Perceived Access Inventory Reflects Experience of Access to Mental Healthcare
Over the last few decades, VA has identified improving access to healthcare as a priority area. VA focus on access intensified substantially with the waitlist crisis and the subsequent Veterans Access, Choice, and Accountability Act (VACAA) of 2014. The VACAA authorized the Veterans Choice Program (VCP) as a temporary program to enable eligible Veterans to receive inpatient, outpatient, pharmacy, and ancillary medical services in the community. More recently, the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act of 2018 continues to emphasize access to care by consolidating community care programs, improving the coordination of VA and non-VA care, and increasing the use of telemedicine technologies.
During this time, VA HSR&D and other VA offices have also focused on improving access to VA healthcare. For example, in 2010, VA HSR&D convened the State of the Art (SOTA) Access conference. One of the results of this SOTA conference was a re-conceptualized access model that added a fifth domain (digital access) to the four commonly recognized domains of access: geographical, temporal, financial, and cultural. In keeping with this model, the 2010 SOTA conference defined access as “…the potential ease of having virtual or face-to-face encounters with a broad array of health care providers and resources including clinicians, caregivers, peers, and computer applications.”1 In 2012, VA Office of Inspector General (OIG) recommended that VA “reevaluate alternative measures or combinations of measures that could effectively and accurately reflect the patient experience of access to mental health appointments.”
In 2014, HSR&D funded the Center for Mental Healthcare and Outcomes Research (CeMHOR) to develop a patient-centered Perceived Access Inventory (PAI) that would reflect the patient experience of access to mental healthcare and include access to digital (e.g., telemedicine) technologies. The PAI project was part of a VA HSR&D CREATE (Collaborative Research to Enhance and Advance Transformation and Excellence) suite of projects with the overall title of Improving Rural Veterans’ Access/Engagement in Evidence-Based Mental Healthcare.
We used a multiphase, mixed-methods approach to develop the PAI. In Phase 1, we conducted individual, semi-structured, qualitative interviews with 80 Veterans to explore their experiences and elicit the barriers and facilitators they faced in seeking VA mental healthcare. We recruited Phase 1 Veterans from VA community-based outpatient clinics in Northern California, Arkansas, and Maine. In Phase 2, we generated a preliminary set of survey items based on Phase 1 qualitative data. In Phase 3, an external expert panel rated preliminary PAI items in terms of relevance and importance, and provided feedback on format and response options. In Phase 4, Veterans gave feedback on the readability and understandability of the PAI item-set generated through Phase 3. The resulting PAI included 43 items addressing five domains: Logistics (5 items), Culture (3 items), Digital (9 items), Systems of Care (13 items), and Experiences of Care (13 items).2 The PAI is structured so that most items consist of two parts. Part One is a Yes/No question assessing the presence/prevalence of a potential barrier. Respondents who answer “Yes” to Part One are then asked to rate the impact of that barrier using a 5-point Likert scale ranging from no interference with getting needed mental health services to complete interference.
In response to the Veterans Choice Program, we conducted mixed qualitative and quantitative interviews with 25 Veterans who had experience using community mental health services through the Veterans Choice Program in 2017. This study was funded by the South Central Mental Illness Research, Education and Clinical Center (MIRECC) and used the same research infrastructure that was used to develop the PAI. Analysis of qualitative interview data identified four topics that were not raised by the initial sample of Veterans receiving VA mental healthcare: Veterans being billed directly by a VCP mental healthcare provider, lack of care coordination and communication between VCP and VA mental healthcare providers, Veterans needing to travel to a VA facility to have VCP provider prescriptions filled, and delays in VCP re-authorization.3 These additional barriers were largely administrative (rather than arising from the clinical encounter itself) and were included in a version of the PAI designed for use with Veterans receiving mental healthcare in the community.
Current VA access measures include: wait times, Veteran satisfaction with mental health appointment access, Veterans’ perspectives as reflected in the Survey of Healthcare Experiences of Patients (SHEP), and Strategic Analytics for Improvement and Learning (SAIL) measures. The PAI differs from each of these access measures. For example, wait times are averages calculated from administrative data and may not reflect Veterans’ experiences trying to get an appointment. The Veteran Satisfaction Survey asks Veterans about the timeliness of mental health appointments but does not ask about specific access barriers. The SHEP asks Veterans about the timeliness of mental health appointments and about a limited number of barriers (e.g., inconvenient appointment times, transportation problems, cost). SAIL measures include items from the Veteran Satisfaction Survey and SHEP questionnaires plus composite measures of continuity of care and experiences of care. In contrast, the PAI includes a comprehensive list of specific perceived access items across five domains derived from Veterans’ experiences accessing VA mental health services.
In general, the PAI fulfills the OIG recommendation for measures that accurately reflect the patient perspective and experience of accessing mental healthcare. Going forward, the PAI may be useful for VA in several ways. First, as VA expands its coverage of community-based mental healthcare through the 2018 MISSION Act, the PAI for community care could be used to assess access to mental healthcare in the community. More specifically, as the Veterans Choice Program transitions to the Veterans Community Care Program, the PAI could be used alongside other access measures to provide the Veteran perspective on access during the transition period. Most of the items in the community care and VA versions of the PAI are identical, which allows for comparison of access to VA and community mental health services at the same point in time. Second, the specific barriers included in the PAI could be used to develop interventions to improve access to care. One such project will use the PAI to identify barriers for an individual Veteran that are specific to the treatment that is preferred by the Veteran. This information will be used by a peer specialist to improve initiation and engagement in mental healthcare. Third, customer service is the first priority for VA and is an important determinant of where Veterans choose to receive care, even if they qualify for care in the community. According to the SOTA access model, perceived access to care is associated with treatment satisfaction, care quality, and clinical outcomes. As mentioned above, the SHEP asks about a limited number of access barriers, but the PAI includes a more comprehensive list of specific and actionable perceived access items that were developed from patient interviews and experience. As such, the PAI can be used to identify actionable access barriers that can be addressed to improve customer service and satisfaction. Future work with the PAI includes concurrent and predictive validation and use of the PAI for intervention development and implementation.
*PAI Development Team: P. Adam Kelly, PhD, Ellen P. Fischer, PhD, Christopher J. Miller, PhD, Patricia Wright, PhD, Kara Zamora, MA, Christopher J. Koenig, PhD, Regina Stanley, BA, Karen Seal, MD, and John C. Fortney, PhD.