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Ball DD, Sadler AG, Steffen MJ, Paez MB, Mengeling MA. The impact of patient-provider relationships on choosing between VA and VA-purchased care: A qualitative study of health care decision-making among rural veterans. J Rural Health 2024; 40:430-437. [PMID: 37942663 DOI: 10.1111/jrh.12804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 08/25/2023] [Accepted: 10/26/2023] [Indexed: 11/10/2023]
Abstract
PURPOSE Since the Choice Act in 2014, many Veterans have had greater options for seeking Veteran Affairs (VA)-purchased care in the community. We investigated factors that influence rural Veterans' decisions regarding where to seek care. METHODS We utilized semi-structured telephone interviews to query Veterans living in rural or highly rural areas of Midwestern states about their health care options, preferences, and experiences. Interviews were recorded and transcribed, thematically coded, and deductively analyzed using a socioecological approach. FINDINGS Forty rural Veterans (20 men/20 women) ages 28-76 years completed interviews in 2019. We found that rural Veterans often spoke about their relationships and interactions with providers as an important factor in deciding where to seek care. They expressed three socioecological qualities of patient-provider relationships that affected their decisions: (1) personal level-rural Veterans traveled longer distances for more compatible patient-provider relationships; (2) interpersonal level-they sought stable patient-provider relationships that encouraged familiarity, trust, and communication; and (3) organizational level-they emphasized shared identities and expertise that fostered a sense of belonging with their provider. Participants also described how impersonal interactions, status differences, and staff turnover impacted their choice of provider and were disruptive to patient-provider relationships. CONCLUSIONS Rural Veterans' interview responses suggest exploring innovative ways to measure socioecological dimensions (i.e., personal, interpersonal, and organizational) of access-related decisions and patient-provider relationships to better understand health care barriers and needs. Such measures align with the VA's Whole Health approach that emphasizes person-centered care and the value of social relationships to Veterans' health.
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Affiliation(s)
- Daniel D Ball
- Center for Access & Delivery Research and Evaluation (CADRE) and the VA Office of Rural Health (ORH) Veterans Rural Health Resource Center-Iowa City (VRHRC-IC), Iowa City VA Health Care System, Iowa City, Iowa, USA
| | - Anne G Sadler
- Center for Access & Delivery Research and Evaluation (CADRE) and the VA Office of Rural Health (ORH) Veterans Rural Health Resource Center-Iowa City (VRHRC-IC), Iowa City VA Health Care System, Iowa City, Iowa, USA
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Melissa J Steffen
- Center for Access & Delivery Research and Evaluation (CADRE) and the VA Office of Rural Health (ORH) Veterans Rural Health Resource Center-Iowa City (VRHRC-IC), Iowa City VA Health Care System, Iowa City, Iowa, USA
| | - Monica B Paez
- Center for Access & Delivery Research and Evaluation (CADRE) and the VA Office of Rural Health (ORH) Veterans Rural Health Resource Center-Iowa City (VRHRC-IC), Iowa City VA Health Care System, Iowa City, Iowa, USA
| | - Michelle A Mengeling
- Center for Access & Delivery Research and Evaluation (CADRE) and the VA Office of Rural Health (ORH) Veterans Rural Health Resource Center-Iowa City (VRHRC-IC), Iowa City VA Health Care System, Iowa City, Iowa, USA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
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O’Hanlon CE, Zeliadt SB, DeFaccio R, Gaj L, Bokhour BG, Taylor SL. Patient-reported pain and physical health for acupuncture and chiropractic care delivered by Veterans Affairs versus community providers. PLoS One 2024; 19:e0303651. [PMID: 38748671 PMCID: PMC11095679 DOI: 10.1371/journal.pone.0303651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 04/26/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND Acupuncture and chiropractic care are evidence-based pain management alternatives to opioids. The Veterans Health Administration (VA) provides this care in some VA facilities, but also refers patients to community providers. We aimed to determine if patient-reported outcomes differ for acupuncture and chiropractic care from VA versus community providers. MATERIALS AND METHODS We conducted an observational study using survey outcome data and electronic medical record utilization data for acupuncture and chiropractic care provided in 18 VA facilities or in community facilities reimbursed by VA. Study participants were users of VA primary care, mental health, pain clinic, complementary and integrative therapies, coaching or education services in 2018-2019. Patients received 1) 4+ acupuncture visits (N = 201) or 4+ chiropractic care visits (N = 178) from a VA or community provider from 60 days prior to baseline to six-months survey and 2) no acupuncture or chiropractic visits from 1 year to 60 days prior to baseline. Outcomes measured included patient-reported pain (PEG) and physical health (PROMIS) at baseline and six-month surveys. Multivariate analyses examined outcomes at six months, adjusting for baseline outcomes and demographics. RESULTS In unadjusted analyses, pain and physical health improved for patients receiving community-based acupuncture, while VA-based acupuncture patients experienced no change. Unadjusted analyses also showed improvements in physical health, but not pain, for patients receiving VA-based chiropractic care, with no changes for community-based chiropractic care patients. Using multivariate models, VA-based acupuncture was no different from community-based acupuncture for pain (-0.258, p = 0.172) or physical health (0.539, p = 0.399). Similarly, there were no differences between VA- and community-based chiropractic care in pain (-0.273, p = 0.154) or physical health (0.793, p = 0.191). CONCLUSIONS Acupuncture and chiropractic care were associated with modest improvements at six months, with no meaningful differences between VA and community providers. The choice to receive care from VA or community providers could be based on factors other than quality, like cost or convenience.
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Affiliation(s)
- Claire E. O’Hanlon
- Veterans Affairs Greater Los Angeles Healthcare System, Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), Los Angeles, California, United States of America
- RAND Corporation, Santa Monica, California, United States of America
| | - Steven B. Zeliadt
- Veterans Affairs Puget Sound Health Care System, VA Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington, United States of America
- Department of Health Systems and Population Health, Hans Rosling Center for Population Health, University of Washington School of Public Health, Seattle, Washington, United States of America
| | - Rian DeFaccio
- Veterans Affairs Puget Sound Health Care System, VA Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington, United States of America
| | - Lauren Gaj
- VA Bedford Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), Bedford, Massachusetts, United States of America
| | - Barbara G. Bokhour
- VA Bedford Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), Bedford, Massachusetts, United States of America
- Division of Preventive and Behavioral Medicine, Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, Massachusetts, United States of America
| | - Stephanie L. Taylor
- Veterans Affairs Greater Los Angeles Healthcare System, Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), Los Angeles, California, United States of America
- Department of Health Policy and Management, Fielding School of Public Health, Los Angeles, California, United States of America
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
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Daus M, Lee M, Ujano-De Motta LL, Holstein A, Morgan B, Albright K, Ayele R, McCarthy M, Sjoberg H, Jones CD. Perspectives on supporting Veterans' social needs during hospital to home health transitions: findings from the Transitions Nurse Program. BMC Health Serv Res 2024; 24:520. [PMID: 38658937 PMCID: PMC11043030 DOI: 10.1186/s12913-024-10900-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 03/26/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND Veterans who need post-acute home health care (HHC) are at risk for adverse outcomes and unmet social needs. Veterans' social needs could be identified and met by community-based HHC clinicians due to their unique perspective from the home environment, acuity of Veterans they serve, and access to Veterans receiving community care. To understand these needs, we explored clinician, Veteran, and care partner perspectives to understand Veterans' social needs during the transition from hospital to home with skilled HHC. METHODS Qualitative data were collected through individual interviews with Veterans Health Administration (VHA) inpatient & community HHC clinicians, Veterans, and care partners who have significant roles facilitating Veterans' hospital to home with HHC transition. To inform implementation of a care coordination quality improvement intervention, participants were asked about VHA and HHC care coordination and Veterans' social needs during these transitions. Interviews were recorded, transcribed, and analyzed inductively using thematic analysis and results were organized deductively according to relevant transitional care domains (Discharge Planning, Transition to Home, and HHC Delivery). RESULTS We conducted 35 interviews at 4 VHA Medical Centers located in Western, Midwestern, and Southern U.S. regions during March 2021 through July 2022. We organized results by the three care transition domains and related themes by VHA, HHC, or Veteran/care partner perspective. Our themes included (1) how social needs affected access to HHC, (2) the need for social needs screening during hospitalization, (3) delays in HHC for Veterans discharged from community hospitals, and (4) a need for closed-loop communication between VHA and HHC to report social needs. CONCLUSIONS HHC is an underexplored space for Veterans social needs detection. While this research is preliminary, we recommend two steps forward from this work: (1) develop closed-loop communication and education pathways with HHC and (2) develop a partnership to integrate a social risk screener into HHC pathways.
