- Nurse Practitioners as Primary Care Providers May Be a High-Value Solution to Increasing Access to Care for All Veterans
Investigators in this study assessed patient outcomes between primary care nurse practitioners (NPs) and MDs, including utilization, costs, and quality of care – one year after patient reassignment to a new primary care provider (due to a Veteran’s prior MD PCP leaving VA). Findings showed that compared to Veterans newly assigned to MDs, those newly assigned to NPs were less likely to use primary care and specialty care services – and incurred fewer hospitalizations. Further, Veterans assigned to NPs achieved similar quality of care in the management of
chronic disease compared to those assigned to MDs. Differences in costs, clinical outcomes, and the receipt of diagnostic tests between NP and MD groups were not statistically significant. Findings suggest that the general use of nurse practitioners as primary care providers may be a high-value solution to increasing access to care for all Veterans. Also, comparable or better outcomes achieved at similar costs for patients across differing levels of comorbidity suggest NPs as primary care providers need not be limited to less complex patients.
Date: April 1, 2020
- Veteran-Directed Care Adds to Options for Medically Complex Veterans Living in the Community – Without Raising Costs
One way in which VA facilitates independence and supports caregivers is through the Veteran-Directed Care (VDC) program, part of VA’s Office of Geriatrics and Extended Care Services. VDC enables enrollees to hire family members, friends, or neighbors as paid caregivers and also provides caregiver support, including caregiver training and burden monitoring. This study evaluated the incidence of VA hospital admissions, ambulatory care-sensitive admissions, and costs associated with inpatient care in the year after the initial receipt of a VDC service. Findings showed that Veterans enrolled in VDC had indicators of higher
chronic disease burden and more functional limitations than Veterans enrolled in other purchased-care service programs, but experienced similar decreases in hospital use and costs from before to after enrollment in services. During the 6th month before receiving services, mean monthly hospital costs were $2,131 for VDC patients, $1,054 for comparison group patients at sites with an active VDC program, and $974 for comparison group patients at sites without an active VDC program. In the 6th month after receiving services, mean monthly costs were $1,569, $1,170, and $1,049, respectively. In the 12th month after receiving services, VDC patients still had higher mean monthly hospital costs ($1,331) than patients in the active or inactive comparison group ($1,007 and $1,027, respectively), but the difference between costs among VDC patients and comparison-group patients had decreased. Given VDC’s popularity among Veterans and caregivers, it is a valuable model for supporting medically complex patients who are living in the community.
Date: June 1, 2019
- VA Geriatric Patient Aligned Care Teams Need Additional Mental Health Integration for Older Veterans
Geriatric Patient Aligned Care Teams (GeriPACT) provide healthcare for a subset of older Veterans with
chronic disease, functional dependency, cognitive decline, and psychosocial challenges. This study examines mental healthcare integration within GeriPACT by describing the role of psychiatrists/psychologists to help inform geriatric mental health policy. Findings showed that mental health integration was less than 50% in the GeriPACT teams in this study: only 43% of GeriPACT teams had a mental health provider – either a psychiatrist (29%) and/or psychologist (24%). Teams with psychiatrist/psychologist providers were more likely to endorse management of psychosocial issues, dementia, and depression, indicating the potential benefit of including mental healthcare providers on teams.
Date: September 13, 2018
- More Patient-Aligned Care Team Components Translates to Improved Quality of Care for Veterans with
This study examined whether the extent to which clinics had implemented PACT components was associated with improvements in the quality of care for Veterans with chronic conditions over a four year period. Findings showed that over four years concurrent with PACT implementation, primary care clinics with the most PACT components in place had greater improvements in 5 of 7
chronic disease intermediate clinical outcome and 2 of 8
chronic disease process measures when compared to clinics with the least PACT components in place. Quality measures that improved more among the clinics with highest PACT implementation included LDL< 100 in CAD and DM patients, and BP < 160/100 in DM and HTN patients. Improvements in percentage of clinic patient population meeting clinical outcome quality measures over four years in the high PACT implementation clinics ranged from 1.3% to 5.2%. VA primary care clinics may be able to achieve improved quality of care for patients with common chronic conditions through patient-centered medical home-aligned changes in care delivery across all patients, if those changes are extensively implemented.
