Top

Journal of General Internal Medicine

Published in:

01-11-2011 | Reviews

Interventions to Improve Veterans’ Access to Care: A Systematic Review of the Literature

Authors: Shannon M. Kehle, PhD, Nancy Greer, PhD, Indulis Rutks, BA, Timothy Wilt, MD, MPH

Published in: Journal of General Internal Medicine | Special Issue 2/2011

Abstract

Objectives

To conduct a systematic review to address the following key questions: (1) what interventions have been successful in improving access for veterans with reduced health care access? (2) Have interventions that have improved health care access led to improvements in process and clinical outcomes?

Data Sources

OVID MEDLINE, CINAHL, PsychINFO.

Study Eligibility Criteria, Participants, and Interventions

English language articles published in peer-reviewed journals from 1990 to June 2010. All interventions designed to improve access to health care for US veterans that reported the impact of the intervention on perceived (e.g., satisfaction with access) or objective (e.g., travel time, wait time) access were included.

Appraisal and Synthesis Methods

Investigators abstracted data on study design, study quality, intervention, and impact of the intervention on access, process outcomes, and clinical outcomes.

Results

Nineteen articles (16 unique studies) met the inclusion criteria. While there were a small number of studies in support of any one intervention, all showed a positive impact on either perceived or objective measures of access. Implementation of Community Based Outpatient Clinics (n = 5 articles), use of Telemedicine (n = 5 articles), and Primary Care Mental Health Integration (n = 6 articles) improved access. All 16 unique studies reported process outcomes, most often satisfaction with care and utilization. Four studies reported clinical outcomes; three found no differences.

Limitations

Included studies were largely of poor to fair methodological quality.

Conclusions and Implications of Key Findings

Interventions can improve access to health care for veterans. Increased access was consistently linked to increased primary care utilization. There was a lack of data regarding the link between access and clinical outcomes; however, the limited data suggest that increased access may not improve clinical outcomes. Future research should focus on the quality and appropriateness of care and clinical outcomes.

Available only for authorised users

Agency for Healthcare Research and Quality. 2007 National Healthcare Disparities Report. Rockville, MD: US Department of Health and Human Services, Agency for Healthcare Research and Quality, AHRQ Pub. No. 08–0041, February 2008.

Demakis JG. “Rural Health-Improving Access to Improve Outcomes.” Management Brief, Health Services Research & Development Service, No. 13:1–3, Jan 2000.

Institute of Medicine Committee on Monitoring Access to Personal Healthcare Services. In: Millman M, ed. Access to healthcare in America. Washington, DC: National Academy Press; 1993.

Miller LJ. “Improving Access to Care in the VA Health System: A progress report.” FORUM, VA Health Services Research & Development Service, June 2001.

Fortney J. “A Re-conceptualization of Access for 21stCentury Healthcare.” Oral presentation given to the VA Health Services Research & Development Service Timely Topics of Interest Cyber Seminar Series, August 2010.

Mayo-Smith MF. “Access Issues Within VA Offer Challenges Research Opportunities.” FORUM, VA Health Services Research & Development Service, July 2008.

Weeks WB. “Access to Care: A VA Research Agenda.” FORUM, VA Health Services Research & Development Service. July 2008.

Harris RP, Helfand M, Woolf SH, Lohr KN, Mulrow CD, Teutsch SM, Atkins D. Current methods of the US Preventive Services Task Force: a review of the process. Am J Prev Med. 2001;20(3S):21–35.PubMedCrossRef

Fortney JC, Borowsky SJ, et al. VA community-based outpatient clinics: access and utilization performance measures. Med Care. 2002;40:561–9.PubMedCrossRef

10.

Fortney JC, Maciejewski ML, et al. Does improving geographic access to VA primary care services impact patients' patterns of utilization and costs? Inquiry. 2005;42:29–42.PubMedCrossRef

11.

Fortney JC, Steffick DE, et al. Are primary care services a substitute or complement for specialty and inpatient services? Health Serv Res. 2005;40:1422–42.PubMedCrossRef

12.

Borowsky SJ, Nelson DB, et al. VA community-based outpatient clinics: performance measures based on patient perceptions of care. Med Care. 2002;40:578–86.PubMedCrossRef

13.

Morgester WA, Biggs CJ. Community-based VHA clinics: effect on patient satisfaction and resource utilization. J Healthc Qual. 2002;24:34–8.PubMedCrossRef

14.

