BackgroundUncontrolled diabetes contributes to serious comorbidities and mortality. Effective self-management can improve outcomes, though barriers such as limited education and support often prevent patients from engaging in such behaviors. Automated texting systems show promise to deliver diabetes self-management education as they are accessible and scalable. Furthermore, customizing these systems may further enhance patient engagement compared to standard, one-size-fits-all approaches. However, such customization is more resource-intensive, and it remains unclear whether the added effort meaningfully enhances diabetes self-management and outcomes. ObjectiveThis study aimed to describe the development of 2 versions of an automated texting system intervention for diabetes self-management: (1) a standard, education-only intervention (Diabetes Self-Management Support; DSMS) and (2) an interactive, customizable intervention (Diabetes Self-Management Support + Interactive and Customizable Messages; DSMS+). MethodsTwo versions of an automated texting system intervention were developed using a participatory design approach that incorporated input from veterans and expert clinicians. Message content was refined through feedback from a multidisciplinary team, veteran coinvestigators, national surveys, interviews, clinical expert panel reviews, and beta testing. Surveys were mailed to 1000 potential participants, oversampling rural, low-income, minority, and female participants. Respondents rated message relevance and provided preferences for content, timing, and frequency. Interviews provided customization preferences. A clinical expert panel reviewed all messages for safety and appropriateness. Beta testing informed final refinements. ResultsNinety-two surveys were completed (9.2% response rate). Respondents rated 62% of the messages as personally relevant and 61% confidence-enhancing. Interviews with 23 respondents revealed a preference for 1-2 texts per day, emphasizing topics such as healthy eating and weight management. The clinical expert panel reviewed 536 messages, flagging 81 for revision. Beta testing confirmed feasibility and informed refinements to clarity and timing. The 2 resulting interventions were built in the US Department of Veterans Affairs’ automated texting system, Annie. ConclusionsTwo text messaging interventions, DSMS and DSMS+, were developed to support diabetes self-management among US veterans. DSMS delivers standard educational content, while DSMS+ incorporates interactive features and personalization. The subsequent clinical trial will assess whether customization enhances engagement and improves diabetes outcomes, providing insights into the potential of tailored mobile health interventions for chronic disease management.

Objectives To evaluate the quantitative portion of a larger longitudinal mixed-methods implementation of the TelePain-Empower Veterans Program (EVP), a nonpharmacological chronic pain intervention. Chronic pain is a leading cause of disability and negatively impacts biological/physical, psychological, and social aspects of life resulting in pain interference or disability. The quantitative portion of this project followed veterans enrolled in TelePain-EVP from December 2021 to June 2023 to examine: (1) electronic patient-reported outcome measures (ePROs) including primary pain-related and secondary outcomes to determine TelePain-EVP effectiveness; and (2) dosing effects to understand relationships between TelePain-EVP use and ePROs. Design The quantitative portion of this evaluation project leveraged a within-participants repeated-measured design to examine veteran ePROs across multiple timepoints (weeks: 1 [baseline], 10 [post-EVP], 26 [follow-up]). Linear mixed models were fit to assess changes for each primary and secondary ePRO. Setting TelePain-EVP is telehealth intervention delivered from an urban Veterans Affairs medical center in the southeast United States. Participants In total, 442 veterans with chronic pain attended at least 1 TelePain-EVP session. Of these veterans, 221 (survey response, 50.00%) completed at least 1 ePRO survey response and were included in analyses. Interventions TelePain-EVP is a 10-week program. Each week, veterans participate in 3 hourly group sessions (Acceptance and Commitment Therapy; Mindful Movement; and Whole Health). Main Outcome Measures Primary pain-related ePROS were intensity, interference, catastrophizing, and kinesiophobia. Secondary ePROS included physical functioning, psychological (depression, anxiety, and sleep disturbance), social isolation, acceptance (activities engagement, pain willingness), and readiness for change (motivation, self-efficacy). Results Participants (n=221) reported a significant decrease in pain catastrophizing from baseline to post TelePain-EVP (P<.001). Catastrophizing returned to baseline levels at 6-months (P=.116). Pain interference decreased from baseline to posttreatment (P=.05), but this improvement did not exceed the adjusted significance threshold. Pre-post improvements were also observed for certain secondary ePROs (P<.01): psychological (anxiety, depression), acceptance (activities engagement). The activities engagement effect persisted at 6-months (P<.001). TelePain-EVP dose was not associated with primary and secondary outcomes. Conclusions Evidence from this evaluation indicate TelePain-EVP has positive outcomes for pain, psychological, and acceptance for veterans with chronic pain. Studies are needed with comparative and cost effectiveness methods to determine patient benefits and economic value of TelePain programs. Disclosures This project was supported in part by the James A Haley Veterans’ Hospital Research and Development Service, and the VAs Pain Management, Opioid Safety and Prescription Drug Monitoring Program. The contents do not represent the views of the Department of Veterans Affairs of the United States Government.

