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Telehealth use, including video visits and secure messages, expanded significantly in Veterans Health Administration (VHA) primary care during the COVID-19 pandemic. However, primary care provider (PCP) burnout also increased during this period. Each modality may have affected primary care workloads differently (either by substituting for or complementing in-person visits) and thereby had varying effects on PCP burnout. This study aims to examine the associations between PCP burnout and the volumes of video visits and secure messages within the health care systems in which the PCPs practiced. This study examined the associations between telehealth modalities (ie, video visits and secure messages) and burnout as reported by 17,034 PCPs in 138 health care systems in VHA from 2020 to 2023. Individual-level data were obtained from annual cross-sectional surveys, and health care system-level data were drawn from administrative data sources. We created logistic regression models using generalized estimating equations to analyze the relationships between individual-level PCP burnout and average volumes of health care system-level video visits and secure messages per 1000 patients, controlling for age, sex, race or ethnicity, and VHA tenure as well as health care system complexity and year. We then predicted the marginal means of PCP burnout by video visit or secure message volume, based on the model results. From 2020 to 2023, average PCP burnout, across repeated, annual cross-sections, increased from 42.1% to 52.7% (survey response rates of 68%-74%). Most survey respondents were aged 50 years and above (9607/17,034, 56.40%), female (10,189/17,034, 59.82%), non-White (9460/17,034, 55.54%), and with less than 10 years of tenure in the VHA (10,990/17,034, 64.52%). Over these 4 years, median annual video visits per 1000 patients in health care systems increased from 15.9 (IQR 8.4-25.5) to 227.6 (IQR 127.1-320.7), and median annual secure messages per 1000 patients increased from 23.4 (IQR 9.4-65.5) to 35.3 (IQR 11.0-87.0). In our fully adjusted models, video visit volumes in a health care system were not related to burnout, but secure message volumes were related to burnout. Burnout was significantly higher among PCPs in health care systems receiving additional secure messages per 1000 patients (odds ratio 1.001, 95% CI 1.000-1.002). On average, PCP burnout increased by 1% point for each additional increase of 43.7 (95% CI 14.0-73.4) secure messages in a health care system. Video visit volumes in a health care system were not associated with PCP burnout, but secure message volumes were associated with PCP burnout. As video visits and secure messages continue to grow, solutions to better manage message volume (eg, automation and provider-led quality improvement) are needed to mitigate the concurrent rise in PCP burnout.

Background The Veterans Affairs (VA) Clinical Resource Hub (CRH) program aims to improve patient access to care by implementing time-limited, regionally based primary or mental health staffing support to cover local staffing vacancies. VA’s Office of Primary Care (OPC) designed CRH to support more than 1000 geographically disparate VA outpatient sites, many of which are in rural areas, by providing virtual contingency clinical staffing for sites experiencing primary care and mental health staffing deficits. The subsequently funded CRH evaluation, carried out by the VA Primary Care Analytics Team (PCAT), partnered with CRH program leaders and evaluation stakeholders to develop a protocol for a six-year CRH evaluation. The objectives for developing the CRH evaluation protocol were to prospectively: 1) identify the outcomes CRH aimed to achieve, and the key program elements designed to achieve them; 2) specify evaluation designs and data collection approaches for assessing CRH progress and success; and 3) guide the activities of five geographically dispersed evaluation teams. Methods The protocol documents a multi-method CRH program evaluation design with qualitative and quantitative elements. The evaluation’s overall goal is to assess CRH’s return on investment to the VA and Veterans at six years through synthesis of findings on program effectiveness. The evaluation includes both observational and quasi-experimental elements reflecting impacts at the national, regional, outpatient site, and patient levels. The protocol is based on program evaluation theory, implementation science frameworks, literature on contingency staffing, and iterative review and revision by both research and clinical operations partners. Discussion Health systems increasingly seek to use data to guide management and decision-making for newly implemented clinical programs and policies. Approaches for planning evaluations to accomplish this goal, however, are not well-established. By publishing the protocol, we aim to increase the validity and usefulness of subsequent evaluation findings. We also aim to provide an example of a program evaluation protocol developed within a learning health systems partnership.

BackgroundCivility, or politeness, is an important part of the healthcare workplace, and its absence can lead to healthcare provider and staff burnout. Lack of civility is well-documented among mostly female nurses, but is not well-described among the gender-mixed primary care provider (PCP) workforce. Understanding civility and its relationship to burnout among male and female PCPs could help lead to tailored interventions to improve civility and reduce burnout in primary care.ObjectiveTo analyze gender differences in civility, burnout, and the relationship between civility and burnout among male and female PCPs.DesignMulti-level logistic regression analysis of a cross-sectional national survey.ParticipantsA total of 3216 PCP respondents (1946 women and 1270 men) in 135 medical centers from a 2019 national Veterans Health Administration (VA) survey.Main MeasuresOutcomes: burnout; predictors: workplace civility and gender; controls: race, ethnicity, VA tenure, and supervisory status.Key ResultsWorkplace civility was rated higher (p<0.001) among male (mean = 4.07, standard deviation [SD] = 0.36, range 1–5) compared to female (mean = 3.88, SD = 0.33) PCPs. Almost half of the sample reported burnout (47.6%), but this difference was not significant (p = 0.73) between the genders. Higher workplace civility was significantly related to lower burnout among female PCPs (odds ratio [OR] = 0.46, 95% confidence interval [CI] = 0.31 to 0.69), but not among male PCPs (OR = 0.71, 95% CI = 0.42 to 1.22). Interactions between civility and other demographic variables (race, ethnicity, VA tenure, or supervisory status) were not significantly related to burnout.ConclusionFemale PCPs report lower workplace civility than male PCPs. An inverse relationship between civility and burnout is present for women but not men. More research is needed on this phenomenon. Interventions tailored to gender- and primary care-specific needs should be employed to increase civility and reduce burnout among PCPs.

