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In 2008, the Veterans Health Administration published a groundbreaking policy on disclosing large-scale adverse events to patients in order to promote transparent communication in cases where harm may not be obvious or even certain. Without embedded research, the evidence on whether or not implementation of this policy was generating more harm than good among Veteran patients was unknown. Through an embedded research-operations partnership, we conducted four research projects that led to the development of an evidence-based large-scale disclosure toolkit and disclosure support program, and its implementation across VA healthcare. Guided by the Consolidated Framework for Implementation Research, we identified specific activities corresponding to planning, engaging, executing, reflecting and evaluating phases in the process of implementation. These activities included planning with operational leaders to establish a shared research agenda; engaging with stakeholders to discuss early results, establishing buy-in of our efforts and receiving feedback; joining existing operational teams to execute the toolkit implementation; partnering with clinical operations to evaluate the toolkit during real-time disclosures; and redesigning the toolkit to meet stakeholders' needs. Critical lessons learned for implementation success included a need for stakeholder collaboration and engagement, an organizational culture involving a strong belief in evidence, a willingness to embed researchers in clinical operation activities, allowing for testing and evaluation of innovative practices, and researchers open to constructive feedback. At the conclusion of the research, VA operations worked with the researchers to continue to support efforts to spread, scale-up and sustain toolkit use across the VA healthcare system, with the final goal to establish long-term sustainability.

AbstractThis investigation examined how the interpretive practices of a speech–language pathologist (SLP) contributed to the construction of identity among adults with traumatic brain injury (TBI) during group therapy in a hospital setting. Six group therapy sessions were video-recorded and transcribed (yielding a total of 8,056 utterances). Attention was paid to patient expressions of identity and ability, the communicative functions of these expressions, and the manner in which these expressions were evaluated by the SLP. The SLP was also interviewed regarding the nature of therapy practice. Analysis revealed that the interpretive voice of the SLP dominated in ascribing a patient identity of self as damaged goods. Implications are discussed in terms of how the institutional setting, the perceived nature of TBI, the agenda of the SLP, and the interactional substrate combined to motivate such interpretive practices on the part of the SLP.

AbstractFew diagnoses present as great a challenge to one's life as cancer. Many men each year are confronted with a diagnosis of early stage prostate cancer and find themselves making decisions about treatment in the face of side effects that present often devastating effects, including problems controlling one's urine and an inability to perform sexually. In this paper, we explore the narratives of men who, having chosen and undergone treatment for early stage prostate cancer, are living with the consequences. Faced with what Charmaz calls an 'identity dilemma', how do these men linguistically construct their identities in the face of challenges to their bodily, personal, and social integrity? Drawing upon theories of social languages and Discourses, we examine how men linguistically resolve the identity dilemmas they encounter and in turn construct an identity in response to a question about the quality of their lives in the face of the adverse event of prostate cancer. We present an analysis of the interview narratives of two men and show how they 're-collage' an identity in the face of fundamental changes in their functioning as men. We argue that these men draw upon alternative discourses to construct themselves as whole, competent, and 'no less a man'.

The Veterans Health Administration (VHA) is implementing a Whole Health System (WHS) of care that empowers and equips Veterans to take charge of their health and well-being and live their lives to the fullest, and increasingly leaders recognize the need and value in implementing a similar approach to support the health and well-being of employees. The purpose of this paper is to do the following: 1) provide an overview of the WHS of care in VHA and applicability in addressing employee resiliency; 2) provide a brief history of employee well-being efforts in VHA to date; 3) share new priorities from VHA leadership as they relate to Employee Whole Health strategy and implementation; and 4) provide a summary of the impacts of WHS of care delivery on employees. The WHS of care utilizes all therapeutic, evidence-based approaches to support self-care goals and personal health planning. Extending these approaches to employees builds upon 10 years of foundational work supporting employee health and well-being in VHA. In 2017, one facility in each of the 18 Veterans Integrated Service Networks (VISNs) in VHA was selected to participate in piloting the WHS of care with subsequent evaluation by VA's Center for Evaluating Patient-Centered Care (EPCC). Early outcomes, from an employee perspective, suggest involvement in the delivery of the WHS of care and personal use of the whole health approach have a meaningful impact on the well-being of employees and how they experience the workplace. During the COVID-19 pandemic, VHA has continued to support employees through virtual resources to support well-being and resiliency. VHA's shift to this patient-centered model is supporting not only Veteran care but also employee health and well-being at a time when increased support is needed.