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Affiliation(s)
- Marguerite Daus
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VHA Eastern Colorado Healthcare System, 1700 N Wheeling St, Aurora, CO, 80045, USA.
| | - Marcie Lee
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VHA Eastern Colorado Healthcare System, 1700 N Wheeling St, Aurora, CO, 80045, USA
| | - Lexus L Ujano-De Motta
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VHA Eastern Colorado Healthcare System, 1700 N Wheeling St, Aurora, CO, 80045, USA
| | | | - Brianne Morgan
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VHA Eastern Colorado Healthcare System, 1700 N Wheeling St, Aurora, CO, 80045, USA
| | - Karen Albright
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- OCHIN, Inc., Portland, OR, USA
| | - Roman Ayele
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VHA Eastern Colorado Healthcare System, 1700 N Wheeling St, Aurora, CO, 80045, USA
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Michaela McCarthy
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VHA Eastern Colorado Healthcare System, 1700 N Wheeling St, Aurora, CO, 80045, USA
| | - Heidi Sjoberg
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VHA Eastern Colorado Healthcare System, 1700 N Wheeling St, Aurora, CO, 80045, USA
| | - Christine D Jones
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VHA Eastern Colorado Healthcare System, 1700 N Wheeling St, Aurora, CO, 80045, USA
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Carlo AD, Sterling RA, Mao J, Fiorella RP, Fortney JC, Unützer J, Wong ES. Characteristics of Veterans With Depression Who Use the Veterans Choice Program of the Veterans Health Administration. Psychiatr Serv 2024; 75:349-356. [PMID: 37933135 PMCID: PMC11152459 DOI: 10.1176/appi.ps.202100731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
OBJECTIVE The Veterans Choice Program (VCP) of the Veterans Health Administration (VHA) allowed eligible veterans to use their benefits with participating providers outside the VHA. The authors aimed to identify characteristics of veterans with depression who used or did not use mental health care through the VCP. METHODS In this cross-sectional study, the authors analyzed secondary data from the national VHA Corporate Data Warehouse. VHA administrative data were linked with VCP claims to examine characteristics of VCP-eligible veterans with depression. The study sample included 595,943 unique veterans who were enrolled in the VHA before 2013, were eligible for the VCP in 2016, were alive in 2018, and had an assessed Patient Health Questionnaire-9 (PHQ-9) score or depressive disorder diagnosis documented in the VHA between 2016 and 2018. RESULTS Veterans who used the VCP had lower medical comorbidity scores and lived in less socioeconomically disadvantaged counties, compared with veterans who received only VHA care. VCP veterans were also more likely to have a PHQ-9 score assessment and to have higher mean depression scores. Mean counts of annual mental health visits per 1,000 veterans were markedly higher for direct VHA care than for care provided via the VCP. As a percentage of the total counts of visits per 1,000 veterans across the VCP and VHA, residential programs and outpatient procedures were the services that were most frequently delivered through the VCP. CONCLUSIONS Between 2016 and 2018, the VCP was used primarily to augment mental health care provided by the VHA, rather than to fill a gap in care.
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Affiliation(s)
- Andrew D Carlo
- Meadows Mental Health Policy Institute, Dallas, and Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago (Carlo); VA Puget Sound Healthcare System, U.S. Department of Veterans Affairs (VA), Seattle (Sterling, Mao, Fortney, Wong); Earth and Environmental Sciences Division, Los Alamos National Laboratory, Los Alamos, New Mexico (Fiorella); Departments of Psychiatry and Behavioral Sciences (Fortney, Unützer) and Health Systems and Population Health (Wong), School of Medicine, University of Washington, Seattle
| | - Ryan A Sterling
- Meadows Mental Health Policy Institute, Dallas, and Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago (Carlo); VA Puget Sound Healthcare System, U.S. Department of Veterans Affairs (VA), Seattle (Sterling, Mao, Fortney, Wong); Earth and Environmental Sciences Division, Los Alamos National Laboratory, Los Alamos, New Mexico (Fiorella); Departments of Psychiatry and Behavioral Sciences (Fortney, Unützer) and Health Systems and Population Health (Wong), School of Medicine, University of Washington, Seattle
| | - Johnny Mao
- Meadows Mental Health Policy Institute, Dallas, and Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago (Carlo); VA Puget Sound Healthcare System, U.S. Department of Veterans Affairs (VA), Seattle (Sterling, Mao, Fortney, Wong); Earth and Environmental Sciences Division, Los Alamos National Laboratory, Los Alamos, New Mexico (Fiorella); Departments of Psychiatry and Behavioral Sciences (Fortney, Unützer) and Health Systems and Population Health (Wong), School of Medicine, University of Washington, Seattle
| | - Richard P Fiorella
- Meadows Mental Health Policy Institute, Dallas, and Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago (Carlo); VA Puget Sound Healthcare System, U.S. Department of Veterans Affairs (VA), Seattle (Sterling, Mao, Fortney, Wong); Earth and Environmental Sciences Division, Los Alamos National Laboratory, Los Alamos, New Mexico (Fiorella); Departments of Psychiatry and Behavioral Sciences (Fortney, Unützer) and Health Systems and Population Health (Wong), School of Medicine, University of Washington, Seattle
| | - John C Fortney
- Meadows Mental Health Policy Institute, Dallas, and Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago (Carlo); VA Puget Sound Healthcare System, U.S. Department of Veterans Affairs (VA), Seattle (Sterling, Mao, Fortney, Wong); Earth and Environmental Sciences Division, Los Alamos National Laboratory, Los Alamos, New Mexico (Fiorella); Departments of Psychiatry and Behavioral Sciences (Fortney, Unützer) and Health Systems and Population Health (Wong), School of Medicine, University of Washington, Seattle
| | - Jürgen Unützer
- Meadows Mental Health Policy Institute, Dallas, and Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago (Carlo); VA Puget Sound Healthcare System, U.S. Department of Veterans Affairs (VA), Seattle (Sterling, Mao, Fortney, Wong); Earth and Environmental Sciences Division, Los Alamos National Laboratory, Los Alamos, New Mexico (Fiorella); Departments of Psychiatry and Behavioral Sciences (Fortney, Unützer) and Health Systems and Population Health (Wong), School of Medicine, University of Washington, Seattle
| | - Edwin S Wong
- Meadows Mental Health Policy Institute, Dallas, and Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago (Carlo); VA Puget Sound Healthcare System, U.S. Department of Veterans Affairs (VA), Seattle (Sterling, Mao, Fortney, Wong); Earth and Environmental Sciences Division, Los Alamos National Laboratory, Los Alamos, New Mexico (Fiorella); Departments of Psychiatry and Behavioral Sciences (Fortney, Unützer) and Health Systems and Population Health (Wong), School of Medicine, University of Washington, Seattle
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Zullig LL, Lewinski AA, Woolson SL, White-Clark C, Miller C, Bosworth HB, Burleson SC, Garrett MP, Darling KL, Crowley MJ. Research-practice partnerships: Adapting a care coordination intervention for rural Veterans over 3 years at multiple sites. J Rural Health 2023; 39:575-581. [PMID: 36661336 DOI: 10.1111/jrh.12740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
PURPOSE Rural Veterans are more likely than urban Veterans to qualify for community care (Veterans Health Administration [VHA]-paid care delivered outside of VHA) due to wait times ≥30 days and longer travel times for VHA care. For rural Veterans receiving both VHA and community care, suboptimal care coordination between VHA and community providers can result in poor follow-up and care fragmentation. We developed Telehealth-based Coordination of Non-VHA Care (TECNO Care) to address this problem. METHODS We iteratively developed and adapted TECNO Care with partners from the VHA Office of Rural Health and site-based Home Telehealth Care in the Community programs. Using templated electronic health record notes, Home Telehealth nurses contacted Veterans monthly to facilitate communication with VHA/community providers, coordinate referrals, reconcile medications, and follow up on acute episodes. We evaluated TECNO Care using a patient-level, pre-post effectiveness assessment and rapid qualitative analysis with individual interviews of Veterans and VHA collaborators. Our primary effectiveness outcome was a validated care coordination quality measure. We calculated mean change scores for each care continuity domain. FINDINGS Between March 2019 and October 2021, 83 Veterans received TECNO Care. Veterans were predominately White (86.4%) and male (88.6%) with mean age 71.4 years (SD 10.4). Quantitative data demonstrated improvements in perceived care coordination following TECNO Care in 7 categories. Qualitative interviews indicated that Veterans and Home Telehealth nurses perceived TECNO Care as beneficial and addressing an area of high need. CONCLUSIONS TECNO Care appeared to improve the coordination of VHA and community care and was valued by Veterans.
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Affiliation(s)
- Leah L Zullig
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Allison A Lewinski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- School of Nursing, Duke University, Durham, North Carolina, USA
| | - Sandra L Woolson
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
| | - Courtney White-Clark
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
| | - Christopher Miller
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Hayden B Bosworth
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- School of Nursing, Duke University, Durham, North Carolina, USA
- Department of Psychiatry and Behavioral Sciences, School of Nursing, Duke University, Durham, North Carolina, USA
| | | | - Mary P Garrett
- Durham VA Health Care System, Durham, North Carolina, USA
| | - Kristen L Darling
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
| | - Matthew J Crowley
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- Division of Endocrinology, Diabetes, and Metabolism, Duke University School of Medicine, Durham, North Carolina, USA
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Franzosa E, Judon KM, Gottesman EM, Koufacos NS, Runels T, Augustine M, Van Houtven CH, Boockvar KS. Improving Care Coordination Between Veterans Health Administration Primary Care Teams and Community Home Health Aide Providers: A Qualitative Study. J Appl Gerontol 2023; 42:552-560. [PMID: 36464953 DOI: 10.1177/07334648221142014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022] Open
Abstract
Effective coordination between medical and long-term services is essential to high-quality primary care for older adults, but can be challenging. Our study assessed coordination and communication through semi-structured interviews with Veterans Health Administration (VHA) primary care clinicians (n = 9); VHA-contracted home health agencies (n = 6); and home health aides (n = 8) caring for veterans at an urban VHA medical center. Participants reported (1) establishing home health services is complex, requiring collaboration between many individuals and systems; (2) communication between medical teams and agencies is often reactive; (3) formal communication channels between medical teams and agencies are lacking; (4) aides are an important source of patient information; and (5) aides report important information, but rarely receive it. Removing structural communication barriers; incentivizing reporting channels and information sharing between aides, agencies, and primary care teams; and integrating aides into interdisciplinary teams may improve coordination of medical and long-term care.
