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1.  Challenges in Referral Communication Between VHA Primary Care and Specialty Care 
Poor communication between primary care providers (PCPs) and specialists is a significant problem and a detriment to effective care coordination. Inconsistency in the quality of primary–specialty communication persists even in environments with integrated delivery systems and electronic medical records (EMRs), such as the Veterans Health Administration (VHA).
The purpose of this study was to measure ease of communication and to characterize communication challenges perceived by PCPs and primary care personnel in the VHA, with a particular focus on challenges associated with referral communication.
The study utilized a convergent mixed-methods design: online cross-sectional survey measuring PCP-reported ease of communication with specialists, and semi-structured interviews characterizing primary–specialty communication challenges.
191 VHA PCPs from one regional network were surveyed (54 % response rate), and 41 VHA PCPs and primary care staff were interviewed.
Main Measures/Approach
PCP-reported ease of communication mean score (survey) and recurring themes in participant descriptions of primary–specialty referral communication (interviews) were analyzed.
Key Results
Among PCPs, ease-of-communication ratings were highest for women’s health and mental health (mean score of 2.3 on a scale of 1–3 in both), and lowest for cardiothoracic surgery and neurology (mean scores of 1.3 and 1.6, respectively). Primary care personnel experienced challenges communicating with specialists via the EMR system, including difficulty in communicating special requests for appointments within a certain time frame and frequent rejection of referral requests due to rigid informational requirements. When faced with these challenges, PCPs reported using strategies such as telephone and e-mail contact with specialists with whom they had established relationships, as well as the use of an EMR-based referral innovation called “eConsults” as an alternative to a traditional referral.
Primary–specialty communication is a continuing challenge that varies by specialty and may be associated with the likelihood of an established connection already in place between specialty and primary care. Improvement in EMR systems is needed, with more flexibility for the communication of special requests. Building relationships between PCPs and specialists may also facilitate referral communication.
PMCID: PMC4351287  PMID: 25410884
primary care; specialty care; communication; electronic health records; veterans
2.  Targeting Primary Care Referrals to Smoking Cessation Clinics Does Not Improve Quit Rates: Implementing Evidence-Based Interventions into Practice 
Health Services Research  2008;43(5 Pt 1):1637-1661.
To evaluate the impact of a locally adapted evidence-based quality improvement (EBQI) approach to implementation of smoking cessation guidelines into routine practice.
Data Sources/Study Setting
We used patient questionnaires, practice surveys, and administrative data in Veterans Health Administration (VA) primary care practices across five southwestern states.
Study Design
In a group-randomized trial of 18 VA facilities, matched on size and academic affiliation, we evaluated intervention practices’ abilities to implement evidence-based smoking cessation care following structured evidence review, local priority setting, quality improvement plan development, practice facilitation, expert feedback, and monitoring. Control practices received mailed guidelines and VA audit-feedback reports as usual care.
Data Collection
To represent the population of primary care-based smokers, we randomly sampled and screened 36,445 patients to identify and enroll eligible smokers at baseline (n = 1,941) and follow-up at 12 months (n = 1,080). We used computer-assisted telephone interviewing to collect smoking behavior, nicotine dependence, readiness to change, health status, and patient sociodemographics. We used practice surveys to measure structure and process changes, and administrative data to assess population utilization patterns.
Principal Findings
Intervention practices adopted multifaceted EBQI plans, but had difficulty implementing them, ultimately focusing on smoking cessation clinic referral strategies. While attendance rates increased (p<.0001), we found no intervention effect on smoking cessation.
EBQI stimulated practices to increase smoking cessation clinic referrals and try other less evidence-based interventions that did not translate into improved quit rates at a population level.
PMCID: PMC2653889  PMID: 18522670
Smoking cessation; quality of health care; veterans
3.  VA Health Service Utilization for Homeless and Low-income Veterans 
Medical care  2014;52(5):454-461.
The US Department of Housing and Urban Development (HUD)-VA Supportive Housing (VASH) program—the VA’s Housing First effort—is central to efforts to end Veteran homelessness. Yet, little is known about health care utilization patterns associated with achieving HUD-VASH housing.
We compare health service utilization at the VA Greater Los Angeles among: (1) formerly homeless Veterans housed through HUD-VASH (HUD-VASH Veterans); (2) currently homeless Veterans; (3) housed, low-income Veterans not in HUD-VASH; and (4) housed, not low-income Veterans.
Research Design
We performed a secondary database analysis of Veterans (n = 62,459) who received VA Greater Los Angeles care between October 1, 2010 and September 30, 2011. We described medical/surgical and mental health utilization [inpatient, outpatient, and emergency department (ED)]. We controlled for demographics, need, and primary care use in regression analyses of utilization data by housing and income status.
