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Carolyn Clancy, M.D.Deputy Under Secretary of Health for Organizational ExcellenceVeterans Health Administration
FY 16-17: Agency Priority Goal
Improve Access to Health Care as Experienced by the Veteran
Priority Goal
Goal Overview
VA has experienced unprecedented growth in demand for its services as a result of better recognition of service-connected conditions; innovative and favorable clinical offerings for complex and costly health conditions; and the growing needs of an aging Veteran population. VA is also embedded within the larger U.S. health system, which is similarly experiencing increased demand for services and shortages of key clinical professions due to advances in technology and the aging of the population[1].
In 2015, a congressionally-mandated Independent Assessment of VA Healthcare Capabilities[2] as well as an Institute of Medicine report[3] highlighted that VA access, while meeting timeliness standards on average, still had unacceptable levels of variation by site for specific services. These independent reviews are candid in stating that highly specialized services required by Veterans are frequently not available in their communities even from private sector providers. Those independent reports interviewed many of U.S. medicine’s thought leaders, and these experts highlighted the critical importance of addressing access challenges by taking a systems approach, and recommended strategies such as modeling system supply and demand relationships, exploring design and policy changes, and creating a culture of service excellence that empowers the front line to experiment, identify limitations, and learn from trials.
The ultimate success of these strategies and programs must be evaluated through the eyes of the Veteran, as a noticeable improvement in their self-reported ability to receive needed care. Assessing access to health care through direct survey of patients is the only access measure currently endorsed by the National Quality Forum. Using a survey-based approach to measure access also provides additional advantages, such as 1) ability to benchmark with private sector health systems and 2) avoiding the shortcomings of current VA scheduling software (a replacement scheduling system will not be in place until late 2017).
[1] Rosenthal E. Long waits for doctors’ appointments have become the norm. New York Times July 5, 2014.
[2] www.va.gov/opa/choiceact/factsheets_and_details.asp
[3] Institute of Medicine, Transforming Health Care Scheduling and Access. Washington: National Academies Press, 2015.
Strategies
Improving access to care will require VA to adopt a multi-pronged approach to manage its clinical processes at each of its sites of care with attention to supply, demand, contingencies, and clinical urgency. This includes the recent (January 2016) deployment of a real-time Health Operations Dashboard and training staff at all sites in principles of clinical practice management. In the second quarter of FY 2016, VA will launch a MyAccess initiative that will provide coaching and consultation in the tools of Lean Improvement, which each site of care will use to identify bottlenecks and constraints in patient scheduling and clinic flow. A newly created Office of Community Care will provide leadership in building a nationwide, high performing network of community-based providers that can serve Veterans when VA care is too distant or delayed. VA will also expand its alternatives to an office-based visit using Telehealth, Secure Messaging, and other modalities. Finally, VA will deploy new guidance on assessing the time sensitivity and urgency of clinical needs, so that we can assure that Veterans with the most urgent needs can have same or next-day access.
Progress Update
Year to date performance through July 2016, is 77.5 percent on the Composite measure, with component scores of 72.4 percent for Urgent Primary Care, 83.6 percent for Routine Primary Care, 72.1 percent for Urgent Specialty Care, and 82.0 percent for Routine Specialty Care. July results show performance is comparable to prior quarters.
It is important to note that, since November 2015, VA has launched a multi-pronged effort (“MyVA Access”) focused on improving the ability to provide same or next-day services in primary care and mental health settings and reducing the backlog of specialty care consults. For instance, 39 VA facilities now have same-day services, and our plan is to expand that capability to all sites by December 2016. That is likely to have a major impact on our lowest performing component of the Access APG, Urgent Access. In addition, we mounted a successful focused effort to address the backlog in time-critical Specialty Care consultations (see http://catalyst.nejm.org/va-stand-down-resolved-56000-plus-urgent-care-c... for a detailed case study). We are in the first phases of deploying a web-based Veteran Appointment Request (VAR) application that will allow Veterans to directly select an open appointment slot that best matches their needs. Finally, VA is poised to launch a new interactive website that will provide site-specific Access results to the public, with the intent of providing a transparent accounting of our performance and information that will help Veterans select clinic location that best meets their needs.
There are risks to achieving this APG. Veteran reliance upon and demand for VA services is dependent on many factors, including state of the economy; availability of alternative coverage (employer health coverage and Medicaid expansion); out-of-pocket costs for those alternatives; and technology advances (e.g., hepatitis C drugs; advances in prosthetics, vision, and hearing aids). Critical shortages and maldistribution in primary care, mental health, and other specialties make recruitment of clinical providers exceptionally challenging in many markets. We note, however, that VA is implementing mitigation approaches for all of these risks – for instance, redesigning our processes to simplify purchasing care in the community; mounting efforts to expand recruitment of physicians and expand the practice authority and autonomy of advance-practice nurses; and providing new modes of accessing care such as telehealth that will reduce the need for office visits. All of these represent long-term strategies, and so our success will be best gauged over years rather than months.
