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Stryczek KC, Honsberger M, Ball SL, Barnard JG, Young JP, Felker B, Au DH, Ho PM, Kirsh SR, Sayre GG. VA Outreach Is an Essential Area for Improving Veterans' Health Care Accessibility. Mil Med 2023; 188:usad019. [PMID: 36790439 DOI: 10.1093/milmed/usad019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 12/05/2022] [Accepted: 01/25/2023] [Indexed: 02/16/2023] Open
Abstract
INTRODUCTION The Veterans Health Administration (VHA) is tasked with providing access to health care to veterans of military service. However, many eligible veterans have either not yet enrolled or underutilized VHA services. Further study of barriers to access before veterans enroll in VHA care is necessary to understand how to address this issue. The ChooseVA (née MyVA Access) initiative aims to achieve this mission to improve veterans' health care access. Although veteran outreach was not specifically addressed by the initiative, it is a critical component of improving veterans' access to health care. Findings from this multisite evaluation of ChooseVA implementation describe sites' efforts to improve VHA outreach and veterans' experiences with access. MATERIALS AND METHODS This quality improvement evaluation employed a multi-method qualitative methodology, including 127 semi-structured interviews and 81 focus groups with VHA providers and staff ("VHA staff") completed during 21 VHA medical center facility site visits between July and November 2017 and 48 telephone interviews with veterans completed between May and October 2018. Interviews and focus groups were transcribed and analyzed using deductive and inductive analysis to capture challenges and strategies to improve VHA health care access (VHA staff data), experiences with access to care (veteran data), barriers and facilitators to care (staff and veteran data), contextual factors, and emerging categories and themes. We developed focused themes describing perceived challenges, descriptions of VHA staff efforts to improve veteran outreach, and veterans' experiences with accessing VHA health care. RESULTS VHA staff and veteran respondents reported a lack of veteran awareness of eligibility for VHA services. Veterans reported limited understanding of the range of services offered. This awareness gap served as a barrier to veterans' ability to successfully access VHA health care services. Veterans described this awareness gap as contributing to delayed VHA enrollment and delayed or underutilized health care benefits and services. Staff focused on community outreach and engaging veterans for VHA enrollment as part of their efforts to implement the ChooseVA access initiative. Staff and veteran respondents agreed that outreach efforts were helpful for engaging veterans and facilitating access. CONCLUSIONS Although efforts across VHA programs informed veterans about VHA services, our results suggest that both VHA staff and veterans agreed that missed opportunities exist. Gaps include veterans' lack of awareness or understanding of VHA benefits for which they qualify for. This can result in delayed access to care which may negatively impact veterans, including those separating from the military and vulnerable populations such as veterans who experience pregnancy or homelessness.
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Affiliation(s)
- Krysttel C Stryczek
- VA Northeast Ohio Healthcare System, Research & Development, Cleveland, OH 44106, USA
| | - Mark Honsberger
- VA Northeast Ohio Healthcare System, Research & Development, Cleveland, OH 44106, USA
| | - Sherry L Ball
- VA Northeast Ohio Healthcare System, Research & Development, Cleveland, OH 44106, USA
| | - Juliana G Barnard
- VA Eastern Colorado Health Care System, Center of Innovation for Veteran-Centered and Value-Driven Care, Aurora, CO 80045, USA
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Jessica P Young
- VA Puget Sound Health Care System, Health Services Research & Development, Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA 98108, USA
| | - Bradford Felker
- VA Puget Sound Health Care System, Health Services Research & Development, Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA 98108, USA
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA 98195, USA
| | - David H Au
- VA Puget Sound Health Care System, Health Services Research & Development, Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA 98108, USA
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, WA 98195-6522, USA
| | - P Michael Ho
- VA Eastern Colorado Health Care System, Center of Innovation for Veteran-Centered and Value-Driven Care, Aurora, CO 80045, USA
