INTRODUCTION:Intimate partner violence (IPV)-related traumatic brain injury (TBI) is understudied and underrecognized. Missed opportunities for managing IPV-TBI in the clinical setting leave survivors at risk for repeated injury and reduced access to care for cognitive and psychosocial repercussions. The objective of this study was to describe clinician perspectives with screening and managing IPV-related TBI in the clinical setting. MATERIALS AND METHODS:Clinicians across the United States completed an online, cross-sectional survey regarding their perspectives on IPV-related TBI. Likert-scale questions were summarized, and open-text responses were analyzed using qualitative content analysis. RESULTS:Respondents (n = 60) were primarily physicians (38%) or nurses (42%) working in emergency (52%), trauma (52%), and rehabilitation (30%). Most (73%) agreed that IPV-related TBI was difficult to diagnose, reported no training/education on identification (63%) or treatment (67%), and were not aware of organizational (53%) or state/federal policies (48%). Content analysis revealed challenges, facilitators, and recommendations with the following higher order themes: 'Education and Training,' 'Clinical Practice,' and 'Policy.' DISCUSSION:Standardizing education and training across clinical disciplines and specialties may improve routine screening for IPV-related TBI, resulting in improved access to care pathways and enhanced treatment approaches.

Objectives To assess the facilitators and barriers of health care needs of persons with traumatic brain injury (TBI) across health care systems. Design The study used an access to health care framework, to guide the development of qualitative research on stakeholders’ perceptions of the facilitators and barriers to accessing care for individuals with brain injury. Setting Research activities were conducted virtually through Microsoft Teams. Participants Participants were from state and national level brain injury organizations. Interventions No intervention was used. Main Outcome Measures Demographic survey and semistructured qualitative interviews and focus groups. Results Civilian stakeholders reported perceived facilitators and barriers to accessing care for individuals with brain injury. Perceived facilitators included resource facilitation provided by brain injury organizations, utilization of organizational partnerships, and utilization of telehealth to increase engagement and reduce barriers. Perceived barriers included understaffed service systems, transportation, access to case management services, appropriate long-term care facilities, housing insecurity, inadequate insurance coverage allowances, and meeting eligibility criteria regarding state-level resources. Stakeholders also reported admiration for the ability of VA health care systems to provide comprehensive multidisciplinary care compared with fragmented civilian health care systems. Conclusions Findings from this study highlighted strengths within the civilian health care system including organizational partnerships, telehealth, and resources such as the brain injury associations and alliances. The barriers such as transportation, housing, case management, and insurance are consistent with prior research. Challenges identified related to community-based care can inform the VA health care system on ways to improve services available to Veterans. These findings provide insight into ways to improve the civilian health care system. Disclosures The authors have no disclosures to report. The views expressed in this abstract are those of the authors and do not necessarily represent the official policy or position of the Defense Health Agency, Department of Defense, or any other U.S. government agency. For more information, please contact dha.TBICOEinfo@health.mil.

Objective: To describe the self-reported needs of family caregivers of service members and veterans (SMVs) with traumatic brain injury (TBI) at 10 to 15 years post-injury and to identify unique predictors of unmet family needs. Setting: Five Department of Veterans Affairs Polytrauma Rehabilitation Centers. Participants: A total of 209 family caregivers of SMVs with TBI from the VA TBI Model Systems national database who completed a 10- or 15-year follow-up assessment. Design: Observational study. Main Outcome Measure: Family Needs Questionnaire-Revised (FNQ-R). Results: Item-, domain-, and total score-level descriptive analyses of FNQ-R responses were conducted. On average, 56.3% of the FNQ-R family caregiver needs were reported as met. Health information and involvement in care needs were the most often met, and emotional support and instrumental support needs were the least often met. Adjusted multivariable regression models demonstrated that urban-dwelling SMVs (compared to suburban) and spouses/significant others (compared to parents) were associated with more unmet family needs. Distinct associations were identified between the 6 FNQ-R domains and SMV environmental factors (ie, urbanicity, rurality, and being active duty at follow-up), SMV comorbidities (ie, receiving mental health treatment in the year prior to the follow-up), and caregiver factors (ie, spouses/significant others). Conclusion: Family caregivers of SMVs with TBI reported multiple unmet needs at 10 to 15 years post-injury, emphasizing the importance of ongoing caregiver support after TBI. Policy and programming to support military caregivers should consider the current findings to direct resources to address the identified unmet needs.

