Racial/Ethnic Differences in Primary Care Experiences in Patient-Centered Medical Homes among Veterans with Mental Health and Substance Use Disorders

Experiences of physical healthcare services in Māori and non-Māori with mental health and substance use conditions

OBJECTIVES

Inequities in physical health outcomes exist for people with mental health and substance use conditions and for Indigenous populations (Māori in Aotearoa New Zealand). These inequities may be partly explained by poorer quality of physical healthcare services, including discrimination at systemic and individual levels. This study investigated the experiences of people with mental health and substance use conditions accessing physical healthcare and differences in service quality for non-Māori relative to Māori.

METHODS

A cross-sectional online survey of people with mental health and substance use conditions in New Zealand asked about four aspects of service quality in four healthcare settings: general practice, emergency department, hospital and pharmacy. The quality domains were: treated with respect; listened to; treated unfairly due to mental health and substance use conditions; mental health and substance use condition diagnoses distracting clinicians from physical healthcare (diagnostic and treatment overshadowing).

RESULTS

Across the four health services, pharmacy was rated highest for all quality measures and emergency department lowest. Participants rated general practice services highly for being treated with respect and listened to but reported relatively high levels of overshadowing in general practice, emergency department and hospital services. Experiences of unfair treatment were more common in emergency department and hospital than general practice and pharmacy. Compared to Māori, non-Māori reported higher levels of being treated with respect and listened to in most services and were more likely to report 'never' experiencing unfair treatment and overshadowing for all health services.

CONCLUSION

Interventions to address discrimination and poor-quality health services to people with mental health and substance use conditions should be tailored to the physical healthcare setting. More needs to be done to address institutional racism in systems that privilege non-Māori.

Health Equity in the Veterans Health Administration From Veterans' Perspectives by Race and Sex

Importance

Advancing equitable patient-centered care in the Veterans Health Administration (VHA) requires understanding the differential experiences of unique patient groups.

Objective

To inform a comprehensive strategy for improving VHA health equity through the comparative qualitative analysis of care experiences at the VHA among veterans of Black and White race and male and female sex.

Design, Setting, and Participants

This qualitative study used a technique termed freelisting, an anthropologic technique eliciting responses in list form, at an urban academic VHA medical center from August 2, 2021, to February 9, 2022. Participants included veterans with chronic hypertension. The length of individual lists, item order in those lists, and item frequency across lists were used to calculate a salience score for each item, allowing comparison of salient words and topics within and across different groups. Participants were asked about current perceptions of VHA care, challenges in the past year, virtual care, suggestions for change, and experiences of racism. Data were analyzed from February 10 through September 30, 2022.

Main Outcomes and Measures

The Smith salience index, which measures the frequency and rank of each word or phrase, was calculated for each group.

Results

Responses from 49 veterans (12 Black men, 12 Black women, 12 White men, and 13 White women) were compared by race (24 Black and 25 White) and sex (24 men and 25 women). The mean (SD) age was 64.5 (9.2) years. Some positive items were salient across race and sex, including "good medical care" and telehealth as a "comfortable/great option," as were some negative items, including "long waits/delays in getting care," "transportation/traffic challenges," and "anxiety/stress/fear." Reporting "no impact" of racism on experiences of VHA health care was salient across race and sex; however, reports of race-related unprofessional treatment and active avoidance of race-related conflict differed by race (present among Black and not White participants). Experiences of interpersonal interactions also diverged. "Impersonal/cursory" telehealth experiences and the need for "more personal/attentive" care were salient among women and Black participants, but not men or White participants, who associated VHA care with courtesy and respect.

Conclusions and Relevance

In this qualitative freelist study of veteran experiences, divergent experiences of interpersonal care by race and sex provided insights for improving equitable, patient-centered VHA care. Future research and interventions could focus on identifying differences across broader categories both within and beyond race and sex and bolstering efforts to improve respect and personalized care to diverse veteran populations.

Phencyclidine Positivity on Urine Drug Screening in Patients Treated for Alcohol Withdrawal on a Dual-diagnosis Medically Assisted Withdrawal Unit

OBJECTIVES

Little contemporary research has explored phencyclidine (PCP) use in people with alcohol use disorder. Therefore, we sought to determine the prevalence of PCP positivity on urine toxicology screening among patients admitted for alcohol withdrawal, identify correlates of PCP positivity, and investigate PCP positivity's relationship to length of stay (LOS) and risk of facility readmission.

METHODS

This was a retrospective study of patients admitted to a dual-diagnosis medically assisted withdrawal unit for alcohol withdrawal from 2014 to 2019. Univariate tests and logistic regression were used to investigate potential correlates of PCP positivity on admission toxicology screening (primary outcome). Multivariable linear regression models and survival analyses analyzing LOS and risk of readmission (secondary outcomes) were also developed.

RESULTS

Ninety of 3731 patients (2.4%) screened positive for PCP. There were significant associations on univariate testing between PCP positivity and age, race, homeless status, and urine toxicology positivity for amphetamines, benzodiazepines, barbiturates, cocaine, tetrahydrocannabinol, and oxycodone. On multivariate logistic regression, only tetrahydrocannabinol, barbiturates, and cocaine positivity were associated with PCP positivity. Multivariate logistic regression and survival analysis found no statistically significant associations between PCP positivity and LOS or risk of readmission.

CONCLUSIONS

This study provides rare analysis of contemporary data on PCP use among patients undergoing medically assisted alcohol withdrawal. Phencyclidine positivity was uncommon, but use appears considerably higher among this patient population than the general population. There was no significant association between PCP positivity and LOS or readmission risk.

