The Veterans Health Administration: Opportunities and Considerations for Implementing Innovations in a National, Integrated Health Care System

The Veterans Health Administration (VA) is the largest integrated health-care system in the United States. On average, the VA serves more than nine million veterans annually across 171 medical centers and more than 1,112 ambulatory care centers and community-based clinics (Department of Veterans Affairs, 2021d). The VA has a long history of and commitment to innovation in aging programs and services (Shay et al., 2008, 2013). The VA has also been a leader within the field of implementation science. The VA has had a program office dedicated to implementation science for more than 20 years. The field’s leading journal, Implementation Science, was introduced by a multidisciplinary team, including researchers housed within the VA Health Services Research & Development (HSR&D). More details on these initiatives are described below. More than 90% of veterans utilizing the VA receive VA primary care services (Shay & Schectman, 2010). In addition to primary care, the VA provides specialty services and a continuum of services designed for older veterans (see Figure 1). Some of these programs include adult day health care, community living centers (i.e., nursing homes), home- and community-based services, hospice care, respite care, and caregiver support programs (Department of Veteran Affairs, 2021a). These programs are diverse in their physical settings and locations, services provided, and the sizes and disciplines of the care team(s) involved. Older veterans aged 65 and over are one of the fastest growing subgroups of VA users (Amaral et al., 2018). Older VA users tend to experience more chronic conditions, face greater sociodemographic challenges, and exhibit poorer health behaviors compared to those veterans not utilizing VA care and to non-veteran peers (Agha et al., 2000; Eibner et al., 2016). The complexity of older veteran patients necessitates complex care interventions delivered across the range of settings and services described above. Continuum of VA Aging Services and Programs. Developed from www.va.gov/GERIATRICS/index.asp. *Some hospice and palliative care can be provided in residential and nursing home settings. VA = Veterans Health Administration. Continuum of VA Aging Services and Programs. Developed from www.va.gov/GERIATRICS/index.asp. *Some hospice and palliative care can be provided in residential and nursing home settings. VA = Veterans Health Administration. A central priority across these services is to support veterans’ choices to age in place. This natural continuum of services housed within the VA enables veterans to remain within the health care system over time. This long-term follow-up presents an ideal case for researchers to observe how programs are implemented in different settings and how such programs must be adapted across settings and conditions, including any changes over time. The expansive nature of the VA also lends itself to natural research questions around the scalability of implementation strategies. These characteristics, together with the learning health-care culture, make the VA a natural laboratory for studying and applying principles of implementation science. The VA research encompasses three distinct branches—health services, rehabilitation, and clinical research—with each branch consisting of a diverse project portfolio. Some common aging-related research priorities include: diseases and conditions of aging; mobility and functional independence; mental health, including posttraumatic stress disorder; caregiving; geriatric models of care; and care utilization. One primary advantage of VA research is the ability to embed tightly controlled randomized trial into the health care system and to partner with clinical and operational partners in conducting research and other rigorous quality improvement and evaluation projects. This pragmatic nature of VA research provides an excellent opportunity for researchers to simultaneously observe the implementation climate, culture, and experience, in addition to more traditional clinical or utilization outcomes. Furthermore, all researchers are required to describe the research implications and their dissemination plans when submitting new proposals. The VA also includes an office dedicated to implementation. Housed within VA HSR&D, the Quality Enhancement Research Initiative (QUERI) program was founded in 1998 with the goal of transforming the VA Healthcare System and accelerating the adoption of effective clinical practices into routine care (Demakis et al., 2000; Stetler et al., 2008). From its inception, QUERI has emphasized research partnerships with programmatic and operational partners at local, regional, and national levels. Through a range of funded centers, partnered initiatives, and learning hubs, QUERI focuses on implementation, evaluation, dissemination, and sustainment of Evidence-Based Practices (EBPs) and effective clinical practices. Together, these QUERI resources and initiatives help to cultivate and maintain a culture of innovation within the VA. QUERI also offers resources to the larger VA research and clinical communities, including a comprehensive implementation roadmap that outlines activities in the pre-implementation, implementation, and sustainment phases (Kilbourne et al., 2019). Quality