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Affiliation(s)
- Emily Franzosa
- Geriatric Research, Education and Clinical Center (GRECC), 20071James J. Peters VA Medical Center, Bronx, NY, USA.,Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kimberly M Judon
- Geriatric Research, Education and Clinical Center (GRECC), 20071James J. Peters VA Medical Center, Bronx, NY, USA
| | - Eve M Gottesman
- Geriatric Research, Education and Clinical Center (GRECC), 20071James J. Peters VA Medical Center, Bronx, NY, USA
| | - Nicholas S Koufacos
- Geriatric Research, Education and Clinical Center (GRECC), 20071James J. Peters VA Medical Center, Bronx, NY, USA
| | - Tessa Runels
- Pain, Research, Informatics, Medical Comorbidities, and Education (PRIME) Center, 583458VA Connecticut Healthcare System, West Haven, CT, USA
| | - Matthew Augustine
- Geriatric Research, Education and Clinical Center (GRECC), 20071James J. Peters VA Medical Center, Bronx, NY, USA.,Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Courtney H Van Houtven
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health System HSR&D, Durham, NC, USA.,Department of Population Health Sciences, School of Medicine, Duke University, Durham, NC, USA.,Duke-Margolis Center for Health Policy, Durham, NC, USA.,Duke Center for the Study of Aging and Human Development, Durham, NC, USA
| | - Kenneth S Boockvar
- Geriatric Research, Education and Clinical Center (GRECC), 20071James J. Peters VA Medical Center, Bronx, NY, USA.,Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Graham LA, Schoemaker L, Rose L, Morris AM, Aouad M, Wagner TH. Expansion of the Veterans Health Administration Network and Surgical Outcomes. JAMA Surg 2022; 157:1115-1123. [PMID: 36223115 PMCID: PMC9558067 DOI: 10.1001/jamasurg.2022.4978] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 07/16/2022] [Indexed: 01/11/2023]
Abstract
Importance The US Department of Veterans Affairs (VA) Veterans Choice Program (VCP) expanded health care access to community settings outside the VA for eligible patients. Little is known about the effect of VCP on access to surgery and postoperative outcomes. Since its initiation, care coordination issues, which are often associated with adverse postoperative outcomes, have been reported. Research findings on the association of VCP and postoperative outcomes are limited to only a few select procedures and have been mixed, potentially due to bias from unmeasured confounding. Objective To investigate the association of the VCP with access to surgery and postoperative outcomes using a nonrandomized controlled regression discontinuity design (RDD) to reduce the impact of unmeasured confounders. Design, Setting, and Participants This was a nonrandomized RDD study of the Veterans Health Administration (VHA). Participants included veterans enrolled in the VHA who required surgery between October 1, 2014, and June 1, 2019. Interventions The VCP, which expanded access to VA-paid community care for eligible veterans living 40 miles or more from their closest VA hospital. Main Outcomes and Measures Postoperative emergency department visits, inpatient readmissions, and mortality at 30 and 90 days. Results A total of 615 473 unique surgical procedures among 498 427 patients (mean [SD] age, 63.0 [12.9] years; 450 366 male [90.4%]) were identified. Overall, 94 783 procedures (15.4%) were paid by the VHA, and the proportion of VHA-paid procedures varied by procedure type. Patients who underwent VA-paid procedures were more likely to be women (9209 [12.7%] vs men, 38 771 [9.1%]), White race (VA paid, 54 544 [74.4%] vs VA provided, 310 077 [73.0%]), and younger than 65 years (VA paid, 36 054 [49.1%] vs 229 411 [46.0%] VA provided), with a significantly lower comorbidity burden (mean [SD], 1.8 [2.2] vs 2.6 [2.7]). The nonrandomized RDD revealed that VCP was associated with a slight increase of 0.03 in the proportion of VA-paid surgical procedures among eligible veterans (95% CI, 0.01-0.05; P = .01). However, there was no difference in postoperative mortality, readmissions, or emergency department visits. Conclusions and Relevance Expanded access to health care in the VHA was associated with a shift in the performance of surgical procedures in the private sector but had no measurable association with surgical outcomes. These findings may assuage concerns of worsened patient outcomes resulting from care coordination issues when care is expanded outside of a single health care system, although it remains unclear whether these additional procedures were appropriate or improved patient outcomes.
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Affiliation(s)
- Laura A. Graham
- Health Economics Resource Center, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
- Stanford Surgery Policy Improvement Research and Education Center, Stanford School of Medicine, Stanford, California
| | - Lena Schoemaker
- Health Economics Resource Center, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
| | - Liam Rose
- Health Economics Resource Center, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
- Stanford Surgery Policy Improvement Research and Education Center, Stanford School of Medicine, Stanford, California
| | - Arden M. Morris
- Stanford Surgery Policy Improvement Research and Education Center, Stanford School of Medicine, Stanford, California
| | - Marion Aouad
- Department of Economics, University of California, Irvine
| | - Todd H. Wagner
- Health Economics Resource Center, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
- Stanford Surgery Policy Improvement Research and Education Center, Stanford School of Medicine, Stanford, California
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Sterling RA, Liu CF, Hebert PL, Fortney JC, Swankoski KE, Katon JG, Wong ES. How Did Veterans' Reliance on Veterans Health Administration Outpatient Care Change After Expansion of the Veterans Community Care Program? Med Care 2022; 60:784-791. [PMID: 35950930 DOI: 10.1097/mlr.0000000000001764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The Veterans Community Care Program (VCCP) aims to address access constraints in the Veterans Health Administration (VA) by reimbursing care from non-VA community providers. Little existing research explores how veterans' choice of VA versus VCCP providers has evolved as a significant VCCP expansion in 2014 as part of the Veterans Access, Choice, and Accountability Act. OBJECTIVES We examined changes in reliance on VA for primary care (PC), mental health (MH), and specialty care (SC) among VCCP-eligible veterans. RESEARCH DESIGN We linked VA administrative data with VCCP claims to retrospectively examine utilization during calendar years 2016-2018. SUBJECTS 1.78 million veterans enrolled in VA before 2013 and VCCP-eligible in 2016 due to limited VA capacity or travel hardship. MEASURES We measured reliance as the proportion of total annual outpatient (VA+VCCP) visits occurring in VA for PC, MH, and SC. RESULTS Of the 26.1 million total outpatient visits identified, 45.6% were for MH, 29.9% for PC, and 24.4% for SC. Over the 3 years, 83.2% of veterans used any VA services, 23.8% used any VCCP services, and 20.0% were dual VA-VCCP users. Modest but statistically significant declines in reliance were observed from 2016-2018 for PC (94.5%-92.2%), and MH (97.8%-96.9%), and a more significant decline was observed for SC (88.5%-79.8%). CONCLUSIONS Veterans who have the option of selecting between VA or VCCP providers continued using VA for most of their outpatient care in the initial years after the 2014 VCCP expansion.
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Affiliation(s)
- Ryan A Sterling
- Center for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System
| | - Chuan-Fen Liu
- Center for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System
- Health System and Population Health
| | - Paul L Hebert
- Center for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System
- Health System and Population Health
| | - John C Fortney
- Center for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System
- Medicine, University of Washington, Seattle, WA
| | - Kaylyn E Swankoski
- Center for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System
- Health System and Population Health
| | - Jodie G Katon
- Center for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System
- Health System and Population Health
| | - Edwin S Wong
- Center for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System
- Health System and Population Health
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9
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Friedman S, Shaw JG, Hamilton AB, Vinekar K, Washington DL, Mattocks K, Yano EM, Phibbs CS, Johnson AM, Saechao F, Berg E, Frayne SM. Gynecologist Supply Deserts Across the VA and in the Community. J Gen Intern Med 2022; 37:690-697. [PMID: 36042097 PMCID: PMC9481821 DOI: 10.1007/s11606-022-07591-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 04/01/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND The Veterans Health Administration (VA) refers patients to community providers for specialty services not available on-site. However, community-level specialist shortages may impede access to care. OBJECTIVE Compare gynecologist supply in veterans' county of residence versus at their VA site. DESIGN We identified women veteran VA patients from fiscal year (FY) 2017 administrative data and assessed availability of a VA gynecologist within 50 miles (hereafter called "local") of veterans' VA homesites (per national VA organizational survey data). For the same cohort, we then assessed community-level gynecologist availability; counties with < 2 gynecologists/10,000 women (per the Area Health Resource File) were "inadequate-supply" counties. We examined the proportion of women veterans with local VA gynecologist availability in counties with inadequate versus adequate gynecologist supply, stratified by individual and VA homesite characteristics. Chi-square tests assessed statistical differences. PARTICIPANTS All women veteran FY2017 VA primary care users nationally. MAIN MEASURES Availability of a VA gynecologist within 50 miles of a veteran's VA homesite; county-level "inadequate-supply" of gynecologists. KEY RESULTS Among 407,482 women, 9% were in gynecologist supply deserts (i.e., lacking local VA gynecologist and living in an inadequate-supply county). The sub-populations with the highest proportions in gynecologist supply deserts were rural residents (24%), those who got their primary care at non-VAMC satellite clinics (13%), those who got their care at a site without a women's clinic (13%), and those with American Indian or Alaska Native (12%), or white (12%) race. Among those in inadequate-supply counties, 59.9% had gynecologists at their local VA; however, 40.1% lacked a local VA gynecologist. CONCLUSIONS Most veterans living in inadequate-supply counties had local VA gynecology care, reflecting VA's critical role as a safety net provider. However, for those in gynecologist supply deserts, expanded transportation options, modified staffing models, or tele-gynecology hubs may offer solutions to extend VA gynecology capacity.
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Affiliation(s)
- Sarah Friedman
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA, USA.