Perceived discrimination enhances the association between distress and impact related to the murder of George Floyd and unhealthy alcohol use in a survey sample of U.S. Veterans who report drinking

Introduction

On May 25, 2020, George Floyd was murdered by a Minneapolis police officer leading to increased social justice and antiracism movements (SJARM) across the United States. Vicarious exposure to racism and perceived discrimination are salient sources of distress which may lead to increased alcohol use as means of coping. The primary aim of the current study was to examine how perceived discrimination and the subjective impact and personal distress related to the SJARM following the George Floyd murder interact and relate to unhealthy alcohol use among U.S. Veterans.

Methods

286 Veterans were assessed for unhealthy alcohol use (AUDIT-10), perceived discrimination (EDS), and subjective impact and personal distress related to the SJARM. Two moderation analyses were performed to examine whether subjective impact and personal distress moderated relations between perceived discrimination and alcohol use. In-depth follow-up analyses were conducted to examine differences and relationships among variables.

Results

In two different moderation models, perceived discrimination moderated the association between both subjective impact (p <.001) and personal distress (p <.001) felt by the SJARM and unhealthy alcohol use. In planned exploratory analyses, Veterans who reported perceived discrimination reported higher levels of unhealthy alcohol use (M = 14.71, SD = 9.39) than those who did not t(2 8 4) = 5.61, p <.001. In post-hoc analyses, racial/ethnic minorities were significantly more likely to report perceived racial discrimination (p <.001) while non-Hispanic Whites were more likely to report perceived discrimination based on education or income level (p <.01).

Conclusions

In the context of a socially unjust event amidst a global pandemic, perceived discrimination contributes to unhealthy alcohol use and subjective impact and personal distress associated with the SJARM following the murder of George Floyd. Results highlight the importance of addressing discrimination experiences in Veterans who seek alcohol treatment, particularly as rates of unhealthy alcohol use are on the rise.

Understanding the Context for Incorporating Equity into Quality Improvement Throughout a National Health Care System

Purpose

Although health care systems aspire to deliver equitable care, practical tools that empower the health care workforce to weave equity throughout quality improvement (QI) processes are lacking. In this article, we report findings from context of use interviews that informed the development of a user-centered tool to support equity-focused QI.

Methods

Semistructured interviews were conducted from February to April of 2019. Participants included 14 medical center administrators, departmental or service line leaders, and clinical staff involved in direct patient care from three Veterans Affairs (VA) Medical Centers within a single region. Interviews covered existing practices for monitoring health care quality (i.e., priorities, tasks, workflow, and resources) and explored how equity data might fit into current processes. Themes extracted through rapid qualitative analysis were used to draft initial functional requirements for a tool to support equity-focused QI.

Results

Although the potential value of examining disparities in health care quality was clearly recognized, the data necessary for examining disparities were lacking for most quality measures. Interviewees also desired guidance on how inequities could be addressed through QI. The ways in which QI initiatives were selected, carried out, and supported also had important design implications for tools to support equity-focused QI.

Discussion

The themes identified in this work guided the development of a national VA Primary Care Equity Dashboard to support equity-focused QI within VA. Understanding the ways in which QI was carried out across multiple levels of the organization provided a successful foundation upon which to build functional tools to support thoughtful engagement around equity in clinical settings.

Perceived Contraceptive Counseling Quality Among Veterans Using VA Primary Care: Data from the ECUUN Study

BACKGROUND

High-quality contraceptive counseling is critical to support Veterans' reproductive autonomy and promote healthy outcomes.

OBJECTIVE

To describe perceived quality of contraceptive counseling in Veterans Health Administration (VA) primary care and assess factors associated with perceived high- and low-quality contraceptive counseling.

DESIGN

Cross-sectional study using data from the Examining Contraceptive Use and Unmet Need in women Veterans (ECUUN) national telephone survey.

PARTICIPANTS

Veterans aged 18-44 who received contraceptive services from a VA primary care clinic in the past year (N=506).

MAIN MEASURES

Perceived quality of contraceptive counseling was captured by assessing Veterans' agreement with 6 statements regarding provider counseling adapted from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. High-quality counseling was defined as a top score of strongly agreeing on all 6 items; low-quality counseling was defined as not agreeing (neutral, disagreeing, or strongly disagreeing) with >3 items. We constructed two multivariable models to assess associations between patient-, provider-, and system-level factors and perceived high-quality (Model 1) and perceived low-quality counseling (Model 2).

KEY RESULTS

Most participants strongly agreed that their providers listened carefully (74%), explained things clearly (77%), and spent enough time discussing things (71%). Lower proportions strongly agreed that their provider discussed more than one option (54%), discussed pros/cons of various methods (44%), or asked which choice they thought was best for them (62%). In Model 1, Veterans who received care in a Women's Health Clinic (WHC) had twice the odds of perceiving high-quality counseling (aOR=1.99; 95%CI=1.24-3.22). In Model 2, Veterans who received care in a WHC (aOR=0.49; 95%CI=0.25-0.97) or from clinicians who provide cervical cancer screening (aOR=0.49; 95%CI=0.26-0.95) had half the odds of perceiving low-quality counseling.

CONCLUSIONS

Opportunities exist to improve the quality of contraceptive counseling within VA primary care settings, including more consistent efforts to seek patients' perspectives with respect to contraceptive decisions.

Cohort study of team-based care among marginalized people who use drugs in Ottawa

OBJECTIVE

To describe team-based care use among a cohort of people who use drugs (PWUD) and to determine factors associated with receipt of team-based care.

