1079 — Access to emergency care for Veterans: factors influencing setting choice

Lead/Presenter: Anita Vashi,  COIN - Palo Alto
All Authors: Vashi AA (VA Palo Alto HCS), Wong E (VA Health Economics Resource Center) Egelfeld, J (VA Palo Alto HCS) Asch, S (VA Palo Alto HCS) Nevedal, A (Ann Arbor VA)

Objectives:
VA both delivers emergency care in its own facilities and, increasingly, purchases care for Veterans in the community. Changes in emergency care payment authorities, notification processes, and reimbursement rates have simplified the process of approving and paying for community emergency care. As a result, VA has experienced increased demand for community-based emergency care and emergency care is now the single largest contributor to VA community care spending. No study to date has examined Veteran decision-making as it relates to ED setting choice. Better understanding of this decision-making process is paramount in improving and developing programs and policies to promote equitable access to emergency care, prevent costly delays in treatment, and provide insights into the value of community-based ED care. In this study, we used qualitative methods to identify and describe the reasons that Veterans use or do not use VA and community (non-VA) emergency care when acute care needs arise.

Methods:
VA data were used to identify Veterans who recently used emergency care. We conducted semi-structured, qualitative interviews with 50 Veterans to understand the factors influencing Veterans’ ED setting choice. Interviews were audio recorded and we conducted directed content analysis of interview transcripts. Our data collection and analysis were guided by a conceptual model that integrates two existing frameworks and contained the following domains: 1) Community resources (e.g., availability of EDs in their community, distance/travel time) 2) Condition specific needs (e.g., acuity); 3) Financial factors (e.g., affordability); 4) Preferences (e.g., prior experiences, trust).

Results:
Of the 50 Veterans in our geographically diverse sample, 78% were male and 48% were over 65. The majority (34/50) of Veterans preferred VA care and did so for a variety of reasons including: appreciation for the VA mission, inviting atmosphere of VA, and confidence in VA providers. Self-perceived severity and/or urgency of their condition (condition specific needs) was the most cited factor from our model influencing where Veterans decided to go for ED care. We identified three different patterns of Veterans’ decision making when seeking ED care: (1) Veterans prefer to go to the closest ED, which is often a community ED, especially for acute conditions; (2) Veterans will drive farther to obtain care at a VA ED due to preferences and financial concerns; (3) Veterans with similar geographic access to VA and community EDs, usually chose VA care.

Implications:
To our knowledge, this is the first study to elucidate the factors Veterans consider when choosing between VA and community EDs. As reflected in our conceptual model, Veteran’s decision-making is made in the context of community resources, condition-specific needs, financial considerations, and preferences.

Impacts:
This study provides key insights into how Veterans weigh and prioritize key factors when accessing emergency care, and how these factors interact to form distinct decision-making patterns. These results provide a foundation for identifying mutable system characteristics and policy levers that may improve timely access to emergency care. Finally, understanding the barriers Veterans face in community ED settings is vitally important as an increasing number of Veterans are treated in community EDs.