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2015 HSR&D/QUERI National Conference Abstract

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1020 — Triggers of Dual Use for VA and Non-VA Emergency Department (ED) and Other Services: Veteran Perspectives of Decision-Making with Heart Failure

Pope CA, COIN Charleston; Wine L, COIN Charleston; Nemeth LS, Medical University of South Carolina College of Nursing; Axon RN, COIN Charleston;

Objectives:
Heart failure (HF) is the most frequent cause for VA hospital admission and unplanned hospital readmission. Dual healthcare system use (dual use) occurs when Veterans enrolled for VA care also receive care from non-VA providers or healthcare facilities. Dual use occurs frequently among Veterans, decreasing care coordination, efficiency and safety. This qualitative study explored dual use from Veterans living with HF to: 1) characterize perceptions regarding VA access, non-VA care, decision-making about where to seek care and HF care quality among Veterans living with HF; 2) identify motivations for single VA and dual use, 3) synthesize qualitative findings for evidence based intervention mapping.

Methods:
Constructivist grounded theory guided open-ended, semi-structured questions, interviewing Veterans with HF and at least one VA primary care visit in the last year. Twenty-five purposively sampled participants were prompted to reflect on their typical reasoning and decision-making to seek services. Participants discussed internal and external factors they considered relevant as triggers to single VA or dual use VA-non-VA services. Transcripts were analyzed using NVivo software, coded by two investigators and themes confirmed through immersion and crystallization.

Results:
One of the most frequent triggers for ED use was VA staff referral by telephone for escalating symptoms, instead of care coordination or problem-solving. Veterans choosing dual use tended to report: unmet needs for post-discharge follow-up care; non-response to requests for services; faster services in ED; and, confusion about monitoring labs and follow-up. Single VA users tended to: name specific providers; describe VA services as helpful; and, express more positive agency about HF. Most Veterans portrayed high dependency on providers and a passive approach to self-care that involved limitations and loss.

Implications:
Findings suggest differences in degree and quality of primary care engagement and communication between VA single and dual users and their providers, which may respond to better discharge preparation, follow-up care coordination, provider-patient problem-solving, and building self-care confidence.

Impacts:
Veterans can contribute to recommendations for quality improvement and reduction in ED services and dual use. Priorities for HF improvement should focus on decreasing the learned behavior of accessing ED care and increase care coordination within VA resources.