Partnership Forum
The Role of Research in the Transformation of Veterans Affairs Community Care
Datos Bibliográficos
In response to concerns about Veterans’ access to Veterans Affairs (VA) health care services, Congress passed the Veterans Access, Choice and Accountability Act of 2014 (Choice), which broadened Veterans’ eligibility to receive health care delivered by non-VA community providers paid for by VA (ie, Community Care).1 Specifically, the Veterans Choice Program (VCP) allowed Veterans waiting longer than 30 days for specific services in VA, who lived >40 miles from a VA clinic, or who experienced specific hardships in accessing VA care, the option of receiving Community Care. To help implement VCP successfully, the VA established the Office of Community Care (OCC) in fiscal year (FY) 2015 to lead the coordination of Community Care expansion. This included reorganizing local departments at each VA facility to ensure that VA/Community Care referrals across systems occurred seamlessly. With the passage of Choice, one of VA’s top priorities—to become a high-performing integrated network—was changed to reflect the inclusion of both VA and Community providers. Similarly, the VA’s Health Services Research and Development Service (HSR&D) portfolio began to incorporate the new priorities arising from the expansion of Community Care.2 The initial call for Community Care research funding set the stage for collaborations between operations and research. Although the implementation of the VCP was underway, new contracts for Community Care were still in process, and therefore researchers were expected to conduct their activities in active partnership with OCC. The purpose of these collaborations was to achieve “a scientifically rigorous product that is also relevant, feasible, and sustainable in real-world medical practice.”3 By partnering with OCC, our research teams’ interests and methodologic expertise were and continue to be informed by OCC’s knowledge of changing health care delivery practices and policies.4,5 Through communicating early and frequently with OCC, having a shared understanding of our mutual goal to increase Veteran access to high-quality timely health care, and leveraging our respective scientific and organizational strengths,3 we were well-positioned to ensure that our research efforts would have maximal impact and relevance for real-world clinical practice in the VA Health Care System. In 2017, HSR&D awarded planning grants to our 3 research teams to develop methods to evaluate VCP’s impact on Veterans’ health care quality, costs, and access and to investigate Community Care Network (CCN) adequacy. These research efforts were undertaken with the expectation that they would be conducted in active partnership and collaboration with OCC. Relationships between our HSR&D research teams and OCC began informally, with each team reaching out separately to OCC based on their specific research needs. Simultaneously, the research teams began working collaboratively with one another and with the VA’s Partnered Evidence-Based Policy Resource Center (PEPReC) to share what we each learned and prevent duplication of efforts across projects. These early partnerships resulted in our HSR&D research teams and OCC leadership coming together on common areas of interest, such as at the Network Adequacy Expert Panel meeting in 20176 and the Evaluation Data Strategy meeting in 2018 where we exchanged knowledge about Community Care processes and data resources to support evaluation. By 2018, each of our 3 research teams had a strong partnership with OCC and growing numbers of HSR&D researchers who were developing proposals focused on Community Care were also interested in establishing partnerships with OCC. As Veterans’ utilization of Community Care continued to increase, HSR&D awarded additional grants, including 3 additional years of research funding to each team following successful completion of the planning grants. These new grants focused on the accuracy and missingness of Community Care data and its impact on care coordination; the impact of the implementation of the Choice Act on Veterans’ health care quality, costs, and access; and the adequacy of the CCNs. About this same time, the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act of 20187 was passed, which further expanded eligibility for Veterans to Community Care and created a more permanent and consolidated Community Care Program, the Veterans Community Care Program (VCCP). This Act not only increased Veterans’ options to seek care in the community but provided a stronger “raison d’être” for the partnership between research and OCC. By 2019, with increasing numbers of grants awarded to HSR&D researchers, OCC was frequently asked to provide needed information on Community Care data, policy, and implementation updates. Each of our 3 research teams was also contacted more often by other researchers interested in learning about our experiences in working with Community Care data. Recognizing the need to disseminate information more widely and systematically throughout the VA research community, we proposed a Partnership Forum with OCC entitled “VA Community Care: Ongoing Evaluation