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Purpose: The U.S. Department of Veterans Affairs has adopted two functional assessment systems that guide care planning: one for nursing home residents (the Resident Assessment Instrument [RAI]) and a compatible one for home care clients (RAI-HC). The purpose of this article is to describe the RAI-HC (often referred to as the Minimum Data Set-Home Care or MDS-HC) and its uses and offer lessons learned from implementation experiences in other settings. Design and Methods: We reviewed implementation challenges associated both with the RAI and the RAI-HC in the United States, Canada, and other adopter countries, and drew on these to suggest lessons for the Department of Veterans Affairs as well as other entities implementing the RAI-HC. Results: Beyond its clinical utility, there are a number of evidence-based uses for the assessment system. The resident-level data can be aggregated and analyzed, and scales identify clinical conditions and risk for various types of negative outcomes. In addition, the data can be used for other programmatic and research purposes, such as determining eligibility, setting payment rates for contract care, and evaluating clinical interventions. At the same time, there are a number of implementation challenges the Department of Veterans Affairs and other organizations may face. Implications: Policy makers and program managers in any setting, including state long-term-care programs, who wish to implement an assessment system must anticipate and address a variety of implementation problems with a clear and consistent message from key leadership, adequate training and clinical support for assessors, and appropriate planning and resources for data systems.

Objective: The Department of Veterans Affairs funded assisted living, adult family home, and adult residential care for the first time in the Assisted Living Pilot Program (ALPP). This article compares the use and cost for individuals that entered ALPP and a comparison group. Method: This was a nonrandomized study. The comparison group consisted of VA patients who were eligible but did not enter an ALPP facility. The ALPP (n = 393) and comparison (n = 259) groups were followed for 12 months to assess ALPP facility, case management, and health care costs. Results: ALPP facility and ALPP case management costs were respectively $5,560 and $2,830 per individual. Total health care costs, including ALPP costs, were $11,533 higher for the ALPP group compared to the comparison group after adjusting for baseline differences. Discussion: Although ALPP successfully helped individuals transition to longer term care in these facilities, it was more costly than the comparison group. [ABSTRACT FROM AUTHOR]

Objectives: The Department of Veterans Affairs (VA) funded assisted living (AL), adult family home (AFH), and residential care for the first time in the Assisted Living Pilot Program (ALPP). This article describes the background and methods of the ALPP evaluation and the characteristics and experiences of the facilities. Method: Facility data were collected from the contracting/inspection process and a survey of ALPP facilities and those contacted but not participating in ALPP. Results: Data on 131 participating facilities are presented: 41 AFHs, 47 assisted living facilities ALFs), and 43 residential care facilities (RCFs). The average facility had 33 beds (about one quarter Medicaid beds), for-profit ownership, and private rooms for ALPP residents, and about half had private baths. About two thirds of ALPP AFH providers spoke a primary language other than English. Discussion: Findings indicate that a wide range of community facilities were willing to provide care to residents with heterogeneous needs on VA funding. [ABSTRACT FROM AUTHOR]

Purpose: The number of residents in assisted living has rapidly increased, although these facilities still primarily serve people who can pay out of pocket. The U.S. Department of Veterans Affairs was authorized to provide this level of care for the first time in the Assisted Living Pilot Program (ALPP). We describe the residents and providers, comparing them across three facility types and other populations, to assess the characteristics and feasibility of this new approach. Design and Methods: We assessed ALPP residents and providers across seven Veterans Affairs Medical Centers. We obtained information from medical records, assessment tools, and a provider survey. Results: We report here on 743 residents placed from 2002 to 2004. The Department of Veterans Affairs contracted with 58 adult family homes, 56 assisted living facilities, and 46 residential care facilities. The average ALPP resident was a 70-year-old unmarried White man referred from an inpatient hospital and living in a private residence prior to placement. Adult family homes enrolled residents requiring greater levels of assistance with activities of daily living than other facility types. Assisted living facilities were less likely than adult family homes to admit residents with functional disabilities and less likely than either adult family homes or adult residential care facilities to admit residents with certain care needs. Implications: ALPP placed residents with a wide range of characteristics in community facilities that varied widely in size and services. This information can help determine the role of this type of care in and outside of the Department of Veterans Affairs. [ABSTRACT FROM PUBLISHER]

