Reproductive Life Planning in Primary Care: A Qualitative Study of Women Veterans' Perceptions

BackgroundWomen veterans using Veterans Administration (VA) health care have high rates of medical and mental health comorbidities, placing them at increased risk of poor outcomes from unplanned pregnancy. Reproductive life planning is a strategy recommended by the U.S. Centers of Disease Control and Prevention that could promote healthy pregnancies and reduce unplanned pregnancy in the VA. However, no data exist on women veterans' perceptions of reproductive life planning discussions.MethodsWe trained six VA primary care physicians at two VA Women's Health Clinics to conduct reproductive life planning discussions with veterans aged 18 to 44 during primary care visits. After the visit, we performed semistructured telephone interviews with consenting veterans to explore perceptions of 1) reproductive life planning content and 2) provider–patient communication in reproductive life planning discussions. Interviews were audiorecorded, transcribed, and analyzed using content analysis.ResultsWe interviewed 27 veterans with a mean age of 31 years (range, 22–42). Women veterans perceived generally reproductive life planning discussions as important opportunities to discuss reproductive goals with providers and to obtain new and relevant information about contraception, planning healthy pregnancies, and available VA reproductive health services. Perceptions of reproductive life planning content were influenced by women's pregnancy intentions. Perceptions related to provider–patient communication included preferences for provider-initiated discussions and nonjudgmental counseling that incorporates patients' values and preferences.ConclusionsWomen veterans perceived reproductive life planning as valuable and important to their health. Reproductive life planning has the potential to enhance patient-centered delivery of reproductive health services in VA primary care.     

Comparing the smoking behavior of veterans and nonveterans.

OBJECTIVES: The authors analyzed self-reported questionnaire data from the 1987 National Medical Expenditure Survey (NMES) to determine the smoking patterns of veterans. METHODS: Using NMES data, the authors compared veterans versus nonveterans overall, women veterans versus women nonveterans, Vietnam-era veterans versus other veterans, and veterans whose usual source of medical care was the Department of Veterans Affairs (VA) system versus veterans who received care elsewhere. RESULTS: The likelihood of ever having smoked cigarettes was higher for veterans than for nonveterans and for women veterans than for women nonveterans. The prevalence of current smoking was higher for veterans than for nonveterans and higher for those seeking care within the VA system than for other veterans. CONCLUSIONS: Given the enormous health care costs associated with smoking, health promotion efforts should be developed to reduce the high rate of smoking among veterans--especially those who are consumers of VA health care.     

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.     

Veterans using and uninsured veterans not using Veterans Affairs (VA) health care

OBJECTIVES: The objectives of this study were to: (1) examine veteran reliance on health services provided by the Veterans Health Administration (VA), (2) describe the characteristics of veterans who receive VA care, and (3) report rates of uninsurance among veterans and characteristics of uninsured veterans. METHODS: The authors analyzed data from the 2000 Behavioral Risk Factor Surveillance System. Using bivariate and multivariate analyses, the association of veteran's demographic characteristics, health insurance coverage, and use of VA services were examined. Veterans not reporting VA coverage and having no other source of health insurance were considered uninsured. RESULTS: Among veteran respondents, 6.2% reported receiving all of their health care at the VA, 6.9% reported receiving some of their health care at the VA, and 86.9% did not use VA health care. Poor, less-educated, and minority veterans were more likely to receive all of their health care at the VA. Veterans younger than age 65 who utilized the VA for all of their health care also reported coverage with either private insurance (42.6%) or Medicare (36.3%). Of the veterans younger than age 65, 8.6% (population estimate: 1.3 million individuals) were uninsured. Uninsured veterans were less likely to be able to afford a doctor or see a doctor within the last year. CONCLUSIONS: Veterans who utilized the VA for all of their health care were more likely to be from disadvantaged groups. A large number of veterans who could use VA services were uninsured. They should be targeted for VA enrollment given the detrimental clinical effects of being uninsured.     

