A combined analysis of the quantitative data and direct quotes from veteran participants provides a window into the effects of the early COVID-19 pandemic on the health care experience of veterans engaged in primary care at a large VA Medical Center. Our participants perceived new difficulty with accessing primary care despite frequent encounters, and a substantial minority expressed decreased satisfaction with their care at the beginning of the COVID-19 pandemic. In addition, veterans frequently reported psychosocial stressors related to the COVID pandemic and their consequences, including worsening of mental health conditions and feelings of isolation.
We focused our analysis on access and satisfaction, as well as perceived differences between VHA and non-VHA care. Though the quantitative data did not suggest a decrease in access, but a shift to virtual means, the narrative comments indicated veterans perceived more difficulty in accessing care during the first four months of the COVID-19 pandemic than prior to the pandemic. Explanations deduced from the interviews included inadequate time with their provider, difficulty scheduling provider visits due to administrative barriers, and the inadequacy of telehealth services. Due to stringent screening procedures and access protocols, only patients with scheduled appointments were allowed into the facility. No patient attendants were allowed with few exceptions (Personal communication with Himabindu Kadiyala, Director, PrimeCare). This may have contributed to patients’ perceptions of lack of access. Satisfaction ratings implied that many of these barriers existed prior to, but were exacerbated by, the pandemic. The majority of veterans had no change in satisfaction in their overall care experience; however, a sizable minority were less satisfied. Of note, VHA physicians were rated favorably overall.
While many of our veterans had access to non-VHA ambulatory care covered by TRICARE and Medicare, few reported utilizing these options, which is consistent with available literature.11 Even with the COVID pandemic-related changes, only six veterans chose to receive care outside of the VHA system during the reference period. Direct quotes from veterans who sought non-VHA care suggested they did so because of perceived ease of access to non-VHA care and inadequate resources for care at the VHA. The frequency of non-VHA use in this sample appears lower than the general population of VHA users and may reflect a sicker, more service-connected group of VHA users. For example, previous research showed that more than 60% of Medicare eligible older veterans with diabetes received at least some care from non-VHA physicians.12 This sample had a relatively large portion of African Americans (48%) as compared to both the overall veteran population who utilize VHA care (about 15%)13 and the general Houston population.14 Given the disparities in access to private sector health care faced by people of color, this could have impacted their ability or choice to utilize VHA vs. non-VHA care.15
On a scale from 0-10, six respondents rated their non-VHA physicians 9.5 (median: 10, IQR: 9.25-10 compared to the 34 respondents who only used VHA PCPs and rated them an average of 8.6 (median: 9, IQR: 8-10). Also, a higher percentage of veterans who sought non-VHA care were ‘very satisfied’ with their experience. This could be due in part to the reported perception of more time spent with their non-VHA physicians and their non-VHA physicians more frequently addressing patient goals for their health. Our understanding of the relationship between VHA and non-VHA care was limited by the small number of veterans in our sample (6 of 40) who did seek care from non-VHA physicians, but our findings suggest that veterans perceived non-VHA care to be more accessible during the early response to the COVID pandemic. This is an important finding as there are few direct comparisons between VHA and non-VHA care and the VHA may wish to adjust its response to pandemics and other disasters to ensure a perception of continued access to care, in line with the private sector.16 However, this should be balanced by the fact that the COVID-19 pandemic, especially during the period referenced in this study, was associated with much uncertainty and healthcare facilities responded with the best information and approaches available to them at the time. Restricting access to ambulatory care was a widespread response to overwhelmed healthcare and important beneficial impact on other, more urgent demands, such as inpatient care of acutely and critically ill patients.
While none of our participants had experienced COVID-19 at the time of the interviews, a substantial proportion of the veterans reported the exacerbation and/or development of mental health conditions such as anxiety and PTSD even without direct questioning. Participants attributed this to multiple psychosocial stressors related to the pandemic, including less opportunities for social engagement (“I stay inside and away from people.” – Veteran 45) and physical activity, increased occupational stress and financial uncertainty (“I did get furloughed when [the pandemic] happened.” – Veteran 24), and general anxiety concerning the virus (“I suffer from anxiety attacks. It has increased since corona...” – Veteran 23). Notably, a substantial proportion (17.5%) of the veterans did not feel that telehealth was meeting their healthcare needs, with some specifically mentioning their mental health care. In addition, the majority of veterans reported not receiving guidance from a physician on how to seek COVID-19-related care, perhaps contributing to their feelings of uncertainty. Of note, however, more veterans reported receiving this information from VHA providers than non-VHA providers.
During this time, the local VA medical center was communicating daily COVID-related updates, guidance to access care, and resources through its website, social media accounts, and occasional text messages to registered VHA users (Personal communication with Maureen Dyman, Public Affairs Officer). Given the high prevalence of mental health conditions among veterans who use VHA primary care, exploring ways to enhance communication about accessing care, including virtual mental health, represents an important opportunity to improve the veteran care experience.
VHA PCPs, nurses and support staff were pulled from primary care responsibilities to augment several other critical COVID-related care responses, including staffing the inpatient COVID service and public health screening activities at the campus (Personal communication with Himabindu Kadiyala, Director, PrimeCare). These activities created real shortages among primary care personnel which were felt by our respondents. Some respondents recognized the cause of the decreased access to primary care, but not all. Once again, VHA communicated extensively about availability of services and how to receive urgent and emergent care and encouraged telephone and video modalities for more routine encounters to overcome the loss of primary care capacity and restricted physical access, but perhaps the messages and channels used could be re-evaluated and their effectiveness more closely appraised during situations like the early pandemic response.
Our findings suggest several opportunities to improve the veteran care experience. While most veterans were able to access care from the VHA during the pandemic, as evidenced by the report of completed encounters, there was a general sense of difficulty in accessing that care. Perhaps, the greatest challenge to the VHA system is to enhance veterans’ perception of access.
This study suggests that the VHA system can benefit veterans through more streamlined, timely, and consistent communication with veterans. In addition to the online and social media presence, more robust telephone triage and response might address concerns we heard about dropped, unanswered, and unreturned phone calls, for example. Given the age, multiple chronic illnesses, and mental health issues of the population, the telephone call center response may be the most important means of reassuring and assisting veterans.
Our study highlights the importance of the psychosocial impact of COVID-related factors that impact veterans’ lives and may color their healthcare experience. Some of these factors are outside the scope of the VHA system but given the high prevalence of mental health conditions among veterans who use the VHA, the VHA system could help veterans by further expanding the visibility and reach of their virtual mental health care services, which were in fact bolstered during the pandemic. Lessons from this pandemic could be used to better advertise, communicate, and engage veterans on various virtual platforms to more fully meet their care needs.17,18
Finally, while efforts were made by the VHA system to communicate with veterans about the pandemic – apparent from the results given the higher percentage of VHA providers communicating about COVID compared to non-VHA physicians – many veterans still perceived a lack of communication. Future work could explore how the content, framing, and timing of these communications impact perceptions of access and satisfaction.
Strengths of our study include our study sample composed of ‘real world’ participants, which approximates the local VHA user population. Our findings are enhanced by the combination of quantitative and qualitative results. Further, incorporating the feedback provided by the veteran community engagement community into the research activities enhanced the rigor and relevance of the work. Limitations include this being a cross-sectional study with self-reported information, which makes our results susceptible to recall bias. Our results may not be generalizable to the larger veteran population due to the small number of participants, who all sought care at a single site.