Patient Safety Indicators at an Academic Veterans Affairs Hospital: Addressing Dual Goals of Clinical Care and Validity.

BACKGROUND: Hospital-acquired complications add to patient morbidity and mortality, costs, length of stay, and negative patient experience. Patient Safety Indicators (PSIs) are a validated and widely used metric to evaluate hospital administrative data on preventing these events. Although many studies have addressed PSI validity, few have aimed to reduce PSI through clinical care. The authors aimed to reduce PSI events by addressing both validity and clinical care. METHODS: Frontline clinicians used a deep dive template to provide input on all PSI cases, which were then reviewed by a PSI task force to identify performance gaps. After analyzing the frequency of gaps and cost-vs.-impact of potential solutions, five interventions were implemented to address the three most common, highly weighted PSIs: pressure ulcers, postoperative venous thromboembolism (VTE), and postoperative sepsis. Clinical care interventions included increasing patient mobility by creating a specialized mobility technician position, skin care audits to prevent pressure ulcers, and increasing use of pharmacologic VTE prophylaxis. Administrative interventions addressed improving clinician-coding concordance for sepsis and increasing documentation of comorbidities. RESULTS: After interventions, the number of PSI events for composite PSI, VTE, and sepsis decreased by 41.3% (p = 0.039), 85.2% (p = 0.0091), and 51.5% (p = 0.063), respectively, relative to the preintervention period. Pressure ulcers increased by 33.3% (p = 0.0091). CONCLUSION: Hospital complications cause substantial burden to hospitals, patients, and caregivers. Addressing administrative and clinical factors with targeted interventions led to reduction in composite PSI. Further efforts are needed locally to reduce the pressure ulcer PSI.

Why Veterans Choose VA Versus non-VA Emergency Care: A Qualitative Study.

INTRODUCTION: In ensuring the timely delivery of emergency care to Veterans, Veterans Affairs (VA) offers both emergency care services in its own facilities and, increasingly, purchases care for Veterans in non-VA (community) emergency department (ED) settings. Although in recent years emergency care coverage has become the single largest contributor to VA community care spending, no study to date has examined Veteran decision-making as it relates to ED setting choice. The purpose of this study is to identify and describe reasons why Veterans choose VA versus non-VA emergency care settings. MATERIALS AND METHODS: Veterans Health Administration data were used to identify geographically diverse Veterans who recently used emergency care. We conducted semi-structured telephone interviews from December 2018 through March 2020 with 50 Veterans to understand the factors Veterans consider when deciding where to obtain ED care. Interviews were audio-recorded and transcribed verbatim. We conducted a directed content analysis of interview transcripts and developed a matrix to summarize and categorize each Veteran's decision-making process to compare participants and to identify common patterns. RESULTS: When choosing between VA and non-VA-EDs, Veterans described 3 distinct patterns of decision-making: (1) choosing the closest ED (often community) for acute conditions; (2) traveling farther for VA care due to preference and financial coverage; and (3) selecting VA when both types of ED care were equidistant. Perceptions of community resources, condition-specific needs, financial considerations, and personal preferences dominated the decision-making. For example, most Veterans (74%) rated their acuity as high, and self-perceived severity/urgency of their condition was the most cited factor influencing where Veterans decided to go for ED care. CONCLUSIONS: Our qualitative results help provide insight into how and why Veterans choose to seek emergency care. As the number of Veterans treated in non-VA EDs continues to rise, VA and non-VA ED providers as well as policy makers may benefit from understanding the challenges Veterans face when making this decision.

What Should Healthcare Systems Consider When Modernizing Call Centers? Early Considerations From the Veterans Health Administration.

