Program Profile

Research has consistently identified remarkably high rates of addiction, mental illness, and health problems in the homeless population.^1-9 Yet in spite of extensive service needs for these problems, abundant evidence exists of consistent underuse of health care services by homeless populations.^10-12 Most of the homeless population reside in emergency shelters or in transitional or supportive housing, but many remain in places not meant for human habitation.

Homelessness is significantly overrepresented among military veterans.¹³ The January 2016 national point-in-time count identified 39,471 veterans experiencing homelessness.¹³ Iraq and Afghanistan veterans seem to have an especially high risk for homelessness.^13-15 Disheartening statistics such as these prompted former VA Secretary Eric Shinseki to pledge to end veteran homelessness by December 2015.¹⁶ He argued in support of this mission that 85% of veteran homeless resources go to health care—implying that homelessness among veterans is primarily a health care issue, which is heavily burdened by substance abuse and other psychiatric and medical illnesses.¹⁷

Health care service use has been associated with improved health, mental health, and outcomes among homeless populations.^12,18 Unfortunately, access to these services is limited by barriers associated with homelessness, such as transportation or lack of proper identification.^19,20 Veterans experiencing homelessness also face these common barriers to health care, and unsheltered veterans especially underutilize VA health care services.²¹

Housing First—a successful model that places individuals into housing without prerequisites for sobriety, active participation in treatment, or other behavioral accomplishments, such as gainful employment—has not managed yet to place all the disengaged homeless veteran population into stable housing.²² However, the Housing First model, which is based on the individual’s priorities, is consistent with the approach of a new program at the VA North Texas Health Care System (VANTHCS).

The VHA, similar to other health care systems, is engaged in a cultural transformation to convert its health care approach from a traditional medical model to patient-centered care (PCC).²³ In this priority area, a strategic objective is for the VHA to partner with each veteran to create a personalized, proactive strategy to optimize health and well-being and when needed provide state-of-the-art disease management. Patient-centered care is designed to address veterans’ specific needs in spiritual, environmental, physical, mental, and social domains and empower veterans to become active participants in their care. Patient-centered care differs from the traditional medical model in that patients are active participants in their treatment, partnering and collaborating with their providers on care that is quality-of-life centered instead of disease centered.²³ This model is based on both respect for patients as unique individuals and on the obligation to care for them on their own terms, focused on their self-identified goals and aspirations.²⁴

At VANTHCS, the Homeless Mobile Medical/Mental Veteran (HMMM-V) pilot program was designed to deliver effective health care services to a homeless subpopulation of veterans who historically have been the most difficult to serve—those living in unsheltered environments, such as under bridges and in encampments. The purpose of the HMMM-V program was to contact and serve veterans not currently being reached by the VA system of care, using a PCC model.

This pilot program was initially funded in January 2013 by a 2-year grant from the Office of Patient Centered Care and Cultural Transformation to apply the PCC approach to engage veteran participation. For this project, the VA Personal Health Inventory tool—originally designed for use with the general veteran population—was adapted for use with the homeless veteran population. The grant funding period covered the design, development, and implementation of the HMMM-V program; thereafter, VANTHCS provided resources through its Comprehensive Homeless Center Programs to assure its sustainability and continued use of the clinical assessment tool created for this project.

This article describes the development and implementation of this novel program with sufficient detail to inform the development of similar programs in other sites. Descriptions of the program and staffing, creation of community partnerships, and modification of an assessment instrument are provided. It also illustrates the original implementation period of the HMMM-V program through presentation of self-reported data on the first homeless veterans it served.

Equipment and Staffing

A custom 28-foot mobile outreach vehicle was assembled according to specifications identified by the HMMM-V team as necessary to conduct the program’s interventions. The van became fully operational on April 8, 2015, after it underwent all the required reviews and inspections (eg, safety, infection control, etc) and was accredited in 2015 by the Commission on Accreditation of Rehabilitation Facilities.

The HMMM-V van has a driver compartment that is separate from its services rooms, which include a patient registration area, a fully equipped examination room, a laboratory area, and a bathroom. The vehicle is equipped with a wheelchair lift and an awning to shade outdoor areas where tables and chairs are set up for patient/staff waiting and rest areas. The vehicle is stocked with essential equipment and supplies needed to conduct work in off-street locations, vacant lots, under bridges, fields, unpaved paths, etc. It also is equipped with telemedicine capabilities to provide clinical supervision and access to attending physicians and specialists at VANTHCS. Personnel carry cell phones and laptop computers with secure Internet connections using a commercially available mobile wireless Wi-Fi hotspot to facilitate documentation of medical records and communication from the field.

This reliable type of equipment is routine for use in VA field operations; the only hurdle using these technologies for the program was acquiring funding and purchasing the equipment. The vehicle is further equipped with a refrigerator solely for secure storage of pharmaceutical supplies, a second refrigerator for specimens, and wall-mounted blood pressure and otoscope/ophthalmoscope units. The vehicle is supplied with thermometers, scales, phlebotomy supplies, and first-aid kits and is stocked with vaccines and medications, including antibiotic, hypertensive, diabetic, allergy, and over-the-counter pain medications. A more comprehensive list of supplies for the vehicle is available from the authors on request.

Medication provisions supplied to the HMMM-V mobile clinic conform to the Texas State Board of Pharmacy compliance regulations. Because the vehicle is designated as federal property and has U.S. government license plates, it is considered an extension of VANTHCS Pharmacy Service and falls under its pharmacy license. A medication formulary was created with input from HMMM-V prescribers and Dallas VAMC Pharmacy Service pharmacists. To safeguard the integrity of these pharmaceutical agents, the HMMM-V physician assistant picks up the medications before field deployment and returns the unused medications to the Dallas VAMC at the end of the day. The medications are transported in locked containers and placed either in a locked medication refrigerator or cabinet on the mobile unit.

For medication prescriptions that need laboratory testing before prescribing them, HMMM-V prescribers can check the VA electronic medical record from the field to determine whether these tests have been completed recently. If not, then HMMM-V team has an agreement with Dallas VA Pathology and Laboratory Medicine Service for testing samples obtained in the field.

The program was designed for staffing of the vehicle by 2 professional teams, each includes medical (physician’s assistant or registered nurse), mental health (psychiatrist, residents), and social work providers (licensed social workers, clinical social workers); trainees of these disciplines; a peer support specialist; and an administrative clerk. The staffing varies daily, depending on available personnel. When personnel deploy to the field, they go in pairs or groups to address potential safety issues. Cell phones are available to summon police or ambulance services in an emergency. Systematic safety training was conducted with all field personnel before their first deployment to guard against vulnerability to danger in these settings.

Once in the field, personnel engage unsheltered homeless individuals to assess eligibility for VA services. Veterans found ineligible are assisted with application for military discharge upgrade, service-connected compensation, or appeal for health care coverage. Veterans eligible for VA care receive physical examinations, vital and glucose checks, influenza and pneumonia vaccinations, first-aid skin and wound care, medication management with limited medications provided at point of care, blood and urine testing, peer support services, suicide assessments, clinical mental health evaluations, and social work services through the HMMM-V program.

Social work assistance provided includes psychosocial assessment and care coordination for psychosocial needs such as mental health, substance abuse, vision, dental, housing, employment, legal aid, transportation, food, income, hygiene, and weather-appropriate provision needs.

Community Partnerships

The HMMM-V program benefitted from a number of partnerships with community agencies. During development of the program, HMMM-V personnel accompanied the Dallas Police Department’s Crisis Intervention Unit on typical homeless crisis services deployments into the field to learn about the locations and nature of encampments and homeless peregrination patterns in the Dallas area.

To aid in the design and selection of features for the mobile outreach vehicle, team members toured Homeless Outreach Medical Service mobile clinics from 2 local county hospitals, Parkland Hospital and John Peter Smith Hospital. The staff for these mobile clinics were interviewed about their experience with various components of their programs and their recommendations for optimal design of the mobile medical clinic for service delivery.

Numerous agencies in the Dallas area that serve the homeless population assisted with locating and connecting homeless veterans to HMMM-V programs. These partnering agencies also serve homeless individuals who do not qualify for the HMMM-V program, such as veterans with other-than-honorable military discharges.

The HMMM-V mobile outreach vehicle travels to partnering agencies and provides services on a recurring basis. These agencies are the Dallas International Street Church, a church and faith-based agency aiding the recovery of people with “broken lives”; Cornerstone Ministries, a church-based ministry serving people with adverse circumstances; and City Square’s Opportunity Center, human services and community development programs for low-income city residents. The mobile clinic also travels regularly to other areas to serve homeless veterans residing in unsheltered locations, such as homeless encampments and under bridges.

Clinical Assessment

The project used a modification of the VA Personalized Health Inventory (PHI) for general veteran populations, which assesses 8 areas of self-identified needs to address the specific concerns of homeless veterans served by a mobile clinic.²⁵ Version 19 of the PHI (revised September 18, 2012), the version of the instrument available to the team at the inception of the project, was deployed with the HMMM-V personnel into the field. It imposed a heavy interview time burden (several hours), and its content areas did not seem appropriate to address the immediate concerns of homeless populations (eg, sections pertaining to personal development through hobbies, recreation, or volunteering; healthy living spaces with plenty of lighting and color; “eating healthy, balanced meals with plenty of fruits and vegetables each day”).²⁵

Based on HMMM-V personnel feedback, the team modified this tool and developed a patient-centered health inventory (P-CHI) for homeless veterans that was acceptable in length and applicable to the situational characteristics of homeless existence. The tool’s 10 “current and desired states” were revised to remove domains of exercise and flexibility, sleep and relaxation, and mind-body techniques. The intervention and prevention domains were combined. A material needs (clothing, furniture, transportation, financial benefits) domain was added, and a new domain on reducing alcohol/drug use was created by moving this material from the food and drink domain.

The remaining domains were modified to fit the homeless living situation (Food and Drink = Nutrition; Personal Development = Employment/Vocation; Family, Friends, and Co-Workers = Family/Social/Legal Support; Spirit and Soul = Personal/Spiritual Fulfillment; Surroundings = Housing). Current state ratings were revised to reflect level of satisfaction, and ratings of Desired State were replaced with level of importance.

The modifications resulted in 9 domains, which were assembled into a grid for efficient rating of both satisfaction and importance for each domain (rated 1 to 10, lowest to highest, respectively), followed by an instruction to mark an X in a designated space in all the domains with which the individual would like help (Table). The intent was to reduce the burden of the instrument by having the participant complete sections providing detailed information about only the domains selected by the participant.

The details of each domain in the original VA PHI tool were captured through open-ended questions in text responses provided by the veteran. Because open-ended text responses are not conducive for summarizing characteristics of the population served or for evaluating program activities, the detailed sections covering the domains were revised completely to capture data within categoric and numeric variables. Items from the validated Homeless Supplement Interview were added to collect information not provided in the Homeless Operations Management and Evaluation System interview that is routinely administered to all veterans accessing homeless VA services.^26-28

The information collected in these domains cover duration of current homeless episode, lifetime number of homeless episodes, current living arrangements and dissatisfactions with these arrangements, frequency and source of meals, employment history and current work status, sources of income, special material needs, medical and dental problems and sources of care, current medications, mental health problems and sources of care, urgent mental health concerns, current amount and frequency of alcohol and drug use, substance abuse treatment history, relationships with family and intimate partners, legal assistance needs, and self-identified needs for spiritual and personal fulfillment. This instrument is available on request to the authors.

Veterans Served

The project began with 1 team of professionals deploying with the HMMM-V vehicle while a second team was being assembled. Currently, the 2 HMMM-V teams deploy the mobile clinic 4 days per week. The mobile clinic visits agencies that serve the homeless, including emergency shelters and food ministries, as well as homeless encampments. To date, 195 homeless veterans have been served by the mobile clinic, 111 were currently enrolled with the VA, 8 were not enrolled but eligible for services, and 77 were not eligible for VA services. Of the unenrolled veterans, those eligible for services were offered VA enrollment assistance; those ineligible for VA services were offered a community referral.

For the veterans encountered in the field, the following interventions were provided: 49 housing placement referrals, 4 rental assistance referrals, 4 legal referrals, 27 medical care interventions, 13 dental referrals, 11 vision/hearing referrals, 12 mental health interventions, 9 substance abuse treatment referrals, 14 employment assistance referrals, 13 disability benefit applications, 18 transportation assists, 23 goods delivered, and 159 information assists. The HMMM-V mobile clinic also is deployed to participate in various educational and outreach events. At the time this article was written, the mobile clinic has reached nearly 2,000 veterans and community partners in at least 25 such events.

Of the veterans served to date, 73 completed the P-CHI. These veterans were predominantly male (77%), and the majority (60%) were black. The median age of the sample was 58 years, and typically they had a high school level of education (12.7; SD, 2.1 mean years of education). About half (49%) the sample were separated or divorced, and only a minority were currently married (8%). Half (50%) the sample served in the U.S. Army, with the post-Vietnam era being the era of service most represented (19%). Few (21%) veterans reported exposure to hostile or friendly fire during their service. More than three-fourths (80%) of the sample had experienced a homeless episode prior to their current one. On average, members of the sample had experienced a median of 3 lifetime homeless episodes. They had a mean 4.1 (SD, 5.8) lifetime number of years of homelessness, and 3.0 (SD, 5.2) years in their current homeless episode. Nearly one-third (31%) reported that they were currently staying in a homeless shelter, and nearly one-sixth (16%) were currently unsheltered in street settings, such as under bridges or in outdoor encampments at the time of the initial visit.

The mean number of minutes spent completing the P-CHI was 18.5 (SD, 9.4). The veterans indicated that they would like assistance with a mean 3.2 (SD, 2.2) number of domains. The domains with the highest average importance ratings were housing (mean, 9.4; SD, 1.7) and medical/dental care (mean, 8.9; SD, 2.2); the domains with the lowest average importance rating were reducing alcohol/drug use (mean, 6.4; SD, 4.1) and employment/vocation (mean, 6.3; SD, 4.2). The domains with the highest average satisfaction ratings were personal/spiritual fulfillment (mean, 7.3; SD, 2.9) and reducing substance use (mean, 5.9; SD, 4.0), and the domains with the lowest average satisfaction ratings were housing (mean, 2.9; SD, 2.9), material needs (mean, 4.2; SD, 3.3), and employment/vocation (mean, 4.2; SD, 3.2). The domain with the greatest indication of desire for help was housing, endorsed by more than four-fifths (84%) of the sample. This highly endorsed housing domain also was one of the lowest in satisfaction. The domains with the least expressed interest in obtaining help were reducing substance use (18%) and personal/spiritual fulfillment (15%).Reducing substance abuse also was one of the lowest domains of importance and the least for dissatisfaction.

Challenges and Barriers

As anticipated from its inception, this project encountered many challenges and barriers. The first was with the design, construction, and delivery of the mobile clinic unit. The vehicle took more than 2 years to be delivered. There were delays in progress necessitated by required selection of an approved vendor to build the vehicle, extensive specification of details and features, and stocking it with equipment and supplies. The weight of the unit had to be < 26,000 pounds to avoid the requirement of a commercial driver’s license, which limited the size of the vehicle to 28 feet. Stocking the unit with equipment and supplies required attention to a myriad of specifications and decisions. For example, separate refrigerators were needed for specimens, medications, and food; pharmaceutical regulations governing medications in mobile clinics required strict adherence; and difficulties were encountered in attempting to establish adequate and secure connectivity for communications devices in the field.

Once the mobile unit was delivered and prepared for deployment, the next set of challenges pertained to learning all of the instructions required to operate and drive the vehicle and learning how to maneuver the vehicle in the field. Specific challenges for driving the vehicle encountered included unexpectedly low overpasses that prohibited passage, narrow spaces for passage, rough and uneven terrain in off-road settings, and lateral and vertical tilt of roads creating potential for sideswipes and undercarriage scrapes. Maintenance schedules needed to be developed and implemented for cleaning the unit, inspection compliance, repairs, refueling, and emptying waste materials.

Staffing the vehicle required the development of unique job specifications addressing special expertise in accessing VA databases for veteran verification and registration and for driving the mobile clinic vehicle. Schedules and deployment plans for 2 teams that shared the same vehicle had to be established and followed. Locating veterans in unsheltered settings, such as under bridges and in encampments, required community intelligence facilitated through partnerships with knowledgeable members of the Dallas police crisis unit and by gaining field experience to locate where the usual homeless gathering places are, especially those inhabited by veterans. Safety of team members and equipment/supplies in the field was paramount from the start, and additional steps beyond safety training required extra measures, such as special care in navigating known dangerous areas. Provision of services necessitated completion of everything needed in a single visit due to the likelihood of loss to follow-up and acceptance of the limited types of service that could be provided in a mobile clinic. Special procedures were needed to provide referrals to sources of available care for non-VA-qualifying veterans.

Discussion

The HMMM-V program for delivery of PCC to homeless veterans is an innovative pilot program designed to connect with difficult-to-reach homeless veterans and engage them in care. The deliverables provided by this project are (1) A mobile outreach vehicle to deliver care to homeless veterans and outreach to other veterans and community agencies in North Texas; (2) The P-CHI assessment tool for homeless veterans modified and adapted for use with this special population; and (3) pilot data on its first cohort of homeless veterans served, describing their baseline characteristics and their stated satisfaction and preferences about their goals and aspirations for their physical, emotional, and mental health and well-being.

The HMMM-V program successfully identified homeless veterans in need of services, and more than one-third of these veterans were not previously engaged in VA services. Compared with the “typical” veterans served at VANTHCS homeless programs, veterans served by the HMMM-V comprised a greater proportion of minorities and a higher proportion who had been exposed to combat.²⁹ Age and gender characteristics were similar.²⁹ When compared with veterans who access care at VANTHCS and have not experienced homelessness, those served by the HMMM-V were younger and more likely to belong to a minority group; however, they were similar in combat exposure and gender.¹ The veterans served by the HMMM-V program also were considerably older and had more homeless chronicity than did nonveteran homeless populations, consistent with other research.^4,29,30

The veterans served by the HMMM-V program not surprisingly made housing their top priority in need of help, consistent with the Housing First model.^22,31 They also indicated that employment/vocation and reducing substance use were of lower importance. Need for assistance with reducing substance use and social support were the domains least often identified as areas where help was needed, which seems inconsistent with the higher established rates of substance abuse problems among homeless veterans.¹

With additional fieldwork, the HMMM-V program is expected to allow refinement of procedures for identifying and serving veterans from a patient-centered care perspective. The P-CHI will be further tested and developed, and the next step will be to create and pilot intervention templates for a Patient-Centered Health Improvement Plan, based on the P-CHI results. This process parallels the original development treatment plans for the VA’s Personalized Health Plan based on the PHI.²⁵ Once the HMMM-V program is fully established in Dallas, the plans are for an expansion that will cover a broader geographic area in North Texas that includes rural areas.

The HMMM-V program was designed to address the barriers to health care that are encountered by homeless veterans. It is unique in homeless veteran care due to its patient-centered approach that partners with homeless veterans to prioritize their needs as determined by them rather than based solely on policies or provider conceptualizations of their needs. Access to services, engagement in care, and successful utilization of needed services may lead to measurable improvements in health care outcomes among homeless populations of veterans. Desired goals include remission of illness through appropriate medical intervention, preventing morbidity, achieving healthy lifestyles, recovery from addiction, stabilization of psychiatric illness, and attainment of stable housing.

The first hurdle for implementing this type of program in other settings is the identification of resources needed for these efforts. Need of additional staffing resources, however, may be circumvented by allowing employees working in other areas to rotate in community outreach shifts in the mobile unit. Another hurdle encountered in implementation of the HMMM-V initiative was the initial difficulty finding homeless veterans in community settings, especially those in unsheltered locations. The HMMM-V program addressed this issue by partnering with other agencies serving the homeless in the community. Therefore, a general recommendation for other entities seeking to implement this type of program is to reach out to these community partners from the outset.

Conclusion

The HMMM-V has the potential to engage the most difficult-to-reach homeless veterans in need of health services by delivering care and providing resources in challenging environments. Further work is needed to validate the P-CHI for use with this program and to conduct well-designed and implemented research to demonstrate effectiveness of this intervention on veteran outcomes, especially quality of life. Once this additional work is accomplished, this innovative program can potentially be implemented by VAMCs across the nation, and potentially in more general community care settings, to more effectively reach out and deliver services to homeless members of the community.

Acknowledgments
Grant support was received from the Department of Veterans Affairs, Office of Patient Centered Care. The authors would like to acknowledge all the clinicians, trainees, and support staff who have contributed to the success of the HMMM-V program: Tara Ayala, Jose Cabrera, Tony Castillo, Rachael Lynn David, Teresa DeShazo, Sylvia Figueroa, Steven Fisher, Eric Gary, Evelyn Gibbs, Kevin Hosey, JoAnn Joseph, Taly Drimer Kagan, Miranda Kelly, Michelle King-Thompson, Sharon Marcus, Shiji Mathew, Moneeza Matin, John Moreno, Joseph Neifert, Joel Price, Tiffany Price, Natalie Qualls, Reginald Robertson, Kristine Rodrigues, Jon Saffelder, Jill Stokes, Scott Stone, and John Smith.

Research has consistently identified remarkably high rates of addiction, mental illness, and health problems in the homeless population.^1-9 Yet in spite of extensive service needs for these problems, abundant evidence exists of consistent underuse of health care services by homeless populations.^10-12 Most of the homeless population reside in emergency shelters or in transitional or supportive housing, but many remain in places not meant for human habitation.

Homelessness is significantly overrepresented among military veterans.¹³ The January 2016 national point-in-time count identified 39,471 veterans experiencing homelessness.¹³ Iraq and Afghanistan veterans seem to have an especially high risk for homelessness.^13-15 Disheartening statistics such as these prompted former VA Secretary Eric Shinseki to pledge to end veteran homelessness by December 2015.¹⁶ He argued in support of this mission that 85% of veteran homeless resources go to health care—implying that homelessness among veterans is primarily a health care issue, which is heavily burdened by substance abuse and other psychiatric and medical illnesses.¹⁷

Health care service use has been associated with improved health, mental health, and outcomes among homeless populations.^12,18 Unfortunately, access to these services is limited by barriers associated with homelessness, such as transportation or lack of proper identification.^19,20 Veterans experiencing homelessness also face these common barriers to health care, and unsheltered veterans especially underutilize VA health care services.²¹

Housing First—a successful model that places individuals into housing without prerequisites for sobriety, active participation in treatment, or other behavioral accomplishments, such as gainful employment—has not managed yet to place all the disengaged homeless veteran population into stable housing.²² However, the Housing First model, which is based on the individual’s priorities, is consistent with the approach of a new program at the VA North Texas Health Care System (VANTHCS).

The VHA, similar to other health care systems, is engaged in a cultural transformation to convert its health care approach from a traditional medical model to patient-centered care (PCC).²³ In this priority area, a strategic objective is for the VHA to partner with each veteran to create a personalized, proactive strategy to optimize health and well-being and when needed provide state-of-the-art disease management. Patient-centered care is designed to address veterans’ specific needs in spiritual, environmental, physical, mental, and social domains and empower veterans to become active participants in their care. Patient-centered care differs from the traditional medical model in that patients are active participants in their treatment, partnering and collaborating with their providers on care that is quality-of-life centered instead of disease centered.²³ This model is based on both respect for patients as unique individuals and on the obligation to care for them on their own terms, focused on their self-identified goals and aspirations.²⁴

At VANTHCS, the Homeless Mobile Medical/Mental Veteran (HMMM-V) pilot program was designed to deliver effective health care services to a homeless subpopulation of veterans who historically have been the most difficult to serve—those living in unsheltered environments, such as under bridges and in encampments. The purpose of the HMMM-V program was to contact and serve veterans not currently being reached by the VA system of care, using a PCC model.

This pilot program was initially funded in January 2013 by a 2-year grant from the Office of Patient Centered Care and Cultural Transformation to apply the PCC approach to engage veteran participation. For this project, the VA Personal Health Inventory tool—originally designed for use with the general veteran population—was adapted for use with the homeless veteran population. The grant funding period covered the design, development, and implementation of the HMMM-V program; thereafter, VANTHCS provided resources through its Comprehensive Homeless Center Programs to assure its sustainability and continued use of the clinical assessment tool created for this project.

This article describes the development and implementation of this novel program with sufficient detail to inform the development of similar programs in other sites. Descriptions of the program and staffing, creation of community partnerships, and modification of an assessment instrument are provided. It also illustrates the original implementation period of the HMMM-V program through presentation of self-reported data on the first homeless veterans it served.

Equipment and Staffing

A custom 28-foot mobile outreach vehicle was assembled according to specifications identified by the HMMM-V team as necessary to conduct the program’s interventions. The van became fully operational on April 8, 2015, after it underwent all the required reviews and inspections (eg, safety, infection control, etc) and was accredited in 2015 by the Commission on Accreditation of Rehabilitation Facilities.

The HMMM-V van has a driver compartment that is separate from its services rooms, which include a patient registration area, a fully equipped examination room, a laboratory area, and a bathroom. The vehicle is equipped with a wheelchair lift and an awning to shade outdoor areas where tables and chairs are set up for patient/staff waiting and rest areas. The vehicle is stocked with essential equipment and supplies needed to conduct work in off-street locations, vacant lots, under bridges, fields, unpaved paths, etc. It also is equipped with telemedicine capabilities to provide clinical supervision and access to attending physicians and specialists at VANTHCS. Personnel carry cell phones and laptop computers with secure Internet connections using a commercially available mobile wireless Wi-Fi hotspot to facilitate documentation of medical records and communication from the field.

This reliable type of equipment is routine for use in VA field operations; the only hurdle using these technologies for the program was acquiring funding and purchasing the equipment. The vehicle is further equipped with a refrigerator solely for secure storage of pharmaceutical supplies, a second refrigerator for specimens, and wall-mounted blood pressure and otoscope/ophthalmoscope units. The vehicle is supplied with thermometers, scales, phlebotomy supplies, and first-aid kits and is stocked with vaccines and medications, including antibiotic, hypertensive, diabetic, allergy, and over-the-counter pain medications. A more comprehensive list of supplies for the vehicle is available from the authors on request.

Medication provisions supplied to the HMMM-V mobile clinic conform to the Texas State Board of Pharmacy compliance regulations. Because the vehicle is designated as federal property and has U.S. government license plates, it is considered an extension of VANTHCS Pharmacy Service and falls under its pharmacy license. A medication formulary was created with input from HMMM-V prescribers and Dallas VAMC Pharmacy Service pharmacists. To safeguard the integrity of these pharmaceutical agents, the HMMM-V physician assistant picks up the medications before field deployment and returns the unused medications to the Dallas VAMC at the end of the day. The medications are transported in locked containers and placed either in a locked medication refrigerator or cabinet on the mobile unit.

For medication prescriptions that need laboratory testing before prescribing them, HMMM-V prescribers can check the VA electronic medical record from the field to determine whether these tests have been completed recently. If not, then HMMM-V team has an agreement with Dallas VA Pathology and Laboratory Medicine Service for testing samples obtained in the field.

The program was designed for staffing of the vehicle by 2 professional teams, each includes medical (physician’s assistant or registered nurse), mental health (psychiatrist, residents), and social work providers (licensed social workers, clinical social workers); trainees of these disciplines; a peer support specialist; and an administrative clerk. The staffing varies daily, depending on available personnel. When personnel deploy to the field, they go in pairs or groups to address potential safety issues. Cell phones are available to summon police or ambulance services in an emergency. Systematic safety training was conducted with all field personnel before their first deployment to guard against vulnerability to danger in these settings.

Once in the field, personnel engage unsheltered homeless individuals to assess eligibility for VA services. Veterans found ineligible are assisted with application for military discharge upgrade, service-connected compensation, or appeal for health care coverage. Veterans eligible for VA care receive physical examinations, vital and glucose checks, influenza and pneumonia vaccinations, first-aid skin and wound care, medication management with limited medications provided at point of care, blood and urine testing, peer support services, suicide assessments, clinical mental health evaluations, and social work services through the HMMM-V program.

Social work assistance provided includes psychosocial assessment and care coordination for psychosocial needs such as mental health, substance abuse, vision, dental, housing, employment, legal aid, transportation, food, income, hygiene, and weather-appropriate provision needs.

Community Partnerships

The HMMM-V program benefitted from a number of partnerships with community agencies. During development of the program, HMMM-V personnel accompanied the Dallas Police Department’s Crisis Intervention Unit on typical homeless crisis services deployments into the field to learn about the locations and nature of encampments and homeless peregrination patterns in the Dallas area.

To aid in the design and selection of features for the mobile outreach vehicle, team members toured Homeless Outreach Medical Service mobile clinics from 2 local county hospitals, Parkland Hospital and John Peter Smith Hospital. The staff for these mobile clinics were interviewed about their experience with various components of their programs and their recommendations for optimal design of the mobile medical clinic for service delivery.

Numerous agencies in the Dallas area that serve the homeless population assisted with locating and connecting homeless veterans to HMMM-V programs. These partnering agencies also serve homeless individuals who do not qualify for the HMMM-V program, such as veterans with other-than-honorable military discharges.

The HMMM-V mobile outreach vehicle travels to partnering agencies and provides services on a recurring basis. These agencies are the Dallas International Street Church, a church and faith-based agency aiding the recovery of people with “broken lives”; Cornerstone Ministries, a church-based ministry serving people with adverse circumstances; and City Square’s Opportunity Center, human services and community development programs for low-income city residents. The mobile clinic also travels regularly to other areas to serve homeless veterans residing in unsheltered locations, such as homeless encampments and under bridges.

Clinical Assessment

The project used a modification of the VA Personalized Health Inventory (PHI) for general veteran populations, which assesses 8 areas of self-identified needs to address the specific concerns of homeless veterans served by a mobile clinic.²⁵ Version 19 of the PHI (revised September 18, 2012), the version of the instrument available to the team at the inception of the project, was deployed with the HMMM-V personnel into the field. It imposed a heavy interview time burden (several hours), and its content areas did not seem appropriate to address the immediate concerns of homeless populations (eg, sections pertaining to personal development through hobbies, recreation, or volunteering; healthy living spaces with plenty of lighting and color; “eating healthy, balanced meals with plenty of fruits and vegetables each day”).²⁵

Based on HMMM-V personnel feedback, the team modified this tool and developed a patient-centered health inventory (P-CHI) for homeless veterans that was acceptable in length and applicable to the situational characteristics of homeless existence. The tool’s 10 “current and desired states” were revised to remove domains of exercise and flexibility, sleep and relaxation, and mind-body techniques. The intervention and prevention domains were combined. A material needs (clothing, furniture, transportation, financial benefits) domain was added, and a new domain on reducing alcohol/drug use was created by moving this material from the food and drink domain.

The remaining domains were modified to fit the homeless living situation (Food and Drink = Nutrition; Personal Development = Employment/Vocation; Family, Friends, and Co-Workers = Family/Social/Legal Support; Spirit and Soul = Personal/Spiritual Fulfillment; Surroundings = Housing). Current state ratings were revised to reflect level of satisfaction, and ratings of Desired State were replaced with level of importance.

The modifications resulted in 9 domains, which were assembled into a grid for efficient rating of both satisfaction and importance for each domain (rated 1 to 10, lowest to highest, respectively), followed by an instruction to mark an X in a designated space in all the domains with which the individual would like help (Table). The intent was to reduce the burden of the instrument by having the participant complete sections providing detailed information about only the domains selected by the participant.

The details of each domain in the original VA PHI tool were captured through open-ended questions in text responses provided by the veteran. Because open-ended text responses are not conducive for summarizing characteristics of the population served or for evaluating program activities, the detailed sections covering the domains were revised completely to capture data within categoric and numeric variables. Items from the validated Homeless Supplement Interview were added to collect information not provided in the Homeless Operations Management and Evaluation System interview that is routinely administered to all veterans accessing homeless VA services.^26-28

The information collected in these domains cover duration of current homeless episode, lifetime number of homeless episodes, current living arrangements and dissatisfactions with these arrangements, frequency and source of meals, employment history and current work status, sources of income, special material needs, medical and dental problems and sources of care, current medications, mental health problems and sources of care, urgent mental health concerns, current amount and frequency of alcohol and drug use, substance abuse treatment history, relationships with family and intimate partners, legal assistance needs, and self-identified needs for spiritual and personal fulfillment. This instrument is available on request to the authors.

Veterans Served

The project began with 1 team of professionals deploying with the HMMM-V vehicle while a second team was being assembled. Currently, the 2 HMMM-V teams deploy the mobile clinic 4 days per week. The mobile clinic visits agencies that serve the homeless, including emergency shelters and food ministries, as well as homeless encampments. To date, 195 homeless veterans have been served by the mobile clinic, 111 were currently enrolled with the VA, 8 were not enrolled but eligible for services, and 77 were not eligible for VA services. Of the unenrolled veterans, those eligible for services were offered VA enrollment assistance; those ineligible for VA services were offered a community referral.

For the veterans encountered in the field, the following interventions were provided: 49 housing placement referrals, 4 rental assistance referrals, 4 legal referrals, 27 medical care interventions, 13 dental referrals, 11 vision/hearing referrals, 12 mental health interventions, 9 substance abuse treatment referrals, 14 employment assistance referrals, 13 disability benefit applications, 18 transportation assists, 23 goods delivered, and 159 information assists. The HMMM-V mobile clinic also is deployed to participate in various educational and outreach events. At the time this article was written, the mobile clinic has reached nearly 2,000 veterans and community partners in at least 25 such events.

Of the veterans served to date, 73 completed the P-CHI. These veterans were predominantly male (77%), and the majority (60%) were black. The median age of the sample was 58 years, and typically they had a high school level of education (12.7; SD, 2.1 mean years of education). About half (49%) the sample were separated or divorced, and only a minority were currently married (8%). Half (50%) the sample served in the U.S. Army, with the post-Vietnam era being the era of service most represented (19%). Few (21%) veterans reported exposure to hostile or friendly fire during their service. More than three-fourths (80%) of the sample had experienced a homeless episode prior to their current one. On average, members of the sample had experienced a median of 3 lifetime homeless episodes. They had a mean 4.1 (SD, 5.8) lifetime number of years of homelessness, and 3.0 (SD, 5.2) years in their current homeless episode. Nearly one-third (31%) reported that they were currently staying in a homeless shelter, and nearly one-sixth (16%) were currently unsheltered in street settings, such as under bridges or in outdoor encampments at the time of the initial visit.

The mean number of minutes spent completing the P-CHI was 18.5 (SD, 9.4). The veterans indicated that they would like assistance with a mean 3.2 (SD, 2.2) number of domains. The domains with the highest average importance ratings were housing (mean, 9.4; SD, 1.7) and medical/dental care (mean, 8.9; SD, 2.2); the domains with the lowest average importance rating were reducing alcohol/drug use (mean, 6.4; SD, 4.1) and employment/vocation (mean, 6.3; SD, 4.2). The domains with the highest average satisfaction ratings were personal/spiritual fulfillment (mean, 7.3; SD, 2.9) and reducing substance use (mean, 5.9; SD, 4.0), and the domains with the lowest average satisfaction ratings were housing (mean, 2.9; SD, 2.9), material needs (mean, 4.2; SD, 3.3), and employment/vocation (mean, 4.2; SD, 3.2). The domain with the greatest indication of desire for help was housing, endorsed by more than four-fifths (84%) of the sample. This highly endorsed housing domain also was one of the lowest in satisfaction. The domains with the least expressed interest in obtaining help were reducing substance use (18%) and personal/spiritual fulfillment (15%).Reducing substance abuse also was one of the lowest domains of importance and the least for dissatisfaction.

Challenges and Barriers

As anticipated from its inception, this project encountered many challenges and barriers. The first was with the design, construction, and delivery of the mobile clinic unit. The vehicle took more than 2 years to be delivered. There were delays in progress necessitated by required selection of an approved vendor to build the vehicle, extensive specification of details and features, and stocking it with equipment and supplies. The weight of the unit had to be < 26,000 pounds to avoid the requirement of a commercial driver’s license, which limited the size of the vehicle to 28 feet. Stocking the unit with equipment and supplies required attention to a myriad of specifications and decisions. For example, separate refrigerators were needed for specimens, medications, and food; pharmaceutical regulations governing medications in mobile clinics required strict adherence; and difficulties were encountered in attempting to establish adequate and secure connectivity for communications devices in the field.

Once the mobile unit was delivered and prepared for deployment, the next set of challenges pertained to learning all of the instructions required to operate and drive the vehicle and learning how to maneuver the vehicle in the field. Specific challenges for driving the vehicle encountered included unexpectedly low overpasses that prohibited passage, narrow spaces for passage, rough and uneven terrain in off-road settings, and lateral and vertical tilt of roads creating potential for sideswipes and undercarriage scrapes. Maintenance schedules needed to be developed and implemented for cleaning the unit, inspection compliance, repairs, refueling, and emptying waste materials.

Staffing the vehicle required the development of unique job specifications addressing special expertise in accessing VA databases for veteran verification and registration and for driving the mobile clinic vehicle. Schedules and deployment plans for 2 teams that shared the same vehicle had to be established and followed. Locating veterans in unsheltered settings, such as under bridges and in encampments, required community intelligence facilitated through partnerships with knowledgeable members of the Dallas police crisis unit and by gaining field experience to locate where the usual homeless gathering places are, especially those inhabited by veterans. Safety of team members and equipment/supplies in the field was paramount from the start, and additional steps beyond safety training required extra measures, such as special care in navigating known dangerous areas. Provision of services necessitated completion of everything needed in a single visit due to the likelihood of loss to follow-up and acceptance of the limited types of service that could be provided in a mobile clinic. Special procedures were needed to provide referrals to sources of available care for non-VA-qualifying veterans.

Discussion

The HMMM-V program for delivery of PCC to homeless veterans is an innovative pilot program designed to connect with difficult-to-reach homeless veterans and engage them in care. The deliverables provided by this project are (1) A mobile outreach vehicle to deliver care to homeless veterans and outreach to other veterans and community agencies in North Texas; (2) The P-CHI assessment tool for homeless veterans modified and adapted for use with this special population; and (3) pilot data on its first cohort of homeless veterans served, describing their baseline characteristics and their stated satisfaction and preferences about their goals and aspirations for their physical, emotional, and mental health and well-being.

The HMMM-V program successfully identified homeless veterans in need of services, and more than one-third of these veterans were not previously engaged in VA services. Compared with the “typical” veterans served at VANTHCS homeless programs, veterans served by the HMMM-V comprised a greater proportion of minorities and a higher proportion who had been exposed to combat.²⁹ Age and gender characteristics were similar.²⁹ When compared with veterans who access care at VANTHCS and have not experienced homelessness, those served by the HMMM-V were younger and more likely to belong to a minority group; however, they were similar in combat exposure and gender.¹ The veterans served by the HMMM-V program also were considerably older and had more homeless chronicity than did nonveteran homeless populations, consistent with other research.^4,29,30

The veterans served by the HMMM-V program not surprisingly made housing their top priority in need of help, consistent with the Housing First model.^22,31 They also indicated that employment/vocation and reducing substance use were of lower importance. Need for assistance with reducing substance use and social support were the domains least often identified as areas where help was needed, which seems inconsistent with the higher established rates of substance abuse problems among homeless veterans.¹

With additional fieldwork, the HMMM-V program is expected to allow refinement of procedures for identifying and serving veterans from a patient-centered care perspective. The P-CHI will be further tested and developed, and the next step will be to create and pilot intervention templates for a Patient-Centered Health Improvement Plan, based on the P-CHI results. This process parallels the original development treatment plans for the VA’s Personalized Health Plan based on the PHI.²⁵ Once the HMMM-V program is fully established in Dallas, the plans are for an expansion that will cover a broader geographic area in North Texas that includes rural areas.

The HMMM-V program was designed to address the barriers to health care that are encountered by homeless veterans. It is unique in homeless veteran care due to its patient-centered approach that partners with homeless veterans to prioritize their needs as determined by them rather than based solely on policies or provider conceptualizations of their needs. Access to services, engagement in care, and successful utilization of needed services may lead to measurable improvements in health care outcomes among homeless populations of veterans. Desired goals include remission of illness through appropriate medical intervention, preventing morbidity, achieving healthy lifestyles, recovery from addiction, stabilization of psychiatric illness, and attainment of stable housing.

The first hurdle for implementing this type of program in other settings is the identification of resources needed for these efforts. Need of additional staffing resources, however, may be circumvented by allowing employees working in other areas to rotate in community outreach shifts in the mobile unit. Another hurdle encountered in implementation of the HMMM-V initiative was the initial difficulty finding homeless veterans in community settings, especially those in unsheltered locations. The HMMM-V program addressed this issue by partnering with other agencies serving the homeless in the community. Therefore, a general recommendation for other entities seeking to implement this type of program is to reach out to these community partners from the outset.

Conclusion

The HMMM-V has the potential to engage the most difficult-to-reach homeless veterans in need of health services by delivering care and providing resources in challenging environments. Further work is needed to validate the P-CHI for use with this program and to conduct well-designed and implemented research to demonstrate effectiveness of this intervention on veteran outcomes, especially quality of life. Once this additional work is accomplished, this innovative program can potentially be implemented by VAMCs across the nation, and potentially in more general community care settings, to more effectively reach out and deliver services to homeless members of the community.

Acknowledgments
Grant support was received from the Department of Veterans Affairs, Office of Patient Centered Care. The authors would like to acknowledge all the clinicians, trainees, and support staff who have contributed to the success of the HMMM-V program: Tara Ayala, Jose Cabrera, Tony Castillo, Rachael Lynn David, Teresa DeShazo, Sylvia Figueroa, Steven Fisher, Eric Gary, Evelyn Gibbs, Kevin Hosey, JoAnn Joseph, Taly Drimer Kagan, Miranda Kelly, Michelle King-Thompson, Sharon Marcus, Shiji Mathew, Moneeza Matin, John Moreno, Joseph Neifert, Joel Price, Tiffany Price, Natalie Qualls, Reginald Robertson, Kristine Rodrigues, Jon Saffelder, Jill Stokes, Scott Stone, and John Smith.

Research has consistently identified remarkably high rates of addiction, mental illness, and health problems in the homeless population.^1-9 Yet in spite of extensive service needs for these problems, abundant evidence exists of consistent underuse of health care services by homeless populations.^10-12 Most of the homeless population reside in emergency shelters or in transitional or supportive housing, but many remain in places not meant for human habitation.

Homelessness is significantly overrepresented among military veterans.¹³ The January 2016 national point-in-time count identified 39,471 veterans experiencing homelessness.¹³ Iraq and Afghanistan veterans seem to have an especially high risk for homelessness.^13-15 Disheartening statistics such as these prompted former VA Secretary Eric Shinseki to pledge to end veteran homelessness by December 2015.¹⁶ He argued in support of this mission that 85% of veteran homeless resources go to health care—implying that homelessness among veterans is primarily a health care issue, which is heavily burdened by substance abuse and other psychiatric and medical illnesses.¹⁷

Health care service use has been associated with improved health, mental health, and outcomes among homeless populations.^12,18 Unfortunately, access to these services is limited by barriers associated with homelessness, such as transportation or lack of proper identification.^19,20 Veterans experiencing homelessness also face these common barriers to health care, and unsheltered veterans especially underutilize VA health care services.²¹

Housing First—a successful model that places individuals into housing without prerequisites for sobriety, active participation in treatment, or other behavioral accomplishments, such as gainful employment—has not managed yet to place all the disengaged homeless veteran population into stable housing.²² However, the Housing First model, which is based on the individual’s priorities, is consistent with the approach of a new program at the VA North Texas Health Care System (VANTHCS).

The VHA, similar to other health care systems, is engaged in a cultural transformation to convert its health care approach from a traditional medical model to patient-centered care (PCC).²³ In this priority area, a strategic objective is for the VHA to partner with each veteran to create a personalized, proactive strategy to optimize health and well-being and when needed provide state-of-the-art disease management. Patient-centered care is designed to address veterans’ specific needs in spiritual, environmental, physical, mental, and social domains and empower veterans to become active participants in their care. Patient-centered care differs from the traditional medical model in that patients are active participants in their treatment, partnering and collaborating with their providers on care that is quality-of-life centered instead of disease centered.²³ This model is based on both respect for patients as unique individuals and on the obligation to care for them on their own terms, focused on their self-identified goals and aspirations.²⁴

At VANTHCS, the Homeless Mobile Medical/Mental Veteran (HMMM-V) pilot program was designed to deliver effective health care services to a homeless subpopulation of veterans who historically have been the most difficult to serve—those living in unsheltered environments, such as under bridges and in encampments. The purpose of the HMMM-V program was to contact and serve veterans not currently being reached by the VA system of care, using a PCC model.

This pilot program was initially funded in January 2013 by a 2-year grant from the Office of Patient Centered Care and Cultural Transformation to apply the PCC approach to engage veteran participation. For this project, the VA Personal Health Inventory tool—originally designed for use with the general veteran population—was adapted for use with the homeless veteran population. The grant funding period covered the design, development, and implementation of the HMMM-V program; thereafter, VANTHCS provided resources through its Comprehensive Homeless Center Programs to assure its sustainability and continued use of the clinical assessment tool created for this project.

This article describes the development and implementation of this novel program with sufficient detail to inform the development of similar programs in other sites. Descriptions of the program and staffing, creation of community partnerships, and modification of an assessment instrument are provided. It also illustrates the original implementation period of the HMMM-V program through presentation of self-reported data on the first homeless veterans it served.

Equipment and Staffing

A custom 28-foot mobile outreach vehicle was assembled according to specifications identified by the HMMM-V team as necessary to conduct the program’s interventions. The van became fully operational on April 8, 2015, after it underwent all the required reviews and inspections (eg, safety, infection control, etc) and was accredited in 2015 by the Commission on Accreditation of Rehabilitation Facilities.

