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Providing Culturally Competent Services for American Indian and Alaska Native Veterans to Reduce Health Care Disparities Timothy D. Noe, PhD, Carol E. Kaufman, PhD, L. Jeanne Kaufmann, MS, Elizabeth Brooks, PhD, and Jay H. Shore, MD
Limited data available indicate significant disparities in health status and health care between American Indian and Alaska Native (AI/AN) veterans and other populations. AI/AN veterans often live in rural areas; roughly 40% live on geographically dispersed reservations and tribal lands. Many of these areas are remote and isolated, making delivery of health care a significant challenge.1,2 AI/AN veterans rank poorly on several important dimensions of quality of life, including educational attainment, income, home ownership, and employment.2---4 In addition to transportation difficulties and distance to care, they face several other access barriers, including lack of appropriate diagnostic services and specialty care.2---4 AI/AN veterans are significantly more likely than White veterans to delay care because they have difficulty getting timely appointments, locating and accessing specialty care, and reaching providers by phone.2---5 AI/AN veterans have higher incidences of mental health problems3,5 and are 4 times as likely as White veterans to report unmet health care needs.6,7 AI/AN veterans often report impersonal care, limited knowledge about Department of Veterans Affairs (VA) services and eligibility, lack of understanding within the VA regarding their culture and their needs, a preference to obtain mental health services from traditional healers from within their own tribal culture, and dissatisfaction with the VA as barriers to obtaining VA care.8 The VA is committed to delivering highquality, equitable care and to eliminating racial and ethnic disparities in health care. Proposed strategies to address health and health care disparities among minorities include a stronger focus on patient-centered care and a more culturally congruent health care environment.9 Culturally congruent, patient-centered care aims to improve health outcomes by
Objectives. We conducted an exploratory study to determine what organizational characteristics predict the provision of culturally competent services for American Indian and Alaska Native (AI/AN) veterans in Department of Veterans Affairs (VA) health facilities. Methods. In 2011 to 2012, we adapted the Organizational Readiness to Change Assessment (ORCA) for a survey of 27 VA facilities in the Western Region to assess organizational readiness and capacity to adopt and implement native-specific services and to profile the availability of AI/AN veteran programs and interest in and resources for such programs. Results. Several ORCA subscales (Program Needs, Leader’s Practices, and Communication) statistically significantly predicted whether VA staff perceived that their facilities were meeting the needs of AI/AN veterans. However, none predicted greater implementation of native-specific services. Conclusions. Our findings may aid in developing strategies for adopting and implementing promising native-specific programs and services for AI/AN veterans, and may be generalizable for other veteran groups. (Am J Public Health. 2014;104:S548–S554. doi:10.2105/AJPH.2014.302140)
empowering patients to participate in the health care decision-making process and by increasing trust, reducing skepticism, and enhancing acceptability of care.9,10 Patientcentered health care encompasses (1) respect for patients, (2) collaborative communication strategies, (3) knowledge sharing between patients and their health care providers, and (4) sociocultural competence. Cultural competence encompasses understanding and consideration of culture, economic and educational status, health literacy level, family patterns and situations, and traditions (including alternative and folk remedies), as well as communication at a level that the patient understands.10 Cultural competence in health care involves understanding of and respect for culturally different patient groups, ideally resulting in health care tailored to accommodate cultural differences in health-related values and beliefs. Cultural competency is a key part of delivering patient-centered care because both concepts stress respect for the patient, clear communication, shared decision-making, and building strong doctor---patient relationships.10
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Patient centeredness and cultural competence are important elements of delivering quality care to AI/AN veterans and may help reduce health care disparities among this special population. AI/AN peoples have their own long tradition of medicine and healing. The literature contains several arguments for the incorporation of traditional healing practices into health care for native groups. Some authors advocate individualized medicine that is culturally and linguistically appropriate.11---13 Others argue that the holistic approach of traditional healing in understanding the mind, body, and spirit is particularly relevant in the treatment of disorders related to trauma13 and may be especially relevant for AI/AN veterans, who have a high prevalence of traumatic disorders.14 One study found that although most AI/AN veterans were generally satisfied with the quality of care received in VA facilities, they considered that the care they received was not fully culturally competent regarding AI/AN health beliefs and behaviors.7 However, efforts by the VA, including the newly revised
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VA---Indian Health Service Memorandum of Understanding,15 as well as VA contracting agreements, have renewed the focus on improving care to these veterans.
ORGANIZATIONAL READINESS TO CHANGE Experts on the adoption of innovative programs and services contend that organizational readiness to change is critical to successful implementation and could predict, prior to the investment of resources, whether attempts will be successful in a particular organization or could allow tailoring of an intervention to the specific needs of participating sites.16---22 Consensus is also growing that adoption of innovations in health care depends more on organizational factors than on dissemination activities.22,23 Of particular importance are institutional and personnel readiness (e.g., resources and motivation) and organizational dynamics (e.g., climate for change and staff attributes).21,24 Motivational readiness of the leader and staff members (defined by perceived need and pressure for change) combined with personal attributes (e.g., professional growth, efficacy, influence, and adaptability) are also essential to implementation of an innovation.24 Organizational climate factors (e.g., clarity of mission and goals, staff cohesion, communication, and openness to change), along with institutional resources (staffing levels, physical resources, training levels, and computer usage) are also significant.21,24 The Organizational Readiness to Change Assessment (ORCA) is designed to measure key organizational readiness and capacity variables.21 This instrument was developed in conjunction with the VA Ischemic Heart Disease Quality Enhancement Research Initiative for assessing organizational readiness for implementation of evidence-based health care interventions.21,25,26 Hagedorn and Heideman assessed the predictive validity of the ORCA in a study of 9 clinic teams from VA facilities across the United States.21 The results of this study support the use of the ORCA to identify organizational characteristics related to successful implementation of innovative practices in clinical settings.
implementation of native-specific programs and practices for AI/AN veterans.
Recognizing the importance of patientcentered care and cultural competence in reducing health care disparities among AI/AN veterans, we sought to understand how native-specific services could be further developed and implemented within the VA. We conducted an exploratory study to determine what organizational characteristics predict the provision of native-specific services among VA health care facilities and to assess their organizational readiness and capacity to adopt and implement these services. We also examined the availability of and resources for programs for AI/AN veterans and the level of interest among VA employees in them. We adapted the ORCA for our survey of 27 VA facilities and hypothesized that higher scores would be positively associated with the likelihood of staff perceiving that their facilities were meeting the needs of AI/AN veterans and with
METHODS The VA is divided into 23 regional Veterans Integrated Service Networks (VISNs). They comprise medical centers, veteran centers, outpatient clinics, and community-based outpatient clinics that offer primary and specialized care. We focused on the Western Region because it contains the highest concentration of AI/AN veterans. In 2012, we invited all VISNs in the Western Region (numbers 18---22) to participate, and 3 VISNs (19, 21, and 22) agreed. A total of 27 VA health care facilities (VA medical centers and outpatient clinics), from a potential pool of 67 facilities in the 3 participating VISNs, took part. We targeted 5 nonunion employees of each
TABLE 1—Organizational Readiness to Change Continuous Variable Scores for Meeting the Needs of American Indian/Alaska Native Veterans: US Department of Veterans Affairs, Western Region, 2012 Score No.
