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Response to Commentary

Rising to the Challenge: VA Health Systems Research Is Uniquely Positioned to Reimagine Unplanned Care for Veterans

The delivery of emergency care in the United States continues to be in a state of flux. Long wait times and crowded conditions have been the norm for decades, along with steady increases in overall patient volumes and in the number of patients waiting to be admitted. And just when conditions seemed like they could not get worse, the COVID- 19 pandemic exacerbated what many have called the “canary in the coal mine” of the U.S. healthcare system: its emergency departments. Despite workplace violence, fractured clinician and staff wellness, complex coordination between hospitals and modalities of care, and worsening boarding (the practice of holding admitted patients in the emergency department while they await an available inpatient bed), the U.S. emergency care system plays a vital role in the delivery of healthcare, particularly for the most vulnerable patients.

The commentary by Dr. Patel underscores the changing dynamic of emergency care for Veterans and the Veterans Health Administration (VA). No longer is emergency care simply about the heart attack patient nor the traumatically injured patient. Today’s emergency care system, and particularly the system within VA, attempts to be responsive to patients’ unplanned care needs. The make versus buy question that the CHOICE and MISSION Acts have evoked further compounds today’s emergency care challenges for both VA and Veterans. Non-VA emergency care and subsequent hospitalizations now comprise over $500M in expenses per month and are the leading cause of non-VA care expenditures borne by VA. Multiple studies have demonstrated that the quality of VA healthcare is as good, if not better than, civilian healthcare; however, there are only 110 VA emergency departments compared with the more than 5,000 non-VA emergency departments, 1,800 retail clinics, and 10,000 urgent care centers in the United States. Delivering emergency carethat is Veteran-centric and that incorporates the three Rs – right care at the right place and at the right time – while also being sustainable, is an enormous challenge that requires the interplay of both key operational and research partners. VA’s Health Systems Research (HSR) is exceptionally well positioned to be one of these key partners.

In 2022, then VA HSR&D (Health Services Research & Development Service) conducted the State of the Art (SOTA) XVI Conference on VA Emergency Medicine (SAVE) focusing on Veteran emergency care. The SOTA focused on three priority populations within Veteran emergency care: geriatrics, mental health, and non-VA care. Academic Emergency Medicine ¹ published the SAVE proceedings in an April 2023 special issue, which included the history of VA emergency care, the rationale for the SOTA,² and the SOTA’s research and policy recommendations.³ The research priorities by workgroup are presented below.

Non-VA (Community) Emergency Care Workgroup

1. Examine how the expansion of community emergency care impacted emergency department utilization, access, and
2. Understand the follow-up needs among Veterans who have received community emergency care or urgent
3. Compare the quality, safety, and Veteran experience between VA and community emergency care.

Geriatric Workgroup

1. Examine the variation in care for older Veterans in the emergency department, and how variation affects
2. Identify and develop successful strategies to improve the quality of emergency department discharges.
3. Examine the quality, safety, and effectiveness of telehealth to support care of older adults with emergency care
4. Examine the impact of geriatric emergency department (GED) initiatives.
5. Improve implementation of geriatric assessment tools in the emergency

Mental Health Workgroup

1. Enhance the reach of effective suicide
2. Develop and rigorously evaluate interventions to manage substance use
3. Identify and examine safe and effective practices to manage acute psychosis.

Beyond these three priority populations, the SOTA identified cross-cutting themes impacting Veteran emergency care including telehealth, implementation science to refine multicomponent interventions, care coordination, and data needs from both VA and non-VA sources. HSR has responded with not only the SOTA and the special journal issue but has also recognized emergency medicine as a priority topic area within healthcare system organization and delivery science.

Since the SOTA, several key operational changes have enhanced the prominence of emergency care within VA. The establishment of the National Emergency Medicine Office (NEMO) as a national VA program office with an operational budget and oversight of clinical programs provides emergency medicine with needed resources for clinical program delivery and administrative oversight to enhance the quality of and access to care. Other key initiatives include the national launch of the Tele-Emergency Care (TeleEC) program, along with oversight of the emergency ambulance service, and VA urgent care clinics.

Dr. Patel’s report on operational priorities highlights critical areas that HSR investigators are well positioned to address. Specifically, the non-VA population aligns with the SOTA priority groups.

The implementation of TeleEC represents an important innovation and studies are needed to understand how cost, access, quality, and outcomes of TeleEC care differ between VA and non-VA settings and how Veterans access non-VA TeleEC care. Particularly in rural settings where VA EDs and urgent care clinics are less available, HSR investigators should address the question of whether VA TeleEC represents an opportunity to engage Veterans. Moreover, studies are needed to examine whether disparities in access, quality, or outcomes of TeleEC care exist for vulnerable Veteran populations (e.g., rural-dwelling, older patients).

An additional facet of access to emergency services is through interfacility ambulance transportation. A NEMO-funded programmatic evaluation is currently being led by Dr. Anita Vashi (Palo Alto VA). There is a dearth of research on VA ambulance transports, including how state laws impact their use, and how their limited capacity should be made available. The need to further examine non-VA emergency care suggests several key questions. What are the non-VA emergency ambulance expenses, particularly for helicopter EMS (which routinely costs over $50,000 per trip)? What proportion of non-VA expenditures are related to helicopter EMS expenses? Do these ambulance services represent an opportunity for expansion, or should VA purchase these services from non-VA vendors?

The geriatric emergency care population, as noted by Dr. Patel, represents the majority of Veterans seeking emergency care. There has been substantial investment on the part of VA to make VA emergency care geriatric-friendly through the implementation of geriatric emergency departments. However, studies are needed to understand the implementation and outcomes of this investment. For example, variations in the allocation of resources within geriatric emergency departments and the sustainability of those resources are topics that merit further research.

The third priority group mentioned in the commentary but not explicitly addressed regarding potential questions, is the mental health population. Specifically identified in the SOTA conference as a key population served by VA emergency departments, research needs include identifying the effectiveness and reach of suicide interventions, substance use disorders, and the management of acute psychosis in VA emergency departments and urgent care clinics. 

The prevention of workplace violence is recognized within the national context as a problem for emergency care nurses and clinicians. While not unique to the emergency department, HSR investigators are similarly well positioned to examine this issue from a systems perspective. What is truly unique to the emergency department? How have other VA and non-VA clinical settings addressed this problem? And how is intervention development and implementation challenged by the clinical context?

Veterans increasingly have a choice about where to seek emergency or unplanned care, and HSR investigators are exceptionally well positioned to study how the structure and implementation of the emergency medicine system impacts that choice and patient outcomes.

References

1. Special Issue on Veteran Emergency Care. Academic Emergency Medicine Web site. https://onlinelibrary.wiley. com/toc/15532712/2023/30/4. Published 2023. Accessed June 12, 2024.
2. Ward MJ, et “Continuing the Transformation – Charting the Path for the Future Delivery of Veteran Emergency Care,” Academic Emergency Medicine 2023;30(4):232-9.
3. Ward MJ, et al. “Research and Policy Recommendations from the SOTA XVI: State of the Art Conference on VA Emergency Medicine,” Academic Emergency Medicine 2023;30(4):240-51.