DESIGN

A cohort study using survey data collected between March and December 2013. These data were then linked to provincial-level health administrative databases to assess patterns of primary care among PWUD in the 2 years before survey completion.

SETTING

Ottawa, Ont.

PARTICIPANTS

Marginalized PWUD 16 years of age or older.

MAIN OUTCOME MEASURES

Patients were assigned to primary care models based on survey responses and then were categorized as attached to team-based medical homes, attached to non-team-based medical homes, not attached to a medical home, and no primary care. Descriptive statistics and multinomial logistic regression were used to determine associations between PWUD and medical home models.

RESULTS

Of 663 total participants, only 162 (24.4%) received team-based care, which was associated with high school level of education (adjusted odds ratio [AOR] = 2.18; 95% CI 1.13 to 4.20), receipt of disability benefits (AOR = 2.47; 95% CI 1.22 to 5.02), and HIV infection (AOR = 2.88; 95% CI 1.28 to 6.52), and was inversely associated with recent overdose (AOR = 0.49; 95% CI 0.25 to 0.94). In comparison, 125 (18.8%) received non-team-based medical care, which was associated with university or college education (AOR = 2.31; 95% CI 1.04 to 5.15) and mental health comorbidity (AOR = 4.18; 95% CI 2.33 to 7.50), and was inversely associated with being detained in jail in the previous 12 months (AOR = 0.51; 95% CI 0.28 to 0.90).

CONCLUSION

Although team-based, integrated models of care will benefit disadvantaged groups the most, few PWUD receive such care. Policy makers should mitigate barriers to physician care and improve integration across health and social services.

Prevalence of cannabis use, disorder, and medical card possession in U.S. military veterans: Results from the 2019-2020 National Health and Resilience in Veterans Study

More than half of U.S. states legalized medical or recreational sale and possession of cannabis since the prevalence of cannabis use was last estimated among U.S. military veterans in 2014. To provide updated estimates of the prevalence and correlates of cannabis use, cannabis use disorder (CUD), and medical cannabis card possession in this population, data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, a nationally representative survey of 4,069 veterans ages 22-99 years who reported on their past-6-month cannabis use, CUD symptoms, and possession of a medical cannabis card. An estimated 11.9% [95% confidence interval (CI) = 10.9-12.9%)] of veterans reported using cannabis, 2.7% (95% CI = 2.3-3.3%) screened positive for CUD, and 1.5% (95% CI = 1.2-2.0%) reported possessing a medical card. Prevalence of cannabis use, CUD, and card possession were higher among younger veterans (use: 20.2%, CUD: 5.6%, card: 2.1%) and those with psychiatric conditions (use: 24.0%-30.0%, CUD: 8.9%-13.0%, card: 3.1%-4.0%). Younger age, alcohol use disorder, and childhood adversity explained a large proportion of variance in cannabis use and CUD, and depression was independently associated with CUD (odds ratio [OR] = 2.76). Physical disability (OR = 3.59), combat veteran status (OR = 2.84), and non-Hispanic black (OR = 0.23) relative to white race/ethnicity most strongly predicted using cannabis with a medical card. The estimated prevalence of cannabis use in veterans-nearly 12%-is higher than the most recently reported estimate (9% in 2014). Veteran cannabis use may be increasing and is particularly prevalent among veterans with psychiatric conditions.

Reasons Older Veterans Use the Veterans Health Administration and Non-VHA Care in an Urban Environment

BACKGROUND

Older veterans in urban settings rely less on the Veterans Health Administration (VHA) health care, suggesting deficits of access and services for aging veterans. We aimed to identify reasons for VHA and non-VHA use across the health status of older, urban-dwelling veterans.

METHODS

We examined open-ended responses from 177 veterans who were enrolled in primary care at the Bronx VA Medical Center, used non-VHA care in prior 2 years, and completed baseline interviews in a care coordination trial from March 2016 to August 2017. Using content analysis, we coded and categorized key terms and concepts into an established access framework. This framework included 5 categories: acceptability (relationship, second opinion), accessibility (distance, travel); affordability; availability (supply, specialty care); and accommodation (organization, wait-time). Self-reported health status was stratified by excellent/very good, good, and fair/poor.

RESULTS

We were able to categorize the responses of 166 veterans, who were older (≥75 years, 61%), minority race and ethnicity (77%), and low income (<$25,000/y, 51%). Veterans mentioned acceptability (42%) and accessibility (37%) the most, followed by affordability (33%), availability (25%), and accommodation (11%). With worse self-reported health status, accessibility intensified (excellent/very good, 24%; fair/poor, 46%; P = .031) particularly among minority veterans, while acceptability remained prominent (excellent/very good, 49%; fair/poor, 37%; P = .25). Other categories were mentioned less with no significant difference across health status.

CONCLUSIONS

Even in an urban environment, proximity was a leading issue with worse health. Addressing urban accessibility and coordination for older, sicker veterans may enhance care for a growing vulnerable VHA population.

