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A mixed-methods, multi-site evaluation of the Implementation of the Veterans Choice Act
P. Michael Ho, MD PhD
Rocky Mountain Regional VA Medical Center, Aurora, CO
Funding Period: April 2015 - September 2015
The Veterans Access, Choice and Accountability Act of 2014 (VCA), was signed into law in August 2014. The VCA authorized expanded availability of medical services from non-VA entities for three years. This evaluation was funded to identify actionable insights to inform the Veterans Choice Program (VCP) implementation.
We assessed whether the VCP achieves the goal of improving access, current access to internal VA care by specialty and what makes the VCP work or not work. We conducted rigorous formative and summative in-depth evaluations of the VCP implementation at 3 medical centers and 3 VISNs (10, 19, and 20) comprising 2 VCP regions. This work was guided by the RE-AIM evaluation framework. The spatial work was conducted using Geographic Information Systems (GIS) across 3 VISNs with large variation in population density and service area coverage.
We conducted in-depth interviews with key personnel, clinical providers, and Veterans involved with the VCP between April and October 2015. The qualitative data provided insights into the VCP processes as well as the quality of care provided by the VCP. The culminated data produced detailed perspectives of the Veterans, clinical providers, and staff, which resulted in the creation of value stream process maps, and an analysis of the VCP process efficiency and quality for each site. We interviewed 6 key informants/stakeholders, 17 VHA providers, 13 Non-VHA Providers, 8 MSAs, 12 NVCC/Choice Team, one Third Party Administrator (TPA), and 47 veterans across 3 medical centers in Denver, Seattle, and Cleveland (located in VISNs 10, 19 and 20).
Additionally, we conducted several geospatial analyses at these 3 VISNs. The first analyses focused on examining approved VCP external providers in relationship to existing VA service areas as defined by the 40-mile service area. The second analyses focused on defining access to existing VA clinics. We integrated VA site and specialty clinic information to create new 40 mile service areas that were specialty specific, and reflected temporal access based on wait times.
The intent of the VCP was to improve access to care for all Veterans. However, in the haste to roll out the VCP, a transition period was not implemented to allow for gradual adoption of the program by staff and providers in the VHA, TPA, and Non-VHA providers. Initial education and information of the process to staff, providers, and, most importantly, to the Veterans was disseminated ineffectively and insufficiently. Additionally, the multiple changes to the program resulted in confusion regarding Veteran eligibility for the program and staff implementation of the specific components of the program. The main recommendation to improve the program was to mandate continuous education and information in multiple forums to everyone involved with the process, especially when program changes occur.
As a whole the Veterans spoke positively about the VA and the care they receive within the VA system, however the concept of having a choice program when care was not available through the VA, due to wait times or lack of local services, was universally seen as a good idea. The VCP was viewed as an excellent idea not without limitations. Dealing with multiple parties in their care was difficult for many Veterans, especially those who were used to the single payer care model of the VA. For Veterans who had successfully navigated the VCP and received care, it appears to have strengthened their preexisting favorable disposition to the VA.
As expected, the spatial analyses were variable by VISN. In VISN 10, the majority of the network is covered by the 40 mile service areas, and few Veterans or external providers fall outside of the 40 miles. In VISN's 19 and 20, there is much more geographic space outside of the existing service areas. Despite these larger spatial gaps, the majority of external providers still fall within existing 40 mile service areas. The finding that external providers approved through VCP are primarily located in close proximity to existing VA resources is intriguing. Implementing a more sophisticated definition of access that reflected both wait times (temporal access) and clinic availability within sites (spatial access) revealed a different picture of access. Generally, clinics contributed primary care and mental health access, but not to specialty care access. Although medical centers generally had all specialty clinics physically available, they showed variation in wait times and thus temporal access to specialty care was variable across the VISNs. The specialty and VISN specific maps of current access to care, combined with Veteran density, can be used to identify high value spaces to target VCP provider enrollment to ensure external providers are increasing the VA network of available care.
The potential benefits of this evaluation include increasing understanding of: 1) VCP implementation across 3 sites, 2) patient and other stakeholder experience with VCP, 3) variation in VCP implementation across sites, and 4) barriers and facilitators to VCP usage. The knowledge gained through this evaluation can benefit VA and partners by identifying best practices, and addressing implementation challenges.
Implementing a national program comprising of a singular process that fits into different VA facilities with various organizational systems, staffing, and Veteran population demographics is a difficult task. Program implementation should allow for tailoring of the program based on local variation in staffing capability, clinical resources, and Veteran population needs. Front line staff are a valuable resource, and their opinions and feedback should be sought before, during, and after the implementation process.
The spatial evaluation of external providers showed that the majority of TPA approved providers are within the existing 40 mile service areas. Since the goal of the VCP is to increase access for Veterans, further development of TPA networks should be strategically directed based on knowledge of existing VA network resources. The analysis of temporal and spatial access demonstrated that a definition of existing VA network resources should be site and specialty specific, and consider both temporal and spatial access based on recent data. We have provided a proof of concept of this approach that can be further refined by clinical expertise.
External Links for this Project
NIH ReporterGrant Number: I50HX001967-01
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DRA: Health Systems
DRE: Epidemiology, Treatment - Observational
MeSH Terms: none