The HMMM-V van has a driver compartment that is separate from its services rooms, which include a patient registration area, a fully equipped examination room, a laboratory area, and a bathroom. The vehicle is equipped with a wheelchair lift and an awning to shade outdoor areas where tables and chairs are set up for patient/staff waiting and rest areas. The vehicle is stocked with essential equipment and supplies needed to conduct work in off-street locations, vacant lots, under bridges, fields, unpaved paths, etc. It also is equipped with telemedicine capabilities to provide clinical supervision and access to attending physicians and specialists at VANTHCS. Personnel carry cell phones and laptop computers with secure Internet connections using a commercially available mobile wireless Wi-Fi hotspot to facilitate documentation of medical records and communication from the field.

This reliable type of equipment is routine for use in VA field operations; the only hurdle using these technologies for the program was acquiring funding and purchasing the equipment. The vehicle is further equipped with a refrigerator solely for secure storage of pharmaceutical supplies, a second refrigerator for specimens, and wall-mounted blood pressure and otoscope/ophthalmoscope units. The vehicle is supplied with thermometers, scales, phlebotomy supplies, and first-aid kits and is stocked with vaccines and medications, including antibiotic, hypertensive, diabetic, allergy, and over-the-counter pain medications. A more comprehensive list of supplies for the vehicle is available from the authors on request.

Medication provisions supplied to the HMMM-V mobile clinic conform to the Texas State Board of Pharmacy compliance regulations. Because the vehicle is designated as federal property and has U.S. government license plates, it is considered an extension of VANTHCS Pharmacy Service and falls under its pharmacy license. A medication formulary was created with input from HMMM-V prescribers and Dallas VAMC Pharmacy Service pharmacists. To safeguard the integrity of these pharmaceutical agents, the HMMM-V physician assistant picks up the medications before field deployment and returns the unused medications to the Dallas VAMC at the end of the day. The medications are transported in locked containers and placed either in a locked medication refrigerator or cabinet on the mobile unit.

For medication prescriptions that need laboratory testing before prescribing them, HMMM-V prescribers can check the VA electronic medical record from the field to determine whether these tests have been completed recently. If not, then HMMM-V team has an agreement with Dallas VA Pathology and Laboratory Medicine Service for testing samples obtained in the field.

The program was designed for staffing of the vehicle by 2 professional teams, each includes medical (physician’s assistant or registered nurse), mental health (psychiatrist, residents), and social work providers (licensed social workers, clinical social workers); trainees of these disciplines; a peer support specialist; and an administrative clerk. The staffing varies daily, depending on available personnel. When personnel deploy to the field, they go in pairs or groups to address potential safety issues. Cell phones are available to summon police or ambulance services in an emergency. Systematic safety training was conducted with all field personnel before their first deployment to guard against vulnerability to danger in these settings.

Once in the field, personnel engage unsheltered homeless individuals to assess eligibility for VA services. Veterans found ineligible are assisted with application for military discharge upgrade, service-connected compensation, or appeal for health care coverage. Veterans eligible for VA care receive physical examinations, vital and glucose checks, influenza and pneumonia vaccinations, first-aid skin and wound care, medication management with limited medications provided at point of care, blood and urine testing, peer support services, suicide assessments, clinical mental health evaluations, and social work services through the HMMM-V program.

Social work assistance provided includes psychosocial assessment and care coordination for psychosocial needs such as mental health, substance abuse, vision, dental, housing, employment, legal aid, transportation, food, income, hygiene, and weather-appropriate provision needs.

Community Partnerships

The HMMM-V program benefitted from a number of partnerships with community agencies. During development of the program, HMMM-V personnel accompanied the Dallas Police Department’s Crisis Intervention Unit on typical homeless crisis services deployments into the field to learn about the locations and nature of encampments and homeless peregrination patterns in the Dallas area.

To aid in the design and selection of features for the mobile outreach vehicle, team members toured Homeless Outreach Medical Service mobile clinics from 2 local county hospitals, Parkland Hospital and John Peter Smith Hospital. The staff for these mobile clinics were interviewed about their experience with various components of their programs and their recommendations for optimal design of the mobile medical clinic for service delivery.

Numerous agencies in the Dallas area that serve the homeless population assisted with locating and connecting homeless veterans to HMMM-V programs. These partnering agencies also serve homeless individuals who do not qualify for the HMMM-V program, such as veterans with other-than-honorable military discharges.

The HMMM-V mobile outreach vehicle travels to partnering agencies and provides services on a recurring basis. These agencies are the Dallas International Street Church, a church and faith-based agency aiding the recovery of people with “broken lives”; Cornerstone Ministries, a church-based ministry serving people with adverse circumstances; and City Square’s Opportunity Center, human services and community development programs for low-income city residents. The mobile clinic also travels regularly to other areas to serve homeless veterans residing in unsheltered locations, such as homeless encampments and under bridges.

Clinical Assessment

The project used a modification of the VA Personalized Health Inventory (PHI) for general veteran populations, which assesses 8 areas of self-identified needs to address the specific concerns of homeless veterans served by a mobile clinic.²⁵ Version 19 of the PHI (revised September 18, 2012), the version of the instrument available to the team at the inception of the project, was deployed with the HMMM-V personnel into the field. It imposed a heavy interview time burden (several hours), and its content areas did not seem appropriate to address the immediate concerns of homeless populations (eg, sections pertaining to personal development through hobbies, recreation, or volunteering; healthy living spaces with plenty of lighting and color; “eating healthy, balanced meals with plenty of fruits and vegetables each day”).²⁵

Based on HMMM-V personnel feedback, the team modified this tool and developed a patient-centered health inventory (P-CHI) for homeless veterans that was acceptable in length and applicable to the situational characteristics of homeless existence. The tool’s 10 “current and desired states” were revised to remove domains of exercise and flexibility, sleep and relaxation, and mind-body techniques. The intervention and prevention domains were combined. A material needs (clothing, furniture, transportation, financial benefits) domain was added, and a new domain on reducing alcohol/drug use was created by moving this material from the food and drink domain.

The remaining domains were modified to fit the homeless living situation (Food and Drink = Nutrition; Personal Development = Employment/Vocation; Family, Friends, and Co-Workers = Family/Social/Legal Support; Spirit and Soul = Personal/Spiritual Fulfillment; Surroundings = Housing). Current state ratings were revised to reflect level of satisfaction, and ratings of Desired State were replaced with level of importance.

The modifications resulted in 9 domains, which were assembled into a grid for efficient rating of both satisfaction and importance for each domain (rated 1 to 10, lowest to highest, respectively), followed by an instruction to mark an X in a designated space in all the domains with which the individual would like help (Table). The intent was to reduce the burden of the instrument by having the participant complete sections providing detailed information about only the domains selected by the participant.

The details of each domain in the original VA PHI tool were captured through open-ended questions in text responses provided by the veteran. Because open-ended text responses are not conducive for summarizing characteristics of the population served or for evaluating program activities, the detailed sections covering the domains were revised completely to capture data within categoric and numeric variables. Items from the validated Homeless Supplement Interview were added to collect information not provided in the Homeless Operations Management and Evaluation System interview that is routinely administered to all veterans accessing homeless VA services.^26-28

The information collected in these domains cover duration of current homeless episode, lifetime number of homeless episodes, current living arrangements and dissatisfactions with these arrangements, frequency and source of meals, employment history and current work status, sources of income, special material needs, medical and dental problems and sources of care, current medications, mental health problems and sources of care, urgent mental health concerns, current amount and frequency of alcohol and drug use, substance abuse treatment history, relationships with family and intimate partners, legal assistance needs, and self-identified needs for spiritual and personal fulfillment. This instrument is available on request to the authors.

Veterans Served

The project began with 1 team of professionals deploying with the HMMM-V vehicle while a second team was being assembled. Currently, the 2 HMMM-V teams deploy the mobile clinic 4 days per week. The mobile clinic visits agencies that serve the homeless, including emergency shelters and food ministries, as well as homeless encampments. To date, 195 homeless veterans have been served by the mobile clinic, 111 were currently enrolled with the VA, 8 were not enrolled but eligible for services, and 77 were not eligible for VA services. Of the unenrolled veterans, those eligible for services were offered VA enrollment assistance; those ineligible for VA services were offered a community referral.

For the veterans encountered in the field, the following interventions were provided: 49 housing placement referrals, 4 rental assistance referrals, 4 legal referrals, 27 medical care interventions, 13 dental referrals, 11 vision/hearing referrals, 12 mental health interventions, 9 substance abuse treatment referrals, 14 employment assistance referrals, 13 disability benefit applications, 18 transportation assists, 23 goods delivered, and 159 information assists. The HMMM-V mobile clinic also is deployed to participate in various educational and outreach events. At the time this article was written, the mobile clinic has reached nearly 2,000 veterans and community partners in at least 25 such events.

Of the veterans served to date, 73 completed the P-CHI. These veterans were predominantly male (77%), and the majority (60%) were black. The median age of the sample was 58 years, and typically they had a high school level of education (12.7; SD, 2.1 mean years of education). About half (49%) the sample were separated or divorced, and only a minority were currently married (8%). Half (50%) the sample served in the U.S. Army, with the post-Vietnam era being the era of service most represented (19%). Few (21%) veterans reported exposure to hostile or friendly fire during their service. More than three-fourths (80%) of the sample had experienced a homeless episode prior to their current one. On average, members of the sample had experienced a median of 3 lifetime homeless episodes. They had a mean 4.1 (SD, 5.8) lifetime number of years of homelessness, and 3.0 (SD, 5.2) years in their current homeless episode. Nearly one-third (31%) reported that they were currently staying in a homeless shelter, and nearly one-sixth (16%) were currently unsheltered in street settings, such as under bridges or in outdoor encampments at the time of the initial visit.

The mean number of minutes spent completing the P-CHI was 18.5 (SD, 9.4). The veterans indicated that they would like assistance with a mean 3.2 (SD, 2.2) number of domains. The domains with the highest average importance ratings were housing (mean, 9.4; SD, 1.7) and medical/dental care (mean, 8.9; SD, 2.2); the domains with the lowest average importance rating were reducing alcohol/drug use (mean, 6.4; SD, 4.1) and employment/vocation (mean, 6.3; SD, 4.2). The domains with the highest average satisfaction ratings were personal/spiritual fulfillment (mean, 7.3; SD, 2.9) and reducing substance use (mean, 5.9; SD, 4.0), and the domains with the lowest average satisfaction ratings were housing (mean, 2.9; SD, 2.9), material needs (mean, 4.2; SD, 3.3), and employment/vocation (mean, 4.2; SD, 3.2). The domain with the greatest indication of desire for help was housing, endorsed by more than four-fifths (84%) of the sample. This highly endorsed housing domain also was one of the lowest in satisfaction. The domains with the least expressed interest in obtaining help were reducing substance use (18%) and personal/spiritual fulfillment (15%).Reducing substance abuse also was one of the lowest domains of importance and the least for dissatisfaction.

Challenges and Barriers

As anticipated from its inception, this project encountered many challenges and barriers. The first was with the design, construction, and delivery of the mobile clinic unit. The vehicle took more than 2 years to be delivered. There were delays in progress necessitated by required selection of an approved vendor to build the vehicle, extensive specification of details and features, and stocking it with equipment and supplies. The weight of the unit had to be < 26,000 pounds to avoid the requirement of a commercial driver’s license, which limited the size of the vehicle to 28 feet. Stocking the unit with equipment and supplies required attention to a myriad of specifications and decisions. For example, separate refrigerators were needed for specimens, medications, and food; pharmaceutical regulations governing medications in mobile clinics required strict adherence; and difficulties were encountered in attempting to establish adequate and secure connectivity for communications devices in the field.

Once the mobile unit was delivered and prepared for deployment, the next set of challenges pertained to learning all of the instructions required to operate and drive the vehicle and learning how to maneuver the vehicle in the field. Specific challenges for driving the vehicle encountered included unexpectedly low overpasses that prohibited passage, narrow spaces for passage, rough and uneven terrain in off-road settings, and lateral and vertical tilt of roads creating potential for sideswipes and undercarriage scrapes. Maintenance schedules needed to be developed and implemented for cleaning the unit, inspection compliance, repairs, refueling, and emptying waste materials.

Staffing the vehicle required the development of unique job specifications addressing special expertise in accessing VA databases for veteran verification and registration and for driving the mobile clinic vehicle. Schedules and deployment plans for 2 teams that shared the same vehicle had to be established and followed. Locating veterans in unsheltered settings, such as under bridges and in encampments, required community intelligence facilitated through partnerships with knowledgeable members of the Dallas police crisis unit and by gaining field experience to locate where the usual homeless gathering places are, especially those inhabited by veterans. Safety of team members and equipment/supplies in the field was paramount from the start, and additional steps beyond safety training required extra measures, such as special care in navigating known dangerous areas. Provision of services necessitated completion of everything needed in a single visit due to the likelihood of loss to follow-up and acceptance of the limited types of service that could be provided in a mobile clinic. Special procedures were needed to provide referrals to sources of available care for non-VA-qualifying veterans.

Discussion

The HMMM-V program for delivery of PCC to homeless veterans is an innovative pilot program designed to connect with difficult-to-reach homeless veterans and engage them in care. The deliverables provided by this project are (1) A mobile outreach vehicle to deliver care to homeless veterans and outreach to other veterans and community agencies in North Texas; (2) The P-CHI assessment tool for homeless veterans modified and adapted for use with this special population; and (3) pilot data on its first cohort of homeless veterans served, describing their baseline characteristics and their stated satisfaction and preferences about their goals and aspirations for their physical, emotional, and mental health and well-being.

The HMMM-V program successfully identified homeless veterans in need of services, and more than one-third of these veterans were not previously engaged in VA services. Compared with the “typical” veterans served at VANTHCS homeless programs, veterans served by the HMMM-V comprised a greater proportion of minorities and a higher proportion who had been exposed to combat.²⁹ Age and gender characteristics were similar.²⁹ When compared with veterans who access care at VANTHCS and have not experienced homelessness, those served by the HMMM-V were younger and more likely to belong to a minority group; however, they were similar in combat exposure and gender.¹ The veterans served by the HMMM-V program also were considerably older and had more homeless chronicity than did nonveteran homeless populations, consistent with other research.^4,29,30

The veterans served by the HMMM-V program not surprisingly made housing their top priority in need of help, consistent with the Housing First model.^22,31 They also indicated that employment/vocation and reducing substance use were of lower importance. Need for assistance with reducing substance use and social support were the domains least often identified as areas where help was needed, which seems inconsistent with the higher established rates of substance abuse problems among homeless veterans.¹

With additional fieldwork, the HMMM-V program is expected to allow refinement of procedures for identifying and serving veterans from a patient-centered care perspective. The P-CHI will be further tested and developed, and the next step will be to create and pilot intervention templates for a Patient-Centered Health Improvement Plan, based on the P-CHI results. This process parallels the original development treatment plans for the VA’s Personalized Health Plan based on the PHI.²⁵ Once the HMMM-V program is fully established in Dallas, the plans are for an expansion that will cover a broader geographic area in North Texas that includes rural areas.

The HMMM-V program was designed to address the barriers to health care that are encountered by homeless veterans. It is unique in homeless veteran care due to its patient-centered approach that partners with homeless veterans to prioritize their needs as determined by them rather than based solely on policies or provider conceptualizations of their needs. Access to services, engagement in care, and successful utilization of needed services may lead to measurable improvements in health care outcomes among homeless populations of veterans. Desired goals include remission of illness through appropriate medical intervention, preventing morbidity, achieving healthy lifestyles, recovery from addiction, stabilization of psychiatric illness, and attainment of stable housing.

The first hurdle for implementing this type of program in other settings is the identification of resources needed for these efforts. Need of additional staffing resources, however, may be circumvented by allowing employees working in other areas to rotate in community outreach shifts in the mobile unit. Another hurdle encountered in implementation of the HMMM-V initiative was the initial difficulty finding homeless veterans in community settings, especially those in unsheltered locations. The HMMM-V program addressed this issue by partnering with other agencies serving the homeless in the community. Therefore, a general recommendation for other entities seeking to implement this type of program is to reach out to these community partners from the outset.

Conclusion

The HMMM-V has the potential to engage the most difficult-to-reach homeless veterans in need of health services by delivering care and providing resources in challenging environments. Further work is needed to validate the P-CHI for use with this program and to conduct well-designed and implemented research to demonstrate effectiveness of this intervention on veteran outcomes, especially quality of life. Once this additional work is accomplished, this innovative program can potentially be implemented by VAMCs across the nation, and potentially in more general community care settings, to more effectively reach out and deliver services to homeless members of the community.

Acknowledgments
Grant support was received from the Department of Veterans Affairs, Office of Patient Centered Care. The authors would like to acknowledge all the clinicians, trainees, and support staff who have contributed to the success of the HMMM-V program: Tara Ayala, Jose Cabrera, Tony Castillo, Rachael Lynn David, Teresa DeShazo, Sylvia Figueroa, Steven Fisher, Eric Gary, Evelyn Gibbs, Kevin Hosey, JoAnn Joseph, Taly Drimer Kagan, Miranda Kelly, Michelle King-Thompson, Sharon Marcus, Shiji Mathew, Moneeza Matin, John Moreno, Joseph Neifert, Joel Price, Tiffany Price, Natalie Qualls, Reginald Robertson, Kristine Rodrigues, Jon Saffelder, Jill Stokes, Scott Stone, and John Smith.

Opioid overdoses have quadrupled since 1999, with 78 Americans dying every day of opioid overdoses. More than half of all opioid overdose deaths involve prescription opioids.¹ Attacking this problem from both ends—prescribing and disposal—can have a greater impact than focusing on a single strategy.

Background

In 2016, the CDC issued opioid prescription guidelines that included encouraging health care providers to discuss “options for safe disposal of unused opioids.”² Pharmacies are prohibited from directly taking possession of controlled substances from a user. Historically, the Richard L. Roudebush VAMC (RLRVAMC) in Indianapolis, Indiana, recommended that patients follow FDA guidance for household medication disposal, which includes a list of medications that should be flushed down the toilet.³ As more data became available about the negative downstream environmental effects of pharmaceuticals on the water supply, this method of destruction made many patients feel uncomfortable.^4,5

The Secure and Responsible Drug Disposal Act of 2010 presented additional options for hospitals and pharmacies to assist the public with medication disposal.^6,7 These options offer convenience and anonymity for the end user, reduce potential for diversion, and enhance patient safety by ridding homes of unwanted and expired medications.

Prior to the 2010 act, the only legal methods of controlled substance disposal were via trash disposal, flushing, or delivery to law enforcement, typically at a community-based drug take-back event. These methods were not always convenient, environmentally friendly, or safe for other family members and pets in the home. The Secure and Responsible Drug Disposal Act of 2010 added 2 additional collection options for pharmacies: collection receptacles and mail-back programs.

The RLRVAMC treats > 62,000 veterans annually. The RLRVAMC Pharmacy Service had been providing pharmaceutical mail-back envelopes to patients since May 2015 with moderate success (271 lb of medications returned and a 22.8% envelope return rate through September 2016). Although the mail-back envelopes offer at-home convenience, there was no on-site disposal option. It is not uncommon for patients to bring medications to their appointment or the emergency department (ED). When medication reconciliation is performed, some medications are discontinued, and the prescriber wants them to be safely out of the patient’s possession to avoid confusion and/or accidental overdose. The purpose of this project was to offer more disposal options to patients through the addition of an on-site medication collection receptacle that would be in compliance with U.S. Drug Enforcement Agency (DEA) regulations.

Methods

A policy was developed between the RLRVAMC pharmacy and police departments for the management of a medication collection receptacle. Police would oversee the disposal program so that the pharmacy would not have to change its DEA registration to collector status. The 2 access keys to the receptacle were maintained by police and secured within a key accountability system in the police station.

Full liners are removed from the receptacle by 2 police officers and sealed securely according to vendor guidelines. In accordance with DEA regulations, a form is completed that documents the dates the inner liner was acquired, installed, removed, and transferred for destruction as well as the unique identification number and size of the liner, the address of the location where it was installed, and the names and signatures of the 2 employees that witnessed the removal.

Arrangements are made to have a mail courier present during the removal of the liner. Once removed, the liner is immediately sealed and released to the mail courier who transports the liner to the DEA authorized reverse distributor. The reverse distributor is a licensed entity that has the authority to take control of the medications, including controlled substances, for disposal. The liner tracking numbers are kept in a police log book so that delivery can be confirmed and destruction certificates obtained from the vendor’s website at a later date. The records are kept for 3 years.

Funding was obtained for a 38-gallon collection receptacle and 12 liners from Pharmacy Benefits Management Services (PBM). Approval was obtained from RLRVAMC leadership to locate the receptacle in a high-traffic area, anchored to the floor, under video surveillance, and away from the ED entrance (a DEA requirement). Public Affairs promoted the receptacle to veterans. E-mails were sent to staff to provide education on regulatory requirements. Weight and frequency of medications returned were obtained from data collected by the reverse distributor. Descriptive statistics are reported.

Results

The Federal Supply Schedule cost to procure a DEA-compliant receptacle was $1,450. The additional 12 inner liners cost $2,024.97.⁸ Staff from Engineering Service were able to install the receptacle at no additional cost to the facility. The collection receptacle was opened to the public in May 2016. From May through October 2016, the facility collected and returned 10 liners to the reverse distributor containing 452 lb of medications. An additional 30 lb of drugs were returned through the mailback envelope program for a total weight of 482 lb over the 6-month period (Figure). The average time between inner liner changes was 2.6 weeks.

Discussion

The most challenging aspect of implementation was identification of a location for the receptacle. The location chosen, an alcove in the hallway between the coffee shop and outpatient pharmacy, was most appropriate. It is a high-traffic area, under video surveillance, and provides easy access for patients. Another challenge was determining the frequency of liner changes. There was no historic data to assist with predicting how quickly the liner would fill up. Initially, Police Service checked the receptacle every week, and it was emptied about every 2 weeks. Aspatients cleaned out their medicine cabinets, the liner needed to be replaced closer to every 4 weeks. An ongoing challenge has been determining how full the liner is without requiring the police to open the receptacle. Consideration is being given to installing a scale in the receptacle under the liner and having the display affixed to the outside of the container.

The receptacle seemed to be the preferred method of disposal, considering that it generated nearly 15 times more waste than did the mail-back envelopes during the same time period. Anecdotal patient feedback has been extremely positive on social media and by word-of-mouth.

Limitations

One limitation of this disposal program is that the specific amount of controlled substance waste vs noncontrolled substance waste cannot be determined since the liner contents are not inventoried. The University of Findlay in Ohio partnered with local law enforcement to host 7 community medication take-back events over a 3-year period, inventoried the drugs, and found that about one-third of the dosing units (eg, tablet or capsule) returned in the analgesic category were controlled substances, suggesting that take-back events may play a role in reducing unauthorized access to prescription painkillers.⁹ By witnessing the changing of inner liners, it can be anecdotally confirmed that a significant amount of controlled substances were collected and returned at RLRVAMC. These results have been shared with respective VISN leadership, and additional facilities are installing receptacles.

Conclusion

Changes to DEA regulations offer medical centers more options for developing a comprehensive drug disposal program. Implementation of a pharmaceutical take-back program can assist patients with disposal of unwanted and expired medications, promote safety and environmental stewardship, and reduce the risk of diversion.

Opioid overdoses have quadrupled since 1999, with 78 Americans dying every day of opioid overdoses. More than half of all opioid overdose deaths involve prescription opioids.¹ Attacking this problem from both ends—prescribing and disposal—can have a greater impact than focusing on a single strategy.

Background

In 2016, the CDC issued opioid prescription guidelines that included encouraging health care providers to discuss “options for safe disposal of unused opioids.”² Pharmacies are prohibited from directly taking possession of controlled substances from a user. Historically, the Richard L. Roudebush VAMC (RLRVAMC) in Indianapolis, Indiana, recommended that patients follow FDA guidance for household medication disposal, which includes a list of medications that should be flushed down the toilet.³ As more data became available about the negative downstream environmental effects of pharmaceuticals on the water supply, this method of destruction made many patients feel uncomfortable.^4,5

The Secure and Responsible Drug Disposal Act of 2010 presented additional options for hospitals and pharmacies to assist the public with medication disposal.^6,7 These options offer convenience and anonymity for the end user, reduce potential for diversion, and enhance patient safety by ridding homes of unwanted and expired medications.

Prior to the 2010 act, the only legal methods of controlled substance disposal were via trash disposal, flushing, or delivery to law enforcement, typically at a community-based drug take-back event. These methods were not always convenient, environmentally friendly, or safe for other family members and pets in the home. The Secure and Responsible Drug Disposal Act of 2010 added 2 additional collection options for pharmacies: collection receptacles and mail-back programs.

The RLRVAMC treats > 62,000 veterans annually. The RLRVAMC Pharmacy Service had been providing pharmaceutical mail-back envelopes to patients since May 2015 with moderate success (271 lb of medications returned and a 22.8% envelope return rate through September 2016). Although the mail-back envelopes offer at-home convenience, there was no on-site disposal option. It is not uncommon for patients to bring medications to their appointment or the emergency department (ED). When medication reconciliation is performed, some medications are discontinued, and the prescriber wants them to be safely out of the patient’s possession to avoid confusion and/or accidental overdose. The purpose of this project was to offer more disposal options to patients through the addition of an on-site medication collection receptacle that would be in compliance with U.S. Drug Enforcement Agency (DEA) regulations.

Methods

A policy was developed between the RLRVAMC pharmacy and police departments for the management of a medication collection receptacle. Police would oversee the disposal program so that the pharmacy would not have to change its DEA registration to collector status. The 2 access keys to the receptacle were maintained by police and secured within a key accountability system in the police station.

Full liners are removed from the receptacle by 2 police officers and sealed securely according to vendor guidelines. In accordance with DEA regulations, a form is completed that documents the dates the inner liner was acquired, installed, removed, and transferred for destruction as well as the unique identification number and size of the liner, the address of the location where it was installed, and the names and signatures of the 2 employees that witnessed the removal.

Arrangements are made to have a mail courier present during the removal of the liner. Once removed, the liner is immediately sealed and released to the mail courier who transports the liner to the DEA authorized reverse distributor. The reverse distributor is a licensed entity that has the authority to take control of the medications, including controlled substances, for disposal. The liner tracking numbers are kept in a police log book so that delivery can be confirmed and destruction certificates obtained from the vendor’s website at a later date. The records are kept for 3 years.

Funding was obtained for a 38-gallon collection receptacle and 12 liners from Pharmacy Benefits Management Services (PBM). Approval was obtained from RLRVAMC leadership to locate the receptacle in a high-traffic area, anchored to the floor, under video surveillance, and away from the ED entrance (a DEA requirement). Public Affairs promoted the receptacle to veterans. E-mails were sent to staff to provide education on regulatory requirements. Weight and frequency of medications returned were obtained from data collected by the reverse distributor. Descriptive statistics are reported.

Results

The Federal Supply Schedule cost to procure a DEA-compliant receptacle was $1,450. The additional 12 inner liners cost $2,024.97.⁸ Staff from Engineering Service were able to install the receptacle at no additional cost to the facility. The collection receptacle was opened to the public in May 2016. From May through October 2016, the facility collected and returned 10 liners to the reverse distributor containing 452 lb of medications. An additional 30 lb of drugs were returned through the mailback envelope program for a total weight of 482 lb over the 6-month period (Figure). The average time between inner liner changes was 2.6 weeks.

Discussion

The most challenging aspect of implementation was identification of a location for the receptacle. The location chosen, an alcove in the hallway between the coffee shop and outpatient pharmacy, was most appropriate. It is a high-traffic area, under video surveillance, and provides easy access for patients. Another challenge was determining the frequency of liner changes. There was no historic data to assist with predicting how quickly the liner would fill up. Initially, Police Service checked the receptacle every week, and it was emptied about every 2 weeks. Aspatients cleaned out their medicine cabinets, the liner needed to be replaced closer to every 4 weeks. An ongoing challenge has been determining how full the liner is without requiring the police to open the receptacle. Consideration is being given to installing a scale in the receptacle under the liner and having the display affixed to the outside of the container.

The receptacle seemed to be the preferred method of disposal, considering that it generated nearly 15 times more waste than did the mail-back envelopes during the same time period. Anecdotal patient feedback has been extremely positive on social media and by word-of-mouth.

Limitations

One limitation of this disposal program is that the specific amount of controlled substance waste vs noncontrolled substance waste cannot be determined since the liner contents are not inventoried. The University of Findlay in Ohio partnered with local law enforcement to host 7 community medication take-back events over a 3-year period, inventoried the drugs, and found that about one-third of the dosing units (eg, tablet or capsule) returned in the analgesic category were controlled substances, suggesting that take-back events may play a role in reducing unauthorized access to prescription painkillers.⁹ By witnessing the changing of inner liners, it can be anecdotally confirmed that a significant amount of controlled substances were collected and returned at RLRVAMC. These results have been shared with respective VISN leadership, and additional facilities are installing receptacles.

Conclusion

Changes to DEA regulations offer medical centers more options for developing a comprehensive drug disposal program. Implementation of a pharmaceutical take-back program can assist patients with disposal of unwanted and expired medications, promote safety and environmental stewardship, and reduce the risk of diversion.

Opioid overdoses have quadrupled since 1999, with 78 Americans dying every day of opioid overdoses. More than half of all opioid overdose deaths involve prescription opioids.¹ Attacking this problem from both ends—prescribing and disposal—can have a greater impact than focusing on a single strategy.

Background

In 2016, the CDC issued opioid prescription guidelines that included encouraging health care providers to discuss “options for safe disposal of unused opioids.”² Pharmacies are prohibited from directly taking possession of controlled substances from a user. Historically, the Richard L. Roudebush VAMC (RLRVAMC) in Indianapolis, Indiana, recommended that patients follow FDA guidance for household medication disposal, which includes a list of medications that should be flushed down the toilet.³ As more data became available about the negative downstream environmental effects of pharmaceuticals on the water supply, this method of destruction made many patients feel uncomfortable.^4,5

The Secure and Responsible Drug Disposal Act of 2010 presented additional options for hospitals and pharmacies to assist the public with medication disposal.^6,7 These options offer convenience and anonymity for the end user, reduce potential for diversion, and enhance patient safety by ridding homes of unwanted and expired medications.

Prior to the 2010 act, the only legal methods of controlled substance disposal were via trash disposal, flushing, or delivery to law enforcement, typically at a community-based drug take-back event. These methods were not always convenient, environmentally friendly, or safe for other family members and pets in the home. The Secure and Responsible Drug Disposal Act of 2010 added 2 additional collection options for pharmacies: collection receptacles and mail-back programs.

The RLRVAMC treats > 62,000 veterans annually. The RLRVAMC Pharmacy Service had been providing pharmaceutical mail-back envelopes to patients since May 2015 with moderate success (271 lb of medications returned and a 22.8% envelope return rate through September 2016). Although the mail-back envelopes offer at-home convenience, there was no on-site disposal option. It is not uncommon for patients to bring medications to their appointment or the emergency department (ED). When medication reconciliation is performed, some medications are discontinued, and the prescriber wants them to be safely out of the patient’s possession to avoid confusion and/or accidental overdose. The purpose of this project was to offer more disposal options to patients through the addition of an on-site medication collection receptacle that would be in compliance with U.S. Drug Enforcement Agency (DEA) regulations.

Methods

A policy was developed between the RLRVAMC pharmacy and police departments for the management of a medication collection receptacle. Police would oversee the disposal program so that the pharmacy would not have to change its DEA registration to collector status. The 2 access keys to the receptacle were maintained by police and secured within a key accountability system in the police station.

Full liners are removed from the receptacle by 2 police officers and sealed securely according to vendor guidelines. In accordance with DEA regulations, a form is completed that documents the dates the inner liner was acquired, installed, removed, and transferred for destruction as well as the unique identification number and size of the liner, the address of the location where it was installed, and the names and signatures of the 2 employees that witnessed the removal.

Arrangements are made to have a mail courier present during the removal of the liner. Once removed, the liner is immediately sealed and released to the mail courier who transports the liner to the DEA authorized reverse distributor. The reverse distributor is a licensed entity that has the authority to take control of the medications, including controlled substances, for disposal. The liner tracking numbers are kept in a police log book so that delivery can be confirmed and destruction certificates obtained from the vendor’s website at a later date. The records are kept for 3 years.

Funding was obtained for a 38-gallon collection receptacle and 12 liners from Pharmacy Benefits Management Services (PBM). Approval was obtained from RLRVAMC leadership to locate the receptacle in a high-traffic area, anchored to the floor, under video surveillance, and away from the ED entrance (a DEA requirement). Public Affairs promoted the receptacle to veterans. E-mails were sent to staff to provide education on regulatory requirements. Weight and frequency of medications returned were obtained from data collected by the reverse distributor. Descriptive statistics are reported.

Results

The Federal Supply Schedule cost to procure a DEA-compliant receptacle was $1,450. The additional 12 inner liners cost $2,024.97.⁸ Staff from Engineering Service were able to install the receptacle at no additional cost to the facility. The collection receptacle was opened to the public in May 2016. From May through October 2016, the facility collected and returned 10 liners to the reverse distributor containing 452 lb of medications. An additional 30 lb of drugs were returned through the mailback envelope program for a total weight of 482 lb over the 6-month period (Figure). The average time between inner liner changes was 2.6 weeks.

Discussion

The most challenging aspect of implementation was identification of a location for the receptacle. The location chosen, an alcove in the hallway between the coffee shop and outpatient pharmacy, was most appropriate. It is a high-traffic area, under video surveillance, and provides easy access for patients. Another challenge was determining the frequency of liner changes. There was no historic data to assist with predicting how quickly the liner would fill up. Initially, Police Service checked the receptacle every week, and it was emptied about every 2 weeks. Aspatients cleaned out their medicine cabinets, the liner needed to be replaced closer to every 4 weeks. An ongoing challenge has been determining how full the liner is without requiring the police to open the receptacle. Consideration is being given to installing a scale in the receptacle under the liner and having the display affixed to the outside of the container.

The receptacle seemed to be the preferred method of disposal, considering that it generated nearly 15 times more waste than did the mail-back envelopes during the same time period. Anecdotal patient feedback has been extremely positive on social media and by word-of-mouth.

Limitations

One limitation of this disposal program is that the specific amount of controlled substance waste vs noncontrolled substance waste cannot be determined since the liner contents are not inventoried. The University of Findlay in Ohio partnered with local law enforcement to host 7 community medication take-back events over a 3-year period, inventoried the drugs, and found that about one-third of the dosing units (eg, tablet or capsule) returned in the analgesic category were controlled substances, suggesting that take-back events may play a role in reducing unauthorized access to prescription painkillers.⁹ By witnessing the changing of inner liners, it can be anecdotally confirmed that a significant amount of controlled substances were collected and returned at RLRVAMC. These results have been shared with respective VISN leadership, and additional facilities are installing receptacles.

Conclusion

Changes to DEA regulations offer medical centers more options for developing a comprehensive drug disposal program. Implementation of a pharmaceutical take-back program can assist patients with disposal of unwanted and expired medications, promote safety and environmental stewardship, and reduce the risk of diversion.

Over the past 10 years, the VHA has been a national leader in primary care-mental health integration (PC-MHI) within patient aligned care teams (PACTs).^1,2 Studies of the PC-MHI collaborative care model consistently have shown increased access to MH services, higher levels of MH treatment engagement, improved MH treatment outcomes, and high patient and provider satisfaction.^3-7 Primary care-mental health integration relies heavily on interprofessional team-based practice with providers from diverse educational and clinical backgrounds who work together to deliver integrated mental and behavioral health services within PACTs. This model requires a unique blending of professional cultures and communication and practice styles.

To sustain PC-MHI in PACT, health care professionals (HCPs) must be well trained to work effectively in interprofessional teams. Across health care organizations, training in collaborative interprofessional team-based practice has been identified as an important and challenging task.^8-11

Integrating educational experiences among different HCP learners is an approach to developing competency in interprofessional collaboration early in training. The World Health Organization defined interprofessional education (IPE) as occurring “when students from two or more professions learn about, from, and with each other to enable effective collaboration and improve health outcomes.”⁹ Fundamental to this definition is the belief that interaction among learners from different disciplines during their training develops competency in subsequent effective collaborative practice. Studies of IPE in MH professional training have found that prelicensure IPE contributes to increased knowledge of roles and responsibilities of different disciplines, improved interprofessional communication and attitudes, and increased willingness to work in teams.^12-17

Interprofessional education is a valuable training model, but developing interprofessional learning experiences in a system of diverse and often siloed training programs is difficult. More information about design and implementation of IPE training experiences is needed, particularly in outpatient settings in which integration of traditionally separate discipline-specific care is central to the health care mission. The VA PACT PC-MHI is a strong team-based care model that represents a unique opportunity for training across disciplines in interprofessional collaborative care.

To find innovative approaches to meeting the need for IPE in PACT PC-MHI, the authors developed a new IPE program in PC-MHI at the William S. Middleton Memorial Veterans Hospital (WSMMVH) in Madison, Wisconsin. This article reviews the development, implementation, and first-year evaluation of the training program and discusses the challenges and the IPE areas in need of improvement in PACT PC-MHI.

Methods

In 2012, the VHA launched phase 1 of the Mental Health Education Expansion Initiative (MHEEI), a collaboration of the Office of Academic Affiliations (OAA), VHA Mental Health Services (VHA-MHS), and the Office of Mental Health Operations (OMHO).¹⁸ The MHEEI was intended to “increase expertise in critical areas of need, expand the recruitment pipeline of well-trained, highly qualified health care providers in behavioral and mental health disciplines, and promote the utilization of interprofessional team-based care.”¹⁸ In response, WSMMVH organized a planning committee and submitted a funding request through the section of MHEEI called PACT With Integrated Behavioral Health Providers. The planning committee included training program directors and staff from psychiatry, pharmacy, social work, psychology, and primary care. The authors received funding for trainees in psychiatry (postgraduate year 4 [PGY-4]), pharmacy/MH residency (PGY-2), pharmacy/ambulatory care (PGY-1), and social work (interns).

Curriculum Development

The planning committee met regularly for 6 months to develop the organization, learning objectives, educational strategies, and implementation plan for the IPE program. The program was organized as a 4- to 12-month clinical rotation with the PC-MHI team in PACT, combined with 12 months of protected weekly IPE time (Table 1).

Learning Objectives

To better understand the educational needs and foci for learning objectives, the interprofessional planning committee reviewed guidelines on training in integrated care and collaborative team-based practice.^2,9,10,19-21 These guidelines were compared with existing training opportunities for each discipline to identify training gaps and needs.

Learning objectives were organized into 3 domains: patient-centered PC-MHI, collaborative team-based practice, and population health and program improvement. Table 2 outlines the shared learning objectives linked to each domain that were common to the psychiatry, pharmacy, and social work disciplines. Although many of the learning objectives were shared among all disciplines, each trainee also had discipline-specific clinical activities and learning objectives. Psychiatry and pharmacy residents focused on primary care psychiatric medication consultation and care management for antidepressant medication starts. Social work interns focused on psychosocial and functional assessment and brief problem-focused psychotherapies. Learning objectives were met through direct veteran care in the primary care clinic as part of the PACT PC-MHI team and through interprofessional learning activities during protected weekly education time.

Implementation

Critical stakeholders in implementing the IPE program involved themselves early and throughout the planning process. Stakeholders included VAMC leadership, primary care and MH service line chiefs and clinic managers, training program directors, and PACT staff. Planning committee members gave presentations on the IPE program at MH service line and PACT meetings in the 2 months before program initiation in order to orient staff to learning objectives, program structure, and impact on PACT PC-MHI operations. Throughout the first year, the planning committee continued to meet every 2 weeks to review progress, solve implementation problems, and revise learning objectives and activities.

Trainee Clinical Activities

A wide range of educational strategies were planned to meet learning objectives across the 3 domains. There was strong emphasis on experiential learning through daily PACT and PC-MHI clinical work, team huddles and meetings, and trainee-led program improvement projects.

Psychiatry and PGY-2 pharmacy/MH residents focused on direct and indirect medication consultation and problem-focused assessments. Their clinical activities included PC-MHI medication evaluation and follow-up visits; chart reviews and e-consults for medication recommendations to PACT providers; reviews of care management data and consultations on veterans enrolled in depression and anxiety care management; “curbside consultations” for providers in PACT huddles and meetings and throughout the clinic day; and “warm handoffs,” same-day initial PC-MHI problem-focused assessments performed on PACT provider request. The residents were part of a pool of staff and trainees who performed these assessments.

PGY-1 pharmacy residents made care management phone calls for antidepressant trials for depression and anxiety. These residents were trained in motivational interviewing (MI). They applied their MI skills during care management calls focused on medication adherence and behavioral interventions for depression (eg, exercise, planning pleasurable activity) and during other clinical rotations, including tobacco cessation and medication management for diabetes and hypertension. Particularly challenging veteran cases from these clinics were cosupervised with medication management and PC-MHIstaff for added consultation on engagement, behavior change, and treatment plan adherence.

Social work interns completed initial PC-MHI psychosocial and functional assessments by phone and directly by same-day warm handoffs from PACT staff. The PC-MHI therapies they provided included problem-solving therapy, behavioral activation, stress management based on cognitive behavioral therapy, and brief alcohol interventions.

Group IPE Activities

All trainees had a weekly protected block of 3 hours during which they came together for group IPE that was designed to elicit active participation; facilitate interprofessional communication; and develop an understanding of and respect for the knowledge, culture, and practice style of the different disciplines.

Trainees participated in a Herrmann Brain Dominance Instrument (HBDI) workshop focused on developing a better understanding of individual differences in thinking and problem solving, with the goal of improving communication and learning within teams.²² In a seminar series on professionalism and boundaries in health care, trainees from each discipline gave a presentation on the traditional structure and content of their discipline’s training and discussed similarities and differences in their disciplines’ professional oaths, codes of ethics, and boundary guidelines.

Motivational interviewing training was conducted early in the year so trainees would be prepared to apply MI skills in their daily PACT PC-MHI clinical work. Motivational inteviewing is a patient-centered approach to engaging patients in health promoting behavior change. It is defined as a “directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence.”²³

Trainees recorded MI sessions with at least 2 live-patient visits and at least 2 simulated-patient interviews (with staff serving as patient actors). The structure of MI training and supervision was deliberately designed to facilitate interprofessional communication and learning. In accord with a group supervision model for MI recorded reviews, the trainees presented their tapes to the entire learning group in the presence of a facilitating supervisor. Trainees had the opportunity to observe different interview styles and exchange feedback within a peer group of interprofessional learners.

Seminars were focused on core PC-MHI clinical content (eg, depression, anxiety, alcohol use disorders) and organized around case-based learning. Trainees divided into small teams in which representatives of each discipline offered their perspective on how to approach planning patient assessment and treatment. During the seminars, the authors engaged trainees as teachers and leaders whenever possible. All trainees presented on a topic in which they had some discipline expertise. For example, social work interns led a seminar on support and social services for victims of domestic violence, and PGY-1 pharmacy/ambulatory care residents led seminars and a panel management project focused on diabetes and depression.

Trainees participated in several PACT PC-MHI projects focused on population- and measurement-based care, panel management, and program improvement (Table 3). Protected IPE time was used to teach trainees about population health principles and different tools for process improvement (eg, Vision-Analysis Team-Aim-Map-Measure-Change-Sustain) and provide a forum in which trainees could share their work with one another.

Evaluations

Several tools were used for trainee and program evaluations. Clinical skills were evaluated during daily supervision. Trainees began the year with PC-MHI staff directly observing all their clinical contacts with veterans. Staff evaluated and offered feedback on trainee clinical interviewing and on assessment and treatment planning skills. Once they were assessed to be ready to see veterans on their own, trainees were advanced by staff to “drop-in” direct supervision: Toward the end of a veteran’s visit, a staff preceptor entered the room to review relevant clinical findings, assessment and finalized treatment planning with the trainee and veteran. When appropriate for trainee competence level, clinical contacts were indirectly supervised: Trainees discussed their assessment and treatment plan with a staff supervisor at the end of the day.

Motivational interviewing recordings were reviewed during group supervision. To objectively evaluate MI skills, supervisors who were VA-certified in MI used the Motivational Interviewing Treatment Integrity (MITI) coding tool to review and code both the live- and simulated-patient recordings.²⁴ The MITI coding involves quantitative and qualitative analysis using standardized coding items.

Quantitative items included percentage of open-ended questions (Proficiency: 50%; competency: 70%); percentage of reflections considered complex reflections, or reflective statements adding substantial meaning or emphasis and conveying a deeper or more complex picture of what patients say (Proficiency: 40%; competency: 50%); reflection-to-question ratio (Proficiency: 1:1; competency: 2:1); and percentage of MI-adherent provider statements (Proficiency: 90%; competency: 100%).

Qualitative coding items were a global rating of therapist “empathy,” which evaluated the extent to which the trainee understood or made an effort to grasp the patient’s perspective, and “MI spirit.” This coding intended to capture the overall competence of the trainee in emphasizing collaboration, patient autonomy, and evocation of the patient experience (Proficiency score: 5; competency score: 6).

The PC-MHI teaching staff met midyear and end of year as a team to complete trainee evaluations focused on the 3 areas of learning objectives: patient-centered PC-MHI, collaborative team-based practice, and population health and program improvement. Patient-centered PC-MHI involves direct observation and supervision of trainee clinical contacts with veterans, including assessment and treatment planning, clinical documentation, and review of live- and simulated-patient MI recordings. Collaborative team-based practice involves review of trainee participation in day-to-day teamwork, huddles, team meetings, and IPE activities. Population health and program improvement involves review of trainee work on a panel measurement-based care management or program improvement project. In each learning objectives area, trainees were rated on a 3-point scale: needs improvement (1); satisfactory (2); achieved (3). Core knowledge about PC-MHI evidence base, structure, and clinical topics was assessed with case-based written examination at midyear and end of year.