GOAL: Growing numbers of hospitals and payers are using call centers to answer patients' clinical and administrative questions, schedule appointments, address billing issues, and offer supplementary care during public health emergencies and national disasters. In 2020, the Veterans Health Administration (VA) implemented VA Health Connect, an enterprise-wide initiative to modernize call centers. VA Health Connect is designed to improve the care experience with the convenience, flexibility, and simplicity of a single toll-free number connected to a range of 24/7 virtual services. The services are organized into four areas: administrative guidance for scheduling and general inquiries; pharmacy support for medication matters; clinical triage for evaluation of symptoms and recommended care; and virtual visits with providers for urgent and episodic care. Through a qualitative evaluation of VA Health Connect, we sought to identify the factors that affected the development of this program and to compile considerations to support the implementation of other enterprise-wide initiatives. METHODS: The evaluation team interviewed 29 clinical and administrative leads from across the VA. These leads were responsible for the modernization of their local service networks. PhD-level qualitative methodologists conducted the interviews, asking participants to reflect on barriers and facilitators to modernization and implementation. The team employed a rapid qualitative analytic approach commonly used in healthcare research to distill robust results. PRINCIPAL FINDINGS: A review of the early implementation of VA Health Connect found: (1) deadlines proved challenging but provided momentum for the initiative; (2) a balance between standardized processes and local adaptations facilitated implementation; (3) attention to staffing, hiring, and training of call center staff before implementation expedited workflows; (4) establishing national and local leadership commitment to the innovation from the onset increased team cohesion and efficacy; and (5) anticipating information technology infrastructure needs prevented delays to modernization and implementation. PRACTICAL APPLICATIONS: Our findings suggest that healthcare systems would benefit from anticipating likely obstacles (e.g., delays in software implementations and negotiations with unions), thus providing ample time to secure leadership buy-in and identify local champions, communicating early and often, and supporting flexible implementation to meet local needs. VA leadership can use this evaluation to refine implementation, and it could also have important implications for regulators, federal health exchanges, insurers, and other healthcare systems when determining resource levels for call centers.

Emergency Department Use Among Combat and Non-Combat Post-9/11 Military Veterans.

INTRODUCTION: Most post-9/11 Veterans have completed at least 1 combat deployment-a known factor associated with adverse health outcomes. Such Veterans are known to have unmet health care needs, and the emergency department (ED) may serve as a safety net, yet little is known about whether combat status is associated with more frequent ED use. We sought to evaluate the relationship between combat status and frequency of ED use among post-9/11 Veterans and assess the most common reasons for ED visits. MATERIALS AND METHODS: This retrospective cohort study consisted of post-9/11 Veterans who enrolled in U.S. Department of Veterans Affairs (VA) care between fiscal years (FYs) 2005 and 2015. Data were obtained from the VA Corporate Data Warehouse. Incidence rates for ED visits for combat and non-combat Veterans were compared from FY 2010 to 2019 using zero-inflated negative binomial regression. The most frequent reasons for ED visits were determined using International Classification of Diseases codes. This study was approved by the Stanford Institutional Review Board. RESULTS: Among 1.3 million Veterans included in analyses, 70.4% had deployed to a combat zone. The mean (SD) age of our cohort was 32.6 (5.0) years and 83.5% of Veterans were male. After controlling for other factors, combat Veterans had 1.84 times the rate of ED visits compared to non-combat Veterans (95% CI, 1.83-1.85). Only combat Veterans had a mental health-related ED visit (suicidal ideations) among the top 3 reasons for ED presentation. CONCLUSIONS: Those who deployed to a combat zone had a significantly higher rate of ED use compared to those who did not. Further, mental health-related ED diagnoses appeared to be more prevalent in combat Veterans. These findings highlight the unique health care needs faced by combat Veterans and emphasize the importance of tailored interventions and support services for this specific population.

Community Emergency Care Use by Veterans in an Era of Expanding Choice.