Shiner B, Watts BV, et al. Access to what? An evaluation of the key ingredients to effective advanced mental health access at a VA medical center and its affiliated community-based outreach clinics. Mil Med. 2009;174:1024–32.PubMed

15.

Watts BV, Shiner B, et al. Outcomes of a quality improvement project integrating mental health into primary care. Qual Saf Healthcare. 2007;16:378–81.CrossRef

16.

Druss BG, Rohrbaugh RM, et al. Integrated medical care for patients with serious psychiatric illness. Arch Gen Psychiat. 2001;58:861–8.PubMedCrossRef

17.

Saxon AJ, Malte CA, et al. Randomized trial of onsite versus referral primary medical care for veterans in addictions treatment. Med Care. 2006;44:334–42.PubMedCrossRef

18.

Blue-Howells J, McGuire J, et al. Co-location of healthcare services for homeless veterans: a case study of innovation in program implementation. Soc Work Healthcare. 2008;47:219–231.CrossRef

19.

McGuire J, Gelberg L, et al. Access to primary care for homeless veterans with serious mental illness or substance abuse: a follow-up evaluation of co-located primary care and homeless social services. Admin Policy Ment Health. 2009;36:255–64.CrossRef

20.

Agha Z, Schapira RM, Laud PW, McNutt G, Roter DL. Patient satisfaction with physician-patient communication during telemedicine. Telemed J E Health. 2009;15:830–9.PubMedCrossRef

21.

Whited JD, Hall RP, Foy ME, Marbrey LE, Grambow SC, Dudley TK, Datta SK, Simel DL, Oddone EZ. Patient and clinician satisfaction with a store-and-forward teledermatology consult system. Telemed J E Health. 2004;10:422–31.PubMedCrossRef

22.

Whited JD, Hall RP, Foy ME, Marbrey LE, Grambow SC, Dudley TK, Datta S, Simel DL, Oddone EZ. Teledermatology’s impact on time to intervention among referrals to a dermatology consult service. Telemed J E Health. 2002;8(3):313–21.PubMedCrossRef

23.

Wakefield BJ, Buresh KA, et al. Interactive video specialty consultations in long-term care. J Am Geriatr Soc. 2004;52:789–93.PubMedCrossRef

24.

Wilkins E, et al. Feasibility of virtual wound care. Adv Skin Wound Care. 2007;20:275–8.PubMedCrossRef

25.

Weinberger M, Oddone EZ, et al. Does increased access to primary care reduce hospital readmissions? Veterans Affairs Cooperative Study Group on Primary Care and Hospital Readmission. New Engl J Med. 1986;334:1441–7.CrossRef

26.

Wray NP, Weiss TW, Menke TJ, Gregor PJ, Ashton CM, Christian CE, Hollingsworth JC. Evaluation of the VA mobile clinics demonstration project. J Healthc Manag. 1999;44:133–47.PubMed

27.

Rodriguez KL, Appelt CJ, et al. African American veterans’ experiences with mobile geriatric care. J Healthcare Poor Underserved. 2007;18:44–53.CrossRef

28.

Frueh BC, Monnier J, Yim E, Grubaugh AL, Hamner MB, Knapp RG. A randomized trial of telepsychiatry for post-traumatic stress disorder. J Telemed Telecare. 2007;13:142–7.PubMedCrossRef

29.

Bauer MS, McBride L, et al. Impact of an easy-access VA clinic-based program for patients with bipolar disorder. Psychiatr Serv. 1997;48:491–6.PubMed

30.

Bauer MS, McBride L, et al. Collaborative care for bipolar disorder: part II. Impact on clinical outcome, function, and costs. Psychiatr Serv. 2006;57:937–45.PubMedCrossRef

31.

Boutelle KN, Dubbert P, et al. A pilot study evaluating a minimal contact telephone and mail weight management intervention for primary care patients. Eat Weight Disord. 2005;10:e1–5.PubMed

32.

Chumbler NR, Chuang HC, Wu SS, Wang X, Kobb R, Haggstrom D, Jia H. Mortality risk for diabetes patients in a care coordination, home-telehealth programme. J Telemed Telecare. 2009;15:98–101.PubMedCrossRef

33.

Wakefield BJ, Ward MM, Holman JE, Ray A, Scherubel M, Burns TL, Kienzle MG, Rosenthal GE. Evaluation of home telehealth following hospitalization for heart failure: a randomized trial. Telemed J E Health. 2008;14:753–61.PubMedCrossRef

34.

