End-of-Life Care for Homeless Veterans Essay

The purpose of this evidence-based practice project is to generate new knowledge on homeless veterans’ use of available tools such as mobile health technologies and the characteristics of the veterans and caregivers which influences their utilization of these tools to improve end-of-life care. The study will adopt an interventionist framework which will seek to assess the quality and/or quantity of care that is currently being provided to homeless veterans, consider outcomes for caregivers and care recipients, and consider the set outcomes to facilitate comparison over time and studies.

The study will aim to design a sustainable program within a busy Veteran Affairs system that serves veterans nationally. Mobile health technologies will be provided to the veterans, their caregivers, and their health care givers.End-of-Life Care for Homeless Veterans Essay. Participants for the pilot project were drawn from within the VA system and preliminary data indicates that a rapid rollout of mobile health technologies is necessary based on the pilot evaluation. Funding will be used to procure the mobile health technologies to be used in the pilot project and rollout to improve on the quality of end-of-life care and patient and caregiver outcomes.

As suggested in the caregiver intervention framework, the quality of the intervention will be assessed through care giving quality measures as well as usage rates of the care services. The study will take into consideration a number of factors that predict the veteran and caregiver utilization of mobile technologies to improve the quality of care they receive. The caregiver outcomes will be assessed over time to allow longitudinal assessment. The research aims to progress knowledge on the potential of mobile health technologies to improve care for homeless veterans at their terminal stage.

Background

The United States health care is struggling to deal with pressure of improving the quality of care while minimizing costs that seem to be spiraling out of control. In the recent past, the importance of patients and their families to improving the quality of care has been emphasized which is shift from when it was sole responsibility of the health care provider. This paradigm shift is centered on active participation of the patients and their families to assist in rendering health care (LoBiondo-Wood, 2018).

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Mobile health (mHealth) tools are part of the broader electronic health technologies. The United States has seen a tremendous increase in the number of technologies in the market to promote health self management. However, these technologies are often not available to those who need them the most such the homeless veteran population. The mobile health technologies have shown huge potential in offering point of need tools for health self management.  Because the health applications run on mobile platforms they have come in handy even in field settings to monitor health status and improve health outcomes for the general population. Mobile health technologies include phones, sensors, and devices attached to the body to receive and transmit data wirelessly.End-of-Life Care for Homeless Veterans Essay.

Mobile health technologies have availed information to patients and their families which historically resided with health care professionals. This has completely changed the health care system since the patients and their families are informed through the easy and convenient access to information provided by the mobile health tools. In today’s health care environment, it is possible to obtain mobile health technologies that improve access to health care, improve communication between the patients/caregivers and health care providers, support disease monitoring, and aid patients in disease management. However, research into the potential of mobile health technologies in improving quality of care has not kept pace with the increasing number of mobile health technologies in the health self management marketplace. It is imperative to study the factors that influence the adoption of mobile health technologies by various stakeholders. Studies into how mobile health tools can improve quality of care and patient outcomes had small samples where variations in their applications are often not assessed.

Studies have generally indicated positive results when technology based tools are implemented to help caregivers and receivers. An example of mobile-based health which has received positive reviews among veteran care circles is mCARE. This mobile health application utilizes secure messaging system to link veterans and their caregivers facilitating exchange of important health information for self-management. It has improved quality of care and patient outcomes among the veteran population as it avails important tools for self-management like appointment reminders, health-tips, self-report assessments, as well as secure direct messaging with a care provider. An assessment of the users of the application found that 90 percent rated it as easy to use indicating the potential similar technologies could have on outcomes and quality of end-of-life care for homeless veterans.

A random assessment on the effectiveness of the Comprehensive Health Enhancement Support System (CHESS) an online focused tool to offer information regarding lung cancer, training, and direct communication with caregivers yielded promising results. The trial aimed to find out the impact of factors such as caregiver burden, mood, and disruptiveness on quality of care they gave. The caregivers under the CHESS program reported a lower burden and not prone to negative moods compared to their counterparts under the traditional program of care (Reisman, 2016). This shows the potential mobile based health technologies could have on interventions of making end-of-life care for homeless veterans dignified. Mobile based health technologies have the potential of increasing caregiver coping skills thus reducing their strain and work related stress.

Tele-savvy is a website for helping caregivers of veterans with dementia. End-of-Life Care for Homeless Veterans Essay.Caregivers can access information at the comfort of their homes through video modules and teleconferences. A randomized trial to assess the burden levels, anxiety, depression in caregivers of veterans of dementia showed high initial levels which decreased upon further consultations. Caregiver competence increased significantly with utilization of the application than when not.

Although notable researchers have associated positive outcomes with adoption of technology based interventions, further studies are needed to understand the needs of various stakeholders. Users of these technologies have to see the marginal benefits of using, perceive them easy to use, fit into their workflow, and be helpdesk supported for them to adopt them. It is important to understand what patients and caregivers need from technology based interventions which ultimately determine adoption.

