A Publication of the VA Office of Research & Development, Health Services Research & Development Service,

Management Decision and Research Center, in conjunction with the Academy for Health Services Research

and Health Policy

continued on page 2

Improving Access to Care in the VA

Health System: A Progress Report

By Laura J. Miller, M.P.A., Assistant Deputy Under Secretary for Health,

Veterans Health Administration

FORUM

VA HEALTH SERVICES RESEARCH & DEVELOPMENT JUNE 2001

With the implementation of veterans

integrated service networks (VISNs)

and the shift toward communitybased primary care, VA has made

tremendous strides in improving

access to veterans’ health care. We

know, for example, that the number of veterans served by VA

increased 30 percent from 1996 to

2000. In addition, more than 400

VA community-based outpatient

clinics (CBOCs) currently provide

care to veterans throughout the

system. Moreover, 87 percent of

veterans who enroll for VA health

care services are able to be seen by

a VA provider within 30 miles of

their home. These are substantial

accomplishments!

Technological advances are also

helping VA improve access to care.

Telephone triage and advice programs have been implemented at

all VA hospitals, and health education is available to veterans on the

Internet. Last year, VA provided

more than 350,000 consultations

via telemedicine. Telemedicine

and in-home teleconsultation programs have also been implemented

for spinal cord injury patients. In

1998 and 1999, the Vet Center program implemented the Vet CenterLinked Primary Care Project,

which uses telemedicine to make

primary care more accessible for

high-risk, under-served veterans.

In addition, the use of computers and electronic communication

is improving care coordination and

cutting through barriers of care.

One new software program, Web

Top, allows VA physicians and

nurses to view patient records from

other sites. With “real-time” information sharing, the medical decision-making process is expedited

and patients receive the services

they need faster.

VA has also made it easier for

veterans to apply for VA health

care by eliminating nearly threequarters of the forms we once

required for application and enrollment. Veterans may now obtain

applications for enrollment and

medical care on the Internet. In

addition, they can send the forms

electronically to the VA health care

facilities of their choice, or they can

print out the completed forms and

mail them.

Shortening Waiting Times

While eligibility reform and community clinics have enhanced

access, in some areas the demand

for services has outpaced recruitment, resulting in extended waiting times for appointments. Here

again, VA is making progress. 

We have developed a new data

system and performance goals for

waiting times — commonly known

as “30-30-20” — that fully support

patient expectations for timely

access to care. Our strategic goal is

C DIRECTOR’S LETTER OMMENTARY

In my first FORUM Director’s

Letter published in June 1998, I

mentioned that one reason I decided

to leave the field after 27 years and

come to Headquarters was because

of the unprecedented opportunities

that were available to VA health

services researchers. Today, those

opportunities are brighter than ever.

During the last several months,

HSR&D has issued several solicitations providing researchers with

new and exciting opportunities.

First, in November, we requested

proposals for at least one new Center

of Excellence (COE). 

Second, in December, HSR&D

invited solicitations for the Research

Enhancement Award Program

(REAP). VA facilities that do not

presently have a COE but have at

least three funded projects may

apply for up to $200,000 per year

for four to five years. 

Third, in January, we requested proposals for a COE in Rehabilitation Outcomes. For the first time,

VA’s Rehabilitation Research and

Development Service and HSR&D

are collaborating on a center that

will bring together experts in rehabilitation research and outcomes

research under one roof to learn

from each other and collaborate. 

Finally, in February, a solicitation was jointly released with the

National Cancer Institute (NCI)

and VA’s Quality Enhancement

Research Initiative (QUERI) to fund

a new VA Cancer QUERI. This

new QUERI group will be funded

by NCI but based at a VA facility.

With all of this exciting work to

be done, I look forward to working

with our investigators as HSR&D

continues to play a key role in the

pursuit of quality health care for

veterans. 

John G. Demakis, M.D.

Director, VA HSR&D Service
2

to provide 90 percent of new primary

care and specialty care visits within

30 days, and see 90 percent of

patients within 20 minutes of their

scheduled appointment time.

