Interventions to Improve Veterans' Access to Care - A Systematic Review of the Literature (Paperback)

Access to healthcare has been identified as a critical issue, both by the Department of Veterans Affairs (VA) and the larger medical community. Access has been broadly defined as "the timely use of personal health services to achieve the best health outcomes" and has been hypothesized to have three discrete steps: 1) gaining entry into the system, 2) getting access to sites of care where patients can receive needed services, and 3) finding providers who meet the needs of the patient and with whom a productive working relationship can form. Historically, VA has focused on the first two steps (getting access to the system and sites of care) and has adopted Demakis's conceptualization of access as an individual's ability to obtain the healthcare they need within an appropriate time frame. Recently, researchers within the VA have begun to develop an updated conceptualization of access which takes into account the impact of new technology on access and places a greater focus on outcomes beyond increased access. Specifically, while the definition of access remains limited to the ability to connect with needed care, the reconceptualization acknowledges post-access outcomes such as satisfaction, symptom levels, and functioning. As such, we sought to conduct a review of the literature that would clarify the current state of the knowledge regarding the link between access to healthcare (both objective and perceived access) and system-level (e.g., utilization, satisfaction with care) and patient-level (quality of life, symptoms, mortality) outcomes. Further, the VA has continued its commitment to improving access for Veterans, and has implemented several programs designed to improve access to care for all veterans. Examples include the establishment of clinics located in areas distant from VA facilities (Community-Based Outpatient Clinics or CBOCs), mobile clinics, and increased use of telecommunications (telephone, internet, or videoconferencing). As such, we also examined the efficacy of interventions designed to improve access, with a focus on access, system-level, and patient-level outcomes. The Key Questions addressed in this review are: KEY QUESTION #1: What is the evidence that variation in veterans' ability to obtain needed health care (i.e., access) contributes to variation in system level (e.g., utilization, satisfaction) or patient level (e.g., quality of life, functional ability, mortality) outcomes? KEY QUESTION #1A: Does the effect of access on system and/or patient level outcomes differ by patient (e.g., demographics, overall health, illness severity), treatment (e.g., mental health, physical health), or setting (e.g., rural, urban, community, VA) characteristics? KEY QUESTION #2: What interventions have been successful in improving access for patient populations with reduced health care access? KEY QUESTION #2A: Have interventions that have improved health care access led to improvements in system level and patient level outcomes?