Objectives To identify facilitators and barriers to accessing care for Veterans with brain injury. Design The study used an access to health care framework, one to guide the development of qualitative research on VA providers’ perceptions of the facilitators and barriers to accessing care for Veterans with brain injury. Setting Research activities were conducted virtually through Microsoft Teams. Participants Participants were provider and administrative stakeholders from the Department of Veterans Affairs. Interventions No intervention was used. Main Outcome Measures Demographic survey and semistructured qualitative interviews and focus groups. Results Stakeholders identified organizational factors that facilitated the provision of services for Veterans with brain injuries including access to multidisciplinary teams, organizational partnerships, and interagency consultation. Utilization of community-based resources was also a facilitator to access, highlighting the importance of the relationship between VA and community resources. Stakeholders reported several barriers that could complicate access and engagement in treatment for Veterans seeking care. Barriers included staffing challenges (lack of staff and overburdened staff) within VA systems, wait times for appointments, availability of appointments (hours of operation), transportation for Veterans, and housing or homelessness. Contracting with community-based service providers was perceived as a barrier to providing care for Veterans due to a lack of awareness regarding military culture, a lack of comprehensive integrated care, and a lack of communication between the community provider and VA provider. Conclusions Findings indicate that despite organizational factors that facilitate access to services for Veterans, some VA systems struggle with having enough staff to ensure quality services and existing staff burden. There is a need to address existing resources within VA systems and further strengthen partnerships with community-based providers. Disclosures The authors have no disclosures to report. The views expressed in this abstract are those of the authors and do not necessarily represent the official policy or position of the Defense Health Agency, Department of Defense, or any other U.S. government agency. For more information, please contact dha.TBICOEinfo@health.mil.

Objectives To identify facilitators and barriers to implementing policy within the Department of Defense (DOD). Design Five DOD stakeholders participated in individual qualitative interviews and were recruited through presentations, emails, and snowball sampling. The interviews were conducted by 2 trained interviewers using a semistructured interview script. The interviews were audio-recorded and transcribed for analysis. Analysis was conducted using grounded theory then organized into themes. Setting Research activities were conducted in-person at the James A. Haley VA in Tampa, Florida, and virtually through Microsoft Teams. Participants Participants were administrative stakeholders from the Department of Defense. Interventions No intervention was used. Main Outcome Measures Demographic survey and semistructured qualitative interviews. Results Based on interview findings, the DOD has developed organizational goals related to changing the culture of the military regarding service member brain injury (reducing stigma associated with reporting injury and seeking care), ensuring consistent services across regions, and providing appropriate education and training across the operational and medical specialties within the military. Facilitators to supporting change included implementing policies, leadership buy-in, leveraging partnerships with operational and research communities, stakeholders, and families, changing language to reduce stigma, education, and training. However, implementing change is not without barriers. Participants listed several barriers to implementing change including inability to monitor implementation of policies, leadership changes, lack of buy-in, translating research into practice, overlap and confusion regarding new policies and existing policies, lack of standardized care, and staffing shortages. Conclusions Policy implementation within the DOD has supported a cultural shift in how service member brain injury is recognized and treated. The findings suggest a continued need for strategies to ensure effective policy implementation. Disclosures The authors have no disclosures to report. The views expressed in this abstract are those of the authors and do not necessarily represent the official policy or position of the Defense Health Agency, Department of Defense, or any other U.S. government agency. For more information, please contact dha.TBICOEinfo@health.mil.

Objectives To report baseline data on perceived hopefulness and barriers among job seeking Veterans with Spinal Cord Injury (SCI) as measured by the Employment Hope Scale (EHS) and Perceived Barriers Scale (PEBS) a baseline before beginning vocational interventions as part of the ACCESS-Vets study. Design Four-year, 2-site randomized clinical trial to test the efficacy of customized employment compared with supported employment. Setting Four-year, 2-site randomized clinical trial to test the efficacy of customized employment compared with supported employment. Participants Thirty-five currently enrolled veterans (of a target sample of 50) with SCI aged 18-65 years, who desire employment and live near the VAMC completed a baseline survey before random assignment to treatment arms. Interventions The Individual Placement and Support model of Supported employment will serve the treatment as usual arm. Customized employment a promising vocational intervention being adapted for use in SCI health care will be the intervention arm. Main Outcome Measures (1) Employment Hope Scale collapsed into domains of psychological Empowerment, futuristic self-motivation, utilization of skills and resources, and goal orientation. (2) The Perceived Barrier Scale. Results Each domain was averaged on a 0-10 scale with 10 being the highest levels of hopefulness. Participants reported on average at baseline 8.86 (SD, 1.46) in terms of Psychological Empowerment, 7.47 (SD, 2.28) in terms of Futuristic self-motivation, 7.60 (SD, 2.57) in terms of utilization of skills and resources, and 6.51 (SD, 2.13) in terms of goal orientation. Commonly reported barriers to employment were reported physical disabilities (60.0%) and work limitations due to injury of illness (51.4%). Additionally, lack of information about jobs (31.4%), lack of adequate job skills (25.7%), and a shortage of jobs in the community (25.7%) were reported by over a quarter of all participants. Conclusions This preliminary examination suggests this baseline sample of Veterans with SCI reported above-average levels in most domains of hopefulness when entering vocational rehabilitation among this baseline sample. Barriers reported are consistent with the literature 4. Upon study completion, an analysis of the follow-up data with the full sample will shed light on how hope and perceptions of barriers may be associated with different vocational interventions and their employment outcomes. Disclosures The authors declare that they have no conflict of interest. Funding and disclaimer: VA Office of Research and Development, VA Rehabilitation Research and Development (RR&D) Grant #D3349R. Contents of this poster do not represent the views of the Department of Veterans Affairs or the United States Government. Clinical trial registration number NCT04832802.

