Partnership Forum: The Role of Research in the Transformation of Veterans Affairs Community Care.

Abstract

In response to concerns about Veterans’ access to Veterans Affairs (VA) health care services, Congress passed the Veterans Access, Choice and Accountability Act of 2014 (Choice), which broadened Veterans’ eligibility to receive health care delivered by non-VA community providers paid for by VA (ie, Community Care).1 Specifically, the Veterans Choice Program (VCP) allowed Veterans waiting longer than 30 days for specific services in VA, who lived >40 miles from a VA clinic, or who experienced specific hardships in accessing VA care, the option of receiving Community Care. To help implement VCP successfully, the VA established the Office of Community Care (OCC) in fiscal year (FY) 2015 to lead the coordination of Community Care expansion. This included reorganizing local departments at each VA facility to ensure that VA/Community Care referrals across systems occurred seamlessly. With the passage of Choice, one of VA’s top priorities—to become a high-performing integrated network—was changed to reflect the inclusion of both VA and Community providers. Similarly, the VA’s Health Services Research and Development Service (HSR&D) portfolio began to incorporate the new priorities arising from the expansion of Community Care.2 The initial call for Community Care research funding set the stage for collaborations between operations and research. Although the implementation of the VCP was underway, new contracts for Community Care were still in process, and therefore researchers were expected to conduct their activities in active partnership with OCC. The purpose of these collaborations was to achieve “a scientifically rigorous product that is also relevant, feasible, and sustainable in real-world medical practice.”3 By partnering with OCC, our research teams’ interests and methodologic expertise were and continue to be informed by OCC’s knowledge of changing health care delivery practices and policies.4,5 Through communicating early and frequently with OCC, having a shared understanding of our mutual goal to increase Veteran access to high-quality timely health care, and leveraging our respective scientific and organizational strengths,3 we were well-positioned to ensure that our research efforts would have maximal impact and relevance for real-world clinical practice in the VA Health Care System. In 2017, HSR&D awarded planning grants to our 3 research teams to develop methods to evaluate VCP’s impact on Veterans’ health care quality, costs, and access and to investigate Community Care Network (CCN) adequacy. These research efforts were undertaken with the expectation that they would be conducted in active partnership and collaboration with OCC. Relationships between our HSR&D research teams and OCC began informally, with each team reaching out separately to OCC based on their specific research needs. Simultaneously, the research teams began working collaboratively with one another and with the VA’s Partnered Evidence-Based Policy Resource Center (PEPReC) to share what we each learned and prevent duplication of efforts across projects. These early partnerships resulted in our HSR&D research teams and OCC leadership coming together on common areas of interest, such as at the Network Adequacy Expert Panel meeting in 20176 and the Evaluation Data Strategy meeting in 2018 where we exchanged knowledge about Community Care processes and data resources to support evaluation. By 2018, each of our 3 research teams had a strong partnership with OCC and growing numbers of HSR&D researchers who were developing proposals focused on Community Care were also interested in establishing partnerships with OCC. As Veterans’ utilization of Community Care continued to increase, HSR&D awarded additional grants, including 3 additional years of research funding to each team following successful completion of the planning grants. These new grants focused on the accuracy and missingness of Community Care data and its impact on care coordination; the impact of the implementation of the Choice Act on Veterans’ health care quality, costs, and access; and the adequacy of the CCNs. About this same time, the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act of 20187 was passed, which further expanded eligibility for Veterans to Community Care and created a more permanent and consolidated Community Care Program, the Veterans Community Care Program (VCCP). This Act not only increased Veterans’ options to seek care in the community but provided a stronger “raison d’être” for the partnership between research and OCC. By 2019, with increasing numbers of grants awarded to HSR&D researchers, OCC was frequently asked to provide needed information on Community Care data, policy, and implementation updates. Each of our 3 research teams was also contacted more often by other researchers interested in learning about our experiences in working with Community Care data. Recognizing the need to disseminate information more widely and systematically throughout the VA research community, we proposed a Partnership Forum with OCC entitled “VA Community Care: Ongoing Evaluation Efforts, Preliminary Analyses, Data Systems, and Emerging Issues in the Implementation of The MISSION Act,” for VA’s 2019 Health Services Research & Development/Quality Enhancement Research Initiative (HSR&D/QUERI) conference. THE PARTNERSHIP FORUM The Partnership Forum was designed to bring together individuals interested in Community Care to share ideas, gain knowledge, and discuss the potential synergy between OCC’s and