Temporal Access Barriers among Rural-Residing Veterans with Multiple Chronic Conditions

Abstract

In rural communities, access to healthcare is often challenged by provider shortages and long travel distances which can undermine the timely receipt of care. We are a group of health services researchers from multiple disciplines (sociology, anthropology, medicine, psychology, health coaching) and as part of a Department of Veterans Affairs (VA) quality improvement project, we conducted semi-structured interviews with rural-residing Veterans with multiple chronic conditions and a subset of their caregivers. In this work, we consider rural time-based access factors for Veterans experiencing multiple chronic conditions using a multidimensional access model that considers the intersection of time, geography, culture, and digital technology in healthcare use. We discuss three themes: (1) it is difficult for rural-residing Veterans with multiple chronic conditions to get timely primary and specialty care appointments; (2) Veterans with multiple chronic conditions view primary care visits to be too short to adequately address their questions and care needs; and (3) Veterans with multiple chronic conditions report that long travel times and limited skills with virtual technologies restrict their access to symptom-focused care. We describe how temporal access barriers occur at different points of care and are compounded by symptom burden associated with multiple chronic conditions and discuss potential strategies that can address these barriers.

PLAIN LANGUAGE SUMMARY

As part of quality improvement work in the Department of Veterans Affairs, we examined how time impacts healthcare access for rural-residing Veterans with multiple chronic conditions. Lack of healthcare providers and long delays in care create barriers for people living in rural areas with symptoms of illness. Here we describe how these time and health related difficulties impact the ability to care that is expedient and effective in light of the confines of short visit times, long waits for appointments, and difficulty with travel. We suggest potential strategies to improve healthcare access for rural-residing Veterans with multiple chronic conditions that include support for telehealth use and health coaching surrounding healthcare visits.

Acknowledgements

This work contains findings from a quality improvement project titled Rural Veterans with Multiple Chronic Conditions Design a Whole Health System of Care (PI: David Coultas) that was supported by the Veterans Health Administration (VHA) Office of Rural Health. The content is solely the responsibility of the authors and does not represent the official views of the VHA. The authors wish to thank Christopher Larsen and Chelsea Jacobsen for their participation in the development and coordination of this work as well as the Veterans and caregivers who so openly shared their stories.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Notes on contributors

Elizabeth Hulen

Elizabeth Hulen, PhD is a Medical Sociologist and Health Services Researcher at the Veterans Health Resource Center-Portland and the Center to Improve Veteran Involvement in Care at the VA Portland Health Care System. She is also the Co-site Lead for the Women Veterans Practice-Based Research Network in Portland, OR. Her research interests include rural healthcare access, qualitative research methods, and preventative care for women Veterans.

Sarah Ono

Sarah Ono, PhD is a Cultural Anthropologist and Core Investigator at the Center to Improve Veteran Involvement in Care in the VA Portland Health Care System. She is also the Director (Operations) of the Veterans Health Resource Center-Portland and an Associate Professor of Psychiatry at Oregon Health & Science University. Her research interests include medical anthropology, rural health, and community-based participatory research and patient engagement practices.

Samuel T. Edwards

Samuel T. Edwards MD, MPH is a Staff Physician in the section of General Internal Medicine, a Core Investigator in the Center to Improve Veteran Involvement in Care at the VA Portland Health Care System, and an Associate Professor of Medicine at Oregon Health and Science University (OHSU). He also serves as research Co-director of the RELATE (Relationships, Equity, Leadership and Team Effectiveness) Lab in the department of Family Medicine at OHSU. His interests include primary care health policy, home care medicine, and medical workforce wellbeing.

Traben L. Pleasant

Traben L. Pleasant, PhD is an Applied Anthropologist and Health Services Researcher at the Veterans Rural Health Resource Center-Portland and the Center to Improve Veteran Involvement in Care at the VA Portland Health Care System. He is also a Veteran of the US Marine Corps and is the Veterans Engagement Group Liaison at the Portland, Oregon VA. His research interests include aging and dementia, healthcare access, pain, and mental health therapies for Veterans.

Travis I. Lovejoy

Travis I. Lovejoy, PhD, MPH is a Clinical Psychologist and a Core Investigator at the Center to Improve Veteran Involvement in Care in the VA Portland Health Care System. He currently serves as the Director (Clinical) of the Veterans Health Resource Center-Portland. His research interests include health psychology, behavioral medicine, substance use disorders, and chronic pain.

David Coultas

David Coultas, MD is a Pulmonologist at the VA Portland Health Care System. His research has focused on the epidemiology and prevention of chronic respiratory diseases including investigations of patients with COPD, interstitial lung diseases, and environmental and occupational lung diseases.