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7 Implementation and Models of Care for Veterans Who Have Chronic Multisymptom Illness As previously described, nearly all veterans who have chronic multi- symptom illness (CMI) have comorbid illnesses—illnesses that are them- selves multisymptomatic and that overlap with CMI in complex and highly variable ways. The most common chronic condition in the United States, and probably the world, is multimorbidity (Tinetti et al., 2012), and this is especially true for patients who have CMI. Even though there may be evidence-based treatments for one or more of these conditions, the com- mittee believes that a treatment plan consisting simply of the sum of these practice guidelines will be altogether inadequate and is ill-advised. An integrated approach to care is required. There is a fundamental difference between managing a disease or a condition and caring for a person who has one or more conditions—just as there is a fundamental difference between a linical practice guideline (CPG) and a personal care plan. Anecdotal c evidence suggests that simply adhering to multiple CPGs often is not effec- tive for managing chronic conditions with multiple morbidities such as CMI and can result in incomplete care and decrease patient satisfaction, and increase the likelihood of overtreatment and adverse side effects. Each personal care plan will be peculiar to the individual veteran (although crafted from the therapeutic elements outlined in Chapters 4 and 5), will change, and will almost always be complex and detailed. A clinician car- ing for a veteran who has CMI faces a daunting and time-consuming task that cannot always be accomplished in the course of an ordinary primary care visit and can hardly be implemented by a single clinician; it generally takes a team approach and specific expertise. Special consideration must be 155
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156 GULF WAR AND HEALTH given to the resources and the organization—the system of care—that are m arshaled for the management of CMI patients. This chapter presents a patient-centered management approach for vet- erans who have CMI. It begins by describing some of the current capabili- ties of the Department of Veterans Affairs (VA) for managing the health of veterans. It identifies inadequacies of existing VA models of care for veter- ans who have CMI and recommends a general approach to the management of such veterans. The chapter next describes models of care used by other organizations to manage CMI patients. Building on information presented in Chapter 6, it ends with a discussion of how information about managing CMI might be disseminated to VA clinicians and patients. MODELS OF CARE FOR CHRONIC MULTISYMPTOM ILLNESS IN THE DEPARTMENT OF VETERANS AFFAIRS HEALTH CARE SYSTEM Veterans use the full array of health care benefits and systems for their care: the Veterans Health Administration (VHA); TRICARE, the Depart- ment of Defense (DOD) health care program for active-duty, reserve, and retired armed forces personnel; Medicare; and private care. Fewer than 20% of all veterans receive their health care exclusively in VHA facilities, about one-third of veterans use Medicare benefits, and almost half use both (Hynes et al., 2007; Petersen et al., 2010; Stroupe et al., 2005; West et al., 2008). The distribution among the health care system of veterans who have CMI is not known, nor is there any difference in the pathway of care between veterans of the 1991 Gulf War and veterans of the Iraq and Afghanistan wars (Operation Iraqi Freedom, Operation New Dawn, and Operation Enduring Freedom). More than 8 million veterans are enrolled in VHA (Walters, 2011). In FY 2009, the number of pre–September 2001 Gulf War–era veterans receiving health care through VHA was 571,656 (VA, 2011d).1 That num- ber represents 8.7% of the total Gulf War–era veteran cohort. Of the pre–September 2001 Gulf War–era veterans receiving care from VHA, 145,832 were deployed to the Persian Gulf and 110,487 of the deployed personnel were active participants in the Gulf War. Inpatient care in VHA facilities was used by 24,578 pre–September 2001 Gulf War–era veterans in FY 2009, and outpatient care was used by 540,802 Gulf War–era veterans in the same year. About 55% of veterans of the Iraq and Afghanistan wars (834,463 veterans) have used VHA health care services since October 2001 1 For this case, Gulf War–era veterans are defined as military personnel who served on active duty during August 2, 1990–September 10, 2001. Not all Gulf War–era veterans were deployed to the Persian Gulf or were Gulf War participants.
