Maria Yefimova is a nurse scientist with the Office of Research, Patient Care Services at Stanford Health Care, supporting ambulatory care nursing and patient care service professionals in their research and clinical inquiry. Her work is grounded in her interest in improving care for frail older patients through systematic change in care delivery. Dr. Yefimova obtained her BSN, MSN an PhD in nursing from the University of California, Los Angeles (UCLA). Her postdoctoral fellowship training followed in the National Clinician Scholars Program at UCLA/VA Greater Los Angeles where she was among the first nurses to receive health services research training alongside physicians in the legacy of Robert Wood Johnson Foundation (RWJF) Clinical Scholars Program. Dr. Yefimova was the 2018-2019 Academy Health Delivery Science Fellow, gaining skills in implementation science and learning health systems at VA Palo Alto Health Care System. She is now a clinical assistant professor in the division of Primary Care Population Health at Stanford School of Medicine and is a coinvestigator on multiple NIH-funded projects.

Academic Appointments

All Publications

  • Organizational and External Factors Associated with Video Telehealth Use in the Veterans Health Administration Before and During the COVID-19 Pandemic. Telemedicine journal and e-health : the official journal of the American Telemedicine Association Jacobs, J., Ferguson, J. M., Van Campen, J., Yefimova, M., Greene, L., Heyworth, L., Zulman, D. M. 2021


    Objectives: To identify organizational and external factors associated with medical center video telehealth uptake (i.e., the proportion of patients using telemedicine) before and early in the coronavirus disease 2019 (COVID-19) pandemic. Materials and Methods: We conducted a retrospective, observational study using cross-sectional data for all 139 U.S. Veterans Affairs Medical Centers (VAMCs). We used logistic regression analyses to identify factors that predicted whether a VAMC was in the top quartile of VA Video Connect (VVC) telehealth uptake for primary care and mental health care. Results: All 139 VAMCs increased their VVC uptake at least 2-fold early in the pandemic, with most increasing uptake between 5- and 10-fold. Pre-COVID-19, higher VVC uptake in primary care was weakly and positively associated with having more high-risk patients, negatively associated with having more long-distance patients, and positively associated with the prior fiscal year's VVC uptake. During COVID-19, the positive association with high-risk patients and the negative association with long-distance patients strengthened, while weaker broadband coverage was negatively associated with VVC uptake. For mental health care, having more long-distance patients was positively associated with higher VVC uptake pre-COVID-19, but this relationship reversed during COVID-19. Discussion: Despite the marked increase in VVC uptake early in the COVID-19 pandemic, significant VAMC-level variation indicates that VVC adoption was more difficult for some medical centers, particularly those with poorer broadband coverage and less prior VVC experience. Conclusions and Relevance: These findings highlight opportunities for medical centers, VA Central Office, and other federal entities to ensure equitable access to video telehealth.

    View details for DOI 10.1089/tmj.2020.0530

    View details for PubMedID 33887166

  • Why patients stop using their home telehealth technologies over time: Predictors of discontinuation in Veterans with heart failure NURSING OUTLOOK Guzman-Clark, J., Farmer, M. M., Wakefield, B. J., Viernes, B., Yefimova, M., Lee, M. L., Hahn, T. J. 2021; 69 (2): 159–66


    Daily use of home telehealth (HT) technologies decreases over time. Barriers to continued use are unclear.To examine predictors of drop-out from HT in Veterans with heart failure.Data for Veterans with heart failure enrolled in the Veterans Affairs HT Program were analyzed using a mixed effects Cox regression model to determine risk of dropping-out over a 1-year period.Older (hazard ratio [HR] 1.01), sicker (prior hospital readmission [HR 1.39]), higher probability of hospital admission/death [HR 1.23], functional impairments [1.14]) and white Veterans (compared to black; HR 1.41) had higher risk of drop-out in HT Programs. Users of VA's online patient portal (HR 0.90) had lower risk of drop-out.Older and sicker patients are at most risk of stopping HT use, yet use of a patient portal shows promise in improving continued use. Interventions targeting patients at high risk for HT discontinuation are needed to promote ongoing engagement.

