A Mixed Methods Study of the Association of Non-Veterans Affairs Care With Veterans’ and Clinicians’ Experiences of Care Coordination

Abstract

Background: Poor coordination between the Department of Veterans Affairs (VA) and non-VA care may negatively impact health care quality. Recent legislation is intended to increase Veterans’ access to care, in part through increased use of non-VA care. However, a possible consequence may be diminished patient experiences of coordination. Objective: The objective of this study was to determine VA patients’ and clinicians’ experiences of coordination across VA and non-VA settings. Design: Observational mixed methods using patient surveys and clinician interviews. Sampled patients were diagnosed with type 2 diabetes mellitus and either cardiovascular or mental health comorbidities. Participants and Measures: Patient perspectives on coordination were elicited between April and September 2016 through a national survey supplemented with VA administrative records (N=5372). Coordination was measured with the 8-dimension Patient Perceptions of Integrated Care survey. Receipt of non-VA care was measured through patient self-report. Clinician perspectives were elicited through individual interviews (N=100) between May and October 2017. Results: Veterans who received both VA and non-VA care reported significantly worse care coordination experiences than Veterans who only receive care in VA. Clinicians report limited information exchange capabilities, which, combined with bureaucratic and opaque procedures, adversely impact clinical decision-making. Conclusions: VA is working through a shift in how Veterans receive health care by increasing access to care from non-VA providers. Study findings suggest that VA should prioritize coordination of care in addition to access. This could include requiring monitoring of patient-experienced care coordination, surveys of referring and consulting clinicians, and pilot testing and evaluation of interventions to improve coordination.

Care integration within and outside health system boundaries

“…We developed the survey instrument through an extensive literature review and examination of prior survey instruments, 22‐33 domain and survey expert interviews, and cognitive testing.…”

Coordinating women's preventive health care for rural veterans

“…The majority of veterans will require extensive monitoring, which includes tracking, scheduling, and follow‐up of abnormal results 7–9 . While VA facilities do have a local Office of Community Care (OCC), recent literature has cited the opaque procedures for managing non‐VA referrals, the limited information exchange, and the lack of efficient clinical decision‐making between care settings 10 . Smaller VHA facilities often lack adequate staffing that is required to ensure success at each level of the screening process.…”

“…[7][8][9] While VA facilities do have a local Office of Community Care (OCC), recent literature has cited the opaque procedures for managing non-VA referrals, the limited information exchange, and the lack of efficient clinical decision-making between care settings. 10 Smaller VHA facilities often lack adequate staffing that is required to ensure success at each level of the screening process. In addition to staff shortages, smaller VHA facilities are more likely to serve veterans who rely heavily on the CCN for their preventive screenings and gender-specific care, thus putting women at an increased risk for failure to obtain appropriate screening, delays in care, or missed abnormal results.…”

Behavioral Health Screening and Care Coordination for Rural Veterans in a Federally Qualified Health Center

“…Future research should explore low-touch options for connecting veterans presenting in community care settings to VA services, including eligibility and enrollment. Of note, VA support staff have been embedded in community care settings in some instances, 44 which may be worth examining in clinics serving a large number of veterans. Finally, research demonstrates that patient portals are a valuable tool for those who are dual users, allowing patients to actively participate in information sharing and communication with providers.…”