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. 2025 May 1;8(5):e2511548.
doi: 10.1001/jamanetworkopen.2025.11548.

Experiences With VA-Purchased Community Care for US Veterans With Mental Health Conditions

Megan E Vanneman  1   2   3 , Eric T Roberts  4   5 , Yaming Li  6 , Florentina E Sileanu  6 , Utibe R Essien  7   8 , Maria K Mor  6   9 , Michael J Fine  6   10 , Carolyn T Thorpe  6   11 , Thomas R Radomski  6   10 , Katie J Suda  6   10 , Walid F Gellad  6   10
Affiliations

Experiences With VA-Purchased Community Care for US Veterans With Mental Health Conditions

Megan E Vanneman et al. JAMA Netw Open. .

Abstract

Importance: Veterans with mental health conditions (MHC) face unique challenges obtaining high-quality, coordinated health care. With a growing number of veterans receiving VA-purchased community care (CC) provided outside the Veterans Health Administration (VA), evidence is needed on how veterans in this high-prevalence, marginalized subgroup experience CC.

Objective: To compare experiences with CC over time for US veterans with and without MHC.

Design, setting, and participants: This retrospective, cross-sectional survey study analyzed responses to the Survey of Healthcare Experiences of Patients-Community Care Survey (SHEP-CCS) from 2016 to 2021. Ratings of CC were examined across 9 domains and compared for veterans with and without MHC, adjusting for differences in baseline characteristics using regression models. Data were analyzed from March 2023 to September 2024.

Exposure: Diagnosis of MHC, defined as bipolar disorder, major depression, posttraumatic stress disorder, schizophrenia, or psychosis.

Main outcomes and measures: Veterans' ratings of CC across 9 domains, overall satisfaction, overall clinician rating, clinician communication, eligibility determination, first appointment access, recent appointment access, nonappointment access, care coordination, and billing, were assessed on a scale of 1 to 100. Unadjusted annual ratings of care experiences were analyzed by survey domain. A series of 4 respondent-level linear regression models were examined for each domain and survey responses were pooled to test for differences in experiences between veterans with vs without MHC.

Results: This study included 231 869 veterans, including 62 911 veterans with MHC (27.1%) and 168 958 without MHC (72.9%). Veterans with MHC had a mean (SD) age of 55.8 (14.7) years, 8327 were female (18.5%), and 24 792 had 3 or more comorbidities (29.9%). Veterans without MHC had a mean (SD) age of 62.5 (15.2) years, 11 277 were female (11.0%), and 49 689 had 3 or more comorbidities (24.0%). In fully adjusted models, veterans with vs without MHC had lower adjusted overall satisfaction with CC by -1.8 (95% CI, -2.3 to -1.3) points (P < .001). Ratings in all domains were lower for veterans with vs without MHC (-0.09 to -0.05 SDs of domain scores) (P < .001 for all comparisons). Although ratings improved from 2016 to 2021, significant differences persisted over time for veterans with vs without MHC for all domains.

