title: Dual use of veterans health administration and Indian Health Service: healthcare provider and patient perspectives.
abstract: BACKGROUND
  Many American Indian and Alaska Native veterans are eligible for healthcare from Veterans Health Administration (VHA) and from Indian Health Service (IHS). These organizations executed a Memorandum of Understanding in 2003 to share resources, but little was known about how they collaborated to deliver healthcare.
  
  
  OBJECTIVE
  To describe dual use from the stakeholders' perspectives, including incentives that encourage cross-use, which organization's primary care is "primary," and the potential problems and opportunities for care coordination across VHA and IHS.
  
  
  METHODS
  VHA healthcare staff, IHS healthcare staff and American Indian and Alaska Native veterans.
  
  
  METHODS
  Focus groups were conducted using a semi-structured guide. A software-assisted text analysis was performed using grounded theory to develop analytic categories.
  
  
  RESULTS
  Dual use was driven by variation in institutional resources, leading patients to actively manage health-seeking behaviors and IHS providers to make ad hoc recommendations for veterans to seek care at VHA. IHS was the "primary" primary care for dual users. There was little coordination between VHA and IHS resulting in delays and treatment conflicts, but all stakeholder groups welcomed future collaboration.
  
  
  CONCLUSIONS
  Fostering closer alignment between VHA and IHS would reduce care fragmentation and improve accountability for patient care.
authors.affiliation: Geriatric Research Education and Clinical Center, VA Greater Los Angeles Healthcare System, 16111 Plummer Street, Sepulveda, CA 91343, USA. Josea.Kramer@va.gov
authors.forename: B Josea
authors.initials: BJ
authors.lastname: Kramer
authors.forename: Rebecca L
authors.initials: RL
authors.lastname: Vivrette
authors.forename: Delight E
authors.initials: DE
authors.lastname: Satter
authors.forename: Stella
authors.initials: S
authors.lastname: Jouldjian
authors.forename: Leander Russell
authors.initials: LR
authors.lastname: McDonald
mesh_terms: D001291:Attitude of Health Personnel; D005260:Female; D006282:Health Personnel / Q000523:psychology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D017060:Patient Satisfaction; D014481:United States; D014493:United States Department of Veterans Affairs / Q000706:statistics & numerical data*; D016549:United States Indian Health Service / Q000706:statistics & numerical data*; D014728:Veterans / Q000523:psychology*