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CRE 12-026 – HSR&D Study

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CRE 12-026
Implementation of VA Womens Health Patient Aligned Care Teams WH-PACTs
Elizabeth M Yano PhD MSPH
VA Greater Los Angeles Healthcare System, Sepulveda, CA
Sepulveda, CA
Funding Period: March 2013 - March 2018

BACKGROUND/RATIONALE:
Women Veterans continue to be the fastest growing segment of new VA users, but their numerical minority has created challenges to delivering gender-sensitive comprehensive care in VA settings. Patient Aligned Care Teams (PACT)-VA's medical home model-hold promise for improving such care, but had not been systematically adapted to meet women's needs, including comprehensive women's health services in gender-sensitive care environments.

OBJECTIVE(S):
We assessed the effectiveness of an evidence-based quality improvement (EBQI) approach for developing a WH-PACT model using a cluster randomized trial design (Aim #1); examined impacts of receipt of WH-PACT concordant care on women Veterans' (WVs) outcomes (Aim #2); evaluated processes of EBQI-supported WH-PACT implementation (Aim #3); and developed implementation and evaluation tools for use in EBQI-supported WH-PACT model adaptation, implementation, sustainability and spread to additional VA facilities (Aim #4).

METHODS:
We launched EBQI through VISN-level stakeholder panel meetings, formed and supported local QI teams, delivered EBQI training to all QI teams, provided external practice facilitation through site-specific and across-site calls, delivered formative feedback reports using data collected for the trial, and provided technical support (e.g., focus group methods training) over 24 months. We then convened in-person capstone VISN-level stakeholder meetings to review outcomes.

We evaluated EBQI in a cluster randomized trial in 12 VAMCs in four VISNs, using baseline, 12- and 24-month surveys of WV primary care (PC) patients with 3+ WH or PC visits; baseline and 24-month surveys of all PC and WH providers/staff; baseline and 24-month interviews of key stakeholders in participating VISNs, VAMCs, and clinics and PACT teamlet members; 12-month interviews of EBQI team members; and analyzed retrospective secondary data. We measured provider/staff QI orientation/culture, attitudes, PACT team functioning, provider burnout, and gender sensitivity, as well as achievement of patient survey-derived WH-PACT features (e.g., accessible, continuous, coordinated care), comprehensiveness, and gender-sensitive care delivery. We included an array of patient-reported outcomes and experiences (e.g., harassment) for formative feedback and monitoring. We also examined influences of practice context, including leadership support, local resources, care model type, and other characteristics.

FINDINGS/RESULTS:
Local QI projects spanned efforts to improve PACT team function, breast cancer screening, follow-up of abnormal cervical cytology, assignment of new patients to WH providers, coupled HPV/Pap test result reporting, trauma sensitivity of residents, the culture and environment of care, and teratogen medication prescribing, among others, based on VISN-level QI roadmaps developed in the initial stakeholder panel meetings and adapted to local context. Trial results (Aim #1) demonstrated significant improvements in PACT team functioning and provider gender sensitivity in EBQI vs. control VAMCs, and 24-month differences in provider burnout favoring EBQI sites. We did not find patient-level differences in PACT features of care or WH PACT-ness between EBQI and control sites (Aim #2). Formative analyses of baseline and 12-month follow-up data yielded advanced understanding of the health and healthcare needs of WVs who are routine PC users, variations in access to routine and urgent care, timeliness of mental health access, stranger harassment prevalence, delayed/missed care among LGBT WVs, levels of WVs' food insecurity, and the contribution of positive mental health screens (PTSD, depression, anxiety) to how WVs rate their provider's communication, trust in VA and care quality. They yielded new information about the impact of VA's lack of gender-tailoring of alcohol use disorder screening in PC settings. Key stakeholder interviews (Aim #3) demonstrated substantial internal changes in operations and active multilevel stakeholder engagement in EBQI functions and activities, and corroborated trial findings of positive impacts on provider burnout, team function, and organizational culture, in addition to elucidating recommendations for ideal care and hassles reduction. According to stakeholders who were pivotally involved in EBQI, this implementation strategy had notable value in empowering staff to make locally-driven, spreadable practice improvements. External facilitation via site-specific teleconferences was the most consistently identified important element of EBQI because they helped teams maintain momentum and accountability, especially in the context of competing priorities. Stakeholders described the overall EBQI effort as a "game changer," providing "renewed hope," "encouragement," and "tools, inspiration, and support to come up with ideas to improve our own practice environments." We developed tools for use in EBQI-supported WH-PACT model adaptation, implementation, sustainability and spread to additional VA facilities (Aim #4). These included an array of slide deck templates, EBQI education modules, formative feedback report templates, stakeholder panel methods, training in multilevel stakeholder engagement strategies, and other components of EBQI implementation. These tools have been adapted for use by a contract vendor in WHS's EBQI effort with low-performing VAs, in addition to development and application of technical specifications for the EBQI contract. We redeployed abbreviated versions of EBQI training for use nationally among all WH Medical Directors and WV Program Managers, and, most recently, for use in the WH Practice Based Research Network to explore spread of innovations already tested in EBQI sites to a larger number of facilities. These tools are also being integrated into a QUERI Implementation Strategy Training Hub (Hamilton, PI).

