Impacts of Organizational Variations on Access Management

背景：护理延误（即，获得及时护理的机会少）与对 发病率、死亡率和生活质量，以及身体和精神健康状况的不良结果。 VHA医疗保健系统长期以来一直在与准入问题作斗争，然而，VHA在2014年的“准入危机”， 在举报人揭露故意掩盖长期存在的 拖延，引起了特别的愤怒，因为有证据表明，退伍军人已经死亡，等待看到他们的VHA医生。 改善退伍军人获得护理的机会仍然是VHA的首要任务之一， 社区供应商一直是减少等待和延误的最明显的方法之一，VHA已经 还实施了许多举措，以改善退伍军人及时获得VHA内的护理。这些 包括发展团体业务经理角色，以促进面对面和虚拟的咨询 通过呼叫中心和访问管理工具（例如，网格验证）。改善访问管理- 有效地部署诊所人员、资源和流程，以实现及时访问， 尽管如此，这仍然是一个挑战，特别是在差异很大的组织和地理环境中。尽管他们 重要的是，很少有人知道这些战略已经实施，这些因素， 支持或阻碍它们的使用，或它们与访问指标的关系。 具体目标：为弥补这些差距，我们提出以下具体目标： 目标1：评估当地VA设施如何管理初级保健服务的国家差异。 目标2：评估不同的访问管理策略与访问度量之间的关系。 目标3：在目标1和2的成果基础上，组织一次国家专家小组会议，就以下问题达成共识： 以证据为基础的做法和政策建议，以改善获得护理的机会。 方法：对于目标1，我们建议使用基于关键信息提供者的组织调查来评估实施情况 在全国范围内实施准入管理战略。我们将研究区域和组织的决定因素 通过将调查结果数据与地区资源档案措施联系起来， (e.g.,城市/农村，初级保健短缺地区），设施特征（例如，复杂性，学术联系）， 以及其他组织措施（例如，PACT执行指数）。对于目标2，我们将链接来自 目标1是VHA访问指标，包括管理（例如，预约等待时间）和患者报告 访问措施（例如，在需要的时候得到照顾）。对于目标3，我们将使用修改后的德尔菲面板技术 汇集VA和非VA专家在访问管理，初级保健，护理协调和其他 根据目标1和目标2的数据，提出循证建议的领域。 对退伍军人医疗保健的预期影响：拟议的研究将为VA提供关键信息 领导层更好地了解已实施哪些访问管理策略， 驱动的吸收和实施，使用的障碍和促进因素，以及其中哪些实际上是 与更好的访问指标性能相关。没有其他数据源可用于放置 为循证方法奠定基础，以解决VHA这种规模的访问危机，尽管资源有限 被应用。这项研究将产生多层次的干预目标，并与 高级领导人和其他利益攸关方。 下一步：我们将与初级保健和退伍军人获得护理办公室的领导人合作， 调查结果到外地。在专家小组会议期间，我们将与小组成员讨论，以确定最佳的方法， 沟通，包括但不限于问题简报，工具包，现场指南，工作组或其他方法。

Background: Delays in care (i.e., poor access to timely care) are associated with adverse impacts on morbidity, mortality and quality of life, as well as poor outcomes from physical and mental health conditions. The VHA healthcare system has long struggled with access issues, however, VHA's “access crisis” in 2014, where systemic access problems were identified after whistleblowers revealed intentional cover-ups of long delays, drew particular outrage as evidence emerged that Veterans had died waiting to see their VHA doctors. Improving Veterans' access to care continues to be among VHA's top priorities, and while expansion of access to community providers has been among the most visible approaches to reducing waits and delays, VHA has implemented numerous initiatives to improve Veterans' timely access to care within VHA as well. These include development of a group practice manager role to facilitate face-to-face and virtual appointment-making through call centers and access management tools (e.g., grid validation). Improving access management— effectively deploying clinic personnel, resources, and processes to achieve timely access—remains a major challenge nonetheless, especially across widely varying organizational and geographic contexts. Despite their importance, remarkably little is known about which of these strategies have been implemented, the factors that support or hinder their use, or their relationship to access metrics. Specific Aims: To address these gaps, we propose the following specific aims: Aim 1: To assess national variations in how local VA facilities manage primary care access. Aim 2: To evaluate how different access management strategies relate to access metrics. Aim 3: Building on results from Aims 1 and 2, to conduct a national expert panel to come to consensus on evidence-based practice and policy recommendations to improve access to care. Methods: For Aim 1, we propose to use key informant-based organizational surveys to assess implementation of access management strategies on a national basis. We will examine area and organizational determinants of their uptake, use and implementation by linking resulting survey data with Area Resource File measures (e.g., urban/rural, primary care shortage area), facility characteristics (e.g., complexity, academic affiliation), and other organizational measures (e.g., PACT Implementation Index). For Aim 2, we will then link data from Aim 1 to VHA access metrics, including both administrative (e.g., appointment wait times) and patient-reported access measures (e.g., obtained care when needed). For Aim 3, we will use modified Delphi panel techniques to bring together VA and non-VA experts in access management, primary care, care coordination and other areas to generate evidence-based recommendations based on data from Aims 1 and 2. Anticipated Impacts on Veterans' Healthcare: The proposed study will provide critical information for VA leadership to better understand which access management strategies have been implemented, what has driven uptake and implementation, the barriers and facilitators to their use, and which of them are in fact associated with better performance on access metrics. No other data sources are available to lay the groundwork for evidence-based approaches to solving VHA's access crisis on this scale despite the resources being applied. This study will yield multilevel targets for intervention and implementation in partnership with senior leaders and other stakeholders. Next Steps: We will work with leaders in Primary Care and Office of Veterans' Access to Care to disseminate findings to the field. During the Expert Panel, we will confer with panelists to identify optimal means of communication, including but not limited to issues briefs, toolkits, field guides, workgroups or other methods.