SEATTLE—It’s a big job to ensure that VA’s healthcare system is equipped to provide the best possible care to veterans. It might be an even bigger job to make sure that veterans across the country have access to that care.
As VA looks into new ways of getting veterans the care they need and gears up for the implementation of the MISSION Act, which lays out access guidelines to non-VA providers, researchers like George Sayre, PhD, are providing patients and providers a voice in the process.
Sayre is the recipient of the 2018 HSR&D Health System Impact Award, which honors HSR&D- and QUERI-funded research that has a direct impact on clinical practice and policy. As part of HSR&D’s Center of Innovation for Veteran-Centered and Value-Driven Care, Sayre earned the award for work that directly impacted major VA initiatives such as specialty care evaluations, the access stand-down in 2014, the CHOICE Act, MyVA, Choose VA and the MISSION Act. According to VA, Sayre’s work has been critical in providing a voice for veterans and clinicians in the midst of what can seem like overwhelming policy changes.
A clinical psychologist, Sayre was working at Seattle University and specializing in couples qualitative research when he was approached by VA around 2012. With qualitative research opportunities at the university on the decline, Sayre jumped at the chance to conduct research as part of HSR&D’s CIVIC.
“My first assignment was a project on PTSD and intimate partner violence,” Sayre explained. “But my own research is into access, and when I was hired one of the big projects was through VA’s Office of Specialty Care Services looking at how to implement new specialty care projects.”
Two of those specialty care initiatives were e-Consult and SCAN-ECHO—telehealth initiatives attempting to bridge service gaps for veterans living in areas where specialty providers were in short supply. Both of those projects had access and qualitative components, which made them fascinating to Sayre. Telehealth would play a bigger role in his work further down the line.
“The first thing I did for VA directly on access was the Phoenix waitlist,” Sayre said. In 2014 it was discovered that as many as 1,700 veterans seeking care had never made it onto the Phoenix VA’s waitlist. It also was found that fewer than 20% of patients on the list were getting an appointment within 14 days or less—a goal for VA facilities nationwide.
“The VA did a large stand-down and interviewed a whole lot of front-line staff, but they didn’t have a plan to analyze that data, so I did the analysis of that large group of folks for the VA internal report,” Sayre said. “That was my first view of that.”
It was also his first real understanding of how insufficient VA’s access metrics can be.
“We try to measure access, but the measurements are always somewhat crude,” he explained. “The 14-day issue was problematic, because it wasn’t always clinically rational. Not every issue requires a patient to be seen in 14 days. And for other things, 14 days is way too long.”
Which is why it’s important to include the voices of veterans and providers in the process. “We just finished an interview with veterans on another project, and one thing we learned is that they don’t think in terms of time and distance [when it comes to care],” Sayre explained. “They think in terms of urgent and routine. Urgent when they need care right now. And routine where they can wait.”
“I really want to see how we can better capture provider and veteran preferences down the road,” he added.
In the meantime, he’s continuing to work on ways to get care to a decentralized veteran population, some of whom live where few providers exist.
“One of the problems we ran into with CHOICE is that, in a lot of these communities, there isn’t a specialist or even a provider available,” Sayre explained. “If you live in a small, rural area, there might be no gastroenterologist there, even if you have the money to hire one.”
Sayre is currently helping refine two projects that use telehealth technology to bridge that provider gap. One uses telehealth so providers can virtually fill in at community-based outpatient clinics when that facility loses a member of its care team. The other is a pilot project that will install select Walmart stores with telehealth technology so veterans can consult with a VA provider there. VA also will coordinate with the Walmart clinical pharmacist to meet veterans’ prescription needs.
“There will be limits to what can be provided virtually,” Sayre admitted. “But we need to find ways to meet veterans where they are, so they don’t have to drive 75 miles to a VA.”
While there’s still more to do in terms of metrics and access, Sayre said he thinks VA is on the right track.
“One thing I’ll say is, we’ve gotten much better at including veterans in research,” he said. “A lot of my research involves hearing veterans and their stories. That’s one of the things I like best about my work. To make sure that, as we’re making the decisions, it’s informed by veterans on the ground. What’s their real experience?”