Currently, VA is working with the

Institute for Healthcare Improvement

(IHI) on a major initiative to promote activities within each VISN

for achieving the 30-30-20 performance goals in the six clinics highlighted in the network performance

contracts (audiology, orthopedics,

urology, cardiology, eye care, and

primary care). Already, VA has

seen system-wide improvements in

average clinic waiting times since

the initiative’s launch in April 2001.

Despite these accomplishments,

we still have a great deal of work to

do to ensure and improve access to

care for all veterans. Perhaps most

importantly, we need to understand

the populations we serve — who

they are, what they need, and what

they’re likely to need five, 10, and

15 years from now. There is a tendency to try to freeze the system at

a certain point in development — 

to maintain the current number of

beds or hospitals, for example —

because we’ve arrived at a place

where we feel comfortable.

Patient needs and populations,

however, are neither static nor the

same across VISNs. Every VISN

has to be concerned about providing

appropriate access for specialized

groups, including service-connected

veterans; veterans with post-traumatic

stress disorder; women veterans;

and Persian Gulf War, Agent

Orange, and Ionizing Radiation veterans. In addition, our population

is aging, and our patients will need

not only more services but more

specialized services.

New developments in information technology can help us stay on

top of veterans’ health care needs

and quickly identify new trends.

The VHA Meta Data Registry

(MDR) is being developed to provide a national repository of inforCommentary

continued from page 1

C OMMENTARY

mation about VHA enterprise data

assets. The MDR is a Web-based,

centralized repository that will

improve the quality and speed of

service to all veterans and dependents who submit applications and

related paperwork to the VA. The

MDR will serve as the focal point

for data business definition and

processes, resulting in streamlined

operations and value-added productivity improvements.

Allocating Resources To

Improve Access

The VA will continue to carefully

assess its resources so that they are

allocated wisely and efficiently to

the networks. Some VISNs have

already seen increases in both

funding and staffing allocations;

others have had to accept decreases

due to a declining veteran population. However, all are continuously

identifying more efficient ways of

providing care while maintaining

quality.

We already know that many of

our patients, particularly those

who are elderly or who have specialized needs, require a substantial amount of specialty care.

We’ve come a long way in improving access to primary care, but we

must also provide the right mix of

specialty care so that our patients

get the services they need when

they need them. In addition, VA is

implementing a number of requirements outlined in Public Law 106-

117, the Millennium Health Care

and Benefits Act, which extends

authorities and ensures additional

services for veterans.

Mental health is one specialty

area where VA has made inroads.

When we made the transition to

VISNs in 1996, the planning

process included a review of mental

health needs. Mental health intensive case management services are

also becoming incorporated into

CBOC models. This is allowing

improved access to mental health

services even to veterans in rural

areas. A VHA Directive on Mental

Health Intensive Case Management

was issued in October 2000. VISNs

were required to provide implementation plans, which are currently

being reviewed.

Patient satisfaction data show

that veterans recognize the difference in VA services, both in terms

of the comprehensiveness of those

services and access. For instance,

in VA’s most recent survey, 82 percent of patients report they left

their ambulatory care appointments feeling they had discussed

all of their concerns with their

provider. Also in the same survey,

about 70 percent of outpatients

reported they were involved in

decisions about their care as much

as they wanted to be.

A Role for Health Services

Research

Research by HSR&D can help VA

continue to meet the challenges of

ensuring and improving access to

veterans health care. We need to

know more about our referral

patients — how much of what services we are providing, and where.

We should also take a closer look at

access for specialized groups, such

as women veterans and certain ethnic minorities. We need researchbased knowledge that can help us

develop strategies to provide care

to vulnerable populations, including the homeless, the mentally ill,

the aged, and those infected by the

hepatitis C virus.

Conclusion

Now more that ever, VA is in the

truest sense a health care system.

With the VA’s new focus on populations rather than facilities, we are

doing a better job of bringing needed services to patients in a timely

manner. We are also making more

efficient use of our resources —

increasing the benefits provided to

patients. We will continue to be

challenged by competing and conflicting forces of change, but

addressing these challenges is part

of our task in keeping the promise

to America’s veterans.
3

D IALOGUE

Selecting the Best Strategies for Improving 

Access to Care in Rural Areas

By John Fortney, Ph.D., HSR&D Center for Mental Healthcare and Outcomes Research

Central Arkansas Veterans Healthcare System

To help ensure organizational

survival, VA needs to attract

new enrollees from rural areas

(and, to a lesser extent, some

inner-city areas). How can VA

make high-quality care more

accessible over long distances?