Importance: Recently passed legislation aimed at improving access to care has considerably expanded options for veterans to receive emergency care in community, or non-Veterans Affairs (VA) settings. However, national trends in community emergency department (ED) use by veterans are unknown. Objective: To examine national, temporal trends in the frequencies and types of ED visits provided in community settings and explore the association between facilities' purchase of community care with facility and regional characteristics. Design, Setting, and Participants: Retrospective, observational cross-sectional study of ED visits over fiscal years (FY) 2016 to 2022. VA and community ED encounter data were obtained from the VA Corporate Data Warehouse and the Office of Integrated Veteran Care. Participants were veterans receiving ED care at VA facilities or paid for by the VA in the community. Data were analyzed from June to September 2023. Main Outcomes and Measures: The primary outcome measures included community ED visit volume, disposition, and payments over time. Also, the most common and costly ED visits were assessed. Negative binomial regression analysis examined associations between facility and regional characteristics and the rate of ED visits purchased in community settings relative to all ED visits. Results: There were 19 787 056 ED visits, predominantly at VA facilities (14 532 261 visits [73.4%]), made by 3 972 503 unique veterans from FY 2016 to 2022. The majority of ED users were male (3 576 120 individuals [90.0%]), and the median (IQR) age was 63 (48-73) years. The proportion of community ED visits increased in absolute terms from 18% in FY 2016 to 37% in FY 2022. Total community ED payments, adjusted to 2021 dollars, were $1.18 billion in FY 2016 and over $6.14 billion in FY 2022. The most common reasons for ED visits in the community were for nonspecific chest pain (305 082 visits [6%]), abdominal pain (174 836 visits [3%]), and septicemia (149 968 visits [3%]). The average proportion of ED visits purchased by a VA facility increased from 14% in FY 2016 to 32% by FY 2022. In multivariable analyses, facilities with greater ED volume and low-complexity facilities had higher expected rates of community emergency care than lower volume and high-complexity facilities, respectively. Conclusions and Relevance: As veterans increasingly use community EDs for acute, unscheduled needs, attention to factors associated with veterans' use of acute care services in different settings are important to identify access barriers and to ensure veterans' health care needs are met.

Hypertension Control During the Coronavirus Disease 2019 Pandemic: A Cohort Study Among US Veterans.

DESIGN: Retrospective cohort study. OBJECTIVE: We sought to examine whether disruptions in follow-up intervals contributed to hypertension control. BACKGROUND: Disruptions in health care were widespread during the coronavirus disease 2019 pandemic. PATIENTS AND METHODS: We identified a cohort of individuals with hypertension in both prepandemic (March 2019-February 2020) and pandemic periods (March 2020-February 2022) in the Veterans Health Administration. First, we calculated follow-up intervals between the last prepandemic and first pandemic blood pressure measurement during a primary care clinic visit, and between measurements in the prepandemic period. Next, we estimated the association between the maintenance of (or achieving) hypertension control and the period using generalized estimating equations. We assessed associations between follow-up interval and control separately for periods. Finally, we evaluated the interaction between period and follow-up length. RESULTS: A total of 1,648,424 individuals met the study inclusion criteria. Among individuals with controlled hypertension, the likelihood of maintaining control was lower during the pandemic versus the prepandemic (relative risk: 0.93; 95% CI: 0.93, 0.93). Longer follow-up intervals were associated with a decreasing likelihood of maintaining controlled hypertension in both periods. Accounting for follow-up intervals, the likelihood of maintaining control was 2% lower during the pandemic versus the prepandemic. For uncontrolled hypertension, the likelihood of gaining control was modestly higher during the pandemic versus the prepandemic (relative risk: 1.01; 95% CI: 1.01, 1.01). The likelihood of gaining control decreased with follow-up length during the prepandemic but not pandemic. CONCLUSIONS: During the pandemic, longer follow-up between measurements contributed to the lower likelihood of maintaining control. Those with uncontrolled hypertension were modestly more likely to gain control in the pandemic.

Access to and accessibility of care for rural Veterans with disabilities: A qualitative evaluation of VA healthcare experiences.

BACKGROUND: Persons with disabilities experience significant physical, attitudinal, and communication-based barriers to accessing care. These challenges are exacerbated for rural-dwelling persons with disabilities. Although US Veterans experience disabilities at a higher rate than non-Veterans and are also more likely to dwell in rural locations, research examining the accessibility of VA care for rural Veterans with disabilities is limited. OBJECTIVES: With a focus on access and accessibility, we sought to explore the experiences of rural Veterans with disabilities who receive care at VA. METHODS: We conducted 30 qualitative interviews with rural-dwelling Veterans who experience at least one of three types of disabilities: hearing loss, vision loss, and mobility loss. Using a descriptive qualitative approach, we focused on creating a taxonomy of potential access barriers experienced among this population. RESULTS: Participants reported experiencing access barriers in five main areas, including policies and operational processes at VA clinics; navigating VA campuses and clinics; limited transportation and parking options; communicating with healthcare personnel and occasional negative interactions; and challenges due to pandemic-related changes in policies and procedures. CONCLUSION: These findings suggest that Veterans with disabilities may experience a host of challenges and access barriers while navigating the VA Healthcare system. While these challenges have been reported among individuals with disabilities receiving care in other healthcare settings, they have not been assessed in VA specifically. Given its focus on caring for Veterans with service-aggravated conditions and its commitment to equity and inclusion, addressing access barriers among Veterans with disabilities should be a high priority for VA.