Range
Mean 6SD (95% CI)
Leadership
57
2.00–5.00
3.79 60.76 (3.59, 4.01)
Performance measurement
57
2.75–5.00
3.92 60.63 (3.76, 4.09)
Opinion leader
56
2.25–5.00
3.97 60.66 (3.79, 4.14)
VISN support
56
2.00–5.00
3.89 60.65 (3.75, 4.09)
Resources
57
1.25–5.00
3.22 60.85 (2.98, 3.45)
Leader’s practices
55
3.00–5.00
3.72 60.57 (3.57, 3.88)
Staff needs Program needs
55 55
1.00–5.00 1.00–5.00
3.54 60.86 (3.31, 3.80) 3.42 60.86 (3.19, 3.68)
Item
Change pressure
56
2.00–5.00
3.50 60.68 (3.31, 3.66)
Staffing
56
1.50–4.67
3.13 60.58 (2.98, 3.29)
Training
56
1.25–5.00
3.40 60.63 (3.25, 3.58)
Offices
56
1.33–5.00
3.33 61.01 (3.01, 3.56)
Internet
56
2.00–4.67
3.76 60.48 (3.64, 3.89)
Equipment
56
2.80–5.00
3.74 60.53 (3.58, 3.88)
Mission Change
55 55
2.00–4.80 2.20–4.40
3.60 60.61 (3.43, 3.77) 3.27 60.40 (3.15, 3.37)
Autonomy
55
2.00–4.20
3.35 60.46 (3.21, 3.45)
Communication
55
1.00–4.80
3.29 60.73 (3.08, 3.50)
Cohesion
54
2.00–4.67
3.43 60.70 (3.24, 3.62)
Valid no. (listwise)
52
Belief that needs of AI/AN veterans being met
64
1.00–5.00
3.55 60.872 (3.34, 3.76)
Importance of meeting needs of AI/AN veterans
64
1.00–5.00
4.45 60.991 (4.21, 4.69)
Valid no. (listwise)
64
Note. AI/AN = American Indian/Alaska Native; CI = confidence interval; VISN = Veterans Integrated Service Networks.
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TABLE 2—Organizational Readiness to Change Dichotomous Variable Scores for Meeting the Needs of American Indian/Alaska Native Veterans: US Department of Veterans Affairs, Western Region, 2011–2012 Variable
No. (%)
AI/AN veterans in service area No
4 (6.1)
Yes
62 (93.9)
Missing Facility serves AI/AN veterans
1 (1.5)
No
1 (1.5)
Yes
65 (97.0)
Missing
1 (1.5)
Facility has projects concerned with increasing access and improving care for AI/AN veterans No
19 (28.4)
Yes
40 (59.7)
Missing Facility has projects concerned with promoting patient-centered care and collaboration
8 (11.9)
with VA, IHS, and tribes No
19 (28.4)
Yes
38 (56.7)
Missing
10 (24.9)
Facility has projects concerned with partnerships and sharing agreements to benefit AI/AN veterans No
28 (41.8)
Yes Missing
28 (41.8) 11 (16.4)
Facility has projects concerned with ensuring that appropriate resources are identified and available to support program for AI/AN veterans No
36 (53.7)
Yes
20 (29.9)
Missing
11 (16.4)
Facility provides any traditional healing services for AI/AN veterans No Yes
47 (70.1) 10 (14.9)
Missing
10 (14.9)
Note. AI/AN = American Indian/Alaska Native; IHS = Indian Health Service; VA = Department of Veterans Affairs; VISN = Veterans Integrated Service Networks.
participating facility, for a total sample of 135 respondents. We focused on nonunion employees because of restrictions related to their participation and additional approvals that would have been necessary to involve union employees. Enrollment was not limited on the basis of gender, race, or ethnicity. The recruitment process followed 3 steps: (1) we sent an e-mail to the VA Action Group, an employee group assigned to facilitate new projects, in each participating VISN; (2) the Action Group forwarded the e-mail to contacts at each of the 67 VA health care facilities in the
3 participating VISNs and instructed the contacts to forward a recruitment e-mail to 5 nonunion VA employees at their facility to solicit participation; and (3) the employees receiving the e-mail were provided a brief overview of the nature and purpose of the survey and instructed to follow a link provided to the online survey. To ensure a broad sample of employees, we sought employees in a variety of positions (e.g., manager, care provider, nurse, administrator). Participation was anonymous and completely voluntary. Online surveys were automatically
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uploaded to a secure server via a secure username and password. To reduce respondent burden and to maintain anonymity, we did not collect respondent demographics.
Measures Independent variables. Our survey instrument was an adapted version of the ORCA, with Needs, Leadership, Resources, and Organizational Climate scales. Subscales, derived from ORCA survey questions, were Staff Needs and Program Needs (Needs); VISN Leadership and Support, Leadership Culture, Leadership, Leader’s Practices, Performance Measures, Opinion Leaders (Leadership); General Resources, Office Resources, Staffing, Training, Equipment, Internet (Resources); and Mission, Cohesion, Autonomy, Communication, Pressures for Change (Organizational Climate). We scored all items on 5-point Likert scales (1 = strongly agree, 2 = agree, 3 = neither agree nor disagree, 4 = disagree, 5 = strongly disagree). The ORCA survey items are available at http:// www.ibr.tcu.edu. It was important to determine whether the AI/AN veterans lived in the service areas, were served by the facilities, and were perceived as a priority by the respondents. Therefore, in addition to the ORCA items, we included several items relating specifically to AI/AN veterans’ services. Dependent variables. To analyze which organizational characteristics were associated with staff perceiving that their facilities were meeting the needs of AI/AN veterans, we used the question, “Do you believe the needs of AI/AN veterans are being met by your facility?” To determine which organizational characteristics were associated with greater implementation of services for AI/AN veterans, we constructed a composite continuous variable from the sum of 5 items (each answered yes or no; total score = 0---5) that asked about projects offered for AI/AN veterans at respondents’ facilities: 1. Does your facility currently have projects concerned with increasing access and improving quality of care and services for AI/AN veterans (e.g., increase access to benefits; sharing of technology; interoperability of systems; telehealth; mobile communication technologies; joint access of electronic medical records)?
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2. Does your facility currently have projects concerned with promoting patientcentered collaboration and facilitating communication among VA, IHS [Indian Health Service], veterans, and tribes (e.g., improve coordination of care; increase cultural awareness and culturally competent care)? 3. Does your facility currently have projects concerned with establishing effective partnerships and sharing agreements to benefit AI/AN veterans (e.g., sharing of contracts and purchasing agreements; standard policies when facilities are colocated; develop payment and reimbursement policies and mechanisms; sharing of programs such as collaborations in Consolidated Mail Outpatient Pharmacy, PTSD [posttraumatic stress disorder], home-based primary care, dementia)? 4. Does your facility currently have projects concerned with ensuring that appropriate resources are identified and available to support programs for AI/AN veterans (e.g., increase capacity through joint training and workforce development; sharing of staff; joint facility/service planning; joint credentialing and privileging)? 5. Does your facility currently provide any traditional healing services for AI/AN veterans?