What has research shown to be

our most cost-effective options?

What evidence do we have on

the use of different technologies to reach more veterans?

— Al Perry, M.H.A., FACHE, 

VA Central California Healthcare

System

Improving access to high-quality

outpatient services for rural veterans will be a critical challenge for

VA in coming years. Poor access to

clinical services in rural areas limits VA’s ability to attract new

enrollees from rural market areas

and reduces the continuity and

quality of care provided to existing

enrollees. With the shift in VA’s

focus of care from inpatient to outpatient settings, travel barriers

have become a greater obstacle to

ensuring both high-quality care and

continuity of care for rural veterans.

As a result, VA may find it difficult

to compete in the outpatient arena

with local providers in rural regions,

especially for elderly veterans who

are eligible for Medicare. 

Recently, VA has experimented

with several strategies for improving access to outpatient services in

rural areas. Mobile health units —

such as buses — have been evaluated as one way to bring primary care

services to remote areas, but this

approach was found not to be costeffective. In addition, there were

problems with staff turnover, poor

access to medical records, limited

pharmaceutical supplies, and performance of routine diagnostic tests. 

In contrast, preliminary analyses suggest that community-based

outpatient clinics (CBOCs) may be

a cost-effective mechanism for 

providing primary care services to

veterans living in rural areas (see

related article on page 4).

Encouragingly, no substantial differences in satisfaction and quality

of care were found between CBOCs

and the primary care clinics of parent facilities. Primary care costs

were found to be higher for CBOC

patients than for patients in the

primary care clinics of parent facilities. But, importantly, total

health care costs were lower for

CBOC patients because of lower

use of ancillary services. Likewise,

CBOC patients used fewer specialty outpatient and inpatient services than primary care patients at

parent facilities.

Although CBOCs were originally

intended to improve access for

existing enrollees, CBOC patients

were much more likely to be new

enrollees than were primary care

patients treated at parent facilities.

These findings suggest that CBOCs

represent a cost-effective mechanism for attracting new enrollees. 

In many cases, it may not be 

feasible to establish VA-staffed

CBOCs in remote rural areas.

However, CBOCs operated by community providers through a contractual relationship with VA can

increase access for veterans living

in even the most remote rural areas.

By partnering with local rural providers, VA can effectively gain market

share while minimizing direct competition with the private sector.

Although CBOCs attract new

enrollees by improving access to

primary care services, they do not

necessarily improve access to specialty services. Patients who

require highly specialized care still

must travel to parent facilities for

those services. 

But for those patients with

somewhat lower levels of severity

and comorbidity, telemedicine may

help extend the treatment capacity

of primary care providers.

Through the use of electronic medical records, phone-based communications, interactive video

stations, and other technologies,

telemedicine can provide support

to primary care providers at 

CBOCs from specialists at parent

facilities. Research suggests that

for some specialties, such as psychiatry, CBOC patients could be

effectively referred for interactive

video encounters with appropriate

specialists at parent facilities. For

high-cost patients with chronic illnesses, it may also prove cost-effective

to place telemedicine equipment in

veterans’ homes. 

Although VA has several costeffective mechanisms at its disposal

for providing high-quality services

to veterans in rural areas, the real

challenge lies in maintaining an

efficient balance of resources

between current enrollees and new

enrollees. For example, one objective

of CBOCs is to shorten appointment waiting times at parent facilities — a goal that serves new and

existing enrollees alike. We cannot

focus our resources on attracting

new enrollees from rural areas at

the expense of serving current

enrollees who live in urban areas. 

P reliminary analyses

suggest that communitybased outpatient clinics

(CBOCs) may be a costeffective mechanism for 

providing primary care

services to veterans living

in rural areas.
4

R ESEARCH EVALUATION

VA Community-Based Outpatient Clinics Improve Access to

Care and Increase Patient Satisfaction

By Michael K. Chapko, Ph.D., and Carol VanDeusen Lukas, Ed.D.

