Four decades ago, VA recognized that aging

of World War II and Korean War veterans

would one day challenge its delivery system.

At the time, VA had been focused primarily

on inpatient and acute care, and was not

prepared to address the long-term care

needs of an aging veteran population. In response, VA developed capabilities to meet

these needs by building long-term care facilities and by developing cooperative agreements with state veterans’ homes.

In the 1980s, VA established the Geriatric

Research Education and Clinical Centers

(GRECCs) with the specific mission to

study those medical conditions associated

with aging, train health care providers in the

care of the elderly, and to improve the care

provided to older veterans. Now situated in

20 VA medical centers across the country,

these centers serve a critical role in advancing geriatric expertise across the system.

Shift to Home- and

Community-Based Care

In the 1990s, VA began reassessing the care

it provided to the elderly and recognized the

need to provide a continuum of care rather

than providing care in discrete settings (e.g.,

inpatient acute, long term, etc.). This shift

became more urgent with the rapid aging of

the enrolled veteran population as well as

growing enrollment by aging veterans.

These trends resulted in the landmark 1998

report, VA Long Term Care at the Crossroads,

which urged a shift in long-term care from

inpatient facilities to home- and communitybased settings. This shift was further supported by the Veterans Millenium Healthcare and Benefits Act of 1999, which set

forth basic benefits of home- and community-based long-term care along with Congressionally-mandated nursing home

benefits for select veterans.1

Over the last decade, VA has focused on

implementing the recommendations of the

Crossroads report and the requirements of the

Millenium Act. As a result, VA anticipates a

continued expansion of community-based

programs over the next five years. Today,

VA is focused on implementing a spectrum

of services, which includes relatively minor

assistance that enables veterans to stay in

their homes, skilled nursing care and primary care in the home, and institutional

care in VA, state, and community facilities.

Today, every medical center in the VA system

must implement a range of non-institutional

services. Specifically, medical centers must

implement a care coordination program,

plus at least six of the following services:

■ Homemaker/home health aides

■ Skilled home care

■ Home-based primary care

■ Home respite care

■ Home hospice and palliative care

■ Community and VA operated adult

day care

■ Spinal cord home care

VA recently launched a medical foster home

program that enables veterans to live in

small facilities with a home-like environment. These community residential sites

must be approved by VA, and are especially

well suited to veterans of Operation Iraqi

FORUM

Translating research into quality health care for veterans

Commentary

VA Responds to the Needs of Aging Veterans

James F. Burris, M.D., Chief Consultant for Geriatrics & Extended Care

April 2008

Contents

Director’s Letter 2

Response to Commentary 3

Research Highlights

• Supporting Family Caregivers 4

• Evaluation of the Assisted 5

Living Pilot Program

• SMITREC Initiatives 6

HSR&D National Meeting

Highlights 7

A publication of the VA Office of Research & Development,

Health Services Research & Development Service, Center

for Information Dissemination and Education Resources, in

conjunction with AcademyHealth
Freedom (OIF) and Operation Enduring

Freedom (OEF), who do not want to live in

an institutional setting but cannot live independently at home.

While the increased availability of home- and

community-based services has had the desired effect of reducing inpatient demand,

VA is still experiencing significant need for

nursing home services. In addition to its own

nursing home facilities, VA contracts with

CMS-certified community nursing homes to

provide care for veterans. Typically, a veteran is placed in a community nursing home

on a short-term VA contract, ultimately

transitioning to Medicaid for long-term

care. VA also has a nationwide program

with state homes, paying a per diem for each

day a veteran is a resident of a state home.

Advances in the application of technology

to care delivery, such as wireless devices and

the Internet, also play a role in meeting the

needs of the aging patient population.

Home telehealth offers significant potential

to veterans, particularly in overcoming time

and distance barriers in rural areas. One example is VA’s teleretinal imaging program,

launched in 2007. The program offers initial

screening for eye disease to veterans with

diabetes. Under this program, retinal images

are taken in primary care settings and sent

to an image reading center where they are

evaluated by an eye care specialist.

Trends Point to Research Needs

The rapidly aging veteran population poses

several important research opportunities.

