Perspectives on Co-Management for Rural Veterans from Primary Care Providers in Iowa: A Mixed Methods Study

Charlton ME, Wittrock SM, Cozad A, Lampman MA, Ono SS, Reisinger HS. Perspectives on Co-Management for Rural Veterans from Primary Care Providers in Iowa: A Mixed Methods Study. Poster session presented at: AcademyHealth Annual Research Meeting; 2013 Jun 24; Baltimore, MD.

Research Objective: The majority of rural veterans who use Department of Veterans Affairs (VA) healthcare services are cared for by both VA and non-VA providers. There is limited organizational infrastructure in place to guide information exchange or facilitate care coordination for these veterans. Also, little is known from the perspective of non-VA providers about the current state of communication and coordination between systems, or the perceived impact on the health of veterans. The objective of this study was to obtain perspectives from rural primary care providers on caring for veterans who use both VA and non-VA healthcare. Study Design: A mixed methods design involving quantitative survey data and qualitativedata from semi-structured telephone interviews was used to elicit information from non-VA providers. Population Studied: Survey instruments were mailed to 270 non-VA primary care providers (PCPs) participating in a Midwestern rural practice based research network in 2011. Providers were asked to indicate if they were willing to participate in a telephone interview. Principal Findings: Of the 270 PCPs in the network, 67 (25%) completed questionnaires and 21 (7%) completed a subsequent interview. Providers who completed the written questionnaire were primarily physicians (94%), predominantly male (76%), and had an average of 19.9 years of service at their current practice. Survey responses indicated 74% found communication with VA to be "poor" or "non-existent" and 42% percent believed poor communication with VA has resulted in poor patient outcomes. Interviews underscored the patient as the main vehicle for information transfer between providers; a practice not viewed as ideal. Non-VA providers felt they were interacting with VA as a system rather than communicating with VA providers as individuals, which they attributed to an inability to identify/access VA providers directly. Interview respondents described their role in caring for veterans as providing continuous care as well as acute, urgent, or emergency care due to limited access to these services at the VA. Conclusions: VA system barriers appear to hinder communication between providers across systems, possibly resulting in fragmented care. Community-based, non-VA PCPs who are caring for rural veterans are frustrated by the lack of communication and care coordination with the VA system and have come to rely on the patient as the vehicle of communication between providers. Implications for Policy, Delivery, or Practice: In light of the expansion of VA healthcare benefits for returning veterans, expansion of Medicaid coverage under the Affordable Care Act, and the continued disproportionate contribution of rural counties to the ranks of active military recruits, the population of rural veterans using (both) VA and non-VA systems will continue to increase. By addressing barriers to communication between VA and non-VA systems with education, outreach, and systems-based improvements, the burden of communication could be transferred from the veteran patient to a less haphazard and medically safer venue. In turn, this could potentially result in improved care coordination, patient and provider satisfaction, and improved veteran health outcomes.