Improving dialogue between the patient and care provider has been found to impact positively quality of care. Focus groups in community dwelling places with patients with chronic diseases and disability shows that successful communication and sharing of information were aspects mobile health technologies could prove useful. In the instances where mobile technologies were adopted there was better continuity and coordination of care than when not in use. According to 95 percent of caregivers using mobile technologies in interacting with their patients improved the quality of care significantly (Kontos et al, 2012).  The study will report on veteran outcome data on effectiveness of treatment engagement for a getting to outcomes group who are homeless but have adopted health technology tools and a non-GTO group who are homeless and do not use any technology assistive tool. Other data that the study will compare include drug and alcohol abuse, emergency department visits, hospitalizations and income levels over time.

Proposed Change

The study on the impact of tools such as mobile health technologies on quality of end-of-life care that homeless veterans receive will involve disseminating tablets containing a suite of mobile health technologies to family caregivers or those responsible for veterans in community dwellings. The veterans who will be chosen into the study will be experiencing housing challenges and/or have physical injuries, mental challenges that requires the care of specialist. The study will use the IOWA Model of Evidence-Based practice. A vector model of complexity, a conceptual model for implementing care for patients will be a major determinant of health in understanding the care needs that veterans require. The suite of mobile health technologies will be obtained from developers within the Veteran Affairs system who already understand their daily healthcare challenges. The tools will assist caregivers in managing pain and stress among veterans as well as provide assistance in carrying out routine tasks and managing own stress.

The study will be designed as a prospective cohort study which will try to understand the factors that influence adoption of mobile health tools among homeless veterans and their caregivers. The participants in the pilot and actual study will be obtained from veterans who are homeless but enrolled within the Veteran Affairs Comprehensive Assistance for Family Caregivers program. This is a program which was designed to support veterans who have grievous physical and mental challenges due to their military past. This evidence-based program will empower family caregivers to provide personal care services to veterans who need end-of-life care. The funding sought will seek to provide a stipend to these family caregivers if they do not qualify for it already on top providing a suite of mobile health tools. The program will also seek to train, counsel, and respite care to support the caregivers as they engage with homeless veterans who need end-of-life care. The family caregivers are support coordinators within the VA system who are responsible for homeless veterans who need care. They provide ongoing support and assistance to this group of veterans that might not have any family to care for them.

The current program will seek to replicate the Veteran Affairs Caregiver Mobile Health Pilot, a program that equipped caregivers with tablets that came loaded with VA mobile health tools for one year. The mobile health tools was created for veterans and offered only to pilot participants. This pilot project was the first patient-facing mobile health applications that were integrated within the VA data database which made it permissible for seamless integration of data for veterans and their respective caregivers.

The research will aim for a study population cohort of 882 veterans or family caregivers who will receive a tablet loaded with mobile health applications from the VA. The veterans will be linked to a caregiver that they are familiar with and who they receive care. The study will seek to recruit caregiver participants who will have completed three baseline surveys and participants who had participated in the VA mHealth pilot study (n=882) data which will be used in this study subject to obtaining consent for secondary use.  Consent will be sought from the participants who complete the three baseline surveys and as well the institutional review boards of the university and VA.End-of-Life Care for Homeless Veterans Essay.

The study sample was reached through a letter sent to all 4501 registered caregivers within the Veteran Affairs Family Caregivers project asking them to join in the VA mHealth pilot study. In the pilot study, the VA had a response rate of 23.22%. However, due to a number of reasons like caregivers opting out only 881 of tablets were shipped to caregivers as of June 2013. This made the participants in the study to be 882 because one caregiver had two veterans under his care. A subsequent letter sought the permission of the 882 participants to be part of the study. An initial survey was sent to participants indicating that they were participating in a research to understand the potential for mobile health tools to improve quality of care for veterans and completing it will amount to consent. A post card was also provided that the participant could fill and return to opt-out of the study. The survey information the VA mHealth pilot program sought to establish were Caregiver Traits, Caregiver Preparedness, and Caregiver Zarit Burden inventory.

The current program will seek to supply tablets and a suite of mobile health applications designed to support caregivers and veterans. The caregivers will be offered support in terms of guide to setting up the tablets, an online tool with frequently asked questions, newsletters, and number for help inquiries (Poropatich et al, 2014). The caregiver participants will also be required to have valid credentials to access the VA system. Several focus groups and usability tests will be conducted to determine applications that will be installed within the tablets. Different access information will be provided to the veterans and their caregivers in order to distinguish who is using the applications which will be provided. All the patients will be accessed on their housing conditions, diagnosis and history of care, employment status, drug and substance abuse and other factors which influence utilization of available care.

