Burnout, employee engagement, and changing organizational contexts in VA primary care during the early COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic involved a rapid change to the working conditions of all healthcare workers (HCW), including those in primary care. Organizational responses to the pandemic, including a shift to virtual care, changes in staffing, and reassignments to testing-related work, may have shifted more burden to these HCWs, increasing their burnout and turnover intent, despite their engagement to their organization. Our objectives were (1) to examine changes in burnout and intent to leave rates in VA primary care from 2017-2020 (before and during the pandemic), and (2) to analyze how individual protective factors and organizational context affected burnout and turnover intent among VA primary care HCWs during the early months of the pandemic. METHODS: We analyzed individual- and healthcare system-level data from 19,894 primary care HCWs in 139 healthcare systems in 2020. We modeled potential relationships between individual-level burnout and turnover intent as outcomes, and individual-level employee engagement, perceptions of workload, leadership, and workgroups. At healthcare system-level, we assessed prior-year levels of burnout and turnover intent, COVID-19 burden (number of tests and deaths), and the extent of virtual care use as potential determinants. We conducted multivariable analyses using logistic regression with standard errors clustered by healthcare system controlled for individual-level demographics and healthcare system complexity. RESULTS: In 2020, 37% of primary care HCWs reported burnout, and 31% reported turnover intent. Highly engaged employees were less burned out (OR = 0.57; 95% CI 0.52-0.63) and had lower turnover intent (OR = 0.62; 95% CI 0.57-0.68). Pre-pandemic healthcare system-level burnout was a major predictor of individual-level pandemic burnout (p = 0.014). Perceptions of reasonable workload, trustworthy leadership, and strong workgroups were also related to lower burnout and turnover intent (p < 0.05 for all). COVID-19 burden, virtual care use, and prior year turnover were not associated with either outcome. CONCLUSIONS: Employee engagement was associated with a lower likelihood of primary care HCW burnout and turnover intent during the pandemic, suggesting it may have a protective effect during stressful times. COVID-19 burden and virtual care use were not related to either outcome. Future research should focus on understanding the relationship between engagement and burnout and improving well-being in primary care.

Telework Arrangements and Physician Burnout in the Veterans Health Administration.

This survey study of physicians in the Veterans Health Administration examines the association of burnout with various telework arrangements.

Associations Between Primary Care Providers and Staff-Reported Access Management Challenges and Patient Perceptions of Access.

BACKGROUND/OBJECTIVE: Optimizing patients' access to primary care is critically important but challenging. In a national survey, we asked primary care providers and staff to rate specific care processes as access management challenges and assessed whether clinics with more of these challenges had worse access outcomes. METHODS: Study design: Cross sectional. National Primary Care Personnel Survey (NPCPS) (2018) participants included 6210 primary care providers (PCPs) and staff in 813 clinics (19% response rate) and 158,645 of their patients. We linked PCP and staff ratings of access management challenges to veterans' perceived access from 2018-2019 Survey of Healthcare Experiences of Patients-Patient Centered Medical Home (SHEP-PCMH) surveys (35.6% response rate). MAIN MEASURES: The NPCPS queried PCPs and staff about access management challenges. The mean overall access challenge score was 28.6, SD 6.0. The SHEP-PCMH access composite asked how often veterans reported always obtaining urgent appointments same/next day; routine appointments when desired and having medical questions answered during office hours. ANALYTIC APPROACH: We aggregated PCP and staff responses to clinic level, and use multi-level, multivariate logistic regressions to assess associations between clinic-level access management challenges and patient perceptions of access. We controlled for veteran-, facility-, and area-level characteristics. KEY RESULTS: Veterans at clinics with more access management challenges (> 75th percentile) had a lower likelihood of reporting always receiving timely urgent care appointments (AOR: .86, 95% CI: .78-.95); always receiving routine appointments (AOR: .74, 95% CI: .67-.82); and always reporting same- or next-day answers to telephone questions (AOR: .79, 95% CI: .70-.90) compared to veterans receiving care at clinics with fewer (< 25th percentile) challenges. DISCUSSION/CONCLUSION: Findings show a strong relationship between higher levels of access management challenges and worse patient perceptions of access. Addressing access management challenges, particularly those associated with call center communication, may be an actionable path for improved patient experience.

