Impacts - Center for Healthcare Organization & Implementation Research
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Center for Healthcare Organization & Implementation Research


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CHOIR investigators have contributed to VHA and beyond in crucial, meaningful ways, and we highlight here a few examples:

Impacts: VA and other government organizations

Breaking Down Geographic Barriers to Evidence-Based, Veteran-Centered Specialty Care for Veterans with Complex Mental Health Conditions
Dr. Mark Bauer was approached by VA's Office of Mental Health Operations and Office of Patient Care Services, Mental Health Services (OMHO/MHS), and the VA Office of Telehealth Services (Connected Health), to develop and implement a clinical video-conference based format for the Bipolar Collaborative Care Model, for severe mental health conditions treated in mental health clinics. The Bipolar CCM is designed to overcome the issue of critical mass and breaking down geographic barriers to specialty care access for this condition. To date, the Bipolar Telehealth program has received more than 750 consults and is active in 27 sites across eight VA regional networks. Analyses presented at the 2015 HSR&D National Meeting demonstrate significant improvement in health outcomes for program participants, including Veterans residing in rural settings and those treated at small community-based outpatient clinics (CBOCs). Dr. Bauer and his team have been supported by VA HSR&D, as well as the National Institutes of Health (NIH), and the Agency for Healthcare Research and Quality (AHRQ). The Bipolar CCM has been incorporated into the VA/DoD Practice Guidelines for the Management of Bipolar Disorder in Adults (2010), and has been listed on the prestigious Substance Abuse and Mental Health Services Administration (SAMHSA) National Registry of Evidence-Based Programs and Practices (NREPP, 2013).

Adoption of RAISE Instrument by Long-Term Care Institute

Dr. Christine Hartmann and colleagues developed the Resident-centered Assessment of Interaction and Resident Engagement (RAISE) structured observation tools with VA HSR&D support, and the Office of Geriatrics and Extended Care (GEC) has now selected these tools to replace the currently used measure of person centered care, which will be phased out. The RAISE tools were developed in two HSR&D-funded grants (PPO 09-266 and CRE 11-349: Hartmann, Principal Investigator). RAISE tools measure critical aspects of person-centered care, namely the interactions between Community Living Center (CLC) residents and staff and CLC residents’ engagement in life. RAISE will be rolled out to Community Living Centers nationally in FY17.

Using Proactive Secure Messaging to Enhance Patient-Centeredness and Outcomes
Dr. Thomas Houston* and his team conducted a two phase evaluation of Secure Messaging (SM) implementation with VA Quality Enhancement Research Initiative (QUERI) funding. Secure Messaging has been demonstrated as a patient-desired, efficient form of expanding services that is specifically mentioned by the Institute of Medicine as a part of patient-centered continuous care. The project culminated in a formal proactive secure messaging implementation program at the Providence VAMC and Worcester CBOC. Over six months, over 2000 pre-visit messages were sent to Veterans. Veterans replied to these messages with diverse topics for discussion ranging from medication questions, concerns about current pain levels, and questions about healthcare coverage. Most messages were sent either the same day or the next day after the pre-visit message was received. This roll-out has provided and essential demonstration of use of secure messaging for pre-visit preparation, improved communication, and patient-centered care to reflects the priorities and preferences of Veterans.

Automation of Safety Event Detection for Systems Improvement of Patient Safety
Dr. Amy Rosen and her team, with the support of Patient Safety Center of Inquiry (PSCI) funding, aim to advance the field of patient safety measurement and develop tools that can be disseminated and implemented throughout the VA healthcare system. In FY15, the PSCI conducted projects to develop tools for VA field use, to improve and automate safety event detection. (1) An automated, VA electronic medical record-based, measurement tool to detect catheter-associated urinary tract infections (CAUTI). This tool will improve care by decreasing time spent in infection detection, and conversely, increasing time spent on infection prevention, and informing best prevention practices. (2) A data display to help VA facilities obtain a comprehensive picture of patient safety events occurring at their facility. This tool will help to inform identification, implementation, and prioritization of specific patient safety practices and QI initiatives. (3) A data display to depict falls in the facility. This uses data from multiple sources, including facility incident reports, VA SPOT (a patient safety information system) data, VA Inpatient Evaluation Center (IPEC) data, and the updated VA Nursing Outcomes Database (VANOD) Post-Fall Note. This tool will help facilities better understand the cause of each fall, as well as to identify whether a specific fall is preventable or not in order to design appropriate interventions.