VA researchers’ priorities and interests. Dr Kameron Matthews, Deputy Under Secretary for Health for Community Care, gave researchers the opportunity to learn more about current OCC priorities, the ways in which researchers could contribute to these priorities, and the newly implemented MISSION Act. After Dr Matthews’ presentation, each of our 3 research teams provided a brief overview of our research efforts, sharing what we had learned about VCP and our work in progress. The next sections of this paper provide the highlights of these Forum presentations. Office of Community Care Priorities An aim of the Partnership Forum was for OCC to identify priority areas where research efforts would be most impactful. According to Dr Matthews, the overarching priority is to ensure Veterans have access to a Community Care program that is easy to use, provides greater choice and high-quality care, and allows for robust care coordination. This requires a focus on health care delivery—establishing and managing contracting, facilitating clinical integration, overseeing provider relations and services, and claims reimbursement. Although these activities are not typically within the purview of researchers, the research community has some overlapping interests with OCC’s. For example, how the implementation of VCCP affects the delivery of health care to Veterans is fundamental to the efforts of both researchers and OCC. Greater attention to the realities of the health care delivery system means that research findings may be more rapidly implemented into real-world clinical practices as they are likely to be clinically driven and evidence based. Yet, these same realities may present barriers to implementation that will need to be overcome. Care Coordination OCC spoke of the lack of existing research to guide the implementation of evidence-based care coordination models for multisystem use and the need to better understand Veterans’ care coordination needs. Although OCC monitors the extent to which Veterans receive care from both VA and Community Care providers and seeks to improve processes that facilitate better communication and convenient and secure sharing of medical records,8 it needs researchers’ assistance with the following: (1) methods development; (2) evaluation of care coordination improvement efforts; (3) tailoring care models to specific health conditions9 and patient populations10; and (4) aligning resources with high-risk patients, regardless of where patients receive care. To ensure satisfactory patient outcomes,11 OCC is committed to care coordination that encompasses care delivered through both VA facilities and VA community providers, as well as through public (eg, Medicare, Medicaid) and private providers. Quality of Care OCC identified specific quality of care topics to support their ongoing efforts: (1) evaluation and refinement of established quality metrics; (2) initiation of quality improvement (QI) activities based on available quality metrics; (3) development of innovative methods to evaluate QI efforts; and (4) integration of care coordination and quality metrics to facilitate QI efforts. The metrics used, regardless of the source, should enable equitable comparisons between VA-delivered care and VA-purchased care; they should also account for the potential burden of any data reporting requirements to prevent overwhelming Community Care providers. Community Care Providers’ Knowledge of Veteran-specific Needs OCC leadership would like to learn more about Community Care provider education and competency as it relates to providing Veteran care. Researchers were encouraged to develop and implement methods to ensure that Community Care providers are aware of Veterans’ unique health risks (eg, opioid safety and suicide risk) as well as their medical and psychological conditions, such as cancer, chronic obstructive pulmonary disease, and posttraumatic stress disorder.12 Other questions related to provider education and competency raised at the Forum for researchers to address included: How should provider education and competency be assessed? How is competency ensured over time? How can competency standards be consistently applied across VA and Community Care providers and/or tailored to provider specialty? Who should have responsibility for assessing Community Care providers: VA or its contractors? Researchers interested in Community Care provider education and competency must consider the regulatory and reimbursement environment of these providers, highlighting the importance of an OCC and researcher partnership to produce relevant and impactful outcomes. Network Adequacy OCC’s priorities in this area are focused on understanding network adequacy standards associated with CCN performance. Current CCN contracts include standards for care proximity (ie, drive times), appointment scheduling (ie, wait times), and monthly meetings between VA facility staff and contractors to ensure that each network reflects local priorities and needs. For researchers interested in evaluating network adequacy, questions to consider include: (1) ascertaining whether a CCN’s ability to meet the contractual network standards leads to improved access to care; (2) determining how VA can build long-term and sustainable relationships with its vast network of providers and whether they lead to greater access to care, increased provider and Veteran satisfaction, and better outcomes; (3) assessing what information both providers and Veterans would like that would be helpful in informing them about VA and Community providers and; (4) determining ways in which this information