Health Services Research & Development

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Improving Access to Care for Veterans

December 2017


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Research topic page on Access

VA’s most important mission is providing high-quality healthcare and benefits when and where Veterans need it.1 Through various ways such as the Veterans Transportation Service (VTS), Telehealth, and digital resources such as My HealtheVet and VA Apps, VA takes an active role in improving access to care.2

On April 7, 2014 the Veterans Access, Choice, and Accountability Act (Choice Act) was signed into law. The primary provision of the Choice Act was to expand access to medical services from community providers to eligible Veterans. In FY 2016, VA approved approximately 19 million claims (a 13% increase over FY2015) for Veterans receiving care from community providers.3 Secretary Shulkin further emphasized VA’s commitment to Veterans by extending mental healthcare to Veterans with other-than-honorable discharges.4

A significant part of HSR&D’s mission is to identify and evaluate innovative strategies leading to accessible, cost-effective, high-quality care for Veterans.5 Following are descriptions and findings from several specific research projects conducted by HSR&D and QUERI investigators on issues critical to improving Veterans’ access to quality care.

Improving Access and Outcomes for Rural Veterans with HIV

In large cities, persons with HIV often receive care in high-volume HIV specialty clinics that employ co-located interdisciplinary care teams. Prior research has demonstrated that rural-living Veterans who seek VA care for HIV infection, having no access to these clinics, enter care with more advanced illness, are less likely to be early adopters of important advances in HIV therapy, and experience higher mortality than their urban counterparts. This study sought to better determine gaps in and barriers to care for rural Veterans with HIV, and to develop and evaluate an innovative delivery model using existing VA telehealth resources. Findings were:

  • Rural Veterans in care for HIV infection had to travel nearly four times as far for VA infectious disease specialty care (86 minutes vs 23 minutes for urban Veterans).
  • Despite travel burdens, the majority of rural Veterans who used infectious disease (ID) specialty care received antiretroviral therapy (95%) and had an undetectable viral load on therapy (83%).
  • Rural Veterans with HIV who did not receive ID specialty care were less likely to receive antiretroviral therapy (68%) or have an undetectable viral load on therapy (76%).
  • The Specialty Care Access Network - Extension for Community Health Outcomes (SCAN-ECHO) telemedicine model for improving access to specialized care for Veterans with HIV in rural settings had limited adoption in Community Based Outpatient Clinics (CBOCs) serving rural areas, with only 9 of 21 clinics adopting and only 5% of rural Veterans with HIV being offered SCAN ECHO participating.
  • Due to difficulty engaging primary care providers in HIV treatment, a program integrating HIV specialty care delivered by Veteran-level clinical video telehealth visits with primary care delivered by local Patient Aligned Care Teams (PACTs) in CBOCs serving rural areas may improve outcomes.

Implications: SCAN ECHO had limited uptake for HIV, however a telehealth collaborative care model was developed. This model was subsequently evaluated through an evaluation in three VA facilities between 2015 and 2017. Results are pending.

Moeckli J, Stewart KR, Ono S, et al.. Mixed-Methods Study of Uptake of the Extension for Community Health Outcomes (ECHO) Telemedicine Model for Rural Veterans with HIV. Journal of Rural Health. 2017; 33(3):323-331.

Medical Care Supplement Focuses on VA Choice Act

In response to concerns regarding access to VA healthcare, Congress enacted the Veterans Access, Choice and Accountability Act of 2014 (Choice Act). Provisions of the Choice Act provide Veterans who live more than 40 miles from a VA facility – or who are unable to schedule an appointment with a VA healthcare provider within 30 days – the option of receiving care from eligible non-VA healthcare providers. This special supplement of Medical Care highlights several HSR&D and QUERI studies that focus on the VA Choice Act. Findings from these studies will help inform updates to the Choice Act, thus improving Veterans access to care. Following are brief descriptions of several of the articles.

Ongoing Studies

The following studies are currently collecting and analyzing data.

Measuring Perceived Access through e-Health Technologies

Access to mental health (MH) care continues to be a challenging issue for VA. HSR&D sponsored a 2010 State-of-the-Art (SOTA) conference on “Improving Access to VA Care,” and one recommendation was that investigators develop and validate actual and perceived metrics of Veteran-centered access to VA and non-VA services, and stipulate a “digital” domain as one of five conceptual domains in a perceived access framework. The objective of this ongoing study is to generate a patient-centered measure of Veterans' perceived access to MH treatments, with particular attention to the intersection of perceived access and e-health technologies. Researchers created a preliminary Perceived Access Inventory (PAI) by interviewing VA patients about their experience considering or accessing VA treatment for MH and using an expert panel to analyze content. Next they tested this measure with patients to assess validity and reliability. The final version of the PAI has 43 items including 9 regarding e-health and 13 regarding experiences of care.

Implications: Although instruments are available to measure perceived geographical, temporal, financial, and cultural access to care, none address access to e-health or were developed with extensive Veteran patient input. The PAI will provide a perceived access measure that will allow policymakers and researchers to identify populations and facilities for future quality improvement and treatment engagement efforts – and that will directly measure the impact of these efforts.

Access to Specialty Care for Veterans with Complex Conditions

Difficulties accessing quality care are especially acute for rural Veterans who need specialty care. Community based outpatient clinics (CBOCs) do not typically have specialists on staff, forcing Veterans to rely on their primary care physician, seek non-VA care, or travel to a tertiary VA facility. Distance can lead to delays in accessing care, as well as greater morbidity and mortality, and these problems are often exacerbated when a patient has a mental health condition.

This study seeks to examine how Veterans with heart failure (HF), Hepatitis C virus (HCV), and epilepsy access specialty care and the link between specialty care, quality of care, and health outcomes. Enabling and hindering factors such as monetary pricing and mental health will be included in the evaluation. Additionally, researchers will use qualitative methods to understand the contingences involved when a CBOC provider makes a referral to specialty care.  Anticipated findings are:

  • Types of factors affecting Veterans' use of VA specialty care and the role of non-VA specialty care;
  • Whether having a mental health comorbidity poses an additional barrier to specialty care;
  • Influence of provider volume and practice environment on quality of care; and
  • What providers feel are barriers and facilitators to specialty care referrals.

Implications: This research will contribute to the understanding of how specialty care, including non-VA specialty care, is being used, and whether specialty care access is associated with higher quality of care and improved outcomes.

References

  1. Patient Access Data. https://www.va.gov/health/access-audit.asp. Updated November 9, 2017. Accessed November 13, 2017.
  2. Improving Access. https://www.va.gov/QUALITYOFCARE/new-approach/improving-access.asp. Updated June 3, 2015. Accessed November 14, 2017.
  3. Veterans Choice Program. https://www.va.gov/opa/choiceact. Updated August 14, 2017. Accessed November 14, 2017.
  4. VA Secretary Announces Intention to Expand Mental Health Care to Former Service members. https://www.va.gov/opa/pressrel/pressrelease.cfm?id=2867Updated March 8, 2017. Accessed November 14, 2017.
  5. Health Services Research & Development Mission. Updated January 20, 2014. Accessed November 14, 2017.