Health Services Research & Development

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Spotlight: QUERI Initiatives to Improve Access to Care

July 2014


Established in 1998, the VA's Quality Enhancement Research Initiative (QUERI) Program is devoted to improving Veteran care by supporting the implementation of effective treatments or programs into clinical practice. Currently there are QUERI centers devoted to improving access to and quality of care for particular conditions of high impact for Veterans, including:

Working actively with VA regional and national partners, QUERI investigators have been involved in several initiatives focused on improving access to and quality of care for Veterans, such as implementing effective treatment or programs outside of the traditional clinic walls, engaging frontline providers and Veterans in designing methods to improve access to care, and identifying the best strategies for implementing effective treatments or programs in routine care. A number of QUERI-funded projects focus on enhancing access to care across a wide range of conditions ranging from cardiovascular disease to mental health, and employ a variety of treatment modalities (e.g., telehealth, web-based programs) that are tailored to support frontline providers and incorporate Veteran preferences.

QUERI investigators also have developed implementation strategies that are being used to enhance access to effective treatments or programs. Common elements in these strategies include:

  • Obtaining input and support in implementing effective clinical practices from various VA stakeholders,
  • Disseminating training and coaching techniques to support frontline providers and practices in delivering effective practices, and
  • Ongoing monitoring and quality improvement.

Increasingly, QUERI investigators are also engaging Veterans and other consumers of healthcare in research or quality improvement activities to support the implementation and sustainability of strategies that are being designed and developed to improve access to effective treatments or programs.

HSR&D and QUERI Research on Access

The following are descriptions of just a few of the HSR&D/QUERI studies that will help the VA healthcare system improve access to optimal healthcare for all Veterans.

Video-Conferencing Shared Medical Appointments to Improve Diabetes Care

Despite data showing the success of Share Medical Appointments (SMAs) in the VA healthcare system in improving care for Veterans with diabetes, the spread and access of these services is limited in rural areas due to lack of healthcare specialists of different disciplines and skill sets to conduct SMAs. This geographic barrier may be overcome by another VHA telehealth initiative – video-clinical encounters (referred to as video-SMAs). The overall objective of this QUERI study is to improve diabetes care at VA healthcare facilities without local expertise through video-SMAs, and to conduct a trial to evaluate the efficacy and processes of delivery of this intervention. More specifically, investigators will:

  • Compare the change in A1c, blood pressure and lipid values for Veterans with diabetes before and after receiving video-SMA;
  • Explore the risk-adjusted change in A1c, blood pressure and LDL cholesterol values after the intervention for any Veteran with diabetes (intervened or not) at the video-SMA site versus a control site; and
  • Evaluate changes in provider practice patterns, obstacles of Veterans' self-care that can be overcome by the video-SMA, as well as user satisfaction.

In addition to the potential benefits of SMAs in diabetes care for Veterans, it is expected that local providers will have increased interaction with off-site experts in diabetes care and decision support in the co-management of their patients.

Implementation Facilitation Strategy Enhances Access to Mental Healthcare in Primary Care Settings

Implementation of evidence-based practices (EBPs) is complex, challenging, and rarely sustained. There is evidence that ongoing facilitation can foster EBP implementation. Mental Health-QUERI investigators had previously developed an implementation facilitation (IF) strategy that combines an external facilitator (expert in implementation science and specific EBPs) with a network-level internal facilitator (individual familiar with clinic-level structures, climates, and practices), who, with mentoring, develops expertise in implementation facilitation. This QUERI study tested the effectiveness of the IF strategy versus standard national support on patient outcomes, provider behavior change, and changes in Veterans' service utilization in the context of VA's requirements for primary-care mental health integration (PC-MHI). Investigators also collected data on facilitation process, activities, and time. Findings show that compared to non-IF sites, at IF sites, during both evaluation periods:

  • PC patients were more likely to be seen in PC-MHI,
  • PC providers were more likely to refer patients to PC-MHI, and
  • A greater proportion of providers' patients were referred to PC-MHI,

These findings suggest that sites receiving facilitation to help providers implement PC-MHI more robustly and maintain their gains over time.

An analysis of the process revealed that facilitation helped overcome organizational barriers. In addition, organizational context and stakeholders' needs seemed to play a substantial role in what facilitators did and when they did it. In terms of person hours, facilitators' top three activities were preparation and planning, stakeholder engagement, and education. Stakeholders and facilitators believed that facilitators ideally possess certain characteristics and skills; however, it is possible that coaching and mentoring may help those who do not possess these to obtain them.

Before the study was complete, VA Operations invited investigators to partner with them to incorporate the IF strategy into Operations' efforts to support national implementation of PC-MHI. Therefore, this project has cemented partnerships with national VHA operational leaders, continues to have significant impacts on VA's efforts to ensure that all Veterans have access to needed mental health services, and has informed national policy and planning task forces and other research studies.

Kirchner J, Kearney L, Ritchie M, et al. Research and services partnerships: Lessons learned through a national partnership between clinical leaders and researchers. Psychiatric Services. May 2014;65(5):577-9.

Ritchie M, Dollar K, Kearney L, and Kirchner J. Research and services partnerships: Responding to needs of clinical operations partners: transferring implementation facilitation knowledge and skills. Psychiatric Services. February 2014;65(2):141-3.

