265497 Tracking VA's chiropractic program: Implementation timelines and variations across selected facilities

Tuesday, October 30, 2012 : 11:30 AM - 11:50 AM

Monica Smith, DC, PhD , NUHS Adjunct Faculty -- Off-site, National University Health Sciences -- Off-site Adjunct, San Rafael, CA
Angela Cohen, MPH, CHES , Research, Department of Veterans Affairs, North Hills, CA
Raheleh Khorsan, MA , Military Medical Research and Integrative Medicine, Samueli Institute, Corona del Mar, CA
Deborah Jenkins , VA Center for Implementation Practice and Research Support, Dept of Veterans Affairs, North Hills, CA
Courtney Armstrong , VA Center for Implementation Practice and Research Support, Dept of Veterans Affairs, North Hills, CA
Anthony Lisi, DC , VHA Chiropractic Service, Office of Rehabilitation Services, Dept of Veterans Affairs, West Haven, CT
Brian Mittman, PhD , VA Center for Implementation Practice and Research Support, Dept of Veterans Affairs, North Hills, CA
Background/Introduction: In 2004, VA began providing on-site chiropractic care at select facilities. By January 2010, 38 VA sites were delivering chiropractic services. VA Chiropractic Services collaborated with VA QUERI Center for Implementation Practice and Research Support (CIPRS), with funding from the Samueli Institute, to study the initial planning and implementation of the VA chiropractic program.

Data/Methods: Seven sites were sampled for variation (e.g., urban/rural, small/medium/large facilities, early/mid/late program adopters, collaboration with academic affiliates, etc.). An observational comparative case study approach was employed to collect qualitative and quantitative data via semi-structured interviews with key stakeholders (facility leaders, clinicians, clinic staff, patients, academic affiliates, and other external stakeholders), archival data (e.g., policy and procedure documents), and facility operations data (e.g., number of clinic patients and visits). Interview transcripts (n=118) were subjected to thematic and content analysis using NVivo software (QSR International); Adobe Acrobat (Adobe Systems, Inc), MSWord and MSExcel (Microsoft Corp) software were used for data management and for manual coding of archival source documents (n=75). The study was approved by IRBs at VA Greater Los Angeles Healthcare System, VA Connecticut Healthcare System, Western IRB and US Army Medical Research and Materiel Command.

Analysis/Results: Study findings will be presented describing considerable variability in characteristics of the planning and implementation of the VA chiropractic services program across the 7 facilities. Facilities varied greatly by: implementation timeline (reaching key milestones in program roll-out and establishing benchmarks for monitoring/improving quality), academic affiliate involvement (in either program planning or establishing clinical rotations), continuity of service delivery, and overall access for Veterans. Findings and conclusions will be presented using the Donabedian Structure-Process-Outcome model as a general orienting framework, highlighting variations in Intra-Clinic Structures and Processes (within each clinic), and Inter-Clinic Structures and Processes (between each chiropractic and other VA clinics and providers at each facility).

Discussion: This exploratory descriptive study corroborates prior research and observations of considerable variations in organizational structures, processes and outcomes across the VA healthcare system. During this session, we will also discuss and invite input from session participants regarding (1) other important parameters that may contribute to the pronounced variability we observed in program characteristics, such as external contextual factors (e.g., market environment or catchment area) and internal context (e.g., institutional culture), and (2) study implications for other health systems and initiatives to introduce new clinical services.

Learning Areas:
Implementation of health education strategies, interventions and programs
Planning of health education strategies, interventions, and programs
Program planning
Systems thinking models (conceptual and theoretical models), applications related to public health

Learning Objectives:
Describe the implementation of chiropractic services within VA and identify facility characteristics that may lead to variations in the planning and implementation processes.

Keywords: Chiropractic, Veterans' Health

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: As a member of the project team and co-investigator of this study, I participated in all phases of project design and development of study protocol and data collection instruments, data collection, data analysis, interpretation of results, and reporting/dissemination of findings
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.