IMPACT:
EBQI is a systematic approach to developing a multilevel research-clinical partnership approach to engaging organizational leaders and local QI teams in adapting and implementing new care models in the context of prior evidence, local practice context, and provider behavior change methods, with researchers providing technical support, formative data feedback, and practice facilitation. We found that EBQI has a positive impact on delivering gender-sensitive care in better functioning PACTs while being associated with lower provider burnout, while participating sites made demonstrable, local quality gains, several of which were spread VISN-wide without additional resources. The partnered nature of this trial led to advances in VA policy initiatives in key areas, including launch of the new national VA culture campaign in response to reports of stranger harassment on VA grounds and prospects for gender-tailoring alcohol use screening as current practices may miss some at-risk WV drinkers. This study also provided a foundation for the WH-PACT Roadmap which has been disseminated by WHS nationally to support gender-tailored PACT implementation.

PUBLICATIONS:

Journal Articles

  1. Dyer KE, Potter SJ, Hamilton AB, Luger TM, Bergman AA, Yano EM, Klap R. Gender Differences in Veterans' Perceptions of Harassment on Veterans Health Administration Grounds. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2019 Jun 25; 29 Suppl 1:S83-S93.
  2. Bergman AA, Hamilton AB, Chrystal JG, Bean-Mayberry BA, Yano EM. Primary Care Providers' Perspectives on Providing Care to Women Veterans with Histories of Sexual Trauma. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2019 Apr 23.
  3. Klap R, Darling JE, Hamilton AB, Rose DE, Dyer K, Canelo I, Haskell S, Yano EM. Prevalence of Stranger Harassment of Women Veterans at Veterans Affairs Medical Centers and Impacts on Delayed and Missed Care. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2019 Mar 1; 29(2):107-115.
  4. Brunner J, Cain CL, Yano EM, Hamilton AB. Local Leaders' Perspectives on Women Veterans' Health Care: What Would Ideal Look Like?. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2019 Jan 1; 29(1):64-71.
  5. Hoggatt KJ, Simpson T, Schweizer CA, Drexler K, Yano EM. Identifying women veterans with unhealthy alcohol use using gender-tailored screening. The American journal on addictions. 2018 Mar 1; 27(2):97-100.
  6. Narain K, Bean-Mayberry B, Washington DL, Canelo IA, Darling JE, Yano EM. Access to Care and Health Outcomes Among Women Veterans Using Veterans Administration Health Care: Association With Food Insufficiency. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2018 May 1; 28(3):267-272.
  7. Brunner J, Chuang E, Washington DL, Rose DE, Chanfreau-Coffinier C, Darling JE, Canelo IA, Yano EM. Patient-Rated Access to Needed Care: Patient-Centered Medical Home Principles Intertwined. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2018 Mar 1; 28(2):165-171.
  8. Hamilton AB, Brunner J, Cain C, Chuang E, Luger TM, Canelo I, Rubenstein L, Yano EM. Engaging multilevel stakeholders in an implementation trial of evidence-based quality improvement in VA women's health primary care. Translational behavioral medicine. 2017 Sep 1; 7(3):478-485.