Objectives To identify facilitators and barriers to early implementation of vocational rehabilitation services for Veterans with spinal cord injury. Design Randomized controlled trial. Setting Two spinal cord injury centers with the Department of Veterans’ Affairs. Participants Veterans with Spinal Cord Injury (SCI) randomized into either individualized placement and support (IPS) or customized employment (CE) and their vocational and clinical providers (n=10). Interventions IPS is an evidence-based vocational program that has been found to be 2.5 times more effective than business as usual vocational services. CE is a promising practice for Veterans with spinal cord injury. Main Outcome Measures Semistructured qualitative virtual interviews to identify facilitators and barriers to job seeking by Veterans with SCI. Results Site differences emerged at the early implementation phase of the interventions. At one site, vocational providers for IPS and CE described conducting initial vocational assessment activities according to the intervention but expressed difficulty contacting their caseload Veterans. Veterans from this site concurred, stating lack of communication from their vocational provider led to lack of job seeking activities. In contrast, at the other site, more consistent, frequent communication was established between the CE vocational provider and caseload Veterans, while turnover of the IPS vocational provider limited enrollment of Veterans for that intervention. Veterans felt supported by vocational providers who understands SCI and adapts activities to their individual needs. Conclusions Early implementation of both interventions found that keeping Veterans engaged with job seeking is facilitated by frequent communication. Strategies to improve communication include keeping a weekly schedule and adapting to Veterans’ needs. To support knowledge of SCI by vocational providers, attending SCI team meetings and involving clinical providers in the job seeking process to address health issues that may arise. Disclosures none.

Objective: The purpose of this article is to illustrate the process of stakeholder-engaged intervention mapping approach to identify implementation strategies to overcome data-driven prioritized barriers to receiving chronic pain services for persons with traumatic brain injury (TBI). Setting: Community. Participants: Healthcare providers ( n = 63) with 2 or more years' experience treating persons with TBI, interviewed between October 2020 and November 2021 provided data for identification of barriers. TBI, chronic pain, and qualitative research subject matter experts (SMEs) participated in the mapping approach. Design: Participatory-based research design, using descriptive and intervention mapping approaches. Results: Four barriers to accessing chronic pain treatment by persons with TBI which emerged from provider interviews were prioritized for intervention mapping: cognitive deficits of patients (67%); patient comorbidities (63%); mental health and/or substance abuse issues (59%); and patient participation (62%). SMEs used prioritized barriers to develop 4 primary objectives and implementation strategies designed to: (1) engage consumers to validate and identify strategies; (2) tailor pain treatment and delivery to overcome barriers; (3) develop and disseminate guidelines and best practices when delivering care to persons with TBI to support spread; and (4) increase awareness, skills, and readiness of workforce to deliver pain treatment to persons with TBI. SMEs used an evidence-based approach to develop a mapping matrix of the prioritized barriers, implementation objectives, and aligned implementation strategies to impact change. Conclusion: Implementation science is needed to facilitate knowledge translation into practice for this complex population to overcome barriers to care. Implementation strategies to address barriers to accessing chronic pain care for individuals with TBI were chosen through a participatory approach to engaging SMEs to support these rehabilitation implementation efforts. Future work includes gathering input from individuals with TBI and chronic pain and to move the intervention (implementation) mapping matrix forward to inform future implementation research, policy, and practice.