Background The COVID-19 pandemic involved a rapid change to the working conditions of all healthcare workers (HCW), including those in primary care. Organizational responses to the pandemic, including a shift to virtual care, changes in staffing, and reassignments to testing-related work, may have shifted more burden to these HCWs, increasing their burnout and turnover intent, despite their engagement to their organization. Our objectives were (1) to examine changes in burnout and intent to leave rates in VA primary care from 2017–2020 (before and during the pandemic), and (2) to analyze how individual protective factors and organizational context affected burnout and turnover intent among VA primary care HCWs during the early months of the pandemic. Methods We analyzed individual- and healthcare system-level data from 19,894 primary care HCWs in 139 healthcare systems in 2020. We modeled potential relationships between individual-level burnout and turnover intent as outcomes, and individual-level employee engagement, perceptions of workload, leadership, and workgroups. At healthcare system-level, we assessed prior-year levels of burnout and turnover intent, COVID-19 burden (number of tests and deaths), and the extent of virtual care use as potential determinants. We conducted multivariable analyses using logistic regression with standard errors clustered by healthcare system controlled for individual-level demographics and healthcare system complexity. Results In 2020, 37% of primary care HCWs reported burnout, and 31% reported turnover intent. Highly engaged employees were less burned out (OR = 0.57; 95% CI 0.52–0.63) and had lower turnover intent (OR = 0.62; 95% CI 0.57–0.68). Pre-pandemic healthcare system-level burnout was a major predictor of individual-level pandemic burnout ( p  = 0.014). Perceptions of reasonable workload, trustworthy leadership, and strong workgroups were also related to lower burnout and turnover intent ( p  < 0.05 for all). COVID-19 burden, virtual care use, and prior year turnover were not associated with either outcome. Conclusions Employee engagement was associated with a lower likelihood of primary care HCW burnout and turnover intent during the pandemic, suggesting it may have a protective effect during stressful times. COVID-19 burden and virtual care use were not related to either outcome. Future research should focus on understanding the relationship between engagement and burnout and improving well-being in primary care.

Background/Objective Optimizing patients’ access to primary care is critically important but challenging. In a national survey, we asked primary care providers and staff to rate specific care processes as access management challenges and assessed whether clinics with more of these challenges had worse access outcomes. Methods Study design: Cross sectional. National Primary Care Personnel Survey (NPCPS) (2018) participants included 6210 primary care providers (PCPs) and staff in 813 clinics (19% response rate) and 158,645 of their patients. We linked PCP and staff ratings of access management challenges to veterans’ perceived access from 2018–2019 Survey of Healthcare Experiences of Patients-Patient Centered Medical Home (SHEP-PCMH) surveys (35.6% response rate). Main measures: The NPCPS queried PCPs and staff about access management challenges. The mean overall access challenge score was 28.6, SD 6.0. The SHEP-PCMH access composite asked how often veterans reported always obtaining urgent appointments same/next day; routine appointments when desired and having medical questions answered during office hours. Analytic approach: We aggregated PCP and staff responses to clinic level, and use multi-level, multivariate logistic regressions to assess associations between clinic-level access management challenges and patient perceptions of access. We controlled for veteran-, facility-, and area-level characteristics. Key Results Veterans at clinics with more access management challenges (> 75 th percentile) had a lower likelihood of reporting always receiving timely urgent care appointments (AOR: .86, 95% CI: .78–.95); always receiving routine appointments (AOR: .74, 95% CI: .67–.82); and always reporting same- or next-day answers to telephone questions (AOR: .79, 95% CI: .70–.90) compared to veterans receiving care at clinics with fewer (< 25 th percentile) challenges. Discussion/Conclusion Findings show a strong relationship between higher levels of access management challenges and worse patient perceptions of access. Addressing access management challenges, particularly those associated with call center communication, may be an actionable path for improved patient experience.

