Table 2 Key components of causal-loop diagram of rural veteran access to care
From: Long drives and red tape: mapping rural veteran access to primary care using causal-loop diagramming
Type | Component |
|---|---|
Reinforcing feedback loops | R1: VA provider burnout R2: Institutional stability R3: Strain on VA Office of Community Care staff |
Balancing feedback loops | B1: VA primary care B2: Non-VA primary care B3: PC authorization: Non-VA clinic help B4: PC authorization: veterans navigate B5: Reimbursement B6: Specialty care referrals B7: Enrollment in VA benefits B8: Enrollment in other insurance B9: VA provider retention B10: Community care reduces hiring pressure B11: Downsizing of VA services B12: Non-VA PC: specialist care coordination B13: VA PC: specialist care coordination |
Hubs (number of causal links in parentheses) | Veteran satisfaction with the VA (12); Veteran enrollment in VA benefits (9); Veterans’ desire to seek non-VA primary care (9); Veterans’ community care authorization for primary care (8); Veteran enrollment in other insurance (7); Veterans’ primary care needs (7); Delayed or lost paperwork submitted to the VA (6); Veterans’ ability to navigate VA systems (6); Veterans’ desire to seek VA primary care (6); Veterans receiving non-VA primary care (6) |
Exogenous drivers | Changes to authorization; Concern about cost of non-VA care; Confusion about authorization requirements; Confusion about role of TriWest; Credentialing of non-VA providers; Family/friend assistance; Inability to choose own provider; Inability to contact TriWest by telephone; Inconsistency of information provided by VA; Lack of VA women’s health providers; Limitations on reimbursement; Limitations to VA benefits; Negative VA care experiences; Non-VA clinic identification of veterans; Non-VA clinics’ “insider” contacts at VA; Outdated technology; Procedural communication barriers; Rural veterans’ distance to VA facilities; Rurality of VA facility; Small size of non-VA clinic; TriWest referral errors; Urgency of care need; VA EHR limitations; VA primary care authorization policy; VA providers’ experience caring for veterans; VA staff assistance; Veteran having insurance through job; Veteran Medicare eligibility; Veteran willingness to use telehealth; Veterans feeling that they belong at the VA; Veterans’ “insider” contacts at VA |