Tailoring Care to Vulnerable Populations by Incorporating Social Determinants of Health: The Veterans Health Administration's "Homeless Patient Aligned Care Team" Program

INTRODUCTION:

Although the clinical consequences of homelessness are well described, less is known about the role for health care systems in improving clinical and social outcomes for the homeless. We described the national implementation of a "homeless medical home" initiative in the Veterans Health Administration (VHA) and correlated patient health outcomes with characteristics of high-performing sites.

METHODS:

We conducted an observational study of 33 VHA facilities with homeless medical homes and patient- aligned care teams that served more than 14,000 patients. We correlated site-specific health care performance data for the 3,543 homeless veterans enrolled in the program from October 2013 through March 2014, including those receiving ambulatory or acute health care services during the 6 months prior to enrollment in our study and 6 months post-enrollment with corresponding survey data on the Homeless Patient Aligned Care Team (H-PACT) program implementation. We defined high performance as high rates of ambulatory care and reduced use of acute care services.

RESULTS:

More than 96% of VHA patients enrolled in these programs were concurrently receiving VHA homeless services. Of the 33 sites studied, 82% provided hygiene care (on-site showers, hygiene kits, and laundry), 76% provided transportation, and 55% had an on-site clothes pantry; 42% had a food pantry and provided on-site meals or other food assistance. Six-month patterns of acute-care use pre-enrollment and post-enrollment for 3,543 consecutively enrolled patients showed a 19.0% reduction in emergency department use and a 34.7% reduction in hospitalizations. Three features were significantly associated with high performance: 1) higher staffing ratios than other sites, 1) integration of social supports and social services into clinical care, and 3) outreach to and integration with community agencies.

CONCLUSION:

Integrating social determinants of health into clinical care can be effective for high-risk homeless veterans.

Below:  Homeless-patient aligned care team model for treatment engagement

Full article at:   http://goo.gl/0S9gb5

By:  O'Toole TP1, Johnson EE2, Aiello R2, Kane V3, Pape L2.

• 1National Center on Homelessness Among Veterans, Providence VA Medical Center, 830 Chalkstone Ave, Providence, RI 02909. Email: Thomas.OToole@va.gov.
• 2The National Center on Homelessness Among Veterans, Office of Homeless Programs, US Department of Veterans Affairs, Providence, Rhode Island.
• 3The National Center on Homelessness Among Veterans, Office of Homeless Programs, US Department of Veterans Affairs, Providence, Rhode Island and Lebanon VA Medical Center, Lebanon, Pennsylvania. 
• Prev Chronic Dis. 2016 Mar 31;13:E44. doi: 10.5888/pcd13.150567.

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Nature & Determinants of Suicidal Ideation among U.S. Veterans: Results from the National Health & Resilience in Veterans Study

BACKGROUND:

Suicidal thoughts and behaviors among U.S. military veterans are a major public health concern. To date, however, scarce data are available regarding the nature and correlates of suicidal ideation (SI) among U.S. veterans. This study evaluated the prevalence and correlates of suicidal ideation in a contemporary, nationally representative, 2-year prospective cohort study.

METHOD:

Data were analysed from a total of 2157 U.S. veterans who participated in the National Health and Resilience Veterans Study (NHRVS; Wave 1 conducted in 2011; Wave 2 in 2013). Veterans completed measures assessing SI, sociodemographic characteristics, and potential risk and protective correlates.

RESULTS:

The majority of veterans (86.3%) denied SI at either time point, 5.0% had SI onset (no SI at Wave 1, SI at Wave 2), 4.9% chronic SI (SI at Waves 1 and 2), and 3.8% had remitted SI (SI at Wave 1, no SI Wave 2). 

Greater Wave 1 psychiatric distress was associated with increased likelihood of chronic SI (relative risk ratio [RRR]=3.72), remitted SI (RRR=3.38), SI onset (RRR=1.48); greater Wave 1 physical health difficulties were additionally associated with chronic SI (RRR=1.64) and SI onset (RRR=1.47); and Wave 1 substance abuse history was associated with chronic SI (RRR 1.57). 

