Byron Bair

The Role of Grief in Dementia Caregiving

The literature examining issues of caregiver stress, burden, or depression has focused on the stress-process model of caregiving, which posits that there are characteristics inherent in dementia and in the course of caregiving for a person with dementia that can cause stress in the caregiver’s life. A more recent literature has emerged that argues that issues of loss and grief play a significant role in a caregiver’s ability to cope with the stressors of caregiving. This article reviews the caregiver stress and grief literatures, and proposes a conceptual model of dementia caregiving that outlines pathways of stress and grief in dementia caregiving. Issues specific to caregiver grief are proposed for future research and intervention design.

Personal Characteristics Affecting Veterans' Use of Services for Posttraumatic Stress Disorder

OBJECTIVE Posttraumatic stress disorder (PTSD) is widespread among veterans, but many veterans with PTSD use few health services. This study examined how individual characteristics influenced use of outpatient visits by veterans with PTSD. METHODS The study assessed number of annual visits by 414,748 veterans with PTSD who sought care from October 2007 through September 2008 at U.S. Department of Veteran Affairs (VA) facilities. Negative binomial regression and adjusted risk ratios assessed the relationship of number of visits and demographic characteristics as well as place of residence, era of service, extent to which disability was connected to service history, and having comorbid illnesses. RESULTS Veterans from rural or highly rural areas had 19% (confidence interval [CI]=.80-.82) and 25% (CI=.72-.79), respectively, fewer visits than urban-dwelling veterans. Iraq and Afghanistan veterans had 21% fewer visits than veterans of prior eras (CI=.78-.81). Veterans with comorbid conditions had 64% more visits than veterans with only PTSD (CI=1.62-1.66). Veterans from rural or highly rural areas had 22% (CI=.87-.89) and 33% (CI=.64-.71), respectively, fewer visits to PTSD specialty clinics than veterans from urban areas. CONCLUSIONS Service use by veterans is lower in rural areas. The VA should build on existing efforts to provide more outreach and care opportunities, including telemental health and specialized PTSD services, in rural areas and for veterans of the current service era. Future research should investigate the impact of fewer visits on aspects of functioning, such as interpersonal factors, and the impact of system-level variables on service utilization.

Characterizing “information transfer” by using a Joint Cognitive Systems model to improve continuity of care in the aged

PURPOSE This study explores multidisciplinary and cross-sector health professional experiences with the information needs for safe patient transfers across the care continuum using a Joint Cognitive Systems (JCS) model. Qualitative experiences of three JCS components and their attributes and are presented. METHODS A qualitative content analysis using Joint Cognitive Systems constructs were extracted from sixteen multidisciplinary and cross-sector health professional interviews. Participants were asked to describe their information needs and experiences with the patient transfer process. RESULTS Information transfer associated with three JCS constructs (alignment of goals, enhanced control, and co-agency dynamics) was examined. The breakdown in the information transfer process might be due to the relative strengths of each sectors core expertise. Alignment must cross settings and disciplines and consist of the: (1) transfer of goal relevant and integrated information; (2) accommodation to the control attributes of increased clinical complexity, lack of systematic work processes and feedback or feed forward information; and (3) improvement in the co-agency dynamics of interdependency, trust, inter-related actions and expertise. CONCLUSIONS Economic pressures and care complexities of the aged require improved effectiveness and efficiencies in the information transfer process. This study aims to understand the information transfer needs from hospitals to skilled nursing care laying a foundation towards a medical informatics solution. An informatics solution must accommodate the differing contextual environments and subsequent information needs and paradigms of the Joint Cognitive System of care across the continuum.

Review of American Indian veteran telemental health.

Rural American Indian veterans have unique healthcare needs and face numerous barriers to accessing healthcare services. Over the past decade, the Department of Veterans Affairs in conjunction with the University of Colorado Denver has turned to the promising field of telemental health to develop a series of videoconferencing-based clinics to reach this vulnerable population and improve mental healthcare services. The ongoing development, implementation, and expansion of these clinics have been assessed as part of a program improvement. The outcomes of these assessments have been documented in a series of published articles, controlled studies, program and case reports, and model descriptions. This article summarizes a decade of experience with the American Indian Telemental Health Clinics, the clinic model, and the literature arising from these clinics and presents lessons learned while establishing, maintaining, and evaluating these clinics. The ability to tailor the clinics to individual sites and cultures and to provide various services has been critical to the operation of the clinics. Culturally specific care through culturally knowledgeable providers, onsite tribal outreach workers, and collaboration with community services has proven essential in operating the clinics, as well as building rapport, trust, and engagement with the target patient population. It is hoped that the lessons learned and practices presented here can not only assist others working to improve the care for rural Native veterans but also serve as a model in the use of telemental health services for improving care and access to rural veteran and non-veteran populations.