Surveys and qualitative interviews were used to assess trainee perceptions about the IPE program. A midyear and end-of-year survey assessed trainee satisfaction and perceived efficacy of the IPE training program in meeting core learning objectives. A midyear survey designed by pharmacy residents as part of their program improvement project evaluated attitudes around interprofessional learning and team practice. Trainees met individually with the PC-MHI IPE director at midyear and end of year to gather qualitative feedback on the IPE program.

Outcomes

All trainees advanced to the expected level of supervision for clinical contacts (drop-in or indirect clinical supervision). Over the year, there was significant improvement in trainees’ MI skills as measured by MITI coding of at least 2 live-patient or 2 simulated-patient recordings (Figures 1A and 1B). By end of year, most trainees had reached proficiency or competency in several MITI coded items: percentage of open-ended questions (4/12 proficient, 8/12 competent), percentage of complex reflections (2/12 less than proficient, 3/12 proficient, 7/12 competent), MI adherence (1/12 proficient, 11/12 competent), global empathy rating (2/12 proficient, 10/12 competent), and global MI spirit rating (12/12 competent). Average reflection-to-question ratio for the trainee group increased from 0.63 to 0.96 from midyear to end of year, but only 3 of 12 trainees reached the proficiency level of a 1:1 ratio, and no trainee reached the competency level of a 2:1 ratio.

According to the PC-MHI team’s midyear evaluation, most trainees were already making satisfactory progress in the 3 domains of learning objectives for the training program. At end of year, 13 of 14 trainees were assessed as competent in all 3 domains (Figures 2A and B). All trainees passed the midyear and end-of-year written examinations with overall high scores (average score, 82%) demonstrating acquisition of core PC-MHI clinical knowledge.

Trainee evaluations of the IPE program were overall highly favorable at both midyear and at end of year. Trainees rated the program effective or extremely effective in developing their skills in patient-centered care, interprofessional communication, and collaborative team-based practice. They also rated the program highly effective in preparing them to use team-based practice skills in other settings. On a midyear survey, trainees moderately to strongly agreed with several positive beliefs and attitudes about team-based care.

In qualitative interviews at program completion, trainees across disciplines rated the MI training with group supervision as one of their most valuable interprofessional learning experiences. Other highly valued training experiences were PACT PC-MHI panel management projects, team-based clinical case reviews, and cross-disciplinary supervision.

Discussion

This article describes the successful development and implementation of a VA-based IPE program in PACT PC-MHI. Interprofessional clinical training and educational experiences were highly valued, and trainees identified positive attitudes and improved skills related to team-based care. These findings support previous findings that IPE is associated with high satisfaction and positive attitudes toward team-based collaborative practice.^{12-17 P}rogram implementation presented several challenges: nonsynchronous academic calendars and rotation schedules, cross-disciplinary supervision regulations, variations in clinical and supervisory requirements for accreditation standards, the traditional health care hierarchy, and measurement of the impact of IPE experiences.^11,25,26

Rotation schedules and academic calendars varied across the psychiatry, pharmacy, and social work home programs. Organizing different trainee rotation schedules was a significant challenge. Collaboration with training directors and support staff was crucial in planning rotations that offered a longitudinal training experience in PACT PC-MHI. Given the participants’ different starting dates, protected IPE time early in the calendar year was focused on developing clinical skills specific to the pharmacy and psychiatry trainees who would be starting in July, and IPE activities that required the presence of all trainee disciplines (eg, MI training, HBDI) were planned for after the September start of the social work interns.

Cross-disciplinary supervision was highly valued by trainees because it offered exposure to the disciplines’ different communication styles and approaches to clinical assessment and decision making. Throughout the year, however, trainees encountered several obstacles to cross-disciplinary supervision, with respect to coding/billing and home program supervisory policies. The authors worked closely with the VA administration and each training program to develop and revise supervising policies and procedures to meet the necessary administrative and program supervisory requirements for accreditation standards.

In some cases, this work resulted in dual supervision by a preceptor of the same discipline (to meet requirements for coding/billing and home program supervision) and clinical supervision by a preceptor of a different discipline (eg, in team meetings or in clinical case reviews during protected IPE time). Preceptors from each discipline met regularly to discuss challenges in cross-disciplinary supervision, review scope-of-practice issues, share information on discipline-specific training, and revise supervisory procedures.

Interprofessional education activities during weekly protected time were designed to improve collaboration and to challenge trainees to examine traditional hierarchical roles and patterns of communication in health care. An emphasis on case-based learning in small groups encouraged trainees to share perspectives on their discipline-specific approach to assessment and treatment planning. Motivational interviewing training, one of the IPE experiences most valued by trainees and staff, created the opportunity for a truly shared learning environment, as trainees largely started at about the same skill level despite having different educational backgrounds. Group supervision of MI recordings offered trainees the opportunity to learn from each other and develop comfort in offering and receiving interprofessional constructive feedback.

Limitations

There were considerable methodologic limitations in the authors’ efforts to evaluate the impact of this training program on trainee attitudes and skills in collaborative team-based practice. Although trainee surveys revealed highly positive attitudes and beliefs about team-based care as well as perceived competence in collaborative practice, these were not validated surveys, and changes could not be accurately measured over time (trainees were not assessed at baseline). Trainees also were involved in other clinical teams within the VA during the year, and it is difficult to assess the specific impact of their PC-MHI IPE experiences. The PC-MHI staff evaluations of trainee competence in collaborative team-based practice were largely observational and potentially vulnerable to biases, as the staff evaluating trainee competence also were part of the IPE program planning process and invested in its success.

To address these limitations in the future, the authors will use better assessment tools at baseline and end of year to more effectively evaluate the impact of the training program on teamwork skills as well changes in attitudes and beliefs about interprofessional learning and teamwork. The Attitudes Toward Interprofessional Health Care Teams Scale and the Perceptions of Effective Interpersonal Teams Scale should be considered as they have published reliability and validity.^27,28 The authors could improve the reliability and depth of trainee evaluations with use of a “360-degree evaluation” model for trainee evaluations that includes other PACT members (beyond PC-MHI staff) as well as veterans.

Assessment of MI skills and competency was limited by use of both live- and simulated-patient recordings. Simulation is a valuable learning tool but often does not accurately represent actual clinical situations and challenges. To appropriately assess MI competence, future MI training should emphasize live-patient recordings over simulated-patient visits. Furthermore, whereas trainees reached competency in several MI coding items, none reached competency in the reflection-to-question ratio, and only about half reached competency in percentage of complex reflections. Future MI training will need to focus on further development of reflection skills.

Trainee intentions to remain involved in program improvement and collaborative team-based care in future professional work were core attitudinal learning objectives, but neither was adequately assessed in end-of-year surveys. Ideally, future evaluations will assess subjective trainee intentions and goals around team-based work and objectively measure future professional choices and activities. For example, it would be interesting to determine whether trainees who participated in this program will choose to practice in an interprofessional team-based model or participate in program improvement activities.

Last, the absence of psychology interns was considered a weakness in the learning environment, resulting in a relatively “prescriber-heavy” balance in discipline perspectives for IPE-focused case discussions and other training. Furthermore, the discipline representation in the IPE program did not exemplify the typical PC-MHI team in most VA clinic settings and community practices in which psychology has a strong presence. Adding psychology trainees was an important goal for the IPE program leadership. In 2015, WSMMVH was awarded additional funding for a PACT PC-MHI predoctoral psychology intern through the phase 4 MHEEI. The PC-MHI track psychology intern joined the IPE program in the 2016-2017 training year.

Conclusion

There is broad consensus that interprofessional team-based practice is crucial for providers in the VA and all health care systems. Primary care-mental health integration is an area of VA care in which interprofessional collaboration is uniquely important to implementation and sustainability of the model. Interprofessional education is an effective approach for preparing HCPs for team-based practice, but implementation is challenging. Several factors crucially contributed to the successful implementation of this program: collaboration of the interprofessional planning team with representation from key stakeholders in different departments and training programs; a well-established PACT PC-MHI team with experience in collaborative team-based care; a curriculum structure that emphasized experiential educational strategies designed to promote interprofessional learning and communication; VA leadership support at the national level (MHEEI funding) and local level; and PACT PC-MHI clinical staff committed to teaching and to the IPE mission.

Over the past 10 years, the VHA has been a national leader in primary care-mental health integration (PC-MHI) within patient aligned care teams (PACTs).^1,2 Studies of the PC-MHI collaborative care model consistently have shown increased access to MH services, higher levels of MH treatment engagement, improved MH treatment outcomes, and high patient and provider satisfaction.^3-7 Primary care-mental health integration relies heavily on interprofessional team-based practice with providers from diverse educational and clinical backgrounds who work together to deliver integrated mental and behavioral health services within PACTs. This model requires a unique blending of professional cultures and communication and practice styles.

To sustain PC-MHI in PACT, health care professionals (HCPs) must be well trained to work effectively in interprofessional teams. Across health care organizations, training in collaborative interprofessional team-based practice has been identified as an important and challenging task.^8-11

Integrating educational experiences among different HCP learners is an approach to developing competency in interprofessional collaboration early in training. The World Health Organization defined interprofessional education (IPE) as occurring “when students from two or more professions learn about, from, and with each other to enable effective collaboration and improve health outcomes.”⁹ Fundamental to this definition is the belief that interaction among learners from different disciplines during their training develops competency in subsequent effective collaborative practice. Studies of IPE in MH professional training have found that prelicensure IPE contributes to increased knowledge of roles and responsibilities of different disciplines, improved interprofessional communication and attitudes, and increased willingness to work in teams.^12-17

Interprofessional education is a valuable training model, but developing interprofessional learning experiences in a system of diverse and often siloed training programs is difficult. More information about design and implementation of IPE training experiences is needed, particularly in outpatient settings in which integration of traditionally separate discipline-specific care is central to the health care mission. The VA PACT PC-MHI is a strong team-based care model that represents a unique opportunity for training across disciplines in interprofessional collaborative care.

To find innovative approaches to meeting the need for IPE in PACT PC-MHI, the authors developed a new IPE program in PC-MHI at the William S. Middleton Memorial Veterans Hospital (WSMMVH) in Madison, Wisconsin. This article reviews the development, implementation, and first-year evaluation of the training program and discusses the challenges and the IPE areas in need of improvement in PACT PC-MHI.

Methods

In 2012, the VHA launched phase 1 of the Mental Health Education Expansion Initiative (MHEEI), a collaboration of the Office of Academic Affiliations (OAA), VHA Mental Health Services (VHA-MHS), and the Office of Mental Health Operations (OMHO).¹⁸ The MHEEI was intended to “increase expertise in critical areas of need, expand the recruitment pipeline of well-trained, highly qualified health care providers in behavioral and mental health disciplines, and promote the utilization of interprofessional team-based care.”¹⁸ In response, WSMMVH organized a planning committee and submitted a funding request through the section of MHEEI called PACT With Integrated Behavioral Health Providers. The planning committee included training program directors and staff from psychiatry, pharmacy, social work, psychology, and primary care. The authors received funding for trainees in psychiatry (postgraduate year 4 [PGY-4]), pharmacy/MH residency (PGY-2), pharmacy/ambulatory care (PGY-1), and social work (interns).

Curriculum Development

The planning committee met regularly for 6 months to develop the organization, learning objectives, educational strategies, and implementation plan for the IPE program. The program was organized as a 4- to 12-month clinical rotation with the PC-MHI team in PACT, combined with 12 months of protected weekly IPE time (Table 1).

Learning Objectives

To better understand the educational needs and foci for learning objectives, the interprofessional planning committee reviewed guidelines on training in integrated care and collaborative team-based practice.^2,9,10,19-21 These guidelines were compared with existing training opportunities for each discipline to identify training gaps and needs.

Learning objectives were organized into 3 domains: patient-centered PC-MHI, collaborative team-based practice, and population health and program improvement. Table 2 outlines the shared learning objectives linked to each domain that were common to the psychiatry, pharmacy, and social work disciplines. Although many of the learning objectives were shared among all disciplines, each trainee also had discipline-specific clinical activities and learning objectives. Psychiatry and pharmacy residents focused on primary care psychiatric medication consultation and care management for antidepressant medication starts. Social work interns focused on psychosocial and functional assessment and brief problem-focused psychotherapies. Learning objectives were met through direct veteran care in the primary care clinic as part of the PACT PC-MHI team and through interprofessional learning activities during protected weekly education time.

Implementation

Critical stakeholders in implementing the IPE program involved themselves early and throughout the planning process. Stakeholders included VAMC leadership, primary care and MH service line chiefs and clinic managers, training program directors, and PACT staff. Planning committee members gave presentations on the IPE program at MH service line and PACT meetings in the 2 months before program initiation in order to orient staff to learning objectives, program structure, and impact on PACT PC-MHI operations. Throughout the first year, the planning committee continued to meet every 2 weeks to review progress, solve implementation problems, and revise learning objectives and activities.

Trainee Clinical Activities

A wide range of educational strategies were planned to meet learning objectives across the 3 domains. There was strong emphasis on experiential learning through daily PACT and PC-MHI clinical work, team huddles and meetings, and trainee-led program improvement projects.

Psychiatry and PGY-2 pharmacy/MH residents focused on direct and indirect medication consultation and problem-focused assessments. Their clinical activities included PC-MHI medication evaluation and follow-up visits; chart reviews and e-consults for medication recommendations to PACT providers; reviews of care management data and consultations on veterans enrolled in depression and anxiety care management; “curbside consultations” for providers in PACT huddles and meetings and throughout the clinic day; and “warm handoffs,” same-day initial PC-MHI problem-focused assessments performed on PACT provider request. The residents were part of a pool of staff and trainees who performed these assessments.

PGY-1 pharmacy residents made care management phone calls for antidepressant trials for depression and anxiety. These residents were trained in motivational interviewing (MI). They applied their MI skills during care management calls focused on medication adherence and behavioral interventions for depression (eg, exercise, planning pleasurable activity) and during other clinical rotations, including tobacco cessation and medication management for diabetes and hypertension. Particularly challenging veteran cases from these clinics were cosupervised with medication management and PC-MHIstaff for added consultation on engagement, behavior change, and treatment plan adherence.

Social work interns completed initial PC-MHI psychosocial and functional assessments by phone and directly by same-day warm handoffs from PACT staff. The PC-MHI therapies they provided included problem-solving therapy, behavioral activation, stress management based on cognitive behavioral therapy, and brief alcohol interventions.

Group IPE Activities

All trainees had a weekly protected block of 3 hours during which they came together for group IPE that was designed to elicit active participation; facilitate interprofessional communication; and develop an understanding of and respect for the knowledge, culture, and practice style of the different disciplines.

Trainees participated in a Herrmann Brain Dominance Instrument (HBDI) workshop focused on developing a better understanding of individual differences in thinking and problem solving, with the goal of improving communication and learning within teams.²² In a seminar series on professionalism and boundaries in health care, trainees from each discipline gave a presentation on the traditional structure and content of their discipline’s training and discussed similarities and differences in their disciplines’ professional oaths, codes of ethics, and boundary guidelines.

Motivational interviewing training was conducted early in the year so trainees would be prepared to apply MI skills in their daily PACT PC-MHI clinical work. Motivational inteviewing is a patient-centered approach to engaging patients in health promoting behavior change. It is defined as a “directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence.”²³

Trainees recorded MI sessions with at least 2 live-patient visits and at least 2 simulated-patient interviews (with staff serving as patient actors). The structure of MI training and supervision was deliberately designed to facilitate interprofessional communication and learning. In accord with a group supervision model for MI recorded reviews, the trainees presented their tapes to the entire learning group in the presence of a facilitating supervisor. Trainees had the opportunity to observe different interview styles and exchange feedback within a peer group of interprofessional learners.

Seminars were focused on core PC-MHI clinical content (eg, depression, anxiety, alcohol use disorders) and organized around case-based learning. Trainees divided into small teams in which representatives of each discipline offered their perspective on how to approach planning patient assessment and treatment. During the seminars, the authors engaged trainees as teachers and leaders whenever possible. All trainees presented on a topic in which they had some discipline expertise. For example, social work interns led a seminar on support and social services for victims of domestic violence, and PGY-1 pharmacy/ambulatory care residents led seminars and a panel management project focused on diabetes and depression.

Trainees participated in several PACT PC-MHI projects focused on population- and measurement-based care, panel management, and program improvement (Table 3). Protected IPE time was used to teach trainees about population health principles and different tools for process improvement (eg, Vision-Analysis Team-Aim-Map-Measure-Change-Sustain) and provide a forum in which trainees could share their work with one another.

Evaluations

Several tools were used for trainee and program evaluations. Clinical skills were evaluated during daily supervision. Trainees began the year with PC-MHI staff directly observing all their clinical contacts with veterans. Staff evaluated and offered feedback on trainee clinical interviewing and on assessment and treatment planning skills. Once they were assessed to be ready to see veterans on their own, trainees were advanced by staff to “drop-in” direct supervision: Toward the end of a veteran’s visit, a staff preceptor entered the room to review relevant clinical findings, assessment and finalized treatment planning with the trainee and veteran. When appropriate for trainee competence level, clinical contacts were indirectly supervised: Trainees discussed their assessment and treatment plan with a staff supervisor at the end of the day.

Motivational interviewing recordings were reviewed during group supervision. To objectively evaluate MI skills, supervisors who were VA-certified in MI used the Motivational Interviewing Treatment Integrity (MITI) coding tool to review and code both the live- and simulated-patient recordings.²⁴ The MITI coding involves quantitative and qualitative analysis using standardized coding items.

Quantitative items included percentage of open-ended questions (Proficiency: 50%; competency: 70%); percentage of reflections considered complex reflections, or reflective statements adding substantial meaning or emphasis and conveying a deeper or more complex picture of what patients say (Proficiency: 40%; competency: 50%); reflection-to-question ratio (Proficiency: 1:1; competency: 2:1); and percentage of MI-adherent provider statements (Proficiency: 90%; competency: 100%).

Qualitative coding items were a global rating of therapist “empathy,” which evaluated the extent to which the trainee understood or made an effort to grasp the patient’s perspective, and “MI spirit.” This coding intended to capture the overall competence of the trainee in emphasizing collaboration, patient autonomy, and evocation of the patient experience (Proficiency score: 5; competency score: 6).

The PC-MHI teaching staff met midyear and end of year as a team to complete trainee evaluations focused on the 3 areas of learning objectives: patient-centered PC-MHI, collaborative team-based practice, and population health and program improvement. Patient-centered PC-MHI involves direct observation and supervision of trainee clinical contacts with veterans, including assessment and treatment planning, clinical documentation, and review of live- and simulated-patient MI recordings. Collaborative team-based practice involves review of trainee participation in day-to-day teamwork, huddles, team meetings, and IPE activities. Population health and program improvement involves review of trainee work on a panel measurement-based care management or program improvement project. In each learning objectives area, trainees were rated on a 3-point scale: needs improvement (1); satisfactory (2); achieved (3). Core knowledge about PC-MHI evidence base, structure, and clinical topics was assessed with case-based written examination at midyear and end of year.

Surveys and qualitative interviews were used to assess trainee perceptions about the IPE program. A midyear and end-of-year survey assessed trainee satisfaction and perceived efficacy of the IPE training program in meeting core learning objectives. A midyear survey designed by pharmacy residents as part of their program improvement project evaluated attitudes around interprofessional learning and team practice. Trainees met individually with the PC-MHI IPE director at midyear and end of year to gather qualitative feedback on the IPE program.

Outcomes

All trainees advanced to the expected level of supervision for clinical contacts (drop-in or indirect clinical supervision). Over the year, there was significant improvement in trainees’ MI skills as measured by MITI coding of at least 2 live-patient or 2 simulated-patient recordings (Figures 1A and 1B). By end of year, most trainees had reached proficiency or competency in several MITI coded items: percentage of open-ended questions (4/12 proficient, 8/12 competent), percentage of complex reflections (2/12 less than proficient, 3/12 proficient, 7/12 competent), MI adherence (1/12 proficient, 11/12 competent), global empathy rating (2/12 proficient, 10/12 competent), and global MI spirit rating (12/12 competent). Average reflection-to-question ratio for the trainee group increased from 0.63 to 0.96 from midyear to end of year, but only 3 of 12 trainees reached the proficiency level of a 1:1 ratio, and no trainee reached the competency level of a 2:1 ratio.

According to the PC-MHI team’s midyear evaluation, most trainees were already making satisfactory progress in the 3 domains of learning objectives for the training program. At end of year, 13 of 14 trainees were assessed as competent in all 3 domains (Figures 2A and B). All trainees passed the midyear and end-of-year written examinations with overall high scores (average score, 82%) demonstrating acquisition of core PC-MHI clinical knowledge.

Trainee evaluations of the IPE program were overall highly favorable at both midyear and at end of year. Trainees rated the program effective or extremely effective in developing their skills in patient-centered care, interprofessional communication, and collaborative team-based practice. They also rated the program highly effective in preparing them to use team-based practice skills in other settings. On a midyear survey, trainees moderately to strongly agreed with several positive beliefs and attitudes about team-based care.

In qualitative interviews at program completion, trainees across disciplines rated the MI training with group supervision as one of their most valuable interprofessional learning experiences. Other highly valued training experiences were PACT PC-MHI panel management projects, team-based clinical case reviews, and cross-disciplinary supervision.

Discussion

This article describes the successful development and implementation of a VA-based IPE program in PACT PC-MHI. Interprofessional clinical training and educational experiences were highly valued, and trainees identified positive attitudes and improved skills related to team-based care. These findings support previous findings that IPE is associated with high satisfaction and positive attitudes toward team-based collaborative practice.^{12-17 P}rogram implementation presented several challenges: nonsynchronous academic calendars and rotation schedules, cross-disciplinary supervision regulations, variations in clinical and supervisory requirements for accreditation standards, the traditional health care hierarchy, and measurement of the impact of IPE experiences.^11,25,26

Rotation schedules and academic calendars varied across the psychiatry, pharmacy, and social work home programs. Organizing different trainee rotation schedules was a significant challenge. Collaboration with training directors and support staff was crucial in planning rotations that offered a longitudinal training experience in PACT PC-MHI. Given the participants’ different starting dates, protected IPE time early in the calendar year was focused on developing clinical skills specific to the pharmacy and psychiatry trainees who would be starting in July, and IPE activities that required the presence of all trainee disciplines (eg, MI training, HBDI) were planned for after the September start of the social work interns.

Cross-disciplinary supervision was highly valued by trainees because it offered exposure to the disciplines’ different communication styles and approaches to clinical assessment and decision making. Throughout the year, however, trainees encountered several obstacles to cross-disciplinary supervision, with respect to coding/billing and home program supervisory policies. The authors worked closely with the VA administration and each training program to develop and revise supervising policies and procedures to meet the necessary administrative and program supervisory requirements for accreditation standards.

In some cases, this work resulted in dual supervision by a preceptor of the same discipline (to meet requirements for coding/billing and home program supervision) and clinical supervision by a preceptor of a different discipline (eg, in team meetings or in clinical case reviews during protected IPE time). Preceptors from each discipline met regularly to discuss challenges in cross-disciplinary supervision, review scope-of-practice issues, share information on discipline-specific training, and revise supervisory procedures.

Interprofessional education activities during weekly protected time were designed to improve collaboration and to challenge trainees to examine traditional hierarchical roles and patterns of communication in health care. An emphasis on case-based learning in small groups encouraged trainees to share perspectives on their discipline-specific approach to assessment and treatment planning. Motivational interviewing training, one of the IPE experiences most valued by trainees and staff, created the opportunity for a truly shared learning environment, as trainees largely started at about the same skill level despite having different educational backgrounds. Group supervision of MI recordings offered trainees the opportunity to learn from each other and develop comfort in offering and receiving interprofessional constructive feedback.

Limitations

There were considerable methodologic limitations in the authors’ efforts to evaluate the impact of this training program on trainee attitudes and skills in collaborative team-based practice. Although trainee surveys revealed highly positive attitudes and beliefs about team-based care as well as perceived competence in collaborative practice, these were not validated surveys, and changes could not be accurately measured over time (trainees were not assessed at baseline). Trainees also were involved in other clinical teams within the VA during the year, and it is difficult to assess the specific impact of their PC-MHI IPE experiences. The PC-MHI staff evaluations of trainee competence in collaborative team-based practice were largely observational and potentially vulnerable to biases, as the staff evaluating trainee competence also were part of the IPE program planning process and invested in its success.

To address these limitations in the future, the authors will use better assessment tools at baseline and end of year to more effectively evaluate the impact of the training program on teamwork skills as well changes in attitudes and beliefs about interprofessional learning and teamwork. The Attitudes Toward Interprofessional Health Care Teams Scale and the Perceptions of Effective Interpersonal Teams Scale should be considered as they have published reliability and validity.^27,28 The authors could improve the reliability and depth of trainee evaluations with use of a “360-degree evaluation” model for trainee evaluations that includes other PACT members (beyond PC-MHI staff) as well as veterans.

Assessment of MI skills and competency was limited by use of both live- and simulated-patient recordings. Simulation is a valuable learning tool but often does not accurately represent actual clinical situations and challenges. To appropriately assess MI competence, future MI training should emphasize live-patient recordings over simulated-patient visits. Furthermore, whereas trainees reached competency in several MI coding items, none reached competency in the reflection-to-question ratio, and only about half reached competency in percentage of complex reflections. Future MI training will need to focus on further development of reflection skills.

Trainee intentions to remain involved in program improvement and collaborative team-based care in future professional work were core attitudinal learning objectives, but neither was adequately assessed in end-of-year surveys. Ideally, future evaluations will assess subjective trainee intentions and goals around team-based work and objectively measure future professional choices and activities. For example, it would be interesting to determine whether trainees who participated in this program will choose to practice in an interprofessional team-based model or participate in program improvement activities.

Last, the absence of psychology interns was considered a weakness in the learning environment, resulting in a relatively “prescriber-heavy” balance in discipline perspectives for IPE-focused case discussions and other training. Furthermore, the discipline representation in the IPE program did not exemplify the typical PC-MHI team in most VA clinic settings and community practices in which psychology has a strong presence. Adding psychology trainees was an important goal for the IPE program leadership. In 2015, WSMMVH was awarded additional funding for a PACT PC-MHI predoctoral psychology intern through the phase 4 MHEEI. The PC-MHI track psychology intern joined the IPE program in the 2016-2017 training year.

Conclusion

There is broad consensus that interprofessional team-based practice is crucial for providers in the VA and all health care systems. Primary care-mental health integration is an area of VA care in which interprofessional collaboration is uniquely important to implementation and sustainability of the model. Interprofessional education is an effective approach for preparing HCPs for team-based practice, but implementation is challenging. Several factors crucially contributed to the successful implementation of this program: collaboration of the interprofessional planning team with representation from key stakeholders in different departments and training programs; a well-established PACT PC-MHI team with experience in collaborative team-based care; a curriculum structure that emphasized experiential educational strategies designed to promote interprofessional learning and communication; VA leadership support at the national level (MHEEI funding) and local level; and PACT PC-MHI clinical staff committed to teaching and to the IPE mission.

Over the past 10 years, the VHA has been a national leader in primary care-mental health integration (PC-MHI) within patient aligned care teams (PACTs).^1,2 Studies of the PC-MHI collaborative care model consistently have shown increased access to MH services, higher levels of MH treatment engagement, improved MH treatment outcomes, and high patient and provider satisfaction.^3-7 Primary care-mental health integration relies heavily on interprofessional team-based practice with providers from diverse educational and clinical backgrounds who work together to deliver integrated mental and behavioral health services within PACTs. This model requires a unique blending of professional cultures and communication and practice styles.

To sustain PC-MHI in PACT, health care professionals (HCPs) must be well trained to work effectively in interprofessional teams. Across health care organizations, training in collaborative interprofessional team-based practice has been identified as an important and challenging task.^8-11

Integrating educational experiences among different HCP learners is an approach to developing competency in interprofessional collaboration early in training. The World Health Organization defined interprofessional education (IPE) as occurring “when students from two or more professions learn about, from, and with each other to enable effective collaboration and improve health outcomes.”⁹ Fundamental to this definition is the belief that interaction among learners from different disciplines during their training develops competency in subsequent effective collaborative practice. Studies of IPE in MH professional training have found that prelicensure IPE contributes to increased knowledge of roles and responsibilities of different disciplines, improved interprofessional communication and attitudes, and increased willingness to work in teams.^12-17

Interprofessional education is a valuable training model, but developing interprofessional learning experiences in a system of diverse and often siloed training programs is difficult. More information about design and implementation of IPE training experiences is needed, particularly in outpatient settings in which integration of traditionally separate discipline-specific care is central to the health care mission. The VA PACT PC-MHI is a strong team-based care model that represents a unique opportunity for training across disciplines in interprofessional collaborative care.

To find innovative approaches to meeting the need for IPE in PACT PC-MHI, the authors developed a new IPE program in PC-MHI at the William S. Middleton Memorial Veterans Hospital (WSMMVH) in Madison, Wisconsin. This article reviews the development, implementation, and first-year evaluation of the training program and discusses the challenges and the IPE areas in need of improvement in PACT PC-MHI.

Methods

In 2012, the VHA launched phase 1 of the Mental Health Education Expansion Initiative (MHEEI), a collaboration of the Office of Academic Affiliations (OAA), VHA Mental Health Services (VHA-MHS), and the Office of Mental Health Operations (OMHO).¹⁸ The MHEEI was intended to “increase expertise in critical areas of need, expand the recruitment pipeline of well-trained, highly qualified health care providers in behavioral and mental health disciplines, and promote the utilization of interprofessional team-based care.”¹⁸ In response, WSMMVH organized a planning committee and submitted a funding request through the section of MHEEI called PACT With Integrated Behavioral Health Providers. The planning committee included training program directors and staff from psychiatry, pharmacy, social work, psychology, and primary care. The authors received funding for trainees in psychiatry (postgraduate year 4 [PGY-4]), pharmacy/MH residency (PGY-2), pharmacy/ambulatory care (PGY-1), and social work (interns).

Curriculum Development

The planning committee met regularly for 6 months to develop the organization, learning objectives, educational strategies, and implementation plan for the IPE program. The program was organized as a 4- to 12-month clinical rotation with the PC-MHI team in PACT, combined with 12 months of protected weekly IPE time (Table 1).

Learning Objectives

To better understand the educational needs and foci for learning objectives, the interprofessional planning committee reviewed guidelines on training in integrated care and collaborative team-based practice.^2,9,10,19-21 These guidelines were compared with existing training opportunities for each discipline to identify training gaps and needs.

Learning objectives were organized into 3 domains: patient-centered PC-MHI, collaborative team-based practice, and population health and program improvement. Table 2 outlines the shared learning objectives linked to each domain that were common to the psychiatry, pharmacy, and social work disciplines. Although many of the learning objectives were shared among all disciplines, each trainee also had discipline-specific clinical activities and learning objectives. Psychiatry and pharmacy residents focused on primary care psychiatric medication consultation and care management for antidepressant medication starts. Social work interns focused on psychosocial and functional assessment and brief problem-focused psychotherapies. Learning objectives were met through direct veteran care in the primary care clinic as part of the PACT PC-MHI team and through interprofessional learning activities during protected weekly education time.

Implementation

Critical stakeholders in implementing the IPE program involved themselves early and throughout the planning process. Stakeholders included VAMC leadership, primary care and MH service line chiefs and clinic managers, training program directors, and PACT staff. Planning committee members gave presentations on the IPE program at MH service line and PACT meetings in the 2 months before program initiation in order to orient staff to learning objectives, program structure, and impact on PACT PC-MHI operations. Throughout the first year, the planning committee continued to meet every 2 weeks to review progress, solve implementation problems, and revise learning objectives and activities.

Trainee Clinical Activities

A wide range of educational strategies were planned to meet learning objectives across the 3 domains. There was strong emphasis on experiential learning through daily PACT and PC-MHI clinical work, team huddles and meetings, and trainee-led program improvement projects.

Psychiatry and PGY-2 pharmacy/MH residents focused on direct and indirect medication consultation and problem-focused assessments. Their clinical activities included PC-MHI medication evaluation and follow-up visits; chart reviews and e-consults for medication recommendations to PACT providers; reviews of care management data and consultations on veterans enrolled in depression and anxiety care management; “curbside consultations” for providers in PACT huddles and meetings and throughout the clinic day; and “warm handoffs,” same-day initial PC-MHI problem-focused assessments performed on PACT provider request. The residents were part of a pool of staff and trainees who performed these assessments.

PGY-1 pharmacy residents made care management phone calls for antidepressant trials for depression and anxiety. These residents were trained in motivational interviewing (MI). They applied their MI skills during care management calls focused on medication adherence and behavioral interventions for depression (eg, exercise, planning pleasurable activity) and during other clinical rotations, including tobacco cessation and medication management for diabetes and hypertension. Particularly challenging veteran cases from these clinics were cosupervised with medication management and PC-MHIstaff for added consultation on engagement, behavior change, and treatment plan adherence.

Social work interns completed initial PC-MHI psychosocial and functional assessments by phone and directly by same-day warm handoffs from PACT staff. The PC-MHI therapies they provided included problem-solving therapy, behavioral activation, stress management based on cognitive behavioral therapy, and brief alcohol interventions.

Group IPE Activities

All trainees had a weekly protected block of 3 hours during which they came together for group IPE that was designed to elicit active participation; facilitate interprofessional communication; and develop an understanding of and respect for the knowledge, culture, and practice style of the different disciplines.

Trainees participated in a Herrmann Brain Dominance Instrument (HBDI) workshop focused on developing a better understanding of individual differences in thinking and problem solving, with the goal of improving communication and learning within teams.²² In a seminar series on professionalism and boundaries in health care, trainees from each discipline gave a presentation on the traditional structure and content of their discipline’s training and discussed similarities and differences in their disciplines’ professional oaths, codes of ethics, and boundary guidelines.

Motivational interviewing training was conducted early in the year so trainees would be prepared to apply MI skills in their daily PACT PC-MHI clinical work. Motivational inteviewing is a patient-centered approach to engaging patients in health promoting behavior change. It is defined as a “directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence.”²³

Trainees recorded MI sessions with at least 2 live-patient visits and at least 2 simulated-patient interviews (with staff serving as patient actors). The structure of MI training and supervision was deliberately designed to facilitate interprofessional communication and learning. In accord with a group supervision model for MI recorded reviews, the trainees presented their tapes to the entire learning group in the presence of a facilitating supervisor. Trainees had the opportunity to observe different interview styles and exchange feedback within a peer group of interprofessional learners.

Seminars were focused on core PC-MHI clinical content (eg, depression, anxiety, alcohol use disorders) and organized around case-based learning. Trainees divided into small teams in which representatives of each discipline offered their perspective on how to approach planning patient assessment and treatment. During the seminars, the authors engaged trainees as teachers and leaders whenever possible. All trainees presented on a topic in which they had some discipline expertise. For example, social work interns led a seminar on support and social services for victims of domestic violence, and PGY-1 pharmacy/ambulatory care residents led seminars and a panel management project focused on diabetes and depression.

Trainees participated in several PACT PC-MHI projects focused on population- and measurement-based care, panel management, and program improvement (Table 3). Protected IPE time was used to teach trainees about population health principles and different tools for process improvement (eg, Vision-Analysis Team-Aim-Map-Measure-Change-Sustain) and provide a forum in which trainees could share their work with one another.

Evaluations

Several tools were used for trainee and program evaluations. Clinical skills were evaluated during daily supervision. Trainees began the year with PC-MHI staff directly observing all their clinical contacts with veterans. Staff evaluated and offered feedback on trainee clinical interviewing and on assessment and treatment planning skills. Once they were assessed to be ready to see veterans on their own, trainees were advanced by staff to “drop-in” direct supervision: Toward the end of a veteran’s visit, a staff preceptor entered the room to review relevant clinical findings, assessment and finalized treatment planning with the trainee and veteran. When appropriate for trainee competence level, clinical contacts were indirectly supervised: Trainees discussed their assessment and treatment plan with a staff supervisor at the end of the day.

Motivational interviewing recordings were reviewed during group supervision. To objectively evaluate MI skills, supervisors who were VA-certified in MI used the Motivational Interviewing Treatment Integrity (MITI) coding tool to review and code both the live- and simulated-patient recordings.²⁴ The MITI coding involves quantitative and qualitative analysis using standardized coding items.

Quantitative items included percentage of open-ended questions (Proficiency: 50%; competency: 70%); percentage of reflections considered complex reflections, or reflective statements adding substantial meaning or emphasis and conveying a deeper or more complex picture of what patients say (Proficiency: 40%; competency: 50%); reflection-to-question ratio (Proficiency: 1:1; competency: 2:1); and percentage of MI-adherent provider statements (Proficiency: 90%; competency: 100%).

Qualitative coding items were a global rating of therapist “empathy,” which evaluated the extent to which the trainee understood or made an effort to grasp the patient’s perspective, and “MI spirit.” This coding intended to capture the overall competence of the trainee in emphasizing collaboration, patient autonomy, and evocation of the patient experience (Proficiency score: 5; competency score: 6).

The PC-MHI teaching staff met midyear and end of year as a team to complete trainee evaluations focused on the 3 areas of learning objectives: patient-centered PC-MHI, collaborative team-based practice, and population health and program improvement. Patient-centered PC-MHI involves direct observation and supervision of trainee clinical contacts with veterans, including assessment and treatment planning, clinical documentation, and review of live- and simulated-patient MI recordings. Collaborative team-based practice involves review of trainee participation in day-to-day teamwork, huddles, team meetings, and IPE activities. Population health and program improvement involves review of trainee work on a panel measurement-based care management or program improvement project. In each learning objectives area, trainees were rated on a 3-point scale: needs improvement (1); satisfactory (2); achieved (3). Core knowledge about PC-MHI evidence base, structure, and clinical topics was assessed with case-based written examination at midyear and end of year.

Surveys and qualitative interviews were used to assess trainee perceptions about the IPE program. A midyear and end-of-year survey assessed trainee satisfaction and perceived efficacy of the IPE training program in meeting core learning objectives. A midyear survey designed by pharmacy residents as part of their program improvement project evaluated attitudes around interprofessional learning and team practice. Trainees met individually with the PC-MHI IPE director at midyear and end of year to gather qualitative feedback on the IPE program.

Outcomes

All trainees advanced to the expected level of supervision for clinical contacts (drop-in or indirect clinical supervision). Over the year, there was significant improvement in trainees’ MI skills as measured by MITI coding of at least 2 live-patient or 2 simulated-patient recordings (Figures 1A and 1B). By end of year, most trainees had reached proficiency or competency in several MITI coded items: percentage of open-ended questions (4/12 proficient, 8/12 competent), percentage of complex reflections (2/12 less than proficient, 3/12 proficient, 7/12 competent), MI adherence (1/12 proficient, 11/12 competent), global empathy rating (2/12 proficient, 10/12 competent), and global MI spirit rating (12/12 competent). Average reflection-to-question ratio for the trainee group increased from 0.63 to 0.96 from midyear to end of year, but only 3 of 12 trainees reached the proficiency level of a 1:1 ratio, and no trainee reached the competency level of a 2:1 ratio.

According to the PC-MHI team’s midyear evaluation, most trainees were already making satisfactory progress in the 3 domains of learning objectives for the training program. At end of year, 13 of 14 trainees were assessed as competent in all 3 domains (Figures 2A and B). All trainees passed the midyear and end-of-year written examinations with overall high scores (average score, 82%) demonstrating acquisition of core PC-MHI clinical knowledge.

Trainee evaluations of the IPE program were overall highly favorable at both midyear and at end of year. Trainees rated the program effective or extremely effective in developing their skills in patient-centered care, interprofessional communication, and collaborative team-based practice. They also rated the program highly effective in preparing them to use team-based practice skills in other settings. On a midyear survey, trainees moderately to strongly agreed with several positive beliefs and attitudes about team-based care.

In qualitative interviews at program completion, trainees across disciplines rated the MI training with group supervision as one of their most valuable interprofessional learning experiences. Other highly valued training experiences were PACT PC-MHI panel management projects, team-based clinical case reviews, and cross-disciplinary supervision.

Discussion

This article describes the successful development and implementation of a VA-based IPE program in PACT PC-MHI. Interprofessional clinical training and educational experiences were highly valued, and trainees identified positive attitudes and improved skills related to team-based care. These findings support previous findings that IPE is associated with high satisfaction and positive attitudes toward team-based collaborative practice.^{12-17 P}rogram implementation presented several challenges: nonsynchronous academic calendars and rotation schedules, cross-disciplinary supervision regulations, variations in clinical and supervisory requirements for accreditation standards, the traditional health care hierarchy, and measurement of the impact of IPE experiences.^11,25,26

Rotation schedules and academic calendars varied across the psychiatry, pharmacy, and social work home programs. Organizing different trainee rotation schedules was a significant challenge. Collaboration with training directors and support staff was crucial in planning rotations that offered a longitudinal training experience in PACT PC-MHI. Given the participants’ different starting dates, protected IPE time early in the calendar year was focused on developing clinical skills specific to the pharmacy and psychiatry trainees who would be starting in July, and IPE activities that required the presence of all trainee disciplines (eg, MI training, HBDI) were planned for after the September start of the social work interns.

Cross-disciplinary supervision was highly valued by trainees because it offered exposure to the disciplines’ different communication styles and approaches to clinical assessment and decision making. Throughout the year, however, trainees encountered several obstacles to cross-disciplinary supervision, with respect to coding/billing and home program supervisory policies. The authors worked closely with the VA administration and each training program to develop and revise supervising policies and procedures to meet the necessary administrative and program supervisory requirements for accreditation standards.

In some cases, this work resulted in dual supervision by a preceptor of the same discipline (to meet requirements for coding/billing and home program supervision) and clinical supervision by a preceptor of a different discipline (eg, in team meetings or in clinical case reviews during protected IPE time). Preceptors from each discipline met regularly to discuss challenges in cross-disciplinary supervision, review scope-of-practice issues, share information on discipline-specific training, and revise supervisory procedures.

Interprofessional education activities during weekly protected time were designed to improve collaboration and to challenge trainees to examine traditional hierarchical roles and patterns of communication in health care. An emphasis on case-based learning in small groups encouraged trainees to share perspectives on their discipline-specific approach to assessment and treatment planning. Motivational interviewing training, one of the IPE experiences most valued by trainees and staff, created the opportunity for a truly shared learning environment, as trainees largely started at about the same skill level despite having different educational backgrounds. Group supervision of MI recordings offered trainees the opportunity to learn from each other and develop comfort in offering and receiving interprofessional constructive feedback.

Limitations

There were considerable methodologic limitations in the authors’ efforts to evaluate the impact of this training program on trainee attitudes and skills in collaborative team-based practice. Although trainee surveys revealed highly positive attitudes and beliefs about team-based care as well as perceived competence in collaborative practice, these were not validated surveys, and changes could not be accurately measured over time (trainees were not assessed at baseline). Trainees also were involved in other clinical teams within the VA during the year, and it is difficult to assess the specific impact of their PC-MHI IPE experiences. The PC-MHI staff evaluations of trainee competence in collaborative team-based practice were largely observational and potentially vulnerable to biases, as the staff evaluating trainee competence also were part of the IPE program planning process and invested in its success.

To address these limitations in the future, the authors will use better assessment tools at baseline and end of year to more effectively evaluate the impact of the training program on teamwork skills as well changes in attitudes and beliefs about interprofessional learning and teamwork. The Attitudes Toward Interprofessional Health Care Teams Scale and the Perceptions of Effective Interpersonal Teams Scale should be considered as they have published reliability and validity.^27,28 The authors could improve the reliability and depth of trainee evaluations with use of a “360-degree evaluation” model for trainee evaluations that includes other PACT members (beyond PC-MHI staff) as well as veterans.

Assessment of MI skills and competency was limited by use of both live- and simulated-patient recordings. Simulation is a valuable learning tool but often does not accurately represent actual clinical situations and challenges. To appropriately assess MI competence, future MI training should emphasize live-patient recordings over simulated-patient visits. Furthermore, whereas trainees reached competency in several MI coding items, none reached competency in the reflection-to-question ratio, and only about half reached competency in percentage of complex reflections. Future MI training will need to focus on further development of reflection skills.

Trainee intentions to remain involved in program improvement and collaborative team-based care in future professional work were core attitudinal learning objectives, but neither was adequately assessed in end-of-year surveys. Ideally, future evaluations will assess subjective trainee intentions and goals around team-based work and objectively measure future professional choices and activities. For example, it would be interesting to determine whether trainees who participated in this program will choose to practice in an interprofessional team-based model or participate in program improvement activities.

Last, the absence of psychology interns was considered a weakness in the learning environment, resulting in a relatively “prescriber-heavy” balance in discipline perspectives for IPE-focused case discussions and other training. Furthermore, the discipline representation in the IPE program did not exemplify the typical PC-MHI team in most VA clinic settings and community practices in which psychology has a strong presence. Adding psychology trainees was an important goal for the IPE program leadership. In 2015, WSMMVH was awarded additional funding for a PACT PC-MHI predoctoral psychology intern through the phase 4 MHEEI. The PC-MHI track psychology intern joined the IPE program in the 2016-2017 training year.