Greater protective psychosocial characteristics (e.g., resilience, gratitude) at Wave 1 were negatively related to SI onset (RRR=0.57); and greater social connectedness at Wave 1, specifically perceived social support and secure attachment style, was negatively associated with SI onset (RRR=0.75) and remitted SI (RRR=0.44), respectively.

LIMITATIONS:

Suicidal ideation was assessed using a past two-week timeframe, and the limited duration of follow-up precludes conclusions regarding more dynamic changes in SI over time.

CONCLUSIONS:

These results indicate that a significant minority (13.7%) of U.S. veterans has chronic, onset, or remitted SI. Prevention and treatment efforts designed to mitigate psychiatric and physical health difficulties, and bolster social connectedness and protective psychosocial characteristics may help mitigate risk for SI.

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By:  Smith NB1, Mota N2, Tsai J3, Monteith L4, Harpaz-Rotem I5, Southwick SM2, Pietrzak RH2.

• 1U.S. Department of Veterans Affairs National Center for PTSD , VA Connecticut Healthcare System, West Haven, CT, USA; Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA. Electronic address: Noelle.smith2@va.gov.
• 2U.S. Department of Veterans Affairs National Center for PTSD , VA Connecticut Healthcare System, West Haven, CT, USA; Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA.
• 3Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA; New England Mental Illness, Research, Education, and Clinical Center, VA Connecticut Healthcare System, West Haven, CT, USA.
• 4Denver VA Medical Center, Rocky Mountain MIRECC, Denver, CO, USA; Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
• 5U.S. Department of Veterans Affairs National Center for PTSD , VA Connecticut Healthcare System, West Haven, CT, USA; Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA; VA Northeast Program Evaluation Center, West Haven, CT, USA. 
• J Affect Disord. 2016 Mar 2;197:66-73. doi: 10.1016/j.jad.2016.02.069.

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Cascade of Care for Hepatitis C Virus Infection within the US Veterans Health Administration

OBJECTIVES:

We measured the quality of HCV care using a cascade of HCV care model.

METHODS:

We estimated the number of patients diagnosed with chronic HCV, linked to HCV care, treated with HCV antivirals, and having achieved a sustained virologic response (SVR) in the electronic medical record data from the Veterans Health Administration's Corporate Data Warehouse and the HCV Clinical Case Registry in 2013.

RESULTS:

Of the estimated 233 898 patients with chronic HCV, 

• 77% (181 168) were diagnosed, 
• 69% (160 794) were linked to HCV care, 
• 17% (39 388) were treated with HCV antivirals, and 
• 7% (15 983) had achieved SVR.

CONCLUSIONS:

This Cascade of HCV Care provides a clinically relevant model to measure the quality of HCV care within a health care system and to compare HCV care across health systems.

Purchase full article at:   http://goo.gl/3RmCVj

By:  Maier MM1, Ross DB1, Chartier M1, Belperio PS1, Backus LI1.

• 1Marissa M. Maier is with the VA Portland Health Care System, Veterans Health Administration (VHA), Portland, OR, and the Office of Public Health/HIV, Hepatitis, and Public Health Pathogens Programs, VHA, Washington, DC. David B. Ross is with the VA Washington DC Health Care System, and the Office of Public Health/HIV, Hepatitis, and Public Health Pathogens Programs, VHA, Washington, DC. Maggie Chartier is with the VA San Francisco Health Care System, VHA, San Francisco, CA, and the Office of Public Health/HIV, Hepatitis, and Public Health Pathogens Programs, VHA, Washington, DC. Pamela S. Belperio is with the VA Greater Los Angeles Health Care System, VHA, Los Angeles, CA, and the Office of Public Health/Population Health, VHA, Washington, DC. Lisa I. Backus is with the VA Palo Alto Health Care System, VHA, Palo Alto, CA, and the Office of Public Health/Population Health, VHA, Washington, DC. 
• Am J Public Health. 2016 Feb;106(2):353-8. doi: 10.2105/AJPH.2015.302927. Epub 2015 Nov 12.