should be conveyed to be most useful. Customer Service/Veteran Satisfaction OCC is interested in understanding how Veterans make decisions about where to receive care and how customer service influences Veterans’ choices about using VA or VCCP. The overarching goal of “customer service” is to ensure that Veterans are highly satisfied with the care they receive, which includes providing high-quality health care. Several research questions were posed by OCC for researchers to address: How do Veterans’ experiences with their care providers and facility staff influence their decisions on where to seek care? Can VA researchers evaluate whether VA’s effectiveness as an integrated health care delivery system is associated with efficacious customer service? How can existing consult management metrics be used to identify barriers to Veterans’ use of VA services? RESEARCH PRIORITIES Similar to OCC, VA researchers are interested in ensuring that Veterans receive accessible, high-quality health care. However, researchers’ priorities are primarily focused on generating new scientific knowledge to achieve this goal which often involves lengthy timelines.13 Although this paradigm is slowly changing with VA’s transition to a Learning Health Care System, to accommodate basic differences between researchers’ and operational partners’ priorities and timelines, VA identified 3 models of research-practice relationships that can be effectively used to achieve mutual goals: (1) research produces scientific findings that subsequently inform clinical care and policies; (2) research and operations (eg, clinical programs) work together on common research priorities and implementation strategies; and (3) policy changes within VA’s integrated health care system create natural experiments that generate evidence that can be used to evaluate the outcomes of these policies.14 The passage of Choice and MISSION means that OCC and VA researchers are likely using Models 2 and 3 to address current needs. Researchers need to develop and use methods to evaluate the implementation of VCCP regarding its effectiveness, outcomes, and costs and identify variations across facilities and Veterans Integrated Services Networks within VA. Researchers have addressed VCP and VCCP initiatives slowly. Several foundational steps were needed: (1) understanding the actual process of expanded Community Care implementation and what that entailed; (2) identifying new data sources and assessing the quality of these data and; (3) understanding the data’s strengths and limitations, and the inferences that can be made before addressing our research questions directly. OCC has supported our efforts, and in turn, we have provided OCC with research findings that can inform their policies and practices, whether it be with regard to data collected, clinical operations, or CCN contracts. The next few paragraphs present brief summaries of the work conducted by each of the research teams that participated in the Forum. The summaries include our research findings, the length of time from research initiation to findings, and how our research efforts informed OCC’s needs and priorities presented earlier. Care Coordination To understand VA and VCP care coordination needs, and whether these needs differ by care type, we investigated Veterans’ VA and Community Care use by primary care and specialty outpatient care from FY15 to FY18. We showed that Veterans’ mix of service use over this period differed by race, age, comorbidity score, and rural residence. We also found that for Veterans using specialty services for sleep medicine diagnostic testing, there was a 47% increase over time on VA telehealth home testing, whereas home testing for Community Care services remained low. Further analyses showed that in-person testing studies were much more likely for VCP referrals, for persons living in rural areas, those with higher comorbidity scores, and for older Veterans (age 44 and over) compared with younger Veterans.15 During the Partnership Forum, we shared our current work in progress. This work suggests that Veterans’ care coordination needs will likely differ for those seeking primary care than those seeking specialty services in the community due to different risk profiles and social determinants. This work, completed in ∼3 years, informed OCC’s priority to understand how to tailor care models to specific health conditions, patient populations, and align resources regardless of where patients receive care. Quality of Care While it is well known that VA generally performs similarly or better than non-VA settings on most nationally recognized measures of inpatient and outpatient quality,16–18 virtually little is known about differences in quality between VA and Community Care. To address this gap, we presented our research comparing 90-day postoperative complication rates of cataract surgery between VA and Community Care.19 We selected cataract surgery for the comparison because: (1) 90-day complication is a nationally endorsed outcome measure widely used in the United States; (2) it is a common procedure in the VA and US, with surgery rates increasing as the population ages; and (3) it is a well-defined, high-frequency procedure. Although we hypothesized that Veterans going to Community Care would have higher complication rates than those getting their cataract surgery in the VA due to the potential for fragmented care, this hypothesis was not supported by the data. In fact, we found no differences in complication rates after cataract surgery between VA and Community Care, even after adjusting for covariates such as sociodemographics