VHA's Priorities for Strategic Action
Spotlight on Access: Access in Depth
The following three articles represent just some of the important HSR&D research on access, which contributes to improving Veterans' access to optimal healthcare.
Redefining How We Measure Access to Healthcare in the Digital Age
Many e-health and m-health technologies are now available to promote virtual patient-provider communication outside the context of face-to-face clinical encounters. Digital communication modalities include smartphones, interactive video, web-based portals, and secure chat rooms, to name a few. However, traditional conceptualizations and indicators of access are not well suited to measure access to health services that are delivered digitally.
John Fortney, PhD
John Fortney, PhD, part of HSR&D's Center of Innovation for Veteran-Centered and Value-Driven Care in Seattle, WA, has been working with VA and HSR&D colleagues to rethink how access is measured. This conversation began in 2010 at HSR&D's state-of-the-art conference on "Improving Access to Care," where invited VA and non-VA participants, including researchers, clinicians, and policymakers, convened to identify what we know and need to know about the relationship of access to the needs of patients, healthcare utilization, and patient outcomes. One of the main recommendations that came from this SOTA was to develop and validate actual and perceived metrics of Veteran-centered access to both VA and non-VA services.
Toward this goal, a new access model was created that would highlight the importance of measuring how Veterans perceive their access to care rather than more standard measures, such as the number of available providers or wait-times to a patient's first appointment. In other words, access would represent the "fit" between the clinical needs of patients and the ability of the healthcare system to meet those needs. This new access model also features a framework of Veterans' perceived access to care that targets five conceptual domains:
- Geographical (ease of travel),
- Temporal (time convenience),
- Financial (eligibility, complexity, affordability),
- Cultural (understandability, trust, stigma), and
- Digital (connectivity opportunities, usability, and privacy).1
Building on this work, HSR&D's CREATE: Improving Rural Veterans' Access/Engagement in Evidence-Based Mental Healthcare, led by Dr. Jeffrey Pyne at the HSR&D Center for Mental Healthcare and Outcomes Research, will develop a patient-centered survey instrument to measure perceived access to mental healthcare that Veterans prefer and believe to be effective. This study of Veterans' perceived access to mental health treatments pays particular attention to e-health technologies or virtual care. In addition, he will develop a Perceived Access Inventory (PAI) that will allow policymakers and researchers to identify geographic areas and/or VA facilities with low perceived access to care - and to measure changes in perceived access following the implementation of interventions designed to improve access to mental healthcare.
1. Fortney J, Burgess J, Bosworth H, et al. A re-conceptualization of access for 21st century healthcare. Journal of General Internal Medicine. November 2011;26(2):639-647.
Improving Access to Care: Telehealth Collaborative Care for Veterans with HIV
Michael Ohl, MD, MSPH
Michael Ohl, MD, MSPH, and colleagues at HSR&D's Center for Comprehensive Access and Delivery Research and Evaluation (CADRE) have been working to improve access to high-quality care for Veterans with HIV infection that reside in rural settings. VA is the largest provider of HIV care in the United States, with approximately 26,000 Veterans in care. Since the late 1980s, VA has concentrated care for Veterans with HIV in specialty clinics that focus on treating patients with infectious diseases. These specialty clinics are generally located in large facilities in urban areas. This specialty-centered approach has provided high quality HIV care, but it has two significant limitations in the modern era of highly-effective HIV medicines.
First, Veterans in rural and small urban areas often face travel burdens when obtaining care in these specialty clinics. Approximately 16% of Veterans with HIV live in rural areas, and 24% live more than an hour drive from the nearest infectious disease specialty clinic. Second, in the modern era of highly effective HIV medicines, infectious disease specialty clinics often lack the capacity to provide routine primary care for an aging population of Veterans with HIV. Veterans who reliably take HIV medicines will have an essentially normal lifespan, and are increasingly dealing with common health problems associated with aging, such as high blood pressure, diabetes, and heart disease. Thus, there is need for new models for delivering HIV care that improve access for Veterans in rural areas, and that provide high-quality primary care for an aging population of Veterans with HIV.
