Leveraging Patient Education to help improve the patient experience at VA facilities today


  • The Challenge with Veterans Health
  • Focus on Patient Satisfaction
  • Leveraging Patient Education to Impact Patient Experience
  • Promising Solutions

When news came out that a Phoenix, Arizona Veterans’ hospital had been falsifying information about patient appointment wait times1, accusations and denials went flying.

How could this have happened? How could it be fixed? Why hadn’t we known sooner?.

Issues Surrounding Access

The issues surrounding access to care for our veteran populations are not new, but the tools at our disposal to mitigate or reframe the problem are. While the secretary of Veteran Affairs, David Shulkin, has promised to reengineer the VA Health Information Exchange and hire upwards of 17,000 VA employees2, more immediate and cost-effective measures can be taken today to support and care for our most vulnerable veterans.

In this paper, we will discuss how patient education and engagement can dramatically affect veteran patient experiences, in both VA hospitals and clinics and aid in reducing clinical workflow bottlenecks and patient dissatisfaction. While the need for veteran access to care remains an urgent and necessary focus of the Department of Veterans Affairs, equally important is the quality and long-term effectiveness of that care. Enter patient education and empowerment, the often overlooked opportunity to provide support and resources to patients where and when they can most benefit from it.

“I have to get there an hour early so I have time to get to my appointment from where I have to park, and then once I get there, not all elevators go to the same spot. I still get lost, even though I’ve been coming here for years,” says a Beau Hardy of Memphis, TN, who suffers from chronic pain & PTSD."

Beyond the difficulty of booking an appointment, our most vulnerable veterans struggle with physically accessing facilities that are often maze-like and lacking in parking options. “I have to get there an hour early so I have time to get to my appointment from where I have to park, and then once I get there, not all elevators go to the same spot. I still get lost, even though I’ve been coming here for years,” says a Beau Hardy of Memphis, TN, who suffers from chronic pain & PTSD. Speaking to veterans from Salt Lake City to Philadelphia, a picture of chronic logistical frustration begins to emerge. “They tell me I’m in the wrong spot, but then don’t help me get to where I’m going. It makes me so mad sometimes,” says another, unnamed, Memphis veteran. The VA’s response, naturally, is to seek to improve design and expand facility footprints, with project timelines that can stretch into decades, while sick veterans continue to feel ignored.

In the absence of an architectural solution, something as simple as managing expectations and empowering patients to have a better understanding and sense of control over their situation can help improve satisfaction and overall perception of quality of care.

According to the narrow way in which patient education is defined today, there may not seem to be a digital solution to a wayfinding issue, but with an on-demand patient education platform and sophisticated customization services, Mr. Hardy and the millions of veterans like him, are just a shift in mindset away from receiving tools that help them feel more in control of their health. No new buildings, no valets hired, just an email that allows our veterans to feel prepared, cared for, and reassured: “I just want to feel like someone is paying attention,” says Mr. Hardy.

“I just want to feel like someone is paying attention,” says Mr. Hardy.

While VAs are working to reduce wait times, focusing on ways to turn waiting room experiences into an engagement opportunity can improve the overall experience. Veterans often wait two, three, four hours to receive care. “I get so bored, I read smoking cessation pamphlets even though I don’t even smoke,” says Mr. Hardy. There are three or four televisions on always, with programming that often feels unrelated to the needs and interests of the patient population. Using these screens to share relevant information about the facility or direct them to resources to help them prepare for their appointment is a simple approach to turning wait times into a meaningful engagement.

In the latest Building on Excellence document released by the Department of Veterans Affairs, it states “veteran satisfaction is now our principle index for assessing access.” 4 If that is the case, there needs to be a major shift in perspective from comparing relative length of wait times as a measure of success, to using a comprehensive patient education solution and communication touch points, alongside existing metrics as a benchmark, for patient experience improvement.

Beyond logistical mystification and wait-time frustrations, clinical confusion remains a barrier to patient satisfaction and improved outcomes. Veterans are still being given clinical information in outdated, overwhelming formats. “How am I supposed to understand the side-effects of my new medication when I am given six pages of single-spaced instructions to weed through? I was told to call the number on the handout with any questions, but all I got was a recorded answer.” says a Pittsburg veteran.

Secretary Shulkin promised more responsiveness at his confirmation hearing5, but veterans are still trying to parse out which part of pre-recorded instructions apply to them when calling hotlines for help or clarification. Again, Shulkin’s department has an ambitious plan to improve access to care management, but tangible results to structural change in an organization as massive as the VA are likely still years away. For today’s suffering veterans, how can they understand how their medication works and next steps in their care, when patient instructions continue to be long, often generic and confusing, inventories of possible side effects?

