Care Coordination Challenges Research Articles

Love, support and structural holes: Māori whānau carer experiences in collective family care systems

Abstract As the population of Aotearoa New Zealand ages, informal family carers will play an increasingly important role in caring for older adults at home. Multi-generational living arrangements are a growing trend, particularly among Māori communities, where caring for older relatives within the family home is widespread. This article uses in-depth, semi-structured interviews with Māori whānau (extended family members) caring for kaumātua (older family members) at home to explore how carers experienced care coordination in the broader care collective. The findings centred on three interconnected factors that described the collective organisation of care: (1) whānau care as normal; (2) whānau care as collective coordination; and (3) whānau carer knowledge and needs as unseen. The findings show that although whānau care of kaumātua is highly valued, ‘structural holes’ within care systems contribute to challenges in care coordination. Despite extensive whānau support for kaumātua, primary carers often felt that their knowledge, preferences and self-care needs remained unseen and not translatable to those outside the everyday care situation. Rather than assuming an artificial binary difference between ‘collective’ and ‘individually oriented’ care contexts and cultures, analysing the cultural norms surrounding whānau care-giving confirms that collective care system members face similar and different challenges to carers with smaller caring capacities.

Percutaneous Insertion of Peritoneal Dialysis Catheters.

Patients with end-stage renal disease undergoing hemodialysis encounter significant challenges in care coordination and experience higher complication rates. Peritoneal dialysis (PD) is an evidence-based alternative that significantly improves patients' quality of life.Peritoneal dialysis catheter insertion methods include open surgical, laparoscopic, peritoneoscopic, and percutaneous image-guided approaches. Despite comparable success rates and cost-effectiveness, the US healthcare system underutilizes the percutaneous method.This article aims to provide an overview of the essential components of the technique of percutaneous peritoneal dialysis catheter insertion, as well as address patient selection nuances and considerations for urgent-start dialysis. Additionally, it reviews the outcomes and complications associated with image-guided percutaneous PD catheter placement, advocating for its wider adoption.

The Landscape of Care for Women Veterans with Cancer: An Evidence Map.

Women are the fastest growing veteran group in the US and the number of women veterans (WVs) with cancer is rising; however, little is known about this population. Cancer care for WVs is complex and it is essential to understand their unique needs and care coordination challenges to provide evidence-based care. The purpose of this review is to map the quantity, distribution, and characteristics of literature describing cancer and its treatment among WVs. We searched MEDLINE (via PubMed), Embase (Elsevier), and Web of Science Core Collection (Clarivate) from inception through January, 2024. Publications were eligible that reported gender-specific data on any aspect of cancer care among WVs. Data was abstracted by a single investigator with over-reading. Forty-six reports were included; 44 were observational and 19 had a women-only sample. There were no interventional reports and no qualitative reports had a patient sample. Breast cancer was the most commonly addressed (n = 19). There were six additional reports on sex-specific cancers. Many reports used large VA databases or previous trial data, creating the potential for patient overlap between reports. Among VA-specific areas of interest, only three reports evaluated the potential implications of racial differences and only two included a transgender population. No reports examined the effects of toxic exposures on cancer. Within the NCI Cancer Control Continuum, crosscutting areas were more commonly represented; over half (25) of the reports addressed epidemiology. There were few reports on focus areas and little overlap between focus and crosscutting areas. Existing literature provides an inadequate understanding of the population of WVs with cancer. There is scant information regarding the population of WVs with cancer, their care preferences or experiences, or how to best identify and address unmet healthcare needs. It is imperative to expand research to provide evidence-based care for this population.

