Impacts of Organizational Variations on Access Management

背景：护理延误（即难以获得及时护理）与对健康的不利影响有关

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.