BACKGROUND:Women veterans are the fastest growing group of new Veterans Health Administration (VA) users, with more than half a million women veterans using VA care in 2018. VA has implemented policies and programs to meet the reproductive and sexual health (RSH) needs of women veterans who increasingly rely on VA to provide comprehensive care. OBJECTIVE:We aimed to describe changes in the prevalence of RSH diagnosis categories among women veterans using VA care in fiscal year (FY) 2010 and FY2018. METHODS:Repeated cross-sectional VA administrative data were used to identify women veterans using VA care in FY2010 and FY2018. RSH diagnosis categories were identified from International Classification of Diseases (ICD), Ninth (FY2010) and 10th (FY2018) revision codes for all VA-covered health care encounters. Standardized incidence ratios (SIRs) were used to adjust for age and compare the rates of 15 reproductive health diagnoses in FY2010 and FY2018. RESULTS:Women veterans using VA for RSH care increased by 61% between FY2010 (n = 317,122) and FY2018 (n = 520,179). Prevalence of common RSH diagnoses remained consistent across fiscal years, including urinary conditions (SIR = 1.02; 95% CI [1.02, 1.03]) and reproductive organ conditions (SIR = .96; 95% CI [.95, .97]). Conversely, there were larger than expected increases in diagnoses of female infertility (SIR = 1.71; 95% CI [1.70, 1.76]) and sexual dysfunction (SIR = 1.51; 95% CI [1.47, 1.54]). CONCLUSION:As VA continues to build capacity to provide RSH care to women veterans, understanding changing needs is important for evaluating the impact of programs and policies designed to improve access to care.

BACKGROUND:Historically, US Veterans have reported higher chronic disease burden than non-Veterans. However, whether Veteran and Veterans Affairs (VA) coverage status continue to be associated with chronic disease burden or how these associations vary by age, especially among younger Veterans, is unknown. OBJECTIVE:To examine the number of chronic conditions among male Veterans with and without VA coverage, and male non-Veterans, overall and by age group. DESIGN AND PARTICIPANTS:Using 2018 National Health Interview Survey data, our sample included 2301 male Veterans and 9243 male non-Veterans. MAIN MEASURES:The primary outcome was a number of chronic conditions, measured as a count (range 0-15) and categorically (0, 1, 2, 3+). We created a 3-category main independent variable (Veteran with VA coverage, Veteran without VA coverage, non-Veteran). Generalized linear regression models were used to estimate relationships between Veteran and VA coverage status and count of chronic conditions, overall and by age group (18-44, 45-64, 65+), adjusting for sociodemographic characteristics. KEY RESULTS:Veterans with VA coverage, Veterans without VA coverage, and non-Veterans had an age-standardized mean of 1.44, 1.16, and 1.09 chronic conditions, respectively. In adjusted analyses, Veterans with VA coverage had 0.36 (95% CI: 0.25-0.46) more conditions and Veterans without VA coverage had 0.12 (95% CI: 0.04-0.21) more conditions compared with non-Veterans. In age-stratified analyses, Veterans with VA coverage aged 18-44 had 0.22 (95% CI: 0.06-0.38) more conditions; 45-64, 0.71 (95% CI: 0.41-0.99) more conditions; and 65+, 0.38 (95% CI: 0.18-0.57) more conditions compared with similar-aged non-Veterans. CONCLUSIONS:Veterans with VA coverage had the greatest number of chronic conditions, including when stratified by age group.

Temporary mental health (MH) staffing gaps are common and may compound access challenges due to increasing demand for MH care combined with a shrinking MH workforce. In 2019, the Veterans Health Administration (VA) implemented a system of 18 regionally based Clinical Resource Hubs (CRHs) staffed with remote providers delivering virtual MH care. While the program demonstrated promise during early implementation for effectively addressing some access challenges, its sustainment may depend partly on leaders’ perceptions of its ability to meet and adapt to access-related priorities. Our aim was to explore and describe how VA regional MH leadership identified and weighed values of the CRH during early implementation, and how it might have functioned beyond filling temporary staffing gaps. We conducted semi-structured interviews with CRH MH leaders (n = 36) across all 18 VA administrative regions. We analyzed data using a rapid qualitative approach that included templated summaries and matrix analysis. Three key perceived values of the CRH were identified: (1) its potential to offer a more integrated care experience than community (VA-purchased) care in some cases, (2) its ability to provide specialized MH services (e.g., suicide prevention) to rural areas and, (3) its capacity to improve MH provider recruitment and satisfaction. Virtual care delivered through the CRH can be a flexible option for maintaining access to MH services during staffing shortages. MH leaders’ perspectives suggest the CRH program is not only a contingency staffing solution to access problems, but provides additional values that could be leveraged to improve MH care services more generally.