The Clinical Resource Hub Initiative: First-Year Implementation of the Veterans Health Administration Regional Telehealth Contingency Staffing Program.

Health care systems face challenges providing accessible health care across geographically disparate sites. The Veterans Health Administration (VHA) developed regional telemedicine service focusing initially on primary care and mental health services. The objective of this study is to describe the program and progress during the early implementation. In its first year, the Clinical Resource Hub program provided 244 515 encounters to 95 684 Veterans at 475 sites. All 18 regions met or exceeded minimum implementation requirements. The regionally based telehealth contingency staffing hub met early implementation goals. Further evaluation to review sustainability and impact on provider experience and patient outcomes is needed.

Quality of Depression Care for Veterans Affairs Primary Care Patients with Experiences of Homelessness.

BACKGROUND: Persons who experience homelessness (PEH) have high rates of depression and incur challenges accessing high-quality health care. Some Veterans Affairs (VA) facilities offer homeless-tailored primary care clinics, although such tailoring is not required, within or outside VA. Whether services tailoring enhances care for depression is unstudied. OBJECTIVE: To determine whether PEH in homeless-tailored primary care settings receive higher quality of depression care, compared to PEH in usual VA primary care. DESIGN: Retrospective cohort study of depression treatment among a regional cohort of VA primary care patients (2016-2019). PARTICIPANTS: PEH diagnosed or treated for a depressive disorder. MAIN MEASURES: The quality measures were timely follow-up care (3 + completed visits with a primary care or mental health specialist provider, or 3 + psychotherapy sessions) within 84 days of a positive PHQ-2 screen result, timely follow-up care within 180 days, and minimally appropriate treatment (4 + mental health visits, 3 + psychotherapy visits, 60 + days antidepressant) within 365 days. We applied multivariable mixed-effect logistic regressions to model differences in care quality for PEH in homeless-tailored versus usual primary care settings. KEY RESULTS: Thirteen percent of PEH with depressive disorders received homeless-tailored primary care (n = 374), compared to usual VA primary care (n = 2469). Tailored clinics served more PEH who were Black, who were non-married, and who had low income, serious mental illness, and substance use disorders. Among all PEH, 48% received timely follow-up care within 84 days of depression screening, 67% within 180 days, and 83% received minimally appropriate treatment. Quality metric attainment was higher for PEH in homeless-tailored clinics, compared to PEH in usual VA primary care: follow-up within 84 days (63% versus 46%; adjusted odds ratio [AOR] = 1.61, p = .001), follow-up within 180 days (78% versus 66%; AOR = 1.51, p = .003), and minimally appropriate treatment (89% versus 82%; AOR = 1.58, p = .004). CONCLUSIONS: Homeless-tailored primary care approaches may improve depression care for PEH.

Association Between Availability of Women's Health Services and Women Veterans' Care Experiences.

INTRODUCTION: Few studies have focused on determinants of women's ratings of care experiences in primary care. We assessed associations between availability of women's health services and women veterans' ratings of care experiences. METHODS: In a cross-sectional analysis, we linked Fiscal Year (FY) 2017 (October 1, 2016, to September 30, 2017) survey data from 126 Veterans Health Administration (VA) primary care leaders to 4,254 women veterans' ratings of care from VA's Survey of Healthcare Experiences of Patients-Patient Centered Medical Home (FY 2017). The dependent variables were ratings of optimal access (appointments, information), care coordination, comprehensiveness (behavioral health assessment), patient-provider communication, and primary care provider. Key independent variables were number of women's health services 1) routinely available all weekday hours (compared with some hours or not available) and 2) available in VA general primary care vs. other arrangements. In multilevel logistic regression models, we adjusted for patient-, facility-, and area-level characteristics. RESULTS: A greater number of women's health services routinely available in VA primary care was associated with a higher likelihood of optimal ratings of care coordination (adjusted odds ratio [AOR], 1.06; 95% confidence interval [CI], 1.01-1.10), provider communication (AOR, 1.08; 95% CI, 1.002-1.16), and primary care provider (AOR, 1.07; 95% CI, 1.02-1.13). A greater number of services available in VA primary care was associated with a lower likelihood of optimal ratings for access (AOR, 0.94; 95% CI, 0.88-0.99). CONCLUSION: For the most part, routine availability of women's health services in VA primary care clinics enhanced women's healthcare experiences. These empirical findings offer healthcare leaders evidence-based approaches for improving women's care experiences.

