The transition from the hospital to outpatient setting can be challenging. Problems arising during this period can lead to re-hospitalization which is common among Medicare beneficiaries with up to a 25% re-hospitalization rate for conditions such as heart failure. Prior studies have demonstrated that almost 1 in 2 patients experience at least 1 medical error defined as problems in medication continuity, diagnostic work-up or test follow-up during this transition period. Patients who encounter these problems are at increased risk of being re-hospitalized in the short-term. In addition, other factors found to be associated with increased risk of rehospitalization include not having a discharge summary available at the first outpatient visit, and not having an outpatient visit scheduled at the time of hospital discharge. These studies suggest that problems leading to re-hospitalization are potentially modifiable and addressing these problems may reduce re-hospitalization.
Interventions have been tested to improve the transition from hospital discharge to the outpatient setting, but the results have been mixed. The interventions that have been successful have usually included additional personnel to help patients during this transition period which may be difficult to generalize. However, common elements across successful interventions include: reducing medication discrepancies, ensuring early follow-up after discharge, enhancing communication between inpatient and outpatient providers, and educating patients about symptoms for which to seek medical attention. The Institute for Healthcare Improvement (IHI) and American College of Cardiology (ACC) along with many other stakeholders are collaborating on an effort to improve the transition from hospital to home in a program called H2H. This transition from hospital to home program focuses on 3 components for patients: 1) to be familiar and have access to their medications; 2) to have a follow-up visit shortly after discharge; 3) to understand symptoms that would require medical attention.
Cardiac care in the VHA is regionalized and this organizational structure can further complicate the transition period from hospital to home. Each VISN has tertiary care medical facilities with cardiologists and are equipped to perform specialized cardiac procedures. They serve veterans within their geographic area but also receive patient transfers from surrounding VA primary care facilities without cardiology capabilities. Based on the Chiefs of Cardiology national survey, approximately 20% of patients admitted with a primary cardiac condition at the Denver VAMC are transferred in from referring facilities. In VISN 19, the Denver VAMC is the cardiac referral site for primary care facilities in Grand Junction (243 miles away), Colorado; Cheyenne (98 miles away) and Sheridan (367 miles away), Wyoming; and Fort Harrison (800 miles away), Montana.
Following transfer to and hospitalization at the Denver VAMC, patients are discharged home to follow-up at their primary care facility and with their primary care provider. This can present challenges due to different hospitals/clinics involved, across long distances, between specialty and primary care, and across CPRS systems. For example, in Denver, CPRS notes from referring sites can only be accessed through VistaWeb or Remote data and in general, providers in Denver cannot directly input notes or orders for patients into the CPRS system of the referring sites. This is the same problem in other VISNs and not isolated to VISN 19 nor the Denver VA and its referring facilities. Potential problems with the transition period within the context of a regional cardiac care system have not been specifically evaluated in the literature.
Based on the literature to date, we have identified 4 initial key components for our transitions of care intervention including: 1) timely transfer of hospitalization summary information, 2) medication reconciliation, 3) self-care symptom checklist, and 4) early follow-up. We will refine these components based on the patient and provider qualitative interviews. Our conceptual framework for the intervention stems from Wagner's chronic care model. Central to Wagner's model is the combination of patient self- care support with health system changes leading to efficient, productive interactions between an "activated patient" and a "proactive clinical team" producing improved care transitions and clinical outcomes (e.g., decrease re-hospitalization). The proposed intervention promotes health system changes by providing early follow-up with the patient's PCP following discharge and reconciling pre and post-hospitalization medications as well as ensuring that providers get a hospitalization summary in a timely manner. The intervention promotes patient self-care through the development of a symptoms checklist for when patients should seek medical attention which in turn activates patients to take more responsibility for their own care. This leads to dynamic interactions between the patient and the clinical team, producing improved outcomes.