HUD-VASH Veterans had more inpatient, outpatient, and ED use than currently homeless Veterans. Adjusting for demographics and need, HUD-VASH Veterans and the low-income housed Veterans had similar likelihoods of medical/surgical inpatient and outpatient utilization, compared with the housed, not low-income group. Adjusting first for demographics and need (model 1), then also for primary care use (model 2), HUD-VASH Veterans had the greatest decrease in incident rates of specialty medical/surgical, mental health, and ED care from models 1 to 2, becoming similar to the currently homeless, compared with the housed, not low-income group.
Our findings suggest that currently homeless Veterans underuse health care relative to housed Veterans. HUD-VASH may address this disparity by providing housing and linkages to primary care.
PMCID: PMC4714600  PMID: 24714583
veterans; homelessness; supportive housing
4.  Development of the Quality Improvement Minimum Quality Criteria Set (QI-MQCS): a tool for critical appraisal of quality improvement intervention publications 
BMJ Quality & Safety  2015;24(12):796-804.
Valid, reliable critical appraisal tools advance quality improvement (QI) intervention impacts by helping stakeholders identify higher quality studies. QI approaches are diverse and differ from clinical interventions. Widely used critical appraisal instruments do not take unique QI features into account and existing QI tools (eg, Standards for QI Reporting Excellence) are intended for publication guidance rather than critical appraisal. This study developed and psychometrically tested a critical appraisal instrument, the QI Minimum Quality Criteria Set (QI-MQCS) for assessing QI-specific features of QI publications.
Approaches to developing the tool and ensuring validity included a literature review, in-person and online survey expert panel input, and application to empirical examples. We investigated psychometric properties in a set of diverse QI publications (N=54) by analysing reliability measures and item endorsement rates and explored sources of disagreement between reviewers.
The QI-MQCS includes 16 content domains to evaluate QI intervention publications: Organisational Motivation, Intervention Rationale, Intervention Description, Organisational Characteristics, Implementation, Study Design, Comparator Description, Data Sources, Timing, Adherence/Fidelity, Health Outcomes, Organisational Readiness, Penetration/Reach, Sustainability, Spread and Limitations. Median inter-rater agreement for QI-MQCS items was κ 0.57 (83% agreement). Item statistics indicated sufficient ability to differentiate between publications (median quality criteria met 67%). Internal consistency measures indicated coherence without excessive conceptual overlap (absolute mean interitem correlation=0.19). The critical appraisal instrument is accompanied by a user manual detailing What to consider, Where to look and How to rate.
We developed a ready-to-use, valid and reliable critical appraisal instrument applicable to healthcare QI intervention publications, but recognise scope for continuing refinement.
PMCID: PMC4680162  PMID: 26311020
Quality improvement; Evaluation methodology; Evidence-based medicine; Healthcare quality improvement; Quality improvement methodologies
5.  Wishing Upon a STAR*D: The Promise of Ideal Depression Care by Primary Care Providers 
The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial found that after initial treatment, depressed patients treated in primary care settings had the same or slightly better outcomes than those treated in specialty care settings. The authors describe challenges to using the STAR*D approach and protocols in usual primary care settings. These include inadequate availability of appointments, insufficient resources for care management and treatment monitoring, and lack of payment to primary care providers for providing mental health care. Substantial reengineering of payment and delivery systems is needed in order for the STAR*D approach to be viable in primary care clinics.
PMCID: PMC4670562  PMID: 19880461
6.  The Relationship between Same-Day Access and Continuity in Primary Care and Emergency Department Visits 
PLoS ONE  2015;10(9):e0135274.
We examined how emergency department (ED) visits for potentially preventable, mental health, and other diagnoses were related to same-day access and provider continuity in primary care using administrative data from 71,296 patients in 22 VHA clinics over a three-year period. ED visits were categorized as non-emergent; primary care treatable; preventable; not preventable; or mental health-related. We conducted multi-level regression models adjusted for patient and clinic factors. More same-day access significantly predicted fewer non-emergent and primary care treatable ED visits while continuity was not significantly related to any type of ED visit. Neither measure was related to ED visits for mental health problems.
PMCID: PMC4557991  PMID: 26332981
8.  Managing physician lipid management: a population wide, risk-based decision support approach 
Successful implementation of clinical guidelines for preventing complications of dyslipidemias has been an ongoing challenge. The article by Vinker and colleagues in this journal investigates the results of implementing risk-based guidelines for LDL (Low Density Lipoprotein) management in comparison to the prior approach of using the same LDL cutoff for patients at all levels of risk. Results show LDL levels dropped across the primary care population using the new risk-based approach, suggesting that clinical decision aids that link to individual patient characteristics, rather than promoting a universal target for all, may provide a particularly strong stimulus for changing provider and patient behavior. Results also challenge healthcare organizations, providers and patients to learn more about the pathway from guidelines to clinical reminders and from reminders to lower LDL levels and better population health.
