By triangulating the experiences, attitudes and beliefs of these three stakeholder groups, we were able to systematically describe the drivers of dual use and address which organization delivers “primary” primary care.27
Dual use resulted from the behaviors of healthcare providers, as well as patients, in response to healthcare resource shortages at IHS/tribe facilities. An ad hoc system has developed to extend IHS/tribe rural health networks to include VHA urban partners for diagnostic, specialty and hospital-based care for veterans. The lack of formalized relationships to clearly define roles28
and support communication on mutual patients across organizations and rural/urban settings has resulted in potential overlaps and treatment conflicts. From the clinicians’ perspective, these conflicts arose, in part, because both systems took responsibility for primary care management although, from the patient perspective, IHS/tribe should function as the main primary care provider. Without a mechanism to regularly share medical records these sister federal agencies cannot coordinate primary care effectively.
Our findings build upon prior research on use of multiple healthcare organizations. Both VHA and IHS enrollees seek care in a combination of the private and public sector. Dual users in both the VHA and IHS tend to be older, better educated, have other public or private insurance, and have worse health compared to non-dual users.12,29–33
Of particular relevance to our study, among VHA-users, dual use has been associated with dissatisfaction in VHA healthcare, and when coupled with resources to access other options, leads to VHA services supplementing non-VHA primary care.11,29,32,34
In contrast, among IHS-users, insufficiency of IHS resources is often associated with supplementation of IHS/tribal primary care.12,14,17,35
Our focus groups confirm the finding of resource availability driving care patterns for dual users.
There was a strong preference to improve inter-organizational coordination through a shared electronic health record (EHR). These organizations cooperated in the development of their respective EHRs, which are integrated into their clinical practices. Clinicians recognized a problem in quality of care and were prepared to immediately implement improvements to benefit their patients, highlighting the presence of buy-in from the field for greater coordination of care.36
Closer alignment of these federal organizations has implications outside of health care delivery for AIAN veterans, who comprise about 1% of the US and veteran populations. By demonstrating leadership in coordination of care, VHA and IHS can demonstrate how to overcome technical, policy and administrative challenges in implementing the Institute of Medicine37
recommendations to enhance quality through data sharing and care coordination.
Issues of access and preference were raised in all stakeholder groups. Distance between VHA and IHS/tribal facilities was a concern because of cost and inconvenience, with local delivery of on-going chronic care preferred by patients and providers. We did not identify systematic differences in the VHA-IHS relationship based on distance between facilities. Consistent with prior studies,11
we found that increased distance did not diminish AIAN patients’ use of VHA; perhaps due to fewer acceptable non-VHA and non-IHS options in these rural areas.
Patients were generally satisfied with the quality of care in either organization; however all stakeholders agreed that neither organization was fully culturally competent. IHS/tribes lacked competence about veterans’ health needs and VHA lacked competence about AIAN patients’ health beliefs and behaviors. Future educational interventions should have strong experiential components and involve local tribes to address specific cultural issues.
Focus groups are limited to interpretative insights. Although we achieved sample adequacy, the total variation in VHA-IHS relationships may not be represented, such as clusters with fewer dual users or successful joint pilot projects, including telepsychiatry.38
Since VHA catchment areas included multiple tribal communities, we cannot determine the bias of sampling at only one of these Native communities, although often members of other local tribes were invited to participate. We acknowledge that our recruitment process may have introduced bias toward the interests of a tribal council or COS, nevertheless participants freely critiqued their respective organizations.
Our focus group research allowed the definition of a range of beliefs and elicited potential actions based on individuals’ authentic experiences. Healthcare providers consistently welcomed closer collaboration between VHA and IHS to improve information flow and processes of care for mutual patients. It appears that buy-in already exists among clinicians to implement systematic changes to improve care for mutual patients in these federal organizations. Their various recommendations including a shared electronic health record and formalized regional/local referral process will require both local and national implementation strategies. Future research should evaluate local strategies to foster greater coordination as potential interventions that might be broadly adopted, while future policy initiatives should focus on sharing medical information.