Theses (M.S.N.)--Marshall University, 2005. / Title from document title page. Includes abstract. Document formatted into pages: contains vii, 100 pages. Bibliography: p. 58-61.

Thesis (Ed.M.)--Boston University / PLEASE NOTE: Boston University Libraries did not receive an Authorization To Manage form for this thesis or dissertation. It is therefore not openly accessible, though it may be available by request. If you are the author or principal advisor of this work and would like to request open access for it, please contact us at open-help@bu.edu. Thank you. / 2031-01-01

Healthcare costs have risen from 13.8% in 2000 to 17.9% in 2009 (Gordon, Leiman, Deland, & Pardes, 2014). Poor transitional care has been identified as a cause of the high healthcare costs (Naylor et al., 2013; Obama, 2013). In 2009, the Department of Veterans Health Administration (VHA) implemented a national reform of outpatient care to create Patient-Aligned Care Teams (PACTs) with a goal to improve transitional care and reintegration into outpatient care through registered nurse case managers conducting discharge telephone follow-up calls. However, discharge telephone follow-up calls have not been explored within the VHA. This study explored the relationships among discharge telephone follow-up calls, selected Veteran characteristics including the length of index hospital stay, and 30-day all cause hospital readmissions between fiscal years 2011 and 2013. Hospital readmissions were explored in parallel time periods to the timing of the discharge telephone follow-up calls. Study data were collected retrospectively from VHA inpatient and outpatient records. Descriptive statistics, measures of central tendency, bivariate statistics, and logistic regression were used to analyze the data. The study found 124,069 Veterans were discharged from the VHA from 2011 to 2013. Of those discharges, 15,954 (12.86%) were readmitted to the hospital within 30 days and 35.06% of the readmissions occurred within the first seven days after discharge. Discharge telephone follow-up calls increased from 312 in 2011 to 26,549 in 2013. Increasing Veteran age, number of comorbidities, length of index hospital stay, and being identified as frequently hospitalized in the previous year were significantly related to hospital readmissions at each of the hospital readmission time frames (within two days, between three and seven days, and between eight and thirty days after hospital discharge). This study identified a relationship between discharge telephone follow-up calls and the parallel hospital readmission time period. However, only discharge telephone follow-up calls within two days were found to decrease the likelihood of hospital readmissions and only hospital readmissions within two days after discharge (OR=0.595). The relationships between discharge telephone follow-up calls and hospital readmissions potentially explains previously mixed results and suggests two potential explanations. One, discharge telephone follow-up calls have a limited relationship to hospital readmissions and a short duration of protective effects preventing hospital readmissions. The second explanation is self-selection bias confounds the relationship between discharge telephone follow-up calls and hospital readmissions. Both explanations suggest future research and clinical practice should focus on exploring bundled transitional care interventions as a method to reduce hospital readmissions.

abstract: ABSTRACT Post-Traumatic Stress Disorder (PTSD), depression, and insomnia are prevalent among United States (US) military veterans. This study investigates whether Brain Boosters, a new cognitive enhancement group therapy, improves symptoms of PTSD, depression, and insomnia among veterans completing the groups. The study population includes 64 US military veterans treated in the setting of the Veterans Affairs (VA) Health Care System in Phoenix, AZ. Group members were US military veterans, age 22 to 87 (mean age=53.47), who had served in or after World War II (WWII), who sought mental health care at the Phoenix VA from 2007 through 2011. Participants were treated with Brain Boosters therapy. They completed measures of mental-health related symptoms before and after this therapy. Participants were assessed pre and post group with the PTSD Checklist for military personnel (PCL-M), the Patient Health Questionnaire (PHQ-9; a measure of depression symptoms), and the Insomnia Severity Index (ISI). Statistical analyses were done with paired samples t-tests and McNemar's tests, using SPSS. The hypotheses were that symptoms of PTSD, depression, and insomnia would show statistically significant improvement with Brain Boosters therapy. Results supported the hypotheses that symptoms of PTSD and depression would improve significantly. Insomnia did not show significant improvement. The results showed the mean PCL-M score was 54.84 before Brain Boosters therapy and 51.35 after (p= 0.008). The mean PHQ-9 score was 15.21 before Brain Boosters therapy and 13.05 after (p= 0.002). The mean ISI score was 15.98 before Brain Boosters Therapy and 14.46 after (p= 0.056). Although this is a nonrandom, uncontrolled trial, findings nevertheless suggest that Brain Boosters may be an effective therapy to reduce PTSD symptom severity and depression symptom severity. This may be especially important for veterans seeking alternatives to pharmacological intervention or traditional therapeutic interventions. / Dissertation/Thesis / M.S. Psychology 2012

