BACKGROUND/RATIONALE:
Under the Veterans Choice Act, the Veterans Choice Program (VCP) provides community-based care to eligible Veterans when, for various reasons (e.g., long wait times), their local VAMC cannot provide those services. However, the VCP faced significant barriers during early implementation, leaving it unclear whether providing community-based care for Veterans reduced wait-times for appointments or was of comparable quality to VA care, particularly for complex conditions such as posttraumatic stress disorder (PTSD). Providers treating patients with PTSD require levels of training and support frequently unavailable outside of VA in order to deliver high-quality care. This multi-disciplinary project evaluated how effectively VCP implementation in the first year of the program met the needs of Veterans with PTSD, in collaboration with VA's National Center for PTSD and the Office of Rural Health.

OBJECTIVE(S):
Surveys conducted among Veterans with PTSD and community-based mental health and primary care providers addressed the following objectives:

-Compare characteristics and experiences of care for Veterans with PTSD in Texas and Vermont reporting different patterns of Choice Program eligibility and utilization.
-Compare characteristics, perceptions and experiences of the Choice Program, and use of appropriate care practices among community providers in Texas and Vermont.
-Identify patient-, provider-, and community-level factors associated with utilization of and satisfaction with the Choice Program for Veterans with PTSD.

METHODS:
We first used a crosswalk of VA administrative data to identify Veterans with service connection for PTSD living in two states with marked geographic and population diversity - Texas and Vermont. We then conducted a survey of community-based mental health and primary care providers in the two states to assess participation in VCP, experiences and satisfaction with VCP, perceived barriers and facilitators, and preferred care practices for patients with PTSD. Third, we conducted a survey of Veterans with PTSD to identify knowledge and attitudes about VCP, self-reported utilization of VA and non-VA PTSD care services, and experiences of and satisfaction with VCP. Finally, we integrated patient- and provider-level information with Geographic Information Systems (GIS) data to clarify geographic and community factors impacting access to and quality of care for Veterans with PTSD since implementation of VCP.

FINDINGS/RESULTS:
Characteristics and experiences of VCP care for Veterans with PTSD:

Relatively few Veterans with service connection for PTSD accessed VCP for mental healthcare during the program's first year. Of 73,156 Veterans residing in Texas and 1,416 Veterans residing in Vermont with PTSD service-connection, there were only 6825 total requests for any VCP care in Texas and only 127 in Vermont as of September 30, 2015; only 237 of these requests were for mental health care.

Out of 427 Veterans in Texas and Vermont with service connection for PTSD responding to our survey, 55% had sought professional care for PTSD from the VA in the previous 12 months. Of these, 30% were unable to get an appointment in a VA facility within 30 days, and 45% were more than a 40-mile driving distance from the nearest VA facility, with a total of 66% reporting some eligibility for services under VCP. Among those eligible, 88% reported preferring VA for PTSD care, primarily due to a good relationship with an existing VA provider or being generally satisfied with VA care. The median score for overall quality of PTSD care at a VA facility was 8 out of 10; median score for overall quality of PTSD care received from a VCP provider, among the few Veterans who reported accessing such care (n=12), was 6 out of 10.

Perceptions and experiences of the Choice Program among community providers:

We received 553 responses from a general survey of community mental health and primary care providers in the two states; only 10% of prescribers and 7% of psychotherapists from this sample reported any participation in VCP or PC3. We also received 115 responses from a parallel sample of providers listed as VCP/PC3 participants, of whom only 16% of providers identified themselves as receiving any fee-basis, VCP, or PC3 reimbursement from VA. Providers across all samples reported interest in becoming a VCP provider and learning more about guideline-recommended treatments (GRTs) for PTSD. Few providers in either sample reported actively attempting to become a VCP provider (n=21) and of those, only 12 reported currently serving as a VCP provider. Providers who reported having attempted to become a VCP provider reported low mean satisfaction with the process (4.85 of possible 10). Mean satisfaction among current VCP providers was slightly higher (6.0). Examination of open-ended responses revealed that respondents were frequently dissatisfied with their communications with VA and/or the TPAs (TriWest in Texas; HealthNet in Vermont) and felt VCP processes were "inefficient" or "disorganized".

Assessing variations in appropriateness of PTSD care:

Relatively few community-based providers reported using GRTs for PTSD. Although more than half of psychotherapists reported use of at least one GRT among patients with PTSD, fewer than a third reported frequently utilizing core components of or having received supervision or advanced training in the GRT they use. Even fewer (25%) reported consistently following a PTSD treatment manual. Suboptimal prescribing for PTSD patients was reported more commonly than optimal prescribing across the general sample, although SNRIs and SSRIs were frequently used as first-line medications for PTSD. Despite their contraindication for patients with PTSD, benzodiazepines were prescribed "often" or "always" for patients with PTSD by 15% of providers overall (20% when prescribing for sleep-related symptoms was taken into account). Psychiatric specialty was not a guarantee of more optimal prescribing.

Community factors associated with Choice Program participation:

Spatial analyses indicate a shortage of mental health and primary care providers in rural areas across both Texas and Vermont. Urban Veterans with PTSD are also affected by this lack of available providers, particularly in Texas.

IMPACT:
Because of its complexity and high prevalence, PTSD may provide an important example for understanding the implications of Care in the Community for conditions requiring specialty care. While guideline-recommended psychotherapy and prescribing for PTSD are widely available at VA, providers in community settings may not always be located in rural areas or have adequate training or experience in use of guideline-recommended treatments for PTSD. Relatively few Veterans with service connection for PTSD made use of VCP care for any mental health concern in the program's initial year, and many reported significant confusion about VCP eligibility and how to access the program.

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External Links for this Project

NIH Reporter

Grant Number: I50HX001971-01
Link: https://reporter.nih.gov/project-details/9033438

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PUBLICATIONS:

None at this time.

DRA: Health Systems
DRE: Epidemiology, Treatment - Observational
Keywords: none
MeSH Terms: none