Tuesday, March 10, 2009

Implementing the VI in Hospitals/Clinics/Medical Outreach

Greetings from Nashville,

I hope you are well.

I am looking for guidance on the best way to implement the VI in health care settings - hospitals, clinics, medical outreach teams, etc. Health care settings seem to be a natural environment for the VI, as the VI is a tool to capture someone's known health status. If more physicians used this tool, we would have a better idea if folks are under-reporting or over-reporting their illnesses.

In Nashville, there are a number of medical providers who are interested in implementing the VI. However, I am reluctant to train them on using the VI because the current VI survey is a self-reporting survey. It is not a tool that lends well to objective medical information that a physician could provide. In other words, I would fear that a patient experiencing homelessness would be handed a VI survey while sitting in the waiting room for an appointment...there is nothing on the survey that would require a physician to be there, to give input, etc.

So, we all know that the VI rocks the house!! But, can it or should it be tweaked before we implement it in health care settings? Should we use the current version of the VI for "survey blitzes" with volunteers and develop another "medical" version of the VI for physicians?

Thanks a bunch for your help with this. Robb Nash - a nurse practitioner in Nashville who staffs a respite clinic for the homeless - wants to help think through this with us. Here are some of his initial questions that could help get this discussion going:

"What experience do people have with the VI in terms of clinically ranking a person's acuity of illness? For example, one person's hypertension is not anothers, nor is one person's CD4 count and viral load equal to anothers. Given that, how are people using the VI to accurately rank folks for services/housing based on their health? Is anyone out there using the VI along with some more clinically objective addendum?" - Robb Nash, Clinical Instructor, Vanderbilt School of Nursing

So, is there room for objective medical evidence in the VI? If so, how do we incorporate it? If we want physicians to be involved in the reporting of health conditions, how do we structure the survey so that a physician can use it best?

Thanks again. Take it easy. Peace.


Robertson Nash said...

Gretings all - I'm the ACNP who's quoted in Will's posting above. I welcome dialogue with anybody out there who has insights into the pros/cons of having providers complete the VI rather than relying on self-report data. I do realize that what we're asking about here in Nashville might not immediately align itself with the self-report spirit of the VI, and so I would also like to hear from folks who have accurately used the tool as is to rank persons according to acuity of illnesses.

with warmest regards,

Robertson Nash

Becky Kanis said...

Hi Will and Robb,

Such interesting questions! I'd be really interested to hear from Jim O'Connell on this one because he does not use self-report but actual health data to drive his team's work.

Here's the good news: The Vulnerability Index relies on self-report, and we do not yet know how valid self-report is for measuring mortality risk. What we're really trying to get at is the health conditions associated with high mortality risk, and using self-report as the "best tool we have" on the streets. So, as best as I can tell, you are actually in a better situation to assess for vulnerability and can do so in ways that are much more closely aligned with the existing research.

Again, I would defer to Dr. Jim O'Connell's advice on how to best "triage" in a clinical setting, but you could pretty easily come up with a checklist that the clinician fills out after each exam. The odds ratios for the medical conditions are listed in the 1998 study which we should have posted to this site, but I can't get zoho to work! Email me at bkanis@commonground.org and I'll get you the 1998 study with odds ratios for each condition and let's talk through it.

It might be very interesting to use Nashville as a test-site to compare self-report to actual medical conditions - it is a lingering question.

Over the next year, we will be attempting to validate self-report as a predictor of premature mortality among the homeless population. With over 4,500 surveys done in 2008 alone, we have a lot of data now and soon we will be able to run some regressions with it.

I am not aware of anyone taking acuity of illness into account using this tool, but it is a very interesting question. I'd love to see what you come up with.

Is there anyone else who wants to administer the Vulnerability index - or some version of it - in a clinic? Would love to hear from you!

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