Preimplementation Evaluation of a Self-Directed Care Program in a Veterans Health Administration Regional Network: Protocol for a Mixed Methods Study

The Veteran-Directed Care (VDC) program serves to assist veterans at risk of long-term institutional care to remain at home by providing funding to hire veteran-selected caregivers. VDC is operated through partnerships between Department of Veterans Affairs (VA) Medical Centers (VAMCs) and third-party Aging and Disability Network Agency providers.BACKGROUNDThe Veteran-Directed Care (VDC) program serves to assist veterans at risk of long-term institutional care to remain at home by providing funding to hire veteran-selected caregivers. VDC is operated through partnerships between Department of Veterans Affairs (VA) Medical Centers (VAMCs) and third-party Aging and Disability Network Agency providers.We aim to identify facilitators, barriers, and adaptations in VDC implementation across 7 VAMCs in 1 region: Veterans Integrated Service Network (VISN) 8, which covers Florida, South Georgia, Puerto Rico, and the US Virgin Islands. We also attempted to understand leadership and stakeholder perspectives on VDC programs' reach and implementation and identify veterans served by VISN 8's VDC programs and describe their home- and community-based service use. Finally, we want to compare veterans served by VDC programs in VISN 8 to the veterans served in VDC programs across the VA. This information is intended to be used to identify strategies and propose recommendations to guide VDC program expansion in VISN 8.OBJECTIVEWe aim to identify facilitators, barriers, and adaptations in VDC implementation across 7 VAMCs in 1 region: Veterans Integrated Service Network (VISN) 8, which covers Florida, South Georgia, Puerto Rico, and the US Virgin Islands. We also attempted to understand leadership and stakeholder perspectives on VDC programs' reach and implementation and identify veterans served by VISN 8's VDC programs and describe their home- and community-based service use. Finally, we want to compare veterans served by VDC programs in VISN 8 to the veterans served in VDC programs across the VA. This information is intended to be used to identify strategies and propose recommendations to guide VDC program expansion in VISN 8.The mixed methods study design encompasses electronically delivered surveys, semistructured interviews, and administrative data. It is guided by the Consolidated Framework for Implementation Research (CFIR version 2.0). Participants included the staff of VAMCs and partnering aging and disability network agencies across VISN 8, leadership at these VAMCs and VISN 8, veterans enrolled in VDC, and veterans who declined VDC enrollment and their caregivers. We interviewed selected VAMC site leaders in social work, Geriatrics and Extended Care, and the Caregiver Support Program. Each interviewee will be asked to complete a preinterview survey that includes information about their personal characteristics, experiences with the VDC program, and perceptions of program aspects according to the CFIR (version 2.0) framework. Participants will complete a semistructured interview that covers constructs relevant to the respondent and facilitators, barriers, and adaptations in VDC implementation at their site.METHODSThe mixed methods study design encompasses electronically delivered surveys, semistructured interviews, and administrative data. It is guided by the Consolidated Framework for Implementation Research (CFIR version 2.0). Participants included the staff of VAMCs and partnering aging and disability network agencies across VISN 8, leadership at these VAMCs and VISN 8, veterans enrolled in VDC, and veterans who declined VDC enrollment and their caregivers. We interviewed selected VAMC site leaders in social work, Geriatrics and Extended Care, and the Caregiver Support Program. Each interviewee will be asked to complete a preinterview survey that includes information about their personal characteristics, experiences with the VDC program, and perceptions of program aspects according to the CFIR (version 2.0) framework. Participants will complete a semistructured interview that covers constructs relevant to the respondent and facilitators, barriers, and adaptations in VDC implementation at their site.We will calculate descriptive statistics including means, SDs, and percentages for survey responses. Facilitators, barriers, number of patients enrolled, and staffing will also be presented. Interviews will be analyzed using rapid qualitative techniques guided by CFIR domains and constructs. Findings from VISN 8 will be collated to identify strategies for VDC expansion. We will use administrative data to describe veterans served by the programs in VISN 8.RESULTSWe will calculate descriptive statistics including means, SDs, and percentages for survey responses. Facilitators, barriers, number of patients enrolled, and staffing will also be presented. Interviews will be analyzed using rapid qualitative techniques guided by CFIR domains and constructs. Findings from VISN 8 will be collated to identify strategies for VDC expansion. We will use administrative data to describe veterans served by the programs in VISN 8.The VA has prioritized VDC rollout nationwide and this study will inform these expansion efforts. The findings from this study will provide information about the experiences of the staff, leadership, veterans, and caregivers in the VDC program and identify program facilitators and barriers. These results may be used to improve program delivery, facilitate growth within VISN 8, and inform new program establishment at other sites nationwide as the VDC program expands.CONCLUSIONSThe VA has prioritized VDC rollout nationwide and this study will inform these expansion efforts. The findings from this study will provide information about the experiences of the staff, leadership, veterans, and caregivers in the VDC program and identify program facilitators and barriers. These results may be used to improve program delivery, facilitate growth within VISN 8, and inform new program establishment at other sites nationwide as the VDC program expands.DERR1-10.2196/57341.INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)DERR1-10.2196/57341