Research ObjectivesTo identify Department of Defense-specific facilitators and barriers to delivering healthcare services post military traumatic brain injury and highlight recommendations to improve systems of care.DesignA qualitative descriptive study design will be used.SettingAdministrators and policymakers from the Department of Defense.ParticipantsKey informant stakeholder interviews with high-level policy and administrative staff from within the DoD. Participants had specialized knowledge due to their unique positions and responsibilities. One-hour Interviews were conducted either virtually or in-person.InterventionsN/A.Main Outcome MeasuresFacilitators and barriers to delivering healthcare services post military traumatic brain injury.ResultsThe DoD administrators focused on a cultural shift in TBI care since the implementation of the Warfighter Brain Health Initiative to improve brain health, including the long-term outcomes of service members post-TBI. Specifically, this shift from a deployment and injury-based model of care to a long-term model of care that includes monitoring through baseline and intermittent assessments includes both organizational improvements (e.g., education and training to improve screening practices), as well as patient-specific improvements (e.g., promotion of health literacy and beliefs about TBI). Administrators also identified a lack of funding and personnel as key challenges to implementation, as well as collaborative challenges among the VA and DoD due to siloed funding and leadership turnover within these organizations.ConclusionsEarly implementation of the Warfighter Brain Health Policy to improve brain health, including the long-term outcomes of Service Members and Veterans with TBI, has created a cultural shift in how TBI is perceived, prevented, identified, and monitored from the healthcare system viewpoint. Early implementation efforts highlight the need for strengthening of partnerships between DoD and VA and continued education and training at both the organizational and patient (health belief) levels.Author(s) DisclosuresThe views expressed in this abstract are those of the authors and do not necessarily represent the official policy or position of the Defense Health Agency, Department of Defense, or any other U.S. government agency. For more information, please contact dha.TBICOEinfo@health.mil. UNCLASSIFIED.

Objective: Traumatic brain injury (TBI) clinical practice guidelines for pain management and rehabilitation support the use of nonpharmacologic complementary and integrative health (CIH) modalities, such as acupuncture for remediating pain. Barriers to delivering CIH modalities, such as acupuncture warrant examination. The objective of this study is to explore provider perspectives on challenges to accessing acupuncture treatment for chronic pain in persons with TBI and describe differences across health care settings. Setting: Civilian, Veterans Affairs (VA), and Department of Defense health care systems. Participants: Health care providers (n = 145) were recruited from November 2022 to March 2023 via email through professional organizations and health care systems. Design: Descriptive cross-sectional self-report online survey. Main Measures: A survey assessed barriers using a 5-point Likert scale (always a barrier to never a barrier) using the Levesque Access to Care framework. Results: Of the 137 participants who provided information on setting, 86 (63%) worked in civilian health care; 47 (34%) worked in the Department of VA; and 4 (2.6%) in the Department of Defense (8 were missing data). Overall, providers endorsed all ten items as being barriers to accessing acupuncture treatment. However, these barriers were more statistically more frequently reported for civilian providers compared with VA providers for six of the 10 items, including lack of caregiver support (p < 0.0001); own knowledge and understanding of the treatment (p = 0.0025); health care setting culture discourages the treatment (p = 0.0181); lack of qualified providers (p = 0.0467); insurance does not cover (p < 0.0001), and patient cannot afford (p < 0.0001). VA provider respondents were more likely to answer all six items, as "Rarely/Never a Barrier," while providers in a civilian setting were more likely to respond "Always/Frequently" or "Sometimes" a barrier. Conclusion: Results reflect the cultural, organizational, and structural differences that make acupuncture more accessible within the VA. understanding barriers to delivering care is critical to inform implementation strategy mapping efforts, to tailor strategies that are aimed to increase access and engagement with acupuncture treatment in civilian health care settings.

Objective: To identify facilitators and barriers to reaching and utilizing chronic pain treatments for persons with traumatic brain injury (TBI) organized around an Access to Care framework, which includes dimensions of access to healthcare as a function of supply (ie, provider/system) and demand (ie, patient) factors for a specified patient population. Setting: Community. Participants: Clinicians (n = 63) with experience treating persons with TBI were interviewed between October 2020 and November 2021. Design: Descriptive, qualitative study. Main Measures: Semistructured open-ended interview of chronic pain management for persons with TBI. Informed by the Access to Care framework, responses were coded by and categorized within the core domains (reaching care, utilizing care) and relevant subdimensions from the supply (affordability of providing care, quality, coordination/continuity, adequacy) and demand (ability to pay, adherence, empowerment, caregiver support) perspective. Results: Themes from provider interviews focused on healthcare reaching and healthcare utilization resulted in 19 facilitators and 9 barriers reaching saturation. The most themes fell under the utilization core domain, with themes identified that impact the technical and interpersonal quality of care and care coordination/continuity. Accessibility and availability of specialty care and use of interdisciplinary team that permitted matching patients to treatments were leading thematic facilitators. The leading thematic barrier identified primarily by medical providers was cognitive disability, which is likely directly linked with other leading barriers including high rates of noncompliance and poor follow-up in health care. Medical and behavioral health complexity was also a leading barrier to care and potentially interrelated to other themes identified. Conclusion: This is the first evidence-based study to inform policy and planning for this complex population to improve access to high-quality chronic pain treatment. Further research is needed to gain a better understanding of the perspectives of individuals with TBI/caregivers to inform interventions to improve access to chronic pain treatment for persons with TBI.

