Dual use of VA and non-VA 

Services by Veterans in PACT

Gary Rosenthal, MD, VISN23 PACT Demonstration Lab

Mary Charlton, PhD, Veterans Rural Health Resource CenterCentral Region

Carolyn Turvey, PhD, Center for Comprehensive Access and 

Delivery Research and Evaluation, eHealth QUERI

May 15th 2013
VETERANS HEALTH ADMINISTRATION 2 

Overview of CyberSeminar

• Extent of dual use of non-VA services among VA primary care 

patients and implications of dual use for the PACT model and 

for effective care coordination (Rosenthal)

• Perceptions of VA and non-VA physicians regarding care 

coordination across systems and development of the Comanagement Toolkit (Charlton)

• Use of the My HealtheVet Blue Button to facilitate transfer of 

information from VA to non-VA providers (Turvey)
VETERANS HEALTH ADMINISTRATION 3 

• What is your primary role in VA? 

– student, trainee, or fellow clinician

– researcher

– manager or policy-maker

– Other 

Poll Question #1
VETERANS HEALTH ADMINISTRATION 4 

Extent of Dual Use: Methods 

• Analysis of merged VA-Medicare database for 2010 for 15 of 

22 VISNs

• 65 years and older with Medicare eligibility and 1 or more VA 

primary care visits 

• Total of 1,095,810 patients 

– 53% (n=584,576) assigned to VAMC

– 47% (n=511,234) assigned to CBOC

• Analyses determined the proportions of patients using the VA 

and Medicare services for different types of care
VETERANS HEALTH ADMINISTRATION 5 

Use of Specific Types of VA & Medicare 

Outpatient Services by Older Veterans

7%

44%

100%

22%

45%

37%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Primary Care Specialty Care Emergency

Room

VA

Medicare
VETERANS HEALTH ADMINISTRATION 6 

Use of Specific Types of VA & Medicare 

Outpatient Services

20%

30%

19%

1%

38%

4%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Mental Health Diagnostic

Radiology

Rehabilitation 

(PT/OT)

VA

Medicare
VETERANS HEALTH ADMINISTRATION 7 

Use of VA and Medicare Acute Care 

Inpatient Services

7% 6%

2%

18%

14%

7%

0%

5%

10%

15%

20%

25%

30%

Any

Hospitalization

Medical

Hospitalization

Surgical

Hospitalization

VA

Medicare
VETERANS HEALTH ADMINISTRATION 8 

Use of VA & Medicare Primary Care Services 

by VAMC & CBOC Patients

100% 100%

33%

41%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

VAMC Patients CBOC Patients 

VA

Medicare
VETERANS HEALTH ADMINISTRATION 9 

Use of VA & Medicare Outpatient Specialty 

Care by VAMC & CBOC Patients

51%

35%

40%

50%

0%

10%

20%

30%

40%

50%

60%

VAMC Patients CBOC Patients 

VA

Medicare
VETERANS HEALTH ADMINISTRATION 10

Use of VA & Medicare Emergency Room 

Services by VAMC & CBOC Patients

10%

4%

20%

24%

0%

5%

10%

15%

20%

25%

30%

35%

40%

VAMC Patients CBOC Patients 

VA

Medicare
VETERANS HEALTH ADMINISTRATION 11

Use of VA & Medicare Inpatient Services by 

VAMC and CBOC Patients

11%

5%

16%

19%

0%

5%

10%

15%

20%

25%

30%

VAMC Patients CBOC Patients

VA

Medicare
VETERANS HEALTH ADMINISTRATION 12

Summary of Key Findings

• 37% of Medicare eligible VA primary care (PC) patients 

received non-VA primary care services

• Medicare eligible VA patients were more likely to receive 

mental health & rehab services from the VA

• However, they were: (1) as likely to receive outpatient 

specialty care from non-VA providers as from a VA provider; 

and (2) more likely to receive ER and inpatient care from nonVA providers

• Use of non-VA care was higher in patients receiving PC in 

CBOCs
VETERANS HEALTH ADMINISTRATION 13

Implications of Dual Use for PACT

• The ability to use VA and non-VA care gives dually eligible 

veterans more choices & greater access

• However, the high use of non-VA care by older veterans poses 

challenges to effective care coordination and population 

management through the PACT model

• These challenges may be particularly significant for sicker 

veterans who are more likely to be hospitalized & patients in 

CBOCs
VETERANS HEALTH ADMINISTRATION 14

Implications of Dual Use for PACT (cont.)