Analyses We calculated frequencies, means, ranges, and measures of central tendency for all continuous variables. All variables were normally distributed. We created composite organizational change variables by calculating the mean of all respondent scores for each item on the ORCA subscales. We then determined organizational readiness to change scores (mean scores for each ORCA subscale) aggregately and for each facility. To assess whether organizational readiness to change scores predicted staff perceiving that the needs of AI/AN veterans were being met at their facilities, we tested linear regression models for each ORCA main scale, with subscales serving as the predictors. We conducted multiple linear regression analyses to determine the best linear combination of ORCA subscales for predicting greater
implementation of services for AI/AN veterans for each ORCA scale.
RESULTS A total of 67 respondents from 27 facilities completed the survey. Four respondents worked in VISN 19 (1 facility), 39 in VISN 21 (19 facilities), and 23 in VISN 22 (7 facilities). A total of 5 individuals at each of 67 health care facilities received the invitation to participate in the survey, for a potential sample of 335. Therefore, the response rate was 20%.
Variables Table 1 provides the means and standard deviations for all continuous variables, and Table 2 provides frequencies for all dichotomous variables. A large majority of the respondents (94%) indicated that AI/AN
veterans resided in their service areas. In addition, 97% reported that their facilities served AI/AN veterans. However, only 15% reported that their facilities provided traditional healing services for AI/AN veterans. Mean scores were above the midrange (i.e., 2.5 on 5-point scale) on all organizational readiness to change measures. The Staffing subscale, which indicated whether a facility was adequately staffed, received the lowest score (mean = 3.13). The Opinion Leaders subscale, which indicated whether senior managers encouraged and supported changes in practice to improve patient care, received the highest score (mean = 3.97). The mean score for “How important is it for your facility to meet the needs of AI/AN veterans?” was 4.45, and for “Do you believe the needs of AI/AN veterans are being met by your facility?” was 3.55.
TABLE 3—Regression Results for Staff Perception of Needs of American Indian/Alaska Native Veterans Being Met: US Department of Veterans Affairs, Western Region, 2011–2012 B (95% CI)
P
R2
F(df)
No.
.004
0.149
4.712(4,42)
55
Staff Needs
–0.105 (–0.51, 0.30)
.598
Program Needs
–0.306 (–0.71, 0.09)
.004 0.245
3.123(5,48)
54
0.118
1.09(6,49)
56
0.115
3.374(2,52)
55
Scale/Subscale Needs
Leadership VISN Support Leadership Leader’s Practices Performance Measures
.016 0.001 (–0.50, 0.50)
.985
–0.092 (–0.55, 0.34) 0.523 (0.15, 1.53)
.624 .018
0.225 (–0.22, 0.86)
.246
–0.180 (–0.77, 0.29)
.368
General Resources
0.113 (–0.27, 0.50)
.56
Staffing
0.132 (–0.32, 0.71)
.45
Training
0.029 (–0.39, 0.47)
.85
0.062 (–0.22, 0.33) –0.050 (–0.56, 0.39)
.07 .73
0.236 (–0.08, 0.94)
.1
0.361 (–.21, 4.02)
.257
Opinion Leaders Resources
Offices Equipment Internet
.381
Organizational Climate Mission
.042
Change Pressure
0.314 (–0.40, 0.69)
.13
Autonomy
0.231 (–0.45, 0.76)
.47
Cohesion
0.042 (–0.54, 0.62)
.864
Communication
0.157 (–0.30, 0.74)
.015
Note. CI = confidence interval; VISN = Veterans Integrated Service Networks.
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Regression Analyses Table 3 provides the results of regression analyses to determine whether the ORCA scales predicted staff perceptions that the needs of AI/AN veterans were being met by their facilities. Staff needs and program needs (Needs subscales) significantly predicted needs met (F(df ) = 4.712(4,42); P = .004), with Program Needs significantly contributing to the prediction (B = –0.306; adjusted R 2 = 0.15; data not shown). This indicated a small effect size, with 15% of the variance in needs met explained by the model. VISN Support, Leadership Culture, Leadership, Leader’s Practices, Performance Measures, and Opinion Leaders (Leadership subscales) significantly predicted needs met (F(df ) = 3.123(5,48); P = .01), with Leader’s Practices significantly contributing to the prediction (B = 0.523; R 2 = 0.245). This result indicates that 25% of the variance in needs met was
explained by the model. This is a small-tomedium effect size. Resources (Resources, Staffing, Training, Offices, Equipment, and Internet subscales) did not significantly predict needs met (P = .38). Organizational Climate (Mission, Change, Autonomy, Cohesion, and Communication subscales) significantly predicted needs met (F(df ) = 3.374(2,52); P = .042), with Communication significantly contributing to the prediction (B = 0.157; adjusted R 2 = 0.12; data not shown). This indicated a small effect size, with 12% of the variance in needs met explained by the model. Table 4 lists the results of the regression analyses to determine whether the ORCA scales predicted greater implementation of services for AI/AN veterans. None of the models tested significantly predicted (P £ .05) greater implementation of services for AI/AN veterans.
DISCUSSION The 27 VA facilities we assessed scored highly on all ORCA measures. In accordance with the results of the Hagedorn and Heideman study,21 we anticipated that higher scores on the ORCA organizational readiness to change measures would be associated with greater likelihood of staff perceiving that their facilities were meeting the needs of AI/AN veterans and greater implementation of programs and practices specific for these veterans. Our results provide some support for these hypotheses. Several significant statistical models emerged for predicting whether VA staff perceived that their facilities were meeting the needs of AI/AN veterans. AI/AN veteran needs were perceived to be met when d
TABLE 4—Regression Results for Greater Implementation of Native-Specific Programs and Services: US Department of Veterans Affairs, Western Region, 2011–2012 Scale/Subscale
B (95 % CI)
P
R2
F(df)
No.
–0.029
0.251(2,51)
53
–0.018
0.848(6,46)
53
d
Needs Staff Needs
–0.160 (–0.77, 0.46)
.606
0.026 (–0.59, 0.64)
.933
VISN Support
–0.575 (–1.36, 0.21)
.148
Leadership Culture
–0.124 (–0.89, 0.65)
.748
Leadership Leader’s Practices
0.157 (–0.63, 0.95) –0.023 (–1.10, 1.06)
.692 .966
Program Needs Leadership
Performance Measures Opinion Leaders
.311 (–.54, 1.16)
.469
–.241 (–1.17, 0.68)
.602
–0.363 (–0.96, 0.24)
.19
0.608 (–0.24, 1.41)
.101
Resources General Resources Staffing
0.017
Training
–0.340 (–1.09, 0.29)
.265
Offices Equipment
–0.019 (–0.35, 0.42) –0.234 (–0.95, 0.51)
.922 .487
Internet
–0.341 (–0.95, 0.24)
.346
–0.723 (–1.61, 0.17)
.109
0.036 (–0.47, 0.54)
.887
Organizational Climate Mission Change Pressure
d
0.006
Autonomy
–0.506 (–1.48, 0.45)
.292
Cohesion
0.292 (–0.43, 1.02)
.421
Communication
0.144 (–0.65, 0.94)
.717
Note. CI = confidence interval; VISN = Veterans Integrated Service Networks.