Challenges of care coordination for complex patients among family medicine residents in a community ambulatory clinic: a qualitative study

BackgroundCare coordination has been identified as one of five focuses of HealthierSG. Family medicine residents are expected to collaborate with other healthcare professionals for complex patients by the end of residency. However, many residents felt that it was challenging to coordinate care effectively among healthcare stakeholders. However, to date, no qualitative studies have explored these challenges. Therefore, this study aimed to understand the challenges encountered by family medicine residents when coordinating care for complex patients.MethodsThis was a qualitative descriptive study in which semi structured in-depth interviews were conducted and guided by a topic guide. Total population sampling of 15 third-year family medicine residents in the National Healthcare Group Polyclinics was performed. The interviews were performed over Zoom and were transcribed. Thematic analysis was subsequently performed to analyse the transcripts. Coding was performed iteratively by two independent researchers. Disagreements were adjudicated by a third coder. A coding framework was agreed upon. Potential themes were then independently developed based on the coding framework.ResultsSix themes emerged from the data, namely, interprofessional communications, accessibility, personal knowledge, time constraints, patient factors and caregiver dissent.ConclusionChallenges faced by family medicine residents are multifaceted. While a few are systemic and pertain to the broader healthcare framework, others, such as issues of unfamiliarity with institutional workflows, community resources, and confidentiality, pertain to the microcosm of residency itself. These are reversible areas for improvement. These challenges can be addressed during planning of residency curricula to better equip family medicine residents with coordinating care for complex patients in the future.

Responsible coordination of municipal health and care services for individuals with serious mental illness: a participatory qualitative study with service users and professionals

BackgroundCare coordination is crucial to ensure the health of individuals with serious mental illness. The aim of this study was to describe and analyze an inclusive innovation process for coordinating municipal health and care services for individuals with serious mental illness.MethodsWe conducted café dialogues with professionals and service users with serious mental illness. The café dialogues engaged participants in conversation and knowledge exchange about care coordination, adressing topics of efficiency, challenges, and improvement. We used a responsible innovation framework to analyze the innovation process.ResultsResponsible coordination requires promoting service users’ health and ensuring communication and mutual awareness between professionals. Individual-level factors supporting responsible coordination included service users knowing their assigned professionals, personalized healthcare services, and access to meaningful activities. Provider-level factors included effective coordination routines, communication, information exchange, and professional familiarity. Results reflect professionals’ and service users’ perspectives on efficient care coordination, existing challenges, and measures to improve care coordination.ConclusionCafé dialogues are an inclusive, participatory method that can produce insights into the responsible coordination of municipal health and care services for individuals with serious mental illness. The responsible innovation framework is helpful in identifying care coordination challenges and measures for responsible coordination.

Measuring value in health care: lessons from accountable care organizations.

Accountable care organizations (ACOs) were created to promote health care value by improving health outcomes while curbing health care expenditures. Although a decade has passed, the value of care delivered by ACOs is yet to be fully understood. We proposed a novel measure of health care value using data envelopment analysis and examined its association with ACO organizational characteristics and social determinants of health (SDOH). We observed that the value of care delivered by ACOs stagnated in recent years, which may be partially attributed to challenges in care continuity and coordination across providers. ACOs that were solely led by physicians and included more participating entities exhibited lower value, highlighting the role of coordination across ACO networks. Furthermore, SDOH factors, such as economic well-being, healthy food consumption, and access to health resources, were significant predictors of ACO value. Our findings suggest a "skinny in scale, broad in scope" approach for ACOs to improve the value of care. Health care policy should also incentivize ACOs to work with local communities and enhance care coordination of vulnerable patient populations across siloed and disparate care delivery systems.

Team complexity and care coordination for cancer survivors with multiple chronic conditions: a mixed methods study.

Little is known about the perceptions and experiences of care received from healthcare teams among cancer survivors with multiple chronic conditions (MCCs). Cancer survivors completed an online survey (N=441) of which 12 participated in an interview. Team complexity was operationalized based on team size, clinician specialties, and health system affiliation. Kilpatrick's Patient-Perceptions of Team Effectiveness (PTE) questionnaire measured team effectiveness. Constant comparative method was used to identify care coordination challenges and facilitators from interviews. Mean age at cancer diagnosis was 45 years (SD=14), 68% were 5 years from diagnosis, the most common cancer was breast (27%), and two-thirds had two or more pre-diagnosis comorbidities. Sixty percent rated both cancer and other condition(s) as taking priority. Team complexity varied from low (32%), moderate (49%), and high (20%). Eighty percent rated PTE overall as high, with variation by subscales: coordination (85%) and patient-family focus (47%). Higher team complexity was associated with lower PTE overall (p=0.049). Challenges were identified: sequential referrals with no integration across team members; no shared mental model among team; and cancer survivor having to "referee" conflicting care decisions. This mixed method study found an inverse relationship between team complexity and PTE-overall, where high-complexity teams had lower team effectiveness. Participants reported issues with the problem-solving abilities of their teams and felt like their contributions were not valued by their care team. Improving team effectiveness offers one way to leverage the expertise of multiple specialties to deliver integrated, patient-centered care for the growing population of cancer survivors with MCC.