PMCID: PMC4501078  PMID: 26175893
9.  Predictors of Primary Care Management of Depression in the Veterans Affairs Healthcare System 
Journal of General Internal Medicine  2014;29(7):1017-1025.
Primary care providers (PCPs) vary in skills to effectively treat depression. Key features of evidence-based collaborative care models (CCMs) include the availability of depression care managers (DCMs) and mental health specialists (MHSs) in primary care. Little is known, however, about the relationships between PCP characteristics, CCM features, and PCP depression care.
To assess relationships between various CCM features, PCP characteristics, and PCP depression management.
Cross-sectional analysis of a provider survey.
180 PCPs in eight VA sites nationwide.
Independent variables included scales measuring comfort and difficulty with depression care; collaboration with a MHS; self-reported depression caseload; availability of a collocated MHS, and co-management with a DCM or MHS. Covariates included provider type and gender. For outcomes, we assessed PCP self-reported performance of key depression management behaviors in primary care in the past 6 months.
Response rate was 52 % overall, with 47 % attending physicians, 34 % residents, and 19 % nurse practitioners and physician assistants. Half (52 %) reported greater than eight veterans with depression in their panels and a MHS collocated in primary care (50 %). Seven of the eight clinics had a DCM. In multivariable analysis, significant predictors for PCP depression management included comfort, difficulty, co-management with MHSs and numbers of veterans with depression in their panels.
PCPs who felt greater ease and comfort in managing depression, co-managed with MHSs, and reported higher depression caseloads, were more likely to report performing depression management behaviors. Neither a collocated MHS, collaborating with a MHS, nor co-managing with a DCM independently predicted PCP depression management. Because the success of collaborative care for depression depends on the ability and willingness of PCPs to engage in managing depression themselves, along with other providers, more research is necessary to understand how to engage PCPs in depression management.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-014-2807-z) contains supplementary material, which is available to authorized users.
PMCID: PMC4061347  PMID: 24567200
primary care; mental health; depression; care management
10.  Challenges Facing Primary Care Practices Aiming to Implement Patient-Centered Medical Homes 
Journal of General Internal Medicine  2014;29(Suppl 2):555-562.
While the potential of patient-centered medical homes (PCMH) is promising, little is known empirically about the frontline challenges that primary care (PC) leaders face before making the decision to implement PCMH, let alone in making it a reality.
Prior to the design and implementation of the Veterans Health Administration’s (VA) national PCMH model—Patient Aligned Care Teams (PACT)—we identified the top challenges faced by PC directors and examined the organizational and area level factors that influenced those challenges.
A national cross-sectional key informant organizational survey was fielded to the census of PC directors at VA medical centers and large community-based outpatient clinics (final sample n = 229 sites).
PC directors were asked to rate the degree to which they faced 48 management challenges in eight PCMH-related domains (access, preventive care, chronic diseases requiring care in PC, challenging medical conditions, mental health/substance abuse, special populations, PC coordination of care, and clinical informatics). Responses were dichotomized as moderately-to-extremely challenging versus somewhat-slightly-not at all challenging. Items were rank ordered; chi square or regression techniques were used to examine variations in facility size, type, urban/rural location, and region.
On average, VA PC directors reported 16 moderate-to-extreme challenges, and the top 20 challenges spanned all eight PCMH domains. Four of the top 20 challenges, including the top two challenges, were from the clinical informatics domain. Management of chronic non-malignant pain requiring opiate therapy was the third most reported challenge nationwide. Significant organizational and area level variations in reported challenges were found especially for care coordination.
Better understanding of PC challenges ahead of PCMH implementation provides important context for strategic planning and redesign efforts. As a national healthcare system, the VA provides a unique opportunity to examine organizational and area determinants relevant to other PCMH models.
PMCID: PMC4070226  PMID: 24715394
primary care; patient-centered medical home; Veterans; VA healthcare system; health care management
11.  The Anatomy of Primary Care and Mental Health Clinician Communication: A Quality Improvement Case Study 
Journal of General Internal Medicine  2014;29(Suppl 2):598-606.
The high prevalence of comorbid physical and mental illnesses among veterans is well known. Therefore, ensuring effective communication between primary care (PC) and mental health (MH) clinicians in the Veterans Affairs (VA) health care system is essential. The VA’s Patient Aligned Care Teams (PACT) initiative has further raised awareness of the need for communication between PC and MH. Improving such communication, however, has proven challenging.