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1.158(6,48)
1.061(5,47)
54
52
Facilities provided for the needs of new programs by clearly defining their mission, setting goals for improving services, assigning staff goals and evaluating staff performance, improving communication and relations among staff, employing effective record keeping, and using effective financial--accounting procedures (Needs). Senior leadership or clinical managers proposed new projects that were feasible, provided clear goals for improvement in patient care, established project schedules and deliverables, and designated a champion for new projects (Leadership). Organizations had open discussions about issues, especially among managers; kept staff well informed; made staff feel free to ask questions; and developed robust formal and informal communication (Communication).
Although more evaluation is needed, these preliminary results may provide important guidance for facilitating adoption and implementation of native-specific programs and services targeted to AI/AN veterans. Identifying facilities with these significant organizational characteristics may be critical to successful implementation of new native-specific programs and could provide insight into the likelihood of successful implementation at a particular site prior to the investment of resources or allow tailoring of an implementation intervention to the specific needs of participating sites. In addition, seeking to build the
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capacity of organizations on these key measures may be an important strategy for developing organizational readiness to successfully adopt native-specific programs and practices. Implementing organizational change models that have been shown to be effective through previous research and focusing those models on mission definition, staff goals, and performance evaluation may be a beneficial strategy. Other helpful strategies could be developing the capacity of senior leadership to provide clear goals for improvement in patient care, developing well-planned project schedules and deliverables, and designating a champion for new projects. Working with senior leaders and project managers to encourage them to allow open discussions about issues related to provision of care for AI/AN veterans and developing protocols to improve formal and informal communication may facilitate important organizational change that leads to improved services. Although our findings did not support our hypothesis that higher scores on the ORCA measures would be associated with greater implementation of programs and practices for AI/AN veterans, the scores for the survey items related to services for AI/AN veterans suggest important considerations for improvement. First, only 42% of respondents indicated that their facilities had projects that aimed to establish effective partnerships and sharing agreements to benefit AI/AN veterans. Second, only 30% of respondents reported their facilities had projects concerned with ensuring that appropriate resources were identified and available to support programs for these veterans. Third, only 15% of respondents indicated that their facilities provided traditional healing services for AI/AN veterans, despite advocacy in the literature for the provision of traditional healing for native groups, especially veterans. Fourth, although aggregate respondent scores on the question, “How important do you believe it is for your facility to meet the needs of AI/AN Veterans?” was 4.45 out of 5.0, the mean score was 3.5 on the question, “Do you believe the needs of AI/AN Veterans are being met by your facility?” (data not shown). These scores may indicate that VA employees are willing to do more to meet the needs of AI/AN veterans if they are provided with resources, guidance, and assistance.
One strategy for addressing these gaps may be to identify and assemble promising native-specific programs and practices, implementation consultation, and resources into a Web-based AI/AN veteran program development support system. This system could include a database of promising native-specific programs; guidance on development of outreach and community collaborations; a comprehensive guide for development, implementation, and maintenance of traditional healing services; an online cultural competence training course; additional Web-based resources for successfully working with AI/AN veterans; and linkages for users to connect with experts with knowledge relevant to their needs. Our exploratory study had a small sample size that limited the statistical tests we could use. Our convenience sample might not have been completely representative of all VA facilities. Also, we did not analyze the survey items used for the dependent variables to determine their validity and reliability. However, our findings may be important for developing preliminary strategies for further disseminating and promoting the adoption and implementation of promising native-specific programs and services for AI/AN veterans and may be generalizable for developing services for other veterans groups, such as general population rural veterans and women veterans. The VA has continued to expand services to AI/AN veterans, most notably by engaging in direct care service agreements with the Indian Health Service. As these efforts continue to expand, it may be beneficial to consider how organizational characteristics of VA health facilities serve to facilitate or create barriers to expansion. j
About the Authors
C. E. Kaufman interpreted the data. All authors wrote and revised the article and approved the final version.
Acknowledgments This study was sponsored and funded by the Veterans Rural Health Resource Center---Western Region, Office of Rural Health, Department of Veterans Affairs. Note. The views expressed are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs.
Human Participant Protection The study protocol was approved by the Colorado multiple institutional review board and the Department of Veterans Affairs institutional review board.
References 1. 2005---2007 American Community Survey. Washington, DC: US Census Bureau; 2007. 2. Wallace AE, Weeks WB, Wang S, Lee AF, Kazis LE. Rural and urban disparities in health-related quality of life among veterans with psychiatric disorders. Psychiatr Serv. 2006;57(6):851---856. 3. Weeks WB, Wallace AE, West AN, Heady HR, Hawthorne K. Research on rural veterans: an analysis of the literature. J Rural Health. 2008;24(4):337---344. 4. West A. A ZIP Code Crosswalk for Applying Urban, Rural, and Highly Rural Classifications. Washington, DC: Veterans Rural Health Resource Center---Eastern Region, Office of Rural Health, US Department of Veterans Affairs; 2009. 5. Kramer JB, Wang M, Jouldjian S, Lee ML, Finke B, Saliba D. Veterans Health Administration and Indian Health Service: healthcare utilization by Indian Health Service enrollees. Med Care. 2009;47(6):670---676. 6. Kramer JB, Jouldjian S, Harker J, Washington DL, Yano EM. Healthcare for American Indian and Alaska Native Women: The Roles of the Veterans Health Administration and the Indian Health Service. Sepulvelda, CA: Geriatic Research Education and Clinical Center; 2009. 7. Kramer JB, Vivrette R, Satter D, Jouldjian S, McDonald LR. How Veterans Health Administration and Indian Health Service Work Together to Manage Healthcare for American Indian and Alaska Native Veterans. Sepulveda, CA: Geriatric Research Education and Clinical Center; 2009. 8. Health Services Research and Development Service. Racial and Ethnic Disparities in the VA Healthcare System: A Systematic Review. Washington, DC: Department of Veterans Affairs; 2007.
The authors are with the Department of Veterans Affairs Office of Rural Health, Veterans Rural Health Resource Center---Western Region, Native Domain, and the Centers for American Indian and Alaska Native Health, School of Public Health, University of Colorado, Denver. Correspondence should be sent to Timothy D. Noe, Mail Stop F800, 13055 E 17th Ave, Aurora, CO 80045 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted June 17, 2014.
9. Hunt MR. Patient-centered care and cultural practices: process and criteria for evaluating adaptations of norms and standards in health care institutions. HEC Forum. 2009;21(4):327---339.
Contributors
12. Shore JH, Shore JH, Manson SM. American Indian healers and psychiatrists. In: Incayawar M, ed. Psychiatrists and Traditional Healers. Hoboken, NJ: John Wiley and Sons; 2009: 123---132.
T. D. Noe, C. E. Kaufman, E. Brooks, and J. H. Shore conceptualized and designed the study. T. D. Noe, and L. J. Kaufmann acquired the data. T. D. Noe and
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10. Racial and Ethnic Disparities in Health Care, Updated 2010. Washington, DC: American College of Physicians; 2010. 11. Anderson LM, Scrimshaw SC, Fullilove MT, Fielding JE, Norman J. Culturally competent healthcare systems: a systematic review. Am J Prev Med. 2003;24(3):68---79.