With support from an HSR&D Career Development Award (CDA 11-211), Dr. Ohl has developed a telehealth collaborative care model that provides accessible and comprehensive care for aging Veterans with HIV in rural areas. This model combines infectious disease specialty care delivered using telemedicine with local primary care delivered in VA clinics serving rural areas. In this model, nurse care coordinators use VA's integrated electronic health record and case registries to coordinate local primary care with specialty care delivered using telemedicine. A pilot study in Iowa City found that 96% of Veterans with HIV chose to use the telehealth collaborative care model instead of travelling to the distant specialty clinic for care. In addition, the quality of HIV care remained high in the telehealth program, with more than 90% of Veterans maintaining an undetectable level of HIV in their blood while on medicines.1
Dr. Ohl is currently working VA's Office of Rural Health (ORH) to spread this telehealth collaborative care model to the Dallas, San Antonio, and Houston VA facilities, which serve large areas of Texas. This work will provide detailed and rigorous evidence about the overall effectiveness of the HIV telehealth collaborative care model, in order to inform HIV care in rural areas, both within and outside the VA healthcare system.
1. Ohl ME, Moeckli J, Ono S, et al. Mixed methods evaluation of a telehealth collaborative care program for persons with HIV infection in a rural setting. Journal of General Internal Medicine. 2013 Sep;28(9):1165-1173.
Changes in Veteran-Centered Access and Wait Times
Julia Prentice, PhD
More than a decade ago, the Institute of Medicine identified timely access to healthcare, including improving wait times, as an essential way to improve healthcare in the United States. About the same time, Congress requested that VA systematically measure how long Veterans waited for outpatient care when concerns surfaced regarding excessive wait times. Initially, VA measured access by calculating the number of days between the time a Veteran requested an appointment and the first available appointment in the scheduling system. However, VA recognized that these metrics measured overall supply of clinical appointments, but did not take into account the Veteran's actual experience of care.
Appointment wait times remain an essential measure of access, as the healthcare system continues to struggle with long wait times. Moreover, wait times for outpatient care are expected to increase with the implementation of the Patient Protection and Affordable Care Act that expands health insurance coverage. A study led by Julia Prentice, PhD part of HSR&D/QUERI's Partnered Evidence-Based Policy Resource Center and Health Care Financing and Economics (HCFE), examined the relationship between wait-time measures and patient satisfaction for 221,540 Veterans who had responded to the 2010 Survey of Healthcare Experiences of Patients (SHEP) - an ongoing nation-wide survey used to obtain patient feedback on VA inpatient and outpatient care. Overall, satisfaction with access to VA care was high. More than 80% of Veterans reported obtaining appointments as soon as they wanted them, and found it easy to obtain treatments or specialist appointments. More than 75% of Veterans rated VA care in the past 12 months in the top two categories, and more than 80% did the same for satisfaction with the most recent VA healthcare visit. Wait times were measured separately for new and returning patients and different wait-time measures predicted satisfaction for these two groups of patients. New patients typically want to be seen as soon as possible, perhaps due to a change in health status that is causing concern. Wait time measures that focus on the amount of time between appointment request and scheduled or completed appointments predict satisfaction for new patients. In contrast, returning patients may prioritize convenient appointment times or continuity of care over how long they are waiting for appointments. For these patients, wait time measures that accounted for patient scheduling preferences predicted satisfaction better. Consequently, healthcare systems should utilize a wider variety of wait-time measures than are popular in current practice, because different new and returning wait-time measures were associated with patient satisfaction.1
Access to Specialty Consult Appointments
Recent preliminary work suggests that patients referred to specialty care are likely to have new concerns and want to be seen as soon as possible after the need for a referral is identified. Veterans visiting facilities with longer wait times for specialty consults report lower satisfaction when assessed using a metric with consult "appointment request" date as the starting point. Notably, a metric that measured the time it took to complete behind the scenes administrative processes (e.g., transferring the consult) had no relationship to patient satisfaction. As VA continues to put a greater emphasis on the experiences of patients, these findings indicate that metrics should focus on measuring tangible processes that patients easily understand as action being taken on their behalf, such as scheduling appointments.
Currently, HSR&D researchers are examining whether the new access metrics that measure wait times and were required by the Veterans Access, Choice and Accountability Act (Choice Act) of 2014 reliably predict patient satisfaction. As VA continues to reorganize and provide comprehensive services outside traditional appointments, more comprehensive access metrics that reflect patient experiences with non-traditional encounters (e.g., telemedicine using digital technology) will also be needed. Researchers will need to validate these new metrics by demonstrating that better reported performance is associated with increased patient satisfaction.2
1. Prentice J, Davies M, and Pizer S. Which outpatient wait-time measures are related to patient satisfaction? American Journal of Medical Quality. May-June 2014;29(3):227-235.
2. Prentice J. The evolution of veteran-centric access metrics. FORUM. October, 2015.