This article describes the importance and role of 4 stages of formative evaluation in our growing understanding of how to implement research findings into practice in order to improve the quality of clinical care. It reviews limitations of traditional approaches to implementation research and presents a rationale for new thinking and use of new methods. Developmental, implementation-focused, progress-focused, and interpretive evaluations are then defined and illustrated with examples from Veterans Health Administration Quality Enhancement Research Initiative projects. This article also provides methodologic details and highlights challenges encountered in actualizing formative evaluation within implementation research. [ABSTRACT FROM AUTHOR]

This article discusses the management of pressure ulcers (PUs) in patients with spinal cord injury (SCI). It identifies PUs as a serious complication for patients with reduced mobility and sensation. It also explains the advantage of evidence-based practice (EBD) to the management of PUs. In addition, the article addresses some risk factors in reducing PU incidence and recurrence.

The Department of Veterans Affairs (VA) provides integrated services to more than 25,000 veterans with spinal cord injuries and disorders (SCI/D). VA data offer great potential for providing insights into healthcare utilization and morbidity, and these capabilities are central to efforts to improve healthcare for veterans with SCI/D. The objective of this article is to introduce researchers to the use of VA data to examine questions related to SCI/D using examples from Spinal Cord Injury (SCI) Quality Enhancement Research Initiative studies. Sources of VA data available to investigators interested in SCI/D-related research include national-level VA administrative and clinical databases and primary data (medical record review, patient surveys). Methods used to identify veterans with SCI/D include the Allocation Resource Center cohort, the Spinal Cord Dysfunction (SCD) Registry, and the VA inpatient SCI flag; only 33% of veterans were included in all three groups (n = 12,306). While neurological level of SCI was unknown for approximately a third of veterans (from SCD Registry data alone), the percent decreased to 13% when augmented with diagnostic codes. Primary data can be used to augment other missing SCI data and to provide more detailed information about complications commonly associated with SCI/D. [ABSTRACT FROM AUTHOR]

Objective: Persons with spinal cord injuries (SCI) experience rapid sublesional bone loss following injury (1, 3). Evidence on preventing/managing osteoporosis in SCI is lacking. This project examined how providers manage bone loss in SCI. Design: Telephone interviews with SCI providers. Setting: VA SCI centers and clinics. Participants: Veterans Administration SCI centers and clinics were categorized on their average number of dual-energy X-ray absorptiometry (DXA) scans (FY2014-2016). Twelve SCI providers from high and low DXA-ordering sites were interviewed. Questions included osteoporosis screening/diagnosis, prevention/treatment strategies, secondary causes of osteoporosis, and osteoporotic fracture complications. Interviews were audio-recorded, transcribed, and analyzed. Results: Providers described a lack of standardized guidelines for managing osteoporosis in SCI. They most often screened for osteoporosis using DXA when: (1) considering use of a new device or activity, (2) for patients with a history of fracture. Some providers assumed that non-ambulatory SCI patients already have osteoporosis so infrequently ordered DXAs. Assessment of secondary causes of osteoporosis was uncommon. Fracture prevention strategies identified included weight-bearing and engaging in activities like adaptive sports. Vitamin D and calcium were frequently prescribed as a result of deficiencies identified during lab testing. Providers seldom prescribed FDA-approved medications for osteoporosis. Post-fracture complications encountered included nonunion/malunion and compartment syndrome. Providers indicated that patients often experienced psychological stress, anxiety and depression following fractures. Conclusion: Providers described a lack of evidence for screening and management of patients with SCI and osteoporosis. Future efforts should include developing evidence-informed guidelines to aid providers in osteoporosis management.

Objective: To investigate the association between prescriptions for bisphosphonates; calcium and vitamin D supplements; and receipt of dual-energy x-ray absorptiometry (DXA) screening, and incident fracture risk in men and women with a spinal cord injury (SCI) or disorder (SCID)., Design: Propensity-matched case-control analyses., Setting: United States Veterans Affairs (VA) facilities., Participants: A total of 7989 men and 849 women with an SCID included in VA administrative databases between October 1, 2005 and October 1, 2015 were identified (N=8838). Cases included 267 men and 59 women with a bisphosphonate prescription propensity matched with up to 4 controls., Interventions: Not applicable., Main Outcome Measures: Incident lower extremity fractures., Results: There was no significant association between prescriptions for bisphosphonates and incident lower extremity fractures in men (odds ratio [OR], 1.04; 95% confidence interval [CI], 0.62-1.77) or women (OR, 1.02; 95% CI, 0.28-3.75). In men, similar null associations were seen among those who were adherent to bisphosphonate therapy (OR, 1.25; 95% CI, 0.73-2.16), were concomitant users of vitamin D and calcium and a bisphosphonate (OR, 1.05; 95% CI, 0.57-1.96), had more than 1 fracture on different dates during the study period (OR, 0.13; 95% CI, 0.02-1.16) and in those who had undergone DXA testing prior to the date of the bisphosphonate prescription and incident fracture (OR, 1.26; 95% CI, 0.69-2.32)., Conclusions: In men with a traumatic SCI and women with a traumatic SCID, bisphosphonate therapies for osteoporosis do not appear to significantly affect fracture risk. Adequately powered randomized controlled trials are needed to definitively demonstrate efficacy of bisphosphonates for fracture prevention in this population. There is a compelling need to identify new medications to prevent fractures in this high-risk population., (Published by Elsevier Inc.)