Male combat veterans’ narratives of PTSD,masculinity, and health

This article uniquely examines the ways a group of male combat veterans talk about masculinity and how, following post‐traumatic stress disorder (PTSD), they performed masculinities in the context of a surfing group, and what effects this had upon their health and wellbeing. Participant observations and life history interviews were conducted with a group of combat veterans who belonged to a surfing charity for veterans experiencing PTSD. Data were rigorously explored via narrative analysis. Our findings revealed the ways in which veterans enacted masculinities in accordance with the values that were cultivated during military service. These masculine performances in the surfing group had important effects both on and for the veterans’ wellbeing. Significantly, the study highlights how masculine performances can be seen alternately as a danger and as a resource for health and wellbeing in relation to PTSD. The article advances knowledge on combat veterans and mental health with critical implications for the promotion of male veterans’ mental health. These include the original suggestion that health‐promoting masculine performances might be recognised and supported in PTSD treatment settings. Rather than automatically viewing masculinity as problematic, this article moves the field forward by highlighting how hegemonic masculinities can be reconstructed in positive ways which might improve veterans’ health and wellbeing. A video abstract of this article can be found at: https://www.youtube.com/watch?v=BaYzaOP1kAY     

Comparing the health status of male and female veterans who use VA health care: results from the VA Women's Health Project

BACKGROUND: In recent years the number of women serving in the military has increased substantially, resulting in more demand for VA services by women veterans. This paper describes the characteristics and health status of women veterans who use VA ambulatory services. METHODS: Respondents in the VA Women's Health Project (n = 719) represent a randomly selected subsample from all women who had an ambulatory visit between July 1, 1994 and June 30, 1995 at a large tertiary care VA facility in the Boston area. Summary statistics on eight dimensions of health status (using the SF-36) for women veterans who use VA ambulatory care are provided. Comparisons are made between women veterans and men veterans who use VA services. RESULTS: Women veterans reported consistently low scores on health status across multiple dimensions, reflecting considerable health needs. Among veterans using VA services, women were younger, better educated, and less likely to be married than male veterans. Women veterans who use VA ambulatory services scored lower on every scale except physical functioning and general health perceptions when compared to male VA users. There were more pronounced differences for women on scales measuring emotional health. CONCLUSIONS: Health status among women veterans is moderate to poor. Important differences in health status are observed between men and women who use VA services which have implications for improving health care to women veterans at VA facilities. These findings strongly indicate that increased mental health services need to be available for women veterans seeking VA health care.     

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.     

Racial/ethnic variations in veterans' ambulatory care use

OBJECTIVES: We assessed racial/ethnic variations in patterns of ambulatory care use among Department of Veterans Affairs (VA) health care-eligible veterans to determine if racial/ethnic differences in health care use persist in equal-access systems. METHODS: We surveyed 3227 male veterans about their health and ambulatory care use. RESULTS: Thirty-eight percent of respondents had not had a health care visit in the previous 12 months. Black (odds ratio [OR] = 0.5), Hispanic (OR = 0.4), and Asian/Pacific Islander veterans (OR=0.4) were less likely than White veterans to report any ambulatory care use. Alternately, Whites (OR=2.2) were more likely than other groups to report ambulatory care use. Being White was a greater predictor of health care use than was having fair or poor health (OR=1.4) or functional limitations (OR=1.5). In non-VA settings, racial/ethnic minorities were less likely to have a usual provider of health care. There was no VA racial/ethnic variation in this parameter. CONCLUSIONS: Racial/ethnic disparities in health and health care use are present among VA health care-eligible veterans. Although the VA plays an important role in health care delivery to ethnic minority veterans, barriers to VA ambulatory care use and additional facilitators for reducing unmet need still need to be investigated.     

