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Evolving Access Needs Offer Research Opportunities

VA has made significant strides in improving access to health care services for the veterans it serves. Despite these improvements, VA must address three immediate challenges:

1. Ensure ease of access for patients to existing providers and ensure that service gaps are addressed;
2. Improve our understanding and use of support staff roles and team productivity; and
3. Achieve a higher degree of reliability and standardization in the flow of patients from primary to specialty care.

Three Challenges

The first challenge--ensuring a sufficient complement of physicians at VA's medical centers--demands practical solutions. While access for individual patients to their providers is usually good when providers are present, gaps in care occur when providers are absent for any reason, and any length of time. Medical centers and providers need to innovate and be more proactive in developing contingency plans for such absences. Some options include back-up by other team members, specific providers tasked to cover absences, using support staff in new ways, partnering with other departments, contracts with private provider groups, increased patient waiting, or diversion.

The second challenge--improving utilization of staff--involves deepening our understanding of the potential roles of support staff and leveraging staff roles to improve the efficiency of health services delivered. The idea here is that every team member works at the highest level of their licensure and capability while applying that effort to the patient population that benefits the most. A direct relationship exists between the number of support staff and medical team productivity (in terms of population care), and we need to better understand and leverage those dynamics.

Third, VA needs to learn more about how patients move among the wider team of service providers. What care should primary care be responsible to deliver? Are patients shifting from primary to specialty care at the right time? Do they stay in specialty care for the right length of time? Wide variation exists in what is referred to as specialty care. Increased standardization of the definition of primary care versus specialty care services would improve delivery of care to veterans.

Despite these challenges, VA has successfully used Internet technology to advance access for veterans. The availability of medical records through My HealtheVet, videoteleconferencing, and other computer-enabled technologies has improved both efficiency and access to care.

While VA is taking care of a relatively small number of OIF/OEF veterans, we are a nation at war. These returning veterans are a top priority. Access to care for OIF/OEF veterans should be no different than for other veterans. Recently returning veterans have different needs, however, and VA must be nimble in responding to those needs. An increased demand for rehabilitation services is just one example. Furthermore, VA must do better at reaching out to returning veterans and asking, "How can we help?" To achieve greater efficiencies, VA is opening new ambulatory centers and working more closely with community resources to address gaps in care. VA's recent approach focuses more on partnering with community organizations to provide services when it makes sense, as opposed to building and owning space. This approach is especially important for the delivery of low-volume specialty care.

VA's Bar Code Medication Administration (BCMA) program is just one example of recent efforts to improve efficiency, in this case the efficiency of medications delivered at bedside. While BCMA is a major advance, improvements are still needed to address problems with this new technology. VA delivers thousands of medications daily. Small advances in standardizing and improving the process by which these medications are delivered at bedside would result in huge improvements in the availability of nurses to address other needs.

Research Opportunities

The access challenges facing VA today suggest several compelling research opportunities.

• Waiting times. There is great interest, including by Congress and the Inspector General, in measuring wait times for services, yet not much research has been undertaken in this area.
• Elective vs. emergency procedures. We need to be able to measure and plan for wait times for elective vs. emergency procedures so that we can meet both medical needs and patient expectations.
• Variations in patient expectations by generation. VA needs a better understanding of what our customers want and how those preferences vary by generation.
• Disability exams. The administration of disability exams, necessary for determining pension and disability compensation, is a major new issue and area of dissatisfaction for new veterans.
• Appointment failures. VA needs to explore the reasons why patients fail to "show" for appointments.

Critical to addressing access challenges is the need for VA to improve the efficiency of care provided. VA is keenly interested in process improvement and there is a huge need for knowledge and research in these areas. The academic community has been slow to embrace and value improvement science.

Rural Health, Mental Health

Ensuring ease of access to services for veterans living in rural areas remains a key priority for VA. The Office of Rural Health is focused on ensuring access to VA care for veterans living in sparsely populated areas that lack ease of access to a nearby VA medical center. While veterans living in rural areas may have access to a VA facility, that facility may lack key specialty services. In rural settings, transporting veterans who need specialty care to an appropriate site of care presents a complex logistical challenge.

VA continues to focus on improving access to mental health services. One area of study relates to the supply of providers needed to treat mental health conditions. Key to this focus is improving our understanding of how often and for what duration patients should be seen for mental health conditions. Another challenge is the need to connect patients to the right provider at the right time.

While VA has substantially improved access to health care services over the last decade, additional access improvements remain within reach and must be pursued actively at all levels within VA.