Access is one of the key “domains of value”

for VHA. As access is largely determined by

the structure and functioning of the health

care system, health services research is

uniquely positioned to investigate this aspect

of health care.

The Merriam-Webster dictionary defines

access as: “permission, liberty, or ability to

approach or communicate with a person or

thing,” or “freedom or ability to obtain or

make use of something.” Reflecting on this

definition, it is apparent that access has several dimensions.

Dimensions of Access

Geographical. The first aspect is geographical access. Is a particular health care

service available within a given geographical

area? Traveling long distances for care can

represent a significant barrier to obtaining

needed services. VHA began as a hospital

benefit but has gradually expanded to

include the full spectrum of care. Veterans

live in every community in the country,

often far from the nearest VA Medical

Center. The development of Community

Based Outpatient Clinics (CBOCs) was an

effort on the part of VHA to improve the

geographical availability of its services.

CBOCs have been successful in improving

access to primary care, but providing VHA

primary care far from VHA specialty and

hospital services creates significant difficulties for VHA primary care providers. The

geographic distance between primary and

specialty care services delivery also has contributed to the growth of dual care, with patients receiving care in multiple (VA and

non-VA) systems. The recent creation of an

Office of Rural Health in the Office of Policy

and Planning reflects the continued concern

over providing VA care to patients in sparsely

populated areas far from urban centers.

Financial. The necessary financial resources are a prerequisite to obtaining

health care. In the United States, the lack of

health insurance represents the greatest barrier to accessing health care for millions of

citizens and has been the focus of much

policy and political debate. One of the

strengths of VHA has been the relative

freedom from financial barriers to care once

a patient is enrolled in the system, and it is

often considered an “equal access system.”

Nevertheless, the presence of copayments,

the size of copayments, and decisions about

inclusion or exclusion of priority groups are

all issues that reflect financial influences on

access even within the VA. These issues are

ripe for investigation.

Cultural. Ethnic or socioeconomic factors

can contribute to financial and geographical

barriers, but cultural differences may also

play a role in access. Differences in cultural

expectations and communication styles between patients and health care providers can

result in significant difficulties in patients

obtaining the care they need or desire.

These cultural differences can arise on the

basis of ethnicity, socioeconomic status,

gender, religion, age, and other factors. The

difficulties that vulnerable populations, such

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Commentary

Access Issues Within VA Offer Challenges,

Research Opportunities

Michael F. Mayo-Smith, M.D., M.P.H., Chief Consultant, Primary Care

July 2008

Contents

Director’s Letter 2

Response to Commentary 3

Research Highlights

• Reducing Clinic Wait Times 4

• Telehealth Technologies 5

• Mental Health Treatment 6

Interview with Mike Davies, M.D.,

National Director of

VHA Systems Redesign 7

A publication of the VA Office of Research & Development,

Health Services Research & Development Service, Center

for Information Dissemination and Education Resources, in

conjunction with AcademyHealth
as those with severe mental illness and the

homeless, experience in accessing care can

be considered in this category as well.

Timeliness. Another barrier to access is

delay in receiving needed services. While

services may be geographically available,

affordable, and culturally accessible, long

appointment wait times and treatment delays can lead to disruptions in patient care.

This barrier has been a particular concern

for the VA.

Important research questions arise for all

these areas. How can researchers define and

measure these dimensions? To what degree

does health care utilization vary across these

dimensions? What effect does this variation

have on actual health care outcomes? What

effect do changes in health services delivery

have? For example, VA needs to better understand the impact on access of the presence of CBOCs, variation in copayments,

creation of women’s clinics, and Advanced

Clinic Access initiatives.

A search of the HSR&D publication database found 170 citations where the word

‘access’ appeared. Of these citations, 62

were for publications in peer reviewed journals. These publications fall into the following general subject areas (with some articles

covering more than one area): cultural factors

such as race and vulnerable populations (23

citations); access to health care in general

or specific health care services such as rehabilitation, or automated external defibrillator

(18); access to mental health services (11);

geographical factors (11); communication

technologies such as the Internet (6); insurance (3); and timeliness (1).

“. . .the need for VA HSR&D to

maintain its rigorous focus on

improving our understanding of the

key access challenges experienced by

veterans, especially those related to

geographic, financial, cultural, and

timeliness barriers.”