CLINICIAN AND STAFF PERSPECTIVES IN TRANSITIONS OF CARE FOR DUAL-USE VETERANS LIVING WITH DEMENTIA

Abstract The Veterans Administration (VA) has partnered with non-VA hospitals to improve access to care. However, older Veterans living with dementia (VLWD) who use both VA and non-VA care may experience gaps in care, placing them at risk of adverse health outcomes during transitions. This research aims to understand the barriers and facilitators in transitions of care for VLWD following non-VA hospitalization. We conducted 23 interviews with VA and non-VA clinicians involved in transitions of care for VLWD. Snowball sampling was used to identify participants, and rapid analysis identified themes. VA Participants faced significant challenges in receiving timely discharge communication from non-VA stakeholders, relying on VLWD, who are poor historians, for information about their non-VA hospitalization. Inadequate staffing for care coordination was also a barrier to timely care, resulting in frustration for VLWD and their families when tests had to be redone due to a lack of appropriate documentation from non-VA hospitals. Both VA and non-VA stakeholders experienced similar care coordination challenges for VLWD, their families, and clinicians. Non-VA stakeholders described the VA as a “black box” due to a lack of communication and collaboration. However, stakeholders expressed a desire to provide quality care, improve care coordination, and give timely care to veterans. These findings highlight the barriers experienced by VA and non-VA stakeholders and provide opportunities for improvement in coordinating care for VLWD. Implementing care coordination programs and improving communication and collaboration between VA and non-VA stakeholders can improve the quality of care for VLWD and their families during transitions.

Abstract WP23: Stroke Survivors Experience During The Covid-19 Pandemic: A Phenomenological Investigation

Background and Purpose: Stroke occurs suddenly and can be a life-changing experience. Nearly 800,000 people in the United States each year suffer a stroke leading to major disability. Support of treatment of acute and follow-up care involves complex, evidence-based interventions to reduce death, stroke recurrence, post stroke disability and risk factors management. In 2019, American Heart Association released a policy guiding implementation of stroke systems of care. However, COVID-19 pandemic lockdowns changed public perceptions of when to seek stroke care. Little is known about care transformation due to pandemic. This study describes stroke survivors lived experience and challenges faced while seeking post-stroke care during pandemic across. Methods and Analysis: A qualitative phenomenological methodology was used to conduct the study. We enrolled 15 participants who had telemedicine follow-up visits and conducted in-depth interviews using study guide. Two independent reviewers used Giorgi descriptive method to search for essence of lived experience of surviving stroke and themes related to follow-up care using telemedicine. Results: Lived experience included variety of reactions due to an acute event such as life uncertainly, confusion and frustration, loneliness and worries. Unexpected challenges of care access and quality due to special COVID protocols and limited or no family support during hospital stay, emerged as additional themes. Themes related to follow-up care included post-stroke care coordination challenges, pros and cons of telemedicine encounters and practical aspects of using technology. Conclusions: Having a stroke during pandemic, created unexpected challenges that transformed post-stroke care. Individual approach was most important in dealing with challenges. Positive changes occurred while using telemedicine except in cases where full medical exam was needed. Patients recommended using hybrid approach for post-pandemic visits (in-person and telemedicine). Knowledge gained from this study can be used in a wider context of limitations imposed by other civilization-related epidemics.