Women Veterans' Healthcare Needs, Utilization, and Preferences in Veterans Affairs Primary Care Settings.

BACKGROUND: The Veterans Health Administration (VA) is the largest integrated health system in the US and provides access to comprehensive primary care. Women Veterans are the fastest growing segment of new VA users, yet little is known about the characteristics of those who routinely access VA primary care in general or by age group. OBJECTIVE: Describe healthcare needs, utilization, and preferences of women Veterans who routinely use VA primary care. PARTICIPANTS: 1,391 women Veterans with 3+ primary care visits within the previous year in 12 VA medical centers (including General Primary Care Clinics, General Primary Care Clinics with designated space for women, and Comprehensive Women's Health Centers) in nine states. METHODS: Cross-sectional survey (45% response rate) of sociodemographic characteristics, health status (including chronic disease, mental health, pain, and trauma exposure), utilization, care preferences, and satisfaction. Select utilization data were extracted from administrative data. Analyses were weighted to the population of routine users and adjusted for non-response in total and by age group. KEY RESULTS: While 43% had health coverage only through VA, 62% received all primary care in VA. In the prior year, 56% used VA mental healthcare and 78% used VA specialty care. Common physical health issues included hypertension (42%), elevated cholesterol (39%), pain (35%), and diabetes (16%). Many screened positive for PTSD (41%), anxiety (32%), and depression (27%). Chronic physical and mental health burdens varied by age. Two-thirds (62%) had experienced military sexual trauma. Respondents reported satisfaction with VA women's healthcare and preference for female providers. CONCLUSIONS: Women Veterans who routinely utilize VA primary care have significant multimorbid physical and mental health conditions and trauma histories. Meeting women Veterans' needs across the lifespan will require continued investment in woman-centered primary care, including integrated mental healthcare and emphasis on trauma-informed, age-specific care, guided by women's provider preferences.

Factors Associated With Patient-Centered Medical Home Teams' Use of Resources for Identifying and Approaches for Managing Patients With Complex Needs.

Using data from a Veterans Health Administration national primary care survey, this study identified the most highly rated tools and care approaches for patients with complex needs and how preferences varied by professional role, staffing, and training. Nurses were significantly more likely to rate most tools as very important as compared with primary care providers. Having a fully staffed team was also significantly associated with a very important rating on all tools. Nurses and fully staffed teams reported a greater likeliness to use most care approaches, and those with perceived need for training reporting a lower likeliness to use.

Health System Resiliency and the COVID-19 Pandemic: A Case Study of a New Nationwide Contingency Staffing Program.

When COVID-19 emerged, the U.S. Veterans Health Administration (VA) was in the process of implementing a national contingency staffing program called Clinical Resource Hubs (CRHs). CRHs were intended to provide regional contingency staffing for primary and mental health clinics experiencing staffing shortages primarily through telehealth. Long-term plans (year 2) included emergency management support. Early in the implementation, we conducted semi-structured interviews with CRH directors and national program leaders (n = 26) and used a rapid analysis approach to identify actions taken by CRHs to support the resiliency of the VA healthcare system during the pandemic. We found that the CRH program was flexible and nimble enough to allow VA to leverage providers at hubs to better respond to the demands of COVID-19. Actions taken at hubs to sustain patient access and staff resiliency during the pandemic included supporting call centers and training VA providers on virtual care delivery. Factors that facilitated CRH's emergency response included hub staff expertise in telehealth and the increased acceptability of virtual care among key stakeholders. We conclude that hub providers serving as contingency staff, as well as specialization in delivering virtual outpatient and inpatient care, enabled VA health system resiliency and recovery during the COVID-19 pandemic.

