The role of endomembrane-localized VHA-c in plant growth.

PubMed

Zhou, Aimin; Takano, Tetsuo; Liu, Shenkui

2018-01-02

In plant cells, the vacuolar-type H + -ATPase (V-ATPase), a large multis`ubunit endomembrane proton pump, plays an important role in acidification of subcellular organelles, pH and ion homeostasis, and endocytic and secretory trafficking. V-ATPase subunit c (VHA-c) is essential for V-ATPase assembly, and is directly responsible for binding and transmembrane transport of protons. In previous studies, we identified a PutVHA-c gene from Puccinellia tenuiflora, and investigated its function in plant growth. Subcellular localization revealed that PutVHA-c is mainly localized in endosomal compartments. Overexpression of PutVHA-c enhanced V-ATPase activity and promoted plant growth in transgenic Arabidopsis. Furthermore, the activity of V-ATPase affected intracellular transport of the Golgi-derived endosomes. Our results showed that endomembrane localized-VHA-c contributes to plant growth by influencing V-ATPase-dependent endosomal trafficking. Here, we discuss these recent findings and speculate on the VHA-c mediated molecular mechanisms involved in plant growth, providing a better understanding of the functions of VHA-c and V-ATPase.

Predictors of Army National Guard and Reserve members' use of Veteran Health Administration health care after demobilizing from OEF/OIF deployment.

PubMed

Harris, Alex H S; Chen, Cheng; Mohr, Beth A; Adams, Rachel Sayko; Williams, Thomas V; Larson, Mary Jo

2014-10-01

This study described rates and predictors of Army National Guard and Army Reserve members' enrollment in and utilization of Veteran Health Administration (VHA) services in the 365 days following demobilization from an index deployment. We also explored regional and VHA facility variation in serving eligible members in their catchment areas. The sample included 125,434 Army National Guard and 48,423 Army Reserve members who demobilized after a deployment ending between FY 2008 and FY 2011. Demographic, geographic, deployment, and Military Health System eligibility were derived from Defense Enrollment Eligibility Reporting System and "Contingency Tracking System" data. The VHA National Patient Care Databases were used to ascertain VHA utilization and status (e.g., enrollee, TRICARE). Logistic regression models were used to evaluate predictors of VHA utilization as an enrollee in the year following demobilization. Of the study members demobilizing during the observation period, 56.9% of Army National Guard members and 45.7% of Army Reserve members utilized VHA as an enrollee within 12 months. Demographic, regional, health coverage, and deployment-related factors were associated with VHA enrollment and utilization, and significant variation by VHA facility was found. These findings can be useful in the design of specific outreach efforts to improve linkage from the Military Health System to the VHA. Reprint & Copyright © 2014 Association of Military Surgeons of the U.S.

Rates and correlates of tobacco cessation service use nationally in the Veterans Health Administration.

PubMed

Kelly, Megan M; Sido, Hannah; Rosenheck, Robert

2016-05-01

Tobacco use is a substantial problem for veterans using Veterans Health Administration (VHA) services, but relatively little is known about the association of specific patient characteristics, patterns of service use, the amount of such services, and the frequency of their use. Analysis of national VHA administrative data (N = 5,531,379) from fiscal year 2012 (FY2012) were used to identify use of tobacco cessation counseling services among veterans with a diagnosed tobacco use disorder, and to examine correlates of such use. Only 3.8% of veterans diagnosed with a tobacco use disorder used VHA tobacco cessation services, and only 0.9% met U.S. Public Health Service clinical practice guidelines for the recommended amount of counseling (i.e., 4 or more sessions). Veterans who used intensive tobacco cessation counseling services were more likely to be homeless, had comorbid mental health and substance use disorders, and used more VHA services overall than veterans who did not use tobacco cessation services. An analysis of the supply of tobacco cessation services (counseling visits provided per 100 veteran users of any services at each facility) showed that increasing the supply by just 1 visit for every 100 veterans would increase the percentage of veterans involved in tobacco cessation counseling by 35%. Veterans diagnosed with tobacco use disorder substantially underuse VHA tobacco cessation counseling services, and use is greatest at facilities that provide more tobacco cessation counseling services. Future efforts should focus on increasing the amount of VHA tobacco cessation services and encouraging veterans' awareness of and motivation to use these services. (PsycINFO Database Record (c) 2016 APA, all rights reserved).

The Development of a Veterans Health Administration Emergency Management Research Agenda

PubMed Central

Dobalian, Aram; Claver, Maria; Riopelle, Deborah; Wyte-Lake, Tamar; Canelo, Ismelda

2017-01-01

Introduction: The Veterans Health Administration (VHA), the largest integrated healthcare delivery system in the United States, is charged with ensuring timely access to high-quality care for veterans during disasters, and supporting national, state, local, and tribal emergency management and homeland security efforts. In 2008, the VHA Office of Public Health (OPH) sponsored the first VHA Emergency Management Research Agenda-setting conference to develop research priorities that address the needs of veterans and to position VHA as a national leader in emergency management by having VHA serve as a “laboratory” for the development of evidence-based emergency management practices. Methods: We focused on four steps: #1: Appraising the emergency management research portfolio of VHA-based researchers; #2: Obtaining systematic information on VHA’s role in emergency management and the healthcare needs of veterans during disasters; #3: Based upon gaps between the current research portfolio and the existing evidence base, identifying strategic priorities using a research agenda-setting conference; and #4: Laying the groundwork to foster the conduct of emergency management research within VHA. Results: Identified research priorities included how to prevent and treat behavioral health problems related to a disaster, the efficacy of training programs, crisis communication strategies, workforce resilience, and evacuating veterans from health care facilities. Conclusion: VHA is uniquely situated to answer research questions that cannot be readily addressed in other settings. VHA should partner with other governmental and private entities to build on existing work and establish shared research priorities. PMID:28439447

A Report of the Efforts of the Veterans Health Administration National Antimicrobial Stewardship Initiative.

PubMed

Kelly, Allison A; Jones, Makoto M; Echevarria, Kelly L; Kralovic, Stephen M; Samore, Matthew H; Goetz, Matthew B; Madaras-Kelly, Karl J; Simbartl, Loretta A; Morreale, Anthony P; Neuhauser, Melinda M; Roselle, Gary A

2017-05-01

OBJECTIVE To detail the activities of the Veterans Health Administration (VHA) Antimicrobial Stewardship Initiative and evaluate outcomes of the program. DESIGN Observational analysis. SETTING The VHA is a large integrated healthcare system serving approximately 6 million individuals annually at more than 140 medical facilities. METHODS Utilization of nationally developed resources, proportional distribution of antibiotics, changes in stewardship practices and patient safety measures were reported. In addition, inpatient antimicrobial use was evaluated before and after implementation of national stewardship activities. RESULTS Nationally developed stewardship resources were well utilized, and many stewardship practices significantly increased, including development of written stewardship policies at 92% of facilities by 2015 (P<.05). While the proportional distribution of antibiotics did not change, inpatient antibiotic use significantly decreased after VHA Antimicrobial Stewardship Initiative activities began (P<.0001). A 12% decrease in antibiotic use was noted overall. The VHA has also noted significantly declining use of antimicrobials prescribed for resistant Gram-negative organisms, including carbapenems, as well as declining hospital readmission and mortality rates. Concurrently, the VHA reported decreasing rates of Clostridium difficile infection. CONCLUSIONS The VHA National Antimicrobial Stewardship Initiative includes continuing education, disease-specific guidelines, and development of example policies in addition to other highly utilized resources. While no specific ideal level of antimicrobial utilization has been established, the VHA has shown that improving antimicrobial usage in a large healthcare system may be achieved through national guidance and resources with local implementation of antimicrobial stewardship programs. Infect Control Hosp Epidemiol 2017;38:513-520.

Professional Quality of Life and Changes in Spirituality Among VHA Chaplains: A Mixed Methods Investigation.

PubMed

McCormick, Wesley H; Carroll, Timothy D; Slagel, Brett A; Drescher, Kent D; Nieuwsma, Jason A; Currier, Joseph M

2017-01-01

A mixed method design was implemented to examine the spirituality and emotional well-being of Veterans Health Administration (VHA) chaplains and how potential changes in spirituality and emotional well-being may affect their professional quality of life. Four distinct categories of changes emerged from the narrative statements of a nationally representative sample of 267 VHA chaplains: (1) positive changes (e.g., increased empathy), (2) negative changes (e.g., dysthymic mood, questioning religious beliefs), (3) combination of positive and negative changes, and (4) no change (e.g., sustenance through spirituality or self-care). Most chaplains reported positive (37%) or no change (30%) in their spirituality and/or emotional well-being. However, quantitative analyses revealed that chaplains who reported negative changes endorsed greater burnout and secondary traumatic stress. Overall, these findings suggest VHA chaplains are predominantly spiritually resilient, but negative changes in the spiritual domain can occur, potentially increasing the risk of adverse changes in professional quality of life.

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

PubMed

Jones, Audrey L; Hausmann, Leslie R M; Kertesz, Stefan; Suo, Ying; Cashy, John P; Mor, Maria K; Schaefer, James H; Gundlapalli, Adi V; Gordon, Adam J

2018-05-12

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. 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). 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. Survey respondents from non-HPACT facilities (homeless: n=10,148; nonhomeless: n=309,779) and HPACT facilities (homeless: n=2022; nonhomeless: n=20,941). Negative and positive experiences with access, communication, office staff, provider rating, comprehensiveness, coordination, shared decision-making, and self-management support. 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). 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 Obesity Epidemic in the Veterans Health Administration: Prevalence Among Key Populations of Women and Men Veterans.

PubMed

Breland, Jessica Y; Phibbs, Ciaran S; Hoggatt, Katherine J; Washington, Donna L; Lee, Jimmy; Haskell, Sally; Uchendu, Uchenna S; Saechao, Fay S; Zephyrin, Laurie C; Frayne, Susan M

2017-04-01

Most US adults are overweight or obese. Understanding differences in obesity prevalence across subpopulations could facilitate the development and dissemination of weight management services. To inform Veterans Health Administration (VHA) weight management initiatives, we describe obesity prevalence among subpopulations of VHA patients. Cross-sectional descriptive analyses of fiscal year 2014 (FY2014) national VHA administrative and clinical data, stratified by gender. Differences ≥5% higher than the population mean were considered clinically significant. Veteran VHA primary care patients with a valid weight within ±365 days of their first FY2014 primary care visit, and a valid height (98% of primary care patients). We used VHA vital signs data to ascertain height and weight and calculate body mass index, and VHA outpatient, inpatient, and fee basis data to identify sociodemographic- and comorbidity-based subpopulations. Among nearly five million primary care patients (347,112 women, 4,567,096 men), obesity prevalence was 41% (women 44%, men 41%), and overweight prevalence was 37% (women 31%, men 38%). Across the VHA's 140 facilities, obesity prevalence ranged from 28% to 49%. Among gender-stratified subpopulations, obesity prevalence was high among veterans under age 65 (age 18-44: women 40%, men 46%; age 45-64: women 49%, men 48%). Obesity prevalence varied across racial/ethnic and comorbidity subpopulations, with high obesity prevalence among black women (51%), women with schizophrenia (56%), and women and men with diabetes (68%, 56%). Overweight and obesity are common among veterans served by the VHA. VHA's weight management initiatives have the potential to avert long-term morbidity arising from obesity-related conditions. High-risk groups-such as black women veterans, women veterans with schizophrenia, younger veterans, and Native Hawaiian/Other Pacific Islander and American Indian/Alaska Native veterans-may require particular attention to ensure that

Central implementation strategies outperform local ones in improving HIV testing in Veterans Healthcare Administration facilities.

PubMed

Goetz, Matthew Bidwell; Hoang, Tuyen; Knapp, Herschel; Burgess, Jane; Fletcher, Michael D; Gifford, Allen L; Asch, Steven M

2013-10-01

Pilot data suggest that a multifaceted approach may increase HIV testing rates, but the scalability of this approach and the level of support needed for successful implementation remain unknown. To evaluate the effectiveness of a scaled-up multi-component intervention in increasing the rate of risk-based and routine HIV diagnostic testing in primary care clinics and the impact of differing levels of program support. Three arm, quasi-experimental implementation research study. Veterans Health Administration (VHA) facilities. Persons receiving primary care between June 2009 and September 2011 INTERVENTION: A multimodal program, including a real-time electronic clinical reminder to facilitate HIV testing, provider feedback reports and provider education, was implemented in Central and Local Arm Sites; sites in the Central Arm also received ongoing programmatic support. Control Arm sites had no intervention Frequency of performing HIV testing during the 6 months before and after implementation of a risk-based clinical reminder (phase I) or routine clinical reminder (phase II). The adjusted rate of risk-based testing increased by 0.4 %, 5.6 % and 10.1 % in the Control, Local and Central Arms, respectively (all comparisons, p < 0.01). During phase II, the adjusted rate of routine testing increased by 1.1 %, 6.3 % and 9.2 % in the Control, Local and Central Arms, respectively (all comparisons, p < 0.01). At study end, 70-80 % of patients had been offered an HIV test. Use of clinical reminders, provider feedback, education and social marketing significantly increased the frequency at which HIV testing is offered and performed in VHA facilities. These findings support a multimodal approach toward achieving the goal of having every American know their HIV status as a matter of routine clinical practice.

Zika virus infection in the Veterans Health Administration (VHA), 2015-2016.

PubMed

Schirmer, Patricia L; Wendelboe, Aaron; Lucero-Obusan, Cynthia A; Ryono, Russell A; Winters, Mark A; Oda, Gina; Martinez, Mirsonia; Saavedra, Sonia; Holodniy, Mark

2018-05-01

Zika virus (ZIKV) is an important flavivirus infection. Although ZIKV infection is rarely fatal, risk for severe disease in adults is not well described. Our objective was to describe the spectrum of illness in U.S. Veterans with ZIKV infection. Case series study including patients with laboratory-confirmed or presumed positive ZIKV infection in all Veterans Health Administration (VHA) medical centers. Adjusted odds ratios of clinical variables associated with hospitalization and neurologic complications was performed. Of 1,538 patients tested between 12/2015-10/2016 and observed through 3/2017, 736 (48%) were RT-PCR or confirmed IgM positive; 655 (89%) were male, and 683 (93%) from VA Caribbean Healthcare System (VACHCS). Ninety-four (13%) were hospitalized, 91 (12%) in the VACHCS. Nineteen (3%) died after ZIKV infection. Hospitalization was associated with increased Charlson co-morbidity index (adjusted odds ratio [OR] 1.2; 95% confidence interval [CI], 1.1-1.3), underlying connective tissue disease (OR, 29.5; CI, 3.6-244.7), congestive heart failure (OR, 6; CI, 2-18.5), dementia (OR, 3.6; CI, 1.1-11.2), neurologic symptom presentation (OR, 3.9; CI, 1.7-9.2), leukocytosis (OR, 11.8; CI, 4.5-31), thrombocytopenia (OR, 7.8; CI, 3.3-18.6), acute kidney injury (OR, 28.9; CI, 5.8-145.1), or using glucocorticoids within 30 days of testing (OR, 13.3; CI 1.3-133). Patients presenting with rash were less likely to be hospitalized (OR, 0.29; CI, 0.13-0.66). Risk for neurologic complications increased with hospitalization (OR, 5.9; CI 2.9-12.2), cerebrovascular disease (OR 4.9; CI 1.7-14.4), and dementia (OR 2.8; CI 1.2-6.6). Older Veterans with multiple comorbidities or presenting with neurologic symptoms were at increased risk for hospitalization and neurological complications after ZIKV infection.

Challenges in referral communication between VHA primary care and specialty care.

PubMed

Zuchowski, Jessica L; Rose, Danielle E; Hamilton, Alison B; Stockdale, Susan E; Meredith, Lisa S; Yano, Elizabeth M; Rubenstein, Lisa V; Cordasco, Kristina M

2015-03-01

Poor communication between primary care providers (PCPs) and specialists is a significant problem and a detriment to effective care coordination. Inconsistency in the quality of primary-specialty communication persists even in environments with integrated delivery systems and electronic medical records (EMRs), such as the Veterans Health Administration (VHA). The purpose of this study was to measure ease of communication and to characterize communication challenges perceived by PCPs and primary care personnel in the VHA, with a particular focus on challenges associated with referral communication. The study utilized a convergent mixed-methods design: online cross-sectional survey measuring PCP-reported ease of communication with specialists, and semi-structured interviews characterizing primary-specialty communication challenges. 191 VHA PCPs from one regional network were surveyed (54% response rate), and 41 VHA PCPs and primary care staff were interviewed. PCP-reported ease of communication mean score (survey) and recurring themes in participant descriptions of primary-specialty referral communication (interviews) were analyzed. Among PCPs, ease-of-communication ratings were highest for women's health and mental health (mean score of 2.3 on a scale of 1-3 in both), and lowest for cardiothoracic surgery and neurology (mean scores of 1.3 and 1.6, respectively). Primary care personnel experienced challenges communicating with specialists via the EMR system, including difficulty in communicating special requests for appointments within a certain time frame and frequent rejection of referral requests due to rigid informational requirements. When faced with these challenges, PCPs reported using strategies such as telephone and e-mail contact with specialists with whom they had established relationships, as well as the use of an EMR-based referral innovation called "eConsults" as an alternative to a traditional referral. Primary-specialty communication is a continuing

Innovating team-based outpatient mental health care in the Veterans Health Administration: Staff-perceived benefits and challenges to pilot implementation of the Behavioral Health Interdisciplinary Program (BHIP).

PubMed

Barry, Catherine N; Abraham, Kristen M; Weaver, Kendra R; Bowersox, Nicholas W

2016-05-01

In the past decade, the demand for Veterans Health Administration (VHA) mental health care has increased rapidly. In response to the increased demand, the VHA developed the Behavioral Health Interdisciplinary Program (BHIP) team model as an innovative approach to transform VHA general outpatient mental health delivery. The present formative evaluation gathered information about pilot implementation of BHIP to understand the struggles and successes that staff experienced during facility transitions to the BHIP model. Using a purposive, nonrandom sampling approach, we conducted 1-on-1, semistructured interviews with 37 licensed and nonlicensed clinical providers and 13 clerical support staff assigned to BHIP teams in 21 facilities across the VHA. Interviews revealed that having actively involved facility mental health leaders, obtaining adequate staffing for teams to meet the requirements of the BHIP model, creating clear descriptions and expectations for team member roles within the BHIP framework, and allocating designated time for BHIP team meetings challenged many VHA sites but are crucial for successful BHIP implementation. Despite the challenges, staff reported that the transition to BHIP improved team work and improved patient care. Staff specifically highlighted the potential for the BHIP model to improve staff working relationships and enhance communication, collaboration, morale, and veteran treatment consistency. Future evaluations of the BHIP implementation process and BHIP team functioning focusing on patient outcomes, organizational outcomes, and staff functioning are recommended for fully understanding effects of transitioning to the BHIP model within VHA general mental health clinics and to identify best practices and areas for improvement. (PsycINFO Database Record (c) 2016 APA, all rights reserved).

BoB, a best-of-breed automated text de-identification system for VHA clinical documents.

PubMed

Ferrández, Oscar; South, Brett R; Shen, Shuying; Friedlin, F Jeffrey; Samore, Matthew H; Meystre, Stéphane M

2013-01-01

De-identification allows faster and more collaborative clinical research while protecting patient confidentiality. Clinical narrative de-identification is a tedious process that can be alleviated by automated natural language processing methods. The goal of this research is the development of an automated text de-identification system for Veterans Health Administration (VHA) clinical documents. We devised a novel stepwise hybrid approach designed to improve the current strategies used for text de-identification. The proposed system is based on a previous study on the best de-identification methods for VHA documents. This best-of-breed automated clinical text de-identification system (aka BoB) tackles the problem as two separate tasks: (1) maximize patient confidentiality by redacting as much protected health information (PHI) as possible; and (2) leave de-identified documents in a usable state preserving as much clinical information as possible. We evaluated BoB with a manually annotated corpus of a variety of VHA clinical notes, as well as with the 2006 i2b2 de-identification challenge corpus. We present evaluations at the instance- and token-level, with detailed results for BoB's main components. Moreover, an existing text de-identification system was also included in our evaluation. BoB's design efficiently takes advantage of the methods implemented in its pipeline, resulting in high sensitivity values (especially for sensitive PHI categories) and a limited number of false positives. Our system successfully addressed VHA clinical document de-identification, and its hybrid stepwise design demonstrates robustness and efficiency, prioritizing patient confidentiality while leaving most clinical information intact.

Disaster preparedness and response practices among providers from the Veterans Health Administration and Veterans with spinal cord injuries and/or disorders

PubMed Central

Hogan, Timothy P.; Holmes, Sally A.; Rapacki, Lauren M.; Evans, Charlesnika T.; Lindblom, Laurie; Hoenig, Helen; Goldstein, Barry; Hahm, Bridget; Weaver, Frances M.

2011-01-01

Objectives Few empirical studies have examined the disaster preparedness and response practices of individuals with spinal cord injuries and/or disorders (SCI/D) and the healthcare providers who serve them. This study was conducted to understand the experiences of Veterans Health Administration (VHA) providers and Veterans with SCI/D in recent natural disasters, and to identify lessons learned for disaster preparedness and response in the context of SCI/D. Design Semi-structured interviews were conducted with providers and Veterans recruited through seven VHA facilities that had sustained a disaster since 2003. Audio recordings of the interviews were transcribed; transcripts were analyzed using constant comparative techniques. Results Forty participants completed an interview, including 21 VHA SCI/D providers and 19 Veterans with SCI/D. Disasters experienced by participants were weather related. While many Veterans were evacuated or admitted to nearby VHA facilities, others chose to stay in their communities. All facilities had formal disaster plans and engaged in related training; however, participants explained that many aspects of a response take shape ‘in the moment,’ and must address both provider and Veteran needs. Dispersion of resources hindered well-coordinated care, but effective communication, teamwork, advanced warnings, and VHA's electronic medical record facilitated efforts. Conclusions Even in the case of thorough planning, Veterans with SCI/D and their healthcare providers are faced with pressing needs during disasters, and identifying strategies to coordinate care is critical. The lessons learned are intended to inform the efforts of healthcare providers who may be involved in the care of individuals with SCI/D in future disasters. PMID:21903009

PAs in orthopedics in the VHA's community-based outpatient clinics.

PubMed

Reed, Daniel O; Hooker, Roderick S

2017-04-01

In the Veterans Health Administration (VHA) system, most orthopedic care takes place in the VA medical centers (VAMCs). Because most patients receiving orthopedic care were referred by adult medicine providers, more widely deploying physician assistants (PAs) in orthopedic medicine might help offset this workload. An orthopedic medicine demonstration project recruited, trained, and positioned PAs in community-based outpatient clinics (CBOCs) to improve access to care. The project involved surgeons at the Houston VAMC instructing five newly employed PAs in a wide range of orthopedic evaluation and management strategies before their assignment to a CBOC. An administrative assessment compared encounter data pre- and postproject (2012 and 2014) to determine if this strategy modified orthopedic workload and improved patient access to care. By 2014, orthopedic patient visit volume had increased 31%-10% at the VAMC and 21% at the five CBOCs. Overall, the five deployed PAs managed 28% of all orthopedic encounters spread over 1 year and only 3.2% of visits required VAMC referral for further evaluation or treatment. During the project, the total volume of patient visits increased throughout the Houston VAMC region but access to care for this specialty service also increased, with more veteran musculoskeletal care being met at the five CBOCs, off-loading visit demand centrally. The adaptability and flexibility of new roles has been identified as one of the defining characteristics of PAs. That the VHA can take advantage of this role malleability suggests that employing PAs is useful in meeting medical service needs of veterans.

Organization Complexity and Primary Care Providers' Perceptions of Quality Improvement Culture Within the Veterans Health Administration.

PubMed

Korom-Djakovic, Danijela; Canamucio, Anne; Lempa, Michele; Yano, Elizabeth M; Long, Judith A

2016-01-01

This study examined how aspects of quality improvement (QI) culture changed during the introduction of the Veterans Health Administration (VHA) patient-centered medical home initiative and how they were influenced by existing organizational factors, including VHA facility complexity and practice location. A voluntary survey, measuring primary care providers' (PCPs') perspectives on QI culture at their primary care clinics, was administered in 2010 and 2012. Participants were 320 PCPs from hospital- and community-based primary care practices in Pennsylvania, West Virginia, Delaware, New Jersey, New York, and Ohio. PCPs in community-based outpatient clinics reported an improvement in established processes for QI, and communication and cooperation from 2010 to 2012. However, their peers in hospital-based clinics did not report any significant improvements in QI culture. In both years, compared with high-complexity facilities, medium- and low-complexity facilities had better scores on the scales assessing established processes for QI, and communication and cooperation. © The Author(s) 2014.

Interdisciplinary Transgender Veteran Care: Development of a Core Curriculum for VHA Providers.

PubMed

Shipherd, Jillian C; Kauth, Michael R; Firek, Anthony F; Garcia, Ranya; Mejia, Susan; Laski, Sandra; Walden, Brent; Perez-Padilla, Sonia; Lindsay, Jan A; Brown, George; Roybal, Lisa; Keo-Meier, Colton L; Knapp, Herschel; Johnson, Laura; Reese, Rebecca L; Byne, William

2016-01-01

Purpose: The Veteran's Health Administration (VHA) has created a training program for interdisciplinary teams of providers on the unique treatment needs of transgender veterans. An overview of this program's structure and content is described along with an evaluation of each session and the program overall. Methods: A specialty care team delivered 14 didactic courses supplemented with case consultation twice per month over the course of 7 months through video teleconferencing to 16 teams of learners. Each team, consisting of at least one mental health provider (e.g., social worker, psychologist, or psychiatrist) and one medical provider (e.g., physician, nurse, physician assistant, advanced practice nurse, or pharmacist), received training and consultation on transgender veteran care. Results: In the first three waves of learners, 111 providers across a variety of disciplines attended the sessions and received training. Didactic topics included hormone therapy initiation and adjustments, primary care issues, advocacy within the system, and psychotherapy issues. Responses were provided to 39 veteran-specific consult questions to augment learning. Learners reported an increase in knowledge plus an increase in team cohesion and functioning. As a result, learners anticipated treating more transgender veterans in the future. Conclusion: VHA providers are learning about the unique healthcare needs of transgender veterans and benefitting from the training opportunity offered through the Transgender Specialty Care Access Network-Extension of Community Healthcare Outcomes program. The success of this program in training interdisciplinary teams of providers suggests that it might serve as a model for other large healthcare systems. In addition, it provides a path forward for individual learners (both within VHA and in the community) who wish to increase their knowledge.

Interdisciplinary Transgender Veteran Care: Development of a Core Curriculum for VHA Providers

PubMed Central

Shipherd, Jillian C.; Kauth, Michael R.; Firek, Anthony F.; Garcia, Ranya; Mejia, Susan; Laski, Sandra; Walden, Brent; Perez-Padilla, Sonia; Lindsay, Jan A.; Brown, George; Roybal, Lisa; Keo-Meier, Colton L.; Knapp, Herschel; Johnson, Laura; Reese, Rebecca L.; Byne, William

2016-01-01

Abstract Purpose: The Veteran's Health Administration (VHA) has created a training program for interdisciplinary teams of providers on the unique treatment needs of transgender veterans. An overview of this program's structure and content is described along with an evaluation of each session and the program overall. Methods: A specialty care team delivered 14 didactic courses supplemented with case consultation twice per month over the course of 7 months through video teleconferencing to 16 teams of learners. Each team, consisting of at least one mental health provider (e.g., social worker, psychologist, or psychiatrist) and one medical provider (e.g., physician, nurse, physician assistant, advanced practice nurse, or pharmacist), received training and consultation on transgender veteran care. Results: In the first three waves of learners, 111 providers across a variety of disciplines attended the sessions and received training. Didactic topics included hormone therapy initiation and adjustments, primary care issues, advocacy within the system, and psychotherapy issues. Responses were provided to 39 veteran-specific consult questions to augment learning. Learners reported an increase in knowledge plus an increase in team cohesion and functioning. As a result, learners anticipated treating more transgender veterans in the future. Conclusion: VHA providers are learning about the unique healthcare needs of transgender veterans and benefitting from the training opportunity offered through the Transgender Specialty Care Access Network–Extension of Community Healthcare Outcomes program. The success of this program in training interdisciplinary teams of providers suggests that it might serve as a model for other large healthcare systems. In addition, it provides a path forward for individual learners (both within VHA and in the community) who wish to increase their knowledge. PMID:29159298

Dialectical Behavior Therapy Training and Desired Resources for Implementation: Results From a National Program Evaluation in the Veterans Health Administration.

PubMed

Landes, Sara J; Matthieu, Monica M; Smith, Brandy N; Trent, Lindsay R; Rodriguez, Allison L; Kemp, Janet; Thompson, Caitlin

2016-08-01

Little is known about nonresearch training experiences of providers who implement evidence-based psychotherapies for suicidal behaviors among veterans. This national program evaluation identified the history of training, training needs, and desired resources of clinicians who work with at-risk veterans in a national health care system. This sequential mixed methods national program evaluation used a post-only survey design to obtain needs assessment data from clinical sites (N = 59) within Veterans Health Administration (VHA) facilities that implemented dialectical behavior therapy (DBT). Data were also collected on resources preferred to support ongoing use of DBT. While only 33% of clinical sites within VHA facilities reported that staff attended a formal DBT intensive training workshop, nearly 97% of participating sites reported having staff who completed self-study using DBT manuals. Mobile apps for therapists and clients and templates for documentation in the electronic health records to support measurement-based care were desired clinical resources. Results indicate that less-intensive training models can aid staff in implementing DBT in real-world health care settings. While more training is requested, a number of VHA facilities have successfully implemented DBT into the continuum of care for veterans at risk for suicide. Reprint & Copyright © 2016 Association of Military Surgeons of the U.S.

The Veterans Health Administration: An American Success Story?

PubMed Central

Oliver, Adam

2007-01-01

The Veterans Health Administration (VHA) provides health care for U.S. military veterans. By the early 1990s, the VHA had a reputation for delivering limited, poor-quality care, which led to health care reforms. By 2000, the VHA had substantially improved in terms of numerous indicators of process quality, and some evidence shows that its overall performance now exceeds that of the rest of U.S. health care. Recently, however, the VHA has started to become a victim of its own success, with increased demands on the system raising concerns from some that access is becoming overly restricted and from others that its annual budget appropriations are becoming excessive. Nonetheless, the apparent turnaround in the VHA's performance offers encouragement that health care that is both financed and provided by the public sector can be an effective organizational form. PMID:17319805

The Comparative Effectiveness of Cognitive Processing Therapy for Male Veterans Treated in a VHA Posttraumatic Stress Disorder Residential Rehabilitation Program

ERIC Educational Resources Information Center

Alvarez, Jennifer; McLean, Caitlin; Harris, Alex H. S.; Rosen, Craig S.; Ruzek, Josef I.; Kimerling, Rachel

2011-01-01

Objective: To examine the effectiveness of group cognitive processing therapy (CPT) relative to trauma-focused group treatment as usual (TAU) in the context of a Veterans Health Administration (VHA) posttraumatic stress disorder (PTSD) residential rehabilitation program. Method: Participants were 2 cohorts of male patients in the same program…

Teleconsultation and Training of VHA Providers on Transgender Care: Implementation of a Multisite Hub System.

PubMed

Kauth, Michael R; Shipherd, Jillian C; Lindsay, Jan A; Kirsh, Susan; Knapp, Herschel; Matza, Lexi

2015-12-01

The Veterans Health Administration (VHA) is piloting a national program providing teleconsultation and training to clinicians to increase knowledge and comfort with treating transgender veterans and to expand clinical capacity. This program is based on Project ECHO and uses specialist expertise to train and educate front-line clinicians. Over time, the front-line clinicians increase knowledge and skills, enabling them to provide care locally and obviate need for patient travel. This program is innovative in its national scope, interdisciplinary team model, and multihub structure. This article describes development of the program and initial results for the first cohort of learners. Five interdisciplinary clinical teams participated in the 14-session, 7-month program. Most teams had some experience treating transgender veterans prior to participation. The teams completed at least 12 of 14 sessions. Thirteen of 33 participants completed an evaluation. In general, respondents found the teleconsultation program very helpful and credited the experience with improving their team functioning. Furthermore, respondents reported a significant increase in confidence to treat transgender veterans by the end of the program (59% versus 83%). We explored whether it is possible to recruit VHA clinical teams to participate in lengthy training on a low prevalence but complex condition. Early results support the feasibility and effectiveness of this national VHA teleconsultation and training program for transgender care. Lessons learned from the first group of learners have been applied to two concurrent groups with positive results.

Insights from advanced analytics at the Veterans Health Administration.

PubMed

Fihn, Stephan D; Francis, Joseph; Clancy, Carolyn; Nielson, Christopher; Nelson, Karin; Rumsfeld, John; Cullen, Theresa; Bates, Jack; Graham, Gail L

2014-07-01

Health care has lagged behind other industries in its use of advanced analytics. The Veterans Health Administration (VHA) has three decades of experience collecting data about the veterans it serves nationwide through locally developed information systems that use a common electronic health record. In 2006 the VHA began to build its Corporate Data Warehouse, a repository for patient-level data aggregated from across the VHA's national health system. This article provides a high-level overview of the VHA's evolution toward "big data," defined as the rapid evolution of applying advanced tools and approaches to large, complex, and rapidly changing data sets. It illustrates how advanced analysis is already supporting the VHA's activities, which range from routine clinical care of individual patients--for example, monitoring medication administration and predicting risk of adverse outcomes--to evaluating a systemwide initiative to bring the principles of the patient-centered medical home to all veterans. The article also shares some of the challenges, concerns, insights, and responses that have emerged along the way, such as the need to smoothly integrate new functions into clinical workflow. While the VHA is unique in many ways, its experience may offer important insights for other health care systems nationwide as they venture into the realm of big data. Project HOPE—The People-to-People Health Foundation, Inc.

Obsessive-compulsive disorder in the Veterans Health Administration.

PubMed

Barrera, Terri L; McIngvale, Elizabeth; Lindsay, Jan A; Walder, Annette M; Kauth, Michael R; Smith, Tracey L; Van Kirk, Nathaniel; Teng, Ellen J; Stanley, Melinda A

2018-05-24

Little is known about the diagnosis and treatment of obsessive-compulsive disorder (OCD) in the Veterans Health Administration (VHA). This study examined diagnostic rates of OCD in a national sample of veterans as well as clinical comorbidities and mental health service use following an OCD diagnosis. This study used administrative data extracted from VHA medical records to identify patients with an OCD diagnosis between 2010 and 2011 (N = 20,364). Descriptive analyses examined demographic, clinical, and system-level variables associated with OCD diagnosis as well as mental health service use in a subset of patients newly diagnosed with OCD (n = 5,229). The OCD diagnosis rate in VHA medical records was 0.31% of VHA patients seen in 2010-2011. Examination of new-onset OCD diagnoses in 2010-2011 revealed that OCD was most likely to be diagnosed by physicians (48.6%) and behavioral health providers (31.9%), predominantly in mental health settings (87.5%). In the year following OCD diagnosis, veterans had an average of 3.9 individual psychotherapy and 3.5 psychiatric medication visits. These findings suggest that OCD is likely underrecognized and inadequately treated in the VHA and highlight the need for improved diagnostic and treatment services for veterans with OCD. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Veterans Health Administration and Indian Health Service: healthcare utilization by Indian Health Service enrollees.

PubMed

Kramer, B Josea; Wang, Mingming; Jouldjian, Stella; Lee, Martin L; Finke, Bruce; Saliba, Debra

2009-06-01

The Veterans Health Administration (VHA) and Indian Health Service (IHS) have executed an agreement to share resources to improve access and health outcomes for American Indian and Alaska Native (AIAN) veterans. To describe the extent of dual use, health needs, and utilization patterns for IHS-enrollees served by VHA and IHS. Our objective is to fill those gaps in knowledge to inform strategic planning between these federal agencies. Secondary data analysis of linked and merged VHA and IHS centralized administrative data from FY02 and FY03. Of 64,746 IHS enrollees who used VHA and/or IHS, 25% accessed care at both healthcare organizations, whereas most used either the VHA (28%) or the IHS (46%). The proportion of dual users varied markedly by state. Like all other VHA users, these AIAN veterans have the same 3 most frequent diagnoses associated with healthcare encounters: posttraumatic stress disorder, hypertension, and diabetes. VHA-IHS dual users were more likely to receive primary care from IHS and to receive diagnostic and behavioral healthcare from VHA. Many dual users who had been diagnosed with diabetes, hypertension, and/or cardiovascular disease received overlapping attention in VHA and IHS. Strategies to improve outcomes for AIAN veterans should target those receiving care in both systems and include information sharing or coordination of clinical care to reduce the potential for duplication and for treatment conflicts. Strategies to improve access may differ regionally.

The Veterans Health Administration and military sexual trauma.

PubMed

Kimerling, Rachel; Gima, Kristian; Smith, Mark W; Street, Amy; Frayne, Susan

2007-12-01

We examined the utility of the Veterans Health Administration (VHA) universal screening program for military sexual violence. We analyzed VHA administrative data for 185,880 women and 4139888 men who were veteran outpatients and were treated in VHA health care settings nationwide during 2003. Screening was completed for 70% of patients. Positive screens were associated with greater odds of virtually all categories of mental health comorbidities, including posttraumatic stress disorder (adjusted odds ratio [AOR]=8.83; 99% confidence interval [CI] = 8.34, 9.35 for women; AOR = 3.00; 99% CI = 2.89, 3.12 for men). Associations with medical comorbidities (e.g., chronic pulmonary disease, liver disease, and for women, weight conditions) were also observed. Significant gender differences emerged. The VHA policies regarding military sexual trauma represent a uniquely comprehensive health care response to sexual trauma. Results attest to the feasibility of universal screening, which yields clinically significant information with particular relevance to mental health and behavioral health treatment. Women's health literature regarding sexual trauma will be particularly important to inform health care services for both male and female veterans.

Not of one mind: mental models of clinical practice guidelines in the Veterans Health Administration.

PubMed

Hysong, Sylvia J; Best, Richard G; Pugh, Jacqueline A; Moore, Frank I

2005-06-01

The purpose of this paper is to present differences in mental models of clinical practice guidelines (CPGs) among 15 Veterans Health Administration (VHA) facilities throughout the United States. Two hundred and forty-four employees from 15 different VHA facilities across four service networks around the country were invited to participate. Participants were selected from different levels throughout each service setting from primary care personnel to facility leadership. This qualitative study used purposive sampling, a semistructured interview process for data collection, and grounded theory techniques for analysis. A semistructured interview was used to collect information on participants' mental models of CPGs, as well as implementation strategies and barriers in their facility. Analysis of these interviews using grounded theory techniques indicated that there was wide variability in employees' mental models of CPGs. Findings also indicated that high-performing facilities exhibited both (a) a clear, focused shared mental model of guidelines and (b) a tendency to use performance feedback as a learning opportunity, thus suggesting that a shared mental model is a necessary but not sufficient step toward successful guideline implementation. We conclude that a clear shared mental model of guidelines, in combination with a learning orientation toward feedback are important components for successful guideline implementation and improved quality of care.

Emergency medicine in the Veterans Health Administration-results from a nationwide survey.

PubMed

Ward, Michael J; Collins, Sean P; Pines, Jesse M; Dill, Curt; Tyndall, Gary; Kessler, Chad S

2015-07-01

We describe emergency physician staffing, capabilities, and academic practices in US Veterans Health Administration (VHA) emergency departments (EDs). As part of an ongoing process improvement effort for the VHA emergency care system, VHA-wide surveys are conducted among ED medical directors every 3 years. Web-based surveys of VHA ED directors were conducted in 2013 on clinical operations and academic program development. We describe the results from the 2013 survey. When available, we compare responses with the previously administered survey from 2010. A total of 118 of 118 ED directors filled out the survey in 2013 (100% response rate). Respondents reported that 45.5% of VHA emergency physicians are board certified in emergency medicine, and 95% spend most their time in direct patient care. Clinical care is also provided by part-time (<0.5 full-time employee equivalent) emergency physicians in 59.3% of EDs. More than half of EDs (57%) provide on-site tissue plasminogen activator for acute ischemic stroke patients, and only 39% can administer tissue plasminogen activator 24 hours per day, 7 days per week. Less than half (48.3%) of EDs have emergency Obstetrics and Gynecology consultation availability. Most VHA EDs (78.8%) have a university affiliation, but only 21.5% participated in the respective academic emergency medicine program. Veterans Health Administration emergency physicians have primarily clinical responsibilities, and less than half have formal emergency medicine board certification. Despite most VHA EDs having university affiliations, traditional academic activities (eg, teaching and research) are performed in only 1 in 3 VHA EDs. Less than half of VHA EDs have availability of consulting services, including advanced stroke care and women's health. Published by Elsevier Inc.

The measurement of quality of care in the Veterans Health Administration.

PubMed

Halpern, J

1996-03-01

The Veterans Health Administration (VHA) is committed to continual refinement of its system of quality measurement. The VHA organizational structure for quality measurement has three levels. At the national level, the Associate Chief Medical Director for Quality Management provides leadership, sets policy, furnishes measurement tools, develops and distributes measures of quality, and delivers educational programs. At the intermediate level, VHA has four regional offices with staff responsible for reviewing risk management data, investigating quality problems, and ensuring compliance with accreditation requirements. At the hospital level, staff reporting directly to the chief of staff or the hospital director are responsible for implementing VHA quality management policy. The Veterans Health Administration's philosophy of quality measurement recognizes the agency's moral imperative to provide America's veterans with care that meets accepted standards. Because the repair of faulty systems is more efficient than the identification of poor performers, VHA has integrated the techniques of total quality into a multifaceted improvement program that also includes the accreditation program and traditional quality assurance activities. VHA monitors its performance by maintaining adverse incident databases, conducting patient satisfaction surveys, contracting for external peer review of 50,000 records per year, and comparing process and outcome rates internally and when possible with external benchmarks. The near-term objectives of VHA include providing medical centers with a quality matrix that will permit local development of quality indicators, construction of a report card for VHA's customers, and implementing the Malcolm W. Baldrige system for quality improvement as the road map for systemwide continuous improvement. Other goals include providing greater access to data, creating a patient-centered database, providing real-time clinical decision support, and expanding the

42 CFR 493.1100 - Condition: Facility administration.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 5 2010-10-01 2010-10-01 false Condition: Facility administration. 493.1100... SERVICES (CONTINUED) STANDARDS AND CERTIFICATION LABORATORY REQUIREMENTS Facility Administration for Nonwaived Testing § 493.1100 Condition: Facility administration. Each laboratory that performs nonwaived...

Gender differences in substance abuse, PTSD and intentional self-harm among veterans health administration patients.

PubMed

Gradus, Jaimie L; Leatherman, Sarah; Curreri, Andrew; Myers, Lisa G; Ferguson, Ryan; Miller, Matthew

2017-02-01

Epidemiologic studies have reported substance abuse and posttraumatic stress disorder (PTSD) diagnoses as risk factors for suicide among Veterans Health Administration (VHA) patients. Research on risk factors for suicide may not generalize to our understanding of non-fatal intentional self-harm (ISH), given the evidence that these outcomes have unique risk factors. The aims of this study were to examine (1) gender-stratified rates of non-fatal ISH in VHA patients with alcohol abuse/dependence, drug abuse/dependence, and PTSD and (2) gender-stratified interaction between alcohol abuse and dependence and drug abuse and dependence and PTSD in predicting non-fatal ISH. Participants include all VHA care users who received a PTSD diagnosis in Massachusetts from 2000 to 2008 (n=16,004) and an age- and gender-matched comparison group (n=52,502). Data were obtained from the VHA administrative registries. We found evidence of stronger interactions between substance abuse diagnoses and PTSD in predicting non-fatal ISH for females than for males. The interaction contrast (IC) for alcohol abuse and dependence and PTSD in predicting non-fatal ISH among female VHA patients was 62.35/100,000 person-years; for male VHA patients the comparable IC was 21.49/100,000 person-years. For female VHA patients the IC for drug abuse and dependence and PTSD predicting ISH was 256.33/100,000 person-years; no interaction was observed for male VHA patients. This study contributes to the scant literature on gender differences in substance abuse and PTSD among VHA patients. The findings highlight comorbid diagnoses as particularly important risk factors for non-fatal ISH among female VHA patients. Published by Elsevier B.V.

The Veterans Health Administration and Military Sexual Trauma

PubMed Central

Kimerling, Rachel; Gima, Kristian; Smith, Mark W.; Street, Amy; Frayne, Susan

2007-01-01

Objectives. We examined the utility of the Veterans Health Administration (VHA) universal screening program for military sexual violence. Methods. We analyzed VHA administrative data for 185 880 women and 4139888 men who were veteran outpatients and were treated in VHA health care settings nationwide during 2003. Results. Screening was completed for 70% of patients. Positive screens were associated with greater odds of virtually all categories of mental health comorbidities, including posttraumatic stress disorder (adjusted odds ratio [AOR]=8.83; 99% confidence interval [CI] = 8.34, 9.35 for women; AOR = 3.00; 99% CI = 2.89, 3.12 for men). Associations with medical comorbidities (e.g., chronic pulmonary disease, liver disease, and for women, weight conditions) were also observed. Significant gender differences emerged. Conclusions. The VHA policies regarding military sexual trauma represent a uniquely comprehensive health care response to sexual trauma. Results attest to the feasibility of universal screening, which yields clinically significant information with particular relevance to mental health and behavioral health treatment. Women’s health literature regarding sexual trauma will be particularly important to inform health care services for both male and female veterans. PMID:17971558

Not of One Mind: Mental Models of Clinical Practice Guidelines in the Veterans Health Administration

PubMed Central

Hysong, Sylvia J; Best, Richard G; Pugh, Jacqueline A; Moore, Frank I

2005-01-01

Objective The purpose of this paper is to present differences in mental models of clinical practice guidelines (CPGs) among 15 Veterans Health Administration (VHA) facilities throughout the United States. Data Sources Two hundred and forty-four employees from 15 different VHA facilities across four service networks around the country were invited to participate. Participants were selected from different levels throughout each service setting from primary care personnel to facility leadership. Study Design This qualitative study used purposive sampling, a semistructured interview process for data collection, and grounded theory techniques for analysis. Data Collection A semistructured interview was used to collect information on participants' mental models of CPGs, as well as implementation strategies and barriers in their facility. Findings Analysis of these interviews using grounded theory techniques indicated that there was wide variability in employees' mental models of CPGs. Findings also indicated that high-performing facilities exhibited both (a) a clear, focused shared mental model of guidelines and (b) a tendency to use performance feedback as a learning opportunity, thus suggesting that a shared mental model is a necessary but not sufficient step toward successful guideline implementation. Conclusions We conclude that a clear shared mental model of guidelines, in combination with a learning orientation toward feedback are important components for successful guideline implementation and improved quality of care. PMID:15960693

Educational Preferences and Outcomes From Suicide Prevention Training in the Veterans Health Administration: One-Year Follow-Up With Healthcare Employees in Upstate New York

PubMed Central

Matthieu, Monica M.; Chen, Yufei; Schohn, Mary; Lantinga, Larry J.; Knox, Kerry L.

2016-01-01

This study identifies training outcomes and educational preferences of employees who work within the Veterans Health Administration (VHA). Using a longitudinal pre-postsurvey design, 71 employees from one geographic region of VHA healthcare facilities participated in an evaluation of a brief standardized gatekeeper program and a needs assessment on training preferences for suicide and suicide prevention. Results indicate significant differences in knowledge and self-efficacy from pre to post (p < 0.001), although only self-efficacy remained significant at 1 year follow-up, (M = 3.01; SD = 0.87) as compared to pretraining (M = 2.50, SD = 1.05) (t = −5.64, p < 0.001). At post-training, 90% of the participants were willing to learn more about suicide, with 88% willing to spend more than 1 hour in future training activities on more advanced topics. This training program can increase the knowledge and abilities of VHA staff to engage, identify, and refer veterans at risk for suicide to appropriate care. PMID:19960817

Pain research using Veterans Health Administration electronic and administrative data sources.

PubMed

Abel, Erica A; Brandt, Cynthia A; Czlapinski, Rebecca; Goulet, Joseph L

2016-01-01

Health services researchers are using Veterans Health Administration (VHA) electronic health record (EHR) data sources to examine the prevalence, treatment, and outcomes of pain among Veterans in VHA care. Little guidance currently exists on using these data; thus, findings may vary depending on the methods, data sources, and definitions used. We sought to identify current practices in order to provide guidance to future pain researchers. We conducted an anonymous survey of VHA-affiliated researchers participating in a monthly national pain research teleconference. Thirty-two researchers (89%) responded: 75% conducted pain-focused research, 78% used pain intensity numeric rating screening scale (NRS) scores to identify pain, 41% used International Classification of Diseases-9th Revision codes, and 57% distinguished between chronic and acute pain using either NRS scores or pharmacy data. The NRS and pharmacy data were rated as the most valid pain data sources. Of respondents, 48% reported the EHR data sources were adequate for pain research, while 45% had published peer-reviewed articles based on the data. Despite limitations, VHA researchers are increasingly using EHR data for pain research, and several common methods were identified. More information on the performance characteristics of these data sources and definitions is needed.

75 FR 48412 - Proposed Information Collection (Six-Month Post-Exit Focus Interview of Former VHA Employees...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-08-10

... DEPARTMENT OF VETERANS AFFAIRS [OMB Control No. 2900-New (VA Form 10-0487)] Proposed Information Collection (Six-Month Post-Exit Focus Interview of Former VHA Employees) Activities; Under OMB Review AGENCY...).'' SUPPLEMENTARY INFORMATION: Title: Six-Month Post-Exit Focus Interview of Former VHA Employees, VA Form 10-0487...

Informatics Resources to Support Health Care Quality Improvement in the Veterans Health Administration

PubMed Central

Hynes, Denise M.; Perrin, Ruth A.; Rappaport, Steven; Stevens, Joanne M.; Demakis, John G.

2004-01-01

Information systems are increasingly important for measuring and improving health care quality. A number of integrated health care delivery systems use advanced information systems and integrated decision support to carry out quality assurance activities, but none as large as the Veterans Health Administration (VHA). The VHA's Quality Enhancement Research Initiative (QUERI) is a large-scale, multidisciplinary quality improvement initiative designed to ensure excellence in all areas where VHA provides health care services, including inpatient, outpatient, and long-term care settings. In this paper, we describe the role of information systems in the VHA QUERI process, highlight the major information systems critical to this quality improvement process, and discuss issues associated with the use of these systems. PMID:15187063

Brief report: Comparison of methods to identify Iraq and Afghanistan war veterans using Department of Veterans Affairs administrative data.

PubMed

Bangerter, Ann; Gravely, Amy; Cutting, Andrea; Clothier, Barb; Spoont, Michele; Sayer, Nina

2010-01-01

The Department of Veterans Affairs (VA) has made treatment and care of Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) veterans a priority. Researchers face challenges identifying the OIF/OEF population because until fiscal year 2008, no indicator of OIF/OEF service was present in the Veterans Health Administration (VHA) administrative databases typically used for research. In this article, we compare an algorithm we developed to identify OIF/OEF veterans using the Austin Information Technology Center administrative data with the VHA Support Service Center OIF/OEF Roster and veterans' self-report of military service. We drew data from two different institutional review board-approved funded studies. The positive predictive value of our algorithm compared with the VHA Support Service Center OIF/OEF Roster and self-report was 92% and 98%, respectively. However, this method of identifying OIF/OEF veterans failed to identify a large proportion of OIF/OEF veterans listed in the VHA Support Service Center OIF/OEF Roster. Demographic, diagnostic, and VA service use differences were found between veterans identified using our method and those we failed to identify but who were in the VHA Support Service Center OIF/OEF Roster. Therefore, depending on the research objective, this method may not be a viable alternative to the VHA Support Service Center OIF/OEF Roster for identifying OIF/OEF veterans.

Examining Wrong Eye Implant Adverse Events in the Veterans Health Administration With a Focus on Prevention: A Preliminary Report.

PubMed

Neily, Julia; Chomsky, Amy; Orcutt, James; Paull, Douglas E; Mills, Peter D; Gilbert, Christina; Hemphill, Robin R; Gunnar, William

2018-03-01

The study goals were to examine wrong intraocular lens (IOL) implant adverse events in the Veterans Health Administration (VHA), identify root causes and contributing factors, and describe system changes that have been implemented to address this challenge. This study represents collaboration between the VHA's National Center for Patient Safety (NCPS) and the National Surgery Office (NSO). This report includes 45 wrong IOL implant surgery adverse events reported to established VHA NCPS and NSO databases between July 1, 2006, and June 31, 2014. There are approximately 50,000 eye implant procedures performed each year in the VHA. Wrong IOL implant surgery adverse events are reported by VHA facilities to the NCPS and the NSO. Two authors (A.C. and J.N.) coded the reports for event type (wrong lens or expired lens) and identified the primary contributing factor (coefficient κ = 0.837). A descriptive analysis was conducted, which included the reported yearly event rate. The main outcome measure was the reported wrong IOL implant surgery adverse events. There were 45 reported wrong IOL implant surgery adverse events. Between 2011 and June 30, 2014, there was a significant downward trend (P = 0.02, R = 99.7%) at a pace of -0.08 (per 10,000 cases) every year. The most frequently coded primary contributing factor was incomplete preprocedure time-out (n = 12) followed by failure to perform double check of preprocedural calculations based upon original data and implant read-back at the time the surgical eye implant was performed (n = 10). Preventing wrong IOL implant adverse events requires diligence beyond performance of the preprocedural time-out. In 2013, the VHA has modified policy to ensure double check of preprocedural calculations and implant read-back with positive impact. Continued analysis of contributing human factors and improved surgical team communication are warranted.

Prevalence of gender identity disorder and suicide risk among transgender veterans utilizing veterans health administration care.

PubMed

Blosnich, John R; Brown, George R; Shipherd Phd, Jillian C; Kauth, Michael; Piegari, Rebecca I; Bossarte, Robert M

2013-10-01

We estimated the prevalence and incidence of gender identity disorder (GID) diagnoses among veterans in the Veterans Health Administration (VHA) health care system and examined suicide risk among veterans with a GID diagnosis. We examined VHA electronic medical records from 2000 through 2011 for 2 official ICD-9 diagnosis codes that indicate transgender status. We generated annual period prevalence estimates and calculated incidence using the prevalence of GID at 2000 as the baseline year. We cross-referenced GID cases with available data (2009-2011) of suicide-related events among all VHA users to examine suicide risk. GID prevalence in the VHA is higher (22.9/100 000 persons) than are previous estimates of GID in the general US population (4.3/100 000 persons). The rate of suicide-related events among GID-diagnosed VHA veterans was more than 20 times higher than were rates for the general VHA population. The prevalence of GID diagnosis nearly doubled over 10 years among VHA veterans. Research is needed to examine suicide risk among transgender veterans and how their VHA utilization may be enhanced by new VA initiatives on transgender care.

