Effect of the Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act Scribes Trial on Emergency Department Provider Productivity and Patient Throughput Times.

BACKGROUND: To help improve access to care, section 507 of the VA MISSION (Maintaining Internal Systems and Strengthening Integrated Outside Networks) Act of 2018 mandated a 2-year trial of medical scribes in the Veterans Health Administration (VHA). OBJECTIVE: The impact of scribes on provider productivity and patient throughput time in VHA emergency departments (EDs) was evaluated. METHODS: A clustered randomized trial was designed using intent-to-treat difference-in-differences analysis. The intervention period was from June 30, 2020 to July 1, 2022. The trial included six intervention and six comparison ED clinics. Two ED providers who volunteered to participate in the trial were assigned two scribes each. Scribes assisted providers with documentation and visit-related activities. The outcomes were provider productivity and patient throughput time per clinic-pay period. RESULTS: Randomization to intervention resulted in decreased provider productivity and increased patient throughput time. In adjusted regression models, randomization to scribes was associated with a decrease of 8.4 visits per full-time equivalent (95% confidence interval [CI] 12.4-4.3; p < 0.001) and 0.5 patients per day per provider (95% CI 0.8-0.3; p < 0.001). Intervention was associated with increases in length of stay of 29.1 min (95% CI 21.2-36.9 min; p < 0.001), 6.3 min in door to doctor (95% CI 2.9-9.6 min; p < 0.001), 19.5 min in door to disposition (95% CI 13.2-25.9 min; p < 0.001), and 13.7 min in doctor to disposition (95% CI 8.8-18.6 min; p < 0.001). CONCLUSIONS: Scribes were associated with decreased provider productivity and increased patient throughput time in VHA EDs. Although scribes may have contributed to improvements in other dimensions of quality, further examination of the ways in which scribes were used is advisable before widespread adoption in VHA EDs.

Effect of a National VHA Medical Scribe Pilot on Provider Productivity, Wait Times, and Patient Satisfaction in Cardiology and Orthopedics.

BACKGROUND: Section 507 of the VA MISSION Act of 2018 mandated a 2-year pilot study of medical scribes in the Veterans Health Administration (VHA), with 12 VA Medical Centers randomly selected to receive scribes in their emergency departments or high wait time specialty clinics (cardiology and orthopedics). The pilot began on June 30, 2020, and ended on July 1, 2022. OBJECTIVE: Our objective was to evaluate the impact of medical scribes on provider productivity, wait times, and patient satisfaction in cardiology and orthopedics, as mandated by the MISSION Act. DESIGN: Cluster randomized trial, with intent-to-treat analysis using difference-in-differences regression. PATIENTS: Veterans using 18 included VA Medical Centers (12 intervention and 6 comparison sites). INTERVENTION: Randomization into MISSION 507 medical scribe pilot. MAIN MEASURES: Provider productivity, wait times, and patient satisfaction per clinic-pay period. KEY RESULTS: Randomization into the scribe pilot was associated with increases of 25.2 relative value units (RVUs) per full-time equivalent (FTE) (p < 0.001) and 8.5 visits per FTE (p = 0.002) in cardiology and increases of 17.3 RVUs per FTE (p = 0.001) and 12.5 visits per FTE (p = 0.001) in orthopedics. We found that the scribe pilot was associated with a decrease of 8.5 days in request to appointment day wait times (p < 0.001) in orthopedics, driven by a 5.7-day decrease in appointment made to appointment day wait times (p < 0.001), and observed no change in wait times in cardiology. We also observed no declines in patient satisfaction with randomization into the scribe pilot. CONCLUSIONS: Given the potential improvements in productivity and wait times with no change in patient satisfaction, our results suggest that scribes may be a useful tool to improve access to VHA care. However, participation in the pilot by sites and providers was voluntary, which could have implications for scalability and what effects could be expected if scribes were introduced to the care process without buy-in. Cost was not considered in this analysis but is an important factor for future implementation. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04154462.

Payer shifting after expansions in access to private care among veterans.