- School of Public Health, University of Nevada Reno, Reno, NV, USA.
| | - Jonathan G Shaw
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA, USA
- Stanford University School of Medicine, Stanford, CA, USA
| | - Alison B Hamilton
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Kavita Vinekar
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Donna L Washington
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Kristin Mattocks
- VA Central Western Massachusetts Healthcare System, Leeds, MA, USA
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Elizabeth M Yano
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
- Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA, USA
| | - Ciaran S Phibbs
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA, USA
- Stanford University School of Medicine, Stanford, CA, USA
- VA Health Economics Resource Center, Menlo Park, CA, USA
| | | | - Fay Saechao
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Eric Berg
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Susan M Frayne
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA, USA
- Stanford University School of Medicine, Stanford, CA, USA
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10
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Fortney JC, Carey EP, Rajan S, Rise PJ, Gunzburger EC, Felker BL. A Comparison of Patient-Reported Mental Health Outcomes for the Department of Veterans Affairs' Regional Telehealth and Community Care Programs. Health Serv Res 2022; 57:755-763. [PMID: 35467011 PMCID: PMC9264470 DOI: 10.1111/1475-6773.13993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objectives To compare patient‐reported outcomes for veterans with limited access to Department of Veterans Affairs (VA) mental health services referred to the Veterans Community Care Program (VCCP) or regional telehealth Clinical Resource Hubs‐Mental Health (CRH‐MH). Data Sources This national evaluation used secondary data from the VA Corporate Data Warehouse, chart review, and primary data collected by baseline survey between October 8, 2019 and May 27, 2020 and a 4‐month follow‐up survey. Study Design A quasi‐experimental longitudinal study design was used to sample 545 veterans with VCCP or CRH‐MH referrals for new treatment episodes. Patient‐reported outcomes included symptom severity, perceived access, utilization, and patient‐centeredness. Data Collection During the baseline and follow‐up surveys, all veterans were administered the Patient Health Questionnaire‐8 (PHQ‐8) to assess depression severity, and veterans with a provisional diagnosis of posttraumatic stress disorder (PTSD) were also administered the PTSD Checklist for DSM‐5 (PCL‐5) to assess PTSD symptom severity. The 4‐month follow‐up survey also asked about perceived access using the Perceived Access Inventory, the number of encounters, and patient‐centeredness of care using the Patient‐Centered Care portion of the Veterans Satisfaction Survey. Principal Findings Results indicated that compared to VCCP consults, veterans with CRH‐MH consults reported 0.65 (CI95 = 0.51–0.83, p < 0.01) times the number of barriers to care, but a non‐significant lower number of encounters (−0.792, CI95 −2.221, 0.636, p = 0.28). There was no significant (p = 0.24) difference in satisfaction with patient‐centeredness, with both groups “agreeing” on average to positively worded questions. Veterans in both groups experienced little improvement in depression or PTSD symptom severity, and there were no clinically meaningful differences between groups. Conclusions Overall findings indicate that the CRH‐MH and VCCP generate similar patient‐reported outcomes. Future research should compare the quality and cost of care delivered by the VCCP and CRH‐MH programs.
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Affiliation(s)
- John C Fortney
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA.,Department of Veterans Affairs, Health Services Research and Development, Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, USA
| | - Evan P Carey
- Department of Biostatistics & Informatics, University of Colorado Anschutz Medical Campus, Denver, Colorado, USA.,Department of Veterans Affairs, Health Services Research and Development, Center of Innovation for Veteran-Centered and Value-Driven Care, Denver, Colorado, USA
| | - Suparna Rajan
- Department of Veterans Affairs, Health Services Research and Development, Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, USA
| | - Peter J Rise
- Department of Veterans Affairs, Health Services Research and Development, Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, USA
| | - Elise C Gunzburger
- Department of Veterans Affairs, Health Services Research and Development, Center of Innovation for Veteran-Centered and Value-Driven Care, Denver, Colorado, USA
| | - Bradford L Felker
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA.,Department of Veterans Affairs, Health Services Research and Development, Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, USA
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11
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Zulman DM, Greene L, Slightam C, Singer SJ, Maciejewski ML, Goldstein MK, Vanneman ME, Yoon J, Trivedi RB, Wagner T, Asch SM, Boothroyd D. Outpatient care fragmentation in Veterans Affairs patients at high-risk for hospitalization. Health Serv Res 2022; 57:764-774. [PMID: 35178702 PMCID: PMC9264453 DOI: 10.1111/1475-6773.13956] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 01/28/2022] [Accepted: 02/01/2022] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To examine outpatient care fragmentation and its association with future hospitalization among patients at high risk for hospitalization. DATA SOURCES Veterans Affairs (VA) and Medicare data. STUDY DESIGN We conducted a longitudinal study, using logistic regression to examine how outpatient care fragmentation in FY14 (as measured by number of unique providers, Breslau's Usual Provider of Care (UPC), Bice-Boxerman's Continuity of Care Index (COCI), and Modified Modified Continuity Index (MMCI)) was associated with all-cause hospitalizations and hospitalizations related to ambulatory care sensitive conditions (ACSC) in FY15. We also examined how fragmentation varied by patient's age, gender, race, ethnicity, marital status, rural status, history of homelessness, number of chronic conditions, Medicare utilization, and mental healthcare utilization. DATA EXTRACTION METHODS We extracted data for 130,704 VA patients ≥65 years old with a hospitalization risk ≥90th percentile and ≥ four outpatient visits in the baseline year. PRINCIPAL FINDINGS Mean (standard deviation) of FY14 outpatient visits was 13.2 (8.6). Fragmented care (more providers, less care with a usual provider, more dispersed care based on COCI) was more common among patients with more chronic conditions and those receiving mental health care. In adjusted models, most fragmentation measures were not associated with all-cause hospitalization, and patients with low levels of fragmentation (more concentrated care based on UPC, COCI, and MMCI) had a higher likelihood of an ACSC-related hospitalization (AOR, 95% CI = 1.21 (1.09-1.35), 1.27 (1.14-1.42), and 1.28 (1.18-1.40), respectively). CONCLUSIONS Contrary to expectations, outpatient care fragmentation was not associated with elevated all-cause hospitalization rates among VA patients in the top 10th percentile for risk of admission; in fact, fragmented care was linked to lower rates of hospitalization for ACSCs. In integrated settings such as the VA, multiple providers and dispersed care might offer access to timely or specialized care that offsets risks of fragmentation, particularly for conditions that are sensitive to ambulatory care.
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Affiliation(s)
- Donna M Zulman
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California, United States.,Department of Medicine, Stanford University School of Medicine, Stanford, California, United States
| | - Liberty Greene
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California, United States.,Department of Medicine, Stanford University School of Medicine, Stanford, California, United States
| | - Cindie Slightam
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California, United States
| | - Sara J Singer
- Department of Medicine, Stanford University School of Medicine, Stanford, California, United States
| | - Matthew L Maciejewski
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina, United States.,Department of Population Health Sciences, Duke University, Durham, North Carolina, United States
| | - Mary K Goldstein
- Office of Geriatrics and Extended Care, Veterans Health Administration.,Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, California, United States
| | - Megan E Vanneman
- Informatics, Decision-Enhancement and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, Utah, United States.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, United States.,Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - Jean Yoon
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, United States.,Department of General Internal Medicine, UCSF School of Medicine, San Francisco, California, United States
| | - Ranak B Trivedi
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California, United States.,Division of Public Mental Health and Population Sciences, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, United States
| | - Todd Wagner
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, United States.,Department of Surgery, Stanford University School of Medicine, Palo Alto, California, United States
| | - Steven M Asch
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California, United States.,Department of Medicine, Stanford University School of Medicine, Stanford, California, United States
| | - Derek Boothroyd
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California, United States.,Quantitative Sciences Unit, Stanford University School of Medicine, Palo Alto, California, United States
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12
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Rose L, Aouad M, Graham L, Schoemaker L, Wagner T. Association of Expanded Health Care Networks With Utilization Among Veterans Affairs Enrollees. JAMA Netw Open 2021; 4:e2131141. [PMID: 34698845 PMCID: PMC8548943 DOI: 10.1001/jamanetworkopen.2021.31141] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
IMPORTANCE Health insurers alter the size of their networks, offering lower premiums in exchange for a more limited set of care choices. However, little is known about the association of network size with health care utilization and outcomes, particularly outside of the context of private insurance plans. OBJECTIVE To evaluate changes in health care utilization after an expansion in the Veterans Affairs Health Care System (VA) health care network. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study included individuals enrolled in the VA from 2015 to 2018. Considering that the health care network expansion only affected a portion of enrollees, only those who lived between 20 and 60 miles from a VA facility were included. Data analysis was conducted from September 2020 to February 2021. EXPOSURES Individuals who lived 40 or more miles away from a VA facility were automatically eligible for an expanded health care network through non-VA practitioners (VA community care); those living less than 40 miles away from a VA facility were not automatically eligible. MAIN OUTCOMES AND MEASURES A regression discontinuity analysis of individuals who became eligible for an expanded network based on geographic residence was performed. Inpatient and outpatient utilization rates per VA enrollee during the study period, with utilization differentiated by whether services were provided by a VA or non-VA practitioner, were calculated. RESULTS The study included more than 2.7 million unique individuals whose characteristics largely reflected the demographic characteristics of the VA system (mean [SD] age, 62 [17] years; 2 589 252 [90%] men; 282 168 [10%] Black; 2 203 352 [77%] White). Patient characteristics (age, race, and comorbidities) did not vary significantly by eligibility status. Outpatient utilization was 3.2% higher (95% CI, 1.0% to 5.3%) among those with access to an expanded network. Increased utilization was most pronounced among those with a higher VA disability rating (3.1%; 95% CI, 0.5% to 5.7%) and among younger individuals without service-connected disabilities (7.0%, 95% CI, 1.7% to 12.3%). There was no evidence of changes to inpatient utilization (1.2%; 95% CI. -2.5% to 4.9%; P = .37) for those with access to the expanded network. CONCLUSIONS AND RELEVANCE In this study, expanded network access was associated with increased total health care utilization among affected enrollees in the VA. Understanding how network size affects utilization is immediately informative for the VA, but it can also help to guide policies for insurance markets.