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Susan R Kirsh
- The U.S. Department of Veterans Affairs Central Office, Washington, DC 20420, USA
| | - George G Sayre
- VA Puget Sound Health Care System, Health Services Research & Development, Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA 98108, USA
- Department of Health Services, University of Washington School of Public Health, Seattle, WA 98195, USA
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Hahn CK, Turchik J, Kimerling R. A Latent Class Analysis of Mental Health Beliefs Related to Military Sexual Trauma. J Trauma Stress 2021; 34:394-404. [PMID: 32969098 PMCID: PMC7985046 DOI: 10.1002/jts.22585] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 03/24/2020] [Accepted: 04/27/2020] [Indexed: 11/07/2022]
Abstract
Military veterans with histories of military sexual trauma (MST) are at risk for several negative mental health outcomes and report perceived barriers to treatment engagement. To inform interventions to promote gender-sensitive access to MST-related care, we conducted an exploratory, multiple-group latent class analysis of negative beliefs about MST-related care. Participants were U.S. veterans (N = 1,185) who screened positive for MST within the last 2 months and reported a perceived need for MST-related treatment. Associations between class membership, mental health screenings, logistical barriers, difficulty accessing care, and unmet need for MST-related care were also examined. Results indicated a four-class solution, with classes categorized as (a) low barrier, with few negative beliefs; (b) high barrier, with pervasive negative beliefs; (c) stigma-related beliefs; and (d) negative perceptions of care (NPC). Men were significantly less likely than women to fall into the low barrier class (27.9% vs. 34.5%). Relative to participants in the low barrier class, individuals in all other classes reported more scheduling, ps < .001; transportation, p < .001 to p = .014; and work-related barriers, p < .001 to p = .031. Participants in the NPC class reported the most difficulty with access, p < .001, and those in the NPC and high barrier classes were more likely to report unmet needs compared to other classes, ps < .001. Brief cognitive and behavioral interventions, delivered in primary care settings and via telehealth, tailored to address veterans' negative mental health beliefs may increase the utilization of mental health treatment related to MST.
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Affiliation(s)
- Christine K. Hahn
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jessica Turchik
- National Center for PTSD, Dissemination and Training Division, & Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, California, USA
| | - Rachel Kimerling
- National Center for PTSD, Dissemination and Training Division, & Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, California, USA
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Vest BM, Kulak JA, Homish DL, Hoopsick RA, Homish GG. Mental and physical health factors related to dual use of veterans affairs and non-veterans affairs healthcare among U.S. reserve soldiers. PSYCHOL HEALTH MED 2020; 27:976-986. [PMID: 32997548 DOI: 10.1080/13548506.2020.1828945] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
This study examined the association between mental and physical health factors and dual use of Veterans' Affairs (VA) and non-VA healthcare among previously deployed male Reserve/National Guard (R/NG) soldiers (N = 214). Participants completed online annual surveys on a range of topics, including validated measures of mental and physical health, as well as questions about past-year healthcare utilization. Multinomial logistic regression models separately examined the association between mental health symptoms (PTSD, anxiety, depression, emotional role limitations), physical health symptoms (bodily pain, physical role limitations), and healthcare use (single use and dual use compared to no use), controlling for geography, trust in the VA, age, and race. Anxiety (aRR: 1.13; 95% Confidence Interval (CI): 1.02, 1.26; p<.05), depression (aRR: 1.23; 95% CI: 1.06, 1.43; p<.01), and PTSD (aRR: 1.05; 95% CI: 1.01, 1.10; p<.05) symptoms were all related to past year dual use of VA and non-VA healthcare, even after controlling for known demographic factors. Bodily pain and emotional and physical role limitations were not related to healthcare outcomes. This suggests that mental health symptoms themselves may be a primary factor driving healthcare use. Further study is needed to examine whether dual use of VA and non-VA healthcare is duplicative or complementary.