  9. Yano EM, Hamilton AB. Accelerating delivery of trauma-sensitive care: Using multilevel stakeholder engagement to improve care for women veterans. Families, systems & health : the journal of collaborative family healthcare. 2017 Sep 1; 35(3):373-375.
  10. Meredith LS, Azhar G, Okunogbe A, Canelo IA, Darling JE, Street AE, Yano EM. Primary Care Providers with More Experience and Stronger Self-Efficacy Beliefs Regarding Women Veterans Screen More Frequently for Interpersonal Violence. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2017 Sep 1; 27(5):586-591.
  11. Goldstein KM, Vogt D, Hamilton A, Frayne SM, Gierisch J, Blakeney J, Sadler A, Bean-Mayberry BM, Carney D, DiLeone B, Fox AB, Klap R, Yee E, Romodan Y, Strehlow H, Yosef J, Yano EM. Practice-based research networks add value to evidence-based quality improvement. Healthcare (Amsterdam, Netherlands). 2018 Jun 1; 6(2):128-134.
  12. Meredith LS, Wang Y, Okunogbe A, Bergman AA, Canelo IA, Darling JE, Yano EM. Attitudes, Practices, and Experiences with Implementing a Patient-Centered Medical Home for Women Veterans. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2017 Mar 1; 27(2):221-227.
  13. Chuang E, Brunner J, Mak S, Hamilton AB, Canelo I, Darling J, Rubenstein LV, Yano EM. Challenges with Implementing a Patient-Centered Medical Home Model for Women Veterans. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2017 Mar 1; 27(2):214-220.
  14. Yano EM, Darling JE, Hamilton AB, Canelo I, Chuang E, Meredith LS, Rubenstein LV. Cluster randomized trial of a multilevel evidence-based quality improvement approach to tailoring VA Patient Aligned Care Teams to the needs of women Veterans. Implementation science : IS. 2016 Jul 19; 11(1):101.
  15. Yano EM, Haskell S, Hayes P. Delivery of gender-sensitive comprehensive primary care to women veterans: implications for VA Patient Aligned Care Teams. Journal of general internal medicine. 2014 Jul 1; 29 Suppl 2:S703-7.
Journal Other

  1. Hamilton AB, Yano EM. The importance of symbolic and engaged participation in evidence-based quality improvement in a complex integrated healthcare system: response to "The science of stakeholder engagement in research". Translational behavioral medicine. 2017 Sep 1; 7(3):492-494.
  2. Yano EM, Bair MJ, Carrasquillo O, Krein SL, Rubenstein LV. Patient Aligned Care Teams (PACT): VA's journey to implement patient-centered medical homes. [Editorial]. Journal of general internal medicine. 2014 Jul 1; 29 Suppl 2:S547-9.
Online News Media Articles

  1. Hamilton AB, Yano EM. Improving quality of care for women veterans requires engaging stakeholders at all levels. Springer Open Blog [Internet]. 2017 Sep 12. Available from: http://blogs.biomedcentral.com/on-health/2017/09/12/improving-quality-of-care-for-women-veterans-requires-engaging-stakeholders-at-all-levels/.
  2. Yano EM. VA researchers, clinicians and policymakers partner to help women Veterans. VAntage Point: Official Blog of the U.S. Department of Veterans Affairs [Internet]. 2015 Apr 7. Available from: http://www.blogs.va.gov/VAntage/18744/va-researchers-clinicians-and-policymakers-partner-to-help-women-veterans/.
Center Products

