Literature Collection

BACKGROUND: Virtual health care models that incorporate registered nurse triage with rapid access to same-day virtual visits with clinicians represent a growing innovation in health care delivery. While traditional telephone advice lines focus primarily on registered nurse-led triage and care navigation, systems such as the Department of Veterans Affairs (VA) are beginning to embed physicians and advanced practice providers directly into these platforms. This hybrid model has the potential to enhance clinical responsiveness, reduce unnecessary emergency department and urgent care visits, and increase patient satisfaction by providing timely care from home. OBJECTIVE: This study aimed to explore Veterans' experiences and perceptions of the VA's integrated virtual triage and urgent care model, specifically through the VA Health Connect platform. We sought to understand how Veterans learned about and interacted with these services and to gather their insights on aspects to preserve or improve. METHODS: We conducted in-depth qualitative interviews with 24 Veterans from various geographical regions served by 6 VA health care systems. Interviews were carried out between June 18 and August 8, 2024. Data were analyzed using a qualitative descriptive approach with constant comparison to identify emergent themes and representative quotes. RESULTS: Participants reported high satisfaction with VA Health Connect's nurse triage and virtual clinical visit services. Key benefits included timeliness of care, personal time savings, efficient service organization, and positive interactions with nurses and providers. Veterans appreciated the convenience of resolving health issues quickly and remotely, often citing significant travel burdens avoided. They also highlighted the knowledgeable and personalized clinical advice received. However, several areas for improvement were identified. Some Veterans expressed frustration about being routed to nurse triage instead of directly scheduling with their primary care providers. Moreover, many were initially unaware of the full range of services available through VA Health Connect and suggested enhanced outreach and communication strategies. CONCLUSIONS: Veterans are highly satisfied with the VA Health Connect model, valuing its timeliness, convenience, and the professionalism of clinical staff. Effective promotion and clear communication about the capabilities and limitations of the service could further enhance user experience and uptake. As this integrated care model continues to evolve, its success will depend on effectively integrating virtual services into routine care and ensuring Veterans are well-informed and confident in using these resources.

Aiming to increase care access, the national Primary Care-Mental Health Integration (PC-MHI) initiative of the Veterans Health Administration (VHA) embedded specialists, care managers, or both in primary care clinics to collaboratively care for veterans with psychiatric illness. The initiative's effects on health care use and cost patterns were examined among 5.4 million primary care patients in 396 VHA clinics in 2013-16. The median rate of patients who saw a PC-MHI provider was 6.3 percent. Each percentage-point increase in the proportion of clinic patients seen by these providers was associated with 11 percent more mental health and 40 percent more primary care visits but also with 9 percent higher average total costs per patient per year. At the mean, 2.5 integrated care visits substituted for each specialty-based mental health visit that did not occur. PC-MHI was associated with improved access to outpatient care, albeit at increased total cost to the VHA. Successful implementation of integrated care necessitates significant investment and multidisciplinary partnership within health systems.

Substance use and illicit drug use are a growing problem in the United States. SUDs occur when the recurrent use of alcohol or drugs causes significant impairment, such as health problems. The veteran population has been particularly at risk. Veterans are 1.5 times more likely to die from opioid overdose than the general population, according to VA and Centers for Disease Control and Prevention data. Furthermore, veterans live in rural areas at a higher rate than the general population, which may affect their ability to access SUD services. VA is the largest integrated health care system in the United States, providing care to about 6.2 million veterans. VA provides SUD services through outpatient, inpatient, and residential care settings and offers various treatment options, including individual and group therapy, medication-assisted treatment, and naloxone kits to reverse overdoses. This report describes (1) trends in the number of and expenditures for veterans receiving SUD services, including specialty SUD services; and (2) any differences between veterans' use of SUD services in rural and urban areas, and the issues affecting access to those services in rural areas.; Background. -- Number of veterans receiving, and expenditures for, VHA specialty SUD services have remained unchanged in recent years, community care SUD services have increased. -- Veterans' usage differed between urban and rural areas for some specialty SUD services; VHA is taking steps to address access issues in rural areas. -- Agency comments. -- Appendices.