The satisfaction of veterans and families with

the care they receive in home- and community-based settings is largely unknown. In

addition, the impact of care provision in

these newer settings in reducing emergency

room and hospital usage is an important potential consequence that we need to better

understand. And while we know, in general,

that home- and community-based settings

are less expensive than inpatient settings, we

do not have data on the relative cost of care

across these care settings.

“The rapidly aging veteran population

poses several important research opportunities. The satisfaction of veterans and families with the care they

receive in home- and communitybased settings is largely unknown.”

While VA has successfully negotiated with

pharmaceutical manufacturers to get their best

prices, the cost of drugs continues to rise. It

is quite common for individuals over 65 to

have multiple medications. Unfortunately,

clinical trials typically do not include the elderly, so we suffer from limited data on the

safety and efficacy of drugs for this population.

Patient access to information on the Internet has had quite an impact. Some of this

information is quite reliable and timely, but

other information is dangerous and inaccurate. VA could play a larger role in sorting

this out for veterans. My HealtheVet offers

an important opportunity for veterans to

FORUM — Translating research into quality health care for veterans 2

Director’s Letter

In the past year, HSR&D has announced research initiatives in

medical informatics, health services research (HSR) genomics,

and translating provider education to improved patient outcomes. For nearly two decades, the VA’s electronic medical

record has drawn investigators to the VA because it provides

such a powerful resource for insight into a wide variety of HSR

issues. Unfortunately, much information (e.g., bacteriology,

pathology, narrative provider notes, etc.) is available only in text format, which requires reading individual records, a labor intensive task. The goals of the medical

informatics initiative are to de-identify text information as completely as possible, and to enable electronic analysis of it by researchers.

The HSR genomics initiative assumes that shortly, certain gene polymorphisms will

be unequivocally associated with risk or resilience to common adult diseases,

and will predict responsiveness or adverse risk to a variety of medications. The

two year goal is to create teams of VA HSR genomic researchers who are prepared

to characterize the additional value genomic information provides to diagnosis

and treatment, develop ways to educate providers and patients, and address the

many other important issues that are already beginning to appear. The recent article by Scheuner, et al. in the Journal of the American Medical Association demonstrates that VA’s HSR genomics program is already making national contributions.1

The initiative to translate education into improved patient outcomes recognizes

that while substantial research has examined relationships between education

and knowledge, few studies have examined the most effective educational approaches to improving patient outcomes. This initiative is particularly complex,

since it involves modifying provider behavior in demanding clinical environments where provider-patient time is precious.

The goals of these initiatives will not be attained easily. I expect they will remain

in the HSR&D forefront for many years.

Seth A. Eisen, M.D., M.Sc.

Director, HSR&D

1. Scheuner M, et al. Delivery of Genomic Medicine for Common Chronic Adult Diseases.

Journal of the American Medical Association 2008; 299(11):1320-34.

VA Office of Research & Development, Health Services Research & Development Service April 2008

continued on page 8
VA Office of Research & Development, Health Services Research & Development Service April 2008

VA was among the first health systems to

recognize how aging would impact care and

costs, and, presciently, it prepared by adopting

innovative approaches to research, education,

and clinical care. Recently, national policies

and customer demand have stimulated new

measures focusing on providing care in more

home-like settings that better match the

needs and values of patients and families.

Those of us who care for older veterans

feel passionately about the approaches that

VA has adopted. Yet, when we step into

our administrative or research personae,

questions linger. Who really benefits? What

will it cost? Is it sustainable? Could our

finite resources be used in better ways?

The “market-based” indicators outside VA

are discouraging—with the exception of

academic settings (where graduate medical

education requirements demand minimal

exposure to model geriatric care), the

numbers of practicing geriatricians have

been declining.

For the researcher or administrator seeking

to define better care for aging veterans,

three principles are key.

First, we must get further into the

“black box” of our interventions. VA’s

care delivery is based on a model of primary care, which has been indisputably effective in improving the quality and

coordination of our care. Yet, a dozen years

ago, a VA-sponsored multi-site trial showed

this intervention increased, rather than reduced, the use of inpatient care. VA did not

abandon primary care based on these results, but ongoing work continues to probe

deeper to better understand how structures

(e.g., makeup of teams) and processes of

care (e.g., fidelity to evidence-based practices) determine outcomes.

