Abstract
Background
Chronic pain is common among Veterans, and rural Veterans commonly struggle obtaining chronic pain care due to large travel distances to the nearest Veterans Affairs (VA) medical center. In 2019, the VA established the Community Care Network (CCN) to provide Veterans access to care in community-based settings, including chronic pain management.
Objective
To explore the experiences of rural Veterans receiving chronic pain treatment in the VA CCN, including their perceptions about perceived barriers, facilitators, and benefits to accessing comprehensive chronic pain management.
Design
Qualitative study using semi-structured interviews.
Participants
Ten rural Veterans receiving chronic pain management in the VA CCN took part in a qualitative interview focused on their experiences accessing and utilizing the VA CCN.
Approach
A descriptive qualitative approach was used. Major themes were identified through thematic content analysis.
Key Results
Veterans described challenges navigating the approval process, finding approved CCN providers for pain management, and they perceived that communication between the VA and community providers was not seamless. Once enrolled in the CCN, however, Veterans valued the freedom to choose providers specializing in pain management within their local communities, timely access to appointments, and opportunities to explore a wider range of pain treatment options and alternative therapies, in addition to traditional medical interventions, all in their local community.
Conclusions
As the CCN seeks to improve collaboration between VA and community providers, recognition of Veterans’ experiences could serve to drive the development of network improvements. Findings reported here suggest that Veterans preferred obtaining care in the CCN once they could navigate administrative complexity to access it. Thus, efforts to streamline VA administrative requirements for initiating CCN care would better support Veterans in meeting their needs in this context.
KEY WORDS: Chronic pain, Veterans, Pain management, Rural health
INTRODUCTION
Chronic pain is a public health concern that disproportionately impacts Veterans 1,2. Veterans experience chronic pain due to injuries sustained during their military service, and it contributes to other chronic conditions such as musculoskeletal pain, neuropathic pain, anxiety, depression, and post-traumatic stress disorder, which often coexist 3. For Veterans living rurally, access to specialty pain care is often challenged by large travel distances to reach VA medical center-based services, absence of broadband internet, and a scarcity of specialty healthcare providers in rural areas 4. Thus, Veterans residing in rural areas are more likely to receive opioid-based pain treatment and less likely to receive comprehensive pain care 5.
The VA has implemented changes to improve delivery of care to Veterans. Ten years ago, the Veterans Access, Choice, and Accountability Act of 2014 (VCP) 6 was passed to enhance access to and effectiveness of healthcare. But the VCP had challenges related to organizational limitations and culture,7 and evidence that the program’s effectiveness was limited 8. Subsequently, in 2018, the VCP was replaced with the Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act 9. This legislation sought to improve care delivery by standardizing eligibility criteria and allowing eligible Veterans to receive their care through community providers, termed the Community Care Network (CCN) 10. The CCN was designed to offer Veterans more choices, with expanded autonomy to decide between VA or community care settings. The program was structured to occur at the referral level, with VA providers authorizing episodic and service-specific care 10.
The effectiveness of the CCN in achieving the goals of the MISSION Act has been evaluated in several different specialty contexts in both rural and urban settings, including primary care, colonoscopy, and surgical care 11–15. However, even though rural Veterans can obtain chronic pain management care via the CCN in non-VHA community-based settings 16, there is limited information regarding access to and delivery of chronic pain care in the CCN. Given that Veterans’ utilization of CCN services has increased steadily, we performed this qualitative study to explore experiences of rural Veterans accessing chronic pain management in the CCN.
METHODS
This study was carried out while developing a text-based intervention to monitor pain-related function and overall experience among rural Veterans receiving care in the VA CCN. Data collection occurred during February–May 2022. We used purposeful sampling 17 to recruit ten participants from the VA Eastern Colorado Health Care System. Participants were eligible if they (1) lived in a VA-designated rural health area, (2) had received pain management in the CCN in the past 6 months, and (3) had a phone with text messaging capability. The VA Eastern Colorado Health Care System and Colorado Multiple Institutional Review Board approved the study.
