Article
Regular meetings were conducted with coders and the lead qualitative investigator to discuss disagreements, clarify code definitions, or add new codes as needed. As codes were added, previous transcripts were coded/recoded for content related to the new codes. An audit trail was maintained, and iterative mediation of codes continued throughout the process. The final codebook contained 42 thematic codes, which reached saturation or data redundancy.6 Detailed analysis of the codes dual use, distance, and care coordination were used to inform this study.
Results
Among the 15 sites, 64 in-depth individual interviews were conducted, ranging from 5 to 53 minutes (average 26 minutes). Clinic staff demographic characteristics are depicted in the Table. Analysis of data captured in the codes dual use, distance, and care coordination resulted in notable concentration in 4 thematic areas: (1) clinic staff perceptions of the influence of access, convenience, and distance on dual use for rural patients; (2) communication and patient’s role in comanagement; (3) rules and regulations related to comanagement from the VHA perspective; and (4) barriers to comanagement and recommendations for education.
Influence of Access, Convenience, and Distance
Access to health care was central to the discussion of dual use and comanagement by clinic staff. Convenience was identified as the primary reason for rural patients’ use of non-VHA services, as many rural patients must travel outside their local community to access VHA care. Thus, dual use was most often noted for services typically available in patients’ local communities, especially management of chronic conditions.
The CBOCs provide important services for primary care and management of chronic conditions but are not available in all communities and may have limited hours/days that do not fit with patients’ schedules. The CBOCs are often unable to provide needed services, including but not limited to emergency care, diagnostic tests, physical and occupational therapy, and other specialty care services. As one VHA provider put it, “The biggest factor for [dual use] is availability, access, convenience.… It’s a lot more convenient to go to the hospital down the street than it is to go 120 miles to [the VAMC], or for some guys who live 30, 40 minutes the other side of here it becomes 150, 160-mile one-way trip.”
Related to access, distance and transportation barriers were identified by clinic staff as obstacles to care for rural patients. Despite efforts to offset the expense of travel through reimbursement to qualified veterans and coordinated van transport with Veterans Service Organizations, travel costs—both time and money—were seen as significant barriers to accessing VHA care, as was an inability to travel for those who are ill or frail and elderly. “We send people … in the van and for the most part that works, but eventually it gets expensive, or you’ve got somebody with chronic pain that can’t tolerate the van ride for 2 hours,” one interviewee
reported.
According to clinic staff, dual-use patients also rely on non-VHA providers in particular for urgent or emergency care, while relying on VHA primary care for reduced-cost medications, diagnostic testing, chronic disease management, or annual exams. When asked why rural patients may choose to see more than 1 provider, VHA providers responded. “[It’s] more convenient to have a local doctor just in case something went wrong and they need to see a doctor right away. So distance to this clinic would be the number one reason.” Another reported, “If it’s once or twice a year routine appointments they’ll come here, but… they’d rather go to a walk-in clinic nearby than spend so much [money] on gas.”
Communication and Patients’ Role
Communication between VHA and non-VHA providers is a necessary element of comanagement. Although phone calls or faxing patient medical records are available options, clinic staff reported it was more common to encounter patients hand carrying their records between providers. For dual-use patients, clinic staff indicated it was often unclear who was responsible for relaying information between providers. There is often ambiguity about who will (and should) fulfill this role and not enough time to adequately address or clarify how this is done. Some clinic staff believed that acting as the main conduits of information placed an undue burden on the patients, particularly asking them to be able to accurately relay medical information about tests or prescriptions that they may not fully understand. Others said that it was primarily the patients’ responsibility to give relevant information about their care to all their providers, because of VHA regulations and patient privacy laws. “[The] patient should tell the primary doctor to send them [medical records] because we can’t get the medical records without the patient’s permission,” said one provider.