    View details for DOI 10.1016/j.outlook.2020.11.004

    View details for Web of Science ID 000632663300008

    View details for PubMedID 33279151

    View details for PubMedCentralID PMC8005439

  • Gender Differences in Caregiver Burden Among Family Caregivers of Persons With Dementia. Journal of gerontological nursing Lee, K., Yefimova, M., Puga, F., Pickering, C. E. 2021; 47 (7): 33-42


    The current study aimed to identify gender-dependent factors that influence caregiver burden among family caregivers of persons with dementia through secondary data analysis. We used a nationally representative survey of 379 family caregivers of persons with dementia completed in 2014. We examined factors affecting the burden experience of male and female caregivers, guided by the stress process model, using hierarchical regression. The analytic sample included 159 males (42%) and 220 females (58%). For males, age of care recipient, being an adult child, social support, instrumental activities of daily living performed, and caregiving impact on caregivers' health influenced burden. For females, co-residence, social support, caregivers' current health, and caregiving impact on caregivers' health impacted burden. Understanding gender differences related to caregiving burden is beneficial for developing effective targeted interventions that support the caregiving role and improve the quality of life of caregivers. [Journal of Gerontological Nursing, 47(7), 33-42.].

    View details for DOI 10.3928/00989134-20210610-03

    View details for PubMedID 34191655

  • Adherence to the Use of Home Telehealth Technologies and Emergency Room Visits in Veterans with Heart Failure. Telemedicine journal and e-health : the official journal of the American Telemedicine Association Guzman-Clark, J., Wakefield, B. J., Farmer, M. M., Yefimova, M., Viernes, B., Lee, M. L., Hahn, T. J. 2020


    Background: Prior studies have posited poor patient adherence to remote patient monitoring as the reason for observed lack of benefits. Introduction: The purpose of this study was to examine the relationship between average adherence to the daily use of home telehealth (HT) and emergency room (ER) visits in Veterans with heart failure. Materials and Methods: This was a retrospective study using administrative data of Veterans with heart failure enrolled in Veterans Affairs (VA) HT Program in the first half of 2014. Zero-inflated negative binomial regression was used to determine which predictors affect the probability of having an ER visit and the number of ER visits. Results: The final sample size was 3,449 with most being white and male. There were fewer ER visits after HT enrollment (mean±standard deviation of 1.85±2.8) compared with the year before (2.2±3.4). Patient adherence was not significantly associated with ER visits. Age and being from a racial minority group (not white or black) and belonging to a large HT program were associated with having an ER visit. Being in poorer health was associated with higher expected count of ER visits. Discussion: Subgroups of patients (e.g., with depression, sicker, or from a racial minority group) may benefit from added interventions to decrease ER use. Conclusions: This study found that adherence was not associated with ER visits. Reasons other than adherence should be considered when looking at ER use in patients with heart failure enrolled in remote patient monitoring programs.

    View details for DOI 10.1089/tmj.2020.0312

    View details for PubMedID 33275527

  • Preoperative Conversations About Postoperative Risks, Outcomes, and Quality of Life-Time to Start Thinking Outside the Box. JAMA network open Yefimova, M., Aslakson, R. A. 2020; 3 (11): e2024048