Objective: The Veterans Health Administration (VHA) recently piloted the implementation of the TeleWound Practice Program (TWP), which provides interprofessional wound care to Veterans remotely. We assessed the perceptions of Veterans and healthcare team members (HCTMs), and their experiences with the TWP. Method: We surveyed Veterans from four VHA medical centres who had received at least one TWP visit between 1 May 2020 and 31 May 2021, and HCTMs associated with any TWP encounter between 1 September 2019 and 31 March 2021. Survey data were summarised using descriptive statistics and open-ended question responses were analysed using thematic coding. Results: Out of 534 Veterans approached, 194 completed the survey (a 36% response rate). Most were interested in continuing to use TeleWound care (66%), felt more motivated to participate in their wound care due to the TWP (70%), and reported reductions in travel distance (81%) and cost (81%) related to wound care. Of the 32 HCTMs approached, 19 completed the TWP survey (a 59% response rate). Respondents indicated that the TWP improved their own professional decision-making skills (82%) and supported Veterans to take a more active role in their health (100%). Challenges included insufficient training for HTCMs, lack of stakeholder buy-in, and logistical and technical issues. Suggestions for improvement related to equipment, additional training and dedicated TWP staff. Conclusion: In this study, the Veterans were satisfied with the TWP and were more motivated to engage in wound self-management after receiving care through the TWP. HCTMs also perceived the TWP as beneficial to Veterans. However, additional efforts are needed to address barriers to TWP implementation across the VHA system of care.

OBJECTIVE:To evaluate Veterans' engagement in spinal cord injury and disorder (SCI/D) specialty annual evaluations (AEs). DESIGN:Cross-sectional retrospective cohort study. SETTING:SCI/D System of Care, United States Department of Veterans Affairs (VA). PARTICIPANTS:Veterans with SCI/Ds (N=14,662). INTERVENTIONS:Not applicable. MAIN OUTCOME MEASURES:Receiving SCI/D AEs during the study period (fiscal years [FY] 2019 and 2020). RESULTS:A total of 14,662 Veterans with SCI/Ds were included in the sample; 32.8% (n=4811) received 2 AEs, 28.8% (n=4219) received 1 AE, and 38.4% (n=5632) received no AEs, with an average of 0.9 AEs per Veteran over the 2-year study timeframe (range, 0-2y). Black Veterans had an 8% higher number of AEs than White Veterans after adjusting for other variables (adjusted relative risk [RR], 1.08; 95% confidence interval [CI], 1.04-1.12). Veterans who lived ≥240 minutes away from a VA SCI/D System of Care Center had 45% fewer AEs than Veterans who lived within 30 minutes (adjusted RR, 0.55; 95% CI, 0.52-0.59). Veterans with more SCI/D specialty visits had 90% more AEs than those with fewer visits (adjusted RR, 1.90; 95% CI, 1.78-2.03), whereas Veterans with more outpatient visits in VA primary care had 28% fewer AEs (adjusted RR, 0.72; 95% CI, 0.69-0.76). Veterans with higher comorbidity scores had 9% more AEs than Veterans with lower scores (adjusted RR, 0.66; 95% CI, 0.61-0.70). CONCLUSIONS:More than half (62%) of Veterans received ≥1 SCI/D AE during FY19-20. Veterans living closer to a VA SCI/D System of Care Center/Hub had more engagement in SCI/D AEs. Veterans with SCI/Ds who used VA primary care outside of the SCI/D System of Care had fewer AEs. There were no major racial, age-based, or sex disparities in SCI/D AE usage. Our findings suggest the need for targeted intervention efforts to promote AE use among Veterans.

Objective: To determine frequency that ED visits are needed, and the most common chief complaints and medications prescribed to Veterans with spinal cord injuries and disorders (SCI/D). Methods: The Veterans Health Administration (VHA) SCI and Disorders (SCI/D) Registry (VHA SCIDR) was used to identify Veterans with SCI/D over a five-year period (fiscal years 2018-2022). The primary outcome was the proportion of Veterans with SCI/D who had visits to the ED during the study period. Secondary outcomes included diagnostic codes and medications prescribed in the ED, and other healthcare encounters. Results: Overall, 18,464 Veterans with SCI/D, including 80,661 patient-years were included. Of these Veterans, 10,234 (55.4%) had at least one ED visit and 8230 (44.6%) did not. ED visits were consistent, ranging from 33.5% to 36.4% annually. The number of in-person healthcare encounters decreased over the study period. The most common ED diagnostic codes were paraplegia or quadriplegia, discharge counseling, UTI, neuromuscular dysfunction of the bladder and low back pain. The most common medications prescribed in the ED were analgesics (e.g., acetaminophen, ketorolac), antimicrobials (e.g., ceftriaxone, vancomycin) and ondansetron. Antibiotics were among the most prescribed discharge medications, including ciprofloxacin, sulfamethoxazole/trimethoprim, cephalexin, and doxycycline. Conclusion: This national study of Veterans with SCI/D characterized ED healthcare utilization. Overall, more than half of Veterans with SCI/D required an ED visit during the five-year study period and over one third of Veterans in each fiscal year required an ED visit. Interventions to target prevention of ED visits and subsequent hospitalizations could focus on these areas. Published by Elsevier Inc.