The objective of this pilot study is to help better inform the transition process from hospital to home in this regional model of cardiac care where patients are discharged back to their primary care facility from the tertiary referral center. This project is being conducted by a multi-disciplinary team of investigators, represented by cardiology, primary care, nursing, pharmacy, and implementation scientist. In addition, this proposal has the strong support of the VA for which the results would be directly applicable to better understand barriers and facilitators of the transition process, and to identify potential solutions to reduce hospital re-admission. Furthermore, this proposal is complementary with a VA project evaluating coordination of care between cardiology and primary care. The findings of this study will potentially inform a larger study to improve the transition from hospital to home of patients admitted with cardiac conditions.
1. Describe barriers and facilitators of the transition process from hospital to home through qualitative interviews among patients discharged from Denver VA Medical Center (tertiary facility) after being transferred from a primary care VA facility (e.g., Cheyenne VA Medical Center).
2. Describe barriers and facilitators of the transition process through qualitative interviews among providers at primary care VA facilities who take care of patients discharged from the Denver VA Medical Center for a cardiac condition.
3. Informed by the interviews and best practices from the literature, pilot test the transitions of care intervention that targets patients and providers to evaluate the feasibility of the intervention to improve process of care measures, including: 1) PCP follow-up within 2-4 weeks of hospital discharge; 2) medications reconciled between pre and post-hospital discharge; 3) discharge summary available to PCP at time of visit; and 4) patient awareness of symptoms that require medical attention.
Aim 1. Describe barriers and facilitators of the transition process from hospital to home through qualitative interviews among patients discharged from Denver VA Medical Center (tertiary facility) after being transferred from a primary care VA.
Aim 2. Describe barriers and facilitators of the transition process through qualitative interviews among providers at primary care VA facilities who take care of patients discharged from the Denver VA Medical Center for a cardiac condition.
Aim 3. Informed by the interviews and best practices from the literature, pilot test the transitions of care intervention that targets patients and providers to evaluate the feasibility of the intervention to improve process of care measures, including: 1) PCP follow-up within 2-4 weeks of hospital discharge; 2) medications reconciled between pre and post-hospital discharge; 3) discharge summary available to PCP at time of visit; and 4) patient awareness of symptoms that require medical attention.
Description of Population to be Enrolled: Study Design and Research Methods:
This is a mixed methods study where we will employ both qualitative and quantitative methods. Through a series of qualitative interviews (n=20-40), we will assess potential barriers and facilitators of the current discharge process in this hub and spoke model of cardiac care. Informed by these interviews, we will refine the transitions of care intervention that will include elements from prior studies that have improved this transition process. Finally, we will pilot test this intervention to assess the effectiveness of the intervention to improve important processes of care during this transition period among patients (n=40) discharged from Denver VAMC after transfer from a primary care VA facility.
Aim 1 Patients: Patients who are transferred from primary care VA facilities (i.e., Cheyenne, Grand Junction, Sheridan, and Ft. Harrison) for cardiac care (e.g., heart failure, acute myocardial infarction) or procedures (coronary angiography, pacemaker implantation) to the Denver VAMC and discharged home to follow-up with their primary care provider will be eligible for the patient interviews. They will be consented during their hospitalization at the Denver VAMC but the qualitative interview will not occur until 2-4 weeks following hospital discharge to allow the patient to undergo the current discharge process. These interviews will ask patients or their caregiver, if applicable to describe their transition to home and identify barriers and facilitators of this process, specifically understanding of their cardiac condition, new medications prescribed and whether medications were reconciled with their pre-hospitalization medications, timeliness of follow-up visit with their PCPs and knowledge of signs/symptoms in which they should seek medical attention. Ten to twenty interviews (2-3 patients from each primary care VA facility) will be conducted and more if needed to achieve thematic saturation, the point at which interviews no longer produce new themes about barriers and facilitators. Exclusion criteria will include: 1) planned discharge to nursing home or skilled nursing facility; 2) irreversible, non-cardiac medical condition (e.g. metastatic cancer) likely to affect 6-month survival or ability to execute study protocol; 3) lack of telephone/ cell phone; and 4) VA is not their primary source of care or their PCP is not in the VA system.