Laboratory identification of carbapenem-resistant Enterobacteriaceae (CRE) is a key step in controlling its spread. Our survey showed that most Veterans Affairs laboratories follow VA guidelines for initial CRE identification, whereas 55.0% use PCR to confirm carbapenemase production. Most respondents were knowledgeable about CRE guidelines. Barriers included staffing, training, and financial resources.

Objective: SBP variability may be a target for mitigating end-organ damage associated with vascular disease. We evaluated the relationship between increased SBP variability and risk of incident diabetic foot ulceration., Methods: Using a nested case-control design, we followed patients diagnosed with diabetes and treated within the US Department of Veterans Affairs Healthcare system for development of a diabetic foot ulcer (event) between 2006 and 2010. Each case was randomly matched to up to five controls based on age, sex, race/ethnicity, and calendar time. SBP variability was computed using at least three blood pressure measurements from the year preceding the event. The association between SBP variability and foot ulceration was examined using conditional logistic regression. Potential protective effects of calcium channel blockers, which blunt SBP variability, were also explored., Results: The study sample included 51 111 cases and 129 247 controls. Compared with those in quartile 1 (lowest variability), patients in quartiles 2-4 had higher adjusted odds ratios for diabetic foot ulcer development: 1.11 (95% CI 1.07-1.16), 1.20 (95% CI 1.15-1.25), 1.29 (95% CI 1.24-1.34) (P for trend <0.001). Calcium channel blockers were associated with reduced risks of ulceration for those without peripheral vascular disease (OR = 0.87, 95% CI 0.84-0.90, P < 0.001) or neuropathy (OR = 0.85, 95% CI 0.82-0.89, P < 0.001) in adjusted subgroup analyses., Conclusion: This study describes a graded relationship between SBP variability and risk of diabetic foot ulceration, providing a potential new and modifiable target to reduce this common complication.

Objective: The objective was to implement the evidence-based Spinal Cord Impairment Pressure Ulcer Monitoring Tool (SCI-PUMT) in 23 Spinal Cord Injury/Disorders Centers (SCI/D) in the Veterans Health Administration (VHA)., Setting: A collaborative was held in Minnesota that was attended by key personnel from SCI/D Centers in the VHA., Methods: This initiative was based on a 3-year longitudinal study that established the validity and reliability of a novel pressure ulcer monitoring tool for persons with spinal cord impairment. A multifaceted evidence-based strategy was used to implement the Institute for Healthcare Improvement's framework of Plan-Do-Study-Act. The plan was executed by clinical champions who implemented the tool in their respective SCI/D Centers following a conference that used both didactic and practicum approaches., Outcomes: A 15-item toolkit was developed to educate clinicians and patients regarding use of the SCI-PUMT. Toolkit elements were frequently accessed over the VA intranet (n = 3254). The 1.5-day national conference rolled out the new tool to the SCI/D Centers. Pre/post SCI-PUMT knowledge of the SCI-PUMT improved by 78% during the conference. Following the conference, periodic conference calls cemented the implementation efforts of the SCI-PUMT clinical champions and barriers were mitigated.

