BACKGROUND/RATIONALE:
Women Veterans continue to be the fastest growing segment of new VA users, but their numerical minority has created challenges to delivering gender-sensitive comprehensive care in VA settings. Patient Aligned Care Teams (PACT)-VA's medical home model-hold promise for improving such care, but had not been systematically adapted to meet women's needs, including comprehensive women's health services in gender-sensitive care environments.

OBJECTIVE(S):
We assessed the effectiveness of an evidence-based quality improvement (EBQI) approach for developing a WH-PACT model using a cluster randomized trial design (Aim #1); examined impacts of receipt of WH-PACT concordant care on women Veterans' (WVs) outcomes (Aim #2); evaluated processes of EBQI-supported WH-PACT implementation (Aim #3); and developed implementation and evaluation tools for use in EBQI-supported WH-PACT model adaptation, implementation, sustainability and spread to additional VA facilities (Aim #4).

METHODS:
We launched EBQI through VISN-level stakeholder panel meetings, formed and supported local QI teams, delivered EBQI training to all QI teams, provided external practice facilitation through site-specific and across-site calls, delivered formative feedback reports using data collected for the trial, and provided technical support (e.g., focus group methods training) over 24 months. We then convened in-person capstone VISN-level stakeholder meetings to review outcomes.

We evaluated EBQI in a cluster randomized trial in 12 VAMCs in four VISNs, using baseline, 12- and 24-month surveys of WV primary care (PC) patients with 3+ WH or PC visits; baseline and 24-month surveys of all PC and WH providers/staff; baseline and 24-month interviews of key stakeholders in participating VISNs, VAMCs, and clinics and PACT teamlet members; 12-month interviews of EBQI team members; and analyzed retrospective secondary data. We measured provider/staff QI orientation/culture, attitudes, PACT team functioning, provider burnout, and gender sensitivity, as well as achievement of patient survey-derived WH-PACT features (e.g., accessible, continuous, coordinated care), comprehensiveness, and gender-sensitive care delivery. We included an array of patient-reported outcomes and experiences (e.g., harassment) for formative feedback and monitoring. We also examined influences of practice context, including leadership support, local resources, care model type, and other characteristics.

FINDINGS/RESULTS:
Local QI projects spanned efforts to improve PACT team function, breast cancer screening, follow-up of abnormal cervical cytology, assignment of new patients to WH providers, coupled HPV/Pap test result reporting, trauma sensitivity of residents, the culture and environment of care, and teratogen medication prescribing, among others, based on VISN-level QI roadmaps developed in the initial stakeholder panel meetings and adapted to local context. Trial results (Aim #1) demonstrated significant improvements in PACT team functioning and provider gender sensitivity in EBQI vs. control VAMCs, and 24-month differences in provider burnout favoring EBQI sites. We did not find patient-level differences in PACT features of care or WH PACT-ness between EBQI and control sites (Aim #2). Formative analyses of baseline and 12-month follow-up data yielded advanced understanding of the health and healthcare needs of WVs who are routine PC users, variations in access to routine and urgent care, timeliness of mental health access, stranger harassment prevalence, delayed/missed care among LGBT WVs, levels of WVs' food insecurity, and the contribution of positive mental health screens (PTSD, depression, anxiety) to how WVs rate their provider's communication, trust in VA and care quality. They yielded new information about the impact of VA's lack of gender-tailoring of alcohol use disorder screening in PC settings. Key stakeholder interviews (Aim #3) demonstrated substantial internal changes in operations and active multilevel stakeholder engagement in EBQI functions and activities, and corroborated trial findings of positive impacts on provider burnout, team function, and organizational culture, in addition to elucidating recommendations for ideal care and hassles reduction. According to stakeholders who were pivotally involved in EBQI, this implementation strategy had notable value in empowering staff to make locally-driven, spreadable practice improvements. External facilitation via site-specific teleconferences was the most consistently identified important element of EBQI because they helped teams maintain momentum and accountability, especially in the context of competing priorities. Stakeholders described the overall EBQI effort as a "game changer," providing "renewed hope," "encouragement," and "tools, inspiration, and support to come up with ideas to improve our own practice environments." We developed tools for use in EBQI-supported WH-PACT model adaptation, implementation, sustainability and spread to additional VA facilities (Aim #4). These included an array of slide deck templates, EBQI education modules, formative feedback report templates, stakeholder panel methods, training in multilevel stakeholder engagement strategies, and other components of EBQI implementation. These tools have been adapted for use by a contract vendor in WHS's EBQI effort with low-performing VAs, in addition to development and application of technical specifications for the EBQI contract. We redeployed abbreviated versions of EBQI training for use nationally among all WH Medical Directors and WV Program Managers, and, most recently, for use in the WH Practice Based Research Network to explore spread of innovations already tested in EBQI sites to a larger number of facilities. These tools are also being integrated into a QUERI Implementation Strategy Training Hub (Hamilton, PI).

IMPACT:
EBQI is a systematic approach to developing a multilevel research-clinical partnership approach to engaging organizational leaders and local QI teams in adapting and implementing new care models in the context of prior evidence, local practice context, and provider behavior change methods, with researchers providing technical support, formative data feedback, and practice facilitation. We found that EBQI has a positive impact on delivering gender-sensitive care in better functioning PACTs while being associated with lower provider burnout, while participating sites made demonstrable, local quality gains, several of which were spread VISN-wide without additional resources. The partnered nature of this trial led to advances in VA policy initiatives in key areas, including launch of the new national VA culture campaign in response to reports of stranger harassment on VA grounds and prospects for gender-tailoring alcohol use screening as current practices may miss some at-risk WV drinkers. This study also provided a foundation for the WH-PACT Roadmap which has been disseminated by WHS nationally to support gender-tailored PACT implementation.

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External Links for this Project

NIH Reporter

Grant Number: I01HX000991-01
Link: https://reporter.nih.gov/project-details/8399383

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PUBLICATIONS:

None at this time.

DRA: Health Systems Science
DRE: none
Keywords: none
MeSH Terms: none