Objective: Identify determinants to chronic pain healthcare for persons with traumatic brain injury (TBI) informed by an Access to Care Framework. Findings related to the Access Framework's core domains of identifying a need, perceptions of the need, and seeking healthcare are reported. Setting: Community. Participants: Healthcare providers (n = 63) with 2 or more years of experience treating persons with TBI interviewed between October 2020 and November 2021. Design: Descriptive, qualitative study. Main Measures: Semi-structured interviews with open-ended questions of chronic pain management for persons with TBI. Informed by the Access Framework, responses were coded by and categorized within the domains of identifying healthcare needs, perceptions of needs, and factors related to healthcare seeking from the supply and demand perspective. Results: For the overall sample, 14 facilitators and 6 barriers were endorsed by more than 20% of the provider cohort. Top facilitators included on-site availability of needed resources and treatments (94%), adequate time and provider capability to ensure patient comprehension of diagnosis and treatment plans (83%), and establishing patient motivation and buy-in with the treatment plan (75%). Barriers most endorsed included policies impacting access (46%), wait times for services (41%), and patient uncertainty regarding telehealth commonly due to cognitive and physical challenges (37%). Unique determinants are reported across civilian versus Department of Veterans Affairs (VA) healthcare systems and different provider types. Conclusion: This is the first evidence-based study to inform policy and planning to improve access to high-quality chronic pain treatments for persons with TBI. Results will inform future interventions at the systems, patient, and policy levels of healthcare that can be tailored to healthcare settings (VA, Civilian) and types of providers (rehabilitation therapists, psychologists, and medical). Evidence-informed interventions may help minimize healthcare disparities experienced by persons with TBI and facilitate access to high-quality, evidence-informed chronic pain care.

Research Objectives 1. To identify how service members and veterans access health care services. 2. To describe facilitators and barriers to accessing health care services. 3. To inform programs and practices to improve access to health care services. Design A descriptive, qualitative study guided by a conceptual framework of access to health care services. Setting Five Polytrauma Rehabilitation Centers within the Department of Veterans Affairs. Participants SMVs (N=55, including 10 caregivers as proxies) who were greater than 2 years post-TBI recruited from the VA TBI Model Systems. Interventions Not Applicable. Main Outcome Measures Facilitators and barriers to healthcare services. Results The top four facilitators included ease of communicating with providers to help SMVs identify and utilize appropriate healthcare, family advocates that promoted engagement in healthcare, ability to use VA/Department of Defense/and community facilities, and online resources or equipment. SMVs with severe/DOC TBI also highlighted the role of non-profit organizations in promoting healthcare engagement and the availability of VA specialty residential programs in meeting TBI healthcare needs. Barriers to healthcare access differed across the TBI severity continuum and dimensions of the conceptual framework. Distance to services was uniformly identified as a barrier to seeking healthcare for both patient groups. Having unrecognized healthcare needs in chronic stages and communication breakdowns impacting quality of care were more commonplace for those with greater TBI severity. Those with mild or moderate injury highlighted challenges with specialty programs intended to help pay for services in the community and scheduling challenges limiting availability of services. Conclusions Barriers and facilitators exist across multiple dimensions of a healthcare access framework and vary by TBI severity. Findings support current policies and practices to facilitate healthcare access for SMVs with TBI but identify need for tailored approaches for those with greater disability and injury severity. Author(s) Disclosures None. 1. To identify how service members and veterans access health care services. 2. To describe facilitators and barriers to accessing health care services. 3. To inform programs and practices to improve access to health care services. A descriptive, qualitative study guided by a conceptual framework of access to health care services. Five Polytrauma Rehabilitation Centers within the Department of Veterans Affairs. SMVs (N=55, including 10 caregivers as proxies) who were greater than 2 years post-TBI recruited from the VA TBI Model Systems. Not Applicable. Facilitators and barriers to healthcare services. The top four facilitators included ease of communicating with providers to help SMVs identify and utilize appropriate healthcare, family advocates that promoted engagement in healthcare, ability to use VA/Department of Defense/and community facilities, and online resources or equipment. SMVs with severe/DOC TBI also highlighted the role of non-profit organizations in promoting healthcare engagement and the availability of VA specialty residential programs in meeting TBI healthcare needs. Barriers to healthcare access differed across the TBI severity continuum and dimensions of the conceptual framework. Distance to services was uniformly identified as a barrier to seeking healthcare for both patient groups. Having unrecognized healthcare needs in chronic stages and communication breakdowns impacting quality of care were more commonplace for those with greater TBI severity. Those with mild or moderate injury highlighted challenges with specialty programs intended to help pay for services in the community and scheduling challenges limiting availability of services. Barriers and facilitators exist across multiple dimensions of a healthcare access framework and vary by TBI severity. Findings support current policies and practices to facilitate healthcare access for SMVs with TBI but identify need for tailored approaches for those with greater disability and injury severity.