Conclusion

There is broad consensus that interprofessional team-based practice is crucial for providers in the VA and all health care systems. Primary care-mental health integration is an area of VA care in which interprofessional collaboration is uniquely important to implementation and sustainability of the model. Interprofessional education is an effective approach for preparing HCPs for team-based practice, but implementation is challenging. Several factors crucially contributed to the successful implementation of this program: collaboration of the interprofessional planning team with representation from key stakeholders in different departments and training programs; a well-established PACT PC-MHI team with experience in collaborative team-based care; a curriculum structure that emphasized experiential educational strategies designed to promote interprofessional learning and communication; VA leadership support at the national level (MHEEI funding) and local level; and PACT PC-MHI clinical staff committed to teaching and to the IPE mission.

Despite a 30% decline in heart disease mortality from 2001 to 2011, heart disease prevalence is on the rise, responsible for 1 of every 3 deaths in the U.S.¹ Cardiac rehabilitation (CR) is an evidence-based, secondary prevention strategy that has been proven effective in preventing future cardiovascular events and decreasing heart disease mortality.^2-4 The American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) is the leading authority on CR and provides guidelines for CR programs. The AACVPR and the American Heart Association (AHA) published core components for CR programs deemed essential for all CR/secondary prevention programs, including evaluations, interventions, and expected outcomes.⁵ These core components are aimed at promoting a healthy lifestyle and increasing function and well-being while reducing injury, death, and the reoccurrence of disease.⁶

In a meta-analysis of 47 trials with 10,794 participants, CR reduced cardiovascular disease (CVD) mortality and hospital admissions by 26% and 18%, respectively.² Performance measures (Class 1, Level A) recommend the following types of patients should be referred from the inpatient setting: “all patients hospitalized with a primary diagnosis of an acute myocardial infarction (MI) or chronic stable angina, or who during hospitalization have undergone coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation.”⁷ However, despite overwhelming evidence and widespread endorsement (Class 1, Level A), service utilization, uptake, and patient adherence to CR programs remain suboptimal. In a U.S. study of claims from > 250,000 Medicare beneficiaries, < 30% of eligible patients participated in some type of CR program.⁸ In response to poor participation, a presidential advisory from the AHA in 2011 stated, “the remarkably wide treatment gap between scientific evidence of the benefits of cardiac rehabilitation and clinical implementation of rehabilitation programs is unacceptable.”⁹

This treatment gap is echoed throughout the VHA. Schopfer and colleagues found that only 28% of the 124 VAMCs that provide inpatient care also offer a supervised, facility-based CR program.¹⁰ Furthermore, only 10.3% of eligible veterans participated in at least 1 CR session (VA or non-VA). On a systemic level, low patient referral rates and inadequate third-party reimbursement were the most common barriers to participation in CR.^10,11 On a patient level, distance was by far the largest barrier to veterans receiving CR. Currently, 74% of the 9.3 million VA-enrolled veterans live at least 1 hour by car from a VA facility that offers CR.⁹ Within some regions of the VHA, there are no VA facility-based CR programs. For example, VISN 21 has no facility-based CR programs. At the same time, referral of eligible veterans to facility-based CR outside the VA remains low. Prior to April 2013, < 2% of qualified patients residing in VISN 21 were being referred to Non-VA CR programs, making it the VISN with the lowest participation rate for CR.

One potential solution that addresses both systemic and patient barriers to CR utilization is home-based CR. Veterans within the wide geographic area of VISN 21 are referred to San Francisco VAMC (SFVAMC) for ischemic heart disease, cardiovascular revascularization, and cardiac valve surgeries. In 2013, a comprehensive home-based CR program named The Healthy Heart Program was developed based on a successful evidence-based CVD secondary prevention program. The Healthy Heart Program is designed to be a physician-directed, nurse case-managed, customized exercise and lifestyle program that provides a safe and convenient way for veterans to participate in CR. Exercise and disease self-management education are the cornerstones of the Healthy Heart Program. The program’s multidisciplinary team includes physicians, nurses, a dietician, an exercise physiologist, and a health behavior psychologist.

An Alternative Approach

DeBusk and colleagues demonstrated that a physician-directed, nurse-managed, home-based cardiac risk-factor modification program improved smoking cessation, reduced low-density lipoprotein cholesterol, and increased exercise capacity compared with usual care.¹² The results of this study helped pave the way for one of the first CR programs with a strong home-based element. The MULTIFIT program was jointly developed by the Stanford Coronary Rehabilitation Program and Kaiser Permanente (Oakland, CA) in 1995. MULTIFIT is a nurse-based care model for CVD prevention.

Further research that evaluated other home-based programs showed similar promise. A Cochrane review demonstrated that home- and facility-based CR programs were equal in cardiac risk factor reduction, reduced hospital readmissions and mortality rates, and improved quality of life (QOL).¹³ Cost-effectiveness also seemed to be similar in both home- and hospital-based CR programs.¹⁴ A meta-analysis of telephone support interventions for coronary artery disease demonstrated a 38% decrease in rehospitalizations and a 32% increase in the number of participants who stopped smoking.¹⁵ In addition, patients with time constraints (eg, work, family obligations) preferred home-based CR programs for the convenience and accessibility that these programs offer.¹⁶ Home-based CR programs may have better completion rates compared with that of facility-based programs.¹⁷ The American College of Cardiology and AHA updated guidelines for CR include home-based CR as a substitute for facility-based CR for low-risk patients (Class 1, Level A).¹⁸

Referrals

To address the problems with referrals that plague other CR programs, staff of the Healthy Heart Program worked closely with interventional cardiology and the cardiothoracic team, including the clinical informatics coordinators, to develop an automatic referral system for CR evaluation. Consults for CR evaluation were embedded within the post-CABG and PCI order sets in the electronic health record. Laboratory troponin alerts were created to alert CR staff of patients with elevated troponins, which identified patients admitted for acute MI. Healthy Heart Program staff members received the referrals once a patient was admitted to the unit following their heart procedure. Early referrals for evaluation allowed staff to begin a chart review of all eligible patients and to follow the patient’s course of recovery. Most consults were generated during hospitalization for one of the indications; however, a minority of consults come from both the cardiology and primary care clinics.

Three Phases of CR

The AACVPR describes the challenges and opportunities found throughout the CR continuum.⁵ Over the past several decades, the continuum of care was more program centered and service utilization was more isolated. Today, CR is viewed as more process oriented and coordinates care across many professionals and services. Phase 1 inpatient CR begins in the hospital and is a shared responsibility between several services. Shortened hospital stays have led to innovative solutions for early ambulation, risk factor education, and discharge planning, including enrollment into phase 2 CR. Phase 2, also known as early outpatient, should begin within 1 to 2 weeks postevent in healthier patients and can last between 6 and 12 weeks postdischarge. Phase 3 (maintenance phase) should begin immediately at the conclusion of phase 2.

Phase 1

Prior to the advent of the Healthy Heart Program, secondary prevention education was not done at the bedside for SFVAMC patients following cardiac revascularization. The AACVPR recommends patient assessment, mobilization, risk-factor identification and education, and facilitation into outpatient CR as essential components of phase 1 CR.⁵ The Healthy Heart Program clinician initiates phase 1 CR by examining cardiac risk factor management for all referred patients. Physical and cardiac risk factor assessments are accomplished by completing a detailed chart review and interview with the patient. During this interview with the patient, the clinician evaluates cognitive function and readiness to learn. Staff will interview the patient further to assess the overall patient needs, including availability of social support, resources to maintain optimal health, and the need for secondary preventive education. For the PCI patient, the interview may occur in the hours following their procedure; for the surgical patient, this bedside visit typically occurs postoperative day 3 or 4.

A standardized cardiac risk factor evaluation tool was designed, which also serves as an education form to help guide the conversation on risk factor management. The interactive, patient-centered form includes opportunities to review risk, discuss current laboratory values (eg, lipids and hemoglobin A_1c), and establish individualized goals based on patient preference and recommended guidelines. Healthy Heart Program staff assist the patient in formulating achievable goals using the SMART (specific, measurable, attainable, realistic, and time-related) criteria.¹⁹ Immediately after a heart event or procedure, patients often feel highly motivated to initiate lifestyle changes.²⁰ However, PCI patients may have a short window of opportunity for learning between their readiness to learn state and before the activities of discharge. Staff use these opportunities as a teachable moment and to increase enrollment into outpatient CR (phase 2).

The provider performs a thorough chart review and bedside consultation to determine whether home-based CR is indicated, feasible, and appropriate. Not every patient that is referred will be enrolled in CR. Patients have the option to opt out. In addition, clinical staff adhere to the program protocol’s exclusion criteria.

Absolute contraindications for home enrollment include unstable angina, staged cardiac procedure (PCI and surgery), complex ventricular arrhythmias, severe or symptomatic aortic stenosis, decompensated heart failure, and uncontrolled hypertension (Table). Patients deemed high risk for home-based CR may be referred to a non-VA facility-based CR program. Risk stratification, using the Canadian Cardiovascular Society Grading of Angina Pectoris, is a continuous process that is used to identify patients who may move from moderate to high risk, both before and during the program.^21,22

Phases 2 and 3

Phase 2 of the Healthy Heart Program CR includes physical activity, risk-factor modification, nutritional guidance, psychosocial modification, a return to previous activities, and an improved QOL. Prior to entry into the program, a submaximal exercise test, the 6-minute walk test (6MWT), is used as both a qualifying test and for developing the initial exercise prescription.²² The minimum 6MWT distance needed to qualify is 75 m for postoperative and 150 m for nonsurgical patients. The 6MWT is performed in-hospital for patients who were admitted for stable angina, PCI, and are > 4 days following acute MI.²³ Cardiothoracic surgery patients are tested at their first follow-up clinic visit (typically 2-3 weeks postoperatively). The clinician monitors the heart rate with either a wearable device or via inpatient telemetry monitors. This exercise testing also serves as a motivational tool for patients to gain confidence in their ability to begin to exercise at home.

Each participant receives a workbook and a DVD titled An Active Partnership for the Health of Your Heart. A personal health journal is provided for documenting vital signs, activity, and dietary intake. In addition, each participant receives equipment on an as-needed basis, including resistance bands, a weight scale, a blood pressure cuff, a pedometer/heart rate monitoring device, an exercise peddler or stationary bike, and a dietary video. Baseline assessments include the General Anxiety Disorder (GAD-7), Personal Health Questionnaire (PHQ-9) and a nutrition (Rate Your Plate) questionnaire. A cognitive function test (Montreal Cognitive Assessment) is used on an as-needed basis.

Nine 30-minute telephone follow-up sessions are scheduled within a 12-week period (weekly for the first 6 weeks, then biweekly). Topics covered are customized and include exercise; nutrition; medications; smoking cessation; and diabetes, hypertension, and weight management. Via a telephone follow-up session, the program nurses and patients codevelop an electronic individualized treatment plan that is tailored to the patient’s diagnosis, individual goals, and preferences. Clinicians teach participants how to self-monitor exercise, using a continuous heart rate monitoring device (Mio Alpha II or Fuse) and the 6-20 Borg dyspnea rating scale.²⁴ Initially, moderate intensity exercise is prescribed with a target heart rate that is 60% to 75% of the 6MWT peak heart rate and an initial Borg scale target (11-14 on 20 point scale). The program physicians approve the treatment plan at the first patient visit and every 30 days until phase 2 is complete.

Patients who have completed early outpatient phase 2 CR can benefit from continuing to a phase 3 CR program.²⁵ Participants of the Healthy Heart Program automatically are enrolled in phase 3, which is a long-term maintenance program that includes monthly or bimonthly phone calls for up to 1-year posthospital discharge. The goal is to support each veteran’s transition to a long-term healthy lifestyle that includes regular exercise.

Client-Clinician Partnership

The Healthy Heart Program establishes the client-clinician partnership prior to discharge for hospitalized patients. The nurse who initiates phase 1 at the bedside is the primary clinician throughout phases 2 and 3 with the exception of a dietician, psychologist, and/or exercise physiologist who provide follow-up calls as needed. Throughout these weekly follow-up phone sessions, the clinician gains an appreciation of the patient’s understanding of his or her disease, patterns of behavior, desire to change, confidence in being able to change, potential barriers, and responses to obstacles. Clinicians in this setting are empathetic, supportive, and nonjudgmental. They encourage positive changes no matter how small and express concern when the patient is having difficulty.

Tailored Behavioral Change

The clinician’s responsibility is to listen to the patient’s concerns, assess their level of commitment for changing health behaviors, and provide guidance and support at the patient’s current level. The clinician applies the Transtheoretical Model founded on the Stages of Change principals to help understand and provide guidance based on the patient’s feelings about health behavior change.²⁶ People are actively open to changing behaviors by only 20% at any given time.²⁷ Therefore, action-oriented guidance for patients who are in the contemplative stage would not be helpful. This patient-centered approach promotes patients’ self-awareness, participation, and understanding of their decision-making role in their health management. Ultimately, individuals must take ownership of their health care maintenance for sustained behavioral change and medication management, and clinicians should facilitate that process.

Discussion

Secondary prevention strategies for heart disease continue to be underutilized. The Healthy Heart Program aims to improve participation in CR, improve QOL, help patients understand their heart disease, and support these patients psychologically. An advantage of this program is that it begins inpatient CR immediately following the heart event, when many patients often are more receptive to behavioral change support and guidance. Another advantage is that the program breaks down barriers to access, which is especially important in the veteran population. The Healthy Heart Program provides support and guidance for exercise and cardiac risk factor management to patients who otherwise would have not participated in any type of CR program.

A home-based CR program can be adopted independently or in conjunction with a facility-based program to which patients lack access. Furthermore, home-based CR programs function well as a phase 3 maintenance program at the completion of a traditional CR program. Since its inception, the Healthy Heart Program has increased the number of veterans enrolled in cardiac rehabilitation at the SFVAMC dramatically, from < 1% in FY 2012 to > 40% in FY 2015.

Program Limitations

One potential disadvantage of a home-based CR program is patients’ fear of returning to an exercise routine following a cardiac event. In addition, a lack of in-person supervision in home-based CR can lead patients to engage in less intensive activity than in facility-based CR. Other disadvantages include a lack of social support, less patient accountability, and safety concerns for sicker patients. Staff have consulted on several patients who expressed a lack of confidence in their ability to do well in this type of program, where accountability for exercising is self-reported. Staff referred these patients, who had the means to travel, to a non-VA facility-based CR program of their choice. Ideally, patients would have the choice between facility- or home-based programs or be able to choose a hybrid program that would best meet their needs.

Another identified limitation of this program was the lack of group support and in-person interactions with rehabilitation staff. Finally, although this program uses mobile devices with heart rate monitoring technology, these devices currently lack the capability to remotely share data with clinicians. Clinicians are reliant on the patient’s use of a personal health journal and memory. Subjective patient reporting has been found to be overestimated; therefore, more objective methods to measure important clinical outcomes are necessary^.28

Conclusion

Facility-based CR is effective but underutilized. Alternative secondary programs are needed to help meet patient needs and overcome patient barriers. One promising approach to increase participation is home-based CR. Home-based CR programs have the potential to increase CR uptake and adherence. Home-based CR optimizes enrollment through evidence-based alternative models due to improved access. The future of CR will become highly individualized and multifaceted as a result of available mobile technologies and Internet-based tools, which will help increase the number of participants and expand the reach of cardiac risk factor management programs beyond the facility-based setting. A home-based program will be a valuable addition to facility-based programs as a stand-alone program or adopted into a hybrid program.

Acknowledgments
This work was funded by the VA Quality Enhancement Research Initiative.

Despite a 30% decline in heart disease mortality from 2001 to 2011, heart disease prevalence is on the rise, responsible for 1 of every 3 deaths in the U.S.¹ Cardiac rehabilitation (CR) is an evidence-based, secondary prevention strategy that has been proven effective in preventing future cardiovascular events and decreasing heart disease mortality.^2-4 The American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) is the leading authority on CR and provides guidelines for CR programs. The AACVPR and the American Heart Association (AHA) published core components for CR programs deemed essential for all CR/secondary prevention programs, including evaluations, interventions, and expected outcomes.⁵ These core components are aimed at promoting a healthy lifestyle and increasing function and well-being while reducing injury, death, and the reoccurrence of disease.⁶

In a meta-analysis of 47 trials with 10,794 participants, CR reduced cardiovascular disease (CVD) mortality and hospital admissions by 26% and 18%, respectively.² Performance measures (Class 1, Level A) recommend the following types of patients should be referred from the inpatient setting: “all patients hospitalized with a primary diagnosis of an acute myocardial infarction (MI) or chronic stable angina, or who during hospitalization have undergone coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation.”⁷ However, despite overwhelming evidence and widespread endorsement (Class 1, Level A), service utilization, uptake, and patient adherence to CR programs remain suboptimal. In a U.S. study of claims from > 250,000 Medicare beneficiaries, < 30% of eligible patients participated in some type of CR program.⁸ In response to poor participation, a presidential advisory from the AHA in 2011 stated, “the remarkably wide treatment gap between scientific evidence of the benefits of cardiac rehabilitation and clinical implementation of rehabilitation programs is unacceptable.”⁹

This treatment gap is echoed throughout the VHA. Schopfer and colleagues found that only 28% of the 124 VAMCs that provide inpatient care also offer a supervised, facility-based CR program.¹⁰ Furthermore, only 10.3% of eligible veterans participated in at least 1 CR session (VA or non-VA). On a systemic level, low patient referral rates and inadequate third-party reimbursement were the most common barriers to participation in CR.^10,11 On a patient level, distance was by far the largest barrier to veterans receiving CR. Currently, 74% of the 9.3 million VA-enrolled veterans live at least 1 hour by car from a VA facility that offers CR.⁹ Within some regions of the VHA, there are no VA facility-based CR programs. For example, VISN 21 has no facility-based CR programs. At the same time, referral of eligible veterans to facility-based CR outside the VA remains low. Prior to April 2013, < 2% of qualified patients residing in VISN 21 were being referred to Non-VA CR programs, making it the VISN with the lowest participation rate for CR.

One potential solution that addresses both systemic and patient barriers to CR utilization is home-based CR. Veterans within the wide geographic area of VISN 21 are referred to San Francisco VAMC (SFVAMC) for ischemic heart disease, cardiovascular revascularization, and cardiac valve surgeries. In 2013, a comprehensive home-based CR program named The Healthy Heart Program was developed based on a successful evidence-based CVD secondary prevention program. The Healthy Heart Program is designed to be a physician-directed, nurse case-managed, customized exercise and lifestyle program that provides a safe and convenient way for veterans to participate in CR. Exercise and disease self-management education are the cornerstones of the Healthy Heart Program. The program’s multidisciplinary team includes physicians, nurses, a dietician, an exercise physiologist, and a health behavior psychologist.

An Alternative Approach

DeBusk and colleagues demonstrated that a physician-directed, nurse-managed, home-based cardiac risk-factor modification program improved smoking cessation, reduced low-density lipoprotein cholesterol, and increased exercise capacity compared with usual care.¹² The results of this study helped pave the way for one of the first CR programs with a strong home-based element. The MULTIFIT program was jointly developed by the Stanford Coronary Rehabilitation Program and Kaiser Permanente (Oakland, CA) in 1995. MULTIFIT is a nurse-based care model for CVD prevention.

Further research that evaluated other home-based programs showed similar promise. A Cochrane review demonstrated that home- and facility-based CR programs were equal in cardiac risk factor reduction, reduced hospital readmissions and mortality rates, and improved quality of life (QOL).¹³ Cost-effectiveness also seemed to be similar in both home- and hospital-based CR programs.¹⁴ A meta-analysis of telephone support interventions for coronary artery disease demonstrated a 38% decrease in rehospitalizations and a 32% increase in the number of participants who stopped smoking.¹⁵ In addition, patients with time constraints (eg, work, family obligations) preferred home-based CR programs for the convenience and accessibility that these programs offer.¹⁶ Home-based CR programs may have better completion rates compared with that of facility-based programs.¹⁷ The American College of Cardiology and AHA updated guidelines for CR include home-based CR as a substitute for facility-based CR for low-risk patients (Class 1, Level A).¹⁸

Referrals

To address the problems with referrals that plague other CR programs, staff of the Healthy Heart Program worked closely with interventional cardiology and the cardiothoracic team, including the clinical informatics coordinators, to develop an automatic referral system for CR evaluation. Consults for CR evaluation were embedded within the post-CABG and PCI order sets in the electronic health record. Laboratory troponin alerts were created to alert CR staff of patients with elevated troponins, which identified patients admitted for acute MI. Healthy Heart Program staff members received the referrals once a patient was admitted to the unit following their heart procedure. Early referrals for evaluation allowed staff to begin a chart review of all eligible patients and to follow the patient’s course of recovery. Most consults were generated during hospitalization for one of the indications; however, a minority of consults come from both the cardiology and primary care clinics.

Three Phases of CR

The AACVPR describes the challenges and opportunities found throughout the CR continuum.⁵ Over the past several decades, the continuum of care was more program centered and service utilization was more isolated. Today, CR is viewed as more process oriented and coordinates care across many professionals and services. Phase 1 inpatient CR begins in the hospital and is a shared responsibility between several services. Shortened hospital stays have led to innovative solutions for early ambulation, risk factor education, and discharge planning, including enrollment into phase 2 CR. Phase 2, also known as early outpatient, should begin within 1 to 2 weeks postevent in healthier patients and can last between 6 and 12 weeks postdischarge. Phase 3 (maintenance phase) should begin immediately at the conclusion of phase 2.

Phase 1

Prior to the advent of the Healthy Heart Program, secondary prevention education was not done at the bedside for SFVAMC patients following cardiac revascularization. The AACVPR recommends patient assessment, mobilization, risk-factor identification and education, and facilitation into outpatient CR as essential components of phase 1 CR.⁵ The Healthy Heart Program clinician initiates phase 1 CR by examining cardiac risk factor management for all referred patients. Physical and cardiac risk factor assessments are accomplished by completing a detailed chart review and interview with the patient. During this interview with the patient, the clinician evaluates cognitive function and readiness to learn. Staff will interview the patient further to assess the overall patient needs, including availability of social support, resources to maintain optimal health, and the need for secondary preventive education. For the PCI patient, the interview may occur in the hours following their procedure; for the surgical patient, this bedside visit typically occurs postoperative day 3 or 4.

A standardized cardiac risk factor evaluation tool was designed, which also serves as an education form to help guide the conversation on risk factor management. The interactive, patient-centered form includes opportunities to review risk, discuss current laboratory values (eg, lipids and hemoglobin A_1c), and establish individualized goals based on patient preference and recommended guidelines. Healthy Heart Program staff assist the patient in formulating achievable goals using the SMART (specific, measurable, attainable, realistic, and time-related) criteria.¹⁹ Immediately after a heart event or procedure, patients often feel highly motivated to initiate lifestyle changes.²⁰ However, PCI patients may have a short window of opportunity for learning between their readiness to learn state and before the activities of discharge. Staff use these opportunities as a teachable moment and to increase enrollment into outpatient CR (phase 2).

The provider performs a thorough chart review and bedside consultation to determine whether home-based CR is indicated, feasible, and appropriate. Not every patient that is referred will be enrolled in CR. Patients have the option to opt out. In addition, clinical staff adhere to the program protocol’s exclusion criteria.

Absolute contraindications for home enrollment include unstable angina, staged cardiac procedure (PCI and surgery), complex ventricular arrhythmias, severe or symptomatic aortic stenosis, decompensated heart failure, and uncontrolled hypertension (Table). Patients deemed high risk for home-based CR may be referred to a non-VA facility-based CR program. Risk stratification, using the Canadian Cardiovascular Society Grading of Angina Pectoris, is a continuous process that is used to identify patients who may move from moderate to high risk, both before and during the program.^21,22

Phases 2 and 3

Phase 2 of the Healthy Heart Program CR includes physical activity, risk-factor modification, nutritional guidance, psychosocial modification, a return to previous activities, and an improved QOL. Prior to entry into the program, a submaximal exercise test, the 6-minute walk test (6MWT), is used as both a qualifying test and for developing the initial exercise prescription.²² The minimum 6MWT distance needed to qualify is 75 m for postoperative and 150 m for nonsurgical patients. The 6MWT is performed in-hospital for patients who were admitted for stable angina, PCI, and are > 4 days following acute MI.²³ Cardiothoracic surgery patients are tested at their first follow-up clinic visit (typically 2-3 weeks postoperatively). The clinician monitors the heart rate with either a wearable device or via inpatient telemetry monitors. This exercise testing also serves as a motivational tool for patients to gain confidence in their ability to begin to exercise at home.

Each participant receives a workbook and a DVD titled An Active Partnership for the Health of Your Heart. A personal health journal is provided for documenting vital signs, activity, and dietary intake. In addition, each participant receives equipment on an as-needed basis, including resistance bands, a weight scale, a blood pressure cuff, a pedometer/heart rate monitoring device, an exercise peddler or stationary bike, and a dietary video. Baseline assessments include the General Anxiety Disorder (GAD-7), Personal Health Questionnaire (PHQ-9) and a nutrition (Rate Your Plate) questionnaire. A cognitive function test (Montreal Cognitive Assessment) is used on an as-needed basis.

Nine 30-minute telephone follow-up sessions are scheduled within a 12-week period (weekly for the first 6 weeks, then biweekly). Topics covered are customized and include exercise; nutrition; medications; smoking cessation; and diabetes, hypertension, and weight management. Via a telephone follow-up session, the program nurses and patients codevelop an electronic individualized treatment plan that is tailored to the patient’s diagnosis, individual goals, and preferences. Clinicians teach participants how to self-monitor exercise, using a continuous heart rate monitoring device (Mio Alpha II or Fuse) and the 6-20 Borg dyspnea rating scale.²⁴ Initially, moderate intensity exercise is prescribed with a target heart rate that is 60% to 75% of the 6MWT peak heart rate and an initial Borg scale target (11-14 on 20 point scale). The program physicians approve the treatment plan at the first patient visit and every 30 days until phase 2 is complete.

Patients who have completed early outpatient phase 2 CR can benefit from continuing to a phase 3 CR program.²⁵ Participants of the Healthy Heart Program automatically are enrolled in phase 3, which is a long-term maintenance program that includes monthly or bimonthly phone calls for up to 1-year posthospital discharge. The goal is to support each veteran’s transition to a long-term healthy lifestyle that includes regular exercise.

Client-Clinician Partnership

The Healthy Heart Program establishes the client-clinician partnership prior to discharge for hospitalized patients. The nurse who initiates phase 1 at the bedside is the primary clinician throughout phases 2 and 3 with the exception of a dietician, psychologist, and/or exercise physiologist who provide follow-up calls as needed. Throughout these weekly follow-up phone sessions, the clinician gains an appreciation of the patient’s understanding of his or her disease, patterns of behavior, desire to change, confidence in being able to change, potential barriers, and responses to obstacles. Clinicians in this setting are empathetic, supportive, and nonjudgmental. They encourage positive changes no matter how small and express concern when the patient is having difficulty.

Tailored Behavioral Change

The clinician’s responsibility is to listen to the patient’s concerns, assess their level of commitment for changing health behaviors, and provide guidance and support at the patient’s current level. The clinician applies the Transtheoretical Model founded on the Stages of Change principals to help understand and provide guidance based on the patient’s feelings about health behavior change.²⁶ People are actively open to changing behaviors by only 20% at any given time.²⁷ Therefore, action-oriented guidance for patients who are in the contemplative stage would not be helpful. This patient-centered approach promotes patients’ self-awareness, participation, and understanding of their decision-making role in their health management. Ultimately, individuals must take ownership of their health care maintenance for sustained behavioral change and medication management, and clinicians should facilitate that process.

Discussion

Secondary prevention strategies for heart disease continue to be underutilized. The Healthy Heart Program aims to improve participation in CR, improve QOL, help patients understand their heart disease, and support these patients psychologically. An advantage of this program is that it begins inpatient CR immediately following the heart event, when many patients often are more receptive to behavioral change support and guidance. Another advantage is that the program breaks down barriers to access, which is especially important in the veteran population. The Healthy Heart Program provides support and guidance for exercise and cardiac risk factor management to patients who otherwise would have not participated in any type of CR program.

A home-based CR program can be adopted independently or in conjunction with a facility-based program to which patients lack access. Furthermore, home-based CR programs function well as a phase 3 maintenance program at the completion of a traditional CR program. Since its inception, the Healthy Heart Program has increased the number of veterans enrolled in cardiac rehabilitation at the SFVAMC dramatically, from < 1% in FY 2012 to > 40% in FY 2015.

Program Limitations

One potential disadvantage of a home-based CR program is patients’ fear of returning to an exercise routine following a cardiac event. In addition, a lack of in-person supervision in home-based CR can lead patients to engage in less intensive activity than in facility-based CR. Other disadvantages include a lack of social support, less patient accountability, and safety concerns for sicker patients. Staff have consulted on several patients who expressed a lack of confidence in their ability to do well in this type of program, where accountability for exercising is self-reported. Staff referred these patients, who had the means to travel, to a non-VA facility-based CR program of their choice. Ideally, patients would have the choice between facility- or home-based programs or be able to choose a hybrid program that would best meet their needs.

Another identified limitation of this program was the lack of group support and in-person interactions with rehabilitation staff. Finally, although this program uses mobile devices with heart rate monitoring technology, these devices currently lack the capability to remotely share data with clinicians. Clinicians are reliant on the patient’s use of a personal health journal and memory. Subjective patient reporting has been found to be overestimated; therefore, more objective methods to measure important clinical outcomes are necessary^.28

Conclusion

Facility-based CR is effective but underutilized. Alternative secondary programs are needed to help meet patient needs and overcome patient barriers. One promising approach to increase participation is home-based CR. Home-based CR programs have the potential to increase CR uptake and adherence. Home-based CR optimizes enrollment through evidence-based alternative models due to improved access. The future of CR will become highly individualized and multifaceted as a result of available mobile technologies and Internet-based tools, which will help increase the number of participants and expand the reach of cardiac risk factor management programs beyond the facility-based setting. A home-based program will be a valuable addition to facility-based programs as a stand-alone program or adopted into a hybrid program.

Acknowledgments
This work was funded by the VA Quality Enhancement Research Initiative.

Despite a 30% decline in heart disease mortality from 2001 to 2011, heart disease prevalence is on the rise, responsible for 1 of every 3 deaths in the U.S.¹ Cardiac rehabilitation (CR) is an evidence-based, secondary prevention strategy that has been proven effective in preventing future cardiovascular events and decreasing heart disease mortality.^2-4 The American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) is the leading authority on CR and provides guidelines for CR programs. The AACVPR and the American Heart Association (AHA) published core components for CR programs deemed essential for all CR/secondary prevention programs, including evaluations, interventions, and expected outcomes.⁵ These core components are aimed at promoting a healthy lifestyle and increasing function and well-being while reducing injury, death, and the reoccurrence of disease.⁶

In a meta-analysis of 47 trials with 10,794 participants, CR reduced cardiovascular disease (CVD) mortality and hospital admissions by 26% and 18%, respectively.² Performance measures (Class 1, Level A) recommend the following types of patients should be referred from the inpatient setting: “all patients hospitalized with a primary diagnosis of an acute myocardial infarction (MI) or chronic stable angina, or who during hospitalization have undergone coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation.”⁷ However, despite overwhelming evidence and widespread endorsement (Class 1, Level A), service utilization, uptake, and patient adherence to CR programs remain suboptimal. In a U.S. study of claims from > 250,000 Medicare beneficiaries, < 30% of eligible patients participated in some type of CR program.⁸ In response to poor participation, a presidential advisory from the AHA in 2011 stated, “the remarkably wide treatment gap between scientific evidence of the benefits of cardiac rehabilitation and clinical implementation of rehabilitation programs is unacceptable.”⁹

This treatment gap is echoed throughout the VHA. Schopfer and colleagues found that only 28% of the 124 VAMCs that provide inpatient care also offer a supervised, facility-based CR program.¹⁰ Furthermore, only 10.3% of eligible veterans participated in at least 1 CR session (VA or non-VA). On a systemic level, low patient referral rates and inadequate third-party reimbursement were the most common barriers to participation in CR.^10,11 On a patient level, distance was by far the largest barrier to veterans receiving CR. Currently, 74% of the 9.3 million VA-enrolled veterans live at least 1 hour by car from a VA facility that offers CR.⁹ Within some regions of the VHA, there are no VA facility-based CR programs. For example, VISN 21 has no facility-based CR programs. At the same time, referral of eligible veterans to facility-based CR outside the VA remains low. Prior to April 2013, < 2% of qualified patients residing in VISN 21 were being referred to Non-VA CR programs, making it the VISN with the lowest participation rate for CR.

One potential solution that addresses both systemic and patient barriers to CR utilization is home-based CR. Veterans within the wide geographic area of VISN 21 are referred to San Francisco VAMC (SFVAMC) for ischemic heart disease, cardiovascular revascularization, and cardiac valve surgeries. In 2013, a comprehensive home-based CR program named The Healthy Heart Program was developed based on a successful evidence-based CVD secondary prevention program. The Healthy Heart Program is designed to be a physician-directed, nurse case-managed, customized exercise and lifestyle program that provides a safe and convenient way for veterans to participate in CR. Exercise and disease self-management education are the cornerstones of the Healthy Heart Program. The program’s multidisciplinary team includes physicians, nurses, a dietician, an exercise physiologist, and a health behavior psychologist.

An Alternative Approach

DeBusk and colleagues demonstrated that a physician-directed, nurse-managed, home-based cardiac risk-factor modification program improved smoking cessation, reduced low-density lipoprotein cholesterol, and increased exercise capacity compared with usual care.¹² The results of this study helped pave the way for one of the first CR programs with a strong home-based element. The MULTIFIT program was jointly developed by the Stanford Coronary Rehabilitation Program and Kaiser Permanente (Oakland, CA) in 1995. MULTIFIT is a nurse-based care model for CVD prevention.

Further research that evaluated other home-based programs showed similar promise. A Cochrane review demonstrated that home- and facility-based CR programs were equal in cardiac risk factor reduction, reduced hospital readmissions and mortality rates, and improved quality of life (QOL).¹³ Cost-effectiveness also seemed to be similar in both home- and hospital-based CR programs.¹⁴ A meta-analysis of telephone support interventions for coronary artery disease demonstrated a 38% decrease in rehospitalizations and a 32% increase in the number of participants who stopped smoking.¹⁵ In addition, patients with time constraints (eg, work, family obligations) preferred home-based CR programs for the convenience and accessibility that these programs offer.¹⁶ Home-based CR programs may have better completion rates compared with that of facility-based programs.¹⁷ The American College of Cardiology and AHA updated guidelines for CR include home-based CR as a substitute for facility-based CR for low-risk patients (Class 1, Level A).¹⁸

Referrals

To address the problems with referrals that plague other CR programs, staff of the Healthy Heart Program worked closely with interventional cardiology and the cardiothoracic team, including the clinical informatics coordinators, to develop an automatic referral system for CR evaluation. Consults for CR evaluation were embedded within the post-CABG and PCI order sets in the electronic health record. Laboratory troponin alerts were created to alert CR staff of patients with elevated troponins, which identified patients admitted for acute MI. Healthy Heart Program staff members received the referrals once a patient was admitted to the unit following their heart procedure. Early referrals for evaluation allowed staff to begin a chart review of all eligible patients and to follow the patient’s course of recovery. Most consults were generated during hospitalization for one of the indications; however, a minority of consults come from both the cardiology and primary care clinics.

Three Phases of CR

The AACVPR describes the challenges and opportunities found throughout the CR continuum.⁵ Over the past several decades, the continuum of care was more program centered and service utilization was more isolated. Today, CR is viewed as more process oriented and coordinates care across many professionals and services. Phase 1 inpatient CR begins in the hospital and is a shared responsibility between several services. Shortened hospital stays have led to innovative solutions for early ambulation, risk factor education, and discharge planning, including enrollment into phase 2 CR. Phase 2, also known as early outpatient, should begin within 1 to 2 weeks postevent in healthier patients and can last between 6 and 12 weeks postdischarge. Phase 3 (maintenance phase) should begin immediately at the conclusion of phase 2.

Phase 1

Prior to the advent of the Healthy Heart Program, secondary prevention education was not done at the bedside for SFVAMC patients following cardiac revascularization. The AACVPR recommends patient assessment, mobilization, risk-factor identification and education, and facilitation into outpatient CR as essential components of phase 1 CR.⁵ The Healthy Heart Program clinician initiates phase 1 CR by examining cardiac risk factor management for all referred patients. Physical and cardiac risk factor assessments are accomplished by completing a detailed chart review and interview with the patient. During this interview with the patient, the clinician evaluates cognitive function and readiness to learn. Staff will interview the patient further to assess the overall patient needs, including availability of social support, resources to maintain optimal health, and the need for secondary preventive education. For the PCI patient, the interview may occur in the hours following their procedure; for the surgical patient, this bedside visit typically occurs postoperative day 3 or 4.

A standardized cardiac risk factor evaluation tool was designed, which also serves as an education form to help guide the conversation on risk factor management. The interactive, patient-centered form includes opportunities to review risk, discuss current laboratory values (eg, lipids and hemoglobin A_1c), and establish individualized goals based on patient preference and recommended guidelines. Healthy Heart Program staff assist the patient in formulating achievable goals using the SMART (specific, measurable, attainable, realistic, and time-related) criteria.¹⁹ Immediately after a heart event or procedure, patients often feel highly motivated to initiate lifestyle changes.²⁰ However, PCI patients may have a short window of opportunity for learning between their readiness to learn state and before the activities of discharge. Staff use these opportunities as a teachable moment and to increase enrollment into outpatient CR (phase 2).

The provider performs a thorough chart review and bedside consultation to determine whether home-based CR is indicated, feasible, and appropriate. Not every patient that is referred will be enrolled in CR. Patients have the option to opt out. In addition, clinical staff adhere to the program protocol’s exclusion criteria.

Absolute contraindications for home enrollment include unstable angina, staged cardiac procedure (PCI and surgery), complex ventricular arrhythmias, severe or symptomatic aortic stenosis, decompensated heart failure, and uncontrolled hypertension (Table). Patients deemed high risk for home-based CR may be referred to a non-VA facility-based CR program. Risk stratification, using the Canadian Cardiovascular Society Grading of Angina Pectoris, is a continuous process that is used to identify patients who may move from moderate to high risk, both before and during the program.^21,22

Phases 2 and 3

Phase 2 of the Healthy Heart Program CR includes physical activity, risk-factor modification, nutritional guidance, psychosocial modification, a return to previous activities, and an improved QOL. Prior to entry into the program, a submaximal exercise test, the 6-minute walk test (6MWT), is used as both a qualifying test and for developing the initial exercise prescription.²² The minimum 6MWT distance needed to qualify is 75 m for postoperative and 150 m for nonsurgical patients. The 6MWT is performed in-hospital for patients who were admitted for stable angina, PCI, and are > 4 days following acute MI.²³ Cardiothoracic surgery patients are tested at their first follow-up clinic visit (typically 2-3 weeks postoperatively). The clinician monitors the heart rate with either a wearable device or via inpatient telemetry monitors. This exercise testing also serves as a motivational tool for patients to gain confidence in their ability to begin to exercise at home.

Each participant receives a workbook and a DVD titled An Active Partnership for the Health of Your Heart. A personal health journal is provided for documenting vital signs, activity, and dietary intake. In addition, each participant receives equipment on an as-needed basis, including resistance bands, a weight scale, a blood pressure cuff, a pedometer/heart rate monitoring device, an exercise peddler or stationary bike, and a dietary video. Baseline assessments include the General Anxiety Disorder (GAD-7), Personal Health Questionnaire (PHQ-9) and a nutrition (Rate Your Plate) questionnaire. A cognitive function test (Montreal Cognitive Assessment) is used on an as-needed basis.

Nine 30-minute telephone follow-up sessions are scheduled within a 12-week period (weekly for the first 6 weeks, then biweekly). Topics covered are customized and include exercise; nutrition; medications; smoking cessation; and diabetes, hypertension, and weight management. Via a telephone follow-up session, the program nurses and patients codevelop an electronic individualized treatment plan that is tailored to the patient’s diagnosis, individual goals, and preferences. Clinicians teach participants how to self-monitor exercise, using a continuous heart rate monitoring device (Mio Alpha II or Fuse) and the 6-20 Borg dyspnea rating scale.²⁴ Initially, moderate intensity exercise is prescribed with a target heart rate that is 60% to 75% of the 6MWT peak heart rate and an initial Borg scale target (11-14 on 20 point scale). The program physicians approve the treatment plan at the first patient visit and every 30 days until phase 2 is complete.

Patients who have completed early outpatient phase 2 CR can benefit from continuing to a phase 3 CR program.²⁵ Participants of the Healthy Heart Program automatically are enrolled in phase 3, which is a long-term maintenance program that includes monthly or bimonthly phone calls for up to 1-year posthospital discharge. The goal is to support each veteran’s transition to a long-term healthy lifestyle that includes regular exercise.

Client-Clinician Partnership

The Healthy Heart Program establishes the client-clinician partnership prior to discharge for hospitalized patients. The nurse who initiates phase 1 at the bedside is the primary clinician throughout phases 2 and 3 with the exception of a dietician, psychologist, and/or exercise physiologist who provide follow-up calls as needed. Throughout these weekly follow-up phone sessions, the clinician gains an appreciation of the patient’s understanding of his or her disease, patterns of behavior, desire to change, confidence in being able to change, potential barriers, and responses to obstacles. Clinicians in this setting are empathetic, supportive, and nonjudgmental. They encourage positive changes no matter how small and express concern when the patient is having difficulty.

Tailored Behavioral Change

The clinician’s responsibility is to listen to the patient’s concerns, assess their level of commitment for changing health behaviors, and provide guidance and support at the patient’s current level. The clinician applies the Transtheoretical Model founded on the Stages of Change principals to help understand and provide guidance based on the patient’s feelings about health behavior change.²⁶ People are actively open to changing behaviors by only 20% at any given time.²⁷ Therefore, action-oriented guidance for patients who are in the contemplative stage would not be helpful. This patient-centered approach promotes patients’ self-awareness, participation, and understanding of their decision-making role in their health management. Ultimately, individuals must take ownership of their health care maintenance for sustained behavioral change and medication management, and clinicians should facilitate that process.

Discussion

Secondary prevention strategies for heart disease continue to be underutilized. The Healthy Heart Program aims to improve participation in CR, improve QOL, help patients understand their heart disease, and support these patients psychologically. An advantage of this program is that it begins inpatient CR immediately following the heart event, when many patients often are more receptive to behavioral change support and guidance. Another advantage is that the program breaks down barriers to access, which is especially important in the veteran population. The Healthy Heart Program provides support and guidance for exercise and cardiac risk factor management to patients who otherwise would have not participated in any type of CR program.

A home-based CR program can be adopted independently or in conjunction with a facility-based program to which patients lack access. Furthermore, home-based CR programs function well as a phase 3 maintenance program at the completion of a traditional CR program. Since its inception, the Healthy Heart Program has increased the number of veterans enrolled in cardiac rehabilitation at the SFVAMC dramatically, from < 1% in FY 2012 to > 40% in FY 2015.

Program Limitations

One potential disadvantage of a home-based CR program is patients’ fear of returning to an exercise routine following a cardiac event. In addition, a lack of in-person supervision in home-based CR can lead patients to engage in less intensive activity than in facility-based CR. Other disadvantages include a lack of social support, less patient accountability, and safety concerns for sicker patients. Staff have consulted on several patients who expressed a lack of confidence in their ability to do well in this type of program, where accountability for exercising is self-reported. Staff referred these patients, who had the means to travel, to a non-VA facility-based CR program of their choice. Ideally, patients would have the choice between facility- or home-based programs or be able to choose a hybrid program that would best meet their needs.

Another identified limitation of this program was the lack of group support and in-person interactions with rehabilitation staff. Finally, although this program uses mobile devices with heart rate monitoring technology, these devices currently lack the capability to remotely share data with clinicians. Clinicians are reliant on the patient’s use of a personal health journal and memory. Subjective patient reporting has been found to be overestimated; therefore, more objective methods to measure important clinical outcomes are necessary^.28

Conclusion

Facility-based CR is effective but underutilized. Alternative secondary programs are needed to help meet patient needs and overcome patient barriers. One promising approach to increase participation is home-based CR. Home-based CR programs have the potential to increase CR uptake and adherence. Home-based CR optimizes enrollment through evidence-based alternative models due to improved access. The future of CR will become highly individualized and multifaceted as a result of available mobile technologies and Internet-based tools, which will help increase the number of participants and expand the reach of cardiac risk factor management programs beyond the facility-based setting. A home-based program will be a valuable addition to facility-based programs as a stand-alone program or adopted into a hybrid program.

Acknowledgments
This work was funded by the VA Quality Enhancement Research Initiative.

More than 20% of the U.S. population will be aged ≥ 65 years by 2030, an increase from 13% in 2012.¹ The likelihood of needing assistance with activities of daily living (ADLs) increases with age.² People who need such assistance often depend on informal and unpaid assistance from friends and family. In 2009, about 65.7 million Americans (28.5%) provided informal care for people with an illness or disability, and that number only is expected to rise.³ These informal caregivers provide up to 80% of the total care hours needed by community-dwelling older adults—an estimated economic value of $450 billion in unpaid contributions in 2009.^4,5

Caregiving can lead to significant physical, psychological, social, and financial burdens.⁶ The caregiving burden is associated with a host of adverse health behaviors and outcomes such as poor diet, lack of exercise and sleep, smoking, decreased participation in preventive health care, anxiety, depression, relationship difficulties, employment disruption, financial hardship, suicide, and higher mortality compared with that of noncaregivers.^6-10 Additionally, care recipients are at increased risk for abuse or neglect when the caregiver is experiencing a significant burden.¹¹ Therefore, efforts to improve caregiver support are important for both partners in the caregiver/care recipient dyad.