Aim 2 Providers: Providers from VA primary care facilities (i.e., Cheyenne, Grand Junction, Sheridan, and Ft. Harrison) who take care of patients discharged from the Denver VAMC for cardiology care will be eligible for the qualitative interviews. Interviews with providers will seek to identify barriers and facilitators from their perspective of following-up with patients after their recent hospitalization at the Denver VAMC, including transfer of information about the recent hospitalization (e.g., primary diagnosis, procedures performed, medications discharged on, or pending tests). In addition, the interviews will focus on what would be helpful to providers to make the transition process easier to ensure continuity of care to patients. While we will be interviewing mainly primary care providers, we will also interview providers, including nurses and pharmacists who also take care of patients following discharge to home from a tertiary care facility to get a more complete view of the transition process. Ten to twenty (2-3 providers from each primary care VA facility) interviews will be conducted with providers and more if needed to achieve thematic saturation. The providers will be offered to consent verbally or to sign an informed consent document.
Aim 3 Intervention: Patients who are transferred from primary care VA facilities (i.e., Cheyenne, Grand Junction, Sheridan, and Ft. Harrison) for cardiac care (e.g., heart failure, acute myocardial infarction) or procedures (coronary angiography, pacemaker implantation) to the Denver VAMC and discharged home to follow-up with their primary care provider will be eligible for the intervention. They will be consented during their hospitalization at the Denver VAMC. Exclusion criteria will include: 1) planned discharge to nursing home or skilled nursing facility; 2) irreversible, non-cardiac medical condition (e.g. metastatic cancer) likely to affect 6-month survival or ability to execute study protocol; 3) lack of telephone/ cell phone; and 4) VA is not their primary source of care or their PCP is not in the VA system.
The literature has identified several key components to facilitate the transition from hospital to home, including timely transfer of hospital information to ensure continuity, medication reconciliation, patient understanding of self-care symptoms checklist, and early follow-up.
1. Transfer of information to ensure continuity: The following elements have been identified in prior studies as important information by primary care providers when they see patients after a recent hospitalization: diagnosis, abnormal test findings, important test results, discharge medications, pending test that require follow-up, or need for additional diagnostic testing.3 For each patient, we will create a hospitalization summary at the time of discharge that contains the elements identified from the prior literature and further informed by the PCP qualitative interviews. We will send this summary to the patient's PCP on the day of discharge via an encrypted email consistent with VHA privacy standards. In addition, at the Denver VAMC, the cardiologists have direct access to the CPRS systems of the primary care referring facilities because they read echocardiograms for these hospitals and need to input the reports directly into each facility's respective CPRS systems. We will leverage this capability by also inputting the hospitalization summary into the CPRS of each patient's primary care facility and have the PCPs co-sign the note. For any tests that need to be ordered, we will place an order in CPRS for the PCP to sign off on if they are in agreement. In a prior study of remote consultation for patients with chronic angina by our group, the uptake of recommendations and agreement with orders generated by remote consultation was >90% using the same methodology. This creates 2 means of communication and makes the hospitalization information available in a timely manner.
2. Medication reconciliation: Prior studies suggest that medication discrepancies around the transition period are common and can lead to adverse drug events and rehospitalization. Prior to discharge, we will contact the outpatient pharmacy service of the patients' primary care facility and send them a complete list of discharge medications. Then, we will schedule the patient for either an in-person clinic visit and/or telephone visit whereby the pharmacists at the primary care facility will reconcile pre-hospitalization medications with any new medications prescribed at hospital discharge. This will ensure continuity in medications and reduce discrepancies or duplication.
3. Self-care responsibilities: Patient understanding of symptoms that require medical attention has been identified by the H2H program as one of the key priorities for any program targeting re-hospitalization. (5) We will provide patients with information regarding their cardiac condition using patient material from the American Heart Association or American College of Cardiology. In addition, we will outline a symptoms checklist that requires the patients to seek medication attention (e.g., contact their PCP or the Denver VAMC). For example, for patients admitted with heart failure, we will provide instructions on daily weights and when they should contact providers for advice on additional diuretics should their weight increase by more than five pounds. We will use the "teach-back" method whereby patients will be asked to repeat back what they understand from the instructions. (22) This method has been shown to enhance communication and reduce errors. We will also provide these instructions to the patients' care provider, if present.
