Information and resources VA health system leaders need to manage enrollment and retention for Post‐9/11 veterans

Abstract

Objective

To understand Veterans Health Administration (VA) leaders' information and resource needs for managing post‐9/11 Veterans' VA enrollment and retention.

Data Sources and Study Setting

Interviews conducted from March–May 2022 of VA Medical Center (VAMC) leaders (N = 27) across 15 sites, using stratified sampling based on VAMC characteristics: enrollment rates, number of recently separated Veterans in catchment area, and state Medicaid expansion status.

Study Design

Interview questions were developed using Petersen et al.'s Factors Influencing Choice of Healthcare System framework as a guide. Interviews were transcribed verbatim, and two coders analyzed the interviews using Atlas.ti, a qualitative software program. Coders followed the qualitative coding philosophy developed by Crabtree and Miller, a process of developing codes for salient concepts as they are identified during the analysis process.

Data Collection/Extraction Methods

Two coders analyzed 22% (N = 6) of the interviews and discussed and adjudicated any discrepancies. One coder independently coded the remainder of the interviews.

Principal Findings

Several key themes were identified regarding facilitators and barriers for VA enrollment including reputation for high‐quality VA care, convenience of VA services, awareness of VA services and benefits, and VA mental health services. Nearly every VA leader actively used tools and data to understand enrollment and retention rates and sought to enroll and retain more Veterans. To improve the management of enrollment and retention, VA leaders would like data shared in an easily understandable format and the capability to share data between the VA and community healthcare systems.

Conclusions

Enrollment and retention information is important for healthcare leaders to guide their health system decisions. Various tools are currently being used to try to understand the data. However, a multifunctional tool is needed to better aggregate the data to provide VA leadership with key information on Veterans' enrollment and retention.

What is known on this topic

• Recent policies have expanded Veteran eligibility for the Veterans Health Administration (VA) healthcare system and access to community providers outside VA.

• The expansion of eligibility and access through recent policies has introduced new complexities and challenges for VA leaders to navigate.

• After accounting for access, quality of care plays a role in post‐9/11 Veterans' decisions to enroll in VA health care.

What this study adds

• Explores the specific information and resource needs of VA healthcare leaders in managing post‐9/11 Veterans' enrollment and retention, providing insights into their perspectives and challenges.

• Highlights the use of enrollment and retention tools and the recommendations for improvement provided by VA leaders, offering practical suggestions for enhancing the management of enrollment and retention efforts

• Emphasizes the need for easily understandable formats, such as visual reports and one‐click dashboards, to facilitate informed decision‐making and enable comparisons at the local and national level.

1. INTRODUCTION

The Veterans Health Administration (VA) is the largest healthcare system in the United States with 172 medical centers and 1113 outpatient sites, 9 million healthcare enrollees, and 6 million users per year. ¹ , ² VA plays a critical role in providing comprehensive health care to eligible Veterans, who have unique and diverse healthcare needs that require providers who can understand and address these needs. ³ , ⁴ Veterans are not automatically enrolled in VA when they separate from military service and must reach out to VA to qualify for and enroll in care. When Veterans consider whether to enroll in VA, quality of care and accessibility play crucial roles in those decisions. ¹ , ⁵

The VA system has undergone significant policy changes in recent years, enhancing enrollment eligibility criteria and increasing access to care. The Promise to Address Comprehensive Toxics (PACT) Act of 2022 is expected to be the largest enrollment expansion for VA in recent history. ⁶ The implementation of the Choice Act of 2014; Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act of 2018; and the Comprehensive Prevention, Access to Care, and Treatment (COMPACT) Act of 2020 increased access to care for Veterans by allowing VA to pay for health care in the community for eligible enrollees (“community care”). ⁷ , ⁸ , ⁹

