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Response to Commentary

Improving Veterans' Access to Care through Research-Operations Partnerships

The MISSION Act has placed renewed focus on ensuring access to care among Veterans. In her article, Dr. Kirsh highlights four priority initiatives to improve access that are underway at the Office of Veterans Access to Care (OVAC): improving access in response to MISSION Act mandates; the Increasing Capacity, Efficiency, and Productivity (ICEP) Initiative; increasing provision of same day services; and electronic health record modernization. Partnerships among researchers and OVAC facilitate the generation of robust evidence to support and inform these and other access to care related activities. In this article, we highlight past successful partnerships among researchers and OVAC, ongoing evaluations, and upcoming opportunities to use these partnerships to improve access to care.

HSR&D and Quality Enhancement Research Initiative (QUERI) researchers have a long history of collaboration with OVAC on key evaluations and quality improvement efforts. These include validating administrative waiting time measures for new patients in primary care and established patients referred to specialty care,¹ a pilot study and retrospective evaluation of recall reminder policy changes,² linking variations in access to health outcomes for Veterans,³ and an evaluation of a major resource-based scheduling software investment.

In the context of the MISSION Act, there are many current and upcoming opportunities for enhanced partnerships. Current collaborations involve OVAC and research teams from across the country, and are focused on MISSION Act initiatives, including the medical scribes pilot (MISSION Section 507) and identification and response to underserved facilities (MISSION Sections 401 and 402). These efforts build on past research by using established conceptual models relating supply and demand to waiting times combined with wait time measures validated by HSR&D and QUERI researchers.¹

The future holds many opportunities for research to evaluate and inform strategies to improve access to care. In August 2018, OVAC, the Partnered Evidence-based Policy Resource Center (PEPReC), and HSR&D organized a meeting to inform development of a VA HSR&D access to care research portfolio. The priorities and opportunities identified during the meeting will guide generation of rigorous evidence about the impact of policies and programs in which OVAC is invested, including the ones highlighted by Dr. Kirsh. They also will be useful for informing development of alternative policies and programs to improve access to care.

The meeting began with a list of broad OVAC focus areas, in order to help meeting attendees develop access to care research priorities. To identify opportunities with the greatest potential impact, we solicited feedback from other operations stakeholders on the extent to which OVAC focus areas overlapped with other offices’ priorities. To evaluate HSR&D capacity to address opportunities, investigators engaged in access to care research identified the extent to which these focus areas overlapped with their own research portfolios. All meeting attendees brainstormed opportunities for new areas of investigation that could improve access to care.

To increase the chance that research in OVAC’s focus areas will lead to meaningful real-world impact, we used feedback from the meeting to refine broad foci into a list of research priorities. We identified areas in which research:

• Is likely to directly inform policy or impact outcomes;
• Improves the experience of Veterans interacting with VHA;
• Is not already being funded under a different portfolio;
• Focuses on innovations most likely to be feasible, sustainable, and generalizable throughout VHA; and
• Aligns with researcher interest and expertise.

Access to care research priorities can be categorized by interventions and outcomes of interest. Interventions that should be prioritized for evaluation include those focused on identifying and developing best primary care and specialty care practices, as well as those improving clinic flow within a clinic or between primary and specialty care settings. Innovations may relate to care provided in-person or virtually. To measure improvements, a key near-term objective is to develop administrative measures of access to care that reflect patient experiences with virtual care. Research on all of these topics will enhance OVAC’s ability to respond to the MISSION Act, complete the ICEP initiative, and provide same day services.

Discussions with meeting attendees highlighted the importance of ensuring that access to care studies include a standardized set of high-priority outcomes to facilitate comparisons of the impact of different interventions on access and produc­tivity. Consistent use of access measures will be especially critical for identifying practice innovations that help VHA be maximally responsive to MISSION access standards. The highest priority outcomes include no-show rates, productivity, wait times, and patient satisfaction. Provider turnover also should be evaluated consistently where applicable.

Priorities identified during the meeting informed the request for applications for an Access to Care Consortium of Research (CORE), which provides a more formal structure for OVAC-research partnerships. Among other activities, CORE leaders will facilitate collaborations among access to care researchers and develop specific plans to address identified access to care priorities, as well as conduct research that leads to a demonstrable improvement in access to care outcome measures. In addition, PEPReC will provide technical assistance on best practices in access to care metric use and will help connect research activities to OVAC needs and priorities.

Communication and partnerships among operations stakeholders and researchers are key to the success of any initiatives to improve access to care. Ideally, a robust operations-research partnership should include operations initiatives that can be rapidly implemented and evaluated as well as deeper dives from researchers that investigate mechanisms of action and identify contextual factors that ensure an initiative’s success. In addition, it should include identification and development of a set of uniform, validated access metrics that can be used to compare results across evaluations. The CORE provides a mechanism to coordinate these elements and generate timely, rigorous evidence to improve Veterans’ access to care.

References

1. Prentice JC, Davies ML and Pizer SD. “Which Outpatient Wait-time Measures are Related to Patient Satisfaction?” American Journal of Medical Quality 2014; 29(3): 227-35.
2. Pearson E, Yee C and Pizer S. “VHA Recall Reminder Scheduling Protocol and its Impact on Waiting Times for New Patients,” Partnered Evidence-based Policy Resource Center Policy Brief 4(1), October 2018.
3. Pizer SD and Prentice JC. “What are the Consequences of Waiting for Health Care in the Veteran Population?” Journal of General Internal Medicine 2011; 26(2):676.