To qualitatively understand barriers to PC-MH communication in an academic community-based clinic by using continuous quality improvement (CQI) tools and then initiate a change strategy.
Design, Participants, and Approach
An interdisciplinary quality improvement (QI) work group composed of 11 on-site PC and MH providers, administrators, and researchers identified communication barriers and facilitators using fishbone diagrams and process flow maps. The work group then verified and provided context for the diagram and flow maps through medical record review (32 patients who received both PC and MH care), interviews (6 stakeholders), and reports from four previously completed focus groups. Based on these findings and a previous systematic review of interventions to improve interspecialty communication, the team initiated plans for improvement.
Key Results
Key communication barriers included lack of effective standardized communication processes, practice style differences, and inadequate PC training in MH. Clinicians often accessed advice or formal consultation based on pre-existing across-discipline personal relationships. The work group identified collocated collaborative care, joint care planning, and joint case conferences as feasible, evidence-based interventions for improving communication.
CQI tools enabled providers to systematically assess local communication barriers and facilitators and engaged stakeholders in developing possible solutions. A locally tailored CQI process focusing on communication helped initiate change strategies and ongoing improvement efforts.
PMCID: PMC4070235  PMID: 24715400
primary care; mental health; communication; quality improvement; ambulatory care; primary care redesign
13.  Teamlet Structure and Early Experiences of Medical Home Implementation for Veterans 
Journal of General Internal Medicine  2014;29(Suppl 2):623-631.
High functioning interdisciplinary primary care teams are a critical component of the patient-centered medical home. In 2010, the Veterans Administration (VA) implemented a medical home model termed the Patient Aligned Care Teams (PACT), with reorganization of staff into small teams (“teamlets”) as a core feature.
To examine the early experiences of primary care personnel as they assumed new roles through reorganization into teamlets.
Convergent mixed methods study design involving semi-structured interviews and a survey; data were collected in 2011 and 2012.
We interviewed 41 frontline teamlet members (i.e., primary care physicians and staff) from three practices that were part of a PACT demonstration laboratory and examined clinician and staff survey data from 22 practices.
Semi-structured interview guide and clinician and staff survey questions covering the following domains: teamlet formation and structure, within-teamlet communication, cross-coverage, role changes, teamlet training, impact on Veterans, and leadership facilitation and support.
Respondents had limited input into teamlet structure and indicated limited training on the PACT initiative. Guidelines delineating each teamlet member’s roles and responsibilities were emphasized as important needs. Chronic understaffing also contributed to implementation challenges and territorial attitudes surfaced when cross-coverage was not clear. In addition, several core features of VA’s medical home transformation were not fully implemented by teamlet members. Most also reported limited guidance and feedback from leadership. Despite these challenges, teamlet-based care was perceived to have a positive impact on Veterans’ experiences of primary care and also resulted in improved communication among staff.
The PACT teamlet model holds much promise for improving primary care at the VA. However, more comprehensive training, improving the stability of teamlets, developing clear cross-coverage policies, and better defined teamlet member responsibilities are important areas in need of attention by VA leadership.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-013-2680-1) contains supplementary material, which is available to authorized users.
PMCID: PMC4070242  PMID: 24715392
team structure; patient-centered medical home; practice redesign; primary care teams; veterans
14.  Organizational Cost of Quality Improvement for Depression Care 
Health Services Research  2009;44(1):225-244.
We documented organizational costs for depression care quality improvement (QI) to develop an evidence-based, Veterans Health Administration (VA) adapted depression care model for primary care practices that performed well for patients, was sustained over time, and could be spread nationally in VA.
Data Sources and Study Setting
Project records and surveys from three multistate VA administrative regions and seven of their primary care practices.
Study Design
Descriptive analysis.
Data Collection
We documented project time commitments and expenses for 86 clinical QI and 42 technical expert support team participants for 4 years from initial contact through care model design, Plan–Do–Study–Act cycles, and achievement of stable workloads in which models functioned as routine care. We assessed time, salary costs, and costs for conference calls, meetings, e-mails, and other activities.
Principle Findings
Over an average of 27 months, all clinics began referring patients to care managers. Clinical participants spent 1,086 hours at a cost of $84,438. Technical experts spent 2,147 hours costing $197,787. Eighty-five percent of costs derived from initial regional engagement activities and care model design.
Organizational costs of the QI process for depression care in a large health care system were significant, and should be accounted for when planning for implementation of evidence-based depression care.
PMCID: PMC2669623  PMID: 19146566
Quality improvement; depression; primary care
15.  Effective Implementation of Collaborative Care for Depression: What is Needed? 
To identify the care model factors that were key for successful implementation of collaborative depression care in a statewide Minnesota primary care initiative.
