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

背景：最近，退伍军人管理局经历了两次前所未有的颠覆性变化，从根本上改变了 护理是提供给退伍军人的。首先，退伍军人事务部于2019年6月开始实施。可以说是最大的 退伍军人护理服务政策的变化自“开泽革命”以来，使命的目的是改善退伍军人 获得护理，特别是传统上由于地理/地理原因在退伍军人管理局受到资源限制的服务 时间障碍(例如，专科护理)。虽然退伍军人管理局的医疗保健系统仍处于适应的早期阶段 就任务而言，COVID大流行迅速蔓延到世界各地，导致突然和长期的坡道- 整个美国医疗系统的选择性门诊护理的减少。全国范围内的VAM是独立的 以直接影响退伍军人健康和体验的方式适应这些颠覆性的变化。 意义/影响：目前，我们对任务对退伍军人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 转介。我们也缺乏对单个VAMC如何应对这些颠覆性力量的明确理解 重新调整组织战略/结构，以优化绩效。解决这些知识差距的方法是 评估使命和COVID对退伍军人特殊护理提供和帮助的长期影响至关重要 VAMC根据当地情况量身定做适应方法，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管理局社区护理是最大的自然 在现代任何一种美国医疗体系中进行的提供转型的实验。因此，退伍军人社区 使命下的关怀扩展提供了一个无与伦比的机会来研究快速 环境变化、组织适应和长期绩效。意想不到的系统 COVID引起的“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：审查VAMC组织/环境特征之间的关系 和在特派团/COVID后的纵向业绩，以及设施一级的组织 适应对绩效的影响是可衡量的。目标2：通过以下方式描述组织适应的变化 具有不同组织/环境特征的高性能第三级VAMC。目标3：探索如何 具有特殊护理需求的退伍军人在高性能VAMC中的体验不同，具有明显的 组织适应办法。 方法：在目标1a中，我们将使用纵向比较前/后分析来检查两者之间的关系 VAMC组织/环境特征与纵向绩效的关系 特派团/COVID后，包括准入、护理协调和社区护理转诊的措施。在AIM 1B，使用差异方法，我们将利用财务激励方面的差异 VAMC实证评估VAMC组织适应对VA纵向比率的影响 社区护理转诊和其他结果。在目标2中，我们将采访12个高绩效级别的领导层 1具有不同组织/环境属性的VAMCs，以表征适应中的变化 在任务/后COVID下的方法。在目标3中，我们将探讨VAMC组织适应 通过在选定的AIM 2地点对48名退伍军人进行定性采访，影响退伍军人的特殊护理体验。 实施/后续步骤：本研究将提供有关退伍军人访问位置和方式的关键信息 使命/COVID后的专业护理，不同组织/的第三级VAMC表现如何 环境特点正在适应，以加强特派团/COVID后特殊护理的提供， 以及这些适应方法的差异如何影响老兵的护理体验。格兰特产品公司将 向VHA领导者提供重要信息，说明具有独特设施级特征的第三级VAM如何 最好调整他们的组织方法，以优化绩效并增强退伍军人护理体验。

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.