Context: Recent evidence questions whether formerly documented disparities in care for common mental disorders among African Americans and Hispanics still remain. Also, whether disparities exist mainly in psychiatric settings or primary health care settings is unknown. Objective: To comprehensively examine time trends in outpatient diagnosis and treatment of depression and anxiety among ethnic groups in primary care and psychiatric settings. Design and Setting: Analyses of office-based outpatient visits from the National Ambulatory Medical Care Study from 1995-2005 (n = 96,075). Participants: Visits to office-based primary care physicians and psychiatrists in the United States. Main Outcome Measures: Diagnosed with depression or anxiety, received counseling or a referral for counseling, received an antidepressant prescription, and any counseling or antidepressant care. Results: In these analyses of 10-year trends in treatment of common mental disorders, disparities in counseling/referrals for counseling, antidepressant medications, and any care vastly improved or were eliminated over time in psychiatric visits. Continued disparities in diagnoses, counseling/referrals for counseling, antidepressant medication, and any care are found in primary care visits. Conclusions: Disparities in care for depression and anxiety among African Americans and Hispanics remain in primary care. Quality improvement efforts are needed to address cultural and linguistic barriers to care.

Background Many healthcare systems seek to improve care for complex high-risk patients, but engaging such patients to actively participate in their healthcare can be challenging. Objective To identify and describe types of patient engagement strategies reported as successfully deployed by providers/teams and experienced by patients in a Veterans Health Administration (VA) intensive primary care (IPC) pilot program. Methods We conducted semi-structured qualitative telephone interviews with 29 VA IPC staff (e.g., physicians, nurses, psychologists) and 51 patients who had at least four IPC team encounters. Interviews were recorded, transcribed, and analyzed thematically using a combination a priori/inductive approach. Results The engagement strategies successfully deployed by the IPC providers/teams could be considered either more “facilitative,” i.e., facilitated by and dependent on staff actions, or more “self-sustaining,” i.e., taught to patients, thus cultivating their ongoing patient self-care. Facilitative strategies revolved around enhancing patient access and coordination of care, trust-building, and addressing social determinants of health. Self-sustaining strategies were oriented around patient empowerment and education, caregiver and/or community support, and boundaries and responsibilities. When patients described their experiences with the “facilitative” strategies, many discussed positive proximal outcomes (e.g., increased access to healthcare providers). Self-sustaining strategies led to positive (self-reported) longer-term clinical outcomes, such as behavior change. Conclusion We identified two categories of strategies for successfully engaging complex, high-risk patients: facilitative and self-sustaining. Intensive primary care program leaders may consider thoughtfully building “self-sustaining” engagement strategies into program development. Future research can confirm their effectiveness in improving health outcomes.

Background The scope of care coordination in VA primary care increased with the launch of the Veterans Choice Act, which aimed to increase access through greater use of non-VA Community Care. These changes may have overburdened already busy providers with additional administrative tasks, contributing to provider burnout. Our objective was to understand the role of challenges with care coordination in burnout. We analyzed relationships between care coordination challenges with Community Care reported by VA primary care providers (PCPs) and VA PCP burnout. Methods Our cross-sectional survey contained five questions about challenges with care coordination. We assessed whether care coordination challenges were associated with two measures of provider burnout, adjusted for provider and facility characteristics. Models were also adjusted for survey nonresponse and clustered by facility. Trainee and executive respondents were excluded. 1,543 PCPs in 129 VA facilities nationwide responded to our survey (13 % response rate). Results 51 % of our sample reported some level of burnout overall, and 46 % reported feeling burned out at least once a week. PCPs were more likely to be burned out overall if they reported more than average challenges with care coordination (odds ratio [OR] 2.04, 95 % confidence interval [CI] 1.58 to 2.63). These challenges include managing patients with outside prescriptions or obtaining outside tests or records. Conclusions VA primary care providers who reported greater than average care coordination challenges were more likely to be burned out. Interventions to improve care coordination could help improve VA provider experience.

BackgroundIntensive primary care (IPC) programs for patients with complex needs do not generate cost savings in most settings. Strengthening existing patient-centered medical homes (PCMH) to address the needs of these patients in primary care is a potential high-value alternative.ObjectivesExplore PCMH team functioning and characteristics that may impact their ability to perform IPC tasks; identify the IPC components that could be incorporated into PCMH teams’ workflow; and identify additional resources, trainings, and staff needed to better manage patients with complex needs in primary care.MethodsWe interviewed 44 primary care leaders, PCMH team members (providers, nurses, social workers), and IPC program leaders at 5 VA IPC sites and analyzed a priori themes using a matrix analysis approach.ResultsHigher-functioning PCMH teams were described as already performing most IPC tasks, including panel management and care coordination. All sites reported that PCMH teams had the knowledge and skills to perform IPC tasks, but not with the same intensity as specialized IPC teams. Home visits/assessments and co-attending appointments were perceived as not feasible to perform. Key stakeholders identified 6 categories of supports and capabilities that PCMH teams would need to better manage complex patients, with care coordination/management and fully staffed teams as the most frequently mentioned. Many thought that PCMH teams could make better use of existing VA and non-VA resources, but might need training in identifying and using those resources.ConclusionsPCMH teams can potentially offer certain clinic-based services associated with IPC programs, but tasks that are time intensive or require physical absence from clinic might require collaboration with community service providers and better use of internal and external healthcare system resources. Future studies should explore the feasibility of PCMH adoption of IPC tasks and the impact on patient outcomes.