4. Early follow-up: Prior to discharge, we will obtain a follow-up visit for patients with their PCP that is within 14 days of hospital discharge and preferably within 7 days. This appointment will be given to the patient at the time of discharge and included in any discharge material. In addition, we will contact the patient via telephone within 2-4 days of discharge to re-enforce the symptoms checklist and upcoming pharmacist and PCP visits.
The proposed intervention components are not set in stone and were proposed based on a review of the literature of the processes of care that have been identified as having the potential to improve care transitions. We plan to use the findings of the interviews to further shape the intervention components.
Piloting the intervention: These 4 components will be the basic elements of the transitions of care intervention. We will also incorporate additional findings from the qualitative interviews that address issues specific to veterans or that are specific to the regional cardiac care model in the VHA. We will pilot test the transitions of care intervention at the Denver VAMC on patients who are transferred from outlying primary care VA facilities (i.e., Cheyenne, Grand Junction, Sheridan, and Ft. Harrison) to Denver VAMC for cardiac care (e.g., heart failure, acute myocardial infarction) or procedures (coronary angiography, pacemaker implantation). Exclusion criteria will include: 1) planned discharge to nursing home or skilled nursing facility; 2) irreversible, non-cardiac medical condition (e.g. metastatic cancer) likely to affect 6-month survival or ability to execute study protocol; 3) lack of telephone/ cell phone; and 4) VA is not primary source of care or their PCP is not in the VA system. We will enroll 40 consecutive patients who agree to participate and sign an informed consent. Once the patient is ready for discharge, the research nurse will obtain follow-up appointments with the pharmacist and PCP at the patients' primary care facility. The dates of these appointments will be provided to patients as part of their discharge materials. In addition, the nurse will provide patients with materials about their cardiac condition and the symptom checklist that require medical attention including use of the "teach-back" method to ensure patient comprehension. Following discharge, the nurse will call the patient within 2-4 days to reinforce the symptom checklist and the upcoming appointments. At 2-4 weeks, the nurse will contact the patient again to assess the process of care outcomes of interest as outlined above.
Data Analysis Plan:
Aims 1 and 2: This study will use an iterative, inductive and deductive toolkit of analytical strategies drawing on field notes and memoing, qualitative content methods of analysis, and reflexive team analysis. Analysis will commence as the study commences and will continue alongside and informing data collection. Interviews will be digitally recorded and transcribed, and Dr. Albright will analyze the transcripts using qualitative content analysis methods. Analysis will begin with repeated readings to achieve immersion followed by initial coding using an emergent rather than a priori approach, in order to emphasize respondent perspectives and deemphasize team member speculations.ATLAS.ti v 6.2 (Scientific Software Development, GmbH, Berlin) will be used for data organization and management during analysis. Words, sentences, and paragraphs will be treated as coding units or "meaning units". After initial coding is completed, the resulting shared set of codes will be applied to the transcripts, code categories will be developed, and emergent themes will be identified. Throughout the analysis, new findings will be continually checked and compared with the rest of the data to establish new codes, themes or patterns. The preliminary results of the analysis process will be reviewed by members of the multidisciplinary research team to assess their evocativeness, thoroughness, and comprehensiveness. Finally, the emergent themes will be used in Aim 3 to further refine the transitional care intervention.
Aim 3 - Statistical analysis: We will describe baseline characteristics (demographics, co-morbidities, admitting cardiac condition) and primary care referral facility of patients enrolled in the pilot intervention. We will compare the proportion of patients receiving each process measures between patients enrolled in the initial interviews and in the pilot intervention to get a preliminary estimate of the impact of the intervention. The proportion of patients receiving each process of care measure will be described as proportions for categorical values and means with standard deviations for continuous variables. These preliminary comparisons provide estimates of effect size and inform sample size calculations for a larger study.