BackgroundMore than a decade ago, the Veterans Health Administration (VA) implemented the Patient-Centered Medical Home (PCMH) model in primary care (PC) to improve healthcare access, care coordination, and patient outcomes. In 2021, VA's Office of Primary Care piloted three new PCMH models that aimed to improve provider efficiency and patient healthcare access by adding new team roles and increasing panel sizes.ObjectiveTo describe frontline staff experiences and lessons learned during implementation of expanded PCMH team models.DesignQualitative, semi-structured interviews of 25 frontline staff at 6 VA sites participating in the PCMH Modernization pilot conducted between March and August 2022.ParticipantsInterview participants included physicians, nurses, physical therapists, high-risk care managers, and other staff.ApproachWe used a rapid analysis approach that included creating and validating interview summaries, developing a matrix of interview domains to identify common themes, and iterative discussion among the research team to build consensus and interpret findings.Key ResultsWe found that when the basic PCMH structure and processes (e.g., staffing, huddling, pre-visit planning) were not in place, it was challenging to integrate new team members and to increase panel sizes. Role clarity challenges were also introduced by adding certain roles to PCMH teams. The physical therapist and high-risk care manager roles were seen as positive additions to PCMH models. Lastly, matching panel size expansion with staffing capacity was crucial to optimizing team efficiency while increasing patient healthcare access.ConclusionsHealthcare administrators considering expanding PCMH team models may need to thoroughly assess and address site readiness (e.g., adherence to foundational PCMH model, staffing, and practices) prior to implementation. Role clarity challenges should also be anticipated when adding new team roles. Physical therapists and high-risk care managers could be important contributions to existing PCMH models for offloading provider workload and improving population health management.

OBJECTIVE:To examine the relationship between the penetration (or reach) of a national program aiming to integrate mental health clinicians into all primary care clinics (PC-MHI) and rates of guideline-concordant follow-up and treatment among clinic patients newly identified with depression in the Veterans Health Administration (VA). DATA SOURCES/STUDY SETTING:15,155 screen-positive patients 607,730 patients with 2-item Patient Health Questionnaire scores in 82 primary care clinics, 2015-2019. STUDY DESIGN:In this retrospective cohort study, we used established depression care quality measures to assess primary care patients who (a) newly screened positive (score ≥3) and (b) were identified with depression by clinicians via diagnosis and/or medication (n = 15,155; 15,650 patient-years). Timely follow-up included ≥3 mental health, ≥3 psychotherapy, or ≥3 primary care visits for depression. Minimally appropriate treatment included ≥4 mental health visits, ≥3 psychotherapy, or ≥60 days of medication. In multivariate regressions, we examined whether higher rates of PC-MHI penetration in clinic (proportion of total primary care patients in a clinic who saw any PC-MHI clinician) were associated with greater depression care quality among cohort patients, adjusting for year, healthcare system, and patient and clinic characteristics. DATA COLLECTION/EXTRACTION METHODS:Electronic health record data from 82 VA clinics across three states. PRINCIPAL FINDINGS:A median of 9% of all primary care patients were seen by any PC-MHI clinician annually. In fully adjusted models, greater PC-MHI penetration was associated with timely depression follow-up within 84 days (∆P = 0.5; SE = 0.1; p < 0.001) and 180 days (∆P = 0.3; SE = 0.1; p = 0.01) of a positive depression screen. Completion of at least minimal treatment within 12 months was high (77%), on average, and not associated with PC-MHI penetration. CONCLUSIONS:Greater PC-MHI program penetration was associated with early depression treatment engagement at 84-/180-days among clinic patients newly identified with depression, with no effect on already high rates of completion of minimally sufficient treatment within the year.