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Association of Alcohol Misuse with Sexual Identity and Sexual Behavior in Women Veterans

BACKGROUND:

Sexual minority women report greater alcohol misuse than heterosexual women in the general population, with more pronounced differences found among younger age groups. It is unknown whether these differences exist among women veterans.

OBJECTIVE:

We evaluated differences in alcohol misuse across two dimensions of sexual orientation (identity and behavior) among women veterans, and examined whether these differences were modified by age.

METHODS:

Women veterans were recruited via the internet to participate in an online survey. Participants provided information on their self-reported sexual identity and behavior and responded to the validated 3-item Alcohol Use Disorders Identification Test-Consumption questionnaire (AUDIT-C). Regression models were used to compare the prevalence of alcohol misuse (AUDIT-C ≥ 3) and severity (AUDIT-C scores) across sexual identity and behavior and to test effect modification by age.

RESULTS:

Among the 702 participants (36% lesbian/bisexual), prevalence and severity of alcohol misuse varied by both sexual identity and behavior, but there were significant interactions with age. Prevalence and severity of alcohol misuse were higher among relatively younger self-identified lesbians compared to heterosexual women. Similarly, both prevalence and severity of alcohol misuse were generally higher among younger women who had any sex with women compared to those who had sex only with men. Conclusions/Importance: In this online study of women veterans, younger sexual minority women were more likely to screen positive for alcohol misuse, and they had more severe alcohol misuse, than their heterosexual counterparts. Prevention and treatment efforts focused specifically on sexual minority women veterans may be needed.

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By:  Lehavot K1,2,3,4, Williams EC1,4, Millard SP2, Bradley KA1,4,5, Simpson TL2,3,6.

• 1a VA Health Services Research & Development, Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound , Seattle , Washington , USA.
• 2b Mental Illness Research, Education, and Clinical Center (MIRECC), VA Puget Sound Health Care System , Seattle , Washington , USA.
• 3c Department of Psychiatry and Behavioral Sciences, University of Washington , Seattle , Washington , USA.
• 4d Department of Health Services, University of Washington , Seattle , Washington , USA.
• 5e Group Health Research Institute , Seattle , Washington , USA.
• 6f Center of Excellence in Substance Abuse Treatment and Education (CESATE), VA Puget Sound Health Care System , Seattle , Washington , USA. 
• Subst Use Misuse. 2016 Jan 22:1-14.

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Characteristics of Veterans Receiving Buprenorphine vs Methadone for Opioid Use Disorder Nationally in the Veterans Health Administration

Highlights

• Limited knowledge about agonist treatment choice for opioid use disorder in practice.
• Compared characteristics of veterans on buprenorphine vs methadone nationally.
• The choice was shaped by demographic characteristics rather than clinical factors.
• We also found significant race based variations in choice of agonist therapy.

Background

The advent of buprenorphine as an alternative to methadone has dramatically shifted the landscape of opioid agonist therapy (OAT) for opioid use disorder (OUD). However, there is limited US national level data describing thedifferences between patients who are prescribed these two OAT options.

Methods

From veterans with OUD diagnosis who used Veterans Health Administration services in 2012, we identified 3 mutually exclusive groups: those who received (1) buprenorphine only (n = 5,670); (2) methadone only (n = 6,252); or (3) both buprenorphine and methadone in the same year (n = 2513). We calculated the bi-varate effect size differences (risk ratios and Cohen’s d) forcharacteristics that differentiated these groups. Logistic regression analysis was then used to identify factors independently differentiating the groups.