Prevalence of and Factors Associated With Subclinical Posttraumatic Stress Symptoms and PTSD in Urban and Rural Areas of Montana: A Cross-Sectional Study

PURPOSE Posttraumatic stress disorder (PTSD) is an important clinical problem, but little is known about PTSD in rural, nonclinical populations. To better understand PTSD in rural areas, we examined the prevalence and risk and protective factors in urban, rural, and highly rural communities in Montana for both subclinical posttraumatic stress symptoms (PTSS) and PTSD. METHODS We compared the prevalence of PTSS and PTSD in urban, rural, and highly rural communities in bivariate and multivariable regression analyses using self-reported cross-sectional survey data from the Montana Health Matters study (N = 3,512), a state-representative household-based survey done in 2010-2011. We also explore potential risk and protective factors for PTSS and PTSD and whether risk and protective factors for each differ by rurality. FINDINGS There were no differences in the level of PTSS by rurality in bivariate or multivariate models, and the bivariate relationship between rurality and PTSD became nonsignificant in a multivariate model. Only locus of control was predictive for PTSS; however, gender, age, marital status, income, employment status, community fit, locus of control, and religiosity were associated with PTSD. Some risk and protective factors operate differently by rurality. CONCLUSIONS Although our findings are subject to weaknesses common to cross-sectional data and are based on questionnaire reports, it appears that there are different risk and protective factors for PTSS and PTSD, suggesting that PTSD may be qualitatively different from PTSS. Furthermore, differences in risk and protective factors across urban and rural communities suggest more attention is needed to understand PTSD in rural communities.

Reaching Rural Communities with Culturally Appropriate Care: A Model for Adapting Remote Monitoring to American Indian Veterans with Posttraumatic Stress Disorder

OBJECTIVE Providing specialized healthcare to rural communities can be extremely difficult, and consequently many health organizations are turning to the use of telehealth technologies for care delivery. One such technology, remote monitoring, has been successfully implemented with patients suffering from chronic and other medical conditions. A drawback, however, is that remote monitoring devices are programmed to reach a broad audience, and consequently the content may not be suitable for all patients-especially those who are not a part of the dominant culture. SUBJECTS AND METHODS This report provides a model for adapting remote monitoring to specific populations who are undergoing care for posttraumatic stress disorder. Adaptation changes focus on (1) information gathering, (2) process and dialogue changes, (3) testing, and (4) patient and administrative feedback. Data for such modifications were gathered through a series of community meetings, patient interviews, and provider feedback. A case example highlights the successful implementation of the adaptation model for a rural American Indian Veteran population. RESULTS Patients showed high acceptability of both the programmatic and cultural adaptations. Feasibility of the program also appeared positive, with most patients reporting that the readability of the program was appropriate, the dialogue duration was not burdensome, and technical problems were rare. CONCLUSIONS Remote monitoring provides the ability to be modified for use with certain subpopulations. Procedural recommendations in this report highlight special considerations for working with American Indians living on or near reservation areas, although the model can be broadly adapted to several groups.

Out-of-pocket pharmacy expenditures for veterans under medicare part D.

Objectives:Because the VA pharmacy benefit is deemed equivalent coverage to Medicare Part D, veterans can use either or both of these Federal benefits. We sought to determine how these programs’ different benefit structures and low-income assistance thresholds would affect pharmacy out-of-pocket expenses for veterans. Methods:We reviewed income and asset tests performed at the Salt Lake City VA in fiscal year 2005, and estimated the number of individuals, age 65 and older, who meet eligibility for Part D low-income assistance. Using past VA pharmacy utilization data, we estimated the difference in pharmacy out-of-pocket expenditures for veterans eligible for assistance through Medicare but not through the VA. Results:The income and asset thresholds for low-income assistance through Part D were reached by 4127 veterans. From this group, we identified 926 veterans who had used the VA pharmacy during the prior year, who are ineligible for VA copayment waivers, and who qualify for premium waiver under Part D. These veterans’ estimated annual savings ranged from

Predictors of Attrition in Older Users of a Home-Based Monitoring and Health Information Delivery System

6 to

Reaching Out to Older Veterans in Need: The Elko Clinic Demonstration Project

714, with an average savings of

Rural American Indian and Alaska Native veterans’ telemental health: A model of culturally centered care.

353 per year (or 2% of their average annual income) by using Part D. Conclusions:Although VA pharmacy coverage has been deemed to be, on average, equivalent to Part D, some veterans living near poverty can reduce out-of-pocket expenditures by using Medicare prescription coverage. Currently available data can identify veterans who are likely to achieve savings under Medicare.