Prevalence of Gender Identity Disorder and Suicide Risk Among Transgender Veterans Utilizing Veterans Health Administration Care

PubMed Central

Brown, George R.; Shipherd, PhD, Jillian C.; Kauth, Michael; Piegari, Rebecca I.; Bossarte, Robert M.

2013-01-01

Objectives. We estimated the prevalence and incidence of gender identity disorder (GID) diagnoses among veterans in the Veterans Health Administration (VHA) health care system and examined suicide risk among veterans with a GID diagnosis. Methods. We examined VHA electronic medical records from 2000 through 2011 for 2 official ICD-9 diagnosis codes that indicate transgender status. We generated annual period prevalence estimates and calculated incidence using the prevalence of GID at 2000 as the baseline year. We cross-referenced GID cases with available data (2009–2011) of suicide-related events among all VHA users to examine suicide risk. Results. GID prevalence in the VHA is higher (22.9/100 000 persons) than are previous estimates of GID in the general US population (4.3/100 000 persons). The rate of suicide-related events among GID-diagnosed VHA veterans was more than 20 times higher than were rates for the general VHA population. Conclusions. The prevalence of GID diagnosis nearly doubled over 10 years among VHA veterans. Research is needed to examine suicide risk among transgender veterans and how their VHA utilization may be enhanced by new VA initiatives on transgender care. PMID:23947310

Partnerships Between Health Care and Legal Providers in the Veterans Health Administration.

PubMed

Tsai, Jack; Middleton, Margaret; Retkin, Randye; Johnson, Cindy; Kenneally, Kevin; Sherman, Scott; Rosenheck, Robert A

2017-04-01

Medical-legal partnerships (MLPs) represent an innovative service model in which lawyers are integrated into health care teams to address diverse legal problems that affect vulnerable populations. The Veterans Health Administration (VHA) operates the largest safety-net health care system in the country and serves many low-income and disabled veterans who could benefit from MLP services. In this column, the authors describe the development and operations of MLPs at four VHA medical centers that serve veterans who are homeless or who have serious mental illness. The authors also briefly report on the characteristics of 700 veterans served by these MLPs from 2014 to 2016. MLPs can fit within the interdisciplinary, comprehensive system of care provided by VHA, and they offer opportunities to expand VHA-community partnerships to address social determinants of health.

Tobacco dependence diagnosis and treatment in Veterans Health Administration residential substance use disorder treatment programs.

PubMed

Gifford, Elizabeth V; Tavakoli, Sara; Wang, Ruey; Hagedorn, Hildi J; Hamlett-Berry, Kim W

2013-06-01

To explore tobacco dependence (TD) diagnosis and treatment utilization, and identify predictors of nicotine replacement therapy (NRT) among veterans with substance use disorders (SUDs) enrolled in Veterans Health Administration (VHA) SUD residential treatment programs (SRTPs). Retrospective cohort study. VHA SRTPs, which treat veterans with SUD and multiple severe psychosocial deficits, from 1 October 2009 to 31 September 2010. Identified tobacco users among veterans with SUD treated in SRTPs during fiscal year 2010 (FY10). Rates of documented TD diagnosis and pharmacotherapy were assessed nationally, regionally and by facility. Patient-level predictors of NRT were examined using a mixed-effects logistic regression model with facility as a random effect. A total of 12 097 of the 15 320 veterans in SRTPs in FY10 (79%) were identified as probable tobacco users. Among these, 33% had a documented TD diagnosis, 34% were treated with pharmacotherapy and only 11% were both diagnosed and treated for TD while in SRTP. NRT was more common among patients with a current documented TD diagnosis, recent history of TD treatment, comorbid mental health disorder, age 55 years or younger and identified as white. Most veterans in Veterans Health Administration substance use disorders residential treatment programs appear to use tobacco, yet only one in 10 receives a documented ICD-9 TD diagnosis and pharmacotherapy while in a substance use disorders residential treatment program. © 2013 Society for the Study of Addiction.

Prevalence of Intimate Partner Violence among Women Veterans who Utilize Veterans Health Administration Primary Care.

PubMed

Kimerling, Rachel; Iverson, Katherine M; Dichter, Melissa E; Rodriguez, Allison L; Wong, Ava; Pavao, Joanne

2016-08-01

The objectives of this study were to identify the prevalence of past-year intimate partner violence (IPV) among women Veterans utilizing Veterans Health Administration (VHA) primary care, and to document associated demographic, military, and primary care characteristics. This was a retrospective cohort design, where participants completed a telephone survey in 2012 (84% participation rate); responses were linked to VHA administrative data for utilization in the year prior to the survey. A national stratified random sample of 6,287 women Veteran VHA primary care users participated in the study. Past-year IPV was assessed using the HARK screening tool. Self-report items and scales assessed demographic and military characteristics. Primary care characteristics were assessed via self-report and VHA administrative data. The prevalence of past-year IPV among women Veterans was 18.5% (se = 0.5%), with higher rates (22.2% - 25.5%) among women up to age 55. Other demographic correlates included indicators of economic hardship, lesbian or bisexual orientation, and being a parent/guardian of a child less than 18 years old. Military correlates included service during Vietnam to post-Vietnam eras, less than 10 years of service, and experiences of Military Sexual Trauma (MST). Most (77.3%, se = 1.2%) women who experienced IPV identified a VHA provider as their usual provider. Compared with women who did not report past-year IPV, women who reported IPV had more primary care visits, yet experienced lower continuity of care across providers. The high prevalence of past-year IPV among women beyond childbearing years, the majority of whom primarily rely on VHA as a source of health care, reinforces the importance of screening all women for IPV in VHA primary care settings. Key considerations for service implementation include sensitivity with respect to sexual orientation, race/ethnicity, and other aspects of diversity, as well as care coordination and linkages with social

Demographic characteristics associated with homelessness and risk among female and male veterans accessing VHA outpatient care.

PubMed

Montgomery, Ann Elizabeth; Dichter, Melissa E; Thomasson, Arwin M; Fu, Xiaoying; Roberts, Christopher B

2015-01-01

This study explored demographic influences on veterans' reports of homelessness or imminent risk of homelessness with a particular focus on gender. We analyzed data for a cohort of veterans who responded to the U.S. Department of Veterans Affairs (VA), Veterans Health Administration (VHA) universal screener for homelessness and risk during a 3-month period. Multinomial mixed effects models-stratified by gender-predicted veterans' reports of homelessness or risk based on age, race, marital status, and receipt of VA compensation. The proportion of positive screens-homelessness or risk-was 2.7% for females and 1.7% for males. Women more likely to report being at risk of homelessness were aged 35 to 54 years, Black, and unmarried; those more likely to experience homelessness were Black and unmarried. Among male veterans, the greatest predictors of both homelessness and risk were Black race and unmarried status. Among both genders, receiving VA disability compensation was associated with lesser odds of being homeless or at risk. The findings describe the current population of veterans using VHA health care services who may benefit from homelessness prevention or intervention services, identify racial differences in housing stability, and distinguish subpopulations who may be in particular need of intervention. Interventions to address these needs are described. Published by Elsevier Inc.

Women veterans' preferences for intimate partner violence screening and response procedures within the Veterans Health Administration.

PubMed

Iverson, Katherine M; Huang, Kristin; Wells, Stephanie Y; Wright, Jason D; Gerber, Megan R; Wiltsey-Stirman, Shannon

2014-08-01

Intimate partner violence (IPV) is a significant health issue faced by women veterans, but little is known about their preferences for IPV-related care. Five focus groups were conducted with 24 women Veterans Health Administration (VHA) patients with and without a lifetime history of IPV to understand their attitudes and preferences regarding IPV screening and responses within VHA. Women veterans wanted disclosure options, follow-up support, transparency in documentation, and VHA and community resources. They supported routine screening for IPV and articulated preferences for procedural aspects of screening. Women suggested that these procedures could be provided most effectively when delivered with sensitivity and connectedness. Findings can inform the development of IPV screening and response programs within VHA and other healthcare settings. © 2014 Wiley Periodicals, Inc.

Disproportionate Mental Health Burden Associated With Past-Year Intimate Partner Violence Among Women Receiving Care in the Veterans Health Administration.

PubMed

Dichter, Melissa E; Sorrentino, Anneliese; Bellamy, Scarlett; Medvedeva, Elina; Roberts, Christopher B; Iverson, Katherine M

2017-12-01

Experience of intimate partner violence (IPV) can lead to mental health conditions, including anxiety, depression, and unhealthy substance use. Women seen in the Veterans Health Administration (VHA) face high rates of both IPV and mental health morbidity. This study aimed to identify associations between recent IPV experience and mental health diagnoses among women VHA patients. We examined medical records data for 8,888 female veteran and nonveteran VHA patients across 13 VHA facilities who were screened for past-year IPV between April, 2014 and April, 2016. Compared with women who screened negative for past-year IPV (IPV-), those who screened positive (IPV+; 8.7%) were more than twice as likely to have a mental health diagnosis, adjusted odds ratio (AOR) = 2.27, 95% confidence interval (CI) [1.95, 2.64]; or more than two mental health diagnoses, AOR = 2.29, 95% CI [1.93, 2.72]). Screening IPV+ was also associated with significantly higher odds of each type of mental health morbidity (AOR range = 1.85-3.19) except psychoses. Over half (53.5%) of the women who screened IPV+ had a mental health diagnosis, compared with fewer than one-third (32.6%) of those who screened IPV-. Each subtype of IPV (psychological, physical, and sexual violence) was significantly associated with having a mental health diagnosis (AOR range = 2.25-2.37) or comorbidity (AOR range = 2.17-2.78). Associations remained when adjusting for military sexual trauma and combat trauma among the veteran subsample. These findings highlight the mental health burden associated with past-year IPV among female VHA patients and underscore the need to address psychological and sexual IPV, in addition to physical violence. Published 2017. This article is a U.S. Government work and is in the public domain in the USA.

Postdeployment Behavioral Health Screens and Linkage to the Veterans Health Administration for Army Reserve Component Members.

PubMed

Vanneman, Megan E; Harris, Alex H S; Chen, Cheng; Adams, Rachel Sayko; Williams, Thomas V; Larson, Mary Jo

2017-08-01

Approximately three to six months after returning from deployment, military service members complete the Post-Deployment Health Reassessment (PDHRA), which includes screens for alcohol misuse, depression, and posttraumatic stress disorder (PTSD). To determine whether Army Reserve Component (RC) members (Army National Guard and Army Reserve) with positive screening scores on the PDHRA receive needed care, the investigators examined the association between positive scores and enrollment and utilization of care ("linkage") in the Veterans Health Administration (VHA), as well as rescreening scores, diagnosis, and behavioral treatment in VHA. Mixed-effects regression models were used to predict linkage to VHA within six months after RC members (N=73,164) completed the PDHRA, with alcohol misuse, depression, and PTSD screen scores as key independent variables. Regression models were stratified by gender and National Guard versus Reserve status. Among those who linked to VHA (N=25,168), screening scores and subsequent diagnosis and treatment in VHA were also examined. Army RC members with positive PTSD and depression screening scores were more likely than those with negative screens to link to VHA, and most (54%-84%) received VHA treatment once diagnosed. Positive screens for alcohol misuse were associated with linkage to VHA for men but not for women, and treatment rates for alcohol use disorders were relatively low (0%-25%) for both men and women diagnosed as having an alcohol use disorder. The finding that Army RC members with greater indications of behavioral health problems linked to VHA is encouraging. However, more outreach and treatment engagement strategies could be directed to those with alcohol use disorder, particularly women.

Nationwide Interdisciplinary E-Consultation on Transgender Care in the Veterans Health Administration.

PubMed

Shipherd, Jillian C; Kauth, Michael R; Matza, Alexis

2016-12-01

Veteran's Health Administration (VHA) requires the provision of quality transgender care for the relatively large number of transgender veterans using VHA services. The Office of Patient Care Services has taken a multimethod approach to improving provider knowledge and skill for transgender veteran care. However, unique patient-specific questions can arise. Thus, VHA implemented a 3-year feasibility program to determine if nationwide interdisciplinary e-consultation can offer veteran-specific consultation to providers who treat transgender veterans in VHA. Launch of this program is described along with use to date, types of questions submitted by providers, and length of time to complete a response in the veteran's electronic medical record. In 17 months, the program responded to 303 e-consults, with consultation provided on the care of 230 unique veterans. Nationwide coverage was achieved 1 year after the launch of the program. Common consult questions have been about medications, including hormones (n = 125); primary care concerns (n = 97); mental health evaluations (n = 63); and psychotherapy (n = 18). Consistent with the interdisciplinary model, multiple disciplines typically responded to each consult (x = 2.27). Average time to completion of a consult was 5.9 calendar days (range = 2.4-7.7 days). VHA has established a nationwide interdisciplinary e-consultation program. Additional outreach about the program will be needed if funding is continued. E-consultation on transgender health within VHA is feasible and complements the suite of trainings offered within VHA. Other healthcare organizations may benefit from a similar program.

Virtual Breakthrough Series, Part 1: Preventing Catheter-Associated Urinary Tract Infection and Hospital-Acquired Pressure Ulcers in the Veterans Health Administration.

PubMed

Zubkoff, Lisa; Neily, Julia; King, Beth J; Dellefield, Mary Ellen; Krein, Sarah; Young-Xu, Yinong; Boar, Shoshana; Mills, Peter D

2016-11-01

In 2014 the Veterans Health Administration (VHA) of the Department of Veterans Affairs (VA) implemented a Virtual Breakthrough Series (VBTS) collaborative to help VHA facilities prevent hospital-acquired conditions: catheter-associated urinary tract infection (CAUTI) and hospital-acquired pressure ulcers (HAPUs). During the prework phase, participating facilities assembled a multidisciplinary team, assessed their current system for CAUTI or HAPU prevention, and examined baseline data to set improvement aims. The action phase consisted of educational conference calls, coaching, and monthly team reports. Learning was conducted via phone, web-based options, and e-mail. The CAUTI bundle focused on four key principles: (1) avoidance of indwelling urinary catheters, (2) proper insertion technique, (3) proper catheter maintenance, and (4) timely removal of the indwelling catheter. The HAPU bundle focused on assessment and inspection, pressure-relieving surfaces, turning and repositioning, incontinence management, and nutrition/hydration assessment and intervention. For the 18 participating units, the mean aggregated CAUTI rate decreased from 2.37 during the prework phase to 1.06 per 1,000 catheter-days during the action (implementation) phase (p < 0.001); the rate did not change for CAUTI nonparticipating sites. HAPU data were available only for 21 of the 31 participating units, whose mean aggregated HAPU rate decreased from 1.80 to 0.99 from prework to continuous improvement (p < 0.001). Staff education and documentation improvement were the most frequently implemented changes. This project helped improve CAUTI and HAPU rates in the VHA and presents a promising model for implementing a virtual model for improvement. Copyright 2016 The Joint Commission.

Clinical information seeking in traumatic brain injury: a survey of Veterans Health Administration polytrauma care team members.

PubMed

Hogan, Timothy; Martinez, Rachael; Evans, Charlesnika; Saban, Karen; Proescher, Eric; Steiner, Monica; Smith, Bridget

2018-03-01

The polytraumatic nature of traumatic brain injury (TBI) makes diagnosis and treatment difficult. To (1) characterise information needs among Veterans Health Administration (VHA) polytrauma care team members engaged in the diagnosis and treatment of TBI; (2) identify sources used for TBI related information; and (3) identify barriers to accessing TBI related information. Cross-sectional online survey of 236 VHA polytrauma care team members. Most respondents (95.8%) keep at least somewhat current regarding TBI, but 31.5% need more knowledge on diagnosing TBI and 51.3% need more knowledge on treating TBI. Respondents use VHA affiliated sources for information, including local colleagues (81.7%), VHA offsite conferences/meetings (78.3%) and onsite VHA educational offerings (73.6%); however, limited time due to administrative responsibilities (50.9%), limited financial resources (50.4%) and patient care (50.4%) were prominent barriers. Medical librarians are in a unique position to develop information services, resources and other electronic tools that reflect the clinical context in which polytrauma care team members practice, and the different tasks they perform. Polytrauma care team members could benefit from additional information regarding the diagnosis and treatment of TBI. Addressing their information needs and supporting their information seeking requires a mulit-pronged approach to time and financial constraints. Published 2017. This article is a U.S. Government work and is in the public domain in the USA.

Barriers and facilitators to provide quality TIA care in the Veterans Healthcare Administration

PubMed Central

Miech, Edward J.; Sico, Jason J.; Phipps, Michael S.; Arling, Greg; Ferguson, Jared; Austin, Charles; Myers, Laura; Baye, Fitsum; Luckhurst, Cherie; Keating, Ava B.; Moran, Eileen; Bravata, Dawn M.

2017-01-01

Objective: To identify key barriers and facilitators to the delivery of guideline-based care of patients with TIA in the national Veterans Health Administration (VHA). Methods: We conducted a cross-sectional, observational study of 70 audiotaped interviews of multidisciplinary clinical staff involved in TIA care at 14 VHA hospitals. We de-identified and analyzed all transcribed interviews. We identified emergent themes and patterns of barriers to providing TIA care and of facilitators applied to overcome these barriers. Results: Identified barriers to providing timely acute and follow-up TIA care included difficulties accessing brain imaging, a constantly rotating pool of housestaff, lack of care coordination, resource constraints, and inadequate staff education. Key informants revealed that both stroke nurse coordinators and system-level factors facilitated the provision of TIA care. Few facilities had specific TIA protocols. However, stroke nurse coordinators often expanded upon their role to include TIA. They facilitated TIA care by (1) coordinating patient care across services, communicating across service lines, and educating clinical staff about facility policies and evidence-based practices; (2) tracking individual patients from emergency departments to inpatient settings and to discharge for timely follow-up care; (3) providing and referring TIA patients to risk factor management programs; and (4) performing regular audit and feedback of quality performance data. System-level facilitators included clinical service leadership engagement and use of electronic tools for continuous care across services. Conclusions: The local organization within a health care facility may be targeted to cultivate internal facilitators and a systemic infrastructure to provide evidence-based TIA care. PMID:29117959

A Comparison of Mental Health Diagnoses Treated via Interactive Video and Face to Face in the Veterans Healthcare Administration.

PubMed

Grubbs, Kathleen M; Fortney, John C; Dean, Tisha; Williams, James S; Godleski, Linda

2015-07-01

This study compares the mental health diagnoses of encounters delivered face to face and via interactive video in the Veterans Healthcare Administration (VHA). We compiled 1 year of national-level VHA administrative data for Fiscal Year 2012 (FY12). Mental health encounters were those with both a VHA Mental Health Stop Code and a Mental Health Diagnosis (n=11,906,114). Interactive video encounters were identified as those with a Mental Health Stop Code, paired with a VHA Telehealth Secondary Stop Code. Primary diagnoses were grouped into posttraumatic stress disorder (PTSD), depression, anxiety, bipolar disorder, psychosis, drug use, alcohol use, and other. In FY12, 1.5% of all mental health encounters were delivered via interactive video. Compared with face-to-face encounters, a larger percentage of interactive video encounters was for PTSD, depression, and anxiety, whereas a smaller percentage was for alcohol use, drug use, or psychosis. Providers and patients may feel more comfortable treating depression and anxiety disorders than substance use or psychosis via interactive video.

Paths to partnership: Veterans Health Administration's Journey in pilot testing breast cancer care quality measures.

PubMed

Hogg, Lori Hoffman

2014-01-01

Prioritizing personalized, proactive, patient-driven health care is among the Veterans Health Administration's (VHA's) transformational initiatives. As one of the largest integrated healthcare systems, the VHA sets standards for performance measures and outcomes achieved in quality of care. Evidence-based practice (EBP) is a hallmark in oncology nursing care. EBP can be linked to positive outcomes and improving quality that can be influenced directly by nursing interventions. VHA oncology nurses had the opportunity to partner with the Oncology Nursing Society (ONS), ONS Foundation, and the Joint Commission in the multiyear development of a comprehensive approach to quality cancer care. Building on a platform of existing measures and refining measurement sets culminated in testing evidence-based, nursing-sensitive quality measures for reliability through the ONS Foundation-supported Breast Cancer Care (BCC) Quality Measures Set. The BCC Measures afforded the VHA to have its many sites collectively assess documentation of the symptoms of patients with breast cancer, the use of colony-stimulating factors, and education about neutropenia precautions provided. Parallel paths of the groups, seeking evidence-based measures, led to the perfect partnership in the VHA's journey in pilot testing the BCC Measures in veterans with breast cancer. This generated further quality assessments and continuous improvement projects for spread and sustainability throughout the VHA.

Postdeployment Behavioral Health Screens and Linkage to the Veterans Health Administration for Army Reserve Component Members

PubMed Central

Vanneman, Megan E.; Harris, Alex H. S.; Chen, Cheng; Adams, Rachel Sayko; Williams, Thomas V.; Larson, Mary Jo

2017-01-01

Objective Approximately three to six months after returning from deployment, military service members complete the Post-Deployment Health Reassessment (PDHRA), which includes screens for alcohol misuse, depression, and post-traumatic stress disorder (PTSD). To determine whether Army Reserve Component (RC) members (Army National Guard and Army Reserve) with positive screening scores on the PDHRA receive needed care, the investigators examined the association between positive scores and enrollment and utilization of care (“linkage”) in the Veterans Health Administration (VHA), as well as rescreening scores, diagnosis, and behavioral treatment in VHA. Methods Mixed-effects regression models were used to predict linkage to VHA within six months after RC members (N=73,164) completed the PDHRA, with alcohol misuse, depression, and PTSD screen scores as key independent variables. Regression models were stratified by gender and National Guard versus Reserve status. Among those who linked to VHA (N=25,168), screening scores and subsequent diagnosis and treatment in VHA were also examined. Results Army RC members with positive PTSD and depression screening scores were more likely than those with negative screens to link to VHA, and most (54%–84%) received VHA treatment once diagnosed. Positive screens for alcohol misuse were associated with linkage to VHA for men but not for women, and treatment rates for alcohol use disorders were relatively low (0%–25%) for both men and women diagnosed as having an alcohol use disorder. Conclusions The finding that Army RC members with greater indications of behavioral health problems linked to VHA is encouraging. However, more outreach and treatment engagement strategies could be directed to those with alcohol use disorder, particularly women. PMID:28412888

The Citrus transcription factor, CitERF13, regulates citric acid accumulation via a protein-protein interaction with the vacuolar proton pump, CitVHA-c4

PubMed Central

Li, Shao-jia; Yin, Xue-ren; Xie, Xiu-lan; Allan, Andrew C.; Ge, Hang; Shen, Shu-ling; Chen, Kun-song

2016-01-01

Organic acids are essential to fruit flavor. The vacuolar H+ transporting adenosine triphosphatase (V-ATPase) plays an important role in organic acid transport and accumulation. However, less is known of V-ATPase interacting proteins and their relationship with organic acid accumulation. The relationship between V-ATPase and citric acid was investigated, using the citrus tangerine varieties ‘Ordinary Ponkan (OPK)’ and an early maturing mutant ‘Zaoshu Ponkan (ZPK)’. Five V-ATPase genes (CitVHA) were predicted as important to citric acid accumulation. Among the genes, CitVHA-c4 was observed, using a yeast two-hybrid screen, to interact at the protein level with an ethylene response factor, CitERF13. This was verified using bimolecular fluorescence complementation assays. A similar interaction was also observed between Arabidopsis AtERF017 (a CitERF13 homolog) and AtVHA-c4 (a CitVHA-c4 homolog). A synergistic effect on citric acid levels was observed between V-ATPase proteins and interacting ERFs when analyzed using transient over-expression in tobacco and Arabidopsis mutants. Furthermore, the transcript abundance of CitERF13 was concomitant with CitVHA-c4. CitERF13 or AtERF017 over-expression leads to significant citric acid accumulation. This accumulation was abolished in an AtVHA-c4 mutant background. ERF-VHA interactions appear to be involved in citric acid accumulation, which was observed in both citrus and Arabidopsis. PMID:26837571

The Citrus transcription factor, CitERF13, regulates citric acid accumulation via a protein-protein interaction with the vacuolar proton pump, CitVHA-c4.

PubMed

Li, Shao-jia; Yin, Xue-ren; Xie, Xiu-lan; Allan, Andrew C; Ge, Hang; Shen, Shu-ling; Chen, Kun-song

2016-02-03

Organic acids are essential to fruit flavor. The vacuolar H(+) transporting adenosine triphosphatase (V-ATPase) plays an important role in organic acid transport and accumulation. However, less is known of V-ATPase interacting proteins and their relationship with organic acid accumulation. The relationship between V-ATPase and citric acid was investigated, using the citrus tangerine varieties 'Ordinary Ponkan (OPK)' and an early maturing mutant 'Zaoshu Ponkan (ZPK)'. Five V-ATPase genes (CitVHA) were predicted as important to citric acid accumulation. Among the genes, CitVHA-c4 was observed, using a yeast two-hybrid screen, to interact at the protein level with an ethylene response factor, CitERF13. This was verified using bimolecular fluorescence complementation assays. A similar interaction was also observed between Arabidopsis AtERF017 (a CitERF13 homolog) and AtVHA-c4 (a CitVHA-c4 homolog). A synergistic effect on citric acid levels was observed between V-ATPase proteins and interacting ERFs when analyzed using transient over-expression in tobacco and Arabidopsis mutants. Furthermore, the transcript abundance of CitERF13 was concomitant with CitVHA-c4. CitERF13 or AtERF017 over-expression leads to significant citric acid accumulation. This accumulation was abolished in an AtVHA-c4 mutant background. ERF-VHA interactions appear to be involved in citric acid accumulation, which was observed in both citrus and Arabidopsis.

Receipt of Pharmacotherapy for Opioid Use Disorder by Justice-Involved U.S. Veterans Health Administration Patients

PubMed Central

Finlay, Andrea K.; Harris, Alex H.S.; Rosenthal, Joel; Blue-Howells, Jessica; Clark, Sean; McGuire, Jim; Timko, Christine; Frayne, Susan M.; Smelson, David; Oliva, Elizabeth; Binswanger, Ingrid

2016-01-01

Background Pharmacotherapy – methadone, buprenorphine, or naltrexone – is an evidence-based treatment for opioid use disorder, but little is known about receipt of these medications among veterans involved in the justice system. The current study examines receipt of pharmacotherapy for opioid use disorder among veterans with a history of justice involvement at U.S. Veterans Health Administration (VHA) facilities compared to veterans with no justice involvement. Methods Using national VHA clinical and pharmacy records, we conducted a retrospective cohort study of veterans with an opioid use disorder diagnosis in fiscal year 2012. Using a mixed-effects logistic regression model, we examined receipt of pharmacotherapy in the 1-year period following diagnosis as a function of justice involvement, adjusting for patient and facility characteristics. Results The 1-year rate of receipt for pharmacotherapy for opioid use disorder was 27% for prison-involved veterans, 34% for jail/court-involved veterans, and 33% for veterans not justice-involved. Compared to veterans not justice-involved, those prison-involved had 0.75 lower adjusted odds (95% confidence interval [CI]: 0.65–0.87) of receiving pharmacotherapy whereas jail/court-involved veterans did not have significantly different adjusted odds. Conclusions Targeted efforts to increase receipt of pharmacotherapy for opioid use disorder among veterans exiting prison is needed as they have lower odds of receiving these medications. PMID:26832998

MdSOS2L1 phosphorylates MdVHA-B1 to modulate malate accumulation in response to salinity in apple.

PubMed

Hu, Da-Gang; Sun, Cui-Hui; Sun, Mei-Hong; Hao, Yu-Jin

2016-03-01

Salt-induced phosphorylation of MdVHA-B1 protein was mediated by MdSOS2L1 protein kinase, and thereby increasing malate content in apple. Salinity is an important environmental factor that influences malate accumulation in apple. However, the molecular mechanism by which salinity regulates this process is poorly understood. In this work, we found that MdSOS2L1, a novel AtSOS2-LIKE protein kinase, interacts with V-ATPase subunit MdVHA-B1. Furthermore, MdSOS2L1 directly phosphorylates MdVHA-B1 at Ser(396) site to modulate malate accumulation in response to salt stress. Meanwhile, a series of transgenic analyses in apple calli showed that the MdSOS2L1-MdVHAB1 pathway was involved in the regulation of malate accumulation. Finally, a viral vector-based transformation approach demonstrated that the MdSOS2L1-MdVHAB1 pathway also modulated malate accumulation in apple fruits with or without salt stress. Collectively, our findings provide a new insight into the mechanism by which MdSOS2L1 phosphorylates MdVHA-B1 to modulate malate accumulation in response to salinity in apple.

Barriers and facilitators to provide quality TIA care in the Veterans Healthcare Administration.

PubMed

Damush, Teresa M; Miech, Edward J; Sico, Jason J; Phipps, Michael S; Arling, Greg; Ferguson, Jared; Austin, Charles; Myers, Laura; Baye, Fitsum; Luckhurst, Cherie; Keating, Ava B; Moran, Eileen; Bravata, Dawn M

2017-12-12

To identify key barriers and facilitators to the delivery of guideline-based care of patients with TIA in the national Veterans Health Administration (VHA). We conducted a cross-sectional, observational study of 70 audiotaped interviews of multidisciplinary clinical staff involved in TIA care at 14 VHA hospitals. We de-identified and analyzed all transcribed interviews. We identified emergent themes and patterns of barriers to providing TIA care and of facilitators applied to overcome these barriers. Identified barriers to providing timely acute and follow-up TIA care included difficulties accessing brain imaging, a constantly rotating pool of housestaff, lack of care coordination, resource constraints, and inadequate staff education. Key informants revealed that both stroke nurse coordinators and system-level factors facilitated the provision of TIA care. Few facilities had specific TIA protocols. However, stroke nurse coordinators often expanded upon their role to include TIA. They facilitated TIA care by (1) coordinating patient care across services, communicating across service lines, and educating clinical staff about facility policies and evidence-based practices; (2) tracking individual patients from emergency departments to inpatient settings and to discharge for timely follow-up care; (3) providing and referring TIA patients to risk factor management programs; and (4) performing regular audit and feedback of quality performance data. System-level facilitators included clinical service leadership engagement and use of electronic tools for continuous care across services. The local organization within a health care facility may be targeted to cultivate internal facilitators and a systemic infrastructure to provide evidence-based TIA care. Copyright © 2017 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Neurology.

78 FR 55778 - Geriatrics and Gerontology Advisory Committee, Notice of Meeting

Federal Register 2010, 2011, 2012, 2013, 2014

2013-09-11

... health care facilities and programs to meet the medical, psychological, and social needs of older... research activities; training, recruitment and retention approaches; Veterans Health Administration (VHA...

Decreasing Physical Inactivity in the Veterans Health Administration Employee Population.

PubMed

Schult, Tamara M; Schmunk, Sandra K; Awosika, Ebi R

2016-12-01

The aim of this study was to describe a comprehensive approach to decrease physical inactivity in the Veterans Health Administration (VHA) employee population. The approach included (1) initiatives to decrease physical inactivity in the workplace; (2) two operational surveys to assess system-wide service provision; and (3) two national employee surveys. From 2010 to 2012, 86 employee fitness centers were completed in VA medical centers. A grants program (2010 to 2015) funded smaller projects designed to decrease physical inactivity in the workplace. Projects involved the provision of equipment to decrease sedentary behaviors, including stability balls, treadmill and sit-to-stand desks, stairwell projects, and funding for on-site fitness classes, bicycle racks, and outdoor par courses and walking paths among others. A comprehensive approach to decrease physical inactivity in VHA employees was successful. Overall, self-reported, age-adjusted physical inactivity in VHA employees decreased from 25.3% in 2010 to 16.1% in 2015.

Adopting a corporate perspective on databases. Improving support for research and decision making.

PubMed

Meistrell, M; Schlehuber, C

1996-03-01

The Veterans Health Administration (VHA) is at the forefront of designing and managing health care information systems that accommodate the needs of clinicians, researchers, and administrators at all levels. Rather than using one single-site, centralized corporate database VHA has constructed several large databases with different configurations to meet the needs of users with different perspectives. The largest VHA database is the Decentralized Hospital Computer Program (DHCP), a multisite, distributed data system that uses decoupled hospital databases. The centralization of DHCP policy has promoted data coherence, whereas the decentralization of DHCP management has permitted system development to be done with maximum relevance to the users'local practices. A more recently developed VHA data system, the Event Driven Reporting system (EDR), uses multiple, highly coupled databases to provide workload data at facility, regional, and national levels. The EDR automatically posts a subset of DHCP data to local and national VHA management. The development of the EDR illustrates how adoption of a corporate perspective can offer significant database improvements at reasonable cost and with modest impact on the legacy system.

Treatment experiences among LGBT veterans with discrimination-based trauma exposure: A pilot study.

PubMed

Shipherd, Jillian C; Ruben, Mollie A; Livingston, Nicholas A; Curreri, Andrew; Skolnik, Avy A

2018-01-01

Past research suggests that rates of trauma exposure and Posttraumatic Stress Disorder (PTSD) are elevated among lesbian, gay, bisexual, and transgender (LGBT) veterans compared to heterosexual and cisgender veterans. Given higher rates of trauma exposure and PTSD, and the culture associated with the Department of Defense's history of policies excluding LGBT people, it is important to understand if LGBT veterans are seeking PTSD treatment following discrimination-based traumatic events, where they seek care, and if they are satisfied with treatment. This study aimed to describe the experiences of discrimination-based trauma-exposed LGBT veterans' (n = 47) experiences with PTSD treatment, including location of treatment (Veterans Health Administration [VHA] versus non-VHA) and satisfaction with care. The majority of veterans had received a PTSD diagnosis from a health-care provider in their lifetimes (78.72%, n = 37), and over half reported currently experiencing PTSD symptoms. Approximately 47% of LGBT veterans with discrimination-based trauma histories preferred to seek PTSD treatment exclusively at VHA (46.81%) or with a combination of VHA and non-VHA services (38.30%). Veterans who received PTSD treatment exclusively from VHA reported higher satisfaction ratings (7.44 on 0-9 scale) than veterans who received PTSD treatment exclusively from outside VHA (5.25 on 0-9 scale). For veterans who sought PTSD treatment at both VHA and non-VHA facilities, there were no significant differences regarding satisfaction ratings for their PTSD treatment in the two settings. Results are discussed in terms of VHA's continued efforts to establish equitable, patient-centered health care for all veterans and the importance of non-VHA facilities to recognize veteran identities.

76 FR 54536 - Geriatrics and Gerontology Advisory Committee; Notice of Meeting

Federal Register 2010, 2011, 2012, 2013, 2014

2011-09-01

... health care facilities and programs to meet the medical, psychological, and social needs of older..., recruitment and retention approaches), Veterans Health Administration (VHA) strategic planning activities in...

Effective antibiotic stewardship in spinal cord injury: Challenges and a way forward.

PubMed

Skelton, Felicia; Suda, Katie; Evans, Charlesnika; Trautner, Barbara

2018-01-11

Context Antibiotic stewardship, defined as a multidisciplinary program to reduce the misuse of antibiotics, and in turn, antibiotic resistance, is a high priority. Persons with spinal cord injury/disorder (SCI/D) are vulnerable to receiving multiple courses of antibiotics over their lifetime given frequent healthcare exposure, and have high rates of bacterial infection with multi-drug resistant organisms. Additional challenges to evaluating appropriate use of antibiotics in this population include bacterial colonization in the urine and the differences in the presenting signs and symptoms of infection. Therefore, Veterans Health Administration (VHA) facilities with SCI/D centers need effective antibiotic stewardship programs. Results We analyzed the results of a 2012 VHA-wide survey evaluating available antibiotic stewardship resources, and compared the resources present at facilities with SCI/D (n=23) versus non-SCI/D facilities (n=107). VHA facilities with SCI/D centers are more likely to have components of an antibiotic stewardship program that have led to reduced antibiotic use in previous studies. They are also more likely to have personnel with infectious diseases training. Conclusion VHA facilities with SCI/D centers have the resources needed for antibiotic stewardship. The next step will be to determine how to implement effective antibiotic stewardship tailored for this patient care setting.

VH gene expression and regulation in the mutant Alicia rabbit. Rescue of VHa2 allotype expression.

PubMed

Chen, H T; Alexander, C B; Young-Cooper, G O; Mage, R G

1993-04-01

Rabbits of the Alicia strain, derived from rabbits expressing the VHa2 allotype, have a mutation in the H chain locus that has a cis effect upon the expression of VHa2 and VHa- genes. A small deletion at the most J-proximal (3') end of the VH locus leads to low expression of all the genes on the entire chromosome in heterozygous ali mutants and altered relative expression of VH genes in homozygotes. To study VH gene expression and regulation, we used the polymerase chain reaction to amplify the VH genes expressed in spleens of young and adult wild-type and mutant Alicia rabbits. The cDNA from reverse transcription of splenic mRNA was amplified and polymerase chain reaction libraries were constructed and screened with oligonucleotides from framework regions 1 and 3, as well as JH. Thirty-three VH-positive clones were sequenced and analyzed. We found that in mutant Alicia rabbits, products of the first functional VH gene (VH4a2), (or VH4a2-like genes) were expressed in 2- to 8-wk-olds. Expression of both the VHx and VHy types of VHa- genes was also elevated but the relative proportions of VHx and VHy, especially VHx, decreased whereas the relative levels of expression of VH4a2 or VH4a2-like genes increased with age. Our results suggest that the appearance of sequences resembling that of the VH1a2, which is deleted in the mutant ali rabbits, could be caused by alterations of the sequences of the rearranged VH4a2 genes by gene conversions and/or rearrangement of upstream VH1a2-like genes later in development.

78 FR 6406 - Geriatrics and Gerontology Advisory Committee, Notice of Meeting

Federal Register 2010, 2011, 2012, 2013, 2014

2013-01-30

... facilities and programs to meet the medical, psychological, and social needs of older Veterans and evaluates..., recruitment and retention approaches), Veterans Health Administration (VHA) strategic planning activities in...

77 FR 14860 - Geriatrics and Gerontology Advisory Committee, Notice of Meeting

Federal Register 2010, 2011, 2012, 2013, 2014

2012-03-13

... facilities and programs to meet the medical, psychological, and social needs of older Veterans and evaluates..., recruitment and retention approaches), Veterans Health Administration (VHA) strategic planning activities in...

Older Adult Participation in Health Promotion Programs: Perspectives of Facility Administrators

ERIC Educational Resources Information Center

Wright, Tim; Hyner, Gerald C.

2011-01-01

Administrators of older adult-centered facilities must identify barriers to the planning and implementation of health promotion programs. In this qualitative research those barriers were identified through in-depth interviews with administrators of older adult-centered facilities. As identified by administrators, the predominant barriers to the…

PA and NP productivity in the Veterans Health Administration.

PubMed

Moran, Eileen A; Basa, Edesha; Gao, Jian; Woodmansee, Denni; Almenoff, Peter L; Hooker, Roderick S

2016-07-01

This study assessed the 2014 clinical productivity of 5,959 physician assistants (PAs) and nurse practitioners (NPs) in the US Department of Veterans Affairs' Veterans Health Administration (VHA). Total work relative value units divided by the direct clinical full-time equivalent measured annual productivity, and correlated factors were examined using weighted analysis of variance. PAs and NPs in adult primary care roles were more productive than those in other specialties. Both providers were more productive in rural than in nonrural settings and less productive in teaching than nonteaching hospitals. Men were slightly more productive than women but age and years of VHA employment were not correlates of productivity. PAs were more productive when their scope of practice allowed significant autonomy; NP productivity was unaffected by supervisory requirements. PAs and NPs are an important component of the VHA provider workforce, and their productivity correlates with a number of factors. More organizational research is necessary to better understand the contributing roles PAs and NPs provide in a rapidly evolving, vertically integrated, national health delivery system.

Unsheltered Homelessness Among Veterans: Correlates and Profiles.

PubMed

Byrne, Thomas; Montgomery, Ann Elizabeth; Fargo, Jamison D

2016-02-01

We identified correlates of unsheltered status among Veterans experiencing homelessness and described distinct subgroups within the unsheltered homeless Veteran population using data from a screening instrument for homelessness that is administered to all Veterans accessing outpatient care at a Veterans Health Administration (VHA) facility. Correlates of unsheltered homelessness included male gender, white race, older age, lower levels of VHA eligibility, substance use disorders, frequent use of VHA inpatient and infrequent use of VHA outpatient services, and residing in the West. We identified six distinct subgroups of unsheltered Veterans; the tri-morbid frequent users represented the highest need group, but the largest group was comprised of Veterans who made highly infrequent use of VHA healthcare services. Differences between sheltered and unsheltered Veterans and heterogeneity within the unsheltered Veteran population should be considered in targeting housing and other interventions.

John M. Eisenberg Patient Safety Awards. System innovation: Veterans Health Administration National Center for Patient Safety.

PubMed

Heget, Jeffrey R; Bagian, James P; Lee, Caryl Z; Gosbee, John W

2002-12-01

In 1998 the Veterans Health Administration (VHA) created the National Center for Patient Safety (NCPS) to lead the effort to reduce adverse events and close calls systemwide. NCPS's aim is to foster a culture of safety in the Department of Veterans Affairs (VA) by developing and providing patient safety programs and delivering standardized tools, methods, and initiatives to the 163 VA facilities. To create a system-oriented approach to patient safety, NCPS looked for models in fields such as aviation, nuclear power, human factors, and safety engineering. Core concepts included a non-punitive approach to patient safety activities that emphasizes systems-based learning, the active seeking out of close calls, which are viewed as opportunities for learning and investigation, and the use of interdisciplinary teams to investigate close calls and adverse events through a root cause analysis (RCA) process. Participation by VA facilities and networks was voluntary. NCPS has always aimed to develop a program that would be applicable both within the VA and beyond. NCPS's full patient safety program was tested and implemented throughout the VA system from November 1999 to August 2000. Program components included an RCA system for use by caregivers at the front line, a system for the aggregate review of RCA results, information systems software, alerts and advisories, and cognitive acids. Following program implementation, NCPS saw a 900-fold increase in reporting of close calls of high-priority events, reflecting the level of commitment to the program by VHA leaders and staff.

Facility Focus: Academic and Administrative Buildings.

ERIC Educational Resources Information Center

College Planning & Management, 1999

1999-01-01

Describes how academic and administrative buildings can be designed to support learning into the next century in the following examples: an applied science an engineering facility; a college greenhouse; and a public affairs classroom building. Photos and floor plans accompany each example. (GR)

Tailoring Care to Vulnerable Populations by Incorporating Social Determinants of Health: the Veterans Health Administration's "Homeless Patient Aligned Care Team" Program.

PubMed

O'Toole, Thomas P; Johnson, Erin E; Aiello, Riccardo; Kane, Vincent; Pape, Lisa

2016-03-31

Although the clinical consequences of homelessness are well described, less is known about the role for health care systems in improving clinical and social outcomes for the homeless. We described the national implementation of a "homeless medical home" initiative in the Veterans Health Administration (VHA) and correlated patient health outcomes with characteristics of high-performing sites. We conducted an observational study of 33 VHA facilities with homeless medical homes and patient- aligned care teams that served more than 14,000 patients. We correlated site-specific health care performance data for the 3,543 homeless veterans enrolled in the program from October 2013 through March 2014, including those receiving ambulatory or acute health care services during the 6 months prior to enrollment in our study and 6 months post-enrollment with corresponding survey data on the Homeless Patient Aligned Care Team (H-PACT) program implementation. We defined high performance as high rates of ambulatory care and reduced use of acute care services. More than 96% of VHA patients enrolled in these programs were concurrently receiving VHA homeless services. Of the 33 sites studied, 82% provided hygiene care (on-site showers, hygiene kits, and laundry), 76% provided transportation, and 55% had an on-site clothes pantry; 42% had a food pantry and provided on-site meals or other food assistance. Six-month patterns of acute-care use pre-enrollment and post-enrollment for 3,543 consecutively enrolled patients showed a 19.0% reduction in emergency department use and a 34.7% reduction in hospitalizations. Three features were significantly associated with high performance: 1) higher staffing ratios than other sites, 1) integration of social supports and social services into clinical care, and 3) outreach to and integration with community agencies. Integrating social determinants of health into clinical care can be effective for high-risk homeless veterans.

Implementation of an established algorithm and modifications for the identification of epilepsy patients in the veterans health administration.

PubMed

Rehman, Rizwana; Everhart, Amanda; Frontera, Alfred T; Kelly, Pamela R; Lopez, Maria; Riley, Denise; Sajan, Sheela; Schooff, David M; Tran, Tung T; Husain, Aatif M

2016-11-01

Identification of epilepsy patients from administrative data in large managed healthcare organizations is a challenging task. The objectives of this report are to describe the implementation of an established algorithm and different modifications for the estimation of epilepsy prevalence in the Veterans Health Administration (VHA). For the prevalence estimation during a given time period patients prescribed anti-epileptic drugs and having seizure diagnoses on clinical encounters were identified. In contrast to the established algorithm, which required inclusion of diagnoses data from the time period of interest only, variants were tested by considering diagnoses data beyond prevalence period for improving sensitivity. One variant excluded data from diagnostic EEG and LTM clinics to improve specificity. Another modification also required documentation of seizures on the problem list (electronic list of patients' established diagnoses). Of the variants tested, the one excluding information from diagnostic clinics and extending time beyond base period of interest for clinical encounters was determined to be superior. It can be inferred that the number of patients receiving care for epilepsy in the VHA ranges between 74,000 and 87,000. In the wake of the recent implementation of ICD-10 codes in the VHA, minor tweaks are needed for future prevalence estimation due to significant efforts presented. This review is not only beneficial for researchers interested in VHA related data but can also be helpful for managed healthcare organizations involved in epilepsy care aiming at accurate identification of patients from large administrative databases. Published by Elsevier B.V.

Patient and Facility Variation in Costs of VHA Heart Failure Patients

PubMed Central

Yoon, Jean; Fonarow, Gregg C.; Groeneveld, Peter W.; Teerlink, John; Whooley, Mary A.; Sahay, Anju; Heidenreich, Paul

2017-01-01

Objectives To determine the variation in annual health care costs among heart failure patients in the VA system. Background Heart failure is associated with considerable use of health care resources, but little is known about patterns in patient characteristics related to higher costs. Methods We obtained VA utilization and cost records for all patients with a diagnosis of heart failure in fiscal year 2010. We compared total VA costs by patient demographic factors, comorbid conditions, and facility where they were treated in bivariate analyses. We regressed total costs on patient factors alone; VA facility alone; and all factors combined to determine the relative contribution of patient factors and facility to explaining cost differences. Results There were 117,870 patients with heart failure, and their mean annual VA costs were $30,719 (SD=49,180) with more than half of their costs due to inpatient care. Patients at younger ages, of Hispanic or black race/ethnicity, diagnosed with comorbid drug use disorders, or who died during the year had the highest costs (all P<0.01). There was variation in costs by facility as mean adjusted costs ranged from approximately $15,000 to $48,000. In adjusted analyses patient factors alone explained more of the variation in health care costs (R2=0.116) compared to the facility where the patient was treated (R2=0.018). Conclusion A large variation in costs of heart failure patients was observed across facilities although this was explained largely by patient factors. Improving the efficiency of VA resource utilization may require increased scrutiny of high-cost patients to determine if adequate value is being delivered to those patients. PMID:26970829

Implementation of Lung Cancer Screening in the Veterans Health Administration.

PubMed

Kinsinger, Linda S; Anderson, Charles; Kim, Jane; Larson, Martha; Chan, Stephanie H; King, Heather A; Rice, Kathryn L; Slatore, Christopher G; Tanner, Nichole T; Pittman, Kathleen; Monte, Robert J; McNeil, Rebecca B; Grubber, Janet M; Kelley, Michael J; Provenzale, Dawn; Datta, Santanu K; Sperber, Nina S; Barnes, Lottie K; Abbott, David H; Sims, Kellie J; Whitley, Richard L; Wu, R Ryanne; Jackson, George L

2017-03-01

The US Preventive Services Task Force recommends annual lung cancer screening (LCS) with low-dose computed tomography for current and former heavy smokers aged 55 to 80 years. There is little published experience regarding implementing this recommendation in clinical practice. To describe organizational- and patient-level experiences with implementing an LCS program in selected Veterans Health Administration (VHA) hospitals and to estimate the number of VHA patients who may be candidates for LCS. This clinical demonstration project was conducted at 8 academic VHA hospitals among 93 033 primary care patients who were assessed on screening criteria; 2106 patients underwent LCS between July 1, 2013, and June 30, 2015. Implementation Guide and support, full-time LCS coordinators, electronic tools, tracking database, patient education materials, and radiologic and nodule follow-up guidelines. Description of implementation processes; percentages of patients who agreed to undergo LCS, had positive findings on results of low-dose computed tomographic scans (nodules to be tracked or suspicious findings), were found to have lung cancer, or had incidental findings; and estimated number of VHA patients who met the criteria for LCS. Of the 4246 patients who met the criteria for LCS, 2452 (57.7%) agreed to undergo screening and 2106 (2028 men and 78 women; mean [SD] age, 64.9 [5.1] years) underwent LCS. Wide variation in processes and patient experiences occurred among the 8 sites. Of the 2106 patients screened, 1257 (59.7%) had nodules; 1184 of these patients (56.2%) required tracking, 42 (2.0%) required further evaluation but the findings were not cancer, and 31 (1.5%) had lung cancer. A variety of incidental findings, such as emphysema, other pulmonary abnormalities, and coronary artery calcification, were noted on the scans of 857 patients (40.7%). It is estimated that nearly 900 000 of a population of 6.7 million VHA patients met the criteria for LCS. Implementation of

Molecular characterization, light-dependent expression, and cellular localization of a host vacuolar-type H+-ATPase (VHA) subunit A in the giant clam, Tridacna squamosa, indicate the involvement of the host VHA in the uptake of inorganic carbon and its supply to the symbiotic zooxanthellae.

PubMed

Ip, Yuen K; Hiong, Kum C; Lim, Leon J Y; Choo, Celine Y L; Boo, Mel V; Wong, Wai P; Neo, Mei L; Chew, Shit F

2018-06-15

The giant clam, Tridacna squamosa, represents a clam-zooxanthellae association. In light, the host clam and the symbiotic zooxanthellae conduct light-enhanced calcification and photosynthesis, respectively. We had cloned the cDNA coding sequence of a Vacuolar-type Proton ATPase (VHA) subunit A, ATP6V1A, from T. squamosa, whereby the VHA is an electrogenic transporter that actively 'pumps' H + out of the cell. The ATP6V1A of T. squamosa comprised 1866 bp, encoding a protein of 622 amino acids and 69.9 kDa, and had a host-origin. Its gene expression was strong in the ctenidium and the colorful outer mantle, but weak in the whitish inner mantle, corroborating a previous proposition that VHA might have a trivial role in light-enhanced calcification. Light exposure led to significant increases in the gene and protein expression levels of ATP6V1A/ATP6V1A in the ctenidium and the outer mantle. In the ctenidium, the ATP6V1A was localized in the apical epithelia of the filaments and tertiary water channels, indicating that the VHA could participate in the increased excretion of H + produced during light-enhanced calcification. Additionally, the excreted H + would augment HCO 3 - dehydration in the external medium and facilitate the uptake of CO 2 by the ctenidium during insolation. In the outer mantle, the ATP6V1A was detected in intracellular vesicles in a type of cells, presumably iridocytes, surrounding the zooxanthellal tubules, and in the apical epithelium of zooxanthellal tubules. Hence, the host VHA could participate in the transfer of inorganic carbon from the hemolymph to the luminal fluid of the tubules by increasing the supply of H + for the dehydration of HCO 3 - to CO 2 during insolation to benefit the photosynthesizing zooxanthellae. Copyright © 2018 Elsevier B.V. All rights reserved.

A System-Level Approach to Overweight and Obesity in the Veterans Health Administration.

PubMed

Raffa, Susan D; Maciejewski, Matthew L; Zimmerman, Lindsey E; Damschroder, Laura J; Estabrooks, Paul A; Ackermann, Ronald T; Tsai, Adam G; Histon, Trina; Goldstein, Michael G

2017-04-01

Healthcare systems are challenged by steady increases in the number of patients who are overweight and obese. Large-scale, evidence-based behavioral approaches for addressing overweight and obesity have been successfully implemented in systems such as the Veterans Health Administration (VHA). These population-based interventions target reduction in risk for obesity-associated conditions through lifestyle change and weight loss, and are associated with modest weight loss. Despite the fact that VHA has increased the overall reach of these behavioral interventions, the number of high-risk overweight and obese patients continues to rise. Recommendations for weight loss medications and bariatric surgery are included in clinical practice guidelines for the management of overweight and obesity, but these interventions are underutilized. During a recent state of the art conference on weight management held by VHA, subject matter experts identified challenges and gaps, as well as potential solutions and overarching policy recommendations, for implementing an integrated system-wide approach for improving population-based weight management.

Perceived Stigma, Discrimination, and Disclosure of Sexual Orientation Among a Sample of Lesbian Veterans Receiving Care in the Department of Veterans Affairs.

PubMed

Mattocks, Kristin M; Sullivan, J Cherry; Bertrand, Christina; Kinney, Rebecca L; Sherman, Michelle D; Gustason, Carolyn

2015-06-01

Many lesbian women experience stigma and discrimination from their healthcare providers as a result of their sexual orientation. Additionally, others avoid disclosure of their sexual orientation to their providers for fear of mistreatment. With the increasing number of lesbian, gay, bisexual, and transgender (LGBT) veterans seeking care from the Veterans Health Administration (VHA), it is important to understand lesbian veterans' experiences with stigma, discrimination, and disclosure of sexual orientation. This article examines lesbian veterans' experiences with perceived stigma and discrimination in VHA healthcare, their perspectives on disclosure of sexual orientation to VHA providers, and their recommendations for improvements in VHA healthcare to create a welcoming environment for lesbian veterans. This is a mixed methods study of twenty lesbian veterans at four VHA facilities. The women veterans participated in a one-hour interview and then completed an anonymous survey. Ten percent of lesbian veterans had experienced mistreatment from VHA staff or providers, but nearly 50% feared that their Veterans Affairs (VA) providers would mistreat them if they knew about their sexual orientation. A majority of lesbian veterans (70%) believed that VHA providers should never ask about sexual orientation or should only ask if the veteran wanted to discuss it. A majority (80%) believed the VHA had taken steps to create a welcoming environment for LBGT veterans. Though many lesbian veterans have fears of stigma and discrimination in the context of VHA care, few have experienced this. Most lesbian veterans believed the VHA was trying to create a welcoming environment for its LGBT veterans. Future research should focus on expanding this study to include a larger and more diverse sample of lesbian, gay, bisexual, and transgender veterans receiving care at VA facilities across the country.