OBJECTIVE: To investigate whether expanded access to Veterans Affairs (VA)-purchased care increased overall utilization or induced a shift from other payers to VA for emergency care among VA enrollees. DATA SOURCES AND STUDY SETTING: This study included all emergency department (ED) encounters in 2019 from hospitals in the state of New York. STUDY DESIGN: We conducted a difference-in-differences analysis comparing VA enrollees to the general population before and after the implementation of the Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act in June 2019. DATA COLLECTION/EXTRACTION METHODS: We included all ED visits with individuals aged 30 or older at the time of the encounter. Individuals were considered eligible for the policy change if they were enrolled with VA at the beginning of 2019. PRINCIPAL FINDINGS: Of the 5,577,199 ED visits in the sample, 4.9% (n = 253,799) were made by VA enrollees. Of these, 44.9% of visits were paid by Medicare, 32.8% occurred in VA facilities, and 7% were paid by private health insurance. There was a 6.4% (2.91 percentage points; std. error = 0.18; p < 0.01) decrease in the proportion of ED visits paid by Medicare among VA enrollees relative to the general population after the implementation of the MISSION Act in June 2019. This decrease was larger for ED visits with a subsequent inpatient admission (-8.4%; 4.87 percentage points; std. error = 0.33; p < 0.01). There was no statistically significant change in the total volume of ED visits (0.06%; std. error = 0.08; p = 0.45). CONCLUSIONS: Leveraging a novel dataset, we demonstrate that MISSION Act implementation coincided with a shift in the financing of non-VA ED visits from Medicare to VA without any increase in overall ED utilization. These findings have important implications for VA health care financing and delivery.

VA Outreach Is an Essential Area for Improving Veterans' Health Care Accessibility.

INTRODUCTION: The Veterans Health Administration (VHA) is tasked with providing access to health care to veterans of military service. However, many eligible veterans have either not yet enrolled or underutilized VHA services. Further study of barriers to access before veterans enroll in VHA care is necessary to understand how to address this issue. The ChooseVA (née MyVA Access) initiative aims to achieve this mission to improve veterans' health care access. Although veteran outreach was not specifically addressed by the initiative, it is a critical component of improving veterans' access to health care. Findings from this multisite evaluation of ChooseVA implementation describe sites' efforts to improve VHA outreach and veterans' experiences with access. MATERIALS AND METHODS: This quality improvement evaluation employed a multi-method qualitative methodology, including 127 semi-structured interviews and 81 focus groups with VHA providers and staff ("VHA staff") completed during 21 VHA medical center facility site visits between July and November 2017 and 48 telephone interviews with veterans completed between May and October 2018. Interviews and focus groups were transcribed and analyzed using deductive and inductive analysis to capture challenges and strategies to improve VHA health care access (VHA staff data), experiences with access to care (veteran data), barriers and facilitators to care (staff and veteran data), contextual factors, and emerging categories and themes. We developed focused themes describing perceived challenges, descriptions of VHA staff efforts to improve veteran outreach, and veterans' experiences with accessing VHA health care. RESULTS: VHA staff and veteran respondents reported a lack of veteran awareness of eligibility for VHA services. Veterans reported limited understanding of the range of services offered. This awareness gap served as a barrier to veterans' ability to successfully access VHA health care services. Veterans described this awareness gap as contributing to delayed VHA enrollment and delayed or underutilized health care benefits and services. Staff focused on community outreach and engaging veterans for VHA enrollment as part of their efforts to implement the ChooseVA access initiative. Staff and veteran respondents agreed that outreach efforts were helpful for engaging veterans and facilitating access. CONCLUSIONS: Although efforts across VHA programs informed veterans about VHA services, our results suggest that both VHA staff and veterans agreed that missed opportunities exist. Gaps include veterans' lack of awareness or understanding of VHA benefits for which they qualify for. This can result in delayed access to care which may negatively impact veterans, including those separating from the military and vulnerable populations such as veterans who experience pregnancy or homelessness.

Enhancing the e-consult: empowering efficient and collaborative care.

This editorial provides suggestions for improving the process of e-consults, which are a promising method of expanding access to specialty care.

Pre-endoscopy coronavirus disease 2019 screening and severe acute respiratory syndrome coronavirus-2 nucleic acid amplification testing in the Veterans Affairs healthcare system: clinical practice patterns, outcomes, and relationship to procedure volume.