Aim 1: The majority (6/8) patients reported "I had good understanding of the things I was responsible for in managing my health," and 7/8 reported "When I left the hospital, I clearly understood the purpose of taking each of my medications." Most patients were pleased with the quality of care they received at Denver. Several problems with follow-up care were expressed by the patients including not being able to get a follow-up appointment with their provider (some were still waiting after weeks). Some noted that their local facilities did not to have any information/notes from Denver. Some patients were concerned about the apparent lack of communication between Denver and the local facilities. Finally, for some patients, Denver had prescribed certain medications, but the local facility did not follow through.
Aim 2: Providers expressed the need for a single, comprehensive discharge summary that can be accessed immediately. Most providers agreed that the most important information to know at the time of discharge is why the patient was taken to Denver, what was done in Denver and why, the results of tests done in Denver, what Denver's recommendations are (immediate recommendations for present and future guidelines), and when the patient needs to be seen for follow up. They also noted communication barriers and said they would like more physician to physician communication.
Aim 3: Eight patients were enrolled in the intervention which had four components. First, all enrolled patients had a discharge summary with all of the elements that were found to be important in Aim 2 sent to the patient's primary care provider through an interfacility consult. Second, medication reconciliation was done with the patient at the time of discharge, and again within 5 days of discharge when the study nurse contacted with patient via telephone. At this same time, additional education on self-care and a list of symptoms for which the patient would need to seek medical care was reviewed with the patient. Finally, on discharge, the patient received a follow-up appointment as was arranged by the study nurse. If the study nurse was unable to obtain a follow-up appointment for the patient on the day of discharge, the patient was informed of their appointment at the time of the follow-up phone call.
Of the eight patients who we enrolled in the intervention, seven attended their follow-up appointment and one attended their follow-up one month later than their scheduled follow-up. After the intervention, we contacted four of the providers who cared for patients in the intervention. Two providers felt that the interfacility consults were very helpful in transitioning the patient care back to their office and two providers who received the consult were not aware that it had been sent as the system had not prompted them to sign the note. All providers expressed the same sentiments that we learned in Aim 2 that this intervention is important for patient care and continuity.
Additionally, at the time of the follow-up phone call, the nurse asked each patient the following three questions regarding the transition. In general, the patients felt they had a good understanding of their health.
1)The hospital staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left the hospital. Results: 4 Strongly agreed and 2 Don't Know or Not Applicable
2)When I left the hospital, I had a good understanding of the things I was responsible for in managing my health. Results: 1 Strongly disagreed; 1 Agreed; and 4 Strongly agreed.
3)When I left the hospital, I clearly understood the purpose for taking each of my medications. Results: 1 Agreed and5 Strongly agreed
Finally, the study nurse identified several unanticipated patient issues at the time of the phone call to the patient within 5 days of hospital discharge. First, one patient reported a drug-rash to his antibiotic following pacemaker placement and the nurse in collaboration with the cardiology team was able to have him switch antibiotics. Second, a patient who was to be discharged with home oxygen endorsed dyspnea on follow-up phone call and had not yet had home oxygen delivered. The study nurse was able to assist in having oxygen delivered that evening to his home in Wyoming. These are just two examples of unanticipated problems that can arise during care transitions that the intervention can address.
Impact: The findings from this project will inform a larger grant designed to improve care transitions across a greater number of VA facilities. In the interim, we plan to publish the results of this Pilot and the lessons learned may also apply to other health care systems in addition to the VA.
- Hira RS, Kennedy K, Nambi V, Jneid H, Alam M, Basra SS, Ho PM, Deswal A, Ballantyne CM, Petersen LA, Virani SS. Frequency and practice-level variation in inappropriate aspirin use for the primary prevention of cardiovascular disease: insights from the National Cardiovascular Disease Registry's Practice Innovation and Clinical Excellence registry. Journal of the American College of Cardiology. 2015 Jan 20; 65(2):111-21.