Are parents' geographical origin associated with their evaluation of child and adolescent mental health services? Results from a national survey in Norway

The objective was to assess the association between parents' geographical origin and their evaluation of outpatient child and adolescent mental health services (CAMHS). Data were collected in a national parent's experience survey of all outpatient CAMHS in Norway in 2017. Following exclusions, 16,143 parents were part of the study, of which 5932 responded (36.1%). Diagnosis and global psychosocial functional level were collected from the National Patient Register. Multilevel regression was used to assess the association between parents' geographical origin and parent evaluation of the outpatient CAMHS on ten indicators. Sentiment and content analysis was conducted on open-ended comments from parents. The estimated regression coefficients showed that parents born in Eastern Europe scored the services significantly poorer than parents born in Norway on outcome of treatment (- 7.73, p < 0.01), general satisfaction (- 5.53, p < 0.05), ease of getting in contact with health personnel outside of scheduled appointments (- 17.04, p < 0.001), and knowledge of the services that the child has received at the service (- 10.63, p < 0.001). Parents born in Asia/Africa/South America scored the services similar as Norwegian parents on eight of ten indicators, better on one (waiting time) and poorer on one (ease of getting in contact). Sentiment analysis showed that 54% of the comments from parents born in Eastern Europe were negative, compared to 42% for the Norwegian group and 36% for Asia/Africa/South America. The parents' evaluation of the outpatient CAMHS were partly associated with their geographical origin, with parents born in Eastern Europe reporting poorer experiences than parents born in Norway.

Community social determinants and health outcomes drive availability of patient-centered medical homes

The collaborative design of America's patient-centered medical homes places these practices at the forefront of emerging efforts to address longstanding inequities in the quality of primary care experienced among socially and economically marginalized populations. We assessed the geographic distribution of the country's medical homes and assessed whether they are appearing within communities that face greater burdens of disease and social vulnerability. We assessed overlapping spatial clusters of mental and physical health surveys; health behaviors, including alcohol-impaired driving deaths and drug overdose deaths; as well as premature mortality with clusters of medical home saturation and community socioeconomic characteristics. Overlapping spatial clusters were assessed using odds ratios and marginal effects models, producing four different scenarios of resource need and resource availability. All analyses were conducted using county-level data for the contiguous US states. Counties having lower uninsured rates and lower poverty rates were the most consistent indicators of medical home availability. Overall, the analyses indicated that medical homes are more likely to emerge within communities that have more favorable health and socioeconomic conditions to begin with. These findings suggest that intersecting the spatial footprints of medical homes in relation to health and socioeconomic data can provide crucial information for policy makers and payers invested in narrowing the gaps between clinic availability and the communities that experience the brunt of health and social inequalities.

Explaining racial-ethnic differences in hypertension and diabetes control among veterans before and after patient-centered medical home implementation

Patient-centered medical homes (PCMH) are primary care delivery models that improve care access and population-level health outcomes, yet they have not been observed to narrow racial-ethnic disparities in the Veteran Health Administration (VHA) or other health systems. We aimed to identify and compare underlying drivers of persistent hypertension and diabetes control differences between non-Hispanic Black (Black) and Hispanic versus non-Hispanic White (White) patients before and after PCMH implementation in the VHA. Among Black and Hispanic versus White VHA primary care patients in 2009 (nhypertension = 26,906; ndiabetes = 21,141) and 2014 (nhypertension = 83,809; ndiabetes = 38,887), we retrospectively examined hypertension control (blood pressure<140/90) and diabetes control (hemoglobin A1c <9) obtained through random chart abstraction of patient health records nationally via VHA's quality monitoring program. We fit linear probability regression models, adjusting for age, gender, comorbidity, and socioeconomic status (SES). Blinder-Oaxaca and Smith-Welch decomposition methods were used to parse out explained and unexplained contributors to health disparity between racial-ethnic groups pre- and post-PCMH implementation. Compared to White patients, hypertension and diabetes control remained significantly lower for Black (-6.2%[0.4%] and -3.1%[0.6%], respectively; p's<0.001) and Hispanic (-1.4%[0.8%] and -4.0%[1.0%], respectively; p's<0.001) patients following VHA PCMH implementation. Most racial-ethnic differences (55.7-92.3%; all p<0.05) were not attributed to age, gender, comorbidity, and SES. The contribution of explained versus unexplained factors did not significantly change over time. While many explanations for persistent racial-ethnic disparities in disease control among veterans exist, our study did not find that it was due to an influx of "sick" or "socioeconomically vulnerable" patients into the VHA following PCMH implementation. Instead, unexplained differences may be due to differential healthcare and community experiences (e.g., discrimination). Understanding underlying pathways leading to health disparities will better inform policy and clinical interventions to improve PCMH care delivery to racial-ethnic minority patients in health systems.

Veterans' Experiences With Outpatient Care: Comparing The Veterans Affairs System With Community-Based Care

Timely access to outpatient care was a primary driver behind the Department of Veterans Affairs' (VA's) increased purchase of community-based care under the Veterans Access, Choice, and Accountability Act of 2014, known as the Choice Act. To compare veterans' experiences in VA-delivered and community-based outpatient care after implementation of the act, we assessed veterans' scores on four dimensions of experience-access, communication, coordination, and provider rating-for outpatient specialty, primary, and mental health care received during 2016-17. Patient experiences were better for VA than for community care in all respects except access. For specialty care, access scores were better in the community; for primary and mental health care, access scores were similar in the two settings. Although all specialty care scores and the primary care coordination score improved over time, the gaps between settings did not shrink. As purchased care further expands under the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018, which replaced the Choice Act in 2019, monitoring of meaningful differences between settings should continue, with the results used to inform both VA purchasing decisions and patients' care choices.

Primary care experiences of veterans with opioid use disorder in the Veterans Health Administration

BACKGROUND

While patients with substance use disorders (SUDs) are thought to encounter poor primary care experiences, the perspectives of patients with opioid use disorder (OUD), specifically, are unknown. This study compares the primary care experiences of patients with OUD, other SUDs and no SUD in the Veterans Health Administration.

