The organization and delivery of women's health care in Department of Veterans Affairs Medical Center.

Congressional eligibility reforms have profoundly changed the array of services to be made available to women veterans in Department of Veterans Affairs (VA) health care facilities. These include access not only to primary and specialty care services already afforded VA users, but also to a full spectrum of gender-specific services, including prenatal, obstetric, and infertility services never before provided in VA settings. The implications of this legislative mandate for delivering care to women veterans are poorly understood, as little or no information has been available about how care for women veterans is organized. This article reports on the first national assessment of variations in the organization of care for women veterans.     

Availability of comprehensive women's health care through Department of Veterans Affairs Medical Center.

Despite increased numbers of women veterans, little is known about health services delivery to women across the Department of Veterans Affairs (VA). To assess VA availability of women's health services, we surveyed the senior clinician at each VA site serving 400 or more women veterans. We found that virtually all sites have developed arrangements, either directly or through off-site contracts, to ensure availability of comprehensive women's health care. On-site care, however, is routinely available only for basic services. Future work should evaluate cost and quality trade-offs between using non-VA sites to increase specialized service availability and using VA sites to enhance continuity of care.     

Perception of health care delivery in Israel: women's voices

In this article, we describe the results of nine focus groups in which women were asked to discuss their perception of the women's health care delivery system in Israel. The focus groups, held in Israel in 2001, included nearly 150 women with diverse demographic characteristics. This project solicited focused input from women of different ages from the periphery as well as highly populated areas. The responses were categorized into designated themes and are presented here to demonstrate the range of women's feelings toward health care. The qualitative findings of this research show that place of residence affects the women's sense of responsibility for their health and their use of private care. Age was found to affect knowledge and use of health information, the frequency of visits to the doctor, and the general level of satisfaction with the system. These findings are important to improve health care delivery and can serve as a basis for forging policy changes in Israel.     

Disruptive innovation in health care delivery: a framework for business-model innovation

Disruptive innovation has brought affordability and convenience to customers in a variety of industries. However, health care remains expensive and inaccessible to many because of the lack of business-model innovation. This paper explains the theory of disruptive innovation and describes how disruptive technologies must be matched with innovative business models. The authors present a framework for categorizing and developing business models in health care, followed by a discussion of some of the reasons why disruptive innovation in health care delivery has been slow.     

Retail health clinics drive innovation into primary care practices

A myriad of patient dissatisfaction issues stemming from antiquated approaches to primary care access are resulting in the establishment of retail health clinics (RHCs) throughout the country. RHCs are usually located within retail stores or stand-alone pharmacies and are staffed by nurse practitioners (NPs). They offer treatment for colds, coughs, skin rashes, and ear infections along with offering preventive care and physicals. As disruptive innovations, or innovations that offer services to ignored markets, these clinics are siphoning patient care visits away from primary care physicians because of their attention to quick access, affordable prices, and consumer-friendly approaches. In response, family and internal medicine physicians must follow three strategies to secure their patient population as well as attract new patients: build relationships with RHCs through referral networks and NP supervisory agreements, transform the provision of patient access through the development of physician-owned RHCs, and support the concept of the advanced medical home.     

Marketing retail health clinics: challenges and controversies arising from a health care innovation

Since their founding in 2000, retail-based health care clinics, also called convenient care clinics, have flourished but continue to generate controversy. This article examines the literature with respect to the industry's background, establishment of industry standards, types of services offered, marketing of retail health clinics, industry growth with new target markets, and patient demographics. It also examines the growing relationship with insurers and third-party payers, quality-of-care concerns by medical associations, and legal regulations and their potential impact on industry growth nationwide.     

Convenient care clinics: the future of accessible health care.

The need for accessible, affordable, quality health care in the United States has never been greater. In response to this need, convenient care clinics (CCCs) are being launched across the country to help provide care to meet the basic health needs of the public. In CCCs, highly qualified health care providers diagnose and treat common health problems, triage patients to the appropriate level of care, advocate for a medical home for all patients, and reduce unnecessary visits to emergency rooms and Urgent Care Clinics. CCCs have been called a "disruptive innovation" because they are consumer driven. They serve as a response to many patients who are unhappy with the current conventional health care delivery system--a system that is challenged to provide access to basic health care services when people need it the most. CCCs are based in retail stores and pharmacies. They are primarily staffed by nurse practitioners (NPs). Some CCCs are staffed by physician assistants (PAs) and physicians. The authors acknowledge the important roles of both PAs and physicians in CCCs; however, this paper primarily provides education about the role of NPs in CCCs. CCCs have evolved at a time when our health care system is floundering, and the need for accessible, affordable health care is at its greatest. The CCC model provides an accessible, affordable entry point into the health care system for those who previously were restricted access.     