We used a ten-question, semi-structured interview guide to prompt discussion about healthcare experiences in the CCN. Interview domains focused on perceived barriers, facilitators, and benefits, and preferences for pain self-management strategies. Prior to data collection, the research team met with the VA Pain/Opioid CORE Veteran Engagement Panel to review the interview guide. The Panel consisted of 13 Veterans from around the country with lived experience dealing with chronic pain. We conducted qualitative interviews with Veterans via videoconference. The first author conducted all the interviews, which were digitally recorded with the participants’ verbal consent prior to the interview. The audio-recorded interviews were transcribed, checked for accuracy, and de-identified. Transcripts were entered into ATLAS.ti for data management and analysis. Data included demographic information, audio-recorded interviews, and field notes. Data collection and analysis occurred concurrently using a conventional inductive approach to content analysis 18. The first author read through the transcripts, identifying the initial thematic codes, and the research team met regularly to examine and modify the coding scheme and interpret emergent findings. We maintained an audit trail, documenting all methodological decisions throughout the research process. Iterative data analysis resulted in descriptive themes, which were grouped into domains. This process continued until data saturation was achieved. The research team reviewed the findings and selected exemplar quotes from a variety of participants to illustrate the key themes.
RESULTS
Ten male Veterans participated in the study. The average age of the participants was 52 years (range 30 to 69). The self-identified racial/ethnic profile was a mix of Hispanic, White, Black, and Asian/Pacific Islander. Veterans ranged in their military service years, including Desert Shield/Desert Storm, and Operation Enduring Freedom/Operation Iraqi Freedom eras. Interviews focused on participant experiences accessing chronic pain care in the VA CCN and revealed themes in three domains: perceived barriers, facilitators, and benefits (Table 1).
Table 1.
Summary of Key Findings
Perceived Barriers
Challenges Navigating the CCN Approval Process
Participants described having limited knowledge about the VA CCN, including what pain treatment services were available, how to navigate the approval process, and how to find participating providers in their local communities. They also had limited understanding of the referral and authorization procedures, which resulted in challenges accessing the pain care they needed. As one Veteran described “The system, as far as like Community Care stuff is an awesome idea. That way I don’t have to drive two hours to go to [the nearest VA medical center], like it’s a great idea, but how they implement it is completely asinine.”
Participants described their experiences navigating the VA CCN referral and approval process, which felt like traversing a bureaucratic system, with administrative inefficiencies. The CCN system required excessive communication and involved complicated processes:
The thing is, I get referrals put into Community Care, or consults put into Community Care. They never go through, and when the doctor told me they put in a consult to Community Care, before anything goes on, I call to ask, to make sure they got the consult and what’s going on, and they are totally clueless to what happened. And then the next time I turn around, the consult has been cancelled.
Another Veteran described:
There have been multiple times where I have issues of lapse in proper coverage, so they prescribe me a referral, referral goes to Community Care, Community Care receives 15 appointment visits. I get through 10 of them, they start the re-up process for more referrals, doesn’t go in, takes six months. I’ve even had a year lapse between physical therapy approval because they told me that the VA would probably be able to provide me the care and turns out they can’t.
Although participants valued having access to the CCN, long wait times were challenging. Veterans needing prompt medical attention for chronic pain found themselves caught in a series of administrative hurdles:
The approval process is ... unbearable sometimes because I’ve gotta go back and get another MRI for this, or another MRI for that, and that doesn’t work that way in the real world ... they have the initial MRI, and they all saw it the first time, and they’ll get things done, but the VA must go through such an approval process, and I understand it’s socialized medicine, but I know it’s free, and I appreciate that, but sometimes free doesn’t always mean the best.
Impediments to Care Delivery
When comparing their experiences in the VA system to the CCN, Veterans described the VA system as overburdened due to the complexity of Veterans’ healthcare needs. Some Veterans felt as though their health concerns were not taken seriously:
I’m one of millions of Vets that come in with the same complaints, pain every day that they have, you know, it’s just, they’ve become complacent about it. It’s just the same complaint from everybody ... and how do you fix everybody. You don’t, so they’ve become numb to it.