Gender Differences in the Relationship Between Workplace Civility and Burnout Among VA Primary Care Providers.

BACKGROUND: Civility, or politeness, is an important part of the healthcare workplace, and its absence can lead to healthcare provider and staff burnout. Lack of civility is well-documented among mostly female nurses, but is not well-described among the gender-mixed primary care provider (PCP) workforce. Understanding civility and its relationship to burnout among male and female PCPs could help lead to tailored interventions to improve civility and reduce burnout in primary care. OBJECTIVE: To analyze gender differences in civility, burnout, and the relationship between civility and burnout among male and female PCPs. DESIGN: Multi-level logistic regression analysis of a cross-sectional national survey. PARTICIPANTS: A total of 3216 PCP respondents (1946 women and 1270 men) in 135 medical centers from a 2019 national Veterans Health Administration (VA) survey. MAIN MEASURES: Outcomes: burnout; predictors: workplace civility and gender; controls: race, ethnicity, VA tenure, and supervisory status. KEY RESULTS: Workplace civility was rated higher (p<0.001) among male (mean = 4.07, standard deviation [SD] = 0.36, range 1-5) compared to female (mean = 3.88, SD = 0.33) PCPs. Almost half of the sample reported burnout (47.6%), but this difference was not significant (p = 0.73) between the genders. Higher workplace civility was significantly related to lower burnout among female PCPs (odds ratio [OR] = 0.46, 95% confidence interval [CI] = 0.31 to 0.69), but not among male PCPs (OR = 0.71, 95% CI = 0.42 to 1.22). Interactions between civility and other demographic variables (race, ethnicity, VA tenure, or supervisory status) were not significantly related to burnout. CONCLUSION: Female PCPs report lower workplace civility than male PCPs. An inverse relationship between civility and burnout is present for women but not men. More research is needed on this phenomenon. Interventions tailored to gender- and primary care-specific needs should be employed to increase civility and reduce burnout among PCPs.

Differences in Burnout and Intent to Leave Between Women's Health and General Primary Care Providers in the Veterans Health Administration.

BACKGROUND: Although they are a minority of patients served by the Veterans Health Administration (VHA), women Veterans comprise a fast-growing segment of these patients and have unique clinical needs. Women's health primary care providers (WH-PCPs) are specially trained and designated to provide care for women Veterans. Prior work has demonstrated that WH-PCPs deliver better preventative care and have more satisfied patients than PCPs without the WH designation. However, due to unique clinical demands or other factors, WH-PCPs may experience more burnout and intent to leave practice than general PCPs in the VHA. OBJECTIVE: To examine differences in burnout and intent to leave practice among WH and general PCPs in the VHA. DESIGN: Multi-level logistic regression analysis of three cross-sectional waves of PCPs within the VHA using the national All Employee Survey and practice data (2017-2019). We modeled outcomes of burnout and intent to leave practice as a function of WH provider designation, gender, and other demographics and practice characteristics, such as support staff ratio, panel size, and setting. PARTICIPANTS: A total of 7903 primary care providers (5152 general PCPs and 2751 WH-PCPs; response rates: 63.9%, 65.7%, and 67.5% in 2017, 2018, and 2019, respectively). MAIN MEASURES: Burnout and intent to leave practice. KEY RESULTS: WH-PCPs were more burned out than general PCPs (unadjusted: 55.0% vs. 46.9%, p<0.001; adjusted: OR=1.29, 95% confidence interval [CI] 1.10-1.55) but did not have a higher intention to leave (unadjusted: 33.4% vs. 32.1%, p=0.27; adjusted: OR=1.07, CI 0.81-1.41). WH-PCPs with intentions to leave were more likely to select the response option of "job-related (e.g., type of work, workload, burnout, boredom)" as their primary reason to leave. CONCLUSIONS: Burnout is higher among WH-PCPs compared to general PCPs, even after accounting for provider and practice characteristics. More research on causes of and solutions for these differences in burnout is needed.

