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

Abstract: Rural veterans experience more challenges than their urban peers in accessing primary care services, which can negatively impact their health and wellbeing. The factors driving this disparity are complex and involve patient, clinic, health system, community and policy infuences. Federal policies over the last decade have relaxed requirements for some veterans to receive primary care services from community providers through their VA benefts, known as community care. We used a participatory systems mapping approach involving causal-loop diagramming to identify interrelationships between variables underlying challenges to veteran access to primary care and potential opportunities for change—known as leverage points in systems science. Our methods involved a secondary analysis of semi-structured qualitative interviews with rural veterans, VA staf, non-VA clinic staf and providers who serve rural veterans, and veteran service ofcers (VSOs) in the Northwest region of the US, followed by a two-part participatory modeling session with a study advisory board. We then applied Meadows’s leverage point framework to identify and categorize potential interventions to improve rural veteran access to primary care. The fnal model illustrated challenges at the veteran, clinic, and system levels as experienced by stakeholders. Main components of the diagram pertained to the choice of VA or non-VA primary care, veteran satisfaction with the VA, enrollment in VA benefts and other insurance, community care authorization, reimbursement of non-VA care, referrals to specialty care, record sharing and communication between VA and non-VA providers, institutional stability of the VA, and stafng challenges. Fourteen interventions, including administrative and communications changes, were identifed by analyzing the model using the leverage points framework. Our fndings illustrate how challenges rural veterans face accessing health care are interconnected and persist despite recent changes to federal law pertaining to the VA health care system in recent years. Systems mapping and modeling approaches such as causal-loop diagramming have potential for engaging stakeholders and supporting intervention and implementation planning.