    View details for DOI 10.1001/jamanetworkopen.2020.24048

    View details for PubMedID 33180125

  • Next of Kin Perceptions of End of Life Care: An Investigation of Open-Ended Survey Responses to the VA's Bereaved Family Survey Gray, C., Yefimova, M., Mccaa, M., Goebel, J., Shreve, S., Giannitrapani, K., Lorenz, K. ELSEVIER SCIENCE INC. 2020: 268
  • One-year outcomes from pilot providing home-based primary care services to homebound older adults Yefimova, M., Lestoquoy, A., Sheffrin, M., Martin, M. WILEY. 2020: S37
  • Palliative Care and End of Life Outcomes Following High Risk Surgery Yefimova, M., Aslakson, R., Yang, J., Garcia, A., Boothroyd, D., Giannitrapani, K., Morris, A., Johanning, J., Shreve, S., Wachterman, M., Lorenz, K. ELSEVIER SCIENCE INC. 2020: 535
  • Palliative Care and End-of-Life Outcomes Following High-Risk Surgery. JAMA surgery Yefimova, M., Aslakson, R. A., Yang, L., Garcia, A., Boothroyd, D., Gale, R. C., Giannitrapani, K., Morris, A. M., Johanning, J. M., Shreve, S., Wachterman, M. W., Lorenz, K. A. 2020


    Importance: Palliative care has the potential to improve care for patients and families undergoing high-risk surgery.Objective: To characterize the use of perioperative palliative care and its association with family-reported end-of-life experiences of patients who died within 90 days of a high-risk surgical operation.Design, Setting, and Participants: This secondary analysis of administrative data from a retrospective cross-sectional patient cohort was conducted in the Department of Veterans Affairs (VA) Healthcare System. Patients who underwent any of 227 high-risk operations between January 1, 2012, and December 31, 2015, were included.Exposures: Palliative-care consultation within 30 days before or 90 days after surgery.Main Outcomes and Measures: The outcomes were family-reported ratings of overall care, communication, and support in the patient's last month of life. The VA surveyed all families of inpatient decedents using the Bereaved Family Survey, a valid and reliable tool that measures patient and family-centered end-of-life outcomes.Results: A total of 95 204 patients underwent high-risk operations in 129 inpatient VA Medical Centers. Most patients were 65 years or older (69 278 [72.8%]), and the most common procedures were cardiothoracic (31 157 [32.7%]) or vascular (23 517 [24.7%]). The 90-day mortality rate was 6.0% (5740 patients) and varied by surgical subspecialty (ranging from 278 of 7226 [3.8%] in urologic surgery to 875 of 6223 patients [14.1%] in neurosurgery). A multivariate mixed model revealed that families of decedents who received palliative care were 47% more likely to rate overall care in the last month of life as excellent than those who did not (odds ratio [OR], 1.47 [95% CI, 1.14-1.88]; P=.007), after adjusting for patient's characteristics, surgical subspecialty of the high-risk operation, and survey nonresponse. Similarly, families of decedents who received palliative care were more likely to rate end-of-life communication (OR, 1.43 [95% CI, 1.09-1.87]; P=.004) and support (OR, 1.31 [95% CI, 1.01-1.71]; P=.05) components of medical care as excellent. Of the entire cohort, 3374 patients (3.75%) had a palliative care consultation, and 770 patients (0.8%) received it before surgery. Of all decedents, 1632 (29.9%) had a palliative care consultation, with 319 (5.6%) receiving it before surgery.Conclusions and Relevance: Receipt of a palliative consultation was associated with better ratings of overall end-of-life care, communication, and support, as reported by families of patients who died within 90 days of high-risk surgery. Yet only one-third of decedents was exposed to palliative care. Expanding integration of perioperative palliative care may benefit patients undergoing high-risk operations and their families.

    View details for DOI 10.1001/jamasurg.2019.5083

    View details for PubMedID 31895424

  • Home Telehealth Technologies for Heart Failure: An Examination of Adherence Among Veterans. Journal of gerontological nursing Guzman-Clark, J. n., Yefimova, M. n., Farmer, M. M., Wakefield, B. J., Viernes, B. n., Lee, M. L., Hahn, T. J. 2020; 46 (7): 26–34


    The current retrospective cohort study uses Department of Veterans Affairs (VA) clinical and facility data of Veterans with heart failure enrolled in the VA Home Tele-health (HT) Program. General estimating equations with facility as a covariate were used to model percent average adherence at 1, 3, 6, and 12 months post-enrollment. Most HT patients were White, male, and of older age (mean = 71 years). Average adherence increased the longer patients remained in the HT program. Number of weekly reports of HT use, not having depression, and being of older age were all associated with higher adherence. Compared to White Veterans, Black and other non-White Veterans had lower adherence. These findings identify subgroups of patients (e.g., those with depression, of younger age, non-White) that may benefit from additional efforts to improve adherence to HT technologies. [Journal of Gerontological Nursing, 46(7), 26-34.].