The Coordination Toolkit and Coaching Project: Cluster-Randomized Quality Improvement Initiative to Improve Patient Experience of Care Coordination.

BACKGROUND: Given persistent gaps in coordination of care for medically complex primary care patients, efficient strategies are needed to promote better care coordination. OBJECTIVE: The Coordination Toolkit and Coaching project compared two toolkit-based strategies of differing intensity to improve care coordination at VA primary care clinics. DESIGN: Multi-site, cluster-randomized QI initiative. PARTICIPANTS: Twelve VA primary care clinics matched in 6 pairs. INTERVENTIONS: We used a computer-generated allocation sequence to randomize clinics within each pair to two implementation strategies. Active control clinics received an online toolkit with evidence-based tools and QI coaching manual. Intervention clinics received the online toolkit plus weekly assistance from a distance coach for 12 months. MAIN MEASURES: We quantified patient experience of general care coordination using the Health Care System Hassles Scale (primary outcome) mailed at baseline and 12-month follow-up to serial cross-sectional patient samples. We measured the difference-in-difference (DiD) in clinic-level-predicted mean counts of hassles between coached and non-coached clinics, adjusting for clustering and patient characteristics using zero-inflated negative binomial regression and bootstrapping to obtain 95% confidence intervals. Other measures included care coordination QI projects attempted, tools adopted, and patient-reported exposure to projects. KEY RESULTS: N = 2,484 (49%) patients completed baseline surveys and 2,481 (48%) completed follow-ups. Six coached clinics versus five non-coached clinics attempted QI projects. All coached clinics versus two non-coached clinics attempted more than one project or projects that were multifaceted (i.e., involving multiple components addressing a common goal). Five coached versus three non-coached clinics used 1-2 toolkit tools. Both the coached and non-coached clinics experienced pre-post reductions in hassle counts over the study period (- 0.42 (- 0.76, - 0.08) non-coached; - 0.40 (- 0.75, - 0.06) coached). However, the DiD (0.02 (- 0.47, 0.50)) was not statistically significant; coaching did not improve patient experience of care coordination relative to the toolkit alone. CONCLUSION: Although coached clinics attempted more or more complex QI projects and used more tools than non-coached clinics, coaching provided no additional benefit versus the online toolkit alone in patient-reported outcomes. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03063294.

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

BACKGROUND: The 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. METHODS: Our 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). RESULTS: 51 % 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. CONCLUSIONS: VA 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.

Primary Care Tasks Associated With Nursing Burnout: A Survey of Registered and Licensed Vocational Nurses in Veterans Health Administration Patient-Centered Medical Homes.

Using data from the Veterans Assessment and Improvement Laboratory for Patient-Centered Care (VAIL-PCC) Survey, this study investigated the relationship between registered nurses' (RNs') and licensed vocational nurses' (LVNs') report of responsibility for 14 distinct primary care tasks and burnout, taking into account of practice environment contexts. RNs reported higher levels of burnout than LVNs. The task of "following up on referrals" was associated with significantly higher levels of RN burnout, whereas "responding to prescription requests" was associated with higher levels of LVN burnout. "True collaboration" was associated with significantly lower levels of burnout for both RNs and LVNs.

Burnout Among Primary Care Healthcare Workers During the COVID-19 Pandemic.