Thus, participants wanted opportunities for care in the CCN, but here too they described administrative delays and poor care coordination. Participants provided examples of situations where CCN providers were restricted or delayed in accepting VA patients for follow-up appointments:
It’s silly because all the [CCN] providers have to provide documentation and be approved by the VA. Well, that takes a really long time, like it took over a year to get approval from the VA for my Physical Therapist when they had lapse in coverage, so they couldn’t accept any Veterans for over a year, and that like detrimentally hurt them because of the number of people that were going there that were, you know, getting care through the Community Care system, so that’s just a disservice to the Veterans.
Medication management and billing were identified as other hurdles. Veterans who were routinely receiving non-pharmacologic pain therapies from CCN providers were still working with VA providers for pharmacologic treatment of pain. They had to continue to see VA providers for opioid medication, despite receiving other aspects of their care via CCN providers:
As far as being challenging ... I don’t get any follow-ups [from the VA]. I have to call them to let them know how I’m feeling, which is most of the time not good, but that’s the disadvantage, you administer the treatment, you’re supposed to check with me within a week, you don’t call. It’s two or three weeks and then I have to call you to let you know what’s going on, and I feel in that case, that’s not very good. It’s not very helpful at all.
Regarding billing processes, participants felt there were gaps and described how delays in payment impacted CCN providers and their willingness to participate in the network:
The massage therapist probably turned their back and ran straight away when the [CCN] called and said, ‘Would you like to work with Veterans and take payments from VA?’ ... They’re like ‘Hell no’. The story is out, the word is already out on the VA. They don’t pay or they pay slow, and it’s hard to get them to keep their word, so ... it’s all on the VA’s end. The Community Care is awesome.
Perceived Facilitators
Further Expansion of the CCN Provider Network
Participants valued their CCN healthcare experiences, which allowed them to have access to a variety of pain management services. They also voiced a preference for expanding the CCN provider network: “Open up the provider list. That’s, that’s like the biggest issue.” Another Veteran commented:
If the current medical personnel that they have contracted out in Community Care, if they are the best that the VA could get ... then we’re in a sad position, so hopefully ... I think they could do a little bit more due diligence and find those health professionals that could really help out the VA when it comes to the Community Care.
By reducing the need for long-distance travel to VA facilities, participants reported being able to access services more conveniently:
Well, it would be nice if ... I didn’t have to drive. My VA, to get, any kind of physical therapy, is 45 minutes away, and that’s in traffic, and I still have a job. I work every day. If I could do a provider that’s closer to me ... that would be extremely helpful, maybe some physical therapy or something to help me with that would be amazing, but, you know, that’s something that they don’t do.
Some Veterans also acknowledged that the VA has recently expanded pain treatment options at VA medical centers. Nevertheless, participants voiced a preference to fully transition to the CCN: “the service is much better than it is within the VA, and if I could just, you know, transfer them, my VA benefits to my, my outside sources, my life would be a lot easier.” Another participant commented: “So, the, the civilian, once you get into Community Care, the civilians are great. They, they only want to help you.”
Overall, some participants expressed the view that expanding pain care providers in CCN network would improve access and ensure that Veterans receive the specialized and timely pain management support they need:
Just the amount of time. They usually can see you quicker or if one particular, you know, 20 minutes away can see you, whereas it’s sometimes, you know, like right now [February], you may not be able to get an appointment ‘til August or September ... it’s months and months, and if you miss an appointment, it’s not easily rescheduled, so you’ll lose momentum in your care, whereas my chiropractor in the community right now, I can usually call and possibly get an appointment that day because they have more than one chiropractor available.