    View details for DOI 10.3928/00989134-20200605-05

    View details for PubMedID 32597998

  • Developing Unique Insights from Narrative Responses to Bereaved Family Surveys. Journal of pain and symptom management Gray, C. n., Yefimova, M. n., McCaa, M. n., Goebel, J. R., Shreve, S. n., Lorenz, K. A., Giannitrapani, K. n. 2020


    Although bereaved family surveys are routinely used quantitatively for quality assessment, open-ended, narrative responses are rarely systematically analyzed. Analysis of narrative responses may identify opportunities for improving end-of-life (EOL) care delivery.To highlight the value of routine, systematic analysis of narrative responses, and to thematically summarize narrative responses to the VA's Bereaved Family Survey.We analyzed over 4600 open-ended responses to the Bereaved Family Survey for all 2017 inpatient decedents across VA facilities. We used a descriptive qualitative approach (9) to identify major themes.Thematic findings clustered into three domains: patient needs, family needs, and facility and organizational characteristics. Patient needs include maintenance of Veteran's hygiene, appropriately prescribing medications, adhering to patient wishes, physical presence in patient's final hours, and spiritual and religious care at EOL. Family and caregiver needs included enhanced communication with the patient's care team, assistance with administrative and logistical challenges after death, emotional support, and displays of respect and gratitude for the patient's life. Facility and organizational characteristics included care team coordination, optimal staffing, the importance of non-clinical staff to care, and optimizing facilities to be welcoming, equipped for individuals with disabilities, and able to provide high quality food.Systematic analysis of narrative survey data yields unique findings not routinely available through quantitative data collection and analysis. Organizations may benefit from the collection and regular analysis of narrative survey responses, which facilitates identification of needed improvements in palliative and EOL care that may improve the overall experiences for patients and families.

    View details for DOI 10.1016/j.jpainsymman.2020.05.007

    View details for PubMedID 32428664

  • Virtual Care Expansion in the Veterans Health Administration During the COVID-19 Pandemic: Clinical Services and Patient Characteristics Associated with Utilization. Journal of the American Medical Informatics Association : JAMIA Ferguson, J. M., Jacobs, J. n., Yefimova, M. n., Greene, L. n., Heyworth, L. n., Zulman, D. M. 2020


    To describe the shift from in-person to virtual care within Veterans Affairs (VA) during the early phase of the COVID-19 pandemic, and to identify at-risk patient populations who require greater resources to overcome access barriers to virtual care.Outpatient encounters (N = 42,916,349) were categorized by care type (e.g. primary, mental health, etc.) and delivery method (e.g., in-person, video). For 5,400,878 Veterans, we used Generalized Linear models to identify patient sociodemographic and clinical characteristics associated with: 1) use of virtual (phone or video) care versus no virtual care and 2) use of video care versus no video care; between 3/11/2020 and 6/6/2020.By June, 58% of VA care was provided virtually compared to only 14% prior. Patients with lower income, higher disability, and more chronic conditions were more likely to receive virtual care during the pandemic. Yet, Veterans aged 45-64 and 65+ were less likely to use video care compared to those aged 18-44 (aRR 0.80 [95%CI 0.79, 0.82] and 0.50 [0.48, 0.52], respectively). Rural and homeless Veterans were 12% and 11% less likely to use video care compared to urban (0.88 [0.86, 0.90]) and non-homeless Veterans (0.89 [0.86, 0.92]).Veterans with high clinical or social need had higher likelihood of virtual service use early in the COVID-19 pandemic, however, older, homeless, and rural Veterans were less likely to have video visits, raising concerns for access barriers.While virtual care may expand access, access barriers must be addressed to avoid exacerbating disparities.

