Patients who transition from acute care to primary outpatient care are at high risk for adverse outcomes such as readmissions and medication errors. Primary care patients at the VA who utilize non-VA acute care services are at particularly high risk for these adverse outcomes because of lack of coordination between non-VA and VA sites. The Bronx Regional Health Information Organization (RHIO), a newly established electronic health information network system, provides an opportunity to improve care coordination between non-VA and VA sites by providing a platform for sharing clinical data among facilities. With the consent of patients, providers can access secure clinical information from participating hospitals, clinics and pharmacies in the county. Using the Bronx RHIO as a platform for providing non-VA medical care information, we designed a care transitions intervention to provide patient-centered care targeted at improving communication, coordination of care and provider decision for veterans being discharged from non-VA acute care settings.
The objectives of this study are to: a) determine the feasibility of a care transitions intervention, enhanced by the use of RHIO, designed to improve outcomes of veterans discharged from a non-VA hospital or emergency department; b) demonstrate the implementation fidelity (recruitment, acceptance and adherence to the protocol) of the care transition intervention; c) identify the potential of the care transition intervention to improve the care of veterans, relative to: (i) primary outcomes of the rates of readmission to the hospital or emergency department; and (ii) secondary outcomes of the rates of medication duplication and error, and patient satisfaction.
In order to address these aims, we developed a care transitions intervention (CTI) to serve veterans who were recently discharged from a non-VA hospital, based on the use of the RHIO system. We recruited veterans in the outpatient setting from the primary care and geriatrics clinics at the James J Peters VA Medical Center. Included were veterans who were 65 or older, who reported use of non-VA medical care in the previous 2 years and who were participants of the Bronx RHIO. Participants were followed longitudinally for hospitalization and emergency room visits at non-VA hospitals, using an automated notification tool in the Bronx RHIO. Upon notification of the acute care event, a CTI was delivered by a care transitions coach through a home visit and telephone follow up calls for a duration of 30 days. The intervention contained a structured protocol of monitoring and retrieval of non-VA hospital and emergency department discharge information using the Bronx RHIO, coordination of urgent and follow-up appointments, condition specific patient education and communication, medication reconciliation, and provider communication. Outcomes of 30 and 90 day hospitalization rates, rate of medication discrepancy, and patient satisfaction using the care transitions measure (CTM) were obtained. In addition we collected process data including participation rates and acceptance rates of the intervention to assess the feasibility of the intervention.
100 veterans were recruited; 98% were male, mean age was 80.7 (standard deviation (SD) 7.1); 36% were black, 20% Hispanic. 32% did not complete high school; 41% reported living alone; 18% reported receiving paid help at home. 76% had non-VA outpatient visits and 54% reported non-VA hospitalizations in the previous 2 years. Participants were followed for a median of 390 days (interquartile range: 269, 530 days). Participants had a total of 90 acute care events including hospitalization and emergency room visits for which 54 were at non-VA hospitals for a rate of 0.5 non-VA events per person year. RHIO notifications were accurate and timely at the time of admission except for 1 event which was delayed due to a mismatch in birth date in the RHIO system. In 43 of the 54 visits (80%), participants were discharged to the community where a CTI can be initiated. 30% refused CTI at the time of discharge and 8% were unable to be contacted. A total 25 CTIs were delivered. For outcomes of the intervention, 30 day readmission rate was 16.7% and 90 day readmission rate was 33.3%. Medication discrepancy identified by the care transitions coordinator between discharge instructions and medications taken by patients were common (with a rate of 43%). Patient reported outcomes of care transitions at 30 days using the CTM indicated that 96% reported that they "strongly agree" or "agree" that they understood the things they were responsible for in managing their health and the purposes of their medications.
Findings from this project indicated that utilizing RHIO to notify VA providers of non-VA acute care events among veterans is largely accurate and timely for veterans using both VA and non-VA care. Despite barriers including difficulty with patient contact and refusals, implementing a care transitions intervention after a non-VA acute care event is feasible. This pilot study provides estimates for designing a larger scale, multicenter trial for implementing interventions to serve veterans during the time of care transitions where medication errors and rehospitalization rates can be reduced.
- Hung WW, Morano B, Moodhe N, Boockvar K. Regional Health Information Organization (RHIO): its potential uses to improve veteran health care. Federal practitioner : for the health care professionals of the VA, DoD, and PHS. 2011 Jan 1; 28(3):33-36.
- Hung WW, Morano B, Moodhe N, Boockvar K. RHIOs have potential to improve healthcare of older adults. [Newsletter]. 2011 Jun 2; 2(3).
- Hung WW, Morano B, Boockvar K. Feasibility of integrating the use of Regional Health Information Organization for a VA-based care transition intervention. Paper presented at: Gerontological Society of America Annual Scientific Meeting; 2011 Oct 9; Minneapolis, MN.
- Boockvar K. A RHIO-enhanced care transitions intervention. Poster session presented at: VA Office of Quality and Performance Annual Quality Conference; 2011 Sep 21; Las Vegas, NV.