BACKGROUND AND AIMS: The coronavirus disease 2019 (COVID-19) pandemic has had profound impacts worldwide, including on the performance of GI endoscopy. We aimed to describe the performance and outcomes of pre-endoscopy COVID-19 symptom and exposure screening and severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) nucleic acid amplification testing (NAAT) across the national Veterans Affairs healthcare system and describe the relationship of SARS-CoV-2 NAAT use and resumption of endoscopy services. METHODS: COVID-19 screening and NAAT results from March 2020 to April 2021 were analyzed to determine use, performance characteristics of screening, and association between testing and endoscopic volume trends. RESULTS: Of 220,891 completed endoscopies identified, 115,890 (52.5%) had documented preprocedure COVID-19 symptom and exposure screenings and 154,127 (69.8%) had preprocedure NAAT results within 7 days before scheduled endoscopy. Of 131,894 total canceled endoscopies, 26,475 (20.1%) had screening data and 28,505 (21.6%) had SARS-CoV-2 NAAT results. Overall, positive NAAT results were reported in 1.8% of all individuals tested and in 1.3% of those who screened negative. Among completed and canceled endoscopies, COVID-19 screening had a 34.6% sensitivity (95% confidence interval [CI], 32.4%-36.8%) and 96.4% specificity (95% CI, 96.2%-96.5%) when compared with NAAT. COVID-19 screening had a positive predictive value of 15.0% (95% CI, 14.0%-16.1%) and a negative predictive value of 98.7% (95% CI, 98.7%-98.8%). There was a very weak correlation between monthly testing and monthly endoscopy volume by site (Spearman rank correlation coefficient = .09). CONCLUSIONS: These findings have important implications for decisions about preprocedure testing, especially given breakthrough infections among vaccinated individuals during the SARS-CoV-2 delta and omicron variant surge.

Common Ground: Primary Care and Specialty Clinicians' Perceptions of E-Consults in the Veterans Health Administration.

OBJECTIVE: The US Department of Veterans Affairs (VA) introduced electronic consultation (e-consult) to increase access to specialty care. The objective of this study was to understand perceptions of e-consults that may be relevant to increasing adoption in the VA. METHODS: Deductive and inductive content analysis of semistructured qualitative telephone interviews with VA primary care practitioners (PCPs), specialists, and specialty division chiefs was performed. Participants were identified based on rates of e-consult in 2016 at the individual and facility level within primary care, hematology, cardiology, gastroenterology, and endocrinology. Interview guide development was informed by the Practical, Robust, Implementation, and Sustainability (PRISM) framework. RESULTS: We interviewed 35 PCPs and 25 specialists working in 36 facilities. Four themes emerged across both PCPs and specialists: (1) e-consults are best suited for certain types of clinical questions; (2) high-quality e-consults include complete background information from the requesting clinician and clear diagnostic or treatment recommendations from the responding clinician; (3) PCPs and specialists perceive e-consults as a novel opportunity to provide efficient, transparent care; and (4) lack of awareness of e-consults hinders adoption despite obvious benefits. CONCLUSIONS: We identified themes that are informative for further adoption of high-quality e-consults in the VA. Educating PCPs and specialty practitioners about the benefits of e-consults, and providing support, such as lists of specialties available for e-consults at the facility are 2 such practices.

Staff Experiences with a Team-based Approach to Sleep Medicine Referrals: A Qualitative Evaluation.

Rationale: Sleep disorders are highly prevalent, and the volume of referrals sent to sleep specialists frequently exceeds their capacity. To manage this demand, we will need to consider sustainable strategies to expand the reach of our sleep medicine workforce. The Referral Coordination Initiative (RCI) takes a team-based approach to streamlining care for new specialty care referrals by 1) incorporating registered nurses into initial decision-making, 2) integrating administrative staff for coordination, and 3) sharing resources across facilities. Although prior work shows that the RCI can improve access to sleep care, we have a limited understanding around staff experiences and perspectives with this approach. Objectives: To assess staff experiences with a team-based approach to sleep medicine referrals. Methods: From June 2019 to September 2020, we conducted semistructured interviews with staff members who interacted with the RCI in sleep medicine. We recruited a variety of staff, including RCI team members (nurses and medical support assistants), sleep specialists, and referring providers. Two analysts used content analysis to identify themes. Results: We conducted 48 interviews among 35 unique staff members and identified six themes: 1) efficiency, in which staff described the impacts of the RCI program regarding efficient use of staff time and resources; 2) patient access and experience, in which staff noted improvements to patients' ability to receive care; 3) staff well-being and satisfaction, in which specialists and RCI staff described how the RCI mitigated the adverse impact of triage volume on staff well-being; 4) sharing specialty knowledge, in which nurses and specialists discussed the challenges of sharing specialty knowledge and training nurses to triage; 5) nurse autonomy, in which staff discussed nurses' ability to make triage decisions in the RCI system and highlighted the crucial role that decision support tools play in supporting that autonomy; and 6) coordination and communication, in which staff noted the importance, challenges, and facilitators of coordination and communication across facilities and at the interface of primary and specialty care. Conclusions: Staff endorsed positive and negative experiences around the RCI system, identifying opportunities to further streamline the referral process in support of access, patient experience, and staff well-being.

