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Volume 46 Number 7, 2009
   Pages vii — xi

Guest Editorial

HHV Supports creative expression as rehabilitative tool

Guest Editorial Figure 1

Help Hospitalized Veterans (HHV) is the nation's largest supplier of therapeutic arts and crafts kits used within the Department of Veterans Affairs (VA) and military hospitals. Since its inception, HHV has delivered more than 25 million kits, along with other products and services, valued at (including shipping) $410 million. All products and services are provided free of charge to more than 300 medical facilities that care for our hospitalized veterans and active-duty military personnel.

HHV provides over 350 different kits, including leather items, sun-catchers, paint-by-numbers, latch-hook rugs, poster art, plastic and wood models/crafts, and many more. The kits are rehabilitative devices designed to restore coordination and impaired motor skills, improve attention spans and concentration, and relax frayed nerves. They are also a diversion therapy and entertainment outlet for those veterans who are facing extended hospitalization and/or confinement. Additionally, HHV has provided other products and services to homebound veterans and cash support to many of VA's annual special events.


To ensure maximum craft kit availability, HHV supplements VA staff by employing 62 craft care specialists (CCSs) to work in VA and military hospitals. The primary role of a CCS is to distribute craft kits, participate in the veteran's rehabilitation program, and recommend craft kits suitable for each veteran's condition and skill level, often helping the veteran enhance the finished product. By working closely with hospitalized veterans, CCSs offer meaningful interaction and boost morale. CCSs also conduct arts and crafts workshops in the hospitals they serve, greatly increasing craft kit participation. CCSs also help recruit volunteers for the VA Voluntary Service program.


In today's environment, accountability is an especially pressing concern. Organizations are competing-each must be prepared to demonstrate empirically that their program is appropriate, available, timely, effective, safe, efficient, continuous, respectful, and caring.

Guest Editorial Figure 2

HHV took a far-reaching step by initiating a performance measurement study to determine the effectiveness of its programs and promote understanding and support for hospitalized veterans [1]. The study demonstrated the therapeutic value of HHV's craft kit program to veteran patients, host hospitals, and HHV's generous donors. Measurement is by no means unfamiliar in healthcare. VA, military, and private sector health organizations routinely measure responses to therapy, staffing levels, and cost. However, to our knowledge, no organization similar to HHV has ever conducted a study on arts and crafts used in a therapeutic setting. Four levels of difficulty were assigned to each craft kit category, with level one being the simplest and four the most difficult, as evidenced by the average number of hours it took a patient to complete a particular kit. This voluntary initiative allowed HHV to quantify its craft kit program performance with measures of patient health outcome, satisfaction, and effectiveness of the CCS program. Health Care Data, Inc. (HCD) studied HHV programs in 13 VA hospitals and state veterans nursing homes.


Each medical facility was given a user manual and computer disk to use in the collection of data. Outcome measurement data were collected during 1 week of each quarter by the therapists or CCSs and submitted to HCD.

Innumerable outcomes could produce meaningful data. This initial data collection system targeted only 10 outcome measures. These 10 were chosen for their general applicability and the perceived need for accurate data in these areas:

· Aggregate
Performance measure based on collection and accumulation of data about many events. The events may be desirable or undesirable, and the data may be reported as a continuous variable or as a rate.
· Functional Assessment/Health Status
Method of measuring patient improvement and effectiveness of the treatment plan. (Did the patient improve, remain the same, or regress?)
· Risk Adjusted
Process for reducing, removing, or clarifying the influences of confounding patient factors that differ among comparison groups.
· Patient Satisfaction Surveys
Overall patient impressions of how HHV and the medical centers met their expectations.

The repeated measures of performance will provide trend data by indicator, allowing HHV to establish a benchmark and compare performance of the craft kit program and the participating hospitals. By using comparative data from the reference database, HHV will be able to detect variations in performance. Such variations in benchmarking will assist in the improvement of the HHV craft kit programs and processes.


Each outcome measure was compared with that of all the reporting medical centers. Many medical centers may have had a small size monitored for a particular outcome measure.


As part of the performance measurement program, a patient satisfaction survey was conducted and analyzed. The survey was given to patients upon completion of each craft kit. Patient perceptions were compared with the clinical evaluations to see whether a balance existed between patient satisfaction and quality outcomes.


In addition to HHV, each participating medical center received summary statistics for each outcome measure. The report showed the results of the participating medical centers as compared with all others in the study. HHV received data displays using the appropriate statistical quality control technique (e.g., tables, line graphs, and histograms). From this report, HHV and the medical facilities will focus resources and attention on those areas that may require a more intensive assessment.