Date: November 20, 2017
- VA Experience with Implementing Intensive Primary Care Programs for Veterans at Highest Risk
This case study describes VA’s experience with implementing intensive primary care programs, as well as the program elements that appear to be necessary to meet the complex care needs of these high-risk Veterans. Findings showed that the PACT Intensive Management program (PIM) has been successfully implemented for more than three years at five demonstration sites in the VA healthcare system. The PIM program has evolved over time, eventually converging on implementation of the following elements: an interdisciplinary care team,
chronic disease management, comprehensive patient assessment and evaluation, care and case management, transitional care support, preventive home visits, pharmaceutical services,
chronic disease self-management, caregiver support services, health coaching, and advanced care planning. PIM teams also found that including social workers and mental health providers on the interdisciplinary teams was critical to effectively address the psychosocial needs of these complex patients. In addition, having a central implementation coordinator facilitated the convergence of these program features across diverse demonstration sites.
Date: October 25, 2017
- Online Game Improves Glucose Control in Veterans with Diabetes
This randomized trial sought to determine whether a team-based game on diabetes self-management education (DSME) topics delivered to VA patients with type 2 diabetes could generate sustained improvements in their HbA1c levels. Findings showed that the game delivering DSME content generated significant improvements in HbA1c over 12 months among Veterans with type 2 diabetes, with the difference between cohorts (DSME vs. civics game) manifesting primarily in the 6 months following the games. Among DSME game patients with elevated HbA1c at baseline, the overall reduction in HbA1c was comparable to that of starting a new diabetes medication. The online, interactive methodology used in this intervention may be an effective and scalable method by which to improve health outcomes in Veterans with diabetes and other
Date: September 1, 2017
- Systematic Review Compares Pharmacist-Led Care to Usual Care for
Chronic Disease Management
This systematic review sought to determine the effectiveness and harms of pharmacist-led
chronic disease management for community-dwelling adults. Findings showed that compared with usual care, pharmacist-led care was associated with similar numbers of office visits, urgent care or emergency department visits, and hospitalizations, as well as medication adherence. Compared with usual care, pharmacist-led care increased the number or dose of medications received and improved glycemic, BP, and lipid goal attainment. Mortality and clinical events were similar between patients in usual care versus pharmacist-led care. Pharmacist-led
chronic disease management was associated with effects similar to those of usual care for resource utilization and may improve physiologic goal attainment.
Date: April 26, 2016
- Electronic Patient Portals and their Effect on Health Outcomes
Investigators conducted a systematic review of the relevant literature evaluating peer-reviewed articles on patient portals tied to existing electronic medical record systems, specifically looking at whether or not these systems improve health outcomes, patient satisfaction, healthcare utilization and efficiency, and adherence. Findings showed that the evidence is insufficient as to the effects of patient portals on health outcomes. A limited number of studies and variations in study design, portal functionalities, and implementation processes make it difficult to draw strong conclusions or generalizations about this relatively new technology. Examples were identified in which portal use was associated with improved outcomes for patients with
chronic diseases (i.e., diabetes, hypertension, depression), but these were generally studies that used the portal in conjunction with case management. Evidence was mixed about the effect of portals on healthcare utilization and efficiency. Some findings included more acceptance of portals by patients who were younger and had more computer literacy or trust in the Internet, and more enthusiasm for portals among patients than physicians. Administrative and human factors in the interface were cited as barriers to use. Thus, the jury is still out on whether patient portals such as MyHealtheVet improve health outcomes or increase healthcare efficiency, although patients seem to value the ability to access their own medical records. While patients’ attitudes on portals are generally positive, more widespread use may require efforts to overcome racial, ethnic, and literacy barriers.