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IMPLEMENTATION AND MODELS OF CARE 157 (VA, 2012a). Among those Iraq and Afghanistan war veterans who have sought care at VHA facilities, about 94% have used only outpatient services and about 6% have been hospitalized at least once (VA, 2012a). VHA has substantial experience in treating patients who have chronic illnesses. Its patients have a higher prevalence of the eight most common chronic health conditions than do patients who are using TRICARE and private plans (Gibson et al., 2009), not including CMI. As indicated above, information is not available on the number of veterans who have CMI and receive their care from VHA or elsewhere. Postdeployment Patient-Aligned Care Team Program Gulf War veterans have begun to enter the VHA system by being assigned to a postdeployment patient-aligned care team (PD-PACT) (Hunt, 2012). A PD-PACT serves as a veteran’s medical home in VHA. The move to a medical-home model is relatively recent in VHA and implementation is ongoing (Reisinger et al., 2012). VHA’s implementation of this model of care compares favorably with implementation in most civilian practices and systems, in which the transition to patient-centered medical homes is still in the early stages of implementation. VHA has established principles and guidelines for the implementation of PACTs, educated its clinicians about the principles, and assigned champions to lead the implementation effort (VA, 2012j). It is important to note that this pathway to care did not exist when military personnel were returning from the 1991 Gulf War and enter- ing the VHA system. The 1991 Gulf War veterans are now being served by PD-PACTs, but their enrollment rates have been highly variable among settings (VA, 2012e). The plan is for assignment to a PD-PACT to begin after a postdeployment comprehensive health examination and a post deployment disability determination. At some sites, the wait time for the two steps is extremely long, sometimes more than a year. That is frustrat- ing for veterans, who sometimes seek care elsewhere; it also compromises PACT primary care clinicians’ ability to render high-quality care. Each PD-PACT is overseen by a project manager. Other team members can include primary care clinicians, nursing-care managers, mental health clinicians, social workers, and others who have expertise in such subjects as brain injury and physical rehabilitation. The number, specialty types, relative availability, and extent of integration into the primary care team of specialty-team members vary widely from clinic to clinic; VHA cur- rently assigns behavioral-health clinicians to PACTs in VA medical centers (VAMCs) and outpatient clinics that have more than 5,000 primary care patients, and many smaller clinics also have behavioral clinicians on PACT teams. A veteran being cared for is considered a member of the team. The goal of the PD-PACT model is to provide comprehensive, integrated care,
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158 GULF WAR AND HEALTH including follow-up health care, education, and training (Reisinger et al., 2012). Postdeployment integrated care services are in place in 79% of VAMCs and 35% of community-based outpatient clinics (Hunt, 2012), but the extent to which these teams actually function as teams and contain all the necessary expertise is highly variable. Under ideal circumstances, PD-PACT members work together as a coherent team, but many PD-PACT members operate as consultants without a continuing commitment to patients’ care plans and without close communication with other PACT members. Some 84% of VAMCs have clinical experts who can provide clinical guidance for veterans in the context of their continuing primary care (Hunt, 2012). Educational Materials VHA provides extensive educational materials to patients and their families about such topics as environmental exposures, associated adverse health outcomes, and techniques for self-management of symptoms. For example, materials are available on controlled-breathing techniques (VA, 2009a), complementary and integrative medicine (VA, 2011b), using exercise to manage chronic pain and fatigue (VA, 2011c), and medically u nexplained symptoms (VA, 2011e). Materials also are produced for clini- cians (for example, a resource guide on helping patients self-manage their symptoms) (VA, 2009c). Clinical Practice Guidelines VHA has a CPG for the management of veterans who have symp- toms that remain unexplained after appropriate medical assessment (VA and DOD, 2001b).2 In addition, VHA has developed CPGs for a num- ber of relevant conditions, including postdeployment health and common c omorbidities and conditions that have overlapping symptoms, such as major depressive disorder, posttraumatic stress disorder, traumatic brain injury, and chronic pain (Chou et al., 2007; VA and DOD, 2001a, 2009a,b,c, 2010a,b). The CPG on medically unexplained symptoms provides a general approach for managing CMI patients. For example, the key points made in the CPG (VA and DOD, 2001b) are to • Obtain a thorough medical history, physical examination, and medical record review. 2 VA has plans to update its 2001 CPG on medically unexplained symptoms (personal communication, C. Cassidy, Office of Quality and Safety, Department of Veterans Affairs, March 19, 2012).