Evaluating current automatic de-identification methods with Veteran's health administration clinical documents.

PubMed

Ferrández, Oscar; South, Brett R; Shen, Shuying; Friedlin, F Jeffrey; Samore, Matthew H; Meystre, Stéphane M

2012-07-27

The increased use and adoption of Electronic Health Records (EHR) causes a tremendous growth in digital information useful for clinicians, researchers and many other operational purposes. However, this information is rich in Protected Health Information (PHI), which severely restricts its access and possible uses. A number of investigators have developed methods for automatically de-identifying EHR documents by removing PHI, as specified in the Health Insurance Portability and Accountability Act "Safe Harbor" method.This study focuses on the evaluation of existing automated text de-identification methods and tools, as applied to Veterans Health Administration (VHA) clinical documents, to assess which methods perform better with each category of PHI found in our clinical notes; and when new methods are needed to improve performance. We installed and evaluated five text de-identification systems "out-of-the-box" using a corpus of VHA clinical documents. The systems based on machine learning methods were trained with the 2006 i2b2 de-identification corpora and evaluated with our VHA corpus, and also evaluated with a ten-fold cross-validation experiment using our VHA corpus. We counted exact, partial, and fully contained matches with reference annotations, considering each PHI type separately, or only one unique 'PHI' category. Performance of the systems was assessed using recall (equivalent to sensitivity) and precision (equivalent to positive predictive value) metrics, as well as the F(2)-measure. Overall, systems based on rules and pattern matching achieved better recall, and precision was always better with systems based on machine learning approaches. The highest "out-of-the-box" F(2)-measure was 67% for partial matches; the best precision and recall were 95% and 78%, respectively. Finally, the ten-fold cross validation experiment allowed for an increase of the F(2)-measure to 79% with partial matches. The "out-of-the-box" evaluation of text de

Organization of care and diagnosed depression among women veterans.

PubMed

Sambamoorthi, Usha; Bean-Mayberry, Bevanne; Findley, Patricia A; Yano, Elizabeth M; Banerjea, Ranjana

2010-09-01

To analyze the association between the organizational features of integration of physical and mental healthcare in womens health clinics and the diagnosis of depression among women veterans with or at risk for cardiovascular conditions (ie, diabetes mellitus, heart disease, or hypertension). Retrospective and observational secondary data analyses. We studied 27,972 women veterans from 118 facilities with diagnosed cardiovascular conditions in fiscal year 2001 (FY2001) using merged Medicare claims and Veterans Health Administration (VHA) data merged with the 1999 VHA Survey of Primary Care Practices and the 2001 VHA Survey of Women Veterans Health Programs and Practices. The dependent variable was a binary indicator for diagnosed depression during FY2001 at the individual level. We used a multilevel logistic regression model to control for clustering of women veterans within facilities. Individual-level independent variables included demographics, socioeconomic characteristics, and chronic physical conditions. Overall, 27% of women veterans using the VHA were diagnosed as having depression in FY2001. Across facilities, rates of diagnosed depression varied from 13% to 41%. After controlling for individual-level and facility-level independent variables, women veterans who were served in separate women's health clinics with integrated physical and mental healthcare were more likely to have diagnosed depression. The adjusted odds ratio was 1.12 (95% confidence interval, 1.01-1.25). Existing women-specific VHA organizational features with integration of primary care and mental health seem effective in diagnosing depression. Emerging patient-centered medical home models may facilitate diagnosis and treatment of mental health issues among women with complex chronic conditions.

Teleretinal Imaging to Screen for Diabetic Retinopathy in the Veterans Health Administration

PubMed Central

Cavallerano, Anthony A.; Conlin, Paul R.

2008-01-01

Diabetes is the leading cause of adult vision loss in the United States and other industrialized countries. While the goal of preserving vision in patients with diabetes appears to be attainable, the process of achieving this goal poses a formidable challenge to health care systems. The large increase in the prevalence of diabetes presents practical and logistical challenges to providing quality care to all patients with diabetes. Given this challenge, the Veterans Health Administration (VHA) is increasingly using information technology as a means of improving the efficiency of its clinicians. The VHA has taken advantage of a mature computerized patient medical record system by integrating a program of digital retinal imaging with remote image interpretation (teleretinal imaging) to assist in providing eye care to the nearly 20% of VHA patients with diabetes. We describe this clinical pathway for accessing patients with diabetes in ambulatory care settings, evaluating their retinas for level of diabetic retinopathy with a teleretinal imaging system, and prioritizing their access into an eye and health care program in a timely and appropriate manner. PMID:19885175

Receipt of Prescription Opioids in a National Sample of Pregnant Veterans Receiving Veterans Health Administration Care.

PubMed

Kroll-Desrosiers, Aimee R; Skanderson, Melissa; Bastian, Lori A; Brandt, Cynthia A; Haskell, Sally; Kerns, Robert D; Mattocks, Kristin M

2016-01-01

A growing number of reproductive-age women veterans are returning from Operations Enduring Freedom, Iraqi Freedom, and New Dawn (OEF/OIF/OND). In 2010, 42% of women veterans receiving Veterans Health Administration (VHA) services were aged 18 to 45. Prescription opioid use has increased among all veterans over the past decade; however, exposure among pregnant veterans has not been examined. We identified 2,331 women who delivered babies within the VHA system between 2001 and 2010. Delivery, opioid prescribing history, and demographic and health-related variables were obtained from a national database of veterans receiving VHA services. Receipt of an opioid prescription was defined as any filled VHA prescription for opioids in the 280-day pregnancy window before delivery. We developed a multivariable logistic regression model adjusted for sociodemographic, service-related, psychiatric diagnosis, and physical health variables to examine the odds of filling an opioid prescription during the pregnancy window. Ten percent of pregnant veterans received VHA prescription opioids during their pregnancy window. Significant factors associated with opioid prescriptions included presence of any psychiatric diagnosis (adjusted odds ratio [aOR], 1.67; 95% CI, 1.24-2.26), diagnosis of back problems (aOR, 2.94; 95% CI, 1.92-4.49), or other nontraumatic joint disorders (aOR, 2.20; 95% CI, 1.36-3.58). This study suggests that a substantial proportion of women veterans received VHA prescriptions for opioids during pregnancy. Providers should be aware of the potential risks of prescription opioid use during pregnancy, assess for potential undertreatment of psychiatric diagnoses, and consider alternate pain management strategies when possible. Published by Elsevier Inc.

Health Care Costs for Patients With Chronic Spinal Cord Injury in the Veterans Health Administration

PubMed Central

French, Dustin D; Campbell, Robert R; Sabharwal, Sunil; Nelson, Audrey L; Palacios, Polly A; Gavin-Dreschnack, Deborah

2007-01-01

Background/Objective: Recurring annual costs of caring for patients with chronic spinal cord injury (SCI) is a large economic burden on health care systems, but information on costs of SCI care beyond the acute and initial postacute phase is sparse. The objective of this study was to establish a frame of reference and estimate of the annual direct medical costs associated with health care for a sample of patients with chronic SCI (ie, >2 years after injury). Methods: Patients were recruited from 3 Veterans Health Administration (VHA) SCI facilities; baseline patient information was cross-referenced to the Decision Support System (DSS) National Data Extracts (NDE) to obtain patient-specific health care costs in VHA. Descriptive statistical analysis of annual DSS-NDE cost of patients with SCI (N = 675) for fiscal year (FY) 2005 by level and completeness of injury was conducted. Results: Total (inpatient and outpatient) annual (FY 2005) direct medical costs for 675 patients with SCI exceeded $14.47 million or $21,450 per patient. Average annual total costs varied from $28,334 for cervical complete SCI to $16,792 for thoracic incomplete SCI. Two hundred thirty-three of the 675 patients with SCI who were hospitalized over the study period accounted for a total of 378 hospital discharges, costing in excess of $7.19 million. This approximated a cost of outpatient care received of $7.28 million for our entire sample. Conclusions: The comprehensive nature of health care delivery and related cost capture for people with chronic SCI in the VHA provided us the opportunity to accurately determine health care costs for this population. Future SCI postacute care cost analyses should consider case-mix adjusting patients at high risk for rehospitalization. PMID:18092564

Job satisfaction of advanced practice nurses in the Veterans Health Administration.

PubMed

Faris, Judith A; Douglas, Marilyn K; Maples, Deanna C; Berg, Laurie R; Thrailkill, Ann

2010-01-01

The purpose of this study was to describe the level of job satisfaction and barriers to practice for advanced practice nurses (APNs) employed by the Veterans Health Administration (VHA). The Misener Nurse Practitioner Job Satisfaction Survey (MNPJSS) and an investigator-developed questionnaire were completed by a self-selected, convenience sample of 1,983 APNs who responded to an internal VHA email invitation (61% response rate) to participate in an anonymous on-line survey. Respondents reported being minimally satisfied with their job overall, most satisfied with their benefits and least satisfied with professional growth and intrapractice collegiality. They scored lower than their private sector peers for total job satisfaction and all subscales except benefits, as compared to samples of three smaller studies. Clinical nurse specialists reported greater job satisfaction then NPs. The most frequently cited barriers to practice were: too many non-APN tasks, lack of administrative support, and inadequate time to do research. Strategies for improving professional growth and intra-practice collegiality are needed. APNs' job satisfaction may be improved in these areas by mentoring of new APN graduates and administrative approval for participating in research. Additional administrative support is needed to decrease the amount of non-APN tasks and clerical duties.

Opting out of an integrated healthcare system: dual-system use is associated with poorer glycemic control in veterans with diabetes.

PubMed

Helmer, Drew; Sambamoorthi, Usha; Shen, Yujing; Tseng, Chin-Lin; Rajan, Mangala; Tiwari, Anjali; Maney, Miriam; Pogach, Leonard

2008-06-01

To test for an association between quality of care and patient choice to obtain care outside an integrated healthcare delivery system. We used administrative data to define dual-system use (Veterans Health Administration (VHA) and Medicare) in 1999 for VHA users with diabetes over 65 years old. Quality of diabetes care was determined by the last hemoglobin A1c (HA1c) value in 2000. The distance to nearest VHA facility minus the distance to nearest non-federal hospital was the instrumental variable in a two-part regression model which controlled for observed and unobserved factors. In 1999, 57.4% of subjects received care from both VHA and Medicare providers; their mean proportion of visits to Medicare providers was 0.41 (median 0.38). After controlling for observed and unobserved factors, higher proportions of Medicare visits were significantly associated with higher HA1c values; a 40% increase in the proportion of Medicare visits by those who did not use Medicare was associated with a 0.23% point increase in HA1c value. Dual-system use was associated with higher HA1c values, suggesting that veterans who chose to receive care outside the integrated VHA may have worse intermediate clinical outcomes than those who received care exclusively within the system.

Location of cancer surgery for older veterans with cancer.

PubMed

Kouri, Elena M; Landrum, Mary Beth; Lamont, Elizabeth B; Bozeman, Sam; McNeil, Barbara J; Keating, Nancy L

2012-04-01

Many veterans undergo cancer surgery outside of the Veterans Health Administration (VHA). We assessed to what extent these patients obtained care in the VHA before surgery. VHA-Medicare data, VHA administrative data, and Veterans Affairs Central Cancer Registry data. We identified patients aged ≥65 years in the VHA-Medicare cohort who underwent lung or colon cancer resection outside the VHA and assessed VHA visits in the year before surgery. Over 60% of patients in the VHA-Medicare cohort who received lung or colon cancer surgeries outside the VHA did not receive any care in VHA before surgery. Veterans' receipt of major cancer surgery outside the VHA probably reflects usual private sector care among veterans who are infrequent VHA users. © Health Research and Educational Trust.

Survival of Older Patients With Cancer in the Veterans Health Administration Versus Fee-for-Service Medicare

PubMed Central

Landrum, Mary Beth; Keating, Nancy L.; Lamont, Elizabeth B.; Bozeman, Samuel R.; Krasnow, Steven H.; Shulman, Lawrence; Brown, Jennifer R.; Earle, Craig C.; Rabin, Michael; McNeil, Barbara J.

2012-01-01

Purpose The Veterans Health Administration (VHA) provides high-quality preventive chronic care and cancer care, but few studies have documented improved patient outcomes that result from this high-quality care. We compared the survival rates of older patients with cancer in the VHA and fee-for-service (FFS) Medicare and examined whether differences in the stage at diagnosis, receipt of guideline-recommended therapies, and unmeasured characteristics explain survival differences. Patients and Methods We used propensity-score methods to compare all-cause and cancer-specific survival rates for men older than age 65 years who were diagnosed or received their first course of treatment for colorectal, lung, lymphoma, or multiple myeloma in VHA hospitals from 2001 to 2004 to similar FFS-Medicare enrollees diagnosed in Surveillance, Epidemiology, and End Results (SEER) areas in the same time frame. We examined the role of unmeasured factors by using sensitivity analyses. Results VHA patients versus similar FFS SEER-Medicare patients had higher survival rates of colon cancer (adjusted hazard ratio [HR], 0.87; 95% CI, 0.82 to 0.93) and non–small-cell lung cancer (NSCLC; HR, 0.91; 95% CI, 0.88 to 0.95) and similar survival rates of rectal cancer (HR, 1.05; 95% CI, 0.95 to 1.16), small-cell lung cancer (HR, 0.99; 95% CI, 0.93 to 1.05), diffuse large–B-cell lymphoma (HR, 1.02; 95% CI, 0.89 to 1.18), and multiple myeloma (HR, 0.92; 95% CI, 0.83 to 1.03). The diagnosis of VHA patients at earlier stages explained much of the survival advantages for colon cancer and NSCLC. Sensitivity analyses suggested that additional adjustment for the severity of comorbid disease or performance status could have substantial effects on estimated differences. Conclusion The survival rate for older men with cancer in the VHA was better than or equivalent to the survival rate for similar FFS-Medicare beneficiaries. The VHA provision of high-quality care, particularly preventive care, can result

Survival of older patients with cancer in the Veterans Health Administration versus fee-for-service Medicare.

PubMed

Landrum, Mary Beth; Keating, Nancy L; Lamont, Elizabeth B; Bozeman, Samuel R; Krasnow, Steven H; Shulman, Lawrence; Brown, Jennifer R; Earle, Craig C; Rabin, Michael; McNeil, Barbara J

2012-04-01

The Veterans Health Administration (VHA) provides high-quality preventive chronic care and cancer care, but few studies have documented improved patient outcomes that result from this high-quality care. We compared the survival rates of older patients with cancer in the VHA and fee-for-service (FFS) Medicare and examined whether differences in the stage at diagnosis, receipt of guideline-recommended therapies, and unmeasured characteristics explain survival differences. We used propensity-score methods to compare all-cause and cancer-specific survival rates for men older than age 65 years who were diagnosed or received their first course of treatment for colorectal, lung, lymphoma, or multiple myeloma in VHA hospitals from 2001 to 2004 to similar FFS-Medicare enrollees diagnosed in Surveillance, Epidemiology, and End Results (SEER) areas in the same time frame. We examined the role of unmeasured factors by using sensitivity analyses. VHA patients versus similar FFS SEER-Medicare patients had higher survival rates of colon cancer (adjusted hazard ratio [HR], 0.87; 95% CI, 0.82 to 0.93) and non-small-cell lung cancer (NSCLC; HR, 0.91; 95% CI, 0.88 to 0.95) and similar survival rates of rectal cancer (HR, 1.05; 95% CI, 0.95 to 1.16), small-cell lung cancer (HR, 0.99; 95% CI, 0.93 to 1.05), diffuse large-B-cell lymphoma (HR, 1.02; 95% CI, 0.89 to 1.18), and multiple myeloma (HR, 0.92; 95% CI, 0.83 to 1.03). The diagnosis of VHA patients at earlier stages explained much of the survival advantages for colon cancer and NSCLC. Sensitivity analyses suggested that additional adjustment for the severity of comorbid disease or performance status could have substantial effects on estimated differences. The survival rate for older men with cancer in the VHA was better than or equivalent to the survival rate for similar FFS-Medicare beneficiaries. The VHA provision of high-quality care, particularly preventive care, can result in improved patient outcomes.

Telehealth forging ahead: overcoming barriers in licensure to improve access to care for service members.

PubMed

Stout, Katie Ambrose; Martinez, Kristina

2011-01-01

The telehealth initiatives of the Department of Defense (DoD) and Veterans' Health Administration (VHA) continue to test the limits of technology to provide the best care to our service members, veterans and their families. The DoD and VHA have credentialing systems in place to allow clinical practice between facilities. New legislation in the form of the Servicemembers' Telemedicine and E-Health Portability (STEP) Act will potentially expand telehealth clinical services across state lines into the homes of our service members and veterans.

Patient-centered medical home initiative produced modest economic results for Veterans Health Administration, 2010-12.

PubMed

Hebert, Paul L; Liu, Chuan-Fen; Wong, Edwin S; Hernandez, Susan E; Batten, Adam; Lo, Sophie; Lemon, Jaclyn M; Conrad, Douglas A; Grembowski, David; Nelson, Karin; Fihn, Stephan D

2014-06-01

In 2010 the Veterans Health Administration (VHA) began a nationwide initiative called Patient Aligned Care Teams (PACT) that reorganized care at all VHA primary care clinics in accordance with the patient-centered medical home model. We analyzed data for fiscal years 2003-12 to assess how trends in health care use and costs changed after the implementation of PACT. We found that PACT was associated with modest increases in primary care visits and with modest decreases in both hospitalizations for ambulatory care-sensitive conditions and outpatient visits with mental health specialists. We estimated that these changes avoided $596 million in costs, compared to the investment in PACT of $774 million, for a potential net loss of $178 million in the study period. Although PACT has not generated a positive return, it is still maturing, and trends in costs and use are favorable. Adopting patient-centered care does not appear to have been a major financial risk for the VHA. Project HOPE—The People-to-People Health Foundation, Inc.

The influence of gender on suicidal ideation following military sexual trauma among Veterans in the Veterans Health Administration.

PubMed

Monteith, Lindsey L; Bahraini, Nazanin H; Matarazzo, Bridget B; Gerber, Holly R; Soberay, Kelly A; Forster, Jeri E

2016-10-30

No studies have examined whether military sexual trauma, as measured and defined within the Veterans Health Administration (VHA), is associated with suicidal ideation among Veterans in VHA care, when taking prior suicide attempts into account. Research regarding the role of gender in this association is also limited. The present study examined: (1) whether military sexual trauma was associated with the presence of past-week suicidal ideation among 354 Veterans in VHA (310 men, 44 women); (2) whether gender moderated the association between military sexual trauma and suicidal ideation. Information regarding military sexual trauma, suicidal ideation, suicide attempt, and psychiatric diagnoses was obtained from self-report instruments and medical records. Adjusting for age, gender, combat, posttraumatic stress disorder, depressive disorders, negative affect, and lifetime suicide attempt, Veterans with military sexual trauma were significantly more likely to report suicidal ideation, compared to Veterans without military sexual trauma. Furthermore, the association between military sexual trauma and suicidal ideation was stronger for men compared to women. These results contribute to a growing literature identifying military sexual trauma as a risk factor for suicidal thoughts and behaviors among Veterans in VHA care and emphasize the importance of screening for suicidal ideation among survivors of military sexual trauma. Published by Elsevier Ireland Ltd.

Priority setting and the ethics of resource allocation within VA healthcare facilities: results of a survey.

PubMed

Foglia, Mary Beth; Pearlman, Robert A; Bottrell, Melissa M; Altemose, Jane A; Fox, Ellen

2008-01-01

Setting priorities and the subsequent allocation of resources is a major ethical issue facing healthcare facilities, including the Veterans Health Administration (VHA), the largest integrated healthcare delivery network in the United States. Yet despite the importance of priority setting and its impact on those who receive and those who provide care, we know relatively little about how clinicians and managers view allocation processes within their facilities. The purpose of this secondary analysis of survey data was to characterize staff members' perceptions regarding the fairness of healthcare ethics practices related to resource allocation in Veterans Administration (VA) facilities. The specific aim of the study was to compare the responses of clinicians, clinician managers, and non-clinician managers with respect to these survey items. We utilized a paper and web-based survey and a cross-sectional design of VHA clinicians and managers. Our sample consisted of a purposive stratified sample of 109 managers and a stratified random sample of 269 clinicians employed 20 or more hours per week in one of four VA medical centers. The four medical centers were participating as field sites selected to test the logistics of administering and reporting results of the Integrated Ethics Staff Survey, an assessment tool aimed at characterizing a broad range of ethical practices within a healthcare organization. In general, clinicians were more critical than clinician managers or non-clinician managers of the institutions' allocation processes and of the impact of resource decisions on patient care. Clinicians commonly reported that they did not (a) understand their facility's decision-making processes, (b) receive explanations from management regarding the reasons behind important allocation decisions, or (b) perceive that they were influential in allocation decisions. In addition, clinicians and managers both perceived that education related to the ethics of resource

Burnout in Veterans Health Administration Mental Health Providers in Posttraumatic Stress Clinics

PubMed Central

Garcia, Hector A.; McGeary, Cindy A.; McGeary, Donald D.; Finley, Erin P.; Peterson, Alan L.

2015-01-01

The purpose of this study was to conduct the first assessment of burnout among Veterans Health Administration (VHA) mental health clinicians providing evidence-based posttraumatic stress disorder (PTSD) care. This study consisted of 138 participants and the sample was mostly female (67%), Caucasian (non-Hispanic; 81%), and married (70%) with a mean age of 44.3 years (SD = 11.2). Recruitment was directed through VHA PTSD Clinical Teams (PCT) throughout the United States based on a nationwide mailing list of PCT Clinic Directors. Participants completed an electronic survey that assessed demographics, organizational work factors, absenteeism, and burnout (assessed through the Maslach Burnout Inventory-General Survey, MBI-GS). Twelve percent of the sample reported low Professional Efficacy, 50% reported high levels of Exhaustion, and 47% reported high levels of Cynicism as determined by the MBI-GS cut-off scores. Only workplace characteristics were significantly associated with provider scores on all 3 scales. Exhaustion and Cynicism were most impacted by perceptions of organizational politics/bureaucracy, increased clinical workload and control over how work is done. Organizational factors were also significantly associated with provider absenteeism and intent to leave his/her job. Findings suggest that providers in VHA specialty PTSD care settings may benefit from programs or supports aimed at preventing and/or ameliorating burnout. PMID:24564443

Posttraumatic stress disorder and suicide in 5.9 million individuals receiving care in the veterans health administration health system.

PubMed

Conner, Kenneth R; Bossarte, Robert M; He, Hua; Arora, Jyoti; Lu, Naiji; Tu, Xin M; Katz, Ira R

2014-09-01

Post-traumatic stress disorder (PTSD) confers risk for suicidal ideation and suicide attempts but a link with suicide is not yet established. Prior analyses of users of the Veterans health administration (VHA) Health System suggest that other mental disorders strongly influence the association between PTSD and suicide in this population. We examined the association between PTSD and suicide in VHA users, with a focus on the influence of other mental disorders. Data were based on linkage of VA National Patient Care Database records and the Centers for Disease Control and Prevention׳s National Death Index, with data from fiscal year 2007-2008. Analyses were based on multivariate logistic regression and structural equation models. Among users of VHA services studied (N=5,913,648), 0.6% (N=3620) died by suicide, including 423 who had had been diagnosed with PTSD. In unadjusted analysis, PTSD was associated with increased risk for suicide, with odds ratio, OR (95% confidence interval, 95% CI)=1.34 (1.21, 1.48). Similar results were obtained after adjustment for demographic variables and veteran characteristics. After adjustment for multiple other mental disorder diagnoses, PTSD was associated with decreased risk for suicide, OR (95% CI)=0.77 (0.69, 0.86). Major depressive disorder (MDD) had the largest influence on the association between PTSD and suicide. The analyses were cross-sectional. VHA users were studied, with unclear relevance to other populations. The findings suggest the importance of identifying and treating comorbid MDD and other mental disorders in VHA users diagnosed with PTSD in suicide prevention efforts. Published by Elsevier B.V.

Work Life Stress and Career Resilience of Licensed Nursing Facility Administrators.

PubMed

Myers, Dennis R; Rogers, Rob; LeCrone, Harold H; Kelley, Katherine; Scott, Joel H

2018-04-01

Career resilience provided a frame for understanding how Licensed Nursing Facility Administrators (LNFAs) sustain role performance and even thrive in stressful skilled nursing facility work environments. Quantitative and qualitative analyses of in-depth interviews with18 LNFAs, averaging 24 years of experience were conducted by a five-member research team. Analysis was informed by evidence-based frameworks for career resilience in the health professions as well as the National Association of Long-Term Care Administrator Boards' (NAB) five domains of competent administrative practice. Findings included six sources of work stressors and six sources of professional satisfaction. Also, participants identified seven strategic principles and 10 administrative practices for addressing major sources of stress. Recommendations are provided for research and evidence-based application of the career resilience perspective to LNFA practice aimed at reducing role abandonment and energizing the delivery of the quality of care that each resident deserves.

Contribution of patient, physician, and environmental factors to demographic and health variation in colonoscopy follow-up for abnormal colorectal cancer screening test results.

PubMed

Partin, Melissa R; Gravely, Amy A; Burgess, James F; Haggstrom, David A; Lillie, Sarah E; Nelson, David B; Nugent, Sean M; Shaukat, Aasma; Sultan, Shahnaz; Walter, Louise C; Burgess, Diana J

2017-09-15

Patient, physician, and environmental factors were identified, and the authors examined the contribution of these factors to demographic and health variation in colonoscopy follow-up after a positive fecal occult blood test/fecal immunochemical test (FOBT/FIT) screening. In total, 76,243 FOBT/FIT-positive patients were identified from 120 Veterans Health Administration (VHA) facilities between August 16, 2009 and March 20, 2011 and were followed for 6 months. Patient demographic (race/ethnicity, sex, age, marital status) and health characteristics (comorbidities), physician characteristics (training level, whether primary care provider) and behaviors (inappropriate FOBT/FIT screening), and environmental factors (geographic access, facility type) were identified from VHA administrative records. Patient behaviors (refusal, private sector colonoscopy use) were estimated with statistical text mining conducted on clinic notes, and follow-up predictors and adjusted rates were estimated using hierarchical logistic regression. Roughly 50% of individuals completed a colonoscopy at a VHA facility within 6 months. Age and comorbidity score were negatively associated with follow-up. Blacks were more likely to receive follow-up than whites. Environmental factors attenuated but did not fully account for these differences. Patient behaviors (refusal, private sector colonoscopy use) and physician behaviors (inappropriate screening) fully accounted for the small reverse race disparity and attenuated variation by age and comorbidity score. Patient behaviors (refusal and private sector colonoscopy use) contributed more to variation in follow-up rates than physician behaviors (inappropriate screening). In the VHA, blacks are more likely to receive colonoscopy follow-up for positive FOBT/FIT results than whites, and follow-up rates markedly decline with advancing age and comorbidity burden. Patient and physician behaviors explain race variation in follow-up rates and contribute to

14 CFR 1212.702 - Associate Administrator for Management Systems and Facilities.

Code of Federal Regulations, 2011 CFR

2011-01-01

... 14 Aeronautics and Space 5 2011-01-01 2010-01-01 true Associate Administrator for Management Systems and Facilities. 1212.702 Section 1212.702 Aeronautics and Space NATIONAL AERONAUTICS AND SPACE ADMINISTRATION PRIVACY ACT-NASA REGULATIONS NASA Authority and Responsibilities § 1212.702 Associate...

14 CFR 1212.702 - Associate Administrator for Management Systems and Facilities.

Code of Federal Regulations, 2010 CFR

2010-01-01

... 14 Aeronautics and Space 5 2010-01-01 2010-01-01 false Associate Administrator for Management Systems and Facilities. 1212.702 Section 1212.702 Aeronautics and Space NATIONAL AERONAUTICS AND SPACE ADMINISTRATION PRIVACY ACT-NASA REGULATIONS NASA Authority and Responsibilities § 1212.702 Associate...

Strategic plan for geriatrics and extended care in the veterans health administration: background, plan, and progress to date.

PubMed

Shay, Kenneth; Hyduke, Barbara; Burris, James F

2013-04-01

The leaders of Geriatrics and Extended Care (GEC) in the Veterans Health Administration (VHA) undertook a strategic planning process that led to approval in 2009 of a multidisciplinary, evidence-guided strategic plan. This article reviews the four goals contained in that plan and describes VHA's progress in addressing them. The goals included transforming the healthcare system to a veteran-centric approach, achieving universal access to a panel of services, ensuring that the Veterans Affair's (VA) healthcare workforce was adequately prepared to manage the needs of the growing elderly veteran population, and integrating continuous improvement into all care enhancements. There has been substantial progress in addressing all four goals. All VHA health care has undergone an extensive transformation to patient-centered care, has enriched the services it can offer caregivers of dependent veterans, and has instituted models to better integrate VA and non-VA cares and services. A range of successful models of geriatric care described in the professional literature has been adapted to VA environments to gauge suitability for broader implementation. An executive-level task force developed a three-pronged approach for enhancing the VA's geriatric workforce. The VHA's performance measurement approaches increasingly include incentives to enhance the quality of management of vulnerable elderly adults in primary care. The GEC strategic plan was intended to serve as a road map for keeping VHA aligned with an ambitious but important long-term vision for GEC services. Although no discrete set of resources was appropriated for fulfillment of the plan's recommendations, this initial report reflects substantial progress in addressing most of its goals. © 2013, Copyright the Authors Journal compilation © 2013, The American Geriatrics Society.

Symptom validity test performance and consistency of self-reported memory functioning of Operation Enduring Freedom/Operation Iraqi freedom veterans with positive Veteran Health Administration Comprehensive Traumatic Brain Injury evaluations.

PubMed

Russo, Arthur C

2012-12-01

Operation Enduring Freedom and Operation Iraqi Freedom combat veterans given definite diagnoses of mild Traumatic Brain Injury (TBI) during the Veteran Health Administration (VHA) Comprehensive TBI evaluation and reporting no post-deployment head injury were examined to assess (a) consistency of self-reported memory impairment and (b) symptom validity test (SVT) performance via a two-part study. Study 1 found that while 49 of 50 veterans reported moderate to very severe memory impairment during the VHA Comprehensive TBI evaluation, only 7 had reported any memory problem at the time of their Department of Defense (DOD) post-deployment health assessment. Study 2 found that of 38 veterans referred for neuropsychological evaluations following a positive VHA Comprehensive TBI evaluation, 68.4% failed the Word Memory Test, a forced choice memory recognition symptom validity task. Together, these studies raise questions concerning the use of veteran symptom self-report for TBI assessments and argue for the inclusion of SVTs and the expanded use of contemporaneous DOD records to improve the diagnostic accuracy of the VHA Comprehensive TBI evaluation.

A Health Services Research Agenda for Bariatric Surgery Within the Veterans Health Administration.

PubMed

Funk, L M; Gunnar, W; Dominitz, J A; Eisenberg, D; Frayne, S; Maggard-Gibbons, M; Kalarchian, M A; Livingston, E; Sanchez, V; Smith, B R; Weidenbacher, H; Maciejewski, Matthew L

2017-04-01

In 2016, the Veterans Health Administration (VHA) held a Weight Management State of the Art conference to identify evidence gaps and develop a research agenda for population-based weight management for veterans. Included were behavioral, pharmacologic, and bariatric surgery workgroups. This article summarizes the bariatric surgery workgroup (BSWG) findings and recommendations for future research. The BSWG agreed that there is evidence from randomized trials and large observational studies suggesting that bariatric surgery is superior to medical therapy for short- and intermediate-term remission of type 2 diabetes, long-term weight loss, and long-term survival. Priority evidence gaps include long-term comorbidity remission, mental health, substance abuse, and health care costs. Evidence of the role of endoscopic weight loss options is also lacking. The BSWG also noted the limited evidence regarding optimal timing for bariatric surgery referral, barriers to bariatric surgery itself, and management of high-risk bariatric surgery patients. Clinical trials of pre- and post-surgery interventions may help to optimize patient outcomes. A registry of overweight and obese veterans and a workforce assessment to determine the VHA's capacity to increase bariatric surgery access were recommended. These will help inform policy modifications and focus the research agenda to improve the ability of the VHA to deliver population-based weight management.

Women's Healthcare Utilization Following Routine Screening for Past-Year Intimate Partner Violence in the Veterans Health Administration.

PubMed

Dichter, Melissa E; Sorrentino, Anneliese E; Haywood, Terri N; Bellamy, Scarlett L; Medvedeva, Elina; Roberts, Christopher B; Iverson, Katherine M

2018-06-01

Experience of intimate partner violence (IPV) can have adverse health impacts and has been associated with elevated rates of healthcare service utilization. Healthcare encounters present opportunities to identify IPV-related concerns and connect patients with services. The Veterans Health Administration (VHA) conducts IPV screening within an integrated healthcare system. The objectives of this study were to compare service utilization in the 6 months following IPV screening between those screening positive and negative for past-year IPV (IPV+, IPV-) and to examine the timing and types of healthcare services accessed among women screening IPV+. A retrospective chart review was conducted for 8888 female VHA patients across 13 VHA facilities who were screened for past-year IPV between April 2014 and April 2016. Demographic characteristics (age, race, ethnicity, marital status, veteran status), IPV screening response, and healthcare encounters (based on visit identification codes). In the 6 months following routine screening for past-year IPV, patients screening IPV+ were more likely to utilize outpatient care (aOR = 1.85 [CI 1.26, 2.70]), including primary care or psychosocial care, and to have an inpatient stay (aOR = 2.09 [CI 1.23, 3.57]), compared with patients screening IPV-. Among those with any utilization, frequency of outpatient encounters within the 6-month period following screening was higher among those screening IPV+ compared with those screening IPV-. The majority of patients screening positive for past-year IPV returned for an outpatient visit within a brief time frame following the screening visit (> 70% within 14 days, >95% within 6 months). More than one in four patients screening IPV+ had an emergency department visit within the 6 months following screening. Women who screen positive for past-year IPV have high rates of return to outpatient visits following screening, presenting opportunities for follow-up support. Higher rates of

Provider practices in the primary care behavioral health (PCBH) model: an initial examination in the Veterans Health Administration and United States Air Force.

PubMed

Funderburk, Jennifer S; Dobmeyer, Anne C; Hunter, Christopher L; Walsh, Christine O; Maisto, Stephen A

2013-12-01

The goals of this study were to identify characteristics of both behavioral health providers (BHPs) and the patients seen in a primary care behavioral health (PCBH) model of service delivery using prospective data obtained from BHPs. A secondary objective was to explore similarities and differences between these variables within the Veterans Health Administration (VHA) and United States Air Force (USAF) primary care clinics. A total of 159 VHA and 23 USAF BHPs, representing almost every state in the United States, completed the study, yielding data from 403 patient appointments. BHPs completed a web-based questionnaire that assessed BHP and setting characteristics, and a separate questionnaire after each patient seen on one day of clinical service. Data demonstrated that there are many similarities between the VHA and USAF BHPs and practices. Both systems tend to use well-trained psychologists as BHPs, had systems that support the BHP being in close proximity to the primary care providers, and have seamless operational elements (i.e., shared record, one waiting room, same-day appointments, and administrative support for BHPs). Comorbid anxiety and depression was the most common presenting problem in both systems, but overall rates were higher in VHA clinics, and patients were significantly more likely to meet diagnostic criteria for mental health conditions. This study provides the first systematic, prospective examination of BHPs and practices within a PCBH model of service delivery in two large health systems with well over 5 years of experience with behavioral health integration. Many elements of the PCBH model were implemented in a manner consistent with the model, although some variability exists within both settings. These data can help guide future implementation and training efforts.

Evaluation of safety climate and employee injury rates in healthcare.

PubMed

Cook, Jacqueline M; Slade, Martin D; Cantley, Linda F; Sakr, Carine J

2016-09-01

Safety climates that support safety-related behaviour are associated with fewer work-related injuries, and prior research in industry suggests that safety knowledge and motivation are strongly related to safety performance behaviours; this relationship is not well studied in healthcare settings. We performed analyses of survey results from a Veterans Health Administration (VHA) Safety Barometer employee perception survey, conducted among VHA employees in 2012. The employee perception survey assessed 6 safety programme categories, including management participation, supervisor participation, employee participation, safety support activities, safety support climate and organisational climate. We examined the relationship between safety climate from the survey results on VHA employee injury and illness rates. Among VHA facilities in the VA New England Healthcare System, work-related injury rate was significantly and inversely related to overall employee perception of safety climate, and all 6 safety programme categories, including employee perception of employee participation, management participation, organisational climate, supervisor participation, safety support activities and safety support climate. Positive employee perceptions of safety climate in VHA facilities are associated with lower work-related injury and illness rates. Employee perception of employee participation, management participation, organisational climate, supervisor participation, safety support activities and safety support climate were all associated with lower work-related injury rates. Future implications include fostering a robust safety climate for patients and healthcare workers to reduce healthcare worker injuries. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

A multivariate fall risk assessment model for VHA nursing homes using the minimum data set.

PubMed

French, Dustin D; Werner, Dennis C; Campbell, Robert R; Powell-Cope, Gail M; Nelson, Audrey L; Rubenstein, Laurence Z; Bulat, Tatjana; Spehar, Andrea M

2007-02-01

The purpose of this study was to develop a multivariate fall risk assessment model beyond the current fall Resident Assessment Protocol (RAP) triggers for nursing home residents using the Minimum Data Set (MDS). Retrospective, clustered secondary data analysis. National Veterans Health Administration (VHA) long-term care nursing homes (N = 136). The study population consisted of 6577 national VHA nursing home residents who had an annual assessment during FY 2005, identified from the MDS, as well as an earlier annual or admission assessment within a 1-year look-back period. A dichotomous multivariate model of nursing home residents coded with a fall on selected fall risk characteristics from the MDS, estimated with general estimation equations (GEE). There were 17 170 assessments corresponding to 6577 long-term care nursing home residents. The increased odds ratio (OR) of being classified as a faller relative to the omitted "dependent" category of activities of daily living (ADL) ranged from OR = 1.35 for "limited" ADL category up to OR = 1.57 for "extensive-2" ADL (P < .0001). Unsteady gait more than doubles the odds of being a faller (OR = 2.63, P < .0001). The use of assistive devices such as canes, walkers, or crutches, or the use of wheelchairs increases the odds of being a faller (OR = 1.17, P < .0005) or (OR = 1.19, P < .0002), respectively. Foot problems may also increase the odds of being a faller (OR = 1.26, P < .0016). Alzheimer's or other dementias also increase the odds of being classified as a faller (OR = 1.18, P < .0219) or (OR=1.22, P < .0001), respectively. In addition, anger (OR = 1.19, P < .0065); wandering (OR = 1.53, P < .0001); or use of antipsychotic medications (OR = 1.15, P < .0039), antianxiety medications (OR = 1.13, P < .0323), or antidepressant medications (OR = 1.39, P < .0001) was also associated with the odds of being a faller. This national study in one of the largest managed healthcare systems in the United States has empirically

Microstructures and mechanical properties of powder injection molded Ti-6Al-4V/HA powder.

PubMed

Thian, E S; Loh, N H; Khor, K A; Tor, S B

2002-07-01

Taguchi method with an L9 orthogonal array was employed to investigate the sintered properties of Ti-6Al-4V/HA tensile bars produced by powder injection molding. The effects of sintering factors at the 90% significance level: sintering temperature (1050 degrees C, 1100 degrees C and 1150 degrees C), heating rate (5 degrees C/min, 7.5 degrees C/min and 10 degrees C/min), holding time (30, 45 and 60 min) and cooling rate (5 degrees C/min, 20 degrees C/min and 40 degrees C/min) were investigated. Results showed that sintering temperature, heating rate and cooling rate have significant effects on sintered properties, whereas the influence of holding time was insignificant. It was found that a sintering temperature of 1100 degrees C, a heating rate of 7.5 degrees C/min and a cooling rate of 5 degrees C/min increased the relative density, Vicker's microhardness, flexural strength and flexural modulus. However, a further increment of sintering temperature to 1150 degrees C did not show any discernable improvement in the relative density and Vicker's microhardness, but there was a slight increase of 0.6% and 0.9% in the flexural strength and flexural modulus, respectively. Mechanically strong Ti-6Al-4V/HA parts with an open porosity of around 50% were developed.

Administrators' perspectives on end-of-life care for cancer patients in Japanese long-term care facilities.

PubMed

Fukahori, Hiroki; Miyashita, Mitsunori; Morita, Tatsuya; Ichikawa, Takayuki; Akizuki, Nobuya; Akiyama, Miki; Shirahige, Yutaka; Eguchi, Kenji

2009-10-01

The purpose of this study was to clarify administrators' perspectives on availability of recommended strategies for end-of-life (EOL) care for cancer patients at long-term care (LTC) facilities in Japan. A cross-sectional survey was conducted with administrators at Japanese LTC facilities. Participants were surveyed about their facilities, reasons for hospitalization of cancer patients, and their perspectives on availability of and strategies for EOL care. The 97 responses were divided into medical facility (n = 24) and non-medical facility (n = 73) groups according to physician availability. The most frequent reasons for hospitalization were a sudden change in patient's condition (49.4%), lack of around-the-clock care (43.0%), and inability to palliate symptoms (41.0%). About 50% of administrators believed their facilities could provide EOL care if supported by palliative care experts. There was no significant difference between facility types (P = 0.635). Most administrators (81.2%) regarded unstable cancer patients as difficult to care for. However, many (68.4%) regarded opioids given orally as easy to administer, but regarded continuous subcutaneous infusion/central venous nutrition as difficult. Almost all administrators believed the most useful strategy was transferring patients to hospitals at the request of patients or family members (96.9%), followed by consultation with palliative care experts (88.5%). Although LTC facilities in Japan currently do not provide adequate EOL care for cancer patients, improvement might be possible with support by palliative care teams. Appropriate models are necessary for achieving a good death for cancer patients. Interventions based on these models are necessary for EOL care for cancer patients in LTC facilities.

Risk and Resiliency for Dementia: Comparison of Male and Female Veterans

DTIC Science & Technology

2017-09-01

from the Veterans Health Administration (VHA) National Patient Care Database (NPCD) 2. Obtain data from the Veterans Health Administration (VHA...National Patient Care Database (NPCD): Months 6-12  In the second quarter, we submitted and received approval to receive data from the VHA NPCD  In...injury. We plan to capitalize on our prior experience working with the Veterans Health Administration National Patient Care Database . We will use data

Validating administrative records in post-traumatic stress disorder.

PubMed

Abrams, Thad E; Vaughan-Sarrazin, Mary; Keane, Terence M; Richardson, Kelly

2016-03-01

There is insufficient data on the accuracy of administrative coding data (ACD) for post-traumatic stress disorder (PTSD). Medical records were reviewed for (1) a diagnosis of PTSD; (2) treatment for PTSD. The records were compared against the Veterans Health Administration (VHA) data in order to determine the positive predictive value (PPV) and negative predictive value (NPV) of three commonly used approaches. The PPV and NPV varied according to the ACD approach. Relative to a medical records review, the ACD approach of one or two PTSD coded outpatient encounters had a PPV of 78% and an NPV of 91%; whereas the PPV was 97% and the NPV was 98% for three or more PTSD codes. For pharmacotherapy, the ACD approach with one or two codes for PTSD had a PPV of 33% (NPV = 93%), whereas three or more PTSD coded encounters improved the PPV to 85% (NPV = 100%). When using VHA data, we recommend tailoring the identification strategy according to the research aims. An ACD approach identifying one or more PTSD outpatient encounters should be considered sufficient for a diagnosis of PTSD. Assessments for PTSD associated pharmacotherapy require using an ACD approach that identifies veterans with the presence ≥ 3 outpatient PTSD encounters. Published 2015. This article is a U.S. Government work and is in the public domain in the USA. Published 2015. This article is a U.S. Government work and is in the public domain in the USA.

Organizational correlates of implementation of colocation of mental health and primary care in the Veterans Health Administration.

PubMed

Guerrero, Erick G; Heslin, Kevin C; Chang, Evelyn; Fenwick, Karissa; Yano, Elizabeth

2015-07-01

This study explored the role of organizational factors in the ability of Veterans Health Administration (VHA) clinics to implement colocated mental health care in primary care settings (PC-MH). The study used data from the VHA Clinical Practice Organizational Survey collected in 2007 from 225 clinic administrators across the United States. Clinic degree of implementation of PC-MH was the dependent variable, whereas independent variables included policies and procedures, organizational context, and leaders' perceptions of barriers to change. Pearson bivariate correlations and multivariable linear regression were used to test hypotheses. Results show that depression care training for primary care providers and clinics' flexibility and participation were both positively correlated with implementation of PC-MH. However, after accounting for other factors, regressions show that only training primary care providers in depression care was marginally associated with degree of implementation of PC-MH (p = 0.051). Given the importance of this topic for implementing integrated care as part of health care reform, these null findings underscore the need to improve theory and testing of more proximal measures of colocation in future work.

Organizational Correlates of Implementation of Colocation of Mental Health and Primary Care in the Veterans Health Administration

PubMed Central

Guerrero, Erick G.; Heslin, Kevin C.; Chang, Evelyn; Fenwick, Karissa; Yano, Elizabeth

2014-01-01

This study explored the role of organizational factors in the ability of Veterans Health Administration (VHA) clinics to implement colocated mental health care in primary care settings (PC-MH). The study used data from the VHA Clinical Practice Organizational Survey collected in 2007 from 225 clinic administrators across the United States. Clinic degree of implementation of PC-MH was the dependent variable, whereas independent variables included policies and procedures, organizational context, and leaders’ perceptions of barriers to change. Pearson bivariate correlations and multivariable linear regression were used to test hypotheses. Results show that depression care training for primary care providers and clinics’ flexibility and participation were both positively correlated with implementation of PC-MH. However, after accounting for other factors, regressions show that only training primary care providers in depression care was marginally associated with degree of implementation of PC-MH (p = 0.051). Given the importance of this topic for implementing integrated care as part of health care reform, these null findings underscore the need to improve theory and testing of more proximal measures of colocation in future work. PMID:25096986

Results from the Veterans Health Administration ICD-10-CM/PCS Coding Pilot Study.

PubMed

Weems, Shelley; Heller, Pamela; Fenton, Susan H

2015-01-01

The Veterans Health Administration (VHA) of the US Department of Veterans Affairs has been preparing for the October 1, 2015, conversion to the International Classification of Diseases, Tenth Revision, Clinical Modification and Procedural Coding System (ICD-10-CM/PCS) for more than four years. The VHA's Office of Informatics and Analytics ICD-10 Program Management Office established an ICD-10 Learning Lab to explore expected operational challenges. This study was conducted to determine the effects of the classification system conversion on coding productivity. ICD codes are integral to VHA business processes and are used for purposes such as clinical studies, performance measurement, workload capture, cost determination, Veterans Equitable Resource Allocation (VERA) determination, morbidity and mortality classification, indexing of hospital records by disease and operations, data storage and retrieval, research purposes, and reimbursement. The data collection for this study occurred in multiple VHA sites across several months using standardized methods. It is commonly accepted that coding productivity will decrease with the implementation of ICD-10-CM/PCS. The findings of this study suggest that the decrease will be more significant for inpatient coding productivity (64.5 percent productivity decrease) than for ambulatory care coding productivity (6.7 percent productivity decrease). This study reveals the following important points regarding ICD-10-CM/PCS coding productivity: 1. Ambulatory care ICD-10-CM coding productivity is not expected to decrease as significantly as inpatient ICD-10-CM/PCS coding productivity. 2. Coder training and type of record (inpatient versus outpatient) affect coding productivity. 3. Inpatient coding productivity is decreased when a procedure requiring ICD-10-PCS coding is present. It is highly recommended that organizations perform their own analyses to determine the effects of ICD-10-CM/PCS implementation on coding productivity.

Results from the Veterans Health Administration ICD-10-CM/PCS Coding Pilot Study

PubMed Central

Weems, Shelley; Heller, Pamela; Fenton, Susan H.

2015-01-01

The Veterans Health Administration (VHA) of the US Department of Veterans Affairs has been preparing for the October 1, 2015, conversion to the International Classification of Diseases, Tenth Revision, Clinical Modification and Procedural Coding System (ICD-10-CM/PCS) for more than four years. The VHA's Office of Informatics and Analytics ICD-10 Program Management Office established an ICD-10 Learning Lab to explore expected operational challenges. This study was conducted to determine the effects of the classification system conversion on coding productivity. ICD codes are integral to VHA business processes and are used for purposes such as clinical studies, performance measurement, workload capture, cost determination, Veterans Equitable Resource Allocation (VERA) determination, morbidity and mortality classification, indexing of hospital records by disease and operations, data storage and retrieval, research purposes, and reimbursement. The data collection for this study occurred in multiple VHA sites across several months using standardized methods. It is commonly accepted that coding productivity will decrease with the implementation of ICD-10-CM/PCS. The findings of this study suggest that the decrease will be more significant for inpatient coding productivity (64.5 percent productivity decrease) than for ambulatory care coding productivity (6.7 percent productivity decrease). This study reveals the following important points regarding ICD-10-CM/PCS coding productivity: Ambulatory care ICD-10-CM coding productivity is not expected to decrease as significantly as inpatient ICD-10-CM/PCS coding productivity.Coder training and type of record (inpatient versus outpatient) affect coding productivity.Inpatient coding productivity is decreased when a procedure requiring ICD-10-PCS coding is present. It is highly recommended that organizations perform their own analyses to determine the effects of ICD-10-CM/PCS implementation on coding productivity. PMID:26396553

Effects of performance measure implementation on clinical manager and provider motivation.

PubMed

Damschroder, Laura J; Robinson, Claire H; Francis, Joseph; Bentley, Douglas R; Krein, Sarah L; Rosland, Ann-Marie; Hofer, Timothy P; Kerr, Eve A

2014-12-01

Clinical performance measurement has been a key element of efforts to transform the Veterans Health Administration (VHA). However, there are a number of signs that current performance measurement systems used within and outside the VHA may be reaching the point of maximum benefit to care and in some settings, may be resulting in negative consequences to care, including overtreatment and diminished attention to patient needs and preferences. Our research group has been involved in a long-standing partnership with the office responsible for clinical performance measurement in the VHA to understand and develop potential strategies to mitigate the unintended consequences of measurement. Our aim was to understand how the implementation of diabetes performance measures (PMs) influences management actions and day-to-day clinical practice. This is a mixed methods study design based on quantitative administrative data to select study facilities and quantitative data from semi-structured interviews. Sixty-two network-level and facility-level executives, managers, front-line providers and staff participated in the study. Qualitative content analyses were guided by a team-based consensus approach using verbatim interview transcripts. A published interpretive motivation theory framework is used to describe potential contributions of local implementation strategies to unintended consequences of PMs. Implementation strategies used by management affect providers' response to PMs, which in turn potentially undermines provision of high-quality patient-centered care. These include: 1) feedback reports to providers that are dissociated from a realistic capability to address performance gaps; 2) evaluative criteria set by managers that are at odds with patient-centered care; and 3) pressure created by managers' narrow focus on gaps in PMs that is viewed as more punitive than motivating. Next steps include working with VHA leaders to develop and test implementation approaches to help

[Business administration of PET facilities: a cost analysis of three facilities utilizing delivery FDG].

PubMed

Mitsutake, Naohiro; Oku, Shinya; Fujii, Ryo; Furui, Yuji; Yasunaga, Hideo

2008-05-01

PET (positron emission tomography) has been proved to be a powerful imaging tool in clinical oncology. The number of PET facilities in Japan has remarkably increased over the last decade. Furthermore, the approval of delivery FDG in 2005 resulted in a tremendous expansion of the PET institutions without a cyclotron facility. The aim of this study was to conduct a cost analysis of PET institutions that utilized delivery FDG. Three PET facilities using delivery FDG were investigated about the costs for PET service. Fixed costs included depreciation costs for construction and medical equipments such as positron camera. Variable costs consisted of costs for medical materials including delivery FDG. The break-even point was analyzed in each of three institutions. In the three hospitals (A, B and C), the annual number of PET scan was 1,591, 1,637 and 914, while cost per scan was accounted as yen 110,262, yen 111,091, and yen 134,192, respectively. The break-even point was calculated to be 2,583, 2,679 and 2,081, respectively. PET facilities utilizing delivery FDG seemed to have difficulty in business administration. Such a situation suggests the possibility that the current supply of PET facilities might exceed actual demand for the service. The efficiency of resource allocation should be taken into consideration in the future health service researches on PET.

PTSD Care Among Veterans With and Without Co-Occurring Substance Use Disorders.

PubMed

Mansfield, Alyssa J; Greenbaum, Mark A; Schaper, Kim M; Banducci, Anne N; Rosen, Craig S

2017-06-01

This study examined whether a co-occurring substance use disorder contributed to disparities in receipt of Veterans Health Administration (VHA) posttraumatic stress disorder (PTSD) specialty care or psychotherapy. Logistic regression, controlling for sociodemographic characteristics, was used to examine predictors of PTSD care among 424,211 veterans with confirmed PTSD (two or more PTSD diagnosis encounters) who accessed care in a VHA facility between fiscal years 2009 and 2010. Overall, 16% of veterans had PTSD and a co-occurring substance use disorder diagnosis. In adjusted analyses, veterans with a co-occurring substance use disorder were more likely than veterans with PTSD alone to receive any outpatient PTSD specialty care and complete eight or more sessions of outpatient psychotherapy within 14 weeks, but they were less likely to be treated in inpatient PTSD specialty units. Co-occurring substance use disorders did not appear to hinder receipt of outpatient specialty PTSD treatment or of sufficient psychotherapy among VHA-enrolled veterans.

Instructional Television Facilities: A Guide for School Administrators and Board Members. PREP-1.

ERIC Educational Resources Information Center

Oberholtzer, Kenneth E.

The purpose of this Guide, for school administrators and board members, is to provide newcomers in television with an understanding of Instructional Television (ITV) facilities for school and school systems. The discussions herein provide the reader with information and direction to enable him to select the best facilities for his purposes. For…

Pharmacotherapy for alcohol dependence: perceived treatment barriers and action strategies among Veterans Health Administration service providers.

