BACKGROUND/RATIONALE:
Many American Indian and Alaska Native (AIAN) are eligible for healthcare services from both Veterans Health Affairs (VHA) and Indian Health Service (IHS). Yet, dual use of healthcare systems poses a dilemma for policy-makers and managers whose goals are to provide quality primary care that is comprehensive, coordinated and continuous. In 2003, these healthcare organizations executed a Memorandum of Understanding (MOU) to improve access and health outcomes for American Indian and Alaska Native veterans. At the baseline of the MOU, the extent of dual use and how these two federal agencies work together to coordinate care for American Indian and Alaska Native veterans was largely unknown and a research priority area identified by the VHA.

OBJECTIVE(S):
The immediate objectives were: a) Describe dual utilization of VA and IHS services among AIAN veterans, including fragmentation or potential overlap of services; b) Identify organizational and individual factors that impede or facilitate access to care; c) Generate explicit policy or practice recommendations to improve how VA and IHS work together, including care coordination. The long-range objectives of this study were to improve access to covered services and foster more efficient and coordinated publicly funded healthcare for veterans.

METHODS:
We used a mixed quantitative - qualitative methods approach: 1) secondary data analysis of healthcare utilization in VHA and/or IHS based on linked and merged administrative data, 2) organizational survey, completed anonymously, of VHA and IHS facilities' leaderships; 3) focus group interviews with stakeholders: veterans and staff at VHA and at IHS, and 4) an expert panel to anchor results in practice and policy.

FINDINGS/RESULTS:
(1) A bivariate analysis of VHA and IHS administrative data found that, among dual users, IHS correctly identified 44% of individuals as veterans. (2) From a population of 64,746 AIAN, 25% were dual users of VHA and IHS. (3) AIAN veterans who used VHA for any of their healthcare were similar to all other users of VHA in demographic characteristics (e.g., most served in wartime, especially Viet Nam era, 93% male) and medical needs (e.g., same proportions of service connected illnesses and injuries, same top diagnoses), although AIAN veterans had a greater proportion of complex care patients. (4) Among women dual users of VHA and IHS, the majority (68%) were nonveterans who received VHA care through sharing and other agreements. (5) Key barriers to improving health outcomes and access for AIAN veterans were the distance between VHA and IHS facilities, the lack of formal relationship that hindered sharing information on mutual patients or coordination of clinical care, lack of information about local VHA or IHS resources for AIAN veterans, and difficulty in VHA enrollment and eligibility determination for AIAN veterans. (6) VHA and IHS staff recommended several key opportunities to overcome these barriers including sharing clinical information (e.g., an electronic health record, discharge planning), delivering VHA care in Tribal communities (e.g., CBOC model), and establishing points of contact between local VHA and IHS facilities to facilitate referral and information flow.

IMPACT:
The project systematically identified factors that should be addressed to meet the goals of the VHA-IHS MOU to 1) improve health outcomes for AIAN veterans by developing policy and practices to share information, deliver healthcare in Tribal communities, and staff education initiatives, and 2) improve access by reducing geographic, bureaucratic and cultural barriers for AIAN veterans.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Kramer BJ, Jouldjian S, Wang M, Dang J, Mitchell MN, Finke B, Saliba D. Do correlates of dual use by American Indian and Alaska Native Veterans operate uniformly across the Veterans Health Administration and the Indian Health Service? Journal of general internal medicine. 2011 Nov 1; 26 Suppl 2:662-8. [view]
2. Kramer BJ, Vivrette RL, Satter DE, Jouldjian S, McDonald LR. Dual use of veterans health administration and Indian Health Service: healthcare provider and patient perspectives. Journal of general internal medicine. 2009 Jun 1; 24(6):758-64. [view]
3. Kramer BJ, Finke B, Saliba D, Jouldjian S, Yano EM. Fostering closer alignment of the Veterans Health Administration and the Indian Health Service. Military medicine. 2010 Jul 1; 175(7):463-5. [view]
4. Kramer BJ, Jouldjian S, Washington DL, Harker JO, Saliba D, Yano EM. Health care for American Indian and Alaska native women. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2009 Mar 1; 19(2):135-43. [view]
5. Kramer BJ, Wang M, Hoang T, Harker JO, Finke B, Saliba D. Identification of American Indian and Alaska Native veterans in administrative data of the Veterans Health Administration and the Indian Health Service. American journal of public health. 2006 Sep 1; 96(9):1577-8. [view]
6. Kramer BJ, Wang M, Jouldjian S, Lee ML, Finke B, Saliba D. Veterans Health Administration and Indian Health Service: healthcare utilization by Indian Health Service enrollees. Medical care. 2009 Jun 1; 47(6):670-6. [view]

Reports

1. Kramer BJ, Sarkisyan S, Finke B, Saliba D, Yano EM, Mitchell MN, Dang J. Veterans Health Administration and Indian Health Service: Access for American Indian Veterans. Survey of VHA and IHS Facilities' Leadership. 2007 Nov 28. 32 p. [view]

Conference Presentations

1. Kramer BJ, Finke B, Saliba D, Wang M, Josephson KR, Harker JO. Dual use of VHA and IHS by American Indian and Alaska Native Veterans. Paper presented at: American Public Health Association Annual Meeting and Exposition; 2005 Dec 10; Philadelphia, PA. [view]
2. Kramer J, Sarkisyan S, Harker J, Yano EM, Washington DL. Federal Healthcare for American Indian and Alaska Native Women Veterans. Paper presented at: AcademyHealth Annual Research Meeting; 2007 Jun 4; Orlando, FL. [view]
3. Kramer BJ, Wang M, Finke B, Saliba D. Healthcare for American Indian and Alaska Native Veterans in VHA and IHS. Presented at: VA HSR&D National Meeting; 2008 Feb 13; Baltimore, MD. [view]
4. Kramer BJ, Finke B, Harker JO, Hoang T, Wang M, Saliba D. Linkage of VA and IHS Healthcare Data. Paper presented at: VA HSR&D National Meeting; 2005 Feb 1; Baltimore, MD. [view]
5. Kramer BJ, Saliba D, Sarkisyan S, Yano EM. Measuring the relationship between organizational response and use of health care by American Indian and Alaska Native veterans. Paper presented at: Gerontological Society of America Annual Scientific Meeting; 2007 Nov 19; San Francisco, CA. [view]
6. Kramer BJ, Finke B, Wang M, Saliba D. Use of VHA and IHS by American Indian and Alaska Native Veterans and non-Veterans. Paper presented at: Indian Health Service Research Annual Conference; 2006 Apr 24; Albuquerque, NM. [view]
7. Kramer BJ. VA and IHS classification by race and veteran status. Paper presented at: American Public Health Association Annual Meeting and Exposition; 2005 Dec 1; Philadelphia, PA. [view]

DRA: Health Systems
DRE: none
Keywords: Access, Ethnic/cultural, Organizational issues
MeSH Terms: none