BACKGROUND: To date, the Individual Placement and Support (IPS) model is the only vocational intervention that has been rigorously studied and shown to be effective with Veterans with spinal cord injury (SCI). Customized Employment (CE) is an innovative vocational intervention with promising results among people with disabilities which has yet to be tested in persons with SCI. OBJECTIVE: To determine whether a Customized Employment (CE) intervention adapted for SCI rehabilitation is more effective than the standard care (IPS) for helping Veterans with SCI obtain and maintain employment. METHODS: A 4-year, 2-site randomized clinical trial (RCT) with concurrent mixed methods using an intent-to-treat (ITT) approach. The primary outcome is competitive integrated employment as defined by the Work Innovation and Opportunity Act. Secondary outcomes are employment indicators, quality of life (QOL), and participation. RESULTS: This is a methods paper so there are no results to present at this time. CONCLUSION: The proportion of Veterans who attain employment will be greater for the CE group than the IPS group and they will outperform the IPS group on other employment-related metrics (e.g., higher job satisfaction, wages, and retention). Employed Veterans will demonstrate significant improvements in self-sufficiency, QOL, and participation. Qualitative data obtained from interviews will assist with adaptation strategies and will identify barriers to implementing CE.

Background: Spinal cord injury is a condition that adversely impacts employment and economic stability. The Kessler Foundation National Employment and Disability Survey (KFNEDS) was developed to understand the experience of striving to work among persons with disabilities. However, this survey was not intended to capture the employment experiences of veterans living with spinal cord injury. The aim of this study was to engage veterans living with a spinal cord injury to adapt the KFNEDS for veterans living with this specific disability.Objectives: Describe the process and outcomes of actively engaging veterans living with spinal cord injury in the re -vision of the KFNEDS.Methods: In this multiphase qualitative study, we used an iterative veteran-centered approach to engage veterans living with an SCI in all project phases. We consulted with a Veter-ans' hospital's Veteran Engagement Group and convened a study-specific Community Action Board to engage in a col-laborative partnership with the research team. We recruited 17 veterans living with a spinal cord injury, employed or looking for employment since their spinal cord injury, to participate in focus groups and cognitive interviews that informed the adaptation of the KFNEDS-VS.Results: A provisional version of the KFNEDS-VS included 37 survey questions in the following sections: Disability Screen, Employment Screen, Disability, Employment Over-all, Looking for Work, At Work, and Workplace Accommoda-tions and Supports. Revisions included wording changes for clarity, veteran and spinal cord injury-specific content that was missing from the questions or response options, and removal of irrelevant questions.Conclusions: Engaging veterans in multiple phases of the study lead to the development of a relevant survey that captures the lived experience of veterans seeking, obtaining, and maintaining employment following spinal cord injury.