Over the years, the VA health care

system has shifted focus dramatically. Once chiefly a provider of acute,

episodic, inpatient-based care, the

VA has adopted a more comprehensive approach that attempts to bring

preventive, primary, and specialtybased care to veterans in the communities where they live. 

A fundamental goal of this transition was to improve access to care.

In the early 1990s, VA satellite clinics operated under serious constraints: They had to be at least

100 miles or three hours’ travel

from the nearest VA facility and

they had to handle at least 3,000

visits per year. In 1995, the VA

established the first CommunityBased Outpatient Clinic (CBOC),

which generally is smaller than the

traditional satellite clinic and less

restricted geographically. By the

end of 1998, 175 CBOCs had been

established, and by 2001 that number had grown to about 400 nationally. Recently, the larger satellite

clinics were designated as CBOCs. 

In most cases, CBOCs are affiliated with a “parent” VA medical

facility, which usually provides a

wider range of services — including

primary, specialty, and inpatient

care — than the CBOC. CBOCs

may be staffed by VA providers or

they may use community providers

through a contractual relationship.

CBOCs have several national

objectives:

■ Reduce the need to travel long

distances to receive care, thus improving access for veterans and reducing beneficiary travel expenditures.

■ Redirect patients currently served

at medical center clinics and thereby shorten waiting times or relieve

congestion at these treatment sites.

■ Shorten waiting times for followup care.

■ Shift emphasis from episodic

treatment to prevention, health

promotion, and patient education.

■ Shorten hospital length of stay

through pre-admission work-up or

by providing post-discharge followup care closer to the patient’s

home.

■ Reduce the operating cost of providing care — for example, by providing care at a lower cost in a

community ambulatory care setting

rather than in a hospital-based clinic.

■ Improve customer satisfaction.

Evaluating CBOCs

With the rapid growth of CBOCs,

VA leaders and Congress were

interested in monitoring CBOC 

performance to determine whether

they were meeting their objectives

and whether some types of CBOCs

were more effective than others. 

As a result, in 1998, the Under

Secretary for Health asked HSR&D

through the Management Decision

and Research Center to conduct a

systemwide evaluation of CBOCs. 

The resulting CBOC

Performance Evaluation Project

established a set of CBOC performance measures in consultation

with a national advisory committee,

conducted a survey of CBOCs to

determine their characteristics, and

assessed CBOC performance in six

domains identified by the advisory

committee. Those performance

domains are access, mental health,

quality of care, patient satisfaction,

utilization, and cost. The performance evaluation obtained data

from several sources, including VA

administrative databases, the VA

national customer feedback survey,

and medical record reviews. The

study focused on the 139 congressionally reviewed CBOCs that were

operational when the study began

and that had served at least 50 veterans in the first half of fiscal 1998.

The survey we conducted in 1998

as part of the evaluation project

offers a snapshot of the CBOCs that

were in operation at that time. We

found, for example, that some

CBOCs were quite close to their

parent facilities — less than a mile

away — while others were as far as

253 miles away from their parent

facilities. The median distance was

57 miles. Most CBOCs (61 percent)

were located in urban areas, with

39 percent in rural areas. While

urban CBOCs were predominantly

VA-staffed (71 percent), rural

CBOCs were more equally split

between VA-staffed (53 percent)

and contract (47 percent). 

Ninety-eight percent of CBOCs

offered primary health care, 28 percent reported offering primary

health care and primary mental

health care, and 2 percent offered

only primary mental health care.

While 54 percent of VA-staffed

CBOCs offered both primary health

and mental health care, only 18

percent of contract CBOCs offered

both types of services. 

CBOCs Show Favorable

Results

To assess CBOC performance, we

compared each CBOC with its parent VA medical center across the

six performance dimensions.

Following is a summary of our findings. 

