• B Josea Kramer, Rebecca L Vivrette, Delight E Satter, Stella Jouldjian, and Leander Russell McDonald.
• Geriatric Research Education and Clinical Center, VA Greater Los Angeles Healthcare System, 16111 Plummer Street, Sepulveda, CA 91343, USA. Josea.Kramer@va.gov
• J Gen Intern Med. 2009 Jun 1; 24 (6): 758764758-64.

BackgroundMany 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.ObjectiveTo 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.ParticipantsVHA healthcare staff, IHS healthcare staff and American Indian and Alaska Native veterans.ApproachFocus groups were conducted using a semi-structured guide. A software-assisted text analysis was performed using grounded theory to develop analytic categories.Main ResultsDual 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.ConclusionsFostering closer alignment between VHA and IHS would reduce care fragmentation and improve accountability for patient care.

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