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Affiliation(s)
- Liam Rose
- Health Economics Resource Center, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
- Stanford Surgery Policy Improvement Research and Education Center, Stanford School of Medicine, Stanford, California
| | - Marion Aouad
- Department of Economics, University of California, Irvine
| | - Laura Graham
- Health Economics Resource Center, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
- Stanford Surgery Policy Improvement Research and Education Center, Stanford School of Medicine, Stanford, California
| | - Lena Schoemaker
- Health Economics Resource Center, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
| | - Todd Wagner
- Health Economics Resource Center, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
- Stanford Surgery Policy Improvement Research and Education Center, Stanford School of Medicine, Stanford, California
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13
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Penney LS, Bharath PS, Miake-Lye I, Leng M, Olmos-Ochoa TT, Finley EP, Chawla N, Barnard JM, Ganz DA. Toolkit and distance coaching strategies: a mixed methods evaluation of a trial to implement care coordination quality improvement projects in primary care. BMC Health Serv Res 2021; 21:817. [PMID: 34391443 PMCID: PMC8364700 DOI: 10.1186/s12913-021-06850-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 07/12/2021] [Indexed: 11/29/2022] Open
Abstract
Background Care coordination tools and toolkits can be challenging to implement. Practice facilitation, an active but expensive strategy, may facilitate toolkit implementation. We evaluated the comparative effectiveness of distance coaching, a form of practice facilitation, for improving the implementation of care coordination quality improvement (QI) projects. Methods We conducted a mixed methods evaluation of the Coordination Toolkit and Coaching (CTAC) initiative. Twelve matched US Veterans Health Administration primary care clinics were randomized to receive coaching and an online care coordination toolkit (“coached”; n = 6) or access to the toolkit only (“non-coached”; n = 6). We did interviews at six, 12, and 18 months. For coached sites, we‘ly collected site visit fieldnotes, prospective coach logs, retrospective coach team debriefs, and project reports. We employed matrix analysis using constructs from the Consolidated Framework for Implementation Research and a taxonomy of outcomes. We assessed each site’s project(s) using an adapted Complexity Assessment Tool for Systematic Reviews. Results Eleven sites implemented a local CTAC project. Eight sites (5 coached, 3 non-coached) used at least one tool from the toolkit. Coached sites implemented significantly more complex projects than non-coached sites (11.5 vs 7.5, 95% confidence interval 1.75–6.25, p < 0.001); engaged in more formal implementation processes (planning, engaging, reflecting and evaluating); and generally had larger, more multidisciplinary QI teams. Regardless of coaching status, sites focused on internal organizational improvement and low-intensity educational projects rather than the full suite of care coordination tools. At 12 months, half the coached and non-coached sites had clinic-wide project implementation; the remaining coached sites had implemented most of their project(s), while the remaining non-coached sites had either not implemented anything or conducted limited pilots. At 18 months, coached sites reported ongoing effort to monitor, adapt, and spread their CTAC projects, while non-coached sites did not report much continuing work. Coached sites accrued benefits like improved clinic relationships and team QI skill building that non-coached sites did not describe. Conclusions Coaching had a positive influence on QI skills of (and relationships among) coached sites’ team members, and the scope and rigor of projects. However, a 12-month project period was potentially too short to ensure full project implementation or to address cross-setting or patient-partnered initiatives. Trial registration NCT03063294. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06850-1.
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Affiliation(s)
- Lauren S Penney
- Elizabeth Dole Center of Excellence for Veteran & Caregiver Research, South Texas Veterans Health Care System, San Antonio, TX, USA. .,Department of Medicine, University of Texas Health San Antonio, San Antonio, TX, USA.
| | - Purnima S Bharath
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Sepulveda, CA, USA.,Fielding School of Public Health, University of California at Los Angeles, Los Angeles, CA, USA
| | - Isomi Miake-Lye
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Sepulveda, CA, USA.,Fielding School of Public Health, University of California at Los Angeles, Los Angeles, CA, USA
| | - Mei Leng
- David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | - Tanya T Olmos-Ochoa
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Sepulveda, CA, USA
| | - Erin P Finley
- Elizabeth Dole Center of Excellence for Veteran & Caregiver Research, South Texas Veterans Health Care System, San Antonio, TX, USA.,Department of Medicine, University of Texas Health San Antonio, San Antonio, TX, USA.,HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Sepulveda, CA, USA
| | - Neetu Chawla
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Sepulveda, CA, USA
| | - Jenny M Barnard
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Sepulveda, CA, USA
| | - David A Ganz
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Sepulveda, CA, USA.,David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA.,RAND Corporation, Santa Monica, California, USA
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14
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Kinney RL, Haskell S, Relyea MR, DeRycke EC, Walker L, Bastian LA, Mattocks KM. Coordinating women's preventive health care for rural veterans. J Rural Health 2021; 38:630-638. [PMID: 34310743 DOI: 10.1111/jrh.12609] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE As the number of women veterans receiving care from the Veterans Health Administration (VHA) continues to increase, so does the need to access gender-specific preventive health care services through the VHA. In rural areas, women veterans are the numeric minority, so many preventive screenings are performed outside of the VA by community providers. As the numbers of veterans utilizing both VHA and non-VHA providers for their preventive care continue to increase, so does the need to coordinate this care. This research examines the role of the Women Veterans' Care Coordinator (WVCC) at rural facilities and their perceptions of coordinating preventive care. METHODS Between March and July 2019, semi-structured telephone interviews were conducted with WVCCs at 26 rural VA facilities. Each interview was digitally recorded and transcribed verbatim. Transcripts were loaded into Atlas.ti for further analysis. Once the codes were refined, the investigators coded the 26 interviews independently and conferred to achieve consensus on the underlying themes. FINDINGS Five themes arose from the WVCC interviews: (1) Rural women veterans have varying needs of coordination; (2) Fragmented communication between the VA and non-VA care settings hinders effective coordination; (3) Difficulties in prioritizing rural care coordination; (4) Care coordination impacts patient care; and (5) WVCC recommendations to improve rural care coordination. CONCLUSIONS The recent addition of WVCCs to rural facilities has expanded the VA's reach to veterans living in the most rural areas. As a result, many of these women are now receiving timely, quality, and coordinated health care.
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Affiliation(s)
- Rebecca L Kinney
- VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts, USA
| | - Sally Haskell
- VA CT Healthcare System, West Haven, Connecticut, USA.,Yale School of Medicine, New Haven, Connecticut, USA
| | - Mark R Relyea
- VA CT Healthcare System, West Haven, Connecticut, USA.,Yale School of Medicine, New Haven, Connecticut, USA
| | - Eric C DeRycke
- VA CT Healthcare System, West Haven, Connecticut, USA.,Yale School of Medicine, New Haven, Connecticut, USA
| | - Lorrie Walker
- VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts, USA
| | - Lori A Bastian
- VA CT Healthcare System, West Haven, Connecticut, USA.,Yale School of Medicine, New Haven, Connecticut, USA
| | - Kristin M Mattocks
- VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts, USA.,University of Massachusetts Medical School, Worcester, Massachusetts, USA
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15
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Tummalapalli SL, Vittinghoff E, Hoggatt KJ, Keyhani S. Preventive Care Delivery After the Veterans Choice Program. Am J Prev Med 2021; 61:55-63. [PMID: 33820664 PMCID: PMC8217145 DOI: 10.1016/j.amepre.2021.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 01/12/2021] [Accepted: 01/15/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The Veterans Choice Program expanded Veteran access to community care. The Veterans Choice Program may negatively impact the receipt of preventive care services owing to care fragmentation. This study assesses 10 measures of preventive care in Veterans with the Department of Veterans Affairs coverage before and after the Veterans Choice Program. METHODS The study population included Veterans who responded to the National Health Interview Survey during the 2 time periods before and after Veterans Choice Program implementation: January 2011-October 2014 and November 2015-December 2018. Outcomes were preventive care services categorized as cardiovascular risk reduction (cholesterol monitoring, blood pressure monitoring, aspirin use), infectious disease prevention (influenza vaccination and HIV testing), and diabetes care (fasting blood glucose monitoring, podiatry visits, ophthalmology visits, influenza vaccination, and pneumonia vaccination). Two different analyses were conducted: (1) unadjusted and multivariable-adjusted pre-post analysis and (2) difference-in-differences analyses. Analyses were conducted in 2019. RESULTS Measures of cardiovascular risk reduction and influenza vaccination were not statistically different before and after Veterans Choice Program implementation using the 2 different analytic approaches. In unadjusted pre-post analysis, after Veterans Choice Program implementation, Veterans with Veterans Affairs coverage had increased HIV testing (66.1%‒75.4%, p=0.008), podiatry visits (22.4%‒38.3%, p=0.01), and ophthalmology visits (62.2%‒77.2%, p=0.02). Using multivariable adjustment for participant sociodemographic factors, Veterans Choice Program implementation was associated with higher odds of podiatry visits (AOR=2.28, 95% CI=1.24, 4.20, p=0.009) and ophthalmology visits (AOR=2.11, 95% CI=1.13, 3.94, p=0.02) among Veterans with diabetes. In difference-in-differences analyses, Veterans Choice Program implementation was associated with increased podiatry visits (AOR=2.95, 95% CI=1.49, 5.83, p=0.002) among Veterans with diabetes and Veterans Affairs coverage compared with that among those with other coverage types, but no statistically significant effect was observed for ophthalmology visits. CONCLUSIONS Veterans with Veterans Affairs coverage and diabetes had an increase in podiatry visits after Veterans Choice Program implementation. There was no evidence that Veterans Choice Program implementation had a negative impact on the receipt of preventive care services among Veterans with Veterans Affairs coverage.