Design and implementation of a cluster randomized trial measuring benefits of medical scribes in the VA.

BACKGROUND: Medical scribes are trained professionals who assist health care providers by administratively expediting patient encounters. Section 507 of the MISSION Act of 2018 mandated a 2-year study of medical scribes in VA Medical Centers (VAMC). This study began in 2020 in the emergency departments and specialty clinics of 12 randomly selected VAMCs across the country, in which 48 scribes are being deployed. METHODS: We are using a cluster randomized trial to assess the effects of medical scribes on productivity (visits and relative value units [RVUs]), wait times, and patient satisfaction in selected specialties within the VA that traditionally have high wait times. Scribes will be assigned to emergency departments and/or specialty clinics (cardiology, orthopedics) in VAMCs randomized into the intervention. Remaining sites that expressed interest but were not randomized to the intervention will be used as a comparison group. RESULTS: Process measures from early implementation of the trial indicate that contracting may hold an advantage over direct hiring in terms of reaching staffing targets, although onboarding contractor scribes has taken somewhat longer (from job posting to start date). CONCLUSIONS: Our evaluation findings will provide insight into whether scribes can increase provider productivity and decrease wait times for high demand specialties in the VA without adversely affecting patient satisfaction. IMPLICATIONS: As a learning health care system, this trial has great potential to increase our understanding of the potential effects of scribes while also informing a real policy problem in high wait times and provider administrative burdens.

Defining Access Management in Health Care Delivery Organizations.

Managing patient access to care in health care delivery organizations is instrumental in shaping patient experiences. We convened an inclusive stakeholder panel, informed by evidence, to understand the dimensions and establish definitions of access and access management. The literature varies in access definitions, but the temporal measure "time to third next available appointment" was consistently used as an indicator of access. Panel deliberations highlighted the importance of patient-centeredness and resulted in comprehensive definitions for access management, optimal access management, and optimal access. Health care organizations and researchers can use the developed definitions and concepts as starting points for initiatives to improve access management.

Patient experiences with telehealth in sleep medicine: a qualitative evaluation.

STUDY OBJECTIVES: The field of sleep medicine has been an avid adopter of telehealth, particularly during the COVID-19 pandemic. The goal of this study was to assess patients' experiences receiving sleep care by telehealth. METHODS: From June 2019 to May 2020, the authors recruited a sample of patients for semi-structured interviews, including patients who had 1 of 3 types of telehealth encounters in sleep medicine: in-clinic video, home-based video, and telephone. Two analysts coded transcripts using content analysis and identified themes that cut across patients and categories. RESULTS: The authors conducted interviews with 35 patients and identified 5 themes. (1) Improved access to care: Patients appreciated telehealth as providing access to sleep care in a timely and convenient manner. (2) Security and privacy: Patients described how home-based telehealth afforded them greater feelings of safety and security due to avoidance of anxiety-provoking triggers (eg, crowds). Patients also noted a potential loss of privacy with telehealth. (3) Personalization of care: Patients described experiences with telehealth care that either improved or hindered their ability to communicate their needs. (4) Patient empowerment: Patients described how telehealth empowered them to manage their sleep disorders. (5) Unmet needs: Patients recognized specific areas where telehealth did not meet their needs, including the need for tangible services (eg, mask fitting). CONCLUSIONS: Patients expressed both positive and negative experiences, highlighting areas where telehealth can be further adapted. As telehealth in sleep medicine continues to evolve, the authors encourage providers to consider these aspects of the patient experience. CITATION: Donovan LM, Mog AC, Blanchard KN, et al. Patient experiences with telehealth in sleep medicine: a qualitative evaluation. J Clin Sleep Med. 2021;17(8):1645-1651.

