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Access to healthcare includes a variety of concerns, ranging from how close a Veteran may live to a VA healthcare facility to whether the Veteran is able to travel to a VA clinic. Access to care can also include factors like whether Veterans find VA facilities to be welcoming and adapted to their unique needs. Identifying and evaluating innovative strategies that improve access to care comprises a significant part of the research conducted by investigators with VA’s Health Service Research and Development Service (VA HSR&D). The following HSR&D-funded studies address varying aspects of access to care—as well as their potential impact Veterans’ health or on the VA healthcare system.
Study Questions
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What are Veterans interested in with regard to options for complementary and integrative health (CIH) therapies? What CIH treatments are Veterans already using, what conditions are they using them for and how satisfied are they with those CIH therapies?
Implications for Care
Almost 50 percent of Veterans are already using a variety of CIH therapies as a non-pharmacological way to manage their heath (i.e., acupuncture, biofeedback, meditation/mindfulness, and guided imagery)—and for those Veterans not already using a CIH therapy, interest in doing so is high. Many of these CIH therapies are currently offered in VA medical facilities as medical treatment. To further increase access to CIH therapies and address the gap between Veterans’ interest in, and use of, these therapies, primary care providers should consider discussing evidence-based CIH therapy options, given that most such therapies are safe.
About the Study
The Department of Health and Human Services’ National Pain Strategy and the American College of Physicians’ low back pain clinical practice guidelines recommend CIH therapies, such as Tai Chi, yoga, and acupuncture, among suggested non-pharmacological treatment options for some common conditions (i.e., chronic pain, anxiety, and depression). In part to guide the expansion of evidence-based CIH therapies, VA leaders sought current information on Veterans’ interest in, use of, and satisfaction with various CIH therapies, both inside and outside the VA healthcare system. Thus, investigators in this study analyzed survey results from a large sample of Veterans asked about these topics in July 2017. They used 1,230 members of the national VHA Veteran Insights Panel (VIP) completed the survey. [The VIP is a national online group of Veterans who regularly use VA care; VIP enables them to provide feedback on VA programs and services.] The 26 CIH therapies included in the survey were those being provided at some VA medical centers, 9 of which are considered medical care at the VA (i.e., acupuncture, biofeedback, therapeutic massage, meditation/mindfulness, yoga, Tai Chi, hypnosis, and guided imagery), although the evidence base for some is stronger than for others.
Findings
In the past year, 52% of Veterans in this study used any CIH therapy, with 44% using massage therapy, 37% using chiropractic, 34% using mindfulness, 24% using other meditation, and 25% using yoga. Pain, stress reduction/relaxation, and improving overall health and well-being were the top three reasons for using the 9 CIH therapies.
Overall, 84% of Veterans in this study stated an interest in trying/learning more about at least one CIH therapy, with about half being interested in six specific therapies (chiropractic, acupuncture, acupressure, therapeutic massage, reflexology, and progressive relaxation).
Veterans appeared to be much more likely to use each CIH therapy outside vs. within VA. This is most likely because most VA medical centers have only recently been establishing or strongly publicizing some of these programs—or because many providers are only now learning about their availability or effectiveness.
Principal Investigator
Stephanie Taylor, PhD, is the Principal Investigator for the QUERI Partnered Evaluation Initiative’s Complementary and Integrative Health Evaluation Center, and is an Associate Director with HSR&D’s Center for the Study of Healthcare Implementation, Innovation, and Policy.
CITATION: Taylor S, Hoggatt K, and Kligler B. Complementary and Integrated Health Approaches: What Do Veterans Use and Want? Journal of General Internal Medicine. July 2019, Volume 34, Issue 7, pp 1192–1199.
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The Study Question
For Veterans with access barriers, do VA-provided video-enabled tablets facilitate use of VA services and improve outcomes?
Implications for Care
Distributing video-enabled tablets to Veterans with mental health conditions appeared to improve access to and continuity of mental health services while also improving clinical efficiency. Based on this evaluation, VA's telehealth tablet initiative may serve as a model for other large integrated healthcare systems interested in using virtual technology to address access barriers to care.
About the Study
Of the approximate 9 million enrolled Veterans receiving VA healthcare, nearly one-third live in rural, highly-rural, and insular island areas. Many others experience transportation and financial challenges that prevent them from using VA care. These barriers are further compounded for the 2 million Veterans with mental health conditions, some of whom avoid care due to perceived stigma or privacy concerns. In 2016, VA initiated a program to distribute video-enabled tablets to Veterans with geographic, clinical, or social access barriers to in-person care so that they could receive services in their homes or other convenient locations: 75% of tablet recipients had a mental health diagnosis, providing a unique opportunity to assess the effectiveness of this national tablet distribution. This study evaluated the implementation of this initiative for Veterans with mental health conditions, including whether having a tablet was associated with improved access to and continuity of mental health care; missed opportunities for care; and use of urgent care. Study investigators matched tablet recipients with mental health diagnoses (n=728) to a comparison group (n=1,020) based on sociodemographic characteristics, mental health diagnoses and care, and wireless coverage.