Access. CBOCs improved patient

access. For veterans who used a

CBOC, the average distance

between their home and the CBOC

was 15 miles, compared with an

average distance of 56 miles to the

parent VA medical facility. More

patients were seen within 20 minutes of their scheduled appointment time at a CBOC (83 percent)

continued on page 5
5

R ESEARCH EVALUATION

The CBOC evaluation was conducted by a team of researchers from three HSR&D

Centers of Excellence. The study team included: Michael Chapko, Ph.D., Ashley

Hedeen, M.D., and Matthew Maciejewski, Ph.D., of Seattle; Steven Borowsky,

M.D., M.P.H., of Minneapolis; and John Fortney, Ph.D., of Little Rock. The project

produced five reports of its findings. Reports can be found on the VA Intranet at

http://vaww.va.gov/resdev/cboc.htm.

than at a parent facility (62 percent). However, that difference

was insignificant when the appointment was for a follow-up visit after

a hospitalization. 

Utilization and Cost. Compared

with patients seen at parent facilities, patients at VA-staffed CBOCs

had more primary care visits but

fewer specialty care visits and

fewer hospital bed days. The cost

per primary care visit was slightly

higher at the CBOC compared to

the parent facility. All of this

translated into higher total primary care costs at the CBOC because

of the higher cost per visit and

greater number of visits. But the

total cost of care was lower for

CBOC patients because of their

substantially lower number of specialty care visits and hospital days.

(Reliable data were not available to

analyze the costs of contract CBOCs.)

Mental Health Services. The

percent of CBOC patients receiving

a mental health diagnosis was

equal to the percent of primary

care patients at a parent facility

receiving a mental health diagnosis. We took this to mean that

mental health issues received comparable attention at CBOCs and

parent facilities. Likewise, the percent of patients seen within 30 days

following a psychiatric discharge

was equal at the two facility types.

Quality of Care. Fewer CBOC

patients (75 percent) than parent

facility patients (83 percent)

reported that one provider or team

was in charge of their care.

Although this finding raises some

concerns with regard to continuity

of care, it probably reflects the fact

that CBOC patients are more likely

to view the CBOC and parent

providers as two separate teams

because of their physical separation. However, CBOC patients

actually reported few problems

with care coordination.

The quality of preventive care is

roughly equivalent among CBOCs

and their parent facilities. We

assessed the delivery of preventive

care by determining the percent of

primary care patients who appropriately received Pneumovax,

influenza vaccination, prostate cancer screening, colon cancer screening, tobacco use screening, tobacco

use counseling, and alcohol use 

counseling. We also determined

the percent of patients with chronic

diseases receiving appropriate

screening for hypertension, obesity,

and diabetes. In the aggregate,

CBOCs and their parents differed

significantly on only one preventive

measure: A smaller percent of

CBOC patients (40 percent) with

diabetes received appropriate eye

examinations compared to patients

seen at a parent facility (54 percent). 

Satisfaction. Patient satisfaction

tends to be higher in CBOCs.

CBOC patients reported fewer

problems with their care than parent facility patients in terms of

access, timeliness of care, patient

education, provider receptivity to

patient input, emotional support,

coordination of care, and courtesy.

In addition, the percent of patients

rating their health care as “very

good” or “excellent” was slightly

higher at CBOCs (92 percent) than

at parent facilities (89 percent).

Although most CBOC patients

must obtain their specialty care at

a parent facility, there was no difference in reported ease of access to

specialty care between CBOC

patients and parent facility patients.

Comparing VA-Staffed and

Contract CBOCs

On most dimensions, VA-staffed and

contract CBOCs performance was

similar. For veterans who used a

VA-staffed CBOC, the average distance from their home to the CBOC

was 39 miles less than the distance

between their home and the parent

VA facility. The comparable difference in distance for contract

CBOCs was 47 miles — probably

because contract CBOCs are more

frequently located in rural areas

and therefore tend to serve patients

who live further from the parent

facility. There was little difference

between VA-staffed and contract

CBOCs with regard to percent of

patients seen within 20 minutes of

their scheduled appointment time.

There are also significant differences.

VA-staffed CBOCs were able to see

patients three days earlier following

hospital discharge compared to

contract CBOCs. Also, a smaller

percentage of contract CBOC patients

received a mental health diagnosis

compared to VA-staffed CBOC patients, raising the question of whether

less attention is devoted to mental

health issues at contract CBOCs.