Rural Veterans’ Perspectives of Dual Care

The purpose of this study was to develop an in-depth understanding of the barriers and enablers of effective dual care (care obtained from the Veterans Health Administration [VHA] and the private health system) for rural veterans. Telephone interviews of a random sample of 1,006 veterans residing in rural Nebraska were completed in 2010. A high proportion of the rural veterans interviewed reported receiving dual care. The common reasons cited for seeking care outside the VHA (or VA [Veterans Administration]) included having an established relationship with a non-VA provider and distance to the nearest VA medical center. Almost half of the veterans who reported having a personal doctor or nurse reported that this was a non-VA provider. Veterans reported high levels of satisfaction with the quality of care they receive. Ordinal logistic regression models found that veterans who were Medicare beneficiaries, and who rated their health status higher had higher satisfaction with dual care. The reasons cited by the veterans for seeking care at the VHA (quality of VHA care, lower costs of VHA care, entitlement) and veterans perceptions about dual care (confused about where to seek care for different ailments, perceived lack of coordination between VA and non VA providers) were significant predictors of veterans’ satisfaction with dual care. This study will guide policymakers in the VA to design a shared care system that can provide seamless, timely, high quality and veteran centered care.     

Physical and Mental Health and Access to Care Among Nonmetropolitan Veterans Health Administration Patients Younger Than 65 Years

CONTEXT: The 4.5 million military veterans treated by the Veterans Health Administration (VA) are believed to experience poorer physical and mental health than nonveterans. Furthermore, nonmetropolitan residents have less access to medical services, whether or not they are veterans in VA care. A direct comparison of metropolitan and nonmetropolitan veterans and nonveterans on a national health survey has not been reported, so it is not known whether nonmetropolitan VA patients experience similar medical need or access as other nonmetropolitan residents. PURPOSE: We sought to compare the perceptions of health status and access to care among metropolitan and nonmetropolitan veterans in VA care, other veterans, and nonveterans in a large national sample surveyed under the same conditions. METHODS: Male respondents to the 2000 Behavioral Risk Factor Surveillance System health survey were divided into veterans or nonveterans, VA users or nonusers, metropolitan or nonmetropolitan residents, and 1 of 3 age groups (18-44, 45-64, and 65(+)). Responses to questions about current health status, health coverage, and access to care were submitted to chi-square analyses or analyses of variance, using SUDAAN software to compute survey error variance. FINDINGS: Nonmetropolitan VA patients younger than 65 years consistently reported the worst physical and mental health status and reduced access to care. CONCLUSIONS: VA can anticipate increasing demand for mental and physical health care among rural veterans younger than 65 years.     

Shifting landscapes: immigrant women and postpartum depression

Utilizing an ethnographic narrative approach, we explored in the Canadian context the experiences of three groups of first-generation Punjabi-speaking, Cantonese-speaking, and Mandarin-speaking immigrant women with depression after childbirth. The information emerging from women's narratives of their experiences reveals the critical importance of the sociocultural context of childbirth in understanding postpartum depression. We suggest that an examination of women's narratives about their experiences of postpartum depression can broaden the understanding of the kinds of perinatal supports women need beyond health care provision and yet can also usefully inform the practice of health care professionals.     

Health services utilization of a care coordination/home-telehealth program for veterans with diabetes: a matched-cohort study

This study examined the effectiveness of a veterans affairs (VA) patient-centered care coordination/home-telehealth (CC/HT) program as an adjunct to treatment for veterans with diabetes. Using an adapted version of the Chronic Care Model, we analyzed the differences in healthcare service use between a cohort of 400 veterans with diabetes who were enrolled in a VA CC/HT program and a matched comparison cohort of 400 veterans with diabetes who received no CC/HT intervention. Propensity scores were used to improve the balance between the treatment and comparison groups. Service use outcomes were assessed at 12 months before and after enrollment. A difference-in-differences approach was used in the multivariate models to assess the treatment effect for patients in the CC/HT programs. Twelve months after enrollment, there was a significant difference between the treatment and comparison groups in terms of need-based primary care visits (newly scheduled visits that enable the veteran to be seen "just in time," where the health status is monitored and met before health deteriorates), increasing in the treatment group and decreasing in the comparison group (P < .01). In a subgroup analysis, where we were able to control for the patients' Hb A1c values, we found that the treatment group had a lower likelihood of having 1 or more hospitalizations than patients in the comparison group. Our findings have implications for management in that the CC/HT program appears to improve the ability of older veterans with diabetes to receive appropriate, timely care, thereby improving the quality of care for them and making more efficient use of VA healthcare resources.     

