The primary goal of this application is to nurture the development of Dr. Samantha Solimeo as an independent VA investigator dedicated to improving healthcare delivery to older Veterans with chronic conditions. The application focuses on improving the care of Veterans who are at risk of osteoporosis, in an effort to improve osteoporosis care and as a model for developing strategies to improve care coordination within VA primary care Patient Aligned Care Teams (PACTs), between PACTs and VA specialists, and between VA and non-VA providers. In examining osteoporosis, the application focuses on a condition that causes substantial morbidity and mortality among Veterans, that is frequently under-diagnosed, and for which a 2007 HSR&D sponsored evidence synthesis and a 2011 Office of the Inspector General report highlighted need for improvement efforts. The application presents integrated career development activities and research projects that build on Dr. Solimeo's expertise in qualitative methods, her prior research in geriatric chronic conditions, and her recent work through the VISN 23 PACT Demonstration Lab which evaluates the implementation of PACTs and identifies factors that lead to high functioning PACTs. The career development activities are designed to provide Dr. Solimeo with content knowledge and methodological skills in key areas of implementation science, notably: pragmatic intervention and dissemination design; quantitative methods and secondary analysis of administrative data; and organizational management. Activities include targeted readings; formal coursework through the University of Iowa, University of Indiana, and SAS Institute; and tutorials offered by other organizations. The Research Plan outlines three incremental projects designed to complement her career development and that will ultimately position Dr. Solimeo to lead a multi-site study to improve osteoporosis care in collaboration with VA program offices, facilities, and primary and specialty medicine leadership. Project 1 will involve the secondary analysis of VA and Medicare administrative data to identify variation in testing rates for osteoporosis using dual-energy X-ray absorptiometry (DXA) across individual VA facilities and PACTs for several groups of older veterans who are at risk for osteoporosis, including those with low-trauma fractures after age 50, receiving chronic corticosteroid or anticonvulsant therapy, or receiving androgen deprivation therapy for the treatment of prostate cancer. Project 2 will involve a mixed methods study to identify barriers to DXA testing within VISN 23, factors that underlie variations in DXA testing found in Project 1, and factors affecting primary care-based care coordination for older veterans. Quantitative data that will be collected include surveys to assess osteoporosis knowledge and to measure team function. Survey data will be triangulated with qualitative interviews of a purposeful sample of VISN 23 primary care staff to identify barriers to effective care coordination. Projects 1 and 2 findings will inform the development of Project 3, which will be to develop and pilot-test a multi-level organizational change intervention to improve care coordination using osteoporosis care coordination as a model condition. Data collected for the three projects will be integrally linked to the constructs of the Nadler-Tushman Congruence Model, a widely used conceptual framework for understanding how organizational change and how interdisciplinary groups distribute tasks across members. Importantly, the career development activities and research projects will be conducted under the guidance of a team of accomplished senior mentors with expertise in pragmatic intervention design, quantitative methods, the use of administrative data, and organizational management. The mentors have worked closely with Dr. Solimeo over the past four years and are committed to her development as an independent investigator. The proposed activities will also be done in close partnership with VISN 23 primary care operations and national VA geriatrics and osteoporosis experts.
VA primary care staff nationwide have been reorganized into ?Patient Aligned Care Teams? (PACTs) in order to provide more efficient and better coordinated care for Veterans. However, providing optimal care for Veterans with some conditions, such as osteoporosis, requires the development of effective collaborations between PACTs and VA specialty care providers and between VA PACTs and non-VA providers. Prior research has found that many male Veterans at risk for osteoporosis do not receive recommended testing to identify the condition. The research proposed in this application directly addresses this problem through three related studies. The first study will identify variations in rates of osteoporosis testing in male Veterans. These results will inform a second study to identify perceived barriers to testing. Finally, analysis of these barriers in conjunction with testing rates will be used to design a program to improve osteoporosis care of high-risk male Veterans, and in turn, improve care coordination within VA and between VA and non-VA providers.