Aim 3: Compare key outcomes (e.g., complication rates and SMM) of VA-covered deliveries and of Medicaid-covered Veterans’ deliveries with those in the general population. Examine if known disparities racial/ethnic and urban/rural in birth outcomes are more/less pronounced in VA or Medicaid covered Veterans. Methodology: Established CDC methods will be used to search VA administrative records, including purchased care, to identify all enrolled women Veterans who received pregnancy care, extending back to 2000, when VA first covered pregnancy, through 2021. These data will be supplemented by all years of Medicaid data that are available. In addition to descriptive analysis, regression analyses will be used to adjust for known risk factors and moderators to examine a wide range of pregnancy outcomes. Causal inference techniques will be used to analyze the effect of VA and other policies on key outcomes. The study team is led by internationally recognized experts in the evaluation of perinatal care and they have all of the needed expertise to conduct appropriate analyses and effectively disseminate the findings. Next Steps/Implementation: We work closely WHS to share results and tailor analyses to their information needs. WHS can directly implement change via directives to maternity care coordinators at all VA facilities.	Women's Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 20-322	Funk	Luke		funk@surgery.wisc.edu	Teaching Obesity Treatment Options to Adult Learners (TOTAL): A Multi-site RCT	05/01/2022	08/30/2025	William S. Middleton Memorial Veterans Hospital, Madison, WI	$863,842		Background: Nearly 80% of Veterans meet criteria for overweight (body mass index [BMI] of 25-29.9 kg/m2) or obesity (BMI≥30). VA offers three evidence-based obesity treatments at little to no cost to Veterans: MOVE! (to improve dietary intake and physical activity through behavioral modification); obesity medications; and bariatric surgery, but all are significantly underutilized: <10% of Veterans with obesity participate in MOVE!; 2% receive obesity medications; and 0.3% of those who meet BMI criteria for bariatric surgery (BMI≥35) undergo it. There is an urgent need to increase use of all three treatments to improve Veteran health. Significance/Impact: Nearly 4,000,000 Veterans meet BMI criteria for overweight/obesity. It is essential that Veterans with overweight/obesity are aware of the three treatment options and are motivated to pursue them. Currently, no interventions in VA seek to increase use of all three evidence-based obesity treatment options for Veterans not currently participating in MOVE!. The TOTAL intervention (Teaching Obesity Treatment Options to Adults Learners), if effective, would increase obesity treatment initiation for Veterans, lead to greater weight loss, and improve quality of life. Given that TOTAL is deliverable via VA telemedicine, it could be implemented throughout the VA healthcare system without requiring significant resources and could be integrated into the existing VA behavioral weight management program, MOVE!. Innovation: The research in this proposal would be the first adequately powered RCT in VA testing an intervention to increase use of all three evidence-based obesity treatments: MOVE!, obesity medications, and bariatric surgery. It would leverage the power of the VA electronic health record and would improve access to care by expanding use of a recently developed telemedicine technology – VA Video Connect (VVC) – which was developed by VA researchers. It could be implemented and disseminated efficiently within VA given that MOVE! is available at every VAMC and is supported by NCP. Specific Aims: Aim 1: Compare the effectiveness of TOTAL vs. usual care for increasing obesity treatment initiation among Veterans with overweight/obesity who are not participating in MOVE!; Aim 2: Compare the effectiveness of TOTAL vs. usual care for increasing sustained MOVE! participation, receipt of an obesity medication prescription or bariatric surgery referral, and weight loss; Aim 3: Inform future dissemination efforts of TOTAL via interviews with key stakeholders, a “Reach” analysis, and cost analysis. Methodology: Study population: Veterans at two VAMCs, age 18-75 with a BMI ≥30 or 27-29.9 + an obesity- related comorbidity who have not had a MOVE! visit within the past 12 months and thus are not participating in obesity treatment will participate in the RCT; Intervention: The TOTAL intervention consists of an 18-minute obesity treatment educational video and three motivational sessions (all delivered via VA Video Connect [VVC]); Comparison: Usual care (Veterans who have not had a MOVE! visit in the previous 12 months); Outcomes: MOVE! initiation, sustained MOVE! participation, obesity medication use, bariatric surgery referral, weight change; Timing: Primary and secondary outcomes will be measured 18 months post-randomization. Implementation/Next Steps: Facilitators and barriers to TOTAL implementation will be assessed in Aim 3 interviews with Veteran, provider, and operations stakeholders using the Consolidated Framework for Implementation Research (CFIR). [We will also perform “reach” and cost analyses. We will collaborate with NCP to disseminate TOTAL to all VAMCs that have a MOVE! program. The National MOVE! Director will present study results on a national MOVE! call and make presentation materials available on the national MOVE! SharePoint dissemination site. The National MOVE! Director will support MOVE! coordinators who work directly with health behavior coordinators at every VAMC with MOVE!. The study team will consider partnering with NCP to conduct a QUERI National Partnered Evaluation evaluating how TOTAL can be implemented throughout VA.	Care of Complex Chronic Conditions				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 20-322	Funk	Luke		funk@surgery.wisc.edu	Teaching Obesity Treatment Options to Adult Learners (TOTAL): A Multi-site RCT	05/01/2022	08/30/2025	William S. Middleton Memorial Veterans Hospital, Madison, WI	$863,842		Background: Nearly 80% of Veterans meet criteria for overweight (body mass index [BMI] of 25-29.9 kg/m2) or obesity (BMI≥30). VA offers three evidence-based obesity treatments at little to no cost to Veterans: MOVE! (to improve dietary intake and physical activity through behavioral modification); obesity medications; and bariatric surgery, but all are significantly underutilized: <10% of Veterans with obesity participate in MOVE!; 2% receive obesity medications; and 0.3% of those who meet BMI criteria for bariatric surgery (BMI≥35) undergo it. There is an urgent need to increase use of all three treatments to improve Veteran health. Significance/Impact: Nearly 4,000,000 Veterans meet BMI criteria for overweight/obesity. It is essential that Veterans with overweight/obesity are aware of the three treatment options and are motivated to pursue them. Currently, no interventions in VA seek to increase use of all three evidence-based obesity treatment options for Veterans not currently participating in MOVE!. The TOTAL intervention (Teaching Obesity Treatment Options to Adults Learners), if effective, would increase obesity treatment initiation for Veterans, lead to greater weight loss, and improve quality of life. Given that TOTAL is deliverable via VA telemedicine, it could be implemented throughout the VA healthcare system without requiring significant resources and could be integrated into the existing VA behavioral weight management program, MOVE!. Innovation: The research in this proposal would be the first adequately powered RCT in VA testing an intervention to increase use of all three evidence-based obesity treatments: MOVE!, obesity medications, and bariatric surgery. It would leverage the power of the VA electronic health record and would improve access to care by expanding use of a recently developed telemedicine technology – VA Video Connect (VVC) – which was developed by VA researchers. It could be implemented and disseminated efficiently within VA given that MOVE! is available at every VAMC and is supported by NCP. Specific Aims: Aim 1: Compare the effectiveness of TOTAL vs. usual care for increasing obesity treatment initiation among Veterans with overweight/obesity who are not participating in MOVE!; Aim 2: Compare the effectiveness of TOTAL vs. usual care for increasing sustained MOVE! participation, receipt of an obesity medication prescription or bariatric surgery referral, and weight loss; Aim 3: Inform future dissemination efforts of TOTAL via interviews with key stakeholders, a “Reach” analysis, and cost analysis. Methodology: Study population: Veterans at two VAMCs, age 18-75 with a BMI ≥30 or 27-29.9 + an obesity- related comorbidity who have not had a MOVE! visit within the past 12 months and thus are not participating in obesity treatment will participate in the RCT; Intervention: The TOTAL intervention consists of an 18-minute obesity treatment educational video and three motivational sessions (all delivered via VA Video Connect [VVC]); Comparison: Usual care (Veterans who have not had a MOVE! visit in the previous 12 months); Outcomes: MOVE! initiation, sustained MOVE! participation, obesity medication use, bariatric surgery referral, weight change; Timing: Primary and secondary outcomes will be measured 18 months post-randomization. Implementation/Next Steps: Facilitators and barriers to TOTAL implementation will be assessed in Aim 3 interviews with Veteran, provider, and operations stakeholders using the Consolidated Framework for Implementation Research (CFIR). [We will also perform “reach” and cost analyses. We will collaborate with NCP to disseminate TOTAL to all VAMCs that have a MOVE! program. The National MOVE! Director will present study results on a national MOVE! call and make presentation materials available on the national MOVE! SharePoint dissemination site. The National MOVE! Director will support MOVE! coordinators who work directly with health behavior coordinators at every VAMC with MOVE!. The study team will consider partnering with NCP to conduct a QUERI National Partnered Evaluation evaluating how TOTAL can be implemented throughout VA.	Care of Complex Chronic Conditions				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 21-005	Back	Sudie		Sudie.Back@va.gov	Web-Based Provider Training for Concurrent Treatment of PTSD and Substance Use Disorders using Prolonged Exposure (COPEWeb)	10/01/2023	06/30/2026	Ralph H. Johnson VA Medical Center, Charleston, SC	$195,788		Background: PTSD is the most common mental health disorder among Veterans seeking treatment at Veterans Affairs (VA) hospitals, and more than half of Veterans with PTSD also meet criteria for a substance use disorder (SUD). VA/DoD Clinical Practice Guidelines recommend trauma-focused integrated treatment as a first-line treatment for Veterans with co-occurring PTSD/SUD. However, whereas most VA providers desire training in trauma-focused integrated treatment, most are untrained and therefore cannot adequately meet the needs of these Veterans. To address this critical need, we developed Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE), an evidence-based, integrated, trauma-focused treatment that VA has identified as a gold standard of behavioral healthcare. Randomized controlled trials among Veterans demonstrate COPE’s efficacy in reducing PTSD and substance use. Most Veterans with PTSD/SUD prefer integrated treatment. Significance/Impact: There is a critical shortage of clinicians trained to deliver COPE. Traditional in-person workshops are inefficient and costly. A poll of VA PTSD/SUD Specialists found that 96.9% want COPE training and 99.1% would use a web-based training for COPE if available. A web-based resource for providers is ideal, as it can be rapidly disseminated, is easily accessible, and provides a significant amount of standardized information. The proposed project, conducted in close partnership and with funding provided by the National Center for PTSD, will directly address this critical gap in provider training to improve the care of Veterans with comorbid PTSD/SUD, enhance treatment delivery using innovative in-session provider assistance tools, and enhance knowledge of cost-benefit of technology-enhanced training. The new training program (COPEWeb) may be particularly useful for providers in rural clinic settings where mental health training is less accessible. This proposal has the potential for high military relevance and an immediate impact on dissemination and uptake of COPE, as well as a long-term impact on the overall health of the millions of Veterans suffering from co-occurring PTSD/SUD. Innovation: A new web-based provider training for COPE will be developed along with a highly innovative delivery aid system to guide clinicians during sessions to enhance delivery and fidelity to the protocol and reduce provider burden. A panel of national VA experts and dissemination leaders will develop a best practice VA dissemination guideline on disseminating web- based provider trainings. The proposed project has the potential to significantly enhance provider training and increase patient access to evidence-based care. Furthermore, COPEWeb has the potential to serve a novel role in disaster planning to ensure mental health care providers are equipped to address the anticipated post- pandemic needs of Veterans given the rise in post-traumatic stress and alcohol/drug use during the pandemic. Specific Aims: This project will (1) develop a new web-based training protocol and innovative delivery aid system to strengthen providers’ delivery of COPE to treat Veterans with PTSD/SUD with a high level of fidelity and competence, and (2) compare the COPEWeb training to in-person training on knowledge, satisfaction, and behavior (i.e., fidelity). A cost-effectiveness analysis will compare web-based to in-person training. Methodology: The proposed methods and timeline to develop COPEWeb are based on our team’s prior success developing other widely-used provider training protocols (e.g., PEWeb, CBTIWeb). COPEWeb will be built and refined over the course of three strategic phases: content development, alpha-testing, and beta-testing. Following beta testing, we will compare COPEWeb to in-person training among clinicians. Ongoing assessment will obtain qualitative and quantitative data on measures of provider satisfaction, knowledge, and behavior. Implementation/Next Steps: In collaboration with our operations partners, VA leadership, and EBP Coordinators, COPEWeb will be rapidly disseminated to mental health providers to increase adoption of evidence-based treatment for PTSD/SUD and improve the quality of mental health care for Veterans and the nation.	Mental and Behavioral Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 21-024	Hofer	Timothy		Timothy.Hofer@va.gov	Assessing Quality of VA and Community Care in the MISSION Era	01/01/2023	09/30/2026	VA Ann Arbor Healthcare System, Ann Arbor, MI	$771,886		Background: With the goal of improving Veteran access to timely services, the MISSION Act is shifting the VA from a tightly integrated system to one that is more “dis-integrated,” with a substantial number of specialty visits now provided by community providers. The use of VA-purchased community care (VA-CC) could improve access for Veterans, but could also increase fragmentation of care, potentially resulting in delays, redundancies, and less coordinated treatment plans. While multiple previous studies have shown a quality advantage for VA relative to community care (CC), we have little understanding of how fragmentation will impact timeliness and quality of care, especially for high-risk conditions such as cancer care. Significance: Fragmented care is a common, serious, and urgent problem for individuals with cancer. This study, which is responsive to several HSR&D research priorities, will examine the quality of cancer care after the institution of CHOICE and MISSION, whether the efforts to coordinate VA-CC are successful in maintaining measured quality, and the degree of risk to quality for patients who divide their care between systems. Results can be used by our VA partners and Veterans to understand variation and deficits in quality. Innovation & Impact: This project focuses on systems of care and the potential risks and benefits to quality when policy incentivizes movement across systems, and develops measures that can be used for monitoring and targeting efforts to change practice and improve cancer care quality received by Veterans in all settings. Key products: 1) a report of cancer care quality across VA-delivered and VA-purchased CC; 2) an assessment of quality for providers in the community who contract with VA relative to geographically proximate providers who do not; 3) a set of cancer quality measures ready for implementation and new measures identified as appropriate targets for future implementation; 4) a set of measures requiring further testing and development; and 5) approaches to enhance implementation in VA and non-VA settings. Specific Aims: 1. Adapt and extend a set of claims and registry-based measures designed to assess cancer care quality in national US health systems for use within VA; 2. Compare the quality of cancer care for Veterans who receive their cancer care within an integrated system to those receiving more fragmented care across systems, and examine differences in measure performance across key predictor variables; and 3. Conduct a Stakeholder Expert Panel (SEP) to recommend a cancer performance measurement set for tracking quality of cancer care in VA and/or non-VA settings and an agenda for near term implementation. Methodology: We will operationalize previously designed claims-based measures of cancer care in VA data and extend the measure set (with additional prostate cancer measures). We will compare quality measure performance for Veterans over 64: 1) Receiving VA-delivered care only vs. receiving any VA-purchased CC; and those 2) Predominantly reliant on VA care vs. reliant on both VA and Medicare. (Data for these analyses includes: VA CDW, VA PIT/purchased care, and VA-CMS.) We will also examine, using CMS data, if quality measure performance is similar for all patients over 64 attending practices under contract with VA to provide community cancer care to patients attending non-contracted practices within the same hospital referral region. Finally, we will examine differences in measure performance across key patient and system predictor variables. Through a Stakeholder Expert Panel, we will prioritize measures, assess gaps in the current measure set and potential measures to fill those gaps, and recommend approaches for implementation. Next Steps/Implementation: Through the work of the Advisory Council and Stakeholder Expert Panel, which involve both VA and non-VA experts, we will create a multi-step process for dissemination of the research products. By engaging policy makers in the process of decision making, the results will be more implementable and sustainable.	Systems Modeling, Design, and Delivery				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 21-026	Park	Linda	Joe Nocera	Linda.Park@va.gov	Virtual Care Strategies to Improve Participation in Cardiac Rehabilitation among Veterans	07/01/2022	07/31/2025	San Francisco VA Medical Center, San Francisco, CA	$654,957		Background: Cardiac rehabilitation (CR) is a comprehensive secondary prevention program involving exercise training, behavioral activation, and psychosocial support following cardiac events such as myocardial infarction, coronary revascularization, valve replacement. Randomized clinical trials (RCT) have demonstrated lower mortality and greater physical, mental, and social functioning in patients who participate in CR vs. usual care. However, the long-term mortality benefit of CR is directly proportional to the number of sessions completed, and less than half of Veterans who enroll in CR complete the recommended number of sessions. Significance: Home-based CR (HBCR) is an alternative to traditional CR programs that has comparable efficacy in improving morbidity/mortality and increases access to critical services. Improving participation in home-based CR has been identified as a major priority by the National Director of Cardiology. We propose to test a novel and easily scalable intervention to increase HBCR adherence and improve functional capacity/ physical activity in Veterans at risk for secondary cardiac events. This project addresses a major quality gap and aligns closely with VHA Modernization priorities of: a) virtual care/telehealth utilization; b) digital transformation; and c) MISSION Act implementation by offering high quality, easy to access care. Innovation and Impact: There is major potential to improve Veteran engagement in CR by combining digital coaching (d-Coaching) with existing VA-supported technologies. Our theory-based intervention targets a critical component of successful CR engagement that is not available through traditional programs: virtual social support through a social network. In addition, we propose to improve self-efficacy and self-regulation through interactive digital multi-media education, personalized feedback, and motivation so that Veterans can complete the prescribed HBCR program and maintain physical activity long-term. The innovative features include: 1) the use of the VA-approved MOVN mobile app to deliver the d-Coaching intervention and provide peer social networks; 2) interactive tailored messages via Annie text messaging to reinforce Veteran-centered goals, learning, and support; and 3) optional participation in a Fitbit private group leaderboard. Specific Aims: Aim 1: Determine the effect of the d-Coaching intervention on the number of completed HBCR sessions over 3 months. Aim 2: Determine the effect of the d-Coaching intervention on: a) functional capacity (6-minute walk test), b) physical activity (daily step counts, sedentary time), c) psychosocial outcomes (depressive symptoms, quality of life), and d) clinical outcomes (HbA1C, lipids) and rehospitalization/ mortality. Aim 3: Determine the effect of the d-Coaching intervention on social cognitive factors of self-efficacy, self-regulation, and perceived social support. Aim 3a: Evaluate the extent to which self-efficacy, self-regulation, and perceived social support mediate the effect of the intervention on function and physical activity. Methodology: The VA IMPACT (Improving self-Management of Physical Activity with Cardiac rehabilitation Training through the digital coaching) RCT will evaluate the effects of HBCR alone (usual care) versus HBCR + d-Coaching, including a private social networking group, optimized Annie text messaging, VA Video Connect, and connected devices (Fitbits). We will randomly assign 150 Veterans from 2 HBCR programs to a 3-month intervention with repeated-measures outcome assessments for 12 months. The addition of d- Coaching to existing digital technologies will be operationalized by applying health technology to provide social support, education, personalized feedback, and motivation for patients enrolled in HBCR. Next Steps/Implementation: Leveraging digital technologies is advantageous because of their low cost, scalability, availability across multiple settings (e.g., rural), potential for individual tailoring, and opportunities for real-time modification. Assuming the proposed study demonstrates benefit for the d-Coaching intervention, we plan to implement and disseminate it across all VA facilities with HBCR programs.	Healthcare Informatics				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 21-036	Gellad	Walid	Eric Roberts	walid.gellad@va.gov	Leveraging a natural experiment to identify the effects of VA community care programs on health care quality, equity, and Veteran experiences	04/01/2022	09/30/2025	VA Pittsburgh Healthcare System University Drive Division, Pittsburgh, PA	$646,041		Background: The Veterans Choice Program and MISSION Act have transformed how VA delivers care by expanding Veterans’ eligibility to receive VA-funded care from community providers. The effects of this change on the quality and equity of care are unknown. Understanding these effects is critical, given the importance of these programs to VA and the complexity of managing care for Veterans across different health systems. To address this evidence gap, we will use a quasi-experimental regression discontinuity (RD) design and examine outcomes in medically and socially vulnerable subgroups to determine the impact of Choice and MISSION on quality and equity of Veterans’ health care. To further examine impacts on vulnerable groups, we will analyze disparities in ratings of community care from VA’s Survey of Healthcare Experiences of Patients (SHEP). Significance: This proposal addresses cross-cutting HSR&D research priorities, including evaluating the quality and equity of care for Veterans in the context of a key legislative priority for VA: the MISSION Act. We will examine how the effects of receiving community care, and patient experiences with community care, differ in vulnerable populations, addressing VA priorities related to equity. The project constitutes an advancement in the rigor of research while directly informing ongoing and high priority clinical initiatives within VA. Innovation and Impact: Our project is innovative because it uses an RD design to provide causal evidence about the effects of community care on the quality and equity of outpatient care and prescribing. The project is also innovative and impactful in its attention to subpopulations of socially and medically vulnerable Veterans, including analyses of disparities in community care patient experiences from national survey data. By working closely with operational partners and a Veterans Advisory Board, we will impact VA policy by translating findings into actionable recommendations to improve community care, particularly for vulnerable groups. Specific Aims: (1) Identify the effects of receiving outpatient community care through Choice and MISSION on quality and equity. (2) Identify the effects of community care on the quality and equity of prescribing. (3) Compare Veterans’ experiences with community care in vulnerable and other Veteran populations. Methodology: We will use an RD design and analyses of both administrative and VA survey data to assess the effects of Choice (all program years) and MISSION (2019-2022) on the quality and equity of Veterans’ health care. Aims 1-2 will use a quasi-experimental RD design that compares Veterans just above vs. below distance and travel time eligibility thresholds for VA community care in Choice and MISSION. We will study effects of community care use on quality overall and, to evaluate implications for equity, in vulnerable subpopulations defined by the presence of serious mental illness or substance use disorders, complex chronic conditions, low income, and racial/ethnic minority status. Outcome variables in Aim 1 focus on outpatient processes of care (e.g., continuity of care) and outcomes linked to care coordination (e.g., admissions for ambulatory care-sensitive conditions). Outcome variables in Aim 2 focus on prescribing safety and quality (e.g., drug-drug interactions), therapeutic duplication, and refill non-adherence. These analyses use VA Corporate Data Warehouse, Planning Systems Support Group, Medicare, and Program Integrity Tool data. In Aim 3, we will analyze national data from the VA SHEP Community Care survey (conducted among community care recipients) to compare patient-reported experiences with community care among Veterans in vulnerable populations vs. other Veterans. Outcome variables in Aim 3 include 5 domains of Veterans’ experiences with care coordination, provider communication, and timely access in VA community care. Next Steps/Implementation: Through close partnerships with the Office of Community Care, Pharmacy Benefits Management, Office of Health Equity, and a Veterans Advisory Board, we will rapidly disseminate our findings and translate them into actionable recommendations to improve quality and equity in community care.	Access				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 21-061	Wong	Susan		susan.wong2@va.gov	Home-based conservative care model for advanced kidney disease	07/01/2023	09/30/2027	VA Puget Sound Health Care System Seattle Division, Seattle, WA	$406,765		PROJECT SUMMARY/ABSTRACT Background: Conservative care (CC) is an important therapeutic option for Veterans who do not wish to pursue maintenance dialysis for their advanced chronic kidney disease (CKD) and offers a whole-person, multidisciplinary approach to care that is focused on slowing disease progression, active symptom management, advance care planning, and provision of appropriate palliative care. Recent evidence from observational studies of CC programs in other developed countries indicate that for older patients (aged ≥75 years) with significant comorbidity and functional limitation, dialysis may not meaningfully lengthen survival or improve quality of life beyond what can be achieved with CC. Although 1 in 7 Veterans with advanced CKD do not pursue dialysis, there are no formal CC programs within the VA and few, if any, concerted efforts to establish these programs in non-VA settings. While CC programs do not currently exist in the VA, many of the elements of CC programs found in other developed countries and that are desirable to Veterans, families, and healthcare providers can be found in the VA’s Home-Based Primary Care (HBPC) program. HBPC provides home-based multidisciplinary primary care to Veterans with multimorbidity and functional limitation with the goal of supporting Veterans’ quality of life and mitigating the complications of illness through to the end of life. We hypothesize that the multidisciplinary care (MDC) framework of HBPC serves as the ideal starting ground to build the VA’s first CC program for Veterans with advanced CKD. Significance: The current proposal is a collaboration with operational partners in HBPC, VA Geriatrics and Extended Care Data Analysis Center, and the VA National Kidney Program. It addresses HSRD priorities of improving access to care, healthcare values, management of complex chronic illness, and long-term care by increasing the evidence base for HBPC and filling outstanding care gaps for Veterans with advanced CKD. Innovation and Impact: The proposal will lead to: 1) the first comprehensive investigation of CKD-relevant outcomes associated with receipt of HBPC; and 2) the creation of the first evidence-based CC program for Veterans with advanced CKD in the VA, if not the nation. Specific Aims: Aim 1: To evaluate the impact of the HBPC MDC model on CKD-specific outcomes; and Aim 2: To assess the feasibility and acceptability of a novel CC Program delivered through the MDC infrastructure of HBPC among Veterans with advanced CKD, their caregivers and clinicians and explore preliminary outcomes of this Program. Methodology: Aim 1 is an emulated hypothetical comparative effectiveness “trial” using observational data for a national retrospective cohort of Veterans with advanced CKD. We will use linked VA and Medicare data and augmented VA medical record review using novel natural language processing software to determine the impact of different patterns of MDC provided by HBPC on downstream treatment practices for advanced CKD. Aim 2 is a randomized pilot trial of 30 Veterans with advanced CKD, their caregivers and clinicians using ethnographic research methods to assess the feasibility and acceptability of a novel CC Program for advanced CKD delivered through the existing MDC infrastructure of the HBPC program at VA Puget Sound Health Care System. We will also use medical record review and serial surveys to collect information on CKD progression, quality of life, goal concordant care, caregiver burden, clinician effort, and healthcare utilization and costs. Next Steps: Our proposal is a foundational and necessary step in our efforts to expand treatment options for advanced CKD and to create a scalable, sustainable, and effective model of CC for Veterans with advanced CKD. The findings will be widely disseminated through publications, presentations at national conferences and professional networks of the study team members who are highly connected with policy makers at national VA agencies.	Long Term Care and Aging				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 21-065	Krein	Sarah		Sarah.Krein@va.gov	Putting the puzzle together: Leveraging dual use to improve care for Veterans living with dementia	04/01/2022	09/30/2025	VA Ann Arbor Healthcare System, Ann Arbor, MI	$706,982		Background: The number of Veterans living with dementia (VLWD) will increase by 2030 to nearly 340,000; these VLWD and their caregivers often have complex psychosocial and health needs. Coordinating this care is complicated by the fact that most VLWD are Medicare-eligible and therefore use care both through the VA and Medicare. Unfortunately, dual use is often associated with duplication of services and potentially inappropriate care. In light of these complexities, VHA Directive 1140.12 from October 2019 mandated that VA facilities establish a Dementia System of Care to provide person-centered services for these VLWD. Because the design of dementia care services is left to individual VA facilities, national variation affords a unique opportunity to learn from particularly successful facilities. Significance: The proposed study will provide important new knowledge to advance the HSR&D priorities of long-term care/aging, access to care, and primary care practice. This knowledge will be achieved by linking patient-level VA data, Medicare claims, and the GECDAC Residential History File, enacting the VA Office of Research and Development’s Research Priority of putting VA data to work for Veterans. Innovation and Impact: This will be the first: (1) comprehensive analysis of non-VA care used by VLWD, including both Medicare- and VA-reimbursed community care; (2) analysis of dual use at the VA facility level, which is critical data for operational purposes; and (3) analysis of dementia care since the VHA Dementia System of Care directive. Finally, we will include the voice of VLWD and caregivers in both facility interviews and as Stakeholder Panel members. Specific Aims: (1) Characterize the associations of dual use and continuity of care with the Veteran-centered outcome of home time and how home time varies across VA facilities. (2) Assess facility-level strategies that promote home time and the acceptability of these strategies to Veterans and caregivers. (3) Develop a toolkit of dementia care strategies that facilities can use to enhance VLWD care delivery. Methodology: In this explanatory sequential mixed methods study, we will first identify community-dwelling VLWD and link their VA data and Medicare claims with the GECDAC Residential History File. Then, we will examine the association of dual use of outpatient and prescription medications with home time, and whether this is moderated by continuity of care. We will collapse these findings to examine dual use, continuity of care, and home time at the facility level. With input from a Stakeholder & Expert Panel, we will identify four high- and four low-performing VA facilities and conduct semi-structured interviews focused on local dementia care strategies with VA providers, VLWD-caregiver dyads, and a non-VA community care coordinator (n=9 interviews per facility). Finally, we will integrate our Aims 1 and 2 findings and, with Stakeholder & Expert Panel input, develop a dementia care toolkit consisting of strategies and tools that VA facilities can use to help implement their local Dementia System of Care. Next Steps/Implementation: The 2019 VHA Directive directing VA facilities to establish a local Dementia System of Care was not optional, but some facilities may have launched their systems more successfully than others. The toolkit developed during Aim 3 will provide additional guidance for challenging work facilities are already doing to improve the quality of care provided to VLWD.	Long Term Care and Aging				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 21-088	Sripada	Rebecca		rebecca.sripada@va.gov	Using the Multiphase Optimization Strategy to Adapt Cognitive Processing Therapy	04/01/2022	03/31/2025	VA Ann Arbor Healthcare System, Ann Arbor, MI	$912,466		Background: One third of post-9/11 Veterans in VHA suffer from posttraumatic stress disorder (PTSD), and among those who initiate Cognitive Processing Therapy (CPT), up to 70% drop out before receiving an adequate dose of treatment. Unfortunately, Veterans who drop out prematurely may never receive the most effective components of CPT. Thus, there is an urgent need to use empirical approaches to identify the most effective components of CPT, so that CPT can be adapted into a briefer format. The long-term goal of this line of research is to adapt, test, and implement brief, evidence-based treatment for Veterans with PTSD. The overall objective of the current application is to adapt CPT into a brief, effective format. The rationale is that identifying the most effective intervention components and delivering only those components will make CPT deliverable in a shorter timeframe, thus improving efficiency, reducing drop-out related to poor treatment response, and ensuring that Veterans receive the most beneficial components of treatment, which will significantly improve their quality of life. Significance/Impact: Upon completion of this project, we expect to have produced an empirically-based, brief version of CPT. This contribution is likely to improve clinical practice for Veterans with PTSD by providing the most effective components at an earlier session, thus increasing the overall effectiveness of treatment and mitigating the negative consequences of untreated PTSD, such as lost productivity, substance use, later-life physical disability, reduced quality of life, and increased risk of suicide. Innovation: The status quo for PTSD treatment is lengthy psychotherapy in a specialty mental health setting, which is rarely delivered in its entirety. The proposed research is innovative because it will use a novel engineering-inspired framework, the multiphase optimization strategy (MOST), to adapt this effective psychotherapy into a brief format. Developing a brief, empirically-based version of CPT will open new horizons for PTSD treatment by expanding CPT access to treatment settings where lengthier treatments are not feasible. It will also provide effective options for Veterans who desire a briefer treatment course. Specific Aims: Specific Aim 1: Using a highly efficient experimental design, identify which of five CPT components contribute meaningfully to reduction in PTSD symptoms. We will test the effectiveness of each component and each two-way interaction between components. Specific Aim 2: Identify mediators of component effectiveness. We hypothesize that effects will be mediated by engagement/adherence and change in posttraumatic cognitions. Exploratory Aim 1: Identify moderators of component effectiveness. Methodology: The MOST is an innovative engineering-inspired framework that uses an optimization trial to assess the performance of individual intervention components within a multicomponent intervention such as CPT. Guided by the MOST framework, the goal of the proposed project is to empirically inform an abbreviated version of CPT via a highly efficient fractional factorial design. Veterans (N = 270) at two VAMCs with clinically significant PTSD symptoms who meet minimal inclusion/exclusion criteria will be randomized to receive one or more CPT components. This design will test the effectiveness of each component and each two-way interaction between components, as measured by PTSD symptom reduction on the Clinician-administered PTSD scale for DSM-5 (CAPS-5) across six months of follow-up. Implementation/Next Steps: Upon completion of these aims, our expected outcome is an adapted, abbreviated version of CPT that consists of the most effective elements of the intervention. The adapted intervention will be primed for a future large scale, fully powered effectiveness trial. The adapted intervention can be easily disseminated through the VA CPT training program and will have a positive impact on the health and wellbeing of Veterans with PTSD.	Mental and Behavioral Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 21-100	Gray	Kristen	Kather Hoerster	Kristen.Gray2@va.gov	Telehealth-delivered peer support to improve quality of life among Veterans with multimorbidity	10/01/2022	05/31/2026	VA Puget Sound Health Care System Seattle Division, Seattle, WA	$628,001		Background: More than 50% of Department of Veterans Affairs (VA) patients have multimorbidity: the co- occurrence of >2 chronic conditions. Multimorbidity impairs health-related quality of life (HRQoL); leads to psychologic distress, disability, and mortality; and contributes to high health care utilization and costs. Most chronic conditions require patients to engage in disease self-management, including adhering to treatments, making lifestyle changes, and working with their health care team. Patients with multimorbidity face many barriers to self-management and to attending in-person clinic visits. Given the limited time and competing demands of primary care visits, patients with multimorbidity need additional support for self-management. Peer support – assistance provided by non-professionals who are similar to the populations they serve – delivered via telehealth is suited to address these needs. We developed a virtual, Veteran-led peer health coaching intervention, VetASSiST (Veterans Activating Social Support for Self-management and Treatment engagement), to help patients with multimorbidity overcome barriers to self-management and improve HRQoL. Significance: VetASSiST is timely and efficient and aligns with the HSR&D priority that improving care should support coordination and integration of care for the majority of Veterans who have multiple conditions rather than building new single disease interventions. The proposal also aligns with other HSR&D priorities of Primary Care Practice and Management of Complex Chronic Diseases and Virtual Care/Telehealth. Innovation and Impact: Prior peer support trials address individual chronic conditions or mental health. VetASSiST will be one of the first trials of an intervention to support Veterans with multimorbidity. It will also be one of the first to leverage telehealth to remotely deliver peer support, which has the potential to increase access to care. If effective, the intervention could be broadly implemented to improve patient outcomes. Specific Aims: 1) Test the effect of VetASSiST, compared to usual care, on the primary outcome of baseline to 12-month change in physical HRQoL, and secondary outcomes of mental HRQoL and health care utilization; 2a) Describe differences between VetASSiST and usual care on baseline to 12-month changes in intermediate outcomes reflecting the functions of peer support and intervention targets: self-efficacy, patient activation, health behaviors, social support, perceived access to care, patient-provider communication, and shared decision-making; 2b) Examine whether intermediate outcomes mediate intervention-associated differences in HRQoL; 3) Evaluate feasibility of translating VetASSiST into practice, including evaluation of per patient intervention costs and barriers and facilitators to implementation. Methodology: We plan a hybrid type 1 implementation-effectiveness randomized controlled trial of 320 Veterans with complex multimorbidity, defined as >3 chronic conditions in >3 body systems. Patients must also have >1 of: 1) physical and mental health conditions; 2) frailty; 3) frequent emergency care; 4) polypharmacy; or 5) high treatment burden. We will identify eligible patients using data from the electronic health record, confirmed with self-reported information at screening, and will randomize enrolled patients 1:1 to VetASSiST or usual care control. The primary outcome is change in physical HRQoL from baseline to 12-months, measured with the SF-12. Secondary outcomes include change in mental HRQoL (SF-12) and health care utilization. Guided by the RE-AIM framework, we will use quantitative and qualitative methods to assess barriers and facilitators to implementation among key stakeholder groups. These data will inform future implementation. Next Steps/Implementation: This hybrid type 1 trial will provide data needed to prepare for broader VA implementation if the intervention is effective. Implementation activities will be coordinated with existing local and national operational partners. If the intervention is not effective, Aims 2 and 3 will elucidate how Veterans with multimorbidity could be better supported in the future.	Care of Complex Chronic Conditions				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 21-101	Voils	Corrine		corrine.voils@va.gov	Collaborate2Lose: Collaborating with romantic and non-romantic support persons to improve long-term weight loss	07/01/2022	08/31/2025	William S. Middleton Memorial Veterans Hospital, Madison, WI	$803,044		Background: Over 40% of Veterans have obesity, a risk factor for multiple chronic diseases. Weight loss interventions produce clinically significant weight loss, yet weight regain commonly occurs due to declining adherence to lifestyle changes. These changes are often substantially influenced by others in the home. Thus, involving both Veterans and a cohabiting support person in weight management efforts could improve long- term weight loss. The goal of the proposed trial is to evaluate the efficacy of involving romantic and non- romantic support persons in weight management efforts to sustain long-term weight loss in Veterans. Significance: This study will contribute to our long-term goal of implementing effective approaches to reduce obesity and associated comorbidities among Veterans. This proposal addresses Health Services Research & Development priorities of access, primary care practice, and virtual care and Office of Research & Development priority of providing Veterans with access to high-quality clinical trials. The importance of identifying efficacious strategies for weight loss maintenance was highlighted in a 2016 State-of-the-Art conference on weight management. Innovation: We will substantially enhance prior work and the MOVE! program offered through the VA by 1) teaching Veterans and their support persons to apply communication and support skills to support Veteran weight management and 2) focusing on long-term weight loss. Specific Aims: Aim 1: Compare effects of patient-only and partner-assisted interventions on long-term weight loss (primary outcome) and obesity-specific quality of life (secondary outcome). Our primary hypothesis is that average weight loss from baseline among Veterans will be at least 3 percentage points greater, a clinically meaningful difference, in the partner-assisted arm than the patient-only arm at 72 weeks. Aim 2: Evaluate the extent to which early intervention effects are mediated by changes in interdependence theory constructs (transformation of motivation, couple efficacy, outcome expectancy, and social support). Aim 3: Evaluate implementation outcomes of appropriateness, acceptability, and feasibility among MOVE! Coordinators via validated surveys and qualitative interviews, and evaluate treatment receipt and enactment among a subset of participating Veterans and support persons via qualitative interviews. Methodology: This is a two-arm randomized trial. Participants: Dyads comprising a Veteran with obesity and a cohabiting adult support person. Intervention: Index patients will participate in a group-based weight management program using the Veterans Affairs (VA) national MOVE! weight management curriculum and delivered using the VA virtual technology platform, VA Video Connect. Support persons will join the sessions, and dyads will learn and practice communication skills. Comparison: Veterans will participate in the weight management program without a support person. Outcomes: The primary outcome is percent weight loss from baseline. Time: The intervention is 72 weeks in duration. Outcomes will be assessed at baseline and every 24 weeks, with 72 weeks as the primary endpoint. Implementation: We will assess MOVE! coordinator perceptions of intervention appropriateness, acceptability, and feasibility and Veteran treatment receipt and enactment in Aim 3. Armed with this information, we will be poised to study implementation in the future. The materials developed in this study could be disseminated and implemented as an optional module by MOVE! Coordinators.	Mental and Behavioral Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 21-103	Oh	Dennis		Dennis.Oh@va.gov	Improving Dermatology Access by Direct-to-Patient Teledermatology and Computer-Assisted Diagnosis	10/01/2021	03/31/2025	San Francisco VA Medical Center, San Francisco, CA	$1,400,419		Background: Access to dermatology remains a significant problem in the Department of Veterans Affairs (VA), particularly during the COVD-19 pandemic. To address this need, VA will deploy an asynchronous teledermatology mobile app-My VA Images-which allows new dermatology patients to securely submit history and photos of their skin for evaluation. The app may also eventually provide a conduit for patients to submit skin images at will for analysis and triage by artificial intelligence (AI)-powered computer vision to a dermatologist. Significance: This project addresses the following gaps: 1) The impact of direct-to-patient teledermatology on access to dermatology and on the satisfaction with such care by both patients and health care providers has not been systematically studied; 2) Currently no AI-powered computer vision tool has been developed and validated for patient-generated images; 3) The readiness of large healthcare organizations, such as VA, and their stakeholders to engage in direct-to-patient teledermatology and AI is unknown. Innovation and Impact: Two related innovations will be tested: 1) Direct-to-patient teledermatology for new patients and 2) Evaluation of patient-submitted skin images by AI-powered computer vision. These separately have the potential to transform remote access to expert skin care in VA and together are potentially synergistic. At the conclusion of the project, we anticipate having a systematic understanding of how direct-to-patient technologies perform and of the operational gaps that will need to be addressed by VA before these technologies can be implemented enterprise-wide. The goal is to establish a critical scholarly and operational foundation to safely move toward a transformative vision where Veterans will no longer be tied to a fixed time and place for care, but instead will have the choice of self-directed, convenient and rapid access to expert-level dermatology care wherever and whenever they need it. Specific Aims: 1. Assess the impact of direct-to-patient teledermatology on access and health system utilization. 2. Assess, refine and augment computer-assisted evaluation of patient-submitted images. 3. Assess readiness of VA and Veterans' acceptance to implement direct-to-patient care. Methodology: Aim 1 will use a Type I hybrid pragmatic study design to compare the impact of the direct-to- patient teledermatology intervention relative to usual in-person and usual consultative teledermatology referrals, measuring access chiefly by data from VA's Central Data Warehouse. Aims 1 and 3 will measure patient satisfaction and readiness for change using survey instruments and interviews. Aim 2 will include both testing, training and refinement of the AI-powered computer vision and measure concordance with dermatologists. Population: Veterans referred to Dermatology at three VA medical facilities. Intervention: Eligible and medically appropriate patients will be offered the option to submit history and images to Dermatology using the My VA Images app. Comparison: The intervention will be compared to usual care (in- person and consultative teledermatology) groups. We will also compare two AI-powered computer vision models with dermatologist diagnoses. Outcomes over a 5-year period: 1) Multiple measures of temporal and geographic access to dermatologic care; 2) Patient satisfaction; 3) Concordance of AI with dermatologist diagnoses; 4) Organizational and patient-readiness for remote and computer-assisted dermatologic care; and 5) Implementation and sustainability of the direct-to-new patient teledermatology process. Next Steps/Implementation: Successful completion of the project will provide VA’s Office of Connected Care and other offices tasked with enhancing access to specialty care with critical data that will justify further expansion of the direct-to-patient asynchronous teledermatology program. The project will also provide VA with critical data to evaluate the role of AI-powered computer vision in future remote care strategies.	