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13. Rosenheck RA, Fontana AF. Recent trends in VA treatment of post-traumatic stress disorder and other mental disorders. Health Aff (Millwood). 2007;26 (6):1720---1727. 14. Friedman MJ, Ashcraft ML, Beals JL, Keane TM, Manson SM, Marsella AJ. Final Report: Matsunaga Vietnam Veterans Project. Vol 1. West Haven, CT: National Center for Posttraumatic Stress Disorder and National Center for American Indian and Alaska Native Mental Health Research; 1997. 15. Memorandum of Understanding Between the Veterans Health Administration and the Indian Health Service. Washington, DC: Department of Veterans Affairs; 2004. 16. Amatayakul M. EHR? Assess readiness first. Healthc Financ Manage. 2005;59(5):112---113. 17. Armenakis AA, Harris SG, Mossholder KW. Creating readiness for organizational change. Hum Relat. 1993;46(6):681---703. 18. Hardison CD. Readiness, action, and resolve to change: do health care leaders have what it takes? Qual Manag Health Care. 1998;6(2):44---51. 19. O’Connor EJ, Fiol CM. Creating readiness and involvement. Physician Exec. 2006;32(1):72---74. 20. Sweeney YT, Whitaker C. Successful change: renaissance without revolution. Semin Nurse Manag. 1994;2(4):196---202. 21. Hagedorn HJ, Heideman PW. The relationship between baseline Organizational Readiness to Change Assessment subscale scores and implementation of hepatitis prevention services in substance use disorders treatment clinics: a case study. Implement Sci. 2010;5:46. 22. Backer TE. Assessing and enhancing readiness for change: implications for technology transfer. In: Backer TE, David SL, Soucy G, eds. Reviewing the Behavioral Science Knowledge Base on Technology Transfer. Rockville, MD: National Institute on Drug Abuse; 1995. NIDA Research Monograph 155; NIH publication 95---4035. 23. Rosenheck RA. Organizational process: a missing link between research and practice. Psychiatr Serv. 2001;52(12):1607---1612. 24. Lehman WE, Greener JM, Simpson DD. Assessing organizational readiness for change. J Subst Abuse Treat. 2002;22(4):197---209. 25. Every NR, Fihn SD, Sales AEB, Keane A, Ritchie JR; QUERI IHD Executive Committee. Quality Enhancement Research Initiative in ischemic heart disease: a quality initiative from the Department of Veterans Affairs. Med Care. 2000;38(6 suppl 1):I-49---I-59. 26. Helfrich CD, Li YF, Sharp ND, Sales AE. Organizational readiness to change assessment (ORCA): development of an instrument based on the Promoting Action on Research in Health Services (PARIHS) framework. Implement Sci. 2009;4:38.
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Providing Culturally Competent Services for American Indian and Alaska Native Veterans to Reduce Health Care Disparities Timothy D. Noe, PhD, Carol E. Kaufman, PhD, L. Jeanne Kaufmann, MS, Elizabeth Brooks, PhD, and Jay H. Shore, MD
Limited data available indicate significant disparities in health status and health care between American Indian and Alaska Native (AI/AN) veterans and other populations. AI/AN veterans often live in rural areas; roughly 40% live on geographically dispersed reservations and tribal lands. Many of these areas are remote and isolated, making delivery of health care a significant challenge.1,2 AI/AN veterans rank poorly on several important dimensions of quality of life, including educational attainment, income, home ownership, and employment.2---4 In addition to transportation difficulties and distance to care, they face several other access barriers, including lack of appropriate diagnostic services and specialty care.2---4 AI/AN veterans are significantly more likely than White veterans to delay care because they have difficulty getting timely appointments, locating and accessing specialty care, and reaching providers by phone.2---5 AI/AN veterans have higher incidences of mental health problems3,5 and are 4 times as likely as White veterans to report unmet health care needs.6,7 AI/AN veterans often report impersonal care, limited knowledge about Department of Veterans Affairs (VA) services and eligibility, lack of understanding within the VA regarding their culture and their needs, a preference to obtain mental health services from traditional healers from within their own tribal culture, and dissatisfaction with the VA as barriers to obtaining VA care.8 The VA is committed to delivering highquality, equitable care and to eliminating racial and ethnic disparities in health care. Proposed strategies to address health and health care disparities among minorities include a stronger focus on patient-centered care and a more culturally congruent health care environment.9 Culturally congruent, patient-centered care aims to improve health outcomes by
Objectives. We conducted an exploratory study to determine what organizational characteristics predict the provision of culturally competent services for American Indian and Alaska Native (AI/AN) veterans in Department of Veterans Affairs (VA) health facilities. Methods. In 2011 to 2012, we adapted the Organizational Readiness to Change Assessment (ORCA) for a survey of 27 VA facilities in the Western Region to assess organizational readiness and capacity to adopt and implement native-specific services and to profile the availability of AI/AN veteran programs and interest in and resources for such programs. Results. Several ORCA subscales (Program Needs, Leader’s Practices, and Communication) statistically significantly predicted whether VA staff perceived that their facilities were meeting the needs of AI/AN veterans. However, none predicted greater implementation of native-specific services. Conclusions. Our findings may aid in developing strategies for adopting and implementing promising native-specific programs and services for AI/AN veterans, and may be generalizable for other veteran groups. (Am J Public Health. 2014;104:S548–S554. doi:10.2105/AJPH.2014.302140)
empowering patients to participate in the health care decision-making process and by increasing trust, reducing skepticism, and enhancing acceptability of care.9,10 Patientcentered health care encompasses (1) respect for patients, (2) collaborative communication strategies, (3) knowledge sharing between patients and their health care providers, and (4) sociocultural competence. Cultural competence encompasses understanding and consideration of culture, economic and educational status, health literacy level, family patterns and situations, and traditions (including alternative and folk remedies), as well as communication at a level that the patient understands.10 Cultural competence in health care involves understanding of and respect for culturally different patient groups, ideally resulting in health care tailored to accommodate cultural differences in health-related values and beliefs. Cultural competency is a key part of delivering patient-centered care because both concepts stress respect for the patient, clear communication, shared decision-making, and building strong doctor---patient relationships.10
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Patient centeredness and cultural competence are important elements of delivering quality care to AI/AN veterans and may help reduce health care disparities among this special population. AI/AN peoples have their own long tradition of medicine and healing. The literature contains several arguments for the incorporation of traditional healing practices into health care for native groups. Some authors advocate individualized medicine that is culturally and linguistically appropriate.11---13 Others argue that the holistic approach of traditional healing in understanding the mind, body, and spirit is particularly relevant in the treatment of disorders related to trauma13 and may be especially relevant for AI/AN veterans, who have a high prevalence of traumatic disorders.14 One study found that although most AI/AN veterans were generally satisfied with the quality of care received in VA facilities, they considered that the care they received was not fully culturally competent regarding AI/AN health beliefs and behaviors.7 However, efforts by the VA, including the newly revised
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VA---Indian Health Service Memorandum of Understanding,15 as well as VA contracting agreements, have renewed the focus on improving care to these veterans.