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Affiliation(s)
- Sri Lekha Tummalapalli
- Division of Healthcare Delivery Science & Innovation, Department of Population Health Sciences, Weill Cornell Medicine, New York, New York; Department of Medicine, University of California San Francisco, San Francisco, California.
| | - Eric Vittinghoff
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, California
| | - Katherine J Hoggatt
- Department of Medicine, University of California San Francisco, San Francisco, California; San Francisco VA Health Care System, San Francisco, California
| | - Salomeh Keyhani
- Department of Medicine, University of California San Francisco, San Francisco, California; San Francisco VA Health Care System, San Francisco, California
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16
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Mattocks KM, Kroll-Desrosiers A, Kinney R, Elwy AR, Cunningham KJ, Mengeling MA. Understanding VA's Use of and Relationships With Community Care Providers Under the MISSION Act. Med Care 2021; 59:S252-S258. [PMID: 33976074 PMCID: PMC8132889 DOI: 10.1097/mlr.0000000000001545] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Congress has enacted 2 major pieces of legislation to improve access to care for Veterans within the Department of Veterans Affairs (VA). As a result, the VA has undergone a major transformation in the way that care is delivered to Veterans with an increased reliance on community-based provider networks. No studies have examined the relationship between VA and contracted community providers. This study examines VA facility directors' perspectives on their successes and challenges building relationships with community providers within the VA Community Care Network (CCN). OBJECTIVES To understand who VA facilities partner with for community care, highlight areas of greatest need for partnerships in various regions, and identify challenges of working with community providers in the new CCN contract. RESEARCH DESIGN We conducted a national survey with VA facility directors to explore needs, challenges, and expectations with the CCN. RESULTS The most common care referred to community providers included physical therapy, chiropractic, orthopedic, ophthalmology, and acupuncture. Open-ended responses focused on 3 topics: (1) Challenges in working with community providers, (2) Strategies to maintain strong relationships with community providers, and (3) Re-engagement with community providers who no longer provide care for Veterans. CONCLUSIONS VA faces challenges engaging with community providers given problems with timely reimbursement of community providers, low (Medicare) reimbursement rates, and confusing VA rules related to prior authorizations and bundled services. It will be critical to identify strategies to successfully initiate and sustain relationships with community providers.
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Affiliation(s)
- Kristin M. Mattocks
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester
- VA Central Western Massachusetts Healthcare System, Leeds
| | - Aimee Kroll-Desrosiers
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester
- VA Central Western Massachusetts Healthcare System, Leeds
| | - Rebecca Kinney
- VA Central Western Massachusetts Healthcare System, Leeds
| | - Anashua R. Elwy
- Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA
- Department of Psychiatry and Human Behavior, Alpert Medical School, Brown University, Providence, RI
| | | | - Michelle A. Mengeling
- Center for Access & Delivery Research and Evaluation (CADRE) and Veterans Rural Health Resource Center-Iowa City (VRHRC-IC), Iowa City VA Health Care System
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
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17
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Davila H, Rosen AK, Beilstein-Wedel E, Shwartz M, Chatelain L, Gurewich D. Rural Veterans' Experiences With Outpatient Care in the Veterans Health Administration Versus Community Care. Med Care 2021; 59:S286-S291. [PMID: 33976078 PMCID: PMC8132914 DOI: 10.1097/mlr.0000000000001552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The 2014 Veterans Access, Choice and Accountability Act was intended to improve Veterans' access to timely health care by expanding their options to receive community care (CC) paid for by the Veterans Health Administration (VA). Although CC could particularly benefit rural Veterans, we know little about rural Veterans' experiences with CC. OBJECTIVE The objective of this study was to compare rural Veterans' experiences with CC and VA outpatient health care services to those of urban Veterans and examine changes over time. RESEARCH DESIGN Retrospective, cross-sectional study using data from the Survey of Healthcare Experiences of Patients (SHEP) and VA Corporate Data Warehouse. Subjects: All Veterans who responded to the SHEP survey in Fiscal Year (FY) 16 or FY19. MEASURES Outcomes were 4 measures of care experience (Access, Communication, Coordination, and Provider Rating). Independent variables included care setting (CC/VA), rural/urban status, and demographic and clinical characteristics. RESULTS Compared with urban Veterans, rural Veterans rated CC the same (for specialty care) or better (for primary care). Rural Veterans reported worse experiences in CC versus VA, except for specialty care Access. Rural Veterans' care experiences improved between FY16 and FY19 in both CC and VA, with greater improvements in CC. CONCLUSIONS Rural Veterans' reported comparable or better experiences in CC compared with urban Veterans, but rural Veterans' CC experiences still lagged behind their experiences in VA for primary care. As growing numbers of Veterans use CC, VA should ensure that rural and urban Veterans' experiences with CC are at least comparable to their experiences with VA care.
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Affiliation(s)
- Heather Davila
- VA Boston Healthcare System
- Boston University School of Medicine
| | - Amy K. Rosen
- VA Boston Healthcare System
- Boston University School of Medicine
| | | | - Michael Shwartz
- VA Boston Healthcare System
- Boston University Questrom School of Business, Boston, MA
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Hynes DM, Edwards S, Hickok A, Niederhausen M, Weaver FM, Tarlov E, Gordon H, Jacob RL, Bartle B, O’Neill A, Young R, Laliberte A. Veterans' Use of Veterans Health Administration Primary Care in an Era of Expanding Choice. Med Care 2021; 59:S292-S300. [PMID: 33976079 PMCID: PMC8132904 DOI: 10.1097/mlr.0000000000001554] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND The Veterans Choice Program (VCP), aimed at improving access to care, included expanded options for Veterans to receive primary care through community providers. OBJECTIVES The objective of this study was to characterize and compare Veterans use of Veterans Health Administration (VA) primary care services at VA facilities and through a VA community care network (VA-CCN) provider. RESEARCH DESIGN This was a retrospective, observational over fiscal years (FY) 2015-2018. SUBJECTS Veterans receiving primary care services paid for by the VA. MEASURES Veteran demographic, socioeconomic and clinical factors and use of VA primary care services under the VCP each year. RESULTS There were 6.3 million Veterans with >54 million VA primary care visits, predominantly (98.5% of visits) at VA facility. The proportion of VA-CCN visits increased in absolute terms from 0.7% in 2015 to 2.6% in 2018. Among Veterans with any VA-CCN primary care, the proportion of VA-CCN visits increased from 22.6% to 55.3%. Logistic regression indicated that Veterans who were female, lived in rural areas, had a driving distance >40 miles, had health insurance or had a psychiatric/depression condition were more likely to receive VA-CCN primary care. Veterans who were older, identified as Black race, required to pay VA copayments, or had a higher Nosos score, were less likely to receive VA-CCN primary care. CONCLUSION As the VA transitions from the VCP to MISSION and VA facilities gain experience under the new contracts, attention to factors that impact Veterans' use of primary care services in different settings are important to monitor to identify access barriers and to ensure Veterans' health care needs are met.
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Affiliation(s)
- Denise M. Hynes
- US Department of Veterans Affairs (VA), VA Portland Healthcare System, Center to Improve Veteran Involvement in Care (CIVIC), Portland
- College of Public Health and Human Sciences, Oregon State University, Corvallis
- School of Nursing
| | - Samuel Edwards
- US Department of Veterans Affairs (VA), VA Portland Healthcare System, Center to Improve Veteran Involvement in Care (CIVIC), Portland
- School of Medicine, Oregon Health and Science University
| | - Alex Hickok
- US Department of Veterans Affairs (VA), VA Portland Healthcare System, Center to Improve Veteran Involvement in Care (CIVIC), Portland
| | - Meike Niederhausen
- US Department of Veterans Affairs (VA), VA Portland Healthcare System, Center to Improve Veteran Involvement in Care (CIVIC), Portland
- Oregon Health and Science University, Oregon Health and Science University-Portland State University School of Public Health, Portland, OR
| | - Frances M. Weaver
- US Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare (CINCCH), Hines
- Parkinson School of Health Sciences and Public Health, Loyola University, Maywood
| | - Elizabeth Tarlov
- US Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare (CINCCH), Hines
- University of Illinois at Chicago, College of Nursing
| | - Howard Gordon
- US Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare (CINCCH), Hines
- US Department of Veterans Affairs, Jesse Brown VA Medical Center and University of Illinois at Chicago, College of Medicine, Chicago, IL
| | - Reside L. Jacob
- US Department of Veterans Affairs (VA), VA Portland Healthcare System, Center to Improve Veteran Involvement in Care (CIVIC), Portland
| | - Brian Bartle
- US Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare (CINCCH), Hines
| | - Allison O’Neill
- US Department of Veterans Affairs (VA), VA Portland Healthcare System, Center to Improve Veteran Involvement in Care (CIVIC), Portland
| | - Rebecca Young
- US Department of Veterans Affairs (VA), VA Portland Healthcare System, Center to Improve Veteran Involvement in Care (CIVIC), Portland
| | - Avery Laliberte
- US Department of Veterans Affairs (VA), VA Portland Healthcare System, Center to Improve Veteran Involvement in Care (CIVIC), Portland
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Hodgson A, Bernardin T, Westermeyer B, Hagopian E, Radtke T, Noman A. Development of a specialty intensity score to estimate a patient's need for care coordination across physician specialties. Health Sci Rep 2021; 4:e303. [PMID: 34084946 PMCID: PMC8142625 DOI: 10.1002/hsr2.303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 04/25/2021] [Accepted: 04/27/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUNDS AND AIMS This article develops a Specialty Intensity Score, which uses patient diagnosis codes to estimate the number of specialist physicians a patient will need to access. Conceptually, the score can serve as a proxy for a patient's need for care coordination across doctors. Such a measure may be valuable to researchers studying care coordination practices for complex patients. In contrast with previous comorbidity scores, which focus primarily on mortality and utilization, this comorbidity score approximates the complexity of a patient's the interaction with the health care system. METHODS We use 2015 inpatient claims data from the Centers for Medicare and Medicaid Services to model the relationship between a patient's diagnoses and physician specialty usage. We estimate usage of specialist doctors by using a least absolute shrinkage and selection operator Poisson model. The Specialty Intensity Score is then constructed using this predicted specialty usage. To validate our score, we test its power to predict the occurrence of patient safety incidents and compare that with the predictive power of the Charlson comorbidity index. RESULTS Our model uses 127 of the 279 International Classification of Disease, 10th Revision, Clinical Modification (ICD-10-CM) diagnosis subchapters to predict specialty usage, thus creating the Specialty Intensity Score. This score has significantly greater power in predicting patient safety complications than the widely used Charlson comorbidity index. CONCLUSION The Specialty Intensity Score developed in this article can be used by health services researchers and administrators to approximate a patient's need for care coordination across multiple specialist doctors. It, therefore, can help with evaluation of care coordination practices by allowing researchers to restrict their analysis of outcomes to the patients most impacted by those practices.
