Urgent Care Program Influences on an Integrated Health Care System

Abstract

The Veterans Health Administration (VHA) is the most extensive integrated health care delivery system in the world with over 20,000 physicians, 1,600 facilities, and more than 400,000 employees, caring for nine million veterans (Evans, 2005; Giroir & Wilensky, 2015; Katz, 2023). The health care provided covers traditional outpatient and hospital-based services such as primary care, surgery, critical care, mental health, orthopedics, pharmacy, radiology, and physical therapy. Most VHA facilities offer additional medical and surgical specialties such as audiology, speech pathology, dermatology, dental, geriatrics, urology, oncology, podiatry, prosthetics, and vision care. Some of the more extensive VHA facilities offer advanced health care services, such as organ transplants and plastic surgery (VA History, 2017).

VHA is a large federal organization governed by public policy. Over the past decade, VHA’s community care program has experienced a rapid pace of policy change starting with the passing of Veterans Access, Choice, and Accountability Act (VACAA) in 2014, the Veterans Choice Program Extension and Improvement Act in 2017, and the Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act in 2018.

Each of these pieces of legislations had the goal of solving a public problem. In this context, a public problem is "a usually undesirable situation that, according to people or interest groups, can be alleviated by government action" (Birkland, 2011, p. 8). Over the past decade, VHA has experienced a continuous cycle of the public policy-making process and it was timely to conduct research to determine if some requirements of the MISSION Act were achieving their intended impacts.

One requirement of the MISSION Act was to implement a new community based urgent care (UC) program to increase health care access. The focus of this research was to better understand how these new community based UC locations may be influencing an integrated health care system. In this explanatory mixed method study a descriptive analysis, longitudinal primary care analysis, non-urgent Emergency Room (ER) analysis, and a medical records analysis were conducted. Semi-structured interviews with VHA senior leaders were then completed, which then informed VHA operational and policy recommendations.

The descriptive analysis found the UC program consistently grew with VHA recently recording over 48,000 UC visits per month. Overall, there was substantial uptake of the UC program across all levels of VHA’s health care system. It was found women use the UC program more often than men, those aged 25-34 use the program more often than other age groups, and those that live in rural locations use the program more than urban and highly rural veterans. Furthermore, most care is delivered at UC facilities as opposed to Walk-in Care (WiC) or retail care locations, and the largest CPT grouping was for New Patient Office or Other Outpatient Services.

The longitudinal primary care analysis found longitudinal primary care was not being delivered through VHA’s UC program and that most UC medical records were not making it back into VHA’s electronic health record (32%). The pre/post ER analysis found there were decreases in overall ER utilization with implementation of the UC program and this was found across all ER acuity levels. The largest ER reduction (33%) was found in the ESI Level 5 (non-urgent) category. The semi-structured interviews revealed that VHA leaders perceived challenges with VHA’s dual role of operating as a health care provider and a health care purchaser, expressed concerns around the UC program’s impact on existing VHA care teams, and described VHA as spending inadequate time in each of the eight public policy-making steps. Overall, this research found that, utilizing the IOM Systems Framework and the concept of health care service coproduction, there are operational and policy improvements VHA should consider for their community based UC program.