Quality Measurement Development				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 21-163	Rosen	Amy	Megan Vanneman	amy.rosen2@va.gov	Comparing Quality of Care between VA-Delivered and VA-Purchased Care: The Need for Better Risk Adjustment	11/01/2022	09/30/2026	VA Boston Healthcare System Jamaica Plain Campus, Jamaica Plain, MA	$636,992		Background: The MISSION Act of 2018 further expanded the opportunity for Veterans to receive care in the community. While this may have led to improved access to care, it may also have resulted in decreases in the quality of care that Veterans receive. Significance: This study will be the first to improve existing risk adjustment methods used by VA with an application for VA/Community Care (CC) quality comparisons. As increasing numbers of Veteran enrollees use CC, there is an urgent need to know if the quality of care delivered in the community that is purchased by VA is at least equivalent to the quality of care delivered in VA. We will also examine whether adding social determinants of health (SDOH) to the risk adjustment methods impacts assessments of quality and health disparities. Innovation and Impact: A better understanding of which new data sources and SDOH variables improve risk adjustment methods is needed to enable fairer and more accurate comparisons of VA/CC quality at both the national and local area levels. We will obtain a much richer picture of the conditions and other individual- and community-level factors that affect the risk or disease burden of Veterans by also including data from multi-system use (Medicare and All-Payer Claims Databases). Specific Aims: For federal fiscal years 2020-2022, our specific aims are to: 1) Examine whether adding readily available VA, CC, and pharmacy data and individual- and community-level SDOH variables improve the discrimination and calibration of Gagne (an easily modifiable comorbidity measure); 2) Examine whether adding non-VA system use improves the discrimination and calibration of Gagne; and 3) Compare overall VA/CC quality at the national and local area levels using “Gagne1” (which includes additional VA and SDOH data), “Gagne2” (which includes non-VA system use datasets), and the Nosos risk score (an “off-the-shelf” VA risk adjustment method). We selected two Veteran subgroups to study: Veterans with serious mental illness (SMI) and Veterans undergoing total hip or total knee arthroplasty (THA/TKA). Both of these subgroups are in high-cost, high-volume categories of outsourced CC. Quality of care is defined by 4 health outcomes: emergency department (ED) visits and readmissions for Veterans with SMI, and complications and readmissions after THA/TKA. Methodology: For Aim 1, we will examine the extent to which the coefficients on the Gagne comorbidities change when additional data sources (CC and pharmacy data) are added to VA utilization data and then when SDOH variables are added to predict outcomes. We will also compare discrimination and calibration between Gagne, Gagne1, and Nosos. For Aim 2, we will examine the effect of adding non-VA system use data to Gagne1 and evaluate their effect on model discrimination and calibration of Gagne2. For Aim 3, we will compare overall VA/CC quality at the national and local levels using Gagne1, Gagne2, and Nosos. Next Steps/Implementation: Through collaboration with key operational partners (the Office of Community Care [OCC], Analytics and Performance Integration [API], Office of Health Equity [OHE], Access Office, and Serious Mental Illness Research and Evaluation Center [SMITREC]), we will provide VA leaders and policymakers with equitable comparisons of quality that can be integrated into ongoing development of tools and initiatives that are being implemented nationwide or used to help facilitate practice (which risk adjuster to use) and policy (decisions related to whether to allocate additional resources to VA-provided care or expand use of VA-purchased care). Our findings will also enable more informed staff, clinician, and Veteran shared decision-making about where to receive care.	Health Care Organization and Implementation				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 21-166	Sears	Erika		Erika.Sears@va.gov	Assessing Episode-Based Surgical Quality in VA and Community Care Settings	04/01/2023	03/31/2027	VA Ann Arbor Healthcare System, Ann Arbor, MI	$523,650		Background: Since initiation of the National Surgical Quality Improvement Program nearly 30 years ago, VA has been at the forefront of surgical quality measurement and improvement. Much of this work has been focused on assessing risk-adjusted postoperative complications, with less attention paid to important care processes, and even less attention to evaluating and improving quality across the full continuum of surgical care, including the presurgical period. The importance of adapting current and new measures to reliably and accurately assess the full continuum of surgical care will increase as greater numbers of Veterans use VA- purchased Community Care (CC). While one out of three VA patients receive CC, quality assessment is far less developed for CC than for those receiving care within the VA. Significance: With the focus of quality assessment being on postoperative outcomes and complications, quality of care across the entire surgical continuum is largely ignored, especially issues of timeliness, overuse, and underuse in the presurgical period. Defined episodes of care, which constitute a set of services provided to treat a clinical condition, have been promoted to assess quality, coordination, and cost among providers involved in a patient’s care. Although episode models have not been used by VA to monitor quality, VA has the opportunity to use a surgical episode framework to measure surgical quality more broadly, understand the value of this approach, and inform future quality reporting needs for VA-delivered and VA-purchased CC. The importance of examining surgical episode quality is even more salient given the rapid increase in VA- purchased CC, with an inevitable need to ensure that quality is maintained across all settings. Innovation and Impact: The goal of this proposal is to develop an innovative model to measure condition- specific surgical episode quality, including pre-, peri-, and postoperative care phases, for 3 common procedures of varying complexity. This work will advance the science of quality measurement through assessment across the entire surgical continuum. In applying this model to existing VA and CC data, we will identify new opportunities for surgical quality improvement in VA medical centers and will facilitate a condition- specific comparison of episode quality differences between VA and CC settings. We will also identify limitations in episode quality assessment for CC relative to VA using existing CC data sources. Specific Aims: Aim 1: Define condition-specific quality measures for surgical episode quality evaluation. Aim 2: Measure the performance gap and reliability of episode-based quality measures across VA medical centers. Aim 3: Assess the feasibility of applying episode-based quality measurement in the CC setting. Methodology: Aim 1: We will identify new quality measures in response to identified episode measurement gaps. A Delphi panel will rate the newly proposed quality measures for face validity, importance, and feasibility for inclusion in the surgical episode quality measurement model. Aim 2: We will apply the episode quality measurement model (defined in Aim 1) to VA national data to assess facility-level variation in episode quality and measure the reliability of the model to profile VA facility performance. Aim 3: Using quality measures applicable to both VA and CC administrative data sources, we will compare episode quality in VA and CC settings within similar healthcare markets, identifying limitations in applying the episode quality measurement model to existing CC data for meaningful VA and CC quality comparisons. Next Steps/Implementation: We will use the findings of this research to work with partners to refine and expand the measurement model to other surgical conditions to improve care quality for Veterans more broadly, identify targets for cooperative quality improvement within VA and CC settings, and provide recommendations for improvement of episode quality measurement for CC. This work can also be used by partners to inform Veteran choices and will assist VA leaders to inform “make versus buy” policy decisions.	Systems Modeling, Design, and Delivery				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 21-176	Littman	Alyson		alyson.littman@va.gov	Home foot-temperature monitoring through smart mat technology to improve access, equity, and outcomes in high-risk patients with diabetes	01/01/2023	09/30/2025	VA Puget Sound Health Care System Seattle Division, Seattle, WA	$728,603		Background: Diabetic foot ulcers (DFU) are common, debilitating, and costly complications of diabetes. Those with a history of ulceration are at high risk of future ulcerations -- about 40% of patients experience another ulcer within a year of ulcer healing and 65% within 5 years. DFU and amputation disproportionately impact individuals who are Black and rural. One proposed reason for the higher ulceration and amputation rates in these groups is that they present for care later in the course of illness with ulcers that are more difficult to treat conservatively. Identifying equitable approaches to early detection and treatment could help. Elevated temperatures that are sustained over several days are an early sign of inflammation and can effectively predict ulceration. Several randomized controlled trials demonstrated that daily plantar temperature monitoring using handheld thermometers along with a protocol that instructed patients to reduce activity and be seen by a clinician, reduced the risk of ulceration. Yet adoption was poor because the procedures were burdensome. New technologies are much easier, and only require patients to place their feet on a mat for 20 seconds. Temperature data can now be measured in the patient’s home and analyzed to identify hot spots. A prior study and our own analyses have demonstrated that patients stand on the mat as directed with high compliance. Significance: The only evidence that remote temperature monitoring (RTM) reduces the risk of ulceration and amputation comes from a small observational study (n=77) conducted outside the VA, that used a pre-post design. There have been no randomized trials that have evaluated effectiveness or costs/cost-savings for different at-risk Veterans. Also, no prior studies have evaluated any patient-reported outcomes, or interviewed patients or providers, which will be important to understand and address barriers to implementation and dissemination, should RTM be demonstrated to be effective. The substantial upfront cost ($3400 per patient per year) has prompted some leaders to call for more rigorous data in VA. Innovation and Impact: Widescale remote biometric monitoring involving private-public partnerships will play a major role in the future of healthcare. Our study will be the first large, randomized controlled trial to evaluate effectiveness of RTM embedded in a healthcare system. This study will inform how VA can work with private companies to enhance the health and well-being of Veterans. Specific Aims: The specific aims of this study are to: 1) Evaluate the effectiveness of RTM vs. usual care in terms of primary (ulceration) and secondary outcomes (severity of ulceration, amputation, hospitalization, emergency room visits, quality of life, satisfaction with care, and patient activation) at 12, 18, and 24 months; 2) Collect data on costs of RTM and compare with usual care costs, if effectiveness is demonstrated; and 3) Evaluate the implementation process, including barriers and facilitators to use among key stakeholders using the Consolidated Framework for Implementation Research to guide data collection and analysis. Methodology: To accomplish Aim 1, we will conduct a 3-site randomized controlled study. Patients (n=406) who have had a DFU or amputation within the past 24 months (including active ulcers) will be randomized 1:1 to RTM or usual care (no RTM), with randomization stratified on race, rurality, and active ulcer vs. not. To accomplish Aim 2, we will collect data to conduct a budget impact analysis that will evaluate costs of RTM, which include the mats; provider time for selecting patients, ordering mats, and responding to alerts of “hot spots”; and utilization (ulcer/amputation-related outpatient, inpatient, and emergency room visits). Finally, to accomplish Aim 3, we will conduct observations of, and interviews with stakeholders to understand barriers and facilitators to implementation of RTM. Next steps: Findings from this study will be used to inform effective, efficient, and equitable scaling of RTM in VA.	Care of Complex Chronic Conditions				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 21-184	Suda	Katie		katie.suda@va.gov	The broken drug supply chain: The impact of COVID-19 on drug shortages and Veteran health	04/01/2023	02/28/2027	VA Pittsburgh Healthcare System University Drive Division, Pittsburgh, PA	$415,081		Background: Few of the drugs Veterans take as a cornerstone to prevent and treat disease are produced domestically; the majority of medications consumed in the U.S. are produced in foreign facilities. Thus, the drug supply chain is global and susceptible to disruption due to unanticipated events, such as the 2019 Coronavirus pandemic (COVID-19). Significance: However, little is known on the frequency of drug shortages causing medication treatment gaps and subsequent impact on adverse clinical outcomes. This is especially true in the outpatient setting, where the majority of drug shortages occur. Innovation and Impact: The research is innovative by conducting formative work on: 1) the impact of the pan- demic on drug supply and outcomes, 2) differences in shortages in VA priority groups, 3) incorporating stake- holders to inform methods, 4) direct involvement of VA operations and an expert panel of federal partners, and [unique access to operations data.]. The majority of Rx use and drug shortages in VA occur in outpatients, but prior research on drug shortages has focused on inpatients. We will also evaluate the impact of drug shortages by race, ethnicity, age, location, and co-morbidities. The results obtained here will guide VA policy-makers in the identification of the most effective policies to address this growing problem. Specific aims: 1) Determine the impact of the COVID pandemic on the drug supply chain in VA; 2) Assess the impact of drug shortages on outpatient medication treatment disruption in the VA; and 3) Determine the asso- ciation between drug shortage-related treatment disruption in outpatient prescription refills and serious adverse clinical outcomes. Methodology: Drug supply chain issues will be identified through U.S. reporting systems (e.g., FDA). We will leverage VA data for the quantity of drugs ordered and supplied nationally using VA purchasing and outpatient prescription data. For each drug potentially used in the outpatient setting with a reported supply chain issue, purchase changes will be assessed monthly pre- (2017-2019) and during the pandemic. Aim 1 will use inter- rupted time series (ITS) analyses to test whether the incidence of supply chain issues triggering a decrease in supply increased after pandemic start. Aim 2 will identify outpatient drug shortages leading to treatment disrup- tion using ITS and structural break models. Aim 3 will define cohorts based on the indication for drugs with identified shortages using a time to event analysis with entropy balance weighting to evaluate if adverse out- comes (hospitalizations, death, emergency/urgent care) were greater for patients using drugs affected by short- ages (the exposed group) compared to unexposed controls. Next steps and Implementation: Dissemination will be guided by an expert panel comprised of VA operational partners, other federal partners and experts in drug supply and shortages. The quantitative results will be as- similated with the expert panel discussions to develop a support guide to mitigate drug shortages in VA. The next step will be to; 1) inform the US list of essential medicines and criteria for production (e.g., domestically) and 2) determine effectiveness of our support guide and future VA policy implemented based on our work. Our future research will work to ensure access and equitable distribution of drugs with limited supply and/or at risk for shortages. Even after the pandemic, the research proposed will provide results to mitigate drug shortages which remains a crucial public health issue even in the absence of a national emergency. Thus, this will be one step in our long-term goal to plan for future global emergencies, drug shortages at large, and inform national policy to decrease the impact of drug shortages on patient outcomes.	Systems Modeling, Design, and Delivery				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 21-200	Keyhani	Salomeh	Carolyn Gibson	salomeh.keyhani@va.gov	Gaps in Identification, Referral and Treatment of Cannabis Use in VA Primary Care	06/01/2023	07/31/2027	San Francisco VA Medical Center, San Francisco, CA	$344,197		Background: Cannabis use and cannabis use disorder (CUD) are increasing in the US population, and adults aged 50 and older are among the fastest growing groups of cannabis users. While cannabis use is increasing, it is often perceived as harmless and marketed to patients as helpful for several conditions despite a lack of evidence. There is no data on past month cannabis use, daily cannabis use, and CUD among Veterans using primary care, but there is evidence that cannabis use is common in specific Veteran subgroups (11% to 25%) and that CUD identified using administrative data is increasing. Significance: There are reasons to be concerned about the potential under-identification of cannabis use among Veterans. Smoking cannabis is the most common form of cannabis use among Veterans, and there is evidence that cannabis use is associated with respiratory symptoms and cancer. Comorbid mental health conditions are prevalent among Veterans, and these conditions are commonly reported as motivation for regular cannabis use. Cannabis use negatively impacts treatment outcomes of Veterans with anxiety, depression, and post-traumatic stress disorder (PTSD), and use is associated with psychosis and suicidal ideation. Symptoms of cannabis withdrawal can frequently be confused with symptoms of mental health conditions by patients which can perpetuate use. Finally, there are effective behavioral treatments available for CUD and several medications that have shown benefit in treatment of CUD and withdrawal from cannabis in trials. It is important to identify cannabis users to ensure access to effective therapies. Innovation and Impact: This proposal will address important gaps in the priority areas of women’s health, substance use disorders, and mental health. This proposal will lay the foundation for the validation of a simple, frequency-based screening measure for cannabis use that could be feasible in the primary care setting. Specific Aims: We propose to improve our understanding of at-risk populations and determine whether cannabis treatment services in the Veteran population are being underused. We also propose to determine if certain use patterns are associated with adverse mental and physical health outcomes, placing individuals at higher risk. Such individuals (if identified) may also require brief intervention, referral, and/or treatment. Aim 1: To examine the patterns of cannabis use (past month use, daily use, CUD, persistent use), behaviors (e.g., alcohol use) associated with use, and characteristics associated with use among a nationally representative sample of Veterans 50 and older who receive VA primary care. Aim 2a: To determine whether Veterans discuss cannabis use with their providers and whether providers document use and/or intervene upon use or CUD. Aim 2b: To explore provider experiences assessing cannabis use and initiating CUD-related treatment and referrals in the primary care setting. Aim 3: Using the cohort created in Aim 1, we will prospectively examine the association of cannabis use with depression, anxiety, PTSD, insomnia, emergency department use, and all-cause hospitalization. Methodology: We will construct a nationally representative cohort of Veterans 50 and older using VA data, chart review and phone interviews. We will conduct qualitative interviews with primary care providers to understand gaps in care. Next Steps/Implementation: As with alcohol and tobacco, regular cannabis use may be effectively monitored and managed with identification and brief intervention. This proposal will improve our understanding of the prevalence of unidentified cannabis use and gaps in care in the primary care setting, the need for screening, and improve our understanding of the harms associated with use. This proposal will lay the foundation for addressing gaps in care related to cannabis use and CUD among older Veterans.	Mental and Behavioral Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 21-207	Yarns	Brandon		Brandon.Yarns@va.gov	Evaluating Group-Based Psychological Treatments over Home Video Teleconference for Older Veterans with Chronic Pain	10/01/2023	06/30/2026	VA Greater Los Angeles Healthcare System, West Los Angeles, CA	$280,016		Background: Chronic pain is a critical healthcare challenge for VA, and older Veterans are affected worst. VA guidelines emphasize psychological treatments as first-line for chronic pain. Yet available psychological options in VA, including Cognitive-Behavioral Therapy for Chronic Pain (CBT-CP) and Mindfulness Meditation (MM), produce only modest and time-limited benefits on average and are thus underutilized. To increase effectiveness and uptake, VHA experts have recommended (1) testing treatments with potentially larger and more durable benefits, such as [MM that is tailored for chronic pain] and Emotional Awareness and Expression Therapy (EAET), a unique approach that addresses emotional and relational processes not directly addressed by CBT-CP or MM; (2) testing group and video telehealth delivered treatments to improve access; (3) identifying mechanisms of response so that future treatments can target the most powerful mechanisms; and (4) determining moderators of response to promote treatment matching. A large-scale trial directly comparing telehealth-presented group EAET, CBT-CP, and MM tailored for chronic pain among older Veterans can address all these recommendations. Significance: The proposed randomized clinical trial directly compares EAET, CBT-CP, and MM, each delivered in groups over video telehealth, an important format to promote access and scalability. In performing lagged analyses of mechanisms, the trial will also generate comprehensive results on how psychological pain treatments work, including whether EAET, CBT-CP, and MM work through unique mechanisms based on their respective conceptual models or via shared mechanisms. In evaluating important demographic variables and other moderators that are mechanistically linked to each treatment, we will also learn how to optimize benefits and maximize limited resources by selecting the most appropriate Veterans for each treatment. Innovation & Impact: The trial focuses on older Veterans, an important but understudied group of chronic pain patients. In addition, the trial's direct effectiveness comparison of multiple active interventions to each other is quite rare but allows for sophisticated analyses of mechanisms and moderators. Indeed, the trial uses innovative lagged analyses of mechanisms collected at multiple time points, whereas most other studies only evaluate whether pre-post changes of mechanisms correlate with pre-post changes in outcomes. Finally, the study aims to be performed entirely remotely to increase the impact of findings. Overall, results are expected to impact clinical practice and guidelines within VA. Specific Aims: Test whether there are differences in outcomes among the three treatments, whether EAET is superior to CBT-CP and MM, and whether MM is superior to CBT-CP. Test whether potentially unique mechanisms precede and predict improvements in those assigned to the relevant treatment and potential shared mechanisms precede changes in outcomes across individuals in all three treatments. Test whether psychological characteristics that are mechanistically linked to each treatment moderate treatment response, and explore demographic moderators. Methodology: In a 2-site (VA Greater Los Angeles and VA Connecticut), 3-arm randomized clinical trial, women (at least 20%) and men multiracial/multiethnic Veterans age 60-95 years with chronic musculoskeletal pain (n = [216]) are randomized to EAET, CBT-CP, or MM. All interventions are delivered via video telehealth to Veterans' homes as one 60-minute individual session and eight 90-minute sessions in groups of 6. Veterans complete self-report questionnaires remotely at baseline, mid-treatment, post-treatment, and 6-month follow-up. Next Steps/Implementation: The project addresses the HSR&D priority areas of pain management, aging, and telehealth and is supported by the VA Office of Mental Health and Suicide Prevention, the VA Office of Patient Centered Care & Cultural Transformation, and local COINs and Mental Health Services. Following the trial, resources on treatments, findings, and lessons learned will be sent to our partners, VHA clinicians and researchers, Veterans, and the scientific community.	Long Term Care and Aging				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 22-011	Kocher	Keith	Anita Vashi	Keith.Kocher@va.gov	Improving Value through Comprehensive Episodes of Emergency Care for Veterans	04/01/2024	09/30/2029	VA Ann Arbor Healthcare System, Ann Arbor, MI	$101,326		Background: Through the Choice Act of 2014 and the Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act of 2018, the Veterans Affairs (VA) health system has substantially expanded its role as a purchaser of care with greatly increased opportunities for Veterans to receive care outside VA and in the community. Emergency department (ED) visits and related hospitalizations now represent the largest provision of community-based care, costing over $4 billion to VA in fiscal year 2021— more than 5 times greater than the next category of community care—and with nearly 50% more ED use compared to the previous year, but with uncertain return on that spending. Significance: Current approaches are inadequate for understanding the overall value of ED care for Veterans. Episode of care models, however, a central strategy for measuring population level utilization and quality associated with the full treatment of an illness, are a promising method for characterizing Veteran ED care both in the community and VA with the goal of identifying sources of variability and opportunities for improvement. Yet these models are not available for ED care or for emergency conditions and concerns common to Veterans. Innovation & Impact: Our proposed research represents a departure from the status quo and previous attempts to understand differences in ED practice patterns for Veterans receiving care. Our study will unlock critical insight and substantially move the field forward by evaluating differences in resource use, quality, and care fragmentation patterns indicating opportunities for improvement in emergency care delivery that ultimately shorten the standard cycle of meaningful and successful interventions for widespread adoption within VA. Specific Aims: (1) To define a set of highly promising ED-based episodes of care for common conditions experienced by Veterans; (2) To assess resource use and quality in ED-based episodes of care beginning in the VA vs community setting; (3) To evaluate care fragmentation within ED-based episodes of care in the VA vs community setting. Methodology: Using the national VA datamart, we will define care episodes beginning with the ED visit for several important Veteran conditions: congestive heart failure, chest pain, chronic obstructive pulmonary disease, pneumonia, and suicidality. Employing a technical expert panel with a modified Delphi method, we will determine inclusion and exclusion criteria, standardize risk-adjustment methods, and establish the validity of these episode definitions. Then, using national VA and non-VA Community Care data and the methodologies developed in Aim 1, we will apply ED-based care episodes and test for differences in patient utilization and quality. Finally, we will test for associations between Veteran resource use and quality as developed in Aim 2 with indicators of care fragmentation, an important opportunity for intervention, in Aim 3. Next Steps/Implementation: Discoveries derived from this proposed study will directly address the critical knowledge gap facing VA operational leaders in understanding the value of ED purchased community care relative to VA ED care. Once this project has proven the concept of ED-based episodes of care, these findings can inform VA administrative decisions to systematically reveal opportunities for improvement and spotlight high value targets of intervention. Ultimately, Veterans will derive the greatest benefit as we accelerate our understanding of innovative strategies to maximize the quality and safety of ED care practices.	Systems Modeling, Design, and Delivery				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 22-013	Possemato	Kyle		kyle.possemato@va.gov	Type I Hybrid Effectiveness-Implementation Trial of Primary Care Brief Mindfulness Training for Veterans	04/01/2024	03/31/2027	Syracuse VA Medical Center, Syracuse, NY	$114,070		Background: VHA primary care Veterans often have psychological distress that impairs their functioning, physical health and increases risk for suicide. This distress often goes untreated or undertreated. Innovative interventions must align with patient preferences for the content (e.g., skill-based, transdiagnostic), format (e.g., peer support) and location of services. Primary Care Brief Mindfulness Training (PCBMT) is a series of 4 classes that teach mindfulness exercises to manage psychological distress that is consistent with treatment preferences. PCBMT has been shown to be effective in reducing psychological distress in two preliminary studies. Significance: Results from this proposed trial could lead to more engagement in evidence-based care, better Veteran health, and higher quality and more efficient VHA mental health care. The proposal fits with HSR&D priorities (mental health, Whole Health) and ORD-wide priorities to expand access to high-quality clinical trials, increase the real-world impact of research and promote inclusion and equity. Innovation and Impact: PCBMT is innovative via its delivery in primary care, use of a novel staffing strategy (peers and WH partners) and it is a transdiagnostic approach. The methods of this study are also innovative: 1) this pragmatic clinical trial will maximize generalizability, 2) we will test components of the novel Transtherapeutic Mindfulness Framework to help the scientific community understand how mindfulness interventions impact psychological outcomes, 3) we will explore how social determinants of health (SDoH) impact care, and 4) we will integrate implementation science methods to guide future implementation efforts. Specific aims: 1. Compare PCBMT to a transdiagnostic problem solving group (Moving Forward, MF). We hypothesize that Veterans randomized to PCBMT will experience larger improvements in psychological distress (DASS-21) than MF participants. 2. Test mediators and moderators of treatment gain in PCBMT and MF. a. We hypothesize changes in transdiagnostic processes (e.g., psychological flexibility, thought suppression) will mediate the relationship between mindfulness and psychological distress. b. We will explore if SDoH (race, sex, ability to obtain necessities to live, safe housing) moderate initiation, completion and clinical benefits of PCBMT and MF. 3. Assess implementation barriers and facilitators to inform future implementation efforts. PACT and Whole Health administration and staff, including PCBMT facilitators, will be surveyed pre and post RCT to understand factors that impact optimal implementation and further spread. Methodology: The proposed study seeks to further test the effectiveness of PCBMT in three VHA primary care settings that serve diverse Veteran populations and begin to understand important implementation factors with a Hybrid Type I randomized controlled trial in primary care patients with psychological distress. Next Steps/ Implementation: Should our results support PCBMT effectiveness we will disseminate the manual and training materials to PCMHI and Whole Health staff nationally and provide training to early adopters in PCMHI and Whole Health with the support of OMHSP. We also will prepare a new HSR&D application to conduct a Hybrid Type III Implementation Trial to investigate how PCBMT can be implemented at sites across VA. Primary Care Brief Mindfulness Training (PCBMT) consists of group mindfulness classes designed to be delivered in primary care to Veterans with psychological distress. Many Veterans who are not willing to engage in traditional mental health treatment are willing to take classes to learn skills they can apply in their daily life to manage distress. Earlier research has indicated that Veterans like these classes and that they are associated with reduced mental health symptoms. The current study seeks to test PCBMT in three VA sites to further investigate its effectiveness in helping Veterans reduce psychological distress. Results of this study have the potential to create a new treatment option for Veterans and improve Veteran mental health.	Mental and Behavioral Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 22-033	Rogal	Shari		shari.rogal@va.gov	Project OASIS: Optimizing Approaches to Select Implementation Strategies	01/01/2024	03/31/2027	VA Pittsburgh Healthcare System University Drive Division, Pittsburgh, PA	$238,688		BACKGROUND: Implementation science aims to improve the uptake of evidence-based health care practices (EBPs) by defining the barriers that prevent their use, offering implementation strategies to overcome these barriers, and developing methods that allow clinicians and researchers to choose the strategies that best ad- dress the barriers they encounter. Recognizing that implementation strategy selection is often inefficient and idiosyncratic, implementation experts have called for methods to make strategy selection scientific, data- driven, and “precise”. To actualize “precision implementation”, there is a critical need to develop methods to 1) quickly and uniformly identify implementation barriers and facilitators, 2) track the use and effectiveness of im- plementation strategies, and 3) incorporate data and expert knowledge into the process of matching strategies to barriers. Without these improvements, we risk perpetuating implementation failures and health care dispari- ties. SIGNIFICANCE: Project OASIS (Optimize Approaches to Select Implementation Strategies) will support VA in becoming a “high reliability organization,” that provides Veterans with access to equitable and high-qual- ity care. The resulting methodological advancements are expected to apply outside of VA and across a wide variety of evidence-to-practice gaps. INNOVATION & IMPACT: Project OASIS will engage tremendous interdis- ciplinary expertise and data resources to address the complex, fundamental question of how to efficiently measure and select strategies to promote equitable, high-quality care. This work will leverage a one-of-a-kind dataset (38 project-years of implementation data) and techniques that are innovative in implementation science (e.g., user-centered design, machine learning). Project OASIS will advance the science of precision implemen- tation and our understanding of how to make decision aids that incorporate both machine learning and expert opinion. This work will provide innovative and practical approaches that will support broader public health and health equity goals. SPECIFIC AIMS: 1) Develop and test an implementation strategy selection Decision Aid (DA); 2) Develop and validate a survey to rapidly assess implementation barriers and facilitators; and 3) Refine a survey to track implementation strategy use over time. METHODOLOGY: Aim 1) The DA will be based on our existing, 38 project-years of data, that span 8 years, 12 EBPs, and 145 VA sites. We will first use Latent Class Analysis to identify site “types” using existing data about site barriers and facilitators coded using the Consolidated Framework for Implementation Research (CFIR)—a meta-framework of 39 constructs that can help or hinder implementation. For each site type, we will use tree-based methods to identify which implemen- tation strategies (based on the Evidence-Based Recommendations for Implementation Research, ERIC, taxon- omy of 73 strategies) were associated with best performance on EBPs at the site-level. The empirical output alongside existing expert opinion will form the backbone of a user-centered DA that recommends up to 5 strat- egies which could help to address the barriers users are experiencing to EBP adoption in practice. We will con- duct usability and acceptability testing of the DA followed by a hybrid type-III, cluster-randomized trial of the DA vs. an existing, expert-only tool in 20 VA sites to improve liver cancer screening. Aim 2) We will work with CFIR creators, clinicians, and Veterans to develop a refined, understandable, and relevant CFIR survey and evalu- ate its psychometric properties with n=48 clinicians, comparing results to semi-structured interview data (the traditional gold standard to collecting CFIR data). Aim 3) We will reconvene the ERIC developers and VA lead- ers, clinicians, and Veterans to further develop a user-centered implementation strategy survey. NEXT STEPS and IMPLEMENTATION: The Project OASIS DA and surveys are in high demand, as described in our letters of support. These research products will be immediately used by VA leadership and researchers, shared on the CFIR website—accessed nearly half a million times a year by a global audience—and posted on VA re- search websites.	Health Care Organization and Implementation				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 22-038	Adams	Megan	Pratima Sharma	megan.adams5@va.gov	Optimizing Specialty Care Access for Veterans with End-Stage Organ Diseases	10/01/2023	12/31/2027	VA Ann Arbor Healthcare System, Ann Arbor, MI	$282,897		Background: Low rates of referral to specialty care among Veterans represent a significant barrier to access and optimal clinical outcomes. This is particularly true for Veterans with end-stage organ diseases (e.g., advanced chronic kidney disease (CKD), decompensated cirrhosis), who are potentially eligible for life-saving transplantation and require specialty care for optimal disease management. Despite the high prevalence of end-stage liver and kidney diseases among Veterans, less than a third of Veterans with advanced CKD and decompensated cirrhosis are referred to a specialist and <5% for transplant evaluation. A comprehensive assessment of patient-, provider- and system-level factors influencing specialty care referral and referral for transplant evaluation is critical to developing targeted strategies and approaches to optimize referral appropriateness as there is a clear association between being seen by a specialist and improved survival. Significance/Impact: Ensuring timely access to high-quality primary and specialty care is a core mission of the Veterans Health Administration (VHA). Factors affecting specialty care referral and referral for transplant evaluation among Veterans with advanced chronic liver and kidney diseases are incompletely characterized. This knowledge is critical to designing effective strategies to enhance referral appropriateness and optimize access. Hence, there is an urgent unmet need to improve our understanding of these complex relationships and the mechanisms by which they affect referral to specialty care and referral for transplant evaluation. Innovation: Most existing work has focused on steps downstream of referral to specialty care and for transplant evaluation, such as completion of transplant evaluation, waitlisting, transplant receipt, and post- transplant outcomes -- thus, barriers to specialty care referral and referral for transplant evaluation remain understudied. This study will comprehensively examine and identify the multi-level factors driving referral to specialty care and referral for transplant evaluation, with the goal of generating best practice recommendations to optimize referral appropriateness and equity. This knowledge is critical to improving referral processes/pathways, enhancing Veteran outcomes, and informing policy changes to increase parity in access. Aims: 1) Characterize the multi-level factors associated with specialty referral and referral for transplant evaluation among patients with advanced chronic liver and kidney diseases. 2) Examine patient and provider knowledge, attitudes, and perceived barriers/facilitators of specialty care referral and referral for transplant evaluation. 3) Develop best practice recommendations to optimize referral appropriateness and equity using modified Delphi panels. Project Methods: Aim 1 is a retrospective observational cohort study using multi-level modeling to identify key patient-, provider-, and system-level factors associated with non-referral to specialty care and for transplant evaluation. As part of Aim 1, the impact of social determinants of health on referral to specialty care and for transplant evaluation also will be evaluated. In Aim 2, we will conduct semi-structured qualitative interviews with primary and specialty care providers and patients sampled from 6 VA health systems to explore variation in knowledge, attitudes, and perceived barriers/facilitators of referral to specialty care and for transplant evaluation. In Aim 3, we will use a modified Delphi approach to convene two panels of VA operational leaders and other experts to develop best practice recommendations to maximize referral appropriateness and equity. Implementation/Next Steps: This study will provide critical information regarding key factors impacting specialty care referral and referral for transplant evaluation among vulnerable Veterans with advanced chronic liver and kidney diseases. Products of the grant will provide vital information to VHA leaders on how to enhance referral appropriateness and equity by generating actionable strategies to address key barriers to referral to specialty care and for transplant evaluation.	Systems Modeling, Design, and Delivery				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 22-048	Montgomery	Ann		ann.montgomery2@va.gov	Keeping the Front Door Open: Preventing Homelessness through the National Call Center for Homeless Veterans	10/01/2023	06/30/2026	Birmingham VA Medical Center, Birmingham, AL	$396,155		Background: Between 2009–2020, VA implemented primary, secondary, and tertiary interventions to prevent and end homelessness among Veterans, resulting in a 50% reduction in Veteran homelessness. The need to prevent new episodes of homelessness remains; the National Call Center for Homeless Veterans (NCCHV) is available 24 hours a day, 7 days a week to connect Veterans with resources to address housing instability. During a 2-year period, 60% of the 110,000 Veterans who contacted NCCHV reported being at risk of homelessness. Significance: The proposed study provides the opportunity to assess how NCCHV links Veterans who are at risk of homelessness with needed services to mitigate their housing instability, which is an important social determinant of health. This study is supported specifically by the Homeless Program Office and the U.S. Interagency Council on Homelessness. Innovation & Impact: Unlike other major initiatives to prevent and end homelessness among Veterans, NCCHV has not yet been studied; the proposed study will use NCCHV data linked with other administrative data sources and qualitative methods to explore homelessness prevention among Veterans, which will have important implications for the field at large. Specific Aims: (1) Describe characteristics and needs of Veterans accessing NCCHV using existing administrative data collected through NCCHV and VA’s electronic health record. (2) Assess Veterans’ outcomes following contact with NCCHV. (3) Identify optimal practices for linking Veterans with services following a contact to NCCHV. Methodology: This concurrent mixed methods study will include retrospective quantitative analyses examining Veterans’ contacts with NCCHV, quantitative and qualitative methods assessing how Veterans who are engaged with VA care are connected with services and associated outcomes (e.g., long -term housing stability, health care use, mortality), and observations of NCCHV responders and qualitative interviews with key informants exploring how providers connect Veterans with care following an NCCHV contact and identifying effective strategies. Next Steps/Implementation: This study is intended to identify optimal practices to ensure Veterans are connected with needed resources; future research may develop and study specific interventions to improve access to care and the prevention of homelessness. From a practice perspective, this study will identify intervention points for homelessness prevention as well as effective practices to further implement .	Equity				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 22-062	Brooke	Benjamin		Benjamin.Brooke@hsc.utah.edu	Reducing Chronic Opioid Use Among Veterans Undergoing Community Care Surgery Using a Transitional Pain Service	02/01/2024	09/30/2027	VA Salt Lake City Health Care System, Salt Lake City, UT	$77,867		Background: The VA Community Care program has improved access to surgical care for Veterans unable to have treatment at VA Medical Centers in a timely fashion. However, the delivery of surgical care outside the VA poses barriers to care coordination for pain management during the transitions before and after surgery, leading to increased risk for chronic opioid use (COU). A multidisciplinary approach to perioperative pain management known as the Transitional Pain Service (TPS) has been shown to effectively reduce COU among Veterans after orthopedic surgery, but it is unknown whether this approach can be delivered virtually to reduce COU among at-risk Veterans undergoing similar procedures at non-VA hospitals. Significance: Community Care referrals for orthopedic surgery are very common (>30,000 cases annually) and place Veterans at risk for COU. The proposed study represents a unique opportunity to evaluate a telehealth TPS approach to address care coordination and reduce risks for COU among Veterans when they transition between VA and non-VA surgical care. Innovation & Impact: No prior studies have evaluated the impact of a TPS approach to improve coordination of pain management for Veterans undergoing major surgery at non-VA hospitals. This project presents a unique opportunity to apply an evidence-based approach to help improve the coordination of pain management for Veterans using Community Care for orthopedic surgery at non-VA hospitals and reduce the risk of opioid misuse. Data from this study will be critical to support the broader dissemination of telehealth TPS across the national VHA. Specific Aims: Aim 1. To evaluate a telehealth transitional pain service approach for preventing COU among Veterans referred to non-VA hospitals for orthopedic surgery. Aim 2. To identify barriers and facilitators of care coordination when Veterans undergo orthopedic surgery at non-VA hospitals and use telehealth TPS. Aim 3. To compare patient and payer costs with clinical outcomes among Veterans receiving telehealth transitional pain service versus standard in-person follow-up visits for pain management. Methodology: In Aim 1, we will randomize Veterans referred to non-VA hospitals in VISN-19 for orthopedic joint procedures at two VAMCs to a TPS with regular follow-up telehealth visits after surgery versus only receiving standard care for managing opioid tapering in the 90-days following hospital discharge. In Aim 2, we will conduct interviews with VA providers and Veterans who used Community Care for orthopedic surgery to identify factors that influence coordination of pain management. And in Aim 3, we will estimate patient and VA perspective costs when Veterans use Community Care and perform a cost-effectiveness analysis comparing telehealth TPS to receiving only standard follow-up care with surgical and PCP teams for pain management. Next Steps/Implementation: The research findings from this study will be used to evaluate and refine the telehealth TPS approach designed to improve coordination of pain management for at-risk Veterans undergoing orthopedic surgery at non-VA hospitals. Our study will help identify factors that influence coordination of pain management among Veterans using Community Care and their VA providers, and determine whether a telehealth TPS approach is cost-effective to both patients and payers. There data will determine whether a telehealth TPS approach to coordination of pain management should be dissemination across the VHA.	Care of Complex Chronic Conditions				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 22-071	El-Serag	Hashem		Hashem.El-Serag@va.gov	Testing the Effectiveness of NAFLD Clinical Care Pathway in VA Primary Care	02/01/2024	12/31/2027	Michael E. DeBakey VA Medical Center, Houston, TX	$129,685		Background: In the United States, non-alcoholic fatty liver disease (NAFLD) affects 25-30% of adults and has become a leading cause of chronic liver disease including cirrhosis and liver cancer. The burden of NAFLD and its complications among patients in the Department of Veterans Affairs (VA) is increasing. Most complications occur among patients with advanced hepatic fibrosis. Treatment (e.g., weight loss) improves patients’ outcomes. Significance: Our data indicate that most VA patients with NAFLD are undiagnosed and untreated. There is an urgent need to address this major gap in care. Most people with NAFLD are seen in primary care settings. The NAFLD Clinical Care Pathway (NCCP) is a multistep, algorithmic process that entails identification of patients at risk through an e-trigger (Step 1), targeted history and lab testing (Step 2), noninvasive testing for hepatic fibrosis using FIB-4 (Step 3), elective additional fibrosis testing with Fibroscan for those with indeterminate FIB-4 (Step 4), and subsequent recommended management. The NCCP has face and content validity based on consensus of multiple stakeholders including VA clinicians, and high efficacy in our preliminary data. We propose to adapt the multicomponent NCCP intervention for use in VA primary care and prospectively test its effectiveness for identification and severity stratification of patients with NAFLD. Our approach is consistent with VA strategic priorities to implement a more “Veteran-centered” approach that improves access to care. Innovation & Impact: This is the first study to examine the effectiveness of any NAFLD clinical care pathway in a VA primary care practice. The design is a cluster-randomized controlled trial with randomization at the level of Patient Aligned Care Teams (PACTs) in primary care, and a state-of-the-art technique to diagnose NAFLD and stage the severity of hepatic fibrosis. Our formative and summative evaluation will provide key information about the feasibility, acceptability and determinants of implementation. The NCCP intervention is a paradigm shift in NAFLD care from haphazard and sporadic care into a systematic, equitable, and evidence-based approach. Specific Aims: Aim 1. Conduct a formative evaluation to assess feasibility and acceptability of the NCCP among patients and providers; adapt the NCCP for prospective testing based on feedback. Aim 2. Examine the effectiveness of the NCCP intervention compared to usual care in improving NAFLD care processes and patient outcomes. Aim 3. Conduct a summative evaluation to identify patient and provider characteristics associated with effectiveness of NCCP and to assess future implementation. Our hypothesis is that NCCP when adapted to Patient Aligned Care Teams (PACTs) in VA primary care considerably increases the identification of patients with NAFLD and those with high-risk NAFLD, and results in an increase in guideline-concordant management. Methodology: The study will be conducted in primary care settings in a single large VA Medical Center. We will conduct patient interviews and focus groups with PACTs to inform adaption of the NCCP. We will then conduct a cluster-randomized trial of 16 PACTs in primary care to compare the effectiveness of NCCP to usual care in improving NAFLD care, with PACTs as unit of randomization and patients as the unit of analysis. The multicomponent intervention includes an e-trigger to identify patients eligible for NAFLD screening and calculate fibrosis scores, a structured provider education on NAFLD management and treatment recommendations, and coordination by an interprofessional team. The primary outcome will be a composite binary variable consisting of NAFLD diagnosis and risk stratification. Secondary outcomes include referral to a weight loss program, referral of patients with advanced fibrosis to hepatology specialty care, and enrollment among those referred to weight loss and hepatology specialty care. Summative evaluation will inform future implementation. Next Steps/Implementation: Our study will provide information needed to support future projects to implement the NCCP in VA primary care settings. The study will also lay the foundation for a subsequent project to examine the adopted intervention’s effect on weight loss and NAFLD biomarkers in patients with high-risk NAFLD.	Care of Complex Chronic Conditions				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 22-132	Harris	Jeanette		jeanette.harris2@va.gov	Implementation of Innovative Treatment for Moral Injury Syndrome: A Hybrid Type 2 Study	04/01/2024	04/30/2027	Maine VA Medical Center, Augusta, ME	$146,882		Background: Moral injury syndrome (MIS) consists of the psychological and behavioral sequelae of experiences that challenge moral, spiritual, or values related beliefs. Symptoms of MIS may include hopelessness, helplessness, loss of previously held spiritual beliefs, struggle with a Higher Power, difficulty with forgiveness, lack of meaning or purpose, reduced trust in self or others, or intractable guilt, shame or anger. Individuals managing MIS are up to twice as likely as their peers to consider and attempt suicide, and derive less benefit from psychotherapy. There are few evidence-based interventions for moral injury; one such intervention is a manualized, group intervention called "Building Spiritual Strength (BSS)." In previous randomized controlled trials BSS has been shown to reduce both symptoms of PTSD and spiritual distress. This clinical trial will be one of the first to measure symptoms of MIS as a primary outcome. Hypotheses are: Hypothesis 1: Compared to PCGT, BSS will significantly decrease symptoms of moral injury syndrome (primary effectiveness outcome). Hypothesis 2: Compared to PCGT, BSS will significantly decrease symptoms of depression, decrease suicidal ideation, and reduce functional impairment. (secondary effectiveness outcomes). Significance: To date there are not standard procedures for assessing and treating MIS, so it is likely that untreated MIS is contributing to poor outcomes, including suicides. Developing an implementation toolkit so that BSS is widely available in VA facilities could reduce the impact of MIS on Veterans’ mental health. Innovation and Impact: To date there have not been funded implementation studies on treatments for MIS in Veterans, and very few VA facilities provide evidence-based care for MIS. This study can clear the way to make evidence-based care for MIS more accessible in the VA system. Specific Aims: 1.Conduct a mixed methods pre-implementation evaluation to identify barriers and facilitators for BSS implementation at each site, and to develop local implementation strategies. Specific implementation variables assessed, based on the Proctor and Evidence Based Quality Improvement (EBQI) models include acceptability, appropriateness, and feasibility. Specific variables to be assessed will include a) acceptability of BSS to stakeholders, b) available implementation resources, and c) organizational openness to adding a new EBP. 2. Conduct a randomized controlled trial comparing BSS to Present Centered Group Therapy (PCGT) for Veterans who score above cutoff (score >14) on the Moral Injury Outcomes Scale. Effectiveness and functional outcomes will be informed by the psychospiritual developmental model of MIS. 3. Conduct a mixed methods post-implementation evaluation to compare outcomes across chaplaincy managed vs. mental health managed BSS programs. Proctor20,21model outcomes will include adoption, fidelity, penetration, and sustainability. Specific outcomes related to this framework include a) successful BSS implementation, b) fidelity in implementation of BSS, c) provider awareness of, and willingness to refer to BSS, and d) qualitative reports of intent to maintain the BSS program when the study is complete. Methodology: This will be a type 2 hybrid study, combining pre- and post-implementation evaluations with a randomized clinical trial at 4 culturally diverse VA sites. Next Steps and Implementation: Data on barriers and facilitators will be used to develop a toolkit and collaborate with our partners at the Office of Mental Health and Suicide Prevention and the National Chaplain Service to develop a national dissemination plan for BSS. We will work with existing clinical staffing at our study sites, so that those sites can continue to provide BSS services after the study. Furthermore, after completing this study, BSS leaders will be qualified to train BSS leaders at other sites, creating resources for training and national dissemination.	