Study Design
We used a mixed-methods design incorporating both qualitative data from clinic site visits and quantitative measures of patient activation and 6-month remission rates.
Care model factors identified from the site visits were tested for association with rates of activation into the program and remission rates.
Nine factors were identified as important for successful implementation of collaborative care by the consultants who had trained and interviewed participating clinic teams. Factors correlated with higher patient activation rates were: strong leadership support (0.63), well-defined and implemented care manager roles (0.62), a strong primary care physician champion (0.60), and an on-site and accessible care manager (0.59). However, remission rates at six months were correlated with: an engaged psychiatrist (0.62), not seeing operating costs as a barrier to participation (0.56), and face-to-face communication (warm handoffs) between the care-manager and primary care physician for new patients (0.54).
Care model factors most important for successful program implementation differ for patient activation into the program versus remission at six months. Knowing which implementation factors are most important for successful implementation will be useful for those interested in adopting this evidence-based approach to improve primary care for patients with depression.
PMCID: PMC4270471  PMID: 25365745
collaborative care; depression; implementation; mixed methods
16.  Assessing organizational readiness for depression care quality improvement: relative commitment and implementation capability 
Depression is a major cause of morbidity and cost in primary care patient populations. Successful depression improvement models, however, are complex. Based on organizational readiness theory, a practice’s commitment to change and its capability to carry out the change are both important predictors of initiating improvement. We empirically explored the links between relative commitment (i.e., the intention to move forward within the following year) and implementation capability.
The DIAMOND initiative administered organizational surveys to medical and quality improvement leaders from each of 83 primary care practices in Minnesota. Surveys preceded initiation of activities directed at implementation of a collaborative care model for improving depression care. To assess implementation capability, we developed composites of survey items for five types of organizational factors postulated to be collaborative care barriers and facilitators. To assess relative commitment for each practice, we averaged leader ratings on an identical survey question assessing practice priorities. We used multivariable regression analyses to assess the extent to which implementation capability predicted relative commitment. We explored whether relative commitment or implementation capability measures were associated with earlier initiation of DIAMOND improvements.
All five implementation capability measures independently predicted practice leaders’ relative commitment to improving depression care in the following year. These included the following: quality improvement culture and attitudes (p = 0.003), depression culture and attitudes (p <0.001), prior depression quality improvement activities (p <0.001), advanced access and tracking capabilities (p = 0.03), and depression collaborative care features in place (p = 0.03). Higher relative commitment (p = 0.002) and prior depression quality improvement activities appeared to be associated with earlier participation in the DIAMOND initiative.
The study supports the concept of organizational readiness to improve quality of care and the use of practice leader surveys to assess it. Practice leaders’ relative commitment to depression care improvement may be a useful measure of the likelihood that a practice is ready to initiate evidence-based depression care changes. A comprehensive organizational assessment of implementation capability for depression care improvement may identify specific barriers or facilitators to readiness that require targeted attention from implementers.
Electronic supplementary material
The online version of this article (doi:10.1186/s13012-014-0173-1) contains supplementary material, which is available to authorized users.
PMCID: PMC4276014  PMID: 25443652
Depression; Primary care; Quality improvement; Readiness; Measurement
17.  Variations in Nurse Practitioner Use in Veterans Affairs Primary Care Practices 
Health Services Research  2004;39(4 Pt 1):887-904.
Increasingly, primary care practices include nurse practitioners (NPs) in their staffing mix to contain costs and expand primary care. To achieve these aims in U.S. Department of Veterans Affairs medical centers (VAMCs), national policy endorsed involvement of NPs as primary care (PC) providers.
To evaluate the degree to which VAMCs incorporated NPs into PC practices between 1996 and 1999, and to identify the internal and external practice environment features associated with NP use.
Study Design
We surveyed 131 PC directors of all VAMCs in 1996 and 1999 to ascertain the staffing and characteristics of the PC practice and parent organization (e.g., academic affiliation, level of physician staffing, use of managed care arrangements), and drew on previously published studies and HRSA State Health Workforce Profiles to characterize each practice's regional health care environment (e.g., geographic region, state NP practice laws, state managed care penetration). Using multivariate linear regression, we evaluate the contribution of these environmental and organizational factors on the number of NPs/10,000 PC patients in 1999, controlling for the rate of NP use in 1996.
