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Patient Characteristicis and Eligibility in a Veteran s dm inistration

mb ulatory Care Triage Clinic

JOHN R . FEUSSNER,

M D ,

STEPHANIE L . M CFA LL, P H D , AND WILLIS E . COCKRELL

I I I , M S P H

bstract

We surveyed5 225consecutive patients presenting to

a Veterans Administration (VA) Ambulatory Care Triage Clinic to

ascertain the characteristics of patients and to assess the role of

eligibility iri determining disposition from triage. Most patients (66

per cerit) had non-service connected (low eligibility) conditions and

had no health insurance (64 per cent). Lack of service connected

priority (high eligibility) did not influence access to hospitalization

(8.3 per cent) or longitudinal outpatient care (24.5 per cent). The

stiidy suggests that veterans with no health insurance, with low

eligibility for VA service, use the VA triage clinic for episodic

medical care. {Am J Public Health 1988; 78:1224-1225.)

Introduction

The Veterans Administration (VA) has a complex sys-

tem of entitlement for m edical care determined primarily by

the presence (high eligibility) or absence (low eligibility) of a

service connected disability, but modified by period of

military service and economic means.' Previous research

suggests that lack of heeilth insurance and the presence of a

service connected disability are important determinants of

use ofVAinpatient services.^ However, little is known about

the characteristics of patients seeking medical care in VA

ambulatory care programs, or how eligibility priority influ-

ences access to outpatient care.

Prior to the advent of VA ambulatory care programs in

1973,

the triage clinic functioned as an adm itting office to

determine whether patients required acute hospitalization.

Subseque ntly, triage activities have been redefined to include

not only evalua tion for hosp italization , but also evaluation ifor

placement into general or specialty outpatient clinics, and

episodic evaluation of or treatment forthepresenting inedical

problem. Because of these expanded activities, the triage

clinic has becohie a major access site for patients seeking

mediced care in the VA. The Durham Veterans Administra-

tion Medical Center (VAMC) has over 100,000 outpatient

visits per ye ar; 15 per cen t of visits are to triage, the largest

clinic in our ambulatory care program. We conducted a

prospective survey in our triage clinic to asce rtain the '

characteristics of patients using triage and to assess the role

of service connected priority (high eligibility) in determining

patient disposition.

From the Ambulatory Care Service and the Health Services Research

Field Program of the Durham Veterans Administration Medical Cehter

(VAMC), and the Departments of Medicine and of Community and Family

Medicine, Duke University Medical Center, Durham, NC. Address reprint

requests to John R. Feussner, MD, Director, Region 2 Heaith Services

Research and Development Field Program, VAMC, 508 Fulton Street,

Durham, NC 27705. Dr. Feussner is also an assistant professor with the

Division of Geheral Internal Medicine at Duke Univei-sity Medical Center; Dr.

McFall is currently w ith the Center for Health S ervices and Policy Research,

Northwestern University; Mr. C ockrell is with the Field Program at D urham

VAMC.

This p aper, submitted to the Journal January

27,1987,

was revised and

accepted for publication April 4, 1988.

Methods

The triage process begins with the patient's application

for care. A nurse records presenting complaints, measures

vital signs, and obtains routine tests as appropriate. The

patient then sees a physician (internist) who inquires further

into the patient's history, performs a targeted physical

examination, orders laboratory or radiographic tests if need-

ed, establishes a diagnosis, and initiates treatm ent. While all

veterans are eligible for evaluation of their problems in the

triage clinic, patients with service connected medical prob-

lems have adm inistrative priority to be seen first (except for

the urgently ill) and also have priority for subspecialty

consultations or clinic appointments.

Information was collected prospectively on all patients

attending triage clinic (forafive-monthperiod) with follow-up

data collection for up to seven additional m onths until a final

disposition was made. The sample consisted of 6 360initial

visits hfiade by

5 225

patients. Sociodemographic data includ-

ed age, race, sex, residence, and type of health insurance.

Adm inistrative data included vW eligibility status, period of

service, VA clinics in which tlie patient had appointments

already scheduled, and time since the last visit to the VA. As

many as four presenting com plaints, and problem s identified

and evaluated by the physician, were coded using a modifi-

cation oftheInternational Classification of Health Problem s,

Primary Care.' Information was abstracted from the medical

record within 24 hours of the patient's visit, and all forms

were reviewed within 72 hours for completeness and errors.

In addition, we performed random, periodic review of the

data and verified the eligibility status of all patients with the

VA Regional Office. Dispositions from triage clinic included

hospitalization, admission, to longitudinal care in an outpa-

tient clinic, or denial of further treatment, possibly with

referral to a local physician.

Results \

Patient Characteristics

Overall, 66.0 per cent of patients had non-service con-

nected conditions (low eligibility). Vete rans w ith the highest

priority for VA services included service connec ted veterans

(31.9%

per cent), those receiving aid and attendance or

housebound behefits (.4 per cent), and World W ar I veterans

(1.7 per cent). The majority of patients had only one (69.3 per

cent) or two 20.1per cent) separate visits to the triage clinic,

but 3.3 per cent of patients used the triage clinic four or more

times over the five-month study period. Most triage encoun-

ters involved only the initial triage visit (68.3 per cent) or the

initial visit plus one follow-up Jvisit (26.5 per cent). Service

connected priority did not influence the num ber of visits per

patients, largely determined by|the patient, or the number of

follow-up visits, controlled by imedical personnel.