BACKGROUND: Patients' life contexts are increasingly recognized as important, as evidenced by growing attention to the Social Determinants of Health (SDoH). This attention may be particularly valuable for patients with complex needs, like those with HIV, who are more likely to experience age-related comorbidities, mental health or substance use issues. Understanding patient perceptions of their life context can advance SDoH approaches. OBJECTIVES: We sought to understand how aging patients with HIV think about their life context and explored if and how their reported context was documented in their electronic medical records (EMRs). DESIGN: We combined life story interviews and EMR data to understand the health-related daily life experiences of patients with HIV. Patients over 50 were recruited from two US Department of Veterans Affairs HIV clinics. Narrative analysis was used to organize data by life events and health-related metrics. KEY RESULTS: EMRs of 15 participants documented an average of 19 diagnoses and 10 medications but generally failed to include social contexts salient to patients. In interviews, HIV was discussed primarily in response to direct interviewer questions. Instead, participants raised past trauma, current social engagement, and concern about future health with varying salience. This led us to organize the narratives temporally according to past-, present-, or future-orientation. "Past-focused" narratives dwelled on unresolved experiences with social institutions like the school system, military or marriage. "Present-focused" narratives emphasized daily life challenges, like social isolation. "Future-focused" narratives were dominated by concerns that aging would limit activities. CONCLUSIONS: A temporally informed understanding of patients' life circumstances that are the foundation of their individualized SDoH could better focus care plans by addressing contextual concerns salient to patients. Trust-building may be a critical first step in caring for past-focused patients. Present-focused patients may benefit from support groups. Future-focused patients may desire discussing long term care options.

As health care systems seek to provide patient-centered care as a cornerstone of quality, how to measure this aspect of quality has become a concern. Previous development of quality indicators for treating individual chronic disease has rarely included patient perspectives on quality of care. Using epilepsy as an exemplar, the authors sought to develop an approach to measuring patient-centered quality of care. They conducted six focus groups with adults with epilepsy. Using qualitative methods, the authors initially identified 10 patient-generated quality indicators, 5 of which were subsequently rated, along with literature-based quality indicators, by an expert panel using a modified RAND appropriateness methodology. The authors discuss similarities and differences in aspects of care patients and providers value as essential for good quality. The process presented in this article may serve as a model for incorporating patient perceptions of quality into the future development of quality indicators for chronic diseases.

Background: The US Veterans Health Administration (VA) is transforming its healthcare system to create a Whole Health System (WHS) of care. Akin to such reorganization efforts as creating patient-centered medical homes and primary care behavioral health integration, the WHS goes beyond by transforming the entire system to one that takes a proactive approach to support patient and employee health and wellness. The SARS-CoV-2 pandemic disrupted the VA's healthcare system and added stress for staff and patients, creating an exogenous shock for this transformation towards a WHS. Objective: We examined the relationship between VA's WHS transformation and the pandemic to understand if transformation was sustained during crisis and contributed to VA's response. Methods: Qualitative interviews were conducted as part of a multi-year study of WHS transformation. A single multi-person interview was conducted with 61 WHS leaders at 18 VA Medical Centers, examining WH transformation and use during the pandemic. Data were analyzed using rapid directed content analysis. Results: While the pandemic initially slowed transformation efforts, sites intentionally embraced a WH approach to support patients and employees during this crisis. Efforts included conducting patient wellness calls, and, for patients and employees, promoting complementary and integrative health therapies, self-care, and WH concepts to combat stress and support wellbeing. A surge in virtual technology use facilitated innovative delivery of complementary and integrative therapies and promoted continued use of WH activities. Conclusion: The pandemic called attention to the need for healthcare systems to address the wellbeing of both patients and providers to sustain high quality care delivery. At a time of crisis, VA sites sustained WH transformation efforts, recognizing WH as one strategy to support patients and employees. This response indicates cultural transformation is taking hold, with WH serving as a promising approach for promoting wellbeing among patients and employees alike.

Pay-for-quality (P4Q) initiatives are becoming an increasingly popular mechanism for improving quality performance and reducing health care costs in the United States. Because these programs often target primary care physicians, it is important to understand how these physicians perceive and respond to P4Q to design successful programs going forward. This study reports results of a survey regarding attitudes toward P4Q among physicians participating in such programs in Massachusetts and California. Findings indicate physicians have generally positive attitudes toward the concept of P4Q, but are ambivalent about certain features of these programs as currently designed and implemented.