BackgroundMental health conditions are highly prevalent among US veterans. The Veterans Health Administration (VHA) is committed to enhancing mental health care through the integration of measurement-based care (MBC) practices, guided by its Collect-Share-Act model. Incorporating the use of remote mobile apps may further support the implementation of MBC for mental health care. ObjectiveThis study aims to evaluate veteran experiences with Mental Health Checkup (MHC), a VHA mobile app to support remote MBC for mental health. MethodsOur mixed methods sequential explanatory evaluation encompassed mailed surveys with veterans who used MHC and follow-up semistructured interviews with a subset of survey respondents. We analyzed survey data using descriptive statistics. We then compared responses between veterans who indicated having used MHC for ≥3 versus <3 months using χ2 tests. We analyzed interview data using thematic analysis. ResultsWe received 533 surveys (533/2631, for a 20% response rate) and completed 20 interviews. Findings from these data supported one another and highlighted 4 key themes. (1) The MHC app had positive impacts on care processes for veterans: a majority of MHC users overall, and a greater proportion who had used MHC for ≥3 months (versus <3 months), agreed or strongly agreed that using MHC helped them be more engaged in their health and health care (169/262, 65%), make decisions about their treatment (157/262, 60%), and set goals related to their health and health care (156/262, 60%). Similarly, interviewees described that visualizing progress through graphs of their assessment data over time motivated them to continue therapy and increased self-awareness. (2) A majority of respondents overall, and a greater proportion who had used MHC for ≥3 months (versus <3 months), agreed/strongly agreed that using MHC enhanced their communication (112/164, 68% versus 51/98, 52%; P=.009) and rapport (95/164, 58% versus 42/98, 43%; P=.02) with their VHA providers. Likewise, interviewees described how MHC helped focus therapy time and facilitated trust. (3) However, veterans also endorsed some challenges using MHC. Among respondents overall, these included difficulty understanding graphs of their assessment data (102/245, 42%), not receiving enough training on the app (73/259, 28%), and not being able to change responses to assessment questions (72/256, 28%). (4) Interviewees offered suggestions for improving the app (eg, facilitating ease of log-in, offering additional reminder features) and for increasing adoption (eg, marketing the app and its potential advantages for veterans receiving mental health care). ConclusionsAlthough experiences with the MHC app varied, veterans were positive overall about its use. Veterans described associations between the use of MHC and engagement in their own care, self-management, and interactions with their VHA mental health providers. Findings support the potential of MHC as a technology capable of supporting the VHA’s Collect-Share-Act model of MBC.

Technologies, including mobile health applications (apps) and wearables, offer new potential for gathering patient-generated health data (PGHD) from patients; however, little is known about patient preferences for and willingness to collect and share PGHD with their providers and healthcare systems. Describe how patients use their PGHD and factors important to patients when deciding whether to share PGHD with a healthcare system. Cross-sectional mailed longitudinal survey supplemented with administrative data within the Veterans Health Administration (VHA). National sample of Veterans who use VHA healthcare. Survey questions asked about demographics, willingness to use different devices to collect and share PGHD, what Veterans do with their PGHD, and factors important to Veterans when deciding whether to share PGHD with VHA. Administrative data provided information on Veteran health conditions. Multiple logistic regression models assessed factors associated with sharing PGHD with VHA. Overall, 47

