Reasons Older Veterans Use the Veterans Health Administration and Non-VHA Care in an Urban Environment

Background: Older veterans in urban settings rely less on the Veterans Health Administration (VHA) health care, suggesting deficits of access and services for aging veterans. We aimed to identify reasons for VHA and non-VHA use across the health status of older, urban-dwelling veterans. Methods: We examined open-ended responses from 177 veterans who were enrolled in primary care at the Bronx VA Medical Center, used non-VHA care in prior 2 years, and completed baseline interviews in a care coordination trial from March 2016 to August 2017. Using content analysis, we coded and categorized key terms and concepts into an established access framework. This framework included 5 categories: acceptability (relationship, second opinion), accessibility (distance, travel); affordability; availability (supply, specialty care); and accommodation (organization, wait-time). Selfreported health status was stratified by excellent/very good, good, and fair/poor. Results: We were able to categorize the responses of 166 veterans, who were older (>= 75 years, 61%), minority race and ethnicity (77%), and low income (<$25,000/y, 51%). Veterans mentioned acceptability (42%) and accessibility (37%) the most, followed by affordability (33%), availability (25%), and accommodation (11%). With worse self-reported health status, accessibility intensified (excellent/very good, 24%; fair/poor, 46%; P =.031) particularly among minority veterans, while acceptability remained prominent (excellent/very good, 49%; fair/poor, 37%; P =.25). Other categories were mentioned less with no significant difference across health status. Conclusions: Even in an urban environment, proximity was a leading issue with worse health. Addressing urban accessibility and coordination for older, sicker veterans may enhance care for a growing vulnerable VHA population.