Caregiver support is beneficial to the health of caregivers and care recipients.^10,12 For example, the Resources for Enhancing Alzheimer’s Caregiver Health (REACH) program has been shown to reduce the stress of informal caregiving and the risk of depression in caregivers.^13,14 This program showed similar effects when implemented within the VHA.¹⁴ In the Partners in Dementia Care project, the VHA and Alzheimer’s Association coordinated care and support for veterans with dementia and their family and friends. This intervention resulted in lower caregiver strain and depression scores among participants.¹⁵

With a growing medical literature that shows the benefits of caregiver support interventions, the VHA developed a robust support program for informal caregivers of veterans. The VA caregiver support website (www.caregiver.va.gov) provides information and resources targeted to caregivers for veterans, including psychosocial and functional support for caregivers. The psychosocial support provided by the VA includes caregiver education, counseling, access to caregiver support coordinators, a caregiver support line, support groups, and referral to community support organizations.¹⁶ Functional support on the site includes financial assistance toward skilled home care, home hospice care, adult day care, home-based primary care, homemaker and home health aide services, telehealth, and respite care.¹⁶ Veterans who are caregiving for nonveterans have access to VHA psychosocial support but not to functional support services. For these veterans, functional caregiver support must come from family or referral to community organizations.

Background

In the U.S., about 11% of caregivers are veterans, but the availability of data about these caregivers is limited to veteran subgroups.³ For example, a 2011 study reported that 20% of veterans aged ≥ 60 years are caregivers.¹⁷ However, this estimate included child care for unimpaired children, which is not commonly included in other caregiving estimates. In another study, 30% of middle-aged active-duty officers reported helping their parents with instrumental ADLs (IADLs).¹⁸ These data suggest a significant proportion of veterans may be caregivers; however, the estimates do not identify prevalence of caregiving among a population of VHA enrolled veterans.

Likewise, few studies discuss the burden veterans experience from caregiving. A study of the 2009/2010 CDC Behavioral Risk Factor Surveillance System data found that female caregivers were more likely to report problems with sleep and mental health if they were veterans vs nonveterans.¹⁹ In a second study, caregiving veterans frequently reported physical (39%) and emotional (53%) strain, with emotional strain relating to depressive symptoms. The study of active-duty officers noted that worry was prevalent among military officers caregiving for parents from a distance.¹⁸ In contrast to the negative outcomes of caregiving, Monin and colleagues found that many veterans perceived caregiving as rewarding. Since caregiving may be a positive experience, veterans may benefit and be a potential resource for care to elderly and disabled citizens.¹⁷

Project Rationale and Goals

Social workers are the cornerstone of caregiver support at the George E. Wahlen VA Salt Lake City Health Care System (VASLCHCS) in Utah. They educate veterans and caregivers about VA resources to support caregivers of veterans. For those veterans who are caregiving for a nonveteran, the VASLCHCS social workers provide psychosocial support and help veterans connect to a local area agency on aging (AAA) for access to functional support. In practice, primary care clinic (PCC) providers have observed that directing a veteran to call the AAA does not usually result in a phone call. Therefore, an aim of this quality improvement (QI) project was to determine the most effective means of completing a successful AAA referral.

The VASLCHCS Geriatric Research Education and Clinical Center collaborates with the Utah Aging and Disability Resource Connection (ADRC) to improve awareness of available resources for veterans. Building on this collaborative project, the authors created a formal referral process for veterans needing local AAA services. This QI project had 3 aims: (1) estimate the prevalence of caregiving among veterans in the VASLCHCS primary care clinic; (2) identify perceived caregiving difficulties and resource use difficulty in caregiving tasks; and (3) test different strategies to connect veterans with a referral to community resources through the AAA.

The authors hypothesized that a veteran would be more likely to connect with the AAA if contact was initiated by the AAA rather than the standard practice of asking the veteran to make the call. However, the authors also hypothesized that a veteran who took the time to make the call would be more likely to use AAA resources compared with veterans who were called by the AAA.

Methods

The VASLCHCS Research and Development Office reviewed this project and determined that it met the definition of QI. Therefore, it did not require IRB approval.

The study drew from a convenience sample of veterans who were waiting for appointments in the PCC and who were referred by their health care provider (HCP). To identify caregivers, veterans were asked: “People may provide regular care or assistance to a friend or family member who has a health problem, long-term illness, or disability. During the past month, did you provide any such care or assistance to a friend or family member?” Referrals from HCPs were included in all calculations except the prevalence estimate.

The authors interviewed veterans over a 3-month period in 2015. As of November 2014, the clinic was serving about 11,000 veterans, of which 6,589 lived in Salt Lake County. The clinic also serves veterans who live in other counties in Utah, Nevada, Wyoming, Idaho, and Colorado. 

Intervention and Partnering With Community Resources

All willing caregivers were provided a referral to a local AAA (Figure). Salt Lake County veterans interested in referral to the AAA were randomized to 1 of 2 referral methods: veteran-initiated referral (VIR), in which the veteran was given a handout with the phone number of the Salt Lake County caregiver support program (CSP), or provider-initiated referral (PIR), in which the veteran’s phone number was given to the CSP. Caregiving veterans living outside Salt Lake County were provided the AAA phone number in their area and instructed to call for information.

The interview form was randomized using an even or odd number before the interview. Some veterans who were randomized to a PIR needed to be moved into the VIR intervention arm because of the following reasons: the veteran’s care recipient was aged < 18 years (3); the veteran lived outside of Salt Lake County (20); the veteran did not want his/her name given to an outside agency (5); or the interviewer mistakenly gave the veteran the AAA contact information (4).

The primary author called caregivers in the PIR and VIR groups 2 to 4 weeks after the referral to determine whether they had contacted or were contacted by the AAA. Ten call attempts were made before participants were considered lost to follow-up. Caregivers that had been in contact with the AAA reported in open-ended fashion the resources to which they had been referred and whether those resources had been helpful.

Analysis

In this evaluation, the primary outcome of interest was whether contact between the veteran and AAA occurred. For the VIR group, contact was defined as the veteran having called the AAA, regardless of whether he or she actually spoke to someone. For the PIR group, contact occurred if the veteran reported receiving a phone call from AAA regardless of whether he or she had actually spoken with someone (eg, if the veteran reported that the AAA had left a voice mail, this was considered contact). Veterans also were asked whether connecting with the AAA led to resource referrals and whether these referrals were useful.

To achieve a power of 80% with a 95% confidence interval, 20 people were needed in each intervention group to detect a 40% difference in the rate of contact between the 2 groups. STATA12 (College Station, TX) was used to calculate Fisher exact and chi-square values to evaluate differences between groups.

Results

For the study, 433 PCC veterans were interviewed, and 157 (36%) self-identified as a caregiver. An additional 22 referrals were included for a total of 179 caregivers. Caregiver and care recipient characteristics, caregiver burden, and resource utilization were calculated for all 179 caregivers; however, all caregivers did not answer every question. Ninety-eight percent (176) of caregivers were men; 64% (109/170) were from Salt Lake County, and 5% were from outside Utah (8). Twelve percent (21) of the 179 caregivers were providing care for > 1 person. Of 177 caregivers, 3% (5) were caring for both a veteran and a nonveteran, 69% (122) were caring for a nonveteran only, and 28% (49) were caring for another veteran only (Table 1).

The most common burden reported by caregivers was stress (63%); 70% endorsed family/friends as a resource (Table 2). Just 6% (10) of caregivers used the AAA, whereas 26% (45) received VHA support. Of the 54 veterans who were caring for a veteran, 40 reported using the VHA as a resource. Five people caring for nonveterans reported using the VHA as a resource; however, data about which resources those caregivers were accessing were not collected (Table 3).

AAA Referral and Randomization

Sixty-five percent of caregivers accepted AAA referrals. Of 109 Salt Lake County caregivers, 70% accepted referral to the AAA. There was no statistically significant difference in referral acceptance rates when comparing Salt Lake County residents with nonresidents (P = .09).The authors were unable to obtain the phone number for 1 caregiver who had accepted a referral, and 1 caregiver who accepted referral did not want a follow-up. This left 111 caregivers available for follow-up, 75 in Salt Lake County. Fifty Salt Lake County veterans were randomly assigned to the VIR group and 25 to the PIR group. The 36 caregivers who accepted referrals outside Salt Lake County also were placed in the VIR group, for a total of 86 caregivers.

Follow-up

Ninety-eight percent of caregivers were reached for follow-up. Both people lost to follow-up were in Salt Lake County (1 in each group).

In Salt Lake County, 12% (6) of the VIR group and 64% (16) of the PIR group had connected with the AAA (P < .01). Although 64% of those in the PIR group reported having been called by the AAA, the AAA representative reported all 25 had been called. The AAA records showed 9 of those called were reached by voice mail, 6 were provided information about caregiving resources, 2 formally joined the support program, 5 declined help, 1 was no longer caregiving, 1 was too busy to talk, and 1 was the wrong phone number (and was lost to follow-up as well).

Outside of Salt Lake County 19% (7) reported calling the local AAA. There was no difference in referral completion between the Salt Lake County/non-Salt Lake County VIR groups (P = .4).

Fifteen percent of all VIR caregivers reported calling the AAA. There were no statistical differences between Salt Lake County VIR and non-Salt Lake County VIR for reasons why the veteran had not called the AAA (Table 4).

Of 28 people who connected with the AAA, 16 (57%) said they had received access to a needed resource as a result of the phone call. Seven caregivers (25%) said they had not been referred to other resources as a result of the call. The VIR group was more likely to be referred to other resources after contacting the AAA than was the PIR group, although this difference did not reach significance (69% vs 47%, P = .28).

Discussion

More than one-third (36%) of veterans seen in the VASLCHCS PCC are caregivers. This prevalence is higher than that reported for the general U.S. population and higher than that reported in other veteran groups.^5,17,18 Most caregivers in this project were caring for nonveterans and only had access to VHA psychosocial caregiver support programs because VHA functional caregiver support (eg, respite, homemaker services) is not available to veterans who care for nonveterans. A majority (78%) of caregiving veterans reported some caregiver burden. Despite the burden, most are not using community resources. However when offered, more than half the caregivers were interested in an AAA referral.

Although the VHA does not provide functional caregiver support resources to veterans caring for nonveterans, there are other agencies that can assist veterans: AAAs for care recipients aged ≥ 60 years and the ADRCs for younger veterans. Through AAAs, caregivers can access a variety of support services, including transportation, adult day care, caregiver support, and health promotion programs. Partnership between agencies such as the VHA and the AAAs could benefit caregiving veterans. This QI project suggests ways to strengthen interagency cooperation.

This study also suggests that a provider or clinic-initiated referral is more likely to connect veterans with information and resources than the current practice of recommending that the veteran initiate the referral. Once in contact with the AAA, most caregivers were referred to needed resources. The next step will be to establish an efficient way for clinic staff to identify caregiving veterans and make referrals to community programs. Referrals could be made by any member of the patient aligned care team (PACT) to further standardize and streamline the process.

Thirty-one percent of veterans in this project were eligible for the VHA caregiver support program because they cared for a veteran. However, 25% of these caregiving veterans were not accessing this resource. Increasing awareness of the VHA caregiver support program among veterans caring for other veterans would improve caregiver support to both caregiving and care recipient veterans.

Limitations

One limitation of this project was the intentional exclusion of the women’s clinic from the sampling process. For consistency, the authors wanted to limit the intervention to 1 PCC and so they chose the clinic that serves the majority of the veterans who receive primary care at VASLCHCS. Additionally, the literature showed that male caregivers compared with women caregivers^20,21 have different characteristics in regards to caregiver burden, and a well-designed study of women caregivers already has been published.¹⁹

Also, this study did not obtain data on age, health problems, or socioeconomic status of the caregivers to avoid identifying information. Last, the authors did not ask about time spent caregiving or type of care provided. These questions may be important for future studies. Future investigations should evaluate health care use and health of caregivers vs noncaregivers in the veteran population. It also could be important to determine methods for building bridges between the VHA, AAAs, and other community services.

Conclusion

To minimize the disruption that a research study might have caused to normal clinical workflow, the primary author played the role that a medical social worker or other PACT member might play in the future. This project sheds light on how to improve outcomes for community referrals and an important future step in this research would be to develop and test a process that would integrate the PACT into the referral process.

More than one-third of veterans seen in the VASLCHCS PCC are caregivers. To the authors’ knowledge, this is the first estimate of prevalence of caregiving in veterans who receive primary care from the VHA. About 63% of caregiving veterans perceived some burden due to caregiving, and 66% accepted referral to community resources. However, only 12% who were asked to self-refer made contact with the AAA compared with 64% when a provider made the referral for them. Provider referral is more effective in connecting caregiving veterans with resources. Development of interagency partnerships should be fostered to help veterans decrease caregiving burden.

This project is one of the few studies looking at this special group of caregivers: veterans who serve as caregivers. It highlights the need for the VHA to establish policies and partnerships to improve caregiver support to this valuable group of veterans.

More than 20% of the U.S. population will be aged ≥ 65 years by 2030, an increase from 13% in 2012.¹ The likelihood of needing assistance with activities of daily living (ADLs) increases with age.² People who need such assistance often depend on informal and unpaid assistance from friends and family. In 2009, about 65.7 million Americans (28.5%) provided informal care for people with an illness or disability, and that number only is expected to rise.³ These informal caregivers provide up to 80% of the total care hours needed by community-dwelling older adults—an estimated economic value of $450 billion in unpaid contributions in 2009.^4,5

Caregiving can lead to significant physical, psychological, social, and financial burdens.⁶ The caregiving burden is associated with a host of adverse health behaviors and outcomes such as poor diet, lack of exercise and sleep, smoking, decreased participation in preventive health care, anxiety, depression, relationship difficulties, employment disruption, financial hardship, suicide, and higher mortality compared with that of noncaregivers.^6-10 Additionally, care recipients are at increased risk for abuse or neglect when the caregiver is experiencing a significant burden.¹¹ Therefore, efforts to improve caregiver support are important for both partners in the caregiver/care recipient dyad.

Caregiver support is beneficial to the health of caregivers and care recipients.^10,12 For example, the Resources for Enhancing Alzheimer’s Caregiver Health (REACH) program has been shown to reduce the stress of informal caregiving and the risk of depression in caregivers.^13,14 This program showed similar effects when implemented within the VHA.¹⁴ In the Partners in Dementia Care project, the VHA and Alzheimer’s Association coordinated care and support for veterans with dementia and their family and friends. This intervention resulted in lower caregiver strain and depression scores among participants.¹⁵

With a growing medical literature that shows the benefits of caregiver support interventions, the VHA developed a robust support program for informal caregivers of veterans. The VA caregiver support website (www.caregiver.va.gov) provides information and resources targeted to caregivers for veterans, including psychosocial and functional support for caregivers. The psychosocial support provided by the VA includes caregiver education, counseling, access to caregiver support coordinators, a caregiver support line, support groups, and referral to community support organizations.¹⁶ Functional support on the site includes financial assistance toward skilled home care, home hospice care, adult day care, home-based primary care, homemaker and home health aide services, telehealth, and respite care.¹⁶ Veterans who are caregiving for nonveterans have access to VHA psychosocial support but not to functional support services. For these veterans, functional caregiver support must come from family or referral to community organizations.

Background

In the U.S., about 11% of caregivers are veterans, but the availability of data about these caregivers is limited to veteran subgroups.³ For example, a 2011 study reported that 20% of veterans aged ≥ 60 years are caregivers.¹⁷ However, this estimate included child care for unimpaired children, which is not commonly included in other caregiving estimates. In another study, 30% of middle-aged active-duty officers reported helping their parents with instrumental ADLs (IADLs).¹⁸ These data suggest a significant proportion of veterans may be caregivers; however, the estimates do not identify prevalence of caregiving among a population of VHA enrolled veterans.

Likewise, few studies discuss the burden veterans experience from caregiving. A study of the 2009/2010 CDC Behavioral Risk Factor Surveillance System data found that female caregivers were more likely to report problems with sleep and mental health if they were veterans vs nonveterans.¹⁹ In a second study, caregiving veterans frequently reported physical (39%) and emotional (53%) strain, with emotional strain relating to depressive symptoms. The study of active-duty officers noted that worry was prevalent among military officers caregiving for parents from a distance.¹⁸ In contrast to the negative outcomes of caregiving, Monin and colleagues found that many veterans perceived caregiving as rewarding. Since caregiving may be a positive experience, veterans may benefit and be a potential resource for care to elderly and disabled citizens.¹⁷

Project Rationale and Goals

Social workers are the cornerstone of caregiver support at the George E. Wahlen VA Salt Lake City Health Care System (VASLCHCS) in Utah. They educate veterans and caregivers about VA resources to support caregivers of veterans. For those veterans who are caregiving for a nonveteran, the VASLCHCS social workers provide psychosocial support and help veterans connect to a local area agency on aging (AAA) for access to functional support. In practice, primary care clinic (PCC) providers have observed that directing a veteran to call the AAA does not usually result in a phone call. Therefore, an aim of this quality improvement (QI) project was to determine the most effective means of completing a successful AAA referral.

The VASLCHCS Geriatric Research Education and Clinical Center collaborates with the Utah Aging and Disability Resource Connection (ADRC) to improve awareness of available resources for veterans. Building on this collaborative project, the authors created a formal referral process for veterans needing local AAA services. This QI project had 3 aims: (1) estimate the prevalence of caregiving among veterans in the VASLCHCS primary care clinic; (2) identify perceived caregiving difficulties and resource use difficulty in caregiving tasks; and (3) test different strategies to connect veterans with a referral to community resources through the AAA.

The authors hypothesized that a veteran would be more likely to connect with the AAA if contact was initiated by the AAA rather than the standard practice of asking the veteran to make the call. However, the authors also hypothesized that a veteran who took the time to make the call would be more likely to use AAA resources compared with veterans who were called by the AAA.

Methods

The VASLCHCS Research and Development Office reviewed this project and determined that it met the definition of QI. Therefore, it did not require IRB approval.

The study drew from a convenience sample of veterans who were waiting for appointments in the PCC and who were referred by their health care provider (HCP). To identify caregivers, veterans were asked: “People may provide regular care or assistance to a friend or family member who has a health problem, long-term illness, or disability. During the past month, did you provide any such care or assistance to a friend or family member?” Referrals from HCPs were included in all calculations except the prevalence estimate.

The authors interviewed veterans over a 3-month period in 2015. As of November 2014, the clinic was serving about 11,000 veterans, of which 6,589 lived in Salt Lake County. The clinic also serves veterans who live in other counties in Utah, Nevada, Wyoming, Idaho, and Colorado. 

Intervention and Partnering With Community Resources

All willing caregivers were provided a referral to a local AAA (Figure). Salt Lake County veterans interested in referral to the AAA were randomized to 1 of 2 referral methods: veteran-initiated referral (VIR), in which the veteran was given a handout with the phone number of the Salt Lake County caregiver support program (CSP), or provider-initiated referral (PIR), in which the veteran’s phone number was given to the CSP. Caregiving veterans living outside Salt Lake County were provided the AAA phone number in their area and instructed to call for information.

The interview form was randomized using an even or odd number before the interview. Some veterans who were randomized to a PIR needed to be moved into the VIR intervention arm because of the following reasons: the veteran’s care recipient was aged < 18 years (3); the veteran lived outside of Salt Lake County (20); the veteran did not want his/her name given to an outside agency (5); or the interviewer mistakenly gave the veteran the AAA contact information (4).

The primary author called caregivers in the PIR and VIR groups 2 to 4 weeks after the referral to determine whether they had contacted or were contacted by the AAA. Ten call attempts were made before participants were considered lost to follow-up. Caregivers that had been in contact with the AAA reported in open-ended fashion the resources to which they had been referred and whether those resources had been helpful.

Analysis

In this evaluation, the primary outcome of interest was whether contact between the veteran and AAA occurred. For the VIR group, contact was defined as the veteran having called the AAA, regardless of whether he or she actually spoke to someone. For the PIR group, contact occurred if the veteran reported receiving a phone call from AAA regardless of whether he or she had actually spoken with someone (eg, if the veteran reported that the AAA had left a voice mail, this was considered contact). Veterans also were asked whether connecting with the AAA led to resource referrals and whether these referrals were useful.

To achieve a power of 80% with a 95% confidence interval, 20 people were needed in each intervention group to detect a 40% difference in the rate of contact between the 2 groups. STATA12 (College Station, TX) was used to calculate Fisher exact and chi-square values to evaluate differences between groups.

Results

For the study, 433 PCC veterans were interviewed, and 157 (36%) self-identified as a caregiver. An additional 22 referrals were included for a total of 179 caregivers. Caregiver and care recipient characteristics, caregiver burden, and resource utilization were calculated for all 179 caregivers; however, all caregivers did not answer every question. Ninety-eight percent (176) of caregivers were men; 64% (109/170) were from Salt Lake County, and 5% were from outside Utah (8). Twelve percent (21) of the 179 caregivers were providing care for > 1 person. Of 177 caregivers, 3% (5) were caring for both a veteran and a nonveteran, 69% (122) were caring for a nonveteran only, and 28% (49) were caring for another veteran only (Table 1).

The most common burden reported by caregivers was stress (63%); 70% endorsed family/friends as a resource (Table 2). Just 6% (10) of caregivers used the AAA, whereas 26% (45) received VHA support. Of the 54 veterans who were caring for a veteran, 40 reported using the VHA as a resource. Five people caring for nonveterans reported using the VHA as a resource; however, data about which resources those caregivers were accessing were not collected (Table 3).

AAA Referral and Randomization

Sixty-five percent of caregivers accepted AAA referrals. Of 109 Salt Lake County caregivers, 70% accepted referral to the AAA. There was no statistically significant difference in referral acceptance rates when comparing Salt Lake County residents with nonresidents (P = .09).The authors were unable to obtain the phone number for 1 caregiver who had accepted a referral, and 1 caregiver who accepted referral did not want a follow-up. This left 111 caregivers available for follow-up, 75 in Salt Lake County. Fifty Salt Lake County veterans were randomly assigned to the VIR group and 25 to the PIR group. The 36 caregivers who accepted referrals outside Salt Lake County also were placed in the VIR group, for a total of 86 caregivers.

Follow-up

Ninety-eight percent of caregivers were reached for follow-up. Both people lost to follow-up were in Salt Lake County (1 in each group).

In Salt Lake County, 12% (6) of the VIR group and 64% (16) of the PIR group had connected with the AAA (P < .01). Although 64% of those in the PIR group reported having been called by the AAA, the AAA representative reported all 25 had been called. The AAA records showed 9 of those called were reached by voice mail, 6 were provided information about caregiving resources, 2 formally joined the support program, 5 declined help, 1 was no longer caregiving, 1 was too busy to talk, and 1 was the wrong phone number (and was lost to follow-up as well).

Outside of Salt Lake County 19% (7) reported calling the local AAA. There was no difference in referral completion between the Salt Lake County/non-Salt Lake County VIR groups (P = .4).

Fifteen percent of all VIR caregivers reported calling the AAA. There were no statistical differences between Salt Lake County VIR and non-Salt Lake County VIR for reasons why the veteran had not called the AAA (Table 4).

Of 28 people who connected with the AAA, 16 (57%) said they had received access to a needed resource as a result of the phone call. Seven caregivers (25%) said they had not been referred to other resources as a result of the call. The VIR group was more likely to be referred to other resources after contacting the AAA than was the PIR group, although this difference did not reach significance (69% vs 47%, P = .28).

Discussion

More than one-third (36%) of veterans seen in the VASLCHCS PCC are caregivers. This prevalence is higher than that reported for the general U.S. population and higher than that reported in other veteran groups.^5,17,18 Most caregivers in this project were caring for nonveterans and only had access to VHA psychosocial caregiver support programs because VHA functional caregiver support (eg, respite, homemaker services) is not available to veterans who care for nonveterans. A majority (78%) of caregiving veterans reported some caregiver burden. Despite the burden, most are not using community resources. However when offered, more than half the caregivers were interested in an AAA referral.

Although the VHA does not provide functional caregiver support resources to veterans caring for nonveterans, there are other agencies that can assist veterans: AAAs for care recipients aged ≥ 60 years and the ADRCs for younger veterans. Through AAAs, caregivers can access a variety of support services, including transportation, adult day care, caregiver support, and health promotion programs. Partnership between agencies such as the VHA and the AAAs could benefit caregiving veterans. This QI project suggests ways to strengthen interagency cooperation.

This study also suggests that a provider or clinic-initiated referral is more likely to connect veterans with information and resources than the current practice of recommending that the veteran initiate the referral. Once in contact with the AAA, most caregivers were referred to needed resources. The next step will be to establish an efficient way for clinic staff to identify caregiving veterans and make referrals to community programs. Referrals could be made by any member of the patient aligned care team (PACT) to further standardize and streamline the process.

Thirty-one percent of veterans in this project were eligible for the VHA caregiver support program because they cared for a veteran. However, 25% of these caregiving veterans were not accessing this resource. Increasing awareness of the VHA caregiver support program among veterans caring for other veterans would improve caregiver support to both caregiving and care recipient veterans.

Limitations

One limitation of this project was the intentional exclusion of the women’s clinic from the sampling process. For consistency, the authors wanted to limit the intervention to 1 PCC and so they chose the clinic that serves the majority of the veterans who receive primary care at VASLCHCS. Additionally, the literature showed that male caregivers compared with women caregivers^20,21 have different characteristics in regards to caregiver burden, and a well-designed study of women caregivers already has been published.¹⁹

Also, this study did not obtain data on age, health problems, or socioeconomic status of the caregivers to avoid identifying information. Last, the authors did not ask about time spent caregiving or type of care provided. These questions may be important for future studies. Future investigations should evaluate health care use and health of caregivers vs noncaregivers in the veteran population. It also could be important to determine methods for building bridges between the VHA, AAAs, and other community services.

Conclusion

To minimize the disruption that a research study might have caused to normal clinical workflow, the primary author played the role that a medical social worker or other PACT member might play in the future. This project sheds light on how to improve outcomes for community referrals and an important future step in this research would be to develop and test a process that would integrate the PACT into the referral process.

More than one-third of veterans seen in the VASLCHCS PCC are caregivers. To the authors’ knowledge, this is the first estimate of prevalence of caregiving in veterans who receive primary care from the VHA. About 63% of caregiving veterans perceived some burden due to caregiving, and 66% accepted referral to community resources. However, only 12% who were asked to self-refer made contact with the AAA compared with 64% when a provider made the referral for them. Provider referral is more effective in connecting caregiving veterans with resources. Development of interagency partnerships should be fostered to help veterans decrease caregiving burden.

This project is one of the few studies looking at this special group of caregivers: veterans who serve as caregivers. It highlights the need for the VHA to establish policies and partnerships to improve caregiver support to this valuable group of veterans.

More than 20% of the U.S. population will be aged ≥ 65 years by 2030, an increase from 13% in 2012.¹ The likelihood of needing assistance with activities of daily living (ADLs) increases with age.² People who need such assistance often depend on informal and unpaid assistance from friends and family. In 2009, about 65.7 million Americans (28.5%) provided informal care for people with an illness or disability, and that number only is expected to rise.³ These informal caregivers provide up to 80% of the total care hours needed by community-dwelling older adults—an estimated economic value of $450 billion in unpaid contributions in 2009.^4,5

Caregiving can lead to significant physical, psychological, social, and financial burdens.⁶ The caregiving burden is associated with a host of adverse health behaviors and outcomes such as poor diet, lack of exercise and sleep, smoking, decreased participation in preventive health care, anxiety, depression, relationship difficulties, employment disruption, financial hardship, suicide, and higher mortality compared with that of noncaregivers.^6-10 Additionally, care recipients are at increased risk for abuse or neglect when the caregiver is experiencing a significant burden.¹¹ Therefore, efforts to improve caregiver support are important for both partners in the caregiver/care recipient dyad.

Caregiver support is beneficial to the health of caregivers and care recipients.^10,12 For example, the Resources for Enhancing Alzheimer’s Caregiver Health (REACH) program has been shown to reduce the stress of informal caregiving and the risk of depression in caregivers.^13,14 This program showed similar effects when implemented within the VHA.¹⁴ In the Partners in Dementia Care project, the VHA and Alzheimer’s Association coordinated care and support for veterans with dementia and their family and friends. This intervention resulted in lower caregiver strain and depression scores among participants.¹⁵

With a growing medical literature that shows the benefits of caregiver support interventions, the VHA developed a robust support program for informal caregivers of veterans. The VA caregiver support website (www.caregiver.va.gov) provides information and resources targeted to caregivers for veterans, including psychosocial and functional support for caregivers. The psychosocial support provided by the VA includes caregiver education, counseling, access to caregiver support coordinators, a caregiver support line, support groups, and referral to community support organizations.¹⁶ Functional support on the site includes financial assistance toward skilled home care, home hospice care, adult day care, home-based primary care, homemaker and home health aide services, telehealth, and respite care.¹⁶ Veterans who are caregiving for nonveterans have access to VHA psychosocial support but not to functional support services. For these veterans, functional caregiver support must come from family or referral to community organizations.

Background

In the U.S., about 11% of caregivers are veterans, but the availability of data about these caregivers is limited to veteran subgroups.³ For example, a 2011 study reported that 20% of veterans aged ≥ 60 years are caregivers.¹⁷ However, this estimate included child care for unimpaired children, which is not commonly included in other caregiving estimates. In another study, 30% of middle-aged active-duty officers reported helping their parents with instrumental ADLs (IADLs).¹⁸ These data suggest a significant proportion of veterans may be caregivers; however, the estimates do not identify prevalence of caregiving among a population of VHA enrolled veterans.

Likewise, few studies discuss the burden veterans experience from caregiving. A study of the 2009/2010 CDC Behavioral Risk Factor Surveillance System data found that female caregivers were more likely to report problems with sleep and mental health if they were veterans vs nonveterans.¹⁹ In a second study, caregiving veterans frequently reported physical (39%) and emotional (53%) strain, with emotional strain relating to depressive symptoms. The study of active-duty officers noted that worry was prevalent among military officers caregiving for parents from a distance.¹⁸ In contrast to the negative outcomes of caregiving, Monin and colleagues found that many veterans perceived caregiving as rewarding. Since caregiving may be a positive experience, veterans may benefit and be a potential resource for care to elderly and disabled citizens.¹⁷

Project Rationale and Goals

Social workers are the cornerstone of caregiver support at the George E. Wahlen VA Salt Lake City Health Care System (VASLCHCS) in Utah. They educate veterans and caregivers about VA resources to support caregivers of veterans. For those veterans who are caregiving for a nonveteran, the VASLCHCS social workers provide psychosocial support and help veterans connect to a local area agency on aging (AAA) for access to functional support. In practice, primary care clinic (PCC) providers have observed that directing a veteran to call the AAA does not usually result in a phone call. Therefore, an aim of this quality improvement (QI) project was to determine the most effective means of completing a successful AAA referral.

The VASLCHCS Geriatric Research Education and Clinical Center collaborates with the Utah Aging and Disability Resource Connection (ADRC) to improve awareness of available resources for veterans. Building on this collaborative project, the authors created a formal referral process for veterans needing local AAA services. This QI project had 3 aims: (1) estimate the prevalence of caregiving among veterans in the VASLCHCS primary care clinic; (2) identify perceived caregiving difficulties and resource use difficulty in caregiving tasks; and (3) test different strategies to connect veterans with a referral to community resources through the AAA.

The authors hypothesized that a veteran would be more likely to connect with the AAA if contact was initiated by the AAA rather than the standard practice of asking the veteran to make the call. However, the authors also hypothesized that a veteran who took the time to make the call would be more likely to use AAA resources compared with veterans who were called by the AAA.

Methods

The VASLCHCS Research and Development Office reviewed this project and determined that it met the definition of QI. Therefore, it did not require IRB approval.

The study drew from a convenience sample of veterans who were waiting for appointments in the PCC and who were referred by their health care provider (HCP). To identify caregivers, veterans were asked: “People may provide regular care or assistance to a friend or family member who has a health problem, long-term illness, or disability. During the past month, did you provide any such care or assistance to a friend or family member?” Referrals from HCPs were included in all calculations except the prevalence estimate.

The authors interviewed veterans over a 3-month period in 2015. As of November 2014, the clinic was serving about 11,000 veterans, of which 6,589 lived in Salt Lake County. The clinic also serves veterans who live in other counties in Utah, Nevada, Wyoming, Idaho, and Colorado. 

Intervention and Partnering With Community Resources

All willing caregivers were provided a referral to a local AAA (Figure). Salt Lake County veterans interested in referral to the AAA were randomized to 1 of 2 referral methods: veteran-initiated referral (VIR), in which the veteran was given a handout with the phone number of the Salt Lake County caregiver support program (CSP), or provider-initiated referral (PIR), in which the veteran’s phone number was given to the CSP. Caregiving veterans living outside Salt Lake County were provided the AAA phone number in their area and instructed to call for information.

The interview form was randomized using an even or odd number before the interview. Some veterans who were randomized to a PIR needed to be moved into the VIR intervention arm because of the following reasons: the veteran’s care recipient was aged < 18 years (3); the veteran lived outside of Salt Lake County (20); the veteran did not want his/her name given to an outside agency (5); or the interviewer mistakenly gave the veteran the AAA contact information (4).

The primary author called caregivers in the PIR and VIR groups 2 to 4 weeks after the referral to determine whether they had contacted or were contacted by the AAA. Ten call attempts were made before participants were considered lost to follow-up. Caregivers that had been in contact with the AAA reported in open-ended fashion the resources to which they had been referred and whether those resources had been helpful.

Analysis

In this evaluation, the primary outcome of interest was whether contact between the veteran and AAA occurred. For the VIR group, contact was defined as the veteran having called the AAA, regardless of whether he or she actually spoke to someone. For the PIR group, contact occurred if the veteran reported receiving a phone call from AAA regardless of whether he or she had actually spoken with someone (eg, if the veteran reported that the AAA had left a voice mail, this was considered contact). Veterans also were asked whether connecting with the AAA led to resource referrals and whether these referrals were useful.

To achieve a power of 80% with a 95% confidence interval, 20 people were needed in each intervention group to detect a 40% difference in the rate of contact between the 2 groups. STATA12 (College Station, TX) was used to calculate Fisher exact and chi-square values to evaluate differences between groups.

Results

For the study, 433 PCC veterans were interviewed, and 157 (36%) self-identified as a caregiver. An additional 22 referrals were included for a total of 179 caregivers. Caregiver and care recipient characteristics, caregiver burden, and resource utilization were calculated for all 179 caregivers; however, all caregivers did not answer every question. Ninety-eight percent (176) of caregivers were men; 64% (109/170) were from Salt Lake County, and 5% were from outside Utah (8). Twelve percent (21) of the 179 caregivers were providing care for > 1 person. Of 177 caregivers, 3% (5) were caring for both a veteran and a nonveteran, 69% (122) were caring for a nonveteran only, and 28% (49) were caring for another veteran only (Table 1).

The most common burden reported by caregivers was stress (63%); 70% endorsed family/friends as a resource (Table 2). Just 6% (10) of caregivers used the AAA, whereas 26% (45) received VHA support. Of the 54 veterans who were caring for a veteran, 40 reported using the VHA as a resource. Five people caring for nonveterans reported using the VHA as a resource; however, data about which resources those caregivers were accessing were not collected (Table 3).

AAA Referral and Randomization

Sixty-five percent of caregivers accepted AAA referrals. Of 109 Salt Lake County caregivers, 70% accepted referral to the AAA. There was no statistically significant difference in referral acceptance rates when comparing Salt Lake County residents with nonresidents (P = .09).The authors were unable to obtain the phone number for 1 caregiver who had accepted a referral, and 1 caregiver who accepted referral did not want a follow-up. This left 111 caregivers available for follow-up, 75 in Salt Lake County. Fifty Salt Lake County veterans were randomly assigned to the VIR group and 25 to the PIR group. The 36 caregivers who accepted referrals outside Salt Lake County also were placed in the VIR group, for a total of 86 caregivers.

Follow-up

Ninety-eight percent of caregivers were reached for follow-up. Both people lost to follow-up were in Salt Lake County (1 in each group).

In Salt Lake County, 12% (6) of the VIR group and 64% (16) of the PIR group had connected with the AAA (P < .01). Although 64% of those in the PIR group reported having been called by the AAA, the AAA representative reported all 25 had been called. The AAA records showed 9 of those called were reached by voice mail, 6 were provided information about caregiving resources, 2 formally joined the support program, 5 declined help, 1 was no longer caregiving, 1 was too busy to talk, and 1 was the wrong phone number (and was lost to follow-up as well).

Outside of Salt Lake County 19% (7) reported calling the local AAA. There was no difference in referral completion between the Salt Lake County/non-Salt Lake County VIR groups (P = .4).

Fifteen percent of all VIR caregivers reported calling the AAA. There were no statistical differences between Salt Lake County VIR and non-Salt Lake County VIR for reasons why the veteran had not called the AAA (Table 4).

Of 28 people who connected with the AAA, 16 (57%) said they had received access to a needed resource as a result of the phone call. Seven caregivers (25%) said they had not been referred to other resources as a result of the call. The VIR group was more likely to be referred to other resources after contacting the AAA than was the PIR group, although this difference did not reach significance (69% vs 47%, P = .28).

Discussion

More than one-third (36%) of veterans seen in the VASLCHCS PCC are caregivers. This prevalence is higher than that reported for the general U.S. population and higher than that reported in other veteran groups.^5,17,18 Most caregivers in this project were caring for nonveterans and only had access to VHA psychosocial caregiver support programs because VHA functional caregiver support (eg, respite, homemaker services) is not available to veterans who care for nonveterans. A majority (78%) of caregiving veterans reported some caregiver burden. Despite the burden, most are not using community resources. However when offered, more than half the caregivers were interested in an AAA referral.

Although the VHA does not provide functional caregiver support resources to veterans caring for nonveterans, there are other agencies that can assist veterans: AAAs for care recipients aged ≥ 60 years and the ADRCs for younger veterans. Through AAAs, caregivers can access a variety of support services, including transportation, adult day care, caregiver support, and health promotion programs. Partnership between agencies such as the VHA and the AAAs could benefit caregiving veterans. This QI project suggests ways to strengthen interagency cooperation.

This study also suggests that a provider or clinic-initiated referral is more likely to connect veterans with information and resources than the current practice of recommending that the veteran initiate the referral. Once in contact with the AAA, most caregivers were referred to needed resources. The next step will be to establish an efficient way for clinic staff to identify caregiving veterans and make referrals to community programs. Referrals could be made by any member of the patient aligned care team (PACT) to further standardize and streamline the process.

Thirty-one percent of veterans in this project were eligible for the VHA caregiver support program because they cared for a veteran. However, 25% of these caregiving veterans were not accessing this resource. Increasing awareness of the VHA caregiver support program among veterans caring for other veterans would improve caregiver support to both caregiving and care recipient veterans.

Limitations

One limitation of this project was the intentional exclusion of the women’s clinic from the sampling process. For consistency, the authors wanted to limit the intervention to 1 PCC and so they chose the clinic that serves the majority of the veterans who receive primary care at VASLCHCS. Additionally, the literature showed that male caregivers compared with women caregivers^20,21 have different characteristics in regards to caregiver burden, and a well-designed study of women caregivers already has been published.¹⁹

Also, this study did not obtain data on age, health problems, or socioeconomic status of the caregivers to avoid identifying information. Last, the authors did not ask about time spent caregiving or type of care provided. These questions may be important for future studies. Future investigations should evaluate health care use and health of caregivers vs noncaregivers in the veteran population. It also could be important to determine methods for building bridges between the VHA, AAAs, and other community services.

Conclusion

To minimize the disruption that a research study might have caused to normal clinical workflow, the primary author played the role that a medical social worker or other PACT member might play in the future. This project sheds light on how to improve outcomes for community referrals and an important future step in this research would be to develop and test a process that would integrate the PACT into the referral process.

More than one-third of veterans seen in the VASLCHCS PCC are caregivers. To the authors’ knowledge, this is the first estimate of prevalence of caregiving in veterans who receive primary care from the VHA. About 63% of caregiving veterans perceived some burden due to caregiving, and 66% accepted referral to community resources. However, only 12% who were asked to self-refer made contact with the AAA compared with 64% when a provider made the referral for them. Provider referral is more effective in connecting caregiving veterans with resources. Development of interagency partnerships should be fostered to help veterans decrease caregiving burden.

This project is one of the few studies looking at this special group of caregivers: veterans who serve as caregivers. It highlights the need for the VHA to establish policies and partnerships to improve caregiver support to this valuable group of veterans.

Improving health care safety is one of the top priorities of the U.S. health care system. A key element for health care safety is the elimination of sentinel events—unexpected occurrences involving death or serious physical or psychological injury, such as loss of limb or function—or even the risk.¹ Problems in communication, continuity of care, and planning have been identified as the root cause in more than 80% of documented sentinel events.² As a direct result, The Joint Commission (JC) added National Patient Safety Goal 2E, which instructs each organization to implement a standardized approach to patient handoff.¹ According to the JC, the objective of a handoff is to “provide accurate information about a patient’s care, treatment, and services, current condition, and any recent or anticipated changesand must include open communication and opportunities for questions.”^1,3 The JC identified the patient handoff from anesthesia providers to the Surgical Intensive Care Unit (SICU) and Postanesthesia Care Unit (PACU) an opportunity for an improvement.^1,3

At the Memphis VAMC in Tennessee, there was no established protocol for patient handoff from anesthesia providers to the SICU and PACU. The Anesthesia and SICU staffs were frustrated by inconsistent and incomplete postsurgical handoffs. Issues identified by the anesthesia team included difficulty contacting SICU staff to give a report and inconsistent availability of staff on first arrival to SICU. The SICU staff felt communication was rushed and there were inconsistencies in length and quality of the reports, resulting in incomplete postsurgical handoffs.

A baseline survey showed only 75% of staff felt the handoff report was thorough, and 67% “felt like a team.” In response, a multidisciplinary safe patient handoff committee (SPHOC) was formed by representatives from the involved units to discuss issues and offer solutions. The SPHOC efforts were aided by the VA National Center for Patient Safety (NCPS).

This quality improvement project was implemented as part of the U.S. Army Graduate Program in Anesthesia Nursing (USAGPAN) and the Northeastern University doctorate of nursing practice curriculum. The goal was to develop a simple, reliable, easily trainable handoff protocol for implemententation. This goal aligned with the priorites of the Memphis VAMC, USAGPAN, and VA to establish a culture based on patient safety and continuity of care.⁴

Methods

Standardization of handoffs began with JC National Patient Safety Goal 2E. There has been a wealth of medical literature on the need for standardization of handoffs and the implementation of specific handoff protocols in the postoperative setting. The SPHOC completed a review of the literature supporting standardization of handoff protocols. After completion, a second literature search was completed to identify the concepts for the implementation phase of the project. A critical appraisal of the evidence was completed using the method described by Melnyk and Fineout-Overholt.⁵ Literature from January 2005 through March 2015 was obtained via the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Google Scholar. The search methods included the keywords handover, handoff, transfer, and safety combined with anesthesia, PACU, surgery, operating room, and intensive care. Articles about handoffs not originating in the operating room (OR) were excluded.

The 13 articles found in the literature review established an overall need for standardization of handoffs outside the OR. Four articles identified a correlation between adverse events and poor or incomplete handoffs.^3,6-8 Multiple articles discussed the need to develop a standardized handoff protocol in order to increase team work and quality of care.^3,6,7,9,10 Petrovic and colleagues reported a 10% decrease in missed information and a boost in staff satisfaction from 61% to 81% with a standardized handoff.⁹ Additionally, a decrease in handoff time by > 1 minute was noted.⁸ Two articles identified an increase in quality of care after the implementation of a standardized handoff protocol.^8,10

The second phase of the literature review examined relevant handoff information, best practices for participation in the handoff, and established staff buy-in for the process. Segall and colleagues created a table with handoff strategies consistently identified in the literature.¹⁰ The most relevant of these were using a structured written checklist to guide communication, using protocols to standardize the process, and providing formal team training.¹⁰

Six articles identified a written checklist and standardized handoff process as successful strategies used to improve patient safety.^11-16 Zavalkoff and colleagues discussed the use of a template sheet filled out by the anesthesia provider prior to the handoff for consistency and accuracy of report.¹⁶ Catchpole and colleagues drew correlations between a Formula 1 pit stop and anesthesia handoffs and discussed the teamwork portion of the handoff protocol relating to staff buy-in.¹⁴ After delegating roles and making a set protocol for the handoff process, the study group was able to meet their objectives of efficient and safe handoff.¹⁴

With the information provided from the literature review, the SPHOC established a standardized handoff for the postsurgical patient. The committee created a handoff sheet for the anesthesia provider to use for report. This also included standardizing the handoff process and delineating specific roles for each provider.

After completing a NCPS training workshop, goals were identified at a SPHOC meeting. The SPHOC discussed current barriers to safe patient transfer and suggestions to overcome the barriers. Initial interventions planned by SPHOC focused on the problems of unsafe handoffs and delays in transfer. First, SICU identified the best phone number to call, which was distributed to the anesthesia and OR staffs. Additionally, the committee began tracking the number of attempted calls to reach SICU and availability of the nurse to take the report.

Implementation

A standardized handoff form was created by SPHOC, and anesthesia providers began to call time-out after the patient was deemed stable. After time-out was called, the SICU nurse provided his or her undivided attention and received the report. When SPHOC deemed the process successful, it was implemented in PACU as well. The entire OR, PACU, and anesthesia staffs were updated regarding the progress of the SPHOC on a monthly basis.