Primary care satellite clinics and improved access to general and mental health services

OBJECTIVES: To evaluate the relationship between the implementation of community-based primary care clinics and improved access to general health care and/or mental health care, in both the general population and among people with disabling mental illness. STUDY SETTING: The 69 new community-based primary care clinics in underserved areas, established by the Department of Veterans Affairs (VA) between the last quarter of FY 1995 and the second quarter of FY 1998, including the 21 new clinics with a specialty mental health care component. DATA SOURCES: VA inpatient and outpatient workload files, 1990 U.S. Census data, and VA Compensation and Pension files were used to determine the proportion of all veterans, and the proportion of disabled veterans, living in each U.S. county who used VA general health care services and VA mental health services before and after these clinics began operation. DESIGN: Analysis of covariance was used to compare changes, from late FY 1995 through early FY 1998, in access to VA services in counties in which new primary care clinics were located, in counties in which clinics that included specialized mental health components were located, and for comparison, in other U.S. counties, adjusting for potentially confounding factors. KEY FINDINGS: Counties in which new clinics were located showed a significant increase from the FY 1995-FY 1998 study dates in the proportion of veterans who used general VA health care services. This increase was almost twice as large as that observed in comparison counties (4.2% vs. 2.5%: F = 12.6, df = 1,3118, p = .0004). However, the introduction of these clinics was not associated with a greater use of specialty VA mental health services in the general veteran population, or of either general health care services or mental health services among veterans who received VA compensation for psychiatric disorders. In contrast, in counties with new clinics that included a mental health component the proportion of veterans who used VA mental health services increased to almost three times the proportion in comparison counties (0.87% vs. 0.31%: F = 8.3, df = 1,3091, p = .004). CONCLUSIONS: Community-based primary care clinics can improve access to general health care services, but a specialty mental health care component appears to be needed to improve access to mental health services.     

Uninsured Veterans Who Will Need to Obtain Insurance Coverage Under the Patient Protection and Affordable Care Act