Multisite Agricultural Veterans Affairs Farming and Recovery Mental Health Services (VA FARMS) Pilot Program: Protocol for a Responsive Mixed Methods Evaluation Study

BackgroundVeterans Affairs Farming and Recovery Mental Health Services (VA FARMS) is an innovative pilot program to provide supportive resources for veterans with interests in agricultural vocations. Implemented at 10 pilot sites, VA FARMS will provide mental health services and resources for veterans while supporting training in gardening and agriculture. As each pilot site project has unique goals, outreach strategies, and implementation efforts based on the local environment and veteran population, evaluating the pilot program provides a unique challenge for evaluators. This paper describes the protocol to evaluate VA FARMS, which was specifically designed to enable site variation by providing both site-specific and cross-site understanding of site implementation processes and outcomes. ObjectiveThe objectives of this paper are to (1) describe the protocol used for evaluating VA FARMS, as an innovative Department of Veterans Affairs (VA) agriculturally based, mental health, and employment pilot program serving veterans at 10 pilot sites across the Veterans Health Administration enterprise; and (2) provide guidance to other evaluators assessing innovative programs. MethodsThis evaluation uses the context, inputs, process, product (CIPP) model, which evaluates a program’s content and implementation to identify strengths and areas for improvement. Data collection will use a concurrent mixed methods approach. Quantitative data collection will involve quarterly program surveys, as well as three individual veteran participant surveys administered upon the veteran’s entrance and exit of the pilot program and 3 months postexit. Quantitative data will include baseline descriptive statistics and follow-up statistics on veteran health care utilization, health care status, and agriculture employment status. Qualitative data collection will include participant observation at each pilot site, and interviews with participants, staff, and community stakeholders. Qualitative data will provide insights about pilot program implementation processes, veterans’ experiences, and short-term participation outcomes. ResultsEvaluation efforts began in December 2018 and are ongoing. Between October 2018 and September 2020, 494 veterans had enrolled in VA FARMS and 1326 veterans were reached through program activities such as demonstrations, informational presentations, and town-hall discussions. A total of 1623 community members and 655 VA employees were similarly reached by VA FARMS programming during that time. Data were collected between October 2018 and September 2020 in the form of 336 veteran surveys, 30 veteran interviews, 27 staff interviews, and 11 community partner interviews. Data analysis is expected to be completed by October 2022. ConclusionsThis evaluation protocol will provide guidance to other evaluators assessing innovative programs. In its application to the VA FARMS pilot, the evaluation aims to add to existing literature on nature-based therapies and the rehabilitation outcomes of agricultural training programs for veterans. Results will provide programmatic insights on the implementation of pilot programs, along with needed improvements and modifications for the future expansion of VA FARMS and other veteran-focused agricultural programs. International Registered Report Identifier (IRRID)DERR1-10.2196/4049

Virtual Medical Modality Implementation Strategies for Patient-Aligned Care Teams to Promote Veteran-Centered Care: Protocol for a Mixed-Methods Study

Background: The Veterans Health Administration (VHA) is making system-wide efforts to increase integrated use of health information technology (HIT), including My HealtheVet (MHV), the Veterans Affairs (VA) electronic patient portal, Vet Link kiosks, telehealth, and mobile apps. Integrated use of HIT can increase individual and system efficiency, maximize resources, and enhance patient outcomes. Prior research indicates that provider endorsement and reinforcement are key determinants of patient adoption of HIT. HIT implementation strategies need to reflect providers’ perspectives to promote adoption and endorsement of these tools; however, providers often lack awareness or are unmotivated to incorporate HIT into clinical care with their patients. When these modalities are used by patients, the approach is often fragmented rather than integrated within and across care settings. Research is needed to identify effective implementation strategies for increasing patient-aligned care team (PACT) member (ie, the VHA’s Patient Centered Medical Home) awareness and motivation to use HIT in a proactive and integrated approach with patients. Objective: This paper describes the rationale, design, and methods of the PACT protocol to promote proactive integrated use of HIT. Methods: In Aim 1, focus groups (n=21) were conducted with PACT members (n=65) along with questionnaires and follow-up individual interviews (n=16). In Aim 2, the team collaborated with VA clinicians, electronic health researchers and operational partners to conduct individual expert interviews (n=13), and an environmental scan to collect current and emerging provider-focused implementation tools and resources. Based on Aim 1 findings, a gap analysis was conducted to determine what implementation strategies and content needed to be adapted or developed. Following the adaptation or development of resources, a PACT expert panel was convened to evaluate the resultant content. In Aim 3, a local implementation of PACT-focused strategies to promote integrated use of HIT was evaluated using pre- and postquestionnaire surveys, brief structured interviews, and secondary data analysis with PACT members (n=63). Results: Study enrollment for Aim 1 has been completed. Aims 1 and 2 data collection and analysis are underway. Aim 3 activities are scheduled for year 3. Conclusions: This work highlights the practical, technological, and participatory factors involved in facilitating implementation research designed to engage PACT clinical members in the proactive integrated use of HIT. These efforts are designed to support the integrated and proactive use of VA HIT to support clinical care coordination in ways that are directly aligned with PACT member preferences. This study evaluated integrated VA HIT use employing mixed-methods and multiple data sources. Deliverables included PACT-focused strategies to support integrated use of HIT in the ambulatory care setting that will also inform strategy development in other systems of care and support subsequent implementation efforts at regional and national levels