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IMPLEMENTATION AND MODELS OF CARE 159 • Minimize low-yield diagnostic testing. • Identify treatable causes (conditions) for the patient’s symptoms. • Determine if the patient can be classified as having chronic multi- symptom illness (CMI) (that is, has two or more symptom clusters: pain, fatigue, cognitive dysfunction, or sleep disturbance). • Negotiate treatment options and establish collaboration with the patient. • Provide appropriate patient and family education. • Maximize the use of nonpharmacologic therapies: — Graded aerobic exercise with close monitoring. — Cognitive behavioral therapy. • Empower patients to take an active role in their recovery. The guidelines are useful and appropriate, and VHA has published its method for disseminating and implementing its CPGs in VHA clinics ( icholas et al., 2001; VA and DOD, 2011). N VHA has also published a study guide (not a full CPG) for clinicians on caring for veterans of the 1991 Gulf War (VA, 2011a). It includes information on exposures of concern to veterans of the 1991 Gulf War and instructions for conducting an exposure assessment of veterans. It also contains a section on undiagnosed and unexplained illnesses, including information about CMI. Specialty Care Access Network Although VHA has 153 medical centers and more than 900 outpa- tient clinics nationwide, not all veterans have easy access to VHA facili- ties ( eisinger et al., 2012). Accordingly, VHA developed a specialty care R access network (SCAN) to bring specialty care to veterans who live in rural and other underserved areas, generally areas that do not have VAMCs (VA, 2012e). SCAN is modeled after Project ECHO (Extension for Com- munity Healthcare Outcomes), a program developed by the University of New Mexico Health System. The mission of Project ECHO is to develop the capacity to treat chronic, common, and complex diseases in rural and underserved areas safely and effectively and to monitor outcomes (Arora et al., 2011). The program works by bringing ECHO network specialists with the medical expertise necessary for the condition being addressed into other ise isolated primary care practices. After an initial in-person orien- w tation, a team meets weekly via video conference to present and discuss patients and to formulate care plans. The program fits well into the medical home model by augmenting comprehensiveness, improving continuity and coordination of care, and enhancing quality and safety of care. An impor- tant element of the ECHO program is teaching and implementing concepts of team management of patients (Katzman, 2012).
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160 GULF WAR AND HEALTH VHA adopted the SCAN-ECHO program in 2010 and contracted with Project ECHO to leverage technology and use case-based learning to educate its primary care physicians in chronic pain management and other specialty care topics. Eleven regional VAMCs are using the SCAN-ECHO program. In addition, VAMCs in Denver, Colorado; Richmond, Virginia; Cleveland, Ohio; Albuquerque, New Mexico; greater Los Angeles, California; Salem, Massachusetts; Portland, Oregon; and New Haven, Connecticut, are now replicating the Project ECHO chronic pain program, and clinicians in their regions are calling in each week for consultations related to pain manage- ment (VA, 2012e). War-Related Illness and Injury Study Centers Under a congressional mandate, VA established war-related illness and injury study centers (WRIISCs) in 2001 to serve combat veterans who had unexplained illnesses (Lincoln et al., 2006). Three WRIISCs are operating in East Orange, New Jersey; Palo Alto, California; and Washington, DC. The WRIISCs are multidisciplinary centers of excellence to which veterans who are severely afflicted with CMI can be referred. They also are charged with conducting research on CMI and its constituent symptoms and with creating and disseminating educational materials for veterans, their fami- lies, and clinicians (Lincoln et al., 2006; VA, 2012l). Veterans may be referred to a WRIISC by their clinicians. Referrals generally come about because a veteran has a complex medical history of no known etiology, treatments have resulted in little or no symptom improve- ment, deployment-related environmental exposures may have occurred, or the veteran is not improving and further local expertise is unavailable (Reinhard, 2012). Veterans in a WRIISC are evaluated by a multi isciplinary team that d conducts a comprehensive health assessment and formulates a comprehensive personal care plan aimed at managing symptoms and improving functional health; the plan is implemented in the WRIISC and given to the referring clinicians (Lincoln et al., 2006). As of 2012, the WRIISCs’ clinical programs have conducted health assessments of about 1,000 veterans (Reinhard, 2012). Patient-Centered Medical Care and the Office of Cultural Transformation VHA has established an office of Patient Centered Care and Cultural Transformation (Petzel, 2012; VA, 2012g,h). The goal of the office is to develop personal, patient-centered models of care for veterans who receive their health care at VHA facilities. There will be greater focus on providing team-based care and integrative approaches throughout VHA. The office seeks to address the “full range of physical, emotional, mental, social, spiri- tual, and environmental influences” on veterans (VA, 2012g).