Most people want to work because they want to feel productive, earn money, and build social connections. When you are learning to live with a disability like spinal cord injury (SCI), employment is key to rebuilding your life. Working helps you to live longer and makes your life more meaningful and satisfying (fig 1). 1 Meade M Reed K Saunders L Krause J. It's all of the above: benefits of working for individuals with spinal cord injury. Top Spinal Cord Inj Rehabil. 2015; 21: 1-9 Crossref PubMed Scopus (38) Google Scholar , 2 Krause JS Clark JMR Saunders LL. SCI longitudinal aging study: 40 years of research. Top Spinal Cord Inj Rehabil. 2015; 21: 189-200 Crossref PubMed Scopus (30) Google Scholar , 3 Krause JS Saunders LL Acuna J. Gainful employment and risk of mortality after spinal cord injury: effects beyond that of demographic, injury and socioeconomic factors. Spinal Cord. 2012; 50: 784-788 Crossref PubMed Scopus (44) Google Scholar , 4 Ottomanelli L Barnett SD Goetz LL. A prospective examination of the impact of a supported employment program and employment on health-related quality of life, handicap, and disability among Veterans with SCI. Qual Life Res. 2013; 22: 2133-2141 Crossref PubMed Scopus (21) Google Scholar , 5 Cotner BA Ottomanelli L O'Connor DR Njoh EN Barnett SD Miech EJ Quality of life outcomes for veterans with spinal cord injury receiving individual placement and support (IPS). Top Spinal Cord Inj Rehabil. 2018; 24: 325-335 Crossref PubMed Scopus (7) Google Scholar

Objective: To compare barriers and facilitators to accessing health care services among service members and veterans (SMVs) by traumatic brain injury (TBI) severity groups. Design: Qualitative descriptive study guided by an access to health care services conceptual framework. Setting: Five Veterans Affairs (VA) polytrauma rehabilitation centers. Participants: SMVs (N=55, including 10 caregivers as proxies) & GE;2 years post-TBI recruited from the VA TBI Model Systems and grouped by TBI severity (mild/moderate, severe). Main Outcome Measures: Barriers and facilitators accessing care. Results: The main facilitators included ease of communicating with providers to help SMVs identify and utilize appropriate health care, family advocates who promoted engagement in health care, ability to use government and community facilities, and online resources or equipment. Dis-tance to services was uniformly identified as a main barrier for both patient groups. However, facilitators and barriers to health care access differed by TBI severity. SMVs with severe TBI highlighted the role of nonprofit organizations in promoting health care engagement and the availability of VA specialty residential programs in meeting health care needs. Having unrecognized health care needs in chronic stages and communication difficulties with providers were more commonplace for those with greater TBI severity and affected quality of care. Those with mild/moderate TBI highlighted challenges associated with paying for services in the community and scheduling of services. Conclusions: Barriers and facilitators exist across multiple dimensions of a health care access framework and vary by TBI severity. Results suggest possible mechanistic links between health care access and SMV health outcomes. Findings support current policy and practice efforts to facilitate health care access for SMVs with TBI but highlight the need for tailored approaches for those with greater disability. Archives of Physical Medicine and Rehabilitation 2023;104:380-9 Published by Elsevier Inc. on behalf of the American Congress of Rehabilitation Medicine.

Research Objectives To describe how the COVID-19 pandemic influenced treatment practices for chronic pain in persons with traumatic brain injury (TBI) and facilitators and barriers to rehabilitation care. Design A descriptive, qualitative study. Setting Traumatic brain injury model systems (TBIMS) civilian and Veterans facilities. Participants The secondary analysis included providers consisting of rehabilitation therapists (physical therapists, speech language pathologists, and occupational therapists), medical doctors, nurses, clinical and neuro psychologists, and resource managers (n=63) for persons with TBI and chronic pain. Interventions N/A. Main Outcome Measures A semi-structured qualitative telephone interview consisted of 13 questions asking about treatment practices and facilitators and barriers to rehabilitation for people with TBI and chronic pain during the COVID-19 pandemic. Results The COVID-19 pandemic impacted treatment practice across civilian and VA TBIMS facilities. Thematic analysis revealed that the main changes to treatment practices were switching to virtual visits, the impact of COVID-19 precautions such as social distancing and wearing masks had on providing treatment, and in some cases, treatment was halted. Facilitators to care included improved communication between providers and their patients, the increase in use of telehealth to provide care, and increased access to providers. Barriers to rehabilitation care identified by mainly civilian providers included COVID-19 visitor restrictions on family involvement, and the lack of access patients had to their providers during this time, specifically with cancelled appointments or wait lists. Both civilian and VA providers described how COVID-19 logistics for cleaning and social distance impacted scheduling and the number of patients who could be seen. Conclusions The global COVID-19 pandemic served as a major disruptor to provision of healthcare. The switch from mainly in person care to the use of telehealth to deliver care was a major transition for providers and patients. Future research on the impact of telehealth on patient outcomes and when to use telehealth versus in person is needed. Author(s) Disclosures This work is supported by the National Institute on Disability, Independent Living, and Rehabilitation Research (90DPTB0017 and 90DPTB0008) and General Dynamics Health Solutions (W91YTZ-13-C-0015; HT0014-19-C-0004). To describe how the COVID-19 pandemic influenced treatment practices for chronic pain in persons with traumatic brain injury (TBI) and facilitators and barriers to rehabilitation care. A descriptive, qualitative study. Traumatic brain injury model systems (TBIMS) civilian and Veterans facilities. The secondary analysis included providers consisting of rehabilitation therapists (physical therapists, speech language pathologists, and occupational therapists), medical doctors, nurses, clinical and neuro psychologists, and resource managers (n=63) for persons with TBI and chronic pain. N/A. A semi-structured qualitative telephone interview consisted of 13 questions asking about treatment practices and facilitators and barriers to rehabilitation for people with TBI and chronic pain during the COVID-19 pandemic. The COVID-19 pandemic impacted treatment practice across civilian and VA TBIMS facilities. Thematic analysis revealed that the main changes to treatment practices were switching to virtual visits, the impact of COVID-19 precautions such as social distancing and wearing masks had on providing treatment, and in some cases, treatment was halted. Facilitators to care included improved communication between providers and their patients, the increase in use of telehealth to provide care, and increased access to providers. Barriers to rehabilitation care identified by mainly civilian providers included COVID-19 visitor restrictions on family involvement, and the lack of access patients had to their providers during this time, specifically with cancelled appointments or wait lists. Both civilian and VA providers described how COVID-19 logistics for cleaning and social distance impacted scheduling and the number of patients who could be seen. The global COVID-19 pandemic served as a major disruptor to provision of healthcare. The switch from mainly in person care to the use of telehealth to deliver care was a major transition for providers and patients. Future research on the impact of telehealth on patient outcomes and when to use telehealth versus in person is needed.