Efforts, Preliminary Analyses, Data Systems, and Emerging Issues in the Implementation of The MISSION Act,” for VA’s 2019 Health Services Research & Development/Quality Enhancement Research Initiative (HSR&D/QUERI) conference. THE PARTNERSHIP FORUM The Partnership Forum was designed to bring together individuals interested in Community Care to share ideas, gain knowledge, and discuss the potential synergy between OCC’s and VA researchers’ priorities and interests. Dr Kameron Matthews, Deputy Under Secretary for Health for Community Care, gave researchers the opportunity to learn more about current OCC priorities, the ways in which researchers could contribute to these priorities, and the newly implemented MISSION Act. After Dr Matthews’ presentation, each of our 3 research teams provided a brief overview of our research efforts, sharing what we had learned about VCP and our work in progress. The next sections of this paper provide the highlights of these Forum presentations. Office of Community Care Priorities An aim of the Partnership Forum was for OCC to identify priority areas where research efforts would be most impactful. According to Dr Matthews, the overarching priority is to ensure Veterans have access to a Community Care program that is easy to use, provides greater choice and high-quality care, and allows for robust care coordination. This requires a focus on health care delivery—establishing and managing contracting, facilitating clinical integration, overseeing provider relations and services, and claims reimbursement. Although these activities are not typically within the purview of researchers, the research community has some overlapping interests with OCC’s. For example, how the implementation of VCCP affects the delivery of health care to Veterans is fundamental to the efforts of both researchers and OCC. Greater attention to the realities of the health care delivery system means that research findings may be more rapidly implemented into real-world clinical practices as they are likely to be clinically driven and evidence based. Yet, these same realities may present barriers to implementation that will need to be overcome. Care Coordination OCC spoke of the lack of existing research to guide the implementation of evidence-based care coordination models for multisystem use and the need to better understand Veterans’ care coordination needs. Although OCC monitors the extent to which Veterans receive care from both VA and Community Care providers and seeks to improve processes that facilitate better communication and convenient and secure sharing of medical records,8 it needs researchers’ assistance with the following: (1) methods development; (2) evaluation of care coordination improvement efforts; (3) tailoring care models to specific health conditions9 and patient populations10; and (4) aligning resources with high-risk patients, regardless of where patients receive care. To ensure satisfactory patient outcomes,11 OCC is committed to care coordination that encompasses care delivered through both VA facilities and VA community providers, as well as through public (eg, Medicare, Medicaid) and private providers. Quality of Care OCC identified specific quality of care topics to support their ongoing efforts: (1) evaluation and refinement of established quality metrics; (2) initiation of quality improvement (QI) activities based on quality metrics; (3) of methods to evaluate efforts; and (4) of care coordination and quality to facilitate The regardless of the between care and they also for the potential of data to prevent Community Care providers. Community Care of OCC leadership would to learn more about Community Care provider and as it to Veteran care. were to develop and implement methods to ensure that Community Care providers are of Veterans’ health (eg, and as well as their medical and such as and to provider and at the Forum for researchers to provider and be is be across VA and Community Care providers to provider have for Community Care VA or its interested in Community Care provider and the and of these providers, the of OCC and partnership to and Network Adequacy OCC’s priorities in this are focused on understanding adequacy with contracts for care (ie, (ie, and between VA facility and to ensure that each local priorities and needs. For researchers interested in to (1) a to the to access to (2) how VA and sustainable with its of providers and they lead to greater access to care, increased provider and Veteran and better (3) what information both providers and Veterans would that would be in about VA and Community providers (4) ways in which this information be to be most OCC is interested in understanding how Veterans about where to receive care and how Veterans’ about VA or The overarching goal of is to ensure that Veterans are with the care they which high-quality health care. research were by OCC for researchers to Veterans’ experiences with their care providers and facility their on where to seek VA researchers evaluate VA’s as integrated health care delivery system is with existing be to identify barriers to Veterans’ use of VA to OCC, VA researchers are interested in that Veterans receive high-quality health care. researchers’ priorities are focused on new scientific knowledge to achieve this goal which often Although this is changing with VA’s to a Health Care to between researchers’ and priorities and VA identified 3 models of that be to achieve mutual (1) research scientific findings that clinical care and (2) research and operations (eg, clinical work together on common research priorities and implementation and (3) within VA’s integrated health care system that evidence that be to evaluate the of these The passage of Choice and MISSION means that OCC and VA researchers are likely and 3 to current needs. need to develop and use methods to evaluate the implementation of VCCP its and and identify across facilities and Veterans Integrated Services Networks within have VCP and VCCP were (1) understanding the of expanded Community Care implementation and what that (2) new data and the quality of these data (3) understanding the and and the that be our research OCC has our efforts, and in we have provided OCC with research findings that their and it be with to data clinical or The next present brief of the work conducted by each of the research teams that in the The our research the of from research initiation to and how our research efforts informed OCC’s needs and priorities Care Coordination To understand VA and VCP care coordination and these needs by care we Veterans’ VA and Community Care use by care and care from to that Veterans’ of use this by and also that for Veterans services for was a increase on VA for Community Care services that were more likely for VCP for in with and for Veterans and with the Partnership we shared our current work in progress. This work that Veterans’ care coordination needs will likely for care than services in the community to and This in informed OCC’s priority to understand how to care models to specific health patient and resources regardless of where patients receive care. Quality of Care it is well that VA or better than non-VA on most of and is about in quality between VA and Community Care. To this we our research of between VA and Community for the (1) is a widely in the (2) it is a common in the VA and with increasing as the and (3) it is a Although we that Veterans to Community Care would have than their in the VA to the potential for care, this was not by the data. In we in between VA and Community Care, for such as and clinical through the use of a This in OCC’s priority of between care and care additional data with OCC in this will be for areas where are needed and to help for Network Adequacy research team is interested in how VA adequacy is how are with and how the affects Veterans’ health shared our work from our Expert Panel meeting in 2017, which was by OCC. The Panel adequacy by other health care or the Care Act could be by the The Panel to non-VA adequacy to the these included a better understanding of VA’s services and to provider reimbursement. The Panel that VA develop by care (eg, care and provide Veterans with provider This information adequacy that have into work in on how these new are that facilitate successful VA/Community Care provider and Veterans’ for provider with OCC have and will continue to to understanding how policy, data, and health care use adequacy and support a high-performing integrated health care research some of OCC’s adequacy priorities, but additional research is needed and have of the current research efforts to that we are of that have OCC In the and of these current efforts, which focus on specific of care (eg, care, specific Veteran (eg, and of health care delivery (eg, provides of in This work and will provide OCC with evidence-based information to guide implementation of VA Research and Care coordination Health and Care Coordination for Veterans in a Health Center evaluation of Quality program provider health data, care patient (1) patients for care at Health Center for Veteran a (2) patients for health including use and (3) identify and Veteran patients with accessing VA care and (4) ensure Veteran patients for health are receive timely health care at a VA the or other health care The is of the Care Care Care Coordination and in the VA Choice Program and with from 3 and VA clinical and VA and claims data (1) for and local VA facility implementation of quality, and and (2) organizational and health information needs to support clinical care coordination and quality (3) and quality for and care and (4) methods the extent of of services for Veterans for VCCP Veterans receiving care in VA Care Access, Care Quality of Care, Health Care Care for Veterans Through VA and Community Quality of patient and provider care health data (1) and the of through of and in VA and community health information (2) data of and to health for (3) and clinical of (4) health care coordination for Veterans receiving care in VA and community Care Care Coordination of Care VA and With care coordination data (1) care coordination for VA care care in the community, as experienced by VA providers and both VA and Community Care (2) the between use of to care with coordination as experienced by VA providers and both VA and Care Coordination Quality of care Choice Evaluation of the Quality of Through the MISSION