Pressure ulcers are one of the most common causes of morbidity, mortality and rehospitalization for those living with Spinal Cord Injury (SCI). Literature examining risk and recurrence of pressure ulcers (PrUs) has primarily focused on the nursing home elderly who do not have SCI. More than 200 factors that increase PrU risk have been identified. Yet unlike the elderly who incur pressure ulcers in nursing homes or when hospitalized, most persons with SCI develop their pressure ulcers as outpatients, while residing in the community. The Veterans Health Administration (VHA) provides medical care for a large number of persons with chronic SCI. Included in the VHA SCI model of chronic disease management is the provision of an annual Comprehensive Preventive Health Evaluation, a tool that has potential to identify individuals at high risk for PrUs. This research was motivated by the clinical observation that some individuals appear to be protected from developing PrUs despite apparently 'risky' behaviors while others develop PrUs despite vigilant use of the currently known preventative measures. There is limited literature regarding protective factors and specific risk factors that reduce PrU occurrence in the community dwelling person with chronic SCI have not been delineated. The purpose of this study is to examine the preliminary hypothesis that there are biological and/or psychosocial factors that increase or reduce vulnerability to PrUs among persons with SCI. A limited number of refined hypotheses will be generated for testing in a prospective fashion. A retrospective cross-sectional survey of 119 randomly selected Veterans with SCI undergoing the Comprehensive Health Prevention Evaluation during the year 2009 was performed. Factors that differed between patients with 0, 1 or ⩾2 PrUs were identified and stratified, with an emphasis on modifiable risk factors. Three hypotheses generated from this study warrant further investigation: (1) cumulative smoking history increases the risk of PrUs independent of co-morbidities, (2) being moderately overweight, BMI>25, with or without spasticity, is a modifiable factor that may be protective and (3) increased use of a caregiver does not reduce PrU risk. Prospective studies that focus on these hypotheses will lead to evidence-based risk assessment tools and customized interventions to prevent PrUs in persons with SCI in the outpatient setting., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Objective: To compare a multicomponent motivational interviewing (MI)/self-management (SM) intervention with a multicomponent education intervention to improve skin-protective behaviors and prevent skin worsening in veterans with spinal cord injury (SCI) hospitalized for severe pressure ulcers (PrUs)., Design: Single-blinded, prospective, randomized controlled trial., Setting: Six Veterans Affairs SCI centers., Participants: Veterans admitted for a severe (stage III/IV) PrU were followed up to 6 months postdischarge., Intervention: Telephone-based individual MI counseling plus SM skills group (SM+MI; n=71) versus an active control group of telephone-based individual educational counseling plus group education (n=72)., Main Outcome Measures: Self-reported skin-protective behaviors, objective skin worsening., Results: Intention-to-treat analyses found nonsignificant increases in skin behaviors in the SM+MI versus education control intervention arms at 3 and 6 months. The difference in behaviors used between SM+MI and education control intervention participants was 4.6% (95% confidence interval [CI], -11.3 to 2.7) (0-3mo) and 3.0% (95% CI, -8.7 to 3.9) (0-6mo). High rates of skin worsening were observed (n=74, 51.7%), usually within 3 months postdischarge and most frequently within the month postdischarge. Skin worsening, skin-related visits, and readmissions did not differ by study arm. Study limitations are presented., Conclusions: For persons with chronic SCI and severe PrUs, complicated by multiple comorbidities, a primary focus on improving patient behavior is likely insufficient to address the complex problem of PrUs in SCI. More health care systems-level changes such as collaborative care may be needed to reduce PrU recurrence, especially in this era in which many people are discharged from the hospital unhealed or with little sitting tolerance., (Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives. Assisted living programs demonstrate variation in structure and services. The Department of Veterans Affairs funded this care for the first time in the Assisted Living Pilot Program (ALPP). This article presents resident health outcomes and the relationship between facility characteristics and outcomes. Method. This article presents results on 393 ALPP residents followed for 12 months after admission to 95 facilities. Results. A total of 19.8% residents died, and the average activities of daily living impairment did not change significantly. Half of the residents remained in an ALPP facility, with the average resident spending 315 days in the community during the 12-month follow-up period. This article found a limited number of characteristics of structure and staffing to be significantly associated with outcomes. Discussion. If differences among facility characteristics are not clearly related to differences in outcomes, then choices among type of setting can be based on the match of needs to available services, location, or preferences.

Objectives. The Department of Veterans Affairs (VA) funded assisted living (AL), adult family home (AFH), and residential care for the first time in the Assisted Living Pilot Program (ALPP). This article describes the background and methods of the ALPP evaluation and the characteristics and experiences of the facilities. Method. Facility data were collected from the contracting/inspection process and a survey of ALPP facilities and those contacted but not participating in ALPP. Results. Data on 131 participating facilities are presented: 41 AFHs, 47 assisted living facilities (ALFs), and 43 residential care facilities (RCFs). The average facility had 33 beds (about one quarter Medicaid beds), for-profit ownership, and private rooms for ALPP residents, and about half had private baths. About two thirds of ALPP AFH providers spoke a primary language other than English. Discussion. Findings indicate that a wide range of community facilities were willing to provide care to residents with heterogeneous needs on VA funding.