APG Indicators:
The primary APG is a composite measure of the percentage of Veterans who state they are usually or always able to get a primary care or specialty care appointment, as stated below:
The average of the percent “Usually” or “Always” responses for four access measures found in the Patient Centered Medical Home (PCMH) survey and the Specialty Care Consumer Assessment of Health Providers and Systems (CAHPS) Survey.
This is a Veteran-centered composite measure that assesses Veteran perceptions of their experience with access to VA care by using data from the Survey of Healthcare Experiences of Patients (SHEP) program. It is based on two survey questions that are each included in the Patient Centered Medical Home (PCMH) survey and the Specialty Care Consumer Assessment of Health Providers and Systems (CAHPS) Survey. These questions are part of validated, industry-standard surveys conducted by an external certified vendor.
The survey questions assess:
• Percent of Specialty Care patients who responded “Usually” or “Always” regarding their ability to get an appointment for needed care right away
• Percent of Primary Care patients who responded “Usually” or “Always” regarding their ability to get an appointment for needed care right away
• Percent of Primary Care patients who responded “Usually” or “Always” regarding their ability to get an appointment for a routine checkup as soon as needed
• Percent of Specialty Care patients who responded “Usually” or “Always” regarding their ability to get an appointment for a routine checkup as soon as needed
The composite is calculated as the average of the percent “Usually” or “Always” responses for four questions (two from both the PCMH and CAHPS surveys). The four questions are equally weighted in the average calculation. The composite is reported monthly at the facility, network, and national levels. These SHEP surveys are conducted every month using a robust sampling design with approximately 120,000 surveys distributed via postal and email modalities.
The Composite APG target has been determined after the baseline results were collected in the fourth quarter of FY 2015.
The APG target is an improvement of 15 percent over the baseline score (87 percent) established in the fourth quarter of FY 2015. To properly track the progress on this APG indicator, VA also will provide additional data that will add context and aid understanding of agency efforts. These additional indicators will not have targets associated with them. The contextual indicators will include, at a minimum: 1) growth in demand (total number of health care encounters; total numbers of Veterans served); 2) growth in supply (net increase in clinical staff; net increase in appointment slots); and 3) trends in waiting times and waiting lists for urgent clinical needs.
Reporting systems for these ancillary metrics are currently under construction for the purpose of public reporting.
Next Steps
• A real-time Health Operations Dashboard has already been developed and made operational across all VA facilities. VA continues to expand the site by working closely with Primary Care, MyAccess and Access and Clinic Administration Program staff to develop a new leadership report to assess Primary Care demand with capacity to identify staffing gaps.
• A newly formed Office of Connected Care will leverage advanced information technologies, including Telehealth, mobile applications, secure messaging, and others, to provide alternatives to face-to-face clinic visits, thereby expanding clinic capacity October 1, 2016.
• A Clinical Practice Management curriculum, intended to train all staff in a systems approach to managing supply and demand and optimize the use of VA versus community resources, will be developed and rolled out no later than February 2017 (date mandated by the Veterans Choice Act).
• Baseline results from the fourth quarter of FY 2015 will be used to establish a system-wide target based on 15-percent improvement over baseline by September 30, 2017.
Expand All
Performance Indicators
Percent of Primary Care Patients who responded “Always” or “Usually” regarding their ability to get an appointment for needed care right away
Percent of Specialty Care patients who responded “Always” or “Usually” regarding their ability to get an appointment for a routine checkup as soon as needed
Percent of Primary Care patients who responded “Always” or “Usually” regarding their ability to get an appointment for a routine checkup as soon as needed
Percent of Specialty Care patients who responded “Always” or “Usually” regarding regarding their ability to get an appointment for needed care right away
Composite measure: The average of the percent “Always” or “Usually” responses for four access measures found in the Patient Centered Medical Home (PCMH) survey and the Specialty Care Consumer Assessment of Health Providers and Systems (CAHPS) Survey.
Contributing Programs & Other Factors
Meeting the Access APG cannot be achieved without a strong partnership and alignment of VA, other Federal, and community based programs. Key VA programs contributing to this goal include (with Federal Program Inventory identifier codes): 3.2 Ambulatory Care; 3.3 Mental Health Services – General Outpatient Care; 3.14 Women Veterans Health Care; 3.19 Home Based Primary Care; 3.26 Telehealth. Veterans Care in the Community Programs are the new designation for the spectrum of programs purchasing care from community-based providers, including Veterans Choice Program; PC3; and Project ARCH. VA also plans to optimize its use of Department of Defense Medical Treatment Facilities and clinics, Tricare Program, Indian Health Service Hospitals and clinics, and Federally Qualified Health Centers. The VA Office of Academic Affiliations, working with the Schools of Medicine, Nursing, and Allied Health Professions affiliated with our medical centers, is essential for training and recruiting the next generation of providers that will serve Veterans. Finally, the VA Office of Research and Development (Health Services Research; Quality Enhancement Research Initiative) will contribute to program evaluation, and the rapid dissemination of evidence-based practices that enhance access, capacity, and patient experience.
No Data Available
