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Table 3 Potential leverage points to improve rural veteran access to primary care

From: Long drives and red tape: mapping rural veteran access to primary care using causal-loop diagramming

Meadows’s Places to Intervene

Interventions

12. Parameters (e.g., subsidies, taxes, standards)

Change distance requirements for community care (MISSION Act); broaden benefits eligibility (e.g., service connection, disability)

11. Buffers

Increasing staffing at VA Office of Community Care (weaken loop R3)

10. Material stocks and flows

Improving technological aspects of communication (switching from fax machines)

9. Delays

Extend time between primary care authorization renewals (add delays in loops B3-B4); reduce delays for specialty care authorizations and prescriptions (loop B6); reduce appointment delays through evening and weekend availability (loops B1-B2)

8. Balancing feedback loops

Improving record sharing and provider communication (strengthen loops B12-B13); Veteran identification in non-VA clinics (strengthen loop B7)

7. Reinforcing feedback loops

Reduce VA provider burnout and improve retention to improve continuity of VA care (weaken loop R1; strengthen B9)

6. Information flows

Improve VA communication to other stakeholders about processes (strengthen loops B3-B4); improve online systems for tracking care (referrals, authorizations) or communicating with providers (strengthen loops B6, B12-B13); improve communication between veterans and non-VA, VSO, community; gather & communicate data about wait times between VA & non-VA providers

5. Rules (e.g., incentives, constraints)

Change VA cost of living adjustment disincentivizing rural staff and providers (strengthen loop B9); increase VA budget for veteran healthcare (strengthen loop R2); allow VA benefits to function as secondary insurance

4. Self-organization

Reduce administrative barriers to process redesign and adaptation at the VA; offer case management or navigation services as workarounds (e.g., community health workers, through VSOs); form community coalitions

3. Goals

Change VA’s conflicting incentives between improving access to care and keeping funding inside VA

2. Mindset / paradigm

Single-payer systems (e.g., Australian gold card)

1. Transcending paradigms

None