Improving Care for Rural Veterans: Are High Dual Users Different?


“Background: Rural veterans face considerable barriers to access to care and are likely to seek health care services outside the Veterans Health Administration (VHA), or dual care. Objective: The objective of this study was to examine the characteristics of high users of dual care versus occasional and nonusers of dual care, and the determinants of satisfaction with care received by rural veterans. Design: The design was a cross-sectional observational study. Participants: Structured telephone interviews of a random sample of veterans residing in rural Nebraska were conducted in 2011. Main Measures: Veterans’ frequency of use of dual care and satisfaction with care received were assessed using multinomial and ordinal regression models. Key Results: Veterans who have an established relationship with a VHA provider or a personal doctor or nurse at the VHA and those who were more satisfied with VHA quality of care were less likely to be high users of dual care. Veterans who were Medicare beneficiaries, or had private insurance or chronic illnesses, or were confused about where to seek care were more likely to be users of dual care. Veterans who report being confused about where to seek care, and those who perceive lack of coordination between the VHA and non-VHA systems are less satisfied with care received. Conclusions: Understanding what motivates veterans to use dual care and influences their satisfaction with care received will enable the VHA to implement policy that improves the quality of care provided to rural veterans.”


For Practice

Veterans’ use of dual care is significantly associated with availability of insurance, satisfaction with VHA facilities and doctors, chronic illness or disability, and confusion about services rather than spatial proximity and cost of VHA facilities. To improve overall satisfaction with care received, rural veterans utilizing dual care should try to build solid relationships with their medical care teams. Veterans without insurance should explore the coverage options available to them, particularly those within the VHA system. Rural practitioners should reach out to local and regional VHA facilities to mitigate barriers that rural veterans perceive. Efforts to accomplish this should include localized programs that coordinate programs of care between VHA and non-VHA facilities. Practitioners should also specifically address the additional concerns veterans with disabilities or chronic illnesses face when pursuing dual care. While cost and spatial proximity to care facilities are not significant barriers to dual care, rural practitioners should consider addressing the actual perceived barriers to care through community outreach and education programs that discern which services can be obtained at VHA facilities, non-VHA facilities, or both facilities.

For Policy

Currently, the VHA provides several educational materials on the services and processes offered to veterans. The VHA might reinforce this by providing targeted information regarding healthcare services and access to veterans currently utilizing VHA services. Providing targeted information to current VHA users could reduce confusion about services, improve veteran-facility relations, and increase veteran satisfaction with VHA services. The VHA might also conduct outreach efforts aimed at providing information to veterans
who do not frequently or ever use VHA services. The benefits of improved coordination between VHA and non-VHA facilities include improved veterans perception of dual care and a consistent treatment plan for dual users of treatment. This coordination may ultimately lead to improved satisfaction of care received. The VHA might advise rural health care providers of community- based resources available to address veteran health concerns. As the rural veteran population continues to age, better coordination between VHA and non-VHA facilities might ensure that veterans have access to the care and consistency in care they need.

For Future Research

Though these findings showcase a number of issues in dual care in rural Nebraska, further studies should determine if findings are generally applicable on a nation-wide level. Future researchers should assess if and how small-scale coordination efforts between the VHA and non-VHA facilities address gaps in treatment, patient satisfaction, and veteran confidence in treatment programs. The participants in this study were mostly male, likely due to the demographics of rural veterans who use dual care. Future researchers should oversample female users of dual care to determine if attitudes toward dual care are consistent across sexes. A limitation of this study is that conclusions were drawn from a cross-sectional population. It would be beneficial to evaluate dual care using longitudinal data. Future researchers should investigate the potential benefits of coordination between facilities by conducting an experiment that compares veteran patient satisfaction and barriers to dual care in situations with extensive or non-existent coordination between VHA and non-VHA facilities.

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