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1996 VHA survey of delivery models for primary care

Yano EM, Simon B, Gonzalez I, Wang MM, Lanto AB, Rubenstein LV. 1996 VHA survey of delivery models for primary care. Sepulveda, CA: Center for the Study of Healthcare Provider Behavior; 1999 May 1. Report No.: 98-MC802.


IntroductionThis monograph contains a copy of the VHA Survey of Delivery Models for Primary Care, which was fielded to the Chiefs of Staff and/or their designees in each VA medical center (n = 160) and satellite outpatient clinic (n = 67) nationwide in June 1996. At the time of survey administration, the Veterans Health Administration (VHA) had 173 VA medical centers, 18 of which had been combined into 8 integrated health care systems. Among these 8 integrated systems 5 provided surveys for each facility within the integrations (n = 10) and 3 provided a single survey reflecting results for all of their facilities (i.e., 3 surveys for 8 facilities). Our final sample consists of 160 VA facilities.Integrated into this survey copy are the actual unadjusted frequencies based on our returns. The number and percentage of VA health care facilities indicating a particular answer is provided for discrete or categorical variables (e.g., academic affiliation, yes/no), while means, ranges and standard deviations are included for continuous variables (e.g., number of physicians in primary care) and selected ordinal variables (e.g., level of primary care implementation on a 1-9 scale). We also include the actual variable names we use to generate analysis plans and interpret statistical output (e.g., VA_LOC for VA location in terms of urban, small city, semi-rural and rural settings).Purpose1. To disseminate the content of the 1996 VHA Survey to interested VA and no-VA planners, managers and providers,2. To provide the basic survey results as frequencies for those interested in the variations in organizational structures and primary care features founds in VA health care facilities, and3. To further stimulate discussion about the organizational characteristics of health care facilities that are associated with better performance.Project BackgroundFirm systems are an organizational model for healthcare delivery that have been associated with improved patient and staff satisfaction, lower readmission rates, enhanced continuity and lower healthcare utilization. A principal feature is the firm's accountability for a practice or panel of patients, intended to increase continuity and humanistic care, as well as enhance coordination between inpatient and outpatient arenas as firm providers follow their patients from clinic to ward. Originally intended to create an infrastructure for facilitating randomized trials by randomly assigning patients to 'equivalent' provider teams, firms have grown to encompass an increasingly complex variety of healthcare team approaches in different settings. Definitions and implementation strategies vary widely, with uncertain end results.In 1996, the VHA Office of Ambulatory and Primary Care sponsored a rapid response project through the Management Decision and Research Center (NMRC) and the Center for the Study of Healthcare Provider Behavior (the Sepulveda HSRandD Field Program or SFP), to:(1) Develop a conceptual framework and operational definitions of firm systems by reviewing the literature and interviewing experts both in VHA and in the private sector,In conjunction with the Firms Analysis Work Group appointed by HQ, SFP and N4DRC collaborated to define the principal features of firms and identify the organizational variables that may be associated with firm development and effects. This consensus-building process was facilitated by using a synthesis of the published literature and a rating procedure for each proposed firm system element that served as a guide for discussion.(2) Create an inventory of VA firm systems by surveying all VA Medical Centers;The VHA inventory of firm systems (available under separate cover) was the product of a national survey of all VA Medical Centers and their satellite or community-based outpatient clinics that delivery primary care. The national survey, the VHA Survey of Delivery Models for Primary Care, was built upon earlier survey development work on assessing VA primary care resources through the 1993 VHA Managed Care Survey (available on request). Input from experts in primary care and organizational theory at the Sepulveda Field Program, NMRC, and among members of the Firms Analysis Work Group worked to refine and build upon the organizational variables already compiled and pilot tested prior to completion of a field-ready instrument. The emphasis was on screening individual VA facilities for the presence of operational firms by surveying (a) firm system features, (b) organizational variables associated with developing a firm system, and (d) other institutional features that set a context for programmatic development.(3) Assess the organizational determinants and consequences of firm system implementation.The two principal data sources that served as the basis for the firm system analysis were the quantitative data from the national survey and qualitative information from case studies of actual VA firm systems. Case studies included in-person site visits made by clinician-organizational expert teams and key person interviews by telephone. Site visitor teams included MDRC, SFP and Work Group members. Structured interview techniques were used to standardize core information, while permitting room to explore variations in firm system implementation at selected sites. All site visitors and interviewers were be trained in the use of the structured interview forms and will be debriefed on their return. The emphasis was on further assessing factors associated with firm system development, implementation and outcomes.

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