Laura O. Wray

The Effect of Telephone Support Groups on Costs of Care for Veterans With Dementia

PURPOSEnFew studies have addressed the effects of caregiver interventions on the costs of care for the care recipient. This study evaluated the effects of a caregiver education and support group delivered via the telephone on care recipient health care utilization and cost.nnnDESIGN AND METHODSnThe Telehealth Education Program (TEP) is a manualized program of education and support designed for caregivers of veterans with moderate-to-severe dementia. One hundred fifty-eight spousal caregivers were randomly assigned to either the ten 1-hr sessions of TEP or the usual care (UC). Health care utilization and cost data were extracted from veterans Information System Technology Architecture databases and included outpatient, inpatient, and nursing home data within the VA.nnnRESULTSnTotal health care cost data showed a significant (p = .039) average cost savings of

Behavioral health providers' perspectives of delivering behavioral health services in primary care: a qualitative analysis

2,768 per patient at 6 months for TEP as compared with UC, but these were not maintained at 1 year. All costs included in the total costs measure contributed to this difference. Inpatient, outpatient, and nursing home costs were all assessed separately, but only nursing home costs reached significance (p = .009), with a savings of

Longitudinal assessment of BMI in relation to ADT use among early stage prostate cancer survivors

1,057 per patient at 6 months.nnnIMPLICATIONSnThe TEP caregiver intervention resulted in short-term cost savings for veteran care recipients. Future studies of caregiver interventions should examine their effects on costs of care for the care recipients in addition to their effects on caregiver outcomes.

Managing behavioral health needs of veterans with traumatic brain injury (TBI) in primary care.

BackgroundCo-located, collaborative care (CCC) is one component of VA’s model of Integrated Primary Care that embeds behavioral health providers (BHPs) into primary care clinics to treat commonly occurring mental health concerns among Veterans. Key features of the CCC model include time-limited, brief treatments (up to 6 encounters of 30 minutes each) and emphasis on multi-dimensional functional assessment. Although CCC is a mandated model of care, the barriers and facilitators to implementing this approach as identified from the perspective of BHPs have not been previously identified.MethodsThis secondary data analysis used interview data captured as part of a quality improvement project in 2008. Fourteen BHPs (48% of providers in a regional VA network) agreed to participate in a 30-minute, semi-structured phone interview. The interview included questions about their perceived role as a CCC provider, depiction of usual practice styles and behaviors, and perceptions of typical barriers and facilitators to providing behavioral healthcare to Veterans in CCC. Interviews were transcribed verbatim into a text database and analyzed using grounded theory.ResultsSix main categories emerged from the analysis: (a) Working in the VA Context, (b) Managing Access to Care on the Front Line, (c) Assessing a Care Trajectory, (d) Developing a Local Integrated Model, (e) Working in Collaborative Teams, and (f) Being a Behavioral Health Generalist. These categories pointed to system, clinic, and provider level factors that impacted BHP’s role and ability to implement CCC. Across categories, participants identified ways in which they provided Veteran-centered care within variable environments.ConclusionsThis study provided a contextualized account of the experiences of BHP’s in CCC. Results suggest that these providers play a multifaceted role in delivering clinical services to Veterans while also acting as an interdependent component of the larger VA behavioral health and primary care systems. Based on the inherent challenges of enacting this role, BHPs in CCC may benefit from additional implementation support in their effort to promote health care integration and to increase access to patient-centered care in their local clinics.

Telephone groups for older persons and family caregivers : Key implementation and process issues

IntroductionThe use of androgen deprivation therapy (ADT) for prostate cancer is on the rise, but its adverse side effects may include increased fat mass and decreased lean muscle mass. The net effect of ADT on BMI is unknown.MethodsPrimary, incident cases of early stage prostate cancer (nu2009=u2009473) were identified from the Buffalo VA Medical Center tumor registry and matched to body size, demographic, comorbidity, and treatment exposure data from veteran medical records. Multilevel modeling was used to assess the association between ADT and changes in BMI.ResultsOn average, survivors were overweight at diagnosis and showed small, non-significant changes in BMI over time. However, among those survivors with a history of ADT, a significant decrease of 0.05 BMI units per year was associated with each additional dose of ADT (pu2009<u20090.001). When the association between BMI rate of change and ADT was allowed to vary with respect to age, additional doses of ADT predicted stronger decreases in BMI for younger survivors as compared to older survivors (pu2009<u20090.05). Neither a history of surgery nor radiation influenced the association between ADT use and BMI.ConclusionsDeclines in BMI in relation to ADT exposure may be reflective of unfavorable changes in body composition, especially decreased muscle mass, that is most pronounced in younger survivors.Implications for Cancer SurvivorsSurvivors on ADT may benefit from close monitoring of physical functioning and referral for exercise interventions to preserve muscle mass and improve health related quality of life.

