Greg L. Stewart’s research while affiliated with University of Iowa and other places

Purpose Growing numbers of older adults need home health care, yhese services may be more difficult to access for rural Veterans, who represent one‐third of Veterans Health Administration (VA) enrollees. Our objective was to examine whether home health use differs within VA based on rurality. Methods We examined national VA administrative data for 2019–2021 (January 1, 2019 to December 31, 2021) among Veterans ages ≥65 years. Using descriptive and multivariable analyses, we assessed whether rural versus urban Veterans differed in (1) the likelihood of using any home health and (2) for those who received ≥1 visit, number of visits received. Results Among home health users ( n = 107,229, 33.1% rural), rural and urban Veterans were similar in age (77.0 vs. 77.2 years). Rural Veterans were less likely to be highly frail (38.9% rural vs. 40.4% urban) or diagnosed with dementia (13.5% vs. 17.6%). After adjusting for Veterans’ characteristics, rural Veterans were more likely to receive any home health (odds ratio: 1.10; 95% confidence interval [CI]: 1.07, 1.13). Among Veterans who received ≥1 home health visit, rurality was associated with considerably fewer expected visits (incident rate ratio: 0.70; 95% CI: 0.68, 0.72). Conclusions Although rural Veterans were more likely than urban Veterans to receive any home health services, they received considerably fewer home health visits. This difference may represent an access issue for rural Veterans. Future research is needed to identify reasons for these differences and develop strategies to ensure rural Veterans’ care needs are equitability addressed.

OBJECTIVE To examine the extent to which Veterans Health Administration (VHA) Patient-Aligned Care Team (PACT) members have a shared understanding/ agreement upon and enact responsibilities within the team. BACKGROUND The PACT model focuses on team-based care management. However, lack of a shared understanding of team-based care management roles and responsibilities makes system-wide implementation a challenge. METHODS Quantitative and qualitative analysis of national survey data collected in 2022 from primary care personnel working in a VHA-affiliated primary care facility. RESULTS Significant discrepancies exist in responses about what core team members say they do and what others perceive they should be doing, indicating either a lack of agreement, knowledge, or training about what core team members should do. CONCLUSIONS Successful implementation of a team-based model requires adequate support and training for teamwork including shared mental models to work according to their clinical competency. Clear guidance and communication of expectations are critical for role clarity.

Objective: To understand whether team member support reduces team leader stress. Method: In Phase 1, we used hierarchical linear modeling with survey data and administrative records from 45 Veterans Health Administration teams (73 providers and 228 associated members) to investigate how teamwork support mitigates leader stress. In Phase 2, we adopted a parallel/simultaneous mixed methods design, utilizing open- and close-ended responses from 267 additional Veterans Health Administration providers. With the mixed methods design, we first analyzed open-ended responses using directed content analysis and hypothesis coding. Next, we transformed our codes into counts and compared them with closed-ended responses to understand whether teamwork support allows leaders to engage in work aligned with their qualifications. Results: As predicted, providers’ role conflict corresponded with decreased performance under low teamwork support, but this negative relationship was attenuated with high teamwork support as such support allows leaders to focus on tasks they are uniquely qualified to perform. Conclusions: These findings emphasize the facilitative nature of teams in supporting leaders: Followers provide teamwork support that helps leaders navigate role conflict by allowing leaders to work on tasks consistent with their qualifications.

Objective: The aim of this study was to analyze the perceptions of core team members implementing patient-centered medical home (PCMH) within the Veterans Health Administration regarding delegation of work. Background: Significant overlap exists in the performance of work tasks among PCMH team members (primary care providers, RNs, clinical associates, clerks), and scant literature exists on appropriate delegation within PCMH teams. Methods: This study conducted used a quantitative and qualitative analysis of 4254 respondents to a 2018 survey. Results: Primary care providers rely heavily on team members, and nurses report being relied upon at high levels. Lack of role clarity and a perceived need for a team leader were concerns voiced by participants. Conclusions: Findings indicated a need for clear guidance on roles and responsibilities within the team. Patient-centered medical home team members need information about the scope of practice of each professional group to allow providers to function at the top of their scope of practice and ensure effective delegation.

