Understanding care coordination for Veterans with complex care needs: protocol of a multiple-methods study to build evidence for an effectiveness and implementation study

Background For patients with complex health and social needs, care coordination is crucial for improving their access to care, clinical outcomes, care experiences, and controlling their healthcare costs. However, evidence is inconsistent regarding the core elements of care coordination interventions, and lack of standardized processes for assessing patients’ needs has made it challenging for providers to optimize care coordination based on patient needs and preferences. Further, ensuring providers have reliable and timely means of communicating about care plans, patients’ full spectrum of needs, and transitions in care is important for overcoming potential care fragmentation. In the Veterans Health Administration (VA), several initiatives are underway to implement care coordination processes and services. In this paper, we describe our study underway in the VA aimed at building evidence for designing and implementing care coordination practices that enhance care integration and improve health and care outcomes for Veterans with complex care needs. Methods In a prospective observational multiple methods study, for Aim 1 we will use existing data to identify Veterans with complex care needs who have and have not received care coordination services. We will examine the relationship between receipt of care coordination services and their health outcomes. In Aim 2, we will adapt the Patient Perceptions of Integrated Veteran Care questionnaire to survey a sample of Veterans about their experiences regarding coordination, integration, and the extent to which their care needs are being met. For Aim 3, we will interview providers and care teams about their perceptions of the innovation attributes of current care coordination needs assessment tools and processes, including their improvement over other approaches (relative advantage), fit with current practices (compatibility and innovation fit), complexity, and ability to visualize how the steps proceed to impact the right care at the right time (observability). The provider interviews will inform design and deployment of a widescale provider survey. Discussion Taken together, our study will inform development of an enhanced care coordination intervention that seeks to improve care and outcomes for Veterans with complex care needs

Cold atoms in space: community workshop summary and proposed road-map

We summarise the discussions at a virtual Community Workshop on Cold Atoms in Space concerning the status of cold atom technologies, the prospective scientific and societal opportunities offered by their deployment in space, and the developments needed before cold atoms could be operated in space. The cold atom technologies discussed include atomic clocks, quantum gravimeters and accelerometers, and atom interferometers. Prospective applications include metrology, geodesy and measurement of terrestrial mass change due to, e.g., climate change, and fundamental science experiments such as tests of the equivalence principle, searches for dark matter, measurements of gravitational waves and tests of quantum mechanics. We review the current status of cold atom technologies and outline the requirements for their space qualification, including the development paths and the corresponding technical milestones, and identifying possible pathfinder missions to pave the way for missions to exploit the full potential of cold atoms in space. Finally, we present a first draft of a possible road-map for achieving these goals, that we propose for discussion by the interested cold atom, Earth Observation, fundamental physics and other prospective scientific user communities, together with the European Space Agency (ESA) and national space and research funding agencies.publishedVersio

Cold atoms in space: community workshop summary and proposed road-map

We summarise the discussions at a virtual Community Workshop on Cold Atoms in Space concerning the status of cold atom technologies, the prospective scientific and societal opportunities offered by their deployment in space, and the developments needed before cold atoms could be operated in space. The cold atom technologies discussed include atomic clocks, quantum gravimeters and accelerometers, and atom interferometers. Prospective applications include metrology, geodesy and measurement of terrestrial mass change due to, e.g., climate change, and fundamental science experiments such as tests of the equivalence principle, searches for dark matter, measurements of gravitational waves and tests of quantum mechanics. We review the current status of cold atom technologies and outline the requirements for their space qualification, including the development paths and the corresponding technical milestones, and identifying possible pathfinder missions to pave the way for missions to exploit the full potential of cold atoms in space. Finally, we present a first draft of a possible road-map for achieving these goals, that we propose for discussion by the interested cold atom, Earth Observation, fundamental physics and other prospective scientific user communities, together with the European Space Agency (ESA) and national space and research funding agencies

Cold atoms in space: community workshop summary and proposed road-map

We summarise the discussions at a virtual Community Workshop on Cold Atoms in Space concerning the status of cold atom technologies, the prospective scientific and societal opportunities offered by their deployment in space, and the developments needed before cold atoms could be operated in space. The cold atom technologies discussed include atomic clocks, quantum gravimeters and accelerometers, and atom interferometers. Prospective applications include metrology, geodesy and measurement of terrestrial mass change due to, e.g., climate change, and fundamental science experiments such as tests of the equivalence principle, searches for dark matter, measurements of gravitational waves and tests of quantum mechanics. We review the current status of cold atom technologies and outline the requirements for their space qualification, including the development paths and the corresponding technical milestones, and identifying possible pathfinder missions to pave the way for missions to exploit the full potential of cold atoms in space. Finally, we present a first draft of a possible road-map for achieving these goals, that we propose for discussion by the interested cold atom, Earth Observation, fundamental physics and other prospective scientific user communities, together with the European Space Agency (ESA) and national space and research funding agencies