Principal Findings
From 1996–1999, NP use increased from 75 percent to 90 percent in VA PC practices. The mean number of NPs per practice increased by about 60 percent (2.0 versus 3.2; p<.001), while the rate of NPs/10,000 PC patients trended upward (2.2 versus 2.7; p=.09). Staffing of other primary care clinicians (e.g., physicians and physician assistants per practice) remained stable, while the NP-per-physician rate increased (0.2 versus 0.4; p<.001). After multivariate adjustment, greater reliance on managed-care-oriented provider education programs (p=.02), the presence of NP training programs (p=.05), and more specialty-trained physicians/10,000 PC patients (p=.09) were associated with greater NP involvement in primary care.
Staffing models in VA PC practices have, in fact, changed, with NPs having a greater presence. However, we found substantial practice-based variations in their use, suggesting that more research is needed to better understand how they have been integrated into practice and what impact their involvement has had on the VA's ability to achieve its restructuring goals.
PMCID: PMC1361043  PMID: 15230933
Nurse practitioner; primary care staffing; practice characteristics; environmental characteristics
18.  Quality Improvement Implementation in the Nursing Home 
Health Services Research  2003;38(1 Pt 1):65-83.
To examine quality improvement (QI) implementation in nursing homes, its association with organizational culture, and its effects on pressure ulcer care.
Data Sources/Study Settings
Primary data were collected from staff at 35 nursing homes maintained by the Department of Veterans Affairs (VA) on measures related to QI implementation and organizational culture. These data were combined with information obtained from abstractions of medical records and analyses of an existing database.
Study Design
A cross-sectional analysis of the association among the different measures was performed.
Data Collection/Extraction Methods
Completed surveys containing information on QI implementation, organizational culture, employee satisfaction, and perceived adoption of guidelines were obtained from 1,065 nursing home staff. Adherence to best practices related to pressure ulcer prevention was abstracted from medical records. Risk-adjusted rates of pressure ulcer development were calculated from an administrative database.
Principal Findings
Nursing homes differed significantly (p<.001) in their extent of QI implementation with scores on this 1 to 5 scale ranging from 2.98 to 4.08. Quality improvement implementation was greater in those nursing homes with an organizational culture that emphasizes innovation and teamwork. Employees of nursing homes with a greater degree of QI implementation were more satisfied with their jobs (a 1-point increase in QI score was associated with a 0.83 increase on the 5-point satisfaction scale, p<.001) and were more likely to report adoption of pressure ulcer clinical guidelines (a 1-point increase in QI score was associated with a 28 percent increase in number of staff reporting adoption, p<.001). No significant association was found, though, between QI implementation and either adherence to guideline recommendations as abstracted from records or the rate of pressure ulcer development.
Quality improvement implementation is most likely to be successful in those VA nursing homes with an underlying culture that promotes innovation. While QI implementation may result in staff who are more satisfied with their jobs and who believe they are providing better care, associations with improved care are uncertain.
PMCID: PMC1360874  PMID: 12650381
Quality improvement; quality of care; nursing homes; decubitus ulcers
19.  Understanding Team-based Quality Improvement for Depression in Primary Care 
Health Services Research  2002;37(4):1009-1029.
To assess the impacts of the characteristics of quality improvement (QI) teams and their environments on team success in designing and implementing highquality, enduring depression care improvement programs in primary care (PC) practices.
Study Setting/Data Sources
Two nonprofit managed care organizations sponsored five QI teams tasked with improving care for depression in large PC practices. Data on characteristics of the teams and their environments is from observer process notes, national expert ratings, administrative data, and interviews.
Study Design
Comparative formative evaluation of the quality and duration of implementation of the depression improvement programs developed by Central Teams (CTs) emphasizing expert design and Local Teams (LTs) emphasizing participatory local clinician design, and of the effects of additional team and environmental factors oneach type of team. Both types of teams depended upon local clinicians for implementation.
Principal Findings
The CT intervention program designs were more evidence-based than those of LTs. Expert team leadership, support from local practice management, and support from local mental health specialists strongly influenced the development of successful team programs. The CTs and LTs were equally successful when these conditions could be met, but CTs were more successful than LTs in less supportive environments.
The LT approach to QI for depression requires high local support and expertise from primary care and mental health clinicians. The CT approach is more likely to succeed than the LT approach when local practice conditions are not optimal.
PMCID: PMC1464007  PMID: 12236381
Quality improvement; depression; primary care; health care provider teams
20.  Medical Home Features of VHA Primary Care Clinics and Avoidable Hospitalizations 
Journal of General Internal Medicine  2013;28(9):1188-1194.
As the Veterans Health Administration (VHA) reorganizes providers into the patient-centered medical home, questions remain whether this model of care can demonstrate improved patient outcomes and cost savings.
We measured adoption of medical home features by VHA primary care clinics prior to widespread implementation of the patient-centered medical home and examined if they were associated with lower risk and costs of potentially avoidable hospitalizations.