Findings
Distributing video-enabled tablets to Veterans with mental health conditions appeared to improve access to and continuity of mental health services while also improving clinical efficiency. Compared to Veterans in the control group, Veterans who received tablets experienced an increase of 1.9 psychotherapy encounters; an increase of 1.1 medication management visits; a 19% increase in their likelihood of receiving recommended mental healthcare continuity; and a 20% decrease in their missed opportunity rate (i.e., missed appointments) six months after receiving the tablets.
There were no significant differences in emergency department or urgent care use between groups.
Principal Investigator
Donna Zulman, MD, MS, is an investigator with the HSR&D Center for Innovation to Implementation, at the VA Palo Alto Healthcare System.
CITATIONS:
Zulman DM, Wong EP, Slightam C, Gregory A, Jacobs JC, Kimerling R, Blonigen DM, Peters J, Heyworth L. Making connections: Nationwide implementation of video telehealth tablets to address access barriers in high-need Veterans. JAMIA Open. 2019: 2(3):323-329.
Jacobs JC, Blonigen DM, Kimerling R, Slightam C, Gregory A, Gurmessa T, Zulman DM. Increasing access, continuity, and efficiency of mental health care for Veterans through video telehealth tablets. Psychiatric Services. 2019.
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The Study Question
Despite VA’s mandate that all Veterans be screened for PTSD annually for the first five years after military separation—and every five years thereafter—nearly half of Veterans who receive a new, positive PTSD screen receive no subsequent VA-based mental healthcare. Who is being lost to follow-up, where in the process they are being lost, and why are these Veterans not receiving care?
Implications for Care
The immediate objective of this recently funded pilot study is to develop a method for determining whether and where Veterans are offered care immediately after a positive PTSD screen, and to begin to identify the variables that predict these outcomes. Results regarding system-, provider-, and patient-level (SPP) variables will help increase the understanding of factors associated with access to care following a positive PTSD screen. Ultimately, study results may help improve access to VA mental health care for all Veterans with PTSD.
About the Study
The first aim of the study is to develop a feasible and efficient method for identifying the initial access step for Veterans with a new positive PTSD screen in primary care. Investigators are using VA electronic medical record (EMR) data to identify the initial access steps for Veterans with a new positive PTSD screen in primary care during the most recent year available. Investigators have hypothesized the following categories as likely next steps immediately after a positive PTSD screen in primary care:
The study includes a chart review component to validate the method for classifying Veterans, and to identify other initial access steps by: (1) ensuring the completeness of the first four initial access steps; (2) determining if there are additional initial access steps that should be considered beyond those identified; and (3) recording language for detecting initial access steps that cannot be identified using the EMR which can be used for natural language processing.
In addition to the access step classification and validation, investigators are developing a dataset of SPP variables and begin to describe each initial access steps identified. The investigators will conduct descriptive analyses of these SPP variables to provide preliminary descriptions of each initial access step.
Findings
This study is still ongoing.
PI: Michelle Bovin, PhD, is an investigator with the National Center for PTSD at the VA Boston Healthcare System.
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Study Question
What was the return on investment for VA’s integration of primary care and mental health services (PC-MHI)?
Implications for Care
The initial goal of PC-MHI—increasing overall access by embedding mental health specialists in primary care—was achieved. However, as outpatient mental health and primary care visits increased, the implementation of integrated care led to higher total costs.
About the Study
Investigators conducted a retrospective cohort study examining PC-MHI's effects on healthcare use and cost patterns among 5.4 million primary care patients in 396 VA clinics (FY2014-FY2016), while also accounting for the implementation of VA's Patient Aligned Care Team model of care. Investigators assessed whether attending a clinic where PC-MHI achieved greater reach into its primary care patient population (a VA performance indicator of PC-MHI penetration) was associated with differences in Veterans’ use of VA outpatient and inpatient care and total cost of VA care. Clinic and patient characteristics were also examined, including demographics, psychiatric and medical diagnoses, homelessness, and travel distance to clinic.
Findings
Investigators found that Veterans treated in VA clinics where higher proportions of primary care patients were seen by PC-MHI providers received more outpatient care than those treated in clinics with lower PC-MHI penetration, but at a higher total cost. Each percentage-point increase in the proportion of clinic patients seen by PC-MHI providers was associated with 11% more mental health and 40% more primary care visits, but also 9% higher average total costs per patient per year.
Further, among patients with serious mental illness, increasing PC-MHI penetration was associated with greater use of specialty-based mental healthcare and all other healthcare visits; and among patients seen in hospital-based clinics, increasing PC-MHI penetration was associated with fewer emergency visits per person per year.
Citation
Principal Investigator
Lucinda Leung, MD, PhD, is an investigator with the HSR&D Center for the Study of Healthcare Implementation, Innovation, and Policy at the VA Greater Los Angeles Healthcare System.
