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Prior studies demonstrate that a large
proportion of Veterans access multiple
systems for care, yet Veterans who use both
VA and non-VA services (dual care) are at
increased risk of adverse events, especially
during transitions of care when changes
in medication and plan of care may occur
without the knowledge of VA physicians.1
Understanding how information is
exchanged during care episodes across
multiple systems can help identify gaps and
suggest potential solutions. Furthermore,
identifying factors associated with lapses
in information exchange when Veterans
receive dual care will allow for design of
interventions to prevent such lapses. With
the advent of the VA Choice program
and Veterans' increased access to non-VA
care, the issue of information exchange has
grown in significance.
According to the most recent VHA Directive
on National Dual Care Policy regarding
Veteran use of non-VA care, VA recognizes
that while Veterans have the choice of
obtaining care from VA and non-VA sources,
"coordination and continuity of care are
core features of high-quality primary care,"
particularly with the recent transformation
of primary care to the Patient Aligned Care
Team (PACT).2, 3 By splitting care between
two or more health systems, access to multiple
systems of care "may pose risks to patients."
VA providers are responsible for managing
the care that Veterans receive, "documenting
the list of non-VA providers supplied by
the patient in the patient's electronic health
record, and coordinating care provided by
non-VA providers as made available by the
patient and non-VA provider." Veterans
need to inform their VA provider of all
components of their care outside VA and
obtain all necessary documentation from
their community provider. For example,
when Veterans are discharged from a
non-VA hospital, they need to inform their
VA provider because potential problems
may arise when information sharing is
incomplete. Although the increasing
availability of electronic information from
Health Information Exchanges (HIEs) shows
promise in expanded information exchange
across sites, HIE use is limited by variations in
HIEs across different markets.
Currently, we are conducting an
observational study to determine how
and to what extent information is
exchanged within VA primary care
teams by monitoring a cohort of urban
and rural Veterans recently discharged
from non-VA hospitals or emergency
rooms. Participating study sites include
the James J. Peters VA Medical Center
and the Hudson Valley Health Care
System, where Veterans in urban and
rural areas, respectively, are recruited.
Veterans meet the inclusion criteria if they
are discharged to home from a non-VA
hospital or emergency room; if Veterans
do not receive care from a VA PACT in the
previous year, they are excluded.
Our analysis of 132 Veterans in urban (50
percent) and rural (50 percent) settings,
and of the information exchanged after
a non-VA hospitalization or emergency
room visit includes the following
preliminary findings.
First, information exchange is more
uniform when there is an established
process. These include VA-based care
transition programs where there is VA
staff, notified by the discharging non-VA
hospital or by health information
exchange, initiating contact with Veterans
to assist with coordination of care. Also,
when Veterans' use of non-VA care occurs
in a fee basis manner, for example, when
formal authorizations by VA have been
issued to the non-VA hospital to provide
care, discharge information after non-VA
hospitalization is sent to VA providers
regularly.
Second, there is variability in Veteran
education (6 percent of study cohort has
less than high school education), health
literacy (24 percent with inadequate or
marginal health literacy), self-reported
receipt of post-discharge information
from non-VA setting (11 percent reported
having received none), and confidence in
managing their health after a non-VA visit
(33 percent reported somewhat confident
or not confident). These factors may limit
the ability of some Veterans to act as a
conduit for information exchange.
Third, a substantial proportion (50
percent) of Veterans have not accessed
electronic tools (My HealtheVet) that may
allow them to more easily communicate
with their VA providers electronically;
furthermore, less than half of them have
heard about the VA Choice program, and
few have utilized it.
Our preliminary findings suggest that
it may be important to institute an
agreement between VA and non-VA sites
that defines a process for their information
exchange. Such a step may be particularly
important for Veterans who have limited
ability to serve as a conduit for notification
of non-VA utilization and information
exchange. Our findings also suggest that
certain VA tools and programs can be
further promoted as potential avenues
to enhance non-VA healthcare use and
information exchange.
1. Helmer D, Sambamoorthi U, Shen Y, et al. "Opting
Out of an Integrated Healthcare System: Dual-system
Use is Associated with Poorer Glycemic Control in
Veterans with Diabetes," Primary Care Diabetes 2008;
2(2):73-80.
2. VHA National Dual Care Policy. VHA Directive
2009-038. In: Affairs. DoV, ed2009.
3. Yano EM, et al. "Patient Aligned Care Teams (PACT):
VA's Journey to Implement Patient-Centered Medical
Homes," Journal of General Internal Medicine 2014.
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