Mental and Behavioral Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 22-141	Hawkins	Eric		eric.hawkins@va.gov	Combining a Smartphone App with Medications to Manage Heavy Drinking	04/01/2024	04/30/2027	VA Puget Sound Health Care System Seattle Division, Seattle, WA	$185,040		Background: Alcohol use disorder (AUD) affects 1 in 10 Veterans and is associated with significant morbidity and mortality. However, few individuals receive evidenced-based psychosocial interventions or medications for AUD (MAUD). Common barriers to treatment include long wait times, stigma, and distance from treatment facilities. Despite clinical guidelines and evidence indicating superior outcomes, even fewer individuals receive MAUD and psychosocial interventions conjointly. The VA prioritizes expanding access to AUD interventions in primary care, but it is difficult to deliver psychosocial interventions in primary care, and care often includes MAUD only. Smartphone mobile applications (apps) that deliver psychosocial interventions concurrent with MAUD may address the gap between recommended and current practices for AUD and appeal to Veterans who prefer to receive their AUD care in primary care. Alcohol intervention apps have been associated with improved drinking-related and mental health outcomes. Self-monitoring of alcohol use, a common feature in apps, may also increase MAUD adherence. Step Away, an app for self-management of alcohol use problems, is designed to guide development and use of personalized strategies to moderate or abstain from drinking. In single-arm cohort studies, we assessed the acceptability and usability of Step Away and Stand Down (SD- App), the Veteran version of the app and focus of this proposal, among Veterans with alcohol use problems. The apps received favorable ratings regarding perceived effectiveness, efficiency, and overall satisfaction, and were associated with reductions in heavy drinking days and drinking-related consequences. Significance: This study has the potential to substantially improve Veterans’ receipt of guideline-concordant AUD care and support national VA initiatives to increase access to AUD care in general healthcare clinics. Innovation & Impact: To our knowledge, no prior study has evaluated the effectiveness of an alcohol-related intervention, delivered by smartphone, with MAUD in primary care. Smartphone apps can be scaled up at relatively low cost, potentially saving lives and improving the quality of care of tens of thousands of Veterans. Specific Aims: Our two aims are to: 1) determine whether MAUD plus SD-App offered to primary care patients diagnosed with AUD, compared to MAUD only, results in (a) greater reductions in heavy drinking days, from baseline to 6-months (primary), (b) greater improvements in alcohol consequences, alcohol use risk levels, and mental health outcomes, from baseline to 6-months (secondary), 2) conduct a process evaluation to identify factors that influence the adoption, implementation, and sustainability of SD-App in combination with MAUD in VA primary care from Veterans’, clinical pharmacist specialists’ and clinical leaders’ perspectives. We will also explore whether MAUD plus SD-App increases MAUD 6-month adherence relative to SD-App alone. Methodology: Guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework, this Hybrid 1 effectiveness-implementation trial will enroll 330 Veterans across 10 VA sites. Veterans between ages 18-80, meeting AUD criteria, and planning to initiate MAUD will be randomized to MAUD+SD-App or MAUD only. Participants randomized to MAUD+SD-App will receive access to SD-App. MAUD will be prescribed by primary care-based clinical pharmacists per standard clinical care. The primary and secondary outcomes will be assessed at baseline, 3-, 6- and 12-months using participant self-report and electronic medical record data. We will complete qualitative interviews to assess Veterans’, clinical pharmacists’, and clinical leaders’ perspectives on barriers and facilitators to adoption, implementation, and sustainability of SD- App in combination with MAUD in primary care. Next Steps/Implementation: If MAUD+SD-App improves drinking outcomes, we will work closely with our operations partners to review study findings and to develop a tailored implementation strategy to support widespread implementation across VA primary care.	Mental and Behavioral Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 22-158	Wachterman	Melissa	Ann Kutney Lee	melissa.wachterman@va.gov	Improving Quality of End-of-Life Care for Veterans Receiving Hospice in Community Nursing Homes	03/01/2024	09/30/2028	VA Boston Healthcare System Jamaica Plain Campus, Jamaica Plain, MA	$144,153		Background: With the aging of the Veteran population, the demand for end-of-life (EOL) care, including hospice services, is increasing. VA commits to ensuring that Veterans have access to high-quality hospice in their setting of choice. In addition to home hospice services, VA offers to provide hospice care within VA Community Living Centers (CLCs; i.e., VA nursing homes) or in VA-contracted community nursing homes (CNHs). Until recently, little was known about the quality of EOL care provided to Veterans receiving CNH-based hospice care. Our preliminary work found that an alarmingly low percentage (58%) of family members of Veterans receiving hospice in CNHs gave an “excellent” rating of the overall care received in the last 30 days of life (compared to 83% of families of Veterans who received hospice in CLCs). We have also observed significant variation across CNHs in quality of EOL care ratings. Significance: CNHs are playing an increasingly critical role in VA’s commitment to ensuring Veterans’ access to hospice care. A comprehensive understanding of the structures and processes that underlie variation in quality of EOL care provided to Veterans receiving CNH- based hospice is needed to illuminate levers for intervention to improve quality. Our study aligns with HSR&D’s priority areas related to Community Care and Long-Term Care and Aging and VA’s Strategic Plan that includes a key focus on “Aging, Frail, and End-of-Life Veterans.” Innovation and Impact: Our application of positive deviance and machine learning methods to identify factors underlying the quality of CNH-based hospice care are innovative contributions to the field of EOL care research. Our findings have high potential for impact to guide VA contracting decisions and the delivery of CNH-based hospice care to Veterans. Specific Aims: 1) Examine the associations between CNH and hospice agency structural characteristics, EOL care processes and bereaved family ratings of overall EOL care quality for Veterans receiving hospice in CNHs; 2) Identify high- and low-performing CNHs based on the BFS overall rating for Veterans who receive hospice; and determine the structures and EOL care processes that are associated with high and low performance; 3) Explore bereaved family member perceptions of the quality of EOL care for Veterans who received hospice in high- and low-performing CNHs; and 4) Understand the delivery of CNH-based hospice care for Veterans in high- and low-performing CNHs from the staff perspective. Methodology: The project will employ a sequential explanatory mixed methods design. The quantitative phase will use multi-level logistic regression models to understand the structural characteristics and EOL care processes associated with BFS overall ratings (Aim 1) and a machine learning approach to identify and study high- and low-performing CNHs based on BFS ratings (Aim 2). The qualitative phase will deepen our understanding of the delivery of hospice care in high- and low-performing CNHs using existing BFS data collected from bereaved family members (Aim 3) and interviews with clinical staff and administrators (Aim 4). Next Steps/Implementation: Findings will be used to refine VA’s CNH Dashboard that is used to guide contracting decisions by incorporating EOL-focused measures. The study will also create a Roadmap for Improving CNH-Based Hospice Care, including a Compendium of Best Practices, that will inform quality improvement efforts and the development of a future intervention study.	Long Term Care and Aging				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 22-173	Harrod	Molly	Sarah Krein	Molly.Harrod@va.gov	Ensuring Safe and Effective Delivery of Outpatient Parenteral Antimicrobial Therapy for Veterans	12/01/2023	01/31/2028	VA Ann Arbor Healthcare System, Ann Arbor, MI	$295,122		Background: Every day, hospitals across the United States (US) and Veterans Health Administration (VHA) discharge patients with vascular access devices for outpatient parenteral antimicrobial therapy (OPAT). OPAT has advantages but it is not risk-free and can result in adverse events and hospital readmissions. A high degree of commitment and task performance by patients and caregivers is also required. A 2020 VHA Antimicrobial Stewardship survey found variability in who monitors OPAT patients and that most facilities use outside contract services, which may make it difficult to coordinate care across settings. OPAT is a vital part of Veteran care, yet we know very little about how it is managed across VHA or the challenges Veterans and their caregivers face while receiving at-home therapy. Significance: This research will advance knowledge and improve care delivery by addressing VHA and research clinical and methods priorities related to quality and safety, the use of cross-cutting methods and real-world impact. This work is also aligned with VA strategic goals and core principles, including providing Veterans with care in their homes when needed and the required training and resources for their caregivers. This research will advance knowledge and lead to improvements in quality and safety, a VHA clinical priority, by identifying and deploying strategies to ensure safe and effective OPAT delivery for Veterans. Innovation & Impact: This study is the first comprehensive assessment of OPAT delivery in VHA. Findings will lead to improvements in OPAT delivery and provide knowledge for improving home infusion therapy more broadly. Focusing on the patient journey, we will highlight the interactions across different socio-organizational contexts, providing a more complete view of care delivery. Innovative methods that actively engage Veterans, caregivers and clinical providers are used throughout the research process. We will also use a collaborative co-design approach to bring stakeholders together to develop interventions that are more acceptable and feasible to implement. Methods that could be used to address other care delivery challenges. Specific Aims: Aim 1: Assess how OPAT is delivered by VHA Medical Centers, through semi-structured interviews with clinical providers at selected facilities followed by a survey of all VHA medical centers. Aim 2: Gain an in-depth understanding of the Veteran home experience using video-reflexive ethnography and photo elicitation followed by a survey assessment of Veteran experiences with a broader sample of OPAT patients. Aim 3: Design interventions to enhance OPAT safety and delivery in collaboration with Veterans, their caregivers and clinical care providers. Methodology: This study uses qualitative and quantitative methods to understand how OPAT is delivered across VHA, how patients and caregivers experience at-home OPAT and a user-centered design approach to develop interventions to address OPAT-related challenges and safety concerns. Our research is guided by the Systems Engineering Initiative for Patient Safety (SEIPS) 3.0 framework, which incorporates the patient journey across various care settings. We will conduct semi-structured interviews and surveys of clinical care providers involved in OPAT care, and video-reflexive ethnography, photo elicitation, and surveys with Veterans and caregivers. Analyses of these data will be aligned with the SEIPS framework and used to inform the co- design of interventions with Veterans, caregivers and providers to address OPAT challenges and needs. Next Steps/Implementation: Outcomes from this work will include a detailed understanding of OPAT use and delivery across VHA and an understanding of the patient experience at hospital discharge and post-discharge. Top priority interventions to support in-home OPAT delivery along with implementation steps will be identified. Protocols for using novel methods and co-design to collaborate with healthcare professionals and patients will also be developed. Importantly, this work will inform OPAT related policy and practice within VHA.	Care of Complex Chronic Conditions				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 22-193	Slatore	Christopher		Christopher.Slatore@va.gov	Lung Cancer Screening for Veterans Enrolled in Community Care: Modifiable Mechanisms to Improve Patient-Centered Outcomes	07/01/2024	03/31/2031	VA Portland Health Care System, Portland, OR	$75,878		Background: VA recommends all eligible Veterans be offered lung cancer screening (LCS) using annual low dose computed tomography (LDCT). VA is working to increase the number of Veterans screened in VA-settings but many of them will continue to receive LCS care in non-VA settings. There are several gaps in care processes in both VA and non-VA settings, including low uptake and adherence to recommended follow-up. Non-VA LCS radiology facilities, especially in rural areas, often do not have adequate resources to ensure high quality. Significance: Our proposal has the strong potential to improve care for millions of LCS-eligible Veterans and non-Veterans. The vast majority of eligible patients have not undergone LCS. Of those that have, many are engaged in LCS programs with poor records of adherence that will expose them to harms of screening without the benefits. We will examine data and procedures to help VA and non-VA facilities evaluate LCS processes and identify modifiable components that can positively affect patient outcomes. Innovation/Impact: First, this proposal will be the first to evaluate LCS processes among Veterans in non-VA settings. Second, our study will be the largest to date to evaluate patient-centered outcomes among patients who receive care at likely hundreds of radiology facilities nationwide. Third, we will use a systems dynamics stock-and-flow modeling approach and thematic qualitative analysis to identify modifiable factors for improving outcomes for Veterans engaged in LCS and change components to visualize their effects. Specific Aims - Aim 1a: Among all Veterans, characterize their involvement in lung cancer screening processes including eligibility assessments, referral and receipt of LDCTs for LCS, and adherence to recommended follow-up. Aim 1b: Among Veterans referred for lung cancer screening in VA and non-VA settings, stratify the adherence to recommended follow-up based on facility-level LCS program availability. Aim 2: Among Veterans undergoing lung cancer screening processes, evaluate the association of VA and non- VA communication components with patient-centered outcomes. Aim 3: Among Veterans, VA clinicians, staff, and leaders, and non-VA radiology facility staff, use qualitative methods to elicit their perspective on determinants of providing guideline-concordant care to Veterans referred to VA and non-VA settings for lung cancer screening. Methodology - Aim 1: Conduct a national audit of Veterans eligible for LCS to evaluate care processes and adherence to follow-up based on the Lung CT Screening Reporting & Data System. We will link these data with facility-level information of LCS programs’ characteristics obtained through the National Center for Lung Cancer Screening, to develop models of the association of VA and non-VA LCS program factors with adherence to recommended follow-up. Aim 2: Conduct a nationwide, cross-sectional survey of Veterans referred for LCS in VA and non-VA settings. We will use validated instruments to measure Veterans’ attitudes about care coordination, decision-making about choosing LCS community care, communication with VA and non-VA staff, and patient-centered outcomes such as adherence, decisional regret, satisfaction, and smoking cessation resource utilization. We will conduct in-depth EHR audits of survey respondents to determine adherence to recommended follow-up. Aim 3: Guided by a theoretical model of care coordination, we will conduct qualitative interviews of Veterans and VA and non-VA staff engaged in LCS to collect their thoughts on care coordination and communication practices. We will also use a stock-and-flow modeling approach and thematic qualitative analysis. Next Steps/Implementation: We have very engaged partners who will use our results to guide care processes and plan multiple manuscripts and presentations based on this proposal.	Health Care Organization and Implementation				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IIR 22-201	Jasuja	Guneet		Guneet.Jasuja@va.gov	Understanding Perceived Access and Receipt of Gender-affirming Treatments Among Transgender Veterans	01/01/2024	12/21/2027	VA Bedford HealthCare System, Bedford, MA	$199,385		Background: Transgender people experience discord between their gender identity and birth sex, defined as gender dysphoria. Gender-affirming treatments (GATs) are medically necessary treatments to reduce gender dysphoria. However, among transgender Veterans (trans Vets) who desire GATs, not much is known about barriers and facilitators to accessing and receiving GATs in VA and VA Community Care (CC). To ensure effective and equitable GAT access for trans Vets, it is critical to understand: [1] GATs trans Vets receive and where they receive them, [2] barriers, including social determinants of health (SDOH) barriers that are highly prevalent among trans Vets, and facilitators associated with desired GAT receipt in VA and CC, [3] how barriers and facilitators influence GAT access and desire, and [4] how to improve GAT access in VA and CC. Significance: This study addresses the 2022 HSR&D priority areas of Access to Care, Health Equity/SDOH, MISSION Act, and research gap of underserved LGBTQ+ Veterans. It is also a high priority for our operational partners in VA LGBTQ+ Health Program, Pharmacy Benefits Management, Office of Integrated Veteran Care, and Office of Mental Health and Suicide Prevention. Knowledge gained from this study will ensure that GAT delivery in the VA is patient-centered and is responsive to the lived realities and needs of trans Vets. Innovation and Impact: This study will be the first to characterize the GATs received in VA and/or CC to understand how VA and CC are balanced in terms of delivering GATs. This study will also provide novel data on trans Vet experiences related to GAT access in CC, which will be likely relevant to other underserved Veterans accessing CC. Further, it will be innovative in providing data on services and resources used by trans Vets to address barriers that influence GAT access. This will be key to developing patient-centered implementation strategies to improve GAT access in VA and CC. Specific Aims: We propose a sequential explanatory mixed method study whose aims are to: Aim 1. Characterize the GATs received by trans Vets in VA and/or CC (VA/CC) Aim 2. Identify barriers and facilitators associated with desired GAT receipt in VA and CC Aim 3: Understand trans Vet experiences related to GAT access in VA and CC. Methodology: Database Aim 1: We will expand our VA cohort of 9,608 trans Vets (IIR 17-238) from 2006-18 to the data available at the time of funding. We will add CC data to determine the types of GATs received by trans Vets in VA and/or CC. Survey Aim 2: We will survey a national sample of trans Vets identified from Aim 1. Among trans Vets who desire GATs, we will determine SDOH barriers, other barriers, and facilitators associated with desired GAT receipt. Among trans Vets who did not desire GATs, we will determine reasons for not wanting GATs. Qualitative Aim 3: From Aim 2 participants, we will recruit a purposive sample of trans Vets who received all desired GAT(s), who received some desired GAT(s), and who received no desired GAT(s). We will also recruit a national sample of LGBTQ+ Veteran Care Coordinators. We will seek to understand experiences and perspectives on GAT access in VA and CC, how SDOH barriers, other barriers, and facilitators influence GAT access and desire, and how to improve GAT access in VA and CC. Informed by study findings and in partnership with our Stakeholder Advisory Group, we will develop patient-centered implementation strategies to mitigate barriers and enhance facilitators to improve GAT access in VA and CC. Next Steps/Implementation: We will conduct a follow-up hybrid implementation effectiveness study to deploy these strategies to address barriers that impede GAT access and improve GAT access in VA and CC.	Equity				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
INV 19-171	Dang	Stuti		stuti.dang@va.gov	Targeting and Improving Long Term Care Services and Support for High Need Veterans	10/01/2019	05/31/2024	Miami VA Healthcare System, Miami, FL	$295,834		Background: Using a predictive analytic model with national Veterans Affairs (VA) data, the Geriatrics and Extended Care Data Analysis Center (GECDAC) identifies “High Need High Risk” (HNHR) Veterans every quarter. These Veterans are at high risk for hospitalization and institutionalization, and GEC recommends that they be enrolled in the VA Home Based Primary Care (HBPC) program. However, VA is currently providing HBPC to less than 25% of the identified >200,000 HNHR Veterans because the HBPC program’s reach is constrained by limited program capacity. Significance/potential impact: We expect that our transformative project will shift current clinical practice paradigm in VA by utilizing a novel potential alternative approach for improving care and outcomes of HNHR Veterans, using peer specialists. Peer Specialists are Veterans trained to provide support by drawing on their own personal recovery experience. This timely model capitalizes on the VA MISSION Act of 2018, which supports the development of peer specialists in Patient Aligned Care Teams (PACTs) through the Peers in PACT program. We will develop and pilot test this innovative model for HNHR Veterans specifically, using peer specialists hired through the Peers in PACT program. Specific goal(s) for Phase I: (1) Develop and pilot an innovative care model for HNHR Veterans who cannot get HBPC, by using Peer Specialists as home extenders of the primary care PACTs. This model will use trained Peer Specialists to conduct in-person and virtual home visits with HNHR Veterans for targeted data gathering regarding health, function, social determinants of health, unmet needs, and barriers to care. We will develop a protocol to stratify HNHR veterans into those that are home-limited and frail and in high need of HBPC, vs. non-frail high utilizing with low need for HBPC. The low need HNHR group will receive an integrated PACT clinic/ home intervention supplemented by Peer Specialists. The Peer Specialists will integrate themselves into the PACT to engage HNHR Veterans and connect them with needed GEC services and Long-Term Services and Support. This will also help identify a process to improve HBPC targeting and identify the right HNHR patients for HBPC enrollment. (2) Formalize partnerships with National VA operational partners and recruit additional VA sites for Phase II hybrid implementation trial. (3) Finalize an implementation plan and submit proposal for a Phase II hybrid implementation trial. Long-term goal(s) for Phase II: (1) Conduct a hybrid implementation trial at additional VA sites via Health Service Research and D Phase II funding, working with National VA operational partners. (2) Use the results from the Phase II trial to fine tune the model and partner with the operational partners to disseminate the peer specialist model for HNHR veterans at additional VA sites. Innovation: Although peer specialists have been shown to be beneficial in certain populations and are part of some comprehensive VA programs, to our knowledge, use of peer specialists integrated with VA primary care PACT to conduct home visits for pre-identified HNHR Veterans gather data and identify unmet needs has not been explored. This model offers a new way to engage HNHR Veterans who have the greatest need for care but often face the steepest challenges with access. Information from this pilot will enable VA primary care PACTs to use Peer Specialists to provide care to Veterans with greatest need, enhancing optimal use of available resources by matching services to patients and population subgroups. It will also provide data to help GECDAC refine criteria to identify appropriate HNHR patients for HBPC. Moreover, this innovative timely model capitalizes on the VA MISSION Act of 2018, which supports the development of peer specialists in VA primary care PACTs.	Long Term Care and Aging				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
INV 19-193	Burke	Robert		Robert.Burke5@va.gov	Building a Model VA-State Partnership to Support Non-Institutional Long-Term Care for Veterans	10/01/2019	04/30/2024	Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA	$300,000		The aging Veteran population presents enormous challenges to the VA. There are currently more than 4 million Veterans age 65 and older, and the number of priority 1A Veterans--who are eligible for VA-paid nursing home care--will double to more than 1 million by 2023. Veterans, like most older adults, wish to remain in non-institutional care settings as long as possible. However, nearly two-thirds of the more than $7 billion in annual VA spending on long-term services and supports (LTSS) is consumed by care in nursing homes. States face similar demographic and budget challenges, and are similarly redirecting their spending away from institutional LTSS towards home and community-based services (HCBS). While the incentives of the VA and states are aligned, their efforts are not. VA-based and state-based efforts to enable older adults to age in place are siloed from one another despite the fact that the populations they target substantially overlap. The result is a lack of coordination that prevents most states from answering simple questions, such as “what proportion of Veterans who are at high risk for needing nursing home care are having their needs met through VA and state HCBS?” This lack of coordination represents a tremendous lost opportunity. We propose to address this lost opportunity with an innovation focus—one defined by increasing rates of our primary outcome, days alive and in the community among high-risk Veterans. Establishing best practices for VA-state partnerships to promote community living in high-risk Veterans has the potential to improve quality of life, satisfaction, healthcare utilization, and costs for Veterans. Specifically, during the pilot period, our Specific Aims are to: 1) Establish a process that can be used to establish a shared data infrastructure between the VA, Area Agencies on Aging, states (including Departments of Aging and/or Departments of Military and Veteran Affairs) and managed Medicaid LTSS programs across multiple states. 2) Using an innovation focus, rapidly assess feasibility and acceptability of different models that could help coordinate VA and state supports for high-risk Veterans. 3) Assess barriers and facilitators to dissemination and implementation in other states. 4) Build evidence for a successful Phase II application. Our long-term goals for Phase II are to expand the shared data infrastructure and pilot interventions created in Phase I to other states using an implementation science framework to address barriers and facilitators. Innovation: We propose to address this lost opportunity with an innovation focus—one defined by increasing rates of our primary outcome, days alive and in the community among high-risk Veterans - and largely agnostic to the ways to achieve them. We have ideas for initial solution steps, but we aim to judge ourselves not on the approaches we use, but on our ability to improve these rates. It is that kind of focus that distinguishes us as an innovation program, rather than a more traditional incremental research approach.	Long Term Care and Aging				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
INV 19-200	Pogoda	Terri		terri.pogoda@va.gov	Is Protection of Disability Benefits Associated with Employment in Veterans with TBI and PTSD?	10/01/2019	03/31/2024	VA Boston Healthcare System Jamaica Plain Campus, Jamaica Plain, MA	$341,595		Background: The Veterans Benefits Administration (VBA) and Social Security Administration (SSA) provide financial safety nets for those whose disabilities negatively impact employment. However, these disability payments may unintentionally dis-incentivize return to work (RTW) since safety net payments can be reduced if functional status increases. Hallmark injuries among Post-9/11 Veterans include traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD), which frequently co-occur and are associated with unemployment. Significance/Potential Impact: Our long-term goal for Phase II (separate research effort) is to determine whether protection of disability benefits is associated with RTW or increase in work hours among Veterans with TBI/PTSD. In support of Phase II, the aims of the current Phase I planning proposal are to implement the following. Specific goal(s) for Phase I: 1. Develop Department of Veterans Affairs (VA) intra-agency (Veterans Health Administration (VHA)-VBA) and interagency (VA, SSA) memoranda of understanding (MOU) and partnerships for disability benefits protection, defined here as: (a) current SSA and service-connected disability (SCD) rating/payment not being subject to reduction over a 5-year period, (b) wages earned will not count against the disability benefits after the 5-year period ends, © no change in other disability benefits eligibility that the Veteran is otherwise entitled to, and (d) the Veteran may still apply for disability benefit increases, regardless of RTW. 2. Develop agreement with Internal Revenue Service (IRS) to track Phase II Veteran sample. 3. Review deidentified, aggregated VA administrative data to identify dense regions of Veterans with SCD for Phase II sampling. 4. Foster collaboration with VHA Polytrauma/TBI System of Care and Therapeutic and Supported Employment (TSES) leadership to identify 12 VA medical centers (VAMC) that have the resources to provide: (a) treatment to address unmet physical/ psychological/psychosocial needs and (b) vocational rehabilitation. Long-term goal(s) for Phase II. Phase II protocol development will involve the expertise of health services researchers and health economists. Discussions will include methodology, sample size, Veteran and disability characteristics (e.g., TBI/PTSD, age, gender, SCD%, disability payments), and geographic factors that may impact RTW such as local labor market. The sample will include the target Veterans to receive disability benefits protection and a matched Veteran comparison group that will not receive this protection but will also be tracked concurrently. Key outcomes and analysis over the 5-year period will include: RTW (yes/no), type of job, change in and total number of hours worked, wages, increase in SCD rating (yes/no, % change), and VHA healthcare utilization. We will also develop survey/interview questions to understand Veteran perspectives on and experiences with this initiative. Innovation: Protecting disability benefits may be the platform necessary to assuage individual and family concerns and motivate Veterans to RTW or increase work hours. As part of this process, Veterans can confidently access the full range of VA health services (i.e. engage in therapy/treatment), including, if desired, vocational rehabilitation. As many Post-9/11 Veterans with TBI and PTSD are in their prime working years and have decades of potential productivity ahead of them, removing systemic disincentives to employment is imperative.	Traumatic Brain Injury				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
INV 19-294	Constans	Joseph	Jennifer True	Joseph.Constans@va.gov	Development and Evaluation of a Veteran-Informed Means Restriction Intervention for Suicide Prevention	10/01/2019	05/31/2024	Southeast Louisiana Veterans Health Care System, New Orleans, LA	$379,161		Despite widespread concern and attention over the past decade, the continuing high rate of suicide among U.S. service members and Veterans (SM/V) remains a pressing public health issue. SM/V rates of suicide by firearm is upwards of 84% in states with high gun ownership rates and a highly rural populace. Limiting firearm access for SM/V at high risk for suicide would decrease suicide deaths; however, interventions such as safety messaging and other prevention efforts implemented in Department of Defense (DoD) and Veterans Affairs (VA) settings have not led to decreased firearm suicides. Effectiveness of these interventions has been limited by socio-culturally informed views and attitudes common among some SM/V, while delivery of interventions in VA settings has been problematic given that most SM/V who commit suicide are not actively receiving VA services near time of death. Service members who are transitioning out of military service (i.e. from 6 months prior to separation to 18 months post-separation) are vulnerable to suicide by firearm, but many are not well-connected to support services. Our project will engage SM/V peers, military families, firearm owners, and other community opinion leaders in building a VA-community coalition to bring firearms safety messaging and interventions directly to SM/V and their families. Phase I goals of our project include: 1. identifying Veteran ‘champions’ who will co-lead engagement of key military, VA, and community partners; 2. holding meetings with key VA, DoD, and community stakeholders to gather information about varying perspectives on SM/V suicide by firearm, to understand perceived challenges implementing interventions and delivering available resources to support interventions, and to enlist them in joining a community coalition to promote firearm safety; 3. convening a series of 6 deliberative discussion forums with our key stakeholders to identify and agree upon common goals, strategies, and messaging to promote firearm safety and prevent SM/V suicide by firearm, and to select specific interventions and sites for implementation of an intervention; and 4. developing an implementation toolkit and the relationships necessary to support successful implementation of the intervention in Phase II, including tailoring to different settings (e.g., rural and urban, military and community-based). The long-term goal for Phase II is to implement and evaluate the impact of our VA-community developed intervention, which we anticipate will include adaptations of existing strategies that promote safe firearm storage, as well as new messaging and delivery strategies developed in response to barriers and resources identified through our deliberative discussion forums. Given deliberative discussion groups have not been held, we can only offer a preliminary and speculative vision of the Phase II protocol. However, our discussions with individual coalition partners suggest that our Phase II protocol will involve one or more of the following themes: (1) barriers in current messaging, (2) barriers regarding current messenger (e.g., VA health providers versus firearm or veteran advocates) and (3) barriers regarding SM/V preferences on safe storage methods that are currently offered (e.g., preference for devices that allow storage of loaded weapons). The purpose of the deliberative discussion groups is to allow for developing possible consensus regarding how to address perceived barriers and will thus inform Phase II aims and methods. Innovation: This project is innovative in taking a public health approach to change the conversation and the culture around firearm safety messaging by collaborating with a range of community partners—including firearm owners, firearm sellers, firearm rights and firearm safety advocates, mental health providers, and individual Veterans, service members, and military families—to deliver firearm safety counseling and safe storage materials (e.g. trigger locks, gun cabinets) in community-based settings such as gun stores, gun shows, shooting ranges, and events attended by SM/V during the period of transition from military service to civilian life. An additional innovation involves the inclusion of key stakeholders—including Veterans, service members, and military caregivers—as partners in all phases of this work, including Advisory Board and Veteran “champions” as members of the project team. Finally, our use of deliberative discussion forums is an innovative means to identify and address potential barriers to implementing interventions in a range of urban and rural settings, to define common goals and acceptable messaging, and to build capacity for a community-VA partnership to support future implementation and evaluation of an intervention.	Mental and Behavioral Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
INV 20-111	Vashi	Anita		Anita.Vashi@va.gov	Telehealth for Acute Care in VA	10/01/2020	09/30/2024	VA Palo Alto Health Care System, Palo Alto, CA	$196,768		Project goals: In partnership with VA's National Emergency Medicine Program Office (EM-PO) and the VA Telehealth/Office of Connected Care, we propose to design, implement, and test innovative virtual solutions to rapidly triage and meet urgent care (UC) needs of Veterans. Using innovative solutions developed by public- private partnerships, our proposed program, the Virtual Urgent Care Network (VUCN), will seek to provide on- demand evaluation and treatment of unscheduled, urgent conditions. Our goal is to make health care accessible to those living in rural communities and make services more readily available for people with limited mobility, time, or transportation options. The objectives of this Phase 1 proposal are to: (1) conduct an environmental scan to identify strengths, weaknesses, opportunities and threats related to providing virtual UC services; (2) assess the feasibility, acceptability, and adoption of three specific virtual health strategies: e-visits, self-service options, and novel spaces (e.g., Walmart); and (3) design a VUCN program and a corresponding evaluation plan. Long-term Aim of Phase 2: If selected, we would use our Phase 1 plan to conduct a hybrid, type II large-scale implementation evaluation. Additionally, we would support our partners, the EM-PO, in their implementation of the VUCN. Specifically, our evaluation would seek to: (1) assess variation in implementation across settings, clinicians, and patient subgroups; (2) determine implementation outcomes (i.e., feasibility, fidelity, acceptability, and sustainability); (3) examine clinical outcomes (i.e., efficiency, safety, effectiveness, timeliness, and utilization); and (4) understand patient, provider, and staff-level barriers and facilitators. Innovation: The EM-PO is highly motivated to build on existing momentum and create a VUCN. The timing of the MISSION Act implementation and launch of the VA's Accessing Telehealth through Local Area Station (ATLAS) program have been instrumental in attracting new partners (VA Telehealth/Office of Connected Care and Office of Community Care). VA Telehealth will partner with us to identify how we can modify/adopt existing virtual solutions that are currently used in other sectors (i.e., primary care and mental health) to provide UC triage, evaluation, or treatment. As the ATLAS program continues to expand to include American Legion posts and Walmart spaces, we have the unique opportunity to be the first to test and assess feasibility and acceptability of incorporating this innovative strategy in our VUCN. Impact: Virtual UC services, from e-visits to use of novel spaces, can substantially improve timely access to UC services for the 3.2 million rural Veterans who live over an hour away from a VA ED or UC center. Since the UC benefit under the MISSION Act became available in June 2019, the Office of Community Care estimates there have already been 90,000 visits to non- VA UC centers. This estimate is predicted to rise dramatically over time and suggests existing VA acute care services are not meeting Veteran demand for UC services. If existing VA resources and staff can be used to provide virtual UC needs, VA can continue to be the place Veterans turn to when they have an unscheduled urgent issue. Phase 1 accomplishments: Key milestones for Phase 1 include: (1) using VA data to examine UC utilization and performing a needs assessment; (2) writing and disseminating an environmental scan; (3) convening a stakeholder advisory group to define the goals, target populations, and objectives of the proposed VUCN program; and (4) designing the VUCN program and evaluation plan with partner input. Next steps: VUCN design, implementation, and evaluation will require collaboration between providers, researchers, private industry and VA policymakers. We will reach out to additional VA partners including the Office of Rural Health and VA Clinical Resource Hubs. Phase 1 also provides an opportunity to connect with private sector stakeholders with expertise in the areas of: (1) implementing teleurgent care programs (Kaiser, Teledoc, UnitedHealthcare); (2) creating self-service technologies (Bright.MD, CirrusMD, HealthTap); and (3) creating/hosting novel virtual spaces (Walmart, Philips).	Healthcare Informatics				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IVI 19-486	Purcell	Natalie	Karen Seal	Natalie.Purcell@va.gov	Evaluating the Implementation of a Novel Whole Health Pathway: A Model for Engaging Veterans in VA and Community Wellness Programs Using Telehealth and Web-based Technology	07/01/2019	09/30/2023	San Francisco VA Medical Center, San Francisco, CA	$553,626					Our goal is to facilitate implementation of a sustainable Whole Health Pathway that engages Veterans in proactive wellness programs tailored to their personal health goals; this Pathway model uses a centralized consult process--facilitated by an innovative web-based application and telehealth technology--to coordinate Veterans' access to health coaching and holistic wellness services both at VA and in the community.	All benchmarks for the fiscal year were achieved. Benchmarks 1 through 7 were accomplished during prior reporting periods. We successfully facilitated implementation of the Whole Health Pathway at the San Francisco VA Health Care System (Benchmark #1) and launched an implementation-effectiveness evaluation to assess the new program (Benchmark #2). Pathway referrals are currently being accepted from all SFVAHCS campuses, including all rural CBOCs (Benchmark #3). Since inception in 2019, over 2,000 Veterans have engaged in the Pathway, completing a Whole Health intake visit. We completed data collection for the RE-AIM implementation evaluation last year, including qualitative data collection (Benchmark #4: n= 17 stakeholder interviews, 41 veteran interviews) and quantitative data collection for the observational outcomes study component of the RE-AIM Evaluation. We met all enrollment and data collection targets, with 201 veterans enrolled in the study (Benchmark #5). Of these veterans, 201 completed baseline assessments, 180 completed 3-month assessments, and 167 completed 6-month assessments (Benchmark #6). Data analysis is currently underway. We have now entered Project Phase 2, the goals of which are to develop and refine an implementation toolkit to support dissemination of effective components of the Pathway (Goal 1) and to facilitate partnered dissemination to three additional VA sites (Goal 2). Using data and stakeholder feedback gathered during our Phase 1 RE-AIM evaluation, we prepared a first draft of a fully electronic, Microsoft Teams-based implementation toolkit (with printable key components and updatable checklists) (Benchmark #7). With support from our FIT partners in VA OPCC&CT, we conducted outreach presentations and hosted Q&A sessions for multiple Phase 2 candidate sites in VISNs 21 and 19. We have selected three sites for Phase 2 implementation and received formal endorsement from the facility Directors and Whole Health Program Managers to proceed with facilitated implementation at their sites: VA Pacific Islands Health Care System, VA Northern California Health Care System, and VA Western Colorado Health Care System. Implementation has been initiated at all three sites, with initial kickoff calls completed and quarterly meetings as well as ad hoc meetings in progress to facilitate implementation. All sites are beginning with Whole Health Resource Directory implementation. Directory sites have been built for all three sites and two of three have gone "live." (Benchmark #8, still in progress). In partnership with our team, sites are evaluating which additional components of the Pathway can be implemented locally and which will require adaptation. Since the launch of this project, VHA OPCC&CT has attempted to standardize some components of the Whole Health Pathway nationally and has just published VHA Directive 1445: Whole Health System (October 2023). These developments will influence our implementation plans significantly and are likely to require significant changes to our toolkit. We are currently in discussions with our OPCC&CT Field Implementation Team partners to discuss the impact and modify our implementation plans and goals accordingly. Based on our implementation experience with VA Pacific Islands Health Care System, VA Northern California Health Care System, and VA Western Colorado Health Care System, and based on the results of our Phase 1 data analysis, we will continue to update our RE-AIM toolkit, and we anticipate that it will be completed and published during the current fiscal year (Benchmark #9).	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IVI 22-244	Veazie	Peter		peter.veazie@va.gov	Identifying Best Non-Randomization Methods for Evaluating Program Costs	07/01/2022	12/31/2025	VA Finger Lakes Healthcare System, Canandaigua, NY	$65,927					Using Primary-care Intensive Management (PIM) study results, the project will identify best observational methods in comparison to PIM pragmatic trials (PT) for evaluating costs among high-risk and similar Veterans.	Analyses were approximately 80% completed by end of FY due to unforeseen issues. These analyses are close to be finished and should be completed by end of December.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
IVI 23-180	Baim-Lance	Abigail		abigail.baim-lance@va.gov	Exploring the PACT Act and the Role of Priority Groupings in Delivering VHA Care	05/01/2023	09/30/2027	James J. Peters VA Medical Center, Bronx, NY	$55,185					To understand how the PACT Act is influencing Veteran experiences of the VHA.	In this study, benchmarks are our aims of feasibility to recruit and enroll 20 Veterans with and without PACT-act related reasons for entering VHA, and to enroll 10 providers within the Bronx VA involved in PACT Act implementation. We aimed to complete all data collection by the end of month 10 of the study. To date, we have recruited 40% of the sample: 8 Veterans - 6 coming to VA irrespective of the PACT Act and 2 as a result of its passage and are halfway through with the funding period. We are slightly behind our anticipated timeframe, but have dedicated resources in the coming 6 months to increase our recruitment tempo.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
MDR 00-002	O'Keefe	Gerald		Gerald.Okeefe@va.gov	HSR&D Web Development	10/01/2000	11/30/2021	VA Boston Healthcare System Jamaica Plain Campus, Jamaica Plain, MA	$3,727,818			Capacity Building		To build and maintain a highly functional and usable website about VA HSR&D that serves as a valuable resource for researchers, clinicians and managers within and outside of VA.	The HSR&D website is accessed regularly by thousands of users within VA and tens of thousand of users across the US and abroad. HSR&D publications are downloaded often, with those such as the QUERI Guide and the Organizational Change Primer reaching nearly 1,000 downloads each in 2005.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
PEC 14-272	Van Houtven	Courtney		courtney.vanhoutven@va.gov	VA Caregiver Support Evaluation Center (VA-CARES Evaluation Center)	10/01/2014	06/30/2022	Durham VA Medical Center, Durham, NC	$3,450,971		The Caregivers and Veterans Omnibus Health Services Act of 2010 (Public Law:111-163) enacted legislation to ensure training, services, and assistance for Veteran's caregivers in need through two landmark programs, the Program of Comprehensive Assistance for Family Caregivers and the Program of General Caregiver Support Services enhances support and services for family caregivers, including training and education. With these programs, the Caregivers and Veterans Omnibus Health Services Act of 2010 exceeded past caregiver support policies that were limited to modest tax credits in a few states,1 and now provides informal caregivers an unprecedented level of support. The Comprehensive Program provides a program of support for both the Veteran and the Family Caregiver and a series of benefits for the Family Caregiver such as a monthly stipend, access to health care if not already covered under a health insurance plan, education and training, travel, lodging and subsistence, respite care and caregiver mental health services. It aims to reduce strain for caregivers by providing financial stipends to those who care for severely injured OEF/OIF/OND Veterans who need assistance with Activities of Daily Living (ADLs) or supervision or protection because of the residual effects of their injuries. The General Program offers training to support to caregivers of Veterans of all eras, providing referrals to more services, on-site and phone counseling, and crisis-response. While The VHA responded to and met the requirements of the legislation extremely rapidly, The Comprehensive Program has far surpassed expectations, with 26,000 applicants and outlays of more than $300 million. As a result, the program's return on investment is of immediate interest to the Caregiver Support Program and Congress. Specifically, it is not yet known how the assistance provided by these programs, including caregiver training, stipends, or other services has affected caregivers' financial or emotional strain. It is also unknown how the program has affected Veterans' health and economic outcomes. Our center, The VA-CARES Evaluation Center will evaluate the impacts of The Comprehensive Program and The General Program on Veterans and caregivers. This evaluation will use a multiple and mixed methods approach and rich data sources to provide a full evaluation of VA CSP short-term impacts. We will use VA medical records data to describe how The Comprehensive Program has affected Veteran health care utilization. We will also survey and CSP data to describe caregivers in The Comprehensive Program and how training, the stipend, and other benefits have affected the perceived financial and emotional strain of caregivers and their families. Using mixed qualitative and quantitative methods, we will ascertain the experiences of Comprehensive Program and General Program caregivers and gain important contextual understanding of their perspectives on the helpfulness of the programs, challenges, and/or unmet needs. Finally, we will complement data on services offered by detailing the full delivery costs of the CSP-personnel, programming (e.g. stipend, insurance), and supporting costs.	QUERI				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
