Access to Pain Care From Compensation Clinics: A Relational Coordination Perspective
Background: The Compensation and Pension (C&P) determination process is a potential gateway to accessing pain treatment in the Veterans Health Administration (VHA). However, attitudes about C&P as a gateway and about collaboration with C&P clinics among VHA staff are unknown.
Methods: In preparation for an initiative to link veterans seeking compensation for musculoskeletal disorders to treatment, clinical and administrative staff from the 8 VHA medical centers in New England were invited to complete a relational coordination survey that examined how different workgroups collaborate (communication and relationships) to provide pain care to veterans. A subset of those staff also participated in a semistructured interview about pain treatment referral practices within their medical centers. VHA staff were from primary care, administration, pain management, and C&P teams.
Results: Eighty-three VHA staff were invited to complete the relational coordination survey; 66 completed the survey and 39 participated in the semistructured interview. Most C&P staff interviewed thought of the compensation examination as a forensic process and that C&P-based efforts to engage veterans might interfere with the examination or were not their responsibility. However, some examiners described their efforts to determine new veterans’ eligibility for VHA care and to connect them to specific treatments. VHA staff reported that there was little communication between the C&P team and other teams. The survey results supported this finding. The C&P group’s relational coordination composite scores were lower than any other workgroup.
Conclusion: Outreach to veterans at New England C&P clinics was inconsistent, and C&P teams rated low on a measure of coordination with workgroups involved in pain treatment. Compensation examinations appear to be underused opportunities to help veterans access treatment. C&P-based treatment engagement is feasible; it is being done by some Compensation teams.
The interview data suggest that one reason the C&P teams had low relational coordination scores is that VA staff interpret the emphasis on evaluative rather than therapeutic examinations to preclude other attempts to engage veterans into VHA treatment, even though such treatment engagement is permitted within existing guidelines. VBA referrals for examinations say nothing, either way, about engaging veterans in VHA care. The relational coordination results suggest that an intervention that might increase treatment referrals from the C&P clinics would be to explain the (existing) policy allowing for outreach around the time of compensation examinations to VHA staff so this goal is clearly agreed-upon. Another approach to facilitating treatment engagement at the C&P examination is to use other interventions that have been associated with better relational coordination such as intergroup meetings, horizontal integration more generally, and an atmosphere is which people from different backgrounds feel empowered to speak frankly to each other.15,18,19 An important linkage to forge is between C&P teams and the administrative workgroups responsible for verifying a veteran’s eligibility for VHA care and enrolling eligible veterans in VHA treatment. Having C&P clinicians who are familiar with the eligibility and treatment engagement processes would facilitate providing that information to veterans, without compromising the evaluative format of the compensation examination.
An interesting ancillary finding is that relational coordination ratings by members of 3 of the 4 workgroups were higher than ratings by other staff of that workgroup. A possible explanation for this finding is that workgroup members are more aware of the relational coordination efforts made by their own workgroup than those by other workgroups, and therefore rate their own workgroup higher. This also might be part of a broader self-aggrandizement heuristic that has been described in multiple domains.20 Staff may apply this heuristic in reporting that their staff engage in more relational coordination, reflecting the social desirability of being cooperative.
There are simple facility-level interventions that would facilitate veterans access to care such as conducting C&P examinations for potentially treatment-eligible veterans at VHA facilities (vs conducted outside VHA) and having access to materials that explain the treatment options to veterans when they check in for their compensation examinations. The approach to C&P-based treatment engagement that was successfully employed in 2 clinical trials involved having counselors not connected with the C&P clinic contact veterans around the time of their compensation examination to explain VA treatment options and motivate veterans to pursue treatment.8,9 This independent counselor approach is being evaluated in a larger study.
Limitations
These data are from a small number of VA staff evaluating veterans in a single region of the US. They do not show causation, and it is possible that relational coordination is not necessary for referrals from C&P clinics. Relational coordination might not be necessary when referral processes can be simply routinized with little need for communication.11 However, other analyses in these clinics have found that pain treatment referrals in fact are not routinized, with substantial variability within and across institutions. Another possibility is that features that have been associated with less relational coordination, such as male gender and medical specialist guild, were disproportionately present in C&P clinics compared to the other clinics.21