improvement efforts targeting older veterans are also funded through operational offices in the VA, which are committed to providing resources to further the mission of improving the lives of veterans with certain characteristics. Given older veterans are a large proportion of the veteran population, many of the efforts underway affect the lives of older veterans. We highlight efforts within three VA offices: the Office of Geriatrics and Extended Care (GEC), Office of Rural Health (ORH), and Office of Mental Health and Suicide Prevention (OMHSP). The GEC has funded many innovative programs and Centers, including a total of 20 Geriatric Research Education and Clinical Centers (GRECCs) throughout the VA system. GRECCs have trained many clinician researchers focused on older veterans, as well as funded clinical demonstrations of new and innovative EBPs for older veterans (Shay et al., 2013; Supiano et al., 2012). The GEC has also supported initiatives to improve quality in VA nursing homes through applied work, such as the creation of Community Living Centers’ Ongoing National Center for Enhancing Resources and Training, which resulted in implementation hubs also supported with QUERI funds (Hartmann et al., 2019). Approximately one in four veterans enrolled in VA care reside in a rural area; just over one-half of these 2.7 million rural-residing veterans are over the age of 65 (Department of Veterans Affairs, 2021b). The VA ORH supports implementation of EBPs through two primary channels: the first translating effective programs established at the national level to rural settings and the second focused on integration of best practices that are specific to rural populations and service areas. Implementation in rural settings can take place via direct initiatives or mentored support, in which rural VA sites are partnered with VA sites who have more implementation experience. Relevant examples of national implementation funded by the ORH include the Gerofit program, an exercise program for older veterans targeting health and well-being (Morey et al., 2018); GRECC Connect (Hung et al., 2014), a virtual case consultation program for managing complex patients; and Caring for Older Adults and Caregivers (COACH), a home-based program to support older veterans living with moderate to severe dementia (D’Souza et al., 2015). The final example is OMHSP, which has supported adoption of many EBPs. For example, OMHSP has been a sponsor (in conjunction with GEC and funded through QUERI) of a project to understand the sustainability of the Staff Training in Assisted Living Residences program, an EBP for managing distress behaviors in dementia in the nursing home setting (Karel et al., 2016; Karlin et al., 2014; Mohr et al., 2021). Another recent applied project is a collaboration between the OMHSP and ORH that involves evaluating ways to best utilize scarce geriatric mental health expertise in the VA through assessing a geriatric psychiatry consultation model in one regional area, with the intention of spreading this model to additional regions. The efforts described above illustrate many of the benefits of applied implementation practice taking place via embedded research activities. VA offices can often set policies and expectations and, when working with embedded clinical settings, these offices are able to more quickly translate evidence into routine practice, make adaptions more rapidly compared to traditional research trials, and disseminate findings to the field. However, operational efforts are often funded from one year to the next, which can be challenging when implementation efforts span multiple years and funding levels may fluctuate over time given other priorities. Transitioning from a demonstration project to routine practice can also be challenging if local medical centers face resource issues (e.g., reduced staffing or limited space) or if leadership has transitioned to supporting other initiatives and programs. Operational offices can also partner with the VA Evidence Synthesis Program (ESP) to explore current evidence, develop clinical policies informed by such evidence, and identify gaps in clinical knowledge to be pursued further in subsequent studies (Department of Veterans Affairs, 2021d). Through three centers located across the United States plus a central Coordinating Center, the ESP produces both rapid evidence briefs and rigorous systematic reviews. Topics are nominated by operational offices, and all phases of the review, including initial design and research questions, are developed in partnership between ESP researchers and representatives from operational offices. As illustrated above, the VA represents one ideal environment in which to study implementation. Although there are many strengths of the VA’s “learning laboratory,” there are also challenges in conducting implementation work. As when implementing EBPs in many environments, it is important to consider the implementation context (i.e., determinants) on multiple levels (Damschroder et al., 2009). Below, we highlight some of the challenges on the national level (e.g., VA Central Office) and local level (e.g., VA Medical Center or Community-Based Outpatient Clinic). Although there are many strengths of VA’s “learning laboratory”, there are also challenges in conducting implementation work. The VA is an integrated health care system with national expectations and policies; yet, local