Skip to main content

Veterans utilizing a federally qualified health center: a clinical snapshot

Dear Editor,

The Veterans Health Administration (VHA) provides healthcare for over 9 million enrolled veterans with approximately 2.7 million of those residing in rural areas [1]. The MISSION Act of 2018 emphasizes VHA collaboration with Federally Qualified Healthcare Centers (FQHC) to serve rural residing veterans and nearly all existing collaborations involve arrangement of payment for community-based care by VHA to FQHCs. Unfortunately, there is a paucity of descriptive clinical data on existing cross-system collaborations which may help characterize these veterans and aid understanding of conditions for which they may receive treatment across systems. Such data has implications for workforce training, development, and resource allocation [2]. The objective of this report is to describe different clinical profiles between two mutually exclusive samples: veterans engaged in FQHC only use, and VHA-enrolled veterans engaged in dual VHA and FQHC use.

The VHA Office of Rural Health supported a partnership between a Midwest VHA medical center and rural-based FQHC distant from the VHA aiming to systematically identify veterans presenting for care in the FQHC, screen for mental health issues, and initiate care coordination between organizations [3]. Veterans (n = 782) presenting for care in the FQHC were systematically identified at intake; the sample was then divided according to VHA utilization: (1) FQHC only use (n = 433, 55.4%), and (2) VHA and FQHC dual use (n = 349, 44.6%). Limited releases of information enabled access to each system’s administrative databases to obtain demographic characteristics and clinical diagnoses accordingly. All data presented here reflect patients presenting for care between January 1, 2018 to April 1, 2020.

Demographic characteristics by group are shown in Additional file 1: Table S1. The FQHC only group was younger and more often female. Diagnoses by International Classification of Diseases, Tenth Revision (ICD-10) codes revealed conditions frequently encountered in the veteran population with those most common including hypertension, lipid disorders, musculoskeletal disorders, cardiovascular disorders, anxiety disorders, depressive disorders, and diabetes (Table 1). Notably, relative to FQHC only use, dual users had significantly higher frequencies of post-traumatic stress disorder (PTSD), substance use, and sleep disorders; obesity, infectious diseases, and tobacco use disorders were significantly higher for FQHC only use veterans.

Table 1 ICD-10 diagnoses according to group [n(%)]*

This study presents basic descriptive and clinical diagnosis information for two groups of veterans seeking care at VHA and/or a FQHC, respectively. It is also notable that a considerable number of veterans residing in a rural southeast portion of a Midwest state utilizing FQHC services maintained a relationship with VHA care despite a nearly a 60-min travel time.

Table 1 details diagnoses of PTSD, sleep disorders, and substance use conditions which were higher in dual use veterans relative to their FQHC only peers. This suggests that veterans may prefer treatment for these conditions in VHA, perhaps due to considerable mental and behavioral health resources (including expansive telehealth options) and policy mandates regarding wait times in VHA. Veterans may also choose between VHA and non-VHA resources based on geographic distance and/or be service connected, particularly for mental health conditions such as PTSD [4, 5]. This may also be a function of limited access to such care, especially in rural-serving non-VHA clinics which often are low-resource and located in mental health professional shortage areas. FQHC only veterans had higher frequencies of tobacco use disorder, obesity, and infectious diseases which may be related to different methods of screening between systems and/or targeted focus on certain conditions and possibly reflects veterans use of the nearby FQHC for primary care needs (e.g., upper respiratory tract infections were very common). As noted, this FQHC was > 40 miles from the nearest VHA point of care so such utilization is reasonable [5].

Broadly, these findings may inform future VHA-community care partnerships but more research on healthcare utilization is needed as non-enrolled veterans may seek enrollment and obtain access via the MISSION Act. Caution is needed as we were not able to determine distance to the nearest VHA facility or exemption from copayments for VHA care, which are associated with dual use. Moreover, causality for differences in illness patterns between the two systems also should not be inferred. Future partnerships between FQHC and VHA facilities would benefit from efforts to identify non-enrolled veterans presenting for community care who may gain access to specific VHA services such as mental health [2]. Efforts by community-based clinics to increase screening and care specifically for PTSD, substance use, and sleep disorder may also benefit veterans.

Availability of data and materials

Not applicable.

Abbreviations

FQHC:

Federally Qualified Healthcare Centers

ICD-10:

International Classification of Diseases, Tenth Revision

PTSD:

Post-traumatic stress disorder

VHA:

Veterans Health Administration

References

  1. Office of Rural Health. https://www.ruralhealth.va.gov/aboutus/ruralvets.asp. Accessed May 20, 2021.

  2. Howren MB, Kazmerzak D, Kemp RW, Boesen TJ, Capra G, Abrams TE. Identification of military veterans upon implementation of a standardized screening process in a federally qualified health center. J Community Health. 2020;45(3):465–8.

    Article  PubMed  Google Scholar 

  3. Howren MB, Kazmerzak D, Pruin S, Barbaris W, Abrams TE. Behavioral health screening and care coordination for rural veterans in a federally qualified health center. J Behav Health Serv Res. 2022;49(1):50–60.

    Article  PubMed  Google Scholar 

  4. Liu CF, Chapko M, Bryson CL, Burgess JF Jr, Fortney JC, Perkins M, et al. Use of outpatient care in Veterans Health Administration and Medicare among veterans receiving primary care in community-based and hospital outpatient clinics. Health Serv Res. 2010;45(5 Pt 1):1268–86.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Carey K, Montez-Rath ME, Rosen AK, Christiansen CL, Loveland S, Ettner SL. Use of VA and Medicare services by dually eligible veterans with psychiatric problems. Health Serv Res. 2008;43(4):1164–83.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgements

Not applicable.

Disclaimer

The views expressed in this article are those of the authors and do not necessarily represent the position or policy of the Department of Veterans Affairs or United States Government.

Funding

This work was supported in part by an award from the VHA Office of Rural Health, Veterans Rural Health Resource Center—Iowa City (VRHRC-IC), Iowa City VA Health Care System, Iowa City, IA (Award #7345).

Author information

Affiliations

Authors

Contributions

All authors contributed to the study conception and design. BA performed data analysis. The first draft of the manuscript was written by TEA, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Thad E. Abrams.

Ethics declarations

Ethics approval and consent to participate

A human subject’s research determination was submitted to the University of Iowa/VA’s Institutional Review Board; the project was deemed quality improvement (QI) and thus did not require IRB approval.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Additional file 1: Table S1.

Demographics of mutually exclusive samples of veterans accessing VHA and/or FQHC care*

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Abrams, T.E., Alexander, B., Flores, A. et al. Veterans utilizing a federally qualified health center: a clinical snapshot. Military Med Res 9, 18 (2022). https://doi.org/10.1186/s40779-022-00379-y

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s40779-022-00379-y

Keywords

  • Veterans
  • Federally qualified healthcare centers
  • Healthcare utilization
  • Dual use
  • Mental health