PubMed

Harris, Alex H S; Ellerbe, Laura; Reeder, Rachelle N; Bowe, Thomas; Gordon, Adam J; Hagedorn, Hildi; Oliva, Elizabeth; Lembke, Anna; Kivlahan, Daniel; Trafton, Jodie A

2013-11-01

Although access to and consideration of pharmacological treatments for alcohol dependence are consensus standards of care, receipt of these medications by patients is generally rare and highly variable across treatment settings. The goal of the present project was to survey and interview the clinicians, managers, and pharmacists affiliated with addiction treatment programs within Veterans Health Administration (VHA) facilities to learn about their perceptions of barriers and facilitators regarding greater and more reliable consideration of pharmacological treatments for alcohol dependence. Fifty-nine participants from 19 high-adopting and 11 low-adopting facilities completed the survey (facility-level response rate = 50%) and 23 participated in a structured interview. The top 4 barriers to increased consideration and use of pharmacotherapy for alcohol dependence were consistent across high- and low-adopting facilities and included perceived low patient demand, pharmacy procedures or formulary restrictions, lack of provider skills or knowledge regarding pharmacotherapy for alcohol dependence, and lack of confidence in treatment effectiveness. Low patient demand was rated as the most important barrier for oral naltrexone and disulfiram, whereas pharmacy or formulary restrictions were rated as the most important barrier for acamprosate and extended-release naltrexone. The 4 strategies rated across low- and high-adopting facilities as most likely to facilitate consideration and use of pharmacotherapy for alcohol dependence were more education to patients about existing medications, more education to health care providers about medications, increased involvement of physicians in treatment for alcohol dependence, and more compelling research on existing medications. This knowledge provides a foundation for designing, deploying, and evaluating targeted implementation efforts.

Implementation of a Data-Based Medical Event Reporting System in the U.S. Department of Defense

DTIC Science & Technology

2005-05-01

where patient safety events warrant further investigation. Introduction Department of Defense Instruction 6025.17 established the Military Health ...Administration (VHA) Patient Safety Reporting Program for error tracking and reporting within all military health care facilities. 5 On August 16, 2001...DoD Instruction number 6025.17 “established a Military Health System Patient Safety Center (MHSPSC), including a MHS Patient Safety Registry (MHSPSR

Risk factors for biopsy-proven advanced non-alcoholic fatty liver disease in the Veterans Health Administration.

PubMed

Patel, Y A; Gifford, E J; Glass, L M; McNeil, R; Turner, M J; Han, B; Provenzale, D; Choi, S S; Moylan, C A; Hunt, C M

2018-01-01

With its increasing incidence, nonalcoholic fatty liver disease (NAFLD) is of particular concern in the Veterans Health Administration (VHA). To evaluate risk factors for advanced fibrosis in biopsy-proven NAFLD in the VHA, to identify patients at risk for adverse outcomes. In randomly selected cases from VHA databases (2005-2015), we performed a retrospective case-control study in adults with biopsy-defined NAFLD or normal liver. Of 2091 patients reviewed, 399 met inclusion criteria. Normal controls (n = 65) had normal liver function. The four NAFLD cohorts included: NAFL steatosis (n = 76), nonalcoholic steatohepatitis (NASH) without fibrosis (n = 68), NAFLD/NASH stage 1-3 fibrosis (n = 82), and NAFLD/NASH cirrhosis (n = 70). NAFLD with hepatocellular carcinoma (HCC) was separately identified (n = 38). Most patients were older White men. NAFLD patients with any fibrosis were on average severely obese (BMI>35 kg/m 2 ). Diabetes (54.4%-79.6%) and hypertension (85.8%-100%) were more common in NAFLD with fibrosis or HCC. Across NAFLD, 12.3%-19.5% were enrolled in diet/exercise programs and 0%-2.6% had bariatric surgery. Hispanics exhibited higher rates of NASH (20.6%), while Blacks had low NAFLD rates (1.4%-11.8%), particularly NAFLD cirrhosis and HCC (1.4%-2.6%). Diabetes (OR 11.8, P < .001) and BMI (OR 1.4, P < .001) were the most significant predictors of advanced fibrosis. In the VHA, diabetes and severe obesity increased risk for advanced fibrosis in NAFLD. Of these patients, only a small proportion (~20%) had enrolled in diet/exercise programs or had bariatric surgery (~2%). These results suggest that providers should focus/tailor interventions to improve outcomes, particularly in those with diabetes and severe obesity. © 2017 John Wiley & Sons Ltd.

Implementation of the patient-centered medical home in the Veterans Health Administration: associations with patient satisfaction, quality of care, staff burnout, and hospital and emergency department use.

PubMed

Nelson, Karin M; Helfrich, Christian; Sun, Haili; Hebert, Paul L; Liu, Chuan-Fen; Dolan, Emily; Taylor, Leslie; Wong, Edwin; Maynard, Charles; Hernandez, Susan E; Sanders, William; Randall, Ian; Curtis, Idamay; Schectman, Gordon; Stark, Richard; Fihn, Stephan D

2014-08-01

In 2010, the Veterans Health Administration (VHA) began implementing the patient-centered medical home (PCMH) model. The Patient Aligned Care Team (PACT) initiative aims to improve health outcomes through team-based care, improved access, and care management. To track progress and evaluate outcomes at all VHA primary care clinics, we developed and validated a method to assess PCMH implementation. To create an index that measures the extent of PCMH implementation, describe variation in implementation, and examine the association between the implementation index and key outcomes. We conducted an observational study using data on more than 5.6 million veterans who received care at 913 VHA hospital-based and community-based primary care clinics and 5404 primary care staff from (1) VHA clinical and administrative databases, (2) a national patient survey administered to a weighted random sample of veterans who received outpatient care from June 1 to December 31, 2012, and (3) a survey of all VHA primary care staff in June 2012. Composite scores were constructed for 8 core domains of PACT: access, continuity, care coordination, comprehensiveness, self-management support, patient-centered care and communication, shared decision making, and team-based care. Patient satisfaction, rates of hospitalization and emergency department use, quality of care, and staff burnout. Fifty-three items were included in the PACT Implementation Progress Index (Pi2). Compared with the 87 clinics in the lowest decile of the Pi2, the 77 sites in the top decile exhibited significantly higher patient satisfaction (9.33 vs 7.53; P < .001), higher performance on 41 of 48 measures of clinical quality, lower staff burnout (Maslach Burnout Inventory emotional exhaustion subscale, 2.29 vs 2.80; P = .02), lower hospitalization rates for ambulatory care-sensitive conditions (4.42 vs 3.68 quarterly admissions for veterans 65 years or older per 1000 patients; P < .001), and lower emergency

Charitable intentions. CHA, VHA unveil community-benefit guidelines developed to help not-for-profit hospitals justify their tax exemptions.

PubMed

Becker, Cinda

2006-06-05

With new guidelines from the CHA and VHA on reporting community benefits, not-for-profit hospitals are being advised to drop bad debt and Medicare shortfalls from their accounting of how they fulfill their mission. While the AHA doesn't agree, some experts do. MedPAC member Nancy Kane, right, says bad debt "is a tough one, but I don't think a lot of bad debt is a community benefit.

Barriers, facilitators, and benefits of implementation of dialectical behavior therapy in routine care: results from a national program evaluation survey in the Veterans Health Administration.

PubMed

Landes, Sara J; Rodriguez, Allison L; Smith, Brandy N; Matthieu, Monica M; Trent, Lindsay R; Kemp, Janet; Thompson, Caitlin

2017-12-01

National implementation of evidence-based psychotherapies (EBPs) in the Veterans Health Administration (VHA) provides important lessons on the barriers and facilitators to implementation in a large healthcare system. Little is known about barriers and facilitators to the implementation of a complex EBP for emotional and behavioral dysregulation-dialectical behavioral therapy (DBT). The purpose of this study was to understand VHA clinicians' experiences with barriers, facilitators, and benefits from implementing DBT into routine care. This national program evaluation survey measured site characteristics of VHA sites (N = 59) that had implemented DBT. DBT was most often implemented in general mental health outpatient clinics. While 42% of sites offered all four modes of DBT, skills group was the most frequently implemented mode. Fifty-nine percent of sites offered phone coaching in any form, yet only 11% of those offered it all the time. Providers were often provided little to no time to support implementation of DBT. Barriers that were difficult to overcome were related to phone coaching outside of business hours. Facilitators to implementation included staff interest and expertise. Perceived benefits included increased hope and functioning for clients, greater self-efficacy and compassion for providers, and ability to treat unique symptoms for clinics. There was considerable variability in the capacity to address implementation barriers among sites implementing DBT in VHA routine care. Mental health policy makers should note the barriers and facilitators reported here, with specific attention to phone coaching barriers.

The Federal Aviation Administration's radar training facility and employee selection and training.

DOT National Transportation Integrated Search

1980-09-01

The Federal Aviation Administration (FAA) has recently constructed a Radar Training Facility (RTF) in Oklahoma City, Oklahoma, to aid in screening appropriate personnel for work in radar air traffic control (ATC). The approach is based on the idea th...

Substance use disorders and the risk of suicide mortality among men and women in the US Veterans Health Administration.

PubMed

Bohnert, Kipling M; Ilgen, Mark A; Louzon, Samantha; McCarthy, John F; Katz, Ira R

2017-07-01

Limited information is available regarding links between specific substance use disorders (SUDs) and suicide mortality; however, the preliminary evidence that is available suggests that suicide risk associated with SUDs may differ for men and women. This study aimed to estimate associations between SUDs and suicide for men and women receiving Veterans Health Administration (VHA) care. A cohort study using national administrative health records. National VHA system, USA. All VHA users in fiscal year (FY) 2005 who were alive at the beginning of FY 2006 (n = 4 863 086). The primary outcome of suicide mortality was assessed via FY 2006-2011 National Death Index (NDI) records. Current SUD diagnoses were the primary predictors of interest, and were assessed via FY 2004-2005 VHA National Patient Care Database (NPCD) records. In unadjusted analyses, a diagnosis of any current SUD and the specific current diagnoses of alcohol, cocaine, cannabis, opioid, amphetamine and sedative use disorders were all associated significantly with increased risk of suicide for both males and females [hazard ratios (HRs)] ranging from 1.35 for cocaine use disorder to 4.74 for sedative use disorder for men, and 3.89 for cannabis use disorder to 11.36 for sedative use disorder for women]. Further, the HR estimates for the relations between any SUD, alcohol, cocaine and opioid use disorders and suicide were significantly stronger for women than men (P < 0.05). After adjustment for other factors, most notably comorbid psychiatric diagnoses, associations linking SUDs with suicide were attenuated markedly and the greater suicide risk among females was observed for only any SUD and opioid use disorder (P < 0.05). Current substance use disorders (SUDs) signal increased suicide risk, especially among women, and may be important markers to consider including in suicide risk assessment strategies. None the less, other co-occurring psychiatric disorders may partially explain associations

Validation of key behaviourally based mental health diagnoses in administrative data: suicide attempt, alcohol abuse, illicit drug abuse and tobacco use.

PubMed

Kim, Hyungjin Myra; Smith, Eric G; Stano, Claire M; Ganoczy, Dara; Zivin, Kara; Walters, Heather; Valenstein, Marcia

2012-01-23

Observational research frequently uses administrative codes for mental health or substance use diagnoses and for important behaviours such as suicide attempts. We sought to validate codes (International Classification of Diseases, 9th edition, clinical modification diagnostic and E-codes) entered in Veterans Health Administration administrative data for patients with depression versus a gold standard of electronic medical record text ("chart notation"). Three random samples of patients were selected, each stratified by geographic region, gender, and year of cohort entry, from a VHA depression treatment cohort from April 1, 1999 to September 30, 2004. The first sample was selected from patients who died by suicide, the second from patients who remained alive on the date of death of suicide cases, and the third from patients with a new start of a commonly used antidepressant medication. Four variables were assessed using administrative codes in the year prior to the index date: suicide attempt, alcohol abuse/dependence, drug abuse/dependence and tobacco use. Specificity was high (≥ 90%) for all four administrative codes, regardless of the sample. Sensitivity was ≤75% and was particularly low for suicide attempt (≤ 17%). Positive predictive values for alcohol dependence/abuse and tobacco use were high, but barely better than flipping a coin for illicit drug abuse/dependence. Sensitivity differed across the three samples, but was highest in the suicide death sample. Administrative data-based diagnoses among VHA records have high specificity, but low sensitivity. The accuracy level varies by different diagnosis and by different patient subgroup.

Declining mortality following acute myocardial infarction in the Department of Veterans Affairs Health Care System.

PubMed

Fihn, Stephan D; Vaughan-Sarrazin, Mary; Lowy, Elliott; Popescu, Ioana; Maynard, Charles; Rosenthal, Gary E; Sales, Anne E; Rumsfeld, John; Piñeros, Sandy; McDonell, Mary B; Helfrich, Christian D; Rusch, Roxane; Jesse, Robert; Almenoff, Peter; Fleming, Barbara; Kussman, Michael

2009-08-31

Mortality from acute myocardial infarction (AMI) is declining worldwide. We sought to determine if mortality in the Veterans Health Administration (VHA) has also been declining. We calculated 30-day mortality rates between 2004 and 2006 using data from the VHA External Peer Review Program (EPRP), which entails detailed abstraction of records of all patients with AMI. To compare trends within VHA with other systems of care, we estimated relative mortality rates between 2000 and 2005 for all males 65 years and older with a primary diagnosis of AMI using administrative data from the VHA Patient Treatment File and the Medicare Provider Analysis and Review (MedPAR) files. Using EPRP data on 11,609 patients, we observed a statistically significant decline in adjusted 30-day mortality following AMI in VHA from 16.3% in 2004 to 13.9% in 2006, a relative decrease of 15% and a decrease in the odds of dying of 10% per year (p = .011). Similar declines were found for in-hospital and 90-day mortality.Based on administrative data on 27,494 VHA patients age 65 years and older and 789,400 Medicare patients, 30-day mortality following AMI declined from 16.0% during 2000-2001 to 15.7% during 2004-June 2005 in VHA and from 16.7% to 15.5% in private sector hospitals. After adjusting for patient characteristics and hospital effects, the overall relative odds of death were similar for VHA and Medicare (odds ratio 1.02, 95% C.I. 0.96-1.08). Mortality following AMI within VHA has declined significantly since 2003 at a rate that parallels that in Medicare-funded hospitals.

Declining mortality following acute myocardial infarction in the Department of Veterans Affairs Health Care System

PubMed Central

Fihn, Stephan D; Vaughan-Sarrazin, Mary; Lowy, Elliott; Popescu, Ioana; Maynard, Charles; Rosenthal, Gary E; Sales, Anne E; Rumsfeld, John; Piñeros, Sandy; McDonell, Mary B; Helfrich, Christian D; Rusch, Roxane; Jesse, Robert; Almenoff, Peter; Fleming, Barbara; Kussman, Michael

2009-01-01

Background Mortality from acute myocardial infarction (AMI) is declining worldwide. We sought to determine if mortality in the Veterans Health Administration (VHA) has also been declining. Methods We calculated 30-day mortality rates between 2004 and 2006 using data from the VHA External Peer Review Program (EPRP), which entails detailed abstraction of records of all patients with AMI. To compare trends within VHA with other systems of care, we estimated relative mortality rates between 2000 and 2005 for all males 65 years and older with a primary diagnosis of AMI using administrative data from the VHA Patient Treatment File and the Medicare Provider Analysis and Review (MedPAR) files. Results Using EPRP data on 11,609 patients, we observed a statistically significant decline in adjusted 30-day mortality following AMI in VHA from 16.3% in 2004 to 13.9% in 2006, a relative decrease of 15% and a decrease in the odds of dying of 10% per year (p = .011). Similar declines were found for in-hospital and 90-day mortality. Based on administrative data on 27,494 VHA patients age 65 years and older and 789,400 Medicare patients, 30-day mortality following AMI declined from 16.0% during 2000-2001 to 15.7% during 2004-June 2005 in VHA and from 16.7% to 15.5% in private sector hospitals. After adjusting for patient characteristics and hospital effects, the overall relative odds of death were similar for VHA and Medicare (odds ratio 1.02, 95% C.I. 0.96-1.08). Conclusion Mortality following AMI within VHA has declined significantly since 2003 at a rate that parallels that in Medicare-funded hospitals. PMID:19719849

Accuracy of external cause-of-injury coding in VA polytrauma patient discharge records.

PubMed

Carlson, Kathleen F; Nugent, Sean M; Grill, Joseph; Sayer, Nina A

2010-01-01

Valid and efficient methods of identifying the etiology of treated injuries are critical for characterizing patient populations and developing prevention and rehabilitation strategies. We examined the accuracy of external cause-of-injury codes (E-codes) in Veterans Health Administration (VHA) administrative data for a population of injured patients. Chart notes and E-codes were extracted for 566 patients treated at any one of four VHA Polytrauma Rehabilitation Center sites between 2001 and 2006. Two expert coders, blinded to VHA E-codes, used chart notes to assign "gold standard" E-codes to injured patients. The accuracy of VHA E-coding was examined based on these gold standard E-codes. Only 382 of 517 (74%) injured patients were assigned E-codes in VHA records. Sensitivity of VHA E-codes varied significantly by site (range: 59%-91%, p < 0.001). Sensitivity was highest for combat-related injuries (81%) and lowest for fall-related injuries (60%). Overall specificity of E-codes was high (92%). E-coding accuracy was markedly higher when we restricted analyses to records that had been assigned VHA E-codes. E-codes may not be valid for ascertaining source-of-injury data for all injuries among VHA rehabilitation inpatients at this time. Enhanced training and policies may ensure more widespread, standardized use and accuracy of E-codes for injured veterans treated in the VHA.

The Veterans Health Administration’s Treatment of PTSD and Traumatic Brain Injury Among Recent Combat Veterans

DTIC Science & Technology

2012-02-01

make it more difficult for veterans with PTSD to seek or maintain treatment. VHA provides treatment for PTSD at VHA hospitals , outpatient clinics ...measured in days of inpatient hospital care and outpatient clinic visits. A veteran may have had several outpatient visits on a sin- gle day, each...reproduce the same results precisely. The DSS system takes clinical and financial information from other VHA databases and uses algorithms that merge

Mortality Among Veterans with Transgender-Related Diagnoses in the Veterans Health Administration, FY2000-2009.

PubMed

Blosnich, John R; Brown, George R; Wojcio, Sybil; Jones, Kenneth T; Bossarte, Robert M

2014-12-01

The aims of this project were to document all-cause and suicide mortality among Veteran Healthcare Administration (VHA) utilizers with The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis consistent with transgender status. The study population consisted of VHA patients identified as having any one of four diagnosis codes indicating transgender status (n=5,117) gathered from the VA National Patient Care Database. Mortality data were gathered from the National Death Index from 2000-2009 for 1,277 veterans with transgender-related ICD-9-CM diagnoses. The remaining 3,840 were not searched because they had VHA utilization after 2009 (indicating they were alive). Person-time at risk (person-years) for crude rates were calculated based on the time from an individual's index diagnosis to either death or the end of FY 2009. Causes of death were categorized using ICD-10 code groups. Approximately 9.3% (n=309) veterans with transgender-related ICD-9-CM diagnoses died across the study period. Although diseases of the circulatory system and neoplasms were the first and second leading causes of death, respectively, the other ranked causes of mortality differed somewhat from patterns for the US during the same time span. The crude suicide rate among veterans with transgender-related ICD-9-CM diagnoses across the 10-year period was approximately 82/100,000 person-years, which approximated the crude suicide death rates for other serious mental illness in VHA (e.g., depression, schizophrenia). The average age of suicide decedents was 49.4 years. The crude suicide rate among veterans with transgender-related ICD-9-CM diagnoses is higher than in the general population, and they may be dying by suicide at younger ages than their veteran peers without transgender-related ICD-9-CM diagnoses. Future research, such as age-adjusted rates or accounting for psychiatric co-morbidities, will help to better clarify if the all-cause and suicide

Achieving Medical Currency via Selected Staff Integration in Civilian and Veterans Administration Medical Facilities

DTIC Science & Technology

2012-10-01

medical license as long as care is delivered in a military facility.26 Hurdles—Liability Medical malpractice also presents a formidable challenge. In...AIR UNIVERSITY AIR WAR COLLEGE Achieving Medical Currency via Selected Staff Integration in Civilian and Veterans Administration... Medical Facilities THOMAS W. HARRELL Colonel, USAF, MC, SFS Air War College Maxwell Paper No. 68 Maxwell Air Force Base, Alabama

Cataract surgery practices in the United States Veterans Health Administration.

PubMed

Havnaer, Annika G; Greenberg, Paul B; Cockerham, Glenn C; Clark, Melissa A; Chomsky, Amy

2017-04-01

To describe current cataract surgery practices within the United States Veterans Health Administration (VHA). Veterans Health Administration hospitals in the U.S. Retrospective data analysis. An initial e-mail containing a link to an anonymous 32-question survey of cataract surgery practices was sent to participants in May 2016. Two reminder e-mails were sent to nonresponders 1 week and 2 weeks after the initial survey was sent; the remaining nonresponders were called twice over a 2-week period. The data were analyzed using descriptive statistics. The response rate was 75% (67/89). Cataract surgeons routinely ordered preoperative testing in 29 (45%) of 65 sections and preoperative consultations in 26 (39%) of 66 sections. In 22 (33%) of 66 sections, cataract surgeons administered intracameral antibiotics. In 61 (92%) of 66 sections, cataract surgeons used toric intraocular lenses (IOLs). In 20 (30%) of 66 sections, cataract surgeons used multifocal IOLs. Cataract surgeons in 6 (9%) of 66 sections performed femtosecond laser-assisted cataract surgery. In 6 (9%) of 66 sections, cataract surgeons performed immediate sequential bilateral cataract surgery. Forty-nine (74%) ophthalmology chiefs reported a high level of satisfaction with Veterans Affairs ophthalmology. The survey results indicate that in cataract surgery in the VHA, routine preoperative testing is commonly performed and emerging practices, such as femtosecond laser-assisted cataract surgery and immediate sequential bilateral cataract surgery, have limited roles. The results of this survey could benchmark future trends in U.S. cataract surgery practices, especially in teaching hospital settings. Copyright © 2017 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.

Factors Associated With Missed and Cancelled Colonoscopy Appointments at Veterans Health Administration Facilities.

PubMed

Partin, Melissa R; Gravely, Amy; Gellad, Ziad F; Nugent, Sean; Burgess, James F; Shaukat, Aasma; Nelson, David B

2016-02-01

Cancelled and missed colonoscopy appointments waste resources, increase colonoscopy delays, and can adversely affect patient outcomes. We examined individual and organizational factors associated with missed and cancelled colonoscopy appointments in Veteran Health Administration facilities. From 69 facilities meeting inclusion criteria, we identified 27,994 patients with colonoscopy appointments scheduled for follow-up, on the basis of positive fecal occult blood test results, between August 16, 2009 and September 30, 2011. We identified factors associated with colonoscopy appointment status (completed, cancelled, or missed) by using hierarchical multinomial regression. Individual factors examined included age, race, sex, marital status, residence, drive time to nearest specialty care facility, limited life expectancy, comorbidities, colonoscopy in the past decade, referring facility type, referral month, and appointment lead time. Organizational factors included facility region, complexity, appointment reminders, scheduling, and prep education practices. Missed appointments were associated with limited life expectancy (odds ratio [OR], 2.74; P = .0004), no personal history of polyps (OR, 2.74; P < .0001), high facility complexity (OR, 2.69; P = .007), dual diagnosis of psychiatric disorders and substance abuse (OR, 1.82; P < .0001), and opt-out scheduling (OR, 1.57; P = .02). Cancelled appointments were associated with age (OR, 1.61; P = .0005 for 85 years or older and OR, 1.44; P < .0001 for 65-84 years old), no history of polyps (OR, 1.51; P < .0001), and opt-out scheduling (OR, 1.26; P = .04). Additional predictors of both outcomes included race, marital status, and lead time. Several factors within Veterans Health Administration clinic control can be targeted to reduce missed and cancelled colonoscopy appointments. Specifically, developing systems to minimize referrals for patients with limited life expectancy could reduce missed appointments, and use of opt

Cognitive-behavioral treatments for criminogenic thinking: Barriers and facilitators to implementation within the Veterans Health Administration.

PubMed

Blonigen, Daniel M; Rodriguez, Allison L; Manfredi, Luisa; Nevedal, Andrea; Rosenthal, Joel; McGuire, James F; Smelson, David; Timko, Christine

2018-02-01

Cognitive-behavioral treatments for criminogenic thinking (i.e., antisocial cognitions, attitudes, and traits) are regarded as best practices for reducing criminal recidivism among justice-involved adults. However, the barriers and facilitators to implementation of these treatments within large health care systems such as the Veterans Health Administration (VHA) are largely unknown. To address this gap, we conducted qualitative interviews with 22 Specialists from the VHA's Veterans Justice Programs who had been trained in a cognitive-behavioral treatment for criminogenic thinking (i.e., Moral Reconation Therapy [MRT], Thinking for a Change [T4C]). The time-intensiveness of these treatments emerged as a barrier to implementation. Potential solutions identified were patient incentives for treatment engagement, streamlining the curriculum, and implementing the treatments within long-term/residential programs. At the program level, providers' stigma/bias toward patients with antisocial tendencies was seen as a barrier to implementation, as were time/resource constraints on providers. To address the latter, use of peer providers to deliver the treatments and partnerships between justice programs and behavioral health services were suggested. At the system level, lack of recognition of criminogenic treatments as evidence based, and uncertainty of sustained funds to support ongoing costs of these treatments emerged as implementation barriers. To address the latter, a train-the-trainers model was suggested. Our findings serve as a guide for implementation of criminogenic treatments for providers and policymakers in VHA and other large health care systems, which are increasingly called upon to provide care to justice-involved adults in the community. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Modeling veterans healthcare administration disclosure processes :

DOE Office of Scientific and Technical Information (OSTI.GOV)

Beyeler, Walter E; DeMenno, Mercy B.; Finley, Patrick D.

As with other large healthcare organizations, medical adverse events at the Department of Veterans Affairs (VA) facilities can expose patients to unforeseen negative risks. VHA leadership recognizes that properly handled disclosure of adverse events can minimize potential harm to patients and negative consequences for the effective functioning of the organization. The work documented here seeks to help improve the disclosure process by situating it within the broader theoretical framework of issues management, and to identify opportunities for process improvement through modeling disclosure and reactions to disclosure. The computational model will allow a variety of disclosure actions to be tested acrossmore » a range of incident scenarios. Our conceptual model will be refined in collaboration with domain experts, especially by continuing to draw on insights from VA Study of the Communication of Adverse Large-Scale Events (SCALE) project researchers.« less

Defense Health Care: DOD Needs to Clarify Policies Related to Occupational and Environmental Health Surveillance and Monitor Risk Mitigation Activities

DTIC Science & Technology

2015-05-01

information on the types of illnesses that may result from an exposure. VBA officials told us that they have access to unclassified POEMS through a MESL...Environmental Monitoring Summaries USARCENT U.S. Army Central VA Department of Veterans Affairs VBA Veterans Benefits Administration VHA...Administration ( VBA ) and the Veterans Health Administration (VHA) to identify the ways in which OEHS data is being used, including its use in

Case-Mix Adjusting Performance Measures in a Veteran Population: Pharmacy- and Diagnosis-Based Approaches

PubMed Central

Liu, Chuan-Fen; Sales, Anne E; Sharp, Nancy D; Fishman, Paul; Sloan, Kevin L; Todd-Stenberg, Jeff; Nichol, W Paul; Rosen, Amy K; Loveland, Susan

2003-01-01

Objective To compare the rankings for health care utilization performance measures at the facility level in a Veterans Health Administration (VHA) health care delivery network using pharmacy- and diagnosis-based case-mix adjustment measures. Data Sources/Study Setting The study included veterans who used inpatient or outpatient services in Veterans Integrated Service Network (VISN) 20 during fiscal year 1998 (October 1997 to September 1998; N=126,076). Utilization and pharmacy data were extracted from VHA national databases and the VISN 20 data warehouse. Study Design We estimated concurrent regression models using pharmacy or diagnosis information in the base year (FY1998) to predict health service utilization in the same year. Utilization measures included bed days of care for inpatient care and provider visits for outpatient care. Principal Findings Rankings of predicted utilization measures across facilities vary by case-mix adjustment measure. There is greater consistency within the diagnosis-based models than between the diagnosis- and pharmacy-based models. The eight facilities were ranked differently by the diagnosis- and pharmacy-based models. Conclusions Choice of case-mix adjustment measure affects rankings of facilities on performance measures, raising concerns about the validity of profiling practices. Differences in rankings may reflect differences in comparability of data capture across facilities between pharmacy and diagnosis data sources, and unstable estimates due to small numbers of patients in a facility. PMID:14596393

Screening for Homelessness in the Veterans Health Administration: Monitoring Housing Stability through Repeat Screening.

PubMed

Byrne, Thomas; Fargo, Jamison D; Montgomery, Ann Elizabeth; Roberts, Christopher B; Culhane, Dennis P; Kane, Vincent

2015-01-01

This study examined veterans' responses to the Veterans Health Administration's (VHA's) universal screen for homelessness and risk of homelessness during the first 12 months of implementation. We calculated the baseline annual frequency of homelessness and risk of homelessness among all veterans who completed an initial screen during the study period. We measured changes in housing status among veterans who initially screened positive and then completed a follow-up screen, assessed factors associated with such changes, and identified distinct risk profiles of veterans who completed a follow-up screen. More than 4 million veterans completed an initial screen; 1.8% (n=77,621) screened positive for homelessness or risk of homelessness. Of those who initially screened positive for either homelessness or risk of homelessness and who completed a second screen during the study period, 85.0% (n=15,060) resolved their housing instability prior to their second screen. Age, sex, race, VHA eligibility, and screening location were all associated with changes in housing stability. We identified four distinct risk profiles for veterans with ongoing housing instability. To address homelessness among veterans, efforts should include increased and targeted engagement of veterans experiencing persistent housing instability.

Addressing the Needs of Transgender Military Veterans: Better Access and More Comprehensive Care.

PubMed

Dietert, Michelle; Dentice, Dianne; Keig, Zander

2017-01-01

Purpose: There is a gap in social science literature addressing issues of access and quality of care for transgender military veterans. Psychologists, medical doctors, and other health professionals are beginning to address some of the barriers present in the Department of Veterans Affairs (VA) system that affect veterans who are also transgender and intersex. Over a 7-year period, between 2006 and 2013, 2600 transgender veterans were served by the VA. Data from several surveys revealed that most transgender veterans perceive the Veterans Health Administration (VHA) to be less than accommodating for their special needs. The goal of this study was to investigate the experiences of a sample of transgender veterans with regard to their experiences with healthcare services provided by the VHA. Methods: Using snowball sampling techniques, we were able to recruit 22 transgender military veterans to participate in our study. A combination of telephone interviews and questionnaires provided data from veterans in various branches of the military throughout the United States. Results: Findings indicate that even though the VHA is working to address issues of inequality for transgender veterans, our participants indicated that there are still some problems with administration of care, proper training of staff and physicians, and availability of comprehensive services for the unique healthcare needs of transgender individuals. Conclusion: Since our data were collected, the VA has worked to bridge the gap by focusing on increased training for VHA providers and staff and establishing LGBT programs at VA facilities. However, we suggest that one key area of importance should continue to focus on how mental health and medical providers and ancillary staff are trained to interact with and provide care for their transgender patients.

Battlefield-Acquired Immunogenicity to Metals Affects Orthopaedic Implant Outcome

DTIC Science & Technology

2012-10-01

Attending Physician #N/A Control cpm 1308.0 Positive control (PHA) cpm 38247.3 29.2 Mildly Reactive 2 to 4 Reactive 4 to 8 Highly Reactive above 8...Kyron, The Veterans Health Administration has to follow Handbook 1200.05, which states: VHA HANDBOOK 1200.05 October 15, 2010 n. Advertising ...The facility Director is responsible for ensuring that recruiting documents, flyers, and advertisements for non-VA research are not posted within or

Applying Lean Six Sigma to improve medication management.

PubMed

Nayar, Preethy; Ojha, Diptee; Fetrick, Ann; Nguyen, Anh T

2016-01-01

A significant proportion of veterans use dual care or health care services within and outside the Veterans Health Administration (VHA). In this study conducted at a VHA medical center in the USA, the authors used Lean Six Sigma principles to develop recommendations to eliminate wasteful processes and implement a more efficient and effective process to manage medications for dual care veteran patients. The purpose of this study is to: assess compliance with the VHA's dual care policy; collect data and describe the current process for co-management of dual care veterans' medications; and draft recommendations to improve the current process for dual care medications co-management. Input was obtained from the VHA patient care team members to draw a process map to describe the current process for filling a non-VHA prescription at a VHA facility. Data were collected through surveys and direct observation to measure the current process and to develop recommendations to redesign and improve the process. A key bottleneck in the process that was identified was the receipt of the non-VHA medical record which resulted in delays in filling prescriptions. The recommendations of this project focus on the four domains of: documentation of dual care; veteran education; process redesign; and outreach to community providers. This case study describes the application of Lean Six Sigma principles in one urban Veterans Affairs Medical Center (VAMC) in the Mid-Western USA to solve a specific organizational quality problem. Therefore, the findings may not be generalizable to other organizations. The Lean Six Sigma general principles applied in this project to develop recommendations to improve medication management for dual care veterans are applicable to any process improvement or redesign project and has valuable lessons for other VAMCs seeking to improve care for their dual care veteran patients. The findings of this project will be of value to VA providers and policy makers and health

Development and applications of the Veterans Health Administration's Stratification Tool for Opioid Risk Mitigation (STORM) to improve opioid safety and prevent overdose and suicide.

PubMed

Oliva, Elizabeth M; Bowe, Thomas; Tavakoli, Sara; Martins, Susana; Lewis, Eleanor T; Paik, Meenah; Wiechers, Ilse; Henderson, Patricia; Harvey, Michael; Avoundjian, Tigran; Medhanie, Amanuel; Trafton, Jodie A

2017-02-01

Concerns about opioid-related adverse events, including overdose, prompted the Veterans Health Administration (VHA) to launch an Opioid Safety Initiative and Overdose Education and Naloxone Distribution program. To mitigate risks associated with opioid prescribing, a holistic approach that takes into consideration both risk factors (e.g., dose, substance use disorders) and risk mitigation interventions (e.g., urine drug screening, psychosocial treatment) is needed. This article describes the Stratification Tool for Opioid Risk Mitigation (STORM), a tool developed in VHA that reflects this holistic approach and facilitates patient identification and monitoring. STORM prioritizes patients for review and intervention according to their modeled risk for overdose/suicide-related events and displays risk factors and risk mitigation interventions obtained from VHA electronic medical record (EMR)-data extracts. Patients' estimated risk is based on a predictive risk model developed using fiscal year 2010 (FY2010: 10/1/2009-9/30/2010) EMR-data extracts and mortality data among 1,135,601 VHA patients prescribed opioid analgesics to predict risk for an overdose/suicide-related event in FY2011 (2.1% experienced an event). Cross-validation was used to validate the model, with receiver operating characteristic curves for the training and test data sets performing well (>.80 area under the curve). The predictive risk model distinguished patients based on risk for overdose/suicide-related adverse events, allowing for identification of high-risk patients and enrichment of target populations of patients with greater safety concerns for proactive monitoring and application of risk mitigation interventions. Results suggest that clinical informatics can leverage EMR-extracted data to identify patients at-risk for overdose/suicide-related events and provide clinicians with actionable information to mitigate risk. (PsycINFO Database Record (c) 2017 APA, all rights reserved).

Military service and other socioecological factors influencing weight and health behavior change in overweight and obese Veterans: a qualitative study to inform intervention development within primary care at the United States Veterans Health Administration.

PubMed

Jay, Melanie; Mateo, Katrina F; Squires, Allison P; Kalet, Adina L; Sherman, Scott E

2015-01-01

Obesity affects 37 % of patients at Veterans Health Administration (VHA) medical centers. The VHA offers an intensive weight management program (MOVE!) but less than 10 % of eligible patients ever attend. However, VHA patients see their primary care provider about 3.6 times per year, supporting the development of primary care-based weight management interventions. To address gaps in the literature regarding Veterans' experiences with weight management and determine whether and how to develop a primary care-based weight management intervention to both improve obesity counseling and increase attendance to MOVE!, we conducted a qualitative study to assess: 1) Veterans' personal experiences with healthy weight-related behavior change (including barriers and facilitators to behavior change and experiences with primary care providers, staff, and the MOVE! program), and 2) potential new approaches to improve weight management within primary care at the VHA including goal setting and technology. Overweight/obese VHA patients (aged 18-75, BMI greater than 30 or greater than 25 with at least 1 co-morbidity) were recruited for focus group sessions stratified by gender, MOVE! referral, and attendance. Each session was facilitated by a trained moderator, audio-recorded, and professionally transcribed. Using an iterative coding approach, two coders separately reviewed and coded transcripts, and met frequently to negotiate codes and synthesize emerging themes. Of 161 eligible patients, 54 attended one of 6 focus groups (2 female, 4 male, 9-11 participants per session): 63 % were male, 46 % identified as African-American, 32 % White/Caucasian, 74 % were college-educated or higher, and 61 % reported having attended MOVE!. We identified two major themes: Impact of Military Service and Promotion and Sustainability of Healthy Behaviors. After service in a highly structured military environment, Veterans had difficulty maintaining weight on their own. They perceived physical

Predictors of Use of Monitored Anesthesia Care for Outpatient Gastrointestinal Endoscopy in a Capitated Payment System.

PubMed

Adams, Megan A; Prenovost, Katherine M; Dominitz, Jason A; Holleman, Robert G; Kerr, Eve A; Krein, Sarah L; Saini, Sameer D; Rubenstein, Joel H

2017-12-01

Use of monitored anesthesia care (MAC) for gastrointestinal endoscopy has increased in the Veterans Health Administration (VHA) as in fee-for-service environments, despite the absence of financial incentives. We investigated factors associated with use of MAC in an integrated health care delivery system with a capitated payment model. We performed a retrospective cohort study using multilevel logistic regression, with MAC use modeled as a function of procedure year, patient- and provider-level factors, and facility effects. We collected data from 2,091,590 veterans who underwent outpatient esophagogastroduodenoscopy and/or colonoscopy during fiscal years 2000-2013 at 133 facilities. The adjusted rate of MAC use in the VHA increased 17% per year (odds ratio for increase, 1.17; 95% confidence interval, 1.09-1.27) from fiscal year 2000 through 2013. The most rapid increase occurred starting in 2011. VHA use of MAC was associated with patient-level factors that included obesity, obstructive sleep apnea, higher comorbidity, and use of prescription opioids and/or benzodiazepines, although the magnitude of these effects was small. Provider-level and facility factors were also associated with use of MAC, although again the magnitude of these associations was small. Unmeasured facility-level effects had the greatest effect on the trend of MAC use. In a retrospective study of veterans who underwent outpatient esophagogastroduodenoscopy and/or colonoscopy from fiscal year 2000 through 2013, we found that even in a capitated system, patient factors are only weakly associated with use of MAC. Facility-level effects are the most prominent factor influencing increasing use of MAC. Future studies should focus on better defining the role of MAC and facility and organizational factors that affect choice of endoscopic sedation. It will also be important to align resources and incentives to promote appropriate allocation of MAC based on clinically meaningful patient factors. Copyright

Addressing the Needs of Transgender Military Veterans: Better Access and More Comprehensive Care

PubMed Central

Dietert, Michelle; Dentice, Dianne; Keig, Zander

2017-01-01

Abstract Purpose: There is a gap in social science literature addressing issues of access and quality of care for transgender military veterans. Psychologists, medical doctors, and other health professionals are beginning to address some of the barriers present in the Department of Veterans Affairs (VA) system that affect veterans who are also transgender and intersex. Over a 7-year period, between 2006 and 2013, 2600 transgender veterans were served by the VA. Data from several surveys revealed that most transgender veterans perceive the Veterans Health Administration (VHA) to be less than accommodating for their special needs. The goal of this study was to investigate the experiences of a sample of transgender veterans with regard to their experiences with healthcare services provided by the VHA. Methods: Using snowball sampling techniques, we were able to recruit 22 transgender military veterans to participate in our study. A combination of telephone interviews and questionnaires provided data from veterans in various branches of the military throughout the United States. Results: Findings indicate that even though the VHA is working to address issues of inequality for transgender veterans, our participants indicated that there are still some problems with administration of care, proper training of staff and physicians, and availability of comprehensive services for the unique healthcare needs of transgender individuals. Conclusion: Since our data were collected, the VA has worked to bridge the gap by focusing on increased training for VHA providers and staff and establishing LGBT programs at VA facilities. However, we suggest that one key area of importance should continue to focus on how mental health and medical providers and ancillary staff are trained to interact with and provide care for their transgender patients. PMID:28861546

VA Suicide Prevention Applications Network: A National Health Care System-Based Suicide Event Tracking System.

PubMed

Hoffmire, Claire; Stephens, Brady; Morley, Sybil; Thompson, Caitlin; Kemp, Janet; Bossarte, Robert M

2016-11-01

The US Department of Veterans Affairs' Suicide Prevention Applications Network (SPAN) is a national system for suicide event tracking and case management. The objective of this study was to assess data on suicide attempts among people using Veterans Health Administration (VHA) services. We assessed the degree of data overlap on suicide attempters reported in SPAN and the VHA's medical records from October 1, 2010, to September 30, 2014-overall, by year, and by region. Data on suicide attempters in the VHA's medical records consisted of diagnoses documented with E95 codes from the International Classification of Diseases, Ninth Revision . Of 50 518 VHA patients who attempted suicide during the 4-year study period, data on fewer than half (41%) were reported in both SPAN and the medical records; nearly 65% of patients whose suicide attempt was recorded in SPAN had no data on attempted suicide in the VHA's medical records. Evaluation of administrative data suggests that use of SPAN substantially increases the collection of data on suicide attempters as compared with the use of medical records alone, but neither SPAN nor the VHA's medical records identify all suicide attempters. Further research is needed to better understand the strengths and limitations of both systems and how to best combine information across systems.

Exploring approaches to the administration of a long-term care facility: The application of a community planning and development process.

PubMed

Caldwell, W J

1996-01-01

This article outlines the approaches taken to the management of two long-term care facilities by the County of Huron in southwestern Ontario in 1994. Lay-offs, a move to new facilities, loss of local political confidence, changes in key administrative personnel and low staff morale prompted the county to ask an interim administrative team to develop and implement an appropriate response. The article explains how community development and planning principles and techniques were applied to the management of the homes to achieve an overall improvement in communication, staff morale and attitude. These approaches may prove helpful to other administrations facing major change.

The Department of Veterans Affairs' role in Federal Emergency Management.

PubMed

Kizer, K W; Cushing, T S; Nishimi, R Y

2000-09-01

The Veterans Health Administration (VHA) has been increasingly called on to provide disaster relief health care personnel and other emergency assistance since the role of the Department of Veterans Affairs in emergency management was expanded by the Federal Response Plan in 1992. This article briefly reviews the VHA's emergency management functions currently specified by the Federal Response Plan and its present activities in procuring and maintaining antidotes, antibiotics, and other pharmaceutical stockpiles to be used in response to terrorist incidents involving weapons of mass destruction. In view of VHA's national scope and extensive assets, its administration by the government, and its critical role in health professional training, there are several additional ways that VHA could economically augment the federal government's efforts to better support and prepare local jurisdictions for disasters or incidents involving weapons of mass destruction, if the required authorization and funding were provided.

Tanning facility use: are we exceeding Food and Drug Administration limits?

PubMed

Hornung, Robin L; Magee, Kristin H; Lee, Willie J; Hansen, Lori A; Hsieh, Yi-Ching

2003-10-01

The US Food and Drug Administration (FDA) recommends exposure limits for tanning bed use. Tanning patrons may not be following these recommendations and may be overexposed to damaging ultraviolet radiation (UV). This study was conducted to assess tanning patrons' adherence to FDA-recommended exposure limits and to measure the amount of UVA and UVB radiation emitted by tanning beds. A community-based survey was administered during routine state inspections of North Carolina tanning facilities (n = 50). At each facility, patron records were randomly selected (n = 483) for a survey of exposure records, and UVA and UVB outputs were measured for each tanning bed. The recommended limits were exceeded by 95% of patrons, and 33% of patrons began tanning at the maximum doses recommended for maintenance tanning. Average tanning bed output was 192.1 W/m(2) UVA and 0.35 W/m(2) erythemally weighted UVB. Interventions for tanning bed operators and patrons are needed to increase compliance with federally recommended exposure limits.

Psychological safety and error reporting within Veterans Health Administration hospitals.

PubMed

Derickson, Ryan; Fishman, Jonathan; Osatuke, Katerine; Teclaw, Robert; Ramsel, Dee

2015-03-01

In psychologically safe workplaces, employees feel comfortable taking interpersonal risks, such as pointing out errors. Previous research suggested that psychologically safe climate optimizes organizational outcomes. We evaluated psychological safety levels in Veterans Health Administration (VHA) hospitals and assessed their relationship to employee willingness of reporting medical errors. We conducted an ANOVA on psychological safety scores from a VHA employees census survey (n = 185,879), assessing variability of means across racial and supervisory levels. We examined organizational climate assessment interviews (n = 374) evaluating how many employees asserted willingness to report errors (or not) and their stated reasons. Finally, based on survey data, we identified 2 (psychologically safe versus unsafe) hospitals and compared their number of employees who would be willing/unwilling to report an error. Psychological safety increased with supervisory level (P < 0.001, η = 0.03) and was not meaningfully related to race (P < 0.001, η = 0.003). Twelve percent of employees would not report an error; retaliation fear was the most commonly mentioned deterrent. Furthermore, employees at the psychologically unsafe hospital (71% would report, 13% would not) were less willing to report an error than at the psychologically safe hospital (91% would, 0% would not). A substantial minority would not report an error and were willing to admit so in a private interview setting. Their stated reasons as well as higher psychological safety means for supervisory employees both suggest power as an important determinant. Intentions to report were associated with psychological safety, strongly suggesting this climate aspect as instrumental to improving patient safety and reducing costs.

Defining "Rural" for Veterans' Health Care Planning

ERIC Educational Resources Information Center

West, Alan N.; Lee, Richard E.; Shambaugh-Miller, Michael D.; Bair, Byron D.; Mueller, Keith J.; Lilly, Ryan S.; Kaboli, Peter J.; Hawthorne, Kara

2010-01-01

Purpose: The Veterans Health Administration (VHA) devised an algorithm to classify veterans as Urban, Rural, or Highly Rural residents. To understand the policy implications of the VHA scheme, we compared its categories to 3 Office of Management and Budget (OMB) and 4 Rural-Urban Commuting Area (RUCA) geographical categories. Method: Using…

Specifying and Pilot Testing Quality Measures for the American Society of Addiction Medicine's Standards of Care.

PubMed

Harris, Alex H S; Weisner, Constance M; Chalk, Mady; Capoccia, Victor; Chen, Cheng; Thomas, Cindy Parks

2016-01-01

In 2013, the American Society of Addiction Medicine (ASAM) approved its Standards of Care for the Addiction Specialist Physician. Subsequently, an ASAM Performance Measures Panel identified and prioritized the standards to be operationalized into performance measures. The goal of this study is to describe the process of operationalizing 3 of these standards into quality measures, and to present the initial measure specifications and results of pilot testing these measures in a large health care system. By presenting the process rather than just the end results, we hope to shed light on the measure development process to educate, and also to stimulate debate about the decisions that were made. Each measure was decomposed into major concepts. Then each concept was operationalized using commonly available administrative data sources. Alternative specifications examined and sensitivity analyses were conducted to inform decisions that balanced accuracy, clinical nuance, and simplicity. Using data from the US Veterans Health Administration (VHA), overall performance and variation in performance across 119 VHA facilities were calculated. Three measures were operationalized and pilot tested: pharmacotherapy for alcohol use disorder, pharmacotherapy for opioid use disorder, and timely follow-up after medically managed withdrawal (aka detoxification). Each measure was calculable with available data, and showed ample room for improvement (no ceiling effects) and wide facility-level variability. Next steps include conducting feasibility and pilot testing in other health care systems and other contexts such as standalone addiction treatment programs, and also to study the specification and predictive validity of these measures.

Health Care Expenditures Attributable to Smoking in Military Veterans

PubMed Central

Hamlett-Berry, Kim; Sung, Hai-Yen; Max, Wendy

2015-01-01

Introduction: The health effects of cigarette smoking have been estimated to account for between 6%–8% of U.S. health care expenditures. We estimated Veterans Health Administration (VHA) health care costs attributable to cigarette smoking. Methods: VHA survey and administrative data provided the number of Veteran enrollees, current and former smoking prevalence, and the cost of 4 types of care for groups defined by age, gender, and region. Cost and smoking status could not be linked at the enrollee level, so we used smoking attributable fractions estimated in sample of U.S. residents where the linkage could be made. Results: The 7.7 million Veterans enrolled in VHA received $40.2 billion in VHA provided health services in 2010. We estimated that $2.7 billion in VHA costs were attributable to the health effects of smoking. This was 7.6% of the $35.3 billion spent on the types of care for which smoking-attributable fractions could be determined. The fraction of inpatient costs that was attributable to smoking (11.4%) was greater than the fraction of ambulatory care cost attributable to smoking (5.3%). More cost was attributable to current smokers ($1.7 billion) than to former smokers ($983 million). Conclusions: The fraction of VHA costs attributable to smoking is similar to that of other health care systems. Smoking among Veterans is slowly decreasing, but prevalence remains high in Veterans with psychiatric and substance use disorders, and in younger and female Veterans. VHA has adopted a number of smoking cessation programs that have the potential for reducing future smoking-attributable costs. PMID:25239960

A Review of Studies on the System-Wide Implementation of Evidence-Based Psychotherapies for Posttraumatic Stress Disorder in the Veterans Health Administration.

PubMed

Rosen, C S; Matthieu, M M; Wiltsey Stirman, S; Cook, J M; Landes, S; Bernardy, N C; Chard, K M; Crowley, J; Eftekhari, A; Finley, E P; Hamblen, J L; Harik, J M; Kehle-Forbes, S M; Meis, L A; Osei-Bonsu, P E; Rodriguez, A L; Ruggiero, K J; Ruzek, J I; Smith, B N; Trent, L; Watts, B V

2016-11-01

Since 2006, the Veterans Health Administration (VHA) has instituted policy changes and training programs to support system-wide implementation of two evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD). To assess lessons learned from this unprecedented effort, we used PubMed and the PILOTS databases and networking with researchers to identify 32 reports on contextual influences on implementation or sustainment of EBPs for PTSD in VHA settings. Findings were initially organized using the exploration, planning, implementation, and sustainment framework (EPIS; Aarons et al. in Adm Policy Ment Health Health Serv Res 38:4-23, 2011). Results that could not be adequately captured within the EPIS framework, such as implementation outcomes and adopter beliefs about the innovation, were coded using constructs from the reach, effectiveness, adoption, implementation, maintenance (RE-AIM) framework (Glasgow et al. in Am J Public Health 89:1322-1327, 1999) and Consolidated Framework for Implementation Research (CFIR; Damschroder et al. in Implement Sci 4(1):50, 2009). We highlight key areas of progress in implementation, identify continuing challenges and research questions, and discuss implications for future efforts to promote EBPs in large health care systems.

The reality of virtual learning for nurses in the largest integrated health care system in the nation.

PubMed

Rick, Cathy; Kearns, Martha A; Thompson, Nancy A

2003-01-01

The health care network and hospital system within the Department of Veterans Affairs (VA), the Veterans Health Administration (VHA), provides employment to more than 56,000 nursing personnel and serves as clinical education site to countless other nursing and health professional students. Nurse administrators and educators are posed with the challenge of providing an environment in which each nurse is able to gain needed knowledge, learn new skills, and share and communicate this knowledge with other colleagues. The education of nurses improves the health status of veterans while also realizing individual professional enhancement. Regional and cultural diversity of the system present challenges to education, in both delivery and content. VHA's learning organizations, the Employee Education System and the Office of Special Projects, have maximized new technologies and information systems to provide innovative, virtual education opportunities, capitalizing on the benefits of informal and formal learning, thus moving VHA to the forefront in knowledge sharing and dissemination. The Virtual Learning Center, VA Knowledge Network, Learning Catalog, and VA Learning Online provide VHA's nurses with interactive, desktop virtual learning opportunities.

Creating a sampling frame for population-based veteran research: representativeness and overlap of VA and Department of Defense databases.

PubMed

Washington, Donna L; Sun, Su; Canning, Mark

2010-01-01

Most veteran research is conducted in Department of Veterans Affairs (VA) healthcare settings, although most veterans obtain healthcare outside the VA. Our objective was to determine the adequacy and relative contributions of Veterans Health Administration (VHA), Veterans Benefits Administration (VBA), and Department of Defense (DOD) administrative databases for representing the U.S. veteran population, using as an example the creation of a sampling frame for the National Survey of Women Veterans. In 2008, we merged the VHA, VBA, and DOD databases. We identified the number of unique records both overall and from each database. The combined databases yielded 925,946 unique records, representing 51% of the 1,802,000 U.S. women veteran population. The DOD database included 30% of the population (with 8% overlap with other databases). The VHA enrollment database contributed an additional 20% unique women veterans (with 6% overlap with VBA databases). VBA databases contributed an additional 2% unique women veterans (beyond 10% overlap with other databases). Use of VBA and DOD databases substantially expands access to the population of veterans beyond those in VHA databases, regardless of VA use. Adoption of these additional databases would enhance the value and generalizability of a wide range of studies of both male and female veterans.

Five-year trends in women veterans' use of VA maternity benefits, 2008-2012.