Models of geriatric care demand similar

scrutiny. At one time, home-based primary

care and comprehensive geriatric assessment were considered the “magic bullets”

of caring for complex older patients—yet

trials within VA have shown either modest

benefits or substantial costs.1,2

“Those of us who care for older

veterans feel passionately about the

approaches that VA has adopted.

Yet, when we step into our administrative or research personae,

questions linger. Who really benefits?

What will it cost? Is it sustainable?

Could our finite resources be used in

better ways?”

As with primary care, we now must “muddle through”—probing with quantitative

and qualitative methods to understand what

aspects of care make a difference, and

which patients benefit. In the absence of an

accepted “gold standard,” much variation

exists across VA in geriatric care. Harnessing that variation for self-inquiry requires

that the entire delivery system be engaged in

practice-based learning.

Second, complex chronic illness, not

aging itself, is the challenge. A century

of geriatric bioscience has demonstrated

that age is a poor surrogate for physiological

function, and that the stronger determinant

of quality of life is chronic illness. But there

is growing evidence that care focused on

only a single disease leads to inadequate attention to other problems, to the patient’s

detriment. Our knowledge base for managing complex, co-occurring problems is

sparse, and demands response from the research community.

New methods of inquiry, such as “real

world” trials that do not exclude patients

with comorbid illness, and large scale observational studies that tap into electronic

health records, are needed to understand

such complexity. The physical and psychological effects of combat trauma surely have

impact over the lifespan and must be studied—in both older and younger veterans.

Third, meaningful quality measures

must be developed and validated. Arguably, the greatest contributor to VA’s quality transformation over the past decade has

been the systematic use of evidence-based

measures of quality. Quality measures have

also been used as surrogate outcome measures to test delivery system innovations. Little is known about measuring the quality of

care rendered to patients with complex,

chronic illness, and concerns have been

raised that individual metrics may be inappropriate for frail elderly. Recently, RAND

investigators constructed a quality index

from 21 process-of-care indicators and

showed its association with survival among

older managed care patients.3

While the RAND population was not as

frail as VA’s, and not all measures would be

relevant to older veterans, the potential utility of the RAND approach is obvious. The

major barrier to executing such an approach, the burden of collecting multi-dimensional indicators, could be substantially

mitigated through appropriate use of VA’s

electronic health record.

References

1. Cohen HJ, et al. A Controlled Trial of Inpatient and

Outpatient Geriatric Evaluation and Management. New

England Journal of Medicine 2002; 346(12):905-12.

2. Hughes SL, et al. Effectiveness of Team-Managed

Home-based Primary Care: a Randomized Multicenter

Trial. Journal of the American Medical Association 2000;

284:2877-85.

3. Higashi T, et al. Quality of Care is Associated with

Survival in Vulnerable Older Patients. Annals of Internal

Medicine 2005; 143:274-81.

Response to Commentary

Defining Better Care for Aging Veterans

Joseph Francis, M.D., M.P.H., VA Central Office, Washington, D.C.

FORUM — Translating research into quality health care for veterans 3
Family caregivers are estimated to reach 37

million by 2050, an 85 percent increase from

2000. Of these, about 20 percent provide

care to individuals with dementia. The number of individuals needing dementia care

will rise from 4.5 million to 13.2 million by

2050. Of the 500,000 veterans with dementia, 155,000 sought care in 2006; this figure

is expected to increase to 218,000 by 2017.

Caregiving is characterized by diverse challenges. Caregivers are at moderate risk for

adverse outcomes in multiple domains, but

not extreme risk in any one outcome. However, these multiple risks erode health and

quality of life. Caregivers suffer more from

depression and mental health problems than

non-caregivers. Caregivers to individuals

with dementia report more emotional, physical, social, and financial problems than

other caregivers, and have increased risk of

mortality.1

Dementia Caregiving

Dementia caregiving has been the focus of

recent federally funded studies and initiatives.