Kirchner J, Ritchie M, Dollar K, et al. Implementation Facilitation Training Manual: Using External and Internal Facilitation to Improve Care in the Veterans Health Administration. North Little Rock, AK, US Department of Veterans Affairs, Health Services Research and Development, Mental Health Quality Enhancement Research Initiative, 2013. Available at http://www.queri.research.va.gov/tools/implementation/Facilitation-Manual.pdf

Online Interventions Facilitate Access to Mental Healthcare for Women Veterans

This QUERI study examined web-based screening and tailored education (Web-Ed) to address post-deployment mental health and readjustment concerns. Investigators studied 214 OEF/OIF/OND Reserve and National Guard (RNG) servicewomen who returned from deployment in Iraq or Afghanistan within the prior three years. Telephone interviews were used to determine participant's Web-Ed perceptions, satisfaction, and consequent healthcare utilization two months after Web-Ed participation. Findings showed that:

  • 72% of the servicewomen in this study agreed or strongly agreed that they would recommend Web-Ed to others;
  • 54% indicated they received information through Web-Ed that they might not have otherwise (regarding their post-deployment readjustment and mental health); and
  • 27% reported that the Web-Ed had reduced their discomfort with seeking care.

Web-Ed also appeared to activate servicewomen to seek care. More than one-third (36%) of the servicewomen acknowledged that as a direct result of Web-Ed they would follow up with a VA provider, and 32% said they would follow-up with an outside provider. Servicewomen who participated in the follow-up interviews (N=77) indicated they liked the confidentiality and accessibility of Web-Ed. Almost half (48%) of the servicewomen reported that they would have liked someone from the VA to call them soon after they had completed the screenings to answer questions or to help them make a VA appointment. In addition, most participants (82%) would like their screening results linked to a VA secure network (such as My HealtheVet) so that healthcare providers could access them, and three-quarters of the servicewomen (77%) said they would be more likely to ask questions or send a secure message to a VA provider about their results if was.

These findings suggest that Web-Ed can engage and activate vulnerable and high-risk RNG female populations to seek needed post-deployment mental healthcare.

Improving Access to Care via Video Telehealth for Veterans with Spinal Cord Injury

VA provides comprehensive, life-long services to Veterans with spinal cord injury and disorders (SCI/D) through a "hub and spokes" system of care that includes 24 SCI centers (hubs) and 134 facilities (spokes) that have SCI primary care teams. Across the VA healthcare system, telehealth programs have been implemented to allow Veterans to access services in their home, and at clinics or facilities that are closer to home than the nearest SCI Center. Clinical video telehealth (CVT) programs allow patients to communicate with providers in their home or between different healthcare facilities. Understanding the issues associated with implementing CVT SCI centers – and in the spoke sites will provide the basis for future work to enhance implementation. Therefore, this SCI-QUERI study will examine best practices and challenges associated with implementing different models of CVT for Veterans with SCI/D. Investigators also sought to identify potential strategies that could be used to enhance implementation.

Results of this study will provide knowledge about the successes and challenges that SCI spoke sites are experiencing while implementing CVT, and the strategies that providers are using to overcome these challenges. This information will help VA providers in offering CVT as a treatment option for Veterans with SCI/D. Preliminary results from provider interviews suggest that Veterans are highly satisfied with CVT because it provides access to specialty care while decreasing travel burden, and that it increases coordination.

Using the results of this study, QUERI investigators are working with clinical and operational partners to develop implementation strategies that can be used to increase and enhance the use of CVT to increase access to care for Veterans with SCI/D.

Expanding Access to Outreach Services for Homeless Veterans with Serious Mental Illness

In a landmark quality improvement study by the VHA Office of the Medical Inspector (OMI), Veterans with serious mental illness (i.e., schizophrenia and bipolar disorder) who re-engaged in VA healthcare had a 12-fold decreased risk of mortality compared to Veterans who were not brought back into care (0.5% versus 6%). Given the success of this program, HSR&D investigators in collaboration with National Center on Homelessness among Veterans sought to adapt this approach to re-engage Veterans who are homeless or are at risk of homelessness, starting with the most vulnerable groups, such as Veterans with serious mental illness (SMI). In addition, the VA Office of Mental Health Services recommended that the program be implemented in concert with ongoing VA recovery-oriented initiatives. Therefore, the primary aim of this HSR&D study is to observe the implementation of a program to identify Veterans with a history of homelessness – and an SMI diagnosis – who have dropped out of VA healthcare. Principal outcomes include outpatient treatment engagement (number of medical or mental health visits), employment, housing, hospitalizations, and mortality.

Investigators in this study also will determine whether a centralized facilitation program can assist local Homelessness Points of Contact (HPCs) or local Recovery Coordinators (LRCs) in re-engaging these Veterans in healthcare, housing, and other social services. Secondary aims include:

  • Determining the pathways to healthcare, housing, and other social services used by Veterans with SMI contacted by LRCs/HPCs;
  • Identifying organizational factors associated with the use of social services and time to receipt of services; and
  • Describing how implementation of the re-engagement program is affected by organizational variation in provision of services to Veterans.

    Dissemination of new VA resources for homeless Veterans requires a better understanding of how to efficiently identify the most vulnerable Veterans and enhance access to these services to optimize outcomes. Findings from this study will help improve how health and social services can most efficiently be provided for homeless Veterans with serious mental illness.

    Kilbourne A, Abraham K, Goodrich D, et al. Cluster randomized adaptive implementation trial comparing a standard versus enhanced implementation intervention to improve uptake of an effective re-engagement program for patients with serious mental illness. Implementation Science. November 2013; 8(1):136.

    Birgenheir D, Lai Z, and Kilbourne A. Datapoints: Trends in mortality among homeless VA patients with severe mental illness. Psychiatric Services. July 2013;64(7):608.