Perceived Benefits
Autonomy, Access, and Non-opioid Treatment Modalities in the CCN
Once Veterans were able to access CCN care, they valued the opportunity to choose healthcare providers who specialize in persistent or chronic pain management within their local communities. Most Veterans voiced a preference for the “civilian side” (CCN services), which supported prompt access to appointments and a holistic approach to care:
Everything. I mean, it’s, you know, it’s not government based, so [it’s] not regimental, it’s everyday care. It’s just like going to a private doctor, so everything about it, the care is, you know, the people are nicer, the places are always nicer, and you get in, and they talk to you like you’re human ... I mean, its care given in the community, so yeah, everything about it is different from the VA, which is a military theme, so it’s just the opposite of the VA, so it’s, yeah, it’s very good.
In the CCN, Veterans felt empowered to explore a wider range of pain treatment options and alternative therapies, including acupuncture, dry needling, chiropractic care, and physical therapy. This increased autonomy enabled Veterans to choose treatments that align with their personal preferences, needs, and values: “I really enjoy that the [CCN] has, you know, alternative methods for pain management other than the opioids, which is nice because, obviously, staying away from those is the healthiest long-term solution.” Additionally, the CCN provided greater access: “you can have a different timeline compared to the VA, so you might have provider that is open later two days a week and you can schedule in an appointment after work. That’s nice.”
DISCUSSION
In this study, we explored the experiences of Veterans obtaining chronic pain care in the VA CCN. We learned of perceived barriers to care in this context, and identified specific attributes of the CCN program that Veterans experienced once they were able to receive care. As reported in other care delivery specialties in the CCN, Veterans in this study experienced administrative hurdles, complex referral and approval requirements, and up-front delays accessing care for their chronic pain. However, once these complexities were overcome, Veterans reported a positive experience in the CCN, perceiving timely access to appointments, reduced drive times, autonomy in tailoring their care experience, and a more holistic approach to care. These findings warrant contextualization to prior studies of other specialties available in the CCN.
The VA CCN was created to enhance the overall accessibility to and quality of healthcare services. This legislation immediately changed the healthcare landscape for Veterans; since 2019, greater than 2.6 million Veterans received more than 5 million VA CCN referrals 19,20. This led to expanded access to a broad network of healthcare providers with a goal of providing Veterans access to timely and specialized care closer to their homes. Despite this operational advantage, prior work highlights the challenges to developing a set of adequacy standards for VA CCN,19 including comprehensive services for chronic pain.
Efficiency and effectiveness of CCN-based care delivery to Veterans, particularly to those living in rural areas, have been studied in several specialty care contexts. Findings across the spectrum of care are mixed, with examples of enhanced access and/or efficiency, but also evidence of persistent disconnects that reduce efficiency. For example, regarding delivery of screening colonoscopies, the size of the non-VA provider pool expanded after the MISSION Act, with increases in the number of CCN providers performing the procedure on Veterans 15. This was also observed in the context of surgical care,13 and primary care 12. However, in primary care specifically, delivery of services was found to be fragmented due to bureaucratic burdens on the providers,14 possibly due to the episodic nature of the referral process, which is not well-aligned with the longitudinal nature of primary care 10. More broadly, this may correlate with longer wait times in various care contexts. For example, for primary care, wait times were on average greater than 30 additional days to secure an appointment, compared to primary care in a VA medical center 21. Of note, limited data has been collected to understand access and efficacy in delivery of chronic pain care in the CCN, particularly from the perspective of the Veterans seeking care.
Prior research has documented the difficulty with predicting the demand for Community Care among Veterans, consequently making it difficult to evaluate if the number of CCN providers was adequate prior to implementation 19. Findings from this study of chronic pain management suggest a need to further define the different disciplines involved in chronic pain care in the CCN. Chronic pain often warrants a multidisciplinary approach to address the complex nature of pain conditions 2. Since 2009, the VA has embraced a multidisciplinary approach to pain treatment, including referrals from primary to specialty care providers, relying on the use of care teams and non-pharmacologic pain treatments 22. In this study, Veterans interpreted their chronic pain care to include providers across multiple disciplines, including complementary and integrative therapies, and physical therapy, and not limited to physician-led specialty care. Overall, the VA CCN could play a role in optimizing multidisciplinary pain care for Veterans by emphasizing accessibility, choice, and comprehensive care.
