QUERI – Quality Enhancement Research Initiative

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Factors Affecting Choice Act Implementation and Quality for Veterans with PTSD

South Texas


Under the Veterans Choice Act, the Veterans Choice Program (VCP) provides primary care, inpatient and outpatient specialty care, and mental healthcare for eligible Veterans when, for various reasons (e.g., long wait times), their local VAMC cannot provide those services. The VCP has faced significant barriers in implementation, including a complex set of rules governing eligibility, a multi-step process for Veterans seeking to access the program, lack of non-VA provider availability, and low provider reimbursement rates. As a result, it remains unclear whether providing community-based care for Veterans reduces wait-times for appointments or is of comparable quality to VA care, particularly for complex conditions such as post-traumatic stress disorder (PTSD). Providers treating patients with PTSD require levels of training and support frequently unavailable outside of VA in order to deliver high-quality care. This multi-disciplinary project will evaluate how effectively VCP implementation is meeting the needs of Veterans with PTSD. This work will be done in collaboration with VA's National Center for PTSD and the Office of Rural Health.


This QUERI evaluation project will compare characteristics and experiences of care for Veterans with PTSD in two states (Texas and Vermont), who report different patterns of VCP eligibility and utilization for PTSD care. Investigators will also assess Veterans' perceived access, quality of care, and satisfaction with the Choice Program, as well as barriers and facilitators to Choice Program use and services received. Other project objectives include:

  • Describing perceptions and experiences of the Choice Program among community providers treating Veterans with PTSD in Texas and Vermont;
  • Identifying factors that predict providers' participation in Choice Program referrals;

  • Assessing variations in appropriateness of PTSD care (e.g., evidence-based prescribing and psychotherapy practices), and
  • Identifying patient-, provider-, and community-level factors associated with utilization of and satisfaction with the Choice Program for Veterans with PTSD.

These data will provide immediate support for VA's efforts to refine ongoing implementation of the Choice Program.


Project investigators will use VA administrative data to identify Veterans who have VA service-connection for PTSD and are living in two states with marked geographic and population diversity - Texas and Vermont. They also will conduct surveys of Veterans as well as community-based mental health and primary care providers. Survey data on outcomes, including access to care, quality, and satisfaction with the Choice Program, will be integrated with Geographic Information Systems (GIS) data to identify patient, provider, and community factors associated with Choice Program participation.

Findings will have immediate relevance for VA operation partners, with products that will include a methodological toolkit to support the ongoing evaluation of VCA implementation.

Impacts: Early findings from this ongoing evaluation indicate that very few Veterans with service-connection for PTSD have benefited from VCP for mental healthcare. Of 73,156 Veterans residing in Texas and 1,416 Veterans residing in Vermont with PTSD service-connection, only 456 had been authorized to use VCP for any care (2 in Vermont), and only 35 of those individuals had been authorized to use VCP for mental healthcare (as of August 31, 2015). Additional findings will be disseminated as they become available.

Operations Partners: VA's National Center for PTSD and the Office of Rural Health.

Principal Investigator: Erin P. Finley, PhD, MPH; contact at Erin.Finley@va.gov .