Barriers and Facilitators for Patient-Centered Care for Hospitalized COVID Patients: Lived Experiences from Ex-hospitalized Patients and Health Care Professionals

The COVID pandemic has challenged patient-centeredness, an increasingly valued approach in the pursuit of high-quality care. This research aimed to explore barriers and facilitators for patient-centered care (PCC) in the context of the COVID pandemic. Semi-structured interviews were conducted with seven ex-hospitalized COVID patients and ten health care professionals (HCPs) who have cared for this patient group. A phenomenological design was used with a photo-elicitation method to capture participants’ lived experiences. Findings indicate that COVID entailed multiple and interrelated barriers across all dimensions of PCC. COVID care practices like intubation and isolation also negatively impacted patients’ physical comfort, ability to communicate, and emotional well-being. Despite HCPs’ motivation to improve patients’ well-being, they were hampered by serious barriers, including a lack of time and challenges in care coordination. Due to these difficulties, the question can be raised whether PCC during a communicable disease pandemic is feasible. Nevertheless, as shown in this study, key facilitators such as digital communication tools and a holistic and personal care approach demonstrate that rendering PCC remains vital and should be aimed for and that this could be informed by the lived experiences of HCPs and patients.

A Mixed Methods Analysis of Care Coordination Needs and Desirable Features of an M-Health Application to Support Caregivers of Children With Down Syndrome

Care coordination is critical for the management of health care needs of children with Down syndrome by encompassing management of health information and linking of providers. This study was designed to identify caregiver and health care provider experiences of care coordination to inform the development of an m-health application. In this mixed methods study, caregivers completed survey materials addressing the child's health care needs, m-health use, and care coordination experiences. A sample of caregivers and health care providers were interviewed to further understanding. Most caregivers reported having a primary health care provider but wanted increased communication and help with care coordination. Interview data identified themes related to care coordination challenges, including information management, information sharing, use of health care guidelines, tracking health data, resources, technology use, previous application use, and coordination of schedules. Qualitative themes were linked to desired features of an m-health application to aid in development.

Primary Health Care Experiences of Autistic Adults and Their Caregivers: Utilization, Care Coordination, and Other Challenges as Reported by Caregivers

Abstract Date Presented 03/31/2022 Primary care encounters are reported to be challenging for autistic adults and their caregivers. The purpose of this presentation is to identify challenges experienced by this population, as reported by caregivers, as well as strategies to mitigate these difficulties. Primary Author and Speaker: Leah I. Stein Duker Additional Authors and Speakers: Elizabeth Goodman

Perceptions of cancer care coordination among rural patients in Hawaii.

e18553 Background: Rural residents experience disproportionate burdens of cancer including higher incidence and mortality than urban residents. Disparities in rural cancer health outcomes are partially attributed to limited access to specialty care and care coordination challenges in rural areas. To date, little is known about rural cancer patients’ perceptions of care coordination (CC). In this study, we examined rural patients’ perceptions of cancer CC and compared rural and urban patients’ perceptions of cancer CC using the Care Coordination Instrument (CCI), a validated patient-report measure of CC. Methods: 80 rural patients receiving active treatment for any cancer residing in rural areas of Hawaii (Hawaii Island, Kauai) completed the CCI from Sept. 2020 to Dec. 2021. These rural areas are on separate islands from Oahu (urban) where tertiary care hospitals in Hawaii are located. Data for the urban cohorts ( n = 220) were derived from our archival data. The CCI assesses overall patients’ perceptions of CC (Total) and includes subscales that evaluate CC across three domains (Communication, Navigation, Operational). We used descriptive statistics to describe rural patients’ CC details and linear regression models to compare CCI scores between rural and urban patients. Results: Among 300 patients, demographic and clinical characteristics were similar between the rural and urban cohorts (mean age = 63.6, 56% female, most common cancer type: 28% breast and 25% GI). Patients were racially diverse, with 25% White/Caucasian, 24% Japanese, 16% Native Hawaiian, and 24% two or more race. Among rural patients, 43% indicated having traveled by air to another island (Oahu; urban) for cancer treatment (50% surgery). Of these patients, 38% indicated having paid out-of-pocket for cancer care-related travel costs. 65% of these patients reported travel costs as a burden, with 6% of patients having canceled or delayed treatment due to costs. Overall, there were no differences on the Total CCI scores between rural and urban patients ( p = 0.73). However, significant differences were found for Communication and Navigation ( p = 0.02 and p = 0.04, respectively), with rural patients reporting lower scores on these domains. No differences were found for the Operational domain scores. Conclusions: Our results demonstrate that that while rural patients’ overall perceptions of CC were similar to their urban cohorts, rural patients perceived greater CC challenges related to the communication and navigation aspects of CC. Off-island cancer care-related travel costs were reported as a significant burden for rural patients who must travel to another island for their cancer treatment. These findings highlight the need for interventions to address financial, communication and navigation challenges for rural patients in order to improve the quality of cancer care delivery in rural areas.