Our findings show that the CCN referral and approval process comes with initial challenges. Navigating through the complex approval process was described as time-consuming for both providers and Veterans, leading to delays in accessing care. In some cases, this involved a lack of coordination between the VA and CCN. Payment issues added to the complexity as the VA is required to reimburse community providers at Medicare rates, limiting VA enforcement power in regulating provider networks by negotiating rates 19. As reported by one study participant, reimbursement issues may discourage CCN providers from participating in the network, limiting the choices and quality of care available to Veterans. The evolving nature of VA regulations and reimbursement policies has led to confusion for both providers and Veterans, hindering the integration of Community Care into the VA system 11. Addressing these challenges requires a commitment to streamlining procedures, improving communication channels, and ensuring that the approval process remains adaptable to changes in policies and practices. This way, the CCN can better fulfill its mission of providing accessible and high-quality care to Veterans.
Despite initial frustrations with wait times and the approval process, which has also been documented in accessing primary care in the CCN 11,12,14,21, our participants expressed satisfaction with the “civilian” care once approved. The flexibility to access a broader network of CCN providers closer to home was perceived as a significant advantage, offering convenience, and reducing the burden of travel. Some Veterans appreciated the diversity of healthcare options within the CCN, including specialized services and multimodal pain treatment support, allowing for a more tailored approach to their individual needs. However, Veterans identified challenges with their care coordination, suggesting that streamlined organization between VA facilities and the CCN would promote better care continuity. Ultimately, the positive experiences Veterans have with the CCN underscore its value in delivering accessible, comprehensive, and patient-centered healthcare. In this study, these positive experiences outweighed initial frustrations gaining access to CCN care.
This study had several limitations. Our sample consisted of rural, male Veterans and thus does not provide information on the experiences of women Veterans or non-rural Veterans seeking chronic pain management in the CCN. We recruited Veterans who had received referrals for CCN Chronic Pain Management, but eligibility was not determined by their pain diagnosis, nor did we assess or measure the level of VA-provided care they were receiving. Additionally, this study focused exclusively on Veterans’ experiences with CCN care. Evaluating providers’ perceptions is an important consideration and represents an area for future research. Finally, we explored Veterans’ experiences and perceptions of chronic pain care in the CCN, but this study did not examine the actual timeliness, quality, or safety of care.
CONCLUSIONS
Compared to VA medical centers, the rural Veterans in this study perceived that the CCN has supported them to receive care within their local communities. Veterans voiced that efforts to improve awareness of and access to the CCN would enhance their ability to make independent healthcare decisions that meet their needs locally. While some Veterans were satisfied with CCN care, others expressed continued frustrations with the VA’s handling of local services. But, once set up with a CCN provider, Veterans reported they enjoyed more autonomy in alternative approaches to pain care and perceived shorter wait times to see a provider. Overall, while the CCN seeks to improve collaboration between VA and community providers, recognition of these Veterans’ experiences should inform the development of network improvements. Our findings support that expanding information about CCN chronic pain care options and universal streamlining of CCN referral and authorization processes would enhance access to chronic pain management in the CCN for the rural Veteran population.
Acknowledgements:
Contributors: The authors acknowledge the insightful intellectual contributions of Ebony Miller, John Evans, Brian Schaff, Karen Jones, and members of the VA Pain Opioid CORE Veteran Engagement Panel.
Funding
This material is based on work supported by a Rapid Start Funding Award from the Pain/Opioid Consortium of Research (CORE), funded by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Health Systems Research.
Data Availability
We can make de-identified data available upon request.
Declarations:
Conflict of Interest:
The authors declare that they do not have a conflict of interest.
Footnotes
Prior Presentations
This research was presented at the 2024 Western Institute of Nursing Conference in Salt Lake City, Utah, April 17-20, 2024.
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
We can make de-identified data available upon request.