Joanna Sells is a US Department of Veterans Affairs (VA) and University of California, San Francisco (UCSF) Quality Scholar Psychology Fellow. John McQuaid is Associate Chief of Staff for Mental Health, both at the San Francisco VA Health Care System and Vice Chair, Department of Psychiatry Weill Institute of Neuroscience, UCSF. Correspondence: Joanna Sells (joanna.sells@va.gov)
Author disclosures The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies.
The shift in usage from VA to community care has potential implications for academic affiliates, particularly in education and research.60 If more people are served in community settings, potentially some VAMCs could be reduced, realigned, or closed. If this restructuring happens, academic partnerships could be impacted negatively. The VA is instituting an Infrastructure Review Commission with the task of examining current VA utilization. If a VA site with an academic affiliate was considered for realignment or closure, the reduction would eliminate the ability of the academic affiliate to provide education and research collaborations at that site.
In a less drastic manner, increasing care in the community may change opportunities for academic affiliates to partner with the VA. As noted, the UC system and California veterans benefit immensely from the VHA as an integrated health care system with dedicated missions of education and research. This partnership is a model in which the VA is the primary source of care for eligible enrolled veterans and provides integrated comprehensive services. If the VA moves to serving primarily as a coordinator of community HCPs rather than a direct provider of health care, academic affiliates would need to make major adjustments to both the education and training models. This change could particularly affect specialty training programs that rely on having adequate volumes of patients to provide an extensive experience to meet training needs. If fewer veterans receive care directly from the VA and are instead dispersed in the community, that will reduce the ability of academic faculty to participate in the education of medical and affiliated trainees and to participate in research in VA settings. It is unclear what other model could replace such a system and be as beneficial to the VA and the academic partners with which it is currently affiliated.
Given the needs that led to the VA increasing access to care and the potential implications discussed for the VA and partnerships with academic affiliates, VA health care systems and academic affiliate partners should consider several steps. These steps involve assessment, coordination, and promotion.
Both the VA and academic affiliates would benefit if the VA shared assessment data on the use of community care, particularly identifying changes that relate to key training and/or research missions. Such data sharing can be critical to determine whether any risks (or potential opportunities) need to be addressed. In addition, increasing research on the outcomes related to both VA care and community-based care is of high value to determine whether the current changes are achieving intended goals. The VA recently funded such work through its research service, and such work is critical for guiding future policy for the VA and for the affiliates.
Coordination among the VA, academic affiliates, and community partners is vital for change. The issue of community care expansion should be a standing item on coordination meetings and shared governance councils between the institutions. It may make sense to establish specific workgroups or committees to coordinate tracking and assessment of the effect of community care expansion on the shared academic mission. One way to address the potential effect of increased community care on the research and education missions would be to include community partners into the partnerships. This strategy could potentially take a number of different forms, from providing education and training to community HCPs, having VA trainees rotate to community settings, or inviting community settings to be research sites for clinical trials. Such partnerships could potentially improve patient care and support the other academic missions. Coordination could be meaningfully improved by having community HCPs access the VA EHR, thus easing communications. Funding is available for EHR access in the VA MISSION Act and should be a high priority as community care expands. The more that community partners can access and connect with the VA EHR the better they will be able to coordinate care.
Third, the VA and its academic partners need to promote and educate veterans, their families, and their advocates on the benefits that are available through VA care and that are enhanced through academic partnerships. While the VA has been the target of justified criticism, many of its strengths addressed here are not broadly recognized. The VA could promote its sharing of staff and resources with the top academic health care institutions in an area and that veterans often have access to resources that otherwise would not be available without the academic affiliate. Making sure veterans are aware of the benefits available can potentially mitigate the need for community care.