OBJECTIVE: To measure the prevalence of burnout among healthcare workers (HCWs) in primary care during the COVID-19 pandemic and to understand the association between burnout, job-person fit, and perceptions of the pandemic. METHODS: We surveyed 147 HCWs (73% response rate) in two clinics in the summer of 2020 on their burnout, job-person fit, perceptions of the pandemic, and demographic/job characteristics. Logistic regression analyses were conducted to explore relationships between these variables. RESULTS: Forty-three percent of HCWs reported burnout. Lower HCW burnout was associated with better job-person fit in the areas of recognition or appreciation at work (odds ratio [OR] 0.26, 95% confidence interval [CI] 0.10 to 0.67) and congruent worker-organization goals and values (OR 0.30, 95% CI 0.11 to 0.76). CONCLUSIONS: Working environments with better job-person fit may be key to reducing HCW burnout even after the current crisis.

Identifying knowledge gaps in heart failure research among women using unsupervised machine-learning methods.

Aim: To identify knowledge gaps in heart failure (HF) research among women, especially postmenopausal women. Materials & methods: We retrieved HF articles from PubMed. Natural language processing and text mining techniques were used to screen relevant articles and identify study objective(s) from abstracts. After text preprocessing, we performed topic modeling with non-negative matrix factorization to cluster articles based on the primary topic. Clusters were independently validated and labeled by three investigators familiar with HF research. Results: Our model yielded 15 topic clusters from articles on HF among women. Atrial fibrillation was found to be the most understudied topic. From articles specific to postmenopausal women, five clusters were identified. The smallest cluster was about stress-induced cardiomyopathy. Conclusion: Topic modeling can help identify understudied areas in medical research.

Call Center Remote Triage by Nurse Practitioners Was Associated With Fewer Subsequent Face-to-Face Healthcare Visits.

BACKGROUND: In 2015, the Veterans Health Administration (VHA) incorporated nurse practitioners (NPs) into remote triage call centers to supplement registered nurse (RN)-handled calls. OBJECTIVE: To assess 7-day healthcare use following telephone triage by NPs compared to RNs. We hypothesized that NP clinical decision ability may reduce follow-up healthcare. DESIGN: Retrospective observational comparative effectiveness study of clinical and administrative databases. NP routed calls were matched to RN calls based on chief complaint with propensity score matching and multivariate count data models, adjusting for differences in call severity and patient comorbidity. PARTICIPANTS: Callers to a VHA regional call center, April 2015 to March 2019. MAIN MEASURES: Primary care, specialty care, and emergency department (ED) visits plus hospitalizations within 7 days. KEY RESULTS: NP-handled calls (N = 1554) were matched to RN calls (N = 48,024) for the same chief complaint. NP-handled calls, compared to RNs, had lower comorbidities, fewer hospitalizations, and less urgent complaints. Seven-day healthcare use was lower for NP compared to RN calls for specialty care (0.15 vs. 0.20 visits per person [VPP]; p < 0.001), ED (0.11 vs. 0.27 VPP; p < 0.001), and hospitalizations (0.01 vs. 0.04 VPP; p < 0.001), but not primary care (0.43 vs. 0.42 VPP; p = 0.80). In adjusted analyses, estimated avoided in-person visits per 100 calls routed to NPs were 0.7 primary care visits (95% confidence interval [CI] 0.4, 1.0), 2.6 specialty care visits (95% CI 0.0, 5.1), 5.9 ED visits (95% CI 2.7, 9.1), and 1.4 hospital stays (95% CI 0.1, 2.6). Propensity score-matched models comparing NP (N = 1533) to RN (N = 2646) calls had adjusted odds ratios for 7-day healthcare use of 0.75 (primary care), 0.75 (specialty care), and 0.73 (ED) (all p < 0.003). CONCLUSION: Incorporating NPs into a call center was associated with lower in-person healthcare use in the subsequent 7 days compared to routine RN-triaged calls.

Use of the Veterans' Choice Program and Attrition From Veterans Health Administration Primary Care.