The implementation phase involved SPHOC tracking compliance of handoff sheets and time-outs. Compliance was tracked by counting the number of handoff sheets collected at the end of the day vs the total number of cases on the OR schedule. Tracking compliance with SICU transfers was monitored by the SICU members of the SPHOC through a tracking form. Initially a high level of SICU weekly compliance (93%) was noted.

Building on this success, SPHOC extended use of the handoff sheets and time-out to the PACU. Student registered nurse anesthetists (SRNAs) were tasked with education of the anesthesia and PACU staffs. Education continued via individual teaching, presentation at staff meetings, and e-mail reminders. To prevent confusion, no additional changes were made to the handoff sheet for an extended trial.

Despite these interventions, PACU compliance began to lag, averaging 33% over 3 weeks. Encouraging staff buy-in and a change in culture were identified as strategies to improve compliance. The third month of the trial started with 71% compliance. Interventions regarding staff buy-in emphasized individual accountability. Names were attached to handoff sheets, and those found with < 80% of sheets completed were provided with additional education. Those participants with ≥ 80% compliance were praised for their efforts.

Fostering a culture change proved to be more challenging. Interviews and discussions with anesthesia staff identified forgetting to fill out the sheet as the most common reason for noncompliance. Laminated copies of the handoff sheet were affixed to all anesthesia machines as a visual reminder. A sign denoting where to place the completed handoff sheets was placed in the PACU as a visual cue. The SPHOC stocked each anesthesia machine with handoff sheets on a daily basis.

To strengthen the culture of change, the PACU and SICU RNs were encouraged to ask for a time-out from the anesthesia provider. Handoff sheets were printed on yellow card stock to encourage anesthesia staff to “slow down for patient safety.” With these interventions, compliance increased to 98% by the end of the month.

Survey

An anonymous and voluntary survey was created and distributed to all staff involved in the handoff process. The 5-question survey was based on a 5-point Likert scale from 1 for strongly disagree to 5 for strongly disagree. The survey included the following questions: The new surgery report is very thorough; I feel more comfortable when assuming care of the postoperative patient; staff is more attentive when listening to the surgery report when a time-out is called; I feel the new surgery report is more effective and efficient; I feel I am more of a team with the OR with our changes in handoff of care process.

The survey was used as a baseline and to evaluate further changes in the process. Medical literature has shown that improper handoff communication was the leading cause of adverse events in the postsurgical patient.^3,6

Results

Surgery to SICU transfers using the Handoff card increased from 33% in the first month to an average of 98% after interventions. In the 10-month intervention period, time-outs in SICU increased from 29% to 99%. The SICU staff present at patient arrival increased from 83% to 97%. Anesthesia handoff report for PACU patient transfers increased from 79% to 99%. The time-outs in PACU increased from 39% to 99% after interventions.

After compliance initially increased, SPHOC focused on the more complex aspects of the handoff process—staff satisfaction, which was chosen based on an area of weakness identified in the initial survey results. Overall, staff was satisfied with the handoff sheets; however, only 67% of SICU staff reported that they felt part of the team with the OR as a result of the handoff of care process.

To address this issue, the team delineated roles for providers when a new surgical patient arrived in the SICU. This was dubbed the ABCs of safe handoff with roles for the anesthesia provider or respiratory therapist, the circulating nurse and SICU nurse, and the anesthesia provider. A graphic representation explains the mnemonic, the roles created, and laminated copies were distributed throughout the OR and SICU (Figure). Subsequent surveys showed 80% of staff felt more like a team with the new process.

Conclusion

The overall impact of the project has been to further promote a culture of patient safety at the Memphis VAMC and establish continuity of care as an institutional priority. The existing handoff sheet, time-out, and cross-check have been adapted to all hospital-wide transfers. With the SPHOC guidance and expertise, PACU began using a handoff sheet and time-out when transferring patients to the medical/surgical floors. The handoff sheet has also been adapted to fit the needs of transfers from the emergency department to the medical/surgical floors.

The framework of a standardized handoff is adaptable for other units to customize and has been adopted hospital-wide. The project is sustainable as it requires almost no money to create and sustain. The primary weakness of the process is the requirement of sustained staff participation and buy-in. Each unit and hospital invariably comes with a different culture and priorities; therefore, the process developed at Memphis VAMC may not meet the needs of other facilities. ˜

Acknowledgments
Special thanks to Susan Baldwin, RN; Bianca Mathews, MSN, RN; Wendy Regel, RN; Armance White, CRNA; Reginald Witt, MD; Odie Powell, RN; Alma Farris, RN; Clarisa Reed, RN; Susan Baily, RN; Linda Sueing, RN; Teresa Nguyen, RN; and John Craig, DNP, CRNA.

Improving health care safety is one of the top priorities of the U.S. health care system. A key element for health care safety is the elimination of sentinel events—unexpected occurrences involving death or serious physical or psychological injury, such as loss of limb or function—or even the risk.¹ Problems in communication, continuity of care, and planning have been identified as the root cause in more than 80% of documented sentinel events.² As a direct result, The Joint Commission (JC) added National Patient Safety Goal 2E, which instructs each organization to implement a standardized approach to patient handoff.¹ According to the JC, the objective of a handoff is to “provide accurate information about a patient’s care, treatment, and services, current condition, and any recent or anticipated changesand must include open communication and opportunities for questions.”^1,3 The JC identified the patient handoff from anesthesia providers to the Surgical Intensive Care Unit (SICU) and Postanesthesia Care Unit (PACU) an opportunity for an improvement.^1,3

At the Memphis VAMC in Tennessee, there was no established protocol for patient handoff from anesthesia providers to the SICU and PACU. The Anesthesia and SICU staffs were frustrated by inconsistent and incomplete postsurgical handoffs. Issues identified by the anesthesia team included difficulty contacting SICU staff to give a report and inconsistent availability of staff on first arrival to SICU. The SICU staff felt communication was rushed and there were inconsistencies in length and quality of the reports, resulting in incomplete postsurgical handoffs.

A baseline survey showed only 75% of staff felt the handoff report was thorough, and 67% “felt like a team.” In response, a multidisciplinary safe patient handoff committee (SPHOC) was formed by representatives from the involved units to discuss issues and offer solutions. The SPHOC efforts were aided by the VA National Center for Patient Safety (NCPS).

This quality improvement project was implemented as part of the U.S. Army Graduate Program in Anesthesia Nursing (USAGPAN) and the Northeastern University doctorate of nursing practice curriculum. The goal was to develop a simple, reliable, easily trainable handoff protocol for implemententation. This goal aligned with the priorites of the Memphis VAMC, USAGPAN, and VA to establish a culture based on patient safety and continuity of care.⁴

Methods

Standardization of handoffs began with JC National Patient Safety Goal 2E. There has been a wealth of medical literature on the need for standardization of handoffs and the implementation of specific handoff protocols in the postoperative setting. The SPHOC completed a review of the literature supporting standardization of handoff protocols. After completion, a second literature search was completed to identify the concepts for the implementation phase of the project. A critical appraisal of the evidence was completed using the method described by Melnyk and Fineout-Overholt.⁵ Literature from January 2005 through March 2015 was obtained via the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Google Scholar. The search methods included the keywords handover, handoff, transfer, and safety combined with anesthesia, PACU, surgery, operating room, and intensive care. Articles about handoffs not originating in the operating room (OR) were excluded.

The 13 articles found in the literature review established an overall need for standardization of handoffs outside the OR. Four articles identified a correlation between adverse events and poor or incomplete handoffs.^3,6-8 Multiple articles discussed the need to develop a standardized handoff protocol in order to increase team work and quality of care.^3,6,7,9,10 Petrovic and colleagues reported a 10% decrease in missed information and a boost in staff satisfaction from 61% to 81% with a standardized handoff.⁹ Additionally, a decrease in handoff time by > 1 minute was noted.⁸ Two articles identified an increase in quality of care after the implementation of a standardized handoff protocol.^8,10

The second phase of the literature review examined relevant handoff information, best practices for participation in the handoff, and established staff buy-in for the process. Segall and colleagues created a table with handoff strategies consistently identified in the literature.¹⁰ The most relevant of these were using a structured written checklist to guide communication, using protocols to standardize the process, and providing formal team training.¹⁰

Six articles identified a written checklist and standardized handoff process as successful strategies used to improve patient safety.^11-16 Zavalkoff and colleagues discussed the use of a template sheet filled out by the anesthesia provider prior to the handoff for consistency and accuracy of report.¹⁶ Catchpole and colleagues drew correlations between a Formula 1 pit stop and anesthesia handoffs and discussed the teamwork portion of the handoff protocol relating to staff buy-in.¹⁴ After delegating roles and making a set protocol for the handoff process, the study group was able to meet their objectives of efficient and safe handoff.¹⁴

With the information provided from the literature review, the SPHOC established a standardized handoff for the postsurgical patient. The committee created a handoff sheet for the anesthesia provider to use for report. This also included standardizing the handoff process and delineating specific roles for each provider.

After completing a NCPS training workshop, goals were identified at a SPHOC meeting. The SPHOC discussed current barriers to safe patient transfer and suggestions to overcome the barriers. Initial interventions planned by SPHOC focused on the problems of unsafe handoffs and delays in transfer. First, SICU identified the best phone number to call, which was distributed to the anesthesia and OR staffs. Additionally, the committee began tracking the number of attempted calls to reach SICU and availability of the nurse to take the report.

Implementation

A standardized handoff form was created by SPHOC, and anesthesia providers began to call time-out after the patient was deemed stable. After time-out was called, the SICU nurse provided his or her undivided attention and received the report. When SPHOC deemed the process successful, it was implemented in PACU as well. The entire OR, PACU, and anesthesia staffs were updated regarding the progress of the SPHOC on a monthly basis.

The implementation phase involved SPHOC tracking compliance of handoff sheets and time-outs. Compliance was tracked by counting the number of handoff sheets collected at the end of the day vs the total number of cases on the OR schedule. Tracking compliance with SICU transfers was monitored by the SICU members of the SPHOC through a tracking form. Initially a high level of SICU weekly compliance (93%) was noted.

Building on this success, SPHOC extended use of the handoff sheets and time-out to the PACU. Student registered nurse anesthetists (SRNAs) were tasked with education of the anesthesia and PACU staffs. Education continued via individual teaching, presentation at staff meetings, and e-mail reminders. To prevent confusion, no additional changes were made to the handoff sheet for an extended trial.

Despite these interventions, PACU compliance began to lag, averaging 33% over 3 weeks. Encouraging staff buy-in and a change in culture were identified as strategies to improve compliance. The third month of the trial started with 71% compliance. Interventions regarding staff buy-in emphasized individual accountability. Names were attached to handoff sheets, and those found with < 80% of sheets completed were provided with additional education. Those participants with ≥ 80% compliance were praised for their efforts.

Fostering a culture change proved to be more challenging. Interviews and discussions with anesthesia staff identified forgetting to fill out the sheet as the most common reason for noncompliance. Laminated copies of the handoff sheet were affixed to all anesthesia machines as a visual reminder. A sign denoting where to place the completed handoff sheets was placed in the PACU as a visual cue. The SPHOC stocked each anesthesia machine with handoff sheets on a daily basis.

To strengthen the culture of change, the PACU and SICU RNs were encouraged to ask for a time-out from the anesthesia provider. Handoff sheets were printed on yellow card stock to encourage anesthesia staff to “slow down for patient safety.” With these interventions, compliance increased to 98% by the end of the month.

Survey

An anonymous and voluntary survey was created and distributed to all staff involved in the handoff process. The 5-question survey was based on a 5-point Likert scale from 1 for strongly disagree to 5 for strongly disagree. The survey included the following questions: The new surgery report is very thorough; I feel more comfortable when assuming care of the postoperative patient; staff is more attentive when listening to the surgery report when a time-out is called; I feel the new surgery report is more effective and efficient; I feel I am more of a team with the OR with our changes in handoff of care process.

The survey was used as a baseline and to evaluate further changes in the process. Medical literature has shown that improper handoff communication was the leading cause of adverse events in the postsurgical patient.^3,6

Results

Surgery to SICU transfers using the Handoff card increased from 33% in the first month to an average of 98% after interventions. In the 10-month intervention period, time-outs in SICU increased from 29% to 99%. The SICU staff present at patient arrival increased from 83% to 97%. Anesthesia handoff report for PACU patient transfers increased from 79% to 99%. The time-outs in PACU increased from 39% to 99% after interventions.

After compliance initially increased, SPHOC focused on the more complex aspects of the handoff process—staff satisfaction, which was chosen based on an area of weakness identified in the initial survey results. Overall, staff was satisfied with the handoff sheets; however, only 67% of SICU staff reported that they felt part of the team with the OR as a result of the handoff of care process.

To address this issue, the team delineated roles for providers when a new surgical patient arrived in the SICU. This was dubbed the ABCs of safe handoff with roles for the anesthesia provider or respiratory therapist, the circulating nurse and SICU nurse, and the anesthesia provider. A graphic representation explains the mnemonic, the roles created, and laminated copies were distributed throughout the OR and SICU (Figure). Subsequent surveys showed 80% of staff felt more like a team with the new process.

Conclusion

The overall impact of the project has been to further promote a culture of patient safety at the Memphis VAMC and establish continuity of care as an institutional priority. The existing handoff sheet, time-out, and cross-check have been adapted to all hospital-wide transfers. With the SPHOC guidance and expertise, PACU began using a handoff sheet and time-out when transferring patients to the medical/surgical floors. The handoff sheet has also been adapted to fit the needs of transfers from the emergency department to the medical/surgical floors.

The framework of a standardized handoff is adaptable for other units to customize and has been adopted hospital-wide. The project is sustainable as it requires almost no money to create and sustain. The primary weakness of the process is the requirement of sustained staff participation and buy-in. Each unit and hospital invariably comes with a different culture and priorities; therefore, the process developed at Memphis VAMC may not meet the needs of other facilities. ˜

Acknowledgments
Special thanks to Susan Baldwin, RN; Bianca Mathews, MSN, RN; Wendy Regel, RN; Armance White, CRNA; Reginald Witt, MD; Odie Powell, RN; Alma Farris, RN; Clarisa Reed, RN; Susan Baily, RN; Linda Sueing, RN; Teresa Nguyen, RN; and John Craig, DNP, CRNA.

Improving health care safety is one of the top priorities of the U.S. health care system. A key element for health care safety is the elimination of sentinel events—unexpected occurrences involving death or serious physical or psychological injury, such as loss of limb or function—or even the risk.¹ Problems in communication, continuity of care, and planning have been identified as the root cause in more than 80% of documented sentinel events.² As a direct result, The Joint Commission (JC) added National Patient Safety Goal 2E, which instructs each organization to implement a standardized approach to patient handoff.¹ According to the JC, the objective of a handoff is to “provide accurate information about a patient’s care, treatment, and services, current condition, and any recent or anticipated changesand must include open communication and opportunities for questions.”^1,3 The JC identified the patient handoff from anesthesia providers to the Surgical Intensive Care Unit (SICU) and Postanesthesia Care Unit (PACU) an opportunity for an improvement.^1,3

At the Memphis VAMC in Tennessee, there was no established protocol for patient handoff from anesthesia providers to the SICU and PACU. The Anesthesia and SICU staffs were frustrated by inconsistent and incomplete postsurgical handoffs. Issues identified by the anesthesia team included difficulty contacting SICU staff to give a report and inconsistent availability of staff on first arrival to SICU. The SICU staff felt communication was rushed and there were inconsistencies in length and quality of the reports, resulting in incomplete postsurgical handoffs.

A baseline survey showed only 75% of staff felt the handoff report was thorough, and 67% “felt like a team.” In response, a multidisciplinary safe patient handoff committee (SPHOC) was formed by representatives from the involved units to discuss issues and offer solutions. The SPHOC efforts were aided by the VA National Center for Patient Safety (NCPS).

This quality improvement project was implemented as part of the U.S. Army Graduate Program in Anesthesia Nursing (USAGPAN) and the Northeastern University doctorate of nursing practice curriculum. The goal was to develop a simple, reliable, easily trainable handoff protocol for implemententation. This goal aligned with the priorites of the Memphis VAMC, USAGPAN, and VA to establish a culture based on patient safety and continuity of care.⁴

Methods

Standardization of handoffs began with JC National Patient Safety Goal 2E. There has been a wealth of medical literature on the need for standardization of handoffs and the implementation of specific handoff protocols in the postoperative setting. The SPHOC completed a review of the literature supporting standardization of handoff protocols. After completion, a second literature search was completed to identify the concepts for the implementation phase of the project. A critical appraisal of the evidence was completed using the method described by Melnyk and Fineout-Overholt.⁵ Literature from January 2005 through March 2015 was obtained via the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Google Scholar. The search methods included the keywords handover, handoff, transfer, and safety combined with anesthesia, PACU, surgery, operating room, and intensive care. Articles about handoffs not originating in the operating room (OR) were excluded.

The 13 articles found in the literature review established an overall need for standardization of handoffs outside the OR. Four articles identified a correlation between adverse events and poor or incomplete handoffs.^3,6-8 Multiple articles discussed the need to develop a standardized handoff protocol in order to increase team work and quality of care.^3,6,7,9,10 Petrovic and colleagues reported a 10% decrease in missed information and a boost in staff satisfaction from 61% to 81% with a standardized handoff.⁹ Additionally, a decrease in handoff time by > 1 minute was noted.⁸ Two articles identified an increase in quality of care after the implementation of a standardized handoff protocol.^8,10

The second phase of the literature review examined relevant handoff information, best practices for participation in the handoff, and established staff buy-in for the process. Segall and colleagues created a table with handoff strategies consistently identified in the literature.¹⁰ The most relevant of these were using a structured written checklist to guide communication, using protocols to standardize the process, and providing formal team training.¹⁰

Six articles identified a written checklist and standardized handoff process as successful strategies used to improve patient safety.^11-16 Zavalkoff and colleagues discussed the use of a template sheet filled out by the anesthesia provider prior to the handoff for consistency and accuracy of report.¹⁶ Catchpole and colleagues drew correlations between a Formula 1 pit stop and anesthesia handoffs and discussed the teamwork portion of the handoff protocol relating to staff buy-in.¹⁴ After delegating roles and making a set protocol for the handoff process, the study group was able to meet their objectives of efficient and safe handoff.¹⁴

With the information provided from the literature review, the SPHOC established a standardized handoff for the postsurgical patient. The committee created a handoff sheet for the anesthesia provider to use for report. This also included standardizing the handoff process and delineating specific roles for each provider.

After completing a NCPS training workshop, goals were identified at a SPHOC meeting. The SPHOC discussed current barriers to safe patient transfer and suggestions to overcome the barriers. Initial interventions planned by SPHOC focused on the problems of unsafe handoffs and delays in transfer. First, SICU identified the best phone number to call, which was distributed to the anesthesia and OR staffs. Additionally, the committee began tracking the number of attempted calls to reach SICU and availability of the nurse to take the report.

Implementation

A standardized handoff form was created by SPHOC, and anesthesia providers began to call time-out after the patient was deemed stable. After time-out was called, the SICU nurse provided his or her undivided attention and received the report. When SPHOC deemed the process successful, it was implemented in PACU as well. The entire OR, PACU, and anesthesia staffs were updated regarding the progress of the SPHOC on a monthly basis.

The implementation phase involved SPHOC tracking compliance of handoff sheets and time-outs. Compliance was tracked by counting the number of handoff sheets collected at the end of the day vs the total number of cases on the OR schedule. Tracking compliance with SICU transfers was monitored by the SICU members of the SPHOC through a tracking form. Initially a high level of SICU weekly compliance (93%) was noted.

Building on this success, SPHOC extended use of the handoff sheets and time-out to the PACU. Student registered nurse anesthetists (SRNAs) were tasked with education of the anesthesia and PACU staffs. Education continued via individual teaching, presentation at staff meetings, and e-mail reminders. To prevent confusion, no additional changes were made to the handoff sheet for an extended trial.

Despite these interventions, PACU compliance began to lag, averaging 33% over 3 weeks. Encouraging staff buy-in and a change in culture were identified as strategies to improve compliance. The third month of the trial started with 71% compliance. Interventions regarding staff buy-in emphasized individual accountability. Names were attached to handoff sheets, and those found with < 80% of sheets completed were provided with additional education. Those participants with ≥ 80% compliance were praised for their efforts.

Fostering a culture change proved to be more challenging. Interviews and discussions with anesthesia staff identified forgetting to fill out the sheet as the most common reason for noncompliance. Laminated copies of the handoff sheet were affixed to all anesthesia machines as a visual reminder. A sign denoting where to place the completed handoff sheets was placed in the PACU as a visual cue. The SPHOC stocked each anesthesia machine with handoff sheets on a daily basis.

To strengthen the culture of change, the PACU and SICU RNs were encouraged to ask for a time-out from the anesthesia provider. Handoff sheets were printed on yellow card stock to encourage anesthesia staff to “slow down for patient safety.” With these interventions, compliance increased to 98% by the end of the month.

Survey

An anonymous and voluntary survey was created and distributed to all staff involved in the handoff process. The 5-question survey was based on a 5-point Likert scale from 1 for strongly disagree to 5 for strongly disagree. The survey included the following questions: The new surgery report is very thorough; I feel more comfortable when assuming care of the postoperative patient; staff is more attentive when listening to the surgery report when a time-out is called; I feel the new surgery report is more effective and efficient; I feel I am more of a team with the OR with our changes in handoff of care process.

The survey was used as a baseline and to evaluate further changes in the process. Medical literature has shown that improper handoff communication was the leading cause of adverse events in the postsurgical patient.^3,6

Results

Surgery to SICU transfers using the Handoff card increased from 33% in the first month to an average of 98% after interventions. In the 10-month intervention period, time-outs in SICU increased from 29% to 99%. The SICU staff present at patient arrival increased from 83% to 97%. Anesthesia handoff report for PACU patient transfers increased from 79% to 99%. The time-outs in PACU increased from 39% to 99% after interventions.

After compliance initially increased, SPHOC focused on the more complex aspects of the handoff process—staff satisfaction, which was chosen based on an area of weakness identified in the initial survey results. Overall, staff was satisfied with the handoff sheets; however, only 67% of SICU staff reported that they felt part of the team with the OR as a result of the handoff of care process.

To address this issue, the team delineated roles for providers when a new surgical patient arrived in the SICU. This was dubbed the ABCs of safe handoff with roles for the anesthesia provider or respiratory therapist, the circulating nurse and SICU nurse, and the anesthesia provider. A graphic representation explains the mnemonic, the roles created, and laminated copies were distributed throughout the OR and SICU (Figure). Subsequent surveys showed 80% of staff felt more like a team with the new process.

Conclusion

The overall impact of the project has been to further promote a culture of patient safety at the Memphis VAMC and establish continuity of care as an institutional priority. The existing handoff sheet, time-out, and cross-check have been adapted to all hospital-wide transfers. With the SPHOC guidance and expertise, PACU began using a handoff sheet and time-out when transferring patients to the medical/surgical floors. The handoff sheet has also been adapted to fit the needs of transfers from the emergency department to the medical/surgical floors.

The framework of a standardized handoff is adaptable for other units to customize and has been adopted hospital-wide. The project is sustainable as it requires almost no money to create and sustain. The primary weakness of the process is the requirement of sustained staff participation and buy-in. Each unit and hospital invariably comes with a different culture and priorities; therefore, the process developed at Memphis VAMC may not meet the needs of other facilities. ˜

Acknowledgments
Special thanks to Susan Baldwin, RN; Bianca Mathews, MSN, RN; Wendy Regel, RN; Armance White, CRNA; Reginald Witt, MD; Odie Powell, RN; Alma Farris, RN; Clarisa Reed, RN; Susan Baily, RN; Linda Sueing, RN; Teresa Nguyen, RN; and John Craig, DNP, CRNA.

Dementia is a common, multifaceted problem with significant implications for function and quality of life among older individuals. Current demographic shifts are magnifying this problem. Particularly troubling are neuropsychiatric symptoms, which, in addition to creating caregiver distress, also are linked to functional decline, institutionalization, higher health care costs, and mortality (even after controlling for other potential confounders and severity of cognitive impairment). Furthermore, dementia is often unrecognized and underdiagnosed, and patients with dementia historically have poor access to care, particularly those living in rural areas.

The Geriatrics/Dementia Clinic at the Baltimore Veterans Affairs Medical Center (BVAMC) is a referral resource that provides extensive, multidisciplinary evaluations as well as coordinated subspecialist and interprofessional case review. A diverse group of clinicians (representing geriatrics, geriatric psychiatry, neuropsychology, clinical pharmacy, nursing, and social work) perform a half-day evaluation, followed by a meeting of the interdisciplinary team, and feedback session where patients and their families are given the results of the testing and diagnostic impressions as well as plans for further evaluation and treatment. Finally, in addition to the benefits it provides to veterans and their families, this clinic has proven to be an important resource for professional trainees.

Yet this model can be difficult to access, and those living in more remote regions had challenges availing themselves of this resource. Often, they would have to wake before dawn to drive 2 to 4 hours to the medical center. Furthermore, despite the many obvious benefits of this comprehensive approach, veterans and their families often left the clinic with a staggering amount of information and numerous recommendations for future care but without the assurance of integrated follow-up (a burden borne particularly by those living remotely).

The DEMO Program

In response to the dual challenges of access to and coordination of care, existing resources were leveraged with about $250,000 of VA T21 funds (adding both a full-time geriatric nurse practitioner and a psychology technician to the multidisciplinary team) to design and implement the novel DEMO (Dementia Evaluation, Management and Outreach) program. This program aimed to (1) extend dementia evaluations to regional community-based outpatient clinics (CBOCs) that serve veterans in outlying regions; and (2) improve the management and the follow-up that these veterans receive, with a focus on containing costs, while improving both the quality of and veterans’ (and their families’) satisfaction with health care.

Methods

Dementia evaluations were conducted by a geriatric nurse practitioner and psychology technician teamlet at the CBOCs. In addition to neuropsychological testing, medical records were reviewed, caregivers were interviewed, and the patients were examined. The data were then brought back to the full BVAMC Geriatrics/Dementia Clinic multidisciplinary team for discussion. The team reached a consensus diagnosis and then made a comprehensive plan for the further evaluation and management of these complex patients. The plan was entered into the Computerized Patient Record System and communicated to the patient and caregiver during a follow-up CBOC visit.

The teamlet frequently provided informal education during CBOC visits in addition to formal lectures given by experts from the BVAMC and the University of Maryland. The DEMO program was introduced to providers at the CBOCs by e-mail with follow-up information sessions provided on site.

Rather than having patients simply return to their CBOC primary care providers (PCPs) and exposing patients to the risks of poor communication/coordination of care, services were expanded to include regular phone follow-up calls with case management services that augmented those of their PCPs. The goal was to improve outcomes for these patients and provide alternatives to institutionalization.

Standardized instruments were used to gauge patient and caregiver satisfaction, obtain cost data from the VA and the Centers for Medicare & Medicaid Services, and medication data from the Pharmacy Benefits files.

The institutional review board provided approval to collect data on participants to assess the program’s clinical and economic impacts. Since all patients were suspected to have dementia, the informed consent procedures included additional protections. The patient’s understanding of the pertinent information related to participation in the study was assessed to help ensure that participants with dementia truly understood the conditions to which they were consenting. If the potential participant could not provide informed consent, it was obtained from a surrogate with durable power of attorney (the person recognized by Maryland law as the substitute decision maker or the veteran’s legal guardian). Consent was assessed on an ongoing basis regardless of the patient’s capacity to give informed consent, and those willing to have their data collected were enrolled in a “research” arm. These participants were compared with veterans in the dementia clinic during the enrollment period but who did not consent to participate in the research arm, controlling for sociodemographic characteristics and prior health care utilization.

Data Analysis

Patterns of health care utilization may fluctuate with time, and enrollment may identify potential problems that otherwise would not have been found. The authors looked at health care use over 6-month and 1-year intervals before and after enrollment, examining Occupational Physical Assessment Test (OPAT) data and fee-based outpatient data for both inpatient events (including nursing home utilization and hospitalization events) and outpatient visits (including primary, specialty and mental health care services; home care visits, and emergency department [ED]). The total cost incurred by outpatient visits and inpatient care was then adjusted to 2011 dollars. The relationship between program enrollment and health care use and costs was examined with a multivariate regression analyses, controlling for age and health care use in the prior year among veterans who were in the “consent” group or “nonconsent” group.

Outcome variables included the number of primary care, ED, specialty care, home health care, mental health care clinic, and inpatient visits; total inpatient bed days; and the total costs of all the events. The authors fit different multivariate models for these events according to their distributions. Specifically, the Poisson model was used if the distribution of the outcome variable was not overdispersed (eg, ED, primary care).

A negative binomial was used if the distribution of these events was overdispersed (eg, specialty care visits). Further, because the occurrence of inpatient events is relatively rare, a logit model was used to examine the relationship between enrollment status and probability of any inpatient events, regardless of the number of events. Generalized estimating equation (GEE) model with gamma distribution and log link function was used to examine the relationship between cost and program enrollment. The authors also examined the program’s effect on medication use, focusing on high-risk medications in older adults, comparing both the number of unique medications, as well as frequency such medications prescribed 1 year before and after the enrollment.¹

Results

Two hundred ninety-eight (298) veterans were referred to DEMO from a 150-mile radius of Baltimore. Of these veterans, 132 consented to participate in this study. The study participants largely were representative of the total group as well as both the overall veteran population and the more general population of community-dwelling individuals with dementia (Table).

Veterans in the DEMO program largely had mild-to-moderate cognitive impairment with mean Mini-Mental State Examination (MMSE) score of 22 and significant functional limitations (Table). Only 3% displayed a pattern of “pure” dementia typical of Alzheimer disease, and 11% of those referred did not have significant abnormalities on neurocognitive testing.

The team averaged 10.3 recommendations (range 3-22), which focused on a diverse set of issues related to additional diagnostic and therapeutic concerns. Although screening data, including basic laboratory results and imaging, was requested in the referral form, in 71% of cases further diagnostic investigations were suggested. With regard to therapeutic suggestions, not surprisingly, medicines were cited as targets in a majority of cases (eg, discontinuing high-risk medications, initiating/titrating medications to minimize cardiovascular risk). While remaining mindful of the time to benefit and competing morbidities, measures to modify cardiovascular risk factors were suggested in more than half and treatment of depression in 15% of cases. Similarly, addressing poor sensory input was suggested in 38% of cases, with other common recommendations focusing on multiple environmental and social interventions (> 50%) as well as supports/outlets/respite for the caregivers.

The full multidisciplinary DEMO group met only weekly to review cases, and due to travel and scheduling difficulties, feedback to the patients and their families often was delayed for weeks. Although initial plans included regularly scheduled follow-up phone calls, demand quickly outstripped program resources. Nonetheless, chart reviews and abstracted adherence and utilization data revealed that PCPs successfully implemented 52% of recommendations within 2 weeks, rising to > 60% by 3 months. When patients were reevaluated at 1 year, they were remarkably stable: Mini–Mental State Examination (baseline 22.2 ± 5.0 → 22.3 ± 5.7 at follow-up) and Instrumental Activities of Daily Living scores (15.5 ± 10.6 → 17.7 ± 11.4).

Feedback

This program was enthusiastically received by both patients and their caregivers—100% and 98%, respectively—reporting overall satisfaction with the services received and 93% of caregivers indicating satisfaction with how the program met their needs. Caregivers were happy with the amount of time the provider took to answer questions (100% satisfied with the amount of time the DEMO provider spent and that they explained “what they wanted to know,” with 98% responding “good” or “great” for both), as well as with services and amount of help received (83% and 77% “very satisfied,” respectively).

In the survey, 98% of caregivers and patients felt that the program helped them deal more effectively with their problems, 97% would recommend the program to a friend in need of similar help, and 100% would come back if they were to seek help again. In keeping with DEMO’s initial aim of increasing access, there was favorable feedback on the ability to get in and be seen and convenience of location. In addition, referring providers universally expressed satisfaction with the referral process (referrals increased linearly); timeliness of scheduling; usefulness of the recommendations; and they planned on continuing to refer patients.

Although there was great variability, controlling for age and prior utilization, veterans in DEMO had statistically significant (all P < .05) fewer ED and specialty care visits and more mental health care clinic visits 183 to 365 daysafter referral dates compared with those in the nonconsented group. Veterans in the consented group also were less likely to use inpatient care than were veterans in the nonconsented group 183 to 365 days after referral dates. These trends were similarly reflected after controlling for age and prior utilization as well as when examining health care costs (data not shown). Nonetheless, DEMO did not seem to have any effect on overall inpatient bed days, primary/home-based care visits, or total costs. In fact, utilization of mental health care resources increased (Figures 1, 2, and 3).

Discussion

Cognitive issues in patients within the general population are common, and the patients cared for by the VA are no exception. Dementia is more common in rural compared with urban areas, and those living in more remote locations have reduced access to specialized evaluation, management, and support services.² The authors describe a novel program that dramatically increased patient access, bringing the normally tertiary referral services to geographically remote CBOCs at a minimal investment. These services were well received by patients, caregivers, and PCPs. As anticipated, patients and their caregivers especially appreciated the ease and convenience of access. Considering the already significant burden(s) borne every day by those caring for patients with dementia, the benefit of this approach is evident.

Clinicians often feel uncomfortable in evaluating and managing patients with cognitive deficits. Nonetheless, the role of specialized clinics in diagnosing dementia has been demonstrated previously, and the present results are in agreement with previous studies.³ The novelty here is the provision of specialized care usually found only in large, academic medical centers to local CBOCs. By bringing specialized services to geographically isolated patients, the DEMO program was able to increase both access and utilization. Furthermore, providing coordination and ongoing, focused follow-up provided increases in satisfaction and efficiency.

An additional benefit of this approach is the opportunity for PCP education. The authors even found anecdotal reductions in ED usage as well as acute hospitalization and long-term placement—although it was not a statistical significant difference. The relatively high use of mental health care services in this population is in line with previous reports in similar populations, and greater utilization of mental health care services may be one explanation why overall costs did not differ between the 2 groups.⁴ Nonetheless, this intimates that such a program may yield savings over a longer term, as has been demonstrated in patients with a variety of other psychiatric diagnoses cared for in the community rather than in institutions.^5,6

The prevalence of dementia and its associated costs are nearly $50,000 per year per person—suggesting a total cost in the hundreds of billions of dollars.⁷ Similarly, the importance of caregiver support (including psychosocial interventions, such as the one piloted here) has been demonstrated in a variety of settings (even without improvement in caregiver burden itself).⁸

There were a number of challenges in the rollout and delivery of DEMO. Although CBOC PCPs were initially somewhat uncertain of the benefit of this approach and concerned about the space requirements, referrals rapidly and dramatically increased, and the DEMO teamlet became enmeshed with CBOC staff. Similarly, potential participants and their caregivers sometimes were leery to involve others in their care. Both the CBOC PCPs and caregivers came to depend more on DEMO staff, and the DEMO staff members frequently were the first ones to be called (at times for issues unrelated to dementia).

Unfortunately, DEMO was underresourced to provide either real-time feedback true or first responder services. Misunderstandings concerning this were an early challenge to PCP acceptance. However, the longitudinal presence and close working relationships of the DEMO teamlet in each CBOC allowed their use as an adjunct to primary care, and increased the efficacy of both.

Limitations

A number of additional caveats must be made. First, this study had a relatively small number of participants, and there was great variability in health care utilization. This is particularly germane in this population of patients with dementia, which typically has an asymmetrically high use of health care resources. Additionally, the relatively limited follow-up period may have blunted the programs true effect(s). Further, although veterans in the nonconsented group were not officially enrolled in the program, there was likely spillover of the effects of the program on practice patterns, leading to an underestimation of the program’s impact.

Conclusion

With minimal resources, DEMO successfully brought expert evaluation (usually tertiary referral) services, and provided specialized case management in coordination with existing primary care to remote patients. Although there were a number of features rather unique to this setting (eg, infrastructural support; close working interdisciplinary and interprofessional relationships, buy-in at all levels, relative geographic density/demographic homogeneity of participants), specialized case management is increasingly being adopted throughout the VA (and elsewhere). Although the value of collaborative, interdisciplinary interventions has been shown in a variety of settings and conditions—nursing homes,⁹ chronic low back pain,¹⁰ safety among hospital inpatients¹¹—its utility for dementia care is relatively underexplored.

Yet the effectiveness of team-based care for individuals has been demonstrated in a number of settings, including Alzheimer disease.^12,13 In addition to involving a number of disciplines, collaborative care is marked by coordination. A number of recent systematic reviews have found that behavioral and multicomponent interventions directed towards the caregiver as well as case management were beneficial in improving some outcomes, although there is considerable heterogeneity in the effects.^14,15 Future work will focus on examining methods to focus/optimize interventions based on individual patient characteristics.

Given the epidemiologic trends, care for patients with dementia is expected to grow. Novel interventions, like DEMO, are a particularly promising option to meet this challenge. In fact, just such a collaborative practice-ready workforce has been identified by the World Health Organization as crucial to meeting the challenges of the health needs in the 21st century.¹⁶ With the feasibility of such an approach in this population now evident, further studies (including larger sample sizes, across greater geographic regions, as well as among more diverse populations) should be undertaken. These results, if replicated, suggest a novel approach to the particularly vexing problem of caring for patients with dementia with potentially far-reaching public health implications.

Acknowledgments
Supported with T21 funds from VA to expand noninstitutional alternatives to institutional extended care for veterans, as well as the Geriatrics Research and Clinical Center (GRECC) at the Baltimore VAMC.

Dementia is a common, multifaceted problem with significant implications for function and quality of life among older individuals. Current demographic shifts are magnifying this problem. Particularly troubling are neuropsychiatric symptoms, which, in addition to creating caregiver distress, also are linked to functional decline, institutionalization, higher health care costs, and mortality (even after controlling for other potential confounders and severity of cognitive impairment). Furthermore, dementia is often unrecognized and underdiagnosed, and patients with dementia historically have poor access to care, particularly those living in rural areas.

The Geriatrics/Dementia Clinic at the Baltimore Veterans Affairs Medical Center (BVAMC) is a referral resource that provides extensive, multidisciplinary evaluations as well as coordinated subspecialist and interprofessional case review. A diverse group of clinicians (representing geriatrics, geriatric psychiatry, neuropsychology, clinical pharmacy, nursing, and social work) perform a half-day evaluation, followed by a meeting of the interdisciplinary team, and feedback session where patients and their families are given the results of the testing and diagnostic impressions as well as plans for further evaluation and treatment. Finally, in addition to the benefits it provides to veterans and their families, this clinic has proven to be an important resource for professional trainees.

Yet this model can be difficult to access, and those living in more remote regions had challenges availing themselves of this resource. Often, they would have to wake before dawn to drive 2 to 4 hours to the medical center. Furthermore, despite the many obvious benefits of this comprehensive approach, veterans and their families often left the clinic with a staggering amount of information and numerous recommendations for future care but without the assurance of integrated follow-up (a burden borne particularly by those living remotely).

The DEMO Program

In response to the dual challenges of access to and coordination of care, existing resources were leveraged with about $250,000 of VA T21 funds (adding both a full-time geriatric nurse practitioner and a psychology technician to the multidisciplinary team) to design and implement the novel DEMO (Dementia Evaluation, Management and Outreach) program. This program aimed to (1) extend dementia evaluations to regional community-based outpatient clinics (CBOCs) that serve veterans in outlying regions; and (2) improve the management and the follow-up that these veterans receive, with a focus on containing costs, while improving both the quality of and veterans’ (and their families’) satisfaction with health care.

Methods

Dementia evaluations were conducted by a geriatric nurse practitioner and psychology technician teamlet at the CBOCs. In addition to neuropsychological testing, medical records were reviewed, caregivers were interviewed, and the patients were examined. The data were then brought back to the full BVAMC Geriatrics/Dementia Clinic multidisciplinary team for discussion. The team reached a consensus diagnosis and then made a comprehensive plan for the further evaluation and management of these complex patients. The plan was entered into the Computerized Patient Record System and communicated to the patient and caregiver during a follow-up CBOC visit.

The teamlet frequently provided informal education during CBOC visits in addition to formal lectures given by experts from the BVAMC and the University of Maryland. The DEMO program was introduced to providers at the CBOCs by e-mail with follow-up information sessions provided on site.

Rather than having patients simply return to their CBOC primary care providers (PCPs) and exposing patients to the risks of poor communication/coordination of care, services were expanded to include regular phone follow-up calls with case management services that augmented those of their PCPs. The goal was to improve outcomes for these patients and provide alternatives to institutionalization.

Standardized instruments were used to gauge patient and caregiver satisfaction, obtain cost data from the VA and the Centers for Medicare & Medicaid Services, and medication data from the Pharmacy Benefits files.

The institutional review board provided approval to collect data on participants to assess the program’s clinical and economic impacts. Since all patients were suspected to have dementia, the informed consent procedures included additional protections. The patient’s understanding of the pertinent information related to participation in the study was assessed to help ensure that participants with dementia truly understood the conditions to which they were consenting. If the potential participant could not provide informed consent, it was obtained from a surrogate with durable power of attorney (the person recognized by Maryland law as the substitute decision maker or the veteran’s legal guardian). Consent was assessed on an ongoing basis regardless of the patient’s capacity to give informed consent, and those willing to have their data collected were enrolled in a “research” arm. These participants were compared with veterans in the dementia clinic during the enrollment period but who did not consent to participate in the research arm, controlling for sociodemographic characteristics and prior health care utilization.

Data Analysis

Patterns of health care utilization may fluctuate with time, and enrollment may identify potential problems that otherwise would not have been found. The authors looked at health care use over 6-month and 1-year intervals before and after enrollment, examining Occupational Physical Assessment Test (OPAT) data and fee-based outpatient data for both inpatient events (including nursing home utilization and hospitalization events) and outpatient visits (including primary, specialty and mental health care services; home care visits, and emergency department [ED]). The total cost incurred by outpatient visits and inpatient care was then adjusted to 2011 dollars. The relationship between program enrollment and health care use and costs was examined with a multivariate regression analyses, controlling for age and health care use in the prior year among veterans who were in the “consent” group or “nonconsent” group.

Outcome variables included the number of primary care, ED, specialty care, home health care, mental health care clinic, and inpatient visits; total inpatient bed days; and the total costs of all the events. The authors fit different multivariate models for these events according to their distributions. Specifically, the Poisson model was used if the distribution of the outcome variable was not overdispersed (eg, ED, primary care).

A negative binomial was used if the distribution of these events was overdispersed (eg, specialty care visits). Further, because the occurrence of inpatient events is relatively rare, a logit model was used to examine the relationship between enrollment status and probability of any inpatient events, regardless of the number of events. Generalized estimating equation (GEE) model with gamma distribution and log link function was used to examine the relationship between cost and program enrollment. The authors also examined the program’s effect on medication use, focusing on high-risk medications in older adults, comparing both the number of unique medications, as well as frequency such medications prescribed 1 year before and after the enrollment.¹

Results

Two hundred ninety-eight (298) veterans were referred to DEMO from a 150-mile radius of Baltimore. Of these veterans, 132 consented to participate in this study. The study participants largely were representative of the total group as well as both the overall veteran population and the more general population of community-dwelling individuals with dementia (Table).

Veterans in the DEMO program largely had mild-to-moderate cognitive impairment with mean Mini-Mental State Examination (MMSE) score of 22 and significant functional limitations (Table). Only 3% displayed a pattern of “pure” dementia typical of Alzheimer disease, and 11% of those referred did not have significant abnormalities on neurocognitive testing.

The team averaged 10.3 recommendations (range 3-22), which focused on a diverse set of issues related to additional diagnostic and therapeutic concerns. Although screening data, including basic laboratory results and imaging, was requested in the referral form, in 71% of cases further diagnostic investigations were suggested. With regard to therapeutic suggestions, not surprisingly, medicines were cited as targets in a majority of cases (eg, discontinuing high-risk medications, initiating/titrating medications to minimize cardiovascular risk). While remaining mindful of the time to benefit and competing morbidities, measures to modify cardiovascular risk factors were suggested in more than half and treatment of depression in 15% of cases. Similarly, addressing poor sensory input was suggested in 38% of cases, with other common recommendations focusing on multiple environmental and social interventions (> 50%) as well as supports/outlets/respite for the caregivers.

The full multidisciplinary DEMO group met only weekly to review cases, and due to travel and scheduling difficulties, feedback to the patients and their families often was delayed for weeks. Although initial plans included regularly scheduled follow-up phone calls, demand quickly outstripped program resources. Nonetheless, chart reviews and abstracted adherence and utilization data revealed that PCPs successfully implemented 52% of recommendations within 2 weeks, rising to > 60% by 3 months. When patients were reevaluated at 1 year, they were remarkably stable: Mini–Mental State Examination (baseline 22.2 ± 5.0 → 22.3 ± 5.7 at follow-up) and Instrumental Activities of Daily Living scores (15.5 ± 10.6 → 17.7 ± 11.4).

Feedback

This program was enthusiastically received by both patients and their caregivers—100% and 98%, respectively—reporting overall satisfaction with the services received and 93% of caregivers indicating satisfaction with how the program met their needs. Caregivers were happy with the amount of time the provider took to answer questions (100% satisfied with the amount of time the DEMO provider spent and that they explained “what they wanted to know,” with 98% responding “good” or “great” for both), as well as with services and amount of help received (83% and 77% “very satisfied,” respectively).

In the survey, 98% of caregivers and patients felt that the program helped them deal more effectively with their problems, 97% would recommend the program to a friend in need of similar help, and 100% would come back if they were to seek help again. In keeping with DEMO’s initial aim of increasing access, there was favorable feedback on the ability to get in and be seen and convenience of location. In addition, referring providers universally expressed satisfaction with the referral process (referrals increased linearly); timeliness of scheduling; usefulness of the recommendations; and they planned on continuing to refer patients.

