To examine the hypothesis that a demonstration clinic integrating homeless, primary care, and mental health services for homeless veterans with serious mental illness or substance abuse would improve medical health care access and physical health status. A quasi-experimental design comparing a 'usual VA care' group before the demonstration clinic opened (N = 130) and the 'integrated care' group (N = 130). Regression models indicated that the integrated care group was more rapidly enrolled in primary care, received more prevention services and primary care visits, and fewer emergency department visits, and was not different in inpatient utilization or in physical health status over 18 months. The demonstration clinic improved access to primary care services and reduced emergency services but did not improve perceived physical health status over 18 months. Further research is needed to determine generalizability and longer term effects.
The quality of physician-patient communication is a critical factor in treatment outcomes and patient satisfaction with care. To date, few studies have specifically conducted an in-depth evaluation of the effect of telemedicine (TM) on physician-patient communication in a medical setting. Our objective was to determine whether physical separation and technology used during TM have a negative effect on physician-patient communication. In this noninferiority randomized clinical trial, patients were randomized to receive a single consultation with one of 9 physicians, either in person (IP) or via TM. Patients (n = 221) were recruited from pulmonary, endocrine, and rheumatology clinics at a Midwestern Veterans Administration hospital. Physician-patient communication was measured using a validated self-report questionnaire consisting of 33 items measuring satisfaction with visit convenience and physician's patient-centered communication, clinical competence, and interpersonal skills. Satisfaction for physician's patient-centered communication was similar for both consultation types (TM = 3.76 versus IP = 3.61), and noninferiority of TM was confirmed (noninferiority t-test p = 0.002). Patient satisfaction with physician's clinical competence (TM = 4.63 versus IP = 4.52) and physician's interpersonal skills (TM = 4.79 versus IP = 4.74) were similar, and noninferiority of TM was confirmed (noninferiority t-test p = 0.006 and p = 0.04, respectively). Patients reported greater satisfaction with convenience for TM as compared to IP consultations (TM = 4.41 versus IP = 2.37, noninferiority t-test p < 0.001). Patients were equally satisfied with physician's ability to develop rapport, use shared decision making, and promote patient-centered communication during TM and IP consultations. Our data suggest that, despite physical separation, physician-patient communication during TM is not inferior to communication during IP consultations.
Initial evaluation of an advanced access clinic developed at a VA medical center (VAMC) found decreased Mental Health wait times and improved quality of care for veterans with depression. Subsequently, modified advanced access models were implemented at affiliated community-based outreach clinics (CBOCs). By comparing each site, we sought to determine whether less resource-intensive models could improve care to the same degree. We assessed contributions of the model's components to the improvement of care (i.e., wait times and depression treatment adequacy). The modified advanced access models led to significant improvements, although no such improvements were seen at 2 control sites. Six features related to rapid access, short-term treatment, and barrier-free access to mental health services accounted for most of the observed improvements. CBOCs can implement limited advanced mental health access models and derive similar improvements to those seen in more extensive models at the VAMCs to which they are affiliated.
This case study examines how the Veterans Affairs Greater Los Angeles Healthcare System (GLA) improved homeless veteran service utilization through program innovation that addressed service fragmentation. The new program offered same-day co-located mental health, medical, and homeless services with a coordinated intake system. The program is analyzed using a framework proposed by Rosenheck (2001) that has four phases: the decision to implement, initial implementation, sustained maintenance, and termination or transformation. GLA was able to successfully implement a new program that remains in the sustained maintenance phase five years after the initial decision to implement. Key factors from the Rosenheck innovation model in the program's success included coalition building, linking the project to legitimate goals, program monitoring, and developing communities of practicing clinicians. The key lesson from the case study is the need for a coalition to persistently problem solve and act as advocates for the program, even after successful initial implementation. Social work leadership was critical in all phases of program implementation.
