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VA has made significant strides in improving
access to health care services for the
veterans it serves. Despite these improvements,
VA must address three immediate
challenges:
- Ensure ease of access for patients to existing
providers and ensure that service gaps
are addressed;
- Improve our understanding and use of
support staff roles and team productivity;
and
- Achieve a higher degree of reliability and
standardization in the flow of patients from
primary to specialty care.
The first challenge--ensuring a sufficient
complement of physicians at VA's medical
centers--demands practical solutions. While
access for individual patients to their providers
is usually good when providers are present,
gaps in care occur when providers are absent
for any reason, and any length of time.
Medical centers and providers need to innovate
and be more proactive in developing
contingency plans for such absences. Some
options include back-up by other team
members, specific providers tasked to cover
absences, using support staff in new ways,
partnering with other departments, contracts
with private provider groups,
increased patient waiting, or diversion.
The second challenge--improving utilization
of staff--involves deepening our understanding
of the potential roles of
support staff and leveraging staff roles to
improve the efficiency of health services
delivered. The idea here is that every team
member works at the highest level of their
licensure and capability while applying that
effort to the patient population that benefits
the most. A direct relationship exists between
the number of support staff and
medical team productivity (in terms of population
care), and we need to better understand
and leverage those dynamics.
Third, VA needs to learn more about how
patients move among the wider team of
service providers. What care should primary
care be responsible to deliver? Are patients
shifting from primary to specialty care at
the right time? Do they stay in specialty
care for the right length of time? Wide variation
exists in what is referred to as specialty
care. Increased standardization of the
definition of primary care versus specialty
care services would improve delivery of
care to veterans.
Despite these challenges, VA has successfully
used Internet technology to advance
access for veterans. The availability of medical
records through My HealtheVet, videoteleconferencing,
and other computer-enabled
technologies has improved both efficiency
and access to care.
While VA is taking care of a relatively small
number of OIF/OEF veterans, we are a nation
at war. These returning veterans are a
top priority. Access to care for OIF/OEF
veterans should be no different than for
other veterans. Recently returning veterans
have different needs, however, and VA must
be nimble in responding to those needs. An
increased demand for rehabilitation services
is just one example. Furthermore, VA must
do better at reaching out to returning veterans
and asking, "How can we help?"
To achieve greater efficiencies, VA is opening
new ambulatory centers and working
more closely with community resources to
address gaps in care. VA's recent approach
focuses more on partnering with community
organizations to provide services when
it makes sense, as opposed to building and
owning space. This approach is especially
important for the delivery of low-volume
specialty care.
VA's Bar Code Medication Administration
(BCMA) program is just one example of
recent efforts to improve efficiency, in this
case the efficiency of medications delivered
at bedside. While BCMA is a major advance,
improvements are still needed to address
problems with this new technology. VA
delivers thousands of medications daily.
Small advances in standardizing and improving
the process by which these medications
are delivered at bedside would result in
huge improvements in the availability of
nurses to address other needs.
The access challenges facing VA today suggest
several compelling research opportunities.
- Waiting times. There is great interest,
including by Congress and the Inspector
General, in measuring wait times for services,
yet not much research has been undertaken
in this area.
- Elective vs. emergency procedures.
We need to be able to measure and plan for
wait times for elective vs. emergency procedures
so that we can meet both medical
needs and patient expectations.
- Variations in patient expectations by
generation. VA needs a better understanding
of what our customers want and how
those preferences vary by generation.
- Disability exams. The administration
of disability exams, necessary for determining
pension and disability compensation, is
a major new issue and area of dissatisfaction
for new veterans.
- Appointment failures. VA needs to explore
the reasons why patients fail to
"show" for appointments.
Critical to addressing access challenges is the
need for VA to improve the efficiency of care
provided. VA is keenly interested in process
improvement and there is a huge need for
knowledge and research in these areas. The
academic community has been slow to embrace
and value improvement science.
Ensuring ease of access to services for veterans
living in rural areas remains a key priority
for VA. The Office of Rural Health is
focused on ensuring access to VA care for
veterans living in sparsely populated areas
that lack ease of access to a nearby VA
medical center. While veterans living in rural
areas may have access to a VA facility, that
facility may lack key specialty services. In
rural settings, transporting veterans who
need specialty care to an appropriate site of
care presents a complex logistical challenge.
VA continues to focus on improving access
to mental health services. One area of study
relates to the supply of providers needed to
treat mental health conditions. Key to this
focus is improving our understanding of
how often and for what duration patients
should be seen for mental health conditions.
Another challenge is the need to connect
patients to the right provider at the right
time.
While VA has substantially improved access
to health care services over the last decade,
additional access improvements remain
within reach and must be pursued actively at
all levels within VA.
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