Although there was great variability, controlling for age and prior utilization, veterans in DEMO had statistically significant (all P < .05) fewer ED and specialty care visits and more mental health care clinic visits 183 to 365 daysafter referral dates compared with those in the nonconsented group. Veterans in the consented group also were less likely to use inpatient care than were veterans in the nonconsented group 183 to 365 days after referral dates. These trends were similarly reflected after controlling for age and prior utilization as well as when examining health care costs (data not shown). Nonetheless, DEMO did not seem to have any effect on overall inpatient bed days, primary/home-based care visits, or total costs. In fact, utilization of mental health care resources increased (Figures 1, 2, and 3).

Discussion

Cognitive issues in patients within the general population are common, and the patients cared for by the VA are no exception. Dementia is more common in rural compared with urban areas, and those living in more remote locations have reduced access to specialized evaluation, management, and support services.² The authors describe a novel program that dramatically increased patient access, bringing the normally tertiary referral services to geographically remote CBOCs at a minimal investment. These services were well received by patients, caregivers, and PCPs. As anticipated, patients and their caregivers especially appreciated the ease and convenience of access. Considering the already significant burden(s) borne every day by those caring for patients with dementia, the benefit of this approach is evident.

Clinicians often feel uncomfortable in evaluating and managing patients with cognitive deficits. Nonetheless, the role of specialized clinics in diagnosing dementia has been demonstrated previously, and the present results are in agreement with previous studies.³ The novelty here is the provision of specialized care usually found only in large, academic medical centers to local CBOCs. By bringing specialized services to geographically isolated patients, the DEMO program was able to increase both access and utilization. Furthermore, providing coordination and ongoing, focused follow-up provided increases in satisfaction and efficiency.

An additional benefit of this approach is the opportunity for PCP education. The authors even found anecdotal reductions in ED usage as well as acute hospitalization and long-term placement—although it was not a statistical significant difference. The relatively high use of mental health care services in this population is in line with previous reports in similar populations, and greater utilization of mental health care services may be one explanation why overall costs did not differ between the 2 groups.⁴ Nonetheless, this intimates that such a program may yield savings over a longer term, as has been demonstrated in patients with a variety of other psychiatric diagnoses cared for in the community rather than in institutions.^5,6

The prevalence of dementia and its associated costs are nearly $50,000 per year per person—suggesting a total cost in the hundreds of billions of dollars.⁷ Similarly, the importance of caregiver support (including psychosocial interventions, such as the one piloted here) has been demonstrated in a variety of settings (even without improvement in caregiver burden itself).⁸

There were a number of challenges in the rollout and delivery of DEMO. Although CBOC PCPs were initially somewhat uncertain of the benefit of this approach and concerned about the space requirements, referrals rapidly and dramatically increased, and the DEMO teamlet became enmeshed with CBOC staff. Similarly, potential participants and their caregivers sometimes were leery to involve others in their care. Both the CBOC PCPs and caregivers came to depend more on DEMO staff, and the DEMO staff members frequently were the first ones to be called (at times for issues unrelated to dementia).

Unfortunately, DEMO was underresourced to provide either real-time feedback true or first responder services. Misunderstandings concerning this were an early challenge to PCP acceptance. However, the longitudinal presence and close working relationships of the DEMO teamlet in each CBOC allowed their use as an adjunct to primary care, and increased the efficacy of both.

Limitations

A number of additional caveats must be made. First, this study had a relatively small number of participants, and there was great variability in health care utilization. This is particularly germane in this population of patients with dementia, which typically has an asymmetrically high use of health care resources. Additionally, the relatively limited follow-up period may have blunted the programs true effect(s). Further, although veterans in the nonconsented group were not officially enrolled in the program, there was likely spillover of the effects of the program on practice patterns, leading to an underestimation of the program’s impact.

Conclusion

With minimal resources, DEMO successfully brought expert evaluation (usually tertiary referral) services, and provided specialized case management in coordination with existing primary care to remote patients. Although there were a number of features rather unique to this setting (eg, infrastructural support; close working interdisciplinary and interprofessional relationships, buy-in at all levels, relative geographic density/demographic homogeneity of participants), specialized case management is increasingly being adopted throughout the VA (and elsewhere). Although the value of collaborative, interdisciplinary interventions has been shown in a variety of settings and conditions—nursing homes,⁹ chronic low back pain,¹⁰ safety among hospital inpatients¹¹—its utility for dementia care is relatively underexplored.

Yet the effectiveness of team-based care for individuals has been demonstrated in a number of settings, including Alzheimer disease.^12,13 In addition to involving a number of disciplines, collaborative care is marked by coordination. A number of recent systematic reviews have found that behavioral and multicomponent interventions directed towards the caregiver as well as case management were beneficial in improving some outcomes, although there is considerable heterogeneity in the effects.^14,15 Future work will focus on examining methods to focus/optimize interventions based on individual patient characteristics.

Given the epidemiologic trends, care for patients with dementia is expected to grow. Novel interventions, like DEMO, are a particularly promising option to meet this challenge. In fact, just such a collaborative practice-ready workforce has been identified by the World Health Organization as crucial to meeting the challenges of the health needs in the 21st century.¹⁶ With the feasibility of such an approach in this population now evident, further studies (including larger sample sizes, across greater geographic regions, as well as among more diverse populations) should be undertaken. These results, if replicated, suggest a novel approach to the particularly vexing problem of caring for patients with dementia with potentially far-reaching public health implications.

Acknowledgments
Supported with T21 funds from VA to expand noninstitutional alternatives to institutional extended care for veterans, as well as the Geriatrics Research and Clinical Center (GRECC) at the Baltimore VAMC.

Dementia is a common, multifaceted problem with significant implications for function and quality of life among older individuals. Current demographic shifts are magnifying this problem. Particularly troubling are neuropsychiatric symptoms, which, in addition to creating caregiver distress, also are linked to functional decline, institutionalization, higher health care costs, and mortality (even after controlling for other potential confounders and severity of cognitive impairment). Furthermore, dementia is often unrecognized and underdiagnosed, and patients with dementia historically have poor access to care, particularly those living in rural areas.

The Geriatrics/Dementia Clinic at the Baltimore Veterans Affairs Medical Center (BVAMC) is a referral resource that provides extensive, multidisciplinary evaluations as well as coordinated subspecialist and interprofessional case review. A diverse group of clinicians (representing geriatrics, geriatric psychiatry, neuropsychology, clinical pharmacy, nursing, and social work) perform a half-day evaluation, followed by a meeting of the interdisciplinary team, and feedback session where patients and their families are given the results of the testing and diagnostic impressions as well as plans for further evaluation and treatment. Finally, in addition to the benefits it provides to veterans and their families, this clinic has proven to be an important resource for professional trainees.

Yet this model can be difficult to access, and those living in more remote regions had challenges availing themselves of this resource. Often, they would have to wake before dawn to drive 2 to 4 hours to the medical center. Furthermore, despite the many obvious benefits of this comprehensive approach, veterans and their families often left the clinic with a staggering amount of information and numerous recommendations for future care but without the assurance of integrated follow-up (a burden borne particularly by those living remotely).

The DEMO Program

In response to the dual challenges of access to and coordination of care, existing resources were leveraged with about $250,000 of VA T21 funds (adding both a full-time geriatric nurse practitioner and a psychology technician to the multidisciplinary team) to design and implement the novel DEMO (Dementia Evaluation, Management and Outreach) program. This program aimed to (1) extend dementia evaluations to regional community-based outpatient clinics (CBOCs) that serve veterans in outlying regions; and (2) improve the management and the follow-up that these veterans receive, with a focus on containing costs, while improving both the quality of and veterans’ (and their families’) satisfaction with health care.

Methods

Dementia evaluations were conducted by a geriatric nurse practitioner and psychology technician teamlet at the CBOCs. In addition to neuropsychological testing, medical records were reviewed, caregivers were interviewed, and the patients were examined. The data were then brought back to the full BVAMC Geriatrics/Dementia Clinic multidisciplinary team for discussion. The team reached a consensus diagnosis and then made a comprehensive plan for the further evaluation and management of these complex patients. The plan was entered into the Computerized Patient Record System and communicated to the patient and caregiver during a follow-up CBOC visit.

The teamlet frequently provided informal education during CBOC visits in addition to formal lectures given by experts from the BVAMC and the University of Maryland. The DEMO program was introduced to providers at the CBOCs by e-mail with follow-up information sessions provided on site.

Rather than having patients simply return to their CBOC primary care providers (PCPs) and exposing patients to the risks of poor communication/coordination of care, services were expanded to include regular phone follow-up calls with case management services that augmented those of their PCPs. The goal was to improve outcomes for these patients and provide alternatives to institutionalization.

Standardized instruments were used to gauge patient and caregiver satisfaction, obtain cost data from the VA and the Centers for Medicare & Medicaid Services, and medication data from the Pharmacy Benefits files.

The institutional review board provided approval to collect data on participants to assess the program’s clinical and economic impacts. Since all patients were suspected to have dementia, the informed consent procedures included additional protections. The patient’s understanding of the pertinent information related to participation in the study was assessed to help ensure that participants with dementia truly understood the conditions to which they were consenting. If the potential participant could not provide informed consent, it was obtained from a surrogate with durable power of attorney (the person recognized by Maryland law as the substitute decision maker or the veteran’s legal guardian). Consent was assessed on an ongoing basis regardless of the patient’s capacity to give informed consent, and those willing to have their data collected were enrolled in a “research” arm. These participants were compared with veterans in the dementia clinic during the enrollment period but who did not consent to participate in the research arm, controlling for sociodemographic characteristics and prior health care utilization.

Data Analysis

Patterns of health care utilization may fluctuate with time, and enrollment may identify potential problems that otherwise would not have been found. The authors looked at health care use over 6-month and 1-year intervals before and after enrollment, examining Occupational Physical Assessment Test (OPAT) data and fee-based outpatient data for both inpatient events (including nursing home utilization and hospitalization events) and outpatient visits (including primary, specialty and mental health care services; home care visits, and emergency department [ED]). The total cost incurred by outpatient visits and inpatient care was then adjusted to 2011 dollars. The relationship between program enrollment and health care use and costs was examined with a multivariate regression analyses, controlling for age and health care use in the prior year among veterans who were in the “consent” group or “nonconsent” group.

Outcome variables included the number of primary care, ED, specialty care, home health care, mental health care clinic, and inpatient visits; total inpatient bed days; and the total costs of all the events. The authors fit different multivariate models for these events according to their distributions. Specifically, the Poisson model was used if the distribution of the outcome variable was not overdispersed (eg, ED, primary care).

A negative binomial was used if the distribution of these events was overdispersed (eg, specialty care visits). Further, because the occurrence of inpatient events is relatively rare, a logit model was used to examine the relationship between enrollment status and probability of any inpatient events, regardless of the number of events. Generalized estimating equation (GEE) model with gamma distribution and log link function was used to examine the relationship between cost and program enrollment. The authors also examined the program’s effect on medication use, focusing on high-risk medications in older adults, comparing both the number of unique medications, as well as frequency such medications prescribed 1 year before and after the enrollment.¹

Results

Two hundred ninety-eight (298) veterans were referred to DEMO from a 150-mile radius of Baltimore. Of these veterans, 132 consented to participate in this study. The study participants largely were representative of the total group as well as both the overall veteran population and the more general population of community-dwelling individuals with dementia (Table).

Veterans in the DEMO program largely had mild-to-moderate cognitive impairment with mean Mini-Mental State Examination (MMSE) score of 22 and significant functional limitations (Table). Only 3% displayed a pattern of “pure” dementia typical of Alzheimer disease, and 11% of those referred did not have significant abnormalities on neurocognitive testing.

The team averaged 10.3 recommendations (range 3-22), which focused on a diverse set of issues related to additional diagnostic and therapeutic concerns. Although screening data, including basic laboratory results and imaging, was requested in the referral form, in 71% of cases further diagnostic investigations were suggested. With regard to therapeutic suggestions, not surprisingly, medicines were cited as targets in a majority of cases (eg, discontinuing high-risk medications, initiating/titrating medications to minimize cardiovascular risk). While remaining mindful of the time to benefit and competing morbidities, measures to modify cardiovascular risk factors were suggested in more than half and treatment of depression in 15% of cases. Similarly, addressing poor sensory input was suggested in 38% of cases, with other common recommendations focusing on multiple environmental and social interventions (> 50%) as well as supports/outlets/respite for the caregivers.

The full multidisciplinary DEMO group met only weekly to review cases, and due to travel and scheduling difficulties, feedback to the patients and their families often was delayed for weeks. Although initial plans included regularly scheduled follow-up phone calls, demand quickly outstripped program resources. Nonetheless, chart reviews and abstracted adherence and utilization data revealed that PCPs successfully implemented 52% of recommendations within 2 weeks, rising to > 60% by 3 months. When patients were reevaluated at 1 year, they were remarkably stable: Mini–Mental State Examination (baseline 22.2 ± 5.0 → 22.3 ± 5.7 at follow-up) and Instrumental Activities of Daily Living scores (15.5 ± 10.6 → 17.7 ± 11.4).

Feedback

This program was enthusiastically received by both patients and their caregivers—100% and 98%, respectively—reporting overall satisfaction with the services received and 93% of caregivers indicating satisfaction with how the program met their needs. Caregivers were happy with the amount of time the provider took to answer questions (100% satisfied with the amount of time the DEMO provider spent and that they explained “what they wanted to know,” with 98% responding “good” or “great” for both), as well as with services and amount of help received (83% and 77% “very satisfied,” respectively).

In the survey, 98% of caregivers and patients felt that the program helped them deal more effectively with their problems, 97% would recommend the program to a friend in need of similar help, and 100% would come back if they were to seek help again. In keeping with DEMO’s initial aim of increasing access, there was favorable feedback on the ability to get in and be seen and convenience of location. In addition, referring providers universally expressed satisfaction with the referral process (referrals increased linearly); timeliness of scheduling; usefulness of the recommendations; and they planned on continuing to refer patients.

Although there was great variability, controlling for age and prior utilization, veterans in DEMO had statistically significant (all P < .05) fewer ED and specialty care visits and more mental health care clinic visits 183 to 365 daysafter referral dates compared with those in the nonconsented group. Veterans in the consented group also were less likely to use inpatient care than were veterans in the nonconsented group 183 to 365 days after referral dates. These trends were similarly reflected after controlling for age and prior utilization as well as when examining health care costs (data not shown). Nonetheless, DEMO did not seem to have any effect on overall inpatient bed days, primary/home-based care visits, or total costs. In fact, utilization of mental health care resources increased (Figures 1, 2, and 3).

Discussion

Cognitive issues in patients within the general population are common, and the patients cared for by the VA are no exception. Dementia is more common in rural compared with urban areas, and those living in more remote locations have reduced access to specialized evaluation, management, and support services.² The authors describe a novel program that dramatically increased patient access, bringing the normally tertiary referral services to geographically remote CBOCs at a minimal investment. These services were well received by patients, caregivers, and PCPs. As anticipated, patients and their caregivers especially appreciated the ease and convenience of access. Considering the already significant burden(s) borne every day by those caring for patients with dementia, the benefit of this approach is evident.

Clinicians often feel uncomfortable in evaluating and managing patients with cognitive deficits. Nonetheless, the role of specialized clinics in diagnosing dementia has been demonstrated previously, and the present results are in agreement with previous studies.³ The novelty here is the provision of specialized care usually found only in large, academic medical centers to local CBOCs. By bringing specialized services to geographically isolated patients, the DEMO program was able to increase both access and utilization. Furthermore, providing coordination and ongoing, focused follow-up provided increases in satisfaction and efficiency.

An additional benefit of this approach is the opportunity for PCP education. The authors even found anecdotal reductions in ED usage as well as acute hospitalization and long-term placement—although it was not a statistical significant difference. The relatively high use of mental health care services in this population is in line with previous reports in similar populations, and greater utilization of mental health care services may be one explanation why overall costs did not differ between the 2 groups.⁴ Nonetheless, this intimates that such a program may yield savings over a longer term, as has been demonstrated in patients with a variety of other psychiatric diagnoses cared for in the community rather than in institutions.^5,6

The prevalence of dementia and its associated costs are nearly $50,000 per year per person—suggesting a total cost in the hundreds of billions of dollars.⁷ Similarly, the importance of caregiver support (including psychosocial interventions, such as the one piloted here) has been demonstrated in a variety of settings (even without improvement in caregiver burden itself).⁸

There were a number of challenges in the rollout and delivery of DEMO. Although CBOC PCPs were initially somewhat uncertain of the benefit of this approach and concerned about the space requirements, referrals rapidly and dramatically increased, and the DEMO teamlet became enmeshed with CBOC staff. Similarly, potential participants and their caregivers sometimes were leery to involve others in their care. Both the CBOC PCPs and caregivers came to depend more on DEMO staff, and the DEMO staff members frequently were the first ones to be called (at times for issues unrelated to dementia).

Unfortunately, DEMO was underresourced to provide either real-time feedback true or first responder services. Misunderstandings concerning this were an early challenge to PCP acceptance. However, the longitudinal presence and close working relationships of the DEMO teamlet in each CBOC allowed their use as an adjunct to primary care, and increased the efficacy of both.

Limitations

A number of additional caveats must be made. First, this study had a relatively small number of participants, and there was great variability in health care utilization. This is particularly germane in this population of patients with dementia, which typically has an asymmetrically high use of health care resources. Additionally, the relatively limited follow-up period may have blunted the programs true effect(s). Further, although veterans in the nonconsented group were not officially enrolled in the program, there was likely spillover of the effects of the program on practice patterns, leading to an underestimation of the program’s impact.

Conclusion

With minimal resources, DEMO successfully brought expert evaluation (usually tertiary referral) services, and provided specialized case management in coordination with existing primary care to remote patients. Although there were a number of features rather unique to this setting (eg, infrastructural support; close working interdisciplinary and interprofessional relationships, buy-in at all levels, relative geographic density/demographic homogeneity of participants), specialized case management is increasingly being adopted throughout the VA (and elsewhere). Although the value of collaborative, interdisciplinary interventions has been shown in a variety of settings and conditions—nursing homes,⁹ chronic low back pain,¹⁰ safety among hospital inpatients¹¹—its utility for dementia care is relatively underexplored.

Yet the effectiveness of team-based care for individuals has been demonstrated in a number of settings, including Alzheimer disease.^12,13 In addition to involving a number of disciplines, collaborative care is marked by coordination. A number of recent systematic reviews have found that behavioral and multicomponent interventions directed towards the caregiver as well as case management were beneficial in improving some outcomes, although there is considerable heterogeneity in the effects.^14,15 Future work will focus on examining methods to focus/optimize interventions based on individual patient characteristics.

Given the epidemiologic trends, care for patients with dementia is expected to grow. Novel interventions, like DEMO, are a particularly promising option to meet this challenge. In fact, just such a collaborative practice-ready workforce has been identified by the World Health Organization as crucial to meeting the challenges of the health needs in the 21st century.¹⁶ With the feasibility of such an approach in this population now evident, further studies (including larger sample sizes, across greater geographic regions, as well as among more diverse populations) should be undertaken. These results, if replicated, suggest a novel approach to the particularly vexing problem of caring for patients with dementia with potentially far-reaching public health implications.

Acknowledgments
Supported with T21 funds from VA to expand noninstitutional alternatives to institutional extended care for veterans, as well as the Geriatrics Research and Clinical Center (GRECC) at the Baltimore VAMC.

The Primary Care Chronic Pain Program (PC-CPP) of the Women’s Primary Care Clinics at the VA Salt Lake City Health Care System (VASLCHCS) in Utah was the first VA primary care clinical service to incorporate patient participation in obtaining chronic opioid medications in the treatment of chronic noncancer pain. In addition, the program used a multimodality approach for chronic pain treatment and veteran education about the relationship between physical and mental health issues.

Treatment Complexity

Chronic, noncancer pain is a complex issue in the primary care setting. Diagnosis is difficult, patient education is time consuming, goals and expectations are often unclear, and the experience can be unsatisfying for the patient and the provider.¹ These issues, combined with an estimated prevalence rate of 71% for moderate pain among veterans seen in primary care, present a unique challenge for the primary care provider (PCP), given the limited time available to spend with these complex patients.² Comorbidity rates with mental health issues (eg, depression, anxiety, substance use disorders, etc), which range from 18% to 44%, add to the management challenges for PCPs.³

Veterans also pose unique challenges in pain care as they have a 2-fold greater risk of death from opioid overdose compared with that of the general population, and Utah has been shown to have the highest rate of veteran overdoses.⁴ Developing programs to help PCPs efficiently manage patients with chronic noncancer pain and mental health comorbidities was vital at VASLCHCS.

Before VASLCHCS established the PC-CPP, the treatment for chronic noncancer pain and related mental health comorbidities followed a biomedical model that separated physical and mental health with the treatment focus on pharmacologic management of symptoms by separate services. Consistent with the biomedical model, management of chronic noncancer pain commonly included long-term use of opioids.

Over the past 2 decades, the use of opioids for treating chronic noncancer pain has significantly increased, with more than 62 million opioid prescriptions dispensed in 2012.⁵ There are no longitudinal follow-up studies, however, beyond 16 weeks on the use of opioids.⁶ Further, patients who are prescribed increased opioids continue to report high levels of pain, poor quality of life, and functional disability.⁷ High-dose opioids also are associated with overdose deaths.

Likewise, PCPs in the Women’s Primary Care Clinics at the VASLCHCS struggled with decreasing opioid use, often because other interventions for managing pain and related mental health conditions in primary care were not readily available. Although the VASLCHCS has an effective specialty pain service caring for patients with complex pain issues, opioid morphine equivalent doses > 200 mg/d, and palliative care, patients with chronic noncancer pain treated in the primary care setting did not have a consistent treatment approach.

A chart review of women veterans seen in Women’s Primary Care Clinic (N = 122) revealed that the majority of patients lacked timely urine drug screening, state database queries, signed medication management agreements, and documentation consistent with state and national guidelines. Additionally, many patients lacked provider follow-through regarding alternative and adjunctive therapy consults, which were often discontinued after failed contact attempts or no-shows to scheduled appointments.

There also was a general consensus among the Women’s Primary Care Clinic PCPs that caring for patients with chronic noncancer pain was exhausting, time consuming, ineffective, and often straining on the patient-provider relationship, as evidenced in many patients’ request to change providers secondary to pain management. The PC-CPP was developed to help systematically facilitate safe opioid prescribing, manage chronic pain issues, and document evidence-based care among women veterans receiving treatment for chronic noncancer pain at the Women’s Primary Care Clinics at VASLCHCS while coordinating and following through with nonpharmacologic interventions.

Program Development

National, state, VA, and professional licensure guidelines for chronic noncancer pain treatment standards were reviewed with the goal of creating a program that was evidence based, would benefit the patient in terms of opioid prescribing and pain control, and improve function while identifying key elements of care and documentation that adequately covered the prescriber of retribution.^1,8-10

Concurrent to a review of the guidelines was a review of the literature with the goal of identifying useful patient education and alternative interventions and chronic pain programs that were already established and might meet the clinic’s needs.^10,11 These reviews provided direction for a generalized approach to caring for patients with chronic nonmalignant pain. They also clarified that although pain education programs existed nationally, a program that offered a holistic, reproducible, adherence-driven yet patient-centered approach to the patient prescribed opioids chronically in a primary care setting was lacking.

• Patient education about chronic pain and opioids
• Evaluation of pain, function, opioid misuse risk at least twice yearly
• Patient-centered and driven treatment plans
• A holistic approach to chronic pain interventions
• Review of treatment plan efficacy at least twice yearly
• Enzyme multiplied immunoassay technique urine drug screening (UDS) 2 times per year
• State prescription monitoring program query annually
• Signed iMedConsent for treatment of chronic pain
• Plan for safe discontinuation of opioids
• Documentation that the above has been performed with patient understanding

The literature suggested a multimodality approach to chronic nonmalignant pain by minimizing the use of opioids over time while emphasizing nonpharmacologic therapies, such as cognitive behavioral therapy (CBT), mindfulness, meditation, yoga, and spiritual growth, to name a few.^10,11 These findings are based on several studies, which suggested that passive coping strategies (eg, use of medication for immediate relief, depending on others, restricting medications) result in an increase in subjective pain among chronic nonmalignant pain patients.¹² Helping patients reduce frequent use of passive coping strategies is believed to decrease pain.¹² Active coping strategies (eg, engaging in therapies, staying busy or active, distracting attention from pain) have been found to decrease pain.¹² The PC-CPP program shifted health care outcomes and responsibilities away from the hierarchal PCP-patient relationship toward a collaborative relationship that encourages patient-driven, patient-centered care outcomes and shared responsibilities.

Program Overview

The PC-CPP was shaped by the following hypotheses: (1) Transparent expectations and consequences would increase functional scores and decrease chronic opioid doses; (2) Treatment plans consisting of chronic opioid prescriptions linked with interactive nonpharmacologic interventions led to decreased pain and increased functional scores; (3) Transparent expectations combined with a streamlined approach to the chronic nonmalignant pain patient would improve patient and PCP satisfaction scores.

The PC-CPP was developed to provide an efficient, effective, and evidence-based approach to managing chronic nonmalignant pain and opioid therapy issues in the primary care setting. Referred patients attend 1 shared medical appointment (SMA) every 6 months with up to 19 other female veterans also referred to the PC-CPP. The group was composed of only female veterans as the pilot study for this SMA occurred in the Women’s Clinic. At each 6-month SMA, patients received education from the Taking Opioids Responsibly for Your Safety and the Safety of Others (TORYSSO) guide¹³ and signed the corresponding long-term opioid therapy for pain informed consent form (iMedConsent).

The patient and a staff member developed a treatment plan that was patient driven and included at least 1 nonpharmacologic treatment option. The 1-hour nonpharmacologic sessions were either group or individual and occurred weekly for 6 to 8 weeks. These options included CBT for chronic pain, Living Well With Chronic Conditions, trauma-sensitive yoga, smoking cessation, mindfulness for stress and anxiety, MOVE! weight management, Walk With Ease, and a self-help option (VA-issued Manage Stress Workbook, 2014). The workbook was included as an option for those who lived far away, were limited by work schedules, or were unable to afford the copays for a 6- to 8-session program.

Inclusion and Exclusion Criteria

Any female veteran patient enrolled in the VASLCHCS with a chronic nonmalignant pain diagnosis who received daily opioids for 3 or more consecutive months from a PCP was included. Excluded individuals were those with cognitive decline/dementia, serious mental illness, psychosis, active suicidality, disruptive behavior flag, or those excluded by PCP discretion if it was determined that the patient would do better in a one-on-one setting with the PCP (Table 1). Patients taking > 200 MED/d of opioids who were seen in the VASLCHCS specialty pain clinic were also excluded.

Patient and PCP Responsibilities

The patient was responsible for timely attendance and full participation in all SMA group classes as determined in the veteran’s Treatment Plan Agreement (TPA). In addition, the patient had to provide UDS when requested (a minimum of twice yearly) and communicate with the PCP if having a procedure requiring additional opioids. This was in line with the current standards set forth by the VA Opioid Safety Initiative (OSI) Taskforce.¹²

The PC-CPP provided education, evaluation, documentation, and referral and follow-up with the nonpharmacologic treatment options discussed but did not provide prescription medications. The PCP reviewed the medical documents completed in the PC-CPP, and the PCP was strongly encouraged to follow its recommendations. The expectation was that the PCP would support the PC-CPP when the care recommendation was for a pharmacist-guided opioid taper.

Lack of attendance was defined as a no-show or a reschedule. Patients were considered adherent if they missed fewer than 2 SMA appointments and 2 nonpharmacologic treatment appointments every 6 months. The patient was required to attend the SMA and nonpharmacologic treatment on the third appointment to remain adherent with PC-CPP expectations and agreements. Adherence was acknowledged after 12 and 24 months by a reduction in PC-CPP requirements.

Shared Medical Appointment

Patients referred to the program and who met inclusion criteria received letters explaining the importance of SMA attendance and follow-up reminder calls. At least 30 minutes before the SMA, the patient provided an UDS sample at the laboratory. Next, the patient received an individualized program packet that included the TORYSSO guide, iMedConsent, a TPA specific to the program, a brief pain inventory (BPI) and opioid risk tool, a list of medication disposal sites, and short descriptions of available nonpharmacologic therapies.

Each SMA began with a presentation delivered by a pharmacist, a psychologist, and a medical provider, discussing TORYSSO, program expectations, and holistic approaches to pain. Each SMA also included a rotating chronic pain information topic (eg, nutrition and pain, the physiology of addiction, and the value of multiple modalities in pain treatment). Together, the staff and patients reviewed and completed the blank forms enclosed in the individualized

Each visit was entered into a Computerized Patient Record System (CPRS) template, which included a pain diagnosis, Opioid Risk Tool score, pain and functional scores, opioid fill history, last comprehensive metabolic panel, last electrocardiogram if on methadone, dates of signed agreements, patient adherence with SMA and optional therapies, and follow-up (eFigure).

Every patient enrolled in the PC-CPP had to attend a SMA every 6 months. Patients continued this indefinitely while receiving opioids, and requirements were lessened for patients who had a history of meeting program requirements. For those fully adherent after the first year, only 1 nonpharmacologic intervention was needed (instead of 1 every 6 months) yearly. After 2 years of full adherence, nonpharmacologic interventions were no longer necessary as the expectation was that the patient would continue to use the strategies that they had learned over the previous 2 years. Patients left the PC-CPP if they chose to discontinue opioids, met any of the exclusion criteria, or were nonadherent. Tapering opioid medication was recommended for patients who missed a SMA meeting or 2 nonpharmacologic treatment meetings in a 6-month period; received opioids from more than 1 provider; test positive on a UDS for substances that should not be present; consistently testing negative on a UDS for substances that should be present (indicating diversion); or exhibiting other aberrant behavior (frequent requests for early refills, medications often lost/stolen, etc).

Program Barriers

The PC-CPP took about 2 years to set up, and several barriers were encountered. A thorough understanding of the following factors is necessary for establishing a similar program.

Initially, consults were placed by a designee (someone other than the PCP currently caring for the patient). The designee was usually a member of the PC-CPP who placed consults for all patients who had opioids listed on the CPRS profile. Further, patients who had any opioids within the past 3 months were initially included as were patients who wanted pain education but were not taking opioids. After 12 months, it became apparent that the focus of the PC-CPP should center on patients taking opioids for a minimum of 3 months consecutively. Patients who wanted only education could attend other hospital education opportunities, which helped keep the patient load manageable for PC-CPP staff. Further, to lessen patient confusion and improve adherence, the PCP placed the consult and discussed the program with the patient. Class sizes of 5 to 10 patients seemed to be ideal for patient participation and provider workload.

Patient Education

Initially, the SMA did not follow a standard curriculum, but the current format is more consistent, reproducible, streamlined, and organized. This adjustment improved SMA attendance as well as patient satisfaction, as the class started and finished on time. The SMA also started with numerous handouts, including brochures for nonpharmacologic programs offered at this facility. This led to patients feeling overwhelmed, missing the important forms, and wasted paper. Handouts were simplified to 2 color-coded forms (TPA and BPI).

The take-home assessment was streamlined to a single general assessment. This assessment consisted of 2 questions that asked patients to write a summary of what they learned and then write a summary of how they applied what they learned to their pain management. The VA Manage Stress Workbook also was added to the take-home materials. There are currently 5 different take-home options, which are necessary for those who live more than 50 miles from any VA facility or for those who have transportation issues.

Patient Distress

The SMA could be stressful for patients who felt they were being “punished” or who showed up more than 15 minutes late and had to reschedule the SMA. Having a mental health provider available was crucial for these situations.

Therapeutic Option Development

A cornerstone of the program was getting patients to participate in nonpharmacologic treatment options, which required a robust selection of programs. The VASLCHCS was fortunate to have many programs already available (Table 2), but this was not always the case for the VA community-based outpatient clinics (CBOCs).

Stakeholder Support

Before its start, PC-CPP was presented to the Pentad (a group of 5 individuals in the local facility who hold executive leadership positions) for approval. Tapering opioids can lead to feelings of hostility, frustration, or sadness for patients, so having the Pentad support for the program was crucial to address complaints made to patient advocates or senators. Provider support also was important to reinforce program rules. The PC-CPP inclusion criteria included only those patients whose PCP was agreeable to a taper when the patient did not comply with program expectations. This strategy helped to improve patient adherence with the PC-CPP and decrease patient arguments with clinic staff, as all patients are held to the same standards.

Staff

Finding willing staff can be a challenge. It is estimated that each site needed a program leader who can champion the program objectives and drive organization of staff, space, documentation, and consistency for the patients consulted to the PC-CPP. The goal is that the consistent, reproducible expectations for both the PCP and the patient will reduce overall workload for a clinic. Patients may test the firmness and conviction of the staff to the PC-CPP. Having staff who are able and willing to be firm on relaying information for adherence to the patient is vital.

Administrative Support

At a minimum, a medical support assistant was required to help with scheduling, reminder calls and letters, CPRS check-in/check-out, ensuring necessary forms are ready for the SMA, tracking adherence, and following-up on no-shows and rescheduling.

Documentation

The CPRS consult and note template titles required the approval of the template committee. Although the template is helpful, there is still a great deal that needs to be manually entered in the note, such as BPI scores, opioid risk scores, and chosen nonpharmacologic interventions scores of pain, function, and opioid risk as well individual comorbidities, diagnosis, and follow-up dates. Documentation is geared toward easy review for the PCP who should scan the document prior to renewing opioid medications. The PC-CPP consult became a message board. Once the patient attends the SMA, the designated staff will add a comment to the message board, identifying all dates attended, complete history of the patient’s intervention choices and rate of adherence, as well a follow-up SMA date and whether the patient should bring materials such as take-home tests.

Time Commitment

Program development carries a heavy time burden. One full-time equivalent clinician for 6 weeks for program development is needed. Time allotment is estimated to be the following:

• Medical provider—30 minutes per patient (chart review, documentation, consult resolution). With training, these duties could be completed by support staff
• Pharmacist—30 minutes per patient (chart review, UDS, Utah Division of Occupational and Professional Licensing, fill history). Additional time is needed for writing opioid tapers for qualifying patients
• Primary care mental health integration—a PhD spent 1 to 2 hours per SMA visit assisting patients who became distressed during the visit. Only once has a patient needed to be escorted to the emergency department for active suicidality. A PhD also spent 10+ hours per week running and managing the CBT for Chronic Pain Group
• Support staff—a registered nurse spent 4 hours each month preparing for the SMA (entering consults, ordering EMITs, purchasing snacks)

Conclusion

In this descriptive report, the authors presented an overview of a newly developed program to manage chronic nonmalignant pain and safe opioid prescribing in a primary care setting. A final report is pending. The intent with this interim report was to describe the PC-CPP at the VASLCHCS, its methods and protocols, and logistic considerations for other providers who are working with patients with chronic pain in a primary care model. Standard operating procedure and inclusion/exclusion criteria were included to help with clinical decision making for patients chronic pain for whom aberrant opioid-related behavior presents a problem.

The authors expect that the PC-CPP will provide more comprehensive assisted care, lending to decreased complications associated with accidental overdose, because since patients have been educated about risks for accidental overdose from chronic opioids and have the responsibility for their outcomes. The authors also anticipated that functional scores (as measured by the BPI) will increase despite lowering opioid doses because patients will use ancillary treatments for pain. The desired outcome is that patients will come to understand that pain control is best approached holistically rather than through opioid monotherapy.

There have been several recent initiatives within the VA to decrease opioid prescribing and increase patient safety. With this in mind, continued expansion of this program to CBOCs and male patients could be useful to providers. Also, this program was conducted in a small setting (Women’s Clinic), and there are many challenges with rolling out such a program in a larger clinic (eg, greater chance for provider disagreement, greater need for administrative staff support). Nonetheless, the benefits of close monitoring of prescription opioids and active encouragement to engage in nonpharmacologic therapies are substantial and deserve further advancement.

The Primary Care Chronic Pain Program (PC-CPP) of the Women’s Primary Care Clinics at the VA Salt Lake City Health Care System (VASLCHCS) in Utah was the first VA primary care clinical service to incorporate patient participation in obtaining chronic opioid medications in the treatment of chronic noncancer pain. In addition, the program used a multimodality approach for chronic pain treatment and veteran education about the relationship between physical and mental health issues.

Treatment Complexity

Chronic, noncancer pain is a complex issue in the primary care setting. Diagnosis is difficult, patient education is time consuming, goals and expectations are often unclear, and the experience can be unsatisfying for the patient and the provider.¹ These issues, combined with an estimated prevalence rate of 71% for moderate pain among veterans seen in primary care, present a unique challenge for the primary care provider (PCP), given the limited time available to spend with these complex patients.² Comorbidity rates with mental health issues (eg, depression, anxiety, substance use disorders, etc), which range from 18% to 44%, add to the management challenges for PCPs.³

Veterans also pose unique challenges in pain care as they have a 2-fold greater risk of death from opioid overdose compared with that of the general population, and Utah has been shown to have the highest rate of veteran overdoses.⁴ Developing programs to help PCPs efficiently manage patients with chronic noncancer pain and mental health comorbidities was vital at VASLCHCS.

Before VASLCHCS established the PC-CPP, the treatment for chronic noncancer pain and related mental health comorbidities followed a biomedical model that separated physical and mental health with the treatment focus on pharmacologic management of symptoms by separate services. Consistent with the biomedical model, management of chronic noncancer pain commonly included long-term use of opioids.

Over the past 2 decades, the use of opioids for treating chronic noncancer pain has significantly increased, with more than 62 million opioid prescriptions dispensed in 2012.⁵ There are no longitudinal follow-up studies, however, beyond 16 weeks on the use of opioids.⁶ Further, patients who are prescribed increased opioids continue to report high levels of pain, poor quality of life, and functional disability.⁷ High-dose opioids also are associated with overdose deaths.

Likewise, PCPs in the Women’s Primary Care Clinics at the VASLCHCS struggled with decreasing opioid use, often because other interventions for managing pain and related mental health conditions in primary care were not readily available. Although the VASLCHCS has an effective specialty pain service caring for patients with complex pain issues, opioid morphine equivalent doses > 200 mg/d, and palliative care, patients with chronic noncancer pain treated in the primary care setting did not have a consistent treatment approach.

A chart review of women veterans seen in Women’s Primary Care Clinic (N = 122) revealed that the majority of patients lacked timely urine drug screening, state database queries, signed medication management agreements, and documentation consistent with state and national guidelines. Additionally, many patients lacked provider follow-through regarding alternative and adjunctive therapy consults, which were often discontinued after failed contact attempts or no-shows to scheduled appointments.

There also was a general consensus among the Women’s Primary Care Clinic PCPs that caring for patients with chronic noncancer pain was exhausting, time consuming, ineffective, and often straining on the patient-provider relationship, as evidenced in many patients’ request to change providers secondary to pain management. The PC-CPP was developed to help systematically facilitate safe opioid prescribing, manage chronic pain issues, and document evidence-based care among women veterans receiving treatment for chronic noncancer pain at the Women’s Primary Care Clinics at VASLCHCS while coordinating and following through with nonpharmacologic interventions.

Program Development

National, state, VA, and professional licensure guidelines for chronic noncancer pain treatment standards were reviewed with the goal of creating a program that was evidence based, would benefit the patient in terms of opioid prescribing and pain control, and improve function while identifying key elements of care and documentation that adequately covered the prescriber of retribution.^1,8-10

Concurrent to a review of the guidelines was a review of the literature with the goal of identifying useful patient education and alternative interventions and chronic pain programs that were already established and might meet the clinic’s needs.^10,11 These reviews provided direction for a generalized approach to caring for patients with chronic nonmalignant pain. They also clarified that although pain education programs existed nationally, a program that offered a holistic, reproducible, adherence-driven yet patient-centered approach to the patient prescribed opioids chronically in a primary care setting was lacking.

• Patient education about chronic pain and opioids
• Evaluation of pain, function, opioid misuse risk at least twice yearly
• Patient-centered and driven treatment plans
• A holistic approach to chronic pain interventions
• Review of treatment plan efficacy at least twice yearly
• Enzyme multiplied immunoassay technique urine drug screening (UDS) 2 times per year
• State prescription monitoring program query annually
• Signed iMedConsent for treatment of chronic pain
• Plan for safe discontinuation of opioids
• Documentation that the above has been performed with patient understanding

The literature suggested a multimodality approach to chronic nonmalignant pain by minimizing the use of opioids over time while emphasizing nonpharmacologic therapies, such as cognitive behavioral therapy (CBT), mindfulness, meditation, yoga, and spiritual growth, to name a few.^10,11 These findings are based on several studies, which suggested that passive coping strategies (eg, use of medication for immediate relief, depending on others, restricting medications) result in an increase in subjective pain among chronic nonmalignant pain patients.¹² Helping patients reduce frequent use of passive coping strategies is believed to decrease pain.¹² Active coping strategies (eg, engaging in therapies, staying busy or active, distracting attention from pain) have been found to decrease pain.¹² The PC-CPP program shifted health care outcomes and responsibilities away from the hierarchal PCP-patient relationship toward a collaborative relationship that encourages patient-driven, patient-centered care outcomes and shared responsibilities.

Program Overview

The PC-CPP was shaped by the following hypotheses: (1) Transparent expectations and consequences would increase functional scores and decrease chronic opioid doses; (2) Treatment plans consisting of chronic opioid prescriptions linked with interactive nonpharmacologic interventions led to decreased pain and increased functional scores; (3) Transparent expectations combined with a streamlined approach to the chronic nonmalignant pain patient would improve patient and PCP satisfaction scores.

The PC-CPP was developed to provide an efficient, effective, and evidence-based approach to managing chronic nonmalignant pain and opioid therapy issues in the primary care setting. Referred patients attend 1 shared medical appointment (SMA) every 6 months with up to 19 other female veterans also referred to the PC-CPP. The group was composed of only female veterans as the pilot study for this SMA occurred in the Women’s Clinic. At each 6-month SMA, patients received education from the Taking Opioids Responsibly for Your Safety and the Safety of Others (TORYSSO) guide¹³ and signed the corresponding long-term opioid therapy for pain informed consent form (iMedConsent).

The patient and a staff member developed a treatment plan that was patient driven and included at least 1 nonpharmacologic treatment option. The 1-hour nonpharmacologic sessions were either group or individual and occurred weekly for 6 to 8 weeks. These options included CBT for chronic pain, Living Well With Chronic Conditions, trauma-sensitive yoga, smoking cessation, mindfulness for stress and anxiety, MOVE! weight management, Walk With Ease, and a self-help option (VA-issued Manage Stress Workbook, 2014). The workbook was included as an option for those who lived far away, were limited by work schedules, or were unable to afford the copays for a 6- to 8-session program.

Inclusion and Exclusion Criteria

Any female veteran patient enrolled in the VASLCHCS with a chronic nonmalignant pain diagnosis who received daily opioids for 3 or more consecutive months from a PCP was included. Excluded individuals were those with cognitive decline/dementia, serious mental illness, psychosis, active suicidality, disruptive behavior flag, or those excluded by PCP discretion if it was determined that the patient would do better in a one-on-one setting with the PCP (Table 1). Patients taking > 200 MED/d of opioids who were seen in the VASLCHCS specialty pain clinic were also excluded.

Patient and PCP Responsibilities

The patient was responsible for timely attendance and full participation in all SMA group classes as determined in the veteran’s Treatment Plan Agreement (TPA). In addition, the patient had to provide UDS when requested (a minimum of twice yearly) and communicate with the PCP if having a procedure requiring additional opioids. This was in line with the current standards set forth by the VA Opioid Safety Initiative (OSI) Taskforce.¹²

The PC-CPP provided education, evaluation, documentation, and referral and follow-up with the nonpharmacologic treatment options discussed but did not provide prescription medications. The PCP reviewed the medical documents completed in the PC-CPP, and the PCP was strongly encouraged to follow its recommendations. The expectation was that the PCP would support the PC-CPP when the care recommendation was for a pharmacist-guided opioid taper.

Lack of attendance was defined as a no-show or a reschedule. Patients were considered adherent if they missed fewer than 2 SMA appointments and 2 nonpharmacologic treatment appointments every 6 months. The patient was required to attend the SMA and nonpharmacologic treatment on the third appointment to remain adherent with PC-CPP expectations and agreements. Adherence was acknowledged after 12 and 24 months by a reduction in PC-CPP requirements.

Shared Medical Appointment

Patients referred to the program and who met inclusion criteria received letters explaining the importance of SMA attendance and follow-up reminder calls. At least 30 minutes before the SMA, the patient provided an UDS sample at the laboratory. Next, the patient received an individualized program packet that included the TORYSSO guide, iMedConsent, a TPA specific to the program, a brief pain inventory (BPI) and opioid risk tool, a list of medication disposal sites, and short descriptions of available nonpharmacologic therapies.

Each SMA began with a presentation delivered by a pharmacist, a psychologist, and a medical provider, discussing TORYSSO, program expectations, and holistic approaches to pain. Each SMA also included a rotating chronic pain information topic (eg, nutrition and pain, the physiology of addiction, and the value of multiple modalities in pain treatment). Together, the staff and patients reviewed and completed the blank forms enclosed in the individualized

Each visit was entered into a Computerized Patient Record System (CPRS) template, which included a pain diagnosis, Opioid Risk Tool score, pain and functional scores, opioid fill history, last comprehensive metabolic panel, last electrocardiogram if on methadone, dates of signed agreements, patient adherence with SMA and optional therapies, and follow-up (eFigure).