Table 1 shows the distribution of selected patien t char-

acteristics stratified by eligibility priority. With the exception

of race and period of service (for example, all World War I

veterans are high eligibility), the high and low priority groups

are similar. Almost two-thirds of patients rep orted having no

health insurance 64.0per cent); another28per cent had some

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TABLE 1Demographic and Administrative Characteristics of VA Pa-

tients Stratified by Eilgibiiity C ategory

PUBLIC HEALTH BRIEFS

TABLE 2Disposition of Visits to Triage CUnic by Entitlement Priority*

Patient C haracteristics

Age (XSD) years

Race ( White)

Maie ( )

Period of Servic e ( )

WWI

WWII

Korea

Vietnam

Other

Type ot Health Insurance ( )

None

Private/Group

Medicare/Medicaid

Other

High

(n=1775)

55.3 31.3

73.9

99.2

8.7

48.3

9.7

31.0

66.8

24.6

7.5

0.8

Eiigibility Priority*

Low

(n=3450)

52.8 27.8

65.8

99.2

0

54.5

12.4

30.8

2.3

62.6

29.1

7.5

0.9

Totai

(n=5225)

53.6 28.5

68.5

99.2

3.0

52.3

11.4

30.9

2.3

64.0

27.6

7.5

1.1

Eligibility Priorityt

High

Disposition (n=2177)

Treatment Complete 46.3

Outpatient Clinic 27.8

Consultation Pending 4.6

Hospitai Admission 6.8

Refei-ral to Alterna te Facility 1.5

Other Dispositions * 13,0

Inciudes 6 360visits made by 5 225patients.

tHigh eligibiiity priority inciudes service connected

attendance and housebound benefits, and World War 1

ihdudes veterans with non-service connected conditions.

tinciudes such dispositions as patient ieft the dinic.

toljow-up visits, and visits from active hospital patients.

Low

(n=4183)

48.8

22.9

4.1

9.0

1.3

13.9

Totai

(n=6360)

48.0

24.5

4.3

8.3

1.4

13.5

disability of any level, aid and

veterans. Low eliaihilitv Drioritv

refused appointments, canceled

High eligibility priority includes veterans with service connected disability of any level,

aid and attendance or housebound benefits, and World War veteran s. Low eligibility priority

inclucfes veterans with non-service connected conditions.

form of private insurance; the remainder were covered by

Medicare, Medicaid, or other types of insurance such as

CHAMPUS (Civilian Health & Medical Program of the

Uniformed Services).

Patient Disposition

It is striking that service connected priority played little

role in final disposition from triage (Table 2). Nearly half of

all visits were designated treatm ent com plete, i.e., no further

treatmen t was ordered after the initial encounter. Almost 25

per cent of patients gained access to longitudinal outpatient

care in a general or specialty clinic. Some patients (4.3 per

cent) had a pending consultation at the time data collection

ended. Hospitalization was indicated for 8.3 per cent of

patients who were either admitted acutely, placed on a

waiting list, or scheduled for elective admission. Referrals to

other VAMCs or non-VA hospitals were rare (1.4 per cent).

Discussion

We ascertained the characteristics of veteran patients

presenting to our triage clinic. Most patients were White,

male. World War II or Vietnani War veterans. The majority

of veterans (66.0 per cent) had non-service connected con-

ditions, a low VA eligibility category for outpatient care, and

most had no health insurance (64.0 per cent). The lack of

health insurance appeared to be an important characteristic

of veterans seeking medical care in our ambulatory care

program, as is also the case for VA inpatient care.^ How ever,

unlike hospitalized ve terans , the majority of veterans seeking

access to VA care through the triage clinic were non-service

connected patients (Table 1). These patients, without health

insurance and with low eligibility for outpatient care in the

VA, may have few other options when seeking medical care.

Administrative priority did not influence physician disposi-

tions made from the triage either for hospitalization or

longitudinal outpatient care (Table

2 ,

suggesting that medical

considerations, not VA eligibility priority, influence physi-

cian decisions regarding patient disposition from triage.

However, as VA budgetary resources beconie more con-

strained, triage physicians will have less opportunity to

provide medical care to veterans with non-service conn ected

conditions -'. The impact of reduced VA services on the

health status of these largely uninsured low eligibility veter-

ans,

and their use of alternative comm unity-based sources of

medical care, should be studied.

KNOWLEDGMENTS

This research supported by the Health Information Service, Central

Office, and the Region II Health Services Research and Development Field

Program, Veterans Administration. We are indebted to Drs. Harold Organic,

Chet Davis, Frank Morrone, and Norman Hillar for advice and constructive

criticism during the planning and execution of the project and to Drs. Robert

Ludke arid John Demakis for coriiments oil the draft man uscript. The findings

were presented at the American Public Health Association Annual meeting,

Anaheim, CA, November 1984.

R F R N S

1. FeussnerJR Cockrell WEIII:Medical care and entitlement nthe Veterans

Administration. NC Med J 1983; 44:376-^378.

2.

PageWF :Why veterans choose Veterans Adm inistration hospitalization: A

multivariate model. Med Care 1982; 20:308-320.

3. Bain ST, Spaulding WB: The importance of coding presenting symptoms.

Can Med Assoc J 1967; 97:953-959.

4. Romm FJ, Cockrell WE III, Feussner JR: Veterans Administration and

ambulatory care: The low priority veteran. South Med J 1984; 77:489^

493

5. Horgari CA, Taylor A , Wilensky G: Aging veterans: Will they overwhelm

the VA m edical care system? Health Affairs 1983; 2:77-86.

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