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Community Care in the Era of the MISSION Act: A Qualitative Analysis of the VA Electronic Health Record

Key Points

  • Authors conducted a qualitative analysis of documentation in the VA-wide electronic health record (EHR) related to community care in the era of the MISSION Act, with a particular focus on Veterans with advanced kidney disease.

  • The analysis identified three themes that shed light on community care: 1) VA as Mothership; 2) Hidden Work of Veterans; and 3) Strain on the VA System.

  • Findings within each of these themes highlight the substantial work of VA staff, clinicians, and Veterans and their families to arrange VA-financed care outside VA, and the strain of this work on VA’s own care processes.

In 2014, widespread public concern about prolonged VA wait times set in motion a series of legislative changes that would substantially increase Veterans’ access to VA-financed healthcare outside the VA system (community care). Under the 2014 Choice and 2018 MISSION Acts, the number of Veterans authorized to receive VA-financed care outside VA almost doubled from 1.3 to 2.3 million between 2014 and 2020.1 VA spending on non-VA care more than doubled from $7.9 billion (about 12 percent of the Veterans Health Administration’s (VHA) budget) to $17.6 billion (20 percent of the VHA budget) between 2014 and 2021.

To understand the internal impacts and challenges of greater reliance on community care for the VA system and enrolled Veterans, we conducted a qualitative analysis of documentation in the VA-wide electronic health record (EHR) pertaining to community care in the era of the MISSION Act.2 Our study focused on Veterans with advanced kidney disease, a segment of the Veteran population that exhibits high levels of both care complexity and reliance on non-VA providers. We used national VA administrative and clinical data to identify a random sample of 1,000 Veterans who had evidence of advanced kidney disease and were alive on June 6, 2019 (the starting date for MISSION Act implementation and establishment of the Veterans Community Care Program [VCCP]).

We conducted a qualitative analysis of documentation in the VA-wide EHRs of cohort members, which identified three interrelated themes pertaining to VA-financed non-VA care (community care).

The first of these themes, entitled “VA as Mothership,” highlights the extensive work of VA staff, as well as Veterans’ reliance on VA, to coordinate care in the community. This first theme included three subthemes, the first of which described the formal engagement of designated VA staff in systematic coordination of non-VA care. This process involved a range of different tasks such as directing requests from non-VA providers to the relevant VA providers for authorization, furnishing non-VA providers with medical records for referred patients, and coordinating between VA and non-VA providers to facilitate and deliver care. VA processes also extended to monitoring the care of Veterans hospitalized outside VA and coordinating transfers to VA when needed, retrieving health records from non-VA providers, checking on the status and maintaining the momentum of non-VA referrals, and keeping patients’ VA providers informed about the care they were receiving outside VA. The second subtheme described how VA staff, who were not formally tasked with supporting community care, helped Veterans to access services both within and outside VA that had been recommended by their non-VA providers, by encouraging Veterans to keep non-VA care appointments, and helping to set up travel to non-VA appointments. VA staff and clinicians also sometimes coached Veterans on how to interact with non-VA contractors and providers. The third subtheme described how the work of VA staff and clinicians to support VA-financed non-VA care was in part driven by the tendency of Veterans to turn to VA for assistance with referrals for non-VA care and with filling administrative and clinical gaps in the care they were receiving (or wished to receive) outside VA. Ironically, we found examples of Veterans turning to VA for bridging care while waiting for an appointment with a non-VA provider, and of VA providers encouraging patients to return to VA if specific services were needed.

The second theme, entitled “Hidden Work of Veterans,” described the extensive work of Veterans and their family members to arrange care in the community and to serve as intermediaries between their VA and non-VA providers. This theme included two subthemes, the first of which described the substantial burden placed on Veterans (and/ or their family members). Veterans were expected to be proactive in initiating and maintaining the momentum of referrals. However, many struggled with the referral process and had difficulty accessing needed care, which could be time-consuming and anxiety-provoking. We found numerous examples of referrals that had been stalled or cancelled because a Veteran did not answer their phone or did not respond to calls they had received about their non-VA care, or because a Veteran became confused about the calls they had received. Documentation in the EHR also suggested that the reality and/or prospect of being billed for non-VA services weighed heavily on Veterans and their families. The second subtheme described how, because non-VA providers frequently did not make their records and treatment recommendations available to VA providers in a timely fashion, Veterans (and/or their family members) often had to serve as informants and messengers between their VA and non-VA providers. We found examples of Veterans requesting initiation, continuation, and/or expansion of coverage for services  at the behest of their non-VA providers and conveying messages about treatment recommendations across systems. Veterans and/or their family members also provided VA clinicians with critical contextual information about the care they received outside VA.