BACKGROUND:A welcoming environment may influence patient care experiences, and it may be particularly relevant for underrepresented groups, such as women veterans at Veterans Health Administration (VA) facilities where they represent only 8-10% of patients. Challenges to ensuring a welcoming environment for women veterans may include unwelcome comments from male veterans and staff or volunteers and feeling unsafe inside or outside VA facilities. We assessed associations between reports of gender-related environment of care problems and patient-reported outcomes. PROCEDURES:We merged national patient-reported outcomes from women veterans (n = 4,961) using Consumer Assessment of Health Plans & Systems Patient Centered Medical Home (CAHPS-PCMH) survey composite measures with Women Veteran Program Managers' reports of gender-related environment of care problems (n = 127, 2016-2017) at VA facilities. We performed multilevel bivariate logistic regressions to assess associations between Women Veteran Program Managers' reports of large/extreme problems and likelihood of women veterans' optimal ratings of primary care experiences (access, coordination, comprehensiveness, provider communication, and overall rating of primary care provider). We adjusted for patient-, site-, and area-level characteristics, and clustering of patients within VA facilities, and we applied design weights to address nonresponse bias in the patient data. Response rates were 40% for women veterans and 90% for Women Veteran Program Managers. MAIN FINDINGS:Few (<15%) Women Veteran Program Managers reported large/extreme environment of care problems. Women veterans obtaining care at those sites were less likely to rate provider communication and comprehensiveness (psychosocial health assessed) as optimal. PRINCIPAL CONCLUSIONS:Ensuring a welcoming environment may improve women veterans' primary care experiences.

Background Technological burden and medical complexity are significant drivers of clinician burnout. Electronic health record(EHR)-based population health management tools can be used to identify high-risk patient populations and implement prophylactic health practices. Their impact on clinician burnout, however, is not well understood. Our objective was to assess the relationship between ratings of EHR-based population health management tools and clinician burnout.Methods We conducted cross-sectional analyses of 2018 national Veterans Health Administration(VA) primary care personnel survey, administered as an online survey to all VA primary care personnel (n = 4257, response rate = 17.7%), using bivariate and multivariate logistic regressions. Our analytical sample included providers (medical doctors, nurse practitioners, physicians' assistants) and nurses (registered nurses, licensed practical nurses). The outcomes included two items measuring high burnout. Primary predictors included importance ratings of 10 population health management tools (eg. VA risk prediction algorithm, recent hospitalizations and emergency department visits, etc.).Results High ratings of 9 tools were associated with lower odds of high burnout, independent of covariates including VA tenure, team role, gender, ethnicity, staffing, and training. For example, clinicians who rated the risk prediction algorithm as important were less likely to report high burnout levels than those who did not use or did not know about the tool (OR 0.73; CI 0.61-0.87), and they were less likely to report frequent burnout (once per week or more) (OR 0.71; CI 0.60-0.84).Conclusions Burned-out clinicians may not consider the EHR-based tools important and may not be using them to perform care management. Tools that create additional technological burden may need adaptation to become more accessible, more intuitive, and less burdensome to use. Finding ways to improve the use of tools that streamline the work of population health management and/or result in less workload due to patients with poorly managed chronic conditions may alleviate burnout. More research is needed to understand the causal directional of the association between burnout and ratings of population health management tools.

Objectives:We examined how individual-level turnover among Veterans Health Administration primary care providers (PCPs) from fiscal years 2017 to 2021 was associated with health care system-level burnout and turnover intent.Background:Burnout among PCPs has been well documented in recent studies, but less is known about the potential relationship between burnout and turnover.Methods:We identified a national cohort of 6444 PCPs (physicians, nurse practitioners, and physician assistants) in 129 Veterans Health Administration health care systems in the first quarter of fiscal year 2017 and tracked their employment status for 20 quarters. PCP employment data on turnover were linked to annual health care system-level employee survey data on burnout, turnover intent, and other covariates. We performed logistic regression to estimate the impact of health care system-level burnout and turnover intent on individual PCP turnover, controlling for individual and health care system-level covariates and adjusting for clustering at the health care system level.Results:Median health care system-level burnout ranged from 42.5% to 52.0% annually, and turnover among PCPs ranged from 6.3% to 8.4% (mean = 7.0%; SD = 0.9%). Separation from employment was higher among employees at health care systems with the highest burnout (odds ratio =1.14; 95% CI = 1.01-1.29) and turnover intent (OR = 1.18; 95% CI = 1.03-1.35).Conclusions:PCPs in health care systems with high burnout are more likely to separate from employment. Policymakers and administrators seeking to improve retention should consider system-level interventions to address organizational drivers of burnout.

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.

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.

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

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 (> 75 th 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 (< 25 th 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.