Opportunities to Enhance the Implementation of Veterans Affairs Video-Based Care: Qualitative Perspectives of Providers from Diverse Specialties

BackgroundIncreasing the adoption of digital care tools, including video visits, is a long-term goal for the US Department of Veterans Affairs (VA). While previous work has highlighted patient-specific barriers to the use of video visits, few have examined how clinicians view such barriers and how they have overcome them during the rapid uptake of web-based care. ObjectiveThis study sought input from providers, given their role as critical participants in video visit implementation, to qualitatively describe successful strategies providers used to adapt their practices to a web-based care setting. MethodsWe conducted interviews with 28 VA providers (physicians and nurse practitioners) from 4 specialties that represent diverse clinical services: primary care (n=11), cardiology (n=7), palliative care (n=5), and spinal cord injury (n=5). All interviews were audio recorded and transcribed, and transcripts were reviewed and coded according to an iteratively created codebook. To identify themes, codes were grouped together into categories, and participant comments were reviewed for repetition and emphasis on specific points. Finally, themes were mapped to Expert Recommendations for Implementing Change (ERIC) strategies to identify evidence-based opportunities to support video visit uptake in the VA. ResultsInterviewees were mostly female (57%, 16/28), with an average age of 49 years and with 2-20 years of experience working in the VA across 16 unique VA facilities. Most providers (82%, 23/28) worked in urban facilities. Many interviewees (78%, 22/28) had some experience with video visits prior to the COVID-19 pandemic, though a majority (61%, 17/28) had conducted fewer than 50 video visits in the quarter prior to recruitment. We identified four primary themes related to how providers adapt their practices to a web-based care setting: (1) peer-based learning and support improved providers’ perceived value of and confidence in video visits, (2) providers developed new and refined existing communication and clinical skills to optimize video visits, (3) providers saw opportunities to revisit and refine team roles to optimize the value of video visits for their care teams, and (4) implementing and sustaining web-based care requires institutional and organizational support. We identified several ERIC implementation strategies to support the use of video visits across the individual-, clinic-, and system-levels that correspond to these themes: (1) individual-level strategies include the development of educational materials and conducting education meetings, (2) clinic-level strategies include identifying champions and revising workflows and professional roles, and (3) system-level strategies include altering incentive structures, preparing implementation blueprints, developing and implementing tools for quality monitoring, and involving executive leadership to encourage adoption. ConclusionsThis work highlights strategies to support video visits that align with established ERIC implementation constructs, which can be used by health care systems to improve video visit implementation

Outpatient care fragmentation in Veterans Affairs patients at high-risk for hospitalization.

OBJECTIVE: To examine outpatient care fragmentation and its association with future hospitalization among patients at high risk for hospitalization. DATA SOURCES: Veterans Affairs (VA) and Medicare data. STUDY DESIGN: We conducted a longitudinal study, using logistic regression to examine how outpatient care fragmentation in FY14 (as measured by number of unique providers, Breslaus Usual Provider of Care (UPC), Bice-Boxermans Continuity of Care Index (COCI), and Modified Modified Continuity Index (MMCI)) was associated with all-cause hospitalizations and hospitalizations related to ambulatory care sensitive conditions (ACSC) in FY15. We also examined how fragmentation varied by patients age, gender, race, ethnicity, marital status, rural status, history of homelessness, number of chronic conditions, Medicare utilization, and mental health care utilization. DATA EXTRACTION METHODS: We extracted data for 130,704 VA patients ≥65 years old with a hospitalization risk ≥90th percentile and ≥ four outpatient visits in the baseline year. PRINCIPAL FINDINGS: The mean (SD) of FY14 outpatient visits was 13.2 (8.6). Fragmented care (more providers, less care with a usual provider, more dispersed care based on COCI) was more common among patients with more chronic conditions and those receiving mental health care. In adjusted models, most fragmentation measures were not associated with all-cause hospitalization, and patients with low levels of fragmentation (more concentrated care based on UPC, COCI, and MMCI) had a higher likelihood of an ACSC-related hospitalization (AOR, 95% CI = 1.21 (1.09-1.35), 1.27 (1.14-1.42), and 1.28 (1.18-1.40), respectively). CONCLUSIONS: Contrary to expectations, outpatient care fragmentation was not associated with elevated all-cause hospitalization rates among VA patients in the top 10th percentile for risk of admission; in fact, fragmented care was linked to lower rates of hospitalization for ACSCs. In integrated settings such as the VA, multiple providers, and dispersed care might offer access to timely or specialized care that offsets risks of fragmentation, particularly for conditions that are sensitive to ambulatory care

A couples’ based self-management program for heart failure: Results of a feasibility study

Background: Heart failure (HF) is associated with frequent exacerbations and shortened lifespan. Informal caregivers such as significant others often support self-management in patients with HF. However, existing programs that aim to enhance self-management seldom engage informal caregivers or provide tools that can help alleviate caregiver burden or improve collaboration between patients and their informal caregivers. Objective: To develop and pilot test a program targeting the needs of self-management support among HF patients as well as their significant others. Methods: We developed the Dyadic Health Behavior Change model and conducted semi-structured interviews to determine barriers to self-management from various perspectives. Participants’ feedback was used to develop a family-centered self-management program called SUCCEED: Self-management Using Couples’ Coping EnhancEment in Diseases. The goals of this program are to improve HF self-management, quality of life, communication within couples, relationship quality, and stress and caregiver burden. We conducted a pilot study with 17 Veterans with HF and their significant others to determine acceptability of the program. We piloted psychosocial surveys at baseline and after participants’ program completion to evaluate change in depressive symptoms, caregiver burden, self-management of HF, communication, quality of relationship, relationship mutuality, and quality of life. Results: Of the 17 couples, 14 completed at least 1 SUCCEED session. Results showed high acceptability for each of SUCCEED’s sessions. At baseline, patients reported poor quality of life, clinically significant depressive symptoms, and inadequate self-management of HF. After participating in SUCCEED, patients showed improvements in self-management of HF, communication, and relationship quality, while caregivers reported improvements in depressive symptoms and caregiver burden. Quality of life of both patients and significant others declined over time. Conclusions: In this small pilot study, we showed positive trends with involving significant others in self-management. SUCCEED has the potential of addressing the growing public health problem of HF among patients who receive care from their significant other