PEC 16-001	Frakt	Austin	Melissa Garrido	Austin.Frakt@va.gov	Partnered Evidence Based Policy Resource Center	10/01/2015	06/30/2022	VA Boston Healthcare System Jamaica Plain Campus, Jamaica Plain, MA	$12,631,610		Closing the loop between evidence and operations to enhance value is the hallmark of a learning health care system, and the Blueprint for Excellence’s aspiration for the VHA. We, therefore, propose the Value QUERI as a vital engine of VHA’s learning health care system. The Value QUERI will pursue a suite of projects that build on existing operational relationships to tighten the links between quantitative measures used by managers, the concepts they are intended to reflect, and the evidence that demonstrates their effectiveness. The Value QUERI will build upon VHA’s well-earned national leadership in health care excellence by applying state-of-the-art data analytics, research methods, and validated quality metrics to accelerate the enhancement of value and effectiveness, leveraging team members’ existing, ongoing operational relationships, and data and analytic expertise (BPE strategies 2, 3, 6-9). Across the proposed projects, the Value QUERI will exploit the routine collection of VHA and non-VHA data and operational resources to help operations partners more efficiently improve Veterans’ health outcomes and patient satisfaction. The Value QUERI’s significance and urgency stems from its alignment with BPE, National VA, and QUERI goals, strategies and objectives, including BPE strategy 7h, which is also QUERI strategic goal 1: “rapidly translate research findings and evidence-based treatments into clinical practice”. The Value QUERI will address this strategy and other goals, helping operational partners validate and apply performance and satisfaction metrics to rapidly monitor and improve care. Most significantly for the QUERI program, the Value QUERI is highly responsive to the RFA, which is itself consistent with all three goals of QUERI’s new strategic plan. These collectively express the need to become a more efficient learning health care system. To remain viable and relevant, QUERI must, and we will, supply evidence to inform operational imperatives and leverage operational capabilities to inform investigation and evaluation. We propose an implementation core and five evaluation and quality improvement projects in collaboration with six operations partners. All projects apply cross-cutting methodological innovations to pilot and study the implementation of quality improvement initiatives in several essential areas of VHA care for which existing evidence and prior work strongly support feasibility.  National Access Metrics Development and Validation with the Access and Clinic Administration Program (ACAP). This project will validate new VACAA-required and other access metrics and evaluate clinic administration models on key ACAP policy initiatives.  VistA Evolution National Evaluation with the Office of Informatics and Analytics (OIA). This goals of this project are to refine and implement Key Performance Indicators as and to use them in evaluation of use, performance, and impact of VistA Evolution features.  Clinical Pharmacy Specialist COPD Pilot with Pharmacy Benefits Management (PBM). This quality improvement pilot will apply performance metrics to the enhancement of appropriate medication use for chronic obstructive pulmonary disease (COPD), consistent with clinical guidelines.  National Performance-Based Budgeting Initiative with the Chief Financial Officer and the Office of Policy and Planning (CFO and OPP). This project would refine models to forecast VA enrollment and utilization; it would also evaluate and refine performance and productivity metrics.  Validation of Mental Health Performance Metrics and Evaluation of Local Action Plans with the Office of Mental Health Operations (OMHO). This project would validate and refine Mental Health Information System and SAIL Report metrics. It would then relate OMHO site visits and action plans to performance on these metrics.	QUERI				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
PEC 17-002	Jackson	George	Gemmae Fix	George.Jackson3@va.gov	Spreading Healthcare Access, Activities, Research and Knowledge (SHAARK)	04/01/2017	09/30/2022	Durham VA Medical Center, Durham, NC	$2,169,233	https://www.durham.hsrd.research.va.gov/SHAARK.asp		QUERI				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
PEC 18-204	Rosen	Amy		amy.rosen2@va.gov	Evaluating the Implementation of Patient Safety Practices to Ensure Timely, High-Quality Community Care for Veterans	11/01/2018	08/31/2023	VA Boston Healthcare System Jamaica Plain Campus, Jamaica Plain, MA	$604,580			QUERI				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
PEC 18-205	Zulman	Donna		Donna.Zulman@va.gov	Enhancing Veterans' Access to Care through Video Telehealth Tablets	11/01/2018	08/31/2023	VA Palo Alto Health Care System, Palo Alto, CA	$794,303			QUERI				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
PEC 19-302	Hundt	Natalie		Natalie.Hundt@va.gov	Evaluation of Implementing FLOW in VISN 19: Transitioning Stabilized Mental Health Patients to Management in Primary Care	10/01/2019	03/31/2024	Michael E. DeBakey VA Medical Center, Houston, TX	$449,319		Adequate access to mental health treatment is one of the highest priority problems facing the Veterans Health Administration (VHA) and VISN 19. Chronic staffing shortages and some clinical practices combine to reduce access to mental health treatment. Poor access to care can contribute to suicide and disability, and long wait times contribute to patient dissatisfaction and disengagement from care. Common mental health conditions are expected to remit in many cases or to be substantially improved with evidence-based prescribing and psychotherapy such that patients no longer need intensive specialty mental health services. International clinical guidelines encourage the use of stepped care, in which patients should be treated at the least intensive level of care that is appropriate to their condition. Although VA has embraced stepped care with the recent VA Continuum of Care model, VA manuals do not provide clear guidance on which patients are appropriate for transition back to primary care or how the transition should take place. In the absence of guidance, few patients are appropriately transitioned and specialty mental health panels remain full, contributing to access problems. The FLOW program addresses these problems with an algorithm to identify patients who are potentially appropriate for transition, a user-friendly online report to communicate this information to providers, materials to explain this process to patients and providers, and an electronic medical record (EMR) note template to document the transition. In cases where providers believe continued specialty mental health treatment is warranted or patients object to the transition, patients can remain in specialty mental health. This approach also has high acceptability to remitted patients because of perception of less stigma and reduction in appointment burden when their care is managed in primary care. Preliminary data from VISNs 16 and 17 indicates that FLOW can effectively transition recovered patients to primary care and increase access for new mental health patients. Implementation success differed dramatically across the original pilot sites but data collected did not offer an explanation for this or allow examination of implementation factors associated with success. In preparation for a national rollout of FLOW, we are partnering with VISN 19 to evaluate the impact of FLOW using a stepped wedge design with 7-9 sites randomly allocated into 3 steps in the wedge. An evidence-based implementation facilitation approach will be used at each site. Outcomes assessed will include program effectiveness and the factors that are associated with implementation success across sites. Program effectiveness outcomes will be examined according to the RE-AIM model, with specific outcomes for reach (% of clinic patients transitioned), effectiveness (% of transitions that are successful and impact on future clinic access), adoption (% of providers using FLOW), implementation (fidelity to the model as planned), and maintenance over time after withdrawal of implementation facilitation. We will also evaluate implementation factors, guided by the Consolidated Framework for Implementation Research, related to implementation success across sites, including organizational readiness to change, staffing levels, interservice agreements about care, leadership support, and internal facilitation.	QUERI				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
PEC 22-230	Kim	Bo	Donald McInnes	bo.kim@va.gov	Improving Access to Legal Services for Veterans (LSV)	10/01/2022	09/30/2026	VA Boston Healthcare System Jamaica Plain Campus, Jamaica Plain, MA	$299,660	https://www.va.gov/HOMELESS/LSV.asp		QUERI				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
PII 21-282	Adams	Megan		megan.adams5@va.gov	Improving Access to Gastrointestinal Endoscopy in the Covid-19 Recovery Phase and Beyond	10/01/2021	09/30/2025	VA Ann Arbor Healthcare System, Ann Arbor, MI	$99,997			QUERI				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
PPO 19-373	Borzecki	Ann		ann.borzecki@va.gov	Improving the Evaluation and Management of Penicillin Allergy	08/01/2020	09/30/2024	VA Bedford HealthCare System, Bedford, MA	$95,500		Background: Reported penicillin allergies are present in 10% of the US population, with higher rates in hospitalized and older patients; rates up to 16% have been found in VA nursing home patients. However, fewer than 10% of patients are found to be truly allergic based on skin testing and most patients can safely receive penicillin. The consequences of being labeled as penicillin allergic include use of broader spectrum antibiotics which can result in more treatment failures, more adverse effects, higher healthcare costs, and increased risk for development of antibiotic resistance. The nursing home population is particularly vulnerable to the effects of potentially inappropriate antibiotic use due to factors including high infection burden and frailty. Recognition of the problem of increasing antibiotic resistance and importance of antimicrobial stewardship as a tool to curb it has heightened awareness of this issue of penicillin mis-labelling both in and outside the VA. While guidelines for evaluating and managing penicillin allergy exist, they have been infrequently applied in practice. This in part due to lack of provider knowledge on how to take an appropriate penicillin, the role of allergy testing, risks of mislabeling and lack of access to specialized allergy testing. Significance/Impact: To address these knowledge gaps, an explicit guideline-based clinical pathway and toolkit were recently developed. These have been effectively and safely applied in selected inpatient and outpatient settings to improve outcomes. However, they have not yet been applied to nursing home populations. Thus, this represents a unique opportunity to apply these tools to improve penicillin antibiotic use and outcomes in this vulnerable population. Innovation: This project will be a pre-implementation pilot of a newly available evidence-based clinical pathway and toolkit designed to improve evaluation and management of penicillin allergy. These were developed and thus far only used in the non-long term care setting. Specific Aims: 1) Identify potential barriers and facilitators to successful implementation of a clinical pathway and toolkit aimed at improving use of penicillin in patients with documented penicillin allergies; 1a) examine clinical staff and local leadership perspectives; 1b) examine patients and family members perspectives. 2) Develop a modified pathway and toolkit for use in Community Living Centers (CLCs). Methodology: This is a 1-year qualitative pilot study based at the Bedford VAMC. The Consolidated Framework for Implementation Research (CFIR), supplemented with the Health Belief model for Aim 1b, will guide our assessment to understand contextual factors that may affect uptake of the intervention. For Aim 1a, we will conduct up to 15-20 in-person semi-structured interviews with CLC providers (nurses, physicians, nurse practitioners, clinical pharmacists) and 4-6 with selected local leadership (chiefs of nursing, geriatrics, and pharmacy, patient safety manager). We will examine factors including perceptions of risk of allergy testing, perceived ability to successfully follow the pathway and tools, and solicit recommendations for pathway and toolkit modifications. For Aim 1b, we will conduct up to 15-20 semi-structured interviews with CLC patients with documented penicillin allergies and CLC residents’ family members to assess their knowledge and beliefs including their understanding of allergy mislabeling implications and perceived susceptibility to adverse consequences of the allergy testing strategies. Based on information from Aims 1a and 1b, we will propose changes to the pathway and toolkit. We will establish consensus on proposed changes via input from an expert advisory panel using a 2-round modified Delphi approach. We will then have developed a modified pathway and toolkit for use in CLCs. Aim 1 information will also inform subsequent IIR implementation strategies. Implementation/Next Steps: The modified clinical pathway and toolkit will be implemented at selected CLC sites in a future IIR, with the eventual goal of scaling it up for use across the VA to improve care.	Long Term Care and Aging				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
PPO 19-446	Monteith	Lindsey		lindsey.monteith@va.gov	Perspectives of Female Veterans, VHA Providers, and Family Members on Preventing Firearm-Inflicted Suicides among Female Veterans	12/01/2020	09/30/2024	Rocky Mountain Regional VA Medical Center, Aurora, CO	$199,010		BACKGROUND: In 2017, the age-adjusted suicide rate for female Veterans was 2.2 times that of female non- Veterans. This may relate to a substantial increase in the proportion of female Veterans using firearms as their means of death, particularly among women using Veterans Health Administration (VHA) care. Firearms are now the leading means of suicide among female Veterans. Lethal means safety (LMS; i.e., reducing access to lethal means when suicide risk is elevated) is a highly-recommended suicide prevention strategy. Yet prior firearm LMS research has primarily focused on male Veterans, despite female Veterans idiographically differing in their firearm access, ownership, and use. Data suggest that female Veterans more often obtain firearms and store them loaded and nearby to increase safety following interpersonal violence (e.g., sexual assault, intimate partner violence). Given high rates of interpersonal violence among female Veterans, it is critical to ensure firearm LMS efforts are tailored and delivered to female Veterans from a trauma-focused lens. Further, nearly 40% of female Veterans report having household firearms that they do not personally own, which often occurs through spouses or partners. Thus, including family members in firearm LMS efforts may be particularly important for female Veterans. Prior research also suggests that Veterans rarely initiate firearm discussions with their VHA providers, who seldomly assess firearm access, despite its association with suicide risk. Thus, a multi-systemic perspective that encompasses the perspectives of female Veterans, their spouses or partners, and VHA providers is essential. SIGNIFICANCE/IMPACT: Effective suicide prevention necessitates a well-informed, patient-centered approach. Yet firearm knowledge specific to female Veterans remains limited and has largely relied upon extrapolating data from male Veterans. By understanding the experiences and perspectives of female Veterans, their spouses/partners, and VHA providers, findings will inform development of gender-sensitive conceptual understanding and interventions for approaching firearm LMS in this population. Findings can be used to delineate a tailored firearm LMS intervention for female Veterans that can subsequently be piloted for acceptability, feasibility, and ultimately efficacy. INNOVATION: This study is innovative in its focus on understanding the inherent needs and preferences of female Veterans, rather than extrapolating findings from male Veterans. It will be the first to interview female Veterans, spouses and partners, and VHA providers regarding experiences and preferences for firearm LMS. This is highly innovative as spouses and partners have rarely been included in Veteran suicide prevention research, despite increasing the likelihood of female Veterans’ firearm access. Findings are expected to result in knowledge essential for developing a gender-specific conceptualization and intervention for addressing firearm LMS with female Veterans to ultimately provide a patient-centered approach to a high-priority, understudied problem. SPECIFIC AIMS: Our aims are to: (1) Describe female Veterans’ experiences, perspectives, and preferences regarding firearm access and LMS, and explore the role of interpersonal violence within this; (2) Explore the perspectives and experiences of female Veterans’ partners and spouses regarding engaging in firearm LMS (e.g., ability, willingness); and (3) Describe VHA mental health (MH) and primary care (PC) providers’ experiences and perspectives on discussing firearm access and LMS with female Veterans, including challenges and facilitators. METHODOLOGY: Qualitative interviews will be conducted with: female Veterans who own firearm(s) or reside in a household with firearm(s) and have experienced suicidal ideation or attempt (Aim 1); partners and spouses of female Veterans (Aim 2); and VHA MH and PC providers who work with female Veterans (Aim 3). IMPLEMENTATION/NEXT STEPS: Results will be synthesized to develop a patient-centered, gender-sensitive firearm LMS intervention for female Veterans, and resources for family members and VHA providers. Key operations partners will be engaged in this process to ensure feasible recommendations and wide dissemination of findings.	Mental and Behavioral Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
PPO 20-078	Kamdar	Nipa		Nipa.Kamdar@va.gov	Seeking Food Assistance: Food Insecure Veterans' Experiences Navigating through Systems	04/01/2021	12/31/2024	Michael E. DeBakey VA Medical Center, Houston, TX	$200,000		Background: Food insecurity is defined as limited or uncertain access to adequate food due to a lack of money and is a social determinant of health.6 An estimated 1 in 4 Veterans using VHA services are food insecure.1–3 Working-age Veterans (i.e., those aged 18-59 years) have increased risk for food insecurity compared to elder veterans and non-veterans.1,17 The VHA screens Veterans in primary care for food insecurity. Significance/Impact: However, screening does not equate receiving assistance. Despite having a high prevalence of food insecurity, a smaller percentage of Veterans enroll in the Supplemental Nutrition Assistance Program (SNAP), formally known as food stamps.10,11 We do not know why more Veterans do not use this service. Additionally, as the VHA installs on-site food pantries, we know little about Veterans’ experiences with and perceptions of food pantries. Anecdotal evidence suggest that stigma & concern for quality of food may be barriers to use.12 Innovation: This is the first study to formally take a user-centered approach to learn what Veterans experience as they navigate systems in search of food assistance. Our proposal is set within the design thinking framework which consists of 3 phases: problem identification, solution ideation, & implementation.13,14 Each phase demands stakeholder participation. Our proposal focuses on the first phase. Using journey maps (i.e., visual tools developed through in-depth interviews that document lived experiences), we will identify unmet needs and gaps in service. Specific Aims: 1. Through qualitative, in-depth 1:1 interviews with food insecure Veterans (n=40), we will visually map food insecure Veterans’ experiences with seeking food assistance. 1a) These journey maps will be aggregated and analyzed to identify barriers and facilitators to improve access to food assistance for Veterans living with food insecurity. 1b) Because COVID-19 may have impacted the ability of Veterans to obtain food assistance, we will specifically ask Veterans if and how COVID-19 affected their experience with seeking food assistance. 2. We will strengthen our relationships with community partners and other key stakeholders in preparation for the next two phases of the design thinking framework that require collaboration. We will increase routine communication, host discussion groups, and evaluate responses to the Research Partnership Checklist15,16 which will inform us of partner expectations. Methodology: Using in-depth, 1:1 interviews with 40 Veterans aged 18-59, living in and around southeast Texas, we will construct journey maps to document Veterans’ actions and emotions as they sought food assistance. Aggregated maps will be shared with community partners and other stakeholders. To strengthen relationships, community partners will complete an assessment tool that will help us build working relationships in alignment with their expectations. Implementation/Next Steps: The journey maps will identify areas of difficulty or frustration for Veterans needing food assistance. In collaboration with our community partners and other stakeholders, we will brainstorm and prototype solutions to better meet their needs. Eventually our designed solutions will be trialed and implemented as appropriate.	Equity				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
PPO 20-082	Weiner	Michael		Michael.Weiner4@va.gov	Engaging Transgender Veterans with Communication Technology	09/01/2021	06/30/2025	Richard L. Roudebush VA Medical Center, Indianapolis, IN	$204,607		PROJECT SUMMARY Background: Transgender Veterans die by suicide at twice the rate of cisgender (non-transgender) Veterans. Depression is a risk factor for suicide. Neither the mental healthcare utilization patterns of transgender Veterans with depression, nor the barriers to care experienced by these Veterans, are well understood. Significance/Impact: A 2018 VA directive, Providing Health Care for Transgender Veterans, affirmed the VA’s commitment to addressing health disparities among transgender Veterans. As the number of transgender Veterans increases, so too, does the importance of this commitment. Addressing the mental health needs of transgender Veterans is timely, given the high prevalence of depression and suicidality in this population. The results of this pilot will inform efforts to meet the goals of the directive. Innovation: This pilot study will be the first study to describe the mental healthcare utilization patterns of transgender Veterans with depression using VA data. It is innovative in its focus on a marginalized population for whom the barriers to, and utilization of, mental healthcare, have not been well understood. Furthermore, it is innovative in its examination of potential of communication technology to address barriers to care. Specific Aims The proposed work has the following three specific aims. Aim 1: Characterize mental health utilization patterns of transgender Veterans diagnosed with depression. We will identify and compare the mental healthcare utilization rates of transgender Veterans with depression and a matched cohort of cisgender Veterans with depression. Aim 2: Identify and describe the facilitators and barriers for transgender Veterans in accessing depression treatment, and their experiences using communication technology to access or coordinate related care. We will conduct in-depth, semi-structured interviews with transgender patients to understand their care experiences, and the role that communication technology plays, if any, in those experiences. Aim 3: Design and plan an intervention to overcome barriers to mental healthcare for transgender Veterans with depression. We will elicit iterative feedback from key stakeholder groups to inform the design of a strategy to address barriers identified in Aim 2. Methodology: This project has a mixed-methods design. In Aim 1, the mental healthcare utilization patterns of transgender and cisgender patients diagnosed with depression will be compared. In Aim 2, we will elicit the perspectives and experiences of transgender Veterans with depression, to inform the patterns we observe in Aim 1, and conduct in-depth interviews to contextualize the care-seeking experiences of transgender Veterans with depression, to identify and understand their facilitators and barriers to care. In Aim 3, the quantitative results of Aim 1 and the qualitative results of Aim 2 will be integrated and incorporated into the design of an intervention strategy sensitive to the needs of this population. Implementation/next steps: The expected outcome of this pilot will be the formulation of an intervention strategy to address an important barrier to depression care for transgender Veterans. Following successful completion of Aim 3, we expect to pursue funding to test and then expand the intervention, and evaluate its efficacy.	Equity				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
PPO 20-090	Drapalski	Amy		amy.drapalski@va.gov	Bystander Activation Intervention to Address Gender-Based Harassment	12/01/2020	09/30/2024	Baltimore VA Medical Center VA Maryland Health Care System, Baltimore, MD	$199,865		Project Background: Harassment is a recognized problem in VA facilities. Recent national studies of women Veterans receiving Veterans Health Administration (VHA) health services found that 25% reported experiencing harassment at the VA in the past year. Most often, these incidents involved sexual harassment (e.g., catcalls, being stared at/watched, or sexual/derogatory comments) or sexist harassment (e.g., someone questioning their identity as a Veteran or their right to care). Women Veterans who experience harassment are significantly more likely to feel unsafe and unwelcome at the VA; and to delay or underutilize care, which may place them at risk for poorer health outcomes. Significance/Impact: Harassment has the potential to negatively impact the dignity, privacy, sense of security, safety, and health of women Veterans. Recognizing this, VA has launched several initiatives: Women’s Health Services’ “End Harassment” campaign and, most recently, VHA Executive in Charge, Dr. Stone’s “Stand Up to Harassment Now!” campaign. However, to date, there are no evidence-based interventions to address harassment of service users in healthcare setting such as the VA. The current study attempts to expand the VA’s efforts to address harassment by developing and evaluating a bystander activation intervention that can be used to increase awareness of gender-based harassment (GBH) and confidence in and willingness to help/intervene among a range of individuals within the system (e.g. Veterans, VA staff and leadership). By addressing harassment and the discomfort it creates, this intervention may reduce disparities in access to and the quality of care of women Veterans. Innovation: The lack of evidence-based interventions to address harassment in healthcare settings represents a significant gap in VHA’s ability to provide high-quality, gender-sensitive, comprehensive health care to women Veterans. The project attempts to address this gap by actively partnering and collaborating with Veterans and other stakeholders to develop and evaluate a novel, Veteran-informed bystander harassment intervention that, if effective, has the potential to make VA settings more comfortable, safe and welcoming for women Veterans. Specific Aims: The specific aims of this study are 1) to develop a Veteran-informed harassment bystander activation intervention. 2) to conduct a pilot trial to examine the feasibility, acceptability, potential efficacy, and information regarding implementation of the intervention with Veterans and VA staff. Methodology: We will create a bystander activation harassment intervention using participatory action research (PAR) methods. First, 20 women who have experienced harassment and are receiving services at the VAMHCS will develop photonarratives using Photovoice PAR methods that convey experiences of harassment at VA and its impacts. We will also conduct focus groups with male Veterans, female Veterans, and VA staff to inform the adaptation of existing bystander behavior materials for use in a VA setting. The intervention will be developed using these materials and refined over several meetings with Veterans and VA staff/leadership input. Once developed, we will conduct a pilot trial of the intervention with Veterans receiving VAMHCS services (n=35) and VA staff (n=15). All participants will complete a baseline assessment, a qualitative interview at immediate post-intervention, and a 2-week post-intervention assessment. Feasibility and acceptability will be assessed via rates of recruitment, retention, participant reported acceptability. Outcomes that will be explored include awareness of harassment; recognition of the need to intervene; and responsibility for, knowledge regarding how, and intent to intervene; and input on implementation collected. Implementation/Next Steps: Next steps will include using the results of this study to inform a larger randomized trial to examine the efficacy of the harassment bystander activation intervention.	Women's Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
PPO 20-092	Graham	Laura		laura.graham@va.gov	Real-time Infection Prediction in Inpatient Postoperative Care	08/01/2021	05/31/2025	VA Palo Alto Health Care System, Palo Alto, CA	$197,893		Postoperative infections are the most common surgical complication, affecting upwards of 40 Veterans each day and adding an estimated $25,000 to the total cost of care per infection. More than half of all postoperative SSIs are diagnosed after the patient has been discharged from the hospital. Current decision support tools for postoperative infections suffer from poor predictive accuracy. This makes it particularly hard to identify patients at risk for developing an SSI after hospital discharge which complicates discharge planning. Accurately identifying patients with a high risk of infection at discharge could help to improve discharge planning, identify adequate timing for post-discharge follow up, and better target resource-expensive post-discharge surveillance. Vital signs, such as temperature or pain, have consistently been shown to predict infections. They are routinely collected during inpatient stays but have remained an untapped source of information for infection risk prediction models. We hypothesize that we can improve the accuracy of existing infection risk prediction models by including this real-time vital sign data. While planning our larger study, we have identified several feasibility concerns that should be addressed before we embark on developing the tool and testing it in a clinical environment. Thus, we are seeking HSR&D Pilot funding to finalize the protocol of our planned HSR&D Investigator-Initiated Research study. Our study aims are as follows: 1. Perform a developmental formative evaluation assessing the feasibility, acceptability, potential usefulness and initial design of a decision support tool for predicting infection risk at discharge. 2. Examine the completeness of inpatient vital sign data collected in the VA Corporate Data Warehouse. We have planned our study using a person-centric design thinking framework. For aim 1, we will use qualitative methods to analyze data from 20 structured observations at two VA facilities and 15 semi-structured interviews across at least six VA facilities. These qualitative analyses will verify that our proposed tool can be incorporated into clinical care at the VA, that clinical providers will accept the tool, and that it will be perceived as useful. We will also begin to develop an initial prototype for the tool’s user interface and deployment within VA clinical care. Aim 2 addresses a feasibility concern about building our model with potentially incomplete vital sign data. The VA Corporate Data Warehouse (CDW) is the standard location for accessing inpatient vital signs collected across the entire VA. Unfortunately, we have discovered that not all local vital sign data make it into the CDW and some vital sign data are only captured in VISN-specific databases. This leads us to concerns about the impact of missing data when using national CDW data to refine existing models with vital sign data. For aim 2, we will use quantitative methods to analyze an existing database of all patients admitted to six VA facilities in VISN 21. To confirm the feasibility of developing our model and tool prototype, we plan to determine how all vital signs are captured in the VA, examine the completeness of the vital sign data, and explore the impact and potential biases of using incomplete CDW vital sign data. The findings of aim 2 will determine strategies for developing the tool at VA Palo Alto Health Care System and expanding the tool across other facilities and VISNs. Updating current infection risk prediction scores with vital sign data has the potential to greatly increase the accuracy of risk prediction for postoperative infection. A more accurate prediction of high-risk patients at the time of discharge will improve discharge planning and help providers identify high-risk patients that would benefit from earlier postoperative follow-up. It could also help better allocate other resource-intensive and expensive preventative strategies such as prophylactic antibiotics or negative pressure wound therapy. This would result in substantial reductions in costs, morbidity, and mortality. Also, this study will inform the VA research community on the availability and use of vital sign data stored within the VA.	Care of Complex Chronic Conditions				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
PPO 20-148	Kakumanu	Sujani		sujani.kakumanu@va.gov	Promoting Antimicrobial Stewardship and Patient Safety by Implementing Interventions to Evaluate and Delabel Penicillin Allergy	05/01/2021	01/31/2025	William S. Middleton Memorial Veterans Hospital, Madison, WI	$149,720		BACKGROUND: Penicillin allergy is the most commonly reported drug allergy and significantly impacts antibiotic prescribing practices and patient safety. Although 10% of the U.S population are reported as penicillin allergic, studies have shown that up to 90% of these patients can in fact tolerate the drug. This mislabeling of approximately 32 million Americans adversely affects antimicrobial prescribing practices and increases health care costs and the risk of antibiotic resistant infections. SIGNIFICANCE/IMPACT: To promote patient safety and improve health related outcomes related to antibiotic use, there is an urgent need to create and implement processes that efficiently de-label penicillin allergy in appropriate patients. The William S. Middleton Memorial Veterans Hospital reports a higher prevalence of penicillin allergy as compared to the general population (22.6% vs 10% respectively), and penicillin allergy is associated with increased use of broad-spectrum antibiotics. Implementing processes to de-label patients misdiagnosed with penicillin allergy will decrease non- concordant antibiotic use, improve patient safety, and advance our goals as a high reliability organization (HRO). INNOVATION: The goal of our pilot study is to apply the Consolidated Framework for Implementation Research (CFIR) to study the contextual factors influencing the evaluation of penicillin allergy in the Veteran population. Knowledge gained will be used to develop an implementation package that identifies, evaluates and de-labels patients inappropriately labeled as penicillin allergic. This effort will address a national patient safety issue of antibiotic resistance and provide a usable intervention to promote the judicious use of antibiotics advocated by the VHA Office of the Inspector General, Infectious Disease of America (IDSA), the American Academy of Allergy, Asthma and Immunology (AAAAI) and the Centers of Disease Control (CDC). We will incorporate feedback from Veterans as well as key frontline physicians, pharmacists, primary care providers and nurses to develop a comprehensive implementation package and data extraction tool to study the impact on key clinical outcomes. SPECIFIC AIMS: We hypothesize that determining and addressing the principal factors influencing access to penicillin allergy evaluation will reduce the number of Veterans designated as allergic to penicillin and in turn, decrease the use of broad-spectrum antibiotics in these patients. We will test this hypothesis with the following aims: (1) Using the CFIR framework, we will study the systems level barriers and key facilitators to evaluating patients with penicillin allergy. The CFIR framework offers a validated implementation science approach that optimizes a mixed methods approach with equal value for qualitative and quantitative data. (2) Develop a penicillin allergy evaluation implementation package that effectively identifies, and de-labels patients misdiagnosed with penicillin allergy. (3) Develop a data extraction tool that establishes a comprehensive database of patients in the following groups: patients labeled with an active penicillin allergy, patients who have been de-labeled of penicillin allergy, patients with confirmed penicillin allergy who have undergone recent evaluation. The data extraction tool will track clinical outcomes of these groups using SQL queries of the national VHA Clinical Data Warehouse. METHODOLOGY: We will use a mixed methods approach focused on the generation of qualitative data from focus groups of Veterans, physicians, pharmacists, and nurses and use this information to develop a penicillin allergy implementation package. Quantitative metrics obtained related to the successful de-labeling of penicillin allergy, future antibiotic prescribing practices, rates of drug resistant infections, hospitalizations and survival will be collected via a data extraction tool that will be developed as part of this pilot study. IMPLEMENTATION/NEXT STEPS: The knowledge, implementation package and data extraction tool developed through this pilot will lead to an investigator initiated research proposal (IIR) to test our implementation package in multiple VHA hospital and ambulatory settings.	Healthcare Informatics				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
PPO 20-346	Kiratli	B.		jenny.kiratli@va.gov	Clinical care needs and experiences for patients with spinal cord injury identifying as LGBT	10/01/2021	09/30/2025	VA Palo Alto Health Care System, Palo Alto, CA	$203,737		Background: Numerous challenges are faced by individuals in the general community who identify as lesbian, gay, bisexual or transgender (LGBT) when seeking healthcare. The LGTB community reports harassment, disrespect, discrimination and delay in care as well as reduced likelihood to receive needed screening tests. Many LGBT Veterans are resistant to seeking VA healthcare at all based on past discrimination (perceived and real) and an unwelcoming system. For LGTB Veterans with spinal cord injury and disorders (SCI/D), there are likely additional considerations related to sexuality, bowel and bladder care, body image and mental health. Health care providers often lack experience in dealing with the physical and mental health and sociocultural issues related to LGBT identity, especially in the context of delivering SCI specialty care. Therefore, there is a great need for information on the experiences and unmet needs of this population in order to design VA clinical programs to correctly and sensitively address their complex health care needs and promote their wellbeing. Significance/Impact: This pilot project addresses HSR&D priority areas of Access to Care, Health Equity, and Disability/SCI. Our overarching goal is to open the door to improving VA health care for this vulnerable and understudied population. Based on limited clinical experience, awareness of the problems commonly faced by individuals with SCI/D, and extrapolation from published findings from the non-disabled LGBT population, we expect to find significant disparity in access to knowledgeable clinicians who are sensitive to the specific needs of LGBT Veterans who live with SCI/D. Our study will provide essential information from both Veteran and provider perspectives to begin to fill this gap and contribute invaluable data towards developing solutions. Innovation: This project is innovative as there is a dearth of information regarding health care needs of LGBT Veterans with SCI/D. The investigative team includes experts in LGBT health care within and outside VA; VA SCI clinicians; and VA researchers with expertise in SCI/D clinical care and programs, qualitative methodology, and VA program implementation. Evidence of SCI/D and Veteran-specific experiences and barriers as well as VA provider knowledge and attitudes will be novel information not available in the literature. Specific Aims: 1) Elicit the perspectives of LGBT Veterans with SCI/D about their experiences with VA care, and 2) Elicit the experiences of SCI/D providers and their approaches to caring for LGBT Veterans with SCI/D. Methodology: We will apply qualitative methodology to elicit (i) personal perspectives and lived experiences of 25 Veterans and (ii) attitudes and knowledge/awareness of 15 health care professionals whose focus is SCI/D care. We will sample from the 25 VA SCI/D Centers to include different regions of the country, sampling urban and rural settings. We will aim for inclusion across the LGBT spectrum and will over-recruit female participants to include the potentially unique perspectives of women with SCI/D. We will aim to recruit a range of ages as well as SCI chronicity ranging from recently injured to SCI of long duration. We will include all ethnic/racial groups in order to explore potential cultural issues. The VA SCI/D provider cohort will include physicians and surgeons, nurse practitioners, nurses, therapists, psychologists, social workers, and any relevant disciplines. We will conduct semi-structured interviews with open-ended questions and prompts and then perform matrix analysis drawing from existing SCI/D and LGBT literature to identify barriers, attitudes, and experiences of patient and clinician cohorts. We will probe for positive experiences in addition to barriers and unmet needs. We will primarily use the Health Equity Promotion model as the basis for our domains of enquiry overlaid with the theoretical framework of the International Classification of Functioning, Health and Disability. Implementation / Next Steps: Future research may involve validation of our findings via a more comprehensive qualitative study, a population-based survey, analysis of relevant health services utilization, and development of training programs to better meet the needs of this population through implementation of targeted care.	Equity				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
PPO 21-074	Ashrafioun	Lisham		lisham.ashrafioun@va.gov	Addressing loneliness and substance use with telehealth CBT	04/01/2022	07/31/2025	VA Finger Lakes Healthcare System, Canandaigua, NY	$199,987		Background: Loneliness—a subjective emotional state characterized by the perception of social isolation—is a psychosocial factor that is associated with increased mortality, substance use, and is associated with precipitants of relapse among individuals with substance use disorders (SUD). Importantly, there are effective interventions that can be used to decrease loneliness; however, these have not been tested on Veterans with SUD who are lonely. Significance/Impact: Individuals with SUD have higher prevalence of loneliness and loneliness exacerbates pain and sleep disturbance, risk factors of relapse. Without effectively intervening on loneliness, Veterans with SUD will continue to be at high risk of relapse and will maintain problems engaging with social support, including healthcare providers—factors critical for recovery. Cognitive-behavioral therapies (CBT) has shown the strongest effects on loneliness, however, there are no interventions that are specifically designed for substance using populations who are lonely. Testing CBT for loneliness and SUD (CBT-L/SUD) has the potential to have a broad impact on addressing a critical, unmet need that commonly affects Veterans with SUD. Our approach of national recruitment and telehealth delivery of this intervention highlights how this this study address VHA care priorities including substance use, access to care, and telehealth. Innovation: There are no studies that have tested a loneliness intervention in Veterans with SUD who are lonely, which may neglect a broader impact on mental and physical health. This study is ideally situated to generate new and important knowledge on the association of loneliness and SUD. This study seeks to address a transdiagnostic factor, which may improve engagement with social support thereby reducing substance use. An additional innovative aspect of this study is recruitment being conducted outside the VHA. This may increase access to care among those Veterans who are especially isolated. Specific Aims: We aim to: (1) refine the CBT-L/SUD manual by conducting a one-arm trial among Veterans with a SUD who report loneliness (n = 6), (2) randomize participants to receive either CBT-L/SUD (n = 15) or CBT-SUD (n = 15) to assess feasibility and acceptability among Veterans with a SUD who report loneliness. Methodology: We will elicit feedback on a draft of the CBT-L/SUD manual then conduct a small single-arm trial (n = 6) for further refinement. Specifically, SUD treatment providers and Veterans with SUD will provide feedback on the draft manual, which the research team will integrate to finalize the manual for a small single- arm trial. This trial will allow us to collect feasibility of treatment delivery, and treatment satisfaction and acceptability data to further refine the manual. With the refined manual Veterans with SUD reporting loneliness will be randomized to either CBT-L/SUD (n = 15) or CBT-SUD (n = 15). We will assess: (1) treatment acceptability, (2) participant adherence to treatment, and (3) therapist fidelity. We will also assess outcome measure completion percentage, means and standard deviations, and level of correlation of repeated measurement of primary loneliness outcomes and secondary substance use outcomes. Implementation/Next Steps: Results from this study will provide critical feasibility and acceptability data to inform an HSR&D Merit Award application to conduct a fully-powered randomized controlled trial. The research team will work with the VA Office of Mental Health and Suicide Prevention and the Substance Use Disorder office of the National Mental Health Program to identify implementation and dissemination efforts. For example, we plan to translate findings into applied practice across various settings (e.g., primary care mental health, rehabilitation treatment programs). Additionally, this intervention may be particularly useful for behavioral telehealth centers that deliver evidence-based interventions to rural and other Veterans who have difficulty accessing VHA care.	Mental and Behavioral Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
PPO 21-204	Makris	Konstantinos		konstantinos.makris@va.gov	Understanding Reasons for Underdiagnosis and Undertreatment of Primary Hyperparathyroidism in the VA	04/01/2022	09/30/2025	Michael E. DeBakey VA Medical Center, Houston, TX	$200,000		Background: Primary hyperparathyroidism (pHPT) is a common endocrine disorder, whose incidence has been increasing over time. Untreated pHPT can lead to many preventable complications (nephrolithiasis, osteoporosis and pathologic fractures, neuropsychiatric and cognitive disorders) and significantly decrease the quality of life. Our preliminary work with national data from the Veterans Affairs (VA) Corporate Data Warehouse (CDW) has identified significant under-recognition of pHPT among hypercalcemic patients and underutilization of indicated parathyroidectomy across the VA healthcare system. To design effective interventions, we first need to validate the database-derived results with data from individual medical record review, and to explore the reasons for such a significant deviation from evidence-based guidelines. We also need to uncover possible misconceptions and gaps in knowledge among clinicians, possible system barriers in the management of patients with pHPT, as well as to elicit input from clinicians about possible interventions. Innovation: This is the first study to explore at a granular level with a mixed methods approach the reasons for the under-recognition and undertreatment of pHPT observed both in the VA and in other healthcare systems. We anticipate that this pilot work will serve as the basis for health-informatics-based interventions, which will be some of the first ones addressing surgical diseases, and thus provide a model for other surgical pathologies in the future. The proposal intends to address two VA HSR&D areas of emphasis: Information systems to enhance access and timeliness to care (informatics to facilitate diagnosis and management of a common endocrine disease) and Innovation in Health Services Research (novel approach of broadening the focus of Health Informatics in the management of surgical diseases across the VA system). Specific aims: (1) To evaluate the underlying reasons for underdiagnosis and undertreatment of patients with pHPT in the VA; (2) To explore VA clinician perceptions related to diagnosis and management of hypercalcemia and pHPT, including their attitudes towards potential interventions for improvement. Methodology: In this exploratory pilot project, we will conduct an in-depth medical record review of 200 hypercalcemic Veterans without parathyroid hormone testing (underdiagnosis) and of 200 patients with pHPT without parathyroidectomy (undertreatment) to explore possible reasons for underdiagnosis and undertreatment of pHPT. We will also conduct semi-structured interviews with 30 VA clinicians to explore their knowledge and perceptions on hypercalcemia and pHPT management, external barriers affecting compliance with guidelines and their attitude towards possible interventions. Our goal is to reveal misconceptions, gaps in knowledge, systemic limitations in the management of patients with pHPT in the VA, as well as to elicit input from the providers on proposed interventions. Next steps: The results will inform the design of improvement interventions, which will be trialed at a local level before disseminating implementation more broadly in the VA.	Care of Complex Chronic Conditions				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
PPO 22-004	Goldberg	Richard		Richard.Goldberg@va.gov	Recovery Bridge: A Peer Facilitated Intervention to help bridge the transition from psychiatric inpatient hospitalized to living in the community	08/01/2023	01/31/2027	Baltimore VA Medical Center VA Maryland Health Care System, Baltimore, MD	$149,379		Background: The time following discharge from psychiatric hospitalization is a high-risk period and has been associated with a range of negative outcomes, including high rates of hospital readmission and suicide (1). Because the evidence for transitional discharge interventions with bridging components is mixed and limited in terms of how Peer Specialists (PS) can help support such interventions, additional research is needed. Our proposal calls for the development and preliminary evaluation of a PS facilitated technology-supported intervention based on the existing and frequently used My Recovery Plan program. However, to date, no studies have examined use of this tool to improve post-hospital discharge outcomes. Given the importance of the problem for the VA, and the fact that the VA has both a large PS infrastructure that is valued by both professional providers and Veterans, our work offers sound justification and the unique opportunity to test the proposed intervention in a single integrated system of inpatient and outpatient services. Significance: The significance of this project lies in its ability to actively address an important gap in the research, namely PS interventions focused on reducing readmission and supporting recovery-oriented outcomes in Veterans. Further relating to important HSR&D priorities the project is designed to advance scientific knowledge and clinical practice in the areas of access to care, mental health, and suicide prevention. Innovation and Impact: A key innovation of the proposed research is the potential to efficiently optimize existing resources to target the widespread challenges associated with transitioning out of acute inpatient settings and effectively connect Veterans to preferred services (in this case peer support) in order to prevent re-admission, and improve utilization of VA outpatient mental health services. Finally, in relationship to impact, Recovery Bridge has potential to result in improvement across multiple clinical and functional outcomes that are applicable to a broad Veteran population (rather than only in small select diagnostically specific subpopulations). Specific Aim 1: Integrate the My Recovery Plan tool and existing PS tools and strategies to develop a manualized intervention called Recovery Bridge for use by VA PS working to help Veterans make the transition from acute inpatient psychiatric hospitalization to community living. Specific Aim 2: Complete an open pilot trial (n=15) to examine the feasibility, fidelity, and acceptability of the Recovery Bridge intervention in relation to well specified benchmarks supporting continued and expanded investigation. [Specific Aim 3: As part of the open pilot trial: 1) explore the impact of the intervention on readmission rates (at 30 and 90 days), and connection to outpatient care compared to a control group (n=15) identified from administrative data, and; 2) explore the change in recovery and Quality of Life measures over time in the intervention participants]. Methodology: Source documents described in the proposal will be used to create the Recovery Bridge intervention (as Specified in Aim 1). Quantitative, qualitative, and administrative services data we will be used to complete an open trial of the intervention (as specified in Aim 2 and Aim 3). Next Steps: Benchmarks across the domains of feasibility, fidelity, and acceptability; as well as exploratory outcomes specified in Aim 3, will be used to inform next steps including a larger effectiveness trial followed by a possible hybrid-I effectiveness/implementation trial to inform future dissemination and implementation of the intervention more broadly across the VA.	Mental and Behavioral Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