VA Care for Veterans With and evaluation with and data Veteran utilization of VCCP and care (1) Veteran utilization of VCCP and care (ie, access to care, care of services and for 3 and (2) information about VCCP implementation (eg, barriers and and to and clinical (3) evaluate Veterans’ and and quality of VCCP and (4) gain a understanding of patient and VCCP and care experiences for and Quality of Care for Veterans With and care processes for Veterans who receive care within the VA VCCP to VA data through claims (1) for Veterans with to community providers in VA To identify to improve delivery of for Veterans with Quality of Care the on Access, and the Care for the quality of care, and of Veterans the Choice program with specific focus on and health the data, data (1) in utilization of and access to (2) develop and a to between and (3) use of care, and health Quality of Care, Access, Health Care Network adequacy Network Adequacy and Community in Veteran Care An VA Veteran use, OCC Data data (1) and of adequacy for non-VA and evaluate in adequacy across Veterans in VA and VA’s (2) the by which are at VA and to identify existing and potential to community partnerships to (3) Veterans including for a of providers and quality of providers to more understand their on Network Access, the of VA Care Resource and on in the of and providers, (1) the proposed organizational of care and understand how these will be to care, with a focus on 3 that access and are therefore likely to be to (2) understand how be integrated into care to for care in facilities and further Access, Care Quality of Care The of Policy and on Veteran to of data and utilization of a Veterans and use of as a for of In in (2) to other (3) Veteran experiences accessing VA and non-VA services following implementation of the MISSION Act. In impact of on access to VA and non-VA (2) Veteran and on the and of for Veterans in to from (3) identify priorities and to improve Veteran access to care Access, Community Community and Quality Evaluation including Veteran (1) priority areas of care and in VA on and access for new in these areas of VA provided and VA community (2) quality and in VA of patient for the priority areas of (3) develop for evaluation of MISSION Act on quality, and patient for VA provided and VA community care Access, Veterans methods evaluation of the program VA and data, care use and use and (1) for VA care for both and (2) patient for VA care for both and (3) for VA care for both and Veterans Access, Quality of Care for Act (1) This on additional work to support our and clinical focused on of with community providers, and to Congress Access, and evaluation Veterans’ Choice in Care VCP VCP (1) of the use of VA and non-VA care, VA and is needed to guide the and expansion of the we will the in utilization and on and care in the of other non-VA care will also which patient and VA choice of VA or providers. we will the impact of the Veterans Choice Program on for patients Access, Care Quality of Care Veterans’ to Care through and implementation evaluation of data from VA provider and patient (1) To understand and the and implementation of to Veterans with access (2) to evaluate the of the and the in reaching high-risk (3) to the through a impact Access, Care Veteran About of VA and Health Care methods focus to a of the of information Veterans use and need for about VA and non-VA care (1) how Veterans are about VA and non-VA care and what information they to use these (2) identify of Veterans’ to use and experiences with VA and non-VA health (3) Veterans and VA to identify to Veterans’ about use of VA and non-VA care and VA’s to Veterans’ health care Health care utilization Veterans with methods data Veteran Veteran (1) utilization of VA Veterans with (2) between use and health and Veterans with (3) understand Veterans’ need and experiences with VA Health Care Quality of Care, Care and the methods of claims data, by patient from VA Veteran (1) Veterans’ use of the care the of the including use of care, and use for potential and (2) Veterans’ and coordination experiences with care and Health Care Care Veterans of and Health Care data VA data (1) in Veterans’ in and (2) the between use of health and use of (3) the impact of use on from Health Care and of Health Services by Veterans in VA and health care data, of health services, provider (1) utilization and of health services provided to and in non-VA health care facilities through and across in services provided in each (2) utilization and of health services provided to Veterans in and non-VA facilities through their and across provided in each (3) identify barriers and to of health services in VA and non-VA health care Health Care Quality of Care and Health for Veterans With Health Care models based on a VA and claims data from a (1) the impact of eligibility on VA health care utilization and health on the VA and (2) understand the impact of for on VA health care utilization and health on the VA and (3) identify that access Health Care to and Choice of VA or Health Care by Veterans of methods of health information (1) what information and resources VA facility and need to better understand and and for and health (2) on facility by