PubMed

Mattocks, Kristin M; Frayne, Susan; Phibbs, Ciaran S; Yano, Elizabeth M; Zephyrin, Laurie; Shryock, Holly; Haskell, Sally; Katon, Jodie; Sullivan, J Cherry; Weinreb, Linda; Ulbricht, Christine; Bastian, Lori A

2014-01-01

An increasing number of young women veterans are returning from war and military service and are seeking reproductive health care from the Veterans Health Administration (VHA). Many of these women seek maternity benefits from the VHA, and yet little is known regarding the number of women veterans utilizing VHA maternity benefits nor the characteristics of pregnant veterans using these benefits. In May 2010, VHA maternity benefits were expanded to include 7 days of infant care, which may serve to entice more women to use VHA maternity benefits. Understanding the changing trends in women veterans seeking maternity benefits will help the VHA to improve the quality of reproductive care over time. The goal of this study was to examine the trends in delivery claims among women veterans receiving VHA maternity benefits over a 5-year period and the characteristics of pregnant veterans utilizing VHA benefits. We undertook a retrospective, national cohort study of pregnant veterans enrolled in VHA care with inpatient deliveries between fiscal years (FY) 2008 and 2012. We included pregnant veterans using VHA maternity benefits for delivery. Measures included annualized numbers and rates of inpatient deliveries and delivery-related costs, as well as cesarean section rates as a quality indicator. During the 5-year study period, there was a significant increase in the number of deliveries to women veterans using VHA maternity benefits. The overall delivery rate increased by 44% over the study period from 12.4 to 17.8 deliveries per 1,000 women veterans. A majority of women using VHA maternity benefits were age 30 or older and had a service-connected disability. From FY 2008 to 2012, the VHA paid more than $46 million in delivery claims to community providers for deliveries to women veterans ($4,993/veteran). Over a 5-year period, the volume of women veterans using VHA maternity benefits increased by 44%. Given this sizeable increase, the VHA must increase its capacity to care

Military sexual trauma among homeless veterans.

PubMed

Pavao, Joanne; Turchik, Jessica A; Hyun, Jenny K; Karpenko, Julie; Saweikis, Meghan; McCutcheon, Susan; Kane, Vincent; Kimerling, Rachel

2013-07-01

Military sexual trauma (MST) is the Veteran Health Administration's (VHA) term for sexual assault and/or sexual harassment that occurs during military service. The experience of MST is associated with a variety of mental health conditions. Preliminary research suggests that MST may be associated with homelessness among female Veterans, although to date MST has not been examined in a national study of both female and male homeless Veterans. To estimate the prevalence of MST, examine the association between MST and mental health conditions, and describe mental health utilization among homeless women and men. National, cross-sectional study of 126,598 homeless Veterans who used VHA outpatient care in fiscal year 2010. All variables were obtained from VHA administrative databases, including MST screening status, ICD-9-CM codes to determine mental health diagnoses, and VHA utilization. Of homeless Veterans in VHA, 39.7 % of females and 3.3 % of males experienced MST. Homeless Veterans who experienced MST demonstrated a significantly higher likelihood of almost all mental health conditions examined as compared to other homeless women and men, including depression, posttraumatic stress disorder, other anxiety disorders, substance use disorders, bipolar disorders, personality disorders, suicide, and, among men only, schizophrenia and psychotic disorders. Nearly all homeless Veterans had at least one mental health visit and Veterans who experienced MST utilized significantly more mental health visits compared to Veterans who did not experience MST. A substantial proportion of homeless Veterans using VHA services have experienced MST, and those who experienced MST had increased odds of mental health diagnoses. Homeless Veterans who had experienced MST had higher intensity of mental health care utilization and high rates of MST-related mental health care. This study highlights the importance of trauma-informed care among homeless Veterans and the success of VHA homeless

Evaluating the Implementation of Home-Based Videoconferencing for Providing Mental Health Services.

PubMed

Interian, Alejandro; King, Arlene R; St Hill, Lauren M; Robinson, Claire H; Damschroder, Laura J

2018-01-01

The Veterans Health Administration (VHA) has recently implemented video-to-home (V2H) telehealth as part of a strategy to improve access to mental health treatment. Implementation research of this modality is needed, given that V2H telehealth transforms the traditional face-to-face delivery of mental health services. To address this need, V2H implementation was evaluated by examining barriers and facilitators that were associated with level of staff V2H experience and factors that differentiated facilities with various levels of V2H performance. Semistructured interviews with VHA personnel (N=33) from three facilities were conducted. The facilities were selected by overall number of mental health V2H visits during fiscal year (FY) 2015 as well as by growth in number of visits from FY 2014 through FY 2015. Factors influencing implementation were identified through qualitative analyses that contrasted responses by groups of participants with three different levels of V2H experience (no experience, limited experience, most experience) as well as three facilities that differed in V2H productivity (high visit count, high visit growth, and low visit count and low visit growth). Providers seemed to encounter different barriers and facilitators depending on their level of experience with V2H. Site-level analyses illustrated the importance of logistical support, especially for providers who are newly adopting the technology. Other factors that differentiated the facilities were also identified and described. Key factors related to implementation of V2H telehealth pertained to provider buy-in and logistical support. Facility-level strategies that address these factors may enhance provider progression from nonuse to sustained use.

48 CFR 1830.7001 - Facilities capital employed for facilities in use.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 48 Federal Acquisition Regulations System 6 2011-10-01 2011-10-01 false Facilities capital employed for facilities in use. 1830.7001 Section 1830.7001 Federal Acquisition Regulations System NATIONAL AERONAUTICS AND SPACE ADMINISTRATION GENERAL CONTRACTING REQUIREMENTS COST ACCOUNTING STANDARDS ADMINISTRATION...

Dance Facilities.

ERIC Educational Resources Information Center

Ashton, Dudley, Ed.; Irey, Charlotte, Ed.

This booklet represents an effort to assist teachers and administrators in the professional planning of dance facilities and equipment. Three chapters present the history of dance facilities, provide recommended dance facilities and equipment, and offer some adaptations of dance facilities and equipment, for elementary, secondary and college level…

The effects of organization on medical utilization: an analysis of service line organization.

PubMed

Byrne, Margaret M; Charns, Martin P; Parker, Victoria A; Meterko, Mark M; Wray, Nelda P

2004-01-01

To determine whether clinical service lines in primary care and mental health reduces inpatient and urgent care utilization. All VHA medical centers were surveyed to determine whether service lines had been established in primary care or mental health care prior to the beginning of fiscal year 1997 (FY97). Facility-level data on medical utilization from Veterans Health Affairs (VHA) administrative databases were used for descriptive and multivariate regression analyses of utilization and of changes in measures between FY97 and FY98. Nine primary care-related and 5 mental health-related variables were analyzed. Primary care and mental health service lines had been established in approximately half of all facilities. Service lines varied in duration and extent of restructuring. Mere presence of a service line had no positive and several negative effects on measured outcome variables. More detailed analyses showed that some types of service lines have statistically significant and mostly negative effects on both mental health and primary care-related measures. Newly implemented service lines had significantly less improvement in measures over time than facilities with no service line. Health care organizations are implementing innovative organizational structures in hopes of improving quality of care and reducing resource utilization. We found that service lines in primary care and mental health may lead to an initial period of disruption, with little evidence of a beneficial effect on performance for longer duration service lines.

Multiple Sources of Prescription Payment and Risky Opioid Therapy Among Veterans.

PubMed

Becker, William C; Fenton, Brenda T; Brandt, Cynthia A; Doyle, Erin L; Francis, Joseph; Goulet, Joseph L; Moore, Brent A; Torrise, Virginia; Kerns, Robert D; Kreiner, Peter W

2017-07-01

Opioid overdose and other related harms are a major source of morbidity and mortality among US Veterans, in part due to high-risk opioid prescribing. We sought to determine whether having multiple sources of payment for opioids-as a marker for out-of-system access-is associated with risky opioid therapy among veterans. Cross-sectional study examining the association between multiple sources of payment and risky opioid therapy among all individuals with Veterans Health Administration (VHA) payment for opioid analgesic prescriptions in Kentucky during fiscal year 2014-2015. Source of payment categories: (1) VHA only source of payment (sole source); (2) sources of payment were VHA and at least 1 cash payment [VHA+cash payment(s)] whether or not there was a third source of payment; and (3) at least one other noncash source: Medicare, Medicaid, or private insurance [VHA+noncash source(s)]. Our outcomes were 2 risky opioid therapies: combination opioid/benzodiazepine therapy and high-dose opioid therapy, defined as morphine equivalent daily dose ≥90 mg. Of the 14,795 individuals in the analytic sample, there were 81.9% in the sole source category, 6.6% in the VHA+cash payment(s) category, and 11.5% in the VHA+noncash source(s) category. In logistic regression, controlling for age and sex, persons with multiple payment sources had significantly higher odds of each risky opioid therapy, with those in the VHA+cash having significantly higher odds than those in the VHA+noncash source(s) group. Prescribers should examine the prescription monitoring program as multiple payment sources increase the odds of risky opioid therapy.

Tailoring Care to Vulnerable Populations by Incorporating Social Determinants of Health: the Veterans Health Administration’s “Homeless Patient Aligned Care Team” Program

PubMed Central

Johnson, Erin E.; Aiello, Riccardo; Kane, Vincent; Pape, Lisa

2016-01-01

Introduction Although the clinical consequences of homelessness are well described, less is known about the role for health care systems in improving clinical and social outcomes for the homeless. We described the national implementation of a “homeless medical home” initiative in the Veterans Health Administration (VHA) and correlated patient health outcomes with characteristics of high-performing sites. Methods We conducted an observational study of 33 VHA facilities with homeless medical homes and patient- aligned care teams that served more than 14,000 patients. We correlated site-specific health care performance data for the 3,543 homeless veterans enrolled in the program from October 2013 through March 2014, including those receiving ambulatory or acute health care services during the 6 months prior to enrollment in our study and 6 months post-enrollment with corresponding survey data on the Homeless Patient Aligned Care Team (H-PACT) program implementation. We defined high performance as high rates of ambulatory care and reduced use of acute care services. Results More than 96% of VHA patients enrolled in these programs were concurrently receiving VHA homeless services. Of the 33 sites studied, 82% provided hygiene care (on-site showers, hygiene kits, and laundry), 76% provided transportation, and 55% had an on-site clothes pantry; 42% had a food pantry and provided on-site meals or other food assistance. Six-month patterns of acute-care use pre-enrollment and post-enrollment for 3,543 consecutively enrolled patients showed a 19.0% reduction in emergency department use and a 34.7% reduction in hospitalizations. Three features were significantly associated with high performance: 1) higher staffing ratios than other sites, 1) integration of social supports and social services into clinical care, and 3) outreach to and integration with community agencies. Conclusion Integrating social determinants of health into clinical care can be effective for high

77 FR 15187 - Proposed Information Collection; Comment Request; Deployment Risk and Resilience Inventory (DRRI)

Federal Register 2010, 2011, 2012, 2013, 2014

2012-03-14

...; Comment Request; Deployment Risk and Resilience Inventory (DRRI) AGENCY: Veterans Health Administration, Department of Veterans Affairs. ACTION: Notice. SUMMARY: The Veterans Health Administration (VHA), Department...-Pryor, Veterans Health Administration (193E1), Department of Veterans Affairs, 810 Vermont Avenue NW...

Patient-Centered Medical Home Implementation in the Veterans Health Administration and Primary Care Use: Differences by Patient Comorbidity Burden.

PubMed

Wong, Edwin S; Rosland, Ann-Marie; Fihn, Stephan D; Nelson, Karin M

2016-12-01

The patient-centered medical home (PCMH) model has several components to improve care for patients with high comorbidity, including greater access to face-to-face primary care. We examined whether high-comorbidity patients had larger increases in primary care provider (PCP) visits attributable to PCMH implementation in a large integrated health system relative to other patients enrolled in primary care. This longitudinal study examined a 1 % random sample of 9.3 million patients enrolled in the Veterans Health Administration (VHA) at any time between 2003 and 2013. Face-to-face visits with PCPs per quarter were identified through VHA administrative data. Comorbidity was measured using the Gagne index and patients with a weighted score of ≥ 2 were defined as high comorbidity. We applied interrupted time-series models to estimate marginal changes in PCP visits attributable to PCMH implementation. Differences in marginal changes were calculated across comorbidity groups (high vs. low). Analyses were stratified by age group to account for Medicare eligibility. Among age 65+ patients, PCMH was associated with greater PCP visits starting four and ten quarters following implementation for high- and low-comorbidity patients, respectively. Changes were larger for high-comorbidity patients (eight to 11 greater visits per 1000 patients per quarter). Among patients age < 65, PCMH was associated with greater visits for high-comorbidity patients starting eight quarters following implementation, but fewer visits for low-comorbidity patients in all quarters. The difference in visit changes across groups ranged from 18 to 67 visits per 1000 patients per quarter. Increases in PCP visits attributable to PCMH were greater among patients with higher comorbidity. Health systems implementing PCMH should account for population-level comorbidity burden when planning for PCMH-related changes in PCP utilization.

Association between health literacy and medical care costs in an integrated healthcare system: a regional population based study.

PubMed

Haun, Jolie N; Patel, Nitin R; French, Dustin D; Campbell, Robert R; Bradham, Douglas D; Lapcevic, William A

2015-06-27

Low health literacy is associated with higher health care utilization and costs; however, no large-scale studies have demonstrated this in the Veterans Health Administration (VHA). This research evaluated the association between veterans' health literacy and their subsequent VHA health care costs across a three-year period. This retrospective study used a Generalized Linear Model to estimate the relative association between a patient's health literacy and VHA medical costs, adjusting for covariates. Secondary data sources included electronic health records and administrative data in the VHA (e.g., Medical and DCG SAS Datasets and DSS-National Data Extracts). Health literacy assessments and identifiers were electronically retrieved from the originating health system. Demographic and cost data were retrieved from the VHA centralized databases for the corresponding patients who had VHA use in all three years. In a study of 92,749 veterans with service utilization from 2007-2009, average per patient cost for those with inadequate and marginal health literacy was significantly higher ($31,581 [95 % CI: $30,186 - $32,975]; $23,508 [95 % CI: $22,749 - $24,268]) than adequate health literacy ($17,033 [95 % CI: $16,810 - $17,255]). Estimated three-year cost associated with veterans' with marginal and inadequate health literacy was $143 million dollars more than those with adequate health literacy. Analyses suggest when controlling for other person-level factors within the VHA integrated healthcare system, lower health literacy is a significant independent factor associated with increased health care utilization and costs. This study confirms the association of lower health literacy with higher medical service utilization and pharmacy costs for veterans enrolled in the VHA. Confirmation of higher costs of care associated with lower health literacy suggests that interventions might be designed to remediate health literacy needs and reduce expenditures. These analyses suggest

Building a Diabetes Registry from the Veterans Health Administration's Computerized Patient Record System

PubMed Central

F. O. Kern, Elizabeth; Beischel, Scott; Stalnaker, Randal; Aron, David C.; Kirsh, Susan R.; Watts, Sharon A.

2008-01-01

Background Little information is available describing how to implement a disease registry from an electronic patient record system. The aim of this report is to describe the technology, methods, and utility of a diabetes registry populated by the Veterans Health Information Systems Architecture (VistA), which underlies the computerized patient record system of the Veterans Health Administration (VHA) in Veteran Affairs Integrated Service Network 10 (VISN 10). Methods VISN 10 data from VistA were mapped to a relational SQL-based data system using KB_SQL software. Operational definitions for diabetes, active clinical management, and responsible providers were used to create views of patient-level data in the diabetes registry. Query Analyzer was used to access the data views directly. Semicustomizable reports were created by linking the diabetes registry to a Web page using Microsoft asp.net2. A retrospective observational study design was used to analyze trends in the process of care and outcomes. Results Since October 2001, 81,227 patients with diabetes have enrolled in VISN 10: approximately 42,000 are currently under active management by VISN 10 providers. By tracking primary care visits, we assigned 91% to a clinic group responsible for diabetes care. In the Cleveland Veterans Affairs Medical Center (VAMC), the frequency of mean annual hemoglobin A1c levels ≥9% has declined significantly over 5 years. Almost 4000 patients have been seen in diabetes intervention programs in the Cleveland VAMC over the past 4 years. Conclusions A diabetes registry can be populated from the database underlying the VHA electronic patient record database system and linked to Web-based and ad hoc queries useful for quality improvement. PMID:19885172

Health Policy Initiatives for African American Women Veterans.

PubMed

McClerking, Carolyn A; Wood, Felecia

2016-08-01

America's military has experienced great changes in the demographic makeup of its veterans over the past few decades. In fact, the fastest growing group in the U.S. military is women. This demographic trend has also brought new challenges in dealing with gender issues, something that the Veterans Health Administration (VHA) has only recently begun to acknowledge. The VHA has responded in several ways to gender issues in health care and health outcomes. And, although the VHA is dealing with multiple gender matters, this article will focus on initiatives to combat cardiovascular disease (CVD) in women veterans. It will also highlight the significance of CVD, both to women veterans in general and to African American women veterans specifically. The article concludes with a discussion of VHA activities and strategies to improve the cardiovascular health of African American women veterans. © The Author(s) 2016.

Psychopharmacologic Services for Homeless Veterans: Comparing Psychotropic Prescription Fills Among Homeless and Non-Homeless Veterans with Serious Mental Illness.

PubMed

Hermes, Eric; Rosenheck, Robert

2016-02-01

Using national Veterans Health Administration (VHA) administrative data, this study evaluated differences in psychotropic medication use between homeless and non-homeless adults with serious mental illness (SMI) who used VHA services in 2010. The adjusted mean number of psychotropic prescription fills associated with homeless individuals were identified using regression models adjusted for socio-demographics, diagnoses, and use of health services. Of the 876,989 individuals with SMI using VHA services, 7.2 % were homeless at some time during 2010. In bivariate analysis, homeless individuals filled more psychotropic medication prescriptions compared with non-homeless individuals. However, after adjusting for potentially confounding variables, homeless individuals were found to have filled 16.2 % fewer prescriptions than non-homeless individuals when all psychotropics were analyzed together (F = 6947.1, p < .001) and for most individual classes of psychotropics. Greater use of residential/inpatient mental health services by the homeless was the most important single factor associated with filling more psychotropic prescriptions than non-homeless individuals.

Within-Hospital Variation in 30-Day Adverse Events: Implications for Measuring Quality.

PubMed

Burke, Robert E; Glorioso, Thomas; Barón, Anna K; Kaboli, Peter J; Ho, P Michael

Novel measures of hospital quality are needed. Because quality improvement efforts seek to reduce variability in processes and outcomes, hospitals with higher variability in adverse events may be delivering poorer quality care. We sought to evaluate whether within-hospital variability in adverse events after a procedure might function as a quality metric that is correlated with facility-level mortality rates. We analyzed all percutaneous coronary interventions (PCIs) performed in the Veterans Health Administration (VHA) system from 2007 to 2013 to evaluate the correlation between within-hospital variability in 30-day postdischarge adverse events (readmission, emergency department visit, and repeat revascularization), and facility-level mortality rates, after adjustment for patient demographics, comorbidities, PCI indication, and PCI urgency. The study cohort included 47,567 patients at 48 VHA hospitals. The overall 30-day adverse event rate was 22.0% and 1-year mortality rate was 4.9%. The most variable sites had relative changes of 20% in 30-day rates of adverse events period-to-period. However, within-hospital variability in 30-day events was not correlated with 1-year mortality rates (correlation coefficient = .06; p = .66). Thus, measuring within-hospital variability in postdischarge adverse events may not improve identification of low-performing hospitals. Evaluation in other conditions, populations, and in relationship with other quality metrics may reveal stronger correlations with care quality.

HIGH PREVALENCE OF AGENT ORANGE EXPOSURE AMONG THYROID CANCER PATIENTS IN THE NATIONAL VA HEALTHCARE SYSTEM.

PubMed

Le, Karen T; Sawicki, Mark P; Wang, Marilene B; Hershman, Jerome M; Leung, Angela M

2016-06-01

Thyroid cancer is the most common endocrine malignancy and the most rapidly increasing cancer in the U.S. Little is known regarding the epidemiology and characteristics of patients with thyroid cancer within the national Veterans Health Administration (VHA) integrated healthcare system. The aim of this study was to further understand the characteristics of thyroid cancer patients in the VHA population, particularly in relation to Agent Orange exposure. This is a descriptive analysis of the VA (Veterans Affairs) Corporate Data Warehouse database from all U.S. VHA healthcare sites from October1, 1999, to December 31, 2013. Information was extracted for all thyroid cancer patients based on International Classification of Diseases-ninth revision diagnosis codes; histologic subtypes of thyroid cancer were not available. There were 19,592 patients (86% men, 76% white, 58% married, 42% Vietnam-era Veteran) in the VHA system with a diagnosis of thyroid cancer within this 14-year study period. The gender-stratified prevalence rates of thyroid cancer among the Veteran population during the study period were 1:1,114 (women) and 1:1,023 (men), which were lower for women but similar for men, when compared to the U.S. general population in 2011 (1:350 for women and 1:1,219 for men). There was a significantly higher proportion of self-reported Agent Orange exposure among thyroid cancer patients (10.0%), compared to the general VHA population (6.2%) (P<.0001). Thyroid cancer patients, in this sample, have a higher prevalence of self-reported Agent Orange exposure compared to the overall national VA patient population. T4 = thyroxine TCDD = 2, 3, 7, 8-tetrachlorodibenzo-p-dioxin TSH = thyroid-stimulating hormone VA = Veterans Affairs VHA = Veterans Health Administration.

Fuel conditioning facility zone-to-zone transfer administrative controls.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Pope, C. L.

2000-06-21

The administrative controls associated with transferring containers from one criticality hazard control zone to another in the Argonne National Laboratory (ANL) Fuel Conditioning Facility (FCF) are described. FCF, located at the ANL-West site near Idaho Falls, Idaho, is used to remotely process spent sodium bonded metallic fuel for disposition. The process involves nearly forty widely varying material forms and types, over fifty specific use container types, and over thirty distinct zones where work activities occur. During 1999, over five thousand transfers from one zone to another were conducted. Limits are placed on mass, material form and type, and container typesmore » for each zone. Ml material and containers are tracked using the Mass Tracking System (MTG). The MTG uses an Oracle database and numerous applications to manage the database. The database stores information specific to the process, including material composition and mass, container identification number and mass, transfer history, and the operators involved in each transfer. The process is controlled using written procedures which specify the zone, containers, and material involved in a task. Transferring a container from one zone to another is called a zone-to-zone transfer (ZZT). ZZTs consist of four distinct phases, select, request, identify, and completion.« less

78 FR 66105 - Agency Information Collection Activities Under OMB Review

Federal Register 2010, 2011, 2012, 2013, 2014

2013-11-04

... Health Benefits.'' SUPPLEMENTARY INFORMATION: Title: Application and Renewal for Health Benefits, VA Form... Activities Under OMB Review AGENCY: Veterans Health Administration, Department of Veterans Affairs. ACTION... notice announces that the Veterans Health Administration (VHA), Department of Veterans Affairs, has...

76 FR 70829 - Proposed Information Collection (Architect-Engineer Fee Proposal) Activity; Comment Request

Federal Register 2010, 2011, 2012, 2013, 2014

2011-11-15

... (Architect--Engineer Fee Proposal) Activity; Comment Request AGENCY: Veterans Health Administration, Department of Veterans Affairs. ACTION: Notice. SUMMARY: The Veterans Health Administration (VHA), Department... Docket Management System (FDMS) at www.Regulations.gov or to Cynthia Harvey-Pryor, Veterans Health...

An Administrator's Perspective on the Organization of Physical Activity for Older Adults in Long-Term Care Facilities.

PubMed

Baert, Veerle; Gorus, Ellen; Calleeuw, Koen; De Backer, Werner; Bautmans, Ivan

2016-01-01

The positive influence of physical activity (PA) on health is well documented. Even at old age, PA remains useful but participation in PA decreases with age. In long-term care facilities (LTCFs), PA appears to be reduced to a bare minimum. Because administrators have a key role in developing the care policy of LTCFs, it is important that they support the organization of PA in LTCFs. The main objective of this mixed-method study was to identify motivators and barriers for organizing PA in LTCFs according to administrators. A secondary goal was to examine the knowledge of the World Health Organization (WHO) guidelines regarding PA and to reveal potential motivators and barriers for the implementation of the guidelines. First, 24 administrators completed semistructured interviews. Data were analyzed using the deductive approach of qualitative content analysis. The obtained motivators and barriers were categorized on 3 different levels (intrapersonal, interpersonal, and community) according to the socioecological model by 2 independent reviewers; conflicts were resolved with a third researcher. Next, 127 administrators of Flemish (Belgium) LTCFs completed an online questionnaire survey containing open-ended, unique, and multiple choice questions regarding the LTCFs, PA, and the WHO guidelines, as well as statements (scored on a 5-point Likert scale) regarding perceived motivators and barriers for organizing PA sessions in the LTCF. In the qualitative component, the administrators reported 31 motivators and 24 barriers for organizing PA in the LTCF. In the survey, maintaining or enhancing general health of the residents (98%) and improving the psychological well-being of the residents were marked as key motivators at the intrapersonal level. The administrators (97%) were convinced that PA is a useful way to spend time for LTCF residents. Encouraging social contact (94%) and countering loneliness (86%) are the motivators cited at the interpersonal level. At the community

Care Coordination/Home Telehealth: the systematic implementation of health informatics, home telehealth, and disease management to support the care of veteran patients with chronic conditions.

PubMed

Darkins, Adam; Ryan, Patricia; Kobb, Rita; Foster, Linda; Edmonson, Ellen; Wakefield, Bonnie; Lancaster, Anne E

2008-12-01

Between July 2003 and December 2007, the Veterans Health Administration (VHA) introduced a national home telehealth program, Care Coordination/Home Telehealth (CCHT). Its purpose was to coordinate the care of veteran patients with chronic conditions and avoid their unnecessary admission to long-term institutional care. Demographic changes in the veteran population necessitate VHA increase its noninstitutional care (NIC) services 100% above its 2007 level to provide care for 110,000 NIC patients by 2011. By 2011, CCHT will meet 50% of VHA's anticipated NIC provision. CCHT involves the systematic implementation of health informatics, home telehealth, and disease management technologies. It helps patients live independently at home. Between 2003 and 2007, the census figure (point prevalence) for VHA CCHT patients increased from 2,000 to 31,570 (1,500% growth). CCHT is now a routine NIC service provided by VHA to support veteran patients with chronic conditions as they age. CCHT patients are predominantly male (95%) and aged 65 years or older. Strict criteria determine patient eligibility for enrollment into the program and VHA internally assesses how well its CCHT programs meet standardized clinical, technology, and managerial requirements. VHA has trained 5,000 staff to provide CCHT. Routine analysis of data obtained for quality and performance purposes from a cohort of 17,025 CCHT patients shows the benefits of a 25% reduction in numbers of bed days of care, 19% reduction in numbers of hospital admissions, and mean satisfaction score rating of 86% after enrolment into the program. The cost of CCHT is $1,600 per patient per annum, substantially less than other NIC programs and nursing home care. VHA's experience is that an enterprise-wide home telehealth implementation is an appropriate and cost-effective way of managing chronic care patients in both urban and rural settings.

76 FR 56504 - Proposed Information Collection (Spinal Cord Injury Patient Care Survey) Activity: Comment Request

Federal Register 2010, 2011, 2012, 2013, 2014

2011-09-13

... Collection (Spinal Cord Injury Patient Care Survey) Activity: Comment Request AGENCY: Veterans Health Administration, Department of Veterans Affairs. ACTION: Notice. SUMMARY: The Veterans Health Administration (VHA... satisfaction with VA rehabilitation and health care. DATES: Written comments and recommendations on the...

Nursing Administrators' Views on Oral Health in Long-Term Care Facilities: An exploratory study.

PubMed

Urata, Janelle Y; Couch, Elizabeth T; Walsh, Margaret M; Rowe, Dorothy J

2018-04-01

Purpose: To explore the knowledge, attitudes, and practices of supervising nurse administrators (SNAs) regarding the oral care provided to long-term care facility (LTCF) residents and the role of dental professionals in those facilities. Methods: The investigators of this study partnered with the National Association of Nursing Administrators to send this cross-sectional study consisting of a 35-item electronic survey to its members whose email addresses were in their database. Online software tabulated responses and calculated frequencies (percentages) of responses for each survey item. Results: Of the 2,359 potential participants, 171 (n=171) completed the survey for a 7% response rate. Only 25% of the respondents were familiar with the expertise of dental hygienists (DHs), however once informed, the majority were interested in having DHs perform oral health staff trainings, oral screenings, and dental referrals and initiate fluoride varnish programs. Most respondents correctly answered the oral health-related knowledge items, understood that oral health is important to general health, but reported that the LTCF residents' oral health was only "good" or "fair." Fewer than half, (48%) of the SNAs were "very satisfied" with the quality of oral care provided to the residents. While more than half reported that they had no dentist on staff or on-site dental equipment, 77% reported that they would consider on-site mobile oral care services. Oral health training for staff was provided primarily by registered nurses, however only 32% reported including identification of dental caries as part of the in-service training. Conclusion: This exploratory study lays the foundation for more extensive research investigating various strategies to improve the oral health of LTCF residents, including increased collaboration between DHs and SNAs. Copyright © 2018 The American Dental Hygienists’ Association.

Preferrential rearrangement in normal rabbits of the 3' VHa allotype gene that is deleted in Alicia mutants; somatic hypermutation/conversion may play a major role in generating the heterogeneity of rabbit heavy chain variable region sequences.

PubMed

Allegrucci, M; Young-Cooper, G O; Alexander, C B; Newman, B A; Mage, R G

1991-02-01

The rabbit is unique in having well-defined allotypes in the variable region of the heavy chain. Products of the VHa locus, (with alleles a1, a2, and a3), account for the majority of the serum immunoglobulins. A small percentage of the serum immunoglobulins are a-negative. In 1986, Kelus and Weiss described a mutation that depressed the expression of the Ig VH a2 genes in an a1/a2 rabbit. From this animal the Alicia rabbit strain was developed and the mutation was termed ali. We previously showed, using Southern analysis and the transverse alternating field electrophoresis technique, that the difference between the ali rabbit and normal is a relatively small deletion including some of the most 3' VH genes. The most JH proximal 3' VH1 genes in DNA from normal rabbits of a1, a2 and a3 haplotypes encode a1, a2 and a3 molecules respectively, and it has been suggested that these genes are responsible for allelic inheritance of VHa allotypes. The present study suggests that the 3' end of the VH locus probably plays a key role in regulation of VH gene expression in rabbits because VH gene(s) in this region are the target(s) of preferential VDJ rearrangements. This raises the possibility that mechanisms such as somatic gene conversion and hypermutation are at work to generate the antibody repertoire in this species. Our data support the view that the 3' VH1 gene may be the preferred target for rearrangement in normal rabbits, and for the normal chromosome in heterozygous ali animals. However, homozygous ali rabbits with a deletion that removed the a2-encoding VH1 on both chromosomes do survive, rearrange other VH genes and produce normal levels of immunoglobulins as well as a significant percentage of B cells which bear the a2 allotype. This challenges the view that one VH gene, VH1, is solely responsible for the inheritance pattern of VHa allotypes.

Knowledge of Staff Members of Residential Care Facilities for Individuals with Intellectual Disability on Medication Administration via Enteral Feeding Tube

ERIC Educational Resources Information Center

Joos, E.; Mehuys, E.; Van Bocxlaer, J.; Remon, J. P.; Van Winckel, M.; Boussery, K.

2016-01-01

Background: Guidelines for the safe administration of drugs through enteral feeding tube (EFT) are an important tool to minimise the risk of errors. This study aimed to investigate knowledge of these guidelines among staff of residential care facilities (RCF) for people with ID. Method: Knowledge was assessed using a 13-item self-administered…

Implementation evaluation of the Telephone Lifestyle Coaching (TLC) program: organizational factors associated with successful implementation.

PubMed

Damschroder, Laura J; Reardon, Caitlin M; Sperber, Nina; Robinson, Claire H; Fickel, Jacqueline J; Oddone, Eugene Z

2017-06-01

The Telephone Lifestyle Coaching (TLC) program provided telephone-based coaching for six lifestyle behaviors to 5321 Veterans at 24 Veterans Health Administration (VHA) medical facilities. The purpose of the study was to conduct an evaluation of the TLC program to identify factors associated with successful implementation. A mixed-methods study design was used. Quantitative measures of organizational readiness for implementation and facility complexity were used to purposively select a subset of facilities for in-depth evaluation. Context assessments were conducted using interview transcripts. The Consolidated Framework for Implementation Research (CFIR) was used to guide qualitative data collection and analysis. Factors most strongly correlated with referral rates included having a skilled implementation leader who used effective multi-component strategies to engage primary care clinicians as well as general clinic structures that supported implementation. Evaluation findings pointed to recommendations for local and national leaders to help anticipate and mitigate potential barriers to successful implementation.

The psychologist's role in transgender-specific care with U.S. veterans.

PubMed

Johnson, Laura; Shipherd, Jillian; Walton, Heather M

2016-02-01

Psychologists are integral to the care of transgender individuals. This article details the many roles for psychologists in transgender-specific care, including diagnosing and treating gender dysphoria; providing treatment for comorbid conditions; referring to medical services such as gender confirmation surgeries, voice modification, and cross-sex hormone therapies; serving as consultants within health care systems; and advocating for addressing barriers in systems in which transgender individuals live and work. Transgender veterans have unique experiences and vulnerabilities related to their military service that are detailed from a review of the literature, and we make the case that Veterans Health Administration (VHA) and community psychologists are well-positioned to provide care to transgender veterans (trans-vets). In this article, the authors describe the experiences that many trans-vets have faced, identify the importance of treatment for gender dysphoria (and draw the distinction between gender identity disorder and gender dysphoria) as well as psychologists' roles, and clarify which transgender-related services are available to eligible veterans though VHA per policy and how VHA providers have access to training to provide that care. In addition, we describe how veterans can connect to the VHA, even if they have (and want to continue working with) non-VHA psychologists or other community providers. (c) 2016 APA, all rights reserved).

Responding to traveling patients' seasonal demand for health care services.

PubMed

Al-Haque, Shahed; Ceyhan, Mehmet Erkan; Chan, Stephanie H; Nightingale, Deborah J

2015-01-01

The Veterans Health Administration (VHA) provides care to over 8 million Veterans and operates over 1,700 sites of care across 21 regional networks in the United States. Health care providers within VHA report large seasonal variation in the demand for services, especially in the southern United States because of arrival of "snowbirds" during the winter. Because resource allocation activities are primarily carried out through an annual budgeting process, the seasonal load imposed by "traveling Veterans"-Veterans that seek care at VHA sites outside of their home network-make providing high-quality services more challenging. This work constitutes the first major effort within VHA to understand the impact of traveling Veterans. We discovered strong seasonal fluctuations in demand at a clinic located in the southeastern United States and developed a seasonal autoregressive integrated moving average model to help the clinic forecast demand for its services with significantly less error than historical averaging. Monte Carlo simulation of the clinic revealed that physicians are overutilized, suggesting the need to re-evaluate how the clinic is currently staffed. More broadly, this study demonstrates how operations management methods can assist operational decision making at other clinics and medical centers both within and outside VHA. Reprint & Copyright © 2015 Association of Military Surgeons of the U.S.

Differential Risk for Homelessness Among US Male and Female Veterans With a Positive Screen for Military Sexual Trauma.

PubMed

Brignone, Emily; Gundlapalli, Adi V; Blais, Rebecca K; Carter, Marjorie E; Suo, Ying; Samore, Matthew H; Kimerling, Rachel; Fargo, Jamison D

2016-06-01

Military sexual trauma (MST) is associated with adverse physical and mental health outcomes following military separation. Recent research suggests that MST may be a determinant in several factors associated with postdeployment homelessness. To evaluate MST as an independent risk factor for homelessness and to determine whether risk varies by sex. A retrospective cohort study of US veterans who used Veterans Health Administration (VHA) services between fiscal years 2004 and 2013 was conducted using administrative data from the Department of Defense and VHA. Included in the study were 601 892 US veterans deployed in Iraq or Afghanistan who separated from the military between fiscal years 2001 and 2011 and subsequently used VHA services. Positive response to screen for MST administered in VHA facilities. Administrative evidence of homelessness within 30 days, 1 year, and 5 years following the first VHA encounter after last deployment. The mean (SD) age of the 601 892 participants was 38.9 (9.4) years, 527 874 (87.7%) were male, 310 854 (51.6%) were white, and 382 361 (63.5%) were enlisted in the Army. Among veterans with a positive screen for MST, rates of homelessness were 1.6% within 30 days, 4.4% within 1 year, and 9.6% within 5 years, more than double the rates of veterans with a negative MST screen (0.7%, 1.8%, and 4.3%, respectively). A positive screen for MST was significantly and independently associated with postdeployment homelessness. In regression models adjusted for demographic and military service characteristics, odds of experiencing homelessness were higher among those who screened positive for MST compared with those who screened negative (30-day: adjusted odds ratio [AOR], 1.89; 95% CI, 1.58-2.24; 1-year: AOR, 2.27; 95% CI, 2.04-2.53; and 5-year: AOR, 2.63; 95% CI, 2.36-2.93). Military sexual trauma screen status remained independently associated with homelessness after adjusting for co-occurring mental health and substance abuse diagnoses

48 CFR 1830.7002 - Facilities capital employed for facilities under construction.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 48 Federal Acquisition Regulations System 6 2011-10-01 2011-10-01 false Facilities capital employed for facilities under construction. 1830.7002 Section 1830.7002 Federal Acquisition Regulations System NATIONAL AERONAUTICS AND SPACE ADMINISTRATION GENERAL CONTRACTING REQUIREMENTS COST ACCOUNTING...

Using IHE and HL7 conformance to specify consistent PACS interoperability for a large multi-center enterprise.

PubMed

Henderson, Michael L; Dayhoff, Ruth E; Titton, Csaba P; Casertano, Andrew

2006-01-01

As part of its patient care mission, the U.S. Veterans Health Administration performs diagnostic imaging procedures at 141 medical centers and 850 outpatient clinics. VHA's VistA Imaging Package provides a full archival, display, and communications infrastructure and interfaces to radiology and other HIS modules as well as modalities and a worklist provider In addition, various medical center entities within VHA have elected to install commercial picture archiving and communications systems to enable image organization and interpretation. To evaluate interfaces between commercial PACS, the VistA hospital information system, and imaging modalities, VHA has built a fully constrained specification that is based on the Radiology Technical Framework (Rad-TF) Integrating the Healthcare Enterprise. The Health Level Seven normative conformance mechanism was applied to the IHE Rad-TF and agency requirements to arrive at a baseline set of message specifications. VHA provides a thorough implementation and testing process to promote the adoption of standards-based interoperability by all PACS vendors that want to interface with VistA Imaging.

Telecommunications administration standard

DOE Office of Scientific and Technical Information (OSTI.GOV)

Gustwiller, K.D.

1996-05-01

The administration of telecommunications is critical to proper maintenance and operation. The intent is to be able to properly support telecommunications for the distribution of all information within a building/campus. This standard will provide a uniform administration scheme that is independent of applications, and will establish guidelines for owners, installers, designers and contractors. This standard will accommodate existing building wiring, new building wiring and outside plant wiring. Existing buildings may not readily adapt to all applications of this standard, but the requirement for telecommunications administration is applicable to all buildings. Administration of the telecommunications infrastructure includes documentation (labels, records, drawings,more » reports, and work orders) of cables, termination hardware, patching and cross-connect facilities, telecommunications rooms, and other telecommunications spaces (conduits, grounding, and cable pathways are documented by Facilities Engineering). The investment in properly documenting telecommunications is a worthwhile effort. It is necessary to adhere to these standards to ensure quality and efficiency for the operation and maintenance of the telecommunications infrastructure for Sandia National Laboratories.« less

28 CFR 36.204 - Administrative methods.

Code of Federal Regulations, 2010 CFR

2010-07-01

... 28 Judicial Administration 1 2010-07-01 2010-07-01 false Administrative methods. 36.204 Section 36... PUBLIC ACCOMMODATIONS AND IN COMMERCIAL FACILITIES General Requirements § 36.204 Administrative methods... standards or criteria or methods of administration that have the effect of discriminating on the basis of...

28 CFR 36.204 - Administrative methods.

Code of Federal Regulations, 2014 CFR

2014-07-01

... 28 Judicial Administration 1 2014-07-01 2014-07-01 false Administrative methods. 36.204 Section 36... PUBLIC ACCOMMODATIONS AND IN COMMERCIAL FACILITIES General Requirements § 36.204 Administrative methods... standards or criteria or methods of administration that have the effect of discriminating on the basis of...

28 CFR 36.204 - Administrative methods.

Code of Federal Regulations, 2013 CFR

2013-07-01

... 28 Judicial Administration 1 2013-07-01 2013-07-01 false Administrative methods. 36.204 Section 36... PUBLIC ACCOMMODATIONS AND IN COMMERCIAL FACILITIES General Requirements § 36.204 Administrative methods... standards or criteria or methods of administration that have the effect of discriminating on the basis of...

28 CFR 36.204 - Administrative methods.

Code of Federal Regulations, 2011 CFR

2011-07-01

... 28 Judicial Administration 1 2011-07-01 2011-07-01 false Administrative methods. 36.204 Section 36... PUBLIC ACCOMMODATIONS AND IN COMMERCIAL FACILITIES General Requirements § 36.204 Administrative methods... standards or criteria or methods of administration that have the effect of discriminating on the basis of...

28 CFR 36.204 - Administrative methods.

Code of Federal Regulations, 2012 CFR

2012-07-01

... 28 Judicial Administration 1 2012-07-01 2012-07-01 false Administrative methods. 36.204 Section 36... PUBLIC ACCOMMODATIONS AND IN COMMERCIAL FACILITIES General Requirements § 36.204 Administrative methods... standards or criteria or methods of administration that have the effect of discriminating on the basis of...

Teamwork and delegation in medical homes: primary care staff perspectives in the Veterans Health Administration.

PubMed

True, Gala; Stewart, Greg L; Lampman, Michelle; Pelak, Mary; Solimeo, Samantha L

2014-07-01

The patient-centered medical home (PCMH) relies on a team approach to patient care. For organizations engaged in transitioning to a PCMH model, identifying and providing the resources needed to promote team functioning is essential. To describe team-level resources required to support PCMH team functioning within the Veterans Health Administration (VHA), and provide insight into how the presence or absence of these resources facilitates or impedes within-team delegation. Semi-structured interviews with members of pilot teams engaged in PCMH implementation in 77 primary care clinics serving over 300,000 patients across two VHA regions covering the Mid-Atlantic and Midwest United States. A purposive sample of 101 core members of pilot teams, including 32 primary care providers, 42 registered nurse care managers, 15 clinical associates, and 12 clerical associates. Investigators from two evaluation sites interviewed frontline primary care staff separately, and then collaborated on joint analysis of parallel data to develop a broad, comprehensive understanding of global themes impacting team functioning and within-team delegation. We describe four themes key to understanding how resources at the team level supported ability of primary care staff to work as effective, engaged teams. Team-based task delegation was facilitated by demarcated boundaries and collective identity; shared goals and sense of purpose; mature and open communication characterized by psychological safety; and ongoing, intentional role negotiation. Our findings provide a framework for organizations to identify assets already in place to support team functioning, as well as areas in need of improvement. For teams struggling to make practice changes, our results indicate key areas where they may benefit from future support. In addition, this research sheds light on how variation in medical home implementation and outcomes may be associated with variation in team-based task delegation.

Gender Differences in the Prevalence of Fibromyalgia and in Concomitant Medical and Psychiatric Disorders: A National Veterans Health Administration Study.

PubMed

Arout, Caroline A; Sofuoglu, Mehmet; Bastian, Lori A; Rosenheck, Robert A

2018-04-02

Fibromyalgia is a poorly understood, chronically disabling pain syndrome. While research has focused on its clinical presentation and treatment, less is known about fibromyalgia's clinical epidemiology in real-world healthcare systems. Gender differences have been difficult to study because relatively few males are diagnosed with fibromyalgia. Veterans Health Administration (VHA) patients diagnosed with fibromyalgia nationwide in FY 2012 were compared to Veterans with other pain diagnoses on sociodemographic characteristics, medical and psychiatric diagnoses, health service use, and opioid and psychotropic prescription fills. Additional analyses compared characteristics of men and women diagnosed with fibromyalgia. Risk ratios and Cohen's d were used for bivariate comparisons, followed by logistic regression analyses to identify independent factors associated with a diagnosis of fibromyalgia in the VHA. Altogether, 77,087 of 2,216,621 Veterans with pain diagnoses (3.48%) were diagnosed with fibromyalgia. They were more likely to be female, younger than patients with other pain conditions, more likely to have multiple psychiatric comorbidities and other types of pain, and used more medical outpatient services. Women diagnosed with fibromyalgia were younger and more likely to have headaches, connective tissue diseases (CTD), and psychiatric comorbidities, while men had more comorbid medical conditions. In this large, predominantly older male sample of Veterans with pain diagnoses, those with fibromyalgia were far more likely to be women. Gender comparisons showed women with fibromyalgia were more likely to be diagnosed with psychiatric disorders and CTD, while males were more likely to be diagnosed with medical conditions. Fibromyalgia shows a striking, gender-dependent picture of multimorbidity, which should be considered in treatment.

A multilevel modelling approach to analysis of patient costs under managed care.

PubMed

Carey, K

2000-07-01

The growth of the managed care model of health care delivery in the USA has led to broadened interest in the performance of health care providers. This paper uses multilevel modelling to analyse the effects of managed care penetration on patient level costs for a sample of 24 medical centres operated by the Veterans Health Administration (VHA). The appropriateness of a two level approach to this problem over ordinary least squares (OLS) is demonstrated. Results indicate a modicum of difference in institutions' performance after controlling for patient effects. Facilities more heavily penetrated by the managed care model may be more effective at controlling costs of their sicker patients. Copyright 2000 John Wiley & Sons, Ltd.

Drug Administration via Enteral Feeding Tube in Residential Care Facilities for Individuals with Intellectual Disability: A Focus Group Study on Guideline Implementation

ERIC Educational Resources Information Center

Joos, Elke; Van Tongelen, Inge; Wijnants, Karen; Mehuys, Els; Van Bocxlaer, Jan; Remon, Jean Paul; Grypdonck, Maria; Van Winckel, Myriam; Boussery, Koen

2016-01-01

People with profound intellectual disabilities often receive medication through enteral feeding tube (EFT). In a previous study, we found that current guidelines concerning medication preparation and administration through EFT are often not followed in residential care facilities (RCFs) for individuals with intellectual disabilities. The present…

49 CFR 27.75 - Federal Highway Administration-highways.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 49 Transportation 1 2010-10-01 2010-10-01 false Federal Highway Administration-highways. 27.75... Specific Operating Administration Programs: Airports, Railroads, and Highways § 27.75 Federal Highway Administration—highways. (a) New facilities—(1) Highway rest area facilities. All such facilities that will be...

49 CFR 27.75 - Federal Highway Administration-highways.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 49 Transportation 1 2014-10-01 2014-10-01 false Federal Highway Administration-highways. 27.75... Specific Operating Administration Programs: Airports, Railroads, and Highways § 27.75 Federal Highway Administration—highways. (a) New facilities—(1) Highway rest area facilities. All such facilities that will be...

49 CFR 27.75 - Federal Highway Administration-highways.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 49 Transportation 1 2013-10-01 2013-10-01 false Federal Highway Administration-highways. 27.75... Specific Operating Administration Programs: Airports, Railroads, and Highways § 27.75 Federal Highway Administration—highways. (a) New facilities—(1) Highway rest area facilities. All such facilities that will be...

49 CFR 27.75 - Federal Highway Administration-highways.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 49 Transportation 1 2012-10-01 2012-10-01 false Federal Highway Administration-highways. 27.75... Specific Operating Administration Programs: Airports, Railroads, and Highways § 27.75 Federal Highway Administration—highways. (a) New facilities—(1) Highway rest area facilities. All such facilities that will be...

49 CFR 27.75 - Federal Highway Administration-highways.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 49 Transportation 1 2011-10-01 2011-10-01 false Federal Highway Administration-highways. 27.75... Specific Operating Administration Programs: Airports, Railroads, and Highways § 27.75 Federal Highway Administration—highways. (a) New facilities—(1) Highway rest area facilities. All such facilities that will be...

Facility Design Considerations.

ERIC Educational Resources Information Center

Chase, William W.

1967-01-01

Increasing need for vocational education under the impetus of federal aid is generating a demand for vocational teaching facilities. Factors to be considered in planning these facilities inclued--(1) site development, (2) program needs, (3) administrative considerations, (4) environmental controls. (5) mechanical systems, and (6) area and space…

The impact of a national prescription drug formulary on prices, market share, and spending: lessons for Medicare?

PubMed

Huskamp, Haiden A; Epstein, Arnold M; Blumenthal, David

2003-01-01

Several recent bills in Congress to add a Medicare prescription drug benefit would allow the use of formularies to control costs. However, there is little empirical evidence of the impact of formularies among elderly and disabled populations. We assess the effect of a closed formulary implemented by the Veterans Health Administration (VHA) in 1997 on drug prices, market share, and drug spending. We find that the VHA National Formulary was effective at shifting prescribing behavior toward the selected drugs, achieving sizable price reductions from manufacturers, and greatly decreasing drug spending.

Nursing home facility risk factors for infection and hospitalization: importance of registered nurse turnover, administration, and social factors.

PubMed

Zimmerman, Sheryl; Gruber-Baldini, Ann L; Hebel, J Richard; Sloane, Philip D; Magaziner, Jay

2002-12-01

Determine the relationship between a broad array of structure and process elements of nursing home care and (a) resident infection and (b) hospitalization for infection. Baseline data were collected from September 1992 through March 1995, and residents were followed for 2 years; facility data were collected at the midpoint of follow-up. A stratified random sample of 59 nursing homes across Maryland. Two thousand fifteen new admissions aged 65 and older. Facility-level data were collected from interviews with facility administrators, directors of nursing, and activity directors; record abstraction; and direct observation. Main outcome measures included infection (written diagnosis, a course of antibiotic therapy, or radiographic confirmation of pneumonia) and hospitalization for infection (indicated on medical records). The 2-year rate of infection was 1.20 episodes per 100 resident days, and the hospitalization rate for infection was 0.17 admissions per 100 resident days. Except for registered nurse (RN) turnover, which related to both infection and hospitalization, different variables related to each outcome. High rates of incident infection were associated with more Medicare recipients, high levels of physical/occupational therapist staffing, high licensed practical nurse staffing, low nurses' aide staffing, high intensity of medical and therapeutic services, dementia training, staff privacy, and low levels of psychotropic medication use. High rates of hospitalization for infection were associated with for-profit ownership, chain affiliation, poor environmental quality, lack of resident privacy, lack of administrative emphasis on staff satisfaction, and low family/friend visitation rates. Adjustment for resident sex, age, race, education, marital status, number of morbid diagnoses, functional status, and Resource Utilization Group, Version III score did not alter the relationship between the structure and process of care and outcomes. The association between RN

Anticipating the traumatic brain injury-related health care needs of women veterans after the Department of Defense change in combat assignment policy.

PubMed

Amara, Jomana; Iverson, Katherine M; Krengel, Maxine; Pogoda, Terri K; Hendricks, Ann

2014-01-01

Female service members' presence in combat zones during Operation Enduring Freedom and Operation Iraqi Freedom is unprecedented both in terms of the number of women deployed and the nature of their involvement. In light of changing Department of Defense policy governing the deployment of women in combat zones, this article intends to set the groundwork for estimating future combat-related injuries and subsequent Veterans Health Administration (VHA) utilization while focusing on traumatic brain injury (TBI). The article summarizes and presents the results of a study that examines veterans who present to VHA for TBI evaluation. For a national sample of veterans, a dataset including information on post-screening utilization, diagnoses, and location of care was constructed. The dataset included self-reported health symptoms and other information obtained from a standardized national VHA post-screening clinical evaluation, the comprehensive TBI evaluation (CTBIE). Both women and men utilize high levels of VHA health care after a CTBIE. However, there are gender differences in the volume and types of services used, with women utilizing different services than their male counterparts and incurring higher costs, including higher overall and outpatient costs. As women veterans seek more of their health care from the VHA, there will be a need for more coordinated care to identify and manage deployment-related TBI and common comorbidities such as posttraumatic stress disorder, depression, and chronic pain. Deployment-connected injuries are likely to rise because of the rescinding of the ban on women in combat. This in turn has critical implications for VHA strategic planning and budgeting. Published by Elsevier Inc.

28 CFR 548.13 - Schedules and facilities.

Code of Federal Regulations, 2011 CFR

2011-07-01

... 28 Judicial Administration 2 2011-07-01 2011-07-01 false Schedules and facilities. 548.13 Section 548.13 Judicial Administration BUREAU OF PRISONS, DEPARTMENT OF JUSTICE INSTITUTIONAL MANAGEMENT RELIGIOUS PROGRAMS Religious Beliefs and Practices of Committed Offenders § 548.13 Schedules and facilities...

28 CFR 548.13 - Schedules and facilities.

Code of Federal Regulations, 2010 CFR

2010-07-01

... 28 Judicial Administration 2 2010-07-01 2010-07-01 false Schedules and facilities. 548.13 Section 548.13 Judicial Administration BUREAU OF PRISONS, DEPARTMENT OF JUSTICE INSTITUTIONAL MANAGEMENT RELIGIOUS PROGRAMS Religious Beliefs and Practices of Committed Offenders § 548.13 Schedules and facilities...

28 CFR 548.13 - Schedules and facilities.

Code of Federal Regulations, 2014 CFR

2014-07-01

... 28 Judicial Administration 2 2014-07-01 2014-07-01 false Schedules and facilities. 548.13 Section 548.13 Judicial Administration BUREAU OF PRISONS, DEPARTMENT OF JUSTICE INSTITUTIONAL MANAGEMENT RELIGIOUS PROGRAMS Religious Beliefs and Practices of Committed Offenders § 548.13 Schedules and facilities...

28 CFR 548.13 - Schedules and facilities.

Code of Federal Regulations, 2012 CFR

2012-07-01

... 28 Judicial Administration 2 2012-07-01 2012-07-01 false Schedules and facilities. 548.13 Section 548.13 Judicial Administration BUREAU OF PRISONS, DEPARTMENT OF JUSTICE INSTITUTIONAL MANAGEMENT RELIGIOUS PROGRAMS Religious Beliefs and Practices of Committed Offenders § 548.13 Schedules and facilities...

28 CFR 548.13 - Schedules and facilities.

Code of Federal Regulations, 2013 CFR

2013-07-01

... 28 Judicial Administration 2 2013-07-01 2013-07-01 false Schedules and facilities. 548.13 Section 548.13 Judicial Administration BUREAU OF PRISONS, DEPARTMENT OF JUSTICE INSTITUTIONAL MANAGEMENT RELIGIOUS PROGRAMS Religious Beliefs and Practices of Committed Offenders § 548.13 Schedules and facilities...

20 CFR 404.1623 - Facilities.

Code of Federal Regulations, 2010 CFR

2010-04-01

... 20 Employees' Benefits 2 2010-04-01 2010-04-01 false Facilities. 404.1623 Section 404.1623...- ) Determinations of Disability Administrative Responsibilities and Requirements § 404.1623 Facilities. (a) Space... determinations. (b) Location of facilities. Subject to appropriate Federal funding, the State will determine the...

