The Impact of Community Care Referral on Time to Surgery for Veterans With Carpal Tunnel Syndrome.

BACKGROUND: The US Department of Veterans Affairs (VA) enacted policies offering Veterans care in the community, aiming to improve access challenges. However, the impact of receipt of community care on wait times for Veterans receiving surgical care is poorly understood. OBJECTIVES: To compare wait times for surgery for Veterans with carpal tunnel syndrome who receive VA care plus community care (mixed care) and those who receive care solely within the VA (VA-only). RESEARCH DESIGN: Retrospective cohort study. SUBJECTS: Veterans undergoing carpal tunnel release (CTR) between January 1, 2010 and December 31, 2016. MEASURES: Our primary outcome was time from primary care physician (PCP) referral to CTR. RESULTS: Of the 29,242 Veterans undergoing CTR, 23,330 (79.8%) received VA-only care and 5912 (20.1%) received mixed care. Veterans receiving mixed care had significantly longer time from PCP referral to CTR (median mixed care: 378 days; median VA-only care: 176 days, P<0.001). After controlling for patient and facility covariates, mixed care was associated with a 37% increased time from PCP referral to CTR (adjusted hazard ratio, 0.63; 95% confidence interval, 0.61-0.65). Each additional service provided in the community was associated with a 23% increase in time to surgery (adjusted hazard ratio, 0.77; 95% confidence interval, 0.76-0.78). CONCLUSIONS: VA-only care was associated with a shorter time to surgery compared with mixed care. Moreover, there were additional delays for each service received in the community. With likely increases in Veterans seeking community care, strategies must be used to identify and mitigate sources of delay through the spectrum of care between referral and definitive treatment.

Did Access to Care Improve Since Passage of the Veterans Choice Act?: Differences Between Rural and Urban Veterans.

BACKGROUND: The 2014 Veterans Choice Program aimed to improve care access for Veterans through expanded availability of community care (CC). Increased access to CC could particularly benefit rural Veterans, who often face obstacles in obtaining medical care at the Veterans Health Administration (VHA). However, whether Veterans Choice Program improved timely access to care for this vulnerable population is understudied. OBJECTIVES: To examine wait times among rural and urban Veterans for 5 outpatient specialty care services representing the top requests for CC services among rural Veterans. RESEARCH DESIGN: Retrospective study using VHA and CC outpatient consult data from VHA's Corporate Data Warehouse in Fiscal Year (FY) 2015 (October 1, 2014 to September 30, 2015) and FY2018 (October 1, 2017 to September 30, 2018). SUBJECTS: All Veterans who received a new patient consult for physical therapy, cardiology, optometry, orthopedics, and/or dental services in VHA and/or CC. MEASURES: Wait time, care setting (VHA/CC), rural/urban status, sociodemographics, and comorbidities. RESULTS: Our sample included 1,112,876 Veterans. Between FY2015 and FY2018, mean wait times decreased for all services for both rural and urban Veterans; declines were greatest in VHA (eg, mean optometry wait times for rural Veterans in VHA vs. CC declined 8.3 vs. 6.4 d, respectively, P<0.0001). By FY2018, for both rural and urban Veterans, CC mean wait times for most services were longer than VHA wait times. CONCLUSIONS: Timely care access for all Veterans improved between FY15 and FY18, particularly in VHA. As expansion of CC continues under the MISSION Act, more research is needed to evaluate quality of care across VHA and CC and what role, if any, wait times play.

County-level Predictors of Growth in Community-based Primary Care Use Among Veterans.