As these policies expand eligibility and access, they have introduced new complexities and challenges for VA leaders. Strategic decision‐making is necessary for efficient management of resources within Veterans Affairs Medical Centers (VAMCs) and smooth coordination between VAMCs and community providers. ¹⁰ While VA offers a comprehensive range of services tailored to Veterans' unique needs, there are instances where community providers may be better positioned to deliver particular services. ¹¹ Moreover, recent policy changes acknowledge the importance of choice and flexibility in Veterans' healthcare decisions, offering an alternative to traditional VA facilities. ¹² VA leaders must adapt their decision‐making processes to effectively manage the enrollment and retention of Veterans within the VA system while also facilitating access to community care when appropriate. However, despite the importance of these policy changes, there is limited information on how VA leaders are making strategic decisions about enrollment and retention and about what data they are using to make those decisions.

This study addresses this knowledge gap by examining how VA leaders view these policy changes, what tools they are using to understand enrollment and utilization data, and what information needs they have as health care expands beyond VA facilities. We aimed to understand VA healthcare leaders' information and resource needs for managing post‐9/11 Veterans' VA enrollment and retention, specifically in primary and mental health care because these types of care are critical for engagement in the healthcare system. We focused on post‐9/11 Veterans because they are actively making decisions about health system enrollment and utilization of community care. The insights gained from this study can inform policymakers, administrators, informatics teams, and other stakeholders within the VA healthcare system, enabling them to develop evidence‐based strategies that enhance the accessibility, quality, and sustainability of care for Veterans. These insights can be adapted to health systems outside VA, especially those with provider and purchaser roles (like the Department of Defense's Military Health System or Kaiser Permanente).

2. METHODS

This qualitative research follows the Consolidated criteria for reporting qualitative research (COREQ). ¹³

2.1. Sampling strategy

VA leaders were identified using stratified sampling based on VAMC characteristics: low (≤32%), medium (33%–37%), or high (≥38%) enrollment rates; number of recently separated Veterans in catchment area (≤1500, 1501–3000, and ≥3001); and state Medicaid expansion status (expanded vs. not expanded) (Table 1). Three VA leaders were selected and interviewed from each stratum. In cases where conducting three interviews with VA leaders at the same site was not feasible (no response, not available, etc.), an alternative site within the same stratum was selected. This resulted in 15 different sites, representing 10 unique regions (Veterans Integrated Service Networks (VISNs)). This selection process was designed to provide diverse perspectives.

TABLE 1.

Stratified sampling matrix of veteran leaders.

	Small VAMC, Medicaid expansion	Small VAMC, no expansion	Medium/large VAMC
Low Enrollment	3 VA Leaders	3 VA Leaders	3 VA Leaders
Medium Enrollment	3 VA Leaders	3 VA Leaders	3 VA Leaders
High Enrollment	3 VA Leaders	3 VA Leaders	3 VA Leaders

^a In cases where conducting three interviews with Veterans Health Administration (VA) leaders at the same VA Medical Center (VAMC) site was not feasible, an alternative site with comparable metrics was selected. This approach resulted in the use of a total of 15 different sites for conducting interviews.

^b Overall, the 27 facility leader interviews represent 10 unique regions or Veterans Integrated Service Networks (VISNs).

2.2. Participant selection

VA senior leadership team members eligible to participate included the Medical Center Director, Associate/Assistant/Deputy Medical Center Director, and Chief of Staff/Management. We contacted all senior leadership team members at nine sites, and if we were not able to interview three members per site, we recruited at other sites.

2.3. Data collection

We mailed 69 invitations to site leaders, and conducted semi‐structured interviews, led by a single interviewer with 27 VA leaders (MV). The interviews took place via Microsoft Teams from March to May of 2022. Informed consent was obtained from all participants and interviews were audio‐recorded. Each interview consisted of nine questions to explore health system leaders' information and resource needs for managing post‐9/11 Veterans' enrollment and retention (Table 2). ⁵ , ¹⁴ Interview questions were developed using an adapted version of Petersen et al.'s Factors Influencing Choice of Healthcare System framework as a guide and addressed special programs, the healthcare system's reputation, and patients' perception of the healthcare system. Interview topics included enrollment, retention, managing tools to assess enrollment and retention, and perceptions of VA‐purchased community care. Interviews averaged 19 minutes.

