The association between clinical integration of care and transfer of veterans with acute coronary syndromes from primary care VHA hospitals

Identification of the factors affecting the referral system of veterans' health services: A scoping review

Referral in the health system is a systematic process for the optimal allocation of resources and improves the access of people in need of treatment services. Considering the vulnerability of the veterans and more medical needs in this group, this study aims to identify the components that affect veterans' health services referral system. MEDLINE, Scopus, Web of Science, and ProQuest databases, the international military studies website, and key journals in the field of veterans' health services were searched with related keywords including "veteran," "referral system," and "health services" for the period from January 2000 to July 2022. Studies were screened and selected in accordance with the phases of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses(PRISMA) flow diagram 2020. Data extraction was done by two researchers independently and a thematic content analysis method was used to analyze the findings. Among 40,608 studies searched electronically and 16 studies searched manually, 19 studies that met the inclusion criteria were selected. The research method applied here is a combination of quantitative, qualitative, and mixed methods. The most important findings were extracted from the included studies and analyzed in three general categories: components related to the patient, service provider, and the structural-operational mechanisms of the referral system. The effective performance of the referral system for providing health services to veterans is influenced by the factors affecting components related to the patient, the service provider, and the structural-operational mechanisms of the referral system. Evaluating and improving each of these factors improve the performance of the referral system and provision of health services to veterans.

How personal and standardized coordination impact implementation of integrated care

BACKGROUND

Integrating health care across specialized work units has the potential to lower costs and increase quality and access to mental health care. However, a key challenge for healthcare managers is how to develop policies, procedures, and practices that coordinate care across specialized units. The purpose of this study was to identify how organizational factors impacted coordination, and how to facilitate implementation of integrated care.

METHODS

Semi-structured interviews were conducted in August 2009 with 30 clinic leaders and 35 frontline staff who were recruited from a convenience sample of 16 primary care and mental health clinics across eight medical centers. Data were drawn from a management evaluation of primary care-mental health integration in the US Department of Veterans Affairs. To protect informant confidentiality, the institutional review board did not allow quotations.

RESULTS

Interviews identified antecedents of organizational coordination processes, and highlighted how these antecedents can impact the implementation of integrated care. Overall, implementing new workflow practices were reported to create conflicts with pre-existing standardized coordination processes. Personal coordination (i.e., interpersonal communication processes) between primary care leaders and staff was reported to be effective in overcoming these barriers both by working around standardized coordination barriers and modifying standardized procedures.

DISCUSSION

This study identifies challenges to integrated care that might be solved with attention to personal and standardized coordination. A key finding was that personal coordination both between primary care and mental health leaders and between frontline staff is important for resolving barriers related to integrated care implementation.

CONCLUSION

Integrated care interventions can involve both new standardized procedures and adjustments to existing procedures. Aligning and integrating procedures between primary care and specialty care requires personal coordination amongst leaders. Interpersonal relationships should be strengthened between staff when personal connections are important for coordinating patient care across clinical settings.

Prostate cancer survivorship care in the Veterans Health Administration

The burden of prostate cancer among Veterans is substantial with over 200,000 survivors and 12,000 new diagnoses annually. Most men live with rather than die from this common and expensive disease making prostate cancer survivorship care especially important. In addition, the symptom burden after prostate cancer treatment can be substantial, last well into survivorship and lead to reduced quality of life and greater use of services. For these reasons, it is increasingly recognized that cancer survivorship care is similar to chronic disease management in requiring a combination of primary care providers and cancer specialists to deliver care over long periods of time. Because of its leadership in chronic disease care and the proportion of older men served, the Veterans Health Administration (VHA) is well positioned to become one of the national leaders in prostate cancer survivorship care. However, best practices and portfolios of quality indicators for prostate cancer survivorship care remain underdeveloped. More broadly, there is a limited consensus about who (primary care providers or prostate cancer specialists - urologists, radiation and medical oncologists) has primary responsibility for prostate cancer surveillance, and who manages the often substantial and lingering treatment-related side effects. Unclear roles and regional variation in the VHA cancer specialist workforce also complicate delivery of quality survivorship care. Ultimately, the design and implementation of tools to facilitate the delivery of optimal cancer survivorship care in VHA rests upon understanding how responsibility for survivorship care is managed and the barriers to quality survivorship care. Due to the expanding population of Veteran prostate cancer survivors, improving their quality of survivorship care through effective use of the VHA's provider workforce and latest telemedicine initiatives has potential to transform the national efficiency and effectiveness of cancer specialty care delivery.