"Our Hands Are Tied Until Your Doctor Gets Here": Nursing Perspectives on Inter-hospital Transfers.

BackgroundThe transfer of patients between hospitals (inter-hospital transfer, or IHT) is a common occurrence for patients, but guidelines to ensure safe and effective IHTs are lacking. Poor IHTs result in higher rates of mortality, longer lengths of stay, and higher hospitalization costs compared to admissions from the emergency department. Nurses are often the first point of contact for IHT patients and can provide valuable insights on key challenges to IHT processes.ObjectiveTo characterize the experiences of inpatient floor-level bedside nurses caring for IHT patients and identify care coordination challenges and solutions.Design/Participants/ApproachQualitative study using semi-structured focus groups and interviews conducted from October 2019 to July 2020 with 21 inpatient floor-level nurses caring for adult medicine patients at an academic hospital. Nurses were recruited using a purposive convenience sampling approach. A combined inductive and deductive coding approach guided by thematic analysis was used for data analysis.Key ResultsResults from this study are mapped to the Agency for Healthcare Research and Quality Care Coordination Measurement Framework domains of communication, assessing needs and goals, and negotiating accountability. The following key themes characterize nurses’ experiences with IHT related to these domains: (1) challenges with information exchange and team communication during IHT, (2) environmental and information preparation needed to anticipate transfers, and (3) determining responsibility and care plans after the IHT patient has arrived at the accepting facility.ConclusionsNurses described the absence of standardized processes to coordinate care before or at the time of patient arrival. Challenges to communication and coordination during IHTs negatively impacted patient care and nursing professional satisfaction. To streamline care for IHT patients and reduce nursing stress, future IHT interventions should include standardized handoff reports, timely identification and easy access to admitting clinicians, and timely clinician evaluation and orders.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-07276-5.

Structuring complexity? A systemic perspective on the implementation of a disease management programme for type II diabetes care in Denmark.

Chronic diseases are major causes of death and reduction in the quality of life worldwide, and their prevalence is expected to rise due to changing demographics. Disease management programmes (DMPs) have been presented as a policy response to challenges of care coordination for such chronic diseases. This paper investigates the implementation of DMPs in a National Health Care system in the Nordic region using type II diabetes as an example. DMPs are detailed descriptions of the sequence and responsibilities for diagnostic, treatment, rehabilitation and prevention procedures. The paper applies a systemic implementation perspective to provide detailed analysis of implementation progress, issues and concerns. The implementation analysis shows that the framework of DMP has facilitated the development of new practices and attention to the roles that each of the stakeholders are playing within the service delivery. Many new initiatives contribute to improved coordination and overall management of the Type 2 diabetes (T2DB) population. Yet, there are also several cross-cutting challenges that are affecting the implementation process.

Association between care coordination tasks with non-VA community care and VA PCP burnout: an analysis of a national, cross-sectional survey

BackgroundThe scope of care coordination in VA primary care increased with the launch of the Veterans Choice Act, which aimed to increase access through greater use of non-VA Community Care. These changes may have overburdened already busy providers with additional administrative tasks, contributing to provider burnout. Our objective was to understand the role of challenges with care coordination in burnout. We analyzed relationships between care coordination challenges with Community Care reported by VA primary care providers (PCPs) and VA PCP burnout.MethodsOur cross-sectional survey contained five questions about challenges with care coordination. We assessed whether care coordination challenges were associated with two measures of provider burnout, adjusted for provider and facility characteristics. Models were also adjusted for survey nonresponse and clustered by facility. Trainee and executive respondents were excluded. 1,543 PCPs in 129 VA facilities nationwide responded to our survey (13 % response rate).Results51 % of our sample reported some level of burnout overall, and 46 % reported feeling burned out at least once a week. PCPs were more likely to be burned out overall if they reported more than average challenges with care coordination (odds ratio [OR] 2.04, 95 % confidence interval [CI] 1.58 to 2.63). These challenges include managing patients with outside prescriptions or obtaining outside tests or records.ConclusionsVA primary care providers who reported greater than average care coordination challenges were more likely to be burned out. Interventions to improve care coordination could help improve VA provider experience.