BACKGROUND: The 2014 Choice Act expanded the Veterans Health Administration's (VA) capacity to purchase services for VA enrollees from community providers, yet little is known regarding the growth of Veterans' primary care use in community settings. OBJECTIVES: The aim was to measure county-level growth in VA community-based primary care (CBPC) penetration following the Choice Act and to assess whether CBPC penetration increased in rural counties with limited access to VA facilities. DATA AND SAMPLE: A total of 3132 counties from VA administrative data from 2015 to 2018, Area Health Resources Files, and County Health Rankings. ANALYSIS: We defined the county-level CBPC penetration rate as the proportion of VA-purchased primary care out of all VA-purchased primary care (ie, within and outside VA). We estimated county-level multivariate linear regression models to assess whether rurality and supply of primary care providers and health care facilities were significantly associated with CBPC growth. RESULTS: Nationally, CBPC penetration rates increased from 2.7% in 2015 to 7.3% in 2018. The rurality of the county was associated with a 2-3 percentage point (pp) increase in CBPC penetration growth (P<0.001). The presence of a VA facility was associated with a 1.7 pp decrease in CBPC penetration growth (P<0.001), while lower primary care provider supply was associated with a 0.6 pp increase in CBPC growth (P<0.001). CONCLUSION: CBPC as a proportion of all VA-purchased primary care was small but increased nearly 3-fold between 2015 and 2018. Greater increases in CBPC penetration were concentrated in rural counties and counties without a VA facility, suggesting that community care may enhance primary care access in rural areas with less VA presence.

Infertility Services for Veterans: Policies, Challenges, and Opportunities.

Infertility prevalence and care needs among male and female Veterans are understudied topics. The Veterans Health Administration (VHA) medical benefits package covers full infertility evaluation and many infertility treatments for Veterans but not, by law, for their spouses. In vitro fertilization (IVF) is also specifically excluded from this medical benefits package by regulation. Congress passed a law in 2016 that allowed VHA to provide IVF to Veterans and their legal spouses, and broader infertility benefits to the legal spouse, if the Veteran has a service-connected condition associated with his or her infertility, with some limitations. As the Veteran population becomes increasingly female, research efforts in reproductive health, including infertility, are expanding and evolving. This includes a nationwide study currently underway examining infertility among male and female Veterans and associations with military-related trauma, such as injury, posttraumatic stress disorder, military sexual trauma, and toxin exposure. In this review, we describe the state of the science and policy on infertility care in the VHA along with challenges and opportunities that exist within the VHA system.

Recommendations for the Evaluation of Cross-System Care Coordination from the VA State-of-the-art Working Group on VA/Non-VA Care.

In response to widespread concerns regarding Veterans' access to VA care, Congress enacted the Veterans Access, Choice and Accountability Act of 2014, which required VA to establish the Veterans Choice Program (VCP). Since the inception of VCP, more than two million Veterans have received care from community providers, representing approximately 25% of Veterans enrolled in VA care. However, expanded access to non-VA care has created challenges in care coordination between VA and community health systems. In March 2018, the VA Health Services Research & Development Service hosted a VA State of the Art conference (SOTA) focused on care coordination. The SOTA convened VA researchers, program directors, clinicians, and policy makers to identify knowledge gaps regarding care coordination within the VA and between VA and community systems of care. This article provides a summary and synthesis of relevant literature and provides recommendations generated from the SOTA about how to evaluate cross-system care coordination. Care coordination is typically evaluated using health outcomes including hospital readmissions and death; however, in cross-system evaluations of care coordination, measures such as access, cost, Veteran/patient and provider satisfaction (including with cross-system communication), comparable quality metrics, context (urban vs. rural), and patient complexity (medical and mental health conditions) need to be included to fully evaluate care coordination effectiveness. Future research should examine the role of multiple individuals coordinating VA and non-VA care, and how these coordinators work together to optimize coordination.

A Qualitative Study of Primary Care Providers' Experiences with the Veterans Choice Program.