Results

Ten year increment in age (OR 0.67; 95% CI 0.64–0.70), urban residence (OR 0.26; 95% CI 0.25–0.33), and black race (OR 0.39; 95% CI 0.35–0.43) were strongly and negatively associated with odds of receiving buprenorphine compared to methadone, while medical and psychiatric comorbidities or receipt of other psychiatric medications did not demonstrate substantial differences between groups.

Conclusions

Differences between veterans receiving buprenorphine or methadone based OAT seems to be largely shaped by demographic characteristics rather than medical or psychiatric or service use characteristics. A clearer understanding of the reasons for racial differences could be helpful in assuring that black OUD patients are not denied the opportunity to receive buprenorphine if that is their preference.

Purchase full article at:   http://goo.gl/BIqIrn

By:  Ajay Manhapra, Lantie Quinones, Robert Rosenheck

Affiliations

Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States

VA New England Mental Illness Research and Education Center, West Haven, CT, United States

Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States

Correspondence

Corresponding author at: VA Interprofessional Fellow in Addiction Treatment, VACT Healthcare System, Bldg. 12A, 950 Campbell Avenue, West Haven, CT 06516, United States.

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Receipt of Pharmacotherapy for Opioid Use Disorder by Justice-Involved U.S. Veterans Health Administration Patients

Highlights

• Receipt of pharmacotherapy for opioid use disorder may differ by justice status.
• Prison-involved veterans had a lower rate of receipt of pharmacotherapy.
• Jail/court- and non-justice-involved veterans did not differ in rate of receipt.
• Rates of receipt varied widely within VHA facilities by justice status.

Background

Pharmacotherapy – methadone, buprenorphine, or naltrexone – is an evidence-based treatment for opioid use disorder, but little is known about receipt of these medications among veterans involved in the justice system. The current study examines receipt of pharmacotherapy for opioid use disorder among veterans with a history of justice involvement at U.S. Veterans Health Administration (VHA) facilities compared to veterans with no justice involvement.

Methods

Using national VHA clinical and pharmacy records, we conducted a retrospective cohort study of veterans with an opioid use disorder diagnosis in fiscal year 2012. Using a mixed-effects logistic regression model, we examined receipt of pharmacotherapy in the 1-year period following diagnosis as a function of justice involvement, adjusting for patient and facility characteristics.

Results

The 1-year rate of receipt for pharmacotherapy for opioid use disorder was 27% for prison-involved veterans, 34% for jail/court-involved veterans, and 33% for veterans not justice-involved. Compared to veterans not justice-involved, those prison-involved had 0.75 lower adjusted odds (95% confidence interval [CI]: 0.65–0.87) of receiving pharmacotherapy whereas jail/court-involved veterans did not have significantly different adjusted odds.

Conclusions

Targeted efforts to receipt of pharmacotherapy for opioid use disorder among veterans exiting prison is needed as they have lower odds of receiving these medications.

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By:  Andrea K. Finlay, Alex H.S. Harris, Joel Rosenthal, Jessica Blue-Howells, Sean Clark, Jim McGuire, Christine Timko, Susan M. Frayne, David Smelson, Elizabeth Oliva, Ingrid Binswanger

Affiliations

Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA

Correspondence

Corresponding author at: 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA.

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Mortality in Postmenopausal Women by Sexual Orientation and Veteran Status

PURPOSE OF THE STUDY:

To examine differences in all-cause and cause-specific mortality by sexual orientation and Veteran status among older women.

DESIGN AND METHODS:

Data were from the Women's Health Initiative, with demographic characteristics, psychosocial factors, and health behaviors assessed at baseline (1993-1998) and mortality status from all available data sources through 2014. Women with baseline information on lifetime sexual behavior and Veteran status were included in the analyses (N = 137,639; 1.4% sexual minority, 2.5% Veteran). The four comparison groups included sexual minority Veterans, sexual minority non-Veterans, heterosexual Veterans, and heterosexual non-Veterans. Cox proportional hazard models were used to estimate mortality risk adjusted for demographic, psychosocial, and health variables.