Excess mortality in US Veterans during the COVID-19 pandemic: an individual-level cohort study.

BACKGROUND: Most analyses of excess mortality during the COVID-19 pandemic have employed aggregate data. Individual-level data from the largest integrated healthcare system in the US may enhance understanding of excess mortality. METHODS: We performed an observational cohort study following patients receiving care from the Department of Veterans Affairs (VA) between 1 March 2018 and 28 February 2022. We estimated excess mortality on an absolute scale (i.e. excess mortality rates, number of excess deaths) and a relative scale by measuring the hazard ratio (HR) for mortality comparing pandemic and pre-pandemic periods, overall and within demographic and clinical subgroups. Comorbidity burden and frailty were measured using the Charlson Comorbidity Index and Veterans Aging Cohort Study Index, respectively. RESULTS: Of 5 905 747 patients, the median age was 65.8 years and 91% were men. Overall, the excess mortality rate was 10.0 deaths/1000 person-years (PY), with a total of 103 164 excess deaths and pandemic HR of 1.25 (95% CI 1.25-1.26). Excess mortality rates were highest among the most frail patients (52.0/1000 PY) and those with the highest comorbidity burden (16.3/1000 PY). However, the largest relative mortality increases were observed among the least frail (HR 1.31, 95% CI 1.30-1.32) and those with the lowest comorbidity burden (HR 1.44, 95% CI 1.43-1.46). CONCLUSIONS: Individual-level data offered crucial clinical and operational insights into US excess mortality patterns during the COVID-19 pandemic. Notable differences emerged among clinical risk groups, emphasizing the need for reporting excess mortality in both absolute and relative terms to inform resource allocation in future outbreaks.

Absolute and relative excess mortality across demographic and clinical subgroups during the COVID-19 pandemic: an individual-level cohort study from a nationwide healthcare system of US Veterans.

Background: Most analyses of excess mortality during the COVID-19 pandemic have employed aggregate data. Individual-level data from the largest integrated healthcare system in the US may enhance understanding of excess mortality. Methods: We performed an observational cohort study following patients receiving care from the Department of Veterans Affairs (VA) between 1 March 2018 and 28 February 2022. We estimated excess mortality on an absolute scale (i.e., excess mortality rates, number of excess deaths), and a relative scale by measuring the hazard ratio (HR) for mortality comparing pandemic and pre-pandemic periods, overall, and within demographic and clinical subgroups. Comorbidity burden and frailty were measured using the Charlson Comorbidity Index and Veterans Aging Cohort Study Index, respectively. Results: Of 5,905,747 patients, median age was 65.8 years and 91% were men. Overall, the excess mortality rate was 10.0 deaths/1000 person-years (PY), with a total of 103,164 excess deaths and pandemic HR of 1.25 (95% CI 1.25-1.26). Excess mortality rates were highest among the most frail patients (52.0/1000 PY) and those with the highest comorbidity burden (16.3/1000 PY). However, the largest relative mortality increases were observed among the least frail (HR 1.31, 95% CI 1.30-1.32) and those with the lowest comorbidity burden (HR 1.44, 95% CI 1.43-1.46). Conclusions: Individual-level data offered crucial clinical and operational insights into US excess mortality patterns during the COVID-19 pandemic. Notable differences emerged among clinical risk groups, emphasising the need for reporting excess mortality in both absolute and relative terms to inform resource allocation in future outbreaks.