ORGANIZATIONAL READINESS TO CHANGE Experts on the adoption of innovative programs and services contend that organizational readiness to change is critical to successful implementation and could predict, prior to the investment of resources, whether attempts will be successful in a particular organization or could allow tailoring of an intervention to the specific needs of participating sites.16---22 Consensus is also growing that adoption of innovations in health care depends more on organizational factors than on dissemination activities.22,23 Of particular importance are institutional and personnel readiness (e.g., resources and motivation) and organizational dynamics (e.g., climate for change and staff attributes).21,24 Motivational readiness of the leader and staff members (defined by perceived need and pressure for change) combined with personal attributes (e.g., professional growth, efficacy, influence, and adaptability) are also essential to implementation of an innovation.24 Organizational climate factors (e.g., clarity of mission and goals, staff cohesion, communication, and openness to change), along with institutional resources (staffing levels, physical resources, training levels, and computer usage) are also significant.21,24 The Organizational Readiness to Change Assessment (ORCA) is designed to measure key organizational readiness and capacity variables.21 This instrument was developed in conjunction with the VA Ischemic Heart Disease Quality Enhancement Research Initiative for assessing organizational readiness for implementation of evidence-based health care interventions.21,25,26 Hagedorn and Heideman assessed the predictive validity of the ORCA in a study of 9 clinic teams from VA facilities across the United States.21 The results of this study support the use of the ORCA to identify organizational characteristics related to successful implementation of innovative practices in clinical settings.
implementation of native-specific programs and practices for AI/AN veterans.
Recognizing the importance of patientcentered care and cultural competence in reducing health care disparities among AI/AN veterans, we sought to understand how native-specific services could be further developed and implemented within the VA. We conducted an exploratory study to determine what organizational characteristics predict the provision of native-specific services among VA health care facilities and to assess their organizational readiness and capacity to adopt and implement these services. We also examined the availability of and resources for programs for AI/AN veterans and the level of interest among VA employees in them. We adapted the ORCA for our survey of 27 VA facilities and hypothesized that higher scores would be positively associated with the likelihood of staff perceiving that their facilities were meeting the needs of AI/AN veterans and with
METHODS The VA is divided into 23 regional Veterans Integrated Service Networks (VISNs). They comprise medical centers, veteran centers, outpatient clinics, and community-based outpatient clinics that offer primary and specialized care. We focused on the Western Region because it contains the highest concentration of AI/AN veterans. In 2012, we invited all VISNs in the Western Region (numbers 18---22) to participate, and 3 VISNs (19, 21, and 22) agreed. A total of 27 VA health care facilities (VA medical centers and outpatient clinics), from a potential pool of 67 facilities in the 3 participating VISNs, took part. We targeted 5 nonunion employees of each
TABLE 1—Organizational Readiness to Change Continuous Variable Scores for Meeting the Needs of American Indian/Alaska Native Veterans: US Department of Veterans Affairs, Western Region, 2012 Score No.
Range
Mean 6SD (95% CI)
Leadership
57
2.00–5.00
3.79 60.76 (3.59, 4.01)
Performance measurement
57
2.75–5.00
3.92 60.63 (3.76, 4.09)
Opinion leader
56
2.25–5.00
3.97 60.66 (3.79, 4.14)
VISN support
56
2.00–5.00
3.89 60.65 (3.75, 4.09)
Resources
57
1.25–5.00
3.22 60.85 (2.98, 3.45)
Leader’s practices
55
3.00–5.00
3.72 60.57 (3.57, 3.88)
Staff needs Program needs
55 55
1.00–5.00 1.00–5.00
3.54 60.86 (3.31, 3.80) 3.42 60.86 (3.19, 3.68)
Item
Change pressure
56
2.00–5.00
3.50 60.68 (3.31, 3.66)
Staffing
56
1.50–4.67
3.13 60.58 (2.98, 3.29)
Training
56
1.25–5.00
3.40 60.63 (3.25, 3.58)
Offices
56
1.33–5.00
3.33 61.01 (3.01, 3.56)
Internet
56
2.00–4.67
3.76 60.48 (3.64, 3.89)
Equipment
56
2.80–5.00
3.74 60.53 (3.58, 3.88)
Mission Change
55 55
2.00–4.80 2.20–4.40
3.60 60.61 (3.43, 3.77) 3.27 60.40 (3.15, 3.37)
Autonomy
55
2.00–4.20
3.35 60.46 (3.21, 3.45)
Communication
55
1.00–4.80
3.29 60.73 (3.08, 3.50)
Cohesion
54
2.00–4.67
3.43 60.70 (3.24, 3.62)
Valid no. (listwise)
52
Belief that needs of AI/AN veterans being met
64
1.00–5.00
3.55 60.872 (3.34, 3.76)
Importance of meeting needs of AI/AN veterans
64
1.00–5.00
4.45 60.991 (4.21, 4.69)
Valid no. (listwise)
64
Note. AI/AN = American Indian/Alaska Native; CI = confidence interval; VISN = Veterans Integrated Service Networks.
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TABLE 2—Organizational Readiness to Change Dichotomous Variable Scores for Meeting the Needs of American Indian/Alaska Native Veterans: US Department of Veterans Affairs, Western Region, 2011–2012 Variable
No. (%)
AI/AN veterans in service area No
4 (6.1)
Yes
62 (93.9)
Missing Facility serves AI/AN veterans
1 (1.5)
No
1 (1.5)
Yes
65 (97.0)
Missing
1 (1.5)
Facility has projects concerned with increasing access and improving care for AI/AN veterans No
19 (28.4)
Yes
40 (59.7)
Missing Facility has projects concerned with promoting patient-centered care and collaboration
8 (11.9)
with VA, IHS, and tribes No
19 (28.4)
Yes
38 (56.7)
Missing
10 (24.9)
Facility has projects concerned with partnerships and sharing agreements to benefit AI/AN veterans No
28 (41.8)
Yes Missing
28 (41.8) 11 (16.4)
Facility has projects concerned with ensuring that appropriate resources are identified and available to support program for AI/AN veterans No
36 (53.7)
Yes
20 (29.9)
Missing
11 (16.4)
Facility provides any traditional healing services for AI/AN veterans No Yes
47 (70.1) 10 (14.9)
Missing
10 (14.9)
Note. AI/AN = American Indian/Alaska Native; IHS = Indian Health Service; VA = Department of Veterans Affairs; VISN = Veterans Integrated Service Networks.
participating facility, for a total sample of 135 respondents. We focused on nonunion employees because of restrictions related to their participation and additional approvals that would have been necessary to involve union employees. Enrollment was not limited on the basis of gender, race, or ethnicity. The recruitment process followed 3 steps: (1) we sent an e-mail to the VA Action Group, an employee group assigned to facilitate new projects, in each participating VISN; (2) the Action Group forwarded the e-mail to contacts at each of the 67 VA health care facilities in the
3 participating VISNs and instructed the contacts to forward a recruitment e-mail to 5 nonunion VA employees at their facility to solicit participation; and (3) the employees receiving the e-mail were provided a brief overview of the nature and purpose of the survey and instructed to follow a link provided to the online survey. To ensure a broad sample of employees, we sought employees in a variety of positions (e.g., manager, care provider, nurse, administrator). Participation was anonymous and completely voluntary. Online surveys were automatically
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uploaded to a secure server via a secure username and password. To reduce respondent burden and to maintain anonymity, we did not collect respondent demographics.