While this simple search no doubt identified

only a portion of relevant articles, the results

are of interest. The extensive effort by VA

HSR&D to evaluate cultural factors on

access is impressive. This includes numerous

studies on vulnerable populations, including

those with mental illness and HIV, and their

access to care. Access to mental health services has been a particular focus of activity,

and a variety of these publications explore

geographical factors. Given the relatively

small influence economic factors have on

access within VA, the number of publications in this area is not surprising. The

paucity of research on timeliness represents

an important opportunity for HSR&D.

When discussing access, Dr. Jonathan Perlin, former Under Secretary for Health,

would frequently say “Without access there

is no quality.” His message is a salient reminder of the need for VA HSR&D to

maintain its rigorous focus on improving

our understanding of the key access challenges experienced by veterans, especially

those related to geographic, financial, cultural, and timeliness barriers.

FORUM — Translating research into quality health care for veterans 2

Director’s Letter

Efforts to improve health care for our veterans are at the

heart of VA HSR&D research. Conducting veteran-focused

HSR&D research and implementing findings to improve care

and clinical practice requires dedication, communication,

and in many cases, collaboration with our public- and privatesector colleagues.

Over the past decade, efforts to work in closer collaboration with our partners in

the Department of Defense (DoD) have been numerous. But simply maintaining

those established endeavors is not sufficient—strengthening our connection

with DoD is critical for enhanced research efforts, and ultimately, improved care.

That’s why we are pleased to announce the creation of a Collaborative Research

Listserv (CRL) to foster the connections among VA and DoD researchers. This

exciting endeavor will provide a real-time forum for HRS&D researchers to discuss

ideas with their VA and DoD colleagues, obtain collaborative research partners,

identify researchers interested in a specific area of study, and share expertise.

I encourage HSR&D researchers to participate in the CRL, to establish new

collaborations, and continue building on existing efforts. This valuable tool will

offer a convenient method to further integration and synergy across research

areas and among peers. For information on how you can join, please email

vadodcri@va.gov.

In other news, HSR&D recently held an Office of Research and Development

(ORD) State of the Art Conference (SOTA) on traumatic brain injury (TBI)—

a critical area of concern for our OIF/OEF veterans. Important products from the

SOTA thus far include the inclusion of SOTA-identified research questions in an

upcoming ORD-wide RFA on neurotrauma and the planned publication of commissioned SOTA papers in the Journal of Rehabilitation Research and Development

in early spring 2009.

Seth A. Eisen, M.D., M.Sc.

Director, HSR&D

VA Office of Research & Development, Health Services Research & Development Service July 2008
VA Office of Research & Development, Health Services Research & Development Service July 2008

In his commentary, Dr. Mayo-Smith describes

how geographic, financial, cultural, and

chronological aspects of health services

delivery might influence access to care. He

rightly notes that organization of the health

care system influences access. Three questions should drive a VA research agenda

regarding access to care.

What is the goal of providing access to

care?

It is important that a health care system

articulate the overarching goal for improving access to care. A health care system may

have many such goals—to make shareholders

money, to train new health care providers,

to meet political needs, or to sustain a

bureaucracy. However, for the VA, the goal

of access should be to improve the health

and well-being of its service population.

Competing reasons should be subjugated

to this one.

What kind of health care should VA

provide access to in order to improve the

health of its service population?

Not all health care is created equal. Researchers at The Dartmouth Institute for

Health Policy and Clinical Practice have

defined three categories of health care.

1

Effective care refers to the relatively small set

of clinical services where all patients with a

specific clinical indication should receive the

treatment. The U.S. health care system is able

to deliver such services less than 55 percent

of the time, although VA performance is

somewhat better.

2 To improve the health

and well-being of its service population, VA

should enhance access to effective care.

Preference-sensitive care refers to services

for which there are multiple reasonable

courses of action that present significant

health trade-offs—such as between a potential gain in life expectancy and a greater likelihood of serious side-effects. The volume

of preference-sensitive care that VA provides should depend on the values and

desires of the patient population being

served. Decision aids can help ensure that

care is consistent with those desires. Implementation of decision aids can help patients’ stated needs drive the delivery of

services, while minimizing the costs of

providing care that patients do not want.

Finally, Drs. Jack Wennberg and Elliott

Fisher estimate that 50 percent of all medical

spending in the United States is consumed

in providing supply-sensitive care—where

the supply of resources strongly influences

the frequency of their use. Examples of

supply-sensitive services include the use of

the hospital as a site of care, the frequency

of physician and specialist visits, and the

use of imaging services. Greater use of

supply-sensitive care is associated with

lower quality and with equal or slightly

worse health outcomes—most likely due to

greater difficulty with care coordination and

with unnecessary, but not risk-free, hospital

stays. Provision of more supply-sensitive

care is therefore the ultimate inefficiency.

