Comparing and contrasting Veterans’ experiences of access with the SOTA Access Model

Comparing and contrasting Veterans’ experiences of access with the SOTA Access Model

2015 Academy Health Annual Mee4ng

June 14, 2015

Authors Christopher J. Koenig San Francisco VA & UC San Francisco

Ann M. Cheney University of California, Riverside & Greater Los Angeles VA

Christopher Miller VA Boston Healthcare System & Harvard University

Trish Wright UAMS & LiNle Rock VA

Kara Zamora San Francisco VA

Regina Stanley LiNle Rock VA

Jeff Pyne LiNle Rock VA & UAMS

Supported by VA HSR&D award CRE 12-‐300 (PI: Pyne)

Access Re-‐Conceptualized

J Gen Med, 2011


J Gen Med, 2011

Access to Care

Actual

Perceived

•  Observed •  Measureable

•  Self-‐reported •  Experience


Access Re-‐Conceptualized SOTA Model Geographical

Temporal

Financial

Cultural

Digital

-‐-‐

-‐-‐

-‐-‐

-‐-‐

Knowledge Gap

How does the SOTA Access model compare with Veterans’

experiences of care?

Study Objectives 1.  Elicit rural Veterans’ experiences of

access to mental health. 2.  Compare Veterans’ experiences with the

SOTA Access model. 3.  Develop a Perceived Access Measure

responsive to Veterans’ experiences.

Methods • Mixed Methods •  Quantita4ve & Qualita4ve

• Mul4ple sites •  New England, Mid-‐South, West

•  N=59 par4cipants (n=75-‐80 an4cipated)

• Military Veterans between 18-‐70 • MH Diagnosis or posi4ve MH screen •  Rural, Suburban, Urban areas

Mixed Methods

Data Type Analysis Type

Quan4ta4ve Survey Descrip4ve sta4s4cs

Cultural Domain Analysis Mixed qualita4ve & quan4ta4ve analysis

Semi-‐structured Interviews Qualita4ve content analysis

Analysis #1 Cultural Domain Analysis

Ann M. Cheney, PhD UC Riverside & Greater Los Angeles VA

Cultural Domain Analysis The goals of CDA include: •  elici4ng items from an insider perspec4ve

• understanding how people associate item content to larger domain(s)

•  interpret rela4onship of items within and across domains

Borga<, 1994

Three-‐step Process

Step 1. Free list exercise

Step 2. Pile sort ac4vity

Step 3. Interpreta4on

phase





phase

Master List 1 Legal issues 2 Women veterans can’t seek care 3 Outreach about VA healthcare 4 Concerns about gehng mental healthcare 5 Mental health not asked about 6 Suck it up mentality 7 Transporta4on problems 8 Alcohol & drug use 9 Fear using video teleconferencing 10 Appointments hard to get 11 Civilians not understanding vets 12 Having other priori4es 13 Problems with scheduling 14 Homelessness 15 Too few providers 16 Lack available providers 17 Separa4on from military & transi4on 18 Knowledge of where to go & who contact for mental health services 19 Travel distance 20 Percep4ons mental healthcare 21 Perceived need 22 Anxiety 23 Problems with service connected disability

24 Worry what others think 25 Clinics respond slow 26 Health injury sickness 27 Knowledge of mental health treatments 28 No follow-‐up from providers 29 Veterans abusing system 30 Judgement 31 Racism 32 S4gma 33 Paperwork is daun4ng 34 Wai4ng for appointments 35 Providers changing jobs 36 Not steady employment 37 Finances 38 Friends, family, doctor thinking your crazy 39 Losing rights fought for 40 No follow-‐up from VA 41 Trust 42 Weakness 43 Lack of knowledge & understanding 44 Childcare 45 Fear of losing security clearance 46 Cost of travel





phase

Pile Sort Activity

Multi-‐Dimensional Scaling Analysis

Shorter the distance between points, the stronger the conceptual rela4onships.

