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Identifying and addressing social risks and social needs in healthcare settings is an important step towards achieving health equity. Assessing Circumstances and Offering Resources for Needs (ACORN) is a Department of Veterans Affairs (VA) social risk screening and referral model that aims to systematically identify and address social needs. Since initial piloting in 2018, our team has collaborated with clinical and operations partners to implement ACORN across multiple VA clinical settings while adapting and tailoring the initiative to meet the needs of different populations, specialties, and individuals administering screening. Given ACORN's complexity as a growing initiative with multiple partners and frequent real-time modifications within a large national healthcare system, we recognized a need to systematically document the rationale and process of adaptations over time. We looked to three implementation frameworks—RE-AIM, the Adaptome, and FRAME—to describe the rationale for adaptations, the nature of and context within which adaptations were made, and the details of each adaptation. In this manuscript, we uniquely interweave these three frameworks to document adaptations to ACORN across diverse VA clinical settings, with a focus on how adaptations support the promotion of heath equity in the Veteran population.

Objective: The Diabetes Prevention Program (DPP) is a widely implemented 12-month behavioral weight loss program for individuals with prediabetes. The DPP covers nutrition but does not explicitly incorporate cooking skills education. The objective of the current study is to describe food and cooking skills (FACS) and strategies of recent DPP participants. Design: Photo-elicitation in-depth interviews were conducted from June-August, 2021. Setting: Baltimore, Maryland, U.S. Participants: Thirteen Black women who participated in DPP. Results: The DPP curriculum influenced participants’ healthy cooking practices. Many participants reported shifting from frying foods to air-frying and baking foods to promote healthier cooking and more efficient meal preparation. Participants also reported that their participation in DPP made them more mindful of consuming fruits and vegetables and avoiding foods high in carbohydrates, fats, sugars, and sodium. With respect to food skills, participants reported that they were more attentive to reading labels and packaging on foods and assessing the quality of ingredients when grocery shopping. Conclusions: Overall, participants reported changing their food preferences, shopping practices, and cooking strategies to promote healthier eating after completing the DPP. Incorporating hands-on cooking skills and practices into the DPP curriculum may support sustained behavior change to manage prediabetes and prevent development of type 2 diabetes among participants.

Objectives. This Technical Brief aims to identify: 1) frameworks that describe organizational context and process characteristics relevant to cancer care delivery research, and compare these frameworks to the Integrated Framework recently developed by National Cancer Institute staff Weaver, Breslau, and colleagues; 2) approaches used to improve understanding of how organizational characteristics are described, measured, and analyzed in the context of cancer screening, diagnosis, or treatment; and 3) organizational context and process characteristics examined in studies assessing cancer care; and 4) evidence gaps and future research needs to advance the science of assessing the effects of organizational characteristics on cancer care. Review methods. We integrated discussions with Key Informants and syntheses of evidence from searches of literature published from 2010 to 2023, using PubMed, CINAHL, SCOPUS, PsycINFO, and the Cochrane Central Register of Controlled Trials, as well as select grey literature. Findings. We identified 17 frameworks that were developed or applied to examine the effects of organizational characteristics (including structures, context, and processes) on cancer care delivery. Our analysis of these frameworks supported the comprehensiveness of the Integrated Framework, though a few identified characteristics were not explicitly included in the Integrated Framework. We found 90 studies that take various approaches to describe, measure, and analyze organizational characteristics in the context of cancer care research. Of these, we identified 25 that tested associations between organization characteristics and screening, diagnosis, or treatment outcomes, and described measurement in detail. Cancer-related studies that include organizational measures have used a wide range of study designs and focused mostly on structural characteristics (e.g., type, size), total care models such as the patient-centered medical home, and processes of improvement project implementation and barrier assessment (such as guideline implementation). We identified specific organizational measures examined in the cancer care literature, noting little standardization of measures across studies and a need for multilevel inquiry. Our discussions with Key Informants and review of the literature indicated that many characteristics of healthcare organizations are relevant to cancer care delivery and useful to assess when precisely defined. Studies with stronger designs and more rigorous organizational measurement are needed to better determine the effects of organizational characteristics on the outcomes of cancer care. Conclusion. Our findings suggest that the Integrated Framework generally covers relevant organizational context and process characteristics. The literature has a wide array of studies examining organizational characteristics, but few studies directly associate organizational factors with clinical outcomes. Research and collaboration are needed to improve measurement of organizational factors, to clarify our understanding of multilevel aspects of organizational context and process and how they affect care, and to standardize terminology and measures.

Objective Evaluate self-reported electronic screening (eScreening) in a VA Transition Care Management Program (TCM) to improve the accuracy and completeness of administrative ethnicity and race data. Materials and Methods We compared missing, declined, and complete (neither missing nor declined) rates between (1) TCM-eScreening (ethnicity and race entered into electronic tablet directly by patient using eScreening), (2) TCM-EHR (Veteran-completed paper form plus interview, data entered by staff), and (3) Standard-EHR (multiple processes, data entered by staff). The TCM-eScreening (n = 7113) and TCM-EHR groups (n = 7113) included post-9/11 Veterans. Standard-EHR Veterans included all non-TCM Gulf War and post-9/11 Veterans at VA San Diego (n = 92 921). Results Ethnicity: TCM-eScreening had lower rates of missingness than TCM-EHR and Standard-EHR (3.0% vs 5.3% and 8.6%, respectively, P < .05), but higher rates of “decline to answer” (7% vs 0.5% and 1.2%, P < .05). TCM-EHR had higher data completeness than TCM-eScreening and Standard-EHR (94.2% vs 90% and 90.2%, respectively, P < .05). Race: No differences between TCM-eScreening and TCM-EHR for missingness (3.5% vs 3.4%, P > .05) or data completeness (89.9% vs 91%, P > .05). Both had better data completeness than Standard-EHR (P < .05), which despite the lowest rate of “decline to answer” (3%) had the highest missingness (10.3%) and lowest overall completeness (86.6%). There was strong agreement between TCM-eScreening and TCM-EHR for ethnicity (Kappa = .92) and for Asian, Black, and White Veteran race (Kappas = .87 to .97), but lower agreement for American Indian/Alaska Native (Kappa = .59) and Native Hawaiian/Other Pacific Islander (Kappa = .50) Veterans. Conculsions eScreening is a promising method for improving ethnicity and race data accuracy and completeness in VA.