• The ability to effectively manage patients across VA and nonVA settings will require:

– greater interactivity between VA and non-VA providers 

– active flow of information about diagnostic tests, clinics 

visits, hospitalizations, and medications

• The high level of dual use poses particular challenges to 

understanding the long-term effects on utilization and veteran 

outcomes. 
Development of a Co-Management Toolkit 

Mary Charlton, BSN, PhD & 

Ashley Cozad, MPH

Veterans Rural Health Resource Center- Central Region
VETERANS HEALTH ADMINISTRATION 16

Analysis of Stakeholder Perspectives

VETERANS

LOCAL 

PROVIDERS

VA RURAL HEALTH 

RESOURCE

CENTER

CENTRAL REGION

VA 

PROVIDERS
VETERANS HEALTH ADMINISTRATION 17

• Who should have the primary responsibility for 

communicating information between VA and non-VA 

providers (choose one)?

– Veteran

– Non-VA (local) Provider or Practice 

– VA Provider or VA Healthcare System

– Both VA and Non-VA providers are equally responsible

– Another Entity (e.g., regional health information 

exchange) 

Polling Question #2
VETERANS HEALTH ADMINISTRATION 18

Veteran Perspective: Who is responsible for 

communication between providers?

*91% reported being inconvenienced because of poor 

communication between providers
VETERANS HEALTH ADMINISTRATION 19

VA Provider Perspective: Conducted interviews 

with providers & clinic staff

VISN 23

x 
VETERANS HEALTH ADMINISTRATION 20

VA Provider Perspective: Top 5 themes from 

interviews 

1. Coordination of Care is very challenging

2. Duplication of Diagnostic Services occurs due to 

inadequate communication

3. Relationships with Local Non-VA Providers may be 

underdeveloped 

4. Medical record exchange is a source of inefficiency

5. Misunderstandings over medication prescribing are 

frustrating 
VETERANS HEALTH ADMINISTRATION 21

Local Provider Perspective: Conducted 

surveys & interviews with Iowa PCPs

Iowa Research Network (IRENE): Practice-Based Network of 

Primary Care Providers

– 67 surveys

– 21 interviews
VETERANS HEALTH ADMINISTRATION 22

Local Provider Perspective: How would you describe 

your clinic’s communication with VA clinics?
VETERANS HEALTH ADMINISTRATION 23

Local Provider Perspective

• Non-VA providers felt they were 

interacting with VA as a system

rather than communicating with 

VA providers as individuals

• Difficulties in communication often 

attributed to inability to access or 

identify the VA provider
VETERANS HEALTH ADMINISTRATION 24

Local Provider Perspective: Asked how 

information is exchanged with VA providers

Reported that the patient is the main vehicle of communication

Not an ideal situation 

 "I don’t think we can rely on patients to be totally 

knowledgeable about what they have or have not had done for 

evaluation and testing." 
VETERANS HEALTH ADMINISTRATION 25

Local Provider Perspective: Asked if they felt poor 

communication has lead to poor outcomes 

26%

Disagree

24%

Neutral

42%

Agree

Concerns

Changes in Medication

Continuity of Care

Emergent Transfer Delays

Duplicate Testing
VETERANS HEALTH ADMINISTRATION 26

Co-Management Toolkit

Used existing information and resources 

to build a toolkit to address the biggest 

informational barriers as reported by 

non-VA community providers

Posted to ORH website: 

http://www.ruralhealth.va.gov/resourcecenters/central/comanagementtoolkit.asp
VETERANS HEALTH ADMINISTRATION 27

Toolkit Materials: Overview

Brochure

• Overview of key 

information including:

– ROI 

– Medications 

– Contacting VA 

providers

– My HealtheVet

– Emergency Care

Intro letter

• Meant to provide a basic 

overview

• Ideally, would come directly from 

VA PCP team with customized 

contact information
VETERANS HEALTH ADMINISTRATION 28

Toolkit Materials: Medications

Medication FAQ

• Created to address medication 

management frustrations 

including: 

– Filling outside prescriptions at 

the VA

• Must be re-written by VA 

provider 

• Necessary information to 

include 

– Formulary

Non-Formulary Information

• Displays the information 

generally required for a 

non-formulary request
VETERANS HEALTH ADMINISTRATION 29

Toolkit Materials: Release of Information

Release of Information FAQ

• Created to be a quick 

reference for submitting a 

ROI request

– Including two ways to 

submit 

– How long requests take

– How My HealtheVet can 

help facilitate this 

exchange 

VA Release of Information 

Form

• Included for easy access
VETERANS HEALTH ADMINISTRATION 30

Toolkit Materials: Contacting VA Providers & 

Information about My HealtheVet

My HealtheVet (MHV) 