    View details for DOI 10.1093/jamia/ocaa284

    View details for PubMedID 33125032

  • Daily Context for Abusive and Neglectful Behavior in Family Caregiving for Dementia. The Gerontologist Pickering, C. E., Yefimova, M., Maxwell, C., Puga, F., Sullivan, T. 2019


    BACKGROUND AND OBJECTIVES: The purpose of this study was to identify risk and protective factors for abusive and neglectful behavior in the context of daily caregiving.RESEARCH DESIGN AND METHODS: Family caregivers who co-reside with a care recipient with Alzheimer's disease and related dementia, recruited from social media, completed 21-days of diaries. Multilevel modeling with days (n = 831) nested within caregivers (N = 50) was used to evaluate relationships between hypothesized risk and protective factors and the odds of an abusive or neglectful behavior on a given day.RESULTS: Disruptions in the daily routine and stress of the caregiver related to behavioral symptoms of the care recipient are significant risk factors for abusive and neglectful behavior. Participating in a meaningful activity with the care recipient when it occurs twice in a day is a significant protective factor against use of a neglect behavior (OR = 0.19; CI 0.06-0.64; p = .01), but not for abusive behavior. Hypotheses that spending the full day together would increase risk, and that receipt of instrumental support and caregiver participation in self-care would decrease risk, were not supported.DISCUSSION AND IMPLICATIONS: Findings demonstrate that risk of an abusive or neglectful behavior varies from day-to-day in the presence and absence of contextual factors, and that the majority of the variance in the odds an abusive or neglectful behavior occurring is related to day-level factors. Findings demonstrate that diary surveys are critical to identifying ecologically valid modifiable risk and protective factors for abusive and neglectful behaviors that can be targeted in future interventions.

    View details for DOI 10.1093/geront/gnz110

    View details for PubMedID 31425586

  • Exploratory analysis of older adults' sedentary behavior in the primary living area using kinect depth data JOURNAL OF AMBIENT INTELLIGENCE AND SMART ENVIRONMENTS Banerjee, T., Yefimova, M., Keller, J. M., Skubic, M., Woods, D., Rantz, M. 2017; 9 (2): 163–79

    View details for DOI 10.3233/AIS-170428

    View details for Web of Science ID 000400232200003

  • Detecting and Characterizing Patterns of Behavioral Symptoms of Dementia DISCOVERING HIDDEN TEMPORAL PATTERNS IN BEHAVIOR AND INTERACTION: T-PATTERN DETECTION AND ANALYSIS WITH THEME(TM) Woods, D., YefiMova, M., Kim, H., Phillips, L. R., Magnusson, M. S., Burgoon, J. K., Casarrubea, M. 2016; 111: 125–42
  • A Method for Measuring Person-Centered Interventions: Detecting and Characterizing Complex Behavioral Symptoms of Persons With Dementia CLINICAL GERONTOLOGIST Woods, D., Yefimova, M., Brecht, M. 2014; 37 (2): 139–50
  • Detecting Daily Routines of Older Adults Using Sensor Time Series Clustering Hajihashemi, Z., Yefimova, M., Popescu, M., IEEE IEEE. 2014: 5912–15


    The aim of this paper is to develop an algorithm to identify deviations in patterns of day-to-day activities of older adults to generate alerts to the healthcare providers for timely interventions. Daily routines, such as bathroom visits, can be monitored by automated in-home sensor systems. We present a novel approach that finds periodicity in sensor time series data using clustering approach. For this study, we used data set from TigerPlace, a retirement community in Columbia, MO, where apartments are equipped with a network of motion, pressure and depth sensors. A retrospective multiple case study (N=3) design was used to quantify bathroom visits as parts of the older adult's daily routine, over a 10-day period. The distribution of duration, number, and average time between sensor hits was used to define the confidence level for routine visit extraction. Then, a hierarchical clustering was applied to extract periodic patterns. The performance of the proposed method was evaluated through experimental results.