Date: November 19, 2013
- High TBI Screening Rates among OEF/OIF Veterans
This study describes the early results of VA’s TBI screening program, and identifies patient and facility characteristics associated with receiving a TBI screen. Findings showed that TBI screening rates are high in VA, with more than 90% of eligible Veterans screened. Of Veterans who were screened, 21% met the VA definition of a positive screen, with blast or explosion the most common exposure reported. Factors associated with a positive TBI screen included: male gender, having served in the Army, having had multiple deployments, and having mental health diagnoses in the previous year. A positive TBI screen was less likely among Veterans who were separated from duty for more than 18 months, or Veterans who had a
chronic disease diagnosis. The most common symptoms reported in the period after injury were sleep problems (78%), irritability (69%), and headaches (63%), and these symptoms continued to be current problems at time of screening.
Date: March 1, 2013
- Chronic Disease Management Initiative Reduces Hospitalizations for Ambulatory Care Sensitive Conditions among Veterans
chronic disease management (CDM) initiative in VISN 23 was associated with a significant reduction in hospitalizations for ambulatory care sensitive conditions (ACSCs) compared with other VA healthcare systems. The estimated annual effect of the CDM initiative is 2.9 fewer hospital admissions per 1,000 Veterans who have an ACSC. This is nearly 10% of the average of 30.8 ACSC admissions per 1,000 Veterans in the other networks in 2010. ACSC hospitalization ratios were nearly identical in 2006 (before CDM implementation) between VISN 23 and the other VISNs.
Date: January 1, 2012
- Growing VA Research Agenda for Women Veterans
This paper reports on the 2010 VA Women’s Health Services Research Conference, as well as the resulting research agenda for moving forward on behalf of women who have served in the military. Recommendations for the future VA women’s health research agenda, resulting from this conference, included, to name a few: Address gaps in women Veterans’ knowledge and use of VA services (e.g., outreach/education, social marketing, telemedicine); Evaluate and improve quality of transitions from military to VA care; Assess gender differences in the presentation and outcomes of
chronic diseases; Determine reproductive health needs of women Veterans; Examine the structure and care models that support patient-aligned care teams; Evaluate variations in mental healthcare needs; Assess and reduce the risk of homelessness among women Veterans; Conduct research on post-deployment reintegration and readjustment among women Veterans; and Develop combat exposure measure(s) that reflect women Veterans’ experiences.
Date: July 6, 2011
- Heart Failure Mortality Decreases While Rehospitalization Increases among Veterans
Heart failure is the number one reason for admission among Veterans enrolled in the VA healthcare system. In order to improve care for this
chronic disease, VA has incorporated the use of guideline-recommended treatments; however, it is unclear if the increased performance on process of care measures for hospitalized Veterans has led to improvements in outcomes. This study sought to determine if recent mortality and readmission rates have improved within VA. Findings show that mortality and rehospitalization rates for Veterans with a first hospitalization for heart failure in the VA healthcare system or in a non-VA hospital that was paid for by VA trended in opposite directions between 2002 and 2006. Mortality rates at 30 days decreased (7.1% to 5.0%), while rehospitalization rates for heart failure at 30 days increased (5.6% to 6.1%). Over the same time period, use of guideline recommended therapy increased. During the six months prior to hospital admission and during the three months following admission, there were large increases in the use of beta-blockers. The use of angiotensin-receptor blockers also increased. Examination of patient characteristics showed that most comorbid diagnoses increased significantly from 2002 to 2006, suggesting that Veterans hospitalized in 2006 were more ill. The authors suggest that the use of rehospitalization for heart failure as a marker of poor care may be flawed. Further studies to determine the reasons for the decline in mortality and the portion of hospitalizations that are preventable are recommended.
