Management of mental disorders in VA primary care practices
ABSTRACT The association between facility-level organizational features and management of mental health services was assessed based on a survey of directors from 219 VA primary care facilities. Overall, 26.4% of VA primary care facilities referred patients with depression, while 72.6% and 46.1% referred patients with serious mental illness and substance use disorders, respectively Staffing mix (i.e., physician extenders such as nurse practitioners) was associated with a lesser likelihood of mental health referral. Managed care (preauthorization requirement) was associated with a greater likelihood of referral for depression. VA primary care programs, while tending to refer for more serious mental illnesses, may also be using mental health specialists and physician extenders to provide mental health care within general medical settings.
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ABSTRACT: The formal mission and strategic goals of the Center for the Study of Healthcare Provider Behavior (see bottom of this page) guide our activities in the do- mains of research, dissemination, technical assis- tance and training. Our mission and activities are also guided by the strategic priorities and mission of the Veterans Health Administration (VHA). VHA's current strategic emphasis is provided by the "Eight for Excellence" framework, comprising eight broad goals and associated strategies and initiatives. This overview article highlights selected Center activities supporting key goals and strategies in the Eight for Excellence initiative. Many of the Eight for Excellence goals emphasize continuous improvement in healthcare quality and safety. For example, Goal 1 broadly addresses continuous improvement in the quality and safety of health care for veterans, while Goal 5 calls for in- creased focus of VHA research and development activities on clinical and system improvements, including increased collaboration between VHA research and health care delivery and increased targeting of VHA health services research and the QUERI model to improve care delivery. These goals entail substantial overlap with our Cen- ter's core mission and activities: our portfolio of projects in research, technical assistance and train- ing are designed to strengthen VHA's ability to improve quality and safety through implementation of evidence-based practices. Center researchers are pursing improvement in tobacco use (Judith Katz-
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ABSTRACT: Severe mental illness (SMI) has been associated with more medical co-morbidity and less cardiovascular procedure use for older patients with myocardial infarction. However, it is unknown whether SMI is associated with increased long term mortality risk among patients presenting with acute coronary syndromes (ACS). We tested the hypothesis that SMI is associated with higher one-year mortality following ACS hospitalization. All ACS patients (n = 14,194) presenting to Veterans Health Administration (VHA) hospitals between October 2003 and September 2005 were included. Survival analysis evaluated the association between SMI and one-year all-cause mortality, adjusting for demographics, co-morbidities, in-hospital treatment, and discharge medications. Overall, 18.4 % of ACS patients had SMI. Patients with SMI were more likely female, younger, Caucasian race, have a history of alcohol abuse, liver disease, dementia, hypertension and more likely to be a current smoker; however, prior cardiac history was similar between the 2 groups. There were no significant differences in cardiac procedure use, including coronary angiogram (38.7% vs. 40.3%, p = 0.14) or coronary revascularization (31.0% vs. 32.3%, p = 0.19), and discharge medications between those with and without SMI. One-year mortality was lower for patients with SMI (15.8% vs. 19.1%, p < 0.001). However, in multivariable analysis, there were no significant differences in mortality (HR 0.91; 95% CI 0.81-1.02) between patients with and without SMI. Among ACS patients in the VHA, SMI is prevalent, affecting almost 1 in 5 patients. However, patients with SMI were as likely to undergo coronary revascularization and be prescribed evidence-based medications at hospital discharge, and were not at elevated risk of adverse 1-year outcomes compared to patients without SMI.BMC Health Services Research 09/2007; 7:146. DOI:10.1186/1472-6963-7-146 · 1.66 Impact Factor
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ABSTRACT: Health care organizations exert significant influence on the manner in which clinicians practice and the processes and outcomes of care that patients experience. A greater understanding of the organizational milieu into which innovations will be introduced, as well as the organizational factors that are likely to foster or hinder the adoption and use of new technologies, care arrangements and quality improvement (QI) strategies are central to the effective implementation of research into practice. Unfortunately, much implementation research seems to not recognize or adequately address the influence and importance of organizations. Using examples from the U.S. Department of Veterans Affairs (VA) Quality Enhancement Research Initiative (QUERI), we describe the role of organizational research in advancing the implementation of evidence-based practice into routine care settings. Using the six-step QUERI process as a foundation, we present an organizational research framework designed to improve and accelerate the implementation of evidence-based practice into routine care. Specific QUERI-related organizational research applications are reviewed, with discussion of the measures and methods used to apply them. We describe these applications in the context of a continuum of organizational research activities to be conducted before, during and after implementation. Since QUERI's inception, various approaches to organizational research have been employed to foster progress through QUERI's six-step process. We report on how explicit integration of the evaluation of organizational factors into QUERI planning has informed the design of more effective care delivery system interventions and enabled their improved "fit" to individual VA facilities or practices. We examine the value and challenges in conducting organizational research, and briefly describe the contributions of organizational theory and environmental context to the research framework. Understanding the organizational context of delivering evidence-based practice is a critical adjunct to efforts to systematically improve quality. Given the size and diversity of VA practices, coupled with unique organizational data sources, QUERI is well-positioned to make valuable contributions to the field of implementation science. More explicit accommodation of organizational inquiry into implementation research agendas has helped QUERI researchers to better frame and extend their work as they move toward regional and national spread activities.Implementation Science 06/2008; 3:29. DOI:10.1186/1748-5908-3-29 · 3.47 Impact Factor