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2019 HSR&D/QUERI National Conference Abstract

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1047 — Innovation to Impact: Implementing Transitions of Care Intervention for Veterans Transitioning From Community Hospitals to VA Primary Care

Lead/Presenter: Roman Ayele,  COIN - Seattle/Denver
All Authors: Ayele R (Seattle/Denver Center of Innovation, University of Colorado, Anschutz Medical Campus, Aurora, CO), Liu, W (Seattle/Denver Center of Innovation), McCreight, M (Seattle/Denver Center of Innovation) Mayberry, A (Seattle/Denver Center of Innovation) Glasgow, RE (Seattle/Denver Center of Innovation, University of Colorado, Anschutz Medical Campus, Aurora, CO,) Borsika, RA (Seattle/Denver Center of Innovation,University of Colorado, Anschutz Medical Campus, Aurora, CO, University of California San Diego) Battaglia, C (Seattle/Denver Center of Innovation, University of Colorado, Anschutz Medical Campus, Aurora, CO,)

Veterans are increasingly accessing hospital care outside of the Veterans Health Administration (VA) while maintaining primary care at the VA. Continuity of care can be problematic when services are delivered across multiple systems, resulting in avoidable complications. Delivering comprehensive, quality health care for Veterans is dependent upon coordination across systems. We sought to understand transitions of care for dual-use Veterans and outcomes among those who participated in the nurse-led Community Hospital Transitions Program (CHTP) intervention.

We conducted a qualitative study using in-depth semi-structured interviews with 52 VA and community providers/staff along with 18 Veterans to understand barriers and facilitators of transitional care. Participants were recruited using convenience and snowball sampling. Qualitative analysis was guided by conventional content analysis. Data were managed by Atlas.ti software. This informed the development of the CHTP, nurse care coordination intervention, focused on improving information exchange, post discharge monitoring of symptoms, and follow-up care. We analyzed VA claim data post implementation to compare intervention participants with those who did not participate. A total of 342 veterans were enrolled in CHTP from October 1st, 2017 to July 31st, 2018. Using propensity score, Veterans were matched on age, gender, comorbidities, number of hospitalization and primary care visits in the past year.

Prior to CHTP, VA and community providers agreed there was no standardized transitions process after a community hospitalization. Overall, there was agreement to ensure Veterans received timely follow-up care with their primary care team. With the CHTP intervention, VA primary care received timely notification and discharge records. Veterans participating in the intervention were more likely than controls to receive a follow-up appointment within 14 days (p < 0.05) and 30-days (p < 0.05) post discharge. There were no significant differences in 30-day readmissions or emergency visits.

Implementing CHTP resulted in a significant increase in timely post discharge follow-up. This is an important finding as increasing number of Veterans are seeking care outside the VA for specific services while also maintaining their VA primary care home.

CHTP is applicable to other VAs with dual-use Veterans who face common barriers to a safe transition back to their primary care.