access to care, and quality of care for and health (3) develop or existing information to facility and to and for and health care Health Care Access, Quality of Care Veterans to Care of VA and non-VA and data, Veteran use of care in and the of non-VA use on VA (1) VA resources and (2) VA and non-VA utilization and identify and of VA (3) resources and (4) how care in VA care impact on care use and Health Care Quality of Care, impact Care delivery Systems and Care in the VA data, data (1) VA current and areas in which and more robust of system ongoing and VA (2) identify and data needed for that VA and non-VA care delivery systems on quality, use, and system to evaluate current and the of of in VA Care MISSION Act evaluation and (1) The evaluation goal is to the impact of in Care as of the MISSION Act to the use and of services for use and health in a In we will the of to their to with community health care providers and Veterans by providers as well as the of the program to Veterans and of Veterans Care Access, and evaluation of Veterans to in the methods of and data with VA and Veteran VA patients (1) and other expected to from VA the expansion of (3) the of to with and and (4) experiences of care and their on the between and for VA use Implementation to Care for Veterans quality improvement (1) Care across in and to Veterans with health (2) to evaluate the impact of this implement quality metrics; these will also be to identify to identify and for Quality of Care, Care Coordination Resource Partnered Policy Resource and Evaluation and and data evaluation of and data, These are evaluation activities Partnered activities with (1) of to facilities to with of the MISSION Act and (2) evaluation of the (3) evaluation of impact of medical on provider and patient Partnered activities with OCC of by Resource Act Research Network research with researchers and (1) of communication between OCC and researchers and impact of MISSION assistance to researchers on and Community Care Research Evaluation & Center Policy and data expertise to share and disseminate information across research and operations To collaboration and knowledge in research between VA and VA OCC to support the of both VA researchers and VA OCC leadership to develop quality, information with VA OCC and priorities Community Community Care Data for and fiscal Health Services Research and Development Panel OCC, Office of Community Office of Health and Office of Office of Veterans to Program Quality Enhancement Research of of Data VA, Veterans Veterans Community Care Veterans Choice Veterans Health Veterans Integrated Services Community Care Research Evaluation & Center The meeting provided to a about how to a more sustainable partnership between OCC and VA researchers from each of our 3 and a from to a research together that would use our existing partnership the years as a for a partnership researchers interested in Community Care and OCC. This was and the Community Care Research Evaluation & Center was established in is to collaboration and knowledge in Community Care research between VA and OCC to develop quality and information that is with both OCC priorities and VA research interests and needs. will as information for OCC and practice ongoing Community Care research efforts, and Community Care data Community Care Research Evaluation & and Community Care Data of is to ensure that researchers have access to as well as information about Community Care data. our research and have working with these data for we are to provide the This is time, Community Care have and new of data and data have become the use of these data requires understanding of both the data and at specific in To this is developing support to provide researchers with to Community Care and shared that allows researchers to work together on common data will also researchers to receive OCC data support by and that from the of Community Care Research Evaluation & and Community Care are about 30 VA on Community Care and we this will and is to support these researchers as well as interested in research to Community Care, with the goal of greater for collaboration and information To in the of began to researchers interested in VA Community Care, (1) discuss and program (2) share research and (3) discuss data and HSR&D researchers interested in learning more about Community Care are to these from to who are Community Care grants. As the VA into a Health Care HSR&D the of partnerships between researchers and such as OCC, that research be into real-world HSR&D has their support for Community Care partnerships by funding and facilitating access to OCC and by for OCC and researchers to with one another at and such as the Partnership which was by in and a sustainable partnership between OCC and HSR&D This not provide a of Community Care research it on the of partnerships and highlights areas where research OCC’s current priorities and and how OCC facilitate research and also the of researchers with the and information they need to conduct research projects. As VCCP to with the implementation of the MISSION partnerships such as and such as will become to the of VA’s Health Care System
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