“Video can be a valuable tool for patient activation and to demonstrate a concept that is difficult to put into words. There can be a lot of valuable information in video that typically is remembered completely and in order. Printed media – like checklists and action plans – is a strong adjunct particularly when it is patient-specific. Together, mixed-media education and instruction tailored to the patient can best help the veteran in their self-care.” – Marissa Badders, Senior Clinical Advisor, Krames.

“Imagine the big learning curve when admitted for a new diagnosis, especially for chronic conditions like mental health, emphysema, and heart failure. A college semester could be used to educate the patient on self-care. Instead, we have only brief patient encounters, and the hope that the patient can develop rudimentary knowledge and skills with our help though educational materials and coaching.”

Trifecta of Dissatisfaction

To complete the patient experience “trifecta of dissatisfaction,” veterans feel increasingly marginalized in their access to care and in the way their care is administered on-site. In a 2015 study of Truven Health System, performance metrics compared non-VA hospitals with VA facilities. Even though the VA scored higher on most metrics, it was still behind on patient perception of hospital care.6 Changing this perception — which is now the core focus of Secretary Shulkin’s office — will take a lot more than quicker and easier access to care. Due in part to healthcare information guidelines and EHR workflow, veterans report an increasing feeling of marginalization during their care episodes. It is often a struggle to get their doctor’s full attention, as they type detailed notes into their EHRs, and patient questions and concerns are directed to impersonal online documents or print outs.

In fact, according to a study published in the Annals of Internal Medicine, physicians now spend only 27% of their work day speaking with patients.

“I wish they could get all of that administrative junk taken care of before the appointment,” says Mr. Hardy. “It feels like the entire experience is focused patient.” He continues, “even the TVs in the waiting rooms talk about internal news that has no bearing on patients.”

VA’s currently have a huge emphasis on call center availability for scheduling and refills, but very little resources about mental health and primary care. This is progress, but far from sufficient: true care management and coordination initiatives will necessitate aggressive staffing in these areas, or strategic outsourcing to private live care manager services.

Promising Changes in Progress

Many of these issues have plagued the Department of Veterans Affairs for decades, often promising solutions that run afoul of the massive bureaucratic machine behind governmental initiatives. There have, however, been some promising changes with the recent launch of federal programs like MyVa and SAIL (Strategic Analytics for Improvement and Learning) performance measurement systems, as well as VA-specific initiatives that meet the needs of a specific patient population segment.

The core principles of MyVa and SAIL revolve around a commitment to offering multiple points of access to care, added staff and infrastructure, and more robust and transparent performance measurement metrics. All are necessary, but will take years to fully bring to fruition, as long as we continue to think of access to care as something only taking place in a hospital or ambulatory setting. Even telehealth capabilities are not always necessary when, for example, a patient is suffering from symptoms they don’t know are a side effect of a new medication.

This is where quality, targeted, integrated patient education videos can make a profound impact on the patient experience. Unfortunately, video has not yet been recognized as the powerful tool that it is.


On the other hand, locally-focused initiatives have made a noted difference in VA quality of care throughout the country. Those focused on care coordination and education have been particularly successful:7

Boise VA

The Problem

  • Primary care providers’ schedules were full and nursing staff were overwhelmed, leading to delayed care for patients. New patients were difficult to accommodate, and were often “ping ponged” to different service lines. The ER and Urgent Care saw an increased number of non-emergent patients seeking basic care.

The Project

  • Patients were assigned to an RN Care Manager/Provider to evaluate and treat acute system concerns and unstable chronic disease conditions.
  • Clerical associates assisted in triage of patients requiring same day care services who did not have prior appointments, triggering follow up steps for same day appointment scheduling.
  • The hospital incorporated telephone clinics to increase same day access demand and focused on reducing rework.

The Benefits

  • Increased same day access to Veterans without overloading PCP (Same Day Access rates > 90% upon request)
  • Decreased urgent care/emergency room usage at the main facility despite ongoing growth at the clinic.
  • Increased continuity of care.

San Diego VA

The Problem

  • PCPs were faced with an overwhelming workload and cumbersome processes regarding manual management of clinical measures and reminders. Providers spent excessive time on administrative tasks rather than attending to patients.

The Project

  • Development of eScreening, a mobile technology interfacing with Computerized Patient Record System (CPRS) for immediate results documentation. The system allowed for veteran directed reporting of symptoms, timely patient alerts, individualized patient feedback, and monitoring of treatment outcomes.

What is SMART on FHIR?

  • Improved care coordination and business processes
  • Higher Veteran satisfaction rates
  • Improved clinical impact: 75.56% of veterans surveyed said the ability to share patient education resources with a caregiver made them feel more favorable toward their care facility.