TABLE 2.

Questions and probes for VA leader interviews.

1. What factors do you think influence Post‐9/11 Veterans' decision to enroll (or not enroll) in the VA, and why?

Probes: Financial, quality of healthcare services, good access to care (location, wait‐times), others' experiences with VA?

Based on talking with Veterans, data, intuition?

2. What factors do you think influence Post‐9/11 Veterans' decisions about where to receive their primary care?

Probes: In the VA?/Through VA's purchased care programs, like the Veterans Choice Program?/Through private health insurance, Medicare, Medicaid, a Vet Center, another location?

Ease of use, reputation, prestige, objective quality of care measures, perceptions of quality of care, timeliness of care?

Sources of information Veterans use when making decisions?

3. Are these the same or different factors that would influence where Post‐9/11 Veterans receive their mental health care?

4. Why do you think some Post‐9/11 Veterans receive care from more than one provider and/or more than one healthcare system? Is getting your care at more than one healthcare system beneficial or problematic, and why?

5. Enrollment rate is defined as the portion of eligible Veterans in a VA Medical Center's catchment area that enroll in and start using the VA. How do you assess if the enrollment rates are too high, too low, or just right? If too low or high, how important is it to manage enrollment rates in the VA?

If important, what facility factors do you try to influence to change enrollment?

Do you use the Veterans Benefit Administration's (VBA) catchment area definition when thinking about enrollment, or do you conceive of catchment area in a different way?

6. Reliance is the portion of care received inside versus outside the VA. How do you assess if the reliance rates are too high, too low, or just right? If too low or high, how important is it to manage Veterans' VA reliance rates for primary and mental health care?

If important, what facility factors do you try to influence to change enrollment?

7. Are there any information tools you currently use to understand enrollment and reliance rates for your facility/VISN?

Probes: VHA Support Service Center (VSSC) tools?/Performance Evaluation Center (PEC) Portal Mental Health Balance Scorecard? Mental Health Management System (MHMS)?/Strategic Analytics for Improvement and Learning (SAIL)?/Mental Health Information System (MHIS)?/Performance Measures Report?

If yes, what helpful information do they provide, and what information do they provide that is not helpful to you?

8. What other information or tools would be helpful to you when considering enrollment and reliance rates at your facility/VISN?

9. What do you think is the best way for you to get that information?

Probe: how would you like that information presented to you?

2.4. Data analysis

The audio recordings were professionally transcribed, then two coders analyzed the transcriptions per the qualitative coding philosophy developed by Crabtree and Miller. ¹⁵ They developed codes for salient concepts that were identified during analysis, independently coded a subsample of 22% (N = 6) of interviews, and met to ensure inter‐rater reliability and code validity. ¹⁵ , ¹⁶ Informed by the Petersen et al. framework, the two coders created a codebook. The remaining interviews were coded by one of the coders (the “primary coder”), applying the refined predefined codes using qualitative analysis software (Atlas.ti). ¹⁷ After coding, researchers conducted a thematic analysis to identify patterns, themes, and insights. The researchers selected representative quotes to illustrate key themes, based on their relevance, comprehension, and completeness of thought.

3. RESULTS

We interviewed six Medical Center Directors, nine Associate/Assistant/Deputy Medical Center Directors, and 12 Chiefs of Staff/Management. Our analyses did not identify any key differences in responses across the nine site types (Table 1).

4. ENROLLMENT

4.1. Enrollment facilitators

VA leaders highlighted several key factors they perceived as facilitating higher enrollment rates among post‐9/11 Veterans.