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IMPLEMENTATION AND MODELS OF CARE 161 Summary of Models of Care in the Department of Veterans Affairs Health Care System VHA has developed extensive infrastructure and support for veter- ans who have CMI and the clinicians who care for them: multispecialty teams, practice guidelines, training and educational materials for clinicians and patients, access to consultants when they are not available locally, support for such elements of implementation as practice champions, the basic structure of a system of stepped care, and more. The infrastructure is remarkable and far outstrips the corresponding elements of the civil- ian health care system, which is generally much less developed. All those efforts notwithstanding, however, veterans who have CMI will remain seriously underserved, and their clinicians will remain unable to serve them adequately, until additional measures are put into place. Clinical guidelines for chronic conditions are extraordinarily difficult to implement, and their implementation follows a set of rules and principles that are just now becoming understood. CPGs assume a degree of uniformity of presenta- tion and severity and the availability of time, training, and personnel that are not always available even in the most dedicated and highest-quality settings. But the patients present with highly variable and ever-changing symptom constellations—with a spectrum of severity ranging from just barely symptomatic to profoundly disabled—in a highly variable and con- stantly changing clinical environment. Thus, the treatment burden of and need for care coordination is not uniform among clinical settings. Finally, and most important, even in settings where it is possible to bring a high degree of standardization, the team members themselves—their seniority, previous experiences, personalities, team “chemistry,” and response to the particular local leaders—constitute a source of irreducible variation that must be taken into account in the implementation process. Local practice coaches and other local resources are almost always necessary for success- ful implementation. The issue of implementation will be addressed after a description of the veterans’ experience of care. GULF WAR VETERANS’ EXPERIENCE OF CARE Patient Satisfaction Despite the extensive efforts devoted to improving care for veterans who have CMI, some Gulf War veterans have expressed frustration and anger about what they consider to be subpar care from VHA (public com- ments to the committee, December 17, 2011, and February 1, 2012; Furey, 2012). Often, they do not believe that VHA clinicians take their symptoms
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162 GULF WAR AND HEALTH seriously, and they get the impression that the clinicians believe that their health problems are mental in origin. Gulf War veterans report less satisfaction with waiting-room time, copayment or costs, courtesy of office staff, and clinician time than World War II veterans (Harada et al., 2002). Differences in several other variables were not significant—number of days waited for an appointment, how easy it is to get around a facility, clinician skill, and overall satisfaction. Harada et al. (2002) found that veterans who used both VHA and non-VHA facili- ties (“dual users”) were less satisfied overall with their outpatient care than were veterans who used only VHA or only non-VHA facilities. In a study that compared veterans’ satisfaction with types of clinicians in VHA facilities, satisfaction scores increased as the numbers of nurse practitioners increased (Budzi et al., 2010). Veterans are more satisfied with nurse-practitioners who were trained in particular skills, such as paying attention to and providing for the patient’s educational needs, individual- ized care, and active listening. Health status is significantly associated with patient satisfaction in vet- erans who use VHA outpatient care (Ren et al., 2001). Mental health status correlates more strongly with patient satisfaction than does physical health status. In general, veterans who are healthier are more likely to be satisfied with their care. Satisfaction can be both a consequence and a determinant of health status; in the study by Ren et al. (2001), health status seemed to be more of a determinant of patient satisfaction than the reverse. Veterans who had chronic illnesses and experienced greater satisfac- tion with VHA were less likely to seek care elsewhere after discharge from active duty (Stroupe et al., 2005). Greater dissatisfaction at baseline led to a greater probability that veterans would later go outside the VHA system, thereby seeding the civilian primary care sector with unhappy veterans who had CMI. Veterans older than 65 years old are more likely to use non-VHA health care facilities than younger veterans; this may be due to the older veterans’ Medicare eligibility. Female veterans reported scores similar to those of male veterans on most dimensions of outpatient satisfaction with VHA facilities after adjust- ment for a number of demographic attributes (Wright et al., 2006). Access to Care On discharge from the active-duty military, a portion of veterans (8.57 million of a total of about 22.23 million in FY 2011) enroll in the VA health care system (VA, 2012d). To balance demand with resources, VHA uses health care enrollment priority groups (see Box 7-1). The threshold for enrollment changes on the basis of available resources.