The National Institute on Aging (NIA) and

National Institute of Nursing Research (NINR)

project, Resources for Enhancing Alzheimer’s

Caregiver Health (REACH II), was the first

multi-site, randomized controlled trial to test

the efficacy of a multi-component intervention

for diverse racial/ethnic caregivers. The sixmonth REACH II intervention of 12 individual in-home and telephone sessions and

five telephone support group sessions targeted areas linked to caregiver risk and quality of life: burden, emotional well-being,

self-care/healthy behaviors, social support,

and patient problem behaviors. Control

caregivers received two brief phone calls.

Compared to controls, Latino/Hispanic and

White/Caucasian intervention caregivers experienced significantly greater improvement

in quality of life, as did Black/AfricanAmerican intervention spouse caregivers.

Clinical depression prevalence was also significantly lower for intervention caregivers.2

An underlying assumption was that the intervention would reduce caregivers’ stress

and improve their ability to manage behavior problems, leading to decreased time

spent in caregiving activities. At six months

there was a significant difference for intervention, compared to control, caregivers in

reported hours providing care. The incremental cost effectiveness ratio showed that

intervention caregivers had one extra hour

per day not spent in caregiving at a cost of

$5 per day.3

This time finding was borne out in the

HSR&D-funded Memphis VAMC CONNECT study, a randomized clinical trial of

telephone support groups vs. usual care for

African-American/Black and Caucasian/

White dementia caregivers, who were either

providing care to a veteran or were themselves a veteran. As in REACH II, the study

focus was on caregiver burden, emotional

well-being, self-care/healthy behaviors, social support, and patient problem behaviors.

However, the intervention was delivered

through a low staffing, low technology telephone support group model, with each

group including a group leader and 5 to 6

caregivers. The 14 one-hour sessions over

one year were semi-structured with education, coping skills, cognitive restructuring,

and support components. On average, from

baseline, intervention caregivers reported

0.46 fewer hours of caregiving time per day

compared to usual care caregivers who reported 1.3 hours more.

In addition to caregiver outcomes, telephone support also improves patient cost

outcomes. The HSR&D-funded, Telehealth

Education Program (TEP) dementia caregiver telephone support/education intervention in VISN 2 has shown a significant

health care cost savings of $2,768 per patient at six months. TEP was composed of

10 weekly telephone support groups covering topics similar to the REACH II trial but

focused on spousal caregivers living with

veterans with moderate to severe dementia.

Growing Federal Commitment

Results from studies like these have encouraged increased commitment by Congress

and the VA to support caregivers. The Office of Geriatrics and Extended Care has

convened recent workgroups to develop

best practice recommendations for VHA

concerning dementia training materials, clinical care, care coordination, and administrative practices. In FY08, Congress and the

VA awarded nearly $4.7 million to eight

caregiver assistance pilot programs to expand and improve health care education and

provide needed training and resources for

caregivers who assist disabled and aging veterans in their homes. One of these projects,

REACH VA, is a clinical translation of the

REACH II study that will provide services

to 350 caregivers at 20 sites.

Finding better ways to support family caregivers, who are the largest source of longterm care services in the United States, is a

major public health challenge. These projects

highlight the VA’s commitment to caregivers

and VHA’s leadership in research implementation, the translation of research findings

into clinical practice and personal behavior.

References

1. Schulz R and L Martire. Family Caregiving of Persons

with Dementia: Prevalence, Health Effects, and Support

Strategies. American Journal of Geriatric Psychiatry 2004;

12:240-9.

2. Belle S, et al. for the REACH II Investigators.

Enhancing the Quality of Life of Hispanic/Latino,

Black/African-American, and White/Caucasian Dementia Caregivers: The REACH II Randomized Controlled Trial. Annals of Internal Medicine 2006; 145:727-38.

3. Nichols L, et al. The Cost Effectiveness of a Behavior

Intervention with Caregivers of Alzheimer’s Patients.

Journal of the American Geriatrics Society 2007; Dec 27

[Epub ahead of print].

FORUM — Translating research into quality health care for veterans 4

VA Office of Research & Development, Health Services Research & Development Service April 2008

Research Highlights

Finding Better Ways to Support

Family Caregivers

Linda O. Nichols, Ph.D., VA Medical Center of Memphis
VA Office of Research & Development, Health Services Research & Development Service April 2008

Assisted living and related community-residential care programs such as adult family

homes are of growing importance. These

programs offer the promise of serving persons needing long-term care in settings that

can meet their needs while maximizing autonomy and privacy in a home-like setting.1

While assisted living primarily serves those

who can pay out-of-pocket, the majority of

states have moved to make some Medicaid

funds available to allow those with lower

incomes to access these programs.

