Danielle E. Rose

Gender Differences in Smoking and Smoking Cessation Treatment: An Examination of the Organizational Features Related to Care

OBJECTIVES Veterans experience a particularly heavy burden with smoking rates higher than the general population, and the smoking prevalence for women Veterans has increased in recent years. We examined differences in smoking prevalence and treatment by gender for Veterans receiving at least some of their care at a VA facility, and examined the degree to which organizational factors may be associated with reductions in gender disparities in smoking cessation treatment. METHODS We merged national organizational-level data focused on primary care (sites = 225) and womens health (sites = 195) with patient-level survey data (n = 15,033 smokers). Organizational measures focused on smoking cessation-specific structure and processes in primary care and womens health. Primary outcomes were patient-reported receipt of smoking cessation treatments-advised to quit, medication recommendation, and other treatment recommendation. We used multi-level, random-intercept logistic regression. RESULTS In 2007, 29% of women and 23% of men were smokers. Overall, 83% of smokers reported they had been advised to quit, 62% recommended medications, and 60% recommended other treatments. Women were more likely to report being advised to quit (odds ratio, 1.33; 95% confidence interval, 1.07-1.64) but equally likely as men to have medications or other treatment recommended. Organizational factors did not eliminate the gender differences in being advised to quit. CONCLUSION Despite having equivalent or higher smoking cessation treatment rates, women Veterans were more likely to smoke than men. With the rapid growth of women entering VA care, the need for effective gender-focused and gender-sensitive smoking cessation care arrangements is critical for the future health of women who have served.

National variations in VA mental health care for women veterans.

OBJECTIVES Although the Veterans Health Administration (VA) has recently adopted new policies encouraging gender-specific mental health (MH) care delivery to women veterans, little is known about the potential difficulties local facilities may face in achieving compliance. We assessed variations in womens mental health care delivery arrangements in VA facilities nationwide. METHODS We used results from the VA Survey of Women Veterans Health Programs, a key informant survey of senior womens health clinicians representing all VA facilities serving more than 300 women veterans, to assess the array of gender-sensitive mental health care arrangements (response rate, 86%; n = 195). We also examined organizational and area factors related to availability of womens specialty mental health arrangements using multivariable logistic regression. RESULTS Nationally, over half (53%) of VA facilities had some form of gender-sensitive mental health care arrangements. Overall, 34% of sites reported having designated womens mental health providers in general outpatient mental health clinics (MHCs). Almost half (48%) had therapy groups for women in their MHCs. VAs with womens primary care clinics also delivered mental health services (24%), and 12% of VAs reported having a separate womens MHC, most of which (88%) offered sexual trauma group counseling. Assignment to same-gender mental health providers is not routine. VAs with comprehensive womens primary care clinics were more likely to integrate mental health care for women as well. CONCLUSION Local implementation of gender-sensitive mental health care in VA settings is highly variable. Although this variation may reflect diverse local needs and resources, women veterans may also sometimes face challenges in accessing needed services.

Challenges Facing Primary Care Practices Aiming to Implement Patient-Centered Medical Homes

ABSTRACTBACKGROUNDWhile the potential of patient-centered medical homes (PCMH) is promising, little is known empirically about the frontline challenges that primary care (PC) leaders face before making the decision to implement PCMH, let alone in making it a reality.OBJECTIVEPrior to the design and implementation of the Veterans Health Administration’s (VA) national PCMH model—Patient Aligned Care Teams (PACT)—we identified the top challenges faced by PC directors and examined the organizational and area level factors that influenced those challenges.DESIGN AND PARTICIPANTSA national cross-sectional key informant organizational survey was fielded to the census of PC directors at VA medical centers and large community-based outpatient clinics (final sample n = 229 sites).MAIN MEASURESPC directors were asked to rate the degree to which they faced 48 management challenges in eight PCMH-related domains (access, preventive care, chronic diseases requiring care in PC, challenging medical conditions, mental health/substance abuse, special populations, PC coordination of care, and clinical informatics). Responses were dichotomized as moderately-to-extremely challenging versus somewhat-slightly-not at all challenging. Items were rank ordered; chi square or regression techniques were used to examine variations in facility size, type, urban/rural location, and region.KEY RESULTSOn average, VA PC directors reported 16 moderate-to-extreme challenges, and the top 20 challenges spanned all eight PCMH domains. Four of the top 20 challenges, including the top two challenges, were from the clinical informatics domain. Management of chronic non-malignant pain requiring opiate therapy was the third most reported challenge nationwide. Significant organizational and area level variations in reported challenges were found especially for care coordination.CONCLUSIONSBetter understanding of PC challenges ahead of PCMH implementation provides important context for strategic planning and redesign efforts. As a national healthcare system, the VA provides a unique opportunity to examine organizational and area determinants relevant to other PCMH models.

The Role of Organizational Factors in the Provision of Comprehensive Women's Health in the Veterans Health Administration

BACKGROUND Increasing numbers of women veterans present an organizational challenge to a health care system that historically has served men. Women veterans require comprehensive womens health services traditionally not provided by the Veterans Health Administration. OBJECTIVE Examine the association of organizational factors and adoption of comprehensive womens health care. STUDY DESIGN Cross-sectional analysis of the 2007 Veterans Health Administration National Survey of Women Veterans Health Programs and Practices. METHODS Dependent measures included a) model of womens health care: separate womens health clinic (WHC), designated womens health provider in primary care (DWHP), both (WHC+DWHP), or neither and b) the availability of five womens health services: cervical cancer screening and evaluation and management of vaginitis, menstrual disorders, contraception, and menopause. Exposure variables were organizational factors drawn from the Greenhalgh model of diffusion of innovations including measures of structure, absorptive capacity, and system readiness for innovation. RESULTS The organizational factors of a gynecology clinic, an academic affiliation with a medical school, a womens health representative on one or more high-impact committees, and a greater caseload of women veterans were more common at sites with WHCs and WHC+DWHPs, compared with sites relying on general primary care with or without a DWHP. Academic affiliation and high-impact committee involvement remained significant in multivariable analysis. Sites with WHCs or WHC+DWHPs were more likely to offer all five womens health services. CONCLUSION Facilities with greater apparent absorptive capacity (academic affiliation and womens health representation on high-impact committees) are more likely to adopt WHCs. Facilities with separate WHCs are more likely to deliver a package of womens health services, promoting comprehensive care for women veterans.