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IMPLEMENTATION AND MODELS OF CARE 163 The amount of time it takes veterans to get an appointment to visit a VHA clinician varies widely from one clinic to another. Harada et al. (2002) reported that one of veterans’ highest points of dissatisfaction with VHA was the wait time for an appointment. In 2010, nearly all primary care appointments at VHA facilities occurred within 30 days of the desired date (Walters, 2011). In 2011, the standard for primary care appointments was changed to 14 days, which was already the standard for mental health appointments. Data were not available to describe whether VHA has been able to meet the 14-day standard. However, a review by the VA Office of the Inspector General (VA-OIG) found that many veterans waited more than 14 days past their desired appointment date for their mental health appointments (VA, 2012k). In addition, the VA-OIG determined that the “VHA overstated its success in providing veterans new and follow-up appointments for treatment within 14 days.” The principal reasons for wait times to exceed the established standard were inconsistent application of procedures by VHA schedulers and too few mental health clinicians on staff. Location of VHA facilities affects veterans’ access to care. VHA has over 1,000 facilities, including VAMCs and outpatient clinics, but they are geographically dispersed, and not every veteran has easy access to one (Reisinger et al., 2012). For example, 43% of veterans live in rural areas that may not be readily served by VHA facilities (Walters, 2011). A VA review on interventions to improve access to care found that as distance from a VHA facility increased there was decreased use of outpatient services and that the greatest decrease occurred for distances up to 60 miles from the facility (Kehle et al., 2011). The relationship between facility distance from home and care use was consistent for physical health and mental health appointments. VHA is developing strategies to bring health care to rural veterans through such means as mobile health clinics, telehealth programs, and health care partnerships (Walters, 2011). In its review, VA evaluated whether integration of primary care and mental health care would increase veterans’ access to mental health services (Kehle et al., 2011). Both integrating mental health services into primary care clinics and offering primary care in mental health clinics showed prom- ise, but more research on these models is needed. Veterans have access to their medical records through the VA’s My HealtheVet system (VA, 2012i). Furthermore, they can download their medical records and read, print, or save them to a computer using the Blue Button program (VA, 2012b). Veterans can self-enter several types of information in My HealtheVet, including personal health indicators (such as blood pressure, weight, and heart rate), emergency contact information, names of health care providers, laboratory test results, family health history,
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164 GULF WAR AND HEALTH BOX 7-1 Department of Veterans Affairs (VA) Health Care Enrollment Priority Groups Group 1: Veterans with VA-rated service-connected disabilities 50% or more disabling; and veterans determined by VA to be unemployable due to service-connected conditions. Group 2: Veterans with VA-rated service-connected disabilities 30% or 40% disabling. Group 3: Veterans who are Former Prisoners of War (FPOWs); veterans awarded a Purple Heart medal; veterans whose discharge was for a dis- ability that was incurred or aggravated in the line of duty; veterans with VA-rated service-connected disabilities 10% or 20% disabling; veterans awarded special eligibility classification under Title 38, U.S.C. § 1151, “benefits for individuals disabled by treatment or vocational rehabilita- tion”; and veterans awarded the Medal of Honor. Group 4: Veterans who are receiving aid and attendance or housebound benefits from VA; and veterans who have been determined by VA to be catastrophically disabled. Group 5: Non-service-connected veterans and noncompensable service- connected veterans rated 0% disabled by VA with annual income and/or net worth below the VA national income threshold and geographically- adjusted income threshold for their resident location; veterans receiving VA pension benefits; and veterans eligible for Medicaid programs. Group 6: World War I veterans; Compensable 0% service-connected vet- erans; veterans exposed to ionizing radiation during atmospheric testing or during the occupation of Hiroshima and Nagasaki; Project 112/ hipboard S Hazard and Defense (SHAD) participants; veterans exposed to the defoli- ant Agent Orange while serving in the Republic of Vietnam between 1962 and 1975; veterans of the Gulf War that served between August 2, 1990, and November 11, 1998; veterans who served in a theater of combat