Background: Committed to implementing a person-centered, holistic (Whole Health) system of care, the Veterans Health Administration (VHA) developed a peer-led, group-based, multi-session "Taking Charge of My Life and Health" (TCMLH) program wherein Veterans reflect on values, set health and well-being-related goals, and provide mutual support. Prior work has demonstrated the positive impact of these groups. After face-to-face TCMLH groups were disrupted by the COVID-19 pandemic, VHA facilities rapidly implemented virtual (video-based) TCMLH groups. Objective: We sought to understand staff perspectives on the feasibility, challenges, and advantages of conducting TCMLH groups virtually. Methods: We completed semi-structured telephone interviews with 35 staff members involved in the implementation of virtual TCMLH groups across 12 VHA facilities and conducted rapid qualitative analysis of the interview transcripts. Results: Holding TCMLH groups virtually was viewed as feasible. Factors that promoted the implementation included use of standardized technology platforms amenable to delivery of group-based curriculum, availability of technical support, and adjustments in facilitator delivery style. The key drawbacks of the virtual format included difficulty maintaining engagement and barriers to relationship-building among participants. The perceived advantages of the virtual format included the positive influence of being in the home environment on Veterans' reflection, motivation, and self-disclosure, the greater convenience and accessibility of the virtual format, and the virtual group's role as an antidote to isolation during the COVID-19 pandemic. Conclusion: Faced with the disruption caused by the COVID-19 pandemic, VHA pivoted by rapidly implementing virtual TCMLH groups. Staff members involved in implementation noted that delivering TCMLH virtually was feasible and highlighted both challenges and advantages of the virtual format. A virtual group-based program in which participants set and pursue personally meaningful goals related to health and well-being in a supportive environment of their peers is a promising innovation that can be replicated in other health systems.

<p><strong>Background</strong>. Poor blood pressure (BP) control and racial disparities therein may be a function of clinical inertia and ineffective communication about BP care.</p><p><strong>Methods. </strong>We compared two different interventions (electronic medical record reminder for BP care (Reminder only [RO]), and clinician training on BP care-related communication skills plus the reminder (Reminder + Training, [R+T]) with usual care in three primary care clinics, examining BP outcomes among 8,866 patients, and provider-patient communication and medication adherence among a subsample of 793.</p><p><strong>Results. </strong>Clinician counseling improved most at R+T. BP improved overall; R+T had a small but significantly greater reduction in diastolic BP (DBP; -1.7 mm Hg). White patients at RO experienced greater overall improvements in BP control. Site and race disparities trends suggested that disparities decreased at R+T, either stayed the same or decreased at Control; and stayed the same or increased at RO. </p><p><strong>Conclusions. </strong>More substantial or racial/ethnically tailored interventions are needed. Ethn Dis. 2016;26(1):27-36; doi: 10.18865/ed.26.1.27</p>

Pay-for-performance (P4P) programs offer health care providers financial incentives to achieve predefined quality targets. Practice executives sit at a key nexus point for determining how P4P programs are implemented in physician practices. Using a qualitative interview design, this article examines the role practice executives play in the implementation of P4P programs and how their perspectives and decisions can influence the success of these programs. The authors identified five key findings related to practice executives' views on P4P: quality incentives are better than utilization incentives, quality incentives are bonus rewards, quality incentives are agents for change, providers do not feel they have control over attaining quality targets, and the ways in which quality is measured are problematic. The authors discuss five different ways in which practice executives distribute rewards to physicians. These findings may help payers more effectively design and implement financial rewards for quality.

Objectives: Despite numerous interven­tions to address adherence to antihyperten­sive medications, continued high rates of uncontrolled blood pressure (BP) suggest a need to better understand patient factors beyond adherence associated with BP con­trol. We examined how patients' BP-related beliefs, and aspects of life context affect BP control, beyond medication adherence.Methods: We conducted a cross-sectional telephone survey of primary care patients with hypertension between 2010 and 2011 (N=103; 93 had complete data on all variables and were included in the regression analyses). We assessed patient so­ciodemographics (including race/ethnicity), medication adherence, BP-related beliefs, aspects of life context, and used clinical BP assessments.Results: Regression models including sociodemographics, medication adherence, and either beliefs or context consistently predicted BP control. Adding context after beliefs added no predictive value while adding beliefs after context significantly predicted BP control.Conclusion: Including patients' BP beliefs after context had the strongest effects on BP control.Practice Implications: Results suggest that when clinicians must choose a dimen­sion on which to intervene, focusing on beliefs would be the most fruitful approach to effecting change in BP control.Ethn Dis. 2019;29(4):567-576; doi:10.18865/ ed.29.4.567