Personal health record utilization in Veterans Health Administration
Dr. Stephanie Shimada, as part of her Career Development Award dedicated to optimization of Veterans’ use of eHealth technologies, and colleagues compared adoption (registration, authentication, opt-in to use secure messaging) and use (prescription refill and secure messaging) of VA’s personal health record (PHR) portal across 18 specific clinical conditions prevalent in and of high priority to the VA. Patients with HIV, hyperlipidemia, and spinal cord injury were more likely to adopt the PHR portal; those with schizophrenia/schizoaffective disorder, alcohol or drug abuse, and stroke were least likely. This paper has had a noteworthy impact on VA Connected Health policy. It is important to intervene in the early phases of PHR adoption to reach Veterans with specific medical conditions that require intensive self-management support and treatment so that they can realize the benefits of connected health technologies.

Maintaining Independence and Sobriety through Systems Integration, Outreach, and Networking (MISSION)
Dr. David Smelson and colleagues developed the MISSION Model in the VA. It is an evidence-based intervention that focuses on increasing the use of services for Veterans with co-occurring mental health and substance use disorders. In FY15, MISSION was added to the Substance Abuse and Mental Health Services Administration (SAMSA) National Registry of Evidence Based Practices. This is an important benchmark for promoting the use of evidence-based practices across government agencies. A key reason for MISSION’s inclusion in the registry is the evidence developed in two VA-funded studies. This work developed the evidence for impact on processes and outcomes, and created treatment manuals for field use. MISSION has also been included and integrated into VA Housing First programs to serve the most vulnerable veterans in need of co-occurring disorders Treatment. Implementation dissemination of MISSION work in FY15 has included publication in Implementation Science and inclusion of an issue brief for the National Center for Homelessness and presentation of findings to essential stakeholders.

Impacts: General Public via Mass Media

Dr. Barbara Bokhour in Huffington Post Canada,What You Need to Know About Hypertension” (By Timi Gustafson, 7/19/15):
“More than half of people who have hypertension, a.k.a. high blood pressure, don't know enough about the condition and are unable to control it properly, according to a new survey. Often, patients don't even correctly understand the meaning of the word 'hypertension,' and think of it more in terms of stress, anxiety, or other psychological disturbance rather than what it actually is -- namely a physiological dysfunction that can turn into a chronic disease if untreated, the researchers found.”

Dr. Rani Elwy in Kaiser Health News, “For Surgeons, Talking About Adverse Events Can Be Difficult: Study” (By Zhai Yun Tan, 7/20/16):
“Medical mistakes often happen. National guidelines call for doctors to provide full disclosure about adverse events, and studies have shown that those discussions benefit patients. But new research finds that the act of disclosure, combined with stress from the procedure gone wrong, can be an anxious experience for some doctors — and more training is needed to help them engage in these difficult conversations… The study, published in JAMA Surgery Wednesday, examines what surgeons tell patients and what effect those discussion can have on the doctor.”

Dr. Nancy Kressin in The New York Times blog, "Notifications About Dense Breasts Can Be Hard to Interpret" (By Roni Caryn Rabin, 6/26/16):
“About 40 percent of women who have mammograms are found to have dense breast tissue, a normal finding that can make it harder to detect cancer. But many of these women receive letters in the mail about the finding that can be hard to decipher, a new study found.”

Dr. Melissa Wachterman in HealthDay, “Type of Disease May Dictate End-of-Life Care” (By Steven Reinberg, 6/27/16):
“Patients who have cancer or dementia tend to receive more end-of-life care than those dying from other conditions, a new study of Veteran Affairs hospitals finds... The study also found that fewer cancer and dementia patients died in intensive care units, because these patients had more palliative care and end-of-life planning, such as do-not-resuscitate orders, than people with other serious illnesses. Those other illnesses included end-stage kidney disease, heart failure, lung disease or frailty, researchers said.”

*Indicates former CHOIR investigator or staff.
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