  1. Hanks D, Hecht MI, Auffrey RR, Chanfreau-Coffinier CC, Darling JE, Canelo IA, Yano EM. Podcast-7: Live from the Meeting: The Womens Health Experience Survey. 2017 Jul 24. 1 (7). Available from: https://www.hsrd.research.va.gov/news/podcasts/default.cfm.
  2. Hamilton AB, Yano EM. The importance of multilevel stakeholder engagement in implementation research: Examples from VA women's health research. UCLA CTSI, Southern California Regional Dissemination, Implementation and Improvement Science Initiative Webinar. 2017 Jun 7.
VA Cyberseminars

  1. Hamilton AB. Fostering organizational change to promote uptake of evidence-based HIV prevention practices: lessons and tools from quality improvement approaches. [Cyberseminar]. Clinical Directors Network Capacity Building Assistance Learning Collaborative. 2018 Mar 16.
  2. Yano EM. Using evidence-based quality improvement (EBQI) to tackle healthcare improvement for women Veterans at your VA: Conceptual and practical issues. [Cyberseminar]. National VA Women's Health Practice Based Research Network Full Community. 2018 Jan 17.
  3. Yano EM, Frayne S, Strauss J, Sadler A. Overview of VA Women's Health Research. Research Breakout Session on Women Veterans Health Research in VA [Cyberseminar]. National Women Veterans Summit. 2017 Nov 9.
  4. Yano E, Klap R. Prevalence, Implications and Efforts to Address Stranger Harassment on VA Grounds. Spotlight on Women's Health [Cyberseminar]. HSR&D. 2017 Sep 19.
  5. Yano EM. Implementation of VA Women's Health Patient Aligned Care Teams: Overview of Successful Evidence-Based Quality Improvement Projects. [Cyberseminar]. National VA Women's Health Practice Based Research Network. 2017 Aug 16.
  6. Rubenstein LZ, Stockdale S, Yano EM. Improving improvement: Evidence-based Quality Improvement as a PACT Accelerator. Patient Aligned Care Teams (PACT) Demonstration Labs; Spotlight on Women's Health [Cyberseminar]. HSR&D. 2017 May 17.
  7. Yano EM, Hamilton AB. Quality improvement (QI) basics: Leveraging evidence and local experience to design and conduct women's health QI projects. [Cyberseminar]. National VA Women's Health Field Leaders' Webinar Series. 2017 Apr 12.
  8. Yano EM, Klap R. Women Veterans' experiences with public harassment on VA grounds. [Cyberseminar]. National VA HSR&D Women's Health Practice Based Research Network. 2016 Oct 19.
  9. Yano EM. Challenges and solutions to forming CREATE partnerships. Partnership Based Research Inside and Outside VA [Cyberseminar]. National VA Quality Scholars Program. 2015 Mar 6.
Government Briefings