VA is another possible funding source to

extend assisted living services to moderate

and low income individuals. Long known as

a leader in providing an extensive continuum

of long-term care services, VA was authorized in Public Law 106-117 to provide these

services as part of a pilot demonstration

and evaluation to assess the “feasibility and

practicability of enabling veterans to secure

needed assisted living services as an alternative to nursing home care.”

Findings from the

Evaluation of the ALPP

The Northwest VISN, VISN 20, implemented the Assisted Living Pilot Program

(ALPP) in seven Medical Centers in four

states: Anchorage, Alaska; Boise, Idaho;

Portland, Ore.; Roseburg, Ore.; Spokane,

Wash.; Puget Sound Health Care System

(Seattle and American Lake, Wash.); and

White City, Ore. Investigators from the

Northwest and Hines HSR&D Centers of

Excellence conducted the evaluation. ALPP

was designed to contract with existing community facilities to serve the needs of the

VA patient population while reducing costs

to the system by transitioning residents to

private pay or Medicaid after an initial period of VA payment.

The main findings from our evaluation of

the ALPP program follow.

■ ALPP was successfully implemented.

From January 29, 2002 through December 31,

2004, 789 veterans were placed in 142 ALPP

facilities, indicating that ALPP was able to

attract an impressive number of veterans and

is a feasible program based on this criterion.

■ Veterans were admitted as planned to all

types of community-based programs licensed

under state Medicaid-waiver programs: 56

percent to Assisted Living Facilities, 28 percent to Residential Care Facilities, and 16

percent to Adult Family Homes.

■ The average ALPP veteran was a 70-

year-old, unmarried, white male who was

not service connected, was referred from an

inpatient hospital setting, and was living in a

private home at referral.2

■ ALPP veterans showed very little change

in health status over the 12 months after enrollment. Health status typically deteriorates

over time in a population in need of residential care; this finding suggests that ALPP

may have helped maintain veterans’ health

over time.

■ Veterans, caregivers, ALPP providers,

and VA staff were very satisfied with ALPP

services.

■ The mean ALPP cost per day was $84.89

and the mean length of stay paid for by VA

was 65.5 days. This finding, as well as the

next two, is based on the data for only those

participants who completed the informed

consent for use of their data in publications.

■ The total cost per veteran of all health

care paid for by VA during the 12-month

follow-up period was $29,812 which was

significantly higher by $11,533 than the cost

per comparison group veteran, controlling

for baseline differences. This difference was

the result of additional ALPP facility

($5,560) and case management ($2,830)

costs plus significantly higher primary care,

specialty care, emergency care, phone care,

and pharmacy costs for patients who participated in ALPP. While the ALPP group had

significantly fewer nursing home days and

lower cost for nursing home care, the latter

was not statistically significant.

■ 53 percent of veterans stayed in ALPP

facilities at the end of the VA payment period and 50 percent of surviving veterans

were still in an ALPP facility at 12 months.

“These programs offer the promise of

serving persons needing long-term

care in settings that can meet their

needs while maximizing autonomy

and privacy in a home-like setting.”

Our overall assessment was that ALPP

could fill an important niche in the continuum of long-term care services at a time

when VA is facing a steep increase in the

number of chronically ill elderly who will

need increasing amounts of long-term care.

VA presented a report describing the results

of the pilot evaluation to Congress with an

accompanying letter from the Secretary of

Veterans Affairs.3

This letter highlighted study findings and

stated that VA was “not seeking authority to

provide assisted living services believing that

this is primarily a housing function. VA is,

however, actively coordinating outpatient and

home-based medical services for veterans in

assisted living facilities in a variety of locations.”