OBJECTIVE: Depression is commonly seen, but infrequently adequately treated, in primary care clinics. Improving access to depression care in primary care clinics has improved outcomes in clinical trials; however, these interventions are largely unstudied in clinical settings. This study examined the effectiveness of a quality improvement project improving access to mental healthcare in a large primary care clinic.
METHODS: A before-after study evaluating the efficacy of the integration of a primary mental healthcare (PMHC) clinic into a large primary care clinic at the White River Junction, Vermont Veterans Affairs Medical Center (VAMC). In the before period (2003), a traditional referral and schedule model was used to access mental healthcare services. Patients who had screened positive for depression using a depression screen for 6 months after entry into either model were retrospectively followed. VA clinics without a PMHC were used as a control. The proportion of patients who received any depression treatment and guideline-adhering depression treatment in each model was compared, as well as the volume of patients seen in mental health clinics and the wait time to be seen by mental health personnel.
RESULTS: 383 and 287 patients screened positive for depression at VAMC and the community-based outreach clinic, respectively. Demographics of the before and after cohorts did not differ. The PMHC model was associated with a greater proportion of patients who had screened positive for depression obtaining some depression treatment (52.3% vs 37.8%; p<0.001), an increase in guideline-adherent depression treatment for depression (11% vs 1%; p<0.001).
CONCLUSIONS: Implementation of the PMHC model was associated with more rapid and improved treatment for depression in the population of patients who screened positive for depression. More widespread implementation of this model should be investigated.
OBJECTIVE: A 9-month pilot study was initiated to evaluate the feasibility of a Web-based telemedicine program for remote wound care team consultations for patients with chronic wounds.
METHOD: Wound care nurses in Veterans Health Administration outpatient clinics evaluated 56 patients with chronic wounds over the course of 208 clinic visits. The wounds were predominantly lower-extremity ulcers (diabetic and vascular). The Veterans Affairs Computerized Patient Record System and the Internet were used to obtain consultations and transmit data (store-forward) between the nurse specialists and a multidisciplinary wound care team located at the regional tertiary care center.
RESULTS: During the course of the study, 76% of wounds treated decreased in size; mean response time for consultations was 2.61 days. Exit surveys indicated that 98.2% of patients were satisfied with care; referring providers also indicated a high degree of satisfaction with the teleconsult system.
CONCLUSIONS: This study demonstrated that a multidisciplinary wound care team using a store-forward approach can feasibly provide telemedicine consultations for patients in remote locations.
To explore perspectives concerning use of a mobile geriatrics unit (MGU) by underserved populations in low-income urban neighborhoods, we recruited 18 elderly African American patients and engaged them in in-depth semistructured interviews. Using grounded theory techniques of constant comparative analysis, we found that most patients learned about the MGU from community members and initially visited it to determine whether it would be worth using in the future. In describing their MGU experiences, patients tended to focus on three main factors: quality of care, accessibility of services, and ambience of the care setting. They reported that the MGU allowed them to have their health conditions and medications monitored regularly and functioned as a central link to the larger Veterans Affairs health care system. The findings suggest that using MGUs is an acceptable and effective way to help medically underserved populations receive primary medical care and referrals to specialty care.
