The VA’s specialty care transformational initiatives to improve access and delivery of specialty care

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STATEMENT OF PROBLEM OR QUESTION (ONE SENTENCE): In the VA, Veterans can experience difficult access, fragmented care, long wait times, and significant travel distances for specialty medical care.

OBJECTIVES OF PROGRAM/INTERVENTION (NO MORE THAN THREE OBJECTIVES): In May 2011, the VA Office of Specialty Care Transformation (OSCT) launched four initiatives to improve access and delivery of specialty care to Veterans.

DESCRIPTION OF PROGRAM/INTERVENTION, INCLUDING ORGANIZATIONAL CONTEXT (E.G. INPATIENT VS. OUTPATIENT, PRACTICE OR COMMUNITY CHARACTERISTICS): These initiatives include: 1) Innovations in Consult Management (E-Consults), 2) Specialty Care Access Network-Extension for Community Healthcare Outcomes (SCAN-ECHO), 3) Specialty Care Mini-Residency Program (SC-MRP), and 4) Specialty Care Neighborhood Team (SCNT). In E-consults, primary care providers (PCPs) can ask questions regarding a Veterans’ care to specialists and receive recommendations through the electronic medical record within 48 h. In SCAN-ECHO, there are regular videoconferencing sessions between primary and specialty care providers. During these sessions, there is a didactic lecture about a clinical topic and patient case presentations, including discussions of diagnostic or therapeutic treatment options between providers. The SC-MRP initiative trains physicians, NPs, and PAs to perform procedures (e.g., knee injections) and principles of disease management within the scope of primary care settings. The goal of SCNT is to deliver coordinated medical, surgical and/or psychosocial care based on a Veteran’s condition. A care coordinator facilitates communication among specialists, PCPs, and patients; and a patient navigator helps Veterans with their care.

MEASURES OF SUCCESS (DISCUSS QUALITATIVE AND/OR QUANTITATIVE METRICS WHICH WILL BE USED TO EVALUATE PROGRAM/INTERVENTION): As part of the implementation process, OSCT also funded an evaluation center, whose goals are to provide data to OSCT to inform any changes needed to current and future implementation sites. The center is using a mixed-methods approach. Data sources include cross-sectional, in-depth interviews and surveys of administrators, PCPs, specialists, and patients; and administrative data from central VA data sources. Following data collection, meta-inferences are made based on a merging data approach to ask how the qualitative interview themes helped us understand the quantitative survey data findings, and vice versa.

FINDINGS TO DATE (IT IS NOT SUFFICIENT TO STATE “FINDINGS WILL BE DISCUSSED”): The evaluation is ongoing. By end of November 2012, E-Consults have been implemented at 115 hospitals for 51 specialties. There have been 242,054 E-consults generated for 188,299 Veterans. For SCAN ECHO, 11 sites have implemented the program for 15 specialties with 737 sessions conducted. There are 3 SC-MRP sites initiated in 2011 with 2 sites focused on musculoskeletal care and 1 site on dermatology. For SCNT, 25 sites have begun the initiative focused on 19 specialties/conditions. New sites and specialties are being added on a yearly basis.

KEY LESSONS FOR DISSEMINATION (WHAT CAN OTHERS TAKE AWAY FOR IMPLEMENTATION TO THEIR PRACTICE OR COMMUNITY?): OSCT and the evaluation center have adopted a participatory action research framework where the needs of OSCT drive the evaluation and findings from the evaluation center inform OSCT of how to implement and adapt the initiatives with the goal of enhancing these initiatives and making them sustainable.