How should VA enhance access to

effective, patient-centered care while

limiting access to supply-sensitive care

for its service population?

Much of VA’s service population, by choice,

obtains care outside of the VA. Therefore,

improving the health and well-being of the

service population requires that both VA

and non-VA health services provision be

considered when addressing access issues.

For instance, if additional VA access points

provide redundant, as opposed to complementary or coordinated, care, increasing

access might inadvertently increase supplysensitive care and impair population outcomes.

Given VA patients’ high reliance on the private sector, for effective care, VA might best

improve the health and well-being of its

service population by taking on a new role:

helping those who choose private-sector

services find hospitals that best provide

effective care.

3 Finally, guided by decision

aids, coordinating VA and non-VA care

through collaboration across insurers could

benefit veterans by improving outcomes

and benefits, and by resulting in lower outof-pocket costs. This coordination could

also benefit the VA health care system by

more efficiently and effectively meeting the

needs of its service population and taxpayers by offering greater value for their investment in veterans’ health care.

A Goal of Coordinated Care

Delivery

These three questions should serve as the

basis for research that explores whether

improving the health and well-being of the

service population is the primary goal of

access, whether VA is allowing patient values

to drive resource allocation while minimizing

supply-sensitive care, and whether care

coordination across systems of care can

efficiently provide value. Working with VA

leadership, researchers can both create systems

that inform and engage patients about

health care choices, and help veterans coordinate insurance-mediated access to give

them a better benefits package. Researchers

can also support models of care delivery

that maximize effective care and minimize

wasteful supply-sensitive care—regardless

of which system of care a veteran uses.

References

1. Wennberg JE, et al. Geography and the Debate Over

Medicare Reform. Health Affairs, Web Exclusive

February 13, 2002.

2. Asch SM, et al. Comparison of Quality of Care for

Patients in the Veterans Health Administration and

Patients in a National Sample. Annals of Internal

Medicine 2004; 141(12):938-45.

3. Weeks WB, et al. Reducing Avoidable Deaths Among

Veterans: Directing Private-Sector Surgical Care to

High Performance Hospitals. American Journal of Public

Health 2007; 97(12):2186-92.

Response to Commentary

Access to Care: A VA Research Agenda

William B. Weeks, M.D., M.B.A., Principal Investigator, VA Outcomes Group

REAP, White River Junction, Vermont

FORUM — Translating research into quality health care for veterans 3
Reducing wait times for clinic appointments

is a high and visible priority for VA, and has

been for several years. In 2000, in an environment of growing demand for VA health

care and long wait times for clinic appointments in many areas, VA launched a national

program, the Advanced Clinic Access (ACA)

Initiative, to reduce wait times in targeted

clinic areas across the system.

ACA, by now widely-recognized across VA,

is a well-established set of 10 clinical operational practices called key change principles

for organizing and managing clinics so that

patients have access to the medical care they

need—when and where they want it. To

encourage and support the use of these

principles, the ACA Initiative, working

originally with the Institute for Healthcare

Improvement (IHI), built an extensive infrastructure, including: a national steering

committee, a full-time national clinical director, a person designated to lead ACA in

every VISN and most medical centers, and

a network of clinical access coaches to stimulate peer networks of advocacy and support. As intended, the infrastructure has

continued to strengthen and expand and is

now referred to as VHA Systems Redesign.

An important component of the original

ACA Initiative was a comprehensive evaluation

of the implementation and effectiveness of

ACA. The evaluation, based on the experience

of clinics in 78 VAMCs in 2003, was commissioned by the ACA Steering Committee

and conducted by the HSR&D Management

Decision and Research Center (MDRC), now

the Center for Organization, Leadership,

and Management Research (COLMR).

1

The evaluation found that successful ACA

implementation, defined as the use of a high

proportion of the ACA principles, was significantly associated with shorter wait times,

with the relationship stronger in primary

care than across specialty clinics. Underlying

this overall good news, however, was substantial variation across clinics and medical

centers in the extent to which the ACA

principles were implemented. In order to

implement ACA more consistently, it is important to understand the factors that account for this variation: Why were some

clinics more successful in implementing

ACA principles than others?