BACKGROUND: The Veterans Access, Choice and Accountability Act (hereafter, Choice Program) seeks to improve access to care by enabling eligible Veterans to receive care from community providers. Veterans Affairs (VA) primary care providers (PCPs) play a key role in making referrals to community specialists, but their frontline experiences with referrals are not well understood. OBJECTIVE: To understand VA PCPs' experiences referring patients to community specialists while VA works to expand and refine the implementation of the Choice Program. DESIGN: Qualitative study using interview methods. PARTICIPANTS: Semi-structured telephone interviews were conducted with VA primary care providers (N = 72 out of 599 contacted) recruited nationally. APPROACH: Open-ended interview questions elicited PCP perceptions and experiences with referrals to community specialists via the Choice Program. Keywords were identified using automated coding features in ATLAS.ti and evaluated using conventional content analysis to inductively describe the qualitative data. KEY RESULTS: VA PCPs emphasized problems with care coordination and continuity between the VA and community specialists (e.g., "It is extremely difficult for us to obtain and continue continuity of care because there's not much communication with the community specialist"). They described difficulties with tracking the initial referral, coordinating care after receiving community specialty care, accessing community medical records, and aligning community specialists' prescriptions with the VA formulary. CONCLUSIONS: The VA Choice Program provides access to community specialists for VA patients; however, VA primary care providers face challenges tracking referrals to community specialists and in coordinating care. Strategies to improve care coordination between the VA and community providers should focus on providing PCPs with information to follow Veterans throughout the Choice referral process and follow-up.

Care of veterans in a non-veteran health administration hospital: What is the status of nursing practice after continuing education?

AIMS AND OBJECTIVES: To identify how civilian nurses are caring for military veterans following mandatory continuing education on veterans' mental health needs and to describe challenges nurses are facing in provision of that care. BACKGROUND: Veterans and military personnel experience mental health conditions at a high rate and are increasingly receiving care in civilian healthcare facilities. Nonmilitary providers may not be prepared to address this population's challenging needs. Military culture may influence the presentation of mental health conditions; thus, critical assessment points by nonmilitary medical personnel may be missed. Education is touted internationally as a means to address deficits, but research is lacking to support that statement. METHODS: Adhering to research reporting guidelines, 115 of a proposed 322 civilian nurses in a tertiary hospital volunteered to complete a one-time online survey that contained quantitative and demographic questions. Forty of 115 nurses went on to complete the qualitative query. Descriptive statistics summarised quantitative results, and constant comparative analysis was applied to qualitative responses for theme identification. RESULTS: The study was stopped early due to reports of violence from veterans upon nurses. Results showed continuing education did not change documentation of military status. Following mandatory continuing education, civilian nurses continued to describe uncertainty in how to adapt care, on how to interact with veterans and in how to deal with violence. CONCLUSION: The status of care to veterans remains insufficient, but nurses are asking critical questions on how to update practice. Additional support and research in the clinical setting is needed to promote a safe caring environment. RELEVANCE TO CLINICAL PRACTICE: Continuing education alone may not advance care of the veteran. A multipronged approach to include mandatory documentation of military status and coaching of providers by those experienced with the military way of life may be used to augment staff preparedness.

[Special and marginal: towards a problematization of the state intervention regarding the health of Malvinas veterans (1984-2000)]. / Especial y marginal: hacia una problematización de la intervención estatal en la salud de los veteranos de Malvinas (1984-2000).

The aim of this paper is to account for the modalities in which Malvinas veterans' health was constituted as a problem requiring state intervention between 1984 and 2000. In order to do so, we have focused on the concept of problematization as a way to analyze practices and political thought. The text consists of three sections: the first one presents the methodological basis of the analysis of public policies, whereas the second and third ones intend to analyze a series of laws, bills, decrees, reports and other documents produced by different state spheres about war veterans and their health situation. The hypothesis that we propose is that the Malvinas veterans were problematized as a marginal segment of the population, although the stabilization of a specific treatment took more than fifteen years to materialize.

El objetivo de este artículo es dar cuenta de las modalidades en que fue instituida la salud del veterano argentino de la guerra de Malvinas como un problema de intervención estatal entre 1984 y 2000. Para ello nos centramos en el concepto de problematización como un modo de análisis de las prácticas y el pensamiento político. El texto consta de tres apartados: en el primero se presentan las bases metodológicas para el análisis de las políticas públicas, mientras que el segundo y el tercero están destinados al análisis de una serie de leyes, proyectos de ley, decretos, informes, etc., producidos por diferentes esferas estatales en torno al veterano de guerra y su situación sanitaria. La hipótesis de lectura que proponemos es que el veterano o excombatiente de Malvinas fue problematizado como un segmento poblacional marginal, aunque la estabilización de un tratamiento específico tardó más de quince años en materializarse.