EBP Process model: IOWA

Outcomes

Preliminary data suggests that veterans found that technology-based interventions like in the current study improve the timely and the state of care of homeless veterans at their terminal stage.  The study will aim to replicate the outcomes of the VA mobile study (n=882) because of their significant similarity in baseline characteristics. The study established that most caregivers were women (94.9%) and most recipients of the care were men (95.7%).  The VA mobile study established that the mean age of caregivers was forty years while that of the veterans was thirty-nine years. The distribution of the caregivers was found to be geographically dispersed with 60% living in cities and 39.8% residing in rural localities. Of the 882 study participants only 262 were found to effectively utilize technology based tools provided mostly because of ignorance on how to use or lacking valid credentials to access the VA system (Frisbee, 2016).

The study provided insight into which mHealth applications were popular among veterans and their caregivers. The factors included: time and exertion expected of the caregiver to administer the veteran’s medical state, the caregiver burden and preparedness to care-giving, demographics of the veterans and their caregivers and education qualifications including computing skills and adoption of technology. The current study will establish like in the VA study that veterans with serious injuries such as those in polytrauma care found it difficult to utilize the technology-based interventions (Griffiths et al, 2016).

The VA study established that overall preparedness of the caregiver was associated with frequency in use of the technology interventions and reduced their perceived burden. There was timely diagnosis of medical conditions of the veterans with the exception of PTSD with increased use of mobile health technologies. The current study expects to establish that demographic factors influence the effectiveness of technology-based interventions and the overall palliative care which on the streets veterans receive. Increased age of the caregiver and veterans was found to be negatively correlated to predictability of health applications use (Chi & Demiris, 2015).

Evaluation Plan

The outcomes of this project will be measured through data collected using tools utilized in this study. The tools will evaluate the overall improvement of quality of care that homeless veterans receive in their end-of-life stage. The tools will collect qualitative and quantitative data which will be analyzed through the researcher’s interpretation. The first part of the questionnaire will try to understand characteristics of the veterans while the second part will analyze the quality of care they receive. Patient feedback on the implementation of the recommendations and suggestions of the study will be important. Another tool which be important to the study is focus groups. The frequency with which caregivers tend to the veterans will be identified (Atkins et al, 2017).End-of-Life Care for Homeless Veterans Essay.

The study will analyze the frequency with which veterans utilize available services and specifically the use of mobile health services. The frequency will be computed as the number of times participants utilize applications for information. Predictor variables in the study will include veteran and caregiver characteristics from the VA’s database (Burkhart & Hogan, 2015). Because it is impossible to obtain consent from all the participants in the study a waiver will be sought to be compliant with the health Insurance Portability and Accountability act. The predictor variables will be the same as in the study carried out in the VA mobile health study (U.S. Department of Veterans Affairs, 2019). The participants will be required to respond to the questionnaires in two weeks after which they will be contacted through a telephone interview.

The questions included demographic characteristics like daily living, education, and caregiver burden or strain. The preparedness of the caregiver to serve homeless veterans will be analyzed through data collected in focus groups and interviews. The question of how prepared the caregivers were to tend the veterans will be intergral to the study. The Zarit Caregiver Burden screening inventory will be essential in analyzing this data. It is scored from of 0-4 for the four questions with maximum possible score of 16 which will be essential in analyzing caregiver strain (Poe et al, 2010).

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Statistical analysis will include chi-square tests to determine how groups differed. Bivariate and correlational analysis of the predictor variables will be done. SAS software will be used to analyze statistical data. The study will seek to understand the reason homeless veterans use or do not use available services like mHealth tools to access care (Pavlisckak & mCare, 2010). The Hosmer and Leneshow Goodness of fit will assess multivariate variables. The Pearson chi-square statistic will assess the negative binomial fit and the dispersion parameters will not be equal to zero. Odds ratios will assess model results in the logistic regression model. The study will be guided by a specific research purpose to understand how care can be improved for homeless veterans, therefore, will be reported as is of each p value without distortion for total tests carried out (Tsai & Rosenheck, 2015).

Dissemination Plan               

The research findings will be presented through conferences and publication in nursing journals. Sigma Theta Tau sponsored conferences will be essential in disseminating research findings. Funding will be sought from the university and associated agencies like the Veterans affairs department. Electronic posters and recordings of the research findings will be vital. An abstract describing the study will be presented to be considered for the conferences. End-of-Life Care for Homeless Veterans Essay.For permanent dissemination of the research findings the research findings will be published in nursing journals. There will be acknowledgement of researchers who have presented similar findings in the past. The information will be essential in having a complete view of the research topic. The journal publications will be obtained by attending and presenting the report at conferences. Although it is difficult to obtain publication in journals attending many conferences will be important (Melnyk & Fineout-Overholt, 2011). End-of-Life Care for Homeless Veterans Essay.