A comparison of patient‐reported mental health outcomes for the Department of Veterans Affairs' regional telehealth and Community Care Programs

ObjectivesTo compare patient‐reported outcomes for veterans with limited access to Department of Veterans Affairs (VA) mental health services referred to the Veterans Community Care Program (VCCP) or regional telehealth Clinical Resource Hubs‐Mental Health (CRH‐MH).Data SourcesThis national evaluation used secondary data from the VA Corporate Data Warehouse, chart review, and primary data collected by baseline survey between October 8, 2019 and May 27, 2020 and a 4‐month follow‐up survey.Study DesignA quasi‐experimental longitudinal study design was used to sample 545 veterans with VCCP or CRH‐MH referrals for new treatment episodes. Patient‐reported outcomes included symptom severity, perceived access, utilization, and patient‐centeredness.Data CollectionDuring the baseline and follow‐up surveys, all veterans were administered the Patient Health Questionnaire‐8 (PHQ‐8) to assess depression severity, and veterans with a provisional diagnosis of posttraumatic stress disorder (PTSD) were also administered the PTSD Checklist for DSM‐5 (PCL‐5) to assess PTSD symptom severity. The 4‐month follow‐up survey also asked about perceived access using the Perceived Access Inventory, the number of encounters, and patient‐centeredness of care using the Patient‐Centered Care portion of the Veterans Satisfaction Survey.Principal FindingsResults indicated that compared to VCCP consults, veterans with CRH‐MH consults reported 0.65 (CI₉₅ = 0.51–0.83, p < 0.01) times the number of barriers to care, but a non‐significant lower number of encounters (−0.792, CI₉₅ −2.221, 0.636, p = 0.28). There was no significant (p = 0.24) difference in satisfaction with patient‐centeredness, with both groups “agreeing” on average to positively worded questions. Veterans in both groups experienced little improvement in depression or PTSD symptom severity, and there were no clinically meaningful differences between groups.ConclusionsOverall findings indicate that the CRH‐MH and VCCP generate similar patient‐reported outcomes. Future research should compare the quality and cost of care delivered by the VCCP and CRH‐MH programs.     

Associations Between the Department of Veterans Affairs' Suicide Prevention Campaign and Calls to Related Crisis Lines

Objective

The Transit Authority Suicide Prevention (TASP) campaign was launched by the Department of Veterans Affairs (VA) in a limited number of U.S. cities to promote the use of crisis lines among veterans of military service.

Methods

We obtained the daily number of calls to the VCL and National Suicide Prevention Lifeline (NSPL) for six implementation cities (where the campaign was active) and four control cities (where there was no TASP campaign messaging) for a 14-month period. To identify changes in call volume associated with campaign implementation, VCL and NSPL daily call counts for three time periods of equal length (pre-campaign, during campaign, and post-campaign) were modeled using a Poisson log-linear regression with inference based on the generalized estimating equations.

Results

Statistically significant increases in calls to both the VCL and the NSPL were reported during the TASP campaign in implementation cities, but were not reported in control cities during or following the campaign. Secondary outcome measures were also reported for the VCL and included the percentage of callers who are veterans, and calls resulting in a rescue during the study period.

Conclusions

Results from this study reveal some promise for suicide prevention messaging to promote the use of telephone crisis services and contribute to an emerging area of research examining the effects of campaigns on help seeking.Public communication campaigns have demonstrated efficacy for disseminating strategic messages that address risk and encourage healthy behaviors.^1,2 Such communication efforts are regularly employed to target a range of health issues (e.g., exercise/diet, contraception use, and cancer screening),^3–5 and have recently drawn attention for their potential in the 2012 National Strategy for Suicide Prevention.⁶ Although this type of messaging is prevalent in public health approaches to suicide prevention,⁷ empirical evaluation of it is rare. Limited research suggests that suicide prevention campaigns may be associated with modest, short-term improvements in mental health-related knowledge and attitudes toward treatment;⁸ however, their impact on help-seeking behaviors is unclear.To date, several studies have attempted to identify associations between communication campaigns and help-seeking behavior, such as calls to crisis lines, an important suicide prevention intervention tool that provides immediate, quality care. These studies have yielded conflicting results in that some have reported statistically significant increases in overall call volume during campaign implementation,^9,10 while others have found no change.¹¹ Given that timely help seeking may mitigate the risk for developing suicidal behaviors,¹² further investigation of the role campaigns play in promoting the use of crisis lines, a readily accessible service, is needed.Crisis line promotion may be beneficial to U.S. veterans—who may be at increased risk for suicide^13,14—by providing a tangible resource and instruction for accessing help. Several reports have underscored the importance of using public messaging to support viable help seeking among this population;^15,16 however, little research has been published on such efforts. We addressed this gap by assessing the Transit Authority Suicide Prevention (TASP) campaign, which was launched by the Department of Veterans Affairs (VA) to promote crisis line use. Specifically, we aimed to identify changes in call volume to the Veterans Crisis Line (VCL) and the National Suicide Prevention Lifeline (NSPL) associated with the TASP campaign.     