Excess Mortality Among Patients in the Veterans Affairs Health System Compared With the Overall US Population During the First Year of the COVID-19 Pandemic.

Importance: During the first year of the COVID-19 pandemic, there was a substantial increase in the rate of death in the United States. It is unclear whether those who had access to comprehensive medical care through the Department of Veterans Affairs (VA) health care system had different death rates compared with the overall US population. Objective: To quantify and compare the increase in death rates during the first year of the COVID-19 pandemic between individuals who received comprehensive medical care through the VA health care system and those in the general US population. Design, Setting, and Participants: This cohort study compared 10.9 million enrollees in the VA, including 6.8 million active users of VA health care (those with a visit in the last 2 years), with the general population of the US, with deaths occurring from January 1, 2014, to December 31, 2020. Statistical analysis was conducted from May 17, 2021, to March 15, 2023. Main Outcomes and Measures: Changes in rates of death from any cause during the COVID-19 pandemic in 2020 compared with previous years. Changes in all-cause death rates by quarter were stratified by age, sex, race and ethnicity, and region, based on individual-level data. Multilevel regression models were fit in a bayesian setting. Standardized rates were used for comparison between populations. Results: There were 10.9 million enrollees in the VA health care system and 6.8 million active users. The demographic characteristics of the VA populations were predominantly male (>85% in the VA health care system vs 49% in the general US population), older (mean [SD], 61.0 [18.2] years in the VA health care system vs 39.0 [23.1] years in the US population), and had a larger proportion of patients who were White (73% in the VA health care system vs 61% in the US population) or Black (17% in the VA health care system vs 13% in the US population). Increases in death rates were apparent across all of the adult age groups (≥25 years) in both the VA populations and the general US population. Across all of 2020, the relative increase in death rates compared with expected values was similar for VA enrollees (risk ratio [RR], 1.20 [95% CI, 1.14-1.29]), VA active users (RR, 1.19 [95% CI, 1.14-1.26]), and the general US population (RR, 1.20 [95% CI, 1.17-1.22]). Because the prepandemic standardized mortality rates were higher in the VA populations prior to the pandemic, the absolute rates of excess mortality were higher in the VA populations. Conclusions and Relevance: In this cohort study, a comparison of excess deaths between populations suggests that active users of the VA health system had similar relative increases in mortality compared with the general US population during the first 10 months of the COVID-19 pandemic.

Payer shifting after expansions in access to private care among veterans.

OBJECTIVE: To investigate whether expanded access to Veterans Affairs (VA)-purchased care increased overall utilization or induced a shift from other payers to VA for emergency care among VA enrollees. DATA SOURCES AND STUDY SETTING: This study included all emergency department (ED) encounters in 2019 from hospitals in the state of New York. STUDY DESIGN: We conducted a difference-in-differences analysis comparing VA enrollees to the general population before and after the implementation of the Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act in June 2019. DATA COLLECTION/EXTRACTION METHODS: We included all ED visits with individuals aged 30 or older at the time of the encounter. Individuals were considered eligible for the policy change if they were enrolled with VA at the beginning of 2019. PRINCIPAL FINDINGS: Of the 5,577,199 ED visits in the sample, 4.9% (n = 253,799) were made by VA enrollees. Of these, 44.9% of visits were paid by Medicare, 32.8% occurred in VA facilities, and 7% were paid by private health insurance. There was a 6.4% (2.91 percentage points; std. error = 0.18; p < 0.01) decrease in the proportion of ED visits paid by Medicare among VA enrollees relative to the general population after the implementation of the MISSION Act in June 2019. This decrease was larger for ED visits with a subsequent inpatient admission (-8.4%; 4.87 percentage points; std. error = 0.33; p < 0.01). There was no statistically significant change in the total volume of ED visits (0.06%; std. error = 0.08; p = 0.45). CONCLUSIONS: Leveraging a novel dataset, we demonstrate that MISSION Act implementation coincided with a shift in the financing of non-VA ED visits from Medicare to VA without any increase in overall ED utilization. These findings have important implications for VA health care financing and delivery.

Research and policy recommendations from the SOTA XVI: State of the Art Conference on VA Emergency Medicine.