Depression is common and disproportionately affects those with chronic medical comorbidity, such as diabetes mellitus (DM). Only a limited amount of information is available concerning the quality of guideline-concordant treatment of depression and its influence on glycemic control among those with DM. This is the first study to address these issues in a veteran population with DM. This is a retrospective cohort study (1997-2005) of veterans with and without DM from the Roudebush Veterans Affairs Medical Center in Indianapolis. Veterans with and without DM and a new episode of depression were identified. Administrative, clinical, and pharmacy data were linked to assess initiation of treatment, follow-up care, antidepressant dosage and duration, and change in antidepressant agent based on the Veterans Health Administration (VHA) clinical practice guidelines for depression. HbA1c levels were assessed following initiation of antidepressant therapy. Treatment of depression was not consistent with guideline recommendations. Only 60% of subjects received treatment within 30-days of the depression diagnosis. Veterans with DM were more likely to have received treatment within the first two weeks than veterans without DM. Few subjects received appropriate follow-up care for depression (<40%) or an adequate duration of antidepressant therapy (<9%), although most (88%) received a dosage consistent with guideline recommendations when treatment was provided. Most subjects (>75%) were treated with a serotonigenic agent and only 23% experienced a change in therapy during the treatment period, almost 84% of which received an adequate trial of therapy prior to the change or augmentation in agent. Presence of DM was associated with significantly increased odds for receipt of guideline-concordant care for depression in most multivariate analyses. Receipt of guideline-concordant care for depression was not a significant predictor of glycemic control but was associated with a clinically meaningful reduction of 0.5% in HbA1c levels. This research demonstrates that under-treatment of depression is common and may influence at least one medical outcome. Findings also support that the relationship between depression and DM is complex and that further research is necessary to help align current practice with evidence-based practices in the VHA.

No description available.

The Patient-Centered Medical Home (PCMH) is a new model for primary care delivery intended to improve the care experience for both patients and providers, improve the health of populations, and reduce health care costs. Adopting the PCMH model into practice requires considerable investment of time and resources which often act as barriers for many small primary care practices; especially in rural areas. Few studies have examined performance of the PCMH model in rural clinics that have successfully implemented the model. It is important to obtain a comprehensive understanding of how context from the surrounding environment relates to implementation and performance of the model and whether there are differences between rural and urban primary care clinics. This study used a sequential explanatory mixed methods approach to assess differences in performance of the Patient Aligned Care Team (PACT) model between rural and urban primary care clinics within the Veterans Health Administration (VHA). Generalized Estimating Equations with repeated measures were used to estimate associations between rurality and five process-oriented endpoints among a national sample of 891 VHA primary care clinics. Results indicate that, after adjusting for patient characteristics and clinic structural capacity, clinics located in large rural or small/isolated rural areas demonstrated difficulty with enhancing access through use of non-traditional encounters (i.e. telephone visits, group visits, or secured messaging) and facilitating care coordination through post-discharge follow-up compared to urban clinics. Findings also suggest that rural clinics were more likely to struggle to meet system-wide performance standards for these same two PACT-related processes than their urban counterparts. A multiple-case study of five VHA primary care clinics was conducted to obtain a contextual understanding of the relationships between rurality and performance of PACT processes from the perspective of primary care staff engaged in PACT implementation. A comparison of the experiences of staff across the five cases revealed cross-cutting themes that are important to understanding the implementation and performance of PACT-related processes within these clinics. These themes included: both rural and urban clinics experience distance-related barriers; patient preferences and behavior impact performance of PACT-related processes; and primary care clinics experience frequent change. Findings from this qualitative assessment highlight the importance of understanding the unique context and circumstances experienced by each clinic and how they relate to performance and implementation of the PACT model. Insights gained through the qualitative assessment revealed that performance of PACT is influenced by complex relationships with both internal and external context. Combination of both quantitative and qualitative methods provided a more comprehensive understanding of these relationships beyond what could have been learned from a solitary assessment of standardized metrics by gaining additional context directly from the voices of those engaged in PACT care delivery. Identifying differences in PACT performance between rural and urban clinics calls attention to the possibility of unique advantages and challenges for PACTs delivering care to rural patients which need further exploration. Findings from this study contribute to the current understanding of PCMH implementation in rural settings by moving beyond the barriers related to structural capacity to performance of processes aligned with PCMH principles. More widespread implementation of PCMH will require additional attention to the complex relationships between the PCMH and surrounding context in order for primary care practices to successfully implement the model.

