Access to mental health (MH) care continues to be a challenging issue for VHA. A VA State-of-the-Art Conference (SOTA) in September 2010 on the topic of "Improving Access to VA Care" created a perceived access framework which included five conceptual domains (i.e., geographical, temporal, financial, cultural and digital). To our knowledge, none of the available access measures encompasses all five of these domains. In particular, the perceived access to digital or e-health encounters is absent from existing measures. The first SOTA research recommendation was to develop and validate actual and perceived metrics of Veteran-centered access to VA and non-VA services.
The overall objective of this proposal is to generate a psychometrically sound patient-centered measure of Veterans' perceived access to MH treatments, with particular attention to the intersection of perceived access and e-health technologies.
We will accomplish this by (1) collecting qualitative data from VA patients about their experience considering or accessing mental health services in order to generate survey items that are informed by the SOTA Access model, (2) assessing the content validity of the items and constructing a preliminary version of the Perceived Access Inventory (PAI), and (3) evaluating (concurrent and predictive validity and reliability) and refining a final version of the PAI. We will recruit VA patients from community-based outpatient clinics in three VA Networks (VISNs): Arkansas, Maine, and Northern California. We will conduct qualitative interviews with approximately 90 VA patients and ask them about their perceived access to mental health services using the SOTA Access framework to structure the interviews. We will use content analysis methods including an expert panel to construct a preliminary version of the PAI and then administer this instrument to a sample of 100 VA CBOC patients to evaluate the validity and reliability of this measure and perform analyses for potential item reduction. A fourth aim was added to collect qualitative data from Veterans using Choice Act community care for mental health treatment to see if any items needed to be added to the PAI that are specific to accessing community care mental health services.
Transcripts from 80 Veterans across 3 VISNs were coded, internal expert panel review and external expert panel modified Delphi panel were completed. Qualitative data and existing access items were used to generate 240 items that addressed all five SOTA domains and two additional domains (healthcare systems and experiences of care). The initial 240 items were reduced to 40 through consolidation by the research team and two rounds of external Delphi process. Following Veteran/patient pilot testing, the final version of the PAI has 43 items in six domains (logistics (combines geographical, temporal, financial from SOTA model)=5 items, culture=3, digital=9, systems=13, and experiences of care=13). Separate versions are available for Veterans who used VA mental health services within the past year, those who used services more than a year ago, and those who have never used VA mental health services. Additional work is ongoing for a version that will be specific to the use of Choice Act mental health services.
Although instruments are available to measure perceived geographical, temporal, financial, and cultural access to care, we are not aware of any that address access to e-health or were developed with extensive Veteran patient input. The PAI will provide a perceived access measure that will allow policy makers and researchers to identify populations and facilities for future quality improvement and treatment engagement efforts and directly measure the impact of these efforts. We will also be able to validate the VA State of the Art (SOTA) Access model with the cultural domain analysis from these data. We are working with Central Office partners throughout this project. We will also examine the need for Choice Act specific PAI questions.
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Mental, Cognitive and Behavioral Disorders, Health Systems
Diagnosis, Treatment - Observational, Technology Development and Assessment, Research Infrastructure
Attitudes/Beliefs, Rural, Telemedicine/Telehealth