SUSTAINING STAR-VA: EVALUATING SYSTEMIC OUTCOMES AND TEAM STRATEGIES FOR MANAGING BEHAVIOR SYMPTOMS OF DEMENTIA

The Veterans Health Administration (VHA) has invested in the implementation and evaluation of STAR-VA, a Veteran-centered, interprofessional intervention for managing behavioral symptoms of dementia (BSD), with 86 Community Living Center (CLC nursing home) teams between 2013 and 2018. Results of a VHA Quality Enhancement Research Initiative (QUERI) partnered evaluation project are presented, including a multi-site interprofessional network created to collaborate on evaluation of the longitudinal impact of STAR-VA on CLC Veteran- and site-level outcomes, and to determine factors associated with sustained implementation and positive outcomes. The development and validation of a Minimum Data Set quality indicator of behavior symptoms of dementia (BSD) is presented. Characteristics of STAR-VA trained and untrained CLCs are presented, along with facilitators and barriers to sustained program implementation. Findings support the effectiveness of implementation of STAR-VA on decreased use of psychotropic medication. Qualitative outcomes demonstrate importance of having the appropriate staff, positive team relationships, supportive usual routines, and culture as critical for STAR-VA sustainability efforts. Results emphasize the importance of using a valid, routine measure of BSD to provide feedback to CLC teams, and to develop a sustainability intervention focused on addressing reported barriers to program sustainability through interprofessional networks. Both qualitative and quantitative outcomes will inform development and recommendations for an implementation and evaluation strategy for an outcome-driven, tailored intervention to support CLC teams in sustaining STAR-VA and to improve poor-performer and maintain high-performer outcomes. The potential benefit of our findings for other interprofessional behavioral nursing home interventions will be discussed.

Partnering to improve care: the case of the Veterans’ Health Administration’s Quality Enhancement Research Initiative

Background Within many large health care organizations, researchers and operations partners (i.e., policymakers, managers, clinical leaders) join to conduct studies to improve the quality of patient care. Yet optimal approaches to conducting partnership research and evaluation are only beginning to be clearly defined. The Veterans’ Health Administration (VA) Quality Enhancement Research Initiative (QUERI), funded by operations leaders and administered by the VA’s research service, now has nearly two decades of experience in fostering research–operations partnerships for improving quality of VA care. The work reported here is part of a national evaluation of QUERI. Because individuals in research and operations often have differing backgrounds and perspectives, we aim to identify the main sources of tension in research–operations partnerships and strategies for maximizing partnership success, through the eyes of QUERI participants. Methods We conducted semi-structured interviews with 116 researchers and operations partners chosen randomly from within pre-identified key participant groups. We conducted inductive qualitative analysis of verbatim interview transcripts, limited to the 89 interviews of individuals reporting at least some familiarity with QUERI. Results Tensions in research–operations partnerships were primarily related to diverging incentives and to differing values placed on scientific rigor or integrity versus quick timelines. To alleviate these tensions, operations’ partners highlighted the importance of ‘perspective-taking’ (i.e., putting themselves into the shoes of the researchers) to ensure a mutually beneficial and attractive partnership, whereas researchers identified the importance of overcoming the need for recognition to be apportioned between either research or operations for achieved results. Both researchers and operations participants identified jointly designing each partnership from the beginning, minimizing research bureaucracy burdens, and prioritizing in-person communication and long-term relationships as key partnership building blocks. Conclusions QUERI research and operations participants had largely concordant views on partnership tensions and approaches for improving partnership success. The fact that only researchers mentioned moving beyond recognition for the results achieved and only operations staff mentioned the importance of ‘perspective-taking’ suggests, however, that there may be unresolved tensions. These results suggest that researchers may benefit from better aligning of academic incentives with contributions to the health care organization and establishing formal recognition of operational impacts of research, while preserving some flexibility and independence of the research process.

Abstract P160: Do Clinics With Focus on Heart Failure Provide Better Care for Patients? CHF QUERI

Objectives Heart failure (HF) is increasing in prevalence in the VA. Best processes of care have been identified that can markedly affect the outcomes. This effort was to examine how facilities with formal HF programs varied in terms of providing care for HF patients at all the facilities at the Department of Veterans Affairs (VA). Method The Chronic Heart Failure (CHF) Quality Enhancement Research Initiative (QUERI) conducted a survey of all the VA facilities to examine the processes of care for HF patients. From a total of 144 facilities the Chiefs of Cardiology or the Chiefs of Medicine completed the survey with focus on the facility's current processes of care for HF. 100% response rate was obtained for these surveys. Results Data was analyzed for 144 facilities. Of them 64 facilities (45%) reported having a clinic with special focus on heart failure. Comparison of processes of care for the facilities with and without HF clinics consistently showed that facilities with HF clinics have more HF focused structure and processes of care. They have cardiologists with a special focus on HF (86% vs. 14% p<.001), protocol for diuretic titration by provider (64% vs. 36% p<.05), protocol for diuretic titration by patient (73% vs. 27% p<.001), provided HF related patient education program (64% vs. 36% p<.001), used pharmacists (60% vs. 40% p<.001) and inpatients at their facility were routinely seen by practitioner affiliated with HF program (80% vs. 20% p<.001). Regarding standardized HF orders no significant difference was observed between inpatients and outpatients. Conclusions Facilities which have clinics with special focus on HF programs with standardized programs and activities that have been associated with improved care for patients with heart failure Impact Formal heart failure clinics are associated with improved process of care for patients with heart failure