and regional needs and priorities can contribute to variations in practice and implementation efforts. For example, the VA is driven by several sets of national priorities and these priorities can shift given current political concerns and/or leadership turnover. Thus, the relative priority of aging research can also shift over time and vary at different levels within the organization. In the VA, costs are capitated, allowing clinicians more time with patients to provide quality care versus feeling pressure to see more patients to meet expected levels of reimbursement (Kizer, 2001; Segal et al., 2002). This costing system is a benefit to older veterans, who often need more than the average 20-minute visit with a provider to review their health and discuss potential resources that may be available to help support them. However, because older veterans often have physical and mental health comorbidities, many require additional care coordination, which may not always translate into cost savings or may be cost neutral, and cost is a typical metric of program success. Although the VA’s structure and costing system allow for innovative implementation efforts, questions of generalizability to other environments outside the VA are important to consider. As alluded to above, older veterans receive care across a diverse number of geriatrics services. Although many of these services share the same goal—to promote the health and preserve the independence of older veterans—the structure of such services varies. For example, some services are offered on site at large VA Medical Centers, while others are offered at smaller Ambulatory Care Centers and/or Community-Based Outpatient Clinics. The structural characteristics of each setting can differ (e.g., size, resources, age of facility), as can the staffing characteristics (e.g., disciplines present, team size). Furthermore, the implementation climate, culture, and readiness may also ebb and flow across these settings. At the same time, this diversity provides researchers with the opportunity to examine how variations across settings, teams, and climates impact implementation processes and outcomes. As highlighted above, the VA has both a number of strengths and challenges for engaging in implementation research targeting aging programs and populations. As a learning health care system, the VA continually utilizes internal data and engages in quality improvement cycles to integrate EBPs to improve clinical services. The VA’s continuum of geriatrics service settings offers a rich environment for studying the integration of EBPs across different settings serving a diverse patient population. To further enhance implementation efforts targeting this growing population, we offer recommendations in three main areas: research, coordination, and training and education. As an integrated health care system that sits at the nexus of implementation research and implementation practice, the VA provides an environment conducive to innovative study designs. Such examples include pragmatic trials, implementation–effectiveness hybrid designs, adaptive studies, and cost–benefit analyses. The sheer size of the VA Healthcare System, combined with the long-term nature of VA care, promote studies that focus on matching implementation strategies to determinants, examining both the efficacy and efficiency of implementation strategies across different settings, and exploring mechanisms of successful implementation under diverse conditions. With nearly 171 medical centers, the VA system is ripe for exploring questions of scalability and sustainability. Finally, the unique characteristics of aging veterans, including the heterogeneity and clinical complexity of this population, present opportunities to explore questions around fidelity and adaptation of personalized interventions, as well as care coordination across different services, which may be unique for veterans belonging to different service eras (Barnes et al., 2014; Marini et al., 2020; Wilmoth et al., 2020). We have highlighted a number of resources and opportunities to conduct implementation research in the VA. However, these opportunities are not always well coordinated across research portfolios, various program offices, or national, regional, and local levels. Thus, one major challenge is how to gather information about these efforts into a central hub to best take advantage of the knowledge gained and to disseminate findings to appropriate leaders, service lines, and clinic settings. Although there are many groups (e.g., Communities of Practice, research-driven groups focused on one area) sharing results and lessons learned regarding the effectiveness of EBPs, fewer groups specifically hone in on how to develop implementation strategies and tailor implementation approaches to best support the implementation and sustainability of EBPs for older adults. Additionally, implementation efforts can be siloed by program type, thereby decreasing learning across programs within the same medical center (or across medical centers). Given older veterans seek care across a range of settings, it is critical to identify avenues for sharing best practices related to overcoming similar organizational challenges in the implementation of aging programs and services. The VA has recently embarked on an effort to become an age-friendly organization (Institute for Healthcare Improvement, 