Several leaders believed that the convenience of VA services, including telehealth technologies, played a significant role in enrollment. “We can do things such as Video Connect or something that's simple that's on their phone and get whatever they may need to be addressed, addressed. I think maybe that might make it more attractive to some of them to try to join.” Additionally, leaders thought that the coordinated care approach, which streamlines services between primary and specialty care and comprehensive care management, further contributed to convenience and influenced decisions to enroll.

VA leaders emphasized the importance of benefits awareness in driving enrollment, including financial benefits. “Others were seeking care outside VA, became very frustrated, or frankly were not particularly frustrated with the care but the larger system, particularly the financials, and came to the VA out of desperation.” They thought Veterans with greater awareness of their eligibility for benefits and the range of services available were more likely to enroll.

A few leaders identified positive quality measures, patient satisfaction rates, and overall reputation as influential in attracting Veterans to enroll in VA. “What do they hear from other Veterans in the area? Reputation… quality service and customer service.” Some leaders also noted VA's mental health services as a significant facilitator for enrollment.

4.2. Enrollment barriers

Several leaders identified barriers that might contribute to lower enrollment rates from post‐9/11 Veterans.

Leaders cited VA's poor reputation as contributing to lower enrollment rates:

“If they've had a bad experience or they've known someone that's had a bad experience or its lack of trust [this influences their decision to enroll].”

Leaders noted that convenience of care in the private sector is a reason for Veterans not to enroll in VA. “They have TRICARE, or they have [their] spouse's insurance… Sometimes people nowadays can pick and choose what insurance they want based on what they feel is best for them at the time.” Leaders highlighted that younger post‐9/11 Veterans, who perceive themselves as healthy, may also choose not to enroll in VA.

Lack of awareness or misinformation about VA healthcare benefits and services were other significant enrollment barriers reported. “I think one of the main factors that I've seen in the younger population is, I'm not sure they're all aware of the services and the breadth of services that the VA offers.” Leaders also believed that concerns about taking resources away from others in need deterred some Veterans from enrolling in VA.

4.3. Enrollment rates

Twenty three of the 27 VA leaders reported looking at data to assess enrollment levels at their facility, two did not, and two did not directly respond to the question. Twenty reported that they actively seek enrollments, and one reported not actively seeking enrollments, citing lack of ability to staff appropriately.

Nearly half of all leaders mentioned that their VAMC is engaged in a variety of outreach efforts to promote VA enrollment. These efforts encompassed diverse channels, including:

“… efforts to market and publicize, we put it on Facebook, or we have a webpage. Any time we have an opportunity to speak to Congressmen or any events like that. We do an event every day on Memorial Day where Veterans attend. Every opportunity we get, we encourage them to come enroll and we talk about our facility.”

Some leaders described expanding service sites to attract and accommodate Veterans. They discussed efforts to enhance convenience and eliminate potential barriers to accessing VA health care by opening new VA clinics, particularly in areas where accessibility was limited, to reach a wider population of Veterans. Additionally, leaders explored innovative solutions such as mobile clinics “to go provide care closer to where the Veterans are.”

5. RETENTION

5.1. Retention facilitators for mental health

Most leaders noted the high number of post‐9/11 Veterans relying on VA for mental health care. Some leaders highlighted VA's reputation for excellent mental health and rehabilitation services as a significant factor influencing Veterans' choice:

“I think the mental health issues, at least to some extent, are unique to Veterans and I think the VA does an excellent job at recognizing and supporting those mental health issues.”

A few VA leaders mentioned the availability of a wide range of mental health services as a key factor drawing in more Veterans and contributing to their higher retention in VA mental health services. “I don't think [community care providers are] prepared to handle [post‐traumatic stress disorder] PTSD in the same way…I think that there's a lot more education and engagement in the VA structure about those things.” However, leaders noted that some Veterans may be unaware of the types of mental health services available, which may be why some post‐9/11 Veterans do not choose to use VA mental health services.