TRY plant trait database – enhanced coverage and open access

Plant traits - the morphological, anatomical, physiological, biochemical and phenological characteristics of plants - determine how plants respond to environmental factors, affect other trophic levels, and influence ecosystem properties and their benefits and detriments to people. Plant trait data thus represent the basis for a vast area of research spanning from evolutionary biology, community and functional ecology, to biodiversity conservation, ecosystem and landscape management, restoration, biogeography and earth system modelling. Since its foundation in 2007, the TRY database of plant traits has grown continuously. It now provides unprecedented data coverage under an open access data policy and is the main plant trait database used by the research community worldwide. Increasingly, the TRY database also supports new frontiers of trait‐based plant research, including the identification of data gaps and the subsequent mobilization or measurement of new data. To support this development, in this article we evaluate the extent of the trait data compiled in TRY and analyse emerging patterns of data coverage and representativeness. Best species coverage is achieved for categorical traits - almost complete coverage for ‘plant growth form’. However, most traits relevant for ecology and vegetation modelling are characterized by continuous intraspecific variation and trait–environmental relationships. These traits have to be measured on individual plants in their respective environment. Despite unprecedented data coverage, we observe a humbling lack of completeness and representativeness of these continuous traits in many aspects. We, therefore, conclude that reducing data gaps and biases in the TRY database remains a key challenge and requires a coordinated approach to data mobilization and trait measurements. This can only be achieved in collaboration with other initiatives

Therapy and the Nontraditional Transgender Narrative

The history of transgender identity is inextricable from the mental health industry. Since the late 1970\u27s transgender people have required permission from mental health professionals to make medical modifications to their sex characteristics. During the time of this research, it was difficult for transgender individuals to receive the hormones or surgeries they desire without first being diagnosed with Gender Identity Disorder (GID). This study applies labeling theory to the label of GID. Labeling theory poses that if an individual is labeled with a mental illness, they will either reject or accept the label. Acceptance of the mentally ill label will cause the individual to adopt characteristics expected of the label. The intent of this study is to examine the relationship between mental health therapy and the formation of transgender identities. Utilizing labeling theory, it analyzes whether or not transgender participants of this study accepted or rejected the mental illness label of GID. It was originally posed that if transgender individuals accepted the label of GID, they would experience a shift in their gender identity. However, the overwhelming majority of the twelve participants interviewed rejected the label of GID. Even though most participants rejected the GID label, many still saw a shift in gender identity while attending therapy. This thesis proposes that there may be a link between a transgender person’s reason for entering therapy and identity shift. Those who felt obligated to go to therapy for the sole reason of gaining permission to change their sex characteristics saw no change in identity. However, those who wanted help in exploring their gender with a therapist saw identity changes while in therapy

Identifying Emergency Department Care in the Year Prior to Suicide Death

ObjectiveTo identify potential emergency department (ED) visits prior to suicide deaths in North Carolina (NC) and describe pre-suicide care-seeking in EDs.IntroductionSuicide is a leading cause of mortality in the United States, causing about 45,000 deaths annually1. Research suggests that universal screening in health care settings may be beneficial for prevention, but few studies have combined detailed suicide circumstances with ED encounter data to better understand care-seeking behavior prior to death.MethodsThis project used data from the NC Violent Death Reporting System (NC-VDRS), a repository of all violent deaths in North Carolina, and the NC Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT), which includes all visits to 24/7, acute-care, civilian, hospital-affiliated EDs in NC. We identified all suicide deaths recorded in the NC-VDRS between 1/1/2014 – 9/30/2015, and all NC DETECT ED visits between 1/1/2013 – 9/30/2015. Descriptive analyses were conducted for each data source, separately. For all NC-VDRS suicides, we identified ED visits likely made by the same individual within the 48 hours prior to death. We identified these ED visits based on the variables arrival date, sex, date of birth (DOB), county of residence, and a chief complaint consistent with self-harm/suicide; we refer to these as suicide-related ED visits. For the subset of NC-VDRS suicides with a suicide-related ED visit, made within 48 hours of death, we identified all ED visits associated with the decedent made to the same facility or healthcare system in the year prior to death. We then categorized the pre-suicide ED visits according to the primary reason healthcare was sought by the patient (e.g. mental health problem, substance abuse/overdose, pain, etc.).ResultsFrom 1/1/2014-9/30/2015, there were 2,953 suicide deaths captured in NC-VDRS data; 2,435 (82%) of these included DOB. Between 1/1/2013 – 9/30/2015, there were 13,463,345 ED visits captured by NC DETECT; 12,884,596 (96%) included DOB. For 961 suicides (32.5%), no ED visit was found with the same DOB, sex and county of residence. For the remaining 1,474 suicides, at least one ED visit was found for a patient with the same DOB, sex and county of residence and occurring on or before the date of death. For 406 suicides, a suicide-related ED visit was identified; 122 of these patients had at least one additional ED visit in the year prior to death. A total of 516 ED visits were identified for these 122 suicides, including the suicide-related ED visit, with an average of 3.2 (range: 1-25) visits.ConclusionsFor nearly a third of NC-VDRS suicides, no indication of any ED visit by a patient with the same DOB, sex, and county of residence was found. While it is likely we were unable to identify all ED visits prior to suicide, the findings from this pilot study suggest many suicide victims did not seek NC ED care in the year prior to death. Overall, a suicide-related ED visit was found for only 13.7% of NC suicides in the study period, indicating that most people who self-inflict fatal injury do not make it to an ED for care prior to death. ED visits in the year prior to death by suicide indicated a variety of diagnoses, but rarely depression or suicidality; this suggests that universal screening at ED visits would have been necessary to identify any suicide risk present. Limitations of this study include that we were unable to directly link suicide deaths and ED visits using patient identifiers. Additionally, we relied solely on secondary data used for public health surveillance and, therefore, had no access to medical record information that may have documented depression or suicidal ideation that was not coded as such. Findings from this pilot study can inform future work to identify ED visits prior to suicide.References1National Center for Injury Prevention and Control. Suicide Rising Across the US. Vital Signs, June 2018; Atlanta, GA: Centers for Disease Control and Prevention 2018. https://www.cdc.gov/vitalsigns/suicide/. Accessed Sept 25, 2018.