Summary of Findings

The findings from our evaluation

are encouraging. CBOCs are meeting most of their objectives — indicating that CBOCs offer a

promising strategy for providing

accessible, cost-effective care to veterans outside the traditional hospital setting. CBOC performance

should continue to be monitored,

however, for two reasons. First,

our assessment was done only on a

subset of CBOCs using data that

are quickly becoming outdated.

New analyses should be done with

current data on all CBOCs.

Second, there are many questions

that our study did not answer. For

example, we could not adequately

analyze the costs of contract

CBOCs. In addition, new users

that CBOCs have brought into the

VA system should be tracked to

determine if their low initial use

increases over time or remains low. 
6

R ESEARCH REVIEW

Telemedicine: What Do We Know and What Do We 

Need To Know?

By Adam Darkins, M.D., M.P.H., F.R.C.S., Acting Chief Consultant for Telemedicine, VHA 

Telemedicine stands poised to revolutionize health care in much the

same way the telephone did a century ago. Nobody today would seriously suggest abandoning the use of the

telephone in health care, even

though that use has never been systematically evaluated. As equipment

costs continue to fall and bandwidth

availability further increases,

telemedicine use will become ubiquitous. For VA, the main question is

not whether telemedicine will be

implemented but how. 

That said, however, it would be

wise to take a close look at what the

scientific evidence tells us regarding the effectiveness of telemedicine

before implementation of this medium gets ahead of itself. In that

way, we can do a better job of

ensuring that telemedicine is used

appropriately and for the greatest

possible benefit of patients.

First, let us be clear on what we

are talking about when we discuss

telemedicine. The VA has adopted

the Institute of Medicine’s definition of telemedicine: “the use of

electronic information and communications technologies to provide

and support health care when distance separates the participants.”

VA chose this definition specifically

because it emphasizes telemedicine

as a medium for supporting health

care and not as a health care intervention in itself. This distinction is

crucial in order to correctly assess

the evidence on the use of telemedicine, which facilitates the delivery

of health care services to remote

settings.

Assessing the Effectiveness

of Telemedicine 

There is a fundamental obstacle to

establishing the clinical effectiveness of telemedicine: Most of the

health care interventions it supports are not themselves grounded

in scientific evidence. This poses a

considerable methodological challenge for telemedicine research. If

the effectiveness of a given health

care intervention supported by

telemedicine is unknown, then

studying the effect of telemedicine

may be confounded by the presence of a second independent variable. Many telemedicine research

studies compare the effect of

telemedicine on clinical practice

with traditional face-to-face consultation as a way around this

problem. In doing so, such studies

usually assume that the “status

quo” is implicitly “effective,” and

so they fail to assess telemedicine

in terms of its objective effect on

patient outcomes. 

The literature on telemedicine

follows two distinct approaches.

The first approach examines

telemedicine as a broad generic

medium. The second approach

looks at telemedicine in relation to

how it supports specific areas of

care delivery — assessing, for

example, the results of telecardiology or teledermatology. 

Several comprehensive reviews

of the telemedicine literature have

tried to address the general and

specific applicability of telemedicine in terms of whether it is 

a) effective, b) cost-effective, and 

c) appropriate to use in health care

settings. According to these

reviews, the jury remains very

much “out” with respect to the

appropriateness and effectiveness

of telemedicine in delivering both

general and specialist care. 

Furthermore, these reviews

could not address inconsistencies in

the standards of clinical practice,

technology, and management of

telemedicine programs. To

attribute outcomes to an intervention, we must first know that the

intervention was consistently

applied. Several organizations have

developed or are currently involved

in developing standards for telemedicine, including the Joint Commission

on Accreditation of Healthcare

Organizations, the American College

of Radiology, the National Electrical

Manufacturers Association, the

American Telemedicine Association,

and VA.

Developing a Research

Agenda

In view of the unanswered questions surrounding telemedicine, a

clear research agenda is needed. As

a world leader in telemedicine

development, VA is in a unique

position to contribute to this agenda. VA offers a unique clinical base

from which to study the appropriateness, effectiveness, and costeffectiveness of the clinical,

technical, and managerial dimensions of telemedicine. In addition,

because VA is an integrated health

care system, research questions

testing different models for the diffusion of telemedicine can be

applied across various health care

settings within VA. 

