Defining “Rural” for Veterans’ Health Care Planning

Purpose: The Veterans Health Administration (VHA) devised an algorithm to classify veterans as Urban, Rural, or Highly Rural residents. To understand the policy implications of the VHA scheme, we compared its categories to 3 Office of Management and Budget (OMB) and 4 Rural-Urban Commuting Area (RUCA) geographical categories. Method: Using residence information for VHA health care enrollees, we compared urban-rural classifications under the VHA, OMB, and RUCA schemes; the distributions of rural enrollees across VHA health care networks (Veterans Integrated Service Networks [VISNs]); and how each scheme indicates whether VHA standards for travel time to care are met for the most rural veterans. Results: VHA's Highly Rural and Urban categories are much smaller than the most rural or most urban categories in the other schemes, while its Rural category is much larger than their intermediate categories. Most Highly Rural veterans live in VISNs serving the Rocky Mountains and Alaska. Veterans defined as the most rural by RUCA or OMB are distributed more evenly across most VISNs. Nearly all urban enrollees live within VHA standards for travel time to access VHA care; so do most enrollees defined by RUCA or OMB as the most rural. Only half of Highly Rural enrollees, however, live within an hour of primary care, and 70% must travel more than 2 hours to acute care or 4 hours to tertiary care. Conclusions: VHA's Rural category is very large and broadly dispersed; policy makers should supplement analyses of Rural veterans’ health care needs with more detailed breakdowns. Most of VHA's Highly Rural enrollees live in the western United States where distances to care are great and alternative delivery systems may be needed.     

A Longitudinal Analysis of Rural and Urban Veterans’ Health-Related Quality of Life

Context: Cross-sectional studies have identified rural-urban disparities in veterans’ health-related quality-of-life (HRQOL) scores. Purpose: To determine whether longitudinal analyses confirmed that these disparities in veterans’ HRQOL scores persisted. Methods: We obtained data from the SF-12 portion of the veterans health administration's (VA's) Survey of Healthcare Experiences of Patients (SHEP) collected between 2002 and 2006. During that time, the SHEP was randomly administered to approximately 250,000 veterans annually who had used VA outpatient services. We evaluated 163,709 responses from veterans who had completed 2 or more surveys during the years studied. Respondents were classified into rural-urban groups using ZIP Code-based rural-urban commuting area designations. We estimated linear regression models using generalized estimating equations to determine whether rural and urban veterans’ HRQOL scores were changing at different rates over the time period examined. Findings: After adjustment for sociodemographic differences, we found that urban veterans had substantially better physical HRQOL scores than their rural counterparts and that these differences persisted over the study period. While urban veterans had worse mental HRQOL scores than rural veterans, those differences diminished over the time period studied. Conclusions: Rural-urban disparities in HRQOL scores persist when tracking veterans longitudinally. Reduced access among rural veterans to care may contribute to these disparities. Because rural soldiers are overrepresented in current conflicts, the VA should consider new models of care delivery to improve access to care for rural veterans.     

Providers’ Perspectives on High-Quality Dementia Care in Long-Term Care

ObjectivesTo understand dementia care providers’ perspectives on high-quality care for persons living with dementia (PLWD) in long-term care (LTC).DesignA qualitative study using a directed content analysis approach.Setting and ParticipantsNine national LTC dementia care providers.MethodsWe facilitated 5 listening sessions centered around dementia care philosophies, models, and practices. Two researchers first mapped qualitative data to the Holistic Approach to Transformational Change (HATCh) model for dementia care using a directed content analysis approach. They then identified themes and subthemes emerging from the data using a conventional analysis approach. They coded data iteratively and solicited input from 3 additional researchers to reach consensus where needed. Member checks were performed to ensure the trustworthiness of the data during 2 follow-up listening sessions.ResultsThe 9 participants described the importance of understanding the experiences of PLWDs in order to provide high-quality dementia care and to deliver such care with the residents and their preferences as the focus. They emphasized experiential education as essential for families and all staff, regardless of role. They noted the need to balance safety with resident choice, as well as the corresponding need for facility leadership and regulators to support such choices. The listening sessions revealed areas to foster person-centered care for PLWD, but also highlighted barriers to implementing this philosophy in LTC settings.Conclusions and ImplicationsEmergent themes included care practices that center on resident preferences and are supported by staff with the experiential education and communication skills necessary to relate to and support PLWD. These findings provide contextual information for researchers seeking to identify and test interventions that reflect LTC providers’ priorities for PLWD and emphasize the need to align research priorities with provider priorities.     

