Improving Access to Care for Veterans
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.
- Vanneman and colleagues found that, although Veterans’ use of non-VA providers increased over time, utilization was still low, with approximately 2% of eligible OEF/OIF/OND Veterans utilizing the Program. Other evidence suggested that overall use of VA healthcare was lowest after the program was implemented (FY2015) compared to prior-to-rollout use (FY2012-2014). Article: Iraq and Afghanistan Veterans’ Use of Veterans Health Administration and Purchased Care before and after Veterans Choice Program Implementation.
- Mattocks, et al. surveyed perceptions and experiences of the Choice Program among VA providers and staff at five VAMC’s. As in other studies, VA providers described the limited numbers of community providers enrolled in the Choice Program, as well as highly complex, confusing, and rapidly changing processes related to Choice Program implementation. Article: The Veterans’ Choice Act: A Qualitative Examination of Rapid Policy Implementation in the Department of Veterans Affairs.
- Finley and colleagues compared attitudes and characteristics of community-based primary care and mental health providers in the West, South, and Midwest United States who participated in early implementation of the Choice Program. Findings showed that providers who were already receiving VA reimbursement, or were treating Veterans with PTSD, were significantly more likely to report interest in participating in the Choice Program for PTSD care. However, providers with more positive attitudes toward VA care were not more likely to report interest in the Choice Program. Article: Community Clinicians and the Veterans Choice Program for PTSD Care: Understanding Provider Interest during Early Implementation.
- Tsai and colleagues surveyed perspectives and experiences with the VA Choice Program among Veterans with hepatitis C virus (HCV) and their providers at three VAMCs. Results indicated that that Program has the potential to increase Veterans’ access to HCV treatment, but Veterans and VA providers experienced significant problems in the first years of the program. Complications included difficulties in enrollment, lack of non-
VA treatment centers, challenges in care coordination, and lack of community providers’ experience with advanced cases. Article: "Where’s My Choice?” An Examination of Veteran and Provider Experiences with Hepatitis C Treatment through the Veterans Affairs Choice Program. Medical Care. 2017;55:Supplement 7, (suppl 1).
The following studies are currently collecting and analyzing data.
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.
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.
- Patient Access Data. https://www.va.gov/health/access-audit.asp. Updated November 9, 2017. Accessed November 13, 2017.
- Improving Access. https://www.va.gov/QUALITYOFCARE/new-approach/improving-access.asp. Updated June 3, 2015. Accessed November 14, 2017.
- Veterans Choice Program. https://www.va.gov/opa/choiceact. Updated August 14, 2017. Accessed November 14, 2017.
- 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.
- Health Services Research & Development Mission. Updated January 20, 2014. Accessed November 14, 2017.