Conclusions and relevance: In this survey study of veterans receiving CC from 2016 to 2021, those diagnosed with MHC reported lower ratings of CC across all measured domains, and these differences persisted over time. These findings highlight where focused care coordination and quality improvement efforts could improve CC experiences for this vulnerable subpopulation of veterans.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Vanneman reported receiving grants from Department of Veterans Affairs during the conduct of the study. Dr Roberts reported receiving grants from Department of Veterans Affairs during the conduct of the study and receiving grants from Agency for Healthcare Research and Quality, National Institute on Aging, and Arnold Ventures and personal fees from University of Southern California outside the submitted work. Dr Sileanu reported receiving grants from Department of Veterans Affairs during the conduct of the study. Dr Mor reported receiving grants from Department of Veterans Affairs during the conduct of the study. Dr Thorpe reported receiving grants from the Department of Veterans Affairs and the National Institute on Aging. Dr Gellad reported receiving grants from the Department of Veterans Affairs during the conduct of the study. Dr Suda reported receiving grants from the Department of Veterans Affairs, Agency for Healthcare Research and Quality, and the National Institute of Dental and Craniofacial Research. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Unadjusted Annual Ratings of VA Community Care Experiences for Veterans With and Without Mental Health Condition (MHC) by Survey Domain, 2016-2021
Estimates from the VA Survey of Healthcare Experiences of Patients–Community Care Survey (SHEP-CCS). Estimates weighted using SHEP survey weights. Each panel represents ratings of community care in a particular domain. Domain scores calculated as the equally weighted average of the respondent’s ratings for items under the specified domain (transformed onto a consistent 0 to 100-point scale). Higher scores indicate greater satisfaction with care. FY indicates federal fiscal year.
Figure 2.
Figure 2.. Adjusted Differences in Experiences With VA Community Care for Veterans With vs Without Mental Health Condition (MHC) by Survey Domain, 2016-2021
Plots show the differences in Survey of Healthcare Experiences of Patients–Community Care Survey (SHEP-CCS) survey domain score ratings, of community care experiences of veterans with and without MHC. Estimates use pooled data from 2016 to 2021. Adjusted difference estimated from a respondent-level linear regression model that estimated each domain score as a function of MHC, adjusting for covariates and year fixed effects. Adjusted differences are linear differences on a 100-point scale. Estimates weighted using SHEP-CCS survey weights. Bars indicate 95% CIs. Model 1 is adjusted for demographics and type of community care received. Model 4 is adjusted for demographics; type of community care received; health status; geography; and factors related to socioeconomic status, insurance, and disability. Estimates from Models 2 and 3 are shown in eFigure 2 in Supplement 1.
Figure 3.
Figure 3.. Adjusted Marginal Probability Differences for Positive and Negative Experiences With VA Community Care in Veterans With vs Without Mental Health Condition (MHC) by Survey Domain, 2016-2021
Plots show adjusted marginal differences in the probability that veterans with MHC report positive or negative community care experiences, relative to veterans without MHC. Estimates use pooled data from 2016 to 2021. Estimates from a respondent-level logistic regression model that estimated positive or negative ratings as a function of MHC, adjusting for covariates and year fixed effects. Marginal effects are reported, which reflect the difference in the probability (0-100 percentage point scale) of reporting positive or negative experiences between veterans with vs without MHC. Bars indicate 95% CIs. Positive experiences defined as ratings equal to or higher than the 90th percentile of the domain score distribution (among all Survey of Healthcare Experiences of Patients-Community Care Survey [SHEP-CCS] survey respondents in our sample and study years). Negative experiences defined as ratings equal to or lower than the 10th percentile of the distribution of the domain score (among all SHEP-CCS survey respondents in our sample and study years). Model 1 is adjusted for demographics and type of community care received. Model 4 is adjusted for demographics; type of community care received; health status; geography; and factors related to socioeconomic status, insurance, and disability. Estimates from models 2 and 3 are shown in eFigure 2 in Supplement 1.
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References

    1. Trivedi RB, Post EP, Sun H, et al. . Prevalence, comorbidity, and prognosis of mental health among US veterans. Am J Public Health. 2015; 105(12):2564-2569 doi:10.2105/AJPH.2015.302836 - DOI - PMC - PubMed
    1. Trivedi RB, Post EP, Piegari R, et al. . Mortality among veterans with major mental illnesses seen in primary care: results of a national study of veteran deaths. J Gen Intern Med. 2020;35(1):112-118. doi:10.1007/s11606-019-05307-w - DOI - PMC - PubMed
    1. Vance MC, Wiitala WL, Sussman JB, Pfeiffer P, Hayward RA. Increased cardiovascular disease risk in veterans with mental illness. Circ Cardiovasc Qual Outcomes. 2019;12(10):e005563. doi:10.1161/CIRCOUTCOMES.119.005563 - DOI - PubMed
    1. Frayne SM, Halanych JH, Miller DR, et al. . Disparities in diabetes care: impact of mental illness. Arch Intern Med. 2005;165(22):2631-2638. doi:10.1001/archinte.165.22.2631 - DOI - PubMed
    1. Druss BG, Bradford WD, Rosenheck RA, Radford MJ, Krumholz HM. Quality of medical care and excess mortality in older patients with mental disorders. Arch Gen Psychiatry. 2001;58(6):565-572. doi:10.1001/archpsyc.58.6.565 - DOI - PubMed

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