Objectives. We examined the number and clinical needs of uninsured veterans, including those who will be eligible for the Medicaid expansion and health insurance exchanges in 2014.Methods. We analyzed weighted data for 8710 veterans from the 2010 National Survey of Veterans, classifying it by veterans’ age, income, household size, and insurance status.Results. Of 22 million veterans, about 7%, or more than 1.5 million, were uninsured and will need to obtain coverage by enrolling in US Department of Veterans Affairs (VA) care or the Medicaid expansion or by participating in the health insurance exchanges. Of those uninsured, 55%, or more than 800 000, are likely eligible for the Medicaid expansion if states implement it. Compared with veterans with any health coverage, those who were uninsured were younger and more likely to be single, Black, and low income and to have been deployed to Iraq and Afghanistan.Conclusions. The Patient Protection and Affordable Care Act is likely to have a considerable impact on uninsured veterans, which may have implications for the VA, the Medicaid expansion, and the health insurance exchanges.The Patient Protection and Affordable Care Act (ACA)1 represents one of the most significant overhauls of the US health care system and is expected to affect millions of uninsured people across the country. Military veterans constitute a particularly important segment of the population because of their service to the country, access to US Department of Veterans Affairs (VA) health care, and other special benefits after their service. However, little has been written on the potential impact of the ACA on the health and health care of veterans.2 Although the VA operates an integrated national health care system that offers free or low-cost services to eligible veterans, many veterans are not enrolled in VA health care, and some are ineligible. Enrollment in VA health care satisfies the ACA’s requirement for insurance coverage, but eligibility for VA health care is determined on the basis of a complex system of priorities, mostly based on service-connected disability, income, and age, and it generally requires a military service discharge that is other than dishonorable (i.e., honorable, general).One study estimated that only 13% (3.6 million) of veterans report receiving some or all of their health care at the VA, and the vast majority (> 20 million) receive no health care from the VA.3 Most veterans thus rely on non-VA health care and are covered by various private or other public forms of health insurance, including Medicare and Medicaid. A small, albeit important, minority of veterans have no health insurance coverage. Estimates based on data from 1987 to 2004 showed that 7.7% of veterans were uninsured (including having no VA coverage), which equates to nearly 1.8 million veterans and represents 4.7% of all uninsured US residents.4Lack of health insurance coverage is an important problem because it can hinder access to effective health care, including needed medical visits, preventive care, and other services, and it can ultimately lead to poor health, premature mortality, and high medical costs.5,6 Being uninsured is a growing problem in the United States that the ACA addresses by requiring virtually all legal US residents to have health insurance. The ACA includes various provisions to help US residents, including veterans, accomplish this.One major provision that is optional for states to implement is the expansion of Medicaid coverage to all individuals aged 18 to 65 years with incomes at or below 138% of the federal poverty level. Although not all states will implement this expansion, and the number of participating states is currently unknown, many poor, uninsured adults will be able to obtain Medicaid coverage in states that implement the Medicaid expansion. Uninsured adults who have incomes above the Medicaid expansion limit or who live in states that do not implement the Medicaid expansion will have to purchase health insurance and may participate in the health insurance exchanges.A second major provision of the ACA is the creation of health insurance exchanges in each state whereby individuals may purchase competitive health insurance plans that are eligible for federal subsidies, but those subsidies are only available to those with income above the federal poverty level. Both of these major ACA provisions are planned for implementation in 2014 and will introduce a variety of coverage options for US residents, including veterans.There has been little study of uninsured veterans and no study of the potential impact of the ACA on veterans in general. Moreover, most data that exist on veterans are based on VA data, which only contain information about veterans who use VA health services and do not include information about those who are uninsured or not covered by VA health care. However, 1 population-based study7 has provided some evidence that a substantial number of veterans are uninsured (particularly those younger than 65 years) and that many uninsured veterans are in poor health, often forego needed health care because of costs, and have equal or worse access to health care than other uninsured adults in the general population. As the country moves toward a new era of health care with the ACA and continues to engage in conflicts in the Middle East, the impact of the ACA on the health care of veterans needs to be considered.We used a recent nationally representative survey of veterans to (1) describe the proportion and characteristics of veterans who are currently uninsured because they will likely be required to obtain coverage under the ACA; (2) determine, among those who are uninsured, who will likely be eligible for the Medicaid expansion; and (3) compare the sociodemographic and health characteristics of those who are uninsured and likely eligible for Medicaid expansion (LEME), those who are uninsured and not LEME, and those who currently have health insurance coverage. The results provide information about the number and health characteristics of veterans who will likely be affected by different provisions of the ACA and inform planning efforts for the VA and states that implement the Medicaid expansion and health insurance exchanges.     

Despite improved quality of care in the Veterans Affairs health system, racial disparity persists for important clinical outcomes

Both government and private health care systems have engaged in efforts to improve quality, but the effect of these initiatives on racial and ethnic disparities has not been well studied. In the decade following an organizational transformation, the Veterans Affairs (VA) health care system achieved substantial improvements in quality of care with minimal racial disparities for most process-of-care measures, such as rates of cholesterol screenings. However, in our study we observed a striking disconnect between high levels of performance on widely used process measures and modest levels of improvement in clinical outcomes, such as control of blood pressure, blood glucose, and cholesterol levels. We also observed a gap in clinical outcomes of as much as nine percentage points between African American veterans and white veterans. Almost all of the disparity in outcomes in the VA was explained by within-facility disparity, which suggests that VA medical centers need to measure and address racial gaps in care for their patient populations. Moreover, because cardiovascular disease and diabetes are major contributors to racial disparities in life expectancy, the findings of this study and others underscore the urgency of focused efforts to improve intermediate outcomes among African Americans in the VA and other settings.     