Registration & IPA Info Sheet

• Discusses how a Veteran can 

register and go through the 

IPA process

• Includes information on 

services currently available 

in MHV

Local Facility Locations, Services 

& Contact Information

• Locating this information can 

be a challenge

• This resource is a quick 

information sheet to be used 

to help non-VA providers 

track down the right number 

to call
VETERANS HEALTH ADMINISTRATION 31

Toolkit Materials: Emergency Care &

Wallet Cards

NFPO Emergency Care Sheet

• Provides a general guide to 

emergency care outside the 

VA and proper procedures 

for notifying the VA, etc. Wallet cards

• To be completed by VA PCP team

• Aid as a quick reference so 

Veterans can provide non-VA 

community providers with 

information about their VA care 

team
VETERANS HEALTH ADMINISTRATION 32

Evaluating Usefulness of 

the Toolkit

• Survey mailed to 297 non-VA providers (IRENE)

– Return rate 49%

• Participants indicated the toolkit was useful and 

provided information they did not already know

– 76% indicated it could help improve care coordination 

– 66% agreed that could improve safety and patient 

outcomes 

– 73% indicated they would use the toolkit information in 

practice
Evaluation of the Blue Button: Adoption, Use, & 

Recommendations for the Future

Carolyn Turvey, PhD 

Center for Comprehensive Access & Delivery Research and Evaluation
VETERANS HEALTH ADMINISTRATION 34

What is My HealtheVet and the Blue 

Button?

• My HealtheVet is the VA’s Electronic Personal Health 

Record

– Allows viewing of medical record, online prescription 

refill, secure messaging, appointment viewing.

– As of March 31st 2013 there were 2,224,685 registered 

users

• Blue Button Feature

– Provides a quick executive summary of veterans VA health 

care and information

– As of March 31st 2013, there were 753,433 unique users 

of the Blue Button
VETERANS HEALTH ADMINISTRATION 35

Two Part Study

Online ACSI Survey

• 22,756 MHV 

Users

• Fielded March 

through May 

2012

Qualitative Interviews

• Boston and Iowa 

key stakeholders

• Conducted July 

2012-January 

2013
VETERANS HEALTH ADMINISTRATION 36

American Customer Satisfaction Index

Sampling conditions

Loyalty Factor: 4 pages

Sampling Percentage: 4% 

Average response rate

17.0%, compared to the previous period 

average response rate of 17.1%

Time period

March 12, 2012 – May 21, 2012

Number of completed surveys

22,756 

 
VETERANS HEALTH ADMINISTRATION 37

User Groups
VETERANS HEALTH ADMINISTRATION 38

Care outside the VA- 44% of Blue Button Users 

have Providers who are not Affiliated with the VA 

% 
VETERANS HEALTH ADMINISTRATION 39

How Satisfied are you with the Communication 

between VA and non-VA providers?

% 
40

VETERANS HEALTH ADMINISTRATION

Blue Button Sharing and Helpful/Usefulness

• 21% of Blue Button Users Shared 

their Blue Button print out with a 

Non-VA provider.

• How helpful do you think your 

care provider found the Blue 

Button information in making 

decisions about your care?
VETERANS HEALTH ADMINISTRATION 41

What predict use of Blue Button for Care 

Coordination with non-VA providers?

Predictor Odds Ration (95% C.I.)

Self-Rated Internet Ability 1.5 (1.2-1.9) 

Values having their own copy of their 

medical record

1.1 (1.0-1.3) 

Has a system to organize their health 

information 

1.6 (1.3-2.0) 

Diabetes 1.4 (1.1-1.7) 

Lung Disease 1.5 (1.2-1.9) 
VETERANS HEALTH ADMINISTRATION 42

Quantitative Interviews Non-VA Providers

• Communication with VA providers is unsystematic, highly 

variable, and relies primarily on the patient.

• “With VA, we get nothing. With we need something we have 

to call the VA or have the patient acquire it. We have nothing 

is ever sent automatically from the VA. And most of the time I 

don’t even know that they see the VA. . . I don’t know they’re 

a VA patient.”
VETERANS HEALTH ADMINISTRATION 43

Non-VA providers on the Blue Button Print 

Out

• “It’s not that the information is not useful, it’s just that it’s, 

it’s displayed over too many pages.” 

