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Expanded access to fee-for-service care in the community may be expensive, while the VA will likely continue to care for the most vulnerable veterans.

Objective The purpose of this study was to assess if an end-of-life communication intervention with patients with COPD led to higher long-term documentation of advance care planning discussions at the end-of-life. Background We previously demonstrated that providing clinicians a brief patient-specific feedback form about patients’ preferences for end-of-life communication improved the occurrence and quality of clinician communication about end-of-life care. Methods The study was conducted at the Puget Sound VA Healthcare System. Among those individuals enrolled in the intervention study (2004–2007) who had died during the follow-up period (up to 2013), we assessed if patients in the intervention arm had more goals of care discussions and formal advance directives completed as compared to patients in the control arm. We conducted logistic models accounting for provider level clustering, adjusting for age, FEV1, and race. Results Among the 376 patients in the parent study, 157 died, of which 76 were in the intervention arm and 81 in the control arm. The mean age was 72.5 (SD 9.1), 99% were male, with a mean FEV1% predicted of 45 (SD 17.8). Over an average duration of 3.6 years (from the time of the first study appointment to death), 115 (73%) patients engaged in 451 unique end-of-life care discussions. The intervention was not associated with a higher percentage of patients with documented end-of-life conversations (I:C 75% vs 72%, p=0.63) or completion of advance care directives (26% vs 29%, p=0.55). Conclusions Despite initially improving the occurrence of end-of-life conversations, the intervention did not increase the documentation of subsequent conversations about end-of-life care, nor did it improve documentation of advance directives. Seventy-five percent of the patients in our cohort had documented follow-up conversations showing most have these conversations, but there is room for improvement and an unclear impact on goal-concordant care. Future research should focus on testing multi-faceted, longitudinal, system-level interventions to enhance conversations about goals of care that promote goal-concurrent care.

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BackgroundScreening for colorectal cancer (CRC) with faecal immunochemical test (FIT) is effective at reducing CRC mortality. Unfortunately, the COVID-19 pandemic has been associated with deferred care, especially screening for CRC.AimWe sought to develop a mailed FIT programme (MFP) to increase CRC screening and make recommendations for adoption across the Veterans Health Administration (VHA) and for other large healthcare systems.Setting2 regional VA medical centres in California and Washington state.Participants5667 average risk veterans aged 50–75 overdue or due within 90 days for CRC screening.Programme descriptionA multidisciplinary implementation team collaborated to mail an FIT kit to eligible veterans. Both sites mailed a primer postcard, and one site added an automated reminder call.Programme evaluationWe monitored FIT return and positivity rate, as well as impact of the programme on clinical staff. 34% of FIT kits were returned within 90 days and 7.8% were abnormal.DiscussionWe successfully implemented a population-based MFP at multiple regional VA sites and recommend that these efforts be spread across VA. Our model of regional leadership, facility champions and using centralised resources can be adaptable to other large healthcare systems. MFPs support catch-up from disrupted care by addressing access to CRC screening, unburden primary care visits and conserve limited procedural resources.

BACKGROUND: Following implementation of the patientcentered medical home (PCMH) within the Department of Veterans Affairs (VA), access to primary care improved. However, understanding of how this occurred is lacking. OBJECTIVE: To examine the association between organizational aspects of the PCMH model and access-related initiatives with patient perception of access to urgent, same-day, and routine care within the VA. DESIGN: Cross-sectional PARTICIPANTS: Veterans who responded to the annual Survey of Healthcare Experiences of Patients in 2016 (N = 241,122 patients) and primary staff who responded to VA National Primary Care Provider and Staff Survey (N = 4815 staff). MAIN MEASURES: Three outcomes of perception of access: percentage of patients responding in the highest category for same-day care (waiting ≤ 1 day), urgent care (always receiving care when needed), and routine care (always receiving checkups when desired). Predictors were staff-level report of access-related initiatives and organizational factors in the clinic. We used generalized estimating equations to model associations, adjusting for characteristics of patients and their respective clinics. KEY RESULTS: Access was significantly better in clinics where staff reviewed performance reports (+ 0.9% in the highest perception of access for urgent care, P < 0.01; + 1.2% for routine care, P < 0.001), leadership was supportive of the PCMH (+ 1.6% for urgent care, P < 0.01), and initiatives to improve access included open access (+ 0.8% to + 1.7% across all outcomes, P < 0.01) and telehealth visits (+ 1.2% to + 1.4%, P < 0.001). Perceived access was worse in clinics with moderate staff burnout (− 1.1% to − 1.4%, P < 0.001), primary care provider turnover during the past year (− 1.0% to − 1.6%, P < 0.001), or medical support assistant turnover in the past year (− 0.9% to − 1.4%, P < 0.001). CONCLUSIONS: Perception of access was strongly associated with identifiable organizational factors and accessrelated initiatives within VA primary care clinics that could be adopted by other health systems.