Thematic Analysis of Challenges of Care Coordination for Underinsured and Uninsured Cancer Survivors With Chronic Conditions

Although a majority of underinsured and uninsured patients with cancer have multiple comorbidities, many lack consistent connections with a primary care team to manage chronic conditions during and after cancer treatment. This presents a major challenge to delivering high-quality comprehensive and coordinated care. To describe challenges and opportunities for coordinating care in an integrated safety-net system for patients with both cancer and other chronic conditions. This multimodal qualitative study was conducted from May 2016 to July 2019 at a county-funded, vertically integrated safety-net health system including ambulatory oncology, urgent care, primary care, and specialty care. Participants were 93 health system stakeholders (clinicians, leaders, clinical, and administrative staff) strategically and snowball sampled for semistructured interviews and observation during meetings and daily processes of care. Data collection and analysis were conducted iteratively using a grounded theory approach, followed by systematic thematic analysis to organize data, review, and interpret comprehensive findings. Data were analyzed from March 2019 to March 2020. Multilevel factors associated with experiences of coordinating care for patients with cancer and chronic conditions among oncology and primary care stakeholders. Among interviews and observation of 93 health system stakeholders, system-level factors identified as being associated with care coordination included challenges to accessing primary care, lack of communication between oncology and primary care clinicians, and leadership awareness of care coordination challenges. Clinician-level factors included unclear role delineation and lack of clinician knowledge and preparedness to manage the effects of cancer and chronic conditions. Primary care may play a critical role in delivering coordinated care for patients with cancer and chronic diseases. This study's findings suggest a need for care delivery strategies that bridge oncology and primary care by enhancing communication, better delineating roles and responsibilities across care teams, and improving clinician knowledge and preparedness to care for patients with cancer and chronic conditions. Expanding timely access to primary care is also key, albeit challenging in resource-limited safety-net settings.

Abstract 112: Use of WhatsApp to Improve Medical Provider Communication for Children with Wilms Tumor in Tanzania

Abstract Purpose: Due to the rapid expansion of mobile phone usage throughout the world, mobile health (mHealth) technologies offer an innovative strategy to overcome challenges of care coordination and limited communication between pediatric cancer providers in LMICs. Our objective was to evaluate the use of the social media application WhatsApp to improve provider communication and outcomes for children diagnosed with Wilms tumor at a regional cancer treatment facility in Tanzania. Methods: A WhatsApp provider group was established in 2016 to facilitate communication between surgical, medical and psychosocial support providers at the regional cancer referral hospital in northern Tanzania. All messages exchanged from 2016-2019 were extracted and coded for thematic content. Treatment compliance and process outcomes were compared for patients discussed versus those that were not over the 4-year period. Results: A total of 669 messages for 55 patients were reviewed. Most messages were sent by the pediatric oncologist (44.8%, n=273) and urology resident (43.2%, n=263). Using the application to coordinate patient care reduced time to surgery from 90 days [IQR 65-109] to 60 days [IQR 47-80], and time to post-operative chemotherapy initiation from 46 days [IQR 39-55] to 19 days [IQR 16-30]. Rate of treatment abandonment was decreased for patients discussed in the chat group (26.7%) compared to those not discussed (38.2%). Conclusion: To our knowledge this is the first study to assess the use of WhatsApp to improve provider communication for children with cancer in LMICs. As access to smartphone technology and internet access improves, applications like WhatsApp can be used as a low-cost strategy to target health system inefficiencies and improve outcomes for children with cancer globally. Citation Format: John Igenge, Jacob Stocks, Gloria Zhang, Mocha George, Frank Kiwara, Judy Mafwimbo, Mastidia Maxmilian, Austin Wesevich, Kristin Schroeder. Use of WhatsApp to Improve Medical Provider Communication for Children with Wilms Tumor in Tanzania [abstract]. In: Proceedings of the 9th Annual Symposium on Global Cancer Research; Global Cancer Research and Control: Looking Back and Charting a Path Forward; 2021 Mar 10-11. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2021;30(7 Suppl):Abstract nr 112.