Local Factors Affect Successful

Implementation of ACA

While the ACA infrastructure provided important resources and support for ACA,

local factors were also important. The ACA

efforts at the national and VISN levels interacted with people, processes, and structures within medical centers and their

clinics. One source of variation in factors

affecting implementation is the six clinic

areas targeted by ACA (primary care, orthopedics, eye care, cardiology, audiology, and

urology). Each of the six clinic areas is

based in its own professional history and

practices, and each clinic area approached

ACA differently. However, across target

clinic areas, five factors were significantly

associated with successful ACA implementation:

■ Strong management support for ACA,

as demonstrated in concrete actions of: appointing an ACA oversight body to elevate

the visibility of ACA, incorporating ACA

into facility priorities, holding managers accountable for improvement-related performance, explicitly designating champions

for each clinic area, reporting on ACA

progress and lessons at meetings of senior

managers, and targeting resources to remove obstacles to ACA implementation.

■ Clinic teams having the knowledge

and skill needed to do their work well

and make changes successfully, as reflected in: seeking information and effectively using that information; using data

regularly to design, test, and track process

improvements; regularly assessing team

progress; and learning from efforts of others to implement ACA.

■ Clinic staff review of ACA wait time

performance data that is trustworthy and

timely so that clinic teams providing care

can assess the current level of the problem

and monitor the impact of improvement

efforts.

■ Adequate clinic resources, reflected

in primary care by more exam rooms and in

specialty care by greater use of consulting

physicians.

■ High demand for care in primary care

(but not specialty care), as evidenced by a

high number of patients on the wait list,

suggesting that greater unmet demand provides an impetus for change.

Attention to these factors promises not only

to strengthen future implementation of

ACA, but also to offer lessons in implementing other complex clinical innovations.

References

1. Lukas CV, et al. Implementation of a Clinical Innovation: the Case of Advanced Access in the Department

of Veterans Affairs. Journal of Ambulatory Care Management, 2008; 32(2): 94-108.

FORUM — Translating research into quality health care for veterans 4

VA Office of Research & Development, Health Services Research & Development Service July 2008

Research Highlights

Advanced Clinic Access: Enhancing

Access by Reducing Clinic Wait Times

Carol VanDeusen Lukas, Ed.D., HSR&D Center for Organization, Leadership,

& Management Research, Boston, Massachusetts

ACA 10 Key Change Principles 1. Work down the backlog,

2. Reduce demand,

3. Understand supply and demand,

4. Reduce appointment types,

5. Plan for contingencies,

6. Manage the constraint,

7. Optimize the care team,

8. Synchronize patient, provider, and

information,

9. Predict and anticipate patient needs

at the time of appointment, and

10. Optimize rooms and equipment.
VA Office of Research & Development, Health Services Research & Development Service July 2008

While older adults may be less technologically savvy relative to younger individuals,

they are nonetheless interested in and willing to use technology to improve their quality of life and ability to “age-in-place.”

Three areas of particular importance and

interest to older adults include: 1) health

and well-being, including remote sensing

and monitoring; 2) personal safety, including

personal emergency alarms and motion sensors; and 3) social connectivity.

1

Telehealth technologies are being used to

provide convenient access to these services

in patients’ homes. While much attention

has been paid to technology and development of innovative equipment, less effort

has focused on systematically evaluating the

efficiency and effectiveness of these applications. A notable exception is the use of

the telephone for follow-up care and patient

reminders. Telephone care can improve

outcomes through more frequent contact

between patients and health professionals,

but it requires real-time interaction. With

the increasing introduction of low-cost

remote monitoring devices that allow asynchronous contact, studies are increasingly

being implemented to address the value of

home monitoring.

VA’s Care Coordination/Home

Telehealth Program

The Department of Veterans Affairs has

been a leader in the use of home monitoring. Since 2003, more than 43,000 veterans

have enrolled in the Care Coordination/

Home Telehealth Program (CCHT). Technology is assigned based on patient needs

and includes a range of devices such as

videophones, messaging devices, biometric

devices, digital cameras, and telemonitoring

devices. Each enrolled veteran has an assigned care coordinator to help them manage their condition and coordinate care.

Since 1997, we have been evaluating how

telehealth technologies improve veterans’

access to services in their home setting. Our

earliest studies evaluated the provision of

specialty services between a state veterans

home and VA Medical Center. We evaluated

the feasibility of providing nursing-based

wound consultation services and the provision of specialist physician consultation via

real-time interactive video. In both studies,

clinicians were able to diagnose and treat the

health problem using the technology while

the patient was able to remain at the nursing

home (their home). This eliminated a four

hour round-trip for the patient and saved

transportation costs. Furthermore, both clinicians and patients expressed satisfaction

with the use of telehealth; in fact, most patients felt it was easier to get medical care.