Whereas the predominance of leadership research has focused upon top-down influence processes, we examine the process of leading from the inside out, i.e., self-leadership. Based on a meta-analysis of 57 effect sizes and 16,493 observations, the overall results suggest that self-leadership is positively and strongly related to individual outcomes (ρ = .38). Results also help to clarify when self-leadership is most effective relative to outcome type, showing a stronger relationship between self-leadership and creativity/innovation than between self-leadership and task performance. We further explore the incremental value of cognitive self-leadership strategies over and above basic behaviour-focused self-leadership. Our findings suggest that when individuals engage in cumulative self-leadership involving both behavioural and cognitive strategies, relationships with individual outcomes are stronger than when people employ behaviour-focused self-leadership alone. Finally, we explore a meta-analytic path model examining mediating mechanisms to clarify not only how but also why self-leadership influences outcomes of interest. Implications regarding the nature and importance of the mechanisms through which self-leadership is linked to outcomes and future directions for further advancing self-leadership theory and research are delineated.

Background Learning healthcare systems have invested heavily in training primary care staff to provide care using patient-centered medical home models, but less is known about how to effectively lead such teams to deliver high quality care. Research is needed to better understand which healthcare leadership skills are most utilized or in need of development through additional training. Method Semi-structured telephone interviews with healthcare leaders familiar with Patient-Aligned Care Teams (PACT) implementation in the U.S. Department of Veterans Affairs (VA). We interviewed sixteen (N = 16) physician, nursing, and administrative leaders at VA facilities located in the upper Midwestern United States. Content analysis of interviews transcripts using template techniques. Results Participants described instrumental challenges that they perceived hindered leadership effectiveness, including the supervisory structure; pace of change; complexity of the clinical data infrastructure; an over-reliance on technology for communication; and gaps in available leadership training. Factors perceived as facilitating effective leadership included training in soft skills, face-to-face communication, and opportunities for formal training and mentorship. A cross-cutting theme was the importance of developing “soft skills” for effective PACT leadership. Conclusions Although formal leadership training and development were perceived as beneficial, healthcare leaders familiar with PACT implementation in the VA described a mismatch between the skills and knowledge PACT leaders need to succeed and the training available to them. Closing this gap could improve retention of skilled and knowledgeable healthcare leaders, thereby reducing the costs associated with training and leading to improvements in healthcare delivery.

Objective: The aim of this study was to analyze perceptions and experiences of clinicians implementing the patient-centered medical home (PCMH). Background: The PCMH model focuses on several important concepts, including team-based care management as well as care coordination and continuity among providers and across settings of care. Methods: A qualitative analysis of data collected in 2016 from primary care personnel through a national survey was conducted. Results: Four themes were found consistent with care management and care coordination: the importance of teamwork and optimized team member roles, need for adequate prioritization of care management and care coordination, need to refine tools and resources supporting care management and care coordination, and challenges with managing and coordinating care with and across complex systems. Conclusions: Successful implementation requires adequate support for teamwork and ensuring team members can work according to their clinical competency. Nurses practicing in expanded roles need clear role guidelines and adequate time to function in these roles.

Purpose: Patient engagement has been broadly defined as the process of actively involving and supporting patients in health care and treatment decision making. The aim of this study was to identify organizational factors that are associated with greater use of patient engagement care practices in Veterans Health Administration primary care clinics. Methods: We conducted a cross-sectional analysis of data from the 2016 Patient-Aligned Care Team (PACT) national survey of direct care clinicians (primary care clinicians, registered nurses, and clinical associates). Exploratory factor analysis was used to group conceptually related patient engagement survey items into 3 subscales: planning and goal setting; motivational interviewing; and organizational strategies to promote self-management. Our independent variables included literature-based factors reported to promote team-based care and interdisciplinary collaboration in primary care. We used generalized estimating equations with multivariate logistic regression analysis to identify independent correlates of high performance on each patient engagement domain (top 25th vs bottom 25th percentile). Results: A total of 2,478 direct care clinicians from 609 clinics completed all patient engagement items in the PACT survey. For all patient engagement sub-scales, respondents at high-performing clinics were more likely to report having regular team meetings to discuss performance improvement and having leadership responsible for implementing PACT. For 2 of 3 patient engagement subscales, high performance was also associated with having fully staffed PACT teams (≥3 team members per primary care clinician) and role clarity. Conclusions: Several desirable organizational and contextual factors were associated with high performance of patient engagement care practices. Strategies to improve the organizational functioning of primary care teams may enhance patient engagement in care.