5.2. Retention barriers for mental health

Nearly half of leaders interviewed identified stigma and unawareness of benefits and services as barriers that prevent some Veterans from utilizing VA mental health services:

“[M]aybe a little bit of stigma. Some people just don't wanna get mental health care because it is called mental health care. Some people do think about the stigma of that, and I personally have talked with Veterans in some of the areas just to convince them about getting good mental health care, so I know some people just struggle. They don't want to be labeled.”

5.3. Retention facilitators for primary care

Like mental health care, Veterans enrolled in VA tend to be highly reliant on VA for primary care. Several leaders noted that Veterans rely on VA primary care because: it is convenient; it features accessible services tailored to Veterans; Veterans' have familiarity with their local VA facility; and multiple healthcare services are available in a single integrated system. Some leaders also believed that Veterans might choose VA for primary care due to VA's reputation for providing high‐quality care.

5.4. Retention barriers for primary care

Conversely, convenience of community care led other Veterans to choose care outside the VA. “I think a lot of it has to do with ‘I want health care in my community’. I can see my primary care provider 10 minutes from my home. Why should I drive 30, 45 minutes to get to an appointment?” Some leaders felt powerless to change this dynamic due to the practical limitations of long travel distances.

5.5. Purchased care

In addition to the reasons discussed above that VA leaders cited for Veterans choosing VA‐purchased care instead of VA‐provided care (convenience of community care services, quality and reputation of community care providers, and limitations of their VA facility (e.g., lack of specialty care, short staffed)), several leaders also cited recent policy changes:

“[We] have groups of people that only want to come to VA because Community Care will now pay for things through the MISSION Act.”

6. INFORMATION TOOLS

Figure 1 outlines the tools VA leaders use to assess enrollment and retention and the data VA leaders desire to assess enrollment and retention.

FIGURE 1.

Tools used and data desired for enrollment and retention information.

6.1. Several enrollment monitoring tools in use

VA leaders reported utilizing several tools to monitor enrollment. A couple of leaders described using custom queries to extract and analyze specific datasets relevant to enrollment trends and patterns. These custom queries allowed leaders to retrieve information tailored to their needs.

Some VA leaders use market assessments. These assessments analyze market data and trends to understand the healthcare landscape and identify opportunities for increasing enrollment.

“Even more recently we've had access to the market assessment information that came out, which talked about each of our individual markets in counties and our concentration of Veterans in each of those markets.”

Nearly half of all VA leaders also utilized the Veterans Health Administration Support Service Center (VSSC), a web‐based project application and tracking database, as a resource for enrollment (and retention) management.

A couple of other VA leaders relied on the Veteran Population Projection Model (VetPop) to forecast future enrollment.

“We use VetPop, it's a Pyramid cube, and it shows enrollment patterns and just in the past few weeks we were looking at demographics by age, we were looking at racial demographics for different areas; that's how I'm familiar with the enrollment counts versus our unique patient utilization.”

6.2. Several retention monitoring tools in use

For monitoring retention, VA leaders employed a range of tools to track and assess various aspects of the patient experience. Custom queries, similar to those used for enrollment monitoring, were utilized by a few leaders to extract specific datasets related to retention rates and factors influencing patient continuity of care.

Market assessments remained relevant for retention monitoring as well, enabling some leaders to identify trends and factors that may impact patient retention within the VA system. By understanding the local market dynamics, leaders could tailor retention strategies to address specific barriers and facilitators.

A few leaders cited patient satisfaction surveys, such as VA Customer Profile and Veterans Signals (VSignals):

“We know we have a lot of Veterans experience and patient satisfaction surveys. You know VSignals and a variety of other things where we ask Veterans about their care, was it good? Did they like their provider? Were there opportunities for us to do better? And so that gives me the answers with respect to how they think about us or our health care system.”

Some leaders also used the Survey of Healthcare Experiences of Patients (SHEP) to gather comprehensive data on VA patient experiences, identify factors that contribute to retention or attrition, and implement targeted interventions accordingly.

Several leaders reported using productivity dashboards to monitor key performance indicators and track patient retention metrics. Dashboards provided real‐time data on patient volume, service utilization, and other relevant metrics.