Unfortunately, large gaps in care coordination and management remain.

How can VA administrators engage, assist and support their patients with the tools at their disposal today? A simple-to-implement, cost-effective answer that VA clinics and hospitals have been adopting on their own is patient education. Delivered throughout the continuum of care, patient education consists of simple instructions and educational pieces that can be accessed at any point throughout the patient journey. These user-friendly instructions make a significant impact on the quality of care, and further support existing VA initiatives like SAIL and MyVa and quality measures that VAs strive to align with like HEDIS and ORYX.

“Learning about self-care for a chronic illnesses is like going to school,” says Marissa Badders, Senior Clinical Advisor at Krames. “There’s a lot to learn – over a period of time. Learning shouldn’t just happen at discharge. Consistent, personalized education needs to be assigned, distributed and tracked through software – easily accessible throughout the patient’s journey to becoming their own self-care expert.”

As outpatient care grows exponentially, and evolves through more diversified offerings, VA staff and administrators now need more than ever to have consistent, reliable means to communicate and engage with their patients throughout the continuum of care; across all care facilities and at home.

What you need to look for…

  • Resources align with Joint Commission standards and elements of performance.
  • Content is provided in different formats – print, video, live care management to support patient learning styles.
  • Resources are easily accessible 24/7.
  • Delivery is integrated into CPRS to increase ease of assignment, thereby improving staff utilization and supportive of documentation mandates.
  • Resources meet SAIL and support HEDIS® and ORYX® performance and quality measures.
  • Content is engaging and relevant for the patient.

Patient education providers today are more than publishers: they are care coordinators, teachers, education experts trained in different learning styles and compassionate advocates. They consider the patient’s entire eco-system of care and endeavor to provide content specifically crafted for the needs of the patient. They are dedicated to helping healthcare providers improve community health by providing comprehensive point- of-care health and wellness solutions that accurately and efficiently address the education needs of patients, families and caregivers, and supporting hospitals in meeting accreditation to improve overall quality of health care.


Promising Solutions

Krames offers integrated video and print solutions that help engage veterans in any setting. Our solutions include access to an extensive video and print library focused on chronic care, medication management, mental health, stress reduction, health and wellness topics and more. The library includes over 50 Veteran- specific videos. Veterans can self-serve – accessing the library when and where they need it via any smart device. To ensure relevant messaging while on-site, patient room, specialty and outpatient clinic and waiting room TVs can be leveraged to air programming and deliver relevant information.

Our print instruction library over 5,000 illness, procedure, test, medication, device, diet, wellness and lifestyle topics. Printed instructions include specific “next appointment instructions” and a list of all future appointments. Through our proprietary integration technology, these resources can be assigned, delivered and tracked – and automatically documented in the EMR allowing VAs to further leverage these resource by integrating them into education protocols, care plans or pre-appointment messaging.

Educating our veterans on the challenges and opportunities of their specific conditions when, where, and how they need it is key to transforming the VA patient experience into the transformative and healing encounter all veterans deserve.

VA Solutions

Help engage and educate veterans where and when they need it most


1  “After Scandal, Phoenix VA still troubled by long waits,” Washington Post, https://www.washingtonpost. com/news/powerpost/wp/2017/01/11/after-scandal-phoenix-va-still-troubled-by-long-waits-for-medical- care-investigators-say/?utm_term=.4b6f8a98a665 (January 2017)

2  “Building on Excellence,” Department of Veterans Affairs, https://commissiononcare.sites.usa.gov/build- ing-on-excellence-va-depsec-final/ (April 2016)1

3 “How the VA’s ‘Stand Down’ Resolved 56,000-Plus Urgent-Care Consults,” Case Study, http://catalyst.nejm. org/va-stand-down-resolved-56000-plus-urgent-care-consults/ (April 2016)

4 “Building on Excellence,” Department of Veterans Affairs, https://commissiononcare.sites.usa.gov/build- ing-on-excellence-va-depsec-final/ (April 2016)

5 “VA nominee David Shulkin vows faster improvement, more choices for veterans,” USA Today, https:// www.usatoday.com/story/news/politics/2017/02/01/david-shulkin-veterans-affairs-nominee-fast-er-change-more-choice-veterans/97348212/ (February 2017)

6 “Building on Excellence,” Department of Veterans Affairs, https://commissiononcare.sites.usa.gov/ building-on-excellence-va-depsec-final/ (April 2016)

7 Case study results from MyVa Access Governance study, “Building on Excellence,” Department of Veterans Affairs, https://commission- oncare.sites.usa.gov/building-on-excellence-va-depsec-final/ (April 2016)

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