  1. Yano EM. VA Research Day on the Hill: Women Veterans' Experiences with Harassment at the VA: Briefing before the members and staffers of the US Congress; 2019 Jun 20; Washington, DC.
  2. Yano EM. VA's Research Efforts on Women Veterans. Panelist Briefing at Capitol Hill Lunch and Learn Event on Women Veterans. In Response to "Women Veterans: The Journey Ahead," a Report from Disabled American Veterans (DAV): Briefing before the members and staffers of the US Congress; 2018 Sep 12; Capitol Hill Visitor Center, Washington DC.
  3. Yano EM. Advances in Women Veterans Research: Briefing before the National Association of State Women Veteran Coordinators; 2018 Jun 25; Alexandria, VA.
  4. Yano EM. VA Research Day on the Hill: Briefing before the members and staffers of the US Congress; 2018 Jun 19; Washington, DC.
  5. Yano EM. Women Veterans Research: Briefing before the VA Advisory Committee on Women Veterans; 2018 May 9; Washington, DC.
  6. Yano EM. Using evidence-based quality improvement to tailor PACT to the needs of women Veterans: Briefing before the All Women Veteran Program Managers in VISN 12 (invited talk); 2017 Jan 20;
  7. Yano EM, Hardman L. Tailoring PACT to the needs of women Veterans: Briefing before the VISN 5 Clinical Services Board; 2017 Jan 11;
  8. Yano EM, Gerber M, Vasquez L. Improving primary care team function through evidence-based quality improvement approaches: Briefing before the Invited Primary Care Grand Rounds, VISN 1 (New England); 2016 Dec 16;
  9. Yano EM. Tailoring PACT to the needs of women Veterans: VA Philadelphia Briefing: Briefing before the Women's Health Medical Director and Women Veterans Program Manager (invited telephone briefing); 2016 Nov 30; Philadelphia, PA.
  10. Yano EM, Potter S, Klap RS. Summary of ending harassment on VA grounds expert panel: Briefing before the VHA End Harassment Work Group; 2016 Nov 29; Washington, DC.
  11. Yano EM, Shroff S, McNeil M, Borrero S, Zolko J. Tailoring PACT to the needs of women Veterans: Briefing before the VISN 4 Stakeholder Panel Meeting; 2016 Sep 22; Pittsburgh, PA.
  12. Yano EM, Gerber M, Vasquez L. Tailoring PACT to the needs of women Veterans: Briefing before the VISN 1 Stakeholder Panel Meeting at VISN 1 Network Office; 2016 Sep 20; Bedford, MA.
  13. Yano EM, Deshpande S, Sitzer J, Kohlemainen C, Schumacher S. Tailoring PACT to the needs of women Veterans: Briefing before the VISN 12 Stakeholder Panel Meeting at VISN 12 Network Office; 2016 Sep 15; Chicago, IL.
  14. Yano EM, Hammer K, Trochman G, Leas M, Krebs E, Matthews J, Nolting-Brown J, Danan E. Tailoring PACT to the needs of women Veterans: Briefing before the VISN 23 Stakeholder Panel Meeting at VISN 23 Network Office; 2016 Sep 8; Minneapolis, MN.
  15. Yano EM. Tailoring PACT to the needs of women Veterans: Briefing before the Invited briefing of Acting Chief of Staff (Wilson) at VA Pittsburgh Leadership Update; 2016 Aug 19; Pittsburgh, PA.
  16. Yano EM. Tailoring PACT to the needs of women Veterans: Briefing before the VISN 1 Briefing (invited telephone briefing to the VISN 1 Acting Chief Medical Officer (Hematillake)); 2016 Jul 25;
  17. Yano EM. Tailoring PACT to the needs of women Veterans: Women Veterans' ratings of VISN 12 care: Briefing before the Invited telephone briefing to the VISN 12 Quality Council; 2016 Apr 15;
  18. Haskell S, Yano EM. Veterans Health Research: A Focus on Women: Briefing before the US Congress; 2016 Feb 22; Washington, DC.
  19. Yano EM, Barrett J, Gerber M, Wholley CM, Adams L, Vasquez L. Tailoring PACT to the needs of women Veterans: Briefing before the VISN 1 Update (invited telephone briefing) to the VISN 1 Population Health Committee; 2016 Jan 13;
  20. Yano EM, Krebs E, Hammer K. Tailoring PACT to the needs of women Veterans: Briefing before the VISN 23 Update (invited telephone briefing) to VISN 23 Steering Committee; 2015 Nov 19;
  21. Yano EM, Shroff S, Hardman L. Tailoring PACT to the needs of women Veterans: Briefing before the VISN 4 Update (invited telephone briefing) to the VISN 4 Steering Committee; 2015 Nov 4;
  22. Yano EM. Tailoring PACT to the needs of women Veterans: Briefing before the VISN 23 Update on Formative Feedback (invited telephone briefing) to the VISN 23 Steering Committee; 2015 Nov 2;
  23. Yano EM, Kolehmainen C, Hunt GG, Sitzer J, Deshpande S. Tailoring PACT to the needs of women Veterans: Briefing before the VISN 12 Update (invited telephone briefing) to the VISN 12 Leadership Board; 2015 Apr 17;
  24. Yano EM. Tailoring PACT to the needs of women Veterans: Briefing before the VISN 1 Stakeholder Panel Meeting at VISN 1 Office; 2014 Aug 6; Bedford, MA.
  25. Yano EM. Tailoring PACT to the needs of women Veterans: Briefing before the VISN 23 Stakeholder Panel Meeting at VISN 23 Network Office; 2014 Jul 11; Minneapolis, MN.
  26. Yano EM. Tailoring PACT to the needs of women Veterans: Briefing before the VISN 4 Stakeholder Panel Meeting; 2014 Jun 25; Pittsburgh, PA.
  27. Yano EM. Tailoring PACT to the needs of women Veterans: Briefing before the VISN 12 Stakeholder Panel Meeting at VA Lovell Federal Healthcare Center; 2014 May 6; North Chicago, IL.
  28. Yano EM. Tailoring PACT to the needs of women Veterans: Briefing before the Leadership of VISN 23 (invited telephone briefing); 2014 May 2; Los Angeles.
  29. Yano EM. Tailoring PACT to the needs of women Veterans: Briefing before the VISN 12 Executive Leadership Council (invited telephone briefing); 2014 Apr 30;
Conference Presentations