Lastly, Strategic Analytics for Improvement and Learning (SAIL) was mentioned by a few VA leaders as a way to analyze retention. Specifically, VA leaders used SAIL performance metrics on continuity of care and population coverage for their facility.

6.3. Additional data needs for enrollment and retention monitoring exist

For enrollment monitoring, a few leaders desired population data to understand the demographic composition of the Veteran population and target enrollment efforts accordingly. More leaders emphasized the importance of having access to comprehensive enrollment data to track trends, identify enrollment gaps, and evaluate the impact of various initiatives on enrollment rates. Some leaders identified mental health metrics as crucial data elements for enrollment monitoring, reflecting the significance of mental health services in attracting Veterans to the VA system. Additionally, some leaders highlighted the importance of eligibility data to track and evaluate the impact of eligibility criteria on enrollment rates. Select VA leaders also emphasized the importance of having market data and trends so that they can track what health services are being utilized in the community around them and how patterns change over time. They also emphasized needing benefits disbursement data from the Veterans Benefits Administration (VBA):

“I use [Veteran Population Projection Model] VetPop as the one kind of go‐to tool, and some of it's a little hard because the VBA doesn't always give me the information I want.”

Retention monitoring needs were similar, including the need for population data to understand the composition and characteristics of the patient population, allowing for tailored retention strategies. Retention data, including patient continuity‐of‐care metrics, were also desired to track patient retention rates and assess the effectiveness of retention efforts over time. Mental health metrics remained critical for retention monitoring as well. Leaders again emphasized the importance of having market data and trends to track service use and needs over time.

Data desired specifically for retention information included community care data and internal capacity data, each emphasized by several leaders:

“We try to combine our community, plus our VA consult referrals to have a regular count of that number. [We need a tool that] combine[s] your internal access and then [provides a] comparison of community volumes and referrals.”

6.4. How VA leaders want information shared

Leaders provided various recommendations for sharing data, with the common theme of presenting it in a format that is easy and quick to understand.

“I think if there was a tool where you can just plug in the ZIP Code and have that information populate quickly, that would be extremely helpful. But in my position…I don't have time to pull, take data cubes and dissect it and put it into a readable format. But having something that pulls all those data sources together and tells you all that information would be extremely beneficial, and it should exist already.”

Visual reports were identified as the preferred way to share information with leadership, as several participants believed that visuals are effective in conveying complex data. “It's always nice to have information that's visual first. [It] kind of gives you that snapshot of understanding before it's just like a line of numbers, right?” Suggestions for visualizing data included maps, scatterplots, pivot tables, and graphs.

The ability to access detailed information on why individuals are not enrolled or not using the VA was emphasized as a desirable feature of easy‐to‐use dashboards. One leader commented:

“It's all about dashboards. You click one part of the dashboard and you could go down that rabbit hole and get even more detailed information.”

Several leaders recommended electronic information sharing, as they believed it to be the most efficient method, explaining they do not have time to sit down and flip through paper reports. Additionally, with data changing from day‐to‐day, paper reports would be obsolete quickly.

7. DISCUSSION

Our study findings shed light on VA leaders' information needs and how they currently manage healthcare enrollment and retention. Several key themes were identified regarding barriers and facilitators of Veteran enrollment and retention, tool and data needs of VA leaders in monitoring enrollment and retention, and leaders' perspectives on recent policy changes including the expansion of VA‐purchased community care. While we interviewed VA leaders for this study, leaders of other health systems likely share the need to understand enrollment and retention at their own healthcare system or facility.

Our findings about mental health facilitators of enrollment suggest the importance of informing patients about the benefits and services provided at healthcare facilities, and the importance of continued community outreach efforts. ¹⁸

Leaders identified convenience of care in the private sector and poor‐quality care perception as significant barriers affecting VA enrollment rates. More transparency on VA and community care wait times and quality of care are a result of initiatives related to the MISSION ACT. ¹⁹ , ²⁰ Increasing accessibility to data about convenience and quality of care available at VA and through community providers seems to have benefit for VA and non‐VA leaders and patients.