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20
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Garvin LA, Pugatch M, Gurewich D, Pendergast JN, Miller CJ. Interorganizational Care Coordination of Rural Veterans by Veterans Affairs and Community Care Programs: A Systematic Review. Med Care 2021; 59:S259-S269. [PMID: 33976075 PMCID: PMC8132902 DOI: 10.1097/mlr.0000000000001542] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In the unique context of rural Veterans' health care needs, expansion of US Department of Veterans Affairs and Community Care programs under the MISSION Act, and the uncertainties of coronavirus disease 2019 (COVID-19), it is critical to understand what may support effective interorganizational care coordination for increased access to high-quality care. OBJECTIVES We conducted a systematic review to examine the interorganizational care coordination initiatives that Veterans Affairs (VA) and community partners have pursued in caring for rural Veterans, including challenges and opportunities, organizational domains shaping care coordination, and among these, initiatives that improve or impede health care outcomes. RESEARCH DESIGN We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to search 2 electronic databases (PubMed and Embase) for peer-reviewed articles published between January 2009 and May 2020. Building on prior research, we conducted a systematic review. RESULTS Sixteen articles met our criteria. Each captured a unique health care focus while examining common challenges. Four organizational domains emerged: policy and administration, culture, mechanisms, and relational practices. Exemplars highlight how initiatives improve or impede rural health care delivery. CONCLUSIONS This is the first systematic review, to our knowledge, examining interorganizational care coordination of rural Veterans by VA and Community Care programs. Results provide exemplars of interorganizational care coordination domains and program effectiveness. It suggests that partners' efforts to align their coordination domains can improve health care, with rurality serving as a critical contextual factor. Findings are important for policies, practices, and research of VA and Community Care partners committed to improving access and health care for rural Veterans.
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Affiliation(s)
- Lynn A. Garvin
- United States Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA
| | - Marianne Pugatch
- United States Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, Benioff Children’s Hospital, University of California, San Francisco, San Francisco, CA
| | - Deborah Gurewich
- United States Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System
- Department of Medicine, Boston University School of Medicine
| | - Jacquelyn N. Pendergast
- United States Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System
| | - Christopher J. Miller
- United States Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System
- Department of Psychiatry, Harvard Medical School, Boston, MA
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21
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Sells JR, McQuaid JR. VA Academic Affiliations Matter in the Era of Community Care: A Model From California. Fed Pract 2021; 38:174-182. [PMID: 34177222 DOI: 10.12788/fp.0114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background The Veterans Health Administration (VHA), 1 of 3 administrative branches in the US Department of Veterans Affairs (VA), is the largest integrated health care system in the United States. The VHA has 4 missions: providing health care to eligible veterans; supporting research to benefit veterans and the larger society; providing education for health care trainees; and supporting emergency response. Observations In service of these goals, the VA has academic affiliations with training institutions throughout the country, offering unique and extensive training and research opportunities. These affiliations are a 2-way street where both the VA and the affiliate provide and gain from their partnership. For example, VA affiliations with University of California (UC) medical schools benefit veteran care and are a major contributor to the UC academic mission. This article explores the history of the VA, current veteran demographics and needs, academic affiliations, and the integrated care model of training in all VHA facilities. The VA and UC academic affiliation system is described further with regard to shared research and educational functions. Conclusions We identify risks to academic affiliations if a shift occurs from VHA care to VA-managed community-based care following the implementation of recent legislation. We also provide suggestions for VA academic affiliates to help assess and guide the potential impact of increased VA-managed community care.
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Affiliation(s)
- Joanna R Sells
- is a US Department of Veterans Affairs (VA) and University of California, San Francisco (UCSF) Quality Scholar Psychology Fellow. is Associate Chief of Staff for Mental Health, both at the San Francisco VA Health Care System and Vice Chair, Department of Psychiatry Weill Institute of Neuroscience, UCSF
| | - John R McQuaid
- is a US Department of Veterans Affairs (VA) and University of California, San Francisco (UCSF) Quality Scholar Psychology Fellow. is Associate Chief of Staff for Mental Health, both at the San Francisco VA Health Care System and Vice Chair, Department of Psychiatry Weill Institute of Neuroscience, UCSF
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22
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Reasons Older Veterans Use the Veterans Health Administration and Non-VHA Care in an Urban Environment. J Am Board Fam Med 2021; 34:291-300. [PMID: 33832997 PMCID: PMC9036939 DOI: 10.3122/jabfm.2021.02.200332] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 11/03/2020] [Accepted: 11/03/2020] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Older veterans in urban settings rely less on the Veterans Health Administration (VHA) health care, suggesting deficits of access and services for aging veterans. We aimed to identify reasons for VHA and non-VHA use across the health status of older, urban-dwelling veterans. METHODS We examined open-ended responses from 177 veterans who were enrolled in primary care at the Bronx VA Medical Center, used non-VHA care in prior 2 years, and completed baseline interviews in a care coordination trial from March 2016 to August 2017. Using content analysis, we coded and categorized key terms and concepts into an established access framework. This framework included 5 categories: acceptability (relationship, second opinion), accessibility (distance, travel); affordability; availability (supply, specialty care); and accommodation (organization, wait-time). Self-reported health status was stratified by excellent/very good, good, and fair/poor. RESULTS We were able to categorize the responses of 166 veterans, who were older (≥75 years, 61%), minority race and ethnicity (77%), and low income (<$25,000/y, 51%). Veterans mentioned acceptability (42%) and accessibility (37%) the most, followed by affordability (33%), availability (25%), and accommodation (11%). With worse self-reported health status, accessibility intensified (excellent/very good, 24%; fair/poor, 46%; P = .031) particularly among minority veterans, while acceptability remained prominent (excellent/very good, 49%; fair/poor, 37%; P = .25). Other categories were mentioned less with no significant difference across health status. CONCLUSIONS Even in an urban environment, proximity was a leading issue with worse health. Addressing urban accessibility and coordination for older, sicker veterans may enhance care for a growing vulnerable VHA population.
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23
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Kaul B, Hynes DM, Hickok A, Smith C, Niederhausen M, Totten AM, Whooley MA, Sarmiento K. Does Community Outsourcing Improve Timeliness of Care for Veterans With Obstructive Sleep Apnea? Med Care 2021; 59:111-117. [PMID: 33290324 PMCID: PMC7899214 DOI: 10.1097/mlr.0000000000001472] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Providing timely access to care has been a long-standing priority for the Veterans Affairs Healthcare System. Recent strategies to reduce long wait times have focused on purchasing community care by a fee-for-service model. Whether outsourcing Veterans Affairs (VA) specialty care to the community improves access is unclear. OBJECTIVES We compared time from referral to treatment among Veterans whose care was provided by VA versus community care purchased by the VA, using obstructive sleep apnea as an example condition. METHODS This was a retrospective cohort study of Northern California Veterans seeking sleep apnea care through the San Francisco VA Healthcare System between 2012 and 2018. We used multivariable linear regression with propensity score matching to investigate the relationship between time to care delivery and care setting (VA provided vs. VA-purchased community care). A total of 1347 Northern California Veterans who completed sleep apnea testing within the VA and 88 Veterans who completed sleep apnea testing in the community had complete data for analysis. RESULTS Among Northern California Veterans with obstructive sleep apnea, outsourcing of care to the community was associated with longer time from referral to therapy (mean±SD, 129.6±82.8 d with VA care vs. 252.0±158.8 d with community care, P<0.001) and greater loss to follow-up. CONCLUSIONS These findings suggest that purchasing community care may lead to care fragmentation and not improve wait times nor improve access to subspecialty care for Veterans.