Organizational Factors Affecting the Likelihood of Cancer Screening Among VA Patients.

Background:Preventive service delivery, including cancer screenings, continues to pose a challenge to quality improvement efforts. Although many studies have focused on person-level characteristics associated with screening, less is known about organizational influences on cancer screening. Objectives:This study aims to understand the association between organizational factors and adherence to cancer screenings. Methods:This study employed a cross-sectional design using organizational-level, patient-level, and area-level data. Dependent variables included breast, cervical, and colorectal cancer screening. Organizational factors describing resource sufficiency were constructed using factor analyses from a survey of 250 Veterans Affairs primary care directors. We conducted random-effects logistic regression analyses, modeling cancer screening as a function of organizational factors, controlling for patient-level and area-level factors. Results:Overall, 87% of the patients received mammograms, 92% received cervical and 78% had colorectal screening. Quality improvement orientation increased the odds of cervical [odds ratio (OR): 1.27; 95% confidence interval (CI), 1.03–1.57] and colorectal cancer screening (OR: 1.10; 95% CI, 1.00–1.20). Authority in determining primary care components increased the odds of mammography screening (OR: 1.23; 95% CI, 1.03–1.51). Sufficiency in clinical staffing increased the odds of mammography and cervical cancer screenings. Several patient-level factors, serving as control variables, were associated with achievement of screenings. Conclusions:Resource sufficiency led to increased odds of screening possibly because they promote excellence in patient care by conveying organizational goals and facilitate goal achievement with resources. Complementary to patient-level factors, our findings identified organizational processes associated with better performance, which offer concrete strategies in which facilities can evaluate their capabilities to implement best practices to foster and sustain a culture of quality care.

Access Management in Primary Care: Perspectives from an Expert Panel

This report outlines the results of evidence review, qualitative analysis, and the deliberations of an expert panel to identify access management priorities for health care organizations as they undertake initiatives to improve access to primary care. For each of eight urgent and important priorities, the authors offer recommendations related to organizational structures, processes, and outcomes, as well as suggestions for implementation.

Task Delegation and Burnout Trade-offs Among Primary Care Providers and Nurses in Veterans Affairs Patient Aligned Care Teams (VA PACTs)

Purpose: Appropriate delegation of clinical tasks from primary care providers (PCPs) to other team members may reduce employee burnout in primary care. However, (1) the extent to which delegation occurs within multidisciplinary teams, (2) factors associated with greater delegation, and (3) whether delegation is associated with burnout are all unknown. Methods: We performed a national cross-sectional survey of Veterans Affairs (VA) PCP-nurse dyads in Department of VA primary care clinics, 4 years into the VAs patient-centered medical home initiative. PCPs reported the extent to which they relied on other team members to complete 15 common primary care tasks; paired nurses reported how much they were relied on to complete the same tasks. A composite score of task delegation/reliance was developed by taking the average of the responses to the 15 questions. We performed multivariable regression to explore predictors of task delegation and burnout. Results: Among 777 PCP-nurse dyads, PCPs reported delegating tasks less than nurses reported being relied on (PCP mean ± standard deviation composite delegation score, 2.97± 0.64 [range, 1–4]; nurse composite reliance score, 3.26 ± 0.50 [range, 1–4]). Approximately 48% of PCPs and 35% of nurses reported burnout. PCPs who reported more task delegation reported less burnout (odds ratio [OR], 0.62 per unit of delegation; 95% confidence interval [CI], 0.49–0.78), whereas nurses who reported being relied on more reported more burnout (OR, 1.83 per unit of reliance; 95% CI, 1.33–2.5). Conclusions: Task delegation was associated with less burnout for PCPs, whereas task reliance was associated with greater burnout for nurses. Strategies to improve work life in primary care by increasing PCP task delegation must consider the impact on nurses.

Interprofessional training and team function in patient-centred medical home: Findings from a mixed method study of interdisciplinary provider perspectives

ABSTRACT Transitioning from profession-specific to interprofessional (IP) models of care requires major change. The Veterans Assessment and Improvement Laboratory (VAIL), is an initiative based in the United States that supports and evaluates the Veterans Health Administration’s (VAs) transition of its primary care practices to an IP team based patient-centred medical home (PCMH) care model. We postulated that modifiable primary care practice organizational climate factors impact PCMH implementation. VAIL administered a survey to 322 IP team members in primary care practices in one VA administrative region during early implementation of the PCMH and interviewed 79 representative team members. We used convergent mixed methods to study modifiable organizational climate factors in relationship to IP team functioning. We found that leadership support and job satisfaction were significantly positively associated with team functioning. We saw no association between team functioning and either role readiness or team training. Qualitative interview data confirmed survey findings and explained why the association with IP team training might be absent. In conclusion, our findings demonstrate the importance of leadership support and individual job satisfaction in producing highly functioning PCMH teams. Based on qualitative findings, we hypothesize interprofessional training is important, however, inconsistencies in IP training delivery compromise its potential benefit. Future implementation efforts should improve standardization of training process and train team members together. Interprofessional leadership coordination of interprofessional training is warranted.