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IMPLEMENTATION AND MODELS OF CARE 165 operations after November 11, 1998, as follows: (a) currently enrolled veterans and new enrollees who were discharged from active duty on or after January 28, 2003, are eligible for the enhanced benefits for 5-years post-discharge; (b) veterans discharged from active duty before Janu- ary 28, 2003, who apply for enrollment on or after January 28, 2008, are eligible for this enhanced enrollment benefit through January 27, 2011. Note: At the end of this enhanced enrollment priority group placement time period, veterans will be assigned to the highest Priority Group their unique eligibility status at that time qualifies them for. Group 7: Veterans with gross household income below the geographi- cally adjusted income threshold for their resident location and who agree to pay co-pays. Group 8: Veterans with gross household income above the VA national income threshold and the geographically adjusted income threshold for their resident location and who agree to pay co-pays. a. eterans eligible for enrollment: Noncompensable 0% service- V connected and: Subpriority a: Enrolled as of January 16, 2003, and who have remained enrolled since that date and/or placed in this sub- priority due to changed eligibility status; Subpriority b: Enrolled on or after June 15, 2009, whose income exceeds the current VA National Income Thresholds or VA National Geographic Income Thresholds by 10% or less. b. eterans eligible for enrollment: Nonservice-connected and: Sub V priority c: Enrolled as of January 16, 2003, and who have remained e nrolled since that date and/or placed in this subpriority due to changed eligibility status; Subpriority d: Enrolled on or after June 15, 2009, whose income exceeds the current VA National Income hresholds or T VA National Geographic Income Thresholds by 10% or less. c. Veterans not eligible for enrollment: Veterans not meeting the cri- teria above: Subpriority e: Noncompensable 0% service-connected; and Subpriority g: Nonservice-connected. SOURCE: VA, 2012f.
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172 GULF WAR AND HEALTH opportunities, constraints, and preferences; and especially to address unex- pected difficulties and unintended consequences. It is also necessary to collect data systematically on processes of care, on how to effect process change when necessary, on the results of changes with respect to interme- diate outcomes, on what works and what does not, and on unintended consequences of changes. The implementation team must be prepared not only to collect information but to reflect on its implications and to act on it with the next process-adjustment cycle. Practice redesign requires a series of linked incremental steps—it is not accomplished in one step. The PDSA method described above has been used successfully in a variety of primary care settings to improve practice. Implementation work that uses the PDSA method has a unique approach. If changes in disease-specific outcomes are used as the principal measure of success, valuable progress can occur. The road to improved disease state is long and difficult—it is actually many roads—and is beset with so many problems that it requires an approach to dealing with many unexpected problems. Progress needs to be measured by success in solving operational and functional problems that appear one after another, not just in improved disease outcomes. An improved disease state will appear only after a long run of successful interim problem-solving steps. Many primary care practice redesign organizations (such as TransforMed, HealthTeamWorks, and the Institute for Clinical Systems Improvement) have learned that practice coaches are highly useful (or indispensable) to practices as they begin their redesign efforts. Thus, implementation teams should include health coaches, integrative-medicine practitioners, and other local practice resources that can help practices to work out local changes and solu- tions to the problem of implementing multiple CPGs for their own unique patient-panel demands under variable local conditions. The value of learning collaboratives or learning communities must be stressed. Practices, coaches, and other forms of technical support are valu- able, but local practice teams often benefit most from the experience of their peers in similar circumstances, and periodic meetings in which ideas and solutions can be exchanged will pay handsome dividends. Thus, implementation success depends on teams that work well together, that practice active creative problem solving, that maintain flex- ibility, and that persist in the face of failure—that demonstrate resilience, the ability to learn and improve. Progress toward complete implementation of a guideline is measured in terms of successfully solving one after another the small problems that arise in the course of PDSA work. Use of metrics can lead to improved care and ultimately lead to healthier patients and better outcomes. A practice that is ready for successful redesign cannot be understood by looking only at workflow; it must also be assessed for active, flexible