BACKGROUND: Concerns over timely access and waiting times for appointments in the Veterans Health Administration (VHA) spurred the push towards greater privatization. In 2014, VHA increased the provision of care from community providers through the Veterans' Choice Program (Choice). OBJECTIVES: We examined the characteristics of patients and practices more likely to use Choice care and whether using Choice care affected patients' attrition from VHA primary care. STUDY DESIGN: We conducted a longitudinal study of VHA primary care users in the fiscal year 2015 and their attrition 2 years later. In the multivariate analysis, we examined whether attrition from VHA primary care was related to prior use of Choice care. SUBJECTS: A total of 1.4 million nonelderly patients diagnosed with chronic conditions. MEASURES: Choice outpatient care utilization was measured in the baseline year. Attrition was measured as not receiving any VHA primary care in 2 subsequent years. RESULTS: In our cohort, 93,710 (7%) patients used some Choice outpatient care, and these patients were more likely to be female, White or Hispanic, to have more primary care utilization at baseline, and to have long driving distances to VHA care. Practices which sent more patients out for Choice care had lower mean scores for patient-centered medical home implementation and longer mean waiting times for appointments. In the adjusted analysis, the probability of attrition was significantly lower (-0.009) among patients who used Choice outpatient care (0.036) versus patients who did not (0.044) (P<0.001). CONCLUSION: The use of community outpatient providers in the Choice program was associated with less attrition from VHA primary care.

Greater patient-centered medical home implementation was associated with lower attrition from VHA primary care.

BACKGROUND: Patient-centered medical home models such as the Veterans Health Administration (VHA) Patient Aligned Care Team (PACT) model aim to improve primary care through accessible, comprehensive, continuous team-based care. Practices that adhere to patient-centered medical home principles have been found to exhibit higher patient satisfaction, possibly leading to higher retention of patients longitudinally and reducing attrition from care. We examined whether greater PACT implementation was related to lower attrition from VHA primary care. METHODS: A national cohort of 1.5 million nonelderly patients with chronic conditions and using VHA primary care in the baseline year (fiscal year 2015) was identified. Attrition was measured as not receiving primary care over two subsequent years. PACT implementation in 863 VHA primary care practices was measured by the PACT Implementation Progress Index (Pi2) across 8 domains. RESULTS: Overall, the attrition rate was 4.4%. Predicted attrition was highest for patients treated in practices with the lowest PACT implementation scores (4.8%) compared to 4.0% among patients in practices with the highest PACT implementation scores (difference = -0.8 (95% CI: -1.3, -0.2)). Better performance on most PACT domains was significantly associated with lower attrition. CONCLUSIONS: Primary care practices that facilitate easier access to providers as well as provide more seamless care coordination, better communication with providers, and support for self-management appear to positively affect patients' decisions to stay in VHA care. IMPLICATIONS: Provision of accessible, comprehensive, team-based primary care, as measured in this study, is likely to be a determinant of patient retention in VHA care. LEVEL OF EVIDENCE: 3.

Patient experience of health care system hassles: Dual-system vs single-system users.

OBJECTIVE: To compare health care system problems or "hassles" experienced by Veterans receiving VA health care only versus those receiving dual care from both VA and non-VA community providers. DATA SOURCES: We collected survey data in 2017-2018 from 2444 randomly selected Veterans with four or more primary care visits in the prior year at one of 12 VA primary care clinics located in four geographically diverse regions of the United States. STUDY DESIGN: We used baseline surveys from the Coordination Toolkit and Coaching quality improvement project to explore Veterans' experience of hassles (dependent variable), source of health care, self-rated physical and mental health, and sociodemographics. DATA COLLECTION: Participants responded to mailed surveys by mail, telephone, or online. PRINCIPAL FINDINGS: The number of reported hassles ranged from 0 to 16; 79 percent of Veterans reported experiencing one or more hassles. Controlling for sociodemographic characteristics and self-rated physical and mental health, zero-inflated negative binominal regression indicated that dual care users experienced more hassles than VA-only users (adjusted predicted average 5.5 [CI: 5.2, 5.8] vs 4.3 [CI: 4.1, 4.6] hassles [P < .0001]). CONCLUSIONS: Anticipated increases in Veterans accessing community-based care may require new strategies to help VA primary care teams optimize care coordination for dual care users.