Measures Independent variables. Our survey instrument was an adapted version of the ORCA, with Needs, Leadership, Resources, and Organizational Climate scales. Subscales, derived from ORCA survey questions, were Staff Needs and Program Needs (Needs); VISN Leadership and Support, Leadership Culture, Leadership, Leader’s Practices, Performance Measures, Opinion Leaders (Leadership); General Resources, Office Resources, Staffing, Training, Equipment, Internet (Resources); and Mission, Cohesion, Autonomy, Communication, Pressures for Change (Organizational Climate). We scored all items on 5-point Likert scales (1 = strongly agree, 2 = agree, 3 = neither agree nor disagree, 4 = disagree, 5 = strongly disagree). The ORCA survey items are available at http:// www.ibr.tcu.edu. It was important to determine whether the AI/AN veterans lived in the service areas, were served by the facilities, and were perceived as a priority by the respondents. Therefore, in addition to the ORCA items, we included several items relating specifically to AI/AN veterans’ services. Dependent variables. To analyze which organizational characteristics were associated with staff perceiving that their facilities were meeting the needs of AI/AN veterans, we used the question, “Do you believe the needs of AI/AN veterans are being met by your facility?” To determine which organizational characteristics were associated with greater implementation of services for AI/AN veterans, we constructed a composite continuous variable from the sum of 5 items (each answered yes or no; total score = 0---5) that asked about projects offered for AI/AN veterans at respondents’ facilities: 1. Does your facility currently have projects concerned with increasing access and improving quality of care and services for AI/AN veterans (e.g., increase access to benefits; sharing of technology; interoperability of systems; telehealth; mobile communication technologies; joint access of electronic medical records)?
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2. Does your facility currently have projects concerned with promoting patientcentered collaboration and facilitating communication among VA, IHS [Indian Health Service], veterans, and tribes (e.g., improve coordination of care; increase cultural awareness and culturally competent care)? 3. Does your facility currently have projects concerned with establishing effective partnerships and sharing agreements to benefit AI/AN veterans (e.g., sharing of contracts and purchasing agreements; standard policies when facilities are colocated; develop payment and reimbursement policies and mechanisms; sharing of programs such as collaborations in Consolidated Mail Outpatient Pharmacy, PTSD [posttraumatic stress disorder], home-based primary care, dementia)? 4. Does your facility currently have projects concerned with ensuring that appropriate resources are identified and available to support programs for AI/AN veterans (e.g., increase capacity through joint training and workforce development; sharing of staff; joint facility/service planning; joint credentialing and privileging)? 5. Does your facility currently provide any traditional healing services for AI/AN veterans?
Analyses We calculated frequencies, means, ranges, and measures of central tendency for all continuous variables. All variables were normally distributed. We created composite organizational change variables by calculating the mean of all respondent scores for each item on the ORCA subscales. We then determined organizational readiness to change scores (mean scores for each ORCA subscale) aggregately and for each facility. To assess whether organizational readiness to change scores predicted staff perceiving that the needs of AI/AN veterans were being met at their facilities, we tested linear regression models for each ORCA main scale, with subscales serving as the predictors. We conducted multiple linear regression analyses to determine the best linear combination of ORCA subscales for predicting greater
implementation of services for AI/AN veterans for each ORCA scale.
RESULTS A total of 67 respondents from 27 facilities completed the survey. Four respondents worked in VISN 19 (1 facility), 39 in VISN 21 (19 facilities), and 23 in VISN 22 (7 facilities). A total of 5 individuals at each of 67 health care facilities received the invitation to participate in the survey, for a potential sample of 335. Therefore, the response rate was 20%.
Variables Table 1 provides the means and standard deviations for all continuous variables, and Table 2 provides frequencies for all dichotomous variables. A large majority of the respondents (94%) indicated that AI/AN
veterans resided in their service areas. In addition, 97% reported that their facilities served AI/AN veterans. However, only 15% reported that their facilities provided traditional healing services for AI/AN veterans. Mean scores were above the midrange (i.e., 2.5 on 5-point scale) on all organizational readiness to change measures. The Staffing subscale, which indicated whether a facility was adequately staffed, received the lowest score (mean = 3.13). The Opinion Leaders subscale, which indicated whether senior managers encouraged and supported changes in practice to improve patient care, received the highest score (mean = 3.97). The mean score for “How important is it for your facility to meet the needs of AI/AN veterans?” was 4.45, and for “Do you believe the needs of AI/AN veterans are being met by your facility?” was 3.55.
TABLE 3—Regression Results for Staff Perception of Needs of American Indian/Alaska Native Veterans Being Met: US Department of Veterans Affairs, Western Region, 2011–2012 B (95% CI)
P
R2
F(df)
No.
.004
0.149
4.712(4,42)
55
Staff Needs
–0.105 (–0.51, 0.30)
.598
Program Needs
–0.306 (–0.71, 0.09)
.004 0.245
3.123(5,48)
54
0.118
1.09(6,49)
56
0.115
3.374(2,52)
55
Scale/Subscale Needs
Leadership VISN Support Leadership Leader’s Practices Performance Measures
.016 0.001 (–0.50, 0.50)
.985
–0.092 (–0.55, 0.34) 0.523 (0.15, 1.53)
.624 .018
0.225 (–0.22, 0.86)
.246
–0.180 (–0.77, 0.29)
.368
General Resources
0.113 (–0.27, 0.50)
.56
Staffing
0.132 (–0.32, 0.71)
.45
Training
0.029 (–0.39, 0.47)
.85
0.062 (–0.22, 0.33) –0.050 (–0.56, 0.39)
.07 .73
0.236 (–0.08, 0.94)
.1
0.361 (–.21, 4.02)
.257
Opinion Leaders Resources
Offices Equipment Internet
.381
Organizational Climate Mission
.042
Change Pressure
0.314 (–0.40, 0.69)
.13
Autonomy
0.231 (–0.45, 0.76)
.47
Cohesion
0.042 (–0.54, 0.62)
.864
Communication
0.157 (–0.30, 0.74)
.015
Note. CI = confidence interval; VISN = Veterans Integrated Service Networks.
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Regression Analyses Table 3 provides the results of regression analyses to determine whether the ORCA scales predicted staff perceptions that the needs of AI/AN veterans were being met by their facilities. Staff needs and program needs (Needs subscales) significantly predicted needs met (F(df ) = 4.712(4,42); P = .004), with Program Needs significantly contributing to the prediction (B = –0.306; adjusted R 2 = 0.15; data not shown). This indicated a small effect size, with 15% of the variance in needs met explained by the model. VISN Support, Leadership Culture, Leadership, Leader’s Practices, Performance Measures, and Opinion Leaders (Leadership subscales) significantly predicted needs met (F(df ) = 3.123(5,48); P = .01), with Leader’s Practices significantly contributing to the prediction (B = 0.523; R 2 = 0.245). This result indicates that 25% of the variance in needs met was
explained by the model. This is a small-tomedium effect size. Resources (Resources, Staffing, Training, Offices, Equipment, and Internet subscales) did not significantly predict needs met (P = .38). Organizational Climate (Mission, Change, Autonomy, Cohesion, and Communication subscales) significantly predicted needs met (F(df ) = 3.374(2,52); P = .042), with Communication significantly contributing to the prediction (B = 0.157; adjusted R 2 = 0.12; data not shown). This indicated a small effect size, with 12% of the variance in needs met explained by the model. Table 4 lists the results of the regression analyses to determine whether the ORCA scales predicted greater implementation of services for AI/AN veterans. None of the models tested significantly predicted (P £ .05) greater implementation of services for AI/AN veterans.