Shifting Landscapes: Immigrant Women and Postpartum Depression

Utilizing an ethnographic narrative approach, we explored in the Canadian context the experiences of three groups of first-generation Punjabi-speaking, Cantonese-speaking, and Mandarin-speaking immigrant women with depression after childbirth. The information emerging from women's narratives of their experiences reveals the critical importance of the sociocultural context of childbirth in understanding postpartum depression. We suggest that an examination of women's narratives about their experiences of postpartum depression can broaden the understanding of the kinds of perinatal supports women need beyond health care provision and yet can also usefully inform the practice of health care professionals.     

Geographical proximity and health care utilization in veterans with SCI&D in the USA

In the USA, substantial geographic variation in health care utilization exists in the Department of Veterans Affairs (VA) health care system. Utilization of health care services is especially important for veterans with spinal cord injuries and disorders (SCI&D) who are often at high risk for secondary complications related to their SCI&D. Due to impaired mobility, access to health care for veterans with SCI&D may be even more challenging. The goal of this cross-sectional study was to describe health care utilization relative to SCI&D veteran residential geographic proximity to VA health care facilities. A negative binomial regression model was used to examine VA outpatient utilization. Veterans with SCI&D utilized outpatient services less frequently when VA facilities were farther away from their residences (p<0.000). Female (p<0.000), older (p<0.000), and non-white veterans (p<0.000), and veterans with history of respiratory (p<0.000), kidney/urinary tract (p<0.005), circulatory (p<0.000), or digestive system diseases (p<0.003) were more likely to utilize outpatient care during the study period. A Poisson model was used to examine inpatient utilization. Inpatient utilization decreased when travel distance to VA facility increased (p<0.000). Contrary to outpatient, age did not significantly affect veterans' likelihood of using inpatient health care. Marital status, gender, race, and level of injury were not related to inpatient utilization. However, history of prior illnesses including respiratory (p<0.000), kidney/urinary tract (p<0.000), circulatory (p<0.005), digestive system (p<0.015), or skin/subcutaneous tissue/breast-related illnesses (p<0.000) were associated with a greater likelihood of inpatient utilization. Geographic proximity and other factors on health care use must be considered in order to meet the health care demand patterns of veterans with SCI&D.     

Considering the Issue of Dual Use in Veterans Affairs Patients: Implications & Opportunities for Improved Communication & Counseling

This study sought to ascertain perceptions of communication responsibility in veterans identified as using more than one health care system, otherwise known as dual users. Three hundred and fifteen veterans identified as dual users completed a telephone-based survey including questions about their perspectives regarding communication in the context of dual use. Nearly half (47.3%) indicated that that they believed it was primarily their responsibility to either directly communicate or facilitate communication between their Veterans Affairs (VA) and non-VA providers. Only 11.3% reported that it should be the responsibility of their VA provider, 19.6% believed that their non-VA provider should be responsible, and 7.3% believed both should be involved. Finally, 14.4% believed another person was responsible, such as a system administrator or patient representative. Of those patients indicating that it was their responsibility, a majority (61.7%) indicated that they preferred active involvement in their health care. Patient-centered care allows patients the opportunity to help facilitate communication between multiple health care systems, such as when using VA and non-VA providers, if they so choose. However, given that patient preferences for involvement vary considerably, it is likely that a multifaceted approach to this problem is necessary, involving patients, providers, and other system-level stakeholders. These data suggest a need to inquire about preferred patient roles and counsel patients regarding methods of communication that may serve to decrease fragmentation of care.