42 CFR 485.56 - Condition of participation: Governing body and administration.

Code of Federal Regulations, 2014 CFR

2014-10-01

... behalf of the administrator; and (4) Retains professional and administrative responsibility for all personnel providing facility services. (c) Standard: Group of professional personnel. The facility must have a group of professional personnel associated with the facility that— (1) Develops and periodically...

42 CFR 485.56 - Condition of participation: Governing body and administration.

Code of Federal Regulations, 2012 CFR

2012-10-01

... behalf of the administrator; and (4) Retains professional and administrative responsibility for all personnel providing facility services. (c) Standard: Group of professional personnel. The facility must have a group of professional personnel associated with the facility that— (1) Develops and periodically...

42 CFR 485.56 - Condition of participation: Governing body and administration.

Code of Federal Regulations, 2011 CFR

2011-10-01

... behalf of the administrator; and (4) Retains professional and administrative responsibility for all personnel providing facility services. (c) Standard: Group of professional personnel. The facility must have a group of professional personnel associated with the facility that— (1) Develops and periodically...

42 CFR 485.56 - Condition of participation: Governing body and administration.

Code of Federal Regulations, 2013 CFR

2013-10-01

... behalf of the administrator; and (4) Retains professional and administrative responsibility for all personnel providing facility services. (c) Standard: Group of professional personnel. The facility must have a group of professional personnel associated with the facility that— (1) Develops and periodically...

FEDERAL FACILITIES IN EPA REGION 6

EPA Science Inventory

Locations of federal facilities in EPA Region 6. Facilities from the Corps of Engineers, Veterans Administration, Army, Navy, Air National Guard, etc. are included. This is not a complete set of facilities. The facilities included are only those with value added locations used in...

78 FR 22553 - Generic Drug Facilities, Sites, and Organizations

Federal Register 2010, 2011, 2012, 2013, 2014

2013-04-16

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Food and Drug Administration [Docket No. FDA-2013-N-0391] Generic Drug Facilities, Sites, and Organizations AGENCY: Food and Drug Administration, HHS. ACTION: Notice. SUMMARY: The Food and Drug Administration (FDA) is announcing that the generic drug facility self...

77 FR 60125 - Generic Drug Facilities, Sites and Organizations

Federal Register 2010, 2011, 2012, 2013, 2014

2012-10-02

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Food and Drug Administration [Docket No. FDA-2012-N-1006] Generic Drug Facilities, Sites and Organizations AGENCY: Food and Drug Administration, HHS. ACTION: Notice of Requirement. SUMMARY: The Food and Drug Administration (FDA) is notifying generic drug facilities...

28 CFR 54.410 - Comparable facilities.

Code of Federal Regulations, 2010 CFR

2010-07-01

... 28 Judicial Administration 2 2010-07-01 2010-07-01 false Comparable facilities. 54.410 Section 54... in Education Programs or Activities Prohibited § 54.410 Comparable facilities. A recipient may provide separate toilet, locker room, and shower facilities on the basis of sex, but such facilities...

21 CFR 606.40 - Facilities.

Code of Federal Regulations, 2011 CFR

2011-04-01

... 21 Food and Drugs 7 2011-04-01 2010-04-01 true Facilities. 606.40 Section 606.40 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) BIOLOGICS CURRENT GOOD MANUFACTURING PRACTICE FOR BLOOD AND BLOOD COMPONENTS Plant and Facilities § 606.40 Facilities...

21 CFR 606.40 - Facilities.

Code of Federal Regulations, 2010 CFR

2010-04-01

... 21 Food and Drugs 7 2010-04-01 2010-04-01 false Facilities. 606.40 Section 606.40 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) BIOLOGICS CURRENT GOOD MANUFACTURING PRACTICE FOR BLOOD AND BLOOD COMPONENTS Plant and Facilities § 606.40 Facilities...

A comparative analysis of vaccine administration in urban and non-urban skilled nursing facilities.

PubMed

Pu, Yuan; Dolar, Veronika; Gucwa, Azad L

2016-07-29

The U.S. population is aging at an unprecedented rate, resulting in an increased demand for skilled nursing facilities (SNFs) and long-term care. Residents of these facilities are at a high risk for pneumococcal disease or severe influenza-related illnesses and death. For these reasons, the Centers for Medicare and Medicaid Services use influenza and pneumococcal vaccination rates as a quality measure in the assessment of SNFs, as complications related to these infections increase morbidity and mortality rates. Disparities have been reported amongst vaccination with increased rates in urban areas as compared to their non-urban counterparts. Statistical analyses were performed to compare influenza and pneumococcal vaccination in urban and non-urban SNFs to determine variables that may influence vaccination status. Of the 15,639 nursing homes included in the study, 10,107 were in urban areas, while 5532 were considered non-urban. We found the percent of eligible and willing residents with up-to-date influenza and pneumococcal vaccinations increased with overall five-star ratings of SNFs. Somewhat paradoxically, although urban SNFs had higher mean overall five-star ratings, they showed lower rates of influenza and pneumococcal vaccination compared to non-urban SNFs. Ordinary least squares regression analysis comparing overall ratings, type of ownership, and geographic location by region yielded statistically significant results in which the overall rating, ownership-type and certificate-type favored urban SNFs (p < 0.001). This is the first systematic and comparative analysis to use the Nursing Home Compare database to assess vaccine administration of urban and non-urban SNFs. The findings of this study may be used to encourage the development of programs to improve vaccination rates and the quality of care in these facilities.

Facility-Level Characteristics Associated with Serious Suicide Attempts and Deaths from Suicide in Juvenile Justice Residential Facilities

ERIC Educational Resources Information Center

Gallagher, Catherine A.; Dobrin, Adam

2006-01-01

Little is known about how facility-level characteristics affect the risk of suicide and suicide attempts in juvenile justice residential facilities. This leaves facility administrators and mental health providers without evidence-based guidance on how the facility itself affects risks. The current study uses data from two recently developed…

Administration of Computer Resources.

ERIC Educational Resources Information Center

Franklin, Gene F.

Computing at Stanford University has, until recently, been performed at one of five facilities. The Stanford hospital operates an IBM 370/135 mainly for administrative use. The university business office has an IBM 370/145 for its administrative needs and support of the medical clinic. Under the supervision of the Stanford Computation Center are…

Veterans Experiencing Elder Abuse: Improving Care of a High-Risk Population About Which Little Is Known.

PubMed

Makaroun, Lena K; Taylor, Laura; Rosen, Tony

2018-02-01

At least 10% of older adults experience abuse, neglect, or exploitation annually in the United States, and this problem is expected to grow as our population ages. Little is known about the prevalence and characteristics of elder abuse of veterans, but it is likely that this population is at high risk based on established elder abuse risk factors. Veterans who receive their care through the Veterans Health Administration (VHA) have a higher prevalence of poor psychological health, poor physical health, functional impairment, cognitive impairment, and social isolation than the general population. As the largest integrated healthcare system in the United States, the VHA has long been a leader in the development of innovative, integrated care programs for older adults. The VHA has another opportunity to lead by promoting research, clinical care, and education on elder abuse, furthering their mission of serving those who served. This article outlines the rationale for developing a research agenda for elder abuse in the VHA, as well as potential first steps toward understanding more about this complex problem affecting veterans. © 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society.

30 CFR 71.400 - Bathing facilities; change rooms; sanitary flush toilet facilities.

Code of Federal Regulations, 2010 CFR

2010-07-01

... flush toilet facilities. 71.400 Section 71.400 Mineral Resources MINE SAFETY AND HEALTH ADMINISTRATION, DEPARTMENT OF LABOR COAL MINE SAFETY AND HEALTH MANDATORY HEALTH STANDARDS-SURFACE COAL MINES AND SURFACE... installations and at the surface worksites of such mine. (Note: Sanitary facilities at surface work areas of...

42 CFR 431.105 - Consultation to medical facilities.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 4 2013-10-01 2013-10-01 false Consultation to medical facilities. 431.105 Section... SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS STATE ORGANIZATION AND GENERAL ADMINISTRATION Administrative Requirements: Provider Relations § 431.105 Consultation to medical facilities. (a) Basis and...

42 CFR 431.105 - Consultation to medical facilities.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 4 2014-10-01 2014-10-01 false Consultation to medical facilities. 431.105 Section... SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS STATE ORGANIZATION AND GENERAL ADMINISTRATION Administrative Requirements: Provider Relations § 431.105 Consultation to medical facilities. (a) Basis and...

42 CFR 431.105 - Consultation to medical facilities.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 4 2012-10-01 2012-10-01 false Consultation to medical facilities. 431.105 Section... SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS STATE ORGANIZATION AND GENERAL ADMINISTRATION Administrative Requirements: Provider Relations § 431.105 Consultation to medical facilities. (a) Basis and...

42 CFR 431.105 - Consultation to medical facilities.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 4 2011-10-01 2011-10-01 false Consultation to medical facilities. 431.105 Section... SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS STATE ORGANIZATION AND GENERAL ADMINISTRATION Administrative Requirements: Provider Relations § 431.105 Consultation to medical facilities. (a) Basis and...

Veterans Affairs: Sustained Management Attention Needed to Address Numerous IT Challenges

DTIC Science & Technology

2016-06-22

territories and the Philippines. The department’s three major components—the Veterans Benefits Administration ( VBA ), the Veterans Health Administration...VHA), and the National Cemetery Administration (NCA)—are primarily responsible for carrying out its mission. More specifically, VBA provides a...used for the determination of benefits, benefits claims processing, patient admission to hospitals and clinics, and access to health records, among

78 FR 73926 - Veterans' Rural Health Advisory Committee; Notice of Meeting

Federal Register 2010, 2011, 2012, 2013, 2014

2013-12-09

... Administration (VHA) Office of Rural Health (ORH). The Committee will hear a presentation on the Women's Health... Manager, Regulation Policy and Management, Office of the General Counsel. [FR Doc. 2013-29301 Filed 12-6...

7 CFR 1466.2 - Administration.

Code of Federal Regulations, 2010 CFR

2010-01-01

... 7 Agriculture 10 2010-01-01 2010-01-01 false Administration. 1466.2 Section 1466.2 Agriculture Regulations of the Department of Agriculture (Continued) COMMODITY CREDIT CORPORATION, DEPARTMENT OF... § 1466.2 Administration. (a) The funds, facilities, and authorities of the Commodity Credit Corporation...

7 CFR 1436.2 - Administration.

Code of Federal Regulations, 2010 CFR

2010-01-01

... 7 Agriculture 10 2010-01-01 2010-01-01 false Administration. 1436.2 Section 1436.2 Agriculture Regulations of the Department of Agriculture (Continued) COMMODITY CREDIT CORPORATION, DEPARTMENT OF... Administration. (a) The Farm Storage Facility Loan Program will be administered under the general supervision of...

7 CFR 1436.2 - Administration.

Code of Federal Regulations, 2013 CFR

2013-01-01

... 7 Agriculture 10 2013-01-01 2013-01-01 false Administration. 1436.2 Section 1436.2 Agriculture Regulations of the Department of Agriculture (Continued) COMMODITY CREDIT CORPORATION, DEPARTMENT OF... Administration. (a) The Farm Storage Facility Loan Program will be administered under the general supervision of...

7 CFR 1436.2 - Administration.

Code of Federal Regulations, 2014 CFR

2014-01-01

... 7 Agriculture 10 2014-01-01 2014-01-01 false Administration. 1436.2 Section 1436.2 Agriculture Regulations of the Department of Agriculture (Continued) COMMODITY CREDIT CORPORATION, DEPARTMENT OF... Administration. (a) The Farm Storage Facility Loan Program will be administered under the general supervision of...

7 CFR 1466.2 - Administration.

Code of Federal Regulations, 2013 CFR

2013-01-01

... 7 Agriculture 10 2013-01-01 2013-01-01 false Administration. 1466.2 Section 1466.2 Agriculture Regulations of the Department of Agriculture (Continued) COMMODITY CREDIT CORPORATION, DEPARTMENT OF... § 1466.2 Administration. (a) The funds, facilities, and authorities of the Commodity Credit Corporation...

7 CFR 1436.2 - Administration.

Code of Federal Regulations, 2011 CFR

2011-01-01

... 7 Agriculture 10 2011-01-01 2011-01-01 false Administration. 1436.2 Section 1436.2 Agriculture Regulations of the Department of Agriculture (Continued) COMMODITY CREDIT CORPORATION, DEPARTMENT OF... Administration. (a) The Farm Storage Facility Loan Program will be administered under the general supervision of...

7 CFR 1466.2 - Administration.

Code of Federal Regulations, 2011 CFR

2011-01-01

... 7 Agriculture 10 2011-01-01 2011-01-01 false Administration. 1466.2 Section 1466.2 Agriculture Regulations of the Department of Agriculture (Continued) COMMODITY CREDIT CORPORATION, DEPARTMENT OF... § 1466.2 Administration. (a) The funds, facilities, and authorities of the Commodity Credit Corporation...

A Basic Manual for Physical Plant Administration.

ERIC Educational Resources Information Center

Weber, George O., Ed.; Fincham, Michael W., Ed.

This book provides practical advice on problems of institutional plant management to physical plant administrators. Areas covered include the role, organization, and facilities of the physical plant department; personnel administration; financial administration; buildings maintenance and operation; custodial services; utilities distribution…

Factor structure of posttraumatic stress disorder symptoms in OEF/OIF veterans presenting to a polytrauma clinic.

PubMed

Maestas, Kacey Little; Benge, Jared F; Pastorek, Nicholas J; Lemaire, Ashley; Darrow, Rachel

2011-11-01

A significant number of Operation Iraqi Freedom/Operation Enduring Freedom (OEF/OIF) veterans are returning from deployment and presenting to Veterans Health Administration (VHA) polytrauma clinics with elevated rates of posttraumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI). Inherent to the accurate assessment and treatment of this diagnostically complex group of veterans is the assumption that the construct of PTSD is the same in this population as in other trauma groups. To our knowledge, no previous study has examined the structure of PTSD in this relevant and fast-growing population of treatment-seeking OEF/OIF veterans. Evidence suggests that the latent structure of PTSD symptoms is best represented by a four-factor model, rather than the three-factor model found in the current DSM-IV-TR. Thus, we examined the three and four-factor models using the PTSD Check List-Civilian (PCL-C) in a sample of treatment-seeking OEF/OIF veterans seen through a VHA polytrauma clinic. A chart review was conducted for OEF/OIF veterans (N = 361) seen through a VHA outpatient polytrauma clinic from September 2007 through August 2008. Participants completed the PCL-C as part of a comprehensive polytrauma evaluation. Confirmatory factor analyses showed that the DSM-IV-TR three-factor model did not fit the data well. A direct comparison showed that the four-factor model provided a superior fit relative to the three-factor model. Results extend the generalizability of the four-factor model to OEF/OIF veterans presenting to Veterans Health Administration (VHA) polytrauma clinics.

5 CFR 1636.150 - Program accessibility: Existing facilities.

Code of Federal Regulations, 2010 CFR

2010-01-01

... facilities. 1636.150 Section 1636.150 Administrative Personnel FEDERAL RETIREMENT THRIFT INVESTMENT BOARD... RETIREMENT THRIFT INVESTMENT BOARD § 1636.150 Program accessibility: Existing facilities. (a) General. The... fundamental alteration in the nature of a program or activity or in undue financial and administrative burdens...

Engagement in the Hepatitis C Care Cascade Among Homeless Veterans, 2015.

PubMed

Noska, Amanda J; Belperio, Pamela S; Loomis, Timothy P; O'Toole, Thomas P; Backus, Lisa I

The Veterans Health Administration (VHA) is the largest provider of hepatitis C virus (HCV) care nationally and provides health care to >200 000 homeless veterans each year. We used the VHA's Corporate Data Warehouse and HCV Clinical Case Registry to evaluate engagement in the HCV care cascade among homeless and nonhomeless veterans in VHA care in 2015. We estimated that, among 242 740 homeless veterans in care and 5 424 712 nonhomeless veterans in care, 144 964 (13.4%) and 188 156 (3.5%), respectively, had chronic HCV infection. Compared with nonhomeless veterans, homeless veterans were more likely to be diagnosed with chronic HCV infection and linked to HCV care but less likely to have received antiviral therapy despite comparable sustained virologic response rates. Homelessness should not necessarily preclude HCV treatment eligibility with available all-oral antiviral regimens.

42 CFR 493.1101 - Standard: Facilities.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 5 2010-10-01 2010-10-01 false Standard: Facilities. 493.1101 Section 493.1101... (CONTINUED) STANDARDS AND CERTIFICATION LABORATORY REQUIREMENTS Facility Administration for Nonwaived Testing § 493.1101 Standard: Facilities. (a) The laboratory must be constructed, arranged, and maintained to...

49 CFR 27.71 - Airport facilities.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 49 Transportation 1 2010-10-01 2010-10-01 false Airport facilities. 27.71 Section 27.71... Administration Programs: Airports, Railroads, and Highways § 27.71 Airport facilities. (a) This section applies... financial assistance at a commercial service airport, including parking and ground transportation facilities...

49 CFR 27.71 - Airport facilities.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 49 Transportation 1 2012-10-01 2012-10-01 false Airport facilities. 27.71 Section 27.71... Administration Programs: Airports, Railroads, and Highways § 27.71 Airport facilities. (a) This section applies... financial assistance at a commercial service airport, including parking and ground transportation facilities...

49 CFR 27.71 - Airport facilities.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 49 Transportation 1 2013-10-01 2013-10-01 false Airport facilities. 27.71 Section 27.71... Administration Programs: Airports, Railroads, and Highways § 27.71 Airport facilities. (a) This section applies... financial assistance at a commercial service airport, including parking and ground transportation facilities...

America's neglected veterans: 1.7 million who served have no health coverage.

PubMed

Woolhandler, Steffie; Himmelstein, David U; Distajo, Ronald; Lasser, Karen E; McCormick, Danny; Bor, David H; Wolfe, Sidney M

2005-01-01

Many U.S. military veterans lack health insurance and are ineligible for care in Veterans Administration health care facilities. Using two recently released national government surveys--the 2004 Current Population Survey and the 2002 National Health Interview Survey--the authors examined how many veterans are uninsured (lacking health insurance coverage and not receiving care from the VA) and whether uninsured veterans have problems in access to care. In 2003, 1.69 million military veterans neither had health insurance nor received ongoing care at Veterans Health Administration (VHA) hospitals or clinics; the number of uninsured veterans increased by 235,159 since 2000. The proportion of nonelderly veterans who were uninsured rose from 9.9 percent in 2000 to 11.9 percent in 2003. An additional 3.90 million members of veterans' households were also uninsured and ineligible for VHA care. Medicare covered virtually all Korean War and World War II veterans, but 681,808 Vietnam-era veterans were uninsured (8.7 percent of the 7.85 million Vietnam-era vets). Among the 8.27 million veterans who served during "other eras" (including the Persian Gulf War), 12.1 percent (999,548) lacked health coverage. A disturbingly high number of veterans reported problems in obtaining needed medical care. By almost any measure, uninsured veterans had as much trouble getting medical care as other uninsured persons. Thus millions of U.S. veterans and their family members are uninsured and face grave difficulties in gaining access to even the most basic medical care.

National epidemiology of initial and recurrent Clostridium difficile infection in the Veterans Health Administration from 2003 to 2014.

PubMed

Reveles, Kelly R; Lawson, Kenneth A; Mortensen, Eric M; Pugh, Mary Jo V; Koeller, Jim M; Argamany, Jacqueline R; Frei, Christopher R

2017-01-01

Prior studies demonstrated marked increases in Clostridium difficile infection (CDI) in the United States (U.S.) in recent years. The objective of this study was to describe the epidemiology of initial and recurrent CDI in a national Veterans Health Administration (VHA) cohort over a 12-year period. This was a retrospective cohort study of all adult VHA beneficiaries with CDI (ICD-9-CM code 008.45) plus a positive CDI stool test between October 1, 2002 and September 30, 2014. Data were obtained from the VA Informatics and Computing Infrastructure. Recurrence was defined as a second ICD-9-CM code plus a new course of CDI therapy following a minimum three-day gap after the initial therapy was completed. CDI incidence and outcomes were presented descriptively and longitudinally. Overall, 30,326 patients met study inclusion criteria. CDI incidence increased from FY 2003 (1.6 per 10,000) to FY 2013 (5.1 per 10,000). Thereafter, CDI incidence decreased through FY 2014 (4.6 per 10,000). A total of 5,011 patients (17%) experienced a first recurrence and, of those, 1,713 (34%) experienced a second recurrence. Recurrence incidence increased 10-fold over the study period, from (0.1 per 10,000) in FY 2003, to (1.0 per 10,000) in FY 2014. Overall, 30-day mortality and median hospital length of stay (LOS) decreased among initial episodes over the study period. Mortality was higher for initial episodes (21%) compared to first recurrences (11%) and second recurrences (7%). Median hospital LOS was longer for first episodes (13 days) compared to first (9 days) and second recurrences (8 days). Initial and recurrent CDI episodes increased among veterans over a 12-year period. Outcomes, such as mortality and hospital LOS improved in recent years; both of these outcomes are worse for initial CDI episodes than recurrent episodes.

77 FR 21622 - Special Medical Advisory Group; Notice of Meeting

Federal Register 2010, 2011, 2012, 2013, 2014

2012-04-10

... Affiliations Council, ethics, an update on social services, and the White House initiative, ``Joining Forces... Administrative Operations (10B), VHA, 810 Vermont Avenue NW., Washington, DC 20420, or by email at j.t[email protected

New Trends in Facility Asset Management.

ERIC Educational Resources Information Center

Adams, Matt

2000-01-01

Explains new, positive trends in facility asset management that encompasses greater acceptance and involvement of facility managers in the financial planning process, greater awareness of the need for maintenance, and facility administrators taking a greater role with business officers. The new climate for alternative renewal financing proposals…

Adaptation of Lean Six Sigma Methodologies for the Evaluation of Veterans Choice Program at 3 Urban Veterans Affairs Medical Centers.

PubMed

Ball, Sherry L; Stevenson, Lauren D; Ladebue, Amy C; McCreight, Marina S; Lawrence, Emily C; Oestreich, Taryn; Lambert-Kerzner, Anne C

2017-07-01

The Veterans Health Administration (VHA) is adapting to meet the changing needs of our Veterans. VHA leaders are promoting quality improvement strategies including Lean Six Sigma (LSS). This study used LSS tools to evaluate the Veterans Choice Program (VCP), a program that aims to improve access to health care services for eligible Veterans by expanding health care options to non-VHA providers. LSS was utilized to assess the current process and efficiency patterns of the VCP at 3 VHA Medical Centers. LSS techniques were used to assess data obtained through semistructured interviews with Veterans, staff, and providers to describe and evaluate the VCP process by identifying wastes and defects. The LSS methodology facilitated the process of targeting priorities for improvement and constructing suggestions to close identified gaps and inefficiencies. Identified key process wastes included inefficient exchange of clinical information between stakeholders in and outside of the VHA; poor dissemination of VCP programmatic information; shortages of VCP-participating providers; duplication of appointments; declines in care coordination; and lack of program adaptability to local processes. Recommendations for improvement were formulated using LSS. This evaluation illustrates how LSS can be utilized to assess a nationally mandated health care program. By focusing on stakeholder, staff, and Veteran perspectives, process defects in the VCP were identified and improvement recommendations were made. However, the current LSS language used is not intuitive in health care and similar applications of LSS may consider using new language and goals adapted specifically for health care.

Mortality Disparities in Racial/Ethnic Minority Groups in the Veterans Health Administration: An Evidence Review and Map

PubMed Central

Anderson, Johanna; Boundy, Erin; Ferguson, Lauren; McCleery, Ellen; Waldrip, Kallie

2018-01-01

Background. Continued racial/ethnic health disparities were recently described as “the most serious and shameful health care issue of our time.” Although the 2014 US Affordable Care Act–mandated national insurance coverage expansion has led to significant improvements in health care coverage and access, its effects on life expectancy are not yet known. The Veterans Health Administration (VHA), the largest US integrated health care system, has a sustained commitment to health equity that addresses all 3 stages of health disparities research: detection, understanding determinants, and reduction or elimination. Despite this, racial disparities still exist in the VHA across a wide range of clinical areas and service types. Objectives. To inform the health equity research agenda, we synthesized evidence on racial/ethnic mortality disparities in the VHA. Search Methods. Our research librarian searched MEDLINE and Cochrane Central Registry of Controlled Trials from October 2006 through February 2017 using terms for racial groups and disparities. Selection Criteria. We included studies if they compared mortality between any racial/ethnic minority and nonminority veteran groups or between different minority groups in the VHA (PROSPERO# CRD42015015974). We made study selection decisions on the basis of prespecified eligibility criteria. They were first made by 1 reviewer and checked by a second and disagreements were resolved by consensus (sequential review). Data Collection and Analysis. Two reviewers sequentially abstracted data on prespecified population, outcome, setting, and study design characteristics. Two reviewers sequentially graded the strength of evidence using prespecified criteria on the basis of 5 key domains: study limitations (study design and internal validity), consistency, directness, precision of the evidence, and reporting biases. We synthesized the evidence qualitatively by grouping studies first by racial/ethnic minority group and then by

38 CFR 51.210 - Administration.

Code of Federal Regulations, 2010 CFR

2010-07-01

... FOR NURSING HOME CARE OF VETERANS IN STATE HOMES Standards § 51.210 Administration. A facility must be... (annual at time of survey); (6) The number of nursing home patients who are veterans and non-veterans, the... Veterans. The percent of the facility residents eligible for VA nursing home care must be at least 75...

38 CFR 51.210 - Administration.

Code of Federal Regulations, 2011 CFR

2011-07-01

... FOR NURSING HOME CARE OF VETERANS IN STATE HOMES Standards § 51.210 Administration. A facility must be... (annual at time of survey); (6) The number of nursing home patients who are veterans and non-veterans, the... Veterans. The percent of the facility residents eligible for VA nursing home care must be at least 75...

38 CFR 51.210 - Administration.

Code of Federal Regulations, 2012 CFR

2012-07-01

... FOR NURSING HOME CARE OF VETERANS IN STATE HOMES Standards § 51.210 Administration. A facility must be... (annual at time of survey); (6) The number of nursing home patients who are veterans and non-veterans, the... Veterans. The percent of the facility residents eligible for VA nursing home care must be at least 75...

38 CFR 51.210 - Administration.

Code of Federal Regulations, 2013 CFR

2013-07-01

... FOR NURSING HOME CARE OF VETERANS IN STATE HOMES Standards § 51.210 Administration. A facility must be... (annual at time of survey); (6) The number of nursing home patients who are veterans and non-veterans, the... Veterans. The percent of the facility residents eligible for VA nursing home care must be at least 75...

49 CFR 27.71 - Airport facilities.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 49 Transportation 1 2011-10-01 2011-10-01 false Airport facilities. 27.71 Section 27.71... Administration Programs: Airports, Railroads, and Highways § 27.71 Airport facilities. (a) This section applies to all terminal facilities and services owned, leased, or operated on any basis by a recipient of DOT...

28 CFR 115.252 - Exhaustion of administrative remedies.

Code of Federal Regulations, 2013 CFR

2013-07-01

... 28 Judicial Administration 2 2013-07-01 2013-07-01 false Exhaustion of administrative remedies. 115.252 Section 115.252 Judicial Administration DEPARTMENT OF JUSTICE (CONTINUED) PRISON RAPE ELIMINATION ACT NATIONAL STANDARDS Standards for Community Confinement Facilities Reporting § 115.252...

28 CFR 115.252 - Exhaustion of administrative remedies.

Code of Federal Regulations, 2014 CFR

2014-07-01

... 28 Judicial Administration 2 2014-07-01 2014-07-01 false Exhaustion of administrative remedies. 115.252 Section 115.252 Judicial Administration DEPARTMENT OF JUSTICE (CONTINUED) PRISON RAPE ELIMINATION ACT NATIONAL STANDARDS Standards for Community Confinement Facilities Reporting § 115.252...

28 CFR 115.252 - Exhaustion of administrative remedies.

Code of Federal Regulations, 2012 CFR

2012-07-01

... 28 Judicial Administration 2 2012-07-01 2012-07-01 false Exhaustion of administrative remedies. 115.252 Section 115.252 Judicial Administration DEPARTMENT OF JUSTICE (CONTINUED) PRISON RAPE ELIMINATION ACT NATIONAL STANDARDS Standards for Community Confinement Facilities Reporting § 115.252...

[Autonomy for financial management in public and private healthcare facilities in Brazil].

PubMed

Santos, Maria Angelica Borges dos; Madeira, Fátima Carvalho; Passos, Sonia Regina Lambert; Bakr, Felipe; Oliveira, Klivia Brayner de; Andreazzi, Marco Antonio Ratzsch de

2014-01-01

Autonomy in financial management is an advantage in public administration. A 2009 National Healthcare Facility Survey showed that 3.9% of Brazil's 52,055 public healthcare facilities had some degree of financial autonomy. Such autonomy was more common in inpatient facilities (17.8%), those managed by State governments (26.3%), and in Southern Brazil (6.6%). Autonomy was mainly partial (for resources in specific areas, relating to small outlays, consumables and capital goods, and outsourced services or personnel). 74.3% of 2,264 public facilities with any financial autonomy were under direct government administration. Financial autonomy in public healthcare facilities appears to be linked to local political decisions and not necessarily to the facility's specific legal and administrative status. However, legal status displays distinct scopes of autonomy - those under direct government administration tend to be less autonomous, and those under private businesses more autonomous; 85.8% of the 45,394 private healthcare facilities reported that they were financially autonomous.

Redesign of a computerized clinical reminder for colorectal cancer screening: a human-computer interaction evaluation

PubMed Central

2011-01-01

Background Based on barriers to the use of computerized clinical decision support (CDS) learned in an earlier field study, we prototyped design enhancements to the Veterans Health Administration's (VHA's) colorectal cancer (CRC) screening clinical reminder to compare against the VHA's current CRC reminder. Methods In a controlled simulation experiment, 12 primary care providers (PCPs) used prototypes of the current and redesigned CRC screening reminder in a within-subject comparison. Quantitative measurements were based on a usability survey, workload assessment instrument, and workflow integration survey. We also collected qualitative data on both designs. Results Design enhancements to the VHA's existing CRC screening clinical reminder positively impacted aspects of usability and workflow integration but not workload. The qualitative analysis revealed broad support across participants for the design enhancements with specific suggestions for improving the reminder further. Conclusions This study demonstrates the value of a human-computer interaction evaluation in informing the redesign of information tools to foster uptake, integration into workflow, and use in clinical practice. PMID:22126324

[Design of a supervision model for administration of the Child Development Evaluation Test at primary care facilities in Mexico].

PubMed

Villasís-Keever, Miguel Ángel; Rizzoli-Córdoba, Antonio; Delgado-Ginebra, Ismael; Mares-Serratos, Blanca Berenice; Martell-Valdez, Liliana; Sánchez-Velázquez, Olivia; Reyes-Morales, Hortensia; O'Shea-Cuevas, Gabriel; Aceves-Villagrán, Daniel; Carrasco-Mendoza, Joaquín; Antillón-Ocampo, Fátima Adriana; Villagrán-Muñoz, Víctor Manuel; Halley-Castillo, Elizabeth; Baqueiro-Hernández, César Iván; Pizarro-Castellanos, Mariel; Martain-Pérez, Itzamara Jacqueline; Palma-Tavera, Josuha Alexander; Vargas-López, Guillermo; Muñoz-Hernández, Onofre

The Child Development Evaluation (CDE) test designed and validated in Mexico has been used as a screening tool for developmental problems in primary care facilities across Mexico. Heterogeneous results were found among those states where these were applied, despite using the same standardized training model for application. The objective was to evaluate a supervision model for quality of application of the CDE test at primary care facilities. A study was carried out in primary care facilities from three Mexican states to evaluate concordance of the results between supervisor and primary care personnel who administered the test using two different methods: direct observation (shadow study) or reapplication of the CDE test (consistency study). There were 380 shadow studies applied to 51 psychologists. General concordance of the shadow study was 86.1% according to the supervisor: green 94.5%, yellow 73.2% and red 80.0%. There were 302 re-test evaluations with a concordance of 88.1% (n=266): green 96.8%, yellow 71.7% and red 81.8%. There were no differences between CDE test subgroups by age. Both shadow and re-test study were adequate for the evaluation of the quality of the administration of the CDE Test and may be useful as a model of supervision in primary care facilities. The decision of which test to use relies on the availability of supervisors. Copyright © 2015 Hospital Infantil de México Federico Gómez. Publicado por Masson Doyma México S.A. All rights reserved.

Engineering directorate technical facilities catalog

NASA Technical Reports Server (NTRS)

Maloy, Joseph E.

1993-01-01

The Engineering Directorate Technical Facilities Catalog is designed to provide an overview of the technical facilities available within the Engineering Directorate at the National Aeronautics and Space Administration (NASA), Lyndon B. Johnson Space Center (JSC) in Houston, Texas. The combined capabilities of these engineering facilities are essential elements of overall JSC capabilities required to manage and perform major NASA engineering programs. The facilities are grouped in the text by chapter according to the JSC division responsible for operation of the facility. This catalog updates the facility descriptions for the JSC Engineering Directorate Technical Facilities Catalog, JSC 19295 (August 1989), and supersedes the Engineering Directorate, Principle test and Development Facilities, JSC, 19962 (November 1984).

28 CFR 115.352 - Exhaustion of administrative remedies.

Code of Federal Regulations, 2012 CFR

2012-07-01

... 28 Judicial Administration 2 2012-07-01 2012-07-01 false Exhaustion of administrative remedies. 115.352 Section 115.352 Judicial Administration DEPARTMENT OF JUSTICE (CONTINUED) PRISON RAPE ELIMINATION ACT NATIONAL STANDARDS Standards for Juvenile Facilities Reporting § 115.352 Exhaustion of...

28 CFR 115.352 - Exhaustion of administrative remedies.

Code of Federal Regulations, 2014 CFR

2014-07-01

... 28 Judicial Administration 2 2014-07-01 2014-07-01 false Exhaustion of administrative remedies. 115.352 Section 115.352 Judicial Administration DEPARTMENT OF JUSTICE (CONTINUED) PRISON RAPE ELIMINATION ACT NATIONAL STANDARDS Standards for Juvenile Facilities Reporting § 115.352 Exhaustion of...

28 CFR 115.352 - Exhaustion of administrative remedies.

Code of Federal Regulations, 2013 CFR

2013-07-01

... 28 Judicial Administration 2 2013-07-01 2013-07-01 false Exhaustion of administrative remedies. 115.352 Section 115.352 Judicial Administration DEPARTMENT OF JUSTICE (CONTINUED) PRISON RAPE ELIMINATION ACT NATIONAL STANDARDS Standards for Juvenile Facilities Reporting § 115.352 Exhaustion of...

A Clinical Nurse Leader (CNL) practice development model to support integration of the CNL role into microsystem care delivery.

PubMed

Kaack, Lorraine; Bender, Miriam; Finch, Michael; Borns, Linda; Grasham, Katherine; Avolio, Alice; Clausen, Shawna; Terese, Nadine A; Johnstone, Diane; Williams, Marjory

The Veterans Health Administration (VHA) Office of Nursing Services (ONS) was an early adopter of Clinical Nurse Leader (CNL) practice, generating some of the earliest pilot data of CNL practice effectiveness. In 2011 the VHA ONS CNL Implementation & Evaluation Service (CNL I&E) piloted a curriculum to facilitate CNL transition to effective practice at local VHA settings. In 2015, the CNL I&E and local VHA setting stakeholders collaborated to refine the program, based on lessons learned at the national and local level. The workgroup reviewed the literature to identify theoretical frameworks for CNL practice and practice development. The workgroup selected Benner et al.'s Novice-to-Expert model as the defining framework for CNL practice development, and Bender et al.'s CNL Practice Model as the defining framework for CNL practice integration. The selected frameworks were cross-walked against existing curriculum elements to identify and clarify additional practice development needs. The work generated key insights into: core stages of transition to effective practice; CNL progress and expectations for each stage; and organizational support structures necessary for CNL success at each stage. The refined CNL development model is a robust tool that can be applied to support consistent and effective integration of CNL practice into care delivery. Published by Elsevier Inc.

From the laboratory to the therapy room: National dissemination and implementation of evidence-based psychotherapies in the U.S. Department of Veterans Affairs Health Care System.

PubMed

Karlin, Bradley E; Cross, Gerald

2014-01-01

Despite their established efficacy and recommendation--often as first-line treatments--in clinical practice guidelines, evidence-based psychotherapies (EBPs) have largely failed to make their way into mainstream clinical settings. Numerous attempts over the years to promote the translation of EBPs from science to practice, typically relying on one-dimensional dissemination approaches, have yielded limited success. As part of the transformation of its mental health care system, the Veterans Health Administration (VHA) of the U.S. Department of Veterans Affairs (VA) is working to disseminate and implement a number of EBPs for various mental and behavioral health conditions throughout the VA health care system. This article examines VHA's multidimensional model and specific strategies, involving policy, provider, local systems, patient, and accountability levels, for promoting the national dissemination and implementation of EBPs in VHA. In addition, the article identifies key lessons learned and next steps for further promoting EBP delivery and sustainability in the VA health care system. Beyond promoting the availability of effective treatments for veterans returning from Iraq and Afghanistan and for veterans of previous combat eras, VHA's EBP dissemination and implementation model and key lessons learned may help to inform other private and public health care systems interested in disseminating and implementing EBPs. PsycINFO Database Record (c) 2014 APA, all rights reserved.

Reduced cost and mortality using home telehealth to promote self-management of complex chronic conditions: a retrospective matched cohort study of 4,999 veteran patients.

PubMed

Darkins, Adam; Kendall, Stephen; Edmonson, Ellen; Young, Michele; Stressel, Pamela

2015-01-01

This retrospective analysis of 2009-2012 Veterans Health Administration (VHA) administrative data assessed the efficacy of care coordination home telehealth (CCHT), a model of care designed to reduce institutional care. Outcomes for 4,999 CCHT-non-institutional care (NIC) patients were compared with usual (non-CCHT) care in a matched cohort group (MCG) of 183,872 Veterans. Both cohorts were comprised of patients with complex chronic conditions with statistically similar baseline (pre-CCHT enrollment) healthcare costs, when adjusted for age, sex, chronic disease, emergency room (ER) visits, hospital admissions, hospital lengths of stay, and pharmacy costs. Subsequent analyses after 12 months of CCHT-NIC enrollment showed mean annual healthcare costs for CCHT-NIC patients fell 4%, from $21,071 to $20,206, whereas the corresponding costs for MCG patients increased 48%, from $20,937 to $31,055. Higher mean annual pharmacy expenditure of 22% ($470 over baseline) for CCHT-NIC patients versus 15% for MCG patients ($326 over baseline) was attributable to the medication compliance effect of better care coordination. Several healthcare cost drivers (e.g., ER visits and admissions) had sizable declines in the CCHT-NIC group. Medicare usage review in both cohorts excluded this as a confounding factor in cost analyses. Prefinal case selection criteria analysis of both cohorts yielded a 9.8% mortality rate in CCHT patients versus 16.58% in non-CCHT patients. This study corroborates previous positive VHA analyses of CCHT but contradicts results from recent non-VHA studies, highlighting the efficacy of the VHA's standardized CCHT model, which incorporates a biopsychosocial approach to care that emphasizes patient self-management.

Pregnancy and Mental Health Among Women Veterans Returning from Iraq and Afghanistan

PubMed Central

Skanderson, Melissa; Goulet, Joseph L.; Brandt, Cynthia; Womack, Julie; Krebs, Erin; Desai, Rani; Justice, Amy; Yano, Elizabeth; Haskell, Sally

2010-01-01

Abstract Background Veterans of Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) may experience significant stress during military service that can have lingering effects. Little is known about mental health problems or treatment among pregnant OEF/OIF women veterans. The aim of this study was to determine the prevalence of mental health problems among veterans who received pregnancy-related care in the Veterans Health Administration (VHA) system. Methods Data from the Defense Manpower Data Center (DMDC) deployment roster of military discharges from October 1, 2001, through April 30, 2008, were used to assemble an administrative cohort of female OEF/OIF veterans enrolled in care at the VHA (n = 43,078). Pregnancy and mental health conditions were quantified according to ICD-9-CM codes and specifications. Mental healthcare use and prenatal care were assessed by analyzing VHA stop codes. Results During the study period, 2966 (7%) women received at least one episode of pregnancy-related care, and 32% of veterans with a pregnancy and 21% without a pregnancy received one or more mental health diagnoses (p < 0.0001). Veterans with a pregnancy were twice as likely to have a diagnosis of depression, anxiety, posttraumatic stress disorder (PTSD), bipolar disorder, or schizophrenia as those without a pregnancy. Conclusions Women OEF/OIF veterans commonly experience mental health problems after military service. The burden of mental health conditions is higher among women with an identified instance of pregnancy than among those without. Because women do not receive pregnancy care at the VHA, however, little is known about ongoing concomitant prenatal and mental healthcare or about pregnancy outcomes among these women veterans. PMID:21039234

Building Capacity for Complementary and Integrative Medicine Through a Large, Cross-Agency, Acupuncture Training Program: Lessons Learned from a Military Health System and Veterans Health Administration Joint Initiative Project.

PubMed

Niemtzow, Richard; Baxter, John; Gallagher, Rollin M; Pock, Arnyce; Calabria, Kathryn; Drake, David; Galloway, Kevin; Walter, Joan; Petri, Richard; Piazza, Thomas; Burns, Stephen; Hofmann, Lew; Biery, John; Buckenmaier, Chester

2018-03-26

Complementary and integrative medicine (CIM) use in the USA continues to expand, including within the Military Health System (MHS) and Veterans Health Administration (VHA). To mitigate the opioid crisis and provide additional non-pharmacological pain management options, a large cross-agency collaborative project sought to develop and implement a systems-wide curriculum, entitled Acupuncture Training Across Clinical Settings (ATACS). ATACS curriculum content and structure were created and refined over the course of the project in response to consultations with Subject Matter Experts and provider feedback. Course content was developed to be applicable to the MHS and VHA environments and training was open to many types of providers. Training included a 4-hr didactic and "hands on" clinical training program focused on a single auricular acupuncture protocol, Battlefield Acupuncture. Trainee learning and skills proficiency were evaluated by trainer-observation and written examination. Immediately following training, providers completed an evaluation survey on their ATACS experience. One month later, they were asked to complete another survey regarding their auricular acupuncture use and barriers to use. The present evaluation describes the ATACS curriculum, faculty and trainee characteristics, as well as trainee and program developer perspectives. Over the course of a 19-mo period, 2,712 providers completed the in-person, 4-hr didactic and hands-on clinical training session. Due to the increasing requests for training, additional ATACS faculty were trained. Overall, 113 providers were approved to be training faculty. Responses from the trainee surveys indicated high satisfaction with the ATACS training program and illuminated several challenges to using auricular acupuncture with patients. The most common reported barrier to using auricular acupuncture was the lack of obtaining privileges to administer auricular acupuncture within clinical practice. The ATACS program

76 FR 35949 - Agency Information Collection (Civil Rights Discrimination Complaint) Activity Under OMB Review

Federal Register 2010, 2011, 2012, 2013, 2014

2011-06-20

... Rights Discrimination Complaint) Activity Under OMB Review AGENCY: Veterans Health Administration... refer to ``OMB Control No. 2900-0662.'' SUPPLEMENTARY INFORMATION: Title: Civil Rights Discrimination... collection. Abstract: Veterans and other VHA customers who believe that their civil rights were violated by...

76 FR 30244 - Veterans' Rural Health Advisory Committee; Notice of Meeting

Federal Register 2010, 2011, 2012, 2013, 2014

2011-05-24

... Integrated Service Network (VISN) 19 Women Veterans Healthcare Coordinator, Montana and surrounding region rural health project managers, the Veterans Rural Health Resource Center--Western Region Native Domain... Network Director, VISN 19 Telehealth Manager, Veterans Health Administration (VHA) lead for the Supporting...

2. Credit PSR. The Administration/Shops Building appears here as the ...

Library of Congress Historic Buildings Survey, Historic Engineering Record, Historic Landscapes Survey

2. Credit PSR. The Administration/Shops Building appears here as the camera looks east (84°). To the right in the view is the Guard House (Building 4279/E-80) which controls entry to the JPL facility. At left is a warehouse (Building 4287/E88). Overhead utility lines supply alternating current to the facility. - Jet Propulsion Laboratory Edwards Facility, Administration & Shops Building, Edwards Air Force Base, Boron, Kern County, CA

Accelerating Research Impact in a Learning Health Care System

PubMed Central

Elwy, A. Rani; Sales, Anne E.; Atkins, David

2017-01-01

Background: Since 1998, the Veterans Health Administration (VHA) Quality Enhancement Research Initiative (QUERI) has supported more rapid implementation of research into clinical practice. Objectives: With the passage of the Veterans Access, Choice and Accountability Act of 2014 (Choice Act), QUERI further evolved to support VHA’s transformation into a Learning Health Care System by aligning science with clinical priority goals based on a strategic planning process and alignment of funding priorities with updated VHA priority goals in response to the Choice Act. Design: QUERI updated its strategic goals in response to independent assessments mandated by the Choice Act that recommended VHA reduce variation in care by providing a clear path to implement best practices. Specifically, QUERI updated its application process to ensure its centers (Programs) focus on cross-cutting VHA priorities and specify roadmaps for implementation of research-informed practices across different settings. QUERI also increased funding for scientific evaluations of the Choice Act and other policies in response to Commission on Care recommendations. Results: QUERI’s national network of Programs deploys effective practices using implementation strategies across different settings. QUERI Choice Act evaluations informed the law’s further implementation, setting the stage for additional rigorous national evaluations of other VHA programs and policies including community provider networks. Conclusions: Grounded in implementation science and evidence-based policy, QUERI serves as an example of how to operationalize core components of a Learning Health Care System, notably through rigorous evaluation and scientific testing of implementation strategies to ultimately reduce variation in quality and improve overall population health. PMID:27997456

Which veterans enroll in a VA health information exchange program?

PubMed

Dixon, Brian E; Ofner, Susan; Perkins, Susan M; Myers, Laura J; Rosenman, Marc B; Zillich, Alan J; French, Dustin D; Weiner, Michael; Haggstrom, David A

2017-01-01

To characterize patients who voluntarily enrolled in an electronic health information exchange (HIE) program designed to share data between Veterans Health Administration (VHA) and non-VHA institutions. Patients who agreed to participate in the HIE program were compared to those who did not. Patient characteristics associated with HIE enrollment were examined using a multivariable logistic regression model. Variables selected for inclusion were guided by a health care utilization model adapted to explain HIE enrollment. Data about patients' sociodemographics (age, gender), comorbidity (Charlson index score), utilization (primary and specialty care visits), and access (distance to VHA medical center, insurance, VHA benefits) were obtained from VHA and HIE electronic health records. Among 57 072 patients, 6627 (12%) enrolled in the HIE program during its first year. The likelihood of HIE enrollment increased among patients ages 50-64, of female gender, with higher comorbidity, and with increasing utilization. Living in a rural area and being unmarried were associated with decreased likelihood of enrollment. Enrollment in HIE is complex, with several factors involved in a patient's decision to enroll. To broaden HIE participation, populations less likely to enroll should be targeted with tailored recruitment and educational strategies. Moreover, inclusion of special populations, such as patients with higher comorbidity or high utilizers, may help refine the definition of success with respect to HIE implementation. Published by Oxford University Press on behalf of the American Medical Informatics Association 2016. This work is written by US Government employees and is in the public domain in the United States.

21 CFR 58.45 - Animal supply facilities.

Code of Federal Regulations, 2011 CFR

2011-04-01

... 21 Food and Drugs 1 2011-04-01 2011-04-01 false Animal supply facilities. 58.45 Section 58.45 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL GOOD LABORATORY PRACTICE FOR NONCLINICAL LABORATORY STUDIES Facilities § 58.45 Animal supply facilities. There...

21 CFR 58.45 - Animal supply facilities.

Code of Federal Regulations, 2012 CFR

2012-04-01

... 21 Food and Drugs 1 2012-04-01 2012-04-01 false Animal supply facilities. 58.45 Section 58.45 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL GOOD LABORATORY PRACTICE FOR NONCLINICAL LABORATORY STUDIES Facilities § 58.45 Animal supply facilities. There...

21 CFR 58.45 - Animal supply facilities.

Code of Federal Regulations, 2014 CFR

2014-04-01

... 21 Food and Drugs 1 2014-04-01 2014-04-01 false Animal supply facilities. 58.45 Section 58.45 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL GOOD LABORATORY PRACTICE FOR NONCLINICAL LABORATORY STUDIES Facilities § 58.45 Animal supply facilities. There...

21 CFR 58.45 - Animal supply facilities.

Code of Federal Regulations, 2013 CFR

2013-04-01

... 21 Food and Drugs 1 2013-04-01 2013-04-01 false Animal supply facilities. 58.45 Section 58.45 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL GOOD LABORATORY PRACTICE FOR NONCLINICAL LABORATORY STUDIES Facilities § 58.45 Animal supply facilities. There...

21 CFR 1271.190 - Facilities.

Code of Federal Regulations, 2011 CFR

2011-04-01

... 21 Food and Drugs 8 2011-04-01 2011-04-01 false Facilities. 1271.190 Section 1271.190 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) REGULATIONS UNDER CERTAIN OTHER ACTS ADMINISTERED BY THE FOOD AND DRUG ADMINISTRATION HUMAN CELLS, TISSUES, AND...

21 CFR 1271.190 - Facilities.

Code of Federal Regulations, 2010 CFR

2010-04-01

... 21 Food and Drugs 8 2010-04-01 2010-04-01 false Facilities. 1271.190 Section 1271.190 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) REGULATIONS UNDER CERTAIN OTHER ACTS ADMINISTERED BY THE FOOD AND DRUG ADMINISTRATION HUMAN CELLS, TISSUES, AND...

14 CFR § 1253.410 - Comparable facilities.

Code of Federal Regulations, 2014 CFR

2014-01-01

... 14 Aeronautics and Space 5 2014-01-01 2014-01-01 false Comparable facilities. § 1253.410 Section § 1253.410 Aeronautics and Space NATIONAL AERONAUTICS AND SPACE ADMINISTRATION NONDISCRIMINATION ON... facilities. A recipient may provide separate toilet, locker room, and shower facilities on the basis of sex...

Health Correlates of Criminal Justice Involvement in 4,793 Transgender Veterans.

PubMed

Brown, George R; Jones, Kenneth T

2015-12-01

Transgender (TG) persons are overrepresented in prison settings and in the U.S. veteran population. Health disparities studies of large populations of transgender people involved with the criminal justice system have not been published to date. We studied a large cohort of TG veterans who received care in Veterans Health Administration (VHA) facilities during 2007-2013 (n = 4,793) and a 3:1 matched control group of veterans without known TG identification (n = 13,625). Three hundred twenty six (n = 138 TG, 188 non-TG) had received VHA services in programs designed to address the needs of justice involved (JI) veterans. We linked patients in each of the three groups to their medical and administrative data. TG veterans were more likely to be justice involved than controls (2.88% vs. 1.38%; P < .0001). Compared to non-TG JI veterans, TG JI veterans were more likely to have a history of homelessness (80% vs. 67%; P < .05) and to have reported sexual trauma while serving in the military (23% vs. 12%; P < .01). Significant health disparities were noted for TG JI veterans for depression, hypertension, obesity, posttraumatic stress disorder, serious mental illness, and suicidal ideation/attempts. These data suggest that TG veterans experience a number of health risks compared to non-TG veterans, including an increased likelihood of justice involvement. TG veterans involved with the criminal justice system are a particularly vulnerable group and services designed to address the health care needs of this population, both while incarcerated and when in the community, should take these findings into account in the development of health screenings and treatment plans.

28 CFR 115.372 - Evidentiary standard for administrative investigations.

Code of Federal Regulations, 2013 CFR

2013-07-01

... 28 Judicial Administration 2 2013-07-01 2013-07-01 false Evidentiary standard for administrative investigations. 115.372 Section 115.372 Judicial Administration DEPARTMENT OF JUSTICE (CONTINUED) PRISON RAPE ELIMINATION ACT NATIONAL STANDARDS Standards for Juvenile Facilities Investigations § 115.372 Evidentiary...

28 CFR 115.271 - Criminal and administrative agency investigations.

Code of Federal Regulations, 2014 CFR

2014-07-01

... 28 Judicial Administration 2 2014-07-01 2014-07-01 false Criminal and administrative agency investigations. 115.271 Section 115.271 Judicial Administration DEPARTMENT OF JUSTICE (CONTINUED) PRISON RAPE ELIMINATION ACT NATIONAL STANDARDS Standards for Community Confinement Facilities Investigations § 115.271...

28 CFR 115.371 - Criminal and administrative agency investigations.

Code of Federal Regulations, 2014 CFR

2014-07-01

... 28 Judicial Administration 2 2014-07-01 2014-07-01 false Criminal and administrative agency investigations. 115.371 Section 115.371 Judicial Administration DEPARTMENT OF JUSTICE (CONTINUED) PRISON RAPE ELIMINATION ACT NATIONAL STANDARDS Standards for Juvenile Facilities Investigations § 115.371 Criminal and...

28 CFR 115.272 - Evidentiary standard for administrative investigations.

Code of Federal Regulations, 2013 CFR

2013-07-01

... 28 Judicial Administration 2 2013-07-01 2013-07-01 false Evidentiary standard for administrative investigations. 115.272 Section 115.272 Judicial Administration DEPARTMENT OF JUSTICE (CONTINUED) PRISON RAPE ELIMINATION ACT NATIONAL STANDARDS Standards for Community Confinement Facilities Investigations § 115.272...

28 CFR 115.371 - Criminal and administrative agency investigations.

Code of Federal Regulations, 2012 CFR

2012-07-01

... 28 Judicial Administration 2 2012-07-01 2012-07-01 false Criminal and administrative agency investigations. 115.371 Section 115.371 Judicial Administration DEPARTMENT OF JUSTICE (CONTINUED) PRISON RAPE ELIMINATION ACT NATIONAL STANDARDS Standards for Juvenile Facilities Investigations § 115.371 Criminal and...