The first year of the study was a trial period for testing the survey instruments and ensuring data were collected with the same methodology. Although we feel we have good data for the first year, many changes were made as a result of receiving input from the CCSs.

The veteran patients that received HHV craft kits and CCS assistance were overwhelmingly satisfied with the craft kit program, and had a positive response rate of 98.6 percent. HHV was shown to be one of the top three volunteer organizations with activities in the medical centers that reach 98.7 percent of the veterans.

Also apparent was that the ease or difficulty of craft kits completion varied among patients participating in craft activities based on risk, adjusted by disease (i.e., anxiety disorder, dementia, etc).

This information proved to be extremely helpful when CCSs assign or assist patients in therapeutic craft kit selection. The medical center treatment team may also use this information as an integral part of the multidisciplinary patient treatment plan.

Guest Editorial Figure 3

One of the most important measures within this study was the functional improvement of the patient resulting from craft kit therapy. CCSs, as members of each medical center's multidisciplinary patient treatment teams, participated in defining policies and developing a total care plan for their patients. For this purpose, the CCSs assessed each of their patients to determine if functional improvements had occurred. They found the following improvements in patients:

· Functional improvement: 48 percent.
· Self-assessment: 47 percent.
· Attention span: 45 percent.
· Motivation: 51 percent.

When compared with the patient's overall perception of the impact of the craft kit therapy program in relation to their wellness, 89.6 percent of the patients felt HHV craft therapy helped maintain or improve their physical capabilities. Patients with a good mental attitude and outlook toward treatment have better chances for improvement. We found it remarkable to witness how HHV's program had indeed helped patients in functional improvement, both physically and mentally. Patients' comments reinforced that data. We could see by these comments that many of the veterans gave intrinsic responses, which were measured under the motivation category.

Guest Editorial Figure 4

In terms of craft kit difficulty, 46.7 percent stated that the kits they were working on were somewhat difficult to very difficult. With this quantifiable information and the average time to complete a kit by level of difficulty, CCSs are better able to guide and select an appropriate kit for patients. We saw that veterans not only appreciated HHV but also willingly thanked the donors who make the program possible. Most-96.8 percent-wrote notes of appreciation to the donors directly by completing the "Thank You" postcards that come attached to each craft kit. Often, these postcards are the avenue through which pen-pal relationships form between the donors and hospitalized veterans.


HHV cosponsors four of VA's national special events: National Veterans Creative Arts Festival; National Veterans Golden Age Games; National Veterans Training, Exposure, and Experience Tournament; and National Veterans Summer Sports Clinic. HHV also cosponsors VA's National Salute to Veteran Patients Valentines for Veterans Concerts. HHV has also subsidized performances at VA facilities of the youth entertainment group "Re-Creation, USA" and has funded grants to the Wounded Warrior Ministry at Landstuhl Regional Medical Center (LRMC) in Landstuhl, Germany. The Ministry provides clothing, toiletries, shoes, and other much-needed items to American soldiers injured in combat in Iraq and Afghanistan who are recovering at LRMC.

HHV's involvement with the National Veterans Creative Arts Festival is a natural extension of its commitment to the arts and crafts program. In many instances, it is the direct involvement of a CCS that motivates a veteran to try an HHV craft kit. Veterans often find the activity both enjoyable and fulfilling. With time and patience, many hospitalized veterans increase skill levels to the point of entry into a local arts competition. Established in 1989, the annual National Veterans Creative Arts Festival fosters creative expression in veterans receiving treatment at VA medical facilities, while incorporating the arts into therapy programs. Veterans that win in both local and regional competitions are invited to the week-long National festival, a gala performance and art exhibit that celebrates the veterans' achievements and allows the public to view

the often incredibly creative talents of veterans battling disease, disability, or life-crisis. Spectators are frequently amazed at the quality of the art entries. Working on the individual art pieces and going through the process of creating the finished product is often cathartic for those who suffer from posttraumatic stress disorder. Veterans who have difficulty speaking of their intrusive thoughts with therapists are able to express them on canvas or through other art pieces. Through the generosity of its donors and the leadership of the board of directors, HHV will continue to support VA's efforts to foster a healthy and rewarding life for America's veterans and will continue to do all it can to help hospitalized veterans in their recovery and rehabilitative goals.

1. HCD Executive Summary-Performance Measurement Study. Winchester (CA): Help Hospitalized Veterans; 1999.
Mike Lynch
Help Hospitalized Veterans, President and CEO
Email: mike@hhv.org

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