PPO 22-040	Leung	Lucinda		Lucinda.Leung@va.gov	Virtual Care Coordination in VA Primary Care-Mental Health Integration	08/01/2023	09/30/2027	VA Greater Los Angeles Healthcare System, West Los Angeles, CA	$153,710		Background: Among newly initiated Primary Care-Mental Health Integration (PC-MHI) patients, same day access to PC-MHI from primary care or other select medical clinics (e.g., emergency department/urgent care) is a Veterans Health Administration (VA) Strategic Analytics for Improvement and Learning (SAIL) performance measure (mnemonic: pcmhi7). Prompt initiation of mental health care after a medical visit increases the likelihood of subsequent mental health follow-up visits, enhancing quality of care. Yet, despite the rapid VA virtual care expansion during COVID-19, factors that influence virtual same day access to PC-MHI are unknown. Significance: Preliminary studies from this research group found that in a large VA medical center, PC-MHI same day access rates were nearly twice as high for in-person visits compared to virtual visits. Accordingly, PC-MHI patients who initiate care virtually may experience poorer medical and mental health outcomes from loss to follow-up. This finding reflects a knowledge gap that exists across disciplines in both VA and non-VA settings regarding effective strategies for virtual care coordination. The proposed study addresses multiple HSR&D Priority Areas: Access to Care, Mental Health, Primary Care Practice, Virtual Care/Telehealth. Innovation & Impact: The proposed research would be the first to characterize factors that influence same day access to PC-MHI among patients who use virtual care to initiate mental health services, including mutable clinic characteristics that may be amenable to intervention. By identifying specific predictors of same day access to PC-MHI from primary care, the proposed study will advance understanding of factors that affect virtual same day access while also identifying specific targets for future interventions, improving quality of care, and relatedly, medical and mental health outcomes, for Veterans who seek PC-MHI care virtually. Moreover, the study will advance scientific knowledge by providing data to inform strategies for effective interdisciplinary virtual care coordination. Specific Aims: 1) Identify multi-level characteristics associated with virtual and in-person PC-MHI same day access in a national VA sample. 2) Assess barriers, facilitators, and strategies for successful virtual care coordination in PC-MHI. Methodology: The study will use a mixed methods design. For Aim 1 (Quantitative), a national cohort of Veterans who initiated PC-MHI mental health services during FY2019 − FY2021 will be identified. PC-MHI same day access will be determined based on the presence or absence of a primary care or other select medical clinic visit on the same day as the initial PC-MHI appointment, per the Mental Health SAIL definition. A multi-level generalized linear model will be used to evaluate predictors of virtual and in-person same day access. For Aim 2 (Qualitative), semi-structured qualitative interviews with PC-MHI mental health providers and primary care providers from two VA healthcare systems (one urban, one rural) will be conducted to identify barriers, facilitators, and strategies for virtual care coordination in PC-MHI. Next Steps/Implementation: In partnership with the Office of Mental Health and Suicide Prevention, the Office of Connected Care, and the Office of Primary Care, the findings will be applied toward an HSR&D Merit Review Award grant proposal to develop an intervention to improve virtual care coordination in PC-MHI.	Mental and Behavioral Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
PPO 22-161	Wiener	Renda		renda.wiener@va.gov	Co-Design and Pilot Testing of Peer-led Community Outreach to Improve Equity, Veteran-Centeredness and Uptake of Lung Cancer Screening	01/01/2024	03/31/2028	VA Boston Healthcare System Jamaica Plain Campus, Jamaica Plain, MA	$95,993		Background: Lung cancer screening (LCS) with annual computed tomography can reduce lung cancer mortality, but <10% of the estimated 1 million eligible Veterans have been screened, with lower rates among Black people. Many barriers prevent Black people from engaging in LCS: lack of awareness of LCS or how to access it, stigma, fatalistic expectations about lung cancer, power differentials with providers, mistrust of VA, limited self-efficacy, and adverse social determinants of health [entrenched by structural racism]. As a result, across the US LCS uptake is 50% lower [and adherence is 20% lower] among Black vs white persons. Significance: Fourteen Veterans die of lung cancer each day (5000/year), and Black men have the highest incidence and mortality in the US. To improve equity, the 2022 President’s Cancer Panel recommends using trained community peers (known in VA as Peer Specialists, or “Peers”) to reach vulnerable individuals where they are and support them in engaging in cancer screening. Our overarching hypothesis for this line of research is that community outreach, education, and tailored one-to-one support delivered by Veteran Peers can address barriers that prevent Black Veterans from accessing LCS, thereby closing disparities. Innovation & Impact: We will use co-design with Black Veterans, Peers, and community partners to develop an innovative, Veteran-centered intervention (Peer-led program) that meets the needs of Black Veterans. No prior research has tested VA Peer Specialists in such a role. This work is tightly aligned with Office of Research & Development priorities on health equity and precision oncology. The 2022 HSR&D priorities call for health equity studies and for pilot studies testing strategies for Veteran and community engagement. Specific Aims: This pilot project has the following aims: 1) Co-design the Peer-led program in partnership with Veterans and community stakeholders; 2) Assess feasibility and acceptability of the Peer-led program; and 3) [Establish feasibility of study procedures]. Methodology: In Aim 1, we will convene a virtual co-design team of 1-2 Peers and 5-7 Black LCS-eligible Veterans from across the US, [including at least 2 Black women and Veterans varying in age, ethnicity, and geographic residence. Using best practices for equity-centered co-design], we will create a plan and messages for community outreach, content for group LCS orientation, and the process for one-to-one Peer coaching and navigation to support Black Veterans to engage in LCS. We will seek input from our community partners, [the National Association for Black Veterans and Tri-Ad Veterans League], external Veteran advisory panels, and LCS clinical staff to ensure relatability beyond our team and fit with clinical workflow. In Aim 2, we will conduct a feasibility pilot test of the Peer-led program. The Peer will lead up to 4 group LCS orientations in community partner sites to reach ~40 LCS-eligible Black Veterans. The Peer will provide one-to-one tailored support to 15 Veterans (e.g., coaching, goal-setting, navigation to access VA LCS). We will evaluate program delivery with Peer periodic reflections and activity logs. We will interview Veteran participants, community partners, and LCS clinical staff to explore feasibility and acceptability of the Peer-led program and solicit suggestions for improvement. Aim 3 will pilot test and refine study procedures to be used in the IIR: enrolling Veterans; administering surveys to assess change in Social Cognitive Theory constructs; and extracting LCS uptake and tobacco treatment 3 months post-enrollment from VA’s Corporate Data Warehouse. Next Steps/Implementation: This work will inform a multi-site stepped-wedge trial (IIR) to assess effectiveness, implementation, and cost of the Peer-led program in VA LCS sites and neighboring [branches of the National Association for Black Veterans]. Our operational partners in the National Center for Lung Cancer Screening, Office of Health Equity, and Peer Specialist Services are committed to disseminate the Peer-led program to reduce disparities in LCS and lung cancer outcomes, in line with VA’s 2022-28 Strategic Plan.	Equity				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
PPO 22-181	Ward	Michael		michael.ward1@va.gov	Elucidating Non-Routine Events Arising from Interhospital Transfers	10/01/2023	03/31/2028	Tennessee Valley Healthcare System Nashville Campus, Nashville, TN	$148,375		Veterans experienced more than 3 million emergency department visits in 2021 and nearly one-third of these are in non-VA settings. Non-VA emergency care is the single largest contributor to community care with an estimated $500 million in monthly costs. Interhospital transfers are used either to repatriate Veterans during acute episodes of care or to provide access specialty care (e.g., cardiology) should such skilled services not be available at the initial hospital. However, such transfers are burdensome for Veterans and their families, and are associated with worsened clinical outcomes. The field of Human Factors Engineering uses system science to examine what may contribute to suboptimal clinical outcomes through the evaluation of “Non-Routine Events.” These are sub-optimal deviations from the standards of care or unexpected events that are identified through validated surveys of staff, clinicians, and patients. In this pilot application, we seek to advance the study of Non-Routine Events (NREs) through their application to interhospital transfers from VA and non-VA emergency departments. We will use validated surveys of NREs along with transfer documentation to study transfers for evidence of NREs. Finally, in order to automate NRE data collection, we seek to train an optical character recognition and natural language processing informatics cool, “MIRROR EHR,” to extract data of NRE components from scanned medical records for Veterans who experienced interhospital transfers. Guided by the principles of high reliability, our innovative pilot proposal directly addresses multiple ORD-wide and HSR&D priority areas including Access to Care, Quality & Safety, and Healthcare Informatics by using cross-cutting methods of Health Systems Engineering to study interhospital transfers and addressing data quality and how to integrate non-VA data. This work addresses a major legislative priority of the MISSION Act to address the quality and safety of non-VA emergency care. The Specific Aims are: 1) Examine Non-Routine Events arising from interhospital transfers of Veterans; 2) Identify NREs in transferring hospital clinical documentation amongst Veterans experiencing interhospital transfer; and 3) Demonstrate the feasibility of the MIRROR EHR informatics tool to collect and categorize data that are indicators of NREs. The team is uniquely qualified to accomplish these Aims, with expertise in systems science, human factors engineering, biomedical informatics, implementation science, qualitative methods, and acute hospital-based care (emergency and hospital medicine). The institutional environment at the VA Tennessee Valley Healthcare System and Vanderbilt University Medical Center is outstanding, including the Geriatric Research, Education and Clinical Center (GRECC), a site for VA Quality Scholars, an innovative qualitative research center; nationally ranked graduate programs in the relevant fields of study; and the national CTSA coordinating center. This application will conduct necessary pilot work to evaluate the feasibility of NRE data collection arising from interhospital transfers from both VA and non-VA settings using validated NRE surveys. This is a highly innovative proposal to advance the methods of safety science and biomedical informatics designed to improve the quality and safety for Veterans experiencing care transitions in the form of interhospital transfers. Should this work prove feasible, we plan to use these pilot data to prepare a larger Merit award application to evaluate NREs in interhospital transfers and to develop interventions to mitigate their potential harm of Veterans.	Healthcare Informatics				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
QIS 19-317	Battaglia	Catherine		catherine.battaglia@va.gov	Designing for Dissemination and Implementation Training Hub	10/01/2020	09/30/2024	Rocky Mountain Regional VA Medical Center, Aurora, CO	$198,927		The goal of the Designing for Dissemination and Implementation (D4D&I) Training Hub program is to train Veterans Health Administration (VA) providers, researchers, and operational leaders/staff in the D4D&I implementation strategy. Implementation strategies are designed to translate research into practice to improve patient care. This training will increase the knowledge and skills of VA practitioners and researchers who are ready to disseminate and implement care coordination practices across the VA. Our multifaceted D4D&I strategy combines discrete methods that consider the culture, climate, and work environment (i.e. context) of implementation sites. This will increase the impact, effectiveness, adoption, and maintenance of care coordination programs across clinical settings and patient populations and throughout the continuum of care. The four discrete methods of the D4D&I strategy are: 1) Pre-implementation assessment for proactive planning and assessment of multilevel context using the Practical, Robust Implementation and Sustainability Model (PRISM) to ensure program success and sustainability, 2) Multi-level stakeholder engagement to learn what is important to end-users and garner program buy-in, 3) Implementation and adaptations guided by the pre-implementation assessment and stakeholders while retaining fidelity to care coordination program core components, and 4) Program evaluation using RE-AIM (Reach Effectiveness Adoption Implementation Maintenance) to define program outcomes. The D4D&I Training Hub program will address the following aims: 1) Train participants to use the four discrete methods of the D4D&I strategy; 2) Implement a virtual learning collaborative (VLC) to facilitate peer-to-peer learning by providing participants with a forum for sharing experiences; and 3) Evaluate the D4D&I Training Hub implementation strategy using the RE-AIM Framework. Our evaluation will encompass participant learning and satisfaction with the training and professional growth with the VLC, cost of implementing the training hub, and downstream program outcomes and products. The D4D&I Training Hub uses evidence-based experiential and e-learning educational strategies for adult learning. Each training cohort will participate in a 24 week program. Training will occur through Canvas, an e-learning platform during the first 13 weeks. We selected an e-learning format because of its low cost and potential high-impact. Use of an e- learning platform increases accessibility, scale, and spread across the VA. The training content will be delivered in six, 2-hour training weeks over a 13-week period (12 weeks of training with the 13th week being a capstone presentation) with didactic alternating with VLC meetings. The didactic sessions will cover the D4D&I strategy. Participants will learn how to conduct implementation science-guided assessments, engage stakeholders, adapt their care coordination program based on data and feedback, and care coordination program evaluation. Each training week includes educational resources, an interactive didactic curriculum, and instructions for site work. The VLC meetings will be used to draw reflections from participants about the didactic content, facilitate storytelling of how the information has been applied, support peer-to-peer mentoring, allow for assessment of intervention fidelity, and opportunities to reinforce content if necessary. The VLC meetings will occur bi-weekly for the first 12 weeks since the 13th week is a capstone presentation, and then monthly for the following three months. Participants will meet with Faculty Co-Mentors who will be a resource throughout the 24-week program. Faculty Co-Mentors and participants will establish short- and long-term goals and work together to ensure goal attainment.	QUERI				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
QUE 20-007	Fortney	John	Evan Carey, Paula Langner, Jan Lindsay, Heather Reisinger, Nichole Tanner, Carolyn Turvey	John.Fortney@va.gov	Virtual Care QUERI Program: Implementation of Technology Facilitated Evidence Based Practices to Improve Access to High Quality Care for Rural Veterans	10/01/2020	09/30/2024	VA Puget Sound Health Care System Seattle Division, Seattle, WA	$3,288,350			QUERI				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
RCS 00-001	Timko	Christine		Christine.Timko@va.gov	Quality and Care of Substance Abuse and Psychiatric Treatment	07/01/2000	10/31/2021	VA Palo Alto Health Care System, Palo Alto, CA	$4,559,733			Career Development	The study is developing a Decision Aid for Veteran medical-surgical inpatients with AUD that can be used systemwide. We are adapting a Decision Aid being implemented with AUD patients in non-VA, private, primary care settings to be applicable for Veterans with AUDs in VHA medical-surgical inpatient settings. The project is also evaluating the effectiveness of DO-MoST to improve outcomes of medical-surgical inpatients with AUD. In an RCT, DO-MoST, which incorporates use of Motivational Interviewing, the Decision Aid, and Telemonitoring, is compared to Usual Care (UC) at two VHA facilities (Ann Arbor and Palo Alto). The primary hypotheses are that patients in the DO-MoST condition, compared to patients in UC, are more likely to (1) initiate AUD help and engage in AUD help for a longer duration, (2) have better AUD and medical outcomes, and (3) have fewer and more delayed (i.e., a longer duration of time until) acute care episodes (re-hospitalizations, Emergency Department visits). The project is further informing future broader implementation of DO-MoST. It is conducting a qualitative process evaluation of DO-MoST at the intervention sites, using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework. The purpose is to provide guidance for VA facilities' adoption of DO-MoST in the future, including the operations partner that would hold primary ownership, and possible adaptation for diverse subpopulations of Veterans.	The primary objective of this project is to evaluate DO-MoST as a new and innovative intervention to facilitate the transition from inpatient medical-surgical care to AUD help (behavioral and/or medication-based treatments; mutual-help groups), thereby improving Veterans' AUD and medical outcomes and decreasing VA health care costs. In addition, this project will include a qualitative process evaluation - that is, gather information from providers and patients on DO-MoST's adoptability - to inform VA's potential widespread implementation of DO-MoST with medical-surgical inpatients with AUDs. The study uses an effectiveness-implementation Hybrid Type 1 design, incorporating both a randomized controlled trial (RCT) and process evaluation to facilitate future implementation.	VA Mental Health and Medical Services are committed to eradicating a dangerous and costly pattern: Veterans in inpatient medical/surgical care do not receive the SUD treatment they need. DO-MoST, a promising way to improve treatment access and outcomes by these patients, has not been utilized with the challenging population of medical-surgical inpatients with untreated alcohol use disorders before. This project is helping to accomplish VHA's and HSR&D's missions by increasing Veterans' access to, engagement in, and benefit from SUD treatment services, particularly among Veterans who are using VA medical services and need SUD services but are not receiving them.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
RCS 03-155	Piette	John		john.piette@va.gov	Research Career Scientist Award	01/02/2004	12/31/2021	VA Ann Arbor Healthcare System, Ann Arbor, MI	$3,155,810		The over-arching goal of all my research activity is to develop and evaluate novel clinically-focused approaches to reduce the fear of developing chronic non-healing wounds, in particular pressure injuries. My active current projects center around development and implementation of interventions and technology that will positively impact rehabilitation, healthcare and overall quality of life for Veterans, in particular Veterans with spinal cord injury. Active interdisciplinary clinical studies include determination of personalized pressure injury risk based on identification of novel biomarkers. Current results show that muscle quality critically impacts both safe sitting interface pressure levels and safe sitting times. This represents a paradigm shift in primary pressure injury prevention. A reliable objective pressure injury risk assessment tool based on muscle composition biomarkers is being developed to enable clinicians to provide effective personalized primary prevention for the most susceptible individuals within the high-risk population of Veterans with spinal cord injury. My clinical studies include bioinformatics to support the development of SCIPUD+, a personalized healthcare tool for pressure injury prevention planning. I am leading a team including bioinformaticians and statistical experts in this project to leverage the wealth of information from thousands of Veterans with spinal cord injury securely housed in the VA Informatics and Computing Infrastructure, together with our established noninvasive methodology for tissue health assessment -THEToolbox (Tissue Health Evaluation Toolbox). SCIPUD+ will enable the individual Veterans' risk factor profile to applied as the basis for adaptive care planning based on prioritization of factors in the clinical practice guidelines. The development of SCIPUD+, a tool for Personalized, Proactive, Patient-driven Health care will support identification and validation of best practices in spinal cord injury care for primary and secondary pressure injury prevention. Ultimately this research will be applicable to all individuals with spinal cord injury and could enhance both personal health status and quality of life while reducing healthcare costs. Current technology development studies include a VA Merit Review funded study to develop the next-generation patented smart Modular Adaptive Electrotherapy Delivery System (SmartMAEDS), to enable safe and smart delivery of electrotherapy outside traditional clinical settings. This translational development study will provide a strong foundation for the clinical delivery of personalized adaptive electrotherapy using SmartMAEDS, so that our Veterans will benefit from the most recent advances in wound healing science. I am also leading technology development of flexSTIM, a flexible novel implanted pattern generator to provide dynamic intermittent gluteal stimulation (iGSTIM). The fully implanted iGSTIM system will combine flexSTIM and intermuscular electrodes to bilaterally stimulate the gluteal muscle, providing regular exercise and weight-shifting. iGSTIM will impact fundamental and essential challenges in pressure injury prevention and musculoskeletal heath for Veterans with spinal cord injury, particularly those with high level injury or who have extensive intramuscular adipose tissue and cannot perform independent pressure relief. A pending VA Merit Review project will support further technology development and rapid translation to the market of the patent-pending modular cost-effective wheelchair cushion. Our cushion combines low-cost with high- performance; using advanced dynamic materials a modular support system is created which can be customized for individual seating requirements at very low cost. The cushion can be repaired rather than replaced since components are removable, thus increasing durability. This project impacts the cost of effective wheelchair cushions and pressure injury risk for wheelchair users, particularly Veterans with spinal cord injury.	Career Development	Involvement in VA national working groups, clinical dissemination programs, national review groups, and as the lead for innovative research programs.	Objectives of this SRCS Award are to: (1) Provide national service to the VA HSR&D and national, regional, and local clinical units; (2) Serve as a local and national mentor for VA junior investigators; (3) conduct important health services research that improves the health of veterans and the quality of their care.	John is Co-PI for the CREATE study Comprehensive Opioid Management in Patient Aligned Care Teams. In that study he is working with the National Pain Program to develop and evaluate cost-effective solutions for using patient-centered health IT to improve Veterans' access to pain care. John directs the University of Michigan Center for Managing Chronic Disease - a research center with 40 faculty affiliates. He also sits on the leadership board for the UM Institute for Health Policy and Innovation, and he is Associate Director for the UM Center for Diabetes Translational Research. He recently was invited to a Michigan statewide form of key decision-leaders in criminal justice and mental health to describe best-practices for behavior change interventions and how mobile technology could improve outcomes.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
RCS 08-027	Bosworth	Hayden		hayden.bosworth@va.gov	Research Career Scientist Award	03/01/2008	02/28/2022	Durham VA Medical Center, Durham, NC	$2,642,906		The over-arching goal of all my research activity is to develop and evaluate novel clinically-focused approaches to reduce the fear of developing chronic non-healing wounds, in particular pressure injuries. My active current projects center around development and implementation of interventions and technology that will positively impact rehabilitation, healthcare and overall quality of life for Veterans, in particular Veterans with spinal cord injury. Active interdisciplinary clinical studies include determination of personalized pressure injury risk based on identification of novel biomarkers. Current results show that muscle quality critically impacts both safe sitting interface pressure levels and safe sitting times. This represents a paradigm shift in primary pressure injury prevention. A reliable objective pressure injury risk assessment tool based on muscle composition biomarkers is being developed to enable clinicians to provide effective personalized primary prevention for the most susceptible individuals within the high-risk population of Veterans with spinal cord injury. My clinical studies include bioinformatics to support the development of SCIPUD+, a personalized healthcare tool for pressure injury prevention planning. I am leading a team including bioinformaticians and statistical experts in this project to leverage the wealth of information from thousands of Veterans with spinal cord injury securely housed in the VA Informatics and Computing Infrastructure, together with our established noninvasive methodology for tissue health assessment -THEToolbox (Tissue Health Evaluation Toolbox). SCIPUD+ will enable the individual Veterans' risk factor profile to applied as the basis for adaptive care planning based on prioritization of factors in the clinical practice guidelines. The development of SCIPUD+, a tool for Personalized, Proactive, Patient-driven Health care will support identification and validation of best practices in spinal cord injury care for primary and secondary pressure injury prevention. Ultimately this research will be applicable to all individuals with spinal cord injury and could enhance both personal health status and quality of life while reducing healthcare costs. Current technology development studies include a VA Merit Review funded study to develop the next-generation patented smart Modular Adaptive Electrotherapy Delivery System (SmartMAEDS), to enable safe and smart delivery of electrotherapy outside traditional clinical settings. This translational development study will provide a strong foundation for the clinical delivery of personalized adaptive electrotherapy using SmartMAEDS, so that our Veterans will benefit from the most recent advances in wound healing science. I am also leading technology development of flexSTIM, a flexible novel implanted pattern generator to provide dynamic intermittent gluteal stimulation (iGSTIM). The fully implanted iGSTIM system will combine flexSTIM and intermuscular electrodes to bilaterally stimulate the gluteal muscle, providing regular exercise and weight-shifting. iGSTIM will impact fundamental and essential challenges in pressure injury prevention and musculoskeletal heath for Veterans with spinal cord injury, particularly those with high level injury or who have extensive intramuscular adipose tissue and cannot perform independent pressure relief. A pending VA Merit Review project will support further technology development and rapid translation to the market of the patent-pending modular cost-effective wheelchair cushion. Our cushion combines low-cost with high- performance; using advanced dynamic materials a modular support system is created which can be customized for individual seating requirements at very low cost. The cushion can be repaired rather than replaced since components are removable, thus increasing durability. This project impacts the cost of effective wheelchair cushions and pressure injury risk for wheelchair users, particularly Veterans with spinal cord injury.	Career Development	My own peer-reviewed research continues to be comprised of three main areas that have significant implications for the VA: clinical research that provides knowledge for improving patients' treatment adherence and self-management in chronic care; translation research to improve access to quality of care, and eliminate health care disparities. Outcomes of my research include quality of care, patient-centered measures (e.g., health-related quality of life, patient satisfaction with care), clinical parameters, and improvements in access to health care. I am also the Deputy Director of the Center for Health Services Research in Primary Care at the Durham VAMC where I facilitate coordination of research and training activities for our Center.	Research Career Scientists are expected to: obtain peer-reviewed research; train/mentor junior VA scientists; collaborate with clinician investigators; function as a resource for the research community; and serve on VA research and other committees.	Our previous studies have made both methodological and content contributions to health services research, particularly with respect to improving access to quality of care and align strategically with VA strategic priorities including: 1) greater choice for Veterans (build a high-performing integrated network of care); 2) improve timeliness of services (improve access to care); 3) focus more resources more efficiently (strengthen foundational services in VA). This work also meets HSR&D research priorities including: 1) patient centered care, care management, and health promotion; 2) healthcare access; 3) aging; 4) health equity), 5) primary care practice and management of complex chronic diseases and, 6) virtual care. The findings from our recent and planned studies are intended to provide VA policy makers with evidence about the effectiveness of pragmatic strategies that seek to improve the quality and outcomes of care for veterans.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
RCS 14-232	Sox-Harris	Alexander		Alexander.Harris2@va.gov	HSR&D Career Scientist	10/01/2014	06/30/2022	VA Palo Alto Health Care System, Palo Alto, CA	$2,251,455			Career Development	1) Surgical Health Services - risk and benefit modeling 2) Quality Metrics: Development and validation of quality metrics including developing methods to detect unintended consequences. Also examining the utility of patient-reported outcomes for quality measurement purposes 3) Improvement Science - develop and test a strategy to reduce low value preoperative testing.	1) Surgical Health Services Research: Conducting a HSR&D-funded study to develop and validate a risk and benefit prediction model for VA patients who are considering knee or hip replacement. 2) Quality Metrics: In collaboration with the American Society for Surgery on the Hand, developing an AHRQ proposal to develop and validate new quality measures for carpal tunnel syndrome. 2) Improvement Science: Conduct recently funded study to describe the extent and drivers of low value preoperative testing in VA with the goal of reducing low value testing	Dr. Sox-Harris recently published : (1) A paper evaluating the access-safety trade-offs in enforcing a BMI cutoff for total joint replacement. This work was published in the flagship orthopedics journal and presented a the prestigious Knee Society. 2) A paper questioning the validity of a popular surgical risk calculator; and 3) Prediction models for total joint arthtoplasty in the VHA. (1) Giori NJ, Amanatullah DF, Gupta S, Bowe T, Harris AHS. (2018). Risk Reduction Compared with Access to Care: Quantifying the Trade-Off of Enforcing a Body Mass Index Eligibility Criterion for Joint Replacement. J Bone Joint Surg April 4;100(7):539-545. (2) Harris AHS, Kuo AC, Bozic KJ, Lau E, Bowe T, Gupta S, Giori, NG (2018). American Joint Replacement Registry Risk Calculator Does Not Predict 90-day Mortality in Veterans Undergoing Total Joint Replacement. Clinical Orthopaedics & Related Research. Sept; 476(9): 1869-1875. (3) Harris, AHS, Kuo, A, Nordin, D, Bowe, T, Gupta, S, Giori, NG (2018). Prediction Models for 30-Day Mortality and Complications Following Total Knee and Hip Arthroplasty for Veteran Health Administration Patients with Osteoarthritis. Journal of Arthroplasty, 33(5), 1539-1545.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
RCS 17-153	Fortney	John		John.Fortney@va.gov	RCS	08/01/2017	09/30/2022	VA Puget Sound Health Care System Seattle Division, Seattle, WA	$938,062	https://www.hsrd.research.va.gov/cdp/res_career_scientist.cfm		Career Development	Aim 1 - Mentor graduate students, post-doctoral fellows, and junior faculty members in order to cultivate the next generation of researchers with the content and methodological expertise needed to maximize VHA's population health impact on rural Veteran enrollees. As the Co-Director of the Post Doctoral Fellowship Program at HSR&D CIVCVDC and the Director of the Division of Population Health in the Department of Psychiatry at the University of Washington, I have many opportunities to mentor junior investigators. Aim 2 - Provide scientific leadership to our HSR&D Center of Innovation and QUERI Programs, and facilitate collaboration with our university affiliates, clinical programs, and operational partners in order maximize VHA's population health impact on rural Veteran enrollees. Senior COIN Investigator - I am a core investigator in the HSR&D CIVCVDC. I will participate in weekly "works in progress" meetings and provide one-on-one consultations to COIN investigators. QUERI Program - As PI of the Virtual Specialty Care QUERI Program, I will promote implementation science around the adoption of technology facilitated clinical practices. I will provide oversight for the QUERI Program and the Implementation Core, lead one of the multi-year projects, and provide guidance to the PIs of the other four projects. Division Director - As the Director of the Division of Population Health in the Department of Psychiatry at the University of Washington, I will oversee pre-award grant submissions and post-award grants, and setting a research agenda for this new Division. I will continue to build and strengthen collaborations between investigators at the Puget Sound Veterans Healthcare System and its academic affiliate, the University of Washington. Aim 3 - Conduct policy relevant and methodologically rigorous research to maximize VHA's population health impact on rural Veteran enrollees. In the next five years, I propose to complete my Virtual Specialty Care QUERI Program project to measure the population level effectiveness and cost effectiveness of rolling out a telepsychiatry collaborative care program for PTSD in small rural CBOCs. Our QUERI Program's Implementation Core has developed a novel method for measuring the cost of our implementation activities in preparation for calculating population level cost effectiveness estimates. If this EBP and our implementation strategy are found to be cost effective at the population level, we will conduct a national rollout of this EBP as part of the Office of Rural Health's Promising Practices Program. The Office of Rural Health is currently funding the clinical cost of our QUERI project ($1.8 million) and is committed to a national rollout if our QUERI project is successful.	Aim 1 - Mentor graduate students, post-doctoral fellows, and junior faculty members in order to cultivate the next generation of researchers with the content and methodological expertise needed to maximize VHA's population health impact on rural Veteran enrollees. Aim 2 - Provide scientific leadership to our HSR&D Center of Innovation and QUERI Programs, and facilitate collaboration with our university affiliates, clinical programs, and operational partners in order maximize VHA's population health impact on rural Veteran enrollees. Aim 3 - Conduct policy relevant, clinically actionable, and methodologically rigorous research to maximize VHA's population health impact on rural Veteran enrollees.	Impact Goal - To improve rural Veteran's access to and VHA's capacity to deliver evidence based mental health practices through mentoring, leadership, research, and implementation.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
RCS 23-079	Chinman	Matthew		matthew.chinman@va.gov	HSR&D Research Career Scientist Award	10/01/2023	03/31/2028	VA Pittsburgh Healthcare System University Drive Division, Pittsburgh, PA	$132,712		Dr. Chinman is an accomplished researcher who has made pioneering theoretical, methodological, and empirical contributions to implementation science and to the deployment of VA Peer Specialists—Veterans with serious mental illness, or SMI, who are trained and then employed by VA to help other Veterans with SMI (~1200 are employed VA-wide). Funded by VA HSR&D, RR&D, and QUERI, his current VA portfolio focuses on teaching Veterans with SMI cognitive and social skills and coaching Veterans with SMI who are obese to lose weight—both featuring Peer Specialists as the primary interventionist. Dr. Chinman is also leading an effort to develop and pilot a Peer Specialist-based suicide prevention program. In addition to Peer Specialists, Dr. Chinman has been centrally involved in the development of implementation science since its inception, designing and working on implementation trials in mental health, primary care, and after school settings. In these trials, he has applied, evaluated, and refined Getting To Outcomes® (GTO®), a robust implementation strategy with demonstrated effectiveness, and developed multiple frameworks to aid implementation researchers. Dr. Chinman provides extensive mentoring at multiple levels, locally in Pittsburgh and nationally, on Peer Specialist and implementation research—for example helping seven junior investigators secure HSR&D CDAs. Lastly, Dr. Chinman has a track record of extensive collaborations with other investigators and VA operations partners. For example, Dr. Chinman has been assisting the VA's National Director of Peer Support since the inception of that position, to better understand Peer Specialist contributions and overcome implementation barriers. The goal for this Research Career Scientist (RCS) application is to provide support for an established investigator to expand his current lines of research on Peer Specialists and to advance rigorous methods that benefit implementation science. The outcome of this RCS proposal would be to improve Veterans' with SMI access to care and VHA's capacity to deliver evidence based mental health practices through mentoring, leadership, research, and implementation. The proposed award would help Dr. Chinman expand the breadth and depth of his portfolio of theoretical and applied research on Peer Specialists (e.g., clarifying theoretical mechanisms), further develop his implementation science contributions (including new tools and their dissemination) and increase his mentoring in peer support and implementation science locally and VA-wide.	Career Development				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
RCS 23-080	Blonigen	Daniel		Daniel.Blonigen@va.gov	HSR&D Research Career Scientist Award	10/01/2023	06/30/2031	VA Palo Alto Health Care System, Palo Alto, CA	$212,183		Approximately 1 in 4 Veterans has a substance use or mental health disorder. Yet, the majority of these Veterans do not receive treatment for these problems. My VA research program aims is to develop innovations to improve access and engagement in substance use and mental health care for vulnerable populations, test if these innovations are effective, and facilitate their implementation. This work involves investigating the effectiveness and implementation potential of mobile health and peer-based interventions for Veterans who struggle with homelessness and/or cyclical involvement in the criminal justice system. Such research is critical to the VA’s mission, given that justice system involvement and homelessness disproportionately affect Veterans and increase risk for chronic health problems and use of high-cost services. Using a variety of sophisticated methodologies (e.g., hybrid trials, qualitative analysis), and in collaboration with multidisciplinary teams from institutions in and outside VA and operational partners in VA’s Homeless Program Office, Office of Mental Health and Suicide Prevention, and Office of Connected Care, my research contributions focus on: (1) improving treatment engagement and outcomes for justice-involved and homeless Veterans. My prior and future research in this area tests the effectiveness and implementation potential of interventions that aim to reduce risk for criminal recidivism and acute care service utilization in this high-need patient population; (2) evaluating virtual care services for Veterans with substance use and mental health disorders. My prior and future research in this area studies the scalability and implementation of mobile applications and video-enabled tablets to increase Veterans’ access to behavioral healthcare; (3) developing, testing, and implementing peer-supported mobile health interventions. To date, my research in this area has focused on developing and testing protocols for peers to support patients’ use of mobile apps for self-management of alcohol use and mental health problems. My future research will seek to advance implementation of this model of care into the continuum of behavioral health services for Veteran primary care patients. I have become a leader in these areas of research, as demonstrated by my peer-reviewed publications, grant funding, invited memberships on study sections for VA and NIH, editorial positions for leading addiction and mental health journals, and letters of support from non-VA colleagues. If I am fortunate enough to receive a Research Career Scientist award from VA HSR&D, I will devote my full-time effort to research, mentoring, and VA service activities as a distinguished leader on improving access and engagement in substance use and mental health care for vulnerable populations.	Career Development				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
RCS 97-401	Rosen	Amy		amy.rosen2@va.gov	Research Career Scientist Award	10/01/2006	01/31/2022	VA Boston Healthcare System Jamaica Plain Campus, Jamaica Plain, MA	$3,587,384		The over-arching goal of all my research activity is to develop and evaluate novel clinically-focused approaches to reduce the fear of developing chronic non-healing wounds, in particular pressure injuries. My active current projects center around development and implementation of interventions and technology that will positively impact rehabilitation, healthcare and overall quality of life for Veterans, in particular Veterans with spinal cord injury. Active interdisciplinary clinical studies include determination of personalized pressure injury risk based on identification of novel biomarkers. Current results show that muscle quality critically impacts both safe sitting interface pressure levels and safe sitting times. This represents a paradigm shift in primary pressure injury prevention. A reliable objective pressure injury risk assessment tool based on muscle composition biomarkers is being developed to enable clinicians to provide effective personalized primary prevention for the most susceptible individuals within the high-risk population of Veterans with spinal cord injury. My clinical studies include bioinformatics to support the development of SCIPUD+, a personalized healthcare tool for pressure injury prevention planning. I am leading a team including bioinformaticians and statistical experts in this project to leverage the wealth of information from thousands of Veterans with spinal cord injury securely housed in the VA Informatics and Computing Infrastructure, together with our established noninvasive methodology for tissue health assessment -THEToolbox (Tissue Health Evaluation Toolbox). SCIPUD+ will enable the individual Veterans' risk factor profile to applied as the basis for adaptive care planning based on prioritization of factors in the clinical practice guidelines. The development of SCIPUD+, a tool for Personalized, Proactive, Patient-driven Health care will support identification and validation of best practices in spinal cord injury care for primary and secondary pressure injury prevention. Ultimately this research will be applicable to all individuals with spinal cord injury and could enhance both personal health status and quality of life while reducing healthcare costs. Current technology development studies include a VA Merit Review funded study to develop the next-generation patented smart Modular Adaptive Electrotherapy Delivery System (SmartMAEDS), to enable safe and smart delivery of electrotherapy outside traditional clinical settings. This translational development study will provide a strong foundation for the clinical delivery of personalized adaptive electrotherapy using SmartMAEDS, so that our Veterans will benefit from the most recent advances in wound healing science. I am also leading technology development of flexSTIM, a flexible novel implanted pattern generator to provide dynamic intermittent gluteal stimulation (iGSTIM). The fully implanted iGSTIM system will combine flexSTIM and intermuscular electrodes to bilaterally stimulate the gluteal muscle, providing regular exercise and weight-shifting. iGSTIM will impact fundamental and essential challenges in pressure injury prevention and musculoskeletal heath for Veterans with spinal cord injury, particularly those with high level injury or who have extensive intramuscular adipose tissue and cannot perform independent pressure relief. A pending VA Merit Review project will support further technology development and rapid translation to the market of the patent-pending modular cost-effective wheelchair cushion. Our cushion combines low-cost with high- performance; using advanced dynamic materials a modular support system is created which can be customized for individual seating requirements at very low cost. The cushion can be repaired rather than replaced since components are removable, thus increasing durability. This project impacts the cost of effective wheelchair cushions and pressure injury risk for wheelchair users, particularly Veterans with spinal cord injury.	Career Development	Methods: These objectives will be accomplished through continued funding from the National Center for Patient Safety for expansion and revision of the Guiding Patient Safety data display and toolkit as well as continued HSR&D funding through a SDR proposal for the next three years. We have also received start-up funds from QUERI to begin evaluation of the implementation of safety processes in community care by OCC and NCPS and will hopefully get additional funds for another two years to continue this year through 2021.	The objectives of this RCS Award are: 1) to become a national expert in measuring and evaluating quality and safety in VA and Community Care (CC) 2) to partner with relevant VA stakeholders and stakeholders groups to develop and implement quality improvement initiatives (e.g., National Center for Patient Safety (NCPS) and the Office of Community Care (OCC)) 3) to evaluate and compare the quality and safety of care for Veterans using VA and CC particularly related to surgery and mental health 4) to continue mentoring junior faculty, career development awardees, post-docs, and other investigators in order for them to become successful independent investigators	Impact: Our PSCI GPS tools are currently being used by selected VA facilities to identify the important/prevalent safety events that occur at their facility and to target quality improvement activities. We continue to revise and expand the GPS tools which we hope will be housed at NCPS for national use by the end of FY19. We have continued to enlighten the field with our work in Community Care, uncovering important issues related to the community care data. Working with our operational partners this year was helpful in furthering our knowledge, and those of others, in area. We will continue to have an impact in understanding this area through our SDR project. Additional Information: Publications (2018): 1.Talutis SD, Chen Q, Wang N, Rosen AK. Comparing Risk Standardized Readmission Rates of Surgical Patients at Safety Net and Non-Safety Net Hospitals. JAMA Surgery. In press (2018). 2.Hachey, K, Morgan R, Rosen AK, Rao SR, McAneny D, Tseng J, Doherty G, Sachs T. Quality Comes with the (Anatomic) Territory: Evaluating the Impact of Surgeon Operative Mix on Patient Outcomes after Pancreaticoduodenectomy. Annals of Surgical Oncology. In press (2018). 3.Mull HJ, Itani KMF, Pizer SD, Charns M, Rivard P, McIntosh N, Hawn MT, Rosen AK. Development of an Adverse Event Surveillance Model for Outpatient Surgery in the Veterans Health Administration. Health Services Research. In press (2018). 4.Titan A, Graham L, Rosen AK, Itani K, Copeland LA, Mull HJ, Burns E, Richman J, Kertesz S, Wahl T, Morris M, Whittle J, Telford G, Wilson M, Hawn M. Homeless status, post discharge healthcare utilization and readmission after surgery. Medical Care. In press (2018). 5.Sullivan JL, Shin MH, Engle RL, Yaksic E, VanDeusen Lukas C, Paasche-Orlow MK, Starr LM, Restuccia JD, Holmes S, Rosen AK. Evaluating the Implementation of Project Re-Engineered Discharge (RED) in Veterans Health Administration (VA) Hospitals. The Joint Commission Journal on Quality and Patient Safety. In press (2018). 6.Mull HJ, Itani KMF, MacDonald S, Charns MP, Pizer SD, Hawn MT, Rosen AK. The Nature and Severity of Adverse Events in Select Outpatient Surgeries in the Veterans Health Administration. Quality Management in Health Care. 2018 July/Sep; 27 (3):136-144. 7.Borzecki AM, Chen Q, O'Brien W, Shwartz M, Najjar PA, Rosen AK. The Patient Safety Indicator Perioperative Pulmonary Embolism or Deep Vein Thrombosis: Is There Associated Surveillance Bias in the Veterans Health Administration? American Journal of Surgery. 2018 Jul 4. pii: S0002-9610(17)31603-3. 8.Wahl TS, Graham LA, Morris MS, Richman JS, Hollis RH, Jones CE, Itani KM, Wagner TH, Mull HJ, Whittle JC, Telford GL, Rosen AK, Copeland LA, Burns EA, Hawn MT. Association Between Preoperative Proteinuria and Postoperative Acute Kidney Injury and Readmission. JAMA Surgery; 2018 July 3: e182009. 9.Chen L, Chan JA, Alligood E, Rosen AK, Borzecki AM. Does Surveillance Bias Influence the Validity of Measures of Inpatient Complications? A Systematic Review. American Journal of Medical Quality; 2018 May/Jun;33(3):291-302. 10.Mull HJ, Graham LA, Morris MS, Rosen AK, Richman JS, Whittle J, Burns E, Wagner TH, Copeland LA, Wahl T, Jones C, Hollis RH, Itani KMF, Hawn MT. A Consensus Process to Identify Postoperative Readmission Codes Related to Surgical Quality. JAMA Surgery 2018 April 18. 11.Sterbling H, Rosen AK, Hachey K, Vellanki N, Hewes P, Rao S, Pinjic E, Fernando H, Litle V. Caprini Risk Model Decreases Venous Thromboembolism Rates in Thoracic Surgery Cancer Patients. The Annals of Thoracic Surgery; 2018 Mar;105(3):879-885. 12.Chen Q, Rosen AK, Amirfarzan H, Rochman A, Itani K. Improving Detection of Intraoperative Medical Errors (iMEs) and Adverse Events (iAEs) and their Contribution with Postoperative Outcomes. American Journal of Surgery. 2018 Mar 6. pii: S0002-9610(17)31222-9. 13.Shin MH, Rivard PE, Shwartz M, Borzecki A, Yaksic E, Stolzmann K, Lisa Zubkoff L, Rosen AK. Tailoring an Educational Program on the AHRQ Patient Safety Indicators to Meet Stakeholder Needs: Lessons Learned in the VA. BMC Health Services Research; 2018 Feb 14;18(1):114. 14.Mull H, Rosen AK, O'Brien W, McIntosh N, Legler A, Hawn M, Itani K, Pizer S. Factors Associated with Hospital Admission after Outpatient Surgery in the Veterans Health Administration. Health Services Research. 2018; Jan 23. 1. Mull H, Rosen, AK, O'Brien W, McIntosh N, Legler A, Hawn M, Itani K, Pizer S. Factors Associated with Hospital Admission after Outpatient Surgery in the Veterans Health Administration. HSR. In press (2017). 2. Sterbling H, Rosen AK, Hachey K, Vellanki N, Hewes P, Rao S, Pinjic E, Fernando H, Litle V. Caprini Risk Model Decreases Venous Thromboembolism Rates in Thoracic Surgery Cancer Patients. The Annals of Thoracic Surgery. In Press (2017). 3. Chen L, Chan JA, Alligood E, Rosen AK, Borzecki AM. Does Surveillance Bias Influence the Validity of Measures of Inpatient Complications? A Systematic Review. American Journal of Medical Quality; September 2017; https://doi.org/10.1177/1062860617730900. 4. Chen Q, Oriel B, Rosen AK, Greenan M, Amirfarzan H, Mull HJ, Fisichella P, Itani K. Detection and Potential Consequences of Intraoperative Adverse Events (IAEs): A Pilot Study in the Veterans Health Administration. American Journal of Surgery; In press (2017). 5. Copeland L, Graham L, Richman J, Rosen AK, Mull H, Burns E, Whittle J, Itani K, Hawn M. A Study to Reduce Readmissions after Surgery in the Veterans Health Administration: Design and Methodology. BMC Health Services Research; In press (2017). 6. Rosen AK, O'Brien W, Chen Q, Shwartz M, Itani K, Gunnar W. Trends in the Purchase of Surgical Care in the Community by the Veterans Health Administration. Medical Care. 2017 March 17. Doi: 10.1097/MLR. 0000000000000707. [Epub ahead of print] 7. Hollis RJ, Graham L, Richman J, Morris M, Mull H, Wahl T, Burns E, Copeland C, Telford G, Rosen AK, Itani K, Whittle J, Wagner T, Hawn, M. Hospital Readmissions after Surgery: How Important are Hospital and Specialty Factors? Journal of the American College of Surgery; In press (2017). 8. Mull HJ, Rivard P, Legler A, Pizer S, Hawn M, Itani KMF, Rosen AK. Comparing Definitions of Outpatient Surgery: Implications for Quality Measurement. American Journal of Surgery 2017; Epub ahead of print. https://www.americanjournalofsurgery.com/article/S0002-9610(16)31059-5/abstract From 2016: 1.Chen Qi, Rosen AK, Borzecki A, Shwartz M. Using Harm-based Weights for the AHRQ Patient Safety Indicators Composite (PSI-90): Does it Affect Assessment of Hospital Performance and Financial Penalties in the Veterans Health Administration Hospitals? HSR; In press (2016). 2.Hanchate AD, Stolzmann K, Rosen AK, Fink AS, Shwartz M, Ash A, Abdulkerim H, Pugh MJ, Shokeen P, Borzecki A. Does Adding Clinical Data to Administrative Data Improve Agreement among Hospital Quality Measures? Healthcare; In press (2016). 3.Brady MT, Patts G, Rosen AK, Kasotakis G, Siracuse J, Sachs T, Kuhnen A, Kunitake H. Postoperative Venous Thromboembolism in Patients Undergoing Abdominal Surgery for IBD: A Common but Rarely Addressed Problem. Diseases of the Colon and Rectum; In press (2016). 4.Mull HJ, Rosen AK, Rivard P, Itani K. Defining Outpatient Surgery: Perspectives of Surgical Staff in the Veterans' Health Administration (VA). American Surgeon. In press (2016). 5.Morris MS, Graham LA, Richman JS, Hollis RH, Jones CE, Wahl T, Itani KM, Mull HJ, Rosen AK, Copeland L, Burns E, Telford G, Whittle J, Wilson M, Knight SJ, Hawn MT. Postoperative 30-day Readmission: Time to Focus on What Happens Outside the Hospital. Annals of Surgery. 2016 Oct;264(4):621-31. doi: 10.1097/SLA.0000000000001855. 6.Mull HJ, Rosen AK, Pizer S, Itani K. Association between Postoperative Admission and Location of Hernia Surgery: A Matched Case-Control Study in the Veterans Administration. JAMA Surgery, 2016 Sep 28. doi: 10.1001/jamasurg.2016.3113. [Epub ahead of print] 7.Rosen AK, Chen Q. Measuring Patient Safety Events: Opportunities and Challenges. In: National Quality Measures Clearinghouse (NQMC) [Website]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); [2016 June 13]. Available: http://www.qualitymeasures.ahrq.gov. 8.Borzecki A, Chen Q, Mull, HJ, Shwartz M, Bhatt D, Hanchate A, Rosen AK. Do AMI and HF Readmissions Flagged as Potentially Preventable by the 3MTM PPR Software Have More Process of Care Problems? Circulation Cardiovascular Quality and Outcomes. 2016 Sep;9(5):532-41. doi: 10.1161/CIRCOUTCOMES.115.002509. Epub 2016 Sep 6. 9.Mull HJ, Rosen AK, Charns M, Itani KMF, Rivard P. Identifying Risks and Opportunities in Outpatient Surgical Patient Safety: A Qualitative Analysis of Veterans Health Administration Staff Perceptions. Journal of Patient Safety; In press (2016). 10.Shimada S, Allison J, Rosen AK, Feng H, Houston T. Sustained Use of Patient Portal Features and Improvements in Diabetes Physiologic Measures. Journal of Medical Internet Research; 2016; 18(6):e179. Doi:10.2196/jmir.5663. 11.Sullivan J, Rivard P, Shin M, Rosen AK. Applying the High-Reliability Health Care Maturity Model to Assess Hospital Performance: A VA Case Study. Joint Commission Journal on Quality and Patient Safety; September 2016: Volume 42 (9), 389-399. 12.Elwy AR, Itani KFM, Bokhour B, Mueller N, Glickman M, Zhao S, Rosen AK, Lynge, Perkal M, Brotschi E, Sanchez V, Gallagher T. Surgeons' Disclosures of Clinical Adverse Events. JAMA Surgery; 2016 Jul 20. doi: 10.1001/jamasurg.2016.1787. [Epub ahead of print] 13.Macht R, Rosen AK, Horn G, Carmine B, Hess D. An exploration of system-level factors and geographic variation in bariatric surgery utilization. Obesity Surgery; 2016 Jul;26(7):1635-8. doi: 10.1007/s11695-016-2164-6. 14.Hatoun J, Chan JA, Yaksic E, Greenan MA, Borzecki AM, Shwartz M, Rosen AK. A systematic review of patient safety measures in adult primary care. American Journal of Medical Quality. 2016 Apr 26. pii: 1062860616644328. [Epub ahead of print] 15.Rosen AK, Chen Q, Shwartz M, Pilver C, Mull HJ, Itani K, Borzecki A. Does Use of a Hospital-wide Readmission Measure versus Condition-Specific Readmission Measures Make a Difference for Hospital Profiling and Payment Penalties? Medical Care; 2016(54:2): 155-161. Other Publications (2016): Wagner TH, Gehlert E, Rosen AK, Valenstein M. Updating the Psychiatric Case Mix System (PsyCMS) Mental Health and Substance use Grouper for ICD-10CM. Technical Report 31. Menlo Park, CA. VA Palo Alto, Health Economics Resource Center; August 2016. Conference Presentations (2017) :Strymish J, Jones M, Evans M, Branch-Elliman W, Robillard E, Chan J, Rosen AK, Gupta K. Electronic Detection of MRSA Infections in a National VA Population Augments Current Manual Process. Infectious Diseases Society of America (ID)Week, October 4-8, 2017, San Diego, CA. George J, Parker V,A, Greenan A,, Chan JA, Sullivan JL, Shin MH, Chen Q, Shwartz M, Rosen AK. How do VA Hospitals Determine their Patient Safety Priorities? Assessing Hospital Practices from an Organizational Learning Framework. AcademyHealth Annual Research meeting, June 2017. Chen Q, Rochman A, Amirfarzan H, Rosen AK, Itani K. Can A Surgical Debriefing Process Be Used in Addition to Traditional Incident Reporting to Improve Detection of Intraoperative Adverse Events (IAEs)? A Case Study in the Veterans Health Administration. AcademyHealth Annual Research Meeting, June 2017. Chen Q, Rochman A, Amirfarzan H, Rosen AK, Itani K. Can A Surgical Debriefing Process Be Used in Addition to Traditional Incident Reporting to Improve Detection of Intraoperative Adverse Events (IAEs)? A Case Study in the Veterans Health Administration. Association of VA Surgeons Annual Meeting. May 2017. Rosen AK, O'Brien W, Chen Q, Shwartz M, Itani K, Gunnar W. Trends in the Purchase of Surgical Care in the Community by the Veterans Health Administration. VA National Research Week, VA Boston Healthcare System, May 2017, Boston, MA. Sterbling HM, Rosen AK, Hachey KJ, Vellanki NS, Hewes PD, Rao SR, Pinjic E, FernandoH.C., Litle V.R.. Caprini Risk Assessment Model Implementation Decreases VTE Rates in Thoracic Surgery Cancer Patients. Podium presentation at the Society of Thoracic Surgeons (STS) 53rd Annual Meeting, Houston, TX. January 23, 2017. (Presentations 2016): Rosen AK, Chen Qi, Elwy R, Barnett P, O'Brien W, Itani KFM, Shwartz M. Preliminary Findings on Veterans' Use of Community Care (CC) for Surgery: Pre- and Post-Choice. Care in the Community Conference, August 2016, Arlington VA. Rosen AK, Chen Q, Borzecki A, Shwartz M. Using Harm-Based Weights for the AHRQ Patient Safety for Selected Indicators Composite (PSI-90): Does it Affect Assessment of Hospital Performance and Financial Penalties in Veterans Administration Hospitals? AcademyHealth Annual Research Meeting, June, 2016. Mull HJ, Rosen AK, Charns M, Itani K, Rivard P. Identifying Risks and Opportunities in Outpatient Surgical Patient Safety: A Qualitative Analysis of Surgical Staff Perceptions in the Veterans Health Administration. AcademyHealth Annual Research Meeting, June, 2016, Boston, MA. Mull HJ, Rosen AK, Hawn M, Itani K, Pizer S. Predictors of Hospitalization after Outpatient Surgery in the Veterans Health Administration. AcademyHealth Annual Research Meeting, June, 2016, Boston, MA. Shin M, Rivard P, Shwartz M, Borzecki A, Yaksic E, Stolzmann K, Rosen AK. Educating Hospital Managers about the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs): Lessons Learned in the VA. AcademyHealth Annual Research Meeting, June, 2016, Boston, MA. Greenan MA, Chen Q, Sullivan J, Shwartz M, Shin M, Yaksic E, Chan J, Rosen AK. Development and Implementation of a Tool to Guide Patient Safety in the Veterans Health Administration (VA). AcademyHealth Annual Research Meeting, June, 2016, Boston, MA. Yaksic E, Sullivan J, Chan J, Shwartz M, Shin M, Borzecki A, Greenan MA, George J, Coronel V, Quigly P, Rosen AK. Lessons Learned from Developing an Innovative Data Display to Assist Fall Prevention in the Veterans Health Administration (VA): A Pilot Study at One VA Hospital. AcademyHealth Annual Research Meeting, June, 2016, Boston, MA. Borzecki A, Rao S, Rosen AK, Shwartz M. Assessing the Performance of an Existing Automated Model Identifying Heart Failure Patients at Risk for 30-day Readmission in the VA. AcademyHealth Annual Research Meeting, June, 2016, Boston, MA. Chan J, Shwartz M, Restuccia J, Rosen AK. Improving Performance on Hospital Readmission Rates in the Veterans Health Administration (VA): Organizational FIT and Measure-Based Quality Improvement. AcademyHealth Annual Research Meeting, June, 2016, Boston, MA. Chen Q, Oriel B, Greenan MA, Shapiro M, Amirfarzan H, Mull H, Fisichella P, Itani K, Rosen AK. A Pilot Study to Detect Intraoperative Adverse Events (IAE) and Assess Their Contribution to Postoperative Outcomes. AcademyHealth Annual Research Meeting, June, 2016, Boston, MA. Chan, J, Hatoun J, Yaksic E, Greenan MA, Borzecki A, Shwartz, M, Rosen AK. A Systematic Review of Patient Safety Measures in Adult Primary Care. AcademyHealth Annual Research Meeting, June, 2016, Boston, MA. Mull HJ, Rosen AK, Hawn M, Itani K, Pizer S. Predictors of Hospitalization after Outpatient Surgery in the Veterans Health Administration. 25th Grasberger Research Symposium, May 20, 2016, Boston, MA. Mull HJ, Rosen AK, Rivard P, Pizer S, Itani K. What is the Relationship Between Postoperative Admission and Ambulatory Surgical Center Care Following Hernia Surgery? A matched case control study in the Veterans Health Administration. Association of VA Surgeons, April 9, 2016, Virginia Beach, VA. Mull HJ, Rosen AK, Hawn M, Itani K, Pizer S. Predictors of Hospitalization after Outpatient Surgery in the Veterans Health Administration. Association of VA Surgeons, April 9, 2016, Virginia Beach, VA. Chen Q, Oriel B, Greenan M, Amirfarzan H, Mull H, Fisichella P, Rosen AK, Itani K. Finding Intraoperative Adverse Events and Assessing Their Contribution to Postoperative Outcomes. Association of VA Surgeons, April 9, 2016, Virginia Beach, VA.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