Stigma and lack of awareness of benefits and services were identified in our study as the primary reasons for Veterans not utilizing mental health services. Because we know that suicide occurs more frequently in Veterans who are not connected with VA, and Veteran suicide risk is highest the year after leaving the military, it is crucial for Veterans to be informed about services targeted to Veterans' unique mental health needs. ²¹ , ²² Improving telemedicine services has reduced barriers to care, specifically through improved access and continuity of care, which can increase mental health care retention. ²³ These lessons also apply to non‐VA health systems.

To enhance retention rates at any facility for primary care, addressing barriers to access, improving appointment availability, and effectively communicating about quality of care is essential. The COVID‐19 pandemic drove rapid adoption of virtual technologies, which helped address some of these barriers in and outside VA. However, further research and adoption of technologies is needed. Within VA, the Virtual Care Consortium of Research is currently coordinating related efforts. ²⁴

Leaders have adopted a diverse array of tools and methodologies to access and manage enrollment and retention data to improve care and services. While these tools are crucial, a recurrent challenge arises when data come from numerous resources and tools, causing disintegration of the available data. This fragmentation poses a hurdle to leaders understanding enrollment and retention in any health system.

To combat this challenge, our findings illuminate the data needed to effectively monitor and improve both enrollment and retention. Leaders highlighted the importance of population data, complete and accurate enrollment and retention data, mental health metrics, market data and trends, and the availability of accurate and up‐to‐date eligibility data for enrollment monitoring. Additionally, leaders expressed the need for community care data and internal capacity data specifically for retention monitoring.

These recommendations emphasize the importance of creating a tool that integrates enrollment and retention data in an easy‐to‐understand format with the addition of community care and internal capacity data, which is relevant for any health system that purchases care. Complete and comprehensive data would enable leaders across the healthcare spectrum to make more informed decisions regarding enrollment and retention and enhance decision‐making capabilities. As a VA example, the PACT Act eligibility for special enrollment period for Veterans who served in combat zones ended on September 30th, 2023 ²⁵ ; if a tool was available beforehand that incorporated the enrollment eligibility of Veterans and the likelihood of toxic exposure, VA leaders may have had better insight into how this policy would affect future enrollment.

We acknowledge study limitations. Findings reflect the perspectives and experiences of the VA leaders involved and may not be fully representative of all VA leaders or other stakeholders, such as Veterans and their caregivers. Additionally, our study focused on primary and mental health care, and there may be other factors influencing enrollment and retention that were not explored in‐depth.

Overall, the findings of this study underscore the importance of improving information tools on enrollment and retention for healthcare leaders. There is urgency to develop information tools to support strategic decision‐making. Information tools have the potential to meet the evolving needs of health system leaders and the populations they serve in a changing policy landscape.

FUNDING INFORMATION

The views expressed in this article are those of the authors and do not necessarily reflect the positions or policies of the Department of Veterans Affairs, the United States Government, the University of Utah, or Stanford University. This study was supported by a VA Health Services Research and Development (HSR&D) Career Development Award (CDA 15‐259, 1IK2HX002625‐01A1, Vanneman) and the Informatics, Decision‐Enhancement and Analytic Sciences (IDEAS) Center of Innovation (CIN 13‐414). Dr. Harris is supported by a VA HSR&D Research Career Scientist award (RCS 14‐232).

CONFLICT OF INTEREST STATEMENT

All authors are employees of the U.S. Department of Veterans Affairs. No other conflicts of interest exist for any of the authors.

Brown T, Fagerlin A, Samore MH, et al. Information and resources VA health system leaders need to manage enrollment and retention for Post‐9/11 veterans. Health Serv Res. 2024;59(5):e14351. doi: 10.1111/1475-6773.14351