VA Academic Affiliations Matter in the Era of Community Care: A Model From California
Background: The Veterans Health Administration (VHA), 1 of 3 administrative branches in the US Department of Veterans Affairs (VA), is the largest integrated health care system in the United States. The VHA has 4 missions: providing health care to eligible veterans; supporting research to benefit veterans and the larger society; providing education for health care trainees; and supporting emergency response.
Observations : In service of these goals, the VA has academic affiliations with training institutions throughout the country, offering unique and extensive training and research opportunities. These affiliations are a 2-way street where both the VA and the affiliate provide and gain from their partnership. For example, VA affiliations with University of California (UC) medical schools benefit veteran care and are a major contributor to the UC academic mission. This article explores the history of the VA, current veteran demographics and needs, academic affiliations, and the integrated care model of training in all VHA facilities. The VA and UC academic affiliation system is described further with regard to shared research and educational functions.
Conclusions: We identify risks to academic affiliations if a shift occurs from VHA care to VA-managed community-based care following the implementation of recent legislation. We also provide suggestions for VA academic affiliates to help assess and guide the potential impact of increased VA-managed community care.
VHA Resources
The VHA serves more than 9 million veterans through 170 medical centers and 1,074 outpatient care sites.1 In fiscal year 2017, the VA provided 109 million outpatient visits, and treated 615,000 inpatient medicine/surgical patients and 149,000 patients in inpatient mental health.4 The VHA focuses on the distinct concerns of veterans, which arise from military service as well as their broader health care needs. Veterans have higher rates of medical and mental health conditions than those of the general public; different cohorts in this population experience distinct medical and mental health concerns (Table 1).5
In addition, although veterans are disproportionately older men, the population is diversifying.6 For example, the number of female veterans is growing; furthermore, changes in the law now allow lesbian, gay, bisexual, and transgender (LGBT) individuals to serve openly, which has both reduced barriers for this population and allowed for LGBT veterans who were not eligible for VA care due to less than honorable discharges to have those discharges upgraded. As a result, care has been tailored to include the development of Women Veterans Program Managers and related services and LGBT and related identities resources such as LGBT Veteran Care Coordinators in every VA facility nationwide.7,8 The VA continues to adapt to serve all veterans; part of this adaptation is training HCPs to provide veteran-centered care for a growing and diversifying population.
VHA Resources in California
California has the largest population of veterans in the United States (Table 2).9,10 Of the 9,116,200 VA enrollees nationwide, 760,910 (8%) reside in California, and of those, 463,410 had at least 1 VA visit in the past year.3,10 The VHA is organized into 21 Veterans Integrated Service Networks (VISNs) that include multiple health care systems in the region associated with each VISN. California is part of VISN 21 (Northern California, Nevada, and Pacific Islands) and VISN 22 (Southern California, Nevada, and New Mexico). Among veterans who served in the recent Iraq and Afghanistan conflicts, 5.5% accessed care in VISN 21 and 9.3% accessed care in VISN 22.11 The VHA provides critical infrastructure for meeting complex veteran needs, as well as related specialized training, education, and research for HCPs. This specialization has been the basis for the broad system of affiliations between VA and academic systems.
The VA continues to be a high priority in the federal budget process.12 In 2017, slightly more than 9% of the VA health care budget, $6.4 billion, was spent on medical care in California.10 Consequently, California has a noteworthy portion of VA infrastructure (Table 3).13,14 California has 8 VA medical centers (VAMCs) with hospital service (Fresno, Loma Linda, Long Beach, Palo Alto, Sacramento, San Diego, San Francisco, West Los Angeles), 3 VAMCs without hospital service (2 locations in the Palo Alto system and Sepulveda), 1 stand-alone extended-care facility (Martinez Community Living Center), and 1 stand-alone residential care facility (San Diego Domiciliary).9 The vast VA infrastructure in California and large population of veterans creates a strong demand for HCPs in the state.