In many respects, the development of telemedicine is reminiscent

of that of the Internet before 1995.

The use of the Internet was pioneered in the public sector, but

robust systems and processes were

needed for the transition into the

private sector, where its use exploded. That work was achieved mainly

by a partnership between the federal government and academia. 

Diffusion of a new technology 

frequently takes on a life of its own.

It is important, however, for the

leaders in telemedicine implementation to step up to the plate and

ensure that telemedicine works

safely and effectively to the benefit

of patients. VA can play an important role in introducing needed

rigor and consistency in this effort.
7

VA Researchers Test Integrated Care Model for 

Substance-Abusing Patients

By Andrew J. Saxon, M.D., Daniel R. Kivlahan, Ph.D., and Donelle Howell, B.S.

Preliminary findings from an ongoing study at VA Puget Sound

underscore the difficulties of getting addictions patients — particularly ethnic minorities and those

with less severe medical problems

— to obtain needed primary care.

As the study progresses, VA

researchers hope to clarify whether

an integrated care model that

makes primary medical care available at addictions treatment clinics

can enhance access to care, improve

clinical outcomes, and reduce

health care costs.

Veterans seeking treatment for

alcohol and drug addictions typically have multiple medical conditions, yet many of these patients

are new to VA and do not have an

established relationship with a primary medical provider. For the

addictions patient, maneuvering

through a large health care system

can be overwhelming. As a result,

many addictions patients use the

emergency room when they need

care — leading to poor continuity

of care and potentially higher

health care costs. 

Researchers at VA Puget Sound

are conducting a randomized trial

comparing primary medical care

provided within an Addictions

Treatment Center to the standard

of referring patients to a primary

care clinic. Several hundred veterans beginning addictions treatment

will be followed for one year to

evaluate medical and addictions

outcomes, health-related quality of

life, and total health care costs. 

Participants are veterans starting addictions treatment who lack a

primary medical provider and have

a condition — such as high blood

pressure — that requires primary

care. After an initial research

appointment assessing health status and addiction severity, veterans

are randomly assigned to a primary

care appointment at either the

Addictions Treatment Center

(ATC) or the General Internal

Medicine Clinic.

During the first 14 months of

recruitment, virtually all ATC

patients presented with medical

conditions. Half had no primary

care provider. Nearly 70 percent

reported additional psychiatric conditions. The majority of participants — 62.1 percent — were

Caucasian, 28.2 percent were

African-American, 4.5 percent were

Hispanic, 3.4 percent were Native

American, and less than 1 percent

were Asian-Americans or Pacific

Islanders. 

A greater percentage of ATC

patients (57.7 percent) showed up

for their initial primary care

appointment than did general clinic

patients (42.3 percent). Primary

drug or presence of another psychiatric condition was not related to

primary care attendance. At both

clinics, patients who showed up for

their initial primary care appointment were more likely to be

Caucasian, have more severe medical conditions, and to be actively

obtaining addiction-focused treatment

in the addictions treatment center. 

Lisa Rubenstein Receives Under Secretary’s

Award for Health Services Research

Lisa Rubenstein, M.D., M.S.P.H., received the year 2001 Under

Secretary’s Award for Outstanding Achievement in Health Services

Research. Thomas L. Garthwaite, M.D., Under Secretary for Health

and VHA’s Chief Executive Officer, presented the award at the VA

HSR&D Annual Meeting, Feb. 14-16, in Washington, DC. 

Dr. Rubenstein’s exemplary record demonstrates her unwavering

commitment to veterans and to the improvement of VA health care.

She is a prominent proponent of translating research findings into

practice, and she combines her extensive practical knowledge of ambulatory care management with evidence-based interventions to advance

positive changes in both VA and non-VA settings. Nationally recognized as a leader in the design and evaluation of systems to improve

health care quality, Dr. Rubenstein has spearheaded the development

of several innovative health services research methods, including functional status computer feedback, scale-based methods of quality of care

and sickness assessment, and structured implicit review. 