28 CFR 115.272 - Evidentiary standard for administrative investigations.

Code of Federal Regulations, 2014 CFR

2014-07-01

... 28 Judicial Administration 2 2014-07-01 2014-07-01 false Evidentiary standard for administrative investigations. 115.272 Section 115.272 Judicial Administration DEPARTMENT OF JUSTICE (CONTINUED) PRISON RAPE ELIMINATION ACT NATIONAL STANDARDS Standards for Community Confinement Facilities Investigations § 115.272...

28 CFR 115.372 - Evidentiary standard for administrative investigations.

Code of Federal Regulations, 2014 CFR

2014-07-01

... 28 Judicial Administration 2 2014-07-01 2014-07-01 false Evidentiary standard for administrative investigations. 115.372 Section 115.372 Judicial Administration DEPARTMENT OF JUSTICE (CONTINUED) PRISON RAPE ELIMINATION ACT NATIONAL STANDARDS Standards for Juvenile Facilities Investigations § 115.372 Evidentiary...

28 CFR 115.371 - Criminal and administrative agency investigations.

Code of Federal Regulations, 2013 CFR

2013-07-01

... 28 Judicial Administration 2 2013-07-01 2013-07-01 false Criminal and administrative agency investigations. 115.371 Section 115.371 Judicial Administration DEPARTMENT OF JUSTICE (CONTINUED) PRISON RAPE ELIMINATION ACT NATIONAL STANDARDS Standards for Juvenile Facilities Investigations § 115.371 Criminal and...

28 CFR 115.272 - Evidentiary standard for administrative investigations.

Code of Federal Regulations, 2012 CFR

2012-07-01

... 28 Judicial Administration 2 2012-07-01 2012-07-01 false Evidentiary standard for administrative investigations. 115.272 Section 115.272 Judicial Administration DEPARTMENT OF JUSTICE (CONTINUED) PRISON RAPE ELIMINATION ACT NATIONAL STANDARDS Standards for Community Confinement Facilities Investigations § 115.272...

28 CFR 115.271 - Criminal and administrative agency investigations.

Code of Federal Regulations, 2012 CFR

2012-07-01

... 28 Judicial Administration 2 2012-07-01 2012-07-01 false Criminal and administrative agency investigations. 115.271 Section 115.271 Judicial Administration DEPARTMENT OF JUSTICE (CONTINUED) PRISON RAPE ELIMINATION ACT NATIONAL STANDARDS Standards for Community Confinement Facilities Investigations § 115.271...

28 CFR 115.271 - Criminal and administrative agency investigations.

Code of Federal Regulations, 2013 CFR

2013-07-01

... 28 Judicial Administration 2 2013-07-01 2013-07-01 false Criminal and administrative agency investigations. 115.271 Section 115.271 Judicial Administration DEPARTMENT OF JUSTICE (CONTINUED) PRISON RAPE ELIMINATION ACT NATIONAL STANDARDS Standards for Community Confinement Facilities Investigations § 115.271...

28 CFR 115.372 - Evidentiary standard for administrative investigations.

Code of Federal Regulations, 2012 CFR

2012-07-01

... 28 Judicial Administration 2 2012-07-01 2012-07-01 false Evidentiary standard for administrative investigations. 115.372 Section 115.372 Judicial Administration DEPARTMENT OF JUSTICE (CONTINUED) PRISON RAPE ELIMINATION ACT NATIONAL STANDARDS Standards for Juvenile Facilities Investigations § 115.372 Evidentiary...

28 CFR 54.410 - Comparable facilities.

Code of Federal Regulations, 2013 CFR

2013-07-01

....410 Judicial Administration DEPARTMENT OF JUSTICE (CONTINUED) NONDISCRIMINATION ON THE BASIS OF SEX IN EDUCATION PROGRAMS OR ACTIVITIES RECEIVING FEDERAL FINANCIAL ASSISTANCE Discrimination on the Basis of Sex... provide separate toilet, locker room, and shower facilities on the basis of sex, but such facilities...

Stockpiles and food availability in feeding facilities after the Great East Japan Earthquake.

PubMed

Nozue, Miho; Ishikawa-Takata, Kazuko; Sarukura, Nobuko; Sako, Kazuko; Tsuboyama-Kasaoka, Nobuyo

2014-01-01

Food stockpiles and methods of ensuring food availability after the Great East Japan Earthquake of March 11, 2011 have been studied. Questionnaires were sent to 1911 registered dietitians and general dietitians who were members of the Japan Dietetic Association in August 2012. Four hundred thirty-five dietitians (22.8%) completed the questionnaire about work involved in feeding facilities, types and administration of meals, and food stockpiles. Methods of ensuring food availability, preparation, and accommodating food for special dietary uses were recorded for the three-day period immediately following the earthquake, and the period from 4 days to one month after the earthquake. Three days after the earthquake, differences in administration of meals at feeding facilities providing three meals daily, food stockpiles, organization, contactable facilities, and how to contact them for food items were assessed. Sixty-nine percent of all feeding facilities in this study had stockpiles of food before the Great East Japan Earthquake. Administration of meals in feeding facilities and the possibility of contact with cooperative feeding facilities were found to correlate positively with ensuring the availability of food groups. Food scores were higher in facilities providing three meals daily by direct administration of meals and with accessible public administrators, cooperative facilities and suppliers, and facilities that were contactable by landline telephone, mobile phone, fax or email. The necessity for natural disaster-readiness through continuous stockpiling food at feeding facilities is confirmed. Each prospective feeding facility must be required to plan its stockpiles, their turnover and replaceability to maximise food security in the face of disaster.

28 CFR 41.57 - Existing facilities.

Code of Federal Regulations, 2014 CFR

2014-07-01

... 28 Judicial Administration 1 2014-07-01 2014-07-01 false Existing facilities. 41.57 Section 41.57 Judicial Administration DEPARTMENT OF JUSTICE IMPLEMENTATION OF EXECUTIVE ORDER 12250, NONDISCRIMINATION ON THE BASIS OF HANDICAP IN FEDERALLY ASSISTED PROGRAMS Guidelines for Determining Discriminatory...

28 CFR 41.57 - Existing facilities.

Code of Federal Regulations, 2012 CFR

2012-07-01

... 28 Judicial Administration 1 2012-07-01 2012-07-01 false Existing facilities. 41.57 Section 41.57 Judicial Administration DEPARTMENT OF JUSTICE IMPLEMENTATION OF EXECUTIVE ORDER 12250, NONDISCRIMINATION ON THE BASIS OF HANDICAP IN FEDERALLY ASSISTED PROGRAMS Guidelines for Determining Discriminatory...

28 CFR 41.57 - Existing facilities.

Code of Federal Regulations, 2010 CFR

2010-07-01

... 28 Judicial Administration 1 2010-07-01 2010-07-01 false Existing facilities. 41.57 Section 41.57 Judicial Administration DEPARTMENT OF JUSTICE IMPLEMENTATION OF EXECUTIVE ORDER 12250, NONDISCRIMINATION ON THE BASIS OF HANDICAP IN FEDERALLY ASSISTED PROGRAMS Guidelines for Determining Discriminatory...

28 CFR 41.57 - Existing facilities.

Code of Federal Regulations, 2011 CFR

2011-07-01

... 28 Judicial Administration 1 2011-07-01 2011-07-01 false Existing facilities. 41.57 Section 41.57 Judicial Administration DEPARTMENT OF JUSTICE IMPLEMENTATION OF EXECUTIVE ORDER 12250, NONDISCRIMINATION ON THE BASIS OF HANDICAP IN FEDERALLY ASSISTED PROGRAMS Guidelines for Determining Discriminatory...

28 CFR 41.57 - Existing facilities.

Code of Federal Regulations, 2013 CFR

2013-07-01

... 28 Judicial Administration 1 2013-07-01 2013-07-01 false Existing facilities. 41.57 Section 41.57 Judicial Administration DEPARTMENT OF JUSTICE IMPLEMENTATION OF EXECUTIVE ORDER 12250, NONDISCRIMINATION ON THE BASIS OF HANDICAP IN FEDERALLY ASSISTED PROGRAMS Guidelines for Determining Discriminatory...

National evaluation of obesity screening and treatment among veterans with and without mental health disorders.

PubMed

Littman, Alyson J; Damschroder, Laura J; Verchinina, Lilia; Lai, Zongshan; Kim, Hyungjin Myra; Hoerster, Katherine D; Klingaman, Elizabeth A; Goldberg, Richard W; Owen, Richard R; Goodrich, David E

2015-01-01

The objective was to determine whether obesity screening and weight management program participation and outcomes are equitable for individuals with serious mental illness (SMI) and depressive disorder (DD) compared to those without SMI/DD in Veterans Health Administration (VHA), the largest integrated US health system, which requires obesity screening and offers weight management to all in need. We used chart-reviewed, clinical and administrative VHA data from fiscal years 2010-2012 to estimate obesity screening and participation in the VHA's weight management program (MOVE!) across groups. Six- and 12-month weight changes in MOVE! participants were estimated using linear mixed models adjusted for confounders. Compared to individuals without SMI/DD, individuals with SMI or DD were less frequently screened for obesity (94%-94.7% vs. 95.7%) but had greater participation in MOVE! (10.1%-10.4% vs. 7.4%). MOVE! participants with SMI or DD lost approximately 1 lb less at 6 months. At 12 months, average weight loss for individuals with SMI or neither SMI/DD was comparable (-3.5 and -3.3 lb, respectively), but individuals with DD lost less weight (mean=-2.7 lb). Disparities in obesity screening and treatment outcomes across mental health diagnosis groups were modest. However, participation in MOVE! was low for every group, which limits population impact. Published by Elsevier Inc.

14 CFR 1253.410 - Comparable facilities.

Code of Federal Regulations, 2010 CFR

2010-01-01

... 14 Aeronautics and Space 5 2010-01-01 2010-01-01 false Comparable facilities. 1253.410 Section 1253.410 Aeronautics and Space NATIONAL AERONAUTICS AND SPACE ADMINISTRATION NONDISCRIMINATION ON THE.... A recipient may provide separate toilet, locker room, and shower facilities on the basis of sex, but...

14 CFR 1253.410 - Comparable facilities.

Code of Federal Regulations, 2012 CFR

2012-01-01

... 14 Aeronautics and Space 5 2012-01-01 2012-01-01 false Comparable facilities. 1253.410 Section 1253.410 Aeronautics and Space NATIONAL AERONAUTICS AND SPACE ADMINISTRATION NONDISCRIMINATION ON THE.... A recipient may provide separate toilet, locker room, and shower facilities on the basis of sex, but...

14 CFR 1253.410 - Comparable facilities.

Code of Federal Regulations, 2013 CFR

2013-01-01

... 14 Aeronautics and Space 5 2013-01-01 2013-01-01 false Comparable facilities. 1253.410 Section 1253.410 Aeronautics and Space NATIONAL AERONAUTICS AND SPACE ADMINISTRATION NONDISCRIMINATION ON THE.... A recipient may provide separate toilet, locker room, and shower facilities on the basis of sex, but...

29 CFR 1917.17 - Railroad facilities.

Code of Federal Regulations, 2010 CFR

2010-07-01

... 29 Labor 7 2010-07-01 2010-07-01 false Railroad facilities. 1917.17 Section 1917.17 Labor Regulations Relating to Labor (Continued) OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION, DEPARTMENT OF LABOR (CONTINUED) MARINE TERMINALS Marine Terminal Operations § 1917.17 Railroad facilities. (a) Work shall be...

77 FR 50549 - Agency Information Collection: Emergency Submission for OMB Review (VISN 23 PACT Demonstration...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-08-21

... concerning attitudes toward healthcare. The VHA PACT Demo Lab is a new grant-funded project. No existing... Preferences Surveys); Comment Request AGENCY: Veterans Health Administration, Department of Veterans Affairs... for information needed to improve health care for veterans. DATES: Comments must be submitted on or...

14 CFR 65.41 - Skill requirements: Facility ratings.

Code of Federal Regulations, 2010 CFR

2010-01-01

... 14 Aeronautics and Space 2 2010-01-01 2010-01-01 false Skill requirements: Facility ratings. 65.41 Section 65.41 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION... § 65.41 Skill requirements: Facility ratings. Each applicant for a facility rating at an air traffic...

14 CFR 65.41 - Skill requirements: Facility ratings.

Code of Federal Regulations, 2011 CFR

2011-01-01

... 14 Aeronautics and Space 2 2011-01-01 2011-01-01 false Skill requirements: Facility ratings. 65.41 Section 65.41 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION... § 65.41 Skill requirements: Facility ratings. Each applicant for a facility rating at an air traffic...

Dynamic Scheduling for Veterans Health Administration Patients using Geospatial Dynamic Overbooking.

PubMed

Adams, Stephen; Scherer, William T; White, K Preston; Payne, Jason; Hernandez, Oved; Gerber, Mathew S; Whitehead, N Peter

2017-10-12

The Veterans Health Administration (VHA) is plagued by abnormally high no-show and cancellation rates that reduce the productivity and efficiency of its medical outpatient clinics. We address this issue by developing a dynamic scheduling system that utilizes mobile computing via geo-location data to estimate the likelihood of a patient arriving on time for a scheduled appointment. These likelihoods are used to update the clinic's schedule in real time. When a patient's arrival probability falls below a given threshold, the patient's appointment is canceled. This appointment is immediately reassigned to another patient drawn from a pool of patients who are actively seeking an appointment. The replacement patients are prioritized using their arrival probability. Real-world data were not available for this study, so synthetic patient data were generated to test the feasibility of the design. The method for predicting the arrival probability was verified on a real set of taxicab data. This study demonstrates that dynamic scheduling using geo-location data can reduce the number of unused appointments with minimal risk of double booking resulting from incorrect predictions. We acknowledge that there could be privacy concerns with regards to government possession of one's location and offer strategies for alleviating these concerns in our conclusion.

Innovation in a Learning Health Care System: Veteran-Directed Home- and Community-Based Services.

PubMed

Garrido, Melissa M; Allman, Richard M; Pizer, Steven D; Rudolph, James L; Thomas, Kali S; Sperber, Nina R; Van Houtven, Courtney H; Frakt, Austin B

2017-11-01

A path-breaking example of the interplay between geriatrics and learning healthcare systems is the Veterans Health Administration's (VHA's) planned roll-out of a program for providing participant-directed home- and community-based services to veterans with cognitive and functional limitations. We describe the design of a large-scale, stepped-wedge, cluster-randomized trial of the Veteran-Directed Home- and Community-Based Services (VD-HCBS) program. From March 2017 through December 2019, up to 77 Veterans Affairs Medical Centers will be randomized to times to begin offering VD-HCBS to veterans at risk of nursing home placement. Services will be provided to community-dwelling participants with support from Aging and Disability Network Agencies. The VHA Partnered Evidence-based Policy Resource Center (PEPReC) is coordinating the evaluation, which includes collaboration from operational stakeholders from the VHA and Administration for Community Living and interdisciplinary researchers from the Center of Innovation in Long-Term Services and Supports and the Center for Health Services Research in Primary Care. For older veterans with functional limitations who are eligible for VD-HCBS, we will evaluate health outcomes (hospitalizations, emergency department visits, nursing home admissions, days at home) and healthcare costs associated with VD-HCBS availability. Learning healthcare systems facilitate diffusion of innovation while enabling rigorous evaluation of effects on patient outcomes. The VHA's randomized rollout of VD-HCBS to veterans at risk of nursing home placement is an example of how to achieve these goals simultaneously. PEPReC's experience designing an evaluation with researchers and operations stakeholders may serve as a framework for others seeking to develop rapid, rigorous, large-scale evaluations of delivery system innovations targeted to older adults. © 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society.

Long-acting Reversible Contraception Among Homeless Women Veterans With Chronic Health Conditions: A Retrospective Cohort Study.

PubMed

Gawron, Lori M; Redd, Andrew; Suo, Ying; Pettey, Warren; Turok, David K; Gundlapalli, Adi V

2017-09-01

US women Veterans are at increased risk of homelessness and chronic health conditions associated with unintended pregnancy. Veterans Health Administration (VHA) provision of long-acting reversible contraception (LARC) can assist in healthy pregnancy planning. To evaluate perinatal risk factors and LARC exposure in ever-homeless women Veterans. A retrospective cohort study of women Veterans using VHA administrative data from fiscal years 2002-2015. We included 41,747 ever-homeless women Veterans age 18-44 years and 46,391 housed women Veterans matched by military service period. A subgroup of 7773 ever-homeless and 8674 matched housed women Veterans deployed in Iraq and Afghanistan [Operations Enduring Freedom/Iraqi Freedom/New Dawn (OEF/OIF/OND)] conflicts comprised a second analytic cohort. Descriptive statistics compared demographic, military, health conditions, and LARC exposure in ever-homeless versus housed women Veterans. Multivariable logistic regression explored factors associated with LARC exposure in the OEF/OIF/OND subgroup. All health conditions were significantly higher in ever-homeless versus housed Veterans: mental health disorder in 84.5% versus 48.7% (P<0.001), substance abuse in 35.8% versus 8.6% (P<0.001), and medical conditions in 74.7% versus 55.6% (P<0.001). LARC exposure among all VHA users was 9.3% in ever-homeless Veterans versus 5.4% in housed Veterans (P<0.001). LARC exposure in the OEF/OIF/OND cohort was 14.1% in ever-homeless Veterans versus 8.2% in housed Veterans (P<0.001). In the OEF/OIF/OND cohort, homelessness along Veterans with medical and mental health indicators were leading LARC exposure predictors. The VHA is successfully engaging homeless women Veterans and providing LARC access. The prevalence of perinatal risk factors in ever-homeless women Veterans highlights a need for further programmatic enhancements to improve reproductive planning.

Military sexual trauma is associated with post-deployment eating disorders among Afghanistan and Iraq veterans.

PubMed

Blais, Rebecca K; Brignone, Emily; Maguen, Shira; Carter, Marjorie E; Fargo, Jamison D; Gundlapalli, Adi V

2017-07-01

Evaluate the association of military sexual trauma (MST) screen status with eating disorder diagnoses among veterans within 1- and 5-years after initiating Veterans Health Administration (VHA) care, and whether the association varied by sex. Retrospective cohort study of US Afghanistan/Iraq veterans who used VHA services between FY 2004 and 2014 (N = 595,525). This study used VHA administrative data to assess the presence of eating disorder diagnoses in medical records within 1- and 5-years of initiating VHA care, and whether a positive screen for MST was associated with eating disorders. Three percent (n = 18,488) screened positive for MST. At 1- and 5-year follow up, 0.1% (n= 513, 74% female), and 0.2% (n = 504, 71% female) were diagnosed with an eating disorder, respectively. In regression models adjusted for demographic variables, military service, and psychiatric comorbidities, the presence of an eating disorder diagnosis was nearly two times higher among those with a positive screen for MST in the 1-year (adjusted odds ratio [AOR] = 1.94, 95% confidence interval [CI] = 1.57-2.40) and 5-year (AOR = 1.86, 95%CI = 1.49-2.32) cohorts. The increased likelihood conferred by MST for an eating disorder diagnosis was differentially stronger among male veterans than female veterans in the 1-year cohort only (AOR = 2.13, 95%CI = 1.01-4.50). Veterans with a positive screen for MST, especially male veterans, had a nearly two-fold increased likelihood of having an eating disorder diagnosis. Screening for eating disorders may be important in both male and female veterans who report MST. © 2017 Wiley Periodicals, Inc.

28 CFR 540.41 - Visiting facilities.

Code of Federal Regulations, 2010 CFR

2010-07-01

... 28 Judicial Administration 2 2010-07-01 2010-07-01 false Visiting facilities. 540.41 Section 540.41 Judicial Administration BUREAU OF PRISONS, DEPARTMENT OF JUSTICE INSTITUTIONAL MANAGEMENT CONTACT... visitors. (a) Institutions of minimum and low security levels may permit visits beyond the security...

14 CFR 1253.410 - Comparable facilities.

Code of Federal Regulations, 2011 CFR

2011-01-01

... 14 Aeronautics and Space 5 2011-01-01 2010-01-01 true Comparable facilities. 1253.410 Section 1253.410 Aeronautics and Space NATIONAL AERONAUTICS AND SPACE ADMINISTRATION NONDISCRIMINATION ON THE BASIS... recipient may provide separate toilet, locker room, and shower facilities on the basis of sex, but such...

30 CFR 77.1608 - Dumping facilities.

Code of Federal Regulations, 2010 CFR

2010-07-01

... 30 Mineral Resources 1 2010-07-01 2010-07-01 false Dumping facilities. 77.1608 Section 77.1608 Mineral Resources MINE SAFETY AND HEALTH ADMINISTRATION, DEPARTMENT OF LABOR COAL MINE SAFETY AND HEALTH... Haulage § 77.1608 Dumping facilities. (a) Dumping locations and haulage roads shall be kept reasonably...

14 CFR 158.29 - The Administrator's decision.

Code of Federal Regulations, 2013 CFR

2013-01-01

... (CONTINUED) AIRPORTS PASSENGER FACILITY CHARGES (PFC'S) Application and Approval § 158.29 The Administrator's... process, including any request by the public agency not to require a class of carriers to collect PFC's... 14 Aeronautics and Space 3 2013-01-01 2013-01-01 false The Administrator's decision. 158.29...

14 CFR 158.29 - The Administrator's decision.

Code of Federal Regulations, 2014 CFR

2014-01-01

... (CONTINUED) AIRPORTS PASSENGER FACILITY CHARGES (PFC'S) Application and Approval § 158.29 The Administrator's... process, including any request by the public agency not to require a class of carriers to collect PFC's... 14 Aeronautics and Space 3 2014-01-01 2014-01-01 false The Administrator's decision. 158.29...

14 CFR 158.29 - The Administrator's decision.

Code of Federal Regulations, 2012 CFR

2012-01-01

... (CONTINUED) AIRPORTS PASSENGER FACILITY CHARGES (PFC'S) Application and Approval § 158.29 The Administrator's... process, including any request by the public agency not to require a class of carriers to collect PFC's... 14 Aeronautics and Space 3 2012-01-01 2012-01-01 false The Administrator's decision. 158.29...

14 CFR 158.29 - The Administrator's decision.

Code of Federal Regulations, 2011 CFR

2011-01-01

... (CONTINUED) AIRPORTS PASSENGER FACILITY CHARGES (PFC'S) Application and Approval § 158.29 The Administrator's... process, including any request by the public agency not to require a class of carriers to collect PFC's... 14 Aeronautics and Space 3 2011-01-01 2011-01-01 false The Administrator's decision. 158.29...

Disability rates for cardiovascular and psychological disorders among autoworkers by job category, facility type, and facility overtime hours.

PubMed

Landsbergis, Paul A; Janevic, Teresa; Rothenberg, Laura; Adamu, Mohammed T; Johnson, Sylvia; Mirer, Franklin E

2013-07-01

We examined the association between long work hours, assembly line work and stress-related diseases utilizing objective health and employment data from an employer's administrative databases. A North American automobile manufacturing company provided data for claims for sickness, accident and disability insurance (work absence of at least 4 days) for cardiovascular disease (CVD), hypertension and psychological disorders, employee demographics, and facility hours worked per year for 1996-2001. Age-adjusted claim rates and age-adjusted rate ratios were calculated using Poisson regression, except for comparisons between production and skilled trades workers owing to lack of age denominator data by job category. Associations between overtime hours and claim rates by facility were examined by Poisson regression and multi-level Poisson regression. Claims for hypertension, coronary heart disease, CVD, and psychological disorders were associated with facility overtime hours. We estimate that a facility with 10 more overtime hours per week than another facility would have 4.36 more claims for psychological disorders, 2.33 more claims for CVD, and 3.29 more claims for hypertension per 1,000 employees per year. Assembly plants had the highest rates of claims for most conditions. Production workers tended to have higher rates of claims than skilled trades workers. Data from an auto manufacturer's administrative databases suggest that autoworkers working long hours, and assembly-line workers relative to skilled trades workers or workers in non-assembly facilities, have a higher risk of hypertension, CVD, and psychological disorders. Occupational disease surveillance and disease prevention programs need to fully utilize such administrative data. Copyright © 2013 Wiley Periodicals, Inc.

Sleep Disturbance Preceding Suicide Among Veterans

PubMed Central

Britton, Peter C.; Ilgen, Mark A.; Chapman, Ben; Conner, Kenneth R.

2012-01-01

Objectives. We examined the role of sleep disturbance in time to suicide since the last treatment visit among veterans receiving Veterans Health Administration (VHA) services. Methods. Among 423 veteran suicide decedents from 2 geographic areas, systematic chart reviews were conducted on the 381 (90.1%) who had a VHA visit in the last year of life. Veteran suicides with a documented sleep disturbance (45.4%) were compared with those without sleep disturbance (54.6%) on time to death since their last VHA visit using an accelerated failure time model. Results. Veterans with sleep disturbance died sooner after their last visit than did those without sleep disturbance, after we adjusted for the presence of mental health or substance use symptoms, age, and region. Conclusions. Findings indicated that sleep disturbance was associated with time to suicide in this sample of veterans who died by suicide. The findings had implications for using the presence of sleep disturbance to detect near-term risk for suicide and suggested that sleep disturbance might provide an important intervention target for a subgroup of at-risk veterans. PMID:22390611

The influence of trauma and patient characteristics on provider burnout in VA post-traumatic stress disorder specialty programmes.

PubMed

Garcia, Hector A; McGeary, Cindy A; Finley, Erin P; McGeary, Donald D; Ketchum, Norma S; Peterson, Alan L

2016-03-01

Prolonged exposure (PE) and cognitive processing therapy (CPT) - post-traumatic stress disorder (PTSD) treatments now available at the Veterans Health Administration (VHA) - expose the provider to graphic traumatic material. Little is known about the impact of traumatic material on VHA providers. The purpose of this study was to examine the relationship between trauma content, patient characteristics, and burnout among VHA PTSD Clinical Team (PCT) providers. It was hypothesized that trauma content and patient characteristics would significantly predict burnout in this population. This cross-sectional study consisted of 137 participants. The sample was mostly female (67%), Caucasian (non-Hispanic; 81%), and married (70%) with a mean age of 44.3 years (SD = 11.3). Participants completed an electronic survey that assessed demographics, patient characteristics (i.e., anger, personality disorder, malingering), trauma content characteristics (e.g., killing of women and children) as well as burnout as measured by the Maslach Burnout Inventory-General Survey (MBI-GS; Maslach et al., 1996, Burnout inventory manual. Palo Alto: Consulting Psychologist Press). Over half of the study population reported being bothered by trauma content; however, trauma content did not predict burnout. Treating patients with personality disorders and suspected malingering predicted burnout in PCT providers. High numbers (77%) reported perceiving that emotional exhaustion impacted the quality of care they provided. These findings suggest an important role of burnout assessment, prevention, and treatment strategies at the VHA. This paper addresses the impact of provider burnout on perceived quality of care. This paper also addresses potential predictors of burnout in PCT settings. This paper outlines potential remedies to provider burnout in the VHA. © 2015 The British Psychological Society.

Validation of a Screening Risk Index for Serious Prescription Opioid-Induced Respiratory Depression or Overdose in a US Commercial Health Plan Claims Database

PubMed Central

Zedler, Barbara K; Saunders, William B; Joyce, Andrew R; Vick, Catherine C; Murrelle, E Lenn

2018-01-01

Abstract Objective To validate a risk index that estimates the likelihood of overdose or serious opioid-induced respiratory depression (OIRD) among medical users of prescription opioids. Subjects and Methods A case-control analysis of 18,365,497 patients with an opioid prescription from 2009 to 2013 in the IMS PharMetrics Plus commercially insured health plan claims database (CIP). An OIRD event occurred in 7,234 cases. Four controls were selected per case. Validity of the Risk Index for Overdose or Serious Opioid-induced Respiratory Depression (RIOSORD), developed previously using Veterans Health Administration (VHA) patient data, was assessed. Multivariable logistic regression was used within the CIP study population to develop a slightly refined RIOSORD. The composition and performance of the CIP-based RIOSORD was evaluated and compared with VHA-based RIOSORD. Results VHA-RIOSORD performed well in discriminating OIRD events in CIP (C-statistic = 0.85). Additionally, re-estimation of logistic model coefficients in CIP yielded a 0.90 C-statistic. The resulting comorbidity and pharmacotherapy variables most highly associated with OIRD and retained in the CIP-RIOSORD were largely concordant with VHA-RIOSORD. These variables included neuropsychiatric and cardiopulmonary disorders, impaired drug excretion, opioid characteristics, and concurrent psychoactive medications. The average predicted probability of OIRD ranged from 2% to 83%, with excellent agreement between predicted and observed incidence across risk classes. Conclusions RIOSORD had excellent predictive accuracy in a large population of US medical users of prescription opioids, similar to its performance in VHA. This practical risk index is designed to support clinical decision-making for safer opioid prescribing, and its clinical utility should be evaluated prospectively. PMID:28340046

9 CFR 3.103 - Facilities, outdoor.

Code of Federal Regulations, 2012 CFR

2012-01-01

... Administrator. The fence must be constructed so that it protects marine mammals by restricting animals and... effective natural barrier that restricts the marine mammals to the facility and restricts entry by animals... 9 Animals and Animal Products 1 2012-01-01 2012-01-01 false Facilities, outdoor. 3.103 Section 3...

9 CFR 3.103 - Facilities, outdoor.

Code of Federal Regulations, 2013 CFR

2013-01-01

... Administrator. The fence must be constructed so that it protects marine mammals by restricting animals and... effective natural barrier that restricts the marine mammals to the facility and restricts entry by animals... 9 Animals and Animal Products 1 2013-01-01 2013-01-01 false Facilities, outdoor. 3.103 Section 3...

9 CFR 3.103 - Facilities, outdoor.

Code of Federal Regulations, 2014 CFR

2014-01-01

... Administrator. The fence must be constructed so that it protects marine mammals by restricting animals and... effective natural barrier that restricts the marine mammals to the facility and restricts entry by animals... 9 Animals and Animal Products 1 2014-01-01 2014-01-01 false Facilities, outdoor. 3.103 Section 3...

Health Ethics Education for Health Administration Chaplains

ERIC Educational Resources Information Center

Porter, Russell; Broussard, Amelia; Duckett, Todd

2008-01-01

It is imperative for divinity and health administration programs to improve their level of ethics education for their graduates who work as health administration chaplains. With an initial presentation of the variation of ethical dilemmas presented in health care facilities covering social, organizational, and patient levels, we indicate the need…

21 CFR 200.10 - Contract facilities (including consulting laboratories) utilized as extramural facilities by...

Code of Federal Regulations, 2010 CFR

2010-04-01

... (IND) Application, any information obtained during the inspection of an extramural facility having a... Administration does not consider results of validation studies of analytical and assay methods and control...

Mental Health Service Utilization before and after Receipt of a Service-Connected Disability Award for PTSD: Findings from a National Sample.

PubMed

Sripada, Rebecca K; Hannemann, Claire M; Schnurr, Paula P; Marx, Brian P; Pollack, Stacey J; McCarthy, John F

2018-04-17

To determine patterns of mental health service use before and after VA disability compensation awards for posttraumatic stress disorder (PTSD). A 10 percent random sample of VHA-enrolled Veterans with new or increased PTSD service connection between 2012 and 2014 (n = 22,249). We used latent trajectory analysis to identify utilization patterns and multinomial logistic regression to assess associations between Veteran characteristics and trajectory membership. We assessed receipt of VHA mental health encounters in each of the 52 weeks prior to and following PTSD disability rating or rating increase. The best fitting model had five groups: No Use (36.6 percent), Low Use (37.7 percent), Increasing Use (9.4 percent), Decreasing Use (11.2 percent), and High Use (5.1 percent). Adjusting for demographic characteristics and compared with the No Use group, Veterans in the other groups were more likely to reside closer to a VHA facility, receive a higher PTSD disability rating, and screen positive for military sexual trauma. Service use remained stable (80 percent) or increased (9 percent) for the vast majority of Veterans. Service utilization declined for only 11 percent. Data did not indicate substantial service discontinuation following rating. Low VHA service utilization suggests opportunities to enhance outreach for Veterans with PTSD-related disability benefits. © Published 2018. This article is a U.S. Government work and is in the public domain in the USA.

NNSA B-Roll: MOX Facility

ScienceCinema

None

2017-12-09

In 1999, the National Nuclear Security Administration (NNSA) signed a contract with a consortium, now called Shaw AREVA MOX Services, LLC to design, build, and operate a Mixed Oxide (MOX) Fuel Fabrication Facility. This facility will be a major component in the United States program to dispose of surplus weapon-grade plutonium. The facility will take surplus weapon-grade plutonium, remove impurities, and mix it with uranium oxide to form MOX fuel pellets for reactor fuel assemblies. These assemblies will be irradiated in commercial nuclear power reactors.

NNSA B-Roll: MOX Facility

DOE Office of Scientific and Technical Information (OSTI.GOV)

None

2010-05-21

In 1999, the National Nuclear Security Administration (NNSA) signed a contract with a consortium, now called Shaw AREVA MOX Services, LLC to design, build, and operate a Mixed Oxide (MOX) Fuel Fabrication Facility. This facility will be a major component in the United States program to dispose of surplus weapon-grade plutonium. The facility will take surplus weapon-grade plutonium, remove impurities, and mix it with uranium oxide to form MOX fuel pellets for reactor fuel assemblies. These assemblies will be irradiated in commercial nuclear power reactors.

21 CFR 58.31 - Testing facility management.

Code of Federal Regulations, 2011 CFR

2011-04-01

... Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL GOOD LABORATORY PRACTICE FOR NONCLINICAL LABORATORY STUDIES Organization and Personnel § 58.31 Testing facility management. For each nonclinical laboratory study, testing facility management shall: (a) Designate a study...

Development of the Veterans Healthcare Administration (VHA) Ophthalmic Surgical Outcome Database (OSOD) project and the role of ophthalmic nurse reviewers.

PubMed

Lara-Smalling, Agueda; Cakiner-Egilmez, Tulay; Miller, Dawn; Redshirt, Ella; Williams, Dale

2011-01-01

Currently, ophthalmic surgical cases are not included in the Veterans Administration Surgical Quality Improvement Project data collection. Furthermore, there is no comprehensive protocol in the health system for prospectively measuring outcomes for eye surgery in terms of safety and quality. There are 400,000 operative cases in the system per year. Of those, 48,000 (12%) are ophthalmic surgical cases, with 85% (41,000) of those being cataract cases. The Ophthalmic Surgical Outcome Database Pilot Project was developed to incorporate ophthalmology into VASQIP, thus evaluating risk factors and improving cataract surgical outcomes. Nurse reviewers facilitate the monitoring and measuring of these outcomes. Since its inception in 1778, the Veterans Administration (VA) Health System has provided comprehensive healthcare to millions of deserving veterans throughout the U.S. and its territories. Historically, the quality of healthcare provided by the VA has been the main focus of discussion because it did not meet a standard of care comparable to that of the private sector. Information regarding quality of healthcare services and outcomes data had been unavailable until 1986, when Congress mandated the VA to compare its surgical outcomes to those of the private sector (PL-99-166). 1 Risk adjustment of VA surgical outcomes began in 1987 with the Continuous Improvement in Cardiac Surgery Program (CICSP) in which cardiac surgical outcomes were reported and evaluated. 2 Between 1991 and 1993, the National VA Surgical Risk Study (NVASRS) initiated a validated risk-adjustment model for predicting surgical outcomes and comparative assessment of the quality of surgical care in 44 VA medical centers. 3 The success of NVASRS encouraged the VA to establish an ongoing program for monitoring and improving the quality of surgical care, thus developing the National Surgical Quality Improvement Program (NSQIP) in 1994. 4 According to a prospective study conducted between 1991-1997 in 123

A break-even analysis for dementia care collaboration: Partners in Dementia Care.

PubMed

Morgan, Robert O; Bass, David M; Judge, Katherine S; Liu, C F; Wilson, Nancy; Snow, A Lynn; Pirraglia, Paul; Garcia-Maldonado, Maurilio; Raia, Paul; Fouladi, N N; Kunik, Mark E

2015-06-01

Dementia is a costly disease. People with dementia, their families, and their friends are affected on personal, emotional, and financial levels. Prior work has shown that the "Partners in Dementia Care" (PDC) intervention addresses unmet needs and improves psychosocial outcomes and satisfaction with care. We examined whether PDC reduced direct Veterans Health Administration (VHA) health care costs compared with usual care. This study was a cost analysis of the PDC intervention in a 30-month trial involving five VHA medical centers. Study subjects were veterans (N = 434) 50 years of age and older with dementia and their caregivers at two intervention (N = 269) and three comparison sites (N = 165). PDC is a telephone-based care coordination and support service for veterans with dementia and their caregivers, delivered through partnerships between VHA medical centers and local Alzheimer's Association chapters. We tested for differences in total VHA health care costs, including hospital, emergency department, nursing home, outpatient, and pharmacy costs, as well as program costs for intervention participants. Covariates included caregiver reports of veterans' cognitive impairment, behavior problems, and personal care dependencies. We used linear mixed model regression to model change in log total cost post-baseline over a 1-year follow-up period. Intervention participants showed higher VHA costs than usual-care participants both before and after the intervention but did not differ significantly regarding change in log costs from pre- to post-baseline periods. Pre-baseline log cost (p ≤ 0.001), baseline cognitive impairment (p ≤ 0.05), number of personal care dependencies (p ≤ 0.01), and VA service priority (p ≤ 0.01) all predicted change in log total cost. These analyses show that PDC meets veterans' needs without significantly increasing VHA health care costs. PDC addresses the priority area of care coordination in the National Plan to Address Alzheimer

Geriatric-focused educational offerings in the Department of Veterans Affairs from 1999 to 2009.

PubMed

Thielke, Stephen; Tumosa, Nina; Lindenfeld, Rivkah; Shay, Kenneth

2011-01-01

The scope of geriatrics-related educational offerings in large health care systems, in either the target audiences or topics covered, has not previously been analyzed or reported in the professional literature. The authors reviewed the geriatrics-related educational sessions that were provided between 1999 and 2009 by the Geriatrics Research, Education, and Clinical Centers (GRECCs) and the Employee Education System (EES) of the United States' largest integrated health care system, the Veterans Health Administration (VHA). Using records of attendance and content at local training events and regional and national conferences, the authors estimated the number of attendees in different health disciplines and the number and types of lectures. During the past 11 years, GRECCs and EES provided geriatric-related educational sessions to about one third of a million attendees, most of them nurses and physicians, in about 15,000 lectures. About three-fourths of the educational events occurred through local, rather than regional or national, events. Lectures covered a wide variety of topics, with a particular emphasis on dementia and other mental health topics. A comparison of the number of potential learners in VHA with the number of geriatric-related educational presentations over this time period yields an average of one offering per VHA provider every 3 years; most providers likely never received any. Since 1999 the GRECCs have been the dominant source for geriatrics-related education for VHA health professionals, but given that about one half of VHA patients are older than age 65, there is still a large unmet need to provide geriatric education to VHA providers. Examination of the GRECC resources that have been put to use in the past to develop and deliver the face-to-face education experiences described sheds light on the magnitude of resources that might be required to address remaining unmet need in the future, and supports the prediction that there will need to be

Design of Aircraft Deicing Facilities

DOT National Transportation Integrated Search

1993-08-23

Archival copy of original Federal Aviation Administration standards and : specifications for use in the design of aircraft deicing facilities. To ensure : review of all changes, user should consult . ...

Acting Administrator Lightfoot Visits Ball Aerospace

NASA Image and Video Library

2017-04-06

Acting NASA Administrator Robert Lightfoot, center, is seen during a visit to the environmental test facilities at Ball Aerospace, Thursday, April 6, 2017 in Boulder, Colo. Photo Credit: (NASA/Joel Kowsky)

Medication Administration Errors in an Adult Emergency Department of a Tertiary Health Care Facility in Ghana.

PubMed

Acheampong, Franklin; Tetteh, Ashalley Raymond; Anto, Berko Panyin

2016-12-01

This study determined the incidence, types, clinical significance, and potential causes of medication administration errors (MAEs) at the emergency department (ED) of a tertiary health care facility in Ghana. This study used a cross-sectional nonparticipant observational technique. Study participants (nurses) were observed preparing and administering medication at the ED of a 2000-bed tertiary care hospital in Accra, Ghana. The observations were then compared with patients' medication charts, and identified errors were clarified with staff for possible causes. Of the 1332 observations made, involving 338 patients and 49 nurses, 362 had errors, representing 27.2%. However, the error rate excluding "lack of drug availability" fell to 12.8%. Without wrong time error, the error rate was 22.8%. The 2 most frequent error types were omission (n = 281, 77.6%) and wrong time (n = 58, 16%) errors. Omission error was mainly due to unavailability of medicine, 48.9% (n = 177). Although only one of the errors was potentially fatal, 26.7% were definitely clinically severe. The common themes that dominated the probable causes of MAEs were unavailability, staff factors, patient factors, prescription, and communication problems. This study gives credence to similar studies in different settings that MAEs occur frequently in the ED of hospitals. Most of the errors identified were not potentially fatal; however, preventive strategies need to be used to make life-saving processes such as drug administration in such specialized units error-free.

28 CFR 115.218 - Upgrades to facilities and technologies.

Code of Federal Regulations, 2013 CFR

2013-07-01

... 28 Judicial Administration 2 2013-07-01 2013-07-01 false Upgrades to facilities and technologies....218 Upgrades to facilities and technologies. (a) When designing or acquiring any new facility and in... surveillance system, or other monitoring technology, the agency shall consider how such technology may enhance...

28 CFR 115.318 - Upgrades to facilities and technologies.

Code of Federal Regulations, 2014 CFR

2014-07-01

... 28 Judicial Administration 2 2014-07-01 2014-07-01 false Upgrades to facilities and technologies... facilities and technologies. (a) When designing or acquiring any new facility and in planning any substantial... monitoring technology, the agency shall consider how such technology may enhance the agency's ability to...

28 CFR 115.218 - Upgrades to facilities and technologies.

Code of Federal Regulations, 2012 CFR

2012-07-01

... 28 Judicial Administration 2 2012-07-01 2012-07-01 false Upgrades to facilities and technologies....218 Upgrades to facilities and technologies. (a) When designing or acquiring any new facility and in... surveillance system, or other monitoring technology, the agency shall consider how such technology may enhance...

28 CFR 115.218 - Upgrades to facilities and technologies.

Code of Federal Regulations, 2014 CFR

2014-07-01

... 28 Judicial Administration 2 2014-07-01 2014-07-01 false Upgrades to facilities and technologies....218 Upgrades to facilities and technologies. (a) When designing or acquiring any new facility and in... surveillance system, or other monitoring technology, the agency shall consider how such technology may enhance...

28 CFR 115.318 - Upgrades to facilities and technologies.

Code of Federal Regulations, 2013 CFR

2013-07-01

... 28 Judicial Administration 2 2013-07-01 2013-07-01 false Upgrades to facilities and technologies... facilities and technologies. (a) When designing or acquiring any new facility and in planning any substantial... monitoring technology, the agency shall consider how such technology may enhance the agency's ability to...

28 CFR 115.318 - Upgrades to facilities and technologies.

Code of Federal Regulations, 2012 CFR

2012-07-01

... 28 Judicial Administration 2 2012-07-01 2012-07-01 false Upgrades to facilities and technologies... facilities and technologies. (a) When designing or acquiring any new facility and in planning any substantial... monitoring technology, the agency shall consider how such technology may enhance the agency's ability to...

38 CFR 21.155 - Services to a veteran's family.

Code of Federal Regulations, 2010 CFR

2010-07-01

... training, counseling, and mental health services of brief duration which are designed to enable the family... furnished to family members under these provisions. (c) Providing services to a veteran's family. VR&E Staff... Veterans Health Administration (VHA) to family members of veterans eligible for Chapter 31 should be used...

38 CFR 21.155 - Services to a veteran's family.

Code of Federal Regulations, 2011 CFR

2011-07-01

... training, counseling, and mental health services of brief duration which are designed to enable the family... furnished to family members under these provisions. (c) Providing services to a veteran's family. VR&E Staff... Veterans Health Administration (VHA) to family members of veterans eligible for Chapter 31 should be used...

14 CFR 141.45 - Ground training facilities.

Code of Federal Regulations, 2011 CFR

2011-01-01

... 14 Aeronautics and Space 3 2011-01-01 2011-01-01 false Ground training facilities. 141.45 Section 141.45 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION (CONTINUED... § 141.45 Ground training facilities. An applicant for a pilot school or provisional pilot school...

14 CFR 141.45 - Ground training facilities.

Code of Federal Regulations, 2010 CFR

2010-01-01

... 14 Aeronautics and Space 3 2010-01-01 2010-01-01 false Ground training facilities. 141.45 Section 141.45 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION (CONTINUED... § 141.45 Ground training facilities. An applicant for a pilot school or provisional pilot school...

Assessment of Service Members Knowledge and Trust of the Department of Veterans Affairs

DTIC Science & Technology

2015-06-12

www.va.gov/health/aboutVHA.asp. 24 Veterans Benefits Administration, “About VBA ,” last updated December 18, 2014, accessed May 10, 2015, http...Department of Veterans Affairs, 2014. Veterans Benefits Administration. “About VBA .” Last updated December 18, 2014. Accessed May 10, 2015. http...OIF Operation Iraqi Freedom VA Department of Veterans Affairs VA OIG Department of Veterans Affairs Office of Inspector General VBA Veterans Benefits

Perceived Benefits, Barriers, and Drivers of Telemedicine From the Perspective of Skilled Nursing Facility Administrative Staff Stakeholders.

PubMed

Driessen, Julia; Castle, Nicholas G; Handler, Steven M

2018-01-01

Potentially avoidable hospitalizations (PAHs) of skilled nursing facility (SNF) patients are common and costly. Telemedicine represents a unique approach to manage and potentially reduce PAHs in SNFs, having been used in a variety of settings to improve coordination of care and enhance access to providers. Nonetheless, broad implementation and use of telemedicine lags in SNFs relative to other health care settings. To understand why, we surveyed SNF administrative staff attending a 1-day telemedicine summit. Participants saw the highest value of telemedicine in improving the quality of care and reducing readmissions. They identified hospital and managed care telemedicine requirements as primary drivers of adoption. The most significant barrier to adoption was the initial investment required. A joint research-policy effort to improve the evidence base around telemedicine in SNFs and introduce incentives may improve adoption and continued use of telemedicine in this setting.

14 CFR 1204.1403 - Available airport facilities.

Code of Federal Regulations, 2011 CFR

2011-01-01

... 14 Aeronautics and Space 5 2011-01-01 2010-01-01 true Available airport facilities. 1204.1403 Section 1204.1403 Aeronautics and Space NATIONAL AERONAUTICS AND SPACE ADMINISTRATION ADMINISTRATIVE... for improved braking under wet conditions. (2) Parking Areas and Hangar Space. No hangar space is...

Ethical challenges within Veterans Administration healthcare facilities: perspectives of managers, clinicians, patients, and ethics committee chairpersons.

PubMed

Foglia, Mary Beth; Pearlman, Robert A; Bottrell, Melissa; Altemose, Jane K; Fox, Ellen

2009-04-01

To promote ethical practices, healthcare managers must understand the ethical challenges encountered by key stakeholders. To characterize ethical challenges in Veterans Administration (VA) facilities from the perspectives of managers, clinicians, patients, and ethics consultants. We conducted focus groups with patients (n = 32) and managers (n = 38); semi-structured interviews with managers (n = 31), clinicians (n = 55), and ethics committee chairpersons (n = 21). Data were analyzed using content analysis. Managers reported that the greatest ethical challenge was fairly distributing resources across programs and services, whereas clinicians identified the effect of resource constraints on patient care. Ethics committee chairpersons identified end-of-life care as the greatest ethical challenge, whereas patients identified obtaining fair, respectful, and caring treatment. Perspectives on ethical challenges varied depending on the respondent's role. Understanding these differences can help managers take practical steps to address these challenges. Further, ethics committees seemingly, are not addressing the range of ethical challenges within their institutions.

Naval Facilities Engineering Command Needs to Improve Controls Over Task Order Administration

DTIC Science & Technology

2015-07-02

consolidated joint use Submarine Learning Center and Submarine Squadron Headquarters facility that: • includes training space for submarine crews, and...allows frequent and timely interaction between Headquarters personnel, Submarine Learning Center instructors, and waterfront operations personnel...Introduction DODIG-2015-141 │ 3 Project P-528 provides a Torpedo Exercise Support facility that: • supports submarine crew training and certification to

Medical team training and coaching in the Veterans Health Administration; assessment and impact on the first 32 facilities in the programme.

PubMed

Neily, Julia; Mills, Peter D; Lee, Pamela; Carney, Brian; West, Priscilla; Percarpio, Katherine; Mazzia, Lisa; Paull, Douglas E; Bagian, James P

2010-08-01

Communication is problematic in healthcare. The Veterans Health Administration is implementing Medical Team Training. The authors describe results of the first 32 of 130 sites to undergo the programme. This report is unique; it provides aggregate results of a crew resource-management programme for numerous facilities. Facilities were taught medical team training and implemented briefings, debriefings and other projects. The authors coached teams through consultative phone interviews over a year. Implementation teams self-reported implementation and rated programme impact: 1='no impact' and 5='significant impact.' We used logistic regression to examine implementation of briefing/debriefing. Ninety-seven per cent of facilities implemented briefings and debriefings, and all implemented an additional project. As of the final interview, 73% of OR and 67% of ICU implementation teams self-reported and rated staff impact 4-5. Eighty-six per cent of OR and 82% of ICU implementation teams self-reported and rated patient impact 4-5. Improved teamwork was reported by 84% of OR and 75% of ICU implementation teams. Efficiency improvements were reported by 94% of OR implementation teams. Almost all facilities (97%) reported a success story or avoiding an undesirable event. Sites with lower volume were more likely to conduct briefings/debriefings in all cases for all surgical services (p=0.03). Sites are implementing the programme with a positive impact on patients and staff, and improving teamwork, efficiency and safety. A unique feature of the programme is that implementation was facilitated through follow-up support. This may have contributed to the early success of the programme.

Homelessness in a national sample of incarcerated veterans in state and federal prisons.

PubMed

Tsai, Jack; Rosenheck, Robert A; Kasprow, Wesley J; McGuire, James F

2014-05-01

The Veterans Health Administration (VHA) has been increasing efforts to reach out to assist incarcerated veterans. While previous studies have shown strong associations between incarceration and homelessness, few studies have examined distinctive characteristics of incarcerated homeless and non-homeless veterans. National administrative data on 30,348 incarcerated veterans served by the Health Care for Re-entry Veterans (HCRV) program were analyzed. Incarcerated veterans were classified into four groups based on their history of past homelessness: not homeless, transiently homeless, episodically homeless, and chronically homeless. Multinomial logistic regression was used to compare groups on sociodemographic characteristics, criminal justice status, clinical status, and their interest in using VHA services. Of the sample, 70 % were classified as not homeless, 8 % as transiently homeless, 11 % as episodically homeless, and 11 % as chronically homeless. Thus, 30 % of the sample had a homeless history, which is five times the 6 % rate of past homelessness among adult men in the general population. Compared to non-homeless incarcerated veterans, all three homeless groups reported significantly more mental health problems, more substance abuse, more times arrested in their lifetime, more likely to be incarcerated for a non-violent offense, and were more interested in receiving VHA services after release from prison. Together, these findings suggest re-entry programs, like HCRV, can address relevant mental health-related service needs, especially among formerly homeless veterans and veterans in need of services are receptive to the offer of assistance.

The costs of critical care telemedicine programs: a systematic review and analysis.

PubMed

Kumar, Gaurav; Falk, Derik M; Bonello, Robert S; Kahn, Jeremy M; Perencevich, Eli; Cram, Peter

2013-01-01

Implementation of telemedicine programs in ICUs (tele-ICUs) may improve patient outcomes, but the costs of these programs are unknown. We performed a systematic literature review to summarize existing data on the costs of tele-ICUs and collected detailed data on the costs of implementing a tele-ICU in a network of Veterans Health Administration (VHA) hospitals. We conducted a systematic review of studies published between January 1, 1990, and July 1, 2011, reporting costs of tele-ICUs. Studies were summarized, and key cost data were abstracted. We then obtained the costs of implementing a tele-ICU in a network of seven VHA hospitals and report these costs in light of the existing literature. Our systematic review identified eight studies reporting tele-ICU costs. These studies suggested combined implementation and first year of operation costs for a tele-ICU of $50,000 to $100,000 per monitored ICU-bed. Changes in patient care costs after tele-ICU implementation ranged from a $3,000 reduction to a $5,600 increase in hospital cost per patient. VHA data suggested a cost for implementation and first year of operation of $70,000 to $87,000 per ICU-bed, depending on the depreciation methods applied. The cost of tele-ICU implementation is substantial, and the impact of these programs on hospital costs or profits is unclear. Until additional data become available, clinicians and administrators should carefully weigh the clinical and economic aspects of tele-ICUs when considering investing in this technology.

49 CFR 655.73 - Access to facilities and records.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 49 Transportation 7 2010-10-01 2010-10-01 false Access to facilities and records. 655.73 Section... OPERATIONS Administrative Requirements § 655.73 Access to facilities and records. (a) Except as required by... payment for the production of those records. (c) An employer shall permit access to all facilities...

Financing School Facilities.

ERIC Educational Resources Information Center

Honeyman, David S., Ed.

Millions of students are attending classes in substandard schools, a condition that is becoming a major concern for many public school parents, teachers, students, and administrators. This report is the result of research investigating school facility issues, assessing the scope of the problem, and making recommendations to the membership of the…

MIMI: multimodality, multiresource, information integration environment for biomedical core facilities.

PubMed

Szymanski, Jacek; Wilson, David L; Zhang, Guo-Qiang

2009-10-01

The rapid expansion of biomedical research has brought substantial scientific and administrative data management challenges to modern core facilities. Scientifically, a core facility must be able to manage experimental workflow and the corresponding set of large and complex scientific data. It must also disseminate experimental data to relevant researchers in a secure and expedient manner that facilitates collaboration and provides support for data interpretation and analysis. Administratively, a core facility must be able to manage the scheduling of its equipment and to maintain a flexible and effective billing system to track material, resource, and personnel costs and charge for services to sustain its operation. It must also have the ability to regularly monitor the usage and performance of its equipment and to provide summary statistics on resources spent on different categories of research. To address these informatics challenges, we introduce a comprehensive system called MIMI (multimodality, multiresource, information integration environment) that integrates the administrative and scientific support of a core facility into a single web-based environment. We report the design, development, and deployment experience of a baseline MIMI system at an imaging core facility and discuss the general applicability of such a system in other types of core facilities. These initial results suggest that MIMI will be a unique, cost-effective approach to addressing the informatics infrastructure needs of core facilities and similar research laboratories.