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IMPLEMENTATION AND MODELS OF CARE 173 problem solving. Over time, such a practice can be expected to have shaped workflow to solve the problems of the particular patients in the panel with the particular resources at hand. SELECT MODELS OF CARE USED BY OTHER ORGANIZATIONS As noted above, most veterans receive some of or all their care outside the VHA system of clinics in the civilian sector. Civilian settings are more variable and generally less well resourced, and their clinicians are gener- ally less able to devote the time needed to manage CMI and its attendant comorbidities properly in the context of a busy daily practice. Stepped care is much harder in the civilian setting, because specialty resources are less available. Perhaps most important, primary care clinicians in the civilian setting are less familiar with the characteristics of CMI in veteran popula- tions and therefore less adept at creating the complex personal care plans described above. Nevertheless, PCMHs are rapidly appearing in this sector, and the practice-redesign efforts necessary to produce PCMHs will benefit veterans who have CMI and are seeking care—particularly if VHA can extend its resources to these practices. A civilian PCMH that is rendering care to veterans who have CMI would benefit from the following: • Notification from VHA of the names, disability status, comprehen- sive health assessment, and other medical care records of the veter- ans under care, as allowed under the Health Insurance Portability and Accountability Act. • VHA CPGs applicable to the specific patients, particularly those related to time allocations and team expertise. • Recommended care-team membership for the patients. • Access, via telehealth or other ECHO-like variations, to specific team members who have the expertise necessary for the manage- ment of the patients, such as neurologists adept at managing trau- matic brain injury or acupuncturists adept at pain management. • Access to consultation with or referral to VAMCs, WRIISCs, and other resources that may benefit veterans as specific problems arise that cannot be managed adequately in the civilian PCMH. DISSEMINATING EVIDENCE-BASED GUIDELINES THROUGH THE DEPARTMENT OF VETERANS AFFAIRS SYSTEM The flow of evidence-based information (EBI)—knowledge transfer— through a system to influence policy and practice has become a major topic of focus in the era of evidence-based medicine. It is particularly impor- tant when the sheer volume of research data appears to have only slight
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174 GULF WAR AND HEALTH influence on clinician-practice behaviors. As a result, research has shifted attention from mere generation of guidelines to concerns about their dis- semination and implementation (Grimshaw and Russell, 1993; Thomas et al., 1999). Knowledge transfer, some suggest, may occur in three stages: diffusion, dissemination, and implementation (Lomas, 1993). The stages are characterized by increasing specificity, targeting, and customization, leading, in theory, to the adoption of new information that changes practice and policy. Successful models of knowledge transfer do not yet exist (French et al., 2012), but recent work is offering some useful insights into the pro- cesses that potentially would help in disseminating EBI, such as practice guidelines. It is instructive to elucidate the three stages and the distinctions among them before discussing the relevance of knowledge transfer in treat- ing for CMI by clinicians in the VA health system. Diffusion is a passive process that involves spread of EBI with little attention to specificity in defining the target audience or to the customiza- tion of the information itself. Publication of studies in professional journals or coverage of scientific studies in the mass media may garner a wide- spread audience for the message (Viswanath et al., 2008) but may or may not attract the attention of clinicians and patients unless they are already attuned to the topic. Although print media may remain an important source for some physicians and patients, few physicians read medical journals for the latest scientific findings, given the sheer amount of published literature, busy schedules, and possible lack of suitability in how the information is presented (Lomas, 1993; Thomas et al., 1999). Patient-related factors may also act as barriers to using EBI (Thomas et al., 1999). Dissemination is more deliberate flow of information toward a defined target audience, and the information itself is more customized. Examples include evidence reviews, practice guidelines, and consensus statements. Implementation goes beyond reaching the intended audience, clinicians. The new information is actually used to change practice behaviors. Given its more ambitious goal, implementation is facilitated by a sharper focus on addressing organizational barriers to the adoption of EBI (Ramanadhan et al., 2012). Localization and customization of EBI will go a long way in facilitating implementation. Appropriate incentives and sanctions may help in this phase. Implementation of guidelines for treatment of veterans who have CMI was discussed in detail earlier in this chapter. Channels or sources on which physicians rely for EBI, the nature of the information and messages that appeal to them, and the conditions that improve or hinder their capacity to use EBI define the target audience and guide the methods used to approach them. Diffusion and dissemination, in theory, could create awareness about new developments or consensus guidelines but do not necessarily address the day-to-day reality of the clinicians in VHA. They are, however, critical in creating the necessary