The purpose of this study was to obtain information about Department of Veteran Affairs (VA) long-term care (LTC) referrals that could be used to develop interventions that increase the likelihood of referrals to home and community-based services (HCBS) instead of institutional care. This primarily qualitative study was conducted at five VA Medical Centers. The study used three linked methods: interviews with patients and informal caregivers; focus groups with LTC administrators, providers, and social workers; and written rankings of the barriers to HCBS referrals. We unexpectedly identified a cluster of findings indicating the importance of physicians' role in the LTC referral process and the need for more LTC training, particularly about HCBS.

Objectives: To identify patient risk factors for pressure ulcers in a sample of veterans with spinal cord injuries and disorders., Design: A survey incorporating questions from the Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance System was mailed to individuals with spinal cord injuries and disorders in 2003. A multiple logistic regression model including 2574 respondents was used to examine the association between patient characteristics and the self-report of pressure ulcers., Results: Approximately 36% of respondents reported having pressure ulcers during the previous year. Respondent characteristics significantly associated with report of one or more pressure ulcers included diabetes (incidence rate ratio [IRR] = 1.36, P < 0.001), smoking (IRR = 1.16, P = 0.030), injury duration >30 yrs (IRR = 1.27, P = 0.000), and reporting frequent depressive symptoms (IRR = 1.30, P < 0.001). Veterans who did not have injuries related to their military service (IRR = 1.39, P < 0.001) or who received care at non-VA facilities in addition to or instead of VA facilities (IRR = 1.13, P = 0.024) were more likely than other veterans to report pressure ulcers., Conclusion: Efforts to prevent pressure ulcers should include increased attention to managing diabetes and depressive symptoms. Further research to explore the association between multiple healthcare system use and the risk of pressure ulcers should be pursued.

Objective: To describe the challenges of conducting a large randomized controlled trial (RCT) to assess the effectiveness of an intervention to prevent recurrent pressure ulcers among a high-risk population of subjects with spinal cord injury (SCI)., Design: Prospective multisite, randomized design comparing outcomes of patients who received individualized education and structured telephone counseling follow-up with those of patients receiving customary care. This study was stopped early because of unanticipated recruitment problems., Setting: Six Veterans Affairs SCI specialty centers., Participants: Veterans (N=150) treated for stage III or IV pelvic pressure ulcers., Interventions: Not applicable., Main Outcome Measure: Recurrence (defined as new skin breakdown in the pelvic area) and time to recurrence. The study was stopped early because of slow recruitment, so the focus of this study is lessons learned, not the main planned outcome measures., Results: Subject recruitment did not meet original expectations because almost 50% of those enrolled left the hospital with the study ulcer unhealed (having a healed ulcer was a requirement for participation). No significant differences were observed between groups on rate of or time to recurrence at the time the study was stopped. Among the 6 sites, variability in ulcer management (eg, length of stay, receipt of medical vs surgical treatment, sitting tolerance before discharge) and time to recurrence (median, 4mo) were observed., Conclusions: RCTs in real-world settings are the most robust method of assessing the effectiveness of prevention strategies. However, in complex, rapidly changing health care organizations, blinding is infeasible, it may be impractical to control for every variable that influences a study's outcome, and any assumptions that usual care is static are probably mistaken. Investigators must be prepared to use innovative approaches to maintain the integrity of the study design, including flexibility in inclusion and exclusion criteria to support accrual, obtaining a better understanding of the important aspects of usual care that may need to be standardized, continuous improvement within the intervention arm, and anticipation and minimization of risks from organizational changes. With attention to these delivery system issues and the usual design features of randomized trials, we believe real-world care settings can serve as important laboratories to test pressure ulcer prevention strategies in this population.

This article describes the importance and role of 4 stages of formative evaluation in our growing understanding of how to implement research findings into practice in order to improve the quality of clinical care. It reviews limitations of traditional approaches to implementation research and presents a rationale for new thinking and use of new methods. Developmental, implementation-focused, progress-focused, and interpretive evaluations are then defined and illustrated with examples from Veterans Health Administration Quality Enhancement Research Initiative projects. This article also provides methodologic details and highlights challenges encountered in actualizing formative evaluation within implementation research.