To better understand and prioritize research on emergency care for Veterans, the Department of Veteran Affairs (VA) Health Services Research and Development convened the 16th State of the Art Conference on VA Emergency Medicine (SAVE) in Winter 2022 with emergency clinicians, researchers, operational leaders, and additional stakeholders in attendance. Three specific areas of focus were identified including older Veterans, Veterans with mental health needs, and emergency care in the community (non-VA) settings. Among older Veterans, identified priorities included examination of variation in care and its impact on patient outcomes, utilization, and costs; quality of emergency department (ED) care transitions and strategies to improve them; impact of geriatric ED care improvement initiatives; and use of geriatric assessment tools in the ED. For Veterans with mental health needs, priorities included enhancing the reach of effective, multicomponent suicide prevention interventions; development and evaluation of interventions to manage substance use disorders; and identifying and examining safety and effective acute psychosis practices. Community (non-VA) emergency care priorities included examining changes in patterns of use and costs in VA and the community care settings as a result of recent policy and coverage changes (with an emphasis on modifiable factors); understanding quality, safety, and Veteran experience differences between VA and community settings; and better understanding follow-up needs among Veterans who received emergency care (or urgent care) and how well those needs are being coordinated, communicated, and met. Beyond these three groups, cross-cutting themes included the use of telehealth and implementation science to refine multicomponent interventions, care coordination, and data needs from both VA and non-VA sources. Findings from this conference will be disseminated through multiple mechanisms and contribute to future funding applications focused on improving Veteran health.

Emergency department utilization and presenting chief complaints by Veterans living with dementia.

OBJECTIVES: Veteran persons living with dementia (PLWDs) have high acute care utilization. We aim to understand why PLWDs seek care in the emergency department (ED) and how their utilization differs from older Veterans with no dementia diagnosis. We demonstrate the use of a novel national chief complaint data set in the Veteran Affairs Health Care System. METHODS: This was a retrospective observational study of ED users 65 years or older as of FY2017. The primary outcome is presence of one or more ED visits in FYs 2017-2018 using a logistic regression model controlling for dementia and other variables. Secondary outcomes include counts of ED visits by disposition, Emergency Severity Index, chief complaints defined by a natural language processing program, and ED encounter diagnoses defined by primary International Statistical Classification of Diseases, Tenth Revision (ICD-10-CM) code. RESULTS: Our cohort of Veterans comprised 3,115,263 patients. Of those, 255,372 (8.2%) had a diagnosis of dementia. Logistic regression modeling demonstrated that dementia is a significant predictor of ED use (p < 0.0001), with PLWDs more likely to have an ED visit (odds ratio 1.96, 95% confidence interval 1.94-1.98). PLWDs were admitted at higher rates when accounting for age and acuity. Chief complaints that were more common among PLWDs included falls (6.7% dementia vs. 3.3% without dementia), weakness (3.6% vs. 2.2%), and abnormal mental state (2.2% vs. 0.4%). ICD-10-CM codes were largely similar between the two groups. CONCLUSIONS: Our results reinforce that the ED is a common access point for Veterans with dementia. These patients require special consideration as they are more likely to visit the ED and be admitted. Our use of a novel national chief complaint data set suggests that they more commonly present with certain geriatric syndromes and nonspecific complaints. Further work is needed to determine whether these would warrant targeted interventions to improve quality of acute care.

Hospital-level variation in risk-standardized admission rates for emergency care-sensitive conditions among older and younger Veterans.

