Abstract
IMPORTANCE: Veterans with mental health conditions (MHC) face unique challenges obtaining high-quality, coordinated health care. With a growing number of veterans receiving VA-purchased community care (CC) provided outside the Veterans Health Administration (VA), evidence is needed on how veterans in this high-prevalence, marginalized subgroup experience CC. OBJECTIVE: To compare experiences with CC over time for US veterans with and without MHC. DESIGN, SETTING, AND PARTICIPANTS: This retrospective, cross-sectional survey study analyzed responses to the Survey of Healthcare Experiences of Patients-Community Care Survey (SHEP-CCS) from 2016 to 2021. Ratings of CC were examined across 9 domains and compared for veterans with and without MHC, adjusting for differences in baseline characteristics using regression models. Data were analyzed from March 2023 to September 2024. EXPOSURE: Diagnosis of MHC, defined as bipolar disorder, major depression, posttraumatic stress disorder, schizophrenia, or psychosis. MAIN OUTCOMES AND MEASURES: Veterans' ratings of CC across 9 domains, overall satisfaction, overall clinician rating, clinician communication, eligibility determination, first appointment access, recent appointment access, nonappointment access, care coordination, and billing, were assessed on a scale of 1 to 100. Unadjusted annual ratings of care experiences were analyzed by survey domain. A series of 4 respondent-level linear regression models were examined for each domain and survey responses were pooled to test for differences in experiences between veterans with vs without MHC. RESULTS: This study included 231 869 veterans, including 62 911 veterans with MHC (27.1%) and 168 958 without MHC (72.9%). Veterans with MHC had a mean (SD) age of 55.8 (14.7) years, 8327 were female (18.5%), and 24 792 had 3 or more comorbidities (29.9%). Veterans without MHC had a mean (SD) age of 62.5 (15.2) years, 11 277 were female (11.0%), and 49 689 had 3 or more comorbidities (24.0%). In fully adjusted models, veterans with vs without MHC had lower adjusted overall satisfaction with CC by -1.8 (95% CI, -2.3 to -1.3) points (P < .001). Ratings in all domains were lower for veterans with vs without MHC (-0.09 to -0.05 SDs of domain scores) (P < .001 for all comparisons). Although ratings improved from 2016 to 2021, significant differences persisted over time for veterans with vs without MHC for all domains. CONCLUSIONS AND RELEVANCE: In this survey study of veterans receiving CC from 2016 to 2021, those diagnosed with MHC reported lower ratings of CC across all measured domains, and these differences persisted over time. These findings highlight where focused care coordination and quality improvement efforts could improve CC experiences for this vulnerable subpopulation of veterans.