RVR 19-470	Saini	Sameer		Sameer.Saini@va.gov	Reducing Use of Low-Value Services and Enhancing Appropriate Care in the VA Healthcare System	07/01/2019	09/30/2023	VA Ann Arbor Healthcare System, Ann Arbor, MI	$526,962					The 5-year goal of this project is to reduce low-value colonoscopy and to promote evidence-based and Veteran-centered alternatives to colonoscopy (when appropriate), thereby improving access to resource-limited endoscopic services for Veterans who need them.	In the last year, we have continued our work in two focus areas: (1) measuring and reporting overuse of low-value colonoscopy (in conjunction with VHA Office of Analytics and Performance Integration (API) and the National Gastroenterology and Hepatology Program (NGHP) Office); and, (2) promoting FIT-based colorectal cancer (CRC) screening as an alternative to colonoscopy for average-risk Veterans. In the past year we have: 1. Measuring and reporting overuse of low-value colonoscopy: - Published a paper on the impact of COVID-19 on screening colonoscopy overuse in the VA (Adams MA, Kerr EA, Gao Y, Saini SD. Impacts of COVID-19 on Appropriate Use of Screening Colonoscopy in a Large Integrated Healthcare Delivery System. J Gen Intern Med. 2023 Aug;38(11):2577-2583. doi: 10.1007/s11606-023-08233-0. Epub 2023 May 25. PMID: 37231209; PMCID: PMC10212219.) - Continued work to automate the screening colonoscopy overuse measure with the NGHP and VA Endoscopy Quality Improvement Program (VA-EQuIP; Gawron and Kaltenbach). - Presented the overuse measure development and validation work to a joint meeting of CMS Center for Clinical Standards and Quality, VHA, and Department of Defense, which included leaders in clinical quality measurement from across multiple organizations. This presentation has led to ongoing discussions regarding ways in which to implement our measure both within and outside VA to reduce procedural overuse. -Developed a protocol to expand our understanding of how screening use aligns with screening value using more sophisticated analytic methods (e.g., simulation modeling and multi-level modeling). - Connected with health informatics team to assess the feasibility of integrating the screening colonoscopy overuse measure into point-of-care decision support for colonoscopy ordering at the Ann Arbor VA. 2. Promoting FIT-based CRC screening as an alternative to colonoscopy for average-risk Veterans: - Completed our QUERI-VISN Partnered Implementation Initiative (PII) startup project (PII 21-282; PI: Adams) focused on developing and piloting strategies to systematically shift average-risk Veterans from colonoscopy-based to stool-based colorectal cancer screening (considered equivalent guideline-endorsed screening modalities) in two VISN 10 healthcare systems. We conducted preliminary quantitative analysis to evaluate the impact of this initiative on the proportion of colonoscopies performed for screening indications at the two intervention versus two non-intervention facilities in VISN 10.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
RVR 19-471	Grubaugh	Anouk		Anouk.Grubaugh@va.gov	Telehealth Research Collaborative	07/01/2019	09/30/2023	Ralph H. Johnson VA Medical Center, Charleston, SC	$324,604					The goal of the proposed RIVR is to speed mental health research to impact for Veterans through a Telehealth Research Collaborative focused on expanding the use of Clinical Video Telemental health (CVT; i.e., the delivery of telehealth for Veterans in their homes or other private locations by providers located at a distal VA facility) throughout VAMCs nationwide.	(1) 2022Conduct pilot testing of approved products & refine products/methods as needed (local/VISN/Virtual Care CORE): In addition to our other efforts, we have partnered with the HSR&D and Office of Connected Care funded Virtual Care CORE and developed a Telemental Health Research Subgroup with the goals of facilitating collaboration of VA telemental health researchers, sharing strategies for remote consent and data capture, and sharing approved IRB and R&D language to identify best practices. This subgroup met quarterly throughout 2021; in July 2022 the subgroup and associated meeting was subsumed under the VC CORE Telemental Health Group listserv. During FY21 Dr. Myers served as a research lead for the Access workgroup for the VC CORE State of the Art (SOTA) conference. Dr. Myers assisted with planning and presenting at this conference in April 2022 in New Orleans, LA. We began to review the different remote survey (e.g., REDCap, Qualtrics, Survey Monkey) and consenting (e.g., Doximity, DocuSign) packages in FY 1. However, approval of remote data capture programs (e.g., Docusign) were quickly incorporated into research practice due to COVID-19. A centralized location for tele health research information is ongoing through VC Core. (2) With our vast network of partners and leveraging the mutual interests of the Virtual Care CORE'Telemental Health Research Subgroup' we continued to: facilitate collaboration of fellow telemental health researchers across the VA; shared information about different work arounds and best methods used to remote consent and capture data, and shared approved IRB/R&D language within the group (Share point site) (3) Initiate/maintain funding using IIR, other HSR&D, supplemental funds, and/or other federal sources	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
RVR 19-472	Van Houtven	Courtney		courtney.vanhoutven@va.gov	Advancing Measurement of Veteran Function and Independence: Pursuing a Set of Measures Around the Patient Centered Theme of Home Time	07/01/2019	09/30/2023	Durham VA Medical Center, Durham, NC	$514,063					The impact goal of ASPIRE is to build upon our past work on evaluating administrative home time measures (e.g., days alive and not in an acute or post-acute care setting) and advance research methods by developing a person-centered definition of home time that reflects high quality of life and a shared understanding of its clinical utility.	Benchmark 1 of the ASPIRE project, led by Dr. Sperber, uses qualitative methods to learn how Veterans and caregivers value Home Time and relative effect of each of the specific settings of care (e.g., emergency department, inpatient setting, post-acute setting, and long- term nursing home setting) on their quality of life using a ranking exercise. - In Year 1 (FY20), the team successfully submitted materials and received approval from the IRB and obtained feedback from our Veteran Engagement Panel. Activities included completing IRB requirements, presenting in October 2019 the focus group guide and ranking activity to the Veteran and Caregiver Engagement Panel (VetREP), recruiting Veterans and family caregivers (112 letters sent with 34 assessed for eligibility), and conducting staff training and pilot focus groups in December 2019. In Year 1, according to the original benchmark, the team was to complete 6 focus groups (3 caregiver, 3 Veteran). However, in Year 1, the team completed 3 of those focus groups (2 caregiver, 1 Veteran). Because of the suspension of in-person research as a result of COVID-19, the team ended qualitative data collection in Year 1 (February 2020) and aggregated the results of the 3 focus groups for analysis (two family caregiver focus groups which included 9 and 5 participants, one Veteran focus group which included 6 participants). -In Year 2 (FY21), for the 3 focus groups, the team transcribed and analyzed the aggregated focus group data. The team then presented preliminary findings and 1-page Executive Summary to the ASPIRE expert workgroup in October 2020, where a total of 12 researchers, providers, and operational partners attended and provided input. The ASPIRE team finalized the qualitative Aim 1 findings based on expert input and a manuscript was submitted for review March 2021 in Healthcare: The Journal of Delivery Science and Innovation. - In Year 3 (FY22), the ASPIRE team focus group manuscript was published December 2021: "Developing a person-centered, population based measure of home time: Perspectives of older patients and unpaid caregivers" in Healthcare: The Journal of Delivery Science and Innovation. In March 2022, the team met with VetREP to report out on the focus group process and share results with Veteran and Caregiver panel members. Benchmark 2 of the ASPIRE project, led by Dr. Smith, uses quantitative methods to test how definitions of Home Time relate to well-established patient- and caregiver-reported outcomes known to reflect high quality of life. Ultimately, this data will be combined with the Veteran and caregiver definitions (from Benchmark 1) to determine a Home Time measure that is most closely associated with higher quality of life. - In Year 1 (FY20), the team successfully amended the IRB protocol, finalized the 3 existing study cohorts and quality of life measures to test (self-rated health, depressive symptoms, daily physical function, and social support), outlined an initial analysis plan, successfully obtained access to VA administrative data, and began the application process on accessing Medicare data. - In Year 2 (FY21), the team finalized the primary datasets for each of the existing studies and uploaded the cohorts to VINCI in order to access VA administrative and Fee Basis/PIT data as well as CMS data. - In Year 3 (FY22), the team finalized the analytical dataset using a cohort of 570 Veterans from the GeriPACT study (included national sample of community-dwelling Veterans aged 65 and older and existing patient reported outcomes from telephone surveys). VA and Medicare health care utilization (days of care received in the emergency department, inpatient hospital, post-acute care) within the 6 months and 18 months preceding survey completion were used to predict quality of life measures from the survey. The team constructed models resulting in regression coefficients interpreted as relative importance for each type of utilization. In January 2022, the team presented preliminary findings to the ASPIRE expert workgroup, where a total of 11 researchers, providers, and operational partners attended and provided input. The ASPIRE team adjusted the quantitative Aim 2 analysis, data sources (we added MDS data from CMS to capture post-acute facility care utilization for Medicare Advantage Veterans), limitations, and discussion sections based on expert feedback and submitted a manuscript in October 2022 for review in Health Services Research. - In Year 4 (FY23), the Veteran quantitative manuscript was published in June 2023: "Informing a home time measure reflective of quality of life: A data driven investigation" in Health Services Research. The team also conducted analysis of how cumulative time away from home among Veterans influences family caregiver quality of life measures and completed a draft manuscript. Benchmark 3 of the ASPIRE project, led by Drs. Van Houtven and Sperber, involves using a convergent mixed methods design with the Benchmark 1 qualitative and Benchmark 2 quantitative findings that are then integrated using a modified Delphi approach with the ASPIRE expert workgroup. - In Year 4 (FY23), the team invited the ASPIRE expert workgroup to a live presentation in April 2023 of the ASPIRE focus group and quantitative findings of the Veteran quality of life measures. From May to June, the ASPIRE team led three rounds of Delphi voting with the ASPIRE expert workgroup. The first round was individual voting on the home time measure (engaging 20 ASPIRE expert workgroup members), the second round was a live virtual discussion of round 1 results and a continuation of the consensus making process around what settings and weights to include (engaging 12 expert workgroup members). Round 3 was a final review of the proposed Home Time measure and individual re-voting (engaging 16 expert workgroup members). The team iteratively synthesized the Delphi findings and developed a draft manuscript that was submitted for review in November 2023 in the HSR&D special issue of Medical Care. Benchmark 4 of the ASPIRE project, led by Dr. Van Houtven, involves gathering experts to ultimately prepare for a Year 4 State of the Art workshop to build consensus around a Home Time definition and to set future research agendas. - In Year 1 (FY20), the team identified and invited operational partners and HSR&D collaborators outlined in item 4., "Partnerships to the ASPIRE expert workgroup". Dr. Van Houtven invited the experts to attend the first expert meetings in February 2020 (virtual) to provide an overview of the overall project, workgroup member roles, discuss the value of Home Time as a person-centered measure, potential applications, and input on which settings to include. Additionally, the team began to outline a User's Guide for the VA research community on how to access data and use the Home Time measure. -In Year 2 (FY21), the team convened the experts to review Benchmark 1 focus group methods and preliminary themes. Additionally, experts engaged in a structured discussion on potential weights of settings for a Home Time measure and potential implications for healthcare utilization or spending. -In Year 3 (FY22), the team convened the experts to provide input on the quantitative methods and preliminary results. Experts also engaged in a discussion around inclusion of settings (ED, inpatient, and post-acute care) in a Home Time measure and how to incorporate recency and number of episodes to look at other than 'days'. -In Year 4 (FY23), the team set a date for the State of the Art meeting (May 2, 2024) and began agenda planning. The User's Guide continues to be refined, and beta versions have been shared with two Durham ADAPT projects exploring the use of Home Time, one working with Veterans with dementia and the other Gulf War Era Veterans.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
RVR 19-473	Ganz	David		David.Ganz@va.gov	Enhancing Tools and Resources to Improve Coordination of VA Primary Care: A Research to Impact for Veterans (RIVR) Project	07/01/2019	09/30/2023	VA Greater Los Angeles Healthcare System, West Los Angeles, CA	$499,152					The goal of this effort is to foster improved coordination of care within VA primary care teams, between VA primary care teams and Veteran patients, and between VA primary care and other settings (e.g., specialty care, emergency department, hospital, nursing home or care in the community).	1. Dissemination of Primary Care Tools: This benchmark has been achieved. We have presented our care coordination tools on four calls with program office partners, submitted the "Save a Trip" tool to the Diffusion of Excellence "Shark Tank" and were announced as a semi-finalist, and posted information about the "Save a Trip" to the Diffusion Marketplace. The "Save a Trip" tool has had over 850 clicks on its QR codes in the last two years. 2. Provide a central clearinghouse for care coordination tool dissemination: This benchmark has been achieved and is ongoing. The RIVR SharePoint site is active, available and includes three tools (clinic brochure, Save-a-Trip brochure, and medication brochure). Lifetime visits to the site include: - Homepage - 597 - Clinic Brochure tool page - 172 - Save-a-Trip tool page - 263 - Medication Brochure tool page - 96 3. Investigator Support for Primary Care Focused Area Topics: This benchmark has been achieved and is ongoing. We have hosted four Primary Care Research Area meetings between Sept 2020 - Sept 2022 in which investigators have had the opportunity to present their work. In addition, we hosted a fifth meeting in November 2023 to discuss future directions for this focused area.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
RVR 19-475	Cully	Jeffrey		jeffrey.cully@va.gov	Creating Practice-Ready Evidence-Based Psychotherapies for VA Primary Care and Specialty Medical Settings	07/01/2019	09/30/2023	Michael E. DeBakey VA Medical Center, Houston, TX	$532,451					The overall impact goal of this project is two-fold: 1) to transfer research-developed evidence-based psychotherapies (EBPs) into practice-ready EBPs for use in VHA primary care and specialty medical settings within VISNs 16 and 17 and 2) to create a generalizable implementation approach that can be used for future, Veteran-facing EBPs.	EBP #1 Benchmarks The RIVR team refined and redeployed the implementation strategy. The strategy implemented sought to have EBP coordinators serve as regional champions who could help grow and sustain the program within the VISN. We also planned to have the EBP coordinators identify clinicians who could complete the training. With this strategy, we were able to identify 15 clinicians in VISN 16 and 1 consultant. In VISN 8 the EBP coordinator from Puerto Rico agreed to train as a consultant. In addition, 3 providers from Puerto Rico completed the training. When the strategy was implemented in VISN 17, it didn't yield the same results. VISN 17 EBP coordinators didn't appear comfortable to serve in this capacity. Although this strategy didn't yield much benefit in VISN 17, we did have 2 existing champions through the PCMHI (primary care) program that were extremely engaged and successful. In VISN 19 the program is currently led by a strong consultant/champion, so no additional implementation steps were utilized there. Overall from these VISNs there were 44 providers trained in the program this fiscal year. Two of the providers were EBP coordinators and are now serving as champions/consultants at their respective sites (1 from VISN 16 and 1 from VISN 8). In addition, one provider (from VISN 16) originally trained to provide the treatment later agreed to become a consultant and is training providers at her site (Little Rock). In addition to these 3 consultants, there was a clinician trained in the first year of the program that relocated from a facility in VISN 17 to the Kissimmee CBOC in VISN 8. She reached out to the team to inquire about training some of her providers. However, at the time we were not able to accept any new providers, but she agreed to serve as the consultant. She is now training providers at her facility. Another benchmark for the year was to develop a CPRS national note template. We worked with the National Clinical Template Workgroup this fiscal year to finalize the note template. The template was released in September. Since the national release of the template we have seen a tremendous increase in the interest of the program. To meet the new demand, we have created a Teams Page. As of now, we have over 170 members on the channel. Also, due to the release of the template we have been receiving unsolicited requests for trainings from VISNs we had not approached. In the short time the template has been released nationally, we have expanded to an additional 5 VISNs. The total number of facilities that the program is now offered in is over 75. Implementation of the MyBriefCBT program continues to have a positive impact. Since the MyBriefCBT program was implemented in 2020, over 1000 Veterans have received the treatment. Also, these Veterans have received over 3900 sessions of care. EBP #2 Benchmarks Calmer Life intervention has been progressing well also. The initial implementation into VISN 19, in their HBPC occurred during the fiscal year. Initially, there were several providers interested in completing the training but only 1 completed and has started providing the treatment. The program expanded to another VISN 7 at 2 of the South Carolina VA facilities. Two providers from VISN 7 have started the consultation process. We are unable to report any numbers on Veterans currently. We are still in the development phase of the note template and without it, it is difficult to determine the number of Veterans receiving the treatment. The note template should be completed and ready for deployment the beginning of FY24. Once the template is completed, we can begin development of the data dashboard. Practice Ready EBP Implementation Guide Updates to the guide have been made and were used to guide implementation of both interventions. During the fiscal year, other major intervention pieces necessary for implementation were completed. The main training tools, which include our train the consultant and champion training guides were updated. Additionally, we updated marketing materials geared towards educating MH leadership on the program and advocating for their support. VISN 17 champions asked the team to create a veteran facing brochure which was created and distributed in the Summer of 2023.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
RVR 19-477	Perencevich	Eli		eli.perencevich@va.gov	Targeting and Implementing Antimicrobial Stewardship During End-of-Life Care	07/01/2019	11/30/2023	Iowa City VA Health Care System, Iowa City, IA	$525,000					The 5-year goal of this RIVR collaboration is to address the growing public health crisis of antimicrobial resistance through developing, testing and implementing antimicrobial stewardship interventions to reduce unnecessary antimicrobial prescribing during end-of-life care.	The major benchmark for the fiscal year was to implement the Palliative Care dashboard at the Iowa City VA, and we achieved this goal. We were able to implement both a dashboard and an automated version of the Palliative Care (PC) team's daily report (a list of inpatients who either recently received or were in need of a Palliative Care consult). This has been beneficial and timesaving for the Palliative Care team because this report was previously done daily by a member of the Palliative Care team and was created through time-intensive manual data entry. This report is now automated to run daily and is accessible to members of the PC team. We were also able to provide a dashboard, which provides a list of inpatients, their CAN scores, whether they have received antibiotics in the last 24 hours. This has assisted the Palliative Care team in highlighting patients who may benefit from a discussion around antibiotic stewardship.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
RVR 19-478	Pyne	Jeffrey		Jeffrey.Pyne@va.gov	Addressing Barriers to Mental Health Treatment Initiation and Engagement	07/01/2019	09/30/2023	Central Arkansas Veterans Healthcare System , Little Rock, AR	$298,880					To improve linkage to treatment for veterans who screen positive for PTSD or alcohol use disorder but are not engaged in mental health treatment.	We completed the environmental scan, generated CAVHS CBOC catchment area maps and presented these to the CAVHS Chief of Staff, with the help of the Chief of Staff we selected a rural CBOC to work with, presented the project to the CBOC staff and they are willing to participate as partners in this project. We also have a back-up CBOC if needed for recruitment. We hired and trained a peer specialist to deliver the intervention. To date: 16 enrolled, 14 completed baseline assessments, 11 had at least one session with peer specialist, 4 completed 8-week follow-up assessment, 4 have 8-week follow-up pending, 3 are lost to follow-up. The Connect to Care (C2C) intervention includes up to 5 weekly phone calls from a peer specialist. Our goal is for 20 veterans to have at least one session with the peer specialist, summarize the data, present the results to our partners and shareholders, and then decide on next steps.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
RVR 19-479	Sayer	Nina	Kelly Maieritsch	nina.sayer@va.gov	Promoting Effective, Routine, and Sustained Implementation of Stress Treatments 3.0 (PERSIST 3.0)	07/01/2019	09/30/2023	Minneapolis VA Health Care System, Minneapolis, MN	$499,168					To increase the average level of reach of EBPs for PTSD nationally and to reduce the number of VHA PTSD clinics with low rates of utilization of EBPs for PTSD.	We have made progress on all benchmarks and, as per plan, we have completed benchmarks 1, 3, and 4a. Methods developed through prior HSR&D-funded work for measuring CPT/PE reach to patients with PTSD have been integrate into the national PTSD Mentoring Program and are being used both by the PTSD Mentoring Program leadership team and by all 36 VISN level mentors (2 per VISN) to support best practices in PTSD Clinical Teams (PCTs). The PTSD Mentoring Program uses the PowerBI reports we have developed to identify opportunities for quality improvement (PCTs that have low CPT/PE reach or experience a drop in CPT/PE reach) as well as successes to be celebrated. Based on the PowerBI reports, we customize audit and feedback reports for each VISN that are distributed to leadership of each PCT for sharing with facility mental health leadership and CMHOs. Our partners with the PTSD Mentoring Program decided to integrate data on Measurement Based Care (MBC) into these reports to make it easier for the field and facility leadership to integrate data on clinic performance. The PERSIST 3.0 team has also shared data from PERSIST during various field-based meetings (e.g., EBP Coordinators, National PTSD Mentoring Program meeting). As per plan (3), the PERSIST toolkit has been modified for broader use and integrated into the PTSD Mentoring Program's SharePoint site which is used by PCT leads and VISN Mentors. The targets for two benchmarks (4b and 5b) were exceeded. All 36 VISN Mentors are using the PERSIST audit and feedback reports as demonstrated by their communication with the PTSD Mentoring Program leadership and participation in monthly calls involving all VISN Mentors. We are observing sustainable progress: In FY20, 29% of VHAs PCTs met criteria for "low" reach and 35% met criteria for "high" reach. In FY21, 13% of VHA's PCTs met criteria for low reach and 54% met criteria for "high" reach. This improvement was sustained in FY22, with 13% of VHA's PCTs remaining low and 58% being designated as high reach. Our most significant accomplishment in FY22 has been collaboration with the PTSD Mentoring Program on a quality improvement project to improve CPT/PE reach in hard to change low performing teams (5a). We have completed the implementation phase and in FY23 will complete our evaluation. Results from the evaluation will inform future scaling strategies (5c). In FY22, we also collaborated with another RIVR project in a similar area (RIVR 19-475; PI Cully) to identify similarities and differences across our RIVR projects. A manuscript contrasting our projects is under review.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
RVR 19-480	Schmidt	Eric	Alexander Sox-Harris	Eric.Schmidt4@va.gov	Cataloging and Evaluating Mental Health Care Quality Measures for Better Comparative Performance Management	07/01/2019	09/30/2023	VA Palo Alto Health Care System, Palo Alto, CA	$498,328					The goal of this project is to catalogue and evaluate measures for VA to assess and compare the quality of its MH-SUD care to MH-SUD care provided elsewhere.	Scientific Benchmarks Scientific Benchmark 1 (FY2020): Candidate measures identified and prioritized via Delphi panel with Scientific Advisory Panel. We achieved this benchmark. We conducted a systematic environmental scan for quality measures. Of 4,222 measures scanned, we catalogued and characterized 376 unique measures that met our inclusion criteria. We engaged our Advisory Panel in a priority-setting exercise modelled after expert panel methods. This included an initial meeting, a survey on measurement and operational priorities, and then a second meeting to discuss and hone priorities into themes. The top 3 priority area themes identified included: (1) Process and outcome quality of treatment for depressive disorders, (2) Care continuity and engagement in high-risk populations, and (3) Population coverage and access to care for substance use disorders. Scientific Benchmark 2 (FY 2021): Phase 1 validation analyses are begun on highest-priority measure(s). We met this benchmark. We have calculated a quality measure on antidepressant medication management, which falls under Priority Area 1 (see above). Initial reliability analyses are complete, and we are in the planning phase of an analysis to test the predictive validity of this measure among VA patients (patient-level analysis). Scientific Benchmark 3 (FY 2022): Complete Phase 1 core validation analyses, draft Phase 1 reports of results. We met this scientific benchmark. We published results from our study under Scientific Benchmark 1 in Psychiatric Services. We completed reliability and validity testing on the antidepressant medication management measure from Priority Area 1. Our analyses indicated the measure is reliable but may have poor predictive validity. We have now further confirmed our initial observation about important patterns of racial/ethnic disparity using the measure, but, oddly, not in receipt of other indicators of evidence-based antidepressant treatment (e.g., receipt of clinically indicated follow up). Unfortunately, the editors of Psychiatry Research kept our paper for 7 months in FY2023 without providing a peer review. We since rescinded that submission, and this paper is now under review at Health Services Research. From Priority Area 2 (engagement in high-risk patients), we published a study in Psychiatric Services on VA's rollout of a follow up after mental health hospitalization quality measure, during which VA achieved significantly higher rates of patient engagement nationally. We are also preparing to submit a second study demonstrating associations between VA's follow up measure and lower mortality - indicating strong predictive validity of VA's follow up after hospitalization measure. Of note, in FY23 these pre-publication findings were presented to Dr. Gerard Cox, Asst. Under Secretary for Health for Quality & Patient Safety, to inform executive governance of his QPS Enterprise Level Measure Set. Scientific Benchmark 4 (FY 2023, Current Year): Scientific: Conduct high-priority Phase 2 validation and related analyses. We are on track to meet this benchmark in FY2024. The mid-term Advisory Panel (see Impact benchmark 3, below) strongly recommended that we calculate and evaluate a quality measure that can be used to compare VA's purchased care services with those VA provides to Veterans directly. We selected a measure from Priority Area 2, care continuity in high-risk populations, given VA's exceptional direct care performance on those quality measures. Aligned with our charge, this measure is also relevant to VA/non-VA comparisons with external agencies (e.g., Medicare and Medicaid). We were significantly delayed in FY23, however, by the PIT data corruption issues that onset in February and persisted since. Nonetheless, we obtained access to the IVC office's new datasets for analyzing purchased care claims, and we have calculated initial performance on CMS' new Follow Up after Psychiatric Hospitalization measure, among Veterans discharged from VA or purchased care hospitals. We are on track by the end of our award period to complete analyses to inform recommendations for/against using this measure in operational programming at VA. Impact Oriented Benchmarks Impact Oriented Benchmark 1 (FY 2020): Scientific Advisory Panel established. We met this benchmark. Our Advisory Panel includes 14 scientists, health care operations specialists, and clinicians who are expert in VA health care delivery. Individual panel members and their contributions so far are described above in the Partnerships and Scientific Benchmark sections, respectively. Impact Oriented Benchmark 2 (FY 2021): Interface with agencies in measurement science or that are publicly reporting on MHSUD care quality. We met this benchmark in FY2022. In 2021, we combined FY 2021 and 2022 goals for this benchmark. We interfaced with groups at Centers for Medicare and Medicaid Services and the Department of Defense. We presented multiple findings to quality measurement groups with relevance to VA, for example, our measure cataloguing results as well as findings from Priority Area 1 and 2 studies (described above). Impact Oriented Benchmark 3 (FY 2022): Hold midterm Scientific Advisory Panel meeting, assess progress on impact goal to affect VA public reporting. We met both benchmarks. We held a successful midterm meeting this FY with our advisory panel. The panel was supportive of our intention to redirect focus from risk adjustment to work defining a pathway to evaluate purchased care quality. Specifically, the panel meeting resulted in a recommendation that we focus on Phase 2 on Priority Area 2 (engagement in high-risk patients) and on purchased care. Our group has met our impact goal this year as well by helping to broker an agreement between the Office of Mental Health and Suicide Prevention and Analytics and Performance Integration to (1) avoid reporting publicly VA's performance on the antidepressant medication management quality measure, and (2) develop and report publicly on follow up after hospitalization. Impact Oriented Benchmark 4 (FY 2023, Current Year): Establish Phase 2-related collaborations with broader HSR&D and VA scientific community (explore related funding proposals). We are on track to meet this goal. Highlights of collaborations we explored or secured in FY23 include: adding Dr. Kenneth Nieser (HSR&D Fellow) to our team and supporting his emerging measure science program, and fostering potential collaborations with Dr. Megan Vanneman (HSR&D Career Awardee, VA Scientist) around measurement science relevant to emerging VA vs. non-VA reporting needs at the enterprise level.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
RVR 19-481	Slatore	Christopher	Denise Hynes	Christopher.Slatore@va.gov	Patient-Centered Decision Support for Veterans Making Choices About Where to Get Their Health Care: "Should I Stay or Should I Go"?	07/01/2019	09/30/2023	VA Portland Health Care System, Portland, OR	$318,395					The goal of our proposal is to increase the ability of patients to make informed decisions that incorporate their individual values and preferences about the potential benefits, harms, and burdens of choosing between direct VHA care vs. community care.	In fiscal year 2022, we met our benchmarks in dissemination, integration of aims, and manuscript writing. We presented both our quantitative and qualitative findings to members of the office of community care such as Dr. Clinton Greenstone, and to national partners such as Dr. Joe Francis, the Executive Director of Analytics and Performance Integration at the VHA, and Caitlin O'Brien, Senior Advisor of Analytics and Performance Integration. To integrate our aims in 2022, we have worked on a comprehensive white paper describing, comparing, and contrasting our quantitative and qualitative aims. We discuss reasons for findings and how the two types of data complement one another. Additionally, we are using our established qualitative findings to support or explain our quantitative findings in current analyses. To achieve our manuscript benchmark, we currently have two qualitative papers and one quantitative methodology paper under review for publication. Additionally, we are preparing the previously mentioned white paper for dissemination and eventually publication, as well as a quantitative paper focusing on the barriers and facilitators for Veterans getting care in the community that will be submitted for publication in the coming months.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
RVR 19-482	Mills	Whitney		Whitney.Mills@va.gov	Research Impacting Veterans Using LTSS and Experiencing Transitions (RIVULET)	07/01/2019	09/30/2023	Providence VA Medical Center, Providence, RI	$518,986					The impact goal for the RIVULET project is to 1) build a LTSS research network and 2) understand and improve transitions between providers in the LTSS system.	Benchmark 1: Develop a Shared Research Agenda This work is complete. Benchmark 2: Implement the VA LTSS Research Network We continue to maintain the infrastructure for the VA LTSS Research Network, hosting monthly meetings, regular newsletter, and supporting the workgroups collaboration efforts. We also maintain a sharepoint site which contains archives of past presentations/newsletters, recently published VA LTSS research, and updates. Our membership continues to grow (over 300 members currently), and we continue to draw in new presenters and build our relationship with operations partners (GEC). We have hosted requested presentations where GEC officials discussed expectations for allowing GEC to review papers prior to publication, which was well received by both researchers and GEC officials. We also are embarking on a new relationship with the Office of Nursing Services to further support collaborations between non-clinical researchers, nurse researchers, and nurses in the field interested in LTSS. Dr. Mills will be presenting to the Nursing Science Collaborative in the new year in support of this mission. Benchmark 3: Describe Variability in LTSS Transitions and Benchmark 4: Build Model to Identify Veterans at Risk for Transitions Benchmarks 3 and 4 are now intertwined, so we will report on them together. The goal of these benchmarks is to identify high risk Veterans and test interventions to improve likelihood for Veterans to age in place. The RIVULET team was instrumental in creating a dashboard to identify at risk Veterans. The dashboard is now being implemented and it focuses on creating a list of Veterans at the highest risk for nursing home placement within the next two years. GEC is leading the efforts to implement the second phase of this work with support from the RIVULET team. Within the next year, the second part of the project is expected to kick off. During this phase, a geriatric coordinator will contact Veterans on the list and work with the Veteran and their caregiver(s) to proactively assess needs to arrange additional home and community-based care services as warranted. The study will examine outcomes related to nursing home placement, caregiver burden, hospitalization rates, and emergency room visits. As COVID disrupted initiation of this work, we will likely not have key outcomes to report prior to the end of the RIVULET funding. Benchmark 5: Prepare Report on RIVULET Activities and Outcomes Dr. Mills has prepared a report on the RIVULET's activities each year, which is presented in the fall to the VA LTSS Research Network. We will continue to document our activities and achievements and present them annually. Benchmark 6: Disseminate RIVULET Impacts through LTSS Research Network This year we hosted a field meeting focused on one of the areas identified in our research agenda - mental health and suicide prevention among older Veterans. The LTSS Research Network has been providing administrative support for a group of researchers in this area for 3 years ahead of this meeting. The 2-day meeting included talks from several operations partners including representatives from the Office of Geriatrics and Extended Care, the Office of Mental Health and Suicide Prevention, and research portfolio managers. The attendees discussed challenges and opportunities to expand research in this area and identified potential collaborations for future grant submissions later in FY 24. Many of the attendees also collaborated on a systematic review paper on suicide risk in older Veterans, which was published earlier this year. We intended to host a second workgroup focused on CLC research, but the unexpected death of the national Director of Facility Based Care in GEC derailed these plans.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
RVR 19-483	Halwani	Ahmad		ahmad.halwani@va.gov	Promoting Safe and Effective Use of Health Information Technology (HIT)	08/01/2019	09/30/2023	VA Salt Lake City Health Care System, Salt Lake City, UT	$544,704					Provide enhanced informatics tools to improve the quality, productivity and efficiency of tele-oncology clinical care processes and outcomes in alignment with VISN and VA National Oncology Program priorities and directives.	Extend the scope of the BGSOE system to provide systematic needs assessment Evaluate usability and perceived value of the BGSOE HIS and population level impact of BGSOE and VACARES The BGSOE HIS was extended successfully to include a section that allows BGSOE navigators to perform a systematic needs assessment of Veteran clinical care and needs. Veterans with unmet needs regarding care coordination are therefore prioritized for support by the program. Usability and perceived value of the BGOSE tool was performed. Eight users underwent a structured usability assessment with a validated instrument. The BGSOE HIS was shown to have high usability and associated with high user satisfaction. A paper is in progress describing the HIS development and evaluation.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
RVR 19-484	Gray	Kristen		Kristen.Gray2@va.gov	Evaluating and Enhancing Women's Health Care Quality through the Cerner Transition	07/01/2019	10/01/2023	VA Puget Sound Health Care System Seattle Division, Seattle, WA	$355,831					The purpose of this study is to examine the impact of VA's electronic health record modernization (EHRM) on women's health care coordination and use data from early-transitioning sites to facilitate EHRM in women's health care at later-transitioning VA sites.	-Given the fact that EHRM and Cerner deployments continue to shift (and VA Puget Sound still has no official "go live" date), we have continued to pivot in response to availability of data and the needs of our operational partners. -In the prior fiscal year (2021), we had successfully added and interviewed staff at two new VISN20 study sites (Boise and Roseburg), which got scheduled to transition to Cerner prior to VA Puget Sound. We completed pre-EHRM interviews with staff at both of those sites. Of our three project sites (VA Puget Sound, Boise, and Roseburg), only Roseburg has transitioned to Cerner to-date, and they did so late enough in fiscal year 2022 that it has not been feasible to collect post-EHRM data from them as part of this project. -As discussed in past reports, in 2021, we also gained additional rapid pilot funding to explore mammogram care coordination barriers and facilitators with an additional 7 sites. In fiscal year 2022, we completed analyses of both the pre-EHRM interviews for RIVR VISN 20 sites and the related mammogram-focused interviews from the PROVEN rapid pilot project. -Subsequently, we have conducted many dissemination activities including: presenting findings to the Office of Women's Health; presenting to the HSR&D PROVEN MPIs; presenting an HSR&D national Cyberseminar with operational partners in Office of Women's Health; and presenting findings to a high-level, national mammogram process improvement workgroup which included leadership from Office of Women's Health, Radiology, and the Office of Community Care. We also submitted a manuscript describing barriers and facilitators to mammogram care coordination to journal Women's Health Issues, which is in press. As a result of our Cyberseminar, we were also approached by one VISN and one individual VA health care system to present to multidisciplinary teams at those sites about our findings. Finally, we also disseminated findings to all study participants, which included staff involved in women's health care coordination at 10 VA sites. -Our RIVR funding was not renewed to continue investigations of post-EHRM changes in care coordination.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
SDR 10-012	Yano	Elizabeth	Susan Frayne, Alison Hamilton	Elizabeth.Yano@va.gov	Women's Health Research Consortium/Practice-Based Research Network	06/01/2010	03/31/2022	VA Greater Los Angeles Healthcare System, Sepulveda, CA	$11,692,148	https://www.hsrd.research.va.gov/centers/womens_health/whrn.cfm		Women's Health	WHRN supports training (direct, web-based, and cyber-seminars), technical consultations (including pre-submission scientific review, access to a professional network of experts), collaborative research development (through national topical work groups), and dissemination support (cyber-seminars, conferences, journal supplements, training) for a national Consortium of VA investigators. The Consortium also supports HSR&D as a clearinghouse and synthesizer of WH research (e.g., web summaries, briefings). The PBRN provides PI technical support in use of the PBRN and trains Site Leads to engage local clinicians, managers and staff in the conduct of multisite research. The PBRN also conducts practice scans (brief key informant organizational surveys) and card studies (assessments of WVs' preferences/experiences). Regular calls among PBRN Site Leads promote collaboration and cross-site learning. Qualitative interviews with WV patients, WH providers, VA leaders, and VA researchers have also been conducted to better understand the conceptual and practical tenets underlying multilevel stakeholder engagement needed to strengthen VA WH intervention capabilities, implementation readiness and spread using evidence-based quality improvement (EBQI), which is now being applied to the PBRN with Consortium and engagement training plans underway.	WHRN's current objectives are to: (1) enable conduct of high-quality, progressively actionable WH research, inclusion of WVs, and more systematic analyses of gender differences; (2) further advance VA capabilities for practice-based research, innovation development, evaluation, and implementation using learning healthcare system and multilevel stakeholder engagement principles; and (3) promote multilevel stakeholder engagement in Consortium and PBRN activities and in VA WH research more broadly.	WHRN has supported advances in employee and Veteran engagement in the context of the learning healthcare system initiative and VA priorities and informed the strategic direction for VA WH research, both in terms of identifying evidence gaps requiring research attention (e.g., for under-studied conditions with high prevalence or equity gaps for women) and pushing the boundaries of methodologic frontiers (e.g., multilevel engagement, diffusion, implementation and spread of best practices). WHRN's impacts led to its explicit integration in the Blueprint for Excellence as essential to accelerating innovations in women's health care, high-level briefings, partnerships with critical partners within and outside the VA (e.g., NIH Office of Research on Women's Health), and a community of practice and network capable of accelerating the generation and implementation of evidence for practice and policy. WHRN-informed work has led to a national VA culture campaign, gender-tailored care models and interventions, knowledge about community care needs driving policy, greater inclusion of women in VA research, and increased awareness of women Veterans' health and healthcare needs, recognized by the highest levels of VA leadership, Veteran Service Organizations, and external agencies. WHRN operational partnerships have also grown substantially, as we work with national program offices to generate rapid data for use in policy and planning (e.g., Office of Patient-Centered Care & Cultural Transformation, LGBT National Program Office) and networks and facilities to feedback data to inform regional and local improvements. Long-term goals are to extend HSR&D's ability to support research-driven improvements in practice and policy in increasingly agile ways and to improve system capacity for addressing gender differences in Veterans' health and health care through learning healthcare system principles in action.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