Weakness (42) Trust (41)

Transporta4on problems (7)

(Stress value= 0.181)

Cluster Analysis

Five Cluster SoluEon

Cultural Barriers (Pink Cluster) •  Racism •  S4gma •  Judgment •  Percep4on of mental healthcare •  Civilians not understanding Veterans’ experiences •  “Suck it up” mentality •  Friends, family, doctor thinking your "crazy" •  Trust •  Worry about what others think •  Weakness (example: feeling like a failure or weak) •  Anxiety •  Alcohol and drug use

Comparisons SOTA Model Cultural Domain Analysis Geographical

Logis4cal Problems Temporal

Financial

Cultural Cultural Barriers

Digital -‐-‐

-‐-‐ Systemic Problems

-‐-‐ -‐-‐

-‐-‐ Mental Health Literacy

-‐-‐ Fear & Abuse of VA





phase

Analysis #2 Qualitative Content Analysis

Christopher J. Koenig, PhD San Francisco VA & UC San Francisco

Qualitative Content Analysis The goals of QCA include: •  Systema4c descrip4on of text

•  Iden4fy trends, paNerns, frequencies, and rela4onships of textual informa4on

•  Synthesize codes into paNerns with minimal interpreta4on

Borga<, 1994

Team-‐based Coding Process

Deduc4ve

• SOTA Model • Manual coding • 4 months

Induc4ve

• Emergent codes • Atlas.TI • 6+ months

Domains

•  SOTA • Non-‐SOTA

Codes

Experiences of access

Culture

Digital

Logis4cs Processes of Care

VA System

13 codes

Qualitative Content Domains

12 codes 12 codes

6 codes 7 codes

Comparisons SOTA Model Qual Content Analysis Geographical

Logis4cal Problems Temporal

Financial

Cultural Cultural Barriers

Digital Digital

-‐-‐ VA System

-‐-‐ Processes of Care

-‐-‐ -‐-‐

-‐-‐ -‐-‐

Comparisons SOTA Model Cultural Domain Qual Content Geographical

Logis4cal Problems Logis4cs Temporal

Financial

Cultural Cultural Barriers Culture

Digital -‐-‐ Digital

-‐-‐ Systemic Problems VA Systemic

-‐-‐ -‐-‐ Processes of Care

-‐-‐ Mental Health Literacy -‐-‐

-‐-‐ Fear & Abuse of VA -‐-‐

Strengths & Limitations Strengths • Mul4-‐site, in-‐depth interviews with Veterans •  Two forms of triangula4on: data and analysis

Weaknesses • Generalizability • No road map for combining findings in mixed and mul4ple method analyses

Conclusions •  SOTA model and empirical Veterans’ experiences converge in some areas, but diverge in others

• Veteran data can help determine if some factors are more important than others

• Analyses incorporate Veteran perspec4ve •  To refine SOTA model for access •  To develop a Perceived Access Measure for system-‐wide implementa4on

Acknowledgments The Full ACCESS Team John Fortney, Jeff Pyne, Jim Burgess, Regina Stanley, Mitzi Moser, Debbie Hodges, Trish Wright, Chris Miller, Karen Seal, Gary Tarantovsky, Kara Zamora, Coleen Hill

Veterans who volunteered as par4cipants United States Department of Veteran Affairs VHA Health Services Research & Development

Ann M. Cheney, PhD [email protected] UC Riverside & Greater Los Angeles VA

Christopher J. Koenig, PhD [email protected] San Francisco VA & UC San Francisco

FIN


Step 1. Free List Exercise Goal Elicit Veterans’ perspec4ves on Perceived Barriers to Care AcEvity “List of all the things you can that make it harder for Veterans to get help for emo4onal-‐ and stress-‐related care.” •  N=30 Veterans across 3 sites

Analysis •  Result = 238 unique items •  Similar items were collapsed •  Most frequently and qualita4vely important compiled

Step 2. Pile Sort Activity Goal Understand how Veterans iden4fied barriers to care

AcEvity “Place all the items that you think are similar into piles.” •  N=29 Veterans across 3 sites

Analysis •  Mul$-‐dimensional scaling exposes underlying rela4ons between items

•  Cluster analysis associates items into meaningful groups

Cluster Analysis Cultural Barriers

Fear & Abuse of VA

Mental Health Literacy Systemic Problems

Compe4ng Priori4es & Logis4cal

Step 3. Interpretation Activity Goal Interpret how Veterans understand the rela4onships of barriers to care AcEvity “Why do you think other Veterans put these items together?” •  n =15 (an4cipated) Veterans across 3 sites

Analysis •  Describe the rela4onships of items within & across clusters •  Cri4que clusters

Health & Medicine

Comparing and contrasting Veterans’ experiences of access with the SOTA Access Model