JGIM Special Supplement Highlights Access to VA Healthcare

BACKGROUND:
VA has made access to care one of its three main priorities. To support this goal, HSR&D held a state-of-the-art (SOTA) conference in September 2010 on “Improving Access to VA Care,” in order to identify what we know – and what we need to know about the determinants of access and the impact of access on utilization, quality, and outcomes. Conference attendees comprised an interdisciplinary group of 75 VA and non-VA investigators and policymakers with expertise in telemedicine, informatics, economics, rural health, women’s health, race/ethnic disparities, clinical leadership, and VA operations. SOTA participants met in topic-focused workgroups, then presented their policy and research recommendations in a plenary session, with commentary by a panel of VA leaders. The JGIM Supplement includes both the white papers commissioned as background for the SOTA conference and manuscripts submitted in response to a post-SOTA solicitation for original research and reviews pertaining to improving access to VA care. Articles focus on a myriad of topics related to improving access to care for Veterans, including: eHealth technologies (e.g., Care Coordination Home Telehealth program, and My HealtheVet personal electronic health record); measuring the impact of access on healthcare utilization, quality, and outcomes; and redefining access for 21st century healthcare.

FINDINGS INCLUDE:

• VA employs an assortment of e-health technologies that promote patient-provider digital communications outside the context of a traditional face-to-face clinical encounter. These 21st century innovations have tremendous potential for improving access, yet may also have possible unintended consequences (e.g., providers overloaded by digital communications from their patients).
• VA’s Care Coordination Home Telehealth (CCHT) program and the My HealtheVet (MHV) personal health record represent a significant shift in the way that services are delivered and a profound opportunity to incorporate eHealth technologies into clinical practice that will increase access to patient-centered care.
• Improvements in digital access (e.g., Smartphones, clinic-based interactive video, home-based web cams) may create greater access disparities for some Veteran populations.
• Distance was identified by Veterans, providers, and staff as the most important barrier for rural Veterans seeking healthcare. Improved transportation, flexible fee-based services, more structured communications, and integration with community resources will improve access to care.
• Results from a telephone survey of 3,611 women Veterans show that 19% had delayed healthcare or unmet need, with higher rates in younger age groups. Both general and Veteran-specific factors (e.g., transportation difficulties, perception that VA providers are not gender-sensitive) impact women Veterans’ access to needed services.
• Longer VA wait times lead to small, yet statistically significant decreases in healthcare utilization and are related to poorer health in elderly and vulnerable Veteran populations.

IMPLICATIONS:
As a national integrated healthcare system, VA has the potential to be an exemplar for how to deliver continuous, coordinated healthcare in the digital age. Common barriers to care such as travel distance, cost, and wait time could potentially be addressed through the proactive use of non-encounter-based digital communications between Veterans and their care teams. The articles in this Supplement provide a solid foundation upon which to build policies and research programs to support this vision.

Fortney J, Kaboli P, Eisen S. Improving Access to VA Care. Journal of General Internal Medicine 2011 Nov;26 Suppl 2:621-22.

APPENDIX

Jackson G, Krein S, Alverson D, et al. Defining Core Issues in Utilizing Information Technology to Improve Access: Evaluation and Research Agenda.


Hogan T, Wakefield B, Nazi K, et al. Promoting Access through Complementary eHealth Technologies: Recommendations for VA’s Home Telehealth and Personal Health Record Programs.


Kvedar J, Nesbitt T, Kvedar J, Darkins A. E-patient Connectivity and the Near-Term Future.


Fortney J, Burgess J, Bosworth H, et al. A Re-conceptualization of Access for 21st Century Healthcare.


Buzza C, Ono S, Turvey C, et al. Distance is Relative: Unpacking a Principal Barrier in Rural Healthcare.


Washington D, Bean-Mayberry B, Riopelle D, and Yano E. Access to Care for Women Veterans: Delayed Healthcare and Unmet Need.


Kramer B, Jouldjian S, Wang M, et al. Do Correlates of Dual Use by American Indian and Alaska Native Veterans Operate Uniformly across the Veterans Health Administration and the Indian Health Service?


Ajmera M, Wilkins T, Sambamoorthi U. Dual Medicare and Veteran Health Administration Use and Ambulatory Care Sensitive Hospitalizations.


Pizer S and Prentice J. What are the Consequences of Waiting for Health Care in the Veteran Population?

O’Toole T, Pirraglia P, Dosa D, et al. Building Care Systems to Improve Access for High-Risk and Vulnerable Veteran Populations.

Kehle S, Greer N, Rutks I, and Wilt T. Interventions to Improve Veterans’ Access to Care: A Systematic Review of the Literature.