Every patient enrolled in the PC-CPP had to attend a SMA every 6 months. Patients continued this indefinitely while receiving opioids, and requirements were lessened for patients who had a history of meeting program requirements. For those fully adherent after the first year, only 1 nonpharmacologic intervention was needed (instead of 1 every 6 months) yearly. After 2 years of full adherence, nonpharmacologic interventions were no longer necessary as the expectation was that the patient would continue to use the strategies that they had learned over the previous 2 years. Patients left the PC-CPP if they chose to discontinue opioids, met any of the exclusion criteria, or were nonadherent. Tapering opioid medication was recommended for patients who missed a SMA meeting or 2 nonpharmacologic treatment meetings in a 6-month period; received opioids from more than 1 provider; test positive on a UDS for substances that should not be present; consistently testing negative on a UDS for substances that should be present (indicating diversion); or exhibiting other aberrant behavior (frequent requests for early refills, medications often lost/stolen, etc).

Program Barriers

The PC-CPP took about 2 years to set up, and several barriers were encountered. A thorough understanding of the following factors is necessary for establishing a similar program.

Initially, consults were placed by a designee (someone other than the PCP currently caring for the patient). The designee was usually a member of the PC-CPP who placed consults for all patients who had opioids listed on the CPRS profile. Further, patients who had any opioids within the past 3 months were initially included as were patients who wanted pain education but were not taking opioids. After 12 months, it became apparent that the focus of the PC-CPP should center on patients taking opioids for a minimum of 3 months consecutively. Patients who wanted only education could attend other hospital education opportunities, which helped keep the patient load manageable for PC-CPP staff. Further, to lessen patient confusion and improve adherence, the PCP placed the consult and discussed the program with the patient. Class sizes of 5 to 10 patients seemed to be ideal for patient participation and provider workload.

Patient Education

Initially, the SMA did not follow a standard curriculum, but the current format is more consistent, reproducible, streamlined, and organized. This adjustment improved SMA attendance as well as patient satisfaction, as the class started and finished on time. The SMA also started with numerous handouts, including brochures for nonpharmacologic programs offered at this facility. This led to patients feeling overwhelmed, missing the important forms, and wasted paper. Handouts were simplified to 2 color-coded forms (TPA and BPI).

The take-home assessment was streamlined to a single general assessment. This assessment consisted of 2 questions that asked patients to write a summary of what they learned and then write a summary of how they applied what they learned to their pain management. The VA Manage Stress Workbook also was added to the take-home materials. There are currently 5 different take-home options, which are necessary for those who live more than 50 miles from any VA facility or for those who have transportation issues.

Patient Distress

The SMA could be stressful for patients who felt they were being “punished” or who showed up more than 15 minutes late and had to reschedule the SMA. Having a mental health provider available was crucial for these situations.

Therapeutic Option Development

A cornerstone of the program was getting patients to participate in nonpharmacologic treatment options, which required a robust selection of programs. The VASLCHCS was fortunate to have many programs already available (Table 2), but this was not always the case for the VA community-based outpatient clinics (CBOCs).

Stakeholder Support

Before its start, PC-CPP was presented to the Pentad (a group of 5 individuals in the local facility who hold executive leadership positions) for approval. Tapering opioids can lead to feelings of hostility, frustration, or sadness for patients, so having the Pentad support for the program was crucial to address complaints made to patient advocates or senators. Provider support also was important to reinforce program rules. The PC-CPP inclusion criteria included only those patients whose PCP was agreeable to a taper when the patient did not comply with program expectations. This strategy helped to improve patient adherence with the PC-CPP and decrease patient arguments with clinic staff, as all patients are held to the same standards.

Staff

Finding willing staff can be a challenge. It is estimated that each site needed a program leader who can champion the program objectives and drive organization of staff, space, documentation, and consistency for the patients consulted to the PC-CPP. The goal is that the consistent, reproducible expectations for both the PCP and the patient will reduce overall workload for a clinic. Patients may test the firmness and conviction of the staff to the PC-CPP. Having staff who are able and willing to be firm on relaying information for adherence to the patient is vital.

Administrative Support

At a minimum, a medical support assistant was required to help with scheduling, reminder calls and letters, CPRS check-in/check-out, ensuring necessary forms are ready for the SMA, tracking adherence, and following-up on no-shows and rescheduling.

Documentation

The CPRS consult and note template titles required the approval of the template committee. Although the template is helpful, there is still a great deal that needs to be manually entered in the note, such as BPI scores, opioid risk scores, and chosen nonpharmacologic interventions scores of pain, function, and opioid risk as well individual comorbidities, diagnosis, and follow-up dates. Documentation is geared toward easy review for the PCP who should scan the document prior to renewing opioid medications. The PC-CPP consult became a message board. Once the patient attends the SMA, the designated staff will add a comment to the message board, identifying all dates attended, complete history of the patient’s intervention choices and rate of adherence, as well a follow-up SMA date and whether the patient should bring materials such as take-home tests.

Time Commitment

Program development carries a heavy time burden. One full-time equivalent clinician for 6 weeks for program development is needed. Time allotment is estimated to be the following:

• Medical provider—30 minutes per patient (chart review, documentation, consult resolution). With training, these duties could be completed by support staff
• Pharmacist—30 minutes per patient (chart review, UDS, Utah Division of Occupational and Professional Licensing, fill history). Additional time is needed for writing opioid tapers for qualifying patients
• Primary care mental health integration—a PhD spent 1 to 2 hours per SMA visit assisting patients who became distressed during the visit. Only once has a patient needed to be escorted to the emergency department for active suicidality. A PhD also spent 10+ hours per week running and managing the CBT for Chronic Pain Group
• Support staff—a registered nurse spent 4 hours each month preparing for the SMA (entering consults, ordering EMITs, purchasing snacks)

Conclusion

In this descriptive report, the authors presented an overview of a newly developed program to manage chronic nonmalignant pain and safe opioid prescribing in a primary care setting. A final report is pending. The intent with this interim report was to describe the PC-CPP at the VASLCHCS, its methods and protocols, and logistic considerations for other providers who are working with patients with chronic pain in a primary care model. Standard operating procedure and inclusion/exclusion criteria were included to help with clinical decision making for patients chronic pain for whom aberrant opioid-related behavior presents a problem.

The authors expect that the PC-CPP will provide more comprehensive assisted care, lending to decreased complications associated with accidental overdose, because since patients have been educated about risks for accidental overdose from chronic opioids and have the responsibility for their outcomes. The authors also anticipated that functional scores (as measured by the BPI) will increase despite lowering opioid doses because patients will use ancillary treatments for pain. The desired outcome is that patients will come to understand that pain control is best approached holistically rather than through opioid monotherapy.

There have been several recent initiatives within the VA to decrease opioid prescribing and increase patient safety. With this in mind, continued expansion of this program to CBOCs and male patients could be useful to providers. Also, this program was conducted in a small setting (Women’s Clinic), and there are many challenges with rolling out such a program in a larger clinic (eg, greater chance for provider disagreement, greater need for administrative staff support). Nonetheless, the benefits of close monitoring of prescription opioids and active encouragement to engage in nonpharmacologic therapies are substantial and deserve further advancement.

The Primary Care Chronic Pain Program (PC-CPP) of the Women’s Primary Care Clinics at the VA Salt Lake City Health Care System (VASLCHCS) in Utah was the first VA primary care clinical service to incorporate patient participation in obtaining chronic opioid medications in the treatment of chronic noncancer pain. In addition, the program used a multimodality approach for chronic pain treatment and veteran education about the relationship between physical and mental health issues.

Treatment Complexity

Chronic, noncancer pain is a complex issue in the primary care setting. Diagnosis is difficult, patient education is time consuming, goals and expectations are often unclear, and the experience can be unsatisfying for the patient and the provider.¹ These issues, combined with an estimated prevalence rate of 71% for moderate pain among veterans seen in primary care, present a unique challenge for the primary care provider (PCP), given the limited time available to spend with these complex patients.² Comorbidity rates with mental health issues (eg, depression, anxiety, substance use disorders, etc), which range from 18% to 44%, add to the management challenges for PCPs.³

Veterans also pose unique challenges in pain care as they have a 2-fold greater risk of death from opioid overdose compared with that of the general population, and Utah has been shown to have the highest rate of veteran overdoses.⁴ Developing programs to help PCPs efficiently manage patients with chronic noncancer pain and mental health comorbidities was vital at VASLCHCS.

Before VASLCHCS established the PC-CPP, the treatment for chronic noncancer pain and related mental health comorbidities followed a biomedical model that separated physical and mental health with the treatment focus on pharmacologic management of symptoms by separate services. Consistent with the biomedical model, management of chronic noncancer pain commonly included long-term use of opioids.

Over the past 2 decades, the use of opioids for treating chronic noncancer pain has significantly increased, with more than 62 million opioid prescriptions dispensed in 2012.⁵ There are no longitudinal follow-up studies, however, beyond 16 weeks on the use of opioids.⁶ Further, patients who are prescribed increased opioids continue to report high levels of pain, poor quality of life, and functional disability.⁷ High-dose opioids also are associated with overdose deaths.

Likewise, PCPs in the Women’s Primary Care Clinics at the VASLCHCS struggled with decreasing opioid use, often because other interventions for managing pain and related mental health conditions in primary care were not readily available. Although the VASLCHCS has an effective specialty pain service caring for patients with complex pain issues, opioid morphine equivalent doses > 200 mg/d, and palliative care, patients with chronic noncancer pain treated in the primary care setting did not have a consistent treatment approach.

A chart review of women veterans seen in Women’s Primary Care Clinic (N = 122) revealed that the majority of patients lacked timely urine drug screening, state database queries, signed medication management agreements, and documentation consistent with state and national guidelines. Additionally, many patients lacked provider follow-through regarding alternative and adjunctive therapy consults, which were often discontinued after failed contact attempts or no-shows to scheduled appointments.

There also was a general consensus among the Women’s Primary Care Clinic PCPs that caring for patients with chronic noncancer pain was exhausting, time consuming, ineffective, and often straining on the patient-provider relationship, as evidenced in many patients’ request to change providers secondary to pain management. The PC-CPP was developed to help systematically facilitate safe opioid prescribing, manage chronic pain issues, and document evidence-based care among women veterans receiving treatment for chronic noncancer pain at the Women’s Primary Care Clinics at VASLCHCS while coordinating and following through with nonpharmacologic interventions.

Program Development

National, state, VA, and professional licensure guidelines for chronic noncancer pain treatment standards were reviewed with the goal of creating a program that was evidence based, would benefit the patient in terms of opioid prescribing and pain control, and improve function while identifying key elements of care and documentation that adequately covered the prescriber of retribution.^1,8-10

Concurrent to a review of the guidelines was a review of the literature with the goal of identifying useful patient education and alternative interventions and chronic pain programs that were already established and might meet the clinic’s needs.^10,11 These reviews provided direction for a generalized approach to caring for patients with chronic nonmalignant pain. They also clarified that although pain education programs existed nationally, a program that offered a holistic, reproducible, adherence-driven yet patient-centered approach to the patient prescribed opioids chronically in a primary care setting was lacking.

• Patient education about chronic pain and opioids
• Evaluation of pain, function, opioid misuse risk at least twice yearly
• Patient-centered and driven treatment plans
• A holistic approach to chronic pain interventions
• Review of treatment plan efficacy at least twice yearly
• Enzyme multiplied immunoassay technique urine drug screening (UDS) 2 times per year
• State prescription monitoring program query annually
• Signed iMedConsent for treatment of chronic pain
• Plan for safe discontinuation of opioids
• Documentation that the above has been performed with patient understanding

The literature suggested a multimodality approach to chronic nonmalignant pain by minimizing the use of opioids over time while emphasizing nonpharmacologic therapies, such as cognitive behavioral therapy (CBT), mindfulness, meditation, yoga, and spiritual growth, to name a few.^10,11 These findings are based on several studies, which suggested that passive coping strategies (eg, use of medication for immediate relief, depending on others, restricting medications) result in an increase in subjective pain among chronic nonmalignant pain patients.¹² Helping patients reduce frequent use of passive coping strategies is believed to decrease pain.¹² Active coping strategies (eg, engaging in therapies, staying busy or active, distracting attention from pain) have been found to decrease pain.¹² The PC-CPP program shifted health care outcomes and responsibilities away from the hierarchal PCP-patient relationship toward a collaborative relationship that encourages patient-driven, patient-centered care outcomes and shared responsibilities.

Program Overview

The PC-CPP was shaped by the following hypotheses: (1) Transparent expectations and consequences would increase functional scores and decrease chronic opioid doses; (2) Treatment plans consisting of chronic opioid prescriptions linked with interactive nonpharmacologic interventions led to decreased pain and increased functional scores; (3) Transparent expectations combined with a streamlined approach to the chronic nonmalignant pain patient would improve patient and PCP satisfaction scores.

The PC-CPP was developed to provide an efficient, effective, and evidence-based approach to managing chronic nonmalignant pain and opioid therapy issues in the primary care setting. Referred patients attend 1 shared medical appointment (SMA) every 6 months with up to 19 other female veterans also referred to the PC-CPP. The group was composed of only female veterans as the pilot study for this SMA occurred in the Women’s Clinic. At each 6-month SMA, patients received education from the Taking Opioids Responsibly for Your Safety and the Safety of Others (TORYSSO) guide¹³ and signed the corresponding long-term opioid therapy for pain informed consent form (iMedConsent).

The patient and a staff member developed a treatment plan that was patient driven and included at least 1 nonpharmacologic treatment option. The 1-hour nonpharmacologic sessions were either group or individual and occurred weekly for 6 to 8 weeks. These options included CBT for chronic pain, Living Well With Chronic Conditions, trauma-sensitive yoga, smoking cessation, mindfulness for stress and anxiety, MOVE! weight management, Walk With Ease, and a self-help option (VA-issued Manage Stress Workbook, 2014). The workbook was included as an option for those who lived far away, were limited by work schedules, or were unable to afford the copays for a 6- to 8-session program.

Inclusion and Exclusion Criteria

Any female veteran patient enrolled in the VASLCHCS with a chronic nonmalignant pain diagnosis who received daily opioids for 3 or more consecutive months from a PCP was included. Excluded individuals were those with cognitive decline/dementia, serious mental illness, psychosis, active suicidality, disruptive behavior flag, or those excluded by PCP discretion if it was determined that the patient would do better in a one-on-one setting with the PCP (Table 1). Patients taking > 200 MED/d of opioids who were seen in the VASLCHCS specialty pain clinic were also excluded.

Patient and PCP Responsibilities

The patient was responsible for timely attendance and full participation in all SMA group classes as determined in the veteran’s Treatment Plan Agreement (TPA). In addition, the patient had to provide UDS when requested (a minimum of twice yearly) and communicate with the PCP if having a procedure requiring additional opioids. This was in line with the current standards set forth by the VA Opioid Safety Initiative (OSI) Taskforce.¹²

The PC-CPP provided education, evaluation, documentation, and referral and follow-up with the nonpharmacologic treatment options discussed but did not provide prescription medications. The PCP reviewed the medical documents completed in the PC-CPP, and the PCP was strongly encouraged to follow its recommendations. The expectation was that the PCP would support the PC-CPP when the care recommendation was for a pharmacist-guided opioid taper.

Lack of attendance was defined as a no-show or a reschedule. Patients were considered adherent if they missed fewer than 2 SMA appointments and 2 nonpharmacologic treatment appointments every 6 months. The patient was required to attend the SMA and nonpharmacologic treatment on the third appointment to remain adherent with PC-CPP expectations and agreements. Adherence was acknowledged after 12 and 24 months by a reduction in PC-CPP requirements.

Shared Medical Appointment

Patients referred to the program and who met inclusion criteria received letters explaining the importance of SMA attendance and follow-up reminder calls. At least 30 minutes before the SMA, the patient provided an UDS sample at the laboratory. Next, the patient received an individualized program packet that included the TORYSSO guide, iMedConsent, a TPA specific to the program, a brief pain inventory (BPI) and opioid risk tool, a list of medication disposal sites, and short descriptions of available nonpharmacologic therapies.

Each SMA began with a presentation delivered by a pharmacist, a psychologist, and a medical provider, discussing TORYSSO, program expectations, and holistic approaches to pain. Each SMA also included a rotating chronic pain information topic (eg, nutrition and pain, the physiology of addiction, and the value of multiple modalities in pain treatment). Together, the staff and patients reviewed and completed the blank forms enclosed in the individualized

Each visit was entered into a Computerized Patient Record System (CPRS) template, which included a pain diagnosis, Opioid Risk Tool score, pain and functional scores, opioid fill history, last comprehensive metabolic panel, last electrocardiogram if on methadone, dates of signed agreements, patient adherence with SMA and optional therapies, and follow-up (eFigure).

Every patient enrolled in the PC-CPP had to attend a SMA every 6 months. Patients continued this indefinitely while receiving opioids, and requirements were lessened for patients who had a history of meeting program requirements. For those fully adherent after the first year, only 1 nonpharmacologic intervention was needed (instead of 1 every 6 months) yearly. After 2 years of full adherence, nonpharmacologic interventions were no longer necessary as the expectation was that the patient would continue to use the strategies that they had learned over the previous 2 years. Patients left the PC-CPP if they chose to discontinue opioids, met any of the exclusion criteria, or were nonadherent. Tapering opioid medication was recommended for patients who missed a SMA meeting or 2 nonpharmacologic treatment meetings in a 6-month period; received opioids from more than 1 provider; test positive on a UDS for substances that should not be present; consistently testing negative on a UDS for substances that should be present (indicating diversion); or exhibiting other aberrant behavior (frequent requests for early refills, medications often lost/stolen, etc).

Program Barriers

The PC-CPP took about 2 years to set up, and several barriers were encountered. A thorough understanding of the following factors is necessary for establishing a similar program.

Initially, consults were placed by a designee (someone other than the PCP currently caring for the patient). The designee was usually a member of the PC-CPP who placed consults for all patients who had opioids listed on the CPRS profile. Further, patients who had any opioids within the past 3 months were initially included as were patients who wanted pain education but were not taking opioids. After 12 months, it became apparent that the focus of the PC-CPP should center on patients taking opioids for a minimum of 3 months consecutively. Patients who wanted only education could attend other hospital education opportunities, which helped keep the patient load manageable for PC-CPP staff. Further, to lessen patient confusion and improve adherence, the PCP placed the consult and discussed the program with the patient. Class sizes of 5 to 10 patients seemed to be ideal for patient participation and provider workload.

Patient Education

Initially, the SMA did not follow a standard curriculum, but the current format is more consistent, reproducible, streamlined, and organized. This adjustment improved SMA attendance as well as patient satisfaction, as the class started and finished on time. The SMA also started with numerous handouts, including brochures for nonpharmacologic programs offered at this facility. This led to patients feeling overwhelmed, missing the important forms, and wasted paper. Handouts were simplified to 2 color-coded forms (TPA and BPI).

The take-home assessment was streamlined to a single general assessment. This assessment consisted of 2 questions that asked patients to write a summary of what they learned and then write a summary of how they applied what they learned to their pain management. The VA Manage Stress Workbook also was added to the take-home materials. There are currently 5 different take-home options, which are necessary for those who live more than 50 miles from any VA facility or for those who have transportation issues.

Patient Distress

The SMA could be stressful for patients who felt they were being “punished” or who showed up more than 15 minutes late and had to reschedule the SMA. Having a mental health provider available was crucial for these situations.

Therapeutic Option Development

A cornerstone of the program was getting patients to participate in nonpharmacologic treatment options, which required a robust selection of programs. The VASLCHCS was fortunate to have many programs already available (Table 2), but this was not always the case for the VA community-based outpatient clinics (CBOCs).

Stakeholder Support

Before its start, PC-CPP was presented to the Pentad (a group of 5 individuals in the local facility who hold executive leadership positions) for approval. Tapering opioids can lead to feelings of hostility, frustration, or sadness for patients, so having the Pentad support for the program was crucial to address complaints made to patient advocates or senators. Provider support also was important to reinforce program rules. The PC-CPP inclusion criteria included only those patients whose PCP was agreeable to a taper when the patient did not comply with program expectations. This strategy helped to improve patient adherence with the PC-CPP and decrease patient arguments with clinic staff, as all patients are held to the same standards.

Staff

Finding willing staff can be a challenge. It is estimated that each site needed a program leader who can champion the program objectives and drive organization of staff, space, documentation, and consistency for the patients consulted to the PC-CPP. The goal is that the consistent, reproducible expectations for both the PCP and the patient will reduce overall workload for a clinic. Patients may test the firmness and conviction of the staff to the PC-CPP. Having staff who are able and willing to be firm on relaying information for adherence to the patient is vital.

Administrative Support

At a minimum, a medical support assistant was required to help with scheduling, reminder calls and letters, CPRS check-in/check-out, ensuring necessary forms are ready for the SMA, tracking adherence, and following-up on no-shows and rescheduling.

Documentation

The CPRS consult and note template titles required the approval of the template committee. Although the template is helpful, there is still a great deal that needs to be manually entered in the note, such as BPI scores, opioid risk scores, and chosen nonpharmacologic interventions scores of pain, function, and opioid risk as well individual comorbidities, diagnosis, and follow-up dates. Documentation is geared toward easy review for the PCP who should scan the document prior to renewing opioid medications. The PC-CPP consult became a message board. Once the patient attends the SMA, the designated staff will add a comment to the message board, identifying all dates attended, complete history of the patient’s intervention choices and rate of adherence, as well a follow-up SMA date and whether the patient should bring materials such as take-home tests.

Time Commitment

Program development carries a heavy time burden. One full-time equivalent clinician for 6 weeks for program development is needed. Time allotment is estimated to be the following:

• Medical provider—30 minutes per patient (chart review, documentation, consult resolution). With training, these duties could be completed by support staff
• Pharmacist—30 minutes per patient (chart review, UDS, Utah Division of Occupational and Professional Licensing, fill history). Additional time is needed for writing opioid tapers for qualifying patients
• Primary care mental health integration—a PhD spent 1 to 2 hours per SMA visit assisting patients who became distressed during the visit. Only once has a patient needed to be escorted to the emergency department for active suicidality. A PhD also spent 10+ hours per week running and managing the CBT for Chronic Pain Group
• Support staff—a registered nurse spent 4 hours each month preparing for the SMA (entering consults, ordering EMITs, purchasing snacks)

Conclusion

In this descriptive report, the authors presented an overview of a newly developed program to manage chronic nonmalignant pain and safe opioid prescribing in a primary care setting. A final report is pending. The intent with this interim report was to describe the PC-CPP at the VASLCHCS, its methods and protocols, and logistic considerations for other providers who are working with patients with chronic pain in a primary care model. Standard operating procedure and inclusion/exclusion criteria were included to help with clinical decision making for patients chronic pain for whom aberrant opioid-related behavior presents a problem.

The authors expect that the PC-CPP will provide more comprehensive assisted care, lending to decreased complications associated with accidental overdose, because since patients have been educated about risks for accidental overdose from chronic opioids and have the responsibility for their outcomes. The authors also anticipated that functional scores (as measured by the BPI) will increase despite lowering opioid doses because patients will use ancillary treatments for pain. The desired outcome is that patients will come to understand that pain control is best approached holistically rather than through opioid monotherapy.

There have been several recent initiatives within the VA to decrease opioid prescribing and increase patient safety. With this in mind, continued expansion of this program to CBOCs and male patients could be useful to providers. Also, this program was conducted in a small setting (Women’s Clinic), and there are many challenges with rolling out such a program in a larger clinic (eg, greater chance for provider disagreement, greater need for administrative staff support). Nonetheless, the benefits of close monitoring of prescription opioids and active encouragement to engage in nonpharmacologic therapies are substantial and deserve further advancement.

One in 5 Americans are taking at least 1 psychotropic medication.¹ Elderly dementia patients in extended care facilities are the most likely population to be prescribed psychotropic medication: 87% of these patients are on at least 1 psychotropic medication, 66% on at least 2, 36% on at least 3, and 11% on 4 or more.² Psychotropic medications alleviate the symptoms of mental illness, such as depression, anxiety, and psychosis. Unfortunately, these medications often have adverse effects (AEs), including, but not limited to, excessive sedation, cardiac abnormalities, and tardive dyskinesia.

In 1987, Congress passed the Nursing Home Reform Act (NHRA) as part of the Omnibus Budget Reconciliation Act. The NHRA mandated that residents must remain free of “physical or chemical restraints imposed for the purpose of discipline or convenience.”³

In 1991, in order to meet the NHRA requirements, the Centers for Medicare and Medicaid Services (CMS) issued a guideline that nursing homes should use antipsychotic drug therapy only to treat a specific condition as diagnosed and documented in the clinical record. In 2006, CMS published guidance on the reduction of psychotropic medication usage. These CMS guidelines are the community-accepted standards for prescribing psychotropic medications, and accrediting bodies expect compliance with the guidelines. The guidelines also recommend that antipsychotics should be prescribed at the lowest possible dose, used for the shortest period, and continually undergo gradual dose reduction (GDR).⁴ To ensure these standards are met, a review of the use of psychotropic medications should be performed regularly.

The purpose of this project was to improve documentation of GDR and review of psychotropic medication based on CMS guidelines in the community living centers (CLCs) at the Carl Vinson Veterans Affairs Medical Center (CVVAMC) in Dublin, Georgia.

Background

The CVVAMC provides long-term care to veterans living in CLCs in a comfortable, homelike environment with a person-centered, nursing-home level of care. During a patient’s stay, clinical pharmacy services reviews patient medication use regularly. Additionally, an interdisciplinary team (IDT) of physicians, pharmacists, nurses, recreation therapists, dieticians, and chaplains meet to discuss the medical, psychosocial, and spiritual needs of the residents at the time of admission and quarterly thereafter. Family and caregivers are invited to attend as well.

During the meeting, the IDT care plan is updated and reviewed with the veteran. Currently at the CVVAMC, care plans include discussion of pain management; however, the plan does not address psychotropic medication use. To be compliant with CMS guidelines, during IDT meetings discussion of psychotropic medication use would be advantageous, because physicians could receive input and feedback from other health care team members in determining whether psychotropic medication changes are needed.

Methods

All documentation and chart notes are recorded and stored in the Computerized Patient Record System (CPRS). The purpose of an electronic template within CPRS is to provide standardized, guided documentation in an easy-to-use format that can be integrated smoothly into the existing system. Template utilization has been shown to improve documentation of medication reconciliation, health records, and coding in the VA health system.^5-7 A review of CPRS showed that no template existed for documenting psychotropic medication initiation and GDR.

Objectives

The authors’ primary objective was to improve patient record documentation in CPRS through implementation of staff education and an electronic template for physicians to document the management of psychotropic medications and patients’ GDRs. The secondary objective was to implement a discussion involving the physician and other members of the team during IDT meetings about patient safety and effectiveness of psychotropic medications.

Template

To improve the suboptimal compliance with the CMS guidelines, an electronic template was created to evaluate GDR attempts and facilitate review of prescribed psychotropic medications. The pharmacy and therapeutics committee approved the template, and the clinical applications coordinator implemented the electronic template. The template was then revised as necessary for ease of use, based on health care provider (HCP) and pharmacist feedback.

The use of the electronic template was phased in over a 1-month period. Complete implementation was achieved in January 2014. An in-service was provided for nurses, HCPs, and directors on the importance of psychotropic medication review and GDRs. A second in-service was conducted for the HCPs to learn how to properly complete the electronic template. Providers were instructed to use the template during IDT meetings when completing monthly chart reviews and changing psychotropic medications.

Additionally, resident assessment coordinators who attend all IDT meetings were requested to remind the team to discuss psychotropic medication use if appropriate in an effort to add a psychotropic medication review to the IDT care plan.

To determine whether the electronic template improved documentation, a retrospective chart review of CPRS was conducted February 2014. The study included veterans in the CLC who were prescribed psychotropic medications since January 2014. The subjects who screened positive for psychotropic medication use were further evaluated by chart review. Before and after implementation, information was collected on the number and percentage of patients who had documentation in their CPRS records of a psychotropic medication review and on whether a GDR evaluation was recorded in CPRS. Additionally, a clinical pharmacist specialist attending the IDT meeting monitored the incidence of psychotropic medication review or discussion that took place if the veteran was on an included agent.

Results

A total of 67 patients on psychotropic medication on the CLC wards since January 2014 were included in the program. Before implementation of the program, 35 patients had documentation of psychotropic medication review. Following implementation, this increased to 54 patients. Hence, 80% of the patients had appropriate documentation.

Before implementation, no patients had documentation regarding evaluation of a GDR in CPRS. After the program implementation, 54 patients had documentation of GDR. Of the 54 patients, 50 had documentation that a GDR could not be completed, and 4 patients had undergone a trial of GDR with appropriate documentation in CPRS (Figure).

The secondary objective evaluated how often a review of patient’s psychotropic medication occurred during IDT meetings. During March 2014, 21 patients with scheduled IDT meetings were prescribed psychotropic medications. For 14 of the 21 patients (67%) appropriateness of psychotropic medications was reviewed with the team and the resident’s families.

Discussion

Documentation is fundamental to improving quality of care, patient outcomes, and reimbursement for the facility. Effective since July 1, 2014, the Joint Commission standards for Nursing Care Center accreditation require the physician and consulting pharmacist to review the patients’ or residents’ medication list. The review should verify the following:

• Clinical indication for the antipsychotic medication;
• Necessity for ongoing use of the antipsychotic medication;
• Consideration of GDR of the antipsychotic medication;
• Consideration of an alternative to antipsychotic medication use.⁸

When used correctly, the psychotropic medication review and GDR template ensures veterans’ psychotropic medications are continually reviewed. Furthermore, better psychotropic medication management allows veterans to be adequately treated while minimizing the risk for potential AEs.

At CVVAMC, the electronic template helped improve documentation and evaluation of GDR. The CVVAMC success can be attributed partly to physicians who were willing to use the template.

New standards from the Joint Commission provided an additional incentive to use the template. The Joint Commission also required that patients and their family be involved in decisions about placing the resident on antipsychotic medication. The optimal time for this discussion is during IDT meetings. At CVVAMC, discussion of psychotropic medications took place in IDT meetings for 67% of the patients prescribed psychotropic medication.

It is important to note that tools, such as this template, are successful only if they are used by HCPs. The CPRS does not have any clinical reminders to prompt physicians to complete the task. Instead, HCPs had to develop a routine of entering information into the template. Additionally, if the resident assessment coordinator was not at the IDT meeting, discussion of psychotropic medication was not always completed. After completion of this project, psychotropic medication review has become a permanent component of the IDT care plan.

Conclusion

This project demonstrated that template development and use have the potential to improve documentation, patient care, and survey scores. The electronic template could potentially benefit any long-term care facility that uses an electronic recording system. Further research should focus on ease of use and on ensuring that a psychotropic medication review is added to all CLC IDT care plans.

Acknowledgments

The authors acknowledge Brooke Butler, clinical pharmacy specialist and project mentor for her assistance and guidance; and Deborah Hobbs, residency director, both at the Carl Vinson VA Medical Center for her input and leadership, and Freddie Miles, for her work on development of the electronic order set.

One in 5 Americans are taking at least 1 psychotropic medication.¹ Elderly dementia patients in extended care facilities are the most likely population to be prescribed psychotropic medication: 87% of these patients are on at least 1 psychotropic medication, 66% on at least 2, 36% on at least 3, and 11% on 4 or more.² Psychotropic medications alleviate the symptoms of mental illness, such as depression, anxiety, and psychosis. Unfortunately, these medications often have adverse effects (AEs), including, but not limited to, excessive sedation, cardiac abnormalities, and tardive dyskinesia.

In 1987, Congress passed the Nursing Home Reform Act (NHRA) as part of the Omnibus Budget Reconciliation Act. The NHRA mandated that residents must remain free of “physical or chemical restraints imposed for the purpose of discipline or convenience.”³

In 1991, in order to meet the NHRA requirements, the Centers for Medicare and Medicaid Services (CMS) issued a guideline that nursing homes should use antipsychotic drug therapy only to treat a specific condition as diagnosed and documented in the clinical record. In 2006, CMS published guidance on the reduction of psychotropic medication usage. These CMS guidelines are the community-accepted standards for prescribing psychotropic medications, and accrediting bodies expect compliance with the guidelines. The guidelines also recommend that antipsychotics should be prescribed at the lowest possible dose, used for the shortest period, and continually undergo gradual dose reduction (GDR).⁴ To ensure these standards are met, a review of the use of psychotropic medications should be performed regularly.

The purpose of this project was to improve documentation of GDR and review of psychotropic medication based on CMS guidelines in the community living centers (CLCs) at the Carl Vinson Veterans Affairs Medical Center (CVVAMC) in Dublin, Georgia.

Background

The CVVAMC provides long-term care to veterans living in CLCs in a comfortable, homelike environment with a person-centered, nursing-home level of care. During a patient’s stay, clinical pharmacy services reviews patient medication use regularly. Additionally, an interdisciplinary team (IDT) of physicians, pharmacists, nurses, recreation therapists, dieticians, and chaplains meet to discuss the medical, psychosocial, and spiritual needs of the residents at the time of admission and quarterly thereafter. Family and caregivers are invited to attend as well.

During the meeting, the IDT care plan is updated and reviewed with the veteran. Currently at the CVVAMC, care plans include discussion of pain management; however, the plan does not address psychotropic medication use. To be compliant with CMS guidelines, during IDT meetings discussion of psychotropic medication use would be advantageous, because physicians could receive input and feedback from other health care team members in determining whether psychotropic medication changes are needed.

Methods

All documentation and chart notes are recorded and stored in the Computerized Patient Record System (CPRS). The purpose of an electronic template within CPRS is to provide standardized, guided documentation in an easy-to-use format that can be integrated smoothly into the existing system. Template utilization has been shown to improve documentation of medication reconciliation, health records, and coding in the VA health system.^5-7 A review of CPRS showed that no template existed for documenting psychotropic medication initiation and GDR.

Objectives

The authors’ primary objective was to improve patient record documentation in CPRS through implementation of staff education and an electronic template for physicians to document the management of psychotropic medications and patients’ GDRs. The secondary objective was to implement a discussion involving the physician and other members of the team during IDT meetings about patient safety and effectiveness of psychotropic medications.

Template

To improve the suboptimal compliance with the CMS guidelines, an electronic template was created to evaluate GDR attempts and facilitate review of prescribed psychotropic medications. The pharmacy and therapeutics committee approved the template, and the clinical applications coordinator implemented the electronic template. The template was then revised as necessary for ease of use, based on health care provider (HCP) and pharmacist feedback.

The use of the electronic template was phased in over a 1-month period. Complete implementation was achieved in January 2014. An in-service was provided for nurses, HCPs, and directors on the importance of psychotropic medication review and GDRs. A second in-service was conducted for the HCPs to learn how to properly complete the electronic template. Providers were instructed to use the template during IDT meetings when completing monthly chart reviews and changing psychotropic medications.

Additionally, resident assessment coordinators who attend all IDT meetings were requested to remind the team to discuss psychotropic medication use if appropriate in an effort to add a psychotropic medication review to the IDT care plan.

To determine whether the electronic template improved documentation, a retrospective chart review of CPRS was conducted February 2014. The study included veterans in the CLC who were prescribed psychotropic medications since January 2014. The subjects who screened positive for psychotropic medication use were further evaluated by chart review. Before and after implementation, information was collected on the number and percentage of patients who had documentation in their CPRS records of a psychotropic medication review and on whether a GDR evaluation was recorded in CPRS. Additionally, a clinical pharmacist specialist attending the IDT meeting monitored the incidence of psychotropic medication review or discussion that took place if the veteran was on an included agent.

Results

A total of 67 patients on psychotropic medication on the CLC wards since January 2014 were included in the program. Before implementation of the program, 35 patients had documentation of psychotropic medication review. Following implementation, this increased to 54 patients. Hence, 80% of the patients had appropriate documentation.

Before implementation, no patients had documentation regarding evaluation of a GDR in CPRS. After the program implementation, 54 patients had documentation of GDR. Of the 54 patients, 50 had documentation that a GDR could not be completed, and 4 patients had undergone a trial of GDR with appropriate documentation in CPRS (Figure).

The secondary objective evaluated how often a review of patient’s psychotropic medication occurred during IDT meetings. During March 2014, 21 patients with scheduled IDT meetings were prescribed psychotropic medications. For 14 of the 21 patients (67%) appropriateness of psychotropic medications was reviewed with the team and the resident’s families.

Discussion

Documentation is fundamental to improving quality of care, patient outcomes, and reimbursement for the facility. Effective since July 1, 2014, the Joint Commission standards for Nursing Care Center accreditation require the physician and consulting pharmacist to review the patients’ or residents’ medication list. The review should verify the following:

• Clinical indication for the antipsychotic medication;
• Necessity for ongoing use of the antipsychotic medication;
• Consideration of GDR of the antipsychotic medication;
• Consideration of an alternative to antipsychotic medication use.⁸

When used correctly, the psychotropic medication review and GDR template ensures veterans’ psychotropic medications are continually reviewed. Furthermore, better psychotropic medication management allows veterans to be adequately treated while minimizing the risk for potential AEs.

At CVVAMC, the electronic template helped improve documentation and evaluation of GDR. The CVVAMC success can be attributed partly to physicians who were willing to use the template.

New standards from the Joint Commission provided an additional incentive to use the template. The Joint Commission also required that patients and their family be involved in decisions about placing the resident on antipsychotic medication. The optimal time for this discussion is during IDT meetings. At CVVAMC, discussion of psychotropic medications took place in IDT meetings for 67% of the patients prescribed psychotropic medication.

It is important to note that tools, such as this template, are successful only if they are used by HCPs. The CPRS does not have any clinical reminders to prompt physicians to complete the task. Instead, HCPs had to develop a routine of entering information into the template. Additionally, if the resident assessment coordinator was not at the IDT meeting, discussion of psychotropic medication was not always completed. After completion of this project, psychotropic medication review has become a permanent component of the IDT care plan.

Conclusion

This project demonstrated that template development and use have the potential to improve documentation, patient care, and survey scores. The electronic template could potentially benefit any long-term care facility that uses an electronic recording system. Further research should focus on ease of use and on ensuring that a psychotropic medication review is added to all CLC IDT care plans.

Acknowledgments

The authors acknowledge Brooke Butler, clinical pharmacy specialist and project mentor for her assistance and guidance; and Deborah Hobbs, residency director, both at the Carl Vinson VA Medical Center for her input and leadership, and Freddie Miles, for her work on development of the electronic order set.

One in 5 Americans are taking at least 1 psychotropic medication.¹ Elderly dementia patients in extended care facilities are the most likely population to be prescribed psychotropic medication: 87% of these patients are on at least 1 psychotropic medication, 66% on at least 2, 36% on at least 3, and 11% on 4 or more.² Psychotropic medications alleviate the symptoms of mental illness, such as depression, anxiety, and psychosis. Unfortunately, these medications often have adverse effects (AEs), including, but not limited to, excessive sedation, cardiac abnormalities, and tardive dyskinesia.

In 1987, Congress passed the Nursing Home Reform Act (NHRA) as part of the Omnibus Budget Reconciliation Act. The NHRA mandated that residents must remain free of “physical or chemical restraints imposed for the purpose of discipline or convenience.”³

In 1991, in order to meet the NHRA requirements, the Centers for Medicare and Medicaid Services (CMS) issued a guideline that nursing homes should use antipsychotic drug therapy only to treat a specific condition as diagnosed and documented in the clinical record. In 2006, CMS published guidance on the reduction of psychotropic medication usage. These CMS guidelines are the community-accepted standards for prescribing psychotropic medications, and accrediting bodies expect compliance with the guidelines. The guidelines also recommend that antipsychotics should be prescribed at the lowest possible dose, used for the shortest period, and continually undergo gradual dose reduction (GDR).⁴ To ensure these standards are met, a review of the use of psychotropic medications should be performed regularly.

The purpose of this project was to improve documentation of GDR and review of psychotropic medication based on CMS guidelines in the community living centers (CLCs) at the Carl Vinson Veterans Affairs Medical Center (CVVAMC) in Dublin, Georgia.

Background

The CVVAMC provides long-term care to veterans living in CLCs in a comfortable, homelike environment with a person-centered, nursing-home level of care. During a patient’s stay, clinical pharmacy services reviews patient medication use regularly. Additionally, an interdisciplinary team (IDT) of physicians, pharmacists, nurses, recreation therapists, dieticians, and chaplains meet to discuss the medical, psychosocial, and spiritual needs of the residents at the time of admission and quarterly thereafter. Family and caregivers are invited to attend as well.

During the meeting, the IDT care plan is updated and reviewed with the veteran. Currently at the CVVAMC, care plans include discussion of pain management; however, the plan does not address psychotropic medication use. To be compliant with CMS guidelines, during IDT meetings discussion of psychotropic medication use would be advantageous, because physicians could receive input and feedback from other health care team members in determining whether psychotropic medication changes are needed.

Methods

All documentation and chart notes are recorded and stored in the Computerized Patient Record System (CPRS). The purpose of an electronic template within CPRS is to provide standardized, guided documentation in an easy-to-use format that can be integrated smoothly into the existing system. Template utilization has been shown to improve documentation of medication reconciliation, health records, and coding in the VA health system.^5-7 A review of CPRS showed that no template existed for documenting psychotropic medication initiation and GDR.

Objectives

The authors’ primary objective was to improve patient record documentation in CPRS through implementation of staff education and an electronic template for physicians to document the management of psychotropic medications and patients’ GDRs. The secondary objective was to implement a discussion involving the physician and other members of the team during IDT meetings about patient safety and effectiveness of psychotropic medications.

Template

To improve the suboptimal compliance with the CMS guidelines, an electronic template was created to evaluate GDR attempts and facilitate review of prescribed psychotropic medications. The pharmacy and therapeutics committee approved the template, and the clinical applications coordinator implemented the electronic template. The template was then revised as necessary for ease of use, based on health care provider (HCP) and pharmacist feedback.

The use of the electronic template was phased in over a 1-month period. Complete implementation was achieved in January 2014. An in-service was provided for nurses, HCPs, and directors on the importance of psychotropic medication review and GDRs. A second in-service was conducted for the HCPs to learn how to properly complete the electronic template. Providers were instructed to use the template during IDT meetings when completing monthly chart reviews and changing psychotropic medications.

Additionally, resident assessment coordinators who attend all IDT meetings were requested to remind the team to discuss psychotropic medication use if appropriate in an effort to add a psychotropic medication review to the IDT care plan.

To determine whether the electronic template improved documentation, a retrospective chart review of CPRS was conducted February 2014. The study included veterans in the CLC who were prescribed psychotropic medications since January 2014. The subjects who screened positive for psychotropic medication use were further evaluated by chart review. Before and after implementation, information was collected on the number and percentage of patients who had documentation in their CPRS records of a psychotropic medication review and on whether a GDR evaluation was recorded in CPRS. Additionally, a clinical pharmacist specialist attending the IDT meeting monitored the incidence of psychotropic medication review or discussion that took place if the veteran was on an included agent.

Results

A total of 67 patients on psychotropic medication on the CLC wards since January 2014 were included in the program. Before implementation of the program, 35 patients had documentation of psychotropic medication review. Following implementation, this increased to 54 patients. Hence, 80% of the patients had appropriate documentation.

Before implementation, no patients had documentation regarding evaluation of a GDR in CPRS. After the program implementation, 54 patients had documentation of GDR. Of the 54 patients, 50 had documentation that a GDR could not be completed, and 4 patients had undergone a trial of GDR with appropriate documentation in CPRS (Figure).

The secondary objective evaluated how often a review of patient’s psychotropic medication occurred during IDT meetings. During March 2014, 21 patients with scheduled IDT meetings were prescribed psychotropic medications. For 14 of the 21 patients (67%) appropriateness of psychotropic medications was reviewed with the team and the resident’s families.

Discussion

Documentation is fundamental to improving quality of care, patient outcomes, and reimbursement for the facility. Effective since July 1, 2014, the Joint Commission standards for Nursing Care Center accreditation require the physician and consulting pharmacist to review the patients’ or residents’ medication list. The review should verify the following:

• Clinical indication for the antipsychotic medication;
• Necessity for ongoing use of the antipsychotic medication;
• Consideration of GDR of the antipsychotic medication;
• Consideration of an alternative to antipsychotic medication use.⁸

When used correctly, the psychotropic medication review and GDR template ensures veterans’ psychotropic medications are continually reviewed. Furthermore, better psychotropic medication management allows veterans to be adequately treated while minimizing the risk for potential AEs.

At CVVAMC, the electronic template helped improve documentation and evaluation of GDR. The CVVAMC success can be attributed partly to physicians who were willing to use the template.

New standards from the Joint Commission provided an additional incentive to use the template. The Joint Commission also required that patients and their family be involved in decisions about placing the resident on antipsychotic medication. The optimal time for this discussion is during IDT meetings. At CVVAMC, discussion of psychotropic medications took place in IDT meetings for 67% of the patients prescribed psychotropic medication.

It is important to note that tools, such as this template, are successful only if they are used by HCPs. The CPRS does not have any clinical reminders to prompt physicians to complete the task. Instead, HCPs had to develop a routine of entering information into the template. Additionally, if the resident assessment coordinator was not at the IDT meeting, discussion of psychotropic medication was not always completed. After completion of this project, psychotropic medication review has become a permanent component of the IDT care plan.

Conclusion

This project demonstrated that template development and use have the potential to improve documentation, patient care, and survey scores. The electronic template could potentially benefit any long-term care facility that uses an electronic recording system. Further research should focus on ease of use and on ensuring that a psychotropic medication review is added to all CLC IDT care plans.

Acknowledgments

The authors acknowledge Brooke Butler, clinical pharmacy specialist and project mentor for her assistance and guidance; and Deborah Hobbs, residency director, both at the Carl Vinson VA Medical Center for her input and leadership, and Freddie Miles, for her work on development of the electronic order set.