• Would like to receive the information electronically before 

the clinic visit with the veteran.

• Desired content features: medication, lab results, problem 

list, allergies, immunizations.

– Would like most recent clinic note.

– Laboratory and vital information presented in trending 

format.
VETERANS HEALTH ADMINISTRATION 44

Future Directions

• Collaboration between the VA Office of Rural Health, PACT, 

My HealtheVet, and Health and Human services

– Veterans can now view/download their VA Care Coordination 

Document which includes much of what non-VA providers ask for as a 

summary in tabular form.

– Use Blue Button print out or care coordination document to improve 

care coordination for rural veterans receiving care at critical access 

hospitals.

– Pilot veteran sending electronic file through the Blue Button directly to 

non-VA providers electronic health record. 

– Explore the impact on utilization and provider and veteran satisfaction.
VETERANS HEALTH ADMINISTRATION 45

Poll Question #3

• What are viable approaches for the VA to 

address issues related to dual use of services by 

veterans (choose all that you think are relevant)?

– Nothing, current approaches work well

– Improve access to VA services

– Broaden the types of services available through 

the VA 

– Develop better approaches to exchanging 

information between VA and non-VA providers 

– Facilitate care coordination between VA and nonVA providers
VETERANS HEALTH ADMINISTRATION 46

Contact Information:

• Gary Rosenthal, MD: gary-rosenthal@uiowa.edu

• Mary Charlton, PhD: mary.charlton@va.gov

• Carolyn Turvey, PhD: carolyn.turvey@va.gov

Co-management Toolkit: 

http://www.ruralhealth.va.gov/resourcecenters/central/comanagement-toolkit.asp

Questions?
Answers to remaining questions from TTOI 05/13/2013 

mTBI: Technology advances in Diagnosis: DTI (Diffusion Tensor Imaging)

What other conditions (besides TBI or blast 

exposure) could cause these findings on VBM?

To my knowledge, this type of analysis has not been 

in other disorders with VBM. However, I would 

expect these findings for any disorder that 

has diffuse pattern of damage with non-specific 

lesions. One example is hypertensive vascular injury.

What is the benefit of recognizing this damage 

when no clinical symptoms are seen? What would 

be done if someone has this damage, but no 

symptoms?

If we know about damage but do not have any 

acute or chronic symptoms then we are able to 

monitor at a minimum. If there are no 

acute symptoms, but there are chronic symptoms 

then the chronic symptoms would be attributed to 

these to another disorder but not blast exposure. 

These other disorder might be things like PTSD or 

Depression which would lead to a misdiagnosis.

So - since nearly everyone has had a mild TBI at 

some point in their life (as we now define mild TBI) 

why didn't the control groups show at least some of 

these abnormal findings?

Our unexposed group did not have blast exposure 

and also did not have mTBI. The blast-exposed group 

did not have symptoms after blast-exposure that 

were sufficient to meet mTBI diagnosis.

Is there a similarity between victims of car 

accidents, specifically head on collisions in 

relationship to TBI, loss of white matter and/or 

potholes in the images viewed? 

We don't know about survivors of car accidents. 

There is a belief that the athletes and military TBI 

folks are different because of repetitive which is no 

the case with car accidents.

If there are no clinically observable TBI symptoms, 

what is the functional significance of these 

"potholes"?

If we know about damage but do not have any acute 

or chronic syptoms then we are able to monitor at a 

minimum. If there are no acute symptoms, but there 

are chronic symptoms then the chronic 
Answers to remaining questions from TTOI 05/13/2013 

mTBI: Technology advances in Diagnosis: DTI (Diffusion Tensor Imaging)

symptoms would be attributed to these to another 

disorder but not blast exposure. These other 

disorder might be things like PTSD or Depression 

which would lead to a misdiagnosis.

Should we stick to DTI solely? When can we use this for clinical diagnosis? 

DTI WILL NEVER BE USED AS THE SOLE AVENUE FOR DIAGNOSIS. JUST LIKE OTHER DIAGNOSTIC 

RADIOLOGY THAT IS USED IN THE CLINIC TODAY, ALL IMAGING HAS TO USE IN CONJUNCTION WITH 

CLINICAL OBSERVATION. 

Can Raj Morey be more specific about the multi-site imaging trial DoD is trying to set up. 

THE ONGOING STUDY IS CALLED INTRUST. THE NEW DOD MULTI-SITE TRIAL IS NOT YET FUNDED. THE 

NEW VA MULTI-SITE TRIAL IS ALSO NOT FUNDED.