IMPORTANCE In 2010, the US Veterans Health Administration (VHA) implemented one of the largest patient-centered medical home (PCMH) models in the United States, the Patient Aligned Care Team initiative. Early evaluations demonstrated promising associations with improved patient outcomes, but limited evidence exists on the longitudinal association of PCMH implementation with changes in health care utilization. OBJECTIVE To determine whether a change in PCMH implementation is associated with changes in emergency department (ED) visits, hospitalizations for ambulatory care-sensitive conditions (ACSCs), or all-cause hospitalizations. DESIGN, SETTING, AND PARTICIPANTS This cohort study used national patient-level data from the VHA and Centers for Medicare & Medicaid Services between October 1, 2012, and September 30, 2015. A total of 1 650 976 patients from 897 included clinics were divided into 2 cohorts: patients younger than 65 years who received primary care at VHA sites affiliated with a VHA ED and patients 65 years or older who were enrolled in both VHA and Medicare services. EXPOSURES Clinics were categorized on improvement or decline in PCMH implementation based on their Patient Aligned Care Team implementation progress index (Pi 2) score. MAIN OUTCOMES AND MEASURES Change in the number of ED visits, ACSC hospitalizations, and all-cause hospitalizations among patients at each clinic site. RESULTS The study included a total of 1 650 976 patients, of whom 581 167 (35.20%) were younger than 65 years (mean [SD] age, 49.03 [10.28] years; 495 247 [85.22%] men) and 1 069 809 (64.80%) were 65 years or older (mean [SD] age, 74.64 [7.41] years; 1 050 110 [98.16%] men). Among patients younger than 65 years, there were fewer ED visits among patients seen at clinics that had improved PCMH implementation (110.8 fewer visits per 1000 patients; P < .001) and clinics that had somewhat worse implementation (69.0 fewer visits per 1000 patients; P < .001) compared with clinics that had no change in Pi 2 score. There were no associations of change in Pi 2 scores with all-cause hospitalizations or ACSC hospitalizations among patients younger than 65 years. In patients 65 years or older, those seen at clinics that had somewhat worse PCMH implementation experienced fewer ED visits (20.1 fewer visits per 1000 patients; P = .002) and all-cause hospitalizations (12.4 fewer hospitalizations per 1000 patients; P = .007) compared with clinics with no change in Pi 2 score. There was no association between change in Pi 2 score with ACSC hospitalizations among patients 65 years or older. (continued) Key Points Question Is a change in patientcentered medical home implementation associated with changes in high-cost health care utilization in the US Veterans Health Administration health care system? Findings In this cohort study including 1 650 976 veterans, neither improvement nor decline in patientcentered medical home implementation was consistently associated with changes in the numbers of emergency department visits, ambulatory caresensitiv...

Background Mailed fecal immunochemical testing (FIT) programs are increasingly utilized for population-based colorectal cancer (CRC) screening. Advanced notifications (primers) are one behavioral designed feature of many mailed FIT programs, but few have tested this feature among Veterans. Objective To determine if an advanced notification, a primer postcard, increases completion of FIT among Veterans. Design This is a prospective, randomized quality improvement trial to evaluate a postcard primer prior to a mailed FIT versus mailed FIT alone. Participants A total of 2404 Veterans enrolled for care at a large VA site that were due for average-risk CRC screening. Intervention A written postcard sent 2 weeks in advance of a mailed FIT kit that contained information on CRC screening and completing a FIT. Main Measures Our primary outcome was FIT completion at 90 days, and our secondary outcome was FIT completion at 180 days. Key Results Overall, unadjusted mailed FIT return rates were similar among control vs. primer arms at 90 days (27% vs. 29%, p = 0.11). Our adjusted analysis found a primer postcard did not increase FIT completion compared to mailed FIT alone (OR 1.14 (0.94, 1.37)). Conclusions Though primers are often a standard part of mailed FIT programs, we did not find an increase in FIT completion with mailed postcard primers among Veterans. Given the overall low mailed FIT return rates, testing different ways to improve return rates is essential to improving CRC screening. Supplementary Information: The online version contains supplementary material available at 10.1007/s11606-023-08248-7.