DISCUSSION The 27 VA facilities we assessed scored highly on all ORCA measures. In accordance with the results of the Hagedorn and Heideman study,21 we anticipated that higher scores on the ORCA organizational readiness to change measures would be associated with greater likelihood of staff perceiving that their facilities were meeting the needs of AI/AN veterans and greater implementation of programs and practices specific for these veterans. Our results provide some support for these hypotheses. Several significant statistical models emerged for predicting whether VA staff perceived that their facilities were meeting the needs of AI/AN veterans. AI/AN veteran needs were perceived to be met when d
TABLE 4—Regression Results for Greater Implementation of Native-Specific Programs and Services: US Department of Veterans Affairs, Western Region, 2011–2012 Scale/Subscale
B (95 % CI)
P
R2
F(df)
No.
–0.029
0.251(2,51)
53
–0.018
0.848(6,46)
53
d
Needs Staff Needs
–0.160 (–0.77, 0.46)
.606
0.026 (–0.59, 0.64)
.933
VISN Support
–0.575 (–1.36, 0.21)
.148
Leadership Culture
–0.124 (–0.89, 0.65)
.748
Leadership Leader’s Practices
0.157 (–0.63, 0.95) –0.023 (–1.10, 1.06)
.692 .966
Program Needs Leadership
Performance Measures Opinion Leaders
.311 (–.54, 1.16)
.469
–.241 (–1.17, 0.68)
.602
–0.363 (–0.96, 0.24)
.19
0.608 (–0.24, 1.41)
.101
Resources General Resources Staffing
0.017
Training
–0.340 (–1.09, 0.29)
.265
Offices Equipment
–0.019 (–0.35, 0.42) –0.234 (–0.95, 0.51)
.922 .487
Internet
–0.341 (–0.95, 0.24)
.346
–0.723 (–1.61, 0.17)
.109
0.036 (–0.47, 0.54)
.887
Organizational Climate Mission Change Pressure
d
0.006
Autonomy
–0.506 (–1.48, 0.45)
.292
Cohesion
0.292 (–0.43, 1.02)
.421
Communication
0.144 (–0.65, 0.94)
.717
Note. CI = confidence interval; VISN = Veterans Integrated Service Networks.
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1.158(6,48)
1.061(5,47)
54
52
Facilities provided for the needs of new programs by clearly defining their mission, setting goals for improving services, assigning staff goals and evaluating staff performance, improving communication and relations among staff, employing effective record keeping, and using effective financial--accounting procedures (Needs). Senior leadership or clinical managers proposed new projects that were feasible, provided clear goals for improvement in patient care, established project schedules and deliverables, and designated a champion for new projects (Leadership). Organizations had open discussions about issues, especially among managers; kept staff well informed; made staff feel free to ask questions; and developed robust formal and informal communication (Communication).
Although more evaluation is needed, these preliminary results may provide important guidance for facilitating adoption and implementation of native-specific programs and services targeted to AI/AN veterans. Identifying facilities with these significant organizational characteristics may be critical to successful implementation of new native-specific programs and could provide insight into the likelihood of successful implementation at a particular site prior to the investment of resources or allow tailoring of an implementation intervention to the specific needs of participating sites. In addition, seeking to build the
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capacity of organizations on these key measures may be an important strategy for developing organizational readiness to successfully adopt native-specific programs and practices. Implementing organizational change models that have been shown to be effective through previous research and focusing those models on mission definition, staff goals, and performance evaluation may be a beneficial strategy. Other helpful strategies could be developing the capacity of senior leadership to provide clear goals for improvement in patient care, developing well-planned project schedules and deliverables, and designating a champion for new projects. Working with senior leaders and project managers to encourage them to allow open discussions about issues related to provision of care for AI/AN veterans and developing protocols to improve formal and informal communication may facilitate important organizational change that leads to improved services. Although our findings did not support our hypothesis that higher scores on the ORCA measures would be associated with greater implementation of programs and practices for AI/AN veterans, the scores for the survey items related to services for AI/AN veterans suggest important considerations for improvement. First, only 42% of respondents indicated that their facilities had projects that aimed to establish effective partnerships and sharing agreements to benefit AI/AN veterans. Second, only 30% of respondents reported their facilities had projects concerned with ensuring that appropriate resources were identified and available to support programs for these veterans. Third, only 15% of respondents indicated that their facilities provided traditional healing services for AI/AN veterans, despite advocacy in the literature for the provision of traditional healing for native groups, especially veterans. Fourth, although aggregate respondent scores on the question, “How important do you believe it is for your facility to meet the needs of AI/AN Veterans?” was 4.45 out of 5.0, the mean score was 3.5 on the question, “Do you believe the needs of AI/AN Veterans are being met by your facility?” (data not shown). These scores may indicate that VA employees are willing to do more to meet the needs of AI/AN veterans if they are provided with resources, guidance, and assistance.
One strategy for addressing these gaps may be to identify and assemble promising native-specific programs and practices, implementation consultation, and resources into a Web-based AI/AN veteran program development support system. This system could include a database of promising native-specific programs; guidance on development of outreach and community collaborations; a comprehensive guide for development, implementation, and maintenance of traditional healing services; an online cultural competence training course; additional Web-based resources for successfully working with AI/AN veterans; and linkages for users to connect with experts with knowledge relevant to their needs. Our exploratory study had a small sample size that limited the statistical tests we could use. Our convenience sample might not have been completely representative of all VA facilities. Also, we did not analyze the survey items used for the dependent variables to determine their validity and reliability. However, our findings may be important for developing preliminary strategies for further disseminating and promoting the adoption and implementation of promising native-specific programs and services for AI/AN veterans and may be generalizable for developing services for other veterans groups, such as general population rural veterans and women veterans. The VA has continued to expand services to AI/AN veterans, most notably by engaging in direct care service agreements with the Indian Health Service. As these efforts continue to expand, it may be beneficial to consider how organizational characteristics of VA health facilities serve to facilitate or create barriers to expansion. j
About the Authors
C. E. Kaufman interpreted the data. All authors wrote and revised the article and approved the final version.
Acknowledgments This study was sponsored and funded by the Veterans Rural Health Resource Center---Western Region, Office of Rural Health, Department of Veterans Affairs. Note. The views expressed are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs.
Human Participant Protection The study protocol was approved by the Colorado multiple institutional review board and the Department of Veterans Affairs institutional review board.
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The authors are with the Department of Veterans Affairs Office of Rural Health, Veterans Rural Health Resource Center---Western Region, Native Domain, and the Centers for American Indian and Alaska Native Health, School of Public Health, University of Colorado, Denver. Correspondence should be sent to Timothy D. Noe, Mail Stop F800, 13055 E 17th Ave, Aurora, CO 80045 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted June 17, 2014.
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T. D. Noe, C. E. Kaufman, E. Brooks, and J. H. Shore conceptualized and designed the study. T. D. Noe, and L. J. Kaufmann acquired the data. T. D. Noe and
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