METHODS

The sample included Veterans who responded to the national Patient-Centered Medical Home Survey of Healthcare Experiences of Patients, 2013-2015. Respondents included 3554 patients with OUD, 36,175 with other SUDs, and 756,386 with no SUD; 742 OUD-diagnosed patients received buprenorphine. Multivariable multinomial logistic regressions estimated differences in the probability of reporting positive and negative experiences (0-100 scale) for patients with OUD, compared to patients with other SUDs and no SUD, and for OUD-diagnosed patients treated versus not treated with buprenorphine.

RESULTS

Of all domains, patients with OUD reported the least positive experiences with access (31%) and medication decision-making (35%), and the most negative experiences with self-management support (35%) and provider communication (23%). Compared to the other groups, patients diagnosed with OUD reported fewer positive and/or more negative experiences with access, communication, office staff, provider ratings, comprehensiveness, care coordination, and self-management support (adjusted risk differences[aRDs] range from |2.9| to |7.0|). Among OUD-diagnosed patients, buprenorphine was associated with more positive experiences with comprehensiveness (aRD = 8.3) and self-management support (aRD = 7.1), and less negative experiences with care coordination (aRD = -4.9) and medication shared decision-making (aRD = -5.4).

CONCLUSIONS

In a national sample, patients diagnosed with OUD encounter less positive and more negative experiences than other primary care patients, including those with other SUDs. Buprenorphine treatment relates positively to experiences with care comprehensiveness, medication decisions, and care coordination. As stakeholders encourage more primary care providers to manage OUD, it will be important for healthcare systems to attend to patient access and experiences with care in these settings.

Development of a novel metric of timely care access to primary care services

OBJECTIVE

To develop a model for identifying clinic performance at fulfilling next-day and walk-in requests after adjusting for patient demographics and risk.

DATA SOURCE

Using Department of Veterans Affairs (VA) administrative data from 160 VA primary care clinics from 2014 to 2017.

STUDY DESIGN

Using a retrospective cohort design, we applied Bayesian hierarchical regression models to predict provision of timely care, with clinic-level random intercept and slope while adjusting for patient demographics and risk status. Timely care was defined as the provision of an appointment within 48 hours of any patient requesting the clinic's next available appointment or walking in to receive care.

DATA COLLECTION/EXTRACTION METHODS

We extracted 1 841 210 timely care requests from 613 263 patients.

PRINCIPAL FINDINGS

Across 160 primary care clinics, requests for timely care were fulfilled 86 percent of the time (range 83 percent-88 percent). Our model of timely care fit the data well, with a Bayesian R² of .8. Over the four years of observation, we identified 25 clinics (16 percent) that were either struggling or excelling at providing timely care.

CONCLUSION

Statistical models of timely care allow for identification of clinics in need of improvement after adjusting for patient demographics and risk status. VA primary care clinics fulfilled 86 percent of timely care requests.

Association of the Implementation of the Patient-Centered Medical Home with Quality of Life in Patients with Multimorbidity

BACKGROUND

The patient-centered medical home (PCMH) has clinical benefits for chronic disease care, but the association with patient-reported outcomes such as health-related quality of life (HRQoL) is unexplored in patients with multimorbidity (two or more chronic diseases).

OBJECTIVE

To examine if greater clinic-level PCMH implementation was associated with higher HRQoL in multimorbid adults.

DESIGN

A retrospective cohort study.

PARTICIPANTS

Twenty-two thousand ninety-five multimorbid patients who received primary care at 944 Veterans Health Administration (VHA) clinics.

MAIN MEASURES

Our exposure was the Patient Aligned Care Team Implementation Progress Index (PI²) for the clinic in 2012, a previously validated composite measure of PCMH implementation. Higher PI² scores indicate better performance within eight PCMH domains. Outcomes were patient-reported HRQoL measured by the physical and mental component scores (PCS and MCS) from the Short Form-12 patient experiences survey in 2013-2014. Interaction of the outcomes with total hospitalizations and primary care visit count was also examined. Generalized estimating equations were used for main models after adjusting for patient and clinic characteristics.

RESULTS

The cohort average age was 68 years, mostly male (96%), and had an average of 4.4 chronic diagnoses. Compared with patients seen at the lowest scoring clinics for PCMH implementation, care in the highest scoring clinics was associated with a higher adjusted marginal mean PCS (42.3 (95% CI 41.3-43.4) versus 40.3 (95% CI 39.1-41.5), P = 0.01), but a lower MCS (35.2 (95% CI 34.4-36.1) versus 36.0 (95% CI 35.3-36.8), P = 0.17). Patients with prior hospitalizations seen in clinics with higher compared with lower PI² scores had a 2.7 point greater MCS (95% CI 0.6-4.8; P = 0.01).

CONCLUSIONS

Multimorbid patients seen in clinics with greater PCMH implementation reported higher physical HRQoL, but lower mental HRQoL. The association between PCMH implementation and mental HRQoL may depend on complex interactions with disease severity and prior hospitalizations.

Obesity and Health Care Experiences among Women and Men Veterans

BACKGROUND

Obesity is highly stigmatized, especially for women, and therefore may negatively affect health care experiences. Past findings on the relationship between obesity and health care experiences are mixed, perhaps because few studies examine relationships by gender and obesity class. Our objective was to evaluate whether women and men with more severe obesity report worse health care experiences related to Veterans Health Administration (VA) care.