We hope this study can assist in moving toward the long-term goal of designing the

optimal system of residential care services

Research Highlights

Evaluation of the Assisted Living

Pilot Program

Susan C. Hedrick, Ph.D., Northwest HSR&D Center of Excellence

Marylou Guihan, Ph.D., Hines HSR&D Center of Excellence

Michael Chapko, Ph.D., Northwest HSR&D Center of Excellence

FORUM — Translating research into quality health care for veterans 5

continued on page 8
Older adults comprise the fastest-growing

segment of the U.S. population, with the

most significant growth among those over

age 80. The percentage of older veterans is

even higher than in the general population

(37 percent vs. 13 percent), and from 2000

to 2010, veterans age 85 plus will triple to

1.3 million. A considerable number of older

veterans experience depression which is associated with substantial suffering, disability,

suicide risk, and decreased health-related

quality of life. The majority of elders with

depression receive treatment in primary care

settings where depression is often inadequately treated.

Depression Diagnosis

and Treatment

While depression in elderly patients is highly

treatable, the complexity of patients’ clinical

presentations may result in underdiagnosis

and undertreatment, which, in turn, lead to

poor outcomes and increased health care

utilization. SMITREC investigators have found

low rates of diagnosis of mental disorders

such as depression in the elderly among primary care providers.1 A screening tool increased rates of diagnosis and intervention,

but did not alter age-related disparities.

Patient factors, such as medical illness, neuropsychiatric comorbidity, and patient beliefs, also interact with provider factors to

produce less than optimal management and

outcomes. SMITREC investigators have

found significantly lower rates of depression detection by treating physicians among

subjects with coexisting dementia and depression.2 Only 35 percent of the coexisting

dementia and depression group were correctly diagnosed and receiving adequate

“A considerable number of older

veterans experience depression

which is associated with substantial

suffering, disability, suicide risk,

and decreased health-related quality

of life.”

treatment for their depression. Treatment

inadequacy had both provider-level (lack of

guideline-concordant antidepressant titration) and patient- and caregiver-level (lack

of adherence) contributions. Patient ethnicity may also play a role: SMITREC investigators have documented significantly lower

rates of depression diagnoses in older

African Americans as compared to older

white and Hispanic patients.

Antidepressant treatment is as efficacious

for major depression in elderly patients as

in younger adults. However, many elderly

patients discontinue medications prematurely; SMITREC investigators have found

that up to a third of depressed older

veterans did not consistently fill antidepressant prescriptions during acute treatment.

Thus, while we have effective treatments

for depression for elderly veterans, many

veterans do not adhere to them for multiple

reasons, including cognitive impairment

and beliefs that are often culturally mediated. A current Investigator-Initiated

Research grant led by SMITREC investigators is examining the relationship between

clinical factors (such as anxiety, polypharmacy, and executive impairment) that may

be key modifiable determinants of antidepressant non-adherence for older veterans

with depression. Our goal is to develop

a framework for new interventions to

improve adherence among this vulnerable

population.

Patients with severe depression, as well as

dementia and depression or other neuropsychiatric symptoms require additional pharmacological management. However, in

2005, the FDA warned that use of atypical

antipsychotics to treat neuropsychiatric

symptoms of dementia was associated with

increased mortality. SMITREC investigators

found that antipsychotic medications were

associated with increased mortality in

patients with dementia compared to most

other medications used for neuropsychiatric

symptoms.3 This association is not well

understood, and may be due to a direct

medication effect or to the pathophysiology

underlying neuropsychiatric symptoms that

prompt antipsychotic use. A current NIMH

R01 grant led by SMITREC investigators is

exploring the relationship of antipsychotic

use, mortality, and underlying cognitive

impairment severity and neuropsychiatric

symptoms further within the older veteran

population.

Aging and Suicide

SMITREC investigators also are leading two

federally funded grants that examine suicide

among veterans in depression treatment.

Overall, veterans in depression treatment

had a suicide rate of 88.25 per 100,000

person-years over a five year observation

period. Patient-level predictors of suicide

among this treatment population were

generally congruent with predictors in the

general population; however, suicide risks

associated with age differed. In this depression treatment population, younger veterans

(aged 18–44 years) had a moderately higher

rate of suicide than did middle-aged

patients (94.98 versus 77.93 for patients

aged 45–64 years) and also modestly higher

rates than elderly patients (94.98 versus

90.06 for patients aged 65 years or older).4

The reasons for these findings are unclear,

but suggest that when older patients are

actively engaged in depression treatment,

their suicide risks may be no higher than

that of other patients.