Nutritional regulation of oligodendrocyte differentiation regulates perineuronal net remodeling in the median eminence.

The mediobasal hypothalamus (arcuate nucleus, ARH and median eminence, ME) is a key nutrient sensing site for the production of the complex homeostatic feedback responses required for the maintenance of energy balance. Here we show that refeeding after an overnight fast rapidly triggers proliferation and differentiation of oligodendrocyte progenitors, leading to the production of new oligodendrocytes in the ME specifically. During this nutritional paradigm, ME perineuronal nets (PNN), emerging regulators of ARH metabolic functions, are rapidly remodelled, and this process requires myelin regulatory factor (Myrf) in oligodendrocyte progenitors. In genetically obese ob/ob mice, nutritional regulations of ME oligodendrocyte differentiation and PNN remodelling are blunted, and enzymatic digestion of local PNN increases food intake and weight gain. We conclude that MBH PNN are required for the maintenance of energy balance in lean mice and are remodelled in the adult ME via the nutritional control of oligodendrocyte differentiation

Nutritional regulation of oligodendrocyte differentiation regulates perineuronal net remodeling in the median eminence.

The mediobasal hypothalamus (MBH; arcuate nucleus of the hypothalamus [ARH] and median eminence [ME]) is a key nutrient sensing site for the production of the complex homeostatic feedback responses required for the maintenance of energy balance. Here, we show that refeeding after an overnight fast rapidly triggers proliferation and differentiation of oligodendrocyte progenitors, leading to the production of new oligodendrocytes in the ME specifically. During this nutritional paradigm, ME perineuronal nets (PNNs), emerging regulators of ARH metabolic functions, are rapidly remodeled, and this process requires myelin regulatory factor (Myrf) in oligodendrocyte progenitors. In genetically obese ob/ob mice, nutritional regulations of ME oligodendrocyte differentiation and PNN remodeling are blunted, and enzymatic digestion of local PNN increases food intake and weight gain. We conclude that MBH PNNs are required for the maintenance of energy balance in lean mice and are remodeled in the adult ME by the nutritional control of oligodendrocyte differentiation

Timely intervention and control of a novel coronavirus (COVID-19) outbreak at a large skilled nursing facility-San Francisco, California, 2020.

ObjectiveTo describe epidemiologic and genomic characteristics of a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak in a large skilled-nursing facility (SNF), and the strategies that controlled transmission.Design, setting, and participantsThis cohort study was conducted during March 22-May 4, 2020, among all staff and residents at a 780-bed SNF in San Francisco, California.MethodsContact tracing and symptom screening guided targeted testing of staff and residents; respiratory specimens were also collected through serial point prevalence surveys (PPSs) in units with confirmed cases. Cases were confirmed by real-time reverse transcription-polymerase chain reaction testing for SARS-CoV-2, and whole-genome sequencing (WGS) was used to characterize viral isolate lineages and relatedness. Infection prevention and control (IPC) interventions included restricting from work any staff who had close contact with a confirmed case; restricting movement between units; implementing surgical face masking facility-wide; and the use of recommended PPE (ie, isolation gown, gloves, N95 respirator and eye protection) for clinical interactions in units with confirmed cases.ResultsOf 725 staff and residents tested through targeted testing and serial PPSs, 21 (3%) were SARS-CoV-2 positive: 16 (76%) staff and 5 (24%) residents. Fifteen cases (71%) were linked to a single unit. Targeted testing identified 17 cases (81%), and PPSs identified 4 cases (19%). Most cases (71%) were identified before IPC interventions could be implemented. WGS was performed on SARS-CoV-2 isolates from 4 staff and 4 residents: 5 were of Santa Clara County lineage and the 3 others were distinct lineages.ConclusionsEarly implementation of targeted testing, serial PPSs, and multimodal IPC interventions limited SARS-CoV-2 transmission within the SNF