  1. Darling J, Hamilton A, Klap R, Haskell S, Canelo I, Yano E. Adding Insult to Injury: Women Veterans' Experiences of Stranger Harassment in VA Medical Centers. Poster session presented at: AcademyHealth Annual Research Meeting; 2016 Jun 27; Boston, MA.
  2. Shipherd J, Darling J, Yano E, Canelo IA. Factors Affecting Sexual and Gender Minority Women Veterans Experience of VA Care. Paper presented at: AcademyHealth Annual Research Meeting; 2016 Jun 27; Boston, MA.
  3. Chanfreau-Coffiner C, Darling J, Canelo I, Yano E. Patient Predictors of High Quality Patient-Provider Communication: Implications for Caring for Complex Chronic Conditions. Poster session presented at: AcademyHealth Annual Research Meeting; 2016 Jun 26; Boston, MA.
  4. Hoggatt KJ, Schweizer A, Simpson T, Yano EM, Darling JE. Alcohol misuse among women Veterans. Presented at: VA Geriatric and Extended Care Data Analysis Center Site Visit Meeting; 2016 May 23; Los Angeles, CA.
  5. Hamilton AB, Cohen D, Heurtin-Roberts S, Padgett D, Palinkas L, Rabin B. The value of qualitative methods in implementation research. Paper presented at: National Institutes of Health / AcademyHealth Conference on the Science of Dissemination and Implementation; 2015 Dec 10; Washington, DC.
  6. Darling JE, Hamilton AB, Canelo IA, Haskell S, Yano EA. Women Veterans’ experience of stranger harassment at VA medical centers. Paper presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 8; Philadelphia, PA.
  7. Yano EM, Mor V. Using Partnered Research to Accelerate HSR&D Impacts: Lessons from the CREATE Initiative. Invited Plenary Panel. Presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 8; Philadelphia, PA.
  8. Zuchowski J, Hamilton AB, Washington DL, Cordasco KM. Assessing the learning needs of VHA women’s health primary care providers. Poster session presented at: AcademyHealth Gender and Health Interest Group Annual Meeting; 2014 Jun 8; Arlington, VA.
  9. Yano EM. Tailoring PACT to the needs of women Veterans. Paper presented at: Society of General Internal Medicine Annual Meeting; 2014 Apr 24; San Diego, CA.


DRA: Health Systems
DRE: none
Keywords: Adaptation, Cost-Effectiveness, Effectiveness, Implementation, Models of Care, Organizational Structure, Outcomes - Patient, Quality Improvement, Quality of Care, Utilization
MeSH Terms: none