Multidisciplinary women's health care and quality of care.

Multidisciplinary women's health centers have appeared in academic and community settings throughout the United States as a response to the historical fragmentation of women's health care. This paper addresses the influence of this model for comprehensive primary care on quality of care for women. Attributes of care that may differ between multidisciplinary centers and traditional sites for women's health care and quality measurements sensitive to these differences are considered. The paper reviews the literature on characteristics of patients who attend women's health centers and studies evaluating quality of care in these centers as compared to traditional settings.     

Determining HIV seroprevalence among women in women's health clinics

Human immunodeficiency virus, type 1 (HIV), seroprevalence studies are needed to determine the level and trends of HIV infection among women attending family planning, abortion, and prenatal care clinics in the United States. A review of published and unpublished studies showed that HIV seroprevalence among women attending women's health clinics was 0 to 2.6 percent, although the studies were difficult to compare because of differences in methodology. The Centers for Disease Control, in association with State and local health departments, has developed a standardized protocol to determine HIV seroprevalence among women attending women's health clinics in selected metropolitan areas. Blinded HIV serosurveys (serologic test results not identified with a person) are being conducted annually in selected sentinel clinics in order to obtain estimates of HIV seroprevalence unbiased by self-selection, as well as to monitor trends in infection among clients attending these clinics. In areas with high HIV seroprevalence, nonblinded serosurveys (in which clients voluntarily agree to participate) will be used to assess behaviors that may place women at increased risk of exposure to HIV. Data from the surveys can be used in developing age-specific and culturally appropriate AIDS educational materials, assessing the amount and type of counseling activities required, and evaluating acquired immunodeficiency syndrome (AIDS) prevention activities. The information will provide epidemiologic data to complement the results of other surveys in characterizing the scope of HIV infection among women of childbearing age in the United States.     

Executive management and IT innovation in health: identifying the barriers to adoption

This study aims to understand IT investment decisions from the perspective of senior health system executives. A two-stage study was used to investigate this highly influential, very specialized and small population of interest. The first stage involved qualitative interviews with top health executives and analysed their opinions and beliefs using an innovation diffusion theory framework. The second stage involved quantitative surveys of senior health executives to gain an understanding of their opinions regarding the organizational and technological drivers (the independent variables) and the level of IT adoption (the dependent variable). It was found that the majority of drivers identified as being significant to organizational and technological innovation are degraded in respect to IT and health. It was concluded that health executives hold a range of views that potentially inhibit the increased adoption of IT in health. In particular, beliefs about the technology itself have been identified as the most influential deterrents.     

Planning health care delivery systems.

The increasing concern and interest in the health delivery system in the United States has placed the health system planners in a difficult position. They are inadequately prepared, in many cases, to deal with the management techniques that have been designed for use with system problems. This situation has been compounded by the failure, until recently, of educational programs to train new health professionals in these techniques. Computer simulation is a technique that allows the planners dynamic feedback on his proposed plans. This same technique provides the planning student with a better understanding of the systems planning process.     

From cottage industry to a dominant mode of primary care: stages in the diffusion of a health care innovation (retail clinics)

Primary health care is essential to population health and there is increasing need for it, especially with an aging population with multiple comorbidities. Primary health care in the U.S. is widely considered in an ever-deepening crisis. This paper presents a detailed case study of the recent rise of a "disruptive innovation" - retail clinics - which have the potential to transform the face of primary health care in the US. We describe six stages in the diffusion of retail clinics, from cottage industry to a dominant mode for the delivery of primary health care, and consider sociopolitical influences that facilitate and impede their emerging potential. Retail clinics may provide a strategic opportunity to re-engineer the primary health care system, although they may also produce worrisome unanticipated consequences. Discussion concerning the potential threats and opportunities posed by retail clinics occurs in the absence of sound evidence concerning their comparative effectiveness and quality-of-care. This case study identifies the sociopolitical influences and processes that determine whether health care innovations rise or fall, and highlights critically important points along the pathway to health system change.     

New models of women's health care

A consideration of contemporary U.S. women's health status, causes of morbidity and mortality, and the progress of the women's health care movement prompts a reconsideration of traditional health care models. New models must deliver comprehensive services, invite participation of clients, offer a choice of healers, incorporate new sites for delivery of services, and transcend the boundaries of traditional medicine. Although consumer demand and cost effectiveness may ease the birth of these models, their acceptance by traditional professionals and fiscal and business management will be influential in their survival.