Women Veterans’ Experiences of Harassment and Perceptions of Veterans Affairs Health Care Settings During a National Anti-Harassment Campaign

PurposeIn 2017, Veterans Health Administration (VA) launched a social marketing and training campaign to address harassment of women veterans at VA health care facilities. We assessed women veterans’ experiences of harassment, reported perpetrators of harassment, and perceptions of VA in 2017 (before campaign launch) and 2018 (1 year after campaign implementation).MethodsWe administered surveys to women veterans attending primary care appointments (2017, n = 1,300; 2018, n = 1,711). Participants reported whether they experienced sexual harassment (e.g., catcalls) and gender harassment (e.g., questioning women's veteran status) from patients and/or staff at VA in the past 6 months. They also indicated whether they felt welcome, felt safe, and believed the VA is working to address harassment. We compared variables in 2017 versus 2018 with χ² analyses, adjusting for facility-level clustering.ResultsThere were no significant differences in percentages of participants reporting sexual harassment (20% vs. 17%) or gender harassment (11% vs. 11%) in 2017 versus 2018. Men veterans were the most frequently named perpetrators, but participants also reported harassment from staff. Participant beliefs that VA is working to address harassment significantly improved from 2017 to 2018 (52% vs. 57%; p = .05).ConclusionsOne year after campaign launch, women veterans continued to experience harassment while accessing VA health care services. Findings confirm that ongoing efforts to address and monitor both staff- and patient-perpetrated harassment are essential. Results have implications for future anti-harassment intervention design and implementation and highlight additional opportunities for investigation.     

Predictors of Parent Engagement Based on Child Care Providers’ Perspectives

Objective

Determine the predictors of child care providers’ parent engagement regarding child nutrition in child care centers (CCCs) and family child care homes (FCCHs).

Rural Primary Care Providers’ Perceptions of Their Role in the Breast Cancer Care Continuum

Context: Rural women in the United States experience disparity in breast cancer diagnosis and treatment when compared to their urban counterparts. Given the 11% chance of lifetime occurrence of breast cancer for women overall, the continuum of breast cancer screening, diagnosis, treatment, and recovery are of legitimate concern to rural women and their primary care providers. Purpose: This analysis describes rural primary care providers’ perceptions of the full spectrum of breast cancer screening, treatment, and follow-up care for women patients, and it describes the providers’ desired role in the cancer care continuum. Method: Focus group interviews were conducted with primary care providers in 3 federally qualified community health centers serving a lower income, rural population. Focus group participants (N = 26) consisted of 11 physicians, 14 nurse practitioners, and 1 licensed clinical psychologist. Data were generated from audiotaped interviews transcribed verbatim and investigator field notes. Data were analyzed using constant comparison and findings were reviewed with a group of rural health professionals to judge the fit of findings with the emerging coding scheme. Findings: Provider relationships were characterized as being with women with cancer and comprised an active behind-the-scenes role in supporting their patients through treatment decisions and processes. Three themes emerged from the interview data: Knowing the Patient; Walking Through Treatment With the Patient; and Sending Them Off or Losing the Patient to the System. Conclusions: These findings should be a part of professional education for rural practitioners, and mechanisms to support this role should be implemented in practice settings.     

Women Veterans’ Experiences with Perceived Gender Bias in U.S. Department of Veterans Affairs Specialty Care

BackgroundIn the past decade, the U.S. Department of Veterans Affairs (VA) has responded to a dramatic increase in women veterans seeking care by expanding Women's Health training to more than 5,000 women's health primary care providers and changing the culture of the VA to be more inclusive of women veterans. These initiatives have resulted in increased patient satisfaction and quality of care, but have focused mostly on primary care settings. Less is known about women's experiences in specialty care within VA. This qualitative study sought to examine women veterans' experiences with VA specialty care providers, with a focus on cardiovascular, musculoskeletal, and mental health care settings.MethodsSemistructured interviews were conducted with 80 women veterans who served during the Iraq and Afghanistan conflicts at four VA facilities nationwide. Interviews focused on understanding women veterans’ experiences with VA specialty care providers, including their perceptions of gender bias.ResultsFour major themes emerged from interviews, including that 1) women did not feel that VA specialty care providers listened to them or took their symptoms seriously, 2) women were told their health conditions or symptoms were attributable to hormonal fluctuations, 3) women noted differences in care based on whether the VA specialty provider was male or female, and 4) women provided recommendations for how gender-sensitive specialty care might be improved.ConclusionsThis study is the first to highlight the perceived gender bias experienced by women veterans in VA specialty care. Women felt that their symptoms were disregarded or diminished by their specialty care providers. Although women veterans report positive experiences within women's health clinics and the primary care setting, their negative experiences in VA specialty care suggest that some providers may harbor unintentional or unconscious gender biases.     