The Association Between Mental Health and Cognitive Screening Scores in Older Veterans

Traumatic brain injury (TBI) is a frequent occurrence in the United States, and has been given particular attention in the veteran population. Recent accounts have estimated TBI incidence rates as high as 20xa0% among US veterans who served in Afghanistan or Iraq, and many of these veterans experience a host of co-morbid concerns, including psychiatric complaints (such as depression and post-traumatic stress disorder), sleep disturbance, and substance abuse which may warrant referral to behavioral health specialists working in primary care settings. This paper reviews many common behavioral health concerns co-morbid with TBI, and suggests areas in which behavioral health specialists may assess, intervene, and help to facilitate holistic patient care beyond the acute phase of injury. The primary focus is on sequelae common to mild and moderate TBI which may more readily present in primary care clinics.

Identification and Management of Eating Disorders in Integrated Primary Care: Recommendations for Psychologists in Integrated Care Settings

Abstract Telephone support groups are an important modality for meeting the growing needs of family caregivers and frail older adults. Studies suggest that these groups can provide information, support, coping skills, and other benefits. This paper describes the knowledge and skills that clinicians need to develop, implement, and lead telephone groups. Particular attention is paid to the clinical adaptations that are needed when leading telephone as compared with in-person groups. Technical and ethical issues are also described.

Electronic Medical Record Documentation of Driving Safety for Veterans with Diagnosed Dementia

OBJECTIVESn: To examine overall cognitive screening results and the relationship between cognitive screen score and sociodemographic characteristics, reason for referral, and clinical outcomes of older veterans referred by primary care for a behavioral health assessment.nnnDESIGNn: Cross-sectional, naturalistic study.nnnSETTINGn: Primary care clinics affiliated with two VA Medical Centers.nnnPARTICIPANTSn: The sample included 4,325 older veterans referred to the Behavioral Health Laboratory who completed an initial mental health/substance abuse assessment. Veterans were categorized into the following three groups on the basis of cognitive status: within normal limits, possible cognitive impairment, and possible dementia.nnnMEASUREMENTSn: Sociodemographic and clinical data on reason for referral, cognitive functioning (i.e., Blessed Orientation-Memory-Concentration test), and behavioral health assessment outcomes were extracted from patients medical records. Data were analyzed using multiple linear and logistic regressions.nnnRESULTSn: Results of cognitive screenings indicated that the majority of the sample was within normal limits (62.5%), with 25.8%, 8.1%, and 3.6% of patients evidencing possible cognitive impairment, possible dementia, and Blessed Orientation-Memory-Concentration scores of 17 or more, respectively. With regard to reason for referral, patients with greater cognitive impairment were more likely to be identified by the antidepressant case finder than patients with less impairment. Increased age, non-white ethnicity, self-perceived inadequate finances, major depressive disorder, and symptoms of psychosis were associated with greater cognitive impairment.nnnCONCLUSIONSn: Findings highlight the importance of evaluating cognitive status in older adults who are referred for a behavioral health assessment and/or receive a new mental health/substance abuse diagnosis. Doing so has the potential to improve recognition and treatment of cognitive impairment and dementia, thereby improving quality of care for many older adults.

Growth curve analysis of BMI in relation to primary care utilization in prostate cancer survivors.

Eating disorders are associated with deleterious health consequences, increased risk of mortality, and psychosocial impairment. Although individuals with eating disorders are likely to seek treatment in general medical settings such as primary care (PC), these conditions are often under-detected by PC providers. However, psychologists in integrated PC settings are likely to see patients with eating disorders because of the mental health comorbidities associated with these conditions. Further, due to their training in identifying risk factors associated with eating disorders (i.e., comorbid mental health and medical disorders) and opportunities for collaboration with PC providers, psychologists are well-positioned to improve the detection and management of eating disorders in PC. This paper provides a brief overview of eating disorders and practical guidance for psychologists working in integrated PC settings to facilitate the identification and management of these conditions.

Rates and correlates of disordered eating among women veterans in primary care

ABSTRACT Objectives: Many older adults continue to drive following dementia diagnosis, with medical providers increasingly likely to be involved in addressing such safety concerns. This study examined electronic medical record (EMR) documentation of driving safety for veterans with dementia (N = 118) seen in Veterans Affairs primary care and interdisciplinary geriatrics clinics in one geographic region over a 10-year period. Methods: Qualitative directed content analysis of retrospective EMR data. Results: Assessment of known risk factors or subjective concerns for unsafe driving were documented in fewer than half of observed cases; specific recommendations for driving safety were evident for a minority of patients, with formal driving evaluation the most frequently documented recommendation by providers. Conclusion: Utilizing data from actual clinical encounters provides a unique snapshot of how driving risk and safety concerns are addressed for veterans with dementia. This information provides a meaningful frame of reference for understanding potential strengths and possible gaps in how this important topic area is being addressed in the course of clinical care. Clinical Implications: The EMR is an important forum for interprofessional communication, with documentation of driving risk and safety concerns an essential element for continuity of care and ensuring consistency of information delivered to patients and caregivers.