SDR 18-148	Gawron	Andrew	Tonya Kaltenbach	andrew.gawron@va.gov	Improving Colonoscopy Quality for Colorectal Cancer Screening in the National VA Healthcare System	02/01/2018	09/30/2022	VA Salt Lake City Health Care System, Salt Lake City, UT	$1,148,475		Project Summary / Abstract Colorectal cancer (CRC) prevention is a top VA priority. Colonoscopy is a primary CRC screening modality with >200,000 VA colonoscopies performed each year. The effectiveness of screening colonoscopy in CRC prevention relies on its quality. The adenoma detection rate (ADR), the proportion of screening colonoscopies in which one or more adenomatous polyps are detected, is the primary benchmark for inspection quality during colonoscopy. Increased ADR correlates with a lower risk of CRC incidence and mortality in large studies. A recent Office of the Inspector General (OIG) report highlighted colonoscopy quality deficiencies in the VA, and strongly recommends that the “Acting Under Secretary for Health require standardized documentation of quality indicators based on professional society guidelines and published literature.” Currently, VA cannot easily measure or report quality, because colonoscopy quality measures are not readily available from colonoscopy procedure or pathology notes in either VA’s electronic health record or in structured VA data in the VA Corporate Data Warehouse (CDW). Thus, VA cannot currently ensure Veterans receive high quality colonoscopy for colon cancer prevention. We have developed the novel infrastructure and solution to directly address the OIG recommendations and VA’s critical need to implement evidence-based nationwide colonoscopy quality measurement and reporting. The specific aims of this service directed research proposal are: Aim 1: To determine if implementation of a personalized colonoscopy quality report card and video training program improves adenoma detection rates compared to a video training program alone. Aim 2: To evaluate adoption and identify barriers, facilitators, and clinical practice changes associated with adoption of a personalized colonoscopy quality report card and video training program. We have created a novel operational database of colonoscopy procedures and linked pathology notes, validated natural language processing pipelines to extract colonoscopy procedure and pathology data, and developed a quality reporting infrastructure that visually presents biannual and cumulative colonoscopy quality metrics to VA sites and providers. The report card provides comparison metric data at the local site and national level. We plan to use four existing VA colonoscopy quality webinars for baseline education followed by report card implementation. We will conduct a prospective, multi-center, stepped wedge cluster randomized trial to determine the efficacy of our report card intervention on overall ADRs and provider-level ADRs. We will also use a mixed-methods approach to evaluate the intervention in a multi-faceted manner to evaluate adoption as the primary implementation outcome. We are powered to detect and expect improvements in ADR of at least 1% for providers. This effect is clinically important, because a 1% increase in ADR is associated with a 3% decrease in risk of incident CRC, and a 5% decrease in risk of fatal interval CRC. The critical next step will be to provide access to more intensive interventions for very low performing providers who do not improve after implementation of standardized quality reporting. A directed hands-on training program is being developed through partnerships with the National GI Program Office and SimLEARN center to improve providers who demonstrate refractory colonoscopy quality deficiencies.	Healthcare Informatics				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
SDR 18-150	Iverson	Katherine	Christopher Miller	Katherine.Iverson@va.gov	Addressing Intimate Partner Violence Among Women Veterans: Evaluating the Impact and Effectiveness of VHA's Response	11/01/2019	09/30/2022	VA Boston Healthcare System Jamaica Plain Campus, Jamaica Plain, MA	$1,187,165		Background: Intimate partner violence (IPV) is common among women Veterans (WVs), with nearly 20% of WVs treated in Veterans Health Administration (VHA) primary care clinics experiencing past-year IPV. VHA’s Women’s Health Services (WHS), the IPV Assistance Program, and the Offices of Primary Care and Mental Health and Suicide Prevention developed recommendations for implementing IPV screening programs in primary care. More than two-thirds of WV primary care patients receive care in “Model 1” (i.e., mixed-gender primary care) and “Model 2” (i.e., separate but shared space) clinics, but uptake of screening is low in these clinics. WHS therefore plans to use Blended Facilitation (BF) to roll out IPV screening programs in Model 1 and Model 2 primary care clinics. Given the high number of these clinics throughout VHA, it is unclear whether resource-intensive BF is feasible and whether a less intensive strategy (i.e., toolkit + Implementation as Usual [IAU]) can be effective. Research is also needed on the clinical effectiveness of IPV screening programs. Significance/Impact: Given the high prevalence of IPV among WVs and its significant health effects, successful implementation of IPV screening programs is expected to improve healthcare services and reduce morbidity among WV VHA patients, an HSR&D priority area. Innovation: This study will be the most comprehensive evaluation of both the implementation impact and clinical effectiveness of IPV screening programs globally. It is innovative in its inclusion of four strong VHA operations partners dedicated to successful implementation of IPV screening programs. This project capitalizes on a time-sensitive opportunity to advance IPV screening programs and implementation science. Specific Aims: This objective of this proposal is to comprehensively evaluate two strategies for implementing IPV screening programs through achieving three specific aims. (1) Evaluate the degree of reach, adoption, implementation fidelity, and maintenance achieved using two implementation strategies for IPV screening programs. (2) Evaluate the clinical effectiveness of IPV screening programs, as evidenced by disclosure rates and post-screening psychosocial service use. (3) Identify multi-level barriers to and facilitators of IPV screening program implementation and sustainment. Methodology: We propose a cluster randomized, stepped wedge, Hybrid Type II program evaluation design to compare the impact of two implementation strategies (BF + toolkit vs. toolkit + IAU) and the clinical effectiveness of IPV screening programs. We propose a mixed methods approach to collect quantitative (clinical records data) and qualitative (key informant interviews) implementation outcomes (Aims 1 and 3), as well as quantitative (clinical records data) clinical effectiveness outcomes (Aim 2). We will supplement these data collection methods with surveys to assess implementation strategies survey to be completed pre-BF, post-BF, and in the maintenance phase. The integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework will guide the qualitative data collection and analysis. Summative data will be analyzed using the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) Framework. Next Steps/Implementation: Our four VHA operations partners are eager to use our study results to inform future implementation strategies and clinical practices to spread IPV screening programs to all VHA primary care clinics and other clinical settings so that this vital intervention is accessible to all WV VHA patients.	Women's Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
SDR 18-319	Mattocks	Kristin		kristin.mattocks@va.gov	Understanding Network Adequacy and Community Engagement in Veteran Care	10/01/2018	09/30/2023	VA Central Western Massachusetts Healthcare System, Leeds, MA	$1,112,986		In response to highly publicized concerns regarding Veteran deaths and Veterans’ access to care in the Veterans Health Administration (VHA), Congress enacted the Veterans Access, Choice and Accountability Act (VACAA) in 2014 to establish the Veterans Choice Program (VCP) and expand the availability of community care for eligible Veterans. Since its inception, VCP has grown considerably, comprising nearly half a million providers, and Veterans using VCP now account for represents 17% of all users of VHA care. Due to the recency of VCP implementation, research on its impacts is limited but highlights issues with inadequacies of community provider networks to meet Veterans’ healthcare needs. Simultaneously, Veterans have also not been given access to information regarding VCP provider networks and can be uncertain of which providers are available to them. As a result, further investigation is needed to better understand how Veterans receive information regarding community care and how this information informs their decision to seek VA-purchased community care. This is required in conjunction with a concerted effort define, measure, and evaluate network adequacy for non-VA community care networks. Taken together, these steps will ensure that the needs of Veterans carefully assessed and appropriate standards are developed to meet the healthcare needs among Veterans seeking and requiring non-VA community care. This project will use a mixed methods design to identify healthcare market, medical center, Third Party Administrator, and Veteran characteristics and preferences that support or impede network adequacy and therefore, Veterans’ access to care. We will use quantitative methods to leverage standardized national data and processes combined with qualitative methods to account for individual VA medical center contexts and Veteran preferences. Using this design, the project will complete three main objectives. The first objective of this study is to develop and validate measures of network adequacy for non-VA community care and evaluate regional variations in network adequacy across VAMCs and VA’s 98 markets. Relatedly, the project seeks to examine the process by which Community Care decisions are made at individual VA facilities, and to identify existing and potential opportunities to expand community partnerships to deliver Community Care. The project will also interview Veterans regarding Community Care, including preferences for a network directory of providers and quality ratings of providers to more completely understand their perspectives on Community Care. These objectives have important implications for VHA healthcare and the development of strong community networks and connections between VHA and surrounding community providers to provide quality healthcare to Veterans. As a result, this study team and project will address an important priority with VHA and, in the long-term, improve community services for Veterans who receive care in the VHA.	Health Care Organization and Implementation				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
SDR 19-327	Garrido	Melissa		melissa.garrido@va.gov	Community Care/Mission Act Virtual Research Network	02/01/2019	09/30/2023	VA Boston Healthcare System Jamaica Plain Campus, Jamaica Plain, MA	$490,260			Systems Modeling, Design, and Delivery				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
SDR 19-328	Garrido	Melissa		melissa.garrido@va.gov	Access Core	02/01/2019	09/30/2023	VA Boston Healthcare System Jamaica Plain Campus, Jamaica Plain, MA	$491,472			General HSR				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
SDR 19-443	Pittman	James		james.pittman@va.gov	Effectiveness and Implementation of eScreening in Post 9/11 Transition Programs	10/01/2020	06/30/2024	VA San Diego Healthcare System, San Diego, CA	$1,055,700		Background: Veterans disproportionately account for to 22% of all known suicides in the US. Screening for suicide risk at the first contact with an organization is a best practice in the national Zero Suicide framework and vital to enhancing access to appropriate care. Transition Care Management (TCM) programs are positioned to screen post-9/11 Veterans at the critical moment of enrollment in healthcare. Unfortunately, many Veterans who present for the first time in VHA with recent suicidal thoughts do not receive same day suicide risk evaluation (SRE), partly due to cumbersome screening processes. eScreening is a web-based Gold Standard Promising Practice electronic screening system with real-time scoring and integration into CPRS/VistA. Our eScreening effectiveness pilot in 1,372 post-9/11 Veterans and our 2-site multicomponent implementation strategy (MCIS) pilots showed increase speed and rate of SRE and sustainment of eScreening in two pilot sites. More research is warranted to test both. Significance/Impact: This proposal responds to HSR&D Priority Areas of: Suicide prevention, Increasing the real-world impact of research, and Implementation science. Our data will inform best practices in suicide prevention through early identification. This project will also allow for real-world integration of research into practice and inform implementation efforts for technology. Innovation: eScreening is a unique program developed with feedback from Veterans. To our knowledge, this is the first study to integrate VHA developed mobile patient-report screening technology to improve screening in TCM programs. It is also the first to examine the impact of electronic screening on rates of suicide risk evaluation and referral to care. Specific Aims: Aim 1. Evaluate the effectiveness of eScreening, compared to paper and verbal screening, on rate and speed of screening completion (suicide screening & evaluation, PTSD, depression, alcohol) and referral to mental health care in 8 TCM programs, using a stepped wedge design. Aim 2: Evaluate the implementation, scalability, and sustainability of the eScreening MCIS, guided by RE-AIM. We will also document and calculate replication costs across sites. Aim 3. Use comparative case analysis to compare high and low eScreening adopters, exploring factors influencing the implementation of eScreening and the impact of the eScreening MCIS, using PRISM constructs. Methodology: We propose an 8 site 4-year stepped-wedge mixed-method Hybrid Type 2 pragmatic trial to compare eScreening to screening as usual while evaluating a MCIS in the site’s TMC program. Aim 1 outcomes will be collected via deidentified chart pull at the start and end of the 9-month intervention period and 9-months post intervention. Aim 2 outcomes will be collected quantitatively from TCM staff questionnaires and qualitatively from interviews. Aim 3 data will be collected at the same intervals as Aim 2. Next Steps/Implementation: We will use the findings of this research to inform suicide prevention early identification best practices and enterprise scale-up of eScreening with our VACO partners.	Mental and Behavioral Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
SDR 20-353	Hausmann	Leslie		leslie.hausmann@va.gov	Developing Cross-Sector Collaborations to Meet the Social Needs of Veterans	06/01/2021	12/31/2024	VA Pittsburgh Healthcare System University Drive Division, Pittsburgh, PA	$201,993		A VA HSR&D-funded multi-stakeholder workgroup identified ways in which research could support the VA’s goal of addressing Veterans’ unmet social needs. The workgroup identified the siloed nature of VA, the lack of effective models for finding and connecting VA patients with non-VA social services, and insufficient evidence on the health impact of healthcare-based social needs interventions as three barriers that could be addressed by research. This mixed methods pilot study will begin to address these gaps by building partnerships between the research team, relevant VA program offices, and an organization that has been developing multi-sector networks to increase Veteran access to health and social services since 2015. Through their AmericaServes Initiative, the Institute for Veterans and Military Families (IVMF) builds coordinated networks of public and private organizations to support Veterans. Their breadth of services, wraparound care coordination approach, and military-centric focus make AmericaServes a promising collaborative for VA medical facilities to join to increase Veteran access to non-VA social services. Despite the potential benefits, preliminary analyses of AmericaServes client data and communication with IVMF, the Veterans Experience Office, and other VA program offices, indicate wide variation in whether and how VA medical facilities participate in AmericaServes Networks or similar collaboratives. The impact of such participation on Veteran health-related outcomes is also unknown. The overall objective of this research is to grow the evidence base needed to guide participation of VA medical facilities in collaboratives such as AmericaServes. As a critical first step, this project will identify how VA medical facilities currently participate in AmericaServes Networks and factors that impede or facilitate collaboration across organizations. The project will also establish link AmericaServes and VA administrative data to identify areas of opportunity for increased collaboration and lay the groundwork for determining the impact of such collaboration on Veteran health-related outcomes in future studies. The project has three specific aims. Aim 1 is to characterize the level of, as well as the barriers to and facilitators of, formal and informal participation of VA medical facilities in AmericaServes Networks. Guided by Himmelman’s Developmental Continuum of Change Strategies for inter-organizational collaboration, the team will conduct semi-structured interviews with key informants from a sample of AmericaServes Networks and VA medical facilities. Rapid qualitative analysis will be used to compare the barriers to and facilitators of different levels of participation. Aim 2 is to identify the number, percentage, and characteristics of AmericaServes clients who also receive services from VA medical facilities. AmericaServes data on all 2019 AmericaServes clients will be merged with sociodemographic and clinical data from VA administrative data sources to identify Veterans served by both organizations. Demographic, clinical, and service utilization characteristics of Veterans in the overlapping group will be compared with Veterans served only by VA or only by AmericaServes. Aim 3 is to develop stakeholder-informed recommendations to guide participation of VA medical facilities in community-based social service networks (e.g., AmericaServes). Joint displays will be used to integrate and summarize findings from the qualitative (Aim 1) and quantitative (Aim 2) analyses of VA participation in AmericaServes Networks. Findings will be discussed with a Stakeholder Engagement Panel including representatives from IVMF, VA program offices, and Veterans from Community Veteran Engagement Boards. These discussions will be used to identify areas of opportunity for increased collaboration across organizations and to develop recommendations to guide future participation of VA medical facilities in community- based social service networks. The partnerships, findings, and recommendations from this pilot study will inform future observational and experimental studies examining the impact of working with community-based social service networks to connect Veterans in VA medical facilities to non-VA social services on Veteran health.	Equity				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
SDR 20-361	Navathe	Amol		Amol.Navathe2@va.gov	Racial Bias in a VA Algorithm for High-Risk Veterans	02/01/2021	09/30/2024	Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA	$987,914		PROJECT SUMMARY African-American Veterans are at particular risk of adverse outcomes, including mortality and hospitalization, due to adverse social determinants of health (SDoH) including poor transportation access and housing instability. Identifying individuals at risk of adverse outcomes has been a priority at the Veterans Health Administration (VA), which has implemented novel predictive analytic tools in clinical care settings to target care resources efficiently and equitably. The VA has invested an average of 5% of total VA spending towards health information technology to support such algorithms. One predictive algorithm implemented nationwide and commonly used by VA clinicians is the Care Assessment Needs (CAN) score, which predicts risk of future hospitalization and/or death for over 5 million Veterans receiving primary care. The CAN score is currently used by patient-aligned care teams (PACTs) and nurse care navigators to direct clinical programs and resources, including telehealth, palliative care, and home-based primary care, to high-risk Veterans. The CAN score is primarily based on laboratory, demographic, utilization, and other administrative data. Recent studies have shown that similar algorithms used in non-VA settings may mischaracterize risk for vulnerable patient subgroups – including African-Americans – whose health is heavily influenced by disproportionate exposure to adverse SDoH. Importantly, race and SDoH are not routine inputs into the CAN score. There is a growing concern that algorithms like the CAN score could generate “algorithmically unfair” predictions that systematically mischaracterize risk for subgroups – particularly African-Americans – whose care is heavily influenced by SDoH. However, there has been no systematic investigation into unfairness of the CAN score between African-American and White Veterans. In this project, we will systematically examine algorithmic unfairness in the VA CAN algorithm and develop approaches to mitigate it, including testing the incorporation of SDoH metrics. Our preliminary investigations into the CAN score show that it underestimates risk for African-Americans compared to White Veterans, which may lead to fewer referrals of high risk African-American Veterans to clinical programs. In Aim 1, we will develop methods to mitigate algorithmic unfairness in the CAN score using its existing variables. In Aim 2, we will incorporate race and select metrics of SDoH that are available through VA screening efforts into the CAN score to improve algorithmic unfairness. In Aim 3, we will use the “Fair” CAN score generated in Aim 2 to investigate how mitigating unfairness would change the racial composition of Veterans enrolled in clinical programs targeted at high-risk Veterans.	Equity				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
SDR 20-390	Mattocks	Kristin	Denise Hynes, Michelle Mengeling, Amy Rosen, Megan Vanneman	kristin.mattocks@va.gov	Community Care Research Evaluation and Knowledge (CREEK) Center	07/01/2020	09/30/2024	VA Central Western Massachusetts Healthcare System, Leeds, MA	$629,590	https://www.hsrd.research.va.gov/news/research_news/creek-051820.cfm		Health Care Organization and Implementation				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
SDR 20-390-A	Gurewich	Deborah		deborah.gurewich@va.gov	Examining the Impact of the MISSION Act on Disparities in Access to and Utilization of Primary Care	06/01/2022	09/30/2025	VA Boston Healthcare System Jamaica Plain Campus, Jamaica Plain, MA	$97,558			Health Care Organization and Implementation				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
SDR 20-390-C	Rose	Liam		liam.rose@va.gov	Intended and Unintended Consequences of the MISSION Act for Medicare-Eligible Veterans	07/01/2022	10/31/2025	VA Palo Alto Health Care System, Palo Alto, CA	$99,872			Healthcare Informatics				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
SDR 20-390-D	Garvin	Lynn		Lynn.Garvin@va.gov	Incorporating Virtual Care into VA Care Options to encourage Veterans to Remain in VA Care: Evaluating Veteran Attitudes and Intentions toward VA And Community care Across Multiple Services	10/01/2022	09/30/2026	VA Boston Healthcare System Jamaica Plain Campus, Jamaica Plain, MA	$100,000							View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
SDR 20-390-E	Zogas	Anna		Anna.Zogas@va.gov	Impact of the Referral Coordination Initiative on Veterans'' Decision to Use Community Care	11/01/2022	09/30/2026	VA Boston Healthcare System Jamaica Plain Campus, Jamaica Plain, MA	$99,821							View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
SDR 20-402	Washington	Donna		donna.washington@va.gov	Multi-level Factors Underlying VA Racial/Ethnic Disparities in Covid-19 Infection and Complications	08/01/2020	09/30/2024	VA Greater Los Angeles Healthcare System, West Los Angeles, CA	$165,753			Equity	All aims will rely on secondary analysis of existing data. Aims 1 and 2 will use mixed-effects logistic regression models and GIS analysis. Aim 3 will use Classification and Regression Tree (CART) or similar methodology. Aim 4 will use Cox proportional hazards models.	The objective of this project is to identify multi-level factors underlying VA racial/ethnic disparities along the continuum of Covid-19 infection, presentation, and outcomes. This may inform actions at each stage of increased risk. Specific Aims are to: Aim 1: Identify geographic, residential, and individual characteristics associated with Veteran racial/ethnic disparities in Covid-19 infection rates. Aim 2: Determine racial/ethnic variations in: (a) Covid-19 stage at presentation; (b) multi-level factors associated with presentation stage; and (c) association of presentation stage with outcomes. Stages may include asymptomatic infection or mild illness, and advanced illness requiring hospitalization. Aim 3: Develop a prognostic prediction tool to risk stratify patients with Covid-19 infection on risk for serious outcomes (intensive care unit use, intubation, death), to facilitate clinician decision-making about early escalation of clinical care. Aim 4: To estimate the impact of racial/ethnic disparities in response to the pandemic on non-Covid-19 outcomes and compare racial/ethnic mortality differences for patients with selected chronic conditions before and after the start of the Covid-19 pandemic.	None at this time	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
SDR 21-018	Ashrafioun	Lisham		lisham.ashrafioun@va.gov	Telehealth CBT to increase engagement in pain treatment among Veterans using prescription opioids	05/01/2022	09/30/2025	VA Finger Lakes Healthcare System, Canandaigua, NY	$719,212		Background: Chronic pain and negative consequences of long-term opioid therapy are related public health concerns associated with significant functional impairment, high psychiatric comorbidity, and premature mortality, particularly among Veterans. Clinical Practice Guidelines for opioid prescribing and pain management recommend using non-pharmacological approaches as first-line treatments. Psychosocial interventions (e.g., cognitive-behavioral therapy) have strong evidence supporting their ability to improve pain outcomes. Patient beliefs about the stigma associated with psychological interventions, opioid analgesics, ability of psychosocial intervention to improve pain among others can greatly interfere with the patients’ ability to initiate and maintain engagement in psychosocial interventions and other non-pharmacological approaches. Significance/Impact: Without a concerted effort at affecting beliefs that impede engagement in treatment, Veterans who may benefit from the treatment, will not receive it. This can result in continued risk for negative consequences associated with long-term opioid therapy and inadequate pain management. Cognitive- Behavioral Therapy for Treatment Seeking (CBT-TS) is an evidence-based intervention that directly intervenes on beliefs that act as barriers to treatment initiation and retention. By intervening on these beliefs, this study has the potential to improve engagement in psychosocial pain interventions and other non-pharmacological pain treatments, which will improve pain-related interference and functioning and reduce reliance on opioid analgesics. This study addresses VHA/VA Veteran care priorities including opioid use, pain management, and access and directly addresses priorities of the HSR&D Targeted Solicitation for Service Directed Research on Opioid Safety and Opioid Use Disorder. Innovation: The proposed study is the first application of CBT-TS for Veterans with chronic pain who are receiving opioid analgesics–a notably high-risk, treatment-resistant population. This is the first study to directly intervene on thoughts about psychosocial interventions. Specific Aims: The specific aims are to: test the effects of CBT-TS to increase initiation of psychosocial interventions for pain among Veterans receiving opioid analgesics for chronic pain (Aim 1), test the effects of CBT-TS to increase the retention in psychosocial interventions for pain among Veterans receiving opioid analgesics for chronic pain (Aim 2), and evaluate the effects of CBT-TS in improving pain and substance use outcomes among Veterans receiving opioid analgesics for chronic pain (Aim 3). We will also test the effects of CBT-TS on the initiation of and retention to other non-pharmacological pain treatments (Exploratory Aim). Methodology: Participants (N = 300) will be randomized to either the CBT-TS condition or an education control condition. Participants in both conditions will complete assessments on pain, treatment engagement, and opioid use at baseline, and 1-, 3-, and 6-months post-treatment to assess primary, secondary, and exploratory outcomes. Implementation/Next Steps: Results from this study will provide critical information on increasing engagement of psychosocial interventions for pain, which can be used to inform future implementation and dissemination efforts. The research team will work with the VHA National Pain Management and Opioid Safety office and the VHA Office of Patient Centered Care & Cultural Transformation to identify implementation and dissemination efforts. CBT-TS is undergoing current implementation research to increase mental health functioning and this effort could be expanded to also increase treatment engagement of psychosocial interventions for pain and other non-pharmacological pain treatments.	Care of Complex Chronic Conditions				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
SDR 21-087	Teo	Alan		Alan.Teo@va.gov	Increasing Social Connection Through Crisis Caring Contacts: A Pragmatic Trial	08/01/2022	12/31/2025	VA Portland Health Care System, Portland, OR	$691,727		Background: This is a time of unprecedented loneliness and social isolation. Loneliness in particular is a powerful predictor of suicidal ideation, suicide attempts, functional decline, and death. Loneliness can and should be addressed by health systems. Due to risk for loneliness and negative health outcomes, a group of particular concern is older adults with medical or psychiatric comorbidity who have limited treatment engagement. Caring Contacts is an intervention that can address loneliness and poor treatment engagement. However, it has only been evaluated in a narrow population of psychiatric patients and not examined amongst patients impacted by the COVID-19 pandemic or other disasters. Significance: This project addresses VA’s top clinical priority (suicide prevention), an overarching priority of the Office of Research and Development (clinical trials), and multiple Health Service Research and Development priority areas, including social determinants of health, aging, access to care, mental health, suicide prevention, and population/whole health. The impact of this project is very high because it will advance scientific understanding of key gaps related to the mechanisms and outcomes of Caring Contacts, while also evaluating a timely, pragmatic, low-cost, and scalable intervention for Veterans affected by lack of social connection and treatment engagement. If effective, it will have applicability as a response to treatment disengagement and future disasters. Innovation and Impact: We have taken an empirically-grounded suicide prevention intervention and adapted it for Veterans with poor treatment engagement in VA outpatient care. This study is innovative in testing an intervention responsive to the COVID-19 pandemic and its aftermath, and unique in using a health services intervention strategy to target loneliness. The intervention’s peer support component is highly novel for its low resource demands and potential for scalability. Specific Aims: The overarching objective of this project is to evaluate “Crisis Caring Contacts” (CCC), an adaptation of Caring Contacts tailored to reduce loneliness in the context of the pandemic. To reach this objective we will achieve these aims: 1) Among older Veterans with poor treatment engagement, evaluate the effectiveness of Crisis Caring Contacts in decreasing loneliness, compared to enhanced usual care; 2) Evaluate the effect of Crisis Caring Contacts on other important outcomes, including treatment engagement and suicidal ideation; 3) Explore potential moderators of treatment response to Crisis Caring Contacts; and 4) Explore the effect of Crisis Caring Contacts on all-cause mortality and suicide attempts. Methodology: Our approach is to conduct a multisite, pragmatic randomized controlled trial of CCC. We will target Veterans age 60 and over with active psychiatric or medical diagnoses who have had limited treatment engagement in VA outpatient care. Those in the CCC treatment arm will be sent 10 postcards over 10 months by a Peer Support Specialist. Those in the enhanced usual care arm (control) will be sent non-personalized, general health resource information. We will examine self-report and administrative data outcomes over 24 months of follow-up. Next Steps/Implementation: We will collect pre-implementation data from our study sites and share this with our operational partner, the Office of Mental Health and Suicide Prevention (OMHSP). Crisis Caring Contacts is highly suited to future implementation due to its scalability, ease of creating an operational dashboard to identify Veterans who could receive the intervention, and ability to add study materials to an implementation toolkit for VA Caring Contacts interventions.	Mental and Behavioral Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
SDR 21-089	Oliva	Elizabeth		elizabeth.oliva@va.gov	Strategies to improve Utilization of Post-overdose Evidence-based Risk mitigation among Non-fatal Overdoses in VA (SUPER NOVA)	02/01/2023	02/28/2027	VA Palo Alto Health Care System, Palo Alto, CA	$555,891		Background: Drug overdose is a leading cause of death, accounting for 70,630 deaths in the United States (US) in 20193. The majority of drug overdoses involve opioids, and opioid-involved stimulant deaths are rising with 3 out of every 4 cocaine-related deaths involving opioids and 53% of psychostimulant-related deaths involving opioids7. Drug overdose mortality among Veterans mirror these trends5,6. In Massachusetts, among individuals who died of an opioid overdose, 1 in 6 had a non-fatal overdose in the preceding 12 months17. These non-fatal overdoses serve as a promising target for opioid overdose prevention efforts, especially for evidence-based treatments such as medications for opioid use disorder (MOUD). The increase in stimulant- involved opioid overdoses also highlights the need to investigate strategies to improve uptake of evidence- based treatments for stimulant use disorders. Significance: In March 2019, the VHA Office of Mental Health and Suicide Prevention released a national clinical note template, the Suicide Behavior and Overdose Report (SBOR). The SBOR standardizes the reporting process, enhances the visibility of suicide and overdose events in the medical record, and is intended to improve clinical care after these events (e.g., by incorporating risk factors for overdose and strategies to mitigate risk, including referrals for care). However, the SBOR is currently mandated for intentional overdose and only recommended for unintentional overdose. Moreover, it is unclear the extent to which it is being used and whether its use improves post-overdose care as intended. Innovation and Impact: The proposed study will characterize non-fatal opioid-, stimulant-, and combined opioid and stimulant overdoses among VHA patients and the extent to which they receive recommended post- overdose care. Given that the SBOR will soon be mandated for all overdoses, and to ensure that VHA is doing everything it can to prevent overdose mortality among Veterans, it is critical to understand whether the SBOR is improving post-overdose care as intended and if additional strategies may be needed. Specific Aims: The proposed study will pursue the following specific aims: Aim 1: Characterize non-fatal opioid and/or stimulant overdoses within VHA and patient-, prescriber-, and setting-related factors associated with post-overdose treatment utilization. Aim 2: Describe utilization of the SBOR among providers of patients with non-fatal opioid and/or stimulant overdoses and associations between SBOR use, post-overdose treatment utilization, and treatment outcomes. Aim 3: Identify barriers and facilitators of post-overdose care and ways to improve it via interviews with VHA patients, patients’ concerned others, and treatment providers. Methodology: The Reach, Effectiveness, Adoption, Implementation, and Maintenance—RE-AIM—framework will guide our study. Aim 1: VHA patients with non-fatal overdoses will be identified using Corporate Data Warehouse (CDW), Community Care, and Medicare data from Fiscal Years 2014 to 2021 (FY2014-2021). Regression models will describe patient, prescriber, and setting factors associated with post-overdose care. Aim 2: Using CDW, Community Care, and Medicare data combined with VA Mortality Data Repository data, primary analyses will examine whether providers’ SBOR use is associated with patients’ post-overdose treatment utilization and reduced mortality using marginal structural Cox mediational models. Aim 3: Up to 60 total interviews will be conducted with VHA patients who experienced a non-fatal overdose, their concerned others, and VHA providers who documented a non-fatal overdose. Rapid and in-depth qualitative analytic approaches will be used; the former allows for rapid provision of actionable feedback to operations partners. Next Steps/Implementation: Our research team has strong operational partnerships and helped develop and implement the SBOR. Our team will ensure that findings are quickly translated to improve post-overdose care.	Care of Complex Chronic Conditions				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
SDR 21-092	McGuire	Alan	Marianne Matthias	alan.mcguire@va.gov	COVID-19 Impact on Pain management: Highlighting, Explaining, and Realigning services (CIPHER)	04/01/2022	09/30/2025	Richard L. Roudebush VA Medical Center, Indianapolis, IN	$1,011,392		Background: The COVID-19 pandemic severely disrupted healthcare. These changes are likely to have especially profound implications for Veterans obtaining regular care for chronic conditions, such as chronic pain—particularly when Veterans are obtaining nonpharmacologic treatments, which often require regular, in- person visits. Although virtual care delivery in VA increased dramatically in response to the pandemic and is unlikely to diminish, it is unclear what services Veterans with pain have received via virtual delivery and how Veterans have been affected by these shifts. The goal of this project is to understand changes in VA chronic pain care after COVID-19 and their associated impacts—and use these data to develop strategies to optimize delivery of VA pain services in a post-COVID-19 environment. Significance: This project addresses priorities in HSR&D's Targeted Solicitation on Opioid Safety and Opioid Use Disorder. Specifically, this project is responsive to priority area E, “examination of the impact of the COVID-19 public health emergency on the effective treatment of chronic pain, including effects on access to care, medication and treatment modalities, patient function and satisfaction.” Despite the clear impact on care delivery exerted by the COVID-19 pandemic, little is known about how these changes and disruptions have affected Veterans and their chronic pain care, including their ability to access care after the onset of the pandemic. These concerns are reflected in our pilot data, which indicate that Veterans have felt the impact of service disruptions on their pain management. Innovation and Impact: The effects of the COVID-19 pandemic are not yet well-understood. This project takes a mixed-methods approach to examine changes in chronic pain care since the onset of the pandemic, working with an expert stakeholder panel at each stage of the research to ensure results and recommendations are disseminated rapidly to maximize impact. Specific Aims: Aim 1 (quantitative): Describe changes in pain management visits for Veterans with chronic low- back pain (cLBP) following the onset of the COVID-19 pandemic. Aim 2 (qualitative): Explain differential patterns of receipt of services identified in Aim 1 and perceived impacts. Aim 3: Share findings throughout the project, including final, integrated findings from Aims 1 and 2, and develop short- and long-term strategies to optimize delivery of pain care for Veterans in a post-COVID-19 environment. Methodology: This study uses an embedded mixed-methods design. In Aim 1 a retrospective cohort of Veterans receiving care for cLBP will be established. Receipt of guideline-recommended, nonpharmacological pain management services, including changes in service receipt following the onset of COVID-19, will be examined. Veteran and facility factors associated with differential changes will be tested. Once the first phase of Aim 1 analyses is complete, qualitative sampling for Aim 2 will begin. Thus, consistent with an embedded design, most Aim 1 and Aim 2 activities will take place concurrently. Qualitative interviews with clinicians, administrators, and Veterans will be conducted to better understand how they experienced pandemic-related changes, including any effects on their current practice/service delivery, and to identify positive changes made since the pandemic that could serve as examples for other facilities. In Aim 3 we will work with our stakeholder advisory panel, led by the VA Office of Pain Management, to develop comprehensive recommendations to guide VA on policies to optimize delivery of pain management services in a post-COVID-19 environment. Next Steps: Findings will be directly applied to VA care, as directed by the CIPHER stakeholder panel (led by the VA National Pain Management Office). Future research will examine implementation strategies aimed at supporting VA-wide implementation.	Care of Complex Chronic Conditions				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
SDR 21-098	Mattocks	Kristin		kristin.mattocks@va.gov	Engaging Veterans in Developing an Intervention to Address Racial Disparities in Cesarean Sections	05/01/2022	09/30/2025	VA Central Western Massachusetts Healthcare System, Leeds, MA	$244,289		Background: Our recent research demonstrated racial disparities in cesarean section delivery rates among Veterans of color utilizing VA maternity care coordination (MCC) and delivering at community- based hospitals. Disparate birth outcomes likely result from various factors that impact the Veteran at multiple timepoints during the perinatal period; however, an in-depth examination of the social determinants of health that may contribute to these disparities has yet to be conducted among Veterans. This study will conduct an in-depth examination of the social and clinical factors leading to cesarean deliveries among Veterans of color and test the feasibility of doula services to enhance VA MCC in an effort to mitigate disparities in childbirth delivery outcomes among Veterans of color. Significance: This novel study intensely examines the impact of the social determinants of health on prenatal, labor & delivery, and postpartum care among Veterans of color in effort to mitigate disparities in childbirth outcomes. This is the first study to test the feasibility of an enhanced MCC model that incorporates doula services to improve pregnancy outcomes. The proposed study is directly responsive to several HSR&D priorities including health equity, women Veterans’ health, access to care, and care coordination. Innovation and Impact: This is the first VA study to examine social determinants of health among Veterans of color who have delivered babies using the VA Maternity Care benefit. It is also the first study to examine the feasibility of a doula program that complements VA MCC support for Veterans of color, who are at an increased risk for cesarean delivery. Specific Aim 1: Conduct an in-depth investigation with Veterans of color to better understand their recent cesarean deliveries, using semi-structured interviews and systematic obstetrical chart reviews. Specific Aim 2: Test the feasibility of an enhanced VA Maternity Care Coordination program which incorporates doula care to ensure Veterans of color are receiving continuous support throughout pregnancy, labor and delivery, and the postpartum period. Specific Aim 3: Share our study findings (Aims 1 & 2) with VA stakeholders, including Women’s Health Services leadership, through expert roundtable sessions. Utilize the qualitative data from these proceedings to further inform a larger intervention that will seek to reduce childbirth delivery disparities among Veterans of color. Methodology: This is a mixed methods study that will utilize existing survey data and obstetrical chart audits to augment qualitative interviews in an effort to better understand the impact of social determinants of health and the role continuous perinatal support has on Veterans. Next Steps/Implementation: We plan to disseminate findings among our key stakeholders through expert roundtable discussions. The findings from these sessions will promote and inform a larger VA intervention that will seek to further mitigate childbirth delivery disparities among Veterans. Our findings may result in (1) an improved understanding of the impact of the social determinants on the prenatal and childbirth labor and delivery outcomes among Veterans of color; (2) an understanding of the feasibility of collaborative teams comprised of VA Maternity Care Coordinators and doulas in providing continuous prenatal, labor and delivery, and postpartum support to Veterans; (3) a stakeholder informed intervention developed to address the social determinants of health in effort to improve the quality of care for racial and ethnic minority pregnant Veterans.	Women's Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
SDR 21-107	Lagisetty	Pooja	Susan Zickmund	Pooja.Lagisetty@va.gov	Diagnosing and Treating Veterans with Chronic Pain and Opioid Misuse	01/01/2022	08/31/2025	VA Ann Arbor Healthcare System, Ann Arbor, MI	$806,011		Background: As many as 30% of the ~10 million Americans prescribed long-term opioid therapy (LTOT) are estimated to misuse opioids. Receiving LTOT is associated with opioid-related harms, and misuse leads to an increase in the dose consumed and other risky behavior, further worsening outcomes. However, there is a gap in knowledge on how to identify and treat this patient population particularly when they do not meet diagnostic criteria to be treated by medications for Opioid Use Disorder (OUD). In recent years, guidelines from the Centers for Disease Control and the Veterans Health Administration (VHA) have effected widespread tapering to reduce misuse. Buprenorphine, a medication used for both pain and OUD, may also be effective in reducing opioid-related harms while controlling pain for patients on LTOT with misuse; however, buprenorphine is yet to be tested rigorously in this patient population. Therefore, studies are needed to identify patients on LTOT with misuse and to compare the efficacy of different treatments on patient outcomes. Significance: Chronic pain, LTOT for pain, and opioid misuse are common among Veterans and lead to multiple health-related harms. The VHA has made improving pain care and reducing opioid harms a major priority of clinical initiatives, and this proposal responds to the Health Services Research and Development (HSR&D) Funding Announcement #HX-21-024 to address those opioid-related priorities. By filling a crucial evidence gap, this proposal will significantly impact the way we treat pain and minimize harm for Veterans with opioid misuse. Innovation and Impact: This proposal is innovative and impactful in many ways. First, this project will utilize the unique capabilities of the VHA’s Corporate Data Warehouse (CDW) to develop a novel algorithm to identify patients on LTOT with misuse. If successful, this automated identification process has the potential to be scaled to VHA sites across the country. Second, the comparative effectiveness of different treatments will be determined by an emulated trial, an innovative and efficient study design that can lead to greater generalizability than standard trials, which suffer significantly from selection bias in this area. The treatments being evaluated in the emulated trial are readily available, so if specific treatments are found to improve patient symptoms and reduce adverse outcomes, it will be feasible for Veterans with opioid misuse to access these treatments nationwide. Finally, we will gather feedback from providers and Veterans to understand the best strategies and interventions to scale the identification process and better inform Veterans and providers of evidence-based treatment options. Specific Aims: This project aims to 1) Classify a cohort of patients on LTOT with opioid misuse but without OUD by a) building on a previously developed augmented chart review methodology and b) applying an algorithm to structured data; 2) Conduct an emulated trial to compare the effectiveness of pharmacologic treatment options on patient-centered and patient safety outcomes; and 3) Understand current practices and how to translate our findings into improved care via semi-structured interviews with providers and Veterans. Methodology: The study population is VHA patients on LTOT with opioid misuse 2014-present. The proposal uses mixed quantitative and qualitative methods including augmented structured chart review, large dataset classification using ordinal elastic net regression, emulated trials, and qualitative interviews. Next Steps/Implementation: We expect findings to be of use to VHA leaders, prescribing clinicians, and patients with chronic pain. If successful, the automated identification process from Aim 1 could be scaled to VHA sites, and if treatments evaluated in Aim 2 are effective in improving symptoms and reducing adverse outcomes, these could also be implemented widely. In Aim 3, we will gather Veteran input on how to best implement findings from Aims 1 and Aim 2 into clinical practice in a variety of settings.	Quality Measurement Development				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
SDR 21-108	Black	Anne		Anne.Black@va.gov	Role of Non-pharmacological Pain Treatments in Safe and Effective Opioid Tapering in Chronic Pain	05/01/2022	09/30/2025	VA Connecticut Healthcare System West Haven Campus, West Haven, CT	$720,756		Background: Evidence of risks for serious adverse outcomes and limited benefit of long-term opioid therapy (LTOT) have driven VA recommendations for LTOT tapering or discontinuation when benefits no longer outweigh harms. However, LTOT tapering may also pose risks of harm. Significance: The study addresses a critical need for clear demonstration of LTOT tapering risks and a specific VA call for evaluation of nonpharmacological pain treatments including complementary and integrative health services (NPM/CIH). The goals of this project are to assess the role of NPM/CIH use in effecting safe and clinically meaningful reductions in LTOT regimens for Veterans with chronic pain. Changes in outcomes associated with two major periods -- the implementation of the Whole Health System of care (WHS) and COVID-19 – will be assessed. Innovation and Impact: In ongoing partnership with the Office of Patient-Centered Care and Cultural Transformation (OPCC&CT), the study will broaden the scope of ongoing NPM/CIH evaluation to include outcomes related to substance dependence and addiction. Partnering with Pharmacy Benefits Management Services’ VA Center for Medication Safety (MedSAFE), informed by new pilot data, our team will be one of the first to apply a novel method to optimize determination of LTOT tapering to improve analyses of tapering- related outcomes. The study will inform clinical guidelines addressing multimodal approaches to tapering. Specific Aims are to (1) Characterize NPM/CIH access and utilization among Veterans with LTOT, considering the impact of implementation of the VHA Whole Health System of Care and COVID-19; (2) Compare the effectiveness and safety of opioid tapering for Veterans with LTOT with and without NPM/CIH; (3) Assess the moderating effect of buprenorphine on NPM/CIH effects on outcomes. We hypothesize that use of NPM/CIH will be associated with higher rates of effectiveness and safety, and that use of buprenorphine will be associated with more positive effects of NPM/CIH on these outcomes. Methodology: The project will identify a retrospective cohort between 2016-2020 of approximately 200,000 Veterans receiving LTOT at ≥ 30 mg morphine equivalent daily dose (MEDD) across 54 VA facilities. Leveraging Veterans Health Administration (VHA) electronic health record data, Veterans’ utilization of NPM/CIH within VHA and in the community will be assessed. Applying a novel method developed by VA MedSAFE using VHA electronic pharmacy data within the Corporate Data Warehouse, we will develop models of opioid tapering within the target period. Using quasi-experimental methods, Veterans will be “assigned” to NPM/CIH treatment or no treatment based on their observed service utilization. Propensity score matching will balance baseline differences due to nonrandom assignment. In multilevel models, opioid tapering outcomes will be modeled as a function of NPM/CIH use. The primary tapering effectiveness outcome will be the proportion of Veterans achieving a reduction in prescribed opioid dose of ≥50% of baseline mg MEDD, maintained over six months in the absence of worsened pain intensity. Tapering safety will be measured as the proportion of Veterans experiencing any serious adverse event (SAE), allowing tapering to take all values, including no taper and dose increases. SAE will include hospitalization, emergency department visit, opioid overdose, new mental health disorder, new opioid or other substance use disorder, suicide attempt, and all- cause mortality. Models will assess moderation of NPM/CIH effects by buprenorphine treatment for opioid tapering and for chronic pain. Secondary models will assess the effect of NPM/CIH on LTOT-related side effects and differences in NPM/CIH effect by age, race/ethnicity and gender. Next Steps/Implementation: Operational partners and a Veteran engagement panel will guide interpretation of results and promote dissemination and translation to practice. Results will inform an implementation study to support the scale-up and sustainment of effective practices for pain management and facilitating safe and effective opioid reduction.	Care of Complex Chronic Conditions				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