Overview taken from Facility 2 looking east down Avenue E ...

Library of Congress Historic Buildings Survey, Historic Engineering Record, Historic Landscapes Survey

Overview taken from Facility 2 looking east down Avenue E (Russell Avenue). Facility 1 is on left, Facility 1G and 1C in center. View facing east - U.S. Naval Base, Pearl Harbor, Administration Annex, Near Russell Avenue (previously Avenue E), between of Facility Nos. 1C & 1E , Pearl City, Honolulu County, HI

Engaging multilevel stakeholders in an implementation trial of evidence-based quality improvement in VA women's health primary care.

PubMed

Hamilton, Alison B; Brunner, Julian; Cain, Cindy; Chuang, Emmeline; Luger, Tana M; Canelo, Ismelda; Rubenstein, Lisa; Yano, Elizabeth M

2017-09-01

The Veterans Health Administration (VHA) has undertaken primary care transformation based on patient-centered medical home (PCMH) tenets. VHA PCMH models are designed for the predominantly male Veteran population, and require tailoring to meet women Veterans' needs. We used evidence-based quality improvement (EBQI), a stakeholder-driven implementation strategy, in a cluster randomized controlled trial across 12 sites (eight EBQI, four control) that are members of a Practice-Based Research Network. EBQI involves engaging multilevel, inter-professional leaders and staff as stakeholders in reviewing evidence and setting QI priorities. The goal of this analysis was to examine processes of engaging stakeholders in early implementation of EBQI to tailor VHA's medical home for women. Four inter-professional regional stakeholder planning meetings were conducted; these meetings engaged stakeholders by providing regional data about gender disparities in Veterans' care experiences. Subsequent to each meeting, qualitative interviews were conducted with 87 key stakeholders (leaders and staff). Stakeholders were asked to describe QI efforts and the use of data to change aspects of care, including women's health care. Interview transcripts were summarized and coded using a hybrid deductive/inductive analytic approach. The presentation of regional-level data about gender disparities resulted in heightened awareness and stakeholder buy-in and decision-making related to women's health-focused QI. Interviews revealed that stakeholders were familiar with QI, with regional and facility leaders aware of inter-disciplinary committees and efforts to foster organizational change, including PCMH transformation. These efforts did not typically focus on women's health, though some informal efforts had been undertaken. Barriers to engaging in QI included lack of communication across clinical service lines, fluidity in staffing, and lack of protected time. Inter-professional, multilevel

Out-of-range international normalized ratio values and healthcare cost among new warfarin patients with non-valvular atrial fibrillation.

PubMed

Nelson, Winnie W; Wang, Li; Baser, Onur; Damaraju, C V; Schein, Jeffrey R

2015-05-01

Patients with out-of-range international normalized ratio (INR) values <2.0 and >3.0 have been associated with increased risk of thromboembolic and bleeding events. INR monitoring is costly, because of associated physician and nurse time, laboratory resource use, and dose adjustments. This study assessed the healthcare cost burden associated with out-of-range INR among warfarin initiator patients diagnosed with non-valvular atrial fibrillation (NVAF) in the US Veterans Health Administration (VHA) population. Adult NVAF patients (≥18 years) initiating warfarin were selected from the VHA dataset for the study period October 1, 2007-September 30, 2012. Only valid INR measurements (0.5 ≤ INR ≤ 20) were examined for the follow-up period, from the index date (warfarin initiation date) until the end of warfarin exposure or death. All-cause healthcare costs within 30 days were measured starting from the second month (31 days post-index date) to the end of the study period. Costs for inpatient stays, emergency room, outpatient facility, physician office visits, and other services were computed separately. Multiple regression was performed using the generalized linear model for overall cost analysis. In total, 29,463 patients were included in the study sample. Mean costs for out-of-range INR ranged from $3419 to $5126. Inpatient, outpatient, outpatient pharmacy, and total costs were significantly higher after patients experienced out-of-range results (INR < 2, INR > 3), compared with in-range INR (2 ≤ INR ≤ 3). When exposed to out-of-range INR, patients also incurred higher mean total costs within 2-6 months ($3840-$5820) than after the first 6 months ($2789-$3503) of warfarin therapy. In the VHA population, INR measures outside of the 2-3 range were associated with significantly higher healthcare costs. Increased costs were especially apparent when INR values were below 2, although INR measures above 3 were also associated with higher costs

Planning and Managing School Facilities. Second Edition.

ERIC Educational Resources Information Center

Kowalski, Theodore J.

This book addresses the administrative procedures associated with planning and managing school facilities. As noted at the outset, practitioner interest in school facilities has been growing rapidly in recent years because decades of neglect, poor planning, and cost cutting have created a situation in which large numbers of America's school…

14 CFR § 1204.1404 - Requests for use of NASA airfield facilities.

Code of Federal Regulations, 2014 CFR

2014-01-01

... 14 Aeronautics and Space 5 2014-01-01 2014-01-01 false Requests for use of NASA airfield... ADMINISTRATION ADMINISTRATIVE AUTHORITY AND POLICY Use of NASA Airfield Facilities by Aircraft Not Operated for the Benefit of the Federal Government § 1204.1404 Requests for use of NASA airfield facilities. (a...

14 CFR 145.103 - Housing and facilities requirements.

Code of Federal Regulations, 2014 CFR

2014-01-01

....103 Section 145.103 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF..., Materials, and Data § 145.103 Housing and facilities requirements. (a) Each certificated repair station must provide— (1) Housing for the facilities, equipment, materials, and personnel consistent with its ratings...

14 CFR 145.103 - Housing and facilities requirements.

Code of Federal Regulations, 2012 CFR

2012-01-01

....103 Section 145.103 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF..., Materials, and Data § 145.103 Housing and facilities requirements. (a) Each certificated repair station must provide— (1) Housing for the facilities, equipment, materials, and personnel consistent with its ratings...

14 CFR 145.103 - Housing and facilities requirements.

Code of Federal Regulations, 2011 CFR

2011-01-01

....103 Section 145.103 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF..., Materials, and Data § 145.103 Housing and facilities requirements. (a) Each certificated repair station must provide— (1) Housing for the facilities, equipment, materials, and personnel consistent with its ratings...

14 CFR 145.103 - Housing and facilities requirements.

Code of Federal Regulations, 2013 CFR

2013-01-01

....103 Section 145.103 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF..., Materials, and Data § 145.103 Housing and facilities requirements. (a) Each certificated repair station must provide— (1) Housing for the facilities, equipment, materials, and personnel consistent with its ratings...

Decisionmaker Forums

DTIC Science & Technology

2005-03-01

Committee professional staff, Brian Hurley of Edward Martin & Associates, Michael Kussman of the VA, Steve Lillie of DoD, Steve Mirick ofAMSUSBob...Michael Kussman of VHA; Bruce Levine of VHA; Miklos Losonczy of VHA; Susan Mather of VHA; Theodore Nam of DoD; Harold Wain of DoD; Terry Washam of

78 FR 55282 - Federal Housing Administration (FHA) Healthcare Facility Documents: Notice of Information...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-09-10

... HUD has determined must be submitted with original signatures, in hard copy format. These documents... facility documents, in addition to being presented in an unmarked format, were presented in redline/strikeout format so that reviewers could see the changes proposed to the existing healthcare facility...

14 CFR 21.137 - Location of manufacturing facilities.

Code of Federal Regulations, 2011 CFR

2011-01-01

....137 Section 21.137 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION... manufacturing facilities. The Administrator does not issue a production certificate if the manufacturing... the United States in administering the applicable requirements of the Federal Aviation Act of 1958 or...

Metrics for Success: Strategies for Enabling Core Facility Performance and Assessing Outcomes

PubMed Central

Hockberger, Philip E.; Meyn, Susan M.; Nicklin, Connie; Tabarini, Diane; Auger, Julie A.

2016-01-01

Core Facilities are key elements in the research portfolio of academic and private research institutions. Administrators overseeing core facilities (core administrators) require assessment tools for evaluating the need and effectiveness of these facilities at their institutions. This article discusses ways to promote best practices in core facilities as well as ways to evaluate their performance across 8 of the following categories: general management, research and technical staff, financial management, customer base and satisfaction, resource management, communications, institutional impact, and strategic planning. For each category, we provide lessons learned that we believe contribute to the effective and efficient overall management of core facilities. If done well, we believe that encouraging best practices and evaluating performance in core facilities will demonstrate and reinforce the importance of core facilities in the research and educational mission of institutions. It will also increase job satisfaction of those working in core facilities and improve the likelihood of sustainability of both facilities and personnel. PMID:26848284

Metrics for Success: Strategies for Enabling Core Facility Performance and Assessing Outcomes.

PubMed

Turpen, Paula B; Hockberger, Philip E; Meyn, Susan M; Nicklin, Connie; Tabarini, Diane; Auger, Julie A

2016-04-01

Core Facilities are key elements in the research portfolio of academic and private research institutions. Administrators overseeing core facilities (core administrators) require assessment tools for evaluating the need and effectiveness of these facilities at their institutions. This article discusses ways to promote best practices in core facilities as well as ways to evaluate their performance across 8 of the following categories: general management, research and technical staff, financial management, customer base and satisfaction, resource management, communications, institutional impact, and strategic planning. For each category, we provide lessons learned that we believe contribute to the effective and efficient overall management of core facilities. If done well, we believe that encouraging best practices and evaluating performance in core facilities will demonstrate and reinforce the importance of core facilities in the research and educational mission of institutions. It will also increase job satisfaction of those working in core facilities and improve the likelihood of sustainability of both facilities and personnel.

Projected Use of Long-Term-Care Services by Enrolled Veterans

ERIC Educational Resources Information Center

Kinosian, Bruce; Stallard, Eric; Wieland, Darryl

2007-01-01

Purpose: The purpose of this article is to describe the projected use for long-term-care services through 2012. Design and Methods: We constructed a static-component projection model using age, function, and other covariates. We obtained enrollee projections from the Veterans Health Administration (VHA) and combined these with nursing home and…

Supporting Veteran Transitions to the Academic Setting: VA on Campus

ERIC Educational Resources Information Center

O'Connor, Ashley; Herbst, Ellen; McCaslin, Shannon; Armstrong, Keith; Leach, Bridget; Jersky, Brandina

2018-01-01

In this case study, we assessed academic functioning, service satisfaction, and needs of student veterans at a community college who had accessed the Veterans Health Administration (VHA) Student Veteran Health Program (SVHP) (n = 36). The SVHP provides outreach and behavioral health services directly on a large community college campus to overcome…

44 CFR 321.5 - Retention of industrial facilities.

Code of Federal Regulations, 2011 CFR

2011-10-01

... facilities. 321.5 Section 321.5 Emergency Management and Assistance FEDERAL EMERGENCY MANAGEMENT AGENCY..., DEPARTMENT OF ENERGY, MARITIME ADMINISTRATION) § 321.5 Retention of industrial facilities. (a) Industrial... components in a mobilization period. (b) Each idle plant in the reserves shall be reviewed annually by the...

10 CFR 205.378 - Disconnection of temporary facilities.

Code of Federal Regulations, 2010 CFR

2010-01-01

... 10 Energy 3 2010-01-01 2010-01-01 false Disconnection of temporary facilities. 205.378 Section 205.378 Energy DEPARTMENT OF ENERGY OIL ADMINISTRATIVE PROCEDURES AND SANCTIONS Electric Power System... Electric Facilities and the Transfer of Electricity to Alleviate An Emergency Shortage of Electric Power...

30 CFR 57.6130 - Explosive material storage facilities.

Code of Federal Regulations, 2012 CFR

2012-07-01

... 30 Mineral Resources 1 2012-07-01 2012-07-01 false Explosive material storage facilities. 57.6130 Section 57.6130 Mineral Resources MINE SAFETY AND HEALTH ADMINISTRATION, DEPARTMENT OF LABOR METAL AND... Storage-Surface Only § 57.6130 Explosive material storage facilities. (a) Detonators and explosives shall...

30 CFR 57.6130 - Explosive material storage facilities.

Code of Federal Regulations, 2014 CFR

2014-07-01

... 30 Mineral Resources 1 2014-07-01 2014-07-01 false Explosive material storage facilities. 57.6130 Section 57.6130 Mineral Resources MINE SAFETY AND HEALTH ADMINISTRATION, DEPARTMENT OF LABOR METAL AND... Storage-Surface Only § 57.6130 Explosive material storage facilities. (a) Detonators and explosives shall...

5 CFR 1207.150 - Program accessibility: Existing facilities.

Code of Federal Regulations, 2010 CFR

2010-01-01

... facilities. 1207.150 Section 1207.150 Administrative Personnel MERIT SYSTEMS PROTECTION BOARD ORGANIZATION... CONDUCTED BY THE MERIT SYSTEMS PROTECTION BOARD § 1207.150 Program accessibility: Existing facilities. (a) General. The agency shall operate each program or activity so that the program or activity, when viewed in...

20 CFR 653.105 - Job applications at day-haul facilities.

Code of Federal Regulations, 2012 CFR

2012-04-01

... 20 Employees' Benefits 3 2012-04-01 2012-04-01 false Job applications at day-haul facilities. 653.105 Section 653.105 Employees' Benefits EMPLOYMENT AND TRAINING ADMINISTRATION, DEPARTMENT OF LABOR... Job applications at day-haul facilities. If the State agency is operating a day-haul facility under...

20 CFR 653.105 - Job applications at day-haul facilities.

Code of Federal Regulations, 2011 CFR

2011-04-01

... 20 Employees' Benefits 3 2011-04-01 2011-04-01 false Job applications at day-haul facilities. 653.105 Section 653.105 Employees' Benefits EMPLOYMENT AND TRAINING ADMINISTRATION, DEPARTMENT OF LABOR... Job applications at day-haul facilities. If the State agency is operating a day-haul facility under...

20 CFR 653.105 - Job applications at day-haul facilities.

Code of Federal Regulations, 2014 CFR

2014-04-01

... 20 Employees' Benefits 3 2014-04-01 2014-04-01 false Job applications at day-haul facilities. 653.105 Section 653.105 Employees' Benefits EMPLOYMENT AND TRAINING ADMINISTRATION, DEPARTMENT OF LABOR... Job applications at day-haul facilities. If the State agency is operating a day-haul facility under...

20 CFR 653.105 - Job applications at day-haul facilities.

Code of Federal Regulations, 2013 CFR

2013-04-01

... 20 Employees' Benefits 3 2013-04-01 2013-04-01 false Job applications at day-haul facilities. 653.105 Section 653.105 Employees' Benefits EMPLOYMENT AND TRAINING ADMINISTRATION, DEPARTMENT OF LABOR... Job applications at day-haul facilities. If the State agency is operating a day-haul facility under...

Reducing Avoidable Deaths Among Veterans: Directing Private-Sector Surgical Care to High-Performance Hospitals

PubMed Central

Weeks, William B.; West, Alan N.; Wallace, Amy E.; Lee, Richard E.; Goodman, David C.; Dimick, Justin B.; Bagian, James P.

2007-01-01

Objectives. We quantified older (65 years and older) Veterans Health Administration (VHA) patients’ use of the private sector to obtain 14 surgical procedures and assessed the potential impact of directing that care to high-performance hospitals. Methods. Using a merged VHA–Medicare inpatient database for 2000 and 2001, we determined where older VHA enrollees obtained 6 cardiovascular surgeries and 8 cancer resections and whether private-sector care was obtained in high- or low-performance hospitals (based on historical performance and determined 2 years in advance of the service year). We then modeled the mortality and travel burden effect of directing private-sector care to high-performance hospitals. Results. Older veterans obtained most of their procedures in the private sector, but that care was equally distributed across high- and low-performance hospitals. Directing private-sector care to high-performance hospitals could have led to the avoidance of 376 to 584 deaths, most through improved cardiovascular care outcomes. Using historical mortality to define performance would produce better outcomes with lower travel time. Conclusions. Policy that directs older VHA enrollees’ private-sector care to high-performance hospitals promises to reduce mortality for VHA’s service population and warrants further exploration. PMID:17971543

Predictive Modeling and Concentration of the Risk of Suicide: Implications for Preventive Interventions in the US Department of Veterans Affairs

PubMed Central

McCarthy, John F.; Katz, Ira R.; Thompson, Caitlin; Kemp, Janet; Hannemann, Claire M.; Nielson, Christopher; Schoenbaum, Michael

2015-01-01

Objectives. The Veterans Health Administration (VHA) evaluated the use of predictive modeling to identify patients at risk for suicide and to supplement ongoing care with risk-stratified interventions. Methods. Suicide data came from the National Death Index. Predictors were measures from VHA clinical records incorporating patient-months from October 1, 2008, to September 30, 2011, for all suicide decedents and 1% of living patients, divided randomly into development and validation samples. We used data on all patients alive on September 30, 2010, to evaluate predictions of suicide risk over 1 year. Results. Modeling demonstrated that suicide rates were 82 and 60 times greater than the rate in the overall sample in the highest 0.01% stratum for calculated risk for the development and validation samples, respectively; 39 and 30 times greater in the highest 0.10%; 14 and 12 times greater in the highest 1.00%; and 6.3 and 5.7 times greater in the highest 5.00%. Conclusions. Predictive modeling can identify high-risk patients who were not identified on clinical grounds. VHA is developing modeling to enhance clinical care and to guide the delivery of preventive interventions. PMID:26066914

Predictive Modeling and Concentration of the Risk of Suicide: Implications for Preventive Interventions in the US Department of Veterans Affairs.

PubMed

McCarthy, John F; Bossarte, Robert M; Katz, Ira R; Thompson, Caitlin; Kemp, Janet; Hannemann, Claire M; Nielson, Christopher; Schoenbaum, Michael

2015-09-01

The Veterans Health Administration (VHA) evaluated the use of predictive modeling to identify patients at risk for suicide and to supplement ongoing care with risk-stratified interventions. Suicide data came from the National Death Index. Predictors were measures from VHA clinical records incorporating patient-months from October 1, 2008, to September 30, 2011, for all suicide decedents and 1% of living patients, divided randomly into development and validation samples. We used data on all patients alive on September 30, 2010, to evaluate predictions of suicide risk over 1 year. Modeling demonstrated that suicide rates were 82 and 60 times greater than the rate in the overall sample in the highest 0.01% stratum for calculated risk for the development and validation samples, respectively; 39 and 30 times greater in the highest 0.10%; 14 and 12 times greater in the highest 1.00%; and 6.3 and 5.7 times greater in the highest 5.00%. Predictive modeling can identify high-risk patients who were not identified on clinical grounds. VHA is developing modeling to enhance clinical care and to guide the delivery of preventive interventions.

Veterans Health Administration: Management Attention Is Needed to Address Systemic, Long standing Human Capital Challenges

DTIC Science & Technology

2016-12-01

Effort through Strategic Human Capital Management , GAO-04-85 (Washington, D.C.: Oct. 20, 2003); and A Model of Strategic Human Capital Management , GAO...Washington, D.C.: Jan. 30, 2015). 60See GAO-15-290 for the most recent update on strategic human capital management . VHA Reports Critical HR Competency...systems to obtain and process information to meet operational needs.71 Likewise, our prior work on strategic human capital management notes that high

75 FR 54543 - Changes to NARA Facilities' Hours of Operation

Federal Register 2010, 2011, 2012, 2013, 2014

2010-09-08

... NATIONAL ARCHIVES AND RECORDS ADMINISTRATION 36 CFR Parts 1253, 1254, and 1280 [NARA-10-0004] RIN 3095-AB68 Changes to NARA Facilities' Hours of Operation AGENCY: National Archives and Records Administration. ACTION: Proposed rule. SUMMARY: The National Archives and Records Administration (NARA) is...

Radar Training Facility initial validation.

DOT National Transportation Integrated Search

1983-05-01

The Radar Training Facility (RTF), part of the Federal Aviation Administration Academy located at the Oklahoma City Mike Monroney Aeronautical Center, is designed to identify, as early as possible, air traffic control specialists who do not demonstra...

Administering the Preschool Facility.

ERIC Educational Resources Information Center

Coonrod, Debbie

Securing the right environment for a preschool program requires planning and research. Administrators or searching parties are advised to study zoning codes to become acquainted with state sanitation and safety regulations and laws, to involve teachers in cooperative planning, to design facilities which discourage vandalism, facilitate…

30 CFR 56.6130 - Explosive material storage facilities.

Code of Federal Regulations, 2014 CFR

2014-07-01

... 30 Mineral Resources 1 2014-07-01 2014-07-01 false Explosive material storage facilities. 56.6130 Section 56.6130 Mineral Resources MINE SAFETY AND HEALTH ADMINISTRATION, DEPARTMENT OF LABOR METAL AND... Storage § 56.6130 Explosive material storage facilities. (a) Detonators and explosives shall be stored in...

30 CFR 56.6130 - Explosive material storage facilities.

Code of Federal Regulations, 2012 CFR

2012-07-01

... 30 Mineral Resources 1 2012-07-01 2012-07-01 false Explosive material storage facilities. 56.6130 Section 56.6130 Mineral Resources MINE SAFETY AND HEALTH ADMINISTRATION, DEPARTMENT OF LABOR METAL AND... Storage § 56.6130 Explosive material storage facilities. (a) Detonators and explosives shall be stored in...

Planning Physical Education and Athletic Facilities in Schools.

ERIC Educational Resources Information Center

Penman, Kenneth A.

This book is primarily designed for a course in planning physical education and athletic facilities and as a supplementary textbook for administration courses. It illustrates the skills necessary for designing and planning facilities, stresses the need for effective communication between planners and users, and covers elementary through college…

How Metric Conversion Affects Administrative Practices

ERIC Educational Resources Information Center

Straka, M. K.

1977-01-01

Changes necessary in the administrative activities of educational institutions following conversion to the metric system are outlined for secretarial practices, purchasing, internal reporting and forms, computer operations, travel, publications, buildings and plant, new buildings, sport facilities, and health services. (MF)

77 FR 26304 - Federal Housing Administration (FHA) Healthcare Facility Documents: Proposed Revisions and...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-05-03

...Consistent with the Paperwork Reduction Act of 1995 (PRA), HUD is publishing for public comment a comprehensive set of closing and other documents used in connection with transactions involving healthcare facilities (excluding hospitals) that are insured pursuant to section 232 of the National Housing Act (Section 232). In addition to meeting PRA requirements, this notice seeks public comment for the purpose of enlisting input from the lending industry and other interested parties in the development, updating, and adoption of a set of instruments (collectively, healthcare facility documents) that offer the requisite protection to all parties in these FHA-insured mortgage transactions, consistent with modern real estate and mortgage lending laws and practices. The healthcare facility documents, which are the subject of this notice, can be viewed on HUD's Web site: www.hud.gov/232forms. HUD is also publishing today a proposed rule that will submit for public comment certain revisions to FHA's Section 232 regulations for the purpose of ensuring consistency between the program regulations and the revised healthcare facility documents.

Stroke survivors with severe mental illness: Are they at-risk for increased non-psychiatric hospitalizations?

PubMed

Lilly, Flavius Robert; Culpepper, Joel; Stuart, Mary; Steinwachs, Donald

2017-01-01

This study examined outcomes for two groups of stroke survivors treated in Veteran Health Administration (VHA) hospitals, those with a severe mental illness (SMI) and those without prior psychiatric diagnoses, to examine risk of non-psychiatric medical hospitalizations over five years after initial stroke. This retrospective cohort study included 523 veterans who survived an initial stroke hospitalization in a VHA medical center during fiscal year 2003. The survivors were followed using administrative data documenting inpatient stroke treatment, patient demographics, disease comorbidities, and VHA hospital admissions. Multivariate Poisson regression was used to examine the relationship between patients with and without SMI diagnosis preceding the stroke and their experience with non-psychiatric medical hospitalizations after the stroke. The study included 100 patients with SMI and 423 without SMI. Unadjusted means for pre-stroke non-psychiatric hospitalizations were higher (p = 0.0004) among SMI patients (1.47 ± 0.51) compared to those without SMI (1.00 ± 1.33), a difference which persisted through the first year post-stroke (SMI: 2.33 ± 2.46; No SMI: 1.74 ± 1.86; p = 0.0004). Number of non-psychiatric hospitalizations were not significantly different between the two groups after adjustment for patient sociodemographic, comorbidity, length of stay and inpatient stroke treatment characteristics. Antithrombotic medications significantly lowered risk (OR = 0.61; 95% CI: 0.49-0.73) for stroke-related readmission within 30 days of discharge. No significant differences in medical hospitalizations were present after adjusting for comorbid and sociodemographic characteristics between SMI and non-SMI stroke patients in the five-year follow-up. However, unadjusted results continue to draw attention to disparities, with SMI patients experiencing more non-psychiatric hospitalizations both prior to and up to one year after their initial stroke. Additionally, stroke

48 CFR 801.602-80 - Legal and technical review-Office of Construction and Facilities Management and National Cemetery...

Code of Federal Regulations, 2012 CFR

2012-10-01

...-Office of Construction and Facilities Management and National Cemetery Administration. 801.602-80 Section... Responsibilities 801.602-80 Legal and technical review-Office of Construction and Facilities Management and National Cemetery Administration. An Office of Construction and Facilities Management or National Cemetery...

48 CFR 801.602-80 - Legal and technical review-Office of Construction and Facilities Management and National Cemetery...

Code of Federal Regulations, 2011 CFR

2011-10-01

...-Office of Construction and Facilities Management and National Cemetery Administration. 801.602-80 Section... Responsibilities 801.602-80 Legal and technical review-Office of Construction and Facilities Management and National Cemetery Administration. An Office of Construction and Facilities Management or National Cemetery...

48 CFR 801.602-80 - Legal and technical review-Office of Construction and Facilities Management and National Cemetery...

Code of Federal Regulations, 2013 CFR

2013-10-01

...-Office of Construction and Facilities Management and National Cemetery Administration. 801.602-80 Section... Responsibilities 801.602-80 Legal and technical review-Office of Construction and Facilities Management and National Cemetery Administration. An Office of Construction and Facilities Management or National Cemetery...

48 CFR 801.602-80 - Legal and technical review-Office of Construction and Facilities Management and National Cemetery...

Code of Federal Regulations, 2014 CFR

2014-10-01

...-Office of Construction and Facilities Management and National Cemetery Administration. 801.602-80 Section... Responsibilities 801.602-80 Legal and technical review-Office of Construction and Facilities Management and National Cemetery Administration. An Office of Construction and Facilities Management or National Cemetery...

14 CFR 21.43 - Location of manufacturing facilities.

Code of Federal Regulations, 2012 CFR

2012-01-01

... 14 Aeronautics and Space 1 2012-01-01 2012-01-01 false Location of manufacturing facilities. 21.43 Section 21.43 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION AIRCRAFT.... Except as provided in § 21.29, the FAA does not issue a type certificate if the manufacturing facilities...

14 CFR 21.43 - Location of manufacturing facilities.

Code of Federal Regulations, 2014 CFR

2014-01-01

... 14 Aeronautics and Space 1 2014-01-01 2014-01-01 false Location of manufacturing facilities. 21.43 Section 21.43 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION AIRCRAFT.... Except as provided in § 21.29, the FAA does not issue a type certificate if the manufacturing facilities...

14 CFR 21.43 - Location of manufacturing facilities.

Code of Federal Regulations, 2013 CFR

2013-01-01

... 14 Aeronautics and Space 1 2013-01-01 2013-01-01 false Location of manufacturing facilities. 21.43 Section 21.43 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION AIRCRAFT.... Except as provided in § 21.29, the FAA does not issue a type certificate if the manufacturing facilities...

Prevalence of Suicidality Among Hispanic and African American Veterans Following Surgery

PubMed Central

McIntyre, Raphael T.; Stock, Eileen M.; Zeber, John E.; MacCarthy, Daniel J.; Pugh, Mary Jo

2014-01-01

Objectives. We evaluated factors associated with suicidal behavior and ideation (SBI) during 3 years of follow-up among 89 995 Veterans Health Administration (VHA) patients who underwent major surgery from October 2005 to September 2006. Methods. We analyzed administrative data using Cox proportional hazards models. SBI was ascertained by International Classification of Disease, 9th Revision codes. Results. African Americans (18% of sample; 16 252) were at an increased risk for SBI (hazard ratio [HR] = 1.21; 95% confidence interval [CI]  = 1.10, 1.32), whereas Hispanics were not (HR = 1.10; 95% CI = 0.95, 1.28). Other risk factors included schizophrenia, bipolar disorder, depression, posttraumatic stress disorder, pain disorders, postoperative new-onset depression, and postoperative complications; female gender and married status were protective against SBI. Conclusions. The postoperative period might be a time of heightened risk for SBI among minority patients in the VHA. Tailored monitoring and postoperative management by minority status might be required to achieve care equity. PMID:25100427

38 CFR 39.62 - Space criteria for support facilities.

Code of Federal Regulations, 2013 CFR

2013-07-01

... 10 years. (a) Administrative building. The administrative building should be approximately 1,600 NSF.../work area); (5) Family/conference room; (6) Military honors team; (7) Refreshment unit; (8) Housekeeping aide's closet; and (9) Restroom facilities. (b) Maintenance/service building. The maintenance...

Using Human Factors Methods to Design a New Interface for an Electronic Medical Record

PubMed Central

Saleem, Jason J.; Patterson, Emily S.; Militello, Laura; Asch, Steven M.; Doebbeling, Bradley N.; Render, Marta L.

2007-01-01

The Veterans Health Administration (VHA) is a leader in development and use of electronic patient records and clinical decision support. The VHA is currently reengineering a somewhat dated platform for its Computerized Patient Record System (CPRS). This process affords a unique opportunity to implement major changes to the current design and function of the system. We report on two human factors studies designed to provide input and guidance during this reengineering process. One study involved a card sort to better understand how providers tend to cognitively organize clinical data, and how that understanding can help guide interface design. The other involved a simulation to assess the impact of redesign modifications on computerized clinical reminders, a form of clinical decision support in the CPRS, on the learnability of the system for first-time users. PMID:18693914

14 CFR 21.43 - Location of manufacturing facilities.

Code of Federal Regulations, 2011 CFR

2011-01-01

... 14 Aeronautics and Space 1 2011-01-01 2011-01-01 false Location of manufacturing facilities. 21.43 Section 21.43 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION AIRCRAFT.... Except as provided in § 21.29, the Administrator does not issue a type certificate if the manufacturing...

75 FR 23843 - Discretionary Bus and Bus Facilities Program

Federal Register 2010, 2011, 2012, 2013, 2014

2010-05-04

... transit facilities and equipment. d. For facilities, evidence of proposed project compliance with ``Green Building'' certification. 3. For transit asset management system projects: If asset management system...-New York, Administrator, Region 7-Kansas One Bowling Green, Room 429, New City, MO, 901 Locust Street...

Hanford Facility dangerous waste permit application, liquid effluent retention facility and 200 area effluent treatment facility

DOE Office of Scientific and Technical Information (OSTI.GOV)

Coenenberg, J.G.

1997-08-15

The Hanford Facility Dangerous Waste Permit Application is considered to 10 be a single application organized into a General Information Portion (document 11 number DOE/RL-91-28) and a Unit-Specific Portion. The scope of the 12 Unit-Specific Portion is limited to Part B permit application documentation 13 submitted for individual, `operating` treatment, storage, and/or disposal 14 units, such as the Liquid Effluent Retention Facility and 200 Area Effluent 15 Treatment Facility (this document, DOE/RL-97-03). 16 17 Both the General Information and Unit-Specific portions of the Hanford 18 Facility Dangerous Waste Permit Application address the content of the Part B 19 permit applicationmore » guidance prepared by the Washington State Department of 20 Ecology (Ecology 1987 and 1996) and the U.S. Environmental Protection Agency 21 (40 Code of Federal Regulations 270), with additional information needs 22 defined by the Hazardous and Solid Waste Amendments and revisions of 23 Washington Administrative Code 173-303. For ease of reference, the Washington 24 State Department of Ecology alpha-numeric section identifiers from the permit 25 application guidance documentation (Ecology 1996) follow, in brackets, the 26 chapter headings and subheadings. A checklist indicating where information is 27 contained in the Liquid Effluent Retention Facility and 200 Area Effluent 28 Treatment Facility permit application documentation, in relation to the 29 Washington State Department of Ecology guidance, is located in the Contents 30 Section. 31 32 Documentation contained in the General Information Portion is broader in 33 nature and could be used by multiple treatment, storage, and/or disposal units 34 (e.g., the glossary provided in the General Information Portion). Wherever 35 appropriate, the Liquid Effluent Retention Facility and 200 Area Effluent 36 Treatment Facility permit application documentation makes cross-reference to 37 the General Information Portion, rather than

Patient-centered medical home implementation and primary care provider turnover.

PubMed

Sylling, Philip W; Wong, Edwin S; Liu, Chuan-Fen; Hernandez, Susan E; Batten, Adam J; Helfrich, Christian D; Nelson, Karin; Fihn, Stephan D; Hebert, Paul L

2014-12-01

The Veterans Health Administration (VHA) began implementing a patient-centered medical home (PCMH) model of care delivery in April 2010 through its Patient Aligned Care Team (PACT) initiative. PACT represents a substantial system reengineering of VHA primary care and its potential effect on primary care provider (PCP) turnover is an important but unexplored relationship. This study examined the association between a system-wide PCMH implementation and PCP turnover. This was a retrospective, longitudinal study of VHA-employed PCPs spanning 29 calendar quarters before PACT and eight quarters of PACT implementation. PCP employment periods were identified from administrative data and turnover was defined by an indicator on the last quarter of each uncensored period. An interrupted time series model was used to estimate the association between PACT and turnover, adjusting for secular trend and seasonality, provider and job characteristics, and local unemployment. We calculated average marginal effects (AME), which reflected the change in turnover probability associated with PACT implementation. The quarterly rate of PCP turnover was 3.06% before PACT and 3.38% after initiation of PACT. In adjusted analysis, PACT was associated with a modest increase in turnover (AME=4.0 additional PCPs per 1000 PCPs per quarter, P=0.004). Models with interaction terms suggested that the PACT-related change in turnover was increasing in provider age and experience. PACT was associated with a modest increase in PCP turnover, concentrated among older and more experienced providers, during initial implementation. Our findings suggest that policymakers should evaluate potential workforce effects when implementing PCMH.

The Costs of Critical Care Telemedicine Programs

PubMed Central

Falk, Derik M.; Bonello, Robert S.; Kahn, Jeremy M.; Perencevich, Eli; Cram, Peter

2013-01-01

Background: Implementation of telemedicine programs in ICUs (tele-ICUs) may improve patient outcomes, but the costs of these programs are unknown. We performed a systematic literature review to summarize existing data on the costs of tele-ICUs and collected detailed data on the costs of implementing a tele-ICU in a network of Veterans Health Administration (VHA) hospitals. Methods: We conducted a systematic review of studies published between January 1, 1990, and July 1, 2011, reporting costs of tele-ICUs. Studies were summarized, and key cost data were abstracted. We then obtained the costs of implementing a tele-ICU in a network of seven VHA hospitals and report these costs in light of the existing literature. Results: Our systematic review identified eight studies reporting tele-ICU costs. These studies suggested combined implementation and first year of operation costs for a tele-ICU of $50,000 to $100,000 per monitored ICU-bed. Changes in patient care costs after tele-ICU implementation ranged from a $3,000 reduction to a $5,600 increase in hospital cost per patient. VHA data suggested a cost for implementation and first year of operation of $70,000 to $87,000 per ICU-bed, depending on the depreciation methods applied. Conclusions: The cost of tele-ICU implementation is substantial, and the impact of these programs on hospital costs or profits is unclear. Until additional data become available, clinicians and administrators should carefully weigh the clinical and economic aspects of tele-ICUs when considering investing in this technology. PMID:22797291

38 CFR 39.62 - Space criteria for support facilities.

Code of Federal Regulations, 2011 CFR

2011-07-01

... assignment for the next 10 years. (a) Administrative building. The administrative building should be.../office/equipment/work area); (5) Family/conference room; (6) Military honors team; (7) Refreshment unit; (8) Housekeeping aide's closet; and (9) Restroom facilities. (b) Maintenance/service building. The...

University of Maryland MRSEC - Facilities: TEM

Science.gov Websites

MRSEC Templates Opportunities Search Home » Facilities » Electron Microscopy Shared Experimental for non-profit administrative or educational purposes if proper credit is given to the University of

48 CFR 837.7004 - Administrative necessity.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 48 Federal Acquisition Regulations System 5 2014-10-01 2014-10-01 false Administrative necessity. 837.7004 Section 837.7004 Federal Acquisition Regulations System DEPARTMENT OF VETERANS AFFAIRS... further action, the contracting officer will secure from the facility or VISN director, as appropriate, a...

48 CFR 837.7004 - Administrative necessity.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 48 Federal Acquisition Regulations System 5 2011-10-01 2011-10-01 false Administrative necessity. 837.7004 Section 837.7004 Federal Acquisition Regulations System DEPARTMENT OF VETERANS AFFAIRS... further action, the contracting officer will secure from the facility or VISN director, as appropriate, a...

48 CFR 837.7004 - Administrative necessity.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 48 Federal Acquisition Regulations System 5 2012-10-01 2012-10-01 false Administrative necessity. 837.7004 Section 837.7004 Federal Acquisition Regulations System DEPARTMENT OF VETERANS AFFAIRS... further action, the contracting officer will secure from the facility or VISN director, as appropriate, a...

48 CFR 837.7004 - Administrative necessity.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 48 Federal Acquisition Regulations System 5 2013-10-01 2013-10-01 false Administrative necessity. 837.7004 Section 837.7004 Federal Acquisition Regulations System DEPARTMENT OF VETERANS AFFAIRS... further action, the contracting officer will secure from the facility or VISN director, as appropriate, a...

48 CFR 837.7004 - Administrative necessity.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 48 Federal Acquisition Regulations System 5 2010-10-01 2010-10-01 false Administrative necessity. 837.7004 Section 837.7004 Federal Acquisition Regulations System DEPARTMENT OF VETERANS AFFAIRS... further action, the contracting officer will secure from the facility or VISN director, as appropriate, a...

South Carolina Industrial Arts Safety Guide. Administrator and Instructor Section.

ERIC Educational Resources Information Center

South Carolina State Dept. of Education, Columbia.

This administrator and instructor section of a South Carolina industrial arts safety guide includes sections on responsibility for school safety, safety programming for the teacher, emergency action, suggested forms and outlines, and facility design and layout. School board and superintendent, administrator, and teacher responsibilities for school…

75 FR 13259 - Public Telecommunications Facilities Program: New Closing Date

Federal Register 2010, 2011, 2012, 2013, 2014

2010-03-19

... DEPARTMENT OF COMMERCE National Telecommunications and Information Administration Docket No. 100305127-0127-01 Public Telecommunications Facilities Program: New Closing Date AGENCY: National Telecommunications and Information Administration, U.S. Department of Commerce. ACTION: Notice; to re-open...

7 CFR 353.8 - Accreditation of non-government facilities.

Code of Federal Regulations, 2010 CFR

2010-01-01

... facilities may be obtained by writing to Phytosanitary Issues Management, PPQ, APHIS, 4700 River Road, Unit... Administrator determines that such action is necessary to protect the public health, interest, or safety. Such... the facility is seeking accreditation must be identified and must possess the training, education, or...

Redirecting Under-Utilised Computer Laboratories into Cluster Computing Facilities

ERIC Educational Resources Information Center

Atkinson, John S.; Spenneman, Dirk H. R.; Cornforth, David

2005-01-01

Purpose: To provide administrators at an Australian university with data on the feasibility of redirecting under-utilised computer laboratories facilities into a distributed high performance computing facility. Design/methodology/approach: The individual log-in records for each computer located in the computer laboratories at the university were…

38 CFR 51.210 - Administration.

Code of Federal Regulations, 2014 CFR

2014-07-01

... FOR NURSING HOME CARE OF VETERANS IN STATE HOMES Standards § 51.210 Administration. A facility must be... (annual at time of survey); (6) The number of nursing home patients who are veterans and non-veterans, the... residents eligible for VA nursing home care must be at least 75 percent veterans except that the veteran...

5 CFR 2604.201 - Public reading room facility and Web site.

Code of Federal Regulations, 2011 CFR

2011-01-01

... 5 Administrative Personnel 3 2011-01-01 2011-01-01 false Public reading room facility and Web site... DISCLOSURE REPORTS FOIA Public Reading Room Facility and Web Site; Index Identifying Information for the Public § 2604.201 Public reading room facility and Web site. (a)(1) Location of public reading room...

5 CFR 2604.201 - Public reading room facility and Web site.

Code of Federal Regulations, 2010 CFR

2010-01-01

... 5 Administrative Personnel 3 2010-01-01 2010-01-01 false Public reading room facility and Web site... DISCLOSURE REPORTS FOIA Public Reading Room Facility and Web Site; Index Identifying Information for the Public § 2604.201 Public reading room facility and Web site. (a)(1) Location of public reading room...

28 CFR 115.63 - Reporting to other confinement facilities.

Code of Federal Regulations, 2012 CFR

2012-07-01

... 28 Judicial Administration 2 2012-07-01 2012-07-01 false Reporting to other confinement facilities. 115.63 Section 115.63 Judicial Administration DEPARTMENT OF JUSTICE (CONTINUED) PRISON RAPE ELIMINATION ACT NATIONAL STANDARDS Standards for Adult Prisons and Jails Official Response Following An Inmate...

28 CFR 115.63 - Reporting to other confinement facilities.

Code of Federal Regulations, 2013 CFR

2013-07-01

... 28 Judicial Administration 2 2013-07-01 2013-07-01 false Reporting to other confinement facilities. 115.63 Section 115.63 Judicial Administration DEPARTMENT OF JUSTICE (CONTINUED) PRISON RAPE ELIMINATION ACT NATIONAL STANDARDS Standards for Adult Prisons and Jails Official Response Following An Inmate...

28 CFR 115.63 - Reporting to other confinement facilities.

Code of Federal Regulations, 2014 CFR

2014-07-01

... 28 Judicial Administration 2 2014-07-01 2014-07-01 false Reporting to other confinement facilities. 115.63 Section 115.63 Judicial Administration DEPARTMENT OF JUSTICE (CONTINUED) PRISON RAPE ELIMINATION ACT NATIONAL STANDARDS Standards for Adult Prisons and Jails Official Response Following An Inmate...

9 CFR 72.16 - Designated dipping stations to be approved by the Administrator, APHIS on recommendations of...

Code of Federal Regulations, 2010 CFR

2010-01-01

... approved by the Administrator, APHIS on recommendations of State authorities; facilities. 72.16 Section 72... CATTLE § 72.16 Designated dipping stations to be approved by the Administrator, APHIS on recommendations of State authorities; facilities. When deemed advisable and upon recommendation by the proper...

Using organizational and clinical performance data to increase the value of mental health care.

PubMed

Schmidt, Eric M; Krahn, Dean D; McGuire, Marsden H; Tavakoli, Sara; Wright, David M; Solares, Hugo E; Lemke, Sonne; Trafton, Jodie

2017-02-01

U.S. health systems, policy makers, and patients increasingly demand high-value care that improves health outcomes at lower cost. This study describes the initial design and analysis of the Mental Health Management System (MHMS), a performance data and quality improvement tool used by the Veterans Health Administration (VHA) to increase the value of its mental health care. The MHMS evaluates access to and quality of mental health care, organizational structure and efficiency, implementation of innovative treatment options, and, in collaboration with management, resource needs for delivering care. Performance on 31 measures was calculated for all U.S. VHA facilities (N = 139). Pearson correlations revealed that better access to care was significantly associated with fewer mental health provider staffing vacancies (r = -.24) and higher staff-to-patient ratios for psychiatrists (r = .19) and other outpatient mental health providers (r = .27). Higher staff-to-patient ratios were significantly associated with higher performance on a number of patient and provider satisfaction measures (range of r = .18-.51) and continuity of care measures (range of r = .26-.43). Relationships observed between organizational and clinical performance measures suggest that the MHMS is a robust informatics and quality improvement tool that can serve as a model for health systems planning to adopt a value perspective. Future research should expand the MHMS framework to measure patient and health systems costs and psychosocial outcomes, as well as evaluate whether quality improvement solutions implemented as a result of using organizational information leads to higher-value mental health care. (PsycINFO Database Record (c) 2017 APA, all rights reserved).

Primary Care-Mental Health Integration in the Veterans Affairs Health System: Program Characteristics and Performance.

PubMed

Cornwell, Brittany L; Brockmann, Laurie M; Lasky, Elaine C; Mach, Jennifer; McCarthy, John F

2018-06-01

The Veterans Health Administration (VHA) has achieved substantial national implementation of primary care-mental health integration (PC-MHI) services. However, little is known regarding program characteristics, variation in characteristics across settings, or associations between program fidelity and performance. This study identified core elements of PC-MHI services and evaluated their associations with program characteristics and performance. A principal-components analysis (PCA) of reports from 349 sites identified factors associated with PC-MHI fidelity. Analyses assessed the correlation among factors and between each factor and facility type (medical center or community-based outpatient clinic), primary care population size, and performance indicators (receipt of PC-MHI services, same-day access to mental health and primary care services, and extended duration of services). PCA identified seven factors: core implementation, care management (CM) assessments and supervision, CM supervision receipt, colocated collaborative care (CCC) by prescribing providers, CCC by behavioral health providers, participation in patient aligned care teams (PACTs) for special populations, and treatment of complex mental health conditions. Sites serving larger populations had greater core implementation scores. Medical centers and sites serving larger populations had greater scores for CCC by prescribing providers, CM assessments and supervision, and participation in PACTs. Greater core implementation scores were associated with greater same-day access. Sites with greater scores for CM assessments and supervision had lower scores for treatment of complex conditions. Outpatient clinics and sites serving smaller populations experienced challenges in integrated care implementation. To enhance same-day access, VHA should continue to prioritize PC-MHI implementation. Providing brief, problem-focused care may enhance CM implementation.

77 FR 55120 - Federal Housing Administration (FHA): Section 232 Healthcare Facility Insurance Program...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-09-07

...In 2010 through 2011, HUD commenced and completed the process of revising regulations applicable to, and closing documents used in, FHA insurance of multifamily rental projects, to reflect current policy and practices in the multifamily mortgage market. This final rule results from a similar process that was initiated in 2011 for revising and updating the regulations governing, and the transactional documents used in, the program for insurance of healthcare facilities under section 232 of the National Housing Act (Section 232 program). HUD's Section 232 program insures mortgage loans to facilitate the construction, substantial rehabilitation, purchase, and refinancing of nursing homes, intermediate care facilities, board and care homes, and assisted-living facilities. This rule revises the Section 232 program regulations to reflect current policy and practices, and improve accountability and strengthen risk management in the Section 232 program.

14 CFR 1204.1404 - Requests for use of NASA airfield facilities.

Code of Federal Regulations, 2011 CFR

2011-01-01

... 14 Aeronautics and Space 5 2011-01-01 2010-01-01 true Requests for use of NASA airfield facilities... ADMINISTRATIVE AUTHORITY AND POLICY Use of NASA Airfield Facilities by Aircraft Not Operated for the Benefit of the Federal Government § 1204.1404 Requests for use of NASA airfield facilities. (a) Request for use...

Administration of Maintenance and Operations in California School Districts: A Handbook for School Administrators and Governing Boards.

ERIC Educational Resources Information Center

California State Dept. of Education, Sacramento.

This handbook provides information that administrators of maintenance and operations in California schools can use in systematically planning and scheduling school facility support services. The first unit, chapter 1, is designed to help members of school district governing boards establish board policies, regulations, and procedures. Topics…

Smoke-Free Medical Facility Campus Legislation: Support, Resistance, Difficulties and Cost

PubMed Central

Sheffer, Christine; Stitzer, Maxine; Wheeler, J. Gary

2009-01-01

Although medical facilities restrict smoking inside, many people continue to smoke outside, creating problems with second-hand smoke, litter, fire risks, and negative role modeling. In 2005, Arkansas passed legislation prohibiting smoking on medical facility campuses. Hospital administrators (N=113) were surveyed pre- and post-implementation. Administrators reported more support and less difficulty than anticipated. Actual cost was 10–50% of anticipated cost. Few negative effects and numerous positive effects on employee performance and retention were reported. The results may be of interest to hospital administrators and demonstrate that state legislation can play a positive role in facilitating broad health-related policy change. PMID:19440281

Sabbatical Report: Results of a Survey of Library Microforms Facilities.

ERIC Educational Resources Information Center

McIntosh, Melinda C.

1987-01-01

Highlights findings on the status of academic library microforms facilities in the United States and Canada based on visits to 11 libraries. Topics covered include administration, personnel, collection access and storage, classification, acquisition, circulation, indexes, hours, facilities, signage, equipment, photocopying, cleanliness, vandalism,…

Administrative Segregation for Mentally Ill Inmates

ERIC Educational Resources Information Center

O'Keefe, Maureen L.

2007-01-01

Largely the result of prison officials needing to safely and efficiently manage a volatile inmate population, administrative segregation or supermax facilities are criticized as violating basic human needs, particularly for mentally ill inmates. The present study compared Colorado offenders with mental illness (OMIs) to nonOMIs in segregated and…

45 CFR 3.41 - Admission to facilities or grounds.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 45 Public Welfare 1 2013-10-01 2013-10-01 false Admission to facilities or grounds. 3.41 Section 3.41 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION CONDUCT OF PERSONS AND TRAFFIC ON THE NATIONAL INSTITUTES OF HEALTH FEDERAL ENCLAVE Facilities and Grounds § 3.41...

45 CFR 3.41 - Admission to facilities or grounds.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 45 Public Welfare 1 2014-10-01 2014-10-01 false Admission to facilities or grounds. 3.41 Section 3.41 Public Welfare Department of Health and Human Services GENERAL ADMINISTRATION CONDUCT OF PERSONS AND TRAFFIC ON THE NATIONAL INSTITUTES OF HEALTH FEDERAL ENCLAVE Facilities and Grounds § 3.41...

45 CFR 3.41 - Admission to facilities or grounds.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 45 Public Welfare 1 2012-10-01 2012-10-01 false Admission to facilities or grounds. 3.41 Section 3.41 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION CONDUCT OF PERSONS AND TRAFFIC ON THE NATIONAL INSTITUTES OF HEALTH FEDERAL ENCLAVE Facilities and Grounds § 3.41...

45 CFR 3.41 - Admission to facilities or grounds.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 45 Public Welfare 1 2011-10-01 2011-10-01 false Admission to facilities or grounds. 3.41 Section 3.41 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION CONDUCT OF PERSONS AND TRAFFIC ON THE NATIONAL INSTITUTES OF HEALTH FEDERAL ENCLAVE Facilities and Grounds § 3.41...

45 CFR 3.41 - Admission to facilities or grounds.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 45 Public Welfare 1 2010-10-01 2010-10-01 false Admission to facilities or grounds. 3.41 Section 3.41 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION CONDUCT OF PERSONS AND TRAFFIC ON THE NATIONAL INSTITUTES OF HEALTH FEDERAL ENCLAVE Facilities and Grounds § 3.41...

Developing a Shared Research Facility.

ERIC Educational Resources Information Center

Goodman, Ira S.; Newcomb, Elizabeth W.

1990-01-01

Planning, creation, and current operation of the Transgenic Mouse Research Facility at the New York University Kaplan Cancer Center are discussed. The university considered need, space, funding, supervision, and marketing and followed a logical and structured management process embodying both scientific and administrative input. (Author/MSE)

NASA Plum Brook's B-2 Test Facility: Thermal Vacuum and Propellant Test Facility

NASA Technical Reports Server (NTRS)

Kudlac, Maureen T.; Weaver, Harold F.; Cmar, Mark D.

2012-01-01

The National Aeronautics and Space Administration (NASA) Glenn Research Center (GRC) Plum Brook Station (PBS) Spacecraft Propulsion Research Facility, commonly referred to as B-2, is NASA's third largest thermal vacuum facility. It is the largest designed to store and transfer large quantities of liquid hydrogen and liquid oxygen, and is perfectly suited to support developmental testing of upper stage chemical propulsion systems as well as fully integrated stages. The facility is also capable of providing thermal-vacuum simulation services to support testing of large lightweight structures, Cryogenic Fluid Management (CFM) systems, electric propulsion test programs, and other In-Space propulsion programs. A recently completed integrated system test demonstrated the refurbished thermal vacuum capabilities of the facility. The test used the modernized data acquisition and control system to monitor the facility. The heat sink provided a uniform temperature environment of approximately 77 K. The modernized infrared lamp array produced a nominal heat flux of 1.4 kW/sq m. With the lamp array and heat sink operating simultaneously, the thermal systems produced a heat flux pattern simulating radiation to space on one surface and solar exposure on the other surface.

Informatics can identify systemic sclerosis (SSc) patients at risk for scleroderma renal crisis

PubMed Central

Redd, Doug; Frech, Tracy M.; Murtaugh, Maureen A.; Rhiannon, Julia; Zeng, Qing T.

2016-01-01

Background Electronic medical records (EMR) provide an ideal opportunity for the detection, diagnosis, and management of systemic sclerosis (SSc) patients within the Veterans Health Administration (VHA). The objective of this project was to use informatics to identify potential SSc patients in the VHA that were on prednisone, in order to inform an outreach project to prevent scleroderma renal crisis (SRC). Methods The electronic medical data for this study came from Veterans Informatics and Computing Infrastructure (VINCI). For natural language processing (NLP) analysis, a set of retrieval criteria was developed for documents expected to have a high correlation to SSc. The two annotators reviewed the ratings to assemble a single adjudicated set of ratings, from which a support vector machine (SVM) based document classifier was trained. Any patient having at least one document positively classified for SSc was considered positive for SSc and the use of prednisone ≥ 10 mg in the clinical document was reviewed to determine whether it was an active medication on the prescription list. Results In the VHA, there were 4,272 patients that have a diagnosis of SSc determined by the presence of an ICD-9 code. From these patients, 1,118 patients (21%) had the use of prednisone ≥_10 mg. Of these patients, 26 had a concurrent diagnosis of hypertension, thus these patients should not be on prednisone. By the use of natural language processing (NLP) an additional 16,522 patients were identified as possible SSc, highlighting that cases of SSc in the VHA may exist that are unidentified by ICD-9. A 10-fold cross validation of the classifier resulted in a precision (positive predictive value) of 0.814, recall (sensitivity) of 0.973, and f-measure of 0.873. Conclusions Our study demonstrated that current clinical practice in the VHA includes the potentially dangerous use of prednisone for veterans with SSc. This present study also suggests there may be many undetected cases of SSc

Informatics can identify systemic sclerosis (SSc) patients at risk for scleroderma renal crisis.