Ruskin PE, Silver-Aylaian M, Kling MA, Reed SA, Bradham DD, Hebel JR, Barrett D, Knowles F 3rd, Hauser P. Treatment outcomes in depression: comparison of remote treatment through telepsychiatry to in-person treatment. Am J Psychiat. 2004;161:1471–6.PubMedCrossRef

35.

Dobscha SK, Corson K, Perrin NA, Hanson GC, Leibowitz RQ, Doak MN, Dickinson KC, Sullivan MD, Gerrity MS. Collaborative care for chronic pain in primary care: a cluster randomized trial. JAMA. 2009;301:1242–52.PubMedCrossRef

36.

Dobscha SK, Corson K, Hickam DH, Perrin NA, Kraemer DF, Gerrity MS. Depression decision support in primary care: a cluster randomized trial. Ann Intern Med. 2006;145:477–87.PubMed

37.

Hedrick SC, Chaney EF, Felker B, Liu CF, Hasenberg N, Heagerty P, Buchanan J, Bagala R, Greenberg D, Paden G, Fihn SD, Katon WJ. Effectiveness of collaborative care depression treatment in Veterans' Affairs primary care. Gen Intern Med. 2003;18:9–16.CrossRef

38.

Oslin DW, Sayers S, Ross J, Kane V, Ten Have T, Conigliaro J, Cornelius J. Disease management for depression and at-risk drinking via telephone in an older population of veterans. Psychosom Med. 2003;65:931–7.PubMedCrossRef

39.

Felker BL, Barnes RF, Greenberg DM, Chaney EF, Shores MM, Gillespie-Gateley L, Buike MK, Morton CE. Preliminary outcomes from an integrated mental health primary care team. Psychiatr Serv. 2004;55:442–4.PubMedCrossRef

40.

Ross JT, TenHave T, Eakin AC, Difilippo S, Oslin DW. A randomized controlled trial of a close monitoring program for minor depression and distress. J Gen Intern Med. 2008 Sep;23:1379–85. Epub 2008 May 23.

Title: Interventions to Improve Veterans’ Access to Care: A Systematic Review of the Literature
Authors: Shannon M. Kehle, PhD
Nancy Greer, PhD
Indulis Rutks, BA
Timothy Wilt, MD, MPH
Publication date: 01-11-2011
Publisher: Springer-Verlag
Published in: Journal of General Internal Medicine / Issue Special Issue 2/2011
Print ISSN: 0884-8734
Electronic ISSN: 1525-1497
DOI: https://doi.org/10.1007/s11606-011-1849-8

ACC 2024 Congress Coverage

Heart Failure Video

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

Interventions to Improve Veterans’ Access to Care: A Systematic Review of the Literature

Abstract

Objectives

Data Sources

Study Eligibility Criteria, Participants, and Interventions

Appraisal and Synthesis Methods

Results

Limitations

Conclusions and Implications of Key Findings

ACC 2024 Congress Coverage

Year in Review: Heart failure and cardiomyopathies

Semaglutide benefits people with type 2 diabetes and obesity-related heart failure

Incentivised to exercise

New intervention for STEMI-related cardiogenic shock

» View more highlights on the ACC 2024 congress hub page

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

Abstract

Objectives

Data Sources

Study Eligibility Criteria, Participants, and Interventions

Appraisal and Synthesis Methods

Results

Limitations

Conclusions and Implications of Key Findings

Please log in to get access to this content

Other articles of this Special Issue 2/2011

Distance is Relative: Unpacking a Principal Barrier in Rural Healthcare

Building Care Systems to Improve Access for High-Risk and Vulnerable Veteran Populations

Promoting Access Through Complementary eHealth Technologies: Recommendations for VA’s Home Telehealth and Personal Health Record Programs

Do Correlates of Dual Use by American Indian and Alaska Native Veterans Operate Uniformly Across the Veterans Health Administration and the Indian Health Service?

Improving Access to VA Care

A Re-conceptualization of Access for 21st Century Healthcare

ACC 2024 Congress Coverage

Year in Review: Heart failure and cardiomyopathies

Semaglutide benefits people with type 2 diabetes and obesity-related heart failure

Incentivised to exercise

New intervention for STEMI-related cardiogenic shock

» View more highlights on the ACC 2024 congress hub page