Women Veterans’ Attrition from the VA Health Care System

PurposePatient attrition from the Veterans Health Administration (VA) health care system could undercut its mission to ensure care for eligible veterans. Attrition of women veterans could exacerbate their minority status and impede systemic efforts to provide high-quality care. We obtained women veterans’ perspectives on why they left or continued to use VA health care.MethodsA sampling frame of new women veteran VA patients was stratified by those who discontinued (attriters) and those who continued (non-attriters) using VA care. Semistructured interviews were conducted from 2017 to 2018. Transcribed interviews were coded for women's decision-making, contexts, and recommendations related to health care use.ResultsFifty-one women veterans (25 attriters and 26 non-attriters) completed interviews. Reasons for attrition included challenging patient care experiences (e.g., provider turnover, claim processing challenges) and the availability of private health insurance. Personal experiences with VA care (e.g., gender-specific care) were impactful in women's decision to use VA. The affordability of VA care was influential for both groups to stay connected to services. More than one-third of women originally categorized as attriters described subsequently reentering or planning to reenter VA care. Suggestions to decrease attrition included increasing outreach, improving access, and continuing to tailor care delivery to women veterans' needs.ConclusionsUnderstanding the drivers of patients’ decisions to use or not use the VA is critical for the development of strategies to improve retention of current patients and optimize health outcomes for veterans. Women veterans described complex reasons why they left or continued using VA, with cost/affordability playing an important role even in considerations of returning to VA after a long hiatus.     

Youth and Youth Coordinators’ Perspectives on Youth Involvement in Systems of Care

To increase understanding of the current status of youth involvement in Substance Abuse and Mental Health Services Administration-funded system-of-care communities, focus groups with youth and youth coordinators were conducted as part of the national evaluation of the Comprehensive Community Mental Health Services for Children and Their Families Program. Using focus group discussions as the primary qualitative data analysis method, these discussions addressed the ways in which youths are involved in their communities, the role of youth coordinators, the challenges that hinder youth participation, and strategies for overcoming these challenges. Discussions revealed that the most common form of youth involvement is through youth groups, and that apart from these groups, youth participation is largely absent. Key challenges to youth involvement include stigma and lack of support from system-of-care administrators and staff.     

Postpartum Transition of Care: Racial/Ethnic Gaps in Veterans’ Re-Engagement in VA Primary Care after Pregnancy

IntroductionPregnancy presents an opportunity to engage veterans in health care. Guidelines recommend primary care follow-up in the year postpartum, but loss to follow-up is common, poorly quantified, and especially important for those with gestational diabetes (GDM) and hypertension. Racial maternal inequities are well-documented and might be exacerbated by differential postpartum care. This study explores variation in postpartum re-engagement in U.S. Department of Veteran Affairs health care system (VA) primary care to identify potential racial/ethnic inequities in this care transition.MethodsWe conducted a complete case analysis of the 2005–2014 national VA birth cohort (n = 18,414), and subcohorts of veterans with GDM (n = 1,253) and hypertensive disorders of pregnancy (HDP; n = 2,052) using VA-reimbursed discharge claims and outpatient data. Outcomes included incidence of any VA primary care visit in the postpartum year; in age-adjusted logistic regression, we explored race/ethnicity as a primary predictor.ResultsIn the year after a VA-covered birth, the proportion of veterans with one or more primary care visit was 53.8% overall, and slightly higher in the GDM (56.0%) and HDP (57.4%) subcohorts. In adjusted models, the odds of VA primary care follow-up were significantly lower for Black/African American (odds ratio, 0.87; 95% confidence interval, 0.81–0.93), Asian (odds ratio, 0.76; 95% confidence interval, 0.61–0.95), and Hawaiian/other Pacific Islander (odds ratio, 0.73; 95% confidence interval, 0.55–0.96) veterans, compared with White veterans. Among the subcohorts with GDM or HDP, there were no significant associations between primary care and race/ethnicity.ConclusionsOne-half of veterans re-engage in VA primary care after childbirth, with significant racial differences in this care transition. Re-engagement for those with the common pregnancy complications of HDP and GDM is only slightly higher, and less than 60%. The potential for innovations such as VA maternity care coordinators to address such gaps merits attention.     

Women Veterans’ Perspectives on Suicide Prevention in Reproductive Health Care Settings: An Acceptable,Desired, Unmet Opportunity

BackgroundWomen veterans of reproductive age experience a suicide rate more than double their civilian peers. Developing effective suicide prevention strategies for women veterans requires identifying settings frequented by women veterans where acceptable prevention initiatives can be implemented. Reproductive health care (RHC) settings may provide such an opportunity.MethodsWe conducted semi-structured interviews with 21 cisgender women veterans of reproductive age using RHC services provided or paid for by the Department of Veterans Affairs (VA) to understand their beliefs, attitudes, and preferences regarding suicide risk assessment and prevention within these settings. Interview analysis was inductive and used a thematic analysis framework.ResultsFour major themes emerged from the interviews: 1) positive patient-provider relationships in RHC settings are important; 2) some women veterans prefer women providers for RHC and suicide risk screening; 3) women veterans’ experiences with VA suicide risk screening and assessment vary; and 4) suicide risk screening and prevention in RHC settings is a desired and acceptable, yet unmet opportunity.ConclusionsFindings from this novel study suggest that VA RHC settings may present a viable milieu for implementing upstream, gender-sensitive, veteran-centric suicide prevention strategies. Future research is needed with VA RHC providers to determine their needs for successfully implementing such strategies.     