SDR 21-133	Funderburk	Jennifer		Jennifer.Funderburk@va.gov	Identifying Modifiable Factors that Affect Veterans At-Risk due to Social Determinants of Health and Psychological Distress Access to Care Within Integrated Primary Care Settings	06/01/2022	01/31/2026	Syracuse VA Medical Center, Syracuse, NY	$531,430		Background: Veterans are more likely to report psychological distress, which also elevates their risk for certain social determinants of health, such as unmet social needs (e.g., housing instability). As the entry point for most Veterans into care, the presence of multidisciplinary members on integrated Patient Aligned Care Teams (PACTs) in primary care, such as social workers and Primary Care Mental Health Integration (PCMHI) providers helps to address the wholistic needs of these Veterans by providing increased access to additional resources that have found to improve patient outcomes. Significance: However, prior research has showed that these integrated PACTs continue to demonstrate significant variation in meeting the needs of Veterans with psychological distress and unmet social needs (even with the skillsets brought to the PACT by the new members) leaving opportunities to improve access. Due to the negative impact of the comorbid experience of psychological distress and unmet social needs on Veteran’s health on health, identifying ways to optimize access to care within these integrated PACTs is an opportunity to reach a broad array of Veterans. Innovation and Impact: The proposed research is innovative through its attention to an underdeveloped area of the healthcare structure, integrated PACT characteristics, and its relationship with access. Informed by prior PACT implementation literature and a conceptual framework on patient navigation, integrated PACT characteristics include: structural, provider-specific, and team behaviors. Our aims seek to use mixed methods to provide a comprehensive understanding from multiple perspectives on PACT characteristics predictive of improved access and identify associated processes to achieve access within integrated PACTs within this high need population. These results will provide immediate guidance to VHA on the types of evidence-based interventions that can be utilized and practice changes that may support those interventions in achieving access to care for Veterans with unmet social needs and psychological distress. Specific Aims: Aim 1 will identify integrated PACT characteristics (provider, structural, and team behaviors) that significantly predict initial engagement to care among Veterans with unmet social needs and psychological distress. Hypothesis: Integrated PACT structural, such as staffing, and team behaviors, such as team meetings will be the strongest predictors of initial Veteran engagement in care. Aim 2 will identify best practices and perspectives from members and administrators within high performing integrated PACTs on ways to achieve optimization of significant integrated PACT characteristics supporting high levels of engagement among these Veterans. Aim 3 will test a model of hypothesized relationships between integrated PACT characteris tics and access as measured by Veterans’ perceptions of care (perceived access), ratings of quality of care, and engagement in care. Methodology: Aim 1 will combine data from two data sources (administrative data mixed with integrated PACT (n=160) surveys) to identify which integrated PACT characteristics significantly predict initial engagement, which will be defined as receipt of mental health or social resource care. Eligible Veterans have recently been seen in primary care, report current psychological distress and the presence of at least one unmet social need will be eligible. Aim 2 will use qualitative interviews to provide more in-depth information to identify best practices and perspectives from high-performing integrated PACT members and administrators (n=30). Aim 3 will use Aim 1 data and Veteran surveys (n=2000) to examine the role that Veterans’ perceptions of care and quality of care play within the relationship between integrated PACT characteristics and engagement in care using structural equation modeling. Steps/Implementation: Results will be shared via traditional publications, but also directly with key stakeholders in primary care, who will utilize these results to guide quality improvement projects. For instance, the results could help inform the PCMHI Competency training efforts on various PACT characteristics when training new PCMHI providers.	Equity				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
SDR 21-178	Estock	Jamie		Jamie.Estock@va.gov	Pandemic-Related Disruptions in care for Veterans on Insulin Pumps (PD-VIP): A Mixed Methods Analysis	06/01/2023	03/31/2027	VA Pittsburgh Healthcare System University Drive Division, Pittsburgh, PA	$395,491		Background: Prior to the pandemic, the approximately 10,000 Veterans on insulin pumps (VIPs) were excluded from VA telehealth programs due to the complexity of their care and their risk of adverse events (AEs). The lack of enrollment of VIPs in VA telehealth programs resulted in a gap in knowledge of best practices for remote insulin pump management, making pandemic-related disruptions in care especially difficult and riskier for these Veterans. The urgency to switch all Veterans to telehealth for non-emergent care during the pandemic resulted in the need for VIPs and providers to adapt to new care processes and quickly “piece together” data-sharing technologies to overcome barriers and maintain safe and effective care. The objective of this study is to address the gap in knowledge of best practices for remote insulin pump management to mitigate adverse effects the ongoing pandemic has on high-risk VIPs. The long-term goal of this research is to establish an evidence-based telehealth program for safe and effective remote insulin pump management to improve access to remote care for VIPs and meet the growing demand for insulin pump therapy. Significance: This study will inform the advancement of telehealth processes and tools for remote insulin pump management that will: (1) benefit vulnerable Veterans living in rural communities and other Veterans who face access challenges, (2) expand care options for Veterans with diabetes who may be candidates for insulin pump therapy but are unable to access VA specialty care, and (3) enhance VIPs ability to connect with their care team for critical real-time troubleshooting of unexpected device failures and prevention of AEs. Expanding Veteran access to remote insulin pump management assures continued quality care and connection for VIPs and supports VA's clinical and legislative goals of improving Veteran access to care. Specific Aims: 1. Characterize the pandemic's impact on VIP outcomes, including process of care and clinical outcomes. Using a longitudinal observational design, we will examine VIP process of care and clinical outcomes over a 3-year period beginning 1.5 years prior to onset of the pandemic. We will use mixed effects and Cox regression models to compare outcomes before and during the pandemic while accounting for practice, provider, and patient-level covariates that are likely to influence the outcomes of interest. 2. Examine VIPs' and providers' experiences and satisfaction with insulin pump management before and during the COVID-19 pandemic and identify barriers to and facilitators of safe and effective remote care. We will conduct structured interviews with a VIPs and providers and apply rapid qualitative analysis to examine experiences and satisfaction with insulin pump management before and during the COVID-19 pandemic and identify barriers to and facilitators of safe and effective remote care. 3. Develop recommendations to advance telehealth processes and tools for safe and effective remote insulin pump management. We will integrate our findings from Aims 1 and 2 using joint displays and review them with a VA Expert Advisory Panel and VIP representatives to generate recommendations for immediate improvement to remote insulin pump management and for future research. Methodology: We selected a mixed-methods design to expand the breadth of our inquiry by obtaining an account of pandemic-related outcomes through our quantitative analysis and a sense of the process of transitioning VIPs to telehealth through our qualitative analysis. We will use our integrated findings to generate recommendations to improve how VA delivers remote care to VIPs moving forward. Next Steps/Implementation: Our partners at the VA National Endocrinology/Diabetes Program Office, VA Office of Rural Health, and VA Office of Connected Care will provide guidance and support throughout our study and facilitate the rapid dissemination of our findings across VA.	Care of Complex Chronic Conditions				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
SDR 21-181	Galea	Marinella		marinella.galea@va.gov	Disruption of Health Services: The Impact of COVID-19 on Veterans with SCI/D	06/01/2023	08/31/2027	James J. Peters VA Medical Center, Bronx, NY	$475,925		Background: As of May 19, 2022, 3,427 of the 17,307 Veterans living with spinal cord injury and disorders (SCI/D) who have received services from the Veterans Health Administration (VHA) in fiscal year (FY) 2022 had a confirmed positive COVID-19 test, with 187 COVID-related deaths. Stay-at-home orders and social distancing guidelines during the pandemic have had numerous effects on this population including disrupting healthcare, increased mortality and morbidity as well as negative psychosocial effects. Veterans with SCI/D are a unique population within the VHA who are primarily served at 25 SCI/D Centers nationally. Veterans with SCI/D have higher rates of chronic physical conditions than other Veterans. Research on the pandemic impact on Veterans with SCI/D is scant but critical to study because these individuals utilize VHA health services as their primary source of health care and SCI/D support (e.g., wheelchair repair, home-based care, bowel and bladder care, assistive technology, etc.). To inform program planning and resource allocation, it is essential to know how the COVID-19 pandemic has impacted health service delivery, access to essential resources, and mortality and morbidity among Veterans with SCI/D. This explanatory mixed methods study will fill this gap in knowledge by examining patient-, community-, and system-level factors related to changes in health services care, physical and mental health outcomes in Veterans with SCI/D. Significance: Given the elevated risk of chronic physical conditions and mortality for Veterans with SCI/D, it is imperative that VHA provides health services to address the needs of this population. This study responds to the VA SCI/D National Program Office priorities to support, promote, and maintain the health, independence, quality of life, and productivity of Veterans with SCI/D throughout their lives. Further, this project identifies challenges faced by Veterans with SCI/D during the COVID-19 pandemic and utilizes these results to inform health services for future emergency events and global disasters. Specific Aims: The project’s three aims are scientifically important and reflect extensive input from key Veteran and SCI/D stakeholders regarding how to improve the quality of SCI/D services: (1) Identify COVID-19 related disruptions and adaptations in health services utilization and mortality and morbidity among Veterans with SCI/D; (2) Qualitatively evaluate Veterans’ and providers’ perspectives on how health services utilization changed during the COVID-19 pandemic and the subsequent impact on mortality and morbidity; and (3) Examine Veterans experiences and decision-making during the COVID-19 pandemic. Methodology: Our study is guided by the International Classification of Functioning, Disability, and Health conceptual framework. In Aim 1, we will estimate incidence rate ratios of health services utilization, morbidity, and mortality in the year prior and years 1 and 2 after the start of the pandemic. We will also examine if there are differences between the time periods by Veteran, SCI/D and VHA, and community factors. Finally, we will conduct exploratory analyses of patterns of disrupted care (n=18,331 in FY20). Aim 2 will be to conduct focus groups with Veterans with SCI/D (n=4 groups with ~3-5 Veterans per group) and VHA providers who deliver healthcare services for these Veterans (n=2 groups with ~3-5 providers per group). For Aim 3, we will conduct a national survey with Veterans with SCI/D who use VHA health services (n=~6,100, which approximates 35% of the 17,307 currently living Veterans with SCI/D identified by the National SCI/D Registry). Next Steps/Implementation: Results will be of immediate value to the SCI/D National Program Office to identify health services needs for Veterans with SCI/D and will be used to develop measures for enhanced emergency preparedness for future disasters. This information will have broad and long-ranging impacts on the SCI/D System of Care, informing access improvement projects, telehealth service expansion, performance measures development, and VHA enrollment and health care projection modeling (20+ year timeframe).	Systems Modeling, Design, and Delivery				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
SDR 21-226	Hunt	Kelly		kelly.hunt@va.gov	Examining linkages between disrupted care and chronic disease outcomes during the COVID-19 pandemic: a VAMC level spatio-temporal analysis	06/01/2023	09/30/2027	Ralph H. Johnson VA Medical Center, Charleston, SC	$308,872		ABSTRACT – Background: The global pandemic brought on by SARS-CoV-2 has profoundly impacted health and care for veterans, who are generally older, sicker and more economically vulnerable than the overall U.S. population. Veterans are likely to face lasting risks related to care disruptions. Disruptions and varied responses across VA Medical Centers (VAMC) provide an unprecedented opportunity to examine 1) how massive changes in care delivery impact outcomes and 2) the extent to which disruptions exacerbated health disparities. Significance: Our current work points to the existence of complex linkages between chronic disease care, social vulnerability and outcomes. Ability to adapt to the pandemic may be explained by variation in patient-level resources, community-level resources and access to healthcare. Disruptions in care may also exacerbate known disparities in care. Therefore, we will leverage our expertise in geographic information systems (GIS) analysis and advanced spatio-temporal statistics to conduct a robust evaluation of the impacts of the pandemic on care delivery and outcomes for diabetes and hypertension as chronic disease indicators. Specific Aims: Our aims are (1) to determine the impact of the pandemic on chronic disease outcomes across the nation at the level of the VAMC and to examine the extent to which changes in care delivery explain lower extremity amputation, stroke, hospitalizations and all-cause mortality; (2) to determine the extent to which disparities with respect to race-ethnic group, rural-urban residence and comorbidity burden/profile have widened during the pandemic; and (3) to identify VAMC health system attributes, census tract attributes (e.g., social vulnerability), and pandemic burden metrics that lead to adverse outcomes. Methodology: We will create two retrospective cohorts of Veterans receiving primary care from 2017 through 2022: a diabetes and a hypertension cohort. Social vulnerability measures will be assigned at the census-tract level based on a veterans’ residence. Our models are designed to investigate associations between individual-, census tract- and VAMC- level factors, health care delivery metrics, and health outcomes using complex GIS linkages and advanced spatio-temporal statistical methods. Delivery of care metrics include extent to which HbA1c, blood pressure and diabetic retinopathy are monitored; receipt of appropriate prescriptions; number of visits, visit wait times and mode of visit (i.e., telephone, in-person, video telehealth). Chronic disease outcomes include lower extremity amputations, stroke events, hospitalizations and all-cause mortality. Aspects of our work that set it apart from ongoing projects are (1) our ability to include comprehensive data on inpatient hospital visits and ED visits when analyses are limited to South Carolina, (2) the advanced statistical modeling that enables us to account for multiple factors at multiple levels (i.e., patient, census tract, VAMC); and (3) the spatio-temporal aspects of the proposal which are critical given the spatio-temporal nature of the pandemic Next Steps/Implementation: We plan to create a dashboard in Power BI, a VA supported business intelligence tool, that allows users to display data in visual format allowing data to inform strategic decisions. Our dashboard will provide adjusted quarterly mortality rates and other specified outcomes at the level of the VAMC from 2017 through 2022. The dashboard will also enable leadership/stakeholders to examine quarterly mortality rates for pre-specified categories, including racial-ethnic group, rural-urban residence, and VAMC level metrics of care disruption. Our analyses will focus on identifying healthcare delivery factors potentially responsible for changes in chronic disease outcomes. Variations in response to the pandemic across VAMCs provides a unique learning opportunity. Our use of area-level data and our focus on the VAMC level analyses will inform policy-level decision making during and following the pandemic. Lessons learned on the relationship between changes in care delivery, VAMC-level adaptability and chronic disease outcomes will inform post- pandemic care throughout the VA.	Systems Modeling, Design, and Delivery				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
SDR 21-227	Wang	Virginia	Amal Trivedi	virginia.wang@va.gov	Impact of COVID-era Disrupted Care on Disparities in Outcomes among Veterans with Kidney Failure	08/01/2022	03/31/2026	Durham VA Medical Center, Durham, NC	$643,763		Background: The COVID-19 pandemic significantly disrupted care delivery that limited access to providers, acute and timely non-acute evaluation, and clinical intervention. Dialysis patients with kidney failure are particularly vulnerable to COVID-19 infection, COVID-19 related morbidity and mortality because they commonly have multiple chronic conditions, typically require thrice weekly life-sustaining dialysis treatment in close- quartered clinic settings, are already prone to fragmented care, and especially susceptible to disrupted care. The COVID-19 pandemic presents fundamental threats to dialysis patients, and there is an urgent need to examine the impact of disrupted care for this vulnerable and uniquely healthcare reliant population of patients. Over 16,000 of enrolled Veterans receive chronic dialysis through Veterans Health Administration (VA) Kidney Program’s VA and VA Community Care providers. VA Community Care improves access to life- sustaining dialysis services for 80% of Veterans with kidney failure with limited access to the VHA’s 70 dialysis units. In prior work, we found lower 2-year mortality among Veterans receiving dialysis exclusively in VA compared to those receiving dialysis in non-VA settings, consistent with VA and non-VA comparative studies in other clinical contexts. These differences may be due to more comprehensive integrated services (e.g., co- located primary and tertiary care services, care management, social work, national electronic medical record) in VA, compared with the more fragmented and siloed dialysis care in private sector community settings. Significance: Pandemic-related disruptions may disproportionately affect Veterans with serious conditions and social risk factors like those with kidney failure and the nature and impact of pandemic-related disruptions may differ in VA and non-VA systems. However, rigorous comparisons of COVID-related care disruptions and outcomes between Veterans receiving healthcare in VA and non-VA settings are lacking. Specific Aims: Building on our team’s research expertise, this study will: 1) Quantify the impact of COVID-19 on 1a) disrupted care for prevalent patients and 1b) deferred care for incident patients in a national cohort of Veterans with ESKD and compare the extent of these impacts between VA- financed dialysis care in VA and VA Community Care settings from 2018-2022. 2) Compare patient-level outcomes and racial and socioeconomic disparities in outcomes in VA and non-VA dialysis settings before and during the COVID pandemic time periods. Methodology: We will conduct a longitudinal cohort study of all VA-enrolled patients with end-stage kidney disease receiving VA-financed dialysis care between 2018 and 2022, to observe care patterns before the pre- COVID phase (Jan 2018-Feb 2020), the acute COVID phase defined as the first case of COVID until authorization of the vaccine (Mar 2020-Dec 2020) and the recovery phase when COVID-19 vaccination was available (Jan 2021-Dec 2022). Study data will be derived from linkages of VA and Medicare administrative data with community-level national COVID-19 tracking and neighborhood socioeconomic status data to assess the impacts of pandemic-related disruptions in care on disparities in outcomes among Veterans receiving dialysis in VA and non-VA settings. Next Steps/Implementation: This research is directly responsive to the COVID RFA HX-21-025: Pandemic related disrupted and deferred care and three VA HSR&D priority areas (Access to Care, Complex Disease Management, Social Determinants of Health). The study team is conducting this work partnership with the VHA National Program for Kidney Disease to ensure that our work is poised to shape evolving VA policy around provision of community care and to improve care for Veterans during the COVID-19 pandemic, recovery, and future public health crises. Results will inform how VA manages its Veterans in disaster scenarios, particularly with provider partners in VA community care, for whom the VA relies on for reliable and accessible dialysis care.	Access				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
SDR 21-232	Jutkowitz	Eric		eric.jutkowitz@va.gov	Evaluating the Impact of COVID-19 on Case Management, Health Care Utilization, and Housing Outcomes for HUD-VASH Veterans	06/01/2023	06/30/2026	Providence VA Medical Center, Providence, RI	$410,264		Background: The US Department of Housing and Urban Development-Veterans Affairs Supportive Housing (HUD-VASH) program offers permanent, subsidized independent housing and case management to over 60,000 Veterans annually. In response to COVID-19, HUD-VASH shifted case management from in-person to telephone/video interactions. The goal of this project is to examine the effect of HUD-VASH’s shift to virtual care on Veteran engagement and outcomes in the program. Our proposal is motivated by a working theory that virtual care increased access to case management, primary care, and improved behavioral quality measures conducive to phone/video interactions (e.g., follow-up after a psych hospitalization), but decreased access to specialist care and worsened quality measures not conducive to phone/video interactions (e.g., meds for opioid use disorder). Significance: The VA is dedicated to improving the housing and health of Veterans. Our project will advance policy by helping the National Homeless Programs Office understand the impact of virtual care in HUD-VASH to maximize program reach, engagement, and outcomes. The project addresses VA’s FY 2018- 2024 Strategic Objective 2.2 (“VA ensures at-risk and underserved Veterans receive what they need to eliminate Veteran suicide, homelessness, and poverty”), objectives of RFA HX-21-025 (changes to virtual care on Veteran outcomes), and objectives of HSR&D (virtual care and social determinants of health). Specific Aims: Aim 1. Determine the effect of HUD-VASH’s shift to virtual care during the COVID-19 pandemic on case management services: Hypothesis: HUD-VASH’s shift to virtual care during the pandemic resulted in more total, telephone and video case management as compared to a pre-pandemic period. Secondary analysis: Identify associations between Veteran factors (e.g., mental health diagnosis) with the use of case management before and after the shift to virtual care, and Veteran factors associated with not engaging in any virtual care. Aim 2. Evaluate the effect of HUD-VASH’s shift to virtual care during the pandemic on Veteran’s health care utilization and continuity of care. Hypothesis: HUD-VASH’s shift to virtual care during the pandemic increased the use of primary care and improved some behavioral quality measures while decreased other behavioral quality measures not conducive to virtual care and the use of outpatient specialist care. Secondary analysis: Examine Veteran factors associated with HUD-VASH program exits and utilization of health care in the year after program exit. Aim 3. Examine Veteran and provider experiences with virtual case management in HUD- VASH. Semi-structured interviews with VA leadership, case managers, and Veterans who experienced HUD- VASH’s shift to virtual care, will provide an understanding of the barriers to and facilitators of the implementation of virtual case management. Methodology: A convergent parallel mixed-methods design will be used. Data from the VA’s Corporate Data Warehouse (CDW) will be linked with Homeless Operations Management and Evaluation System (HOMES) for analysis. Using these data, Aims 1 and 2 will use an interrupted time series design with segmented regression to examine utilization outcomes before and after HUD-VASH’s shift to virtual care. For Aim 3, qualitative interviews with VA leadership, case managers and Veterans will capture the experience of implementing and receiving virtual care and give context to our quantitative findings. Next Steps/ Implementation: Our findings will inform the evolution of virtual care within the HUD-VASH program. This project will also inform the Homeless Programs Office of the impact and experience of transitioning to virtual care during the pandemic and the extent this transition and pandemic disrupted VA care of homeless Veterans.	Equity				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
SDR 21-242	Grubaugh	Anouk		Anouk.Grubaugh@va.gov	Impact of COVID-19 on Continuity of Care for Veterans on Antipsychotic Medications	11/01/2022	03/31/2026	Ralph H. Johnson VA Medical Center, Charleston, SC	$403,835		Background: Severe mental illnesses are consistently ranked as some of the most debilitating health conditions worldwide due to their early age of onset, chronicity, and impact on functioning. Fortunately, a number of antipsychotic medications have been found to be effective for managing the symptoms of severe mental illness (SMI) and for preventing relapse and rehospitalization. Despite their efficacy, treatment non-compliance for individuals on these medications is high due to a number of factors including poor insight into illness, negative attitudes about medication, and medication related side effects. Further complicating care and outcomes for this clinical population, providers must maintain close oversight of patients on antipsychotics due to the impact of these medications on metabolic and cardiac functioning which confer an increased risk of obesity, diabetes, heart problems, and other chronic illnesses. This oversight includes regular monitoring of weight, blood pressure, fasting blood glucose, and lipid levels. Additionally, clozapine, indicated for treatment-resistant schizophrenia, requires weekly-to-monthly monitoring of absolute neutrophil counts to prevent potentially fatal clozapine- induced agranulocytosis. Significance: The proposed project has significant and immediate relevance to Veterans and the VHA in that it seeks to better understand if and to what extent COVID-19 related care disruptions impacted care and outcomes for Veterans with SMI prescribed antipsychotic medications. Given pre- existing challenges in the treatment of this Veteran population, this is an important area of inquiry as well as one for which little is known. Added strengths of the proposed study include the use of a mixed methods approach that includes national level data from multiple sources. Aside from addressing a critical knowledge gap, the proposed study targets what is unarguably one of the most vulnerable patient populations within the VA and other healthcare systems—patients with SMI prescribed antipsychotic medications. Specific Aims: Aim 1: To assess the impact of COVID-19 related care disruptions on healthcare use and outcomes for Veterans on antipsychotic medications using robust statistical methods and national level data; Aim 2: To assess whether the impact of COVID-19 related care disruptions differ by race/ethnicity, gender, age, and rural/urban status using national level data; Aim 3: To conduct thematic interviews with provider and patient stakeholder groups at the national level to better understand COVID-19 related care disruptions. Provider stakeholders (e.g., psychiatrists, advanced nurse practitioners) will be interviewed to better understand COVID-19 related changes in practice behaviors, the perceived impact of these changes on care continuity and outcomes, and to solicit suggestions to mitigate the impact of interrupted care in the future; Veterans prescribed antipsychotic medication prescriptions in the pre COVID-19 window will be interviewed to better understand the impact of COVID-19 related care disruptions on treatment seeking behaviors, obstacles encountered with regard to access, and to explore other factors potentially impacting outcomes in this patient group. Methodology: The proposed study will employ a mixed-methods (quantitative/qualitative) approach. For Aims 1 & 2 we will employ retrospective, observational analyses using a national cohort of Veterans (N>250,000) with an ICD-CM-10 diagnostic code for schizophrenia or bipolar disorder prescribed a first-generation or second-generation antipsychotic [1/19-12/21]. Veterans of all ages, genders, racial groups, military eras will be included in the cohort. Aim 3 will involve individual thematic interviews with provider (n=35-45) and patient stakeholders (n=50-60). Next Steps/Implementation: Findings from this 2-year project will be of immediate relevance and impact for local, regional, and national level administrators and mental health providers as well as the VA Office of Mental Health and Suicide Prevention and VA Pharmacy Benefits Management Services. Collectively, data from this project will serve to identify potential strategies to further mitigate the impact of COVID-19 on the care and outcomes of Veterans with SMI as well as prepare for future public health and/or other national emergencies.	Equity				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
SDR 21-251	Min	Lillian		lmin@med.umich.edu	Resilience to Covid-19 Disrupted Chronic Condition Care for Older Veterans At Risk of Hospitalization: Role of VA Ambulatory Care and VA Extended Care Home and Community-Based Care Supports	08/01/2023	06/30/2026	VA Ann Arbor Healthcare System, Ann Arbor, MI	$377,153		Background: The Covid-19 pandemic disrupted the ambulatory health care of Veterans with chronic conditions, including those with the highest need for VA care. Significance/Impact: This research will study the critical role of the VA healthcare system for delivering chronic disease management during the pandemic, including office, video, and telephone care, and assess clinical outcomes of older Veterans at the highest risk for hospitalizations for chronic disease exacerbations and acute fall injuries. In addition, we will explore how VA Geriatric Extended Care Home and Community- Based Services (HCBS) mitigated Covid-19 related healthcare disruptions. Innovation: This research will implement the newest analytic tools for studying health outcomes of older Veterans, approaches to measure access to VA HCBS programs, and identify those at highest risk of disrupted and delayed chronic disease care. Specific Aims: Using state-of-the-art methods, we will address the following Aims: Aim 1A: Examine the effect of disrupted ambulatory care visits on chronic condition management (CCM) for older Veterans. We will identify changes over time (“disruption”) in ambulatory care, including the volume of face-to-face and virtual visits, video and telephone calls, that are provided by outpatient primary and specialty care outpatient clinics. We will study ~ 1 million older (age ≥65) Veterans with at least 1 of 3 chronic medical and geriatric conditions: hypertension, congestive heart failure (CHF), or falls/mobility impairment during the Covid-19 crisis (2020-21). Management of chronic conditions will be measured by medication adherence, intensity, lab monitoring, and physical therapy services. Vulnerability to service disruption will be defined using the established method in VA patients and two other methods developed specifically for geriatric patient populations, the Predicted Long-term Institutionalization (PLI) measure. Next, in Aim 1B, we will test whether facilities who were able to maintain better access to HBCS mitigated the effect of disrupted ambulatory care on performance of chronic condition care management. This critical Aim will focus on 5 HBCS programs: Home-Based Primary Care, Personal Care Services (homemaker and home health aides, respite care), Veteran Directed Care, Adult Day Care, and Skilled Home Care (e.g., physical and occupational therapy, nursing, social work) Aim 2: Examine the effect of chronic condition management disruption on hospitalizations for ACSCs and acute fall injuries. We will determine whether older Veterans with less disrupted care during the initial and second Covid-19 surges also had a lower risk of hospitalization for chronic ACSC-related hospitalizations related to CHF and hypertension or for a fall-related injury. This Aim will result in a better understanding of how to predict hospitalization for ACSCs among older Veterans according to vulnerability. Methodology: This is a longitudinal study of older Veterans in the national VA healthcare system, using VA healthcare data merged with Medicare and Medicaid long-term care data, and pharmacy files from the VA and Medicare. We will use risk scores and data sources in partnership with the GEC Data Analysis Center. Next Steps: We will identify the chronic condition management services that should be prioritized for older Veterans and a potential roadmap for how the future VA ambulatory care and GEC healthcare systems can partner to provide better chronic condition management and attain better health outcomes for older Veterans.	Long Term Care and Aging				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
SDR 21-263	Waldo	Stephen		stephen.waldo@va.gov	Impact of the Coronavirus Disease 2019 Pandemic on Cardiovascular HealthcareUtilization, Quality of Care, and Clinical Outcomes	04/01/2023	03/31/2027	Rocky Mountain Regional VA Medical Center, Aurora, CO	$412,628		Background: During the coronavirus disease 2019 (COVID-19) pandemic, Veterans have deferred inpatient care such as coronary revascularization in the context of an acute myocardial infarction. Simultaneously, cardiovascular care has been disrupted, with clinicians less likely to prescribe guideline indicated medications for common cardiovascular conditions such as stable coronary artery disease or heart failure. Excess deaths have also occurred during the COVID-19 pandemic, particularly among vulnerable populations, raising the possibility of suboptimal healthcare utilization or quality of care among those not directly infected by the virus. However, the extent to which cardiovascular healthcare utilization and quality of care have decreased during the pandemic compared with preceding time periods and whether these changes have impacted Veterans’ risk of mortality is unknown. Significance: Cardiovascular disease is the most common condition in the United States and the leading cause of excess, non-COVID deaths during the early pandemic. The proposed work may identify gaps in VA healthcare utilization and quality of care with the potential to directly inform national improvements in cardiovascular care for Veterans, leading to more accessible, higher-quality, more equitable care in the future. In addition, the evaluation of care for cardiovascular disease could serve as a model for future research in other disciplines within Veterans Affairs medical specialty care. Specific Aims: Aim 1: Compare inpatient and outpatient utilization (clinic visits / hospitalizations / diagnostic testing / procedural care) among Veterans with common cardiovascular diagnoses (atrial fibrillation / coronary artery disease / heart failure) during the COVID-19 pandemic compared with expected utilization based on the corresponding 3-year period preceding the pandemic. Aim 2: Compare quality of care (guideline indicated medication / transitions of care) among Veterans with common cardiovascular diagnoses (atrial fibrillation / coronary artery disease / heart failure) during the COVID- 19 pandemic with that expected based on the corresponding 3-year period preceding the pandemic. Aim 3: Evaluate whether potential pandemic-related changes in healthcare utilization and/or process of care quality metrics are associated with an increased risk for the clinical outcomes of all-cause mortality and/or cardiovascular mortality among Veterans with common cardiovascular diagnoses. Methodology: We propose an observational, retrospective, national cohort study of Veterans with cardiovascular disease. The primary data sources will consist of the VA Corporate Data Warehouse (CDW) and the Non-VA Care Program Integrity Tools (PIT) system. Using indirect standardization, we will compare potential decreases in cardiovascular healthcare utilization and quality of care and a potential increase in mortality to that which occurred prior to the pandemic, performing subgroup analyses focused on age, sex and gender, and race and ethnicity as allowed by sample sizes. In mediation analyses, we will then assess whether the changes in utilization and quality of care were associated with an increased risk of mortality. Next Steps/Implementation: A stakeholder advisory panel, led by VA operational leaders, investigators, and Veterans, will be convened to develop comprehensive recommendations to optimize the access, quality, and equity of VA cardiovascular care and guide VA policies in the late-COVID-19 and/or post-COVID-19 pandemic period.	Systems Modeling, Design, and Delivery				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
SDR 22-046	Leung	Lucinda		Lucinda.Leung@va.gov	Leveraging COVID-19 to modernize depression care for VA primary care populations	09/01/2023	09/30/2027	VA Greater Los Angeles Healthcare System, West Los Angeles, CA	$324,133		Background: As part of comprehensive suicide prevention, VA integrated mental and physical health services to better detect and treat depression. Primary care nurses conduct screening annually. Clinicians, including Primary Care Mental Health Integration (PC-MHI) specialists, follow up as-needed for treatment. Depression detection and management processes are complex, involve multilevel stakeholders, and subject to significant disruption from COVID-19 and from resulting expansion of telehealth aiming to preserve care access. Fewer VA visits during the pandemic may signify lowered depression care quality and worsened patient outcomes. Significance: Depression affects 1 in 5 Veterans and is a leading cause of suicidality and disability. It contributes substantially to the current pandemic-related mental health crisis. Depression symptoms, including suicidal thoughts/behaviors, and related functional impairment have increased since COVID onset. Partnering with Primary Care, Mental Health, and Connected Care leaders, we propose to study pandemic-related service disruptions for depression, which may help to mitigate acute care use and mortality in the Veteran population. We apply established depression quality indicators from our prior research to a broad national scale at a critical time. We will also obtain feedback to improve current hybrid (virtual/in-person) care models from VA providers and Veterans who screened positive, including those who were not detected to have depression. Specific Aims: To improve virtual and in-person services for the VA primary care population during recovery, this proposal will examine how the pandemic disrupted depression care delivery mechanisms, including expanded telehealth, and patient outcomes. Our Specific Aims are: 1) To examine engagement in guideline- concordant care for depression (virtual or in-person) following screening, before and during the pandemic; 2) To compare psychiatric emergency/hospital visits and mortality from suicide between Veterans who screened positive and were detected versus not detected to have depression by clinicians; 3) To understand VA patients’ and providers’ current perspectives on addressing new depressive episodes using virtual and in-person modalities during the pandemic and eventual recovery. Methodology: Given hypothesized care disruption (lowered care quality) during COVID-19, Aim 1 proposes to extend our preliminary VISN methods nationally to assess the VA population’s trajectory from a new positive depression (and suicide-risk) screen to appropriate treatment (i.e., medication, therapy) in FY19-22/23. We will also examine the changing mix of virtual and in-person depression care delivered. Aim 2 will use interrupted time series analyses to explore the extent to which acute care use may be mitigated by clinician detection of depression nationally. We will also compare mortality rates between patients detected and not detected to have depression. Sub-analyses will reveal where (e.g., clinics with low PC-MHI access) and for whom (e.g., minorities) detection does not systematically occur, and downstream negative sequelae, to guide future intervention. Finally, Aim 3 will interview (1) 40 Veterans who were detected and not detected to have depression per Aims 1 & 2 about care-seeking behavior change, digital divide, etc. and (2) 40 VA primary care and PC-MHI providers about staffing shortage, telehealth adoption, etc. across three VAs (GLA, Syracuse, and Durham). In addition to contextualizing disrupted care findings, qualitative data will help isolate best practices on patient-to-provider and provider-to-provider (e.g., handoffs) interactions in hybrid depression care models. Next Steps/Implementation: The COVID-19 pandemic provides the VA with an opportunity to improve upon a system-wide proactive response to depression and suicide, one that is conceptualized to care for the entire Veteran population. This proposed research will provide the basis for testable hypotheses (e.g., acceptable virtual depression treatments in primary care), and clinical recommendations (e.g., satisfactory virtual provider- to-provider handoffs for new patient referrals), to improve virtual and in-person VA depression services.	Mental and Behavioral Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
SDR 22-148	Khazanov	Gabriela		Gabriela.Khazanov@va.gov	Incentivizing Lethal Means Safety Among Veterans at Risk for Suicide	03/01/2024	12/31/2028	Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA	$59,176		Background. Firearm injury accounts for 70% of Veteran suicides, making safer storage of firearms among Veterans at risk for suicide a top VA & HSR&D priority. Although VA providers encourage Veterans to store their firearms more safely during lethal means safety counseling (LMSC), only about half of individuals follow through on these recommendations. Additionally, little is known about methods for verifying firearm storage practices, which are critical for evaluating LMSC interventions. Research shows that offering financial and social incentives increases behavior change, and the Philadelphia VAMC has led a successful national program providing incentive-based interventions to Veterans with substance use disorders. The use of financial and social incentives to increase safe storage of firearms, however, has not yet been assessed. Significance/Impact. This proposal aims to leverage financial and social incentives to increase Veterans’ safe storage of firearms following LMSC, thereby contributing to VA’s suicide prevention efforts. VA’s existing infrastructure supporting the delivery of both LMSC and incentive-based interventions makes it an ideal setting for this work. Operational partners, including the Office of Mental Health and Suicide Prevention, the Rocky Mountain VA, and the Veterans Rural Health Resource Center support this proposal. Innovation. Financial and social incentives increase behavior change and our pilot work suggests that Veterans and VA clinicians are interested in using incentives to encourage safer storage of firearms. This proposal is the first to examine the use of incentives to change firearm storage behavior. It is also the first to evaluate methods for verifying firearm storage practices, which will provide critical information to researchers developing lethal means safety interventions and clinical providers delivering these interventions. Specific Aims. 1) Consult with stakeholders to determine the most acceptable and feasible intervention protocol that offers Veterans at risk for suicide financial and/or social incentives to store their firearms safely. 2) Pilot test the add-on, incentive-based intervention among Veterans receiving LMSC in VA behavioral health. Methodology. Aims will include participants from the VAMCs in Philadelphia and New Orleans, and will be conducted remotely to facilitate recruitment. Veteran participants will be seen in outpatient behavioral health and have access to firearms; equal numbers will be drawn from urban and rural settings and about a quarter will identify as women and racial/ethnic minorities. Aim 1 will include two steps. First, we will conduct qualitative interviews with ~20 Veterans with recent suicidal ideation, as well as ~10 VA clinicians/administrators. Interviews will evaluate the acceptability and feasibility of potential incentives, methods of verifying firearm storage practices, and other intervention components. Second, we will develop an advisory board made up of 8 Veterans and 8 other stakeholders (subject matter experts, VA clinicians/administrators). The advisory board will consider findings from qualitative interviews and use online modified Delphi methods to reach consensus on the most acceptable intervention components and best items to include in the pilot trial outcome measures. The study team will develop an intervention protocol and iteratively modify it to align with study findings. In Aim 2, we will conduct a pilot study with 24 Veterans who have completed LMSC to assess the add-on, incentive- based intervention. We will evaluate the feasibility of recruitment, retainment, provision of incentives, and methods of verifying changes in firearm storage, the acceptability of the intervention, and methods of individualizing the intervention based on Veterans’ preferences and sociodemographic characteristics. Next Steps/Implementation. We will apply for IIR funding to conduct a multi-site, Hybrid Effectiveness- Implementation Type 1 Randomized Clinical Trial. This trial will assess the effectiveness of the add-on LMSC intervention and barriers and facilitators to its implementation. If effective, we will disseminate the intervention in VA behavioral health settings to improve safe storage of firearms among Veterans at risk for suicide.	Mental and Behavioral Health				View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
SDR 23-001	McAndrew	Lisa		Lisa.Mcandrew@va.gov	Leveraging Knowledge of Chronic Multisymptom Illness to Improve Care for Veterans	12/01/2023	06/30/2026	East Orange Campus of the VA New Jersey Health Care System, East Orange, NJ	$267,772		An estimated 10-50% of patients develop persistent, disabling, & poorly understood symptoms after COVID-19 (PASC). For many, PASC is phenomenologically like CMI (e.g., Gulf War Illness). A meta-synthesis found patients with PASC have poor experiences with care. Patients report that, at best, clinicians want to support them but do not know how, and at worst, clinicians dismiss them as having a “mental health” disorder. Clinicians report poorly understood conditions, like PASC, are the most difficult conditions to manage. These descriptions of care for PASC are like those found in decades of research with CMI. Prior research has found as many as 60% of patients with these conditions are dissatisfied with care, which results in low uptake of evidence-based treatments and poor health outcomes. A critical gap exists in our understanding of how to improve the experience of care for patients with poorly understood conditions, like PASC. Our team is well- positioned to lead research to improve experiences with care for Veterans with PASC. We have led VA research efforts to understand and improve care for Veterans with CMI. This work has found 3 factors account for 40% of the variance in satisfaction with care for CMI. We have termed our approach, Concordant Care. The evidence-based Concordant Care approach involves engaging in processes that: 1) validate the patient's experience, 2) develop a shared understanding of the condition, and 3) create a patient-centered, whole health-oriented action plan to manage the condition. This is consistent with published expert opinion that Concordant Care underlies patients' (and clinicians') positive experiences of care for poorly understood conditions. Despite strong evidence supporting this care approach, there are no interventions to train clinicians on practices to provide Concordant Care for Veterans with poorly understood conditions. Our objective is to adapt, optimize, then test if a Concordant Care training improves VA clinicians' engagement in recommended practices to achieve Concordant Care (i.e., validate, shared understanding, action plan) for Veterans with PASC. Achieving this objective is feasible as we have already developed and piloted a CMI Concordant Care training for >300 VA clinicians, who rated it positively and reported it improved their practice. Our preliminary experiences suggests that our training is feasible, acceptable, and perceived as useful by VA clinicians and valued by VA program offices. Design: In Aim 1, we will adapt and optimize our Concordant Care training for PASC. The Concordant Care clinician training will include didactics, tele-mentoring sessions, and a clinician pocket card. Veterans who are cared for by trained clinicians will get a prompt to raise PASC concerns with their clinician. In Aim 2, we will conduct a randomized parallel cluster clinical trial to determine if Concordant Care training improves primary care clinicians' (n=60) provision of Concordant Care among Veterans with PASC (n=240), as compared to education packet control. Specific Aims: Aim 1. Adapt and refine Concordant Care training for PASC using an interactive, iterative, and user-centered design process informed by qualitative interviews and focus groups to optimize clinician access, uptake, and utilization. Aim 2. Determine if Concordant Care training increases clinicians' engagement in recommended practices to provide Concordant Care. Exploratory Aim 3: Explore effectiveness of Concordant Care on Veterans' with PASC care outcomes including satisfaction, adherence, and disability. Significance. Prior research with Gulf War Veterans showed the danger in waiting until we better understand the condition and best treatments before providing Concordant Care. This proposal aims to leverage our experiences with CMI to prevent another generation of Veterans from leaving the VA, feeling betrayed, and not receptive to new treatments when they become available. It is also responsive to President Biden's April 5, 2022 executive order addressing the need to quickly improve care for PASC. Long-term we will use our findings to propose a randomized clinical trial to determine the effectiveness of Concordant Care training on Veterans with PASC care outcomes.					View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
SDR 23-003	Ward	Ralph		ralph.ward@va.gov	DRP: Improving Medication Safety in the Era of the Mission Act	10/01/2022	12/31/2026	Ralph H. Johnson VA Medical Center, Charleston, SC	$30,251							View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact
TPP 97-008	Au	David		david.au@va.gov	Training Program for Fellows (post Ph.D.s) at Seattle COIN	10/01/1996	10/31/2021	VA Puget Sound Health Care System Seattle Division, Seattle, WA	$391,114			Capacity Building	1. Recruit strong candidates from across the US who are interested in an academic career. 2. Work with fellows on design, conduct and analysis of their research proposals. 3. Assist postdoctoral fellows with manuscript preparation and presentations at HSR&D and other national meetings. 4. Assist postdoctoral fellows in proposal development and review strategies. 5. Mentorship is an integral part of this fellowship. Faculty from VA and the University of Washington provide expertise in numerous areas of interest, including epidemiology, ethics, evaluation research, long-term care, quality of care, health policy, health professional education, geriatrics, prevention and ambulatory care. Fellowship support includes: stipend, office space, access to microcomputer support, administrative support, UW faculty affiliation. Fellows are supervised at least monthly by the Fellowship Director. 6. Take relevant courses to prepare for a health services research career (epidemiology, biostatistics, health services, health administration, and environmental health, etc). Funding is one or two years.	To provide postdoctoral level health services education, training and mentoring to PhD’s with strong methodologic skills who are interested in VA health services research careers.	Our new HSR&D postdoctoral fellow coming in October 2004 is Christian Helfrich, PhD.	View Details AbstractProject DescriptionProject MethodsProject ObjectivesProject Impact