Maintaining Preventive Care during Public Health Emergencies through Effective Coordination

BACKGROUND. Screening lies at the heart of preventive care. However, COVID-19 has dramatically disrupted routine screening efforts, resulting in excess veteran mortality not directly attributable to COVID-19. Screening rates at VA during COVID have varied markedly by facility and clinical condition. This is illustrated in cancer and mental health screening; cross-facility variability exists for each, suggesting susceptibilities in the capacity and workflow of the screening and referral process. To better understand these susceptibilities and identify new practices to mitigate interrupted care, we propose a qualitative study comparing facilities that exhibited high, low, and highly variable performance (respectively) in screening rates before and during the pandemic. SIGNIFICANCE. Disruptions to preventive screening lead to excess veteran mortality. Therefore, caring for veterans' regular primary care (PC) needs while fulfilling our Fourth Mission (emergency preparedness) requires top-notch coordination and nimble teamwork from all clinical personnel. Our study will identify the systematic strategies and coordination patterns between primary and specialty care that differentiate successful facilities from struggling ones. Our findings will help design new or adapt existing workflows and interventions for coordination, shaping how screening and preventive care is delivered during and beyond COVID-19. Our study directly addresses: a) this solicitation's goals; b) HSR&D's clinical priorities; c) VA's strategic plan goals for highly reliable care; and d) ORD real-world research impact priorities. SPECIFIC AIMS. Using cancer and mental health screening rates as exemplars, we propose to (1) Compare how PACTs from VHA facilities of varying screening performance patterns (high, low, improving, plummeting, variable) during the COVID-19 pandemic coordinated (a) as a team to conduct screening services, and (b) with specialty care teams at their facility to conduct screening services; and (2) Compare team, facility, and system- based barriers, facilitators, and strategies for continuing screening services during the COVID-19 pandemic amongst PACTs from VHA facilities of varying screening performance patterns during that period. METHOD. Design and Participants. This multi-method study consists of qualitative analysis of interviews and focus groups with primary care personnel, leadership, and patients at 10 VA Medical Centers (VAMCs). Site Selection. We will select study sites using a purposive stratified approach based on site rurality, COVID-19 caseload at the beginning of the pandemic, and performance on five outpatient clinical performance indicators of cancer and mental health screening. Sites will be categorized into one of five screening performance groups: high performers, low performers, improvers, plummeters, and highly variable. Procedure. Using data from prior research by the PI, we will create process maps for each performance measure to create a baseline for comparison to the process used since the pandemic began. We will interview the ACOS for primary care at each site to update the map to reflect the currently used process. We will conduct focus groups with PC and relevant specialty care clinicians to elicit themes regarding clinician coordination patterns (e.g., handoffs), strategies, and barriers/facilitators to screening during COVID (Aims 1- 3). We will also conduct patient interviews to examine their screening experience during this period, for context. Data Analysis: All interview and focus groups will be audio-recorded, transcribed, and enhanced by field notes. We will analyze clinician focus group transcripts and field notes using iterative, rapid analysis. Patient semi- structured interviews will be analyzed using inductive/deductive content analysis. NEXT STEPS/IMPLEMENTATION. We will share our findings, including site-specific recommendations, locally with key stakeholders at participating sites, and nationally through the Office of Primary Care-Mental Health Integration program and the VA National Women Veterans Oncology System of Excellence.