RESULTS:

Sexual minority women had greater all-cause mortality risk than heterosexual women regardless of Veteran status (hazard ratio [HR] = 1.20, 95% confidence interval [CI]: 1.07-1.36) and women Veterans had greater all-cause mortality risk than non-Veterans regardless of sexual orientation (HR = 1.14, 95% CI: 1.06-1.22), but the interaction between sexual orientation and Veteran status was not significant. Sexual minority women were also at greater risk than heterosexual women for cancer-specific mortality, with effects stronger among Veterans compared to non-Veterans (sexual minority × Veteran HR = 1.70, 95% CI: 1.01-2.85).

IMPLICATIONS:

Postmenopausal sexual minority women in the United States, regardless of Veteran status, may be at higher risk for earlier death compared to heterosexuals. Sexual minority women Veterans may have higher risk of cancer-specific mortality compared to their heterosexual counterparts. Examining social determinants of longevity may be an important step to understanding and reducing these disparities.

Full article at:   http://goo.gl/ij9Twq

By:  Lehavot K1, Rillamas-Sun E2, Weitlauf J3, Kimerling R4, Wallace RB5, Sadler AG6, Woods NF7, Shipherd JC8, Mattocks K9, Cirillo DJ10, Stefanick ML11,Simpson TL12.

• 1Health Services Research & Development, VA Puget Sound Health Care System and Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle. keren.lehavot@va.gov.
• 2Division of Public Health Sciences, Fred Hutchinson Cancer Research Center and Health Services Research & Development, VA Puget Sound Health Care System, Seattle, Washington.
• 3Sierra Pacific Mental Illness, Research, Education and Clinical Center and Center for Innovation to Implementation, VA Palo Alto Health Care System, California. Department of Psychiatry & Behavioral Sciences and Stanford Cancer Institute, California.
• 4VA Palo Alto Health Care System, Menlo Park, California.
• 5University of Iowa College of Public Health, Iowa City.
• 6Iowa City VA Medical Center.
• 7University of Washington School of Nursing, Seattle.
• 8VA Boston Healthcare System, National Center for PTSD Women's Health Sciences, Boston University School of Medicine, Massachusetts. LGBTProgram Patient Care Services, Washington DC.
• 9VA Central Western Massachusetts, Leeds. University of Massachusetts Medical School, Worcester.
• 10Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, the University of Iowa Department of Epidemiology, New York.
• 11Stanford Prevention Research Center, Stanford University School of Medicine, California.
• 12Center of Excellence in Substance Abuse Treatment and Education, VA Puget Sound Health Care System and Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle.
• Gerontologist. 2016 Feb;56 Suppl 1:S150-62. doi: 10.1093/geront/gnv125. 

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More about photo: http://www.connecticut.va.gov/services/LGBT.asp 

Mental Health of Transgender Veterans in US States With and Without Discrimination and Hate Crime Legal Protection

OBJECTIVES:

To examine whether indicators of community- and state-level lesbian, gay, bisexual, and transgender equality are associated with transgender veterans' mental health.

METHODS:

We extracted Veterans Administration data for patients who were diagnosed with gender identity disorder, had at least 1 visit in 2013, and lived in a zip code with a Municipality Equality Index score (n = 1640). We examined the associations of whether a state included transgender status in employment nondiscrimination laws and in hate crimes laws with mood disorders; alcohol, illicit drug, and tobacco use disorders; posttraumatic stress disorder; and suicidal ideation or attempt.

RESULTS:

Nearly half (47.3%) of the sample lived in states with employment discrimination protection, and 44.8% lived in states with hate crimes protection. Employment nondiscrimination protection was associated with 26% decreased odds of mood disorders and 43% decreased odds of self-directed violence.

CONCLUSIONS:

Understanding lesbian, gay, bisexual, and transgender social stressors can inform treatment and care coordination for transgender populations.