BACKGROUND:The COVID-19 pandemic has been a catalyst for rapid uptake of virtual care through the use of virtual health resources (VHR). In the Department of Veterans Affairs (VA) Healthcare System, virtual care has been critical to maintaining healthcare access for patients during COVID-19. In the current study we describe primary care patient aligned care team (PACT) VHR use patterns within one VA medical center (i.e., hospital facility and five community-based outpatient clinics) pre- and post-COVID-19 onset.METHODS:VHR provider and patient use data from 106 individual PACTs were extracted monthly between September 2019 to September 2020. Data were extracted from VHA web-based project application and tracking databases. Using longitudinal data, mixed effect models were used to compare pre- and post-COVID onset slopes.RESULTS:Findings highlight an increase in patient users of secure messaging (SM) and telehealth. The rate of utilization among these patients increased for SM but not for telehealth visits or online prescription refill (RxRefill) use. Finally, VetLink Kiosk check ins that are done at in person visits, diminished abruptly after COVID-19 onset.CONCLUSIONS:These data provide a baseline of VHR use at the PACT level after the initial impact of the COVID-19 pandemic and can inform healthcare delivery changes within the VA systems over time. Moreover, this project produced a data extraction blueprint, that is the first of its kind to track VA VHR use leveraging secondary data sources.

OBJECTIVE:To describe the self-reported needs of family caregivers of service members and veterans (SMVs) who sustained a traumatic brain injury (TBI) and to identify predictors of the unmet family caregiver needs.SETTING:Five Department of Veterans Affairs (VA) Polytrauma Rehabilitation Centers (PRCs).PARTICIPANTS:Family caregivers of SMVs enrolled in the VA PRC TBI Model Systems (TBIMS) national database who were within their first 5 years post-TBI ( n = 427).DESIGN:Observational study.MAIN OUTCOME MEASURE:The Family Needs Questionnaire-Revised (FNQ-R) was completed by each SMV's designated caregiver.ANALYSES:Descriptive analyses were conducted on the FNQ-R responses at the item, domain, and total score levels. Unadjusted univariable and adjusted multivariable regression models were fitted to identify predictors of total unmet needs and unmet family need domains.RESULTS:FNQ-R item-level and domain-level descriptive results indicated that health information was the most frequently met need domain. In contrast, emotional and instrumental support domains were the least often met. On average, family caregivers reported that 59.2% of the 37 FNQ-R needs were met at the time of the follow-up assessment. Regression models indicated that both the number of SMV-perceived environmental barriers and whether the SMV received mental health treatment within the past year predicted the number of unmet FNQ-R needs. SMV-reported environmental barriers predicted increased unmet needs in all 6 family caregiver domains, and SMV mental health treatment in the past year predicted more unmet family caregiver emotional support, community support, and professional support needs.CONCLUSIONS:The current findings can be used to inform policy and programming for VA and Department of Defense to proactively address the specific needs of families and caregivers experienced in the first 5 years post-TBI.