Racial/ethnic disparities in cancer care are well documented in the research literature; however, less is known about the extent and potential source of cancer care disparities in the Veterans Health Administration (VA). In my first paper, I use logistic regression and hospital fixed effects models to examine racial disparities in 20 cancer-related quality measures and the extent to which racial differences in site of care explain VA cancer care disparities. I found evidence of racial disparities in 7 out of 20 cancer-related quality measures. In general, these disparities were primarily driven by racial differences in care for black and white patients within the same VA hospital, rather than racial differences in site of care.

The patient-as-consumer has emerged as a narrative in the government health care system that cares for beneficiary veteran patients, elevating the phenomenon of choice in health care legislation and administration. The problem of the submerged state of a health policy was the issue examined within the context of access to health care and what patients experience when choice is present. The purpose of this study was to explore the motivations of beneficiary veteran patients to choose a preventive care option, a seasonal flu shot, at a private sector retail pharmacy rather than at their government health care provider, with the goal of understanding what social marketing strategies supported their decisions, how they defined choice, and what they expected from their choice option. Research questions focused on reasons for patients’ decisions to choose outside preventive care within the context of a social marketing campaign and their interpretation of choice in health care policy. Drawing on the policy feedback theory, an interpretative phenomenological approach was employed. Purposive semistructured interviews of 7 patients were conducted. Data were analyzed using a 3 step process that included descriptive theme-centered coding, emergent sub-coding, and a clustered coding analysis. Two key themes emerged: first, choice in health care policy is relative to a patient’s individual circumstance, and in order to have choice, one must have options; and second, veterans value their earned health care benefits and trust their government provider. Implications for social change include policy maker awareness of the importance of social marketing as a tool for communicating a health policy and legislation so they can make more informed decisions and veterans can feel empowered as patients.

Background: The mood stabilizer lithium has long been reported to be associated with reduced suicide risks, but many studies reporting associations between lithium and reduced suicide risks also have been nonrandomized and lacked adjustment for many potential confounders, active controls, uniform follow-up, or intent-to-treat samples. Concerns also have been raised that medications being considered as potential suicide preventative might increase risks of nonsuicide mortality while reducing risks of suicide. Methods: Three studies of Veterans Health Administration (VHA) patients were conducted combining high-dimensional propensity score matching with intent-to-treat analyses to examine the associations between lithium and valproate and one-year suicide and nonsuicide mortality outcomes. Results: In intention-to-treat analyses, initiation of lithium, compared to valproate, was associated with increased suicide mortality over 0-365 days among patients with bipolar disorder (Hazard Ratio (HR) 1.50 [95% Confidence Interval 1.05, 2.15]) Nonsuicide mortality among VHA patients with or without bipolar disorder was not significantly associated with the initiation of lithium compared to valproate ( HR 0.92 [0.82-1.04]). Rates of treatment discontinuation, however, were very high (≈ 92%). Longitudinal analyses revealed that the increased suicide risks associated with initiating lithium among patients with bipolar disorder occurred exclusively after discontinuation of lithium vii treatment. In secondary analyses restricted to patients still receiving their initial treatment, there was no difference in suicide risk between the initiation of lithium or valproate. Conclusions: Significantly increased risks of suicide were observed at one year among VHA patients with bipolar disorder initiating lithium compared to valproate, related to risks observed after the discontinuation of lithium treatment Since these studies are nonrandomized, confounding may account for some or all of our findings, including the risks observed after lithium discontinuation. Nevertheless, these results suggest that health systems and providers consider steps to minimize any potential lithium discontinuation-associated risk. Approaches might include educating patients about possible risks associated with discontinuation and closely monitoring patients after discontinuation if feasible. Given the obvious importance of any substantive difference between lithium and valproate in suicide or nonsuicide mortality risk, our studies also suggest that further research is needed, especially research that can further minimize the potential for confounding.