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Director's Letter

Emergency Care and Innovation in Health Systems Research

Emergency care is the “canary in a coal mine” when it comes to identifying healthcare access barriers and emerging public health threats. For individuals with limited incomes, Emergency Departments are also a principal source of care. In the Oregon Medicaid Experiment randomized trial, emergency care visits increased up to 40 percent among those randomized to receive Medicaid insurance compared to those not randomized to receive insurance. This effect persisted over time, indicating the continued importance of emergency care services in communities.

VA Emergency Care includes both purchased (community) care and VA-provided services, which makes effective coordination and optimization of best practices especially complex. The proportion of emergency care provided by community providers has doubled for Veterans in the last few years. The dual role of VA as a payer and provider of emergency care services opens new opportunities for research focused on value-based community care, innovations in care efficiency and coordination, and application of emerging technologies to ensure Veterans get the care they need. This FORUM issue focuses on new areas of research that hold the promise of making emergency care more accessible, equitable, and effective for Veterans, including older patients with dementia, mental health issues, those living in rural settings, as well as Veterans with lower incomes in urban settings with limited transportation options.

The VA National Emergency Medicine Office and other VA program offices and policymakers have focused on ways to improve the quality, efficiency, and experience of emergency care for Veterans regardless of location or provider. Working together also creates opportunities to forge research-operational partnership collaborations across VA, including Integrated Veteran Care and the VA Center for Care and Payment Innovation (CCPI) to co-design high-impact research in this area. Established under the Maintaining Systems and Strengthening Integrated Outside Networks (MISSION Act; Sect. 152), CCPI identifies and tests new financial and service delivery models. The MISSION Act further authorizes VA, subject to congressional approval via joint resolution, to waive statutes and regulations that govern Veterans’ benefits related to healthcare, including emergency services. This enables CCPI to pilot innovations in payment, care, and business operations to improve Veteran care, leveraging its unique waiver authority as needed. Potential research areas include developing and validating value-based payment models for community care, including emergency care that rewards providers on quality of care, and alternative models of service delivery such as community outreach workers or virtual emergency services.

VA’s Health Systems Research portfolio (formerly HSR&D) offers a key example of how research can address complex health system needs and is poised to support investigators to conduct  innovative and impactful research in emergency care. HSR supports groundbreaking science focused on the organization, financing, and delivery of healthcare to improve Veteran outcomes and advance VA as a national Learning Health System. HSR seeks to improve Veteran Quintuple Aim goals: access, outcomes, equity, experience, and value (Matheny, NAM 2019; Cahan, 2020; Nundy 2021) using foundational Learning Health Systems (LHS) methods (Friedman, 2022, Lannon et al., 2020; Friedman et al. 2024), including implementation, data, engagement, systems, and policy sciences. These foundational LHS methods also represent tools to improve health and healthcare for Veterans (e.g., direct implementation) that are relevant to HSR’s Quality Enhancement Research Initiative (QUERI) program, thus enabling investigators to respond to scientific research priorities with pragmatic solutions the VA healthcare system can use immediately.

The latest HSR priorities are based on VA leadership and end-user input as described in the VA Strategic Plan and include Veteran- focused legislative and congressional priorities, and ORD priorities that address crucial questions pertaining to emergency care for Veterans.

• Connect Veterans to the soonest and best care: optimize Veteran access, quality, efficiency, experience, and equity of care across in-person, virtual, and community care services.
• Implement value-based care solutions: design and refine value-based care models and tools to ensure care provided in the community leads to improved quality of care and outcomes for Veterans.
• Build an integrated delivery network to meet the diverse and changing needs of Veterans: identify efficient staffing and care models for primary care, specialty care, and mental health services across different regions and healthcare settings.
• Retain, invest in, and support VA employees: implement and evaluate programs focused on employee health and well- being, education, psychological safety, zero harm, innovation, leadership development, and technology training.
• Drive a culture of learning, knowledge translation, and innovation: identify opportunities where emerging technologies (e.g., artificial intelligence (AI), virtual reality), predictive models, and other promising innovations can make VA services more efficient and reduce provider burden associated with burnout.
• Prevent Veteran suicide: prevent Veteran suicide using a public health approach e.g., outside the clinic walls, partnerships with community service organizations.
• Address health disparities: ensure at-risk, underserved, and older Veterans receive early interventions and supportive services to address social determinants of health and preventable

Additional information on HSR and QUERI funding opportunities will be posted soon at https://www.research.va.gov/funding/rfa.cfm