The Focus They Deserve: Improving Women Veterans' Health Care Access.

PURPOSE: Veterans Health Administration (VHA) initiatives aim to provide veterans timely access to quality health care. The focus of this analysis was provider and staff perspectives on women veterans' access in the context of national efforts to improve veterans' access to care. METHODS: We completed 21 site visits at Veterans Health Administration medical facilities to evaluate the implementation of a national access initiative. Qualitative data collection included semistructured interviews (n = 127), focus groups (n = 81), and observations with local leadership, administrators, providers, and support staff across primary and specialty care services at each facility. Deductive and inductive content analysis was used to identify barriers, facilitators, and contextual factors affecting implementation of initiatives and women veterans' access. RESULTS: Participants identified barriers to women veterans' access and strategies used to improve access. Barriers included a limited availability of providers trained in women's health and gender-specific care services (e.g., women's specialty care), inefficient referral and coordination with community providers, and psychosocial factors (e.g., childcare). Participants also identified issues related to childcare and perceived harassment in medical facility settings as distinct access issues for women veterans. Strategies focused on increasing internal capacity to provide on-site women's comprehensive care and specialty services by streamlining provider training and credentialing, contracting providers, using telehealth, and improving access to community providers to fill gaps in women's services. Participants also highlighted efforts to improve gender-sensitive care delivery. CONCLUSIONS: Although some issues affect all veterans, problems with community care referrals may disproportionately affect women veterans' access owing to a necessary reliance on community care for a range of gender-specific services.

Cost savings associated with electronic specialty consultations.

OBJECTIVES: Electronic consultations, or e-consults, between primary care providers and specialists have been shown to improve access to specialty care, shorten wait times, and reduce outpatient visits. The objective of this study was to evaluate differences in health care costs between patients who received an electronic specialty consultation and patients who received a face-to-face specialty consultation. STUDY DESIGN: Retrospective cohort evaluation of patients who received a specialty consultation in the Veterans Health Administration during 2016. METHODS: Patients who received an e-consult were matched 1:1 to patients who received a face-to-face consultation using propensity scores. Total, outpatient, and inpatient health care costs over 3 and 6 months following the specialty consultation were compared using a generalized linear model with a gamma distribution and log link. RESULTS: e-Consults accounted for 1.8% (urology) to 9.6% (hematology) of specialty consultations, on average. Across 11 specialties, patients receiving an e-consult had significantly lower health care costs compared with patients receiving a face-to-face consultation, ranging from 3.6% (cardiology) to 30.7% (hematology) lower. This was largely driven by differences in outpatient costs. Patients receiving an e-consult had significantly lower outpatient costs for all specialties except cardiology, ranging from 6.9% (endocrinology) to 31.2% (hematology) lower. Three-month inpatient costs among those who received an e-consult were significantly lower only in cardiology (5.2%), nephrology (9.3%), pulmonary (13.0%), and gastroenterology (14.3%). CONCLUSIONS: Electronic specialty consultations are a potential mechanism to reduce health care costs and promote the efficient use of health care resources.

Nurse-led triage of new sleep referrals is associated with lower risk of potentially contraindicated sleep testing: a retrospective cohort study.

BACKGROUND: The volume of specialty care referrals often outstrips specialists' capacity. The Department of Veterans Affairs launched a system of referral coordination to augment our workforce, empowering registered nurses to use decision support tools to triage specialty referrals. While task shifting may improve access, there is limited evidence regarding the relative quality of nurses' triage decisions to ensure such management is safe. OBJECTIVE: Within the specialty of sleep medicine, we compared receipt of contraindicated testing for obstructive sleep apnoea (OSA) between patients triaged to sleep testing by nurses in the referral coordination system (RCS) relative to our traditional specialist-led system (TSS). METHODS: Patients referred for OSA evaluation can be triaged to either home sleep apnoea testing (HSAT) or polysomnography, and existing guidelines specify patients for whom HSAT is contraindicated. In RCS, nurses used a decision support tool to make triage decisions for sleep testing but were instructed to seek specialist oversight in complex cases. In TSS, specialists made triage decisions themselves. We performed a single-centre retrospective cohort study of patients without OSA who were referred to sleep testing between September 2018 and August 2019. Patients were assigned to triage by RCS or TSS in quasirandom fashion based on triager availability at time of referral. We compared receipt of contraindicated sleep tests between groups using a generalised linear model adjusted for day of the week and time of day of referral. RESULTS: RCS triaged 793 referrals for OSA evaluation relative to 1787 by TSS. Patients with RCS triages were at lower risk of receiving potentially contraindicated sleep tests relative risk 0.52 (95% CI 0.29 to 0.93). CONCLUSION: Our results suggest that incorporating registered nurses into triage decision-making may improve the quality of diagnostic care for OSA.