METHODS

Health care experiences (self-management support, mental health assessments, office staff courtesy, communication with providers) and overall provider ratings were assessed with the 2014 VA Survey of Health Care Experiences of Patients. Using multiple regression analyses (n = 13,462 women, n = 268,180 men), we assessed associations among obesity classes, health care experiences, and overall provider ratings, adjusting for sociodemographic, health, and primary care use characteristics.

RESULTS

The greatest differences in health care experiences between patients with and without obesity were in self-management support experiences, which were more favorable among women and men of all obesity classes. There were gender differences in associations between obesity and mental health assessments: for men, but not women, those in any obesity class gave higher ratings than those without obesity. For most other health care experiences and provider ratings, men with obesity reported slightly less favorable experiences than those without. There was no consistent pattern for women.

CONCLUSIONS

It is promising that VA patients with obesity report more self-management support, given the behavior change required for weight management. Lower health care experience and provider ratings among men with obesity suggest a need to further investigate possible obesity-related stigma in VA primary care.

How Are Patients Accessing Primary Care Within the Patient-Centered Medical Home? Results From the Veterans Health Administration

The patient-centered medical home (PCMH) expands access by providing care same-day, by phone, and after hours; however, little is known about which patients seek these services. We examined the association of patient, clinical, and local economic characteristics with the self-reported use of 5 routine and nonroutine ways to access primary care within the Veterans Health Administration. We identified sets of characteristics, including gender- and age-specific, racial and ethnic, and socioeconomic differences of how veterans report seeking primary care. As the PCMH model develops, it will be important to further understand the differential demand for these services to optimize patient-centered access.

Dementia and Cognitive Impairment Among U.S. Veterans With a History of MDD or PTSD: A Retrospective Cohort Study Based on Sex and Race

Objective: The aim of this study was to examine major depressive disorder (MDD) and posttraumatic stress disorder (PTSD) diagnosed at age < 55 as predictors, and sex and race as potential moderators, of dementia and other forms of cognitive impairment. Method: Veterans (N = 4,800) aged ⩾ 56 years were grouped by psychiatric history, sex, and race. Hierarchical and stepwise regression were employed to determine significant predictors. Results: MDD and PTSD were associated with almost double the risk for developing dementia or cognitive impairment at age ⩾ 56. Sex, as a moderator, had small effects whereas race increased the risk almost twofold for Black veterans, given the presence of MDD history. Discussion: MDD and PTSD act as significant risk factors for dementia and other forms of cognitive impairment, and Black veterans, given a history of MDD, may be at an increased risk. An important endeavor for future research is to examine how this risk may vary across dementia subtypes and related conditions.

Patient-Reported Access in the Patient-Centered Medical Home and Avoidable Hospitalizations: an Observational Analysis of the Veterans Health Administration

BACKGROUND

The Patient-Centered Medical Home (PCMH) has emphasized timely access to primary care, often by using non-traditional modes of delivery, such as care in person after-hours or by phone during or after normal hours. Limited data exists on whether improving patient-reported access with these service types reduces hospitalization.

OBJECTIVE

To examine the association of patient-reported access to primary care within the Veteran Health Administration (VHA) via five service types and hospitalizations for ambulatory care sensitive conditions (ACSCs).

DESIGN

Retrospective cohort study, using multivariable logistic regression adjusting for patient demographics, comorbidity, characteristics of patients' area of residence, and clinic-level random effects.

PARTICIPANTS

A total of 69,710 VHA primary care patients who responded to the 2012 Survey of Healthcare Experiences of Patients (SHEP), PCMH module.

MAIN MEASURES

Survey questions captured patients' ability to obtain care from VHA for five service types: routine care, immediate care, after-hours care, care by phone during regular office hours, and care by phone after normal hours. Outcomes included binary measures of hospitalization for overall, acute, and chronic ACSCs in 2013, identified in VHA administrative data and Medicare fee-for-service claims.

KEY RESULTS

Patients who reported "always" able to obtain after-hours care compared to "never" were less likely to be hospitalized for chronic ACSCs (OR 0.62, 95% CI 0.44-0.89, p = 0.009). Patients reporting "usually" getting care by phone during regular hours were more likely have a hospitalization for chronic ACSC (OR 1.49, 95% CI 1.03-2.17, p = 0.034). Experiences with routine care, immediate care, and care by phone after-hours demonstrated no significant association with hospitalization for ACSCs.

CONCLUSIONS

Improving patients' ability to obtain after-hours care was associated with fewer hospitalizations for chronic ACSCs, while access to care by phone during regular hours was associated with more hospitalizations. Health systems should consider the benefits, including reduced hospitalizations for chronic ACSCs, against the costs of implementing each of these PCMH services.

Between-Race Differences in Processes Predicting Physician Communication for African American and European American Recipients of Breast Density Notifications

BACKGROUND

Breast density notification laws mandate reporting of dense breast to applicable women. The same psychological and systemic barriers that yield between-race differences in mammography use will probably yield between-race differences in women's psychological and behavioral responses to breast density notifications.

PURPOSE

We used the theory of planned behavior as a framework to examine between-race differences in the likelihood of following-up with physicians after receiving breast density notifications and to examine differences in African American and Caucasian American women's behavioral decision-making processes.

METHODS

A subset of 212 African American and Caucasian American women who participated in an initial and follow-up survey examining responses to breast density notifications were examined for this study. Participants reported background and demographic measures, psychological responses to receiving notifications, and planned behavior measures related to following up with physicians approximately 2 weeks after receiving their mammogram reports. Participants self-reported their behaviors 3 months later.