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By:  Blosnich JR1, Marsiglio MC1, Gao S1, Gordon AJ1, Shipherd JC1, Kauth M1, Brown GR1, Fine MJ1.

• 1At the time of the study, John R. Blosnich, Shasha Gao, Adam J. Gordon, and Michael J. Fine were with the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA. Mary C. Marsiglio was with the Mental Illness Research Education and Clinical Center, Portland VA Medical Center, Portland, OR. Jillian C. Shipherd and Michael Kauth were with the VA Office of Patient Care Services, Department of Veterans Affairs, Washington, DC. George R. Brown was with the Mountain Home VA Medical Center, Mountain Home, TN. 

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An Exploration of Returning Veterans' Sexual Health Issues Using a Brief Self-Report Measure

INTRODUCTION:

Sexual health is an integral aspect of quality of life with important implications for satisfaction with intimate relationships, emotional well-being, and life as a whole. Veterans returning from Iraq and Afghanistan frequently encounter a wide range of known risk factors for sexual health concerns.

AIM:

This article seeks to examine the overall frequency, important covariates associated with sexual difficulties, and the relevant domains of sexual dysfunction among a group of recent US veterans of Iraq and Afghanistan.

METHODS:

This is a retrospective chart review of 247 veterans of conflicts in Iraq and Afghanistan evaluated for an initial visit at the post-deployment clinic of a large veterans affairs medical center (VAMC). Patient demographic and medical characteristics were calculated using descriptive statistics. The prevalence and burden of sexual health issues in our patient sample were calculated using descriptive statistics from these veterans' responses to a self-report measure of sexual functioning. Item-level regression analyses were then conducted between sexual functioning responses and other patient data.

MAIN OUTCOME MEASURES:

The main outcome measures used were the responses to the Arizona Sexual Experience Scale (ASEX).

RESULTS:

Almost 18% of veterans screened positive for sexual functioning difficulties. Self-reported sexual dysfunction was most strongly associated with depression, posttraumatic stress disorder, female sex, and service connection rating. Co-occurring characteristics varied with specific areas of sexual functioning.

CONCLUSIONS:

Screening using an empirically validated self-report instrument indicates that there is a high prevalence of reported sexual dysfunction among recently deployed veterans. Analyses indicated that there are specific characteristics associated with both overall self-reported sexual dysfunction and specific subtypes of sexual dysfunction. Active assessment of specific aspects of sexual dysfunction concerns may allow providers to identify and implement more precise sexual functioning interventions.

Full article at:   http://goo.gl/aKIeqg

By:  Beaulieu GR1, Latini DM2, Helmer DA3, Powers-James C4, Houlette C5, Kauth MR6.

• 1Psychology Service Mental Health Care LineMichael E. DeBakey Veterans Affairs Medical Center Houston TX USA; Menninger Department of Psychiatry and Behavioral Sciences Baylor College of Medicine Houston (https://www.bcm.edu/) TX USA.
• 2Menninger Department of Psychiatry and Behavioral Sciences Baylor College of Medicine Houston TX USA; Scott Department of Urology Baylor College of Medicine Houston TX USA.
• 3War Related Illness and Injury Study Center VA New Jersey Health Care System East Orange NJ USA; Department of Medicine Rutgers University-New Jersey Medical School Newark NJ USA.
• 4Department of Palliative, Rehabilitation, and Integrative Medicine The University of Texas MD Anderson Cancer Center.
• 5Social Work and Transition Care Service Line Michael E. DeBakey Veterans Affairs Medical Center Houston TX USA.
• 6Menninger Department of Psychiatry and Behavioral Sciences Baylor College of Medicine Houston TX USA; VA South Central Mental Illness Research, Education, and Clinical Center (SC-MIRECC)Michael E. DeBakey Veterans Affairs Medical Center Houston TX USA; Center for Innovations in Quality, Effectiveness and SafetyMichael E. DeBakey Veterans Affairs Medical Center Houston TX USA. 

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