OBJECTIVES: Research examining emergency department (ED) admission practices within the Department of Veterans Affairs (VA) is limited. This study investigates facility-level variation in risk-standardized admission rates (RSARs) for emergency care-sensitive conditions (ECSCs) among older (≥65 years) and younger (<65 years) Veterans across VA EDs. METHODS: Veterans presenting to a VA ED for an ECSC between October 1, 2016 and September 30, 2019 were identified and the 10 most common ECSCs established. ECSC-specific RSARs were calculated using hierarchical generalized linear models, adjusting for Veteran and encounter characteristics. The interquartile range ratio (IQR ratio) and coefficient of variation were measures of dispersion for each condition and were stratified by age group. Associations with facility characteristics were also examined in condition-specific multivariable models. RESULTS: The overall cohort included 651,336 ED visits across 110 VA facilities for the 10 most common ECSCs-chronic obstructive pulmonary disease (COPD), heart failure, pneumonia, volume depletion, tachyarrhythmias, acute diabetes mellitus, gastrointestinal (GI) bleeding, asthma, sepsis, and myocardial infarction (MI). After adjusting for case mix, the ECSCs with the greatest variation (IQR ratio, coefficient of variation) in RSARs were asthma (1.43, 32.12), COPD (1.39, 24.64), volume depletion (1.38, 23.67), and acute diabetes mellitus (1.28, 17.52), whereas those with the least variation were MI (1.01, 0.87) and sepsis (1.02, 2.41). Condition-specific RSARs were not qualitatively different between age subgroups. Association with facility characteristics varied across ECSCs and within condition-specific age subgroups. CONCLUSIONS: We identified unexplained facility-level variation in RSARs for Veterans presenting with the 10 most common ECSCs to VA EDs. The magnitude of variation did not appear to be qualitatively different between older and younger Veteran subgroups. Variation in RSARs for ECSCs may be an important target for systems-based levers to improve value in VA emergency care.

Veterans' Experiences With Accessing Community Emergency Care.

INTRODUCTION: Under current regulations, there are three separate authorities for which the Veterans Health Administration (VHA) can pay for emergency medical care received by Veterans in the community. The three VHA authorities have overlapping criteria and eligibility requirements that contribute to a complex and confusing landscape for Veterans when they obtain emergency care in the community. Given the intricacies in how VHA provides coverage for community emergency care and the desire to provide seamless Veteran-centric care, it is imperative to understand Veterans' experiences with navigating coverage for community emergency care. The purpose of this study was to elicit feedback from Veterans about their experiences with and perceptions of community emergency care coverage paid for by VHA. MATERIALS AND METHODS: Veterans Health Administration data were used to identify geographically diverse Veterans who recently used emergency care. We conducted semi-structured, qualitative interviews with 50 Veterans to understand their VHA coverage and experiences with accessing community emergency care. Interviews were audio recorded and transcribed verbatim. We conducted directed content analysis of interview transcripts. RESULTS: Veterans emphasized three major concerns with navigating community emergency care: (1) they lack information about benefits and eligibility when they need it most, (2) they require assistance with medical billing to avoid financial hardship and future delays in care, and (3) they desire multimodal communication about VHA policies or updates in emergency coverage. CONCLUSIONS: Our results highlight the challenges Veterans experience in understanding VHA coverage for community emergency care. Feedback suggests that improving information, support, and communication may help Veterans make timely, informed decisions when experiencing unexpected illness or injury.

Engaging Patients in the Veterans Health Administration's Lean Enterprise Transformation: A Qualitative Study.

BACKGROUND AND OBJECTIVES: Lean management is a strategy for improving health care experiences of patients. While best practices for engaging patients in quality improvement have solidified in recent years, few reports specifically address patient engagement in Lean activities. This study examines the benefits and challenges of incorporating patient engagement strategies into the Veterans Health Administration's (VA) Lean transformation. METHODS: We conducted a multisite, mixed-methods evaluation of Lean deployment at 10 VA medical facilities, including 227 semistructured interviews with stakeholders, including patients. RESULTS: Interviewees noted that a patient-engaged Lean approach is mutually beneficial to patients and health care employees. Benefits included understanding the veteran's point of view, uncovering inefficient aspects of care processes, improved employee participation in Lean events, increased transparency, and improved reputation for the organization. Challenges included a need for focused time and resources to optimize veteran participation, difficulty recruiting a diverse group of veteran stakeholders, and a lack of specific instructions to encourage meaningful participation of veterans. CONCLUSIONS/IMPLICATIONS: As the first study to focus on patient engagement in Lean transformation efforts at the VA, this study highlights ways to effectively partner with patients in Lean-based improvement efforts. Lessons learned may also help optimize patient input into quality improvement more generally.

Achieving transformation to lean management systems in health care.