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IMPLEMENTATION AND MODELS OF CARE 175 “readiness for change” in practice behaviors. Change in practice behaviors requires “enabling factors” that address barriers that deter implementa- tion (Lomas, 1993). Behavior change is most likely when environmental changes accompany dissemination of EBI. System changes and support systems will also reinforce changed practice behaviors and may enable their maintenance. CLINICIANS’ BEHAVIOR CHANGE: SYSTEM AND INTERPERSONAL DETERMINANTS The role of clinicians is critical in any adoption of health care innova- tions, and much of the adoption and maintenance of innovations requires change in clinicians’ behaviors (Gunter and Whittal, 2010). The literature of a variety of fields—including communication, sociology, marketing, psy- chology, and business—offers useful pointers to understanding how practice behaviors could potentially be changed. • Peer networks, such as the learning communities described above, have a profound influence on adoption of new behaviors and skills (Bernstein et al., 2009; IOM, 2012; Ramanadhan et al., 2010). Peers could potentially introduce new information, norms, and skills in a network and thereby facilitate the adoption of EBI. Some peers could model new behaviors and skills, making learning of new skills smoother. A network of peers in which communication and informal transfer are routine may lead to the emergence of “learning organizations” in which acquisition of new information, skills, and behaviors can be made routine. • Opinion leaders and champions, particularly in local health cen- ters, may carry considerable weight in the community of clini- cians, facilitating behavior changes and making adoption of new practices acceptable (Moore et al., 2004). One study of knowledge transfer of evidence-based technology that included screening, brief intervention, and referral to treatment conducted in emergency departments found that having local staff as champions made a big difference in adoption and maintenance of a new practice (Bernstein et al., 2009). • The role of leadership is critical in overcoming barriers to imple- mentation as it ensures quality control, endorsement, priority set- ting, and the creation of an overall climate of innovation support (Yano et al., 2012). • Behaviors that are substantive departures from existing practices could be more difficult to change; in a similar vein, complex inter- ventions in contrast to simpler interventions are difficult to imple-
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176 GULF WAR AND HEALTH ment and less likely to be adopted (McGovern et al., 2004; Rogers, 1995). • Organizational constraints—such as inflexible rules, lack of incen- tives, and potential for negative sanctions—can deter EBI-based changes in practice. • New methods for connecting EBI to practice, such as appropriate methodology, could link evidence to practices better in the context of the reality of clinical variation. The advent of information and communication technologies has enabled the development of decision-support systems that facilitate the adoption of recommendations. Decision-support systems, particularly ones that draw on such electronic health records as those used by VA, may pro- vide patient-specific information to a clinician when needed in a manner that is user-friendly. These systems are especially effective when they are user-friendly, easily available, and part of a physician’s work flow (Thomas et al., 1999). Thomas et al. (1999) argued that such design considerations as easier navigation, clear indexing, and forgiving interfaces enhance the utility of communication technologies to facilitate behavior change. As asserted earlier, customization is a critical element in facilitating adoption of innovations. A recommended innovation should be flexible, easy to try out, and customizable to local conditions, and it should have some advantage over current practices (Rogers, 1995). Customization demands careful audience segmentation and designing of intervention com- ponents that meet the needs of segments of the audience. In one study, VA tried a social marketing approach to disseminate a new model of col- laborative care to treat depression (Luck et al., 2009). In the model, the intervention targeted not just the physicians but other staff, such as local leaders, frontline staff, and managers; it focused on cultural change in the larger organization. Marketing was also reported to be a critical determi- nant in the national dissemination of a new model to promote collaborative care for depression in the VA system (Smith et al., 2008). Those efforts, in theory, reduce resistance from people in an organization to adopt innova- tions and ease the change in clinician behaviors. SUMMARY VHA faces extraordinary challenges in caring for the burgeoning popu- lation of veterans who have CMI. It is possible to meet the challenges with adequate clinician education and support, organization and preparation of care teams that fit the needs of the veterans, establishment of implementa- tion protocols that lead to continuous quality improvement, dissemination of these successes to other clinical teams and settings that are struggling
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