The third theme, entitled “Strain on the VA System,” described the challenging nature of the referral process that stretched clinician and staff roles and compromised the care they could provide. This theme includes three subthemes, the first of which described the challenging nature of the referral process. By design, VA referrals for care outside VA are time-limited, the scope of services covered by each referral is pre-specified, and referrals are intentionally cancelled when Veterans do not respond to phone calls. Requests for continuation of services have to be authorized by VA clinicians as do any changes to, or expansion of, authorized services, and cancelled consults have to be re-submitted. Our analysis found that VA staff and clinicians appeared to have limited control and understanding of the referral process after submitting a consult and were often uncertain about the status of referrals. The second subtheme described how the roles of VA clinicians and other VA staff were stretched. The high level of VA clinician oversight required by the referral process meant that VA Community Care and other support staff routinely routed referral requests to physicians for approval, bureaucratizing their clinical role. Efforts to accommodate the needs of Veterans receiving care outside VA also stretched the traditional roles of other VA clinical staff members, particularly social workers, who served as a common point of contact for community care. The third subtheme described how referrals to the community could interact and conflict with VA’s own care processes. We found examples of VA providers rearranging VA appointment schedules to accommodate Veterans’ appointments outside VA. Changes or delays in the provision of non-VA care limited VA’s ability to help coordinate or otherwise support this care (e.g., arranging transportation). Lack of information about care delivered outside VA or the status of referrals led to duplication of services and increased the work of VA clinical providers while limiting the quality and timeliness of the care they provided. VA providers also routinely made contingency plans (e.g., placeholder appointments) to accommodate uncertainty about whether and when non-VA services would be made available.

Collectively, these findings spotlight the substantial work of VA staff, clinicians, and Veterans and their families to arrange and coordinate VA-financed care outside VA, and how this work can strain VA’s own care processes. In the wake of the Choice and MISSION Acts, VA has been required to interact on an unprecedented scale with private health systems, many of which do not share its programmatic strengths, or its mission and culture of providing lifelong care to the Veteran population.3,4 In this context, it is perhaps not surprising that our results echo familiar refrains about the deficiencies of the U.S. healthcare system including surprise medical billing, the work involved in being a patient, and the invisible work of family members to support patients’ care. Although the Choice and MISSION Acts were intended to improve the timeliness of Veteran care by increasing access to non-VA providers, it is presently unclear whether VA’s substantial investment in non-VA care in recent years has accomplished this goal,5 especially when viewed in light of the increased demands placed on the VA system, VA staff and clinicians, and Veterans and their families. Our findings underscore the importance of accounting for the many indirect consequences of cross-system use when budgeting, evaluating, and planning for the delivery of VA-financed care outside VA.

Acknowledgements: This work was supported by the VA Health Services Research and Development Service (IIR 18-032, PI O’Hare) and the following co-investigators and staff: Evan Carey, Paul Hebert, Virginia Wang, Ryan Laundry, Marieke Van Eijk, Whitney Showalter, Jeff Todd-Stenberg, Pam Green, Kameron Matthews, and Susan T. Crowley.

  1. Accessed 12/7/22.
  2. O’Hare AM, Butler CR, Laundry RJ, et al. “Implications of Cross-System Use Among US Veterans With Advanced Kidney Disease in the Era of the MISSION Act: A Qualitative Study of Health Care Records,” JAMA Internal Medicine 2022; 182(7):710-9.
  3. Longman P. Best Care Anywhere: Why VA Health Care is Better than Yours. Sausalito, CA: PoliPointPress; Distributed by Publishers Group West; 2007.
  4. Gordon S. “Wounds of War: How the VA Delivers Dealth, Healing, and Hope to the Nation’s Veterans.” In: The Culture and Politics of Health Care Work. Ithaca, New York: ILR Press, an imprint of Cornell University Press,; 2018.
  5. Penn M, Bhatnagar S, Kuy S, et al. “Comparison of Wait Times for New Patients Between the Private Sector and United States Department of Veterans Affairs Medical Centers,” JAMA Network Open 2019; 2(1):e187096.

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