2021). Adoption of this designation might be an overarching way to accelerate implementation efforts, given that age-friendly organizations focus on common metrics, including what matters, medication, mentation, and mobility (Department of Veterans Affairs, 2021c). A QUERI partnered evaluation was recently funded to make progress on becoming an age-friendly organization in one region, with hopes for future spread (Burke et al., 2021). Although we estimate that 8% of HSR&D’s current studies and 30% of QUERI programs or partnered evaluations focused specifically on implementation science for aging veterans, we feel more can be done to leverage the VA’s strengths and expertise in implementation science and aging research (Department of Veterans Affairs, 2021e). Specifically, we recommend identifying efforts to coordinate implementation scientists, implementation practitioners, and clinicians working primarily with older veterans. The VA has a long history of educating trainees and learners in both clinical practice and research across a range of disciplines, including medicine, psychology, nursing, and allied health professions. Advanced fellowships and other training opportunities are offered via the VA’s Office of Academic Affiliations, the VA Quality Scholars Program, and the National Clinical Scholars Program (Splaine et al., 2009). Although postdoctoral fellowships offered within various HSR&D Centers may include advanced training in implementation science, no stand-alone opportunities exist, despite the rapid growth of implementation science within VA settings. In the past, the Implementation Research Institute was funded by the National Institute of Mental Health, with supplementary funding provided by the VA (Proctor et al., 2013). However, this selective training program primarily targeted individuals working in mental health services as opposed to broader clinical or health services areas. Additionally, outside the VA, there are newer programs, including the Institute for Implementation Science Scholars program, which is focused on chronic disease and health inequities, and the Center on Health Services Training and Research, which is focused on rehabilitation medicine. To our knowledge, there are no VA training programs dedicated solely to implementation science theory, methods, or practices within geriatrics settings, programs, or populations. Regardless of the lack of formal training programs, there are many ways to become involved in implementation efforts and/or receive training in these methods within the VA. In addition to formally trained implementation scientists or researchers, there is an immense need to provide ongoing professional development to implementation specialists, or practitioners. VA was one the first large health care systems to actively support and employ implementation specialists as a distinct career classification and trajectory. Some recommendations have suggested research training should extend beyond the basics of implementation science theories and frameworks to also include skill-building in leadership, stakeholder engagement, and scientific communication (Yano et al., 2021). In addition, although recent efforts have been made to expand training opportunities to support diversity and inclusion of implementation scientists through initiatives such as QUERI’s Advancing Diversity in Leadership program, more resources should be devoted to training diverse leaders. Finally, training efforts should embrace the diverse range of activities present in the VA, including traditional clinical trial research, quality improvement initiatives, and implementation science, and should train practitioners on more recent developments in the field, such as stakeholder engagement and integration of health equity. The breadth of VA geriatrics services provides an excellent environment in which to study the implementation of EBPs for a diverse older veteran population obtaining care across various settings and over an extended period of time. The wide array of clinic settings allows for examinations of implementation across locations, which may also inform equitable implementation. Second, the complexity of older veterans provides opportunities to build and evaluate multilevel and multicomponent interventions (Perez Jolles et al., 2019). Third, the VA’s continuous culture of innovation makes implementation research and practice accessible, applicable, and impactful. Innovations are embedded in clinical work, and successful, effective program implementation efforts can be applied iteratively to scale up and disseminate practices across many medical centers in diverse regions across the United States. Many of the VA’s strengths and activities are applicable to other large, integrated health care systems and learning environments. The VA is a multisite system that embraces the hiring of implementation specialists, supports communities of practice as central avenues for information exchange, and offers a diverse set of implementation resources to VA and non-VA researchers alike. As the population of older adults continues to rise and increase demand for both practice and we researchers, and to to the VA as an example and leader in implementation science and Many of the VA’s strengths and activities are applicable to other large integrated systems and learning environments. The in this are those of the and not the or of the of Veterans