Family Medicine Physicians’ Perspectives Regarding Rural Behavioral Health Care: Informing Ideas for Increasing Access to High-Quality Services

Primary care settings often function as the front lines for behavioral health services in rural areas. The lack of formal behavioral health care in rural areas is also well documented. Rural family practice physicians were interviewed regarding the state of behavioral health care in their communities and their ideas for increasing access to quality care. Thirteen family practice physicians in rural locations participated in in-depth semi-structured interviews. Interviews were transcribed, coded, and analyzed following a phenomenological design. Physicians described a lack of quality behavioral health services and challenges for integrating and collaborating with those that do exist. Participants also described the changing role of stigma, service delivery strategies that are currently working, and the unique role primary care plays in rural behavioral health care. Several ideas for increasing access to and efficacy of services are discussed; these ideas are informative for future research and interventions.

     

The Focus They Deserve: Improving Women Veterans’ Health Care Access

PurposeVeterans Health Administration (VHA) initiatives aim to provide veterans timely access to quality health care. The focus of this analysis was provider and staff perspectives on women veterans' access in the context of national efforts to improve veterans’ access to care.MethodsWe completed 21 site visits at Veterans Health Administration medical facilities to evaluate the implementation of a national access initiative. Qualitative data collection included semistructured interviews (n = 127), focus groups (n = 81), and observations with local leadership, administrators, providers, and support staff across primary and specialty care services at each facility. Deductive and inductive content analysis was used to identify barriers, facilitators, and contextual factors affecting implementation of initiatives and women veterans’ access.ResultsParticipants identified barriers to women veterans' access and strategies used to improve access. Barriers included a limited availability of providers trained in women's health and gender-specific care services (e.g., women's specialty care), inefficient referral and coordination with community providers, and psychosocial factors (e.g., childcare). Participants also identified issues related to childcare and perceived harassment in medical facility settings as distinct access issues for women veterans. Strategies focused on increasing internal capacity to provide on-site women's comprehensive care and specialty services by streamlining provider training and credentialing, contracting providers, using telehealth, and improving access to community providers to fill gaps in women's services. Participants also highlighted efforts to improve gender-sensitive care delivery.ConclusionsAlthough some issues affect all veterans, problems with community care referrals may disproportionately affect women veterans’ access owing to a necessary reliance on community care for a range of gender-specific services.     

Discontinuity of Women Veterans’ Care in Patient-Centered Medical Homes: Does Workforce Gender Sensitivity Matter?

BackgroundPrior research has found that 25% of women veterans who are new to the Department of Veterans Affairs (VA) health care system discontinue services within 3 years of initial use. Although it has been suggested that providing more gender-sensitive care might improve women veterans' health care experiences, no study has yet documented an empirical relationship between clinic and provider factors associated with the provision of gender-sensitive care and women veterans’ care discontinuity.MethodsSurveys of primary care providers (n = 82) and staff members (n = 108) from 12 VA medical centers were linked to administrative data for women veteran patients with at least one primary care visit in 2014 and 2015 (n = 9,958). Patient care discontinuity was operationalized as having no additional primary care visit within 3 years after the patient's baseline visit. Key indicators of gender-sensitive comprehensive primary care included type of medical home (women's health-focused vs. general primary care), workforce gender sensitivity, team functioning, perceived quality of provider/staff communication, leadership support for medical home implementation, and other structural components of care delivery (e.g., chaperone availability). We used logistic regression to assess the association between these indicators and women's care discontinuity, measuring discontinuity for both new and continuing VA users and controlling for patient characteristics.ResultsEleven percent of women patients discontinued primary care within 3 years. Poor workforce gender sensitivity (lowest quartile vs. top three quartiles) was significantly associated with higher odds of discontinuity (odds ratio, 1.26; 95% confidence interval, 1.01–1.57); other indicators were not associated with discontinuity.ConclusionsThis study is the first to document a relationship between workforce gender sensitivity and women veterans’ care continuity. This finding underscores the need for additional attention to enhancing workforce gender sensitivity in VA.     

Group Well-Child Care and Health Services Utilization: A Bilingual Qualitative Analysis of Parents’ Perspectives

Maternal and Child Health Journal - Objective Alternative primary care structures such as group well-child care (GWCC) may enhance care for families, particularly those subject to structural...