and clinical characteristics through the use of a VA-specific risk-adjustment method.20 This work, completed in <3 years, addressed OCC’s priority of making equitable comparisons between VA-delivered care and VA-purchased care without adding additional data reporting requirements. Collaborations with OCC in this area will be particularly valuable for examining areas where QI initiatives are needed and to help inform “make versus buy” decisions for VA. Network Adequacy Our research team is interested in how VA network adequacy is measured, how network standards are associated with access, and how the network affects Veterans’ health outcomes. We shared our foundational work from our Expert Panel meeting held in October 2017, which was attended by OCC. The Panel discussed whether network adequacy measures used by other health care plans, states, or the Affordable Care Act could be adopted by the VA. The Panel noted several key challenges to applying non-VA network adequacy measures to the VA; these included needing a better understanding of VA’s service capacity, network services demand, and limitations to provider reimbursement. The Panel recommended that VA develop different network standards by care type (eg, primary care vs. specialty care) and provide Veterans with network provider directories. This information helped inform network adequacy standards that have been incorporated into CCN contracts. Our work in progress focuses on how these new networks are functioning, identifying factors that facilitate (and hinder) successful VA/Community Care provider relationships, and Veterans’ preferences for CCN provider information. Collaborations with OCC have been and will continue to be, essential to understanding how policy, data, markets, and health care use inform network adequacy and support a high-performing integrated health care system. Our research addresses some of OCC’s network adequacy priorities, but additional research involvement is needed and already underway. We have compiled an annotated list (Table 1) of all the current research efforts to date that we are aware of that have been funded. Most projects address multiple OCC priorities. In addition, Table 1 reveals the breadth and depth of these current efforts, which focus on specific types of care (eg, primary care, orthopedics, urgent care), specific Veteran populations (eg, rural Veterans, women Veterans), and different aspects of health care delivery (eg, resource hubs, telehealth). Appendix A (Supplemental Digital Content 1, https://links.lww.com/MLR/C168) provides definitions of acronyms used in Table 1. This work includes system-level examinations and will provide OCC with evidence-based information to guide implementation of VCCP. TABLE 1 - Current VA CC Research and Related Activities Care coordination 1. Behavioral Health Screening and Care Coordination for Rural Veterans in a Federally Qualified Health Center (ORH # 7345) PIs: M. Bryant Howren, PhD, MPH; Thad E. Abrams, MD, MS Study Design: Mixed-methods evaluation of Quality Improvement program Methods: Process mapping, provider interviews, behavioral health screening data, care coordination, patient satisfaction Specific Aims: (1) Screen all patients presenting for care at partner Federally Qualified Health Center (FQHC) for Veteran status using a standardized methodology; (2) screen all patients for behavioral health issues, including depression, anxiety, substance use disorder, and posttraumatic stress disorder (PTSD); (3) identify and assist interested, eligible Veteran patients with accessing VA care enrollment and services; (4) ensure Veteran patients screening positive for behavioral health issues are offered and/or receive timely behavioral health care at a VA facility, the FQHC partner, or other health care setting. The FQHC partner is part of the CCN Focus: Care Coordination, Care Delivery 2. Care Coordination and Outcomes in the VA Expanded Choice Program (HRS&D SDR 18-321) PI: Denise Hynes, PhD, MPH, BSN Study Design: Mixed-methods observational study Methods: Aims 1 and 2: Qualitative interviews with key informants from 6 sitesAims 3 and 4: Observational before after study design using routinely collected VA clinical administrative workload and VA CC authorization and claims data Specific Aims: (1) Assess/summarize approaches used for regional and local VA facility implementation of quality, safety and value governance and monitoring under VCCP; (2) identify/evaluate organizational and health information exchange needs to support clinical care coordination and quality monitoring; (3) evaluate/compare process and outcomes-based quality measures for PC and specialty care among select high volume and high cost procedures; (4) develop/apply methods comparing the extent of overuse/duplication of services for Veterans authorized for VCCP vs. Veterans receiving care exclusively in VA Focus: Care Coordination, Access, Care Delivery, Quality of Care, Health Care Utilization, PC, Specialty Care 3. Establishing Technology-facilitated MBC for Rural Veterans Through VA and Community Partners, (ORH 16024) PIs: Carolyn Turvey, PhD; M. Bryant Howren, PhD, MPH Study Design: Quality Improvement implementation/evaluation Methods: Measurement of MBC adoption, patient and provider self-report regarding core MBC components, care coordination, mental health screening data Specific Aims: (1) Implement and refine the process of MBC through repeated measurements of depression and PTSD in VA and community partner clinics using health information tools; (2) capture repeated assessment data of depressive and PTSD symptom severity to tailor