Spreading the Veterans Health Administration's emergency department rapid access clinics (ED-RAC) innovation: Role of champions and local contexts.

BACKGROUND: Champions frequently facilitate change in healthcare, but the literature lacks specificity regarding champion activities and interactions with local contexts. The Veterans' Health Administration (VA) Emergency Department (ED) Rapid Access Clinic (ED-RAC) initiative used champions to spread an innovation aimed at achieving timely specialty follow-up care for ED patients. We assessed the roles champions and local contexts played in successful ED-RAC spread in the initiative's first year. METHODS: Our mixed method formative evaluation included serial questionnaires, fieldnotes from meetings, and champion interviews. We analyzed qualitative data from spread site rapid and non-rapid implementers, assessing champion and contextual factors. RESULTS: Among 24 participating VA sites, 11 were rapid implementers (i.e., implemented ED-RAC in first year), 13 were not. Site champions at rapid sites described crossing multiple organizational units to get tasks accomplished (e.g., gaining buy-in, requesting resources); champions at non-rapid sites experienced inter-departmental communication challenges and competing demands. Champions at rapid and non-rapid sites encountered similar context-related barriers (e.g. scheduling complexities) and facilitators (e.g. enthusiastic buy-in), but differed in leadership and resource barriers. CONCLUSIONS: Identifying site champions was not enough to assure rapid innovation spread. Interdependencies between ED-RAC implementation requirements (e.g., boundary spanning, resources) and champion and contextual factors helped explain variations in progress. IMPLICATIONS: Tailoring spread support to champion and contextual factors may facilitate more rapid spread of innovations.

Competing Demands: Scheduling Challenges in Being Veteran-centric in the Setting of Health System Initiatives to Improve Access.

INTRODUCTION: The Veterans Health Administration's (VHA) history of enhancing Veterans' healthcare access continued in 2016 with the launch of ChooseVA (née: MyVA Access). This initiative was designed to transform the VHA and rapidly increase Veteran's access to care across all the VHA facilities. Relevant to this article include mandates to improve patient-centered scheduling. In prioritizing patient-centered scheduling, the VHA and other large healthcare systems have the paradoxical task of providing health care that meets not only the needs of individual patients but also the collective needs of the population served. To our knowledge, meeting these competing needs has not been explored through the perspectives and experiences of providers and staff implementing patient-centered scheduling practices. MATERIALS AND METHODS: This was a qualitative exploratory study and was sanctioned as quality improvement (and thus exempt from Institutional Review Board review). We conducted visits at 25 VHA facilities. Sites were selected based on rurality, region, and facility access performance ratings. Data collection included semi-structured interviews and focus groups. Key informant participants included local leadership, administrators, providers, and support staff across primary care, specialty care, and mental health service lines. We analyzed transcribed audio recordings using inductive content analysis to identify barriers, facilitators, and contextual factors affecting the implementation of patient-centered scheduling. RESULTS: We conducted 208 individual interviews and focus groups between July and November 2017. Participants expressed dedication to patient-centered approaches to improve access to care for Veterans, stating efforts and challenges to meeting Veterans' needs and preferences. Being Veteran-centric meant accommodating Veterans, with a tension between meeting the needs of one Veteran versus all Veterans, managing expectations of same-day access, and potential hits to performance metrics. Strategies focused on engaging Veterans through education and establishing new expectations while recognizing the differing needs among subgroups receiving VHA care. CONCLUSIONS: Veterans Health Administration staff employed a mission-driven, culturally sensitive approach to meeting the diverse scheduling needs of the Veteran population. While potentially unique to the VHA, it may inform patient-centered scheduling practices for other culturally specific populations in other healthcare systems. Continued efforts to put Veterans at the center of VHA healthcare delivery by engaging them in meaningful ways while honoring their distinct needs are essential. Data are forthcoming on Veterans' perspectives of access, which we hope will further contribute to unfolding understandings of access within the VHA.