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2023 HSR&D/QUERI National Conference Abstract

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1028 — Implementation of Nudges to Encourage Use of Complementary and Integrative Health Therapies in the Veterans Health Administration

Lead/Presenter: Michelle Upham,  COIN - Seattle/Denver
All Authors: Upham ML (Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington), Der-Martirosian C (Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA) Shin MH (Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA) Gelman H (VA Information Resource Center (VIReC), Edward Hines, Jr. VA Hospital, Hines, IL) Lott B (Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA) Zeliadt SB (Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington) Taylor SL (Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA) Elwy AR (Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA)

Objectives:
The Comprehensive Addiction and Recovery Act mandates complementary and integrative health (CIH) therapy provision in the Veterans Health Administration (VA). In 2018, 18 VA medical centers focused on implementing practitioner-delivered (acupuncture, chiropractic care, therapeutic massage) and self-care (yoga, Tai Chi/Qigong, meditation/mindfulness) evidence-based CIH therapies. However, little is known about the best practices for encouraging/nudging patients to use these therapies. Our objective was to identify strategies (i.e., nudges) used by the 18 sites to encourage Veterans to try CIH therapies. We identified different types of nudges to self-care, practitioner-delivered, or both CIH therapies (i.e., dual care).

Methods:
We conducted over 100 interviews with 70 key stakeholders during quarterly site visits at 18 VA medical centers (2018-2021). CIH program/clinical directors and staff at each site participated in virtual site visits with the study team where we learned the strategies sites used to implement the nudges. From site notes, we first identified the strategies (nudges) that sites used to encourage patients to use CIH therapies. We then grouped these identified nudges into categories (i.e., nudge types), and then mapped each individual nudge to the 73 Expert Recommendations for Implementing Change (ERIC) strategies. We conducted two analyses: 1) presented number of nudge types for each site, 2) illustrated which ERIC strategies mapped to which nudge type.

Results:
We identified eight specific nudge types: Referral, Off Pathway, Advertising/Marketing/Outreach, Gateway, Incentive, On Pathway, Site Structure, Availability of Resources, with the more frequently used being the first three. Beyond the first three, there was significant variation across the 18 sites. We defined ‘Referral’ as changing the referral processes to make patients’ access to self-care CIH therapies easier, whereas Off Pathway is defined as exposing patients to dual/self-care through non-CIH providers. Our results will review specific examples of the eight nudge types for each CIH therapy (practitioner-delivered, self-care, or dual care). We also identified specific ERIC strategies that map to the eight nudge types. For example, several ERIC strategies, such as develop and distribute educational materials, conduct educational meetings, outreach visits, and use of mass media, mapped to the Advertising/Marketing/Outreach nudge type (e.g., use of flyers, website, digital waiting room information screens, etc. to encourage Veterans to use CIH therapies). The nudge types: Referral, Advertising, and Off pathway mapped across multiple ERIC strategies.

Implications:
The study results illustrate variation across 18 sites in the number and category of nudge types used to encourage practitioner-delivered, self-care, and dual-care CIH therapies. The eight nudge types identified provide a taxonomy to categorize encouragements to CIH therapies.

Impacts:
The study findings provide valuable, detailed examples of strategies to nudge patients to engage in practitioner-delivered, self-care, as well as dual care CIH therapies that are grounded in the ERIC framework. This approach can create the opportunity to have a shared conceptual model for CIH program directors, providers, and staff to implement and assess the various identified nudge types.