Implications of Cross-System Use Among US Veterans With Advanced Kidney Disease in the Era of the MISSION Act: A Qualitative Study of Health Care Records.

Autor:	O'Hare AM; Hospital and Specialty Medicine Service, VA Puget Sound Health Care System, Seattle, Washington.; VA Health Services Research and Development, Seattle-Denver COIN, VA Puget Sound Health Care System, Seattle, Washington.; Department of Medicine and Kidney Research Institute, University of Washington, Seattle., Butler CR; Hospital and Specialty Medicine Service, VA Puget Sound Health Care System, Seattle, Washington.; VA Health Services Research and Development, Seattle-Denver COIN, VA Puget Sound Health Care System, Seattle, Washington.; Department of Medicine and Kidney Research Institute, University of Washington, Seattle., Laundry RJ; VA Health Services Research and Development, Seattle-Denver COIN, VA Puget Sound Health Care System, Seattle, Washington., Showalter W; VA Health Services Research and Development, Seattle-Denver COIN, VA Puget Sound Health Care System, Seattle, Washington., Todd-Stenberg J; VA Health Services Research and Development, Seattle-Denver COIN, VA Puget Sound Health Care System, Seattle, Washington., Green P; VA Health Services Research and Development, Seattle-Denver COIN, VA Puget Sound Health Care System, Seattle, Washington., Hebert PL; VA Health Services Research and Development, Seattle-Denver COIN, VA Puget Sound Health Care System, Seattle, Washington.; Department of Health Services, University of Washington, Seattle., Wang V; Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina.; Department of Population Health Sciences, Duke University School of Medicine Durham, North Carolina.; Department of Medicine, Duke University School of Medicine, Durham, North Carolina., Taylor JS; Department of Anthropology, University of Toronto, Ontario, Canada., Van Eijk M; Department of Anthropology, University of Washington, Seattle., Matthews KL; City Block Health, Washington, DC., Crowley ST; Department of Medicine, Yale University, New Haven, Connecticut.; VA Connecticut Health Care System, West Haven, Connecticut., Carey E; Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Denver.; Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Denver.
Jazyk:	angličtina
Zdroj:	JAMA internal medicine [JAMA Intern Med] 2022 Jul 01; Vol. 182 (7), pp. 710-719.
DOI:	10.1001/jamainternmed.2022.1379
Abstrakt:	Importance: Since 2014, when Congress passed the Veterans Access Choice and Accountability (Choice) Act (replaced in 2018 with the more comprehensive Maintaining Internal Systems and Strengthening Integrated Outside Networks [MISSION] Act), the Department of Veterans Affairs (VA) has been paying for US veterans to receive increasing amounts of care in the private sector (non-VA care or VA community care). However, little is known about the implications of these legislative changes for the VA system. Objective: To describe the implications for the VA system of recent increases in VA-financed non-VA care. Design, Setting, and Participants: This qualitative study was a thematic analysis of documentation in the electronic health records (EHRs) of a random sample of US veterans with advanced kidney disease between June 6, 2019, and February 5, 2021. Exposures: Mentions of community care in participant EHRs. Main Outcomes and Measures: Dominant themes pertaining to VA-financed non-VA care. Results: Among 1000 study participants, the mean (SD) age was 73.8 (11.4) years, and 957 participants (95.7%) were male. Three interrelated themes pertaining to VA-financed non-VA care emerged from qualitative analysis of documentation in cohort member EHRs: (1) VA as mothership, which describes extensive care coordination by VA staff members and clinicians to facilitate care outside the VA and the tendency of veterans and their non-VA clinicians to rely on the VA to fill gaps in this care; (2) hidden work of veterans, which describes the efforts of veterans and their family members to navigate the referral process, and to serve as intermediaries between VA and non-VA clinicians; and (3) strain on the VA system, which describes a challenging referral process and the ways in which cross-system care has stretched the traditional roles of VA staff and clinicians and interfered with VA care processes. Conclusions and Relevance: The findings of this qualitative study describing VA-financed non-VA care for veterans with advanced kidney disease spotlight the substantial challenges of cross-system use and the strain placed on the VA system, VA staff and clinicians, and veterans and their families in recent years. These difficult-to-measure consequences of cross-system care should be considered when budgeting, evaluating, and planning the provision of VA-financed non-VA care in the private sector.
Databáze:	MEDLINE
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