RESULTS

There were no between-race differences in self-reported physician communication; however, there were differences in processes that predicted behavior. For Caucasian American women, behavioral intentions, education, and income predicted behaviors. Instead of intentions, group-based medical suspicion, confusion, breast cancer worry, and breast density anxiety predicted behaviors for African American women.

CONCLUSIONS

Behavioral decision-making processes for Caucasian American women were in line with well-validated theoretical predictions. For African American women, race-related medical suspicion, prior breast density awareness, and emotional responses to breast density notifications predicted behavior. The results highlight the need to focus on racially distinct psychological targets when designing interventions to support guideline concordant behavioral decisions among women who receive breast density notifications.

Substance Use Disorder-Related Disparities in Patient Experiences of Primary Care

Purpose: To assess disparities in primary care experiences for patients with a substance use disorder (SUD) diagnosis.

Methods: We assessed differences in Veterans Health Administration (VA) primary care patients' experiences using data from the 2014 outpatient VA Patient-Centered Medical Home Survey of Healthcare Experiences of Patients (SHEP; N=286,026). We obtained patient demographics and diagnoses from VA electronic medical record data.

Results: Patients with an SUD diagnosis reported worse experiences for 8 of 12 SHEP measures, including access, provider communication, and information received (p<0.05).

Conclusion: Targeted strategies may be needed to ensure patients with SUD have favorable primary care experiences.

Differences in Experiences With Care Between Homeless and Nonhomeless Patients in Veterans Affairs Facilities With Tailored and Nontailored Primary Care Teams

BACKGROUND

Homeless patients describe poor experiences with primary care. In 2012, the Veterans Health Administration (VHA) implemented homeless-tailored primary care teams (Homeless Patient Aligned Care Team, HPACTs) that could improve the primary care experience for homeless patients.

OBJECTIVE

To assess differences in primary care experiences between homeless and nonhomeless Veterans receiving care in VHA facilities that had HPACTs available (HPACT facilities) and in VHA facilities lacking HPACTs (non-HPACT facilities).

RESEARCH DESIGN

We used multivariable multinomial regressions to estimate homeless versus nonhomeless patient differences in primary care experiences (categorized as negative/moderate/positive) reported on a national VHA survey. We compared the homeless versus nonhomeless risk differences (RDs) in reporting negative or positive experiences in 25 HPACT facilities versus 485 non-HPACT facilities.

SUBJECTS

Survey respondents from non-HPACT facilities (homeless: n=10,148; nonhomeless: n=309,779) and HPACT facilities (homeless: n=2022; nonhomeless: n=20,941).

MEASURES

Negative and positive experiences with access, communication, office staff, provider rating, comprehensiveness, coordination, shared decision-making, and self-management support.

RESULTS

In non-HPACT facilities, homeless patients reported more negative and fewer positive experiences than nonhomeless patients. However, these patterns of homeless versus nonhomeless differences were reversed in HPACT facilities for the domains of communication (positive experience RDs in non-HPACT versus HPACT facilities=-2.0 and 2.0, respectively); comprehensiveness (negative RDs=2.1 and -2.3), shared decision-making (negative RDs=1.2 and -1.8), and self-management support (negative RDs=0.1 and -4.5; positive RDs=0.5 and 8.0).

CONCLUSIONS

VHA facilities with HPACT programs appear to offer a better primary care experience for homeless versus nonhomeless Veterans, reversing the pattern of relatively poor primary care experiences often associated with homelessness.

The role of the psychologist in the veterans administration's patient aligned care team and huddle: A review, practical recommendations, and a call to action

The Veterans Administration (VA)’s Patient Aligned Care Team (PACT) model has been a cornerstone of primary care in the VA healthcare system and has indicated the need for an organizational cultural shift towards interdisciplinary care. Most of the focus in PACT has been on the traditional providers of the medical model, with little attention focused on the role of the psychologist. This paper examines how psychologists can assist in the PACT model and, in particular, within the team VA huddle. Literature on the PACT model, mental health in PACT, and the advantages of the huddle are reviewed. Lessons learned within a large VA clinic are also discussed. Psychologists’ ability to be a clinician, teambuilder, and system specialist is discussed and how it benefits the PACT and the huddling process. Practical recommendations are made for how to best assist during the huddle, and how to advocate for both the huddle, and for a broader cultural shift in care.

An evolutionary view of patient experience in primary care: A concept analysis

AIM

This concept analysis explores "patient experience" in the context of primary care.

BACKGROUND

In the 21st century, person-centered care became the manner to address the healthcare quality needs of the United States. This study led to using measures of patient experience as an evaluation of patient-centered care.

DESIGN

Concept analysis.

DATA SOURCES

CINAHL, Cochrane Review, PUBMED Central, PsycINFO, Web of Science, and Scopus were queried using "patient experience" and "primary care." All peer-reviewed US-based articles were included from January 2000 to October 2017 (n = 59).

REVIEW METHODS

Rodgers' evolutionary view of concept analysis guided this inquiry.

RESULTS

Patient experience is any process discernible by patients, including subjective experiences, objective experiences, and observations of provider or staff behavior. Patient experience reports are mediated and moderated by many variables and reflect care experiences that directly measure patient-centeredness from the patient's viewpoint. Consequences of patient experience may lead to adherence to shared plans of care, patient engagement, and appropriate use of healthcare services.

CONCLUSION

Conceptual clarity of patient experience adds to the understanding of how patients experience healthcare quality. If healthcare aspires to deliver patient-centered care, understanding quality from the viewpoint of the patient is essential.