Secondary patient data was linked to clinic administrative and survey data. Patient and clinic factors in the baseline year (FY2009) were used to predict patient outcomes in the follow-up year.
2,853,030 patients from 814 VHA primary care clinics
Main Measures
Patient outcomes were measured by hospitalizations for an ambulatory care sensitive condition (ACSC) and their costs and identified through diagnosis and procedure codes from inpatient records. Clinic adoption of medical home features was obtained from the American College of Physicians Medical Home Builder®.
Key Results
The overall mean home builder score in the study clinics was 88 (SD = 13) or 69 %. In adjusted analyses an increase of 10 points in the medical home adoption score in a clinic decreased the odds of an ACSC hospitalization for patients by 3 % (P = 0.032). By component, higher access and scheduling (P = 0.004) and care coordination and transitions (P = 0.020) component scores were related to lower risk of an ACSC hospitalization, and higher population management was related to higher risk (P = 0.023). Total medical home features was not related to ACSC hospitalization costs among patients with at least one (P = 0.074).
Greater adoption of medical home features by VHA primary care clinics was found to be significantly associated with lower risk of avoidable hospitalizations with access and scheduling and care coordination/transitions in care as key factors.
PMCID: PMC3744290  PMID: 23529710
medical home; avoidable hospitalizations; access; care coordination
21.  Clinical Inertia in Depression Treatment 
Medical care  2009;47(9):959-967.
To explore reasons for clinical inertia in the management of persistent depression symptoms.
Research Design
We characterized patterns of treatment adjustment in primary care and their relation to the patient’s clinical condition by modeling transition to a given treatment “state” conditional upon the current state of treatment. We assessed associations of patient, clinician, and practice barriers with adjustment decisions.
Survey data on patients in active care for major depression was collected at six-month intervals over a two-year period for the Quality Improvement for Depression (QID) studies.
Patient and clinician characteristics were collected at baseline. Depression severity and treatment were measured at each interval.
Approximately one-third of the observation periods ending with less than a full response resulted in an adjustment recommendation. Clinicians often respond correctly to the combination of severe depression symptoms and less than maximal treatment by changing the treatment. Appropriate adjustment is less common, however, in management of less severely depressed patients who do not improve after starting treatment, particularly if their care already meets minimal treatment intensity guidelines.
Our findings suggest that quality improvement efforts should focus on promoting appropriate adjustments for patients with persistent depression symptoms, particularly those with less severe depression.
PMCID: PMC4003881  PMID: 19704353
Depression; Clinical inertia; Evidence-based medicine; Physician practice patterns
22.  A Feedforward System for Functional Status Information 
The increasing prevalence of chronic disease and disability in our aging patient population requires a model of health care that includes functional status as a major therapeutic goal and outcome measure. Traditionally, physicians have not been trained to evaluate and treat functional status problems. To help physicians identify and treat functional status problems, we developed a computerized functional status questionnaire and reporting system that generates functional status summaries, problem analyses, and suggested management resources. Because the microcomputer-based system supports efficient data entry, reports can be produced just prior to patient encounters and “fed forward” to physicians, allowing functional status information to be immediately useful within the context of a patient encounter. To evaluate the feasibility and impact of this system we conducted a prospective, randomized controlled trial involving 74 resident physicians and 608 patients seen in an ambulatory medical clinic. Our results show that computerized feedforward of functional status information is practical in a clinical setting and can influence physician attitudes toward treating a variety of problems.
PMCID: PMC2245227
23.  A Patient-Centered Primary Care Practice Approach Using Evidence-Based Quality Improvement: Rationale, Methods, and Early Assessment of Implementation 
Journal of General Internal Medicine  2014;29(Suppl 2):589-597.
Healthcare systems and their primary care practices are redesigning to achieve goals identified in Patient-Centered Medical Home (PCMH) models such as Veterans Affairs (VA)’s Patient Aligned Care Teams (PACT). Implementation of these models, however, requires major transformation. Evidence-Based Quality Improvement (EBQI) is a multi-level approach for supporting organizational change and innovation spread.
To describe EBQI as an approach for promoting VA’s PACT and to assess initial implementation of planned EBQI elements.
Regional and local interdisciplinary clinical leaders, patient representatives, Quality Council Coordinators, practicing primary care clinicians and staff, and researchers from six demonstration site practices in three local healthcare systems in one VA region.
EBQI promotes bottom-up local innovation and spread within top-down organizational priorities. EBQI innovations are supported by a research-clinical partnership, use continuous quality improvement methods, and are developed in regional demonstration sites.
