Health Services Research & Development

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2017 HSR&D/QUERI National Conference Abstract

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4041 — Discharge Information and Support for Veterans Receiving Outpatient Care in the Emergency Department: Results from a Randomized Controlled Trial

Lead/Presenter: S. Nicole Hastings, COIN - Durham
All Authors: Hastings SN (Durham COIN) Stechuchak KM (Durham COIN) Coffman CJ (Durham COIN) Mahanna EP (Durham COIN) Weinberger M (UNC Gillings School of Global Public Health) Van Houtven CH (Durham COIN) Schmader KE (Durham GRECC) Kessler CS (VHA Emergency Medicine) Ramos K (Durham COIN) Oddone EZ (Durham COIN)

Objectives:
This study evaluated the impact of a primary care nurse-led telephone intervention (DISPO ED) for Veterans treated and released from the VA Emergency Department (ED) considered high risk for repeat ED visits.

Methods:
513 "high risk" Veterans with an ED visit between 03/2014 and 01/2016 were randomized 1:1 to DISPO ED or usual care. High risk was defined by >= 2 chronic conditions and >= 1 ED visit or hospitalization during 6-months prior to index ED visit. DISPO ED consisted of 2 core calls; the 1st addressed transitional care, the 2nd focused on case finding and referral for chronic disease management programs. Optional calls were available for up to 30 days. The primary outcome was repeat ED use at 30 days. We also examined primary care, mental health, chronic disease management services, and ED use and hospitalization at 180 days. Differences in rates between groups were examined using multivariable logistic and negative binomial regression models adjusted for having > 3 ED visits prior to study index ED visit ("ED super-user").

Results:
Mean age of participants was 59.1 years; 22.2% were female, and 49.6% were black. 26.5% were ED super-users, and 40.2% reported high psychological distress at enrollment. 98.1% of intervention participants completed both core calls. Total intervention call time was 39.5 minutes/participant. There was no difference in ED use at 30 days between intervention and control groups (24.9% vs. 23.1%; OR = 1.1; 95% CI = 0.7,1.7; P = 0.6). The intervention group had a higher rate of having > 1 primary care visit at 30 days (OR = 1.6, 95% CI = 1.1-2.3). At 180 days, the intervention group had more primary care visits/patient (incidence rate ratio = 1.2, 95% CI = 1.0-1.3) and a higher rate of using MOVE!, a weight management program (OR = 3.5, 95% CI = 1.6-7.5), Diabetes or Nutrition services (OR = 1.8, 95% CI = 1.0-3.0), and Care Coordination and Home Telehealth services (OR = 1.7, 95% CI = 1.0-2.9) compared to usual care. There were no between-group differences at 30 or 180 days in mental health visits or at 180 days in ED and hospital use.

Implications:
A brief nurse-led telephone intervention after an ED visit increased engagement with primary care and some chronic disease management services; however, it did not increase mental health visits or reduce repeat ED or hospital use.

Impacts:
Time-limited care management programs may have benefits but be insufficient to reduce additional acute care utilization in medically complex patients.