FORUM — Translating research into quality health care for veterans 6

VA Office of Research & Development, Health Services Research & Development Service April 2008

Research Highlights

Depression and Suicide in Aging

Veterans: SMITREC Initiatives

Helen C. Kales M.D. and Marcia Valenstein M.D., M.S.

VA Serious Mental Illness Treatment Research and Evaluation Center

(SMITREC) and VA HSR&D Center of Excellence, Ann Arbor, Michigan

continued on page 8
VA Office of Research & Development, Health Services Research & Development Service April 2008

“Implementation Across the Nation: From

Bedside and Clinic to Community and

Home” was the theme of the 26th VA

HSR&D National Meeting that was held

February 13-15, 2008 in Baltimore, Md.

Hosted by HSR&D’s Center for Research in

the Implementation of Innovative Strategies

in Practice (Iowa City), the meeting included

580 researchers, clinicians, and policymakers

who participated in more than 30 paper sessions and workshops, and viewed 120 posters

on an array of veteran-related health care issues, as well as several exhibits. This national

forum provided many opportunities for discussion, collaboration, and the development

of strategies that will improve health care for

veterans, including our new generation of

veterans returning from Iraq and Afghanistan.

The theme reflects the need to extend what

we have learned about the dissemination of

information and the implementation of new

interventions in clinics and hospitals to a

broader range of delivery settings and to

new veteran populations. Other research

presentations focused on diseases/conditions that are prevalent among veterans, and

interventions, including: home-based monitoring to improve blood pressure control,

post-traumatic stress disorder (PTSD), pain

management, racial differences in type 2 diabetes, traumatic brain injury in OIF/OEF

veterans, and reducing the risk of cardiovascular disease.

Meeting Highlights

The meeting featured special guest speakers:

Carole Estabrooks, R.N., Ph.D., Professor

of Nursing at the University of Alberta,

who spoke about the state of implementation science; and Garth Stewart, a recent

veteran injured in Iraq, who told attendees

about his experiences with both DoD and

VA health care. Carolyn Clancy, M.D., Director of the Agency for Healthcare Research and Quality (AHRQ) gave the

keynote address, “Quality at All Bedsides.”

Her comments focused on getting clinical

research to the bedside quickly—providing

the right care to the right patient at the right

time. She also discussed AHRQ and VA’s

joint projects, including Partners in Patient

Safety Improvement Corps, which works to

identify the root causes of adverse events.

David Atkins, M.D., M.P.H., the new director of VA HSR&D’s Quality Enhancement

Research Initiative (QUERI), addressed the

importance of bringing research into dayto-day practice. Director of HSR&D, Seth

Eisen, M.D., M.Sc., discussed the importance of implementation science, in addition to focusing on HSR&D research priorities that include VA/DoD collaborations,

genomics, and health issues affecting veterans, particularly the importance of pre-deployment data to understanding the etiology

of conditions affecting these veterans. Joel

Kupersmith, M.D., VA’s Chief Research and

Development Officer, emphasized the importance of health services research in the

field of genomics, as well as a new virtual

informatics consortium that will allow even

better use of VA’s electronic medical record.

Next year’s HSR&D national meeting is

planned for February 2009 under the theme,

“Defining Optimal Care: Balancing Quality,

Cost and Patient Preferences.” A call for abstracts will be disseminated this summer.

Watch the HSR&D website for dates and

details.

Highlights of the

2008 HSR&D National Meeting

FORUM — Translating research into quality health care for veterans 7

Asch Receives 2008 Under Secretary’s Award for

Outstanding Achievement

David A. Asch, M.D., M.B.A., has received this

year’s prestigious Under Secretary’s Award for Outstanding Achievement in Health Services Research.

The award recognizes a VA researcher whose work

has led to major improvements in the quality of

veterans’ health care, has made key contributions

to the future of health services research through excellence in training and mentorship, and has enhanced the visibility and reputation of VA research

through national leadership.

Through nearly twenty years as a VA health services researcher, exceptional mentor, and leader, Dr. Asch has exemplified the qualities the Award represents. Dr.