Dr. Rubenstein also effectively implemented outcomes research at

the organizational level long before it became popular, and her success

as Chief of Evaluation for the Pilot Ambulatory Care and Evaluation

(PACE) project at the Sepulveda VA helped make that Center a national model for VA’s critical shift toward primary care. She has served as

Director of the HSR&D Center for the Study of Healthcare Provider

Behavior, part of the VA Greater Los Angeles Health Care System,

since 1994. 

R ESEARCH HIGHLIGHT

CORRECTION: 

(FORUM, November 2000, page 4)

The QUERI Lipid Project included 24

medical centers and 41,366 patients. Other

results and conclusions change slightly.

See the corrected article at http://www.va.gov/

resdev/prt/fornov00.pdf or on the VA

Intranet at http://vaww.va.gov/resdev/

prt/fornov00.pdf.
8

Martin P. Charns, D.B.A., Editor-in-Chief

Mary Darby, Editor

Geraldine McGlynn, Co-editor

ADVISORY COMMITTEE

John G. Demakis, M.D., Director, VA HSR&D

Rodney A. Hayward, M.D., VA HSR&D

Center of Excellence, Ann Arbor

David H. Law, M.D., VA Medical Center, 

Bay Pines, FL

Shirley Meehan, M.B.A., Ph.D., VA HSR&D

Alan S. Perry, M.H.A., FACHE, VA Medical

Center, Fresno, CA

Robert M. Roswell, M.D., VA Network #8,

Bay Pines, FL

Hanna B. Rubins, M.D., M.P.H., VA HSR&D

Center of Excellence, Minneapolis

FORUM is a publication of the VA Office of Research &

Development, Health Services Research & Development

Service, Management Decision and Research Center, in

conjunction with the Academy for Health Services Research

and Health Policy.

F O R U M

R ESEARCH HIGHLIGHT

Exploring Links in Veteran Identity with VA Health Services Use

By Nancy Harada, Ph.D., VA Greater Los Angeles Healthcare System

How does the way in which veterans identify with their experiences

and status as veterans affect their

use of VA health services? That is

the question that the Veteran Identity

Program (VIP) is trying to answer.

The VIP defines “veteran identity” as an individual veteran’s selfconcept that derives from his or her

military experience, within the

socio-historical context of that

experience. Because of the known

association between race and ethnicity and health services use, the

VIP is particularly interested in the

interface of veteran and ethnic

identification as they relate to health

services use among different war

cohorts. Veteran identity may vary

by race and ethnicity because the

socio-historical context of military

experience varies by race and ethnicity. 

To begin to understand how veteran identity influences VA outpatient services use, VIP

investigators used a three-pronged

research approach: secondary

analysis of the 1992 National

Survey of Veterans, focus groups,

and primary data collection

through a telephone survey.

Secondary analysis was used to document baseline levels of health status and use of VA outpatient care

by racial and ethnic groups. VIP

researchers have found that

upcoming months. Better understanding of veteran identity could

help VA leaders improve both

access to VA care and the quality of

VA care. For example, outreach

strategies that take into consideration aspects of veteran identity may

be more effective in reaching veterans of different racial and ethnic

groups. In addition, interpersonal

care could be improved by educating clinicians about veterans’ experiences during military service. 

African American and Hispanic veterans are more likely to report

worse self-rated health and functioning than non-Hispanic white

veterans. Although these groups

are more likely to use VA outpatient care, they also report greater

unmet health care needs than nonHispanic white veterans. 

Focus groups were then used to

explore relationships between military experience, racial and ethnic

background, and VA health care services use. The main veteran identity themes related to military status,

military experience, and perceptions

of the veteran experience. These

themes were incorporated into the

development of a telephone survey

that was administered to veterans

in the Veterans Integrated Service

Network 22 (Southern California

and Southern Nevada). Analysis of

the survey data is underway.

Preliminary results indicate that

aspects of veteran identity, such as

membership in veterans’ organizations and veteran influence on daily

life, are significantly associated with

preferences to use VA outpatient

care. Once the veteran has become

a VA user, the number of visits is

most strongly determined by health

status. 

VIP researchers plan to extend

their studies to the American

Indian veteran community in