    View details for Web of Science ID 000350044705225

    View details for PubMedID 25571342

  • To Nap or Not to Nap: Excessive Daytime Napping Is Associated With Elevated Evening Cortisol in Nursing Home Residents With Dementia BIOLOGICAL RESEARCH FOR NURSING Woods, D., Kim, H., Yefimova, M. 2013; 15 (2): 185–90


    Alterations in the sleep-wake cycle, including daytime napping, are consistently reported in persons with dementia (PWD). A dysregulation in the hypothalamic-pituitary-adrenal (HPA) axis, indexed by elevated evening cortisol, may offer one explanation for these alterations. Alternatively, excessive daytime sleeping may alter cortisol rhythm and increase intraindividual variability, potentially contributing to increased environmental reactivity and behavioral symptoms. The purpose of this substudy (N = 12) was to examine the association between daytime napping and basal cortisol diurnal rhythm in nursing home residents with dementia.In this within-individual longitudinal design, saliva samples were obtained daily for 5 consecutive days upon waking and 30-45 min, 6 hr, and 12 hr after waking to obtain a cortisol diurnal rhythm. Behavior and sleep-wake state (nap/no nap) were observed and recorded every 20 min for 12 hr per day for 5 days.Participants were categorized as high nappers (HNs) or low nappers (LNs). There was a significant difference in evening cortisol levels (t = -2.38, p = .032) and continence (t = 3.37, p = .007) between groups, with HNs exhibiting higher evening cortisol levels. There were no other significant differences in resident characteristics between the two groups.These data suggest a link between excessive daytime napping and elevated evening cortisol in PWD consistent with findings in children. Elevated evening cortisol is an indication of a dysregulation in the HPA axis. These preliminary data support a close association between the sleep-wake cycle and HPA-axis regulation in PWD.

    View details for DOI 10.1177/1099800411420861

    View details for Web of Science ID 000314367500007

    View details for PubMedID 21998447

  • Evening Cortisol Is Associated With Intra-Individual Instability in Daytime Napping in Nursing Home Residents With Dementia: An Allostatic Load Perspective BIOLOGICAL RESEARCH FOR NURSING Woods, D., Yefimova, M. 2012; 14 (4): 387–95


    Circadian rhythm disruption, reflected in alterations in sleep-wake activity and daytime napping behavior, is consistently reported in nursing home (NH) residents with dementia. This disruption may be reflected in day-to-day instability. The concept of allostatic load (AL), a measure of cumulative biological burden over a lifetime, may be a helpful model for understanding cortisol diurnal rhythm and daytime napping activity in this population. The purpose of this study was to examine the association between intra-individual daytime napping episodes and basal cortisol diurnal rhythm in NH residents with dementia in the context of AL.U sing a within-individual longitudinal design (N = 51), the authors observed and recorded daytime napping activity every 20 min for 10 hr per day across 4 consecutive days. The authors obtained saliva samples 4 times each day (upon participants' waking and within 1 hr, 6 hr, and 12 hr of participants' wake time) for cortisol analysis.The authors categorized participants as high changers (HCs; day-to-day instability in napping activity) or low changers (LCs; day-to-day stability). There were no significant differences in resident characteristics between groups. There was a significant difference between HCs and LCs in napping episodes (F = 4.86, p = .03), with an interaction effect of evening cortisol on napping episodes in the HC group (F = 10.161, p = .001).NH residents with unstable day-to-day napping episodes are more responsive to alterations in evening cortisol, an index of a dysregulated hypothalamic-pituitary-adrenal (HPA) axis. They may also be more amenable to environmental intervention, an avenue for further research.

    View details for DOI 10.1177/1099800412451118

    View details for Web of Science ID 000309126900007

    View details for PubMedID 22811289