OBJECTIVE: To understand what factors and organizational dynamics enable Lean transformation of health care organizations. DATA SOURCES: Primary data were collected through two waves of interviews in 2016-2017 with leaders and staff at seven veterans affairs medical centers participating in Lean enterprise transformation. STUDY DESIGN: Using an observational study design, for each site we coded and rated seven potential enablers of transformation. The outcome measure was the extent of Lean transformation, constructed by coding and rating 11 markers of depth and spread of transformation. Using multivalue coincidence analysis (CNA), we identified enablers that distinguished among sites having different levels of transformation. We identified representative quotes for the enablers. DATA COLLECTION METHODS: We interviewed 121 executive leaders, middle managers, expert consultants, systems redesign staff, frontline supervisors, and staff. PRINCIPAL FINDINGS: Two sites achieved high Lean transformation, three medium, and two low. Together leadership support and capability development were sufficient for the three-level Lean transformation outcomes with 100% consistency and 100% coverage. High scores on both corresponded to high Lean transformation; medium on either one corresponded to medium transformation; and low on both corresponded to low transformation. Additionally, low scores in communication and availability of data and very low scores in alignment characterized low-transformation sites. Sites with high leadership support also had a high veteran engagement. CONCLUSIONS: This multisite study develops a novel measure of the extent of organization-wide Lean transformation and uses CNA to identify enablers linked to transformation. It provides insights into why and how some organizations are more successful at transformation than others. Findings support the applicability of the organization transformation model that guided the study and highlight the roles of executive leadership and capability development in the dynamics of transformation.

Medical advice lines offering on-demand access to providers reduced emergency department visits.

Instant access to clinicians through virtual care is designed to allow patients to receive care they need while avoiding high-cost visits in acute-care settings. This study investigates the effect of offering patients the option to instantly connect with emergency care providers instead of being referred to the emergency department (ED) following calls to a medical advice line. We used a staggered rollout design to assess the effects of implementing this program on key outcomes among Veterans Affairs enrollees. Analyzing over 1 million calls from 2019 to 2022, we found that access to a provider reduced the proportion of patients who subsequently visited the ED compared with those with access to the standard medical advice line (38% vs 36%). There was no significant difference observed in subsequent inpatient admissions or 30-day mortality. We found that a majority of callers (65%) achieved issue resolution or were directed to lower acuity settings for further evaluation. Although substantial direct cost savings were not evident, our findings demonstrate that on-demand access to a virtual provider can effectively decrease ED visits.

Veterans' Use of Telehealth for Veterans Health Administration Community Care Urgent Care During the Early COVID-19 Pandemic.

BACKGROUND: Since the onset of the COVID-19 pandemic, telehealth has been an option for Veterans receiving urgent care through Veterans Health Administration Community Care (CC). OBJECTIVE: We assessed use, arrangements, Veteran decision-making, and experiences with CC urgent care delivered via telehealth. DESIGN: Convergent parallel mixed methods, combining multivariable regression analyses of claims data with semistructured Veteran interviews. SUBJECTS: Veterans residing in the Western United States and Hawaii, with CC urgent care claims March 1 to September 30, 2020. KEY RESULTS: In comparison to having in-person only visits, having a telehealth-only visit was more likely for Veterans who were non-Hispanic Black, were urban-dwelling, lived further from the clinic used, had a COVID-related visit, and did not require an in-person procedure. Predictors of having both telehealth and in-person (compared with in-person only) visits were other (non-White, non-Black) non-Hispanic race/ethnicity, urban-dwelling status, living further from the clinic used, and having had a COVID-related visit. Care arrangements varied widely; telephone-only care was common. Veteran decisions about using telehealth were driven by limitations in in-person care availability and COVID-related concerns. Veterans receiving care via telehealth generally reported high satisfaction. CONCLUSIONS: CC urgent care via telehealth played an important role in providing Veterans with care access early in the COVID-19 pandemic. Use of telehealth differed by Veteran characteristics; lack of in-person care availability was a driver. Future work should assess for changes in telehealth use with pandemic progression, geographic differences, and impact on care quality, care coordination, outcomes, and costs to ensure Veterans' optimal and equitable access to care.