Research ObjectivesIn response to the Veteran pain crisis and the national opioid epidemic, the TelePain-Empower Veterans Program (EVP) was developed as a non-pharmacological intervention to help Veterans manage chronic pain. This evaluation aimed to identify determinants of program implementation, user experiences, and benefits and challenges to participation.DesignQualitative descriptive evaluation using semi-structured telephone interviews, as part of a larger mixed-methods prospective study.SettingA Veterans Health Administration facility in southeastern United States.ParticipantsData were collected with program leaders (n=3), staff (n=10), and Veteran participants (n=15).InterventionsTelePain-EVP is a 10-week synchronous virtual pain management training program incorporating complementary integrated health, acceptance and commitment therapy, and mindful movement.Main Outcome MeasuresInterview questions aligned with the Consolidated Framework for Implementation Research (CFIR). Rapid analysis was used to generate themes for actionable feedback to inform implementation.ResultsCFIR domains and constructs emerged as relevant to program implementation, including innovation, inner and outer settings, individuals, and implementation processes. Identified determinants informed factors which were facilitators and barriers to implementation. Clinical care and administrative respondents reported on factors relevant to intervention characteristics, technology factors, team dynamics and organizational and structural characteristics, which impact implementation. Analysis of Veteran reports gleaned data about intervention experience, outcomes, and recommendations for improving the intervention from a patient-centered perspective.ConclusionsRemotely delivered pain management programs provide a nonpharmacological approach while improving access to care and benefitting participants with chronic pain. Data findings warrant electronic data collection for TelePain-EVP to improve accountability and real-time outcomes assessment. Data warrant consideration for using centralized staff and data management networks to address Staffing needs, training, and data management.Author(s) DisclosuresFunding: Department of Veterans Affairs, Veterans Health Administration, Office of Rural Health (PEC-21-129) and Pain Management, Opioid Safety and Prescription Drug Monitoring Program (SP8E-PMTIA160).

In response to the opioid epidemic and high rates of chronic pain among the veteran population, the U.S. Department of Veterans Affairs implemented the TelePain-Empower Veterans Program (EVP), a nonpharmacological pain management program for veterans. Delivered virtually, TelePain-EVP incorporates integrated health components (Whole Health, Acceptance and Commitment Therapy, and Mindful Movement) through interdisciplinary personalized coaching. The objective of this quality improvement project was to evaluate the implementation of TelePain-EVP to identify determinants to implementation, benefits and challenges to participation, and recommendations for future direction. We used a qualitative descriptive design to conduct semistructured telephone interviews with TelePain-EVP leaders (n = 3), staff (n = 10), and veterans (n = 22). The interview guides aligned with the Consolidated Framework for Implementation Research (CFIR). Thematic content analysis organized and characterized findings. Several CFIR domains emerged as determinants relevant to program implementation, including innovation (eg, design); individuals (eg, deliverers, recipients); inner (eg, communications) and outer settings (eg, local conditions); and implementation process (eg, reflecting and evaluating). Identified determinants included facilitators (eg, virtual delivery) and barriers (eg, staff shortages). Participants reported improvements in pain management coping skills, interpersonal relationships, and sense of community, but no self-reported reductions in pain or medication use. Program improvement recommendations included using centralized staff to address vacancies, collecting electronic data, offering structured training, and providing course materials to veteran participants. Qualitative data can inform the sustained implementation of TelePain-EVP and other similar telehealth pain management programs. These descriptive data should be triangulated with quantitative data to objectively assess participant TelePain-EVP outcomes and associated participant characteristics. PERSPECTIVE: A qualitative evaluation of a telehealth program to manage chronic pain, guided by the CFIR framework, identified determinants of program implementation. Additionally, participants reported improvements in pain management coping skills, interpersonal relationships, and sense of community, but no self-reported reductions in pain or medication use.

Research ObjectivesYoga is a front-line treatment for low back pain, however, yoga adoption among Veterans remains low. One potential barrier to adoption may be Veteran perceptions of yoga, including often inaccurate beliefs of what engaging in yoga entails and how participation may be viewed by others. Our objective was to develop an alternative yoga program for Veterans with chronic low back pain, to facilitate their uptake and sustained use of yoga.DesignRooted in Veteran feedback, we developed the Rage Against the Pain (RAP) ‘High Intensity Stretching’.SettingActivities were completed at a large Midwestern Veterans Affairs Medical Center.ParticipantsRAP development, including its name and branding, reflects direct Veteran feedback, and was inspired by “rage yoga.” RAP was developed by a multidisciplinary team, which encompassed physical, occupational, and recreational therapists; pain psychologists; primary care providers; psychiatrists; and researchers with expertise in pain management, user-centered design and implementation.InterventionsRAP is designed to impart the same pain management benefits as traditional yoga in a way that may better align with Veteran preferences and interests. RAP follows the same yoga sequences as hatha yoga, however, cues and poses are in plain language (vs. Sanskrit) and is set to alternative/rock/metal music.Main Outcome MeasuresDevelopment process and feasibility of RAP.ResultsWe have developed the curriculum for our RAP intervention, including a home practice manual, yoga sequencing and music playlists for 12 weekly sessions, and scripts to translate Sanskrit cuing to plain language. We piloted a 12-week RAP session with 9 Veterans, and are in the process of piloting another session with an additional 9 Veterans.ConclusionsOur team has successfully developed the RAP intervention, and will refine it based on an initial pilot of the program.Author(s) DisclosuresThis work was supported by the Department of Veterans Affairs (VA) Office of Research and Development, Health Services Research and Development Service (PPO 19-362). The views expressed are those of the authors and do not necessarily reflect the position and/or policy of the VA or the US Government.