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Causal-loop diagram notation. In causal-loop diagrams, causal links between variables have a positive or negative valence corresponding to whether the second variable increases or decreases in a way that is the same as or opposite to the first variable. Feedback loops are configurations of causal links that display circular logic and can be reinforcing (exponential behavior) or balancing (trend toward a set point)
Source publication
Background
Rural veterans experience more challenges than their urban peers in accessing primary care services, which can negatively impact their health and wellbeing. The factors driving this disparity are complex and involve patient, clinic, health system, community and policy influences. Federal policies over the last decade have relaxed require...
Citations
... 1, 6 While rural veterans rely heavily on VA coverage for health care, VA locations are limited and rural Veterans often face significant challenges accessing and navigating health care. [7][8][9] Rural veteran age and health status can further complicate the challenges of geographic distance. 8,10,11 The VA contributes significant resources to address the care needs of rural veterans. ...
Background
The 2019 VA Maintaining Systems and Strengthening Integrated Outside Networks Act, or MISSION Act, aimed to improve rural veteran access to care by expanding coverage for services in the community. Increased access to clinicians outside the US Department of Veterans Affairs (VA) could benefit rural veterans, who often face obstacles obtaining VA care. This solution, however, relies on clinics willing to navigate VA administrative processes.
Objective
To investigate the experiences rural, non-VA clinicians and staff have while providing care to rural veterans and inform challenges and opportunities for high-quality, equitable care access and delivery.
Design
Phenomenological qualitative study.
Participants
Non-VA-affiliated primary care clinicians and staff in the Pacific Northwest.
Approach
Semi-structured interviews with a purposive sample of eligible clinicians and staff between May and August 2020; data analyzed using thematic analysis.
Key Results
We interviewed 13 clinicians and staff and identified four themes and multiple challenges related to providing care for rural veterans: (1) Confusion, variability and delays for VA administrative processes, (2) clarifying responsibility for dual-user veteran care, (3) accessing and sharing medical records outside the VA, and (4) negotiating communication pathways between systems and clinicians. Informants reported using workarounds to combat challenges, including using trial and error to gain expertise in VA system navigation, relying on veterans to act as intermediaries to coordinate their care, and depending on individual VA employees to support provider-to-provider communication and share system knowledge. Informants expressed concerns that dual-user veterans were more likely to have duplication or gaps in services.
Conclusions
Findings highlight the need to reduce the bureaucratic burden of interacting with the VA. Further work is needed to tailor structures to address challenges rural community providers experience and to identify strategies to reduce care fragmentation across VA and non-VA providers and encourage long-term commitment to care for veterans.
... Causal Loop Diagrams (CLD) are visual systems thinking tools that "identify and label feedback loops to facilitate understanding, dynamic reasoning and formal modeling" [12]. They are widely used in studies on policy in general [25] and health policy in particular [26][27][28][29][30][31][32][33]. ...
... CLDs originated as a preliminary step toward developing quantitative simulation models but grew into a standalone method to develop a shared understanding of the structure and causal linkages of a system [29]. CLDs serve the purpose of identifying the variables of interest and hypothesizing how they interact because causality in a CLD is based on beliefs and world-views, the "mental models", of the modelers and the stakeholders involved in CLD development. ...
... CLDs follow certain conventions and practices [25,29]. Variables and the driving relationships between them are depicted as nodes and directed edges, respectively. ...
Globally, Emergency Care Systems (ECS) are a critical resource that needs to be used judiciously as demand can easily exceed supply capacity. Sub-optimal ECS use contributes to Emergency Department (ED) crowding; this adversely affects ECS as well as system-wide service performance. Alternate Care Service Pathways (ACSPs) are innovations intended to mitigate ED crowding by re-routing less-urgent cases to sites of care other than the ED. As in other countries, policymakers in Singapore need to respond to increasing ED utilization and are evaluating the introduction of ACSPs. However, developing ACSPs is costly, entails tinkering with established critical services, and runs the risk of unintended adverse consequences. Through a Causal Loop Diagram (CLD) developed in four stages, we present a view of the current Singapore ECS and the intended role of ACSPs in relieving its stress. This exercise suggests that to be successful ACSPs must change the prevailing mental model of the ED as a “one-stop shop” but should focus on integrating with primary care. The discussions stimulated by the development, critiquing, and revision of the CLD highlighted the importance of accounting for the reservations of stakeholders for changes. The CLD has enhanced shared understanding and will be used to guide quantitative simulation modeling to promote informed policy.
Qualitative data are commonly used in the development of system dynamics models, but methods for systematically identifying causal structures in qualitative data have not been widely established. This article presents a modified process for identifying causal structures (e.g., feedback loops) that are communicated implicitly or explicitly and utilizes software to make coding, tracking, and model rendering more efficient. This approach draws from existing methods, system dynamics best practice, and qualitative data analysis techniques. Steps of this method are presented along with a description of causal structures for an audience new to system dynamics. The method is applied to a set of interviews describing mental models of clinical practice transformation from an implementation study of screening and treatment for unhealthy alcohol use in primary care. This approach has the potential to increase rigour and transparency in the use of qualitative data for model building and to broaden the user base for causal‐loop diagramming.
The 2014 Veterans Choice Act and subsequent 2018 Veteran’s Affairs (VA) Maintaining Systems and Strengthening Integrated Outside Networks Act (MISSION Act) are legislation which clarified Veteran access to healthcare provided by non-VA clinicians (community care). These policies are of particular importance to Veterans living in rural areas, who tend to live farther from VA medical facilities than urban Veterans.
To understand Veterans’ experiences of the MISSION Act and how it impacted their access to primary care to inform future interventions with a focus on reaching rural Veterans.
Qualitative descriptive design.
United States (US) Veterans in Northwestern states engaged in VA and/or community care.
Semi-structured interviews were conducted with a purposive sample of Veterans between August 2020 and September 2021. Interview domains focused on barriers and facilitators of healthcare access. Transcripts were analyzed using thematic analysis.
We interviewed 28 Veterans; 52% utilized community care as their primary source of care and 36% were from rural or frontier areas. Three main themes emerged: (1) Veterans described their healthcare experiences as positive but also frustrating (billing and prior authorization were noted as top frustrations); (2) Veterans with medical complexities, living far from healthcare services, and/or seeking women’s healthcare services experienced additional frustration due to increased touch points with VA systems and processes; and (3) financial resources and/or knowledge of the VA system insulated Veterans from frustration with healthcare navigation.
Despite provisions in the MISSION Act, Veteran participants described persistent barriers to healthcare access. Patient characteristics that required increased interaction with VA processes exacerbated these barriers, while financial resources and VA system knowledge mitigated them. Interventions to improve care coordination or address access barriers across VA and community care settings could improve access and reduce health inequities for Veterans—especially those with medical complexities, those living far from healthcare services, or those seeking women’s healthcare.