Especial y marginal: hacia una problematización de la intervención estatal en la salud de los veteranos de Malvinas (1984-2000) / Special and marginal: towards a problematization of the state intervention regarding the health of Malvinas veterans (1984-2000)

RESUMEN El objetivo de este artículo es dar cuenta de las modalidades en que fue instituida la salud del veterano argentino de la guerra de Malvinas como un problema de intervención estatal entre 1984 y 2000. Para ello nos centramos en el concepto de problematización como un modo de análisis de las prácticas y el pensamiento político. El texto consta de tres apartados: en el primero se presentan las bases metodológicas para el análisis de las políticas públicas, mientras que el segundo y el tercero están destinados al análisis de una serie de leyes, proyectos de ley, decretos, informes, etc., producidos por diferentes esferas estatales en torno al veterano de guerra y su situación sanitaria. La hipótesis de lectura que proponemos es que el veterano o excombatiente de Malvinas fue problematizado como un segmento poblacional marginal, aunque la estabilización de un tratamiento específico tardó más de quince años en materializarse.

ABSTRACT The aim of this paper is to account for the modalities in which Malvinas veterans' health was constituted as a problem requiring state intervention between 1984 and 2000. In order to do so, we have focused on the concept of problematization as a way to analyze practices and political thought. The text consists of three sections: the first one presents the methodological basis of the analysis of public policies, whereas the second and third ones intend to analyze a series of laws, bills, decrees, reports and other documents produced by different state spheres about war veterans and their health situation. The hypothesis that we propose is that the Malvinas veterans were problematized as a marginal segment of the population, although the stabilization of a specific treatment took more than fifteen years to materialize

Per Diem Paid to States for Care of Eligible Veterans in State Homes. Final rule.

This rulemaking adopts as final, with changes, proposed amendments to VA's regulations governing payment of per diem to States for nursing home care, domiciliary care, and adult day health care for eligible veterans in State homes. This rulemaking reorganizes, updates, and clarifies State home regulations, authorizes greater flexibility in adult day health care programs, and establishes regulations regarding domiciliary care, with clarifications regarding the care that State homes must provide to veterans in domiciliaries.

Presumption of Herbicide Exposure and Presumption of Disability During Service for Reservists Presumed Exposed to Herbicides. Final rule.

The Department of Veterans Affairs (VA) is adopting as final an interim final rule published on June 19, 2015, to amend its adjudication regulation governing individuals presumed to have been exposed to certain herbicides. Specifically, VA expanded the regulation to include an additional group consisting of individuals who performed service in the Air Force or Air Force Reserve under circumstances in which they had regular and repeated contact with C-123 aircraft known to have been used to spray an herbicide agent ("Agent Orange") during the Vietnam era. In addition, the regulation established a presumption that members of this group who later develop an Agent Orange presumptive condition were disabled during the relevant period of service, thus establishing that service as "active military, naval, or air service." The effect of this action is to presume herbicide exposure for these individuals and to create a presumption that the individuals who are presumed exposed to herbicides during reserve service also meet the statutory definition of "veteran" (hereinafter, "veteran status") for VA purposes and eligibility for some VA benefits.

Schedule for Rating Disabilities: The Hematologic and Lymphatic Systems. Final rule.

This document amends the Department of Veterans Affairs (VA) Schedule for Rating Disabilities (VASRD) by revising the section of the Rating Schedule that addresses the hematologic and lymphatic systems. This action will ensure VA uses current medical terminology and provides detailed and updated criteria for evaluating conditions pertaining to the hematologic and lymphatic systems.

Definition of Domiciliary Care. Final rule.

