Understanding the Effects of the MISSION Act on VA's Specialty Care Referral Networks

背景：最近，VA经历了两次前所未有的颠覆性变化，从根本上改变了 照顾退伍军人。首先，VA使命法案于2019年6月实施。可以说是最大的 自“Kizer革命”以来，VA护理服务的政策变化，使命的目的是改善退伍军人 获得护理，特别是由于地理/地理因素，VA传统上资源有限的服务 时间屏障（例如，专业护理）。虽然VA医疗保健系统仍处于适应的早期阶段， 新冠肺炎疫情在全球迅速蔓延，导致疫情突然和长期恶化- 整个美国医疗系统的选择性门诊治疗减少。全国范围内的VAMC独立地 以直接影响退伍军人健康和体验的方式适应这些破坏性变化。 意义/影响：目前，我们对使命的早期影响知之甚少， 获得专科护理（受COVID相关中断的影响），或影响社区护理的因素 转诊。我们也缺乏对单个VAMC如何应对这些破坏性力量的清晰理解 调整组织战略/结构以优化业绩。解决这些知识差距是 对于评估使命和COVID对VA专科护理服务的长期影响至关重要， VAMC根据当地环境调整适应方法，以优化退伍军人的健康和体验。 创新：根据《使命法案》扩大退伍军人事务部社区护理是最大的自然之一。 现代美国医疗保健系统的交付转型实验。因此，VA社区 根据使命的护理扩展提供了一个无与伦比的机会，研究快速之间的关系， 环境变化、组织适应和长期绩效。意想不到的系统 新冠疫情导致的“重置”只会放大和加速已经在进行的适应过程。 具体目标：目标1：研究VAMC组织/环境特征之间的关系 使命/COVID后的纵向绩效，以及设施级组织 适应对业绩产生了可衡量的影响。目标2：通过以下方式描述组织适应性的变化 具有不同组织/环境特征的高绩效三级VAMC。目标3：探索如何 具有特殊护理需求的退伍军人的经验与具有不同特征的高性能VAMC不同， 组织适应方法。 方法：在目标1a中，使用纵向的前后比较分析，我们将检查 VAMC组织/环境特征与纵向绩效之间的关系 使命/后COVID，包括访问，护理协调和社区护理转介的措施。在Aim中 1b，使用差异中的差异方法，我们将利用 VAMC的实证评估VAMC组织适应对VA纵向率的影响 社区护理转介和其他成果。在目标2中，我们将采访12个高绩效级别的领导者 1具有不同组织/环境属性的VAMC，以表征适应的变化 在使命/后COVID下的方法。在目标3中，我们将探讨VAMC组织如何适应 影响退伍军人的专科护理经验，通过定性访谈48退伍军人在选定的目标2网站。 实施/后续步骤：本研究将提供有关退伍军人在何处以及如何访问 在使命/后COVID的专科护理，如何高性能的三级VAMC与不同的组织/ 环境特征正在适应，以加强使命/后COVID下的专科护理服务， 以及这些适应方法的变化如何影响退伍军人的护理经验。格兰特产品将 向VHA领导人提供重要信息，说明具有独特设施级特征的三级VAMC如何 最好的调整他们的组织方法，以优化性能和提高退伍军人护理经验。

Background: Recently, VA underwent two unprecedented disruptive changes that fundamentally altered how care is delivered to Veterans. First, the VA MISSION Act was implemented in June 2019. Arguably the biggest policy change in VA care delivery since the "Kizer revolution,” MISSION’s purpose is to improve Veteran access to care, especially for services that have traditionally been resource-limited in VA due to geographic/ temporal barriers (e.g., specialty care). While VA healthcare systems were still in the early phases of adapting to MISSION, the COVID pandemic spread rapidly across the world, resulting in a sudden and prolonged ramp- down of elective outpatient care across the entire US healthcare system. VAMCs nationwide are independently adapting to these disruptive changes in ways that directly impact Veterans’ health and experience. Significance/Impact: Currently, we know little about MISSION’s early effects on where and how Veterans access specialty care (as moderated by COVID-related disruptions), or factors influencing community care referral. We also lack a clear understanding of how individual VAMCs are responding to these disruptive forces in realigning organizational strategy/structure to optimize performance. Addressing these knowledge gaps is critical to assessing the long-term impacts of MISSION and COVID on VA specialty care delivery and helping VAMCs to tailor adaptation approaches to their local setting to optimize the health and experience of Veterans. Innovation: Expansion of VA community care under the MISSION Act represents one of the largest natural experiments in delivery transformation in any U.S. healthcare system in modern times. Thus, VA community care expansion under MISSION offers an unparalleled opportunity to study the relationship between rapid environmental change, organizational adaptation, and long-term performance. The unanticipated system "reset" caused by COVID will only amplify and accelerate the adaptation process already underway. Specific Aims: Aim 1: Examine the relationship between VAMC organizational/environmental characteristics and longitudinal performance under MISSION/post-COVID, and the extent to which facility-level organizational adaptation measurably impacts performance. Aim 2: Characterize variation in organizational adaptation by high-performing tertiary VAMCs with different organizational/environmental characteristics. Aim 3: Explore how the experience of Veterans with specialty care needs differs at high-performing VAMCs with distinct organizational adaptation approaches. Methodology: In Aim 1a, using a longitudinal pre-/post- comparison analysis, we will examine the relationship between VAMC organizational/environmental characteristics and longitudinal performance under MISSION/post-COVID, including measures of access, care coordination, and community care referral. In Aim 1b, using a difference-in-differences approach, we will leverage differences in financial incentives between VAMCs to empirically assess the effect of VAMC organizational adaptation on longitudinal rates of VA community care referral and other outcomes. In Aim 2, we will interview leadership at 12 high-performing Level 1 VAMCs with varying organizational/environmental attributes to characterize variation in adaptation approaches under MISSION/post-COVID. In Aim 3, we will explore how VAMC organizational adaptation impacts Veterans’ specialty care experience through qualitative interviews of 48 Veterans at select Aim 2 sites. Implementation/Next Steps: This study will provide critical information about where and how Veterans access specialty care under MISSION/post-COVID, how high-performing tertiary VAMCs with different organizational/ environmental characteristics are adapting to enhance specialty care delivery under MISSION/post-COVID, and how variation in these adaptation approaches affects the Veteran experience of care. Grant products will provide vital information to VHA leaders about how tertiary VAMCs with unique facility-level characteristics can best adapt their organizational approaches to optimize performance and enhance the Veteran care experience.