Patient Engagement, Access to Care, and Perceptions of Competing Priorities in the VA Primary Care Setting

BACKGROUND

Health systems often juggle priorities with limited resources and capacity. Focusing on one area of improvement can result in another falling off the radar. This can make it hard for staff to manage current—and sometimes competing—priorities.

The Veterans Health Administration (VHA) promotes multiple priorities which are addressed simultaneously through standardized policies and guidelines pushed from a central office with an expectation of application across the whole system.¹ Currently, as VHA focuses on improving patient-centered care, two areas of emphasis are improving patient engagement and access to care. These priorities may compete with each other, leading administrators at VHA to label either priority “the flavor of the month.”²

Patient engagement is an integral part of patient-centered care and focuses on active patient involvement by supporting patient participation in health care decisions.³ Patient engagement is also a part of the VHA’s current strategic plan which states that VHA should provide health care that “engages and inspires Veterans to their highest possible level of health and well-being.”⁴

To address another top priority, VHA launched an initiative to guide improvement of patient access to care. As part of the initiative, VHA provided facilities and staff with an implementation guide, outlining specific recommendations for improving access to care.⁵

In this study, we compare priority-driven patient-engagement activities with efforts to improve access to care to determine areas of overlap and conflict.

METHODS

After collecting data through semi-structured, qualitative interviews and site visits, transcripts were coded and analyzed to produce a list of patient engagement activities used by VHA Primary Care staff nationwide. A panel of stakeholders then reviewed successive iterations of the list, taking out the least effective items with each iteration, to produce a toolkit of recommended practices for improving patient engagement.³ The patient engagement toolkit is available online.⁶

The access improvement guidebook details 23 specific solutions to improve access and 6 “Mid and Long-term Recommendations” for VA Medical Centers across the country.⁵ These solutions and recommendations were developed through several meetings of a national team and feedback from subject matter experts and other stakeholders.

The study team made comparisons using qualitative analysis software to determine which specific activities in the two guides overlapped. The team then reviewed the activities and collapsed them into a common set of broader themes to identify types of activities only found in the access guidebook, only found in the patient engagement toolkit, those that overlapped, and any that directly conflicted (Fig. 1).

Figure 1.

Overlapping recommendations for improving access and patient engagement.

RESULTS

Two main areas of overlap emerged from comparing patient-engagement activities and recommendations to improve access (see Fig. 1). The first overlap was leveraging team-based care to reduce the number of patient return visits or walk-in visits with primary care providers (PCPs). This included having patients visit their nurse care managers for blood pressure management or seeing a team’s pharmacist for medication management. Other solutions included having walk-in patients see RNs for triage before seeing PCPs. The second area of overlap was the use of substitutes for face-to-face visits, including phone visits, telehealth programs, and secure messaging technology. Using multiple additional avenues for patients to interact with their health care team reserved face-to-face visits for those who need it most.

Despite these areas of commonality, some suggested activities for patient engagement conflicted with suggested activities for improving access. A few of the recommended patient-engagement activities involve providing direct telephone access to health care team members, in contrast to access recommendations which assume that all VA facilities were using a centralized call center.

DISCUSSION

Overall, we found significant overlap in the VHA recommended activities for improving patient engagement and access to care despite a single area of direct contradiction. Particularly promising are practices that allow patients to interact with their health care team through the utilization of technologies that allow for non-face-to-face encounters. Focusing on the common areas has the greatest potential to improve health system priorities within a system with limited resources while reducing staff fatigue with improvement efforts.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they do not have a conflict of interest.