We developed a logic model for EBQI for PACT (EBQI-PACT) with inputs, outputs, and expected outcomes. We describe implementation of logic model outputs over 18 months, using qualitative data from 84 key stakeholders (104 interviews from two waves) and review of study documents.
Nearly all implementation elements of the EBQI-PACT logic model were fully or partially implemented. Elements not fully achieved included patient engagement in Quality Councils (4/6) and consistent local primary care practice interdisciplinary leadership (4/6). Fourteen of 15 regionally approved innovation projects have been completed, three have undergone initial spread, five are prepared to spread, and two have completed toolkits that have been pretested in two to three sites and are now ready for external spread.
EBQI-PACT has been feasible to implement in three participating healthcare systems in one VA region. Further development of methods for engaging patients in care design and for promoting interdisciplinary leadership is needed.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-013-2703-y) contains supplementary material, which is available to authorized users.
PMCID: PMC4070240  PMID: 24715397
quality improvement; primary care; patient-centered medical home; logic model; interdisciplinary leadership
24.  Determinants of Readiness for Primary Care-Mental Health Integration (PC-MHI) in the VA Health Care System 
Depression management can be challenging for primary care (PC) settings. While several evidence-based models exist for depression care, little is known about the relationships between PC practice characteristics, model characteristics, and the practice’s choices regarding model adoption.
We examined three Veterans Affairs (VA)-endorsed depression care models and tested the relationships between theoretically-anchored measures of organizational readiness and implementation of the models in VA PC clinics.
1) Qualitative assessment of the three VA-endorsed depression care models, 2) Cross-sectional survey of leaders from 225 VA medium-to-large PC practices, both in 2007.
We assessed PC readiness factors related to resource adequacy, motivation for change, staff attributes, and organizational climate. As outcomes, we measured implementation of one of the VA-endorsed models: collocation, Translating Initiatives in Depression into Effective Solutions (TIDES), and Behavioral Health Lab (BHL). We performed bivariate and, when possible, multivariate analyses of readiness factors for each model.
Collocation is a relatively simple arrangement with a mental health specialist physically located in PC. TIDES and BHL are more complex; they use standardized assessments and care management based on evidence-based collaborative care principles, but with different organizational requirements. By 2007, 107 (47.5 %) clinics had implemented collocation, 39 (17.3 %) TIDES, and 17 (7.6 %) BHL. Having established quality improvement processes (OR 2.30, [1.36, 3.87], p = 0.002) or a depression clinician champion (OR 2.36, [1.14, 4.88], p = 0.02) was associated with collocation. Being located in a VA regional network that endorsed TIDES (OR 8.42, [3.69, 19.26], p < 0.001) was associated with TIDES implementation. The presence of psychologists or psychiatrists on PC staff, greater financial sufficiency, or greater spatial sufficiency was associated with BHL implementation.
Both readiness factors and characteristics of depression care models influence model adoption. Greater model simplicity may make collocation attractive within local quality improvement efforts. Dissemination through regional networks may be effective for more complex models such as TIDES.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-012-2217-z) contains supplementary material, which is available to authorized users.
PMCID: PMC3579970  PMID: 23054917
primary care; mental health; depression; collaborative care; implementation; readiness
25.  Alcohol Problems as a Risk Factor for Post-Disaster Depressed Mood among U.S. Veterans 
Alcohol problems may impede adaptive, proactive responses to disaster-related injury and loss, thus prolonging the adverse impact of disasters on mental health. Previous work suggests that veterans of the U.S. armed forces have a relatively high prevalence of alcohol misuse and other psychiatric disorders. This is the first study to estimate the impact of pre-disaster alcohol problems on post-disaster depressed mood among veterans, using data that were collected before and after the 1994 Northridge, California earthquake. We assessed the impact of alcohol problems on post-disaster depressed mood in an existing clinical cohort of veterans who experienced the 6.7-magnitude earthquake that struck Northridge in January 1994. One-to-three months after the disaster, interviewers contacted participants by telephone to administer a follow-up questionnaire based on a survey that had been done pre-earthquake. Post-earthquake data were obtained on 1144 male veterans for whom there were pre-earthquake data. We tested a predictive path model of the relationships between latent variables for pre-disaster alcohol problems, functional limitations, and depressed mood on latent variables representing post-disaster “quake impact” and depressive mood. Results showed that veterans who had more alcohol problems before the earthquake experienced more earthquake-related harms and severely depressed mood after the earthquake, compared with those who had fewer alcohol problems. Programs serving veterans with a high prevalence of alcohol problems should consider designing disaster response protocols to locate and assist these patients in the aftermath of disasters.
PMCID: PMC3604132  PMID: 23106638
alcohol; disasters; mental health; structural equation modeling; longitudinal studies

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