BACKGROUND: Patients presenting for treatment of substance use disorders (SUDs) often exhibit medical comorbidities that affect functional health status and healthcare costs. Providing primary care within addictions clinics (onsite care) may improve medical and SUD treatment outcomes in this population. OBJECTIVE: The objective of this study was to compare outcomes among Veterans' Administration (VA) patients who receive medical care within the SUD clinic and those referred to a general medicine clinic at the same facility. METHODS: Veterans entering SUD treatment with a chronic medical condition and no current primary care were randomized to receive primary medical care: 1) onsite in the VA SUD clinic (n = 358), or 2) in the VA general internal medicine clinic (n = 362). Subjects were assessed at baseline and at 3, 6, and 12 months postrandomization. Intention-to-treat analyses used random-effects regression. Measures: Measures included SF-36 Physical and Mental Component Summaries (PCS, MCS), VA service utilization, SUD treatment retention, Addiction Severity Index (ASI) scores, 30-day abstinence, and total VA healthcare costs. RESULTS: Over the study year, patients assigned to onsite care were more likely to attend primary care (adjusted odds ratio [OR] = 2.20; 95% confidence interval [CI] = 1.53-3.15) and to remain engaged in SUD treatment at 3 months (adjusted OR = 1.36; 1.00-1.84). Overall, outcomes on the MCS (but not the PCS) and the ASI improved significantly over time but did not differ by treatment condition. Total VA healthcare costs did not differ reliably across conditions. CONCLUSIONS: Compared with referral care, providing primary care within a VA addiction clinic increased primary care access and initial SUD treatment retention but showed no effect on overall health status or costs. (PsycInfo Database Record (c) 2021 APA, all rights reserved)
The Department of Veterans Affairs (VA) has been establishing community-based outpatient clinics (CBOCs) across the country to improve veterans' access to and use of primary care services, thereby decreasing the need for costly specialty outpatient and inpatient care. Using a quasi-experimental, pre-post study design, we examined whether the establishment of CBOCs has affected access, use, and costs for VA patients residing in their catchment areas. Most patients residing in CBOC catchment areas did not receive care at CBOCs, resulting in only small increases in primary care utilization. While CBOCs improved veterans' access, they had little impact on overall patterns of utilization and cost.
OBJECTIVE: To determine whether strategies designed to increase members' use of primary care services result in decreases (substitution) or increases (complementation) in the use and cost of other types of health services.
STUDY SETTING: Encounter and cost data were extracted from the Department of Veterans Affairs (VA) administrative data sources for the period 1995-1999. This timeframe captures the VA's natural experiment of increasing geographic access to primary care by establishing new satellite primary care clinics, known as Community-Based Outpatient Clinics (CBOCs).
STUDY DESIGN: We exploited this natural experiment to estimate the substitutability of primary care for other health services and its impact on cost. Hypotheses were tested using ordinary least squares (OLS) regression, which was potentially subject to endogeneity bias. Endogeneity bias was assessed using a Hausman test. Endogeneity bias was accounted for by using instrumental variables analysis, which capitalized on the establishment of CBOCs to provide an exogenous identifier (change in travel distance to primary care).
DATA COLLECTION: Demographic, encounter, and cost data were collected for all veterans using VA health services who resided in the catchment areas of new CBOCs and for a matched group of veterans residing outside CBOC catchment areas.
PRINCIPAL FINDINGS: Change in distance to primary care was a significant and substantial predictor of change in primary care visits. OLS analyses indicated that an increase in primary care service use was associated with increases in the use of all specialty outpatient services and inpatient services, as well as increases in inpatient and outpatient costs. Hausman tests confirmed that OLS results for specialty mental health encounters and mental health admissions were unbiased, but that results for specialty medical encounters, physical health admissions, and outpatient costs were biased. Instrumental variables analyses indicated that an increase in primary care encounters was associated with a decrease in specialty medical encounters and was not associated with an increase in physical health admissions, or outpatient costs.
CONCLUSIONS: Results provide evidence that health systems can implement strategies to encourage their members to use more primary care services without driving up physical health costs.
To examine the hypothesis that a demonstration clinic integrating homeless, primary care, and mental health services for homeless veterans with serious mental illness or substance abuse would improve medical health care access and physical health status. A quasi-experimental design comparing a 'usual VA care' group before the demonstration clinic opened (N = 130) and the 'integrated care' group (N = 130). Regression models indicated that the integrated care group was more rapidly enrolled in primary care, received more prevention services and primary care visits, and fewer emergency department visits, and was not different in inpatient utilization or in physical health status over 18 months. The demonstration clinic improved access to primary care services and reduced emergency services but did not improve perceived physical health status over 18 months. Further research is needed to determine generalizability and longer term effects.
