BACKGROUND: Congress has enacted 2 major pieces of legislation to improve access to care for Veterans within the Department of Veterans Affairs (VA). As a result, the VA has undergone a major transformation in the way that care is delivered to Veterans with an increased reliance on community-based provider networks. No studies have examined the relationship between VA and contracted community providers. This study examines VA facility directors' perspectives on their successes and challenges building relationships with community providers within the VA Community Care Network (CCN). OBJECTIVES: To understand who VA facilities partner with for community care, highlight areas of greatest need for partnerships in various regions, and identify challenges of working with community providers in the new CCN contract. RESEARCH DESIGN: We conducted a national survey with VA facility directors to explore needs, challenges, and expectations with the CCN. RESULTS: The most common care referred to community providers included physical therapy, chiropractic, orthopedic, ophthalmology, and acupuncture. Open-ended responses focused on 3 topics: (1) Challenges in working with community providers, (2) Strategies to maintain strong relationships with community providers, and (3) Re-engagement with community providers who no longer provide care for Veterans. CONCLUSIONS: VA faces challenges engaging with community providers given problems with timely reimbursement of community providers, low (Medicare) reimbursement rates, and confusing VA rules related to prior authorizations and bundled services. It will be critical to identify strategies to successfully initiate and sustain relationships with community providers.

BACKGROUND: Racial disparities in maternal morbidity and mortality remain a pressing public health problem. Variations in cesarean section (C-section) rates among racial and ethnic groups have been well documented, though reasons for these variations remain unknown. In the Department of Veterans Affairs (VA), nearly half of all women Veterans are of reproductive age and > 40% of these women are racial and ethnic minorities. Because the VA does not provide obstetrical services, all obstetrical care is provided by community obstetrical providers under the auspices of the VA Community Care Network. However, little is known regarding the rates and correlates of C-sections among women Veterans receiving community obstetrical care. OBJECTIVE: To examine predictors of C-section deliveries among a cohort of racially diverse pregnant Veterans enrolled in VA care at 15 VA medical facilities nationwide. RESEARCH DESIGN: Cross-sectional analysis of a longitudinal, prospective, multisite, observational cohort study of pregnant, and postpartum Veterans receiving community-based obstetrical care. RESULTS: Overall, 659 Veterans delivered babies during the study period, and 35% of the deliveries were C-sections. Predictors of C-section receipt included being a woman of color [adjusted odds ratio (AOR), 1.76; 95% confidence interval (CI), 1.19-2.60], having an Edinburgh Postnatal Depression Scale score > /=10 (AOR, 1.71; 95% CI, 1.11-2.65), having a higher body mass indexes (AOR, 1.07; 95% CI, 1.04-1.11), and women who were older (AOR, 1.08; 95% CI, 1.03-1.13). There was a substantial racial variation in C-section rates across our 15 study sites, with C-section rates meeting or exceeding 50% for WOC in 8 study sites. CONCLUSIONS: There is substantial racial and geographic variation in C-section rates among pregnant Veterans receiving obstetrical care through VA community care providers. Future research should carefully examine variations in C-sections by the hospital, and which providers and hospitals are included in VA contracts. There should also be an increased focus on the types of providers women Veterans have access to for obstetrical care paid for by the VA and the quality of care delivered by those providers.

Healthcare safety net providers are under increasing pressure to meet the physical and mental health--as well as the range of social service-needs of traditionally vulnerable and hard-to-reach populations. The extent to which health center patients are less well and in poorer health than is the rest of society, thus requiring greater depth and breadth of service, has not generally been the focus of systematic assessment. This case study uses the 12-Item Short-Form Health Survey (SF-12) and selected years of healthy life questions from the National Health Interview Survey to assess the self-perceived health status of patients at one Section 330 community health center in central Massachusetts. Five hundred thirteen patients completed all questions on the SF-12; 619 completed each of the years of healthy life questions. Respondents' physical and mental component summary scores were significantly lower than national norms for all age groups (P < .001). Respondents were also significantly more likely than the civilian noninstitutionalized population to be unable to perform major activities (P < .0001) and to be in fair or poor health (P < .0001). Analyses give an indication of the magnitude of difference in self-perceived health status between this poor, vulnerable population and the citizenry at large and suggest implications for policy related to safety net healthcare facilities.

BACKGROUND: Obesity is at epidemic proportions. This study examined the extent to which obesity is being diagnosed at a community health center residency-training site. Results were examined by provider type. Characteristics of patients with obesity diagnosed by primary care providers were compared with characteristics of patients determined to be obese by body mass index (BMI) calculation exclusively. METHODS: A cross-sectional design was used. Medical records of 465 adult patients were audited. Data collected included diagnosis of obesity, height and weight, demographics, and comorbidity. RESULTS: Of the 465 patients' charts audited, 83 contained a provider diagnosis of obesity, and 74 additional patients were determined to be obese by BMI calculation exclusively. Significant underdiagnosis occurred among all provider types (P = .036). Patients with a diagnosis of obesity had significantly higher BMI scores (38.4 vs 34.4, P = .002). Obesity was more likely to be diagnosed in female than in male patients (P = .001). Differences related to age, insurance coverage, and comorbidity were not significant. CONCLUSIONS: Obesity was found to be an underdiagnosed condition among all provider types. As evidenced by significantly higher BMI scores for provider-diagnosed obesity, the data suggest that the obesity diagnosis is made by appearance. The importance of teaching and modeling the use of BMI to diagnose obesity is underscored.