With the rapid expansion of veterans' access to community care under the Veterans Affairs Maintaining Internal Systems and Strengthening Integrated Outside Networks (VA MISSION) Act of 2018, ensuring that veterans receive high-quality community care has become a national priority. Using Veterans Health Administration (VHA) data and Medicare performance scores, we assessed how clinicians' performance on quality measures differed between those who treated veterans within the VHA Community Care Network and those who did not. We found that in 2022, 66.0 percent of community-based clinicians treated VHA enrollees. These clinicians were more likely to be male, have less practice experience, be affiliated with group practices, and be based in rural and socially vulnerable areas compared with clinicians who did not treat VHA enrollees. Notably, clinicians in the lowest quartile of quality performance measures were 8.8 percentage points more likely to treat VHA enrollees than those in the highest quartile. This pattern was most pronounced among primary care and mental health clinicians, and it persisted across VHA Community Care Network regions. These results underscore the need for federal efforts to ensure that veterans receive care from high-performing community clinicians.

Latina women have a high prevalence of obesity and obesity-related chronic diseases, such as diabetes. Approximately half of Latinas with obesity will also experience food insecurity, or a lack of access to enough food for an active and healthy life. Food insecurity is a barrier for effective prevention and management of obesity-related chronic diseases. The goal of this type 1 hybrid comparative effectiveness trial is to compare a culturally-tailored diabetes prevention intervention with and without medically supportive groceries. Adult Latina women (n = 412) with obesity (Body Mass Index (BMI) of >30 kg/m(2)) and food insecurity will be 1:1 randomized to the Vida Sana intervention (control), or to Vida Sana y Completa (intervention plus integrated treatment for food insecurity). Vida Sana is an evidence-based culturally tailored, 12-month diabetes prevention intervention that targets at least 5% weight loss and at least 150 min/week of moderate-to-vigorous physical activity. Participants enrolled in Vida Sana y Completa will also receive 12 weekly deliveries of medically supportive groceries. Those in Vida Sana alone will receive information on local food resources. Participants will be assessed at baseline and every 6 months for 24 months. The primary outcome is weight loss at 12 months. Secondary outcomes include weight loss maintenance, diet quality, and quality of life. Barriers and facilitators of implementation will be assessed using mixed methods according to the Consolidated Framework for Implementation Research. This study will provide critical evidence for addressing the combination of obesity and food insecurity in primary care for diabetes prevention. Trial Registration: NCT052111.

BACKGROUND: Office-based buprenorphine treatment of opioid use disorder (OUD) does not typically include in-person directly observed therapy (DOT), potentially leading to non-adherence. Video DOT technologies may safeguard against this issue and thus enhance likelihood of treatment success. We describe the rationale and protocol for the Trial of Adherence Application for Buprenorphine treatment (TAAB) study, a pilot randomized controlled trial (RCT) to evaluate the effects of video DOT delivered via a smartphone app on office-based buprenorphine treatment outcomes, namely illicit opioid use and retention. METHODS: Participants will be recruited from office-based opioid addiction treatment programs in outpatient clinics at two urban medical centers and randomized to either video DOT (intervention) delivered via a HIPAA-compliant, asynchronous, mobile health (mHealth) technology platform, or treatment-as-usual (control). Eligibility criteria are: 18 years or older, prescribed sublingual buprenorphine for a cumulative total of 28 days or less from the office-based opioid treatment program, and able to read and understand English. Patients will be considered ineligible if they are unable or unwilling to use the intervention, provide consent, or complete weekly study visits. All participants will complete 13 in-person weekly visits and be followed via electronic health record data capture at 12- and 24-weeks post-randomization. Data gathered include the following: demographics; current and previous treatment for OUD; self-reported diversion of prescribed buprenorphine; status of their mental and physical health; and self-reported lifetime and past 30-day illicit substance use. Participants provide urine samples at each weekly visit to test for illicit drugs and buprenorphine. The primary outcome is percentage of weekly urines that are negative for opioids over the 12-weeks. The secondary outcome is engagement in treatment at week 12. DISCUSSION: Video DOT delivered through mHealth technology platform offers possibility of improving patients' buprenorphine adherence by providing additional structure and accountability. The TAAB study will provide important preliminary estimates of the impact of this mHealth technology for patients initiating buprenorphine, as well as the feasibility of study procedures, thus paving the way for further research to assess feasibility and generate preliminary data for design of a future Phase III trial. Trial Registration ClinicalTrails.gov, NCT03779997, Registered on December 19, 2018.