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Affiliation(s)
- Bonnie M Vest
- Department of Family Medicine, University at Buffalo, Buffalo, NY, USA
| | - Jessica A Kulak
- Department of Health, Nutrition, & Dietetics, Buffalo State College, Buffalo, NY, USA
| | - D Lynn Homish
- Department of Community Health & Health Behavior, University at Buffalo, Buffalo, NY, USA
| | - Rachel A Hoopsick
- Department of Family Medicine, University at Buffalo, Buffalo, NY, USA.,Department of Community Health & Health Behavior, University at Buffalo, Buffalo, NY, USA
| | - Gregory G Homish
- Department of Community Health & Health Behavior, University at Buffalo, Buffalo, NY, USA
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Boulos D, Fikretoglu D. Differences between the Canadian military's Regular and Reserve Forces in perceived need for care, mental health services use and perceived sufficiency of care: a cross-sectional survey. BMJ Open 2019; 9:e028849. [PMID: 31537560 PMCID: PMC6756430 DOI: 10.1136/bmjopen-2018-028849] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE The primary objective was to explore differences in perceived need for care (PNC), mental health services use (MHSU) and perceived sufficiency of care (PSC) between Canadian Armed Forces Regular Force (RegF) and Reserve Force (ResF) personnel with an objective need for mental health services. DESIGN Data came from the 2013 Canadian Armed Forces Mental Health Survey, a cross-sectional survey of serving personnel (n=72 629). Analyses were among those with an Afghanistan deployment and an identified mental disorder (population n=6160; sampled n=868). Logistic regression compared PNC, MHSU and PSC between RegF and ResF. Covariate-adjusted marginal prevalence difference estimates were computed. PRIMARY OUTCOME MEASURE The primary outcomes were PNC, MHSU and PSC. Each had three service categories, including an aggregate 'any' of the three: (1) information about problems, treatments or services; (2) medication and (3) counselling. RESULTS ResF had an 10.5% (95% CI -16.7% to -4.4%) lower perceived need for medication services but PNC differences were not significant for other service categories. MHSU tended to be lower for ResF; 9.1% (95%CI -15.5% to -2.6%) lower for medication, 5.4% (95% CI -11.5% to 0.7%) lower, with marginal significance, for counselling and 11.3% (95% CI -17.3% to -5.2%) lower for the 'any' service category. Additionally, ResF tended to have a lower fully met need for care; 13.4% (95% CI -22.1% to -4.6%) lower for information, 15.3% (95% CI -22.9% to -7.6%) lower for counselling and 14.6% (95% CI -22.4% to -6.8%) lower for the 'any' service category. CONCLUSIONS Our findings suggest MHSU and PSC differences between Canadian RegF and ResF personnel that are not fully accounted for by PNC differences. Deficits in ResF members' perceptions of the sufficiency of information services and counselling services suggest perceived, or experienced, barriers to care beyond any PNC barriers. Additional research assessing barriers to mental healthcare is warranted.
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Affiliation(s)
- David Boulos
- Directorate of Mental Health, Canadian Forces Health Services Group, Ottawa, Ontario, Canada
| | - Deniz Fikretoglu
- Defence Research and Development Canada, Toronto, Ontario, Canada
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Vogt D, Danitz SB, Fox AB, Sanders W, Smith BN. Do functional impairments promote or hinder mental health treatment seeking: Differential results for women and men. Psychiatry Res 2019; 271:614-20. [PMID: 30791333 DOI: 10.1016/j.psychres.2018.12.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 12/04/2018] [Accepted: 12/06/2018] [Indexed: 11/23/2022]
Abstract
Although symptom severity is a known predictor of treatment seeking, the role of functional impairment in this association is unclear. The purpose of this study was to examine the contribution of relationship and work impairment to service use among women and men with posttraumatic stress disorder (PTSD) and depression symptoms. Data from mailed surveys of 363 military veterans were examined longitudinally. Stratified regression analyses were applied to evaluate moderating and mediating effects of functional impairment in association between symptoms and mental health service use, with significant effects observed for relationship but not work impairment. For men, relationship impairment moderated the association between mental health and service use, such that the impact of depression symptoms on treatment seeking was reduced when accompanied by high impairment. For women, subsequently assessed relationship impairment acted as a mediator of the positive association between PTSD symptom severity and service use. The finding that relationship impairment interfered with treatment seeking for men but facilitated treatment seeking for women may help explain widely demonstrated sex differences in treatment seeking. Results underscore the importance of attending to the role of relationship impairment in veterans' treatment seeking and highlight the value of implementing sex-informed approaches to treatment promotion efforts.
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Duan-Porter W, Martinson BC, Greer N, Taylor BC, Ullman K, McKenzie L, Rosebush C, MacDonald R, Falde S, Wilt TJ. Evidence Review-Social Determinants of Health for Veterans. J Gen Intern Med 2018; 33:1785-1795. [PMID: 30030735 PMCID: PMC6153229 DOI: 10.1007/s11606-018-4566-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 06/07/2018] [Accepted: 06/30/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Veterans Health Administration (VHA) is committed to providing high-quality care and addressing health disparities for vulnerable Veterans. To meet these goals, VA policymakers need guidance on how to address social determinants in operations planning and day-to-day clinical care for Veterans. METHOD MEDLINE (OVID), CINAHL, PsycINFO, and Sociological Abstracts were searched from inception to January 2017. Additional articles were suggested by peer reviewers and/or found through search of work associated with US and VA cohorts. Eligible articles compared Veterans vs non-Veterans, and/or Veterans engaged with those not engaged in VA healthcare. Our evidence maps summarized study characteristics, social determinant(s) addressed, and whether health behaviors, health services utilization, and/or health outcomes were examined. Qualitative syntheses and quality assessment were performed for articles on rurality, trauma exposure, and sexual orientation. RESULTS We screened 7242 citations and found 131 eligible articles-99 compared Veterans vs non-Veterans, and 40 included engaged vs non-engaged Veterans. Most articles were cross-sectional and addressed socioeconomic factors (e.g., education and income). Fewer articles addressed rurality (N = 20), trauma exposure (N = 17), or sexual orientation (N = 2); none examined gender identity. We found no differences in rural residence between Veterans and non-Veterans, nor between engaged and non-engaged Veterans (moderate strength evidence). There was insufficient evidence for role of rurality in health behaviors, health services utilization, or health outcomes. Trauma exposures, including from events preceding military service, were more prevalent for Veterans vs non-Veterans and for engaged vs non-engaged Veterans (low-strength evidence); exposures were associated with smoking (low-strength evidence). DISCUSSION Little published literature exists on some emerging social determinants. We found no differences in rural residence between our groups of interest, but trauma exposure was higher in Veterans (vs non-Veterans) and engaged (vs non-engaged). We recommend consistent measures for social determinants, clear conceptual frameworks, and analytic strategies that account for the complex relationships between social determinants and health.