In a second study, we compared the effectiveness of two home telehealth communication modes (telephone or videophone)

to traditional care provided for recently

discharged outpatients with heart failure.

Patients discharged from the hospital

following treatment for heart failure exacerbation were randomized to a 90-day, nursemanaged, telephone- or interactive videofacilitated heart failure disease management

program or control condition. The intervention resulted in significantly longer time

to readmission but had no effect on mortality,

hospital days, or urgent care clinic visits.

Intervention patients reported higher diseasespecific quality of life scores at one year.

We found no substantive differences in

communication patterns between the telephone and videophone group, thus both approaches worked equally well.

In a third study, we evaluated varying doses

of remote monitoring in veterans with comorbid hypertension and diabetes. To date,

most projects have focused on single disease

populations, e.g., heart failure or mental illnesses. Furthermore, few controlled clinical

trials have investigated varying the intervention dose. Subjects were randomized to three

groups: low-intensity monitoring plus nurse

care management intervention, high-intensity

monitoring plus nurse care management intervention, and usual care. In both intervention

groups, patients transmitted vital signs daily.

In addition, the low-intensity group answered two general health questions, while

the high-intensity group responded to a

complete range of questions focused on

diabetes and hypertension, and received

educational tips. The intervention groups

participated in the protocol for six months

following enrollment. Preliminary results

indicate that the intervention was effective

in improving HbA1c and this effect was

more pronounced in the high-intensity group.

Only the high-intensity group showed an

improvement in systolic blood pressure.

Because family members frequently assist

with disease management in the home, a

study currently under way is evaluating how

informal caregivers support veterans enrolled in the VA CCHT program.

Rigorous Evaluation Needed

Through optimal use, telehealth technologies

can be used to leverage limited health care

resources to better meet the needs of older

adults. The wide array of telehealth technologies has created many new and promising

ways to increase access, availability, and

quality while reducing costs. Rigorous evaluation is needed to determine which patients

may benefit most from telehealth and which

technologies are most cost-effective.

References

1. “Aging and Technology: Landscapes and Attitudes

Toward Adoption.” Blue Shield of California Foundation Issue Brief, March 2008.

Research Highlights

Telehealth Technologies: Improving

Veterans’ Access to Care

Bonnie J. Wakefield, Ph.D., R.N., Harry S. Truman Memorial Veterans Hospital,

Columbia, Missouri

FORUM — Translating research into quality health care for veterans 5
The FY ’08 budget request for VA called for

nearly $3 billion in mental health services to

continue improvements in access for veterans with mental health problems. Of course,

much of this budget request funds mental

health specialty care programs. However,

there is growing awareness that a key aspect

of access to mental health treatment involves the bridge between primary care and

mental health specialty programs. In July

2007, then Secretary of Veterans Affairs Jim

Nicholson, while announcing plans to bring

VA mental health and primary care programs

closer together, said, “Given the reluctance

of some veterans to talk about emotional

problems, increasing our mental health

presence in primary care settings will give

veterans a familiar venue in which to receive

care—without actually going to an identified

mental health clinic.”

Building a Bridge from Primary

to Mental Health Care

Historically, the bridge between primary and

mental health care has not been easy to

build. Barriers exist at the patient, provider,

and system levels. Many veterans are concerned about being stigmatized if they

reveal mental health concerns. Many primary

care providers report that they are uncomfortable assessing and discussing mental

health concerns. Early attempts to educate

primary care providers to treat mental

health issues themselves and to screen and

refer patients with more complicated conditions to mental health specialty clinics

proved unsuccessful. At the system level,

although VHA is more integrated than

many other managed care systems, traditional acute care models do not foster crosscare line cooperation. More than physical

co-location is required.

For some years, researchers within and outside the VA have been working to build an

evidence base for bringing mental health

and primary care closer together to improve

access and continuity. Ed Wagner’s Chronic

Illness Care Model helped researchers

understand what changes in the system and

processes of care are necessary to improve

care of chronic conditions, including depression, unipolar and bipolar disorders,

and schizophrenia. Key components of

improving care are clinician education and

decision support, patient education and selfmanagement support, active collaboration

between primary care and mental health

specialists, and care management. Current

implementation research by VA investigators Rubenstein in depression (TIDES),

Bauer in bipolar disorder (CCM), and

Young in schizophrenia (EQUIP) illustrate

application of these care components.