Possible Effects on VA Outpatient Care of Expanding Medicaid: Implications of Having Access to Overlapping Publicly Funded Health Care Services.

Because veterans who use Veterans Health Administration (VA) health care retain VA eligibility while enrolling in Medicaid, increasing Medicaid eligibility may create improved health system access but also create unique challenges for the quality and coordination of health care for veterans. We analyze how pre-Affordable Care Act (ACA) state Medicaid expansions influence VA and Medicaid-funded outpatient care utilization. This study uses Difference-in-difference analysis to evaluate association between pre-ACA 2001 Medicaid expansions and VA utilization in a natural experiment. Veterans aged 18-64 years living in a study state during the study period were the participants. Dependent variables included participants' proportion of outpatient care received at the VA, whether a participant recorded care with both Medicaid and the VA, and total outpatient utilization. We analyzed changes between two states that expanded Medicaid in 2001 against three similar states that did not from 1999 to 2006. We adjusted for age, non-White race, gender, disease burden, and distance to VA facilities. This study was approved by the Baylor College of Medicine Institutional Review Board (IRB), protocol number H-40441. In total, 346,364 VA-enrolled veterans lived in the five study states during the time of our study, 70,987 of whom were enrolled in Medicaid for at least 1 month. For low-income veterans, Medicaid expansion was associated with a 2.88 percentage-point decline in the VA proportion of outpatient services (99% CI -3.26 to -2.49), and a 2.07-point increase (1.80 to 2.35) in the percentage of patients using both VA and Medicaid services. Results also showed small increases in total (VA plus Medicaid) annual per-capita outpatient visits among low-income veterans. We estimate that this corresponds to an annual reduction of 80,338 VA visits across study states (66,155-94,521). This study shows usage shifts when Medicaid expansion allows veterans to gain access to non-VA care. It highlights increased potential for care-coordination challenges among VA patients as states implement ACA Medicaid expansion and policymakers consider additional public health insurance options, as well as programs like CHOICE and the MISSION Act that increase veteran choices of traditional VA and community care providers.

Perceptions of Care Coordination Among Homeless Veterans Receiving Medical Care in the Veterans Health Administration and Community Care Settings: Results From a National Survey.

Initiatives to expand Veterans' access to purchased health care outside Veterans Health Administration (VHA) facilities ("community care") present care coordination challenges for Veterans experiencing homelessness. Among Veterans with homeless experiences, to evaluate community care use and satisfaction, and compare perceptions of care coordination among Veterans using VHA services and community care to those using VHA services without community care. Cross-sectional analysis of responses to a 2018 mailed survey. VHA outpatients with homeless experiences. Self-reported use of community care, Likert-style ratings of satisfaction with that care, and Access/Coordination experiences from the Primary Care Quality-Homeless (PCQ-H) survey. Of 4777 respondents, 1325 (26.7%) reported using community care; most of this subsample affirmed satisfaction with the community care they received (83%) and its timeliness (75%). After covariate adjustment, Veteran characteristics associated with greater community care use included female sex, being of retirement age and nonmarried, and having higher education, more financial hardship, ≥3 chronic conditions, psychological distress, depression, and posttraumatic stress disorder. Satisfaction with community care was lower among patients with travel barriers, psychological distress, and less social support. Compared with those using the VHA without community care, Veterans using VHA services and community care were more likely to report unfavorable access/coordination experiences [odds ratio (OR)=1.34, confidence interval (CI)=1.15-1.57]. This included hassles following referral (OR=1.37, CI=1.14-1.65) and perceived delays in receiving health care (OR=1.38, CI=1.19-1.61). Veterans with homeless experiences value community care options. Potential access benefits are balanced with risks of unfavorable coordination experiences for vulnerable Veterans with limited resources.