TABLE 2.
Description of Identified Responses and Related CFIR Domain23
| Response | Description |
|---|---|
| Structural | |
| VHA context [Inner setting] | Capacity Number of clinicians to meet clinical need; limited physical space at facilities |
| Unique factors Communication among offices; differences among facilities within the VHA | |
| Veteran experience Preference for providers with knowledge of Veteran experience Convenience and continuity of care offered in VHA is a positive | |
| Medications Veterans can obtain medications at VHA pharmacies | |
| Target population [Intervention characteristics] | Illness-specific Patients with a chronic illness, frequent visits to VHA, special populations (eg, mental illness, physical therapy) or polypharmacy |
| Demographic-specific Rural veterans, veterans who obtain medications at VHA, or veterans with challenging social determinants of health | |
| Metrics and outcomes [Process] | Quality of care outcomes Strategic Analytics for Improvement and Learning (SAIL) or Healthcare Effectiveness Data and Information Set (HEDIS) Completed referrals, rehospitalizations |
| Patient-reported outcomes Satisfaction with care, access to care | |
| Core components of the intervention [Intervention characteristics] | Care coordination Facilitate referrals and medication refills and update providers about status Coordinate information sharing (medical records, laboratory/test results) among providers |
| Information sharing Provide information to community providers and veterans about VHA and community care program | |
| System-level | |
| Challenges with the current system [Inner setting] | General challenges Challenges identifying community providers in a timely fashion Confusion about community care processes Referral process for specialty care or medical services is confusing Billing procedures are not transparent |
| VHA-specific Identifying veterans who would benefit from community care is challenging Medical record sharing makes it challenging to re-engage veterans into VHA Care coordination staff are busy | |
| Information needs | |
| Additional observations [Characteristics of individuals] | Veteran-centered Provide timely and personalized care; facilitate continuity of care Provide education on telehealth and share that telehealth is supplementary to care, not a replacement |
Interview sample included: VHA stakeholders (n=8), community providers (n=5), and veterans (n=5).
CFIR indicates Consolidated Framework for Implementation Research; VHA, Veterans Health Administration.