The Role of Primary Care Experiences in Obtaining Treatment for Depression

BACKGROUND

Managing depression in primary care settings has increased with the rise of integrated models of care, such as patient-centered medical homes (PCMHs). The relationship between patient experience in PCMH settings and receipt of depression treatment is unknown.

OBJECTIVE

In a large sample of Veterans diagnosed with depression, we examined whether positive PCMH experiences predicted subsequent initiation or continuation of treatment for depression.

DESIGN AND PARTICIPANTS

We conducted a lagged cross-sectional study of depression treatment among Veterans with depression diagnoses (n = 27,362) in the years before (Y1) and after (Y2) they completed the Veterans Health Administration's national 2013 PCMH Survey of Healthcare Experiences of Patients.

MAIN MEASURES

We assessed patient experiences in four domains, each categorized as positive/moderate/negative. Depression treatment, determined from administrative records, was defined annually as 90 days of antidepressant medications or six psychotherapy visits. Multivariable logistic regressions measured associations between PCMH experiences and receipt of depression treatment in Y2, accounting for treatment in Y1.

KEY RESULTS

Among those who did not receive depression treatment in Y1 (n = 4613), positive experiences in three domains (comprehensiveness, shared decision-making, self-management support) predicted greater initiation of treatment in Y2. Among those who received depression treatment in Y1 (n = 22,749), positive or moderate experiences in four domains (comprehensiveness, care coordination, medication decision-making, self-management support) predicted greater continuation of treatment in Y2.

CONCLUSIONS

In a national PCMH setting, patient experiences with integrated care, including care coordination, comprehensiveness, involvement in shared decision-making, and self-management support predicted patients' subsequent initiation and continuation of depression treatment over time-a relationship that could affect physical and mental health outcomes.

A national evaluation of homeless and nonhomeless veterans' experiences with primary care

Persons who are homeless, particularly those with mental health and/or substance use disorders (MHSUDs), often do not access or receive continuous primary care services. In addition, negative experiences with primary care might contribute to homeless persons' avoidance and early termination of MHSUD treatment. The patient-centered medical home (PCMH) model aims to address care fragmentation and improve patient experiences. How homeless persons with MHSUDs experience care within PCMHs is unknown. This study compared the primary care experiences of homeless and nonhomeless veterans with MHSUDs receiving care in the Veterans Health Administration's medical home environment, called Patient Aligned Care Teams. The sample included VHA outpatients who responded to the national 2013 PCMH-Survey of Health Care Experiences of Patients (PCMH-SHEP) and had a past-year MSHUD diagnosis. Veterans with evidence of homelessness (henceforth "homeless") were identified through VHA administrative records. PCMH-SHEP survey respondents included 67,666 veterans with MHSUDs (9.2% homeless). Compared with their nonhomeless counterparts, homeless veterans were younger, more likely to be non-Hispanic Black and nonmarried, had less education, and were more likely to live in urban areas. Homeless veterans had elevated rates of most MHSUDs assessed, indicating significant co-occurrence. After controlling for these differences, homeless veterans reported more negative and fewer positive experiences with communication; more negative provider ratings; and more negative experiences with comprehensiveness, care coordination, medication decision-making, and self-management support than nonhomeless veterans. Homeless persons with MHSUDs may need specific services that mitigate negative care experiences and encourage their continuation in longitudinal primary care services. (PsycINFO Database Record

Racial, Ethnic, and Gender Equity in Veteran Satisfaction with Health Care in the Veterans Affairs Health Care System

BACKGROUND

Patient satisfaction is an important dimension of health care quality. The Veterans Health Administration (VA) is committed to providing high-quality care to an increasingly diverse patient population.

OBJECTIVE

To assess Veteran satisfaction with VA health care by race/ethnicity and gender.

DESIGN AND PARTICIPANTS

We conducted semi-structured telephone interviews with gender-specific stratified samples of black, white, and Hispanic Veterans from 25 predominantly minority-serving VA Medical Centers from June 2013 to January 2015.

MAIN MEASURES

Satisfaction with health care was assessed in 16 domains using five-point Likert scales. We compared the proportions of Veterans who were very satisfied, somewhat satisfied, and less than satisfied (i.e., neither satisfied nor dissatisfied, somewhat dissatisfied, or very dissatisfied) in each domain, and used random-effects multinomial regression to estimate racial/ethnic differences by gender and gender differences by race/ethnicity.

KEY RESULTS

Interviews were completed for 1222 of the 1929 Veterans known to be eligible for the interview (63.3%), including 421 white, 389 black, and 396 Hispanic Veterans, 616 of whom were female. Veterans were less likely to be somewhat satisfied or less than satisfied versus very satisfied with care in each of the 16 domains. The highest satisfaction ratings were reported for costs, outpatient facilities, and pharmacy (74-76% very satisfied); the lowest ratings were reported for access, pain management, and mental health care (21-24% less than satisfied). None of the joint tests of racial/ethnic or gender differences in satisfaction (simultaneously comparing all three satisfaction levels) was statistically significant (p > 0.05). Pairwise comparisons of specific levels of satisfaction revealed racial/ethnic differences by gender in three domains and gender differences by race/ethnicity in five domains, with no consistent directionality across demographic subgroups.

CONCLUSIONS

Our multisite interviews of a diverse sample of Veterans at primarily minority-serving sites showed generally high levels of health care satisfaction across 16 domains, with few quantitative differences by race/ethnicity or gender.