Impacts of Organizational Variations on Access Management

背景：护理延误(即获得及时护理的机会较少)与对 发病率、死亡率和生活质量，以及因身心健康状况造成的不良后果。 VHA医疗保健系统长期以来一直在为准入问题而苦苦挣扎，然而，VHA在2014年的“准入危机”， 在举报人揭露了故意掩盖Long的情况后，发现了系统性访问问题 延误引发了特别的愤怒，因为有证据表明，退伍军人在等待VHA医生就诊时死亡。 改善退伍军人获得护理的机会仍然是VHA的首要任务之一，同时扩大获得医疗服务的机会 对于社区提供商来说，VHA一直是减少等待和延误的最明显的方法之一 实施了许多举措，以改善退伍军人在退伍军人管理局内及时获得护理的机会。这些 包括发展团体实践经理角色，以促进面对面和虚拟预约 通过呼叫中心和接入管理工具(例如，网格验证)。改进访问管理- 有效部署诊所人员、资源和流程以实现及时访问-仍然是一项重要任务 尽管如此，挑战仍然存在，特别是在组织和地理环境差异很大的情况下。尽管他们 重要的是，人们对这些战略中的哪些已经实施，哪些因素 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：为了弥补这些差距，我们提出了以下具体目标： 目标1：评估地方退伍军人管理局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指标之间的关系。 目标3：在目标1和目标2成果的基础上，领导一个国家专家小组，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线人的组织调查来评估执行情况 在国家基础上制定准入管理战略。我们将研究地区和组织的决定因素 通过将所产生的调查数据与区域资源档案测量相联系来了解其吸收、使用和实施情况 (如城市/农村、初级保健短缺地区)、设施特点(如复杂性、学历)、 和其他组织措施(如《公约》执行指数)。对于目标2，我们将从 目标1到VHA访问指标，包括管理(例如，预约等待时间)和患者报告 准入措施(例如，在需要时获得护理)。对于目标3，我们将使用改进的Delphi面板技术 汇集退伍军人管理局和非退伍军人管理局的准入管理、初级保健、护理协调等方面的专家 根据目标1和目标2的数据生成基于证据的建议的领域。 对退伍军人医疗保健的预期影响：拟议的研究将为退伍军人管理局提供关键信息 领导力，以更好地了解实施了哪些访问管理战略， 推动接受和实施，使用它们的障碍和促进者，以及它们中的哪些实际上是 与更好的访问指标性能相关。没有其他数据源可用于设置 为解决VHA如此规模的准入危机的循证方法奠定基础，尽管资源有限 正在申请中。这项研究将提出多层次的干预和实施目标，并与 高级领导人和其他利益相关者。 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，传播 将调查结果带到现场。在专家小组期间，我们将与小组成员进行磋商，以确定最佳的 交流，包括但不限于问题简报、工具包、实地指南、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.