Collaborative Care Models

TIDES uses a partnership among researchers,

clinicians, and administrators to foster a

stepped-care model of depression care that

builds on the depression screening currently

practiced at high levels in VA primary care

clinics. The key care system change is the

introduction of Nurse Depression Care

Managers (DCMs) bridging primary care

and mental health specialty care. DCMs are

trained to assess depression and comorbid

conditions and suggest treatment alternatives to the primary care clinician. DCMs

may coordinate depression care in primary

care through telephone education and support to the patient or facilitate referral to

specialty care in more complex cases. This

model achieves high levels of patient satisfaction and efficient use of care resources.

One of the primary findings is that depressed patients who were not receiving care

are identified, assisted in accessing care, and

trained and supported in self-management

skills.

Bauer’s collaborative care model for bipolar

disorder also emphasizes patient selfmanagement skill enhancement, making

evidence-based treatment decisions, and

using care management to enhance access

and continuity. Two initial multi-site studies

demonstrated that involving patients with

bipolar disorder in a Life Goals group psychoeducation program, assisting their mental health specialty providers with simplified

practice guidelines, and introducing a nurse

care coordinator significantly reduced symptomatology and duration of manic episodes.

A more recent study using the same model

found that if care coordination included both

mental health and primary care providers,

patients’ physical well-being also improved.

In these studies, improved access to care is

reflected in reduced unplanned care episodes.

Young’s EQUIP studies use a collaborative

care model for schizophrenia to enhance

recovery-oriented care by identifying patients

in need, providing improved access to evidence-based services, and reorganizing care

to support these services. The model incorporates assertive care management, provider

education and decision support, and routine

standardized patient assessment with feedback of information to treating psychiatrists

at the time of the clinical encounter.

Providers report that the intervention improves information about their patients,

particularly in psychosocial domains, and

assists in more effectively monitoring treatment needs.

Together, these three programs of research—

each focused on a different mental health

problem—demonstrate that collaborative

care models can improve access and quality

of mental health care. Important questions

remain. Current work focuses on the implementation of these models under routine

care conditions and identification of what

is required to promote long-term model

fidelity and sustainability.

FORUM — Translating research into quality health care for veterans 6

VA Office of Research & Development, Health Services Research & Development Service July 2008

Research Highlights

Access to Mental Health Treatment:

The Importance of Collaboration

Edmund Chaney, Ph.D., HSR&D Northwest Center for Outcomes Research in

Older Adults, Puget Sound Health Care System, Seattle, Washington
VA Office of Research & Development, Health Services Research & Development Service July 2008

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:

1) Ensure ease of access for patients to existing providers and ensure that service gaps

are addressed;

2) Improve our understanding and use of

support staff roles and team productivity;

and

3) Achieve a higher degree of reliability and

standardization in the flow of patients from

primary to specialty care.

Three Challenges

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.

Research Opportunities

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.

Interview

Evolving Access Needs Offer Research

Opportunities

Recently, FORUM sat down with Mike Davies, M.D., National Director of

VHA Systems Redesign, to ask him his views on the challenges facing VA as it

works to ensure timely and appropriate access to care for all veterans.

FORUM — Translating research into quality health care for veterans 7

continued on page 8
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.

Rural Health, Mental Health

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.

FORUM — Translating research into quality health care for veterans 8

Interview

continued from page 7

Peter Almenoff, M.D.,

Director, VA Network #15,

Kansas City, MO

Martin P. Charns, D.B.A.,

PI, VA HSR&D Center

of Excellence, Boston, MA

Seth A. Eisen, M.D., M.Sc.,

Director, HSR&D

Joseph Francis, M.D., M.P.H.,

Deputy Chief Quality and

Performance Officer,

Central Office

Rodney A. Hayward, M.D.,

PI, VA HSR&D Center

of Excellence, Ann Arbor, MI

Shirley Meehan, M.B.A.,

Ph.D., Deputy Director, VA

HSR&D, Central Office

Michael J. Miller, M.D., Ph.D.,

Chief Medical Officer, VA

Network #1, Bedford, MA

Eugene Z. Oddone, M.D.,

M.H.Sc., PI, VA HSR&D

Center of Excellence,

Durham, NC

Alan S. Perry, M.H.A.,

FACHE, Director, VA

Central California Health

Care System

FORUM

Geraldine McGlynn, Editor-in-Chief

Margaret Trinity, Editor

Editorial Board