Open Access in the Patient-Centered Medical Home: Lessons from the Veterans Health Administration

Abstract

The Veterans Health Administration (VHA) has undertaken a 5-year initiative to transform to a patient-centered medical home model. An early focus of implementation was on creating open access, defined as continuity and capacity in primary care. We describe the impact of readiness for implementation on efforts of pilot teams to make changes to improve access and identify successful strategies used by early adopters to overcome barriers to change. A qualitative, formative evaluation of the first 18 months of implementation in one Veterans Integrated Service Network (VISN) spread across six states. Members of local implementation teams including administrators, primary care providers, and staff from primary care clinics located at 10 medical centers and 45 outpatient clinics. We conducted site visits during the first 6 months of implementation, observations at Learning Collaboratives, semi-structured interviews, and review of internal organizational documents. All data collection took place between April 2010 and December 2011. Early adopters employed various strategies to enhance access, with a focus on decreasing demand for face-to-face care, increasing supply of different types of primary care encounters, and improving clinic efficiencies. Our interviews with key contacts revealed three important areas where readiness for implementation (or lack thereof) had an impact on interventions to improve access: leadership engagement, staffing resources, and access to information and knowledge. Key factors related to readiness for implementation had an impact on which interventions pilot teams could put into place, as well as the viability and sustainability of access gains. Wide variations in interventions to improve access occurring across sites situated within one organization have important implications for efforts to measure the impact of enhanced access on patient outcomes, costs, and other systems-level indicators of the Medical Home.