May 2020

In This Issue: Advancements in VA Primary Care
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Attrition of Women Veterans New to VHA in the Community Care Era

Feature Article

Takeaway: Understanding the association between Community Care (CC) experiences and attrition among women Veterans new to VA healthcare is vital to providing optimal care to this VA patient population, not only because women are far more likely than men to be referred to CC and often receive gender-specific services that require heavy care coordination, but also because the number of women Veteran VA patients has nearly tripled over the past 15 years.

VA outsources care through its Community Care (CC) program, a top VA priority. With the 2014 passage of the Veterans Choice Act came a rapid expansion of CC. While expanded CC is meant to enhance choice and access, emerging evidence raises concerns about how VA patients experience it. Early Community Care implementation was challenging, e.g., with limited availability of CC providers and fragmented care coordination between VA and CC providers. Patient experiences of Community Care may have special relevance for women, who are referred to CC far more than men. Furthermore, nearly one in five new women Veteran VA patients stops using VA care, which is three-fold higher odds of attrition than other women in VA.

Through a recently completed HSR&D project, investigators learned that patient experiences of care can impact attrition. In preliminary analyses, odds of attrition in a cohort from FY2011 were lower for women who received Community Care. However, in this post-expansion era of Community Care, it is not known whether CC will continue to protect against attrition, whether the attrition rate among women will improve or worsen, how specific types of CC may influence women's decisions to continue in versus leave VA care, or what patient subgroups are at particular risk for CC-related attrition (i.e., women new to VA healthcare).

This HSR&D-funded study (May 2019 – October 2022) aims to assess women Veterans’ experiences of community care and their perspectives on the relationship between CC and plans for future VA use by:

• Modeling CC and other factors expected to predict attrition from VA,
• Examining the long-term attrition trajectory pre- and post-expansion of CC, and
• Characterizing the facility-level context of CC.

Methods

Investigators will analyze existing data sources in an FY17 national cohort of new women (N~23,000) and new men (N~200,000) VA primary care patients. They will model the attrition trajectory in sequential national cohorts (FY2007 through the second quarter of FY2019) of all women Veterans new to VA, and separately, men. In addition, investigators will conduct interviews with clinician and staff key stakeholders (n=30) involved in Community Care at 10 purposively selected sites. They also will conduct interviews with new women Veteran primary care patients (n=70) at sites that received a CC referral in FY2020.

Key stakeholders and women Veterans will be asked to provide recommendations for organizational and policy changes that might improve CC and retention of Veterans in VA care. Understanding the potential association between CC experiences and attrition among women Veterans represents a critical topic, not only because women are far more likely than men to be referred to CC and often receive gender-specific services that require heavy care coordination, but also because the number of women Veteran VA patients has nearly tripled over the past 15 years.

Findings

None at this time.

Anticipated Impact

By yielding results relevant to system-level and policy changes, study findings will point to specific types of Community Care that are associated with greater attrition risk, specific subgroups who are at more risk, and specific elements of VA delivery systems that interact with CC to increase risk of attrition. The next step will be to work with policy partners to identify targets for change and intervention, to minimize attrition – and maximize patient-centered care. 

Principal Investigators: Susan Frayne, MD, MPH, is part of HSR&D’s Center for Innovation to Implementation (Ci2i) in Palo Alto, CA. Alison Hamilton, PhD, MPH, is part of HSR&D’s Center for the Study of Innovation, Implementation & Policy (CSHIIP) in Los Angeles, CA

Publications

None at this time.

View study abstract