mental health treatment for rural Veterans; (3) examine clinic adoption, fidelity, and clinical effectiveness of technology-facilitated MBC; (4) explore mental health care coordination opportunities for Veterans receiving care in VA and community partners Focus: Care Coordination, Care Delivery 4. Evaluating Coordination of Specialty Care Within VA and With Non-VA Specialists (HSR&D FOP 20-190) PI: Varsha Vimalananda, MD, MPH Study Design: Cross-sectional survey study Methods: Survey methods, mixed-level regression models, care coordination data Specific Aims: (1) Compare care coordination for VA specialty care vs. VA-paid specialty care in the community, as experienced by VA PC providers and both VA and Community Care (CC) specialists; (2) describe the association between use of mechanisms to coordinate specialty care with coordination as experienced by VA PC providers and both VA and CC specialists Focus: Care Coordination Quality of care 5. Does Choice Equal Quality? A Mixed-Methods Comprehensive Evaluation of the Quality of CC Through the MISSION ACT vs. VA Care for Veterans With PTSD, Depression, and Chronic Pain (HSR&D SDR 19-287) PI: Jennifer Manuel, PhD Study Design: Mixed-methods evaluation Methods: Qualitative interviews with VHA/VCCP clinicians and stakeholders, secondary data analysis comparing Veteran utilization of VCCP and VHA care Specific Aims: (1) Compare Veteran utilization of VCCP and VHA care (ie, access to care, care type, intensity of services and cost) for 3 high-impact conditions: PTSD, depression and chronic pain; (2) obtain preliminary information about VCCP implementation (eg, usability, satisfaction, barriers and facilitators) and to determine important pragmatic and patient-centered clinical outcomes; (3) evaluate Veterans’ and VCCP/VHA clinicians’ experiences, satisfaction and quality of VCCP and VHA; (4) gain a deeper understanding of patient and clinician VCCP and VHA care experiences for PTSD, depression and chronic pain Focus: Quality of Care 6. Optimizing CC for Veterans With Advanced Kidney Disease (HSR&D: IIR 18-032) PI: Ann O’Hare, MD, MA Study Design: Observational study comparing outcomes and care processes for Veterans who receive nephrology care within the VA vs. VCCP Methods: CDW, USRDS registry (linked to VA data through VIReC), Medicare claims Specific Aim: (1) Compare outcomes for Veterans with advanced kidney disease referred to community providers vs. those see in VA facilities. To identify opportunities to improve delivery of CC for Veterans with advanced kidney disease Focus: Quality of Care 7. Make Versus Buy—Examining the Evidence on Access, Utilization, and Cost: Are We Buying the Right Care for the Right Amount? (HSR&D: SDR 18-318) PIs: Amy Rosen, PhD; Todd Wagner, PhD; Megan Vanneman, PhD Study Design: Retrospective study examining utilization, quality of care, and costs of Veterans utilizing the Choice program (FY15-FY19) with specific focus on surgery and mental health Methods: CDW (including the VHA’s PIT) data, fee basis files; SHEP survey data Specific Aims: (1) Examine variation in utilization of and access to VHA vs. CC over time (FY15-19); (2) develop and test a methodology to compare costs between VHA and CC; (3) examine use of specialty care, specifically surgery and mental health Focus: Quality of Care, Access, Cost, Health Care Utilization Network adequacy 8. Understanding Network Adequacy and Community Engagement in Veteran Care (HSR&D SDR 18-319) PIs: Kristin Mattocks, PhD, MPH; Michelle Mengeling, PhD, MS Study Design: An observational study investigating VA CCN, Veteran access, use, preferences Methods: CDW (including PPMS), OCC Data (providers, authorizations), primary data collection Specific Aims: (1) Develop and validate measures of network adequacy for non-VA CC and evaluate regional variations in network adequacy across Veterans in VA Medical Centers (VAMCs) and VA’s 98 markets; (2) examine the process by which CC decisions are made at individual VA facilities, and to identify existing and potential opportunities to expand community partnerships to deliver CC; (3) interview Veterans regarding CC, including preferences for a network directory of providers and quality ratings of providers to more completely understand their perspectives on CC Focus: Network Adequacy, Access, Patient Experience Access 9. Understanding the Role of VA Specialty Care Resource Hubs and Their Potential Impact on Access in the Era of CC (HSR&D SDR 19-400) PI: Megan Adams, MD, MSc Study Design: Planning grant Methods: Subspecialty workshops (gastrointestinal, oncology, and surgery), stakeholder interviews (leadership, providers, patients); environmental scans Specific Aims: (1) Characterize the proposed organizational structure of specialty care resource hubs and understand how these hubs will be used to deliver comprehensive specialty care, with a particular focus on 3 key specialties that face access challenges and are therefore likely to be outsourced to CC; (2) understand how trainees can be integrated into specialty care resource hubs to address unmet demand for specialty care in underserved facilities and further educational/training objectives Focus: Access, Care Delivery, Provider Workforce, Quality of Care 10. The Impact of Policy and Pandemic on Rural Veteran Access to PC (CARAVAN) (ORH OMAT # 15529) PI: Melinda Davis, PhD Study Design: Mixed-methods design Methods: Geospatial mapping of PC deserts, qualitative data collection and analysis, utilization of a rural Veterans Advisory Board and use of group modeling building as a tool for integration of qualitative findings, intervention priori