The Department of Veterans Affairs (VA) adopts as final, with no changes, a proposed rule amending the definition of domiciliary care to encompass VA's Mental Health Residential Rehabilitation Treatment Program (MH RRTP). This rule aligns regulations with VA's administrative decision in 2005 to designate MH RRTP as a type of domiciliary care. We also proposed clarifying that domiciliary care provides temporary, not permanent, residence to affected veterans. We provided a 60-day comment period on this proposed rule and received 4 comments, all of which were generally supportive of the proposed changes. We make no changes based on public comments and adopt the proposed rule as final.

Special Monthly Compensation for Veterans With Traumatic Brain Injury. Final rule.

The Department of Veterans Affairs (VA) amends its adjudication regulations to add an additional compensation benefit for veterans with residuals of traumatic brain injury (TBI). This final rule incorporates in regulations a benefit authorized by the enactment of the Veterans' Benefits Act of 2010. The Veterans' Benefits Act authorizes special monthly compensation (SMC) for veterans with TBI who are in need of aid and attendance, and in the absence of such aid and attendance, would require hospitalization, nursing home care, or other residential institutional care.

Expanded Access to Non-VA Care Through the Veterans Choice Program. Final rule.

The Department of Veterans Affairs (VA) adopts as final, with no change, an interim final rule revising its medical regulations that implement section 101 of the Veterans Access, Choice, and Accountability Act of 2014, as amended, (hereafter referred to as "the Choice Act), which requires VA to establish a program (hereafter referred to as the Veterans Choice Program" or the "Program") to furnish hospital care and medical services through eligible non- VA health care providers to eligible veterans who either cannot be seen within the wait-time goals of the Veterans Health Administration (VHA) or who qualify based on their place of residence or face an unusual or excessive burden in traveling to a VA medical facility. Those revisions contained in the interim final rule, which is now adopted as final, were required by amendments to the Choice Act made by the Construction Authorization and Choice Improvement Act of 2014, and by the Surface Transportation and Veterans Health Care Choice Improvement Act of 2015. VA published an interim final rule on December 1, 2015, implementing those regulatory revisions, and we received seven public comments. This final rule responds to those public comments and does not make any further regulatory revisions.

Authority of Health Care Providers To Practice Telehealth. Final rule.

The Department of Veterans Affairs (VA) is amending its medical regulations by standardizing the delivery of care by VA health care providers through telehealth. This rule ensures that VA health care providers can offer the same level of care to all beneficiaries, irrespective of the State or location in a State of the VA health care provider or the beneficiary. This final rule achieves important Federal interests by increasing the availability of mental health, specialty, and general clinical care for all beneficiaries.

Medical Care in Foreign Countries and Filing for Reimbursement for Community Care Not Previously Authorized by VA. Final rule.

The Department of Veterans Affairs (VA) adopts as final, with no changes, a proposed rule amending its medical regulations related to hospital care and medical services in foreign countries. We simplified and clarified the scope of these regulations, address medical services provided to eligible veterans in the Republic of the Philippines, and removed provisions related to grants to the Republic of the Philippines that are no longer supported by statutory authority. VA also amends its medical regulations related to filing claims for reimbursement of medical expenses incurred for VA care not previously authorized. We provided a 60-day period to receive comments from the public on the proposed changes, and received no comments. VA adopts the proposed rule as final, with no changes.

Third Party Billing for Medical Care Provided Under Special Treatment Authorities. Final rule.

The Department of Veterans Affairs (VA) is amending its medical regulations to clarify that VA will not bill third party payers for care and services provided by VA under certain statutory provisions, which we refer to as "special treatment authorities." These special treatment authorities direct VA to provide care and services to veterans based upon discrete exposures or experiences that occurred during active military, naval, or air service. VA is authorized, but not required by law, to recover or collect charges for care and services provided to veterans for non-service-connected disabilities. This rule establishes that VA will not exercise its authority to recover or collect reasonable charges from third party payers for care and services provided under the special treatment authorities.

Schedule for Rating Disabilities: Skin. Final rule.

On August 12, 2016, VA published in the Federal Register the proposed rule for Schedule for Rating Disabilities: Skin. VA received multiple responses during the 60-day comment period. This final rule implements the Secretary's proposed rule with limited revisions.