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Affiliation(s)
- Bhavika Kaul
- San Francisco Veterans Affairs Healthcare System
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Denise M. Hynes
- Center of Innovation to Improve Veteran Involvement in Care, VA Portland Healthcare System, Portland
- Health Management and Policy, College of Public Health and Human Services, and Center for Genome Research and Biocomputing, Oregon State University, Corvallis, OR
| | - Alex Hickok
- Center of Innovation to Improve Veteran Involvement in Care, VA Portland Healthcare System, Portland
| | - Connor Smith
- Department of Clinical Epidemiology and Medical Informatics
| | - Meike Niederhausen
- Center of Innovation to Improve Veteran Involvement in Care, VA Portland Healthcare System, Portland
- OHSU-PSU School of Public Health, Oregon Health & Science University, Portland, OR
| | - Annette M. Totten
- Department of Clinical Epidemiology and Medical Informatics
- OHSU-PSU School of Public Health, Oregon Health & Science University, Portland, OR
| | - Mary A. Whooley
- San Francisco Veterans Affairs Healthcare System
- Department of Medicine, University of California San Francisco, San Francisco, CA
- Quality Enhancement Research Initiative, Veterans Health Administration, Washington, DC
| | - Kathleen Sarmiento
- San Francisco Veterans Affairs Healthcare System
- Department of Medicine, University of California San Francisco, San Francisco, CA
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24
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Ayele RA, Liu W, Rohs C, McCreight M, Mayberry A, Sjoberg H, Kelley L, Glasgow RE, Rabin BA, Battaglia C. VA Care Coordination Program Increased Primary Care Visits and Improved Transitional Care for Veterans Post Non-VA Hospital Discharge. Am J Med Qual 2020; 36:221-228. [PMID: 32772849 DOI: 10.1177/1062860620946362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Veterans are increasingly eligible for non-VA care through the Veteran Health Administration (VA) Maintaining Internal Systems and Strengthening Integrated Outside Networks Act while maintaining care in the VA. Continuity of care is challenging when delivered across multiple systems resulting in avoidable complications. The Community Hospital Transitions Program (CHTP) intervention was developed to address challenges veterans face post non-VA hospitalization. Propensity score-matched analysis was used to compare outcomes between 334 intervention and matched control patients who were discharged from non-VA hospitals. Veterans in CHTP were more likely than matched controls to receive a follow-up appointment within 14 days (mean: 0.43 vs 0.34, P < .05) and 30 days (mean: 0.62 vs 0.50, P < .05). There were no significant differences in 30-day readmissions or 30-day emergency department visits. CHTP veterans received timely follow-up care post discharge in VA facilities. Providing quality care to dual-use veterans is dependent on coordinated transitional care.
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Affiliation(s)
- Roman A Ayele
- Department of Veterans Affairs, Eastern Colorado Health Care System, Aurora, CO University of Colorado, Anschutz Medical Campus, Aurora, CO University of California San Diego, San Diego, CA
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25
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Vanneman ME, Wagner TH, Shwartz M, Meterko M, Francis J, Greenstone CL, Rosen AK. Veterans' Experiences With Outpatient Care: Comparing The Veterans Affairs System With Community-Based Care. Health Aff (Millwood) 2020; 39:1368-1376. [PMID: 32744943 PMCID: PMC10031805 DOI: 10.1377/hlthaff.2019.01375] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Timely access to outpatient care was a primary driver behind the Department of Veterans Affairs' (VA's) increased purchase of community-based care under the Veterans Access, Choice, and Accountability Act of 2014, known as the Choice Act. To compare veterans' experiences in VA-delivered and community-based outpatient care after implementation of the act, we assessed veterans' scores on four dimensions of experience-access, communication, coordination, and provider rating-for outpatient specialty, primary, and mental health care received during 2016-17. Patient experiences were better for VA than for community care in all respects except access. For specialty care, access scores were better in the community; for primary and mental health care, access scores were similar in the two settings. Although all specialty care scores and the primary care coordination score improved over time, the gaps between settings did not shrink. As purchased care further expands under the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018, which replaced the Choice Act in 2019, monitoring of meaningful differences between settings should continue, with the results used to inform both VA purchasing decisions and patients' care choices.
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Affiliation(s)
- Megan E Vanneman
- Megan E. Vanneman is a core investigator and Career Development Award recipient at the Veterans Affairs (VA) Salt Lake City's Informatics, Decision-Enhancement and Analytic Sciences Center, in Salt Lake City, Utah
| | - Todd H Wagner
- Todd H. Wagner is the director of the Health Economics Resource Center and assistant director and research career scientist at the VA Palo Alto Health Care System's Center for Innovation to Implementation, in Menlo Park, California
| | - Michael Shwartz
- Michael Shwartz is an investigator at the VA Boston Healthcare System's Center for Healthcare Organization and Implementation Research, in Boston, Massachusetts
| | - Mark Meterko
- Mark Meterko is a survey methodologist in the Office of Reporting, Analytics, Performance, Improvement, and Deployment at the ENRM Veterans Affairs Medical Center, in Bedford, Massachusetts
| | - Joseph Francis
- Joseph Francis is the chief improvement and analytics officer in the Office of Reporting, Analytics, Performance, Improvement, and Deployment at the Veterans Health Administration, Department of Veterans Affairs, in Washington, D.C
| | - Clinton L Greenstone
- Clinton L. Greenstone is the deputy executive director of clinical integration in the Office of Community Care at the Veterans Health Administration, Department of Veterans Affairs
| | - Amy K Rosen
- Amy K. Rosen is a core investigator and senior research career scientist at the VA Boston Healthcare System's Center for Healthcare Organization and Implementation Research
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Cordasco KM, Hynes DM, Mattocks KM, Bastian LA, Bosworth HB, Atkins D. Improving Care Coordination for Veterans Within VA and Across Healthcare Systems. J Gen Intern Med 2019; 34:1-3. [PMID: 31098970 PMCID: PMC6542920 DOI: 10.1007/s11606-019-04999-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Kristina M Cordasco
- VA Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation and Policy, Los Angeles, CA, USA.
- Division of General Internal Medicine, Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
- Department of Medicine, University of California Los Angeles (UCLA) Geffen School of Medicine, Los Angeles, CA, USA.
| | - Denise M Hynes
- Center to Improve Veteran Involvement in Care, Portland VA Health Care System, Portland, OR, USA
- College of Public Health and Human Sciences, Oregon State University, Corvallis, OR, USA
| | - Kristin M Mattocks
- VA Central Western Massachusetts, Leeds, MA, USA
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Lori A Bastian
- Pain Research, Informatics, Multimorbidities and Education Center, VA Connecticut, West Haven, CT, USA
- Division of General Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Hayden B Bosworth
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Medical Center, Durham, NC, USA
- Departments of Population Health Sciences, Medicine, Psychiatry, and School of Nursing, Duke University, Durham, NC, USA
| | - David Atkins
- VA Health Services Research and Development Services, Office of Research and Development, Washington, DC, USA
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Cordasco KM, Frayne SM, Kansagara D, Zulman DM, Asch SM, Burke RE, Post EP, Fihn SD, Klobucar T, Meyer LJ, Kirsh SR, Atkins D. Coordinating Care Across VA Providers and Settings: Policy and Research Recommendations from VA's State of the Art Conference. J Gen Intern Med 2019; 34:11-17. [PMID: 31098966 PMCID: PMC6542870 DOI: 10.1007/s11606-019-04970-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Delivering well-coordinated care is essential for optimizing clinical outcomes, enhancing patient care experiences, minimizing costs, and increasing provider satisfaction. The Veterans Health Administration (VA) has built a strong foundation for internally coordinating care. However, VA faces mounting internal care coordination challenges due to growth in the number of Veterans using VA care, high complexity in Veterans' care needs, the breadth and depth of VA services, and increasing use of virtual care. VA's Health Services Research and Development service with the Office of Research and Development held a conference assessing the state-of-the-art (SOTA) on care coordination. One workgroup within the SOTA focused on coordination between VA providers for high-need Veterans, including (1) Veterans with multiple chronic conditions; (2) Veterans with high-intensity, focused, specialty care needs; (3) Veterans experiencing care transitions; (4) Veterans with severe mental illness; (5) and Veterans with homelessness and/or substance use disorders. We report on this workgroup's recommendations for policy and organizational initiatives and identify questions for further research. Recommendations from a separate workgroup on coordinating VA and non-VA care are contained in a companion paper. Leaders from research, clinical services, and VA policy will need to partner closely as they develop, implement, assess, and spread effective practices if VA is to fully realize its potential for delivering highly coordinated care to every Veteran.
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Affiliation(s)
- Kristina M Cordasco
- VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA. .,Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA. .,Department of Medicine, University of California Los Angeles (UCLA) Geffen School of Medicine, Los Angeles, CA, USA.
| | - Susan M Frayne
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA, USA.,Women's Health Section, VA Palo Alto Health Care System, Palo Alto, CA, USA.,Division of Primary Care and Population Health, Stanford University, Stanford, CA, USA
| | - Devan Kansagara
- VA Portland Healthcare System, Portland, OR, USA.,Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Donna M Zulman
- Women's Health Section, VA Palo Alto Health Care System, Palo Alto, CA, USA.,VA Portland Healthcare System, Portland, OR, USA
| | - Steven M Asch
- Women's Health Section, VA Palo Alto Health Care System, Palo Alto, CA, USA.,VA Portland Healthcare System, Portland, OR, USA
| | - Robert E Burke
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA.,Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Edward P Post
- VA Center for Clinical Management Research, Ann Arbor, MI, USA.,University of Michigan Medical School, Ann Arbor, MI, USA
| | - Stephan D Fihn
- VA Office of Clinical System Development and Evaluation, Seattle, WA, USA.,VA Puget Sound Health Care System, Seattle, WA, USA.,Department of Health Services and Department of Medicine, University of Washington, Seattle, WA, USA
| | | | - Laurence J Meyer
- VA Office of Specialty Care Services, Washington, DC, USA.,VA Salt Lake City Health Care System, Salt Lake City, UT, USA.,University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Susan R Kirsh
- Office of Veterans Access to Care, Washington, DC, USA.,Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA.,Department of Medicine, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - David Atkins
- VA Office of Research and Development, Health Services Research and Development, Washington, DC, USA
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