Asch is the co-Director of HSR&D’s Center for Health Equity Research and Promotion (Pittsburgh-Philadelphia), whose mission is to reduce disparities and

promote quality in health and health care among veterans and other populations. Dr. Asch’s research aims to understand how physicians and patients behave and make medical choices in clinical, financial, and ethically-charged

settings, including the adoption of new pharmaceuticals or medical technologies, the purchase of insurance, care at the end of life, organ transplantation, genetic testing, and equity. His research combines elements of economic analysis

with moral and psychological theory and marketing. Dr. Asch practices internal

medicine at the Philadelphia VA Medical Center and teaches health policy at the

Wharton School at the University of Pennsylvania.

In the above photo, Dr. Joel Kupersmith is shown presenting the award to Dr.

Asch at the HSR&D National Meeting.
add information on their conditions and for

providers to monitor their patients.

Finally, while VA has relatively limited authority to provide support to caregivers, we

can offer training to family members and

other caregivers. Research on the most effective training modalities for caregivers

would be helpful.

Reference

1. The Congressionally mandated benefit provided nursing

home benefits for veterans classified as P1A, meaning

any veteran with a 70 percent or greater service-connected disability, or who requires nursing home care

specifically because of a service-connected disability.

FORUM — Translating research into quality health care for veterans 8

Commentary

continued from page 2

Assisted Living

continued from page 5

SMITREC Initiatives

continued from page 6

Peter Almenoff, M.D.,

Director, VA Network #15,

Kansas City, MO

Martin P. Charns, D.B.A.,

Director, VA HSR&D Center

of Excellence, Boston, MA

Seth A. Eisen, M.D., M.Sc.,

Director, HSR&D

Joseph Francis, M.D., M.P.H.,

Deputy Chief Quality and

Performance Officer,

Central Office

Rodney A. Hayward, M.D.,

Director, VA HSR&D Center

of Excellence, Ann Arbor, MI

Shirley Meehan, M.B.A.,

Ph.D., Deputy Director, VA

HSR&D, Central Office

Michael J. Miller, M.D., Ph.D.,

Chief Medical Officer, VA

Network #1, Bedford, MA

Eugene Z. Oddone, M.D.,

M.H.Sc., Director,VA

HSR&D Center of Excellence, Durham, NC

Alan S. Perry, M.H.A.,

FACHE, Director, VA Central California Health Care

System

FORUM

Geraldine McGlynn, Editor-in-Chief

Margaret Trinity, Editor

Editorial Board

SMITREC continues to address critical issues

to the older veteran with depression. Future

SMITREC efforts will be directed to developing and implementing best practice models

to effectively identify and treat later-life 

depression in our aging veteran population. 

References

1. Valenstein M, et al. Psychiatric Diagnosis and Intervention in Older and Younger Patients in a Primary Care 

Clinic: Effect of a Screening and Diagnostic Instrument. Journal of the American Geriatrics Society 1998; 

46:1499-1505.

2. Kales HC, et al. Rates of Clinical Depression Diagnosis, 

Functional Impairment and Nursing Home Placement 

in Coexisting Depression and Dementia. American Journal of Geriatric Psychiatry 2005; 13:441-9.

3. Kales HC, et al. Mortality Risk in Patients with Dementia Treated with Antipsychotics versus other Psychiatric 

Medications. The American Journal of Psychiatry 2007; 

164:1568-76.

4. Zivin K, et al. Suicide Mortality among Individuals 

Receiving Treatment for Depression in the Veterans 

Affairs Health System: Associations with Patient and 

Treatment Setting Characteristics. American Journal of 

Public Health 2007; 97:2193-8.

that provides persons with chronic illnesses

or disabilities a choice of high quality programs that best meet their unique needs

while making the best use of finite resources.

References

1. Hedrick SC, et al. Resident Outcomes of Medicaidfunded Community Residential Care. Gerontologist 2003; 

43(4), 473-82.

2. Hedrick SC, et al. Characteristics of Residents and 

Providers in the Assisted Living Pilot Program. 

Gerontologist 2007; 47(3), 365-77.

3. Principi AJ. Letter to Arlen Specter, Chairman, Committee on Veterans’ Affairs, United States Senate,

November 23, 2004.