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2019 HSR&D/QUERI National Conference Abstract

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1053 — Care Routing for Specialty Care Triage Improves Timeliness of Care and Veteran Experience

Lead/Presenter: Lucas Donovan,  COIN - Seattle/Denver
All Authors: Donovan LM (Center of Innovation for Veteran-Centered & Value-Driven Care, Seattle), Fernandes LF (VA Portland Health Care System), Williams KM (Office of Veterans Access to Care) Eastin L (VA Portland Health Care System) Parsons EC (VA Puget Sound Health Care System; University of Washington, Seattle) O'Hearn DJ (VA Puget Sound Health Care System; University of Washington, Seattle) He K (VA Pittsburgh Health Care System, University of Pittsburgh) McCall CA (VA Puget Sound Health Care System; University of Washington, Seattle) Johnson KA (VA Puget Sound Health Care System; University of Washington, Seattle) Thompson WH (Boise VA Medical Center; University of Washington, Seattle) Spece LJ (VA Puget Sound Health Care System; University of Washington, Seattle) Feemster LC (Center of Innovation for Veteran-Centered & Value-Driven Care, Seattle) Kirsh S (Office of Veterans Access to Care) Palen BN (VA Puget Sound Health Care System; University of Washington, Seattle) Au DH (Center of Innovation for Veteran-Centered & Value-Driven Care, Seattle)

Objectives:
Half of Veterans receive specialty care. Triaging specialty care referrals to ensure appropriate access and services is a necessary step in the referral process. Inefficiency in the triage process results from several sources, including dependence on specialist providers who could otherwise spend that time providing direct patient care and poor communication between providers and schedulers. At VA Puget Sound, sleep providers spend 40hrs/week (40% of all available specialist time) triaging referrals. As part of our learning health system model, we piloted a Care Routing program that utilized nurse-led triage with integrated scheduling support. We compared Care Routing with usual care to assess timeliness, Veteran perceptions, and estimated specialist time that could be reallocated to direct patient care.

Methods:
Care Routing (CR) began triaging Veterans to sleep services in May 2018, and operated alongside usual care (e.g. physician triage and standard scheduling). Veterans received either CR or usual care based on triager (CR nurse or specialist) availability at time of referral. Specialists audited nurse triages to ensure quality. We used administrative data to compare timeliness and community care use, and conducted telephone-based Veteran satisfaction surveys.

Results:
From May 2018 to January 2019, CR triaged 1,463 referrals relative to 2,323 for Usual Care. More Veterans triaged through CR were contacted within 14 days (CR 51.2%; Usual 21.1%, p < 0.001) and received care within 30 days (CR 29.5%; Usual 15.4%, p < 0.001). CR triages were 35% less likely to require community care referrals (CR 7.2%, Usual 10.2%, p < 0.001). On surveys (CR n = 19, Usual n = 21), Veterans with CR triage agreed more often that care was timely (CR 89.5%, Usual 42.9%, p < 0.01) and VA treated them with respect (CR 94.7%, Usual 57.1%, p < 0.01). Using chart audits, we estimate 75% of consults could be triaged independently by nurses, which would translate to 30 more hours/week of direct patient care.

Implications:
Relative to usual practice, Care Routing improved timeliness and access to sleep specialty services. Care Routing also led to lower community care reliance, and favorable Veteran perceptions.

Impacts:
Care Routing improves Veterans' access to specialty care. Optimizing scheduling and incorporation of nurse-led care can reduce service delays and improve Veteran experience.