Caregivers’ Role in In-Home Video Telehealth: National Survey of Occupational Therapy Practitioners

BackgroundOlder adults face barriers to specialty care, such as occupational therapy (OT), and these challenges are worse for rural older adults. While in-home video telehealth may increase access to OT, older adults’ health- and technology-related challenges may necessitate caregiver assistance. ObjectiveThis study examines caregiver assistance with in-home OT video telehealth visits from the perspectives of OT practitioners at Veterans Health Administration (VHA). MethodsA web-based national survey of VHA OT practitioners about caregivers’ role in video telehealth was conducted between January and February 2022. Survey items were developed with input from subject matter experts in geriatrics and OT and identified patient factors that necessitate caregiver participation; the extent to which caregivers assist with different types of tasks (technological and clinical tasks); and the perceived facilitators of, benefits of, and barriers to caregiver involvement. ResultsOf approximately 1787 eligible VHA OT practitioners, 286 (16% response rate) participated. Not all survey items required completion, resulting in different denominators. Most respondents were female (183/226, 81%), White (163/225, 72.4%), and occupational therapists (275/286, 96.2%). Respondents were from 87 VHA medical centers, the catchment areas of which served a patient population that was 34% rural, on average (SD 0.22). Most participants (162/232, 69.8%) had >10 years of OT experience serving a patient cohort mostly aged ≥65 years (189/232, 81.5%) in primarily outpatient rehabilitation (132/232, 56.9%). The top patient factors necessitating caregiver involvement were lack of technical skills, cognitive impairment, and advanced patient age, with health-related impairments (eg, hearing or vision loss) less frequent. Technological tasks that caregivers most frequently assisted with were holding, angling, moving, repositioning, or operating the camera (136/250, 54.4%) and enabling and operating the microphone and setting the volume (126/248, 50.8%). Clinical tasks that caregivers most frequently assisted with were providing patient history (143/239, 59.8%) and assisting with patient communication (124/240, 51.7%). The top facilitator of caregiver participation was clinician-delivered caregiver education about what to expect from video telehealth (152/275, 55.3%), whereas the top barrier was poor connectivity (80/235, 34%). Increased access to video telehealth (212/235, 90.2%) was the top-rated benefit of caregiver participation. Most respondents (164/232, 70.7%) indicated that caregivers were at least sometimes unavailable or unable to assist with video telehealth, in which case the appointment often shifted to phone. ConclusionsCaregivers routinely assist VHA patients with in-home OT video visits, which is invaluable to patients who are older and have complex medical needs. Barriers to caregiver involvement include caregivers’ challenges with video telehealth or inability to assist, or lack of available caregivers. By elucidating the caregiver support role in video visits, this study provides clinicians with strategies to effectively partner with caregivers to enhance older patients’ access to video visits

Development of a Paper-Based Sensor Compatible with a Mobile Phone for the Detection of Common Iron Formulas Used in Fortified Foods within Resource-Limited Settings

A lack of quality control tools limits the enforcement of fortification policies. In alignment with the World Health Organization’s ASSURED criteria (affordable, sensitive, specific, user-friendly, rapid and robust, equipment-free, and deliverable), a paper-based assay that interfaces with a smartphone application for the quantification of iron fortificants is presented. The assay is based on the Ferrozine colorimetric method. The reaction started after deposition of the 5 µL aqueous sample and drying. After developing color, pixel intensity values were obtained using a smartphone camera and image processing software or a mobile application, Nu3px. From these values, the actual iron concentration from ferrous sulfate and ferrous fumarate was calculated. The limits of detection, quantification, linearity, range, and errors (systematic and random) were ascertained. The paper-based values from real samples (wheat flour, nixtamalized corn flour, and infant formula) were compared against atomic emission spectroscopy. The comparison of several concentrations of atomic iron between the spectrophotometric and paper-based assays showed a strong positive linear correlation (y = 47.01x + 126.18; R2 = 0.9932). The dynamic range (5.0–100 µg/mL) and limit of detection (3.691 µg/mL) of the paper-based assay are relevant for fortified food matrices. Random and systematic errors were 15.9% and + 8.65 µg/g food, respectively. The concept can be applied to limited-resource settings to measure iron in fortified foods