Date: July 27, 2010
- Characteristics and Needs of Veteran Cancer Survivors
Findings show that 11% of the Veterans treated within the VA healthcare system in FY07 were cancer survivors. The most common cancer types were prostate, skin (non-melanoma), and colorectal. Compared to the general population, Veteran cancer survivors are older (84% are older than 60) and predominantly male (97%). Cancer site prevalence statistics vary between the VA and general U.S. cancer patient populations due to differences in age, gender, and risk factors. Overall, the four common symptom concerns reported by cancer survivors are sexual dysfunction, fatigue, anxiety, and depression. The authors suggest that Veteran-specific research is needed on topics such as cancer survival among older Veterans, and the role of military exposures (physical, emotional, and psychological) in causing cancer and impacting recovery. The authors also suggest that four models of care may be relevant to improving care for Veterans who have survived cancer: 1) cancer survivorship clinics, 2) cancer care transition plans, 3) rehabilitation, and 4)
chronic disease management. These models of care may help integrate the physical and mental health needs of cancer survivors.
Date: March 1, 2010
- Affective Disorders Strongest Predictor of Suicidal Behavior in Elderly Veterans Receiving Anti-Epileptic Medication
In January 2008, the FDA issued an alert indicating that anti-epileptic drug (AED) treatment is associated with increased risk for suicidal ideation, attempt, and completion. This study sought to assess variation in suicide-related behaviors in a population not well-represented by the data used for the FDA analysis – individuals 66 years and older with new exposure to AEDs. Findings show that in older Veterans who were started on AED monotherapy, the strongest reliable predictor of suicide-related behaviors was the diagnosis of an affective disorder prior to AED treatment. Increased suicide-related behaviors were not associated with individual AEDs. However, while most Veterans in this study received AED prescriptions for gabapentin (76.8%), a trend for increased suicide-related behaviors was found among those prescribed levetiracetam or lamotrigine, but interpretation was difficult since few Veterans received either drug (0.6%). The associations between suicide-related behaviors and chronic pain or
chronic disease burden were not statistically significant, but dementia was significantly associated with suicide-related behaviors (42.2% with dementia vs. 25.8% without).
Date: January 11, 2010
- “Super-obesity” Associated with Risk of Death Among Veterans Following Bariatric Surgery
This retrospective study of 856 bariatric surgical cases conducted in 12 VAMCs between 2000 and 2006 sought to define the risk of death among Veterans with a body mass index (BMI) of 40 or greater – and to identify patient-level factors associated with mortality. Findings show that Veterans classified as “super-obese” (BMI of 50 or higher) and those with a higher
chronic disease burden appear more likely to die within one year of having bariatric surgery. Authors recommend that the risks of bariatric surgery in patients with significant comorbidities should be carefully weighed against potential benefits in older male Veterans and those with super-obesity.
Date: October 1, 2009
- Improving Provider-Patient Communication about Routine HIV Testing in VA
This study sought to understand patient and provider perspectives on the adoption of routine HIV testing within the VA healthcare system. Findings show that Veterans and providers agreed that the implementation of routine HIV testing, treating HIV like other
chronic diseases, and removing requirements for written informed consent and pre-test counseling would benefit both Veterans and public health. Veterans wished to have HIV testing routinely offered by providers so that they could decide whether or not to be tested; they also believed that routine testing would help de-stigmatize HIV. Six steps for providers to use in communicating about routine testing also were identified, such as raising the topic of HIV testing, reassuring the Veteran that he/she is not showing clinical signs of the disease, and responding to Veteran questions about HIV.
Date: October 1, 2009
- Veterans with Hypertension and Comorbidities Receive Better Care than Veterans with Hypertension Alone
This study sought to determine the impact of different types of co-existing
chronic diseases on quality of care for hypertension, as well as patient perceptions of quality. Findings show that Veterans with hypertension and comorbid conditions had greater odds of receiving good quality of care. Moreover, as the number of chronic conditions increased, so did the odds of receiving appropriate overall care for hypertension. No relationship was found between the provision of guideline-recommended care for hypertension and Veterans’ perception of quality of care, nor did Veterans’ assessment of quality of care vary by the presence of co-existing conditions.
Date: June 16, 2009