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Affiliation(s)
- Wei Duan-Porter
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System HSR&D, One Veterans Dr, Minneapolis, MN, 55417, USA.
- University of Minnesota Medical School, Twin Cities Campus, Minneapolis, MN, USA.
| | - Brian C Martinson
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System HSR&D, One Veterans Dr, Minneapolis, MN, 55417, USA
- HealthPartners Institute, Bloomington, MN, USA
- School of Public Health, University of Minnesota, Twin Cities Campus, Minneapolis, MN, USA
| | - Nancy Greer
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System HSR&D, One Veterans Dr, Minneapolis, MN, 55417, USA
| | - Brent C Taylor
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System HSR&D, One Veterans Dr, Minneapolis, MN, 55417, USA
- University of Minnesota Medical School, Twin Cities Campus, Minneapolis, MN, USA
- School of Public Health, University of Minnesota, Twin Cities Campus, Minneapolis, MN, USA
| | - Kristen Ullman
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System HSR&D, One Veterans Dr, Minneapolis, MN, 55417, USA
| | - Lauren McKenzie
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System HSR&D, One Veterans Dr, Minneapolis, MN, 55417, USA
| | - Christina Rosebush
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System HSR&D, One Veterans Dr, Minneapolis, MN, 55417, USA
| | - Roderick MacDonald
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System HSR&D, One Veterans Dr, Minneapolis, MN, 55417, USA
| | - Samuel Falde
- University of Minnesota Medical School, Twin Cities Campus, Minneapolis, MN, USA
| | - Timothy J Wilt
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System HSR&D, One Veterans Dr, Minneapolis, MN, 55417, USA
- University of Minnesota Medical School, Twin Cities Campus, Minneapolis, MN, USA
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Buchholz KR, Bohnert KM, Pfeiffer PN, Valenstein M, Ganoczy D, Anderson RE, Sripada RK. Reengagement in PTSD psychotherapy: A case-control study. Gen Hosp Psychiatry 2017; 48:20-4. [PMID: 28917390 DOI: 10.1016/j.genhosppsych.2017.06.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 06/18/2017] [Accepted: 06/20/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This study sought to identify patient characteristics and care processes related to reengagement in VA psychotherapy. METHODS Using national VA data, a retrospective cohort was constructed (N=24,492) of veterans who received a new PTSD diagnosis in FY08/FY09 and attended only one to five PTSD psychotherapy sessions. A nested case-control study was conducted comparing veterans who reengaged in psychotherapy (n=9649) in a 1:5 ratio with those who did not reengage by the end of FY12. Conditional logistic regression models were run to examine differences in sociodemographic, mental health, and service utilization factors between cases and controls. RESULTS Among veterans in the study cohort, 39.4% reengaged in psychotherapy. In adjusted analyses, all measured types of health system encounters (primary care [OR=1.61], primary care mental health [OR=1.61], non-PTSD psychotherapy [OR=1.76], other non-PTSD mental health care [OR=1.43], other non-psychotherapy PTSD care [OR=3.31], emergency room [OR=1.14], and psychiatric hospitalization [OR=1.56]) were related to greater odds of reengagement in PTSD psychotherapy. CONCLUSIONS Veterans' receipt of a broad range of care services may play an important role in reengagement in PCT psychotherapy, suggesting providers across care settings should be knowledgeable in how to support a Veteran's return to psychotherapy for PTSD.
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