Racial and Ethnic Minority Concentration in Veterans Affairs Facilities and Delivery of Patient-Centered Primary Care

Between and within race differences in patient-centeredness and activation in mental health care

OBJECTIVES

The aim of this study was to compare Black and White mental health care patients' perceptions of their providers' and their own participation in patient-centered mental health care. Perceptions of patient-centered care (PCC) in relation to the Multidimensional Model of Racial Identity were explored.

METHODS

Black and White veterans receiving mental health care (n = 82) completed surveys assessing patient activation, involvement in care, perceptions of PCC, and therapeutic alliance. Black participants (n = 40) also completed the Multidimensional Inventory of Black Identity.

RESULTS

There were no differences by race in perceived PCC, though Black participants had lower levels of therapeutic alliance with their mental health care provider and were less activated. Black identity centrality, private regard, and public regard were positively related to PCC and elements of PCC such as patient information seeking/sharing.

CONCLUSIONS

Intragroup identity variables such as racial centrality, regard, and ideology influenced perceived PCC among Black participants. Race identity variables should be explored in future research on racial disparities and PCC.

PRACTICE IMPLICATIONS

Mental health care providers serving Black patients should create opportunities to discuss racial identity and race-related experiences as part of their efforts to improve therapeutic alliance and increase the patient-centeredness of care.

Psychometric evaluation of a patient-reported item bank for healthcare engagement

PURPOSE

Healthcare engagement is a core measurement target for efforts to improve healthcare systems. This construct is broadly defined as the extent to which healthcare services represent collaborative partnerships with patients. Previous qualitative work operationalized healthcare engagement as generalized self-efficacy in four related subdomains: self-management, collaborative communication, health information use, and healthcare navigation. Building on this work, our objective was to establish a healthcare engagement instrument that is sufficiently unidimensional to yield a single score.

METHOD

We conducted cognitive interviews followed by a nation-wide mail survey of US Veteran Administration (VA) healthcare users. Data were collected on 49 candidate healthcare engagement items, as well as measures of self-efficacy for managing symptoms, provider communication, and perceived access. Items were subjected to exploratory bifactor, statistical learning, and IRT analyses.

RESULTS

Cognitive interviews were completed by 56 patients and 9552 VA healthcare users with chronic conditions completed the mail survey. Participants were mostly white and male but with sizable minority participation. Psychometric analyses and content considerations reduced the item pool to 23 items, which demonstrated a strong general factor (OmegaH of .89). IRT analyses revealed a high level of reliability across the trait range and little DIF across groups. Most health information use items were removed during analyses, suggesting a more independent role for this domain.

CONCLUSION

We provide quantitative evidence for a relatively unidimensional measure of healthcare engagement. Despite developed with VA healthcare users, the measure is intended for general use. Future work includes short-form development and validation with other patient groups.

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.