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Dual Health Systems Users: Strategies to Implement Optimal Care Coordination
Carolyn L Turvey, PhD MS
Iowa City VA Health Care System, Iowa City, IA
Iowa City, IA
Funding Period: February 2015 - July 2016
Recent studies estimate that between 28 and 75% of veterans also receive care from non-VA providers. Moreover, both the VA Choice and VA Budget and Choice Improvement Act call for more collaboration between VA and non-VA providers in shared care. Dual use is a concern because splitting care between two or more health systems and multiple providers may result in poor coordination of services and a loss of continuity -ultimately putting the patient at increased risk of adverse outcomes.
The aim of this program is to pilot a multicomponent intervention aimed at improving overall continuity of care by teaching Veterans and both VA and non-VA providers about strategies to improve care coordination. In addition, study results combined with a thorough literature review will be integrated to develop a white paper recommending best practices for improving dual use care coordination.
The pilot study was a randomized controlled trial of 63 Veterans which compared usual care to an intervention. The intervention arm had three components. First, Veterans were trained about the current ways they can promote bi-directional health information exchange between VA and non-VA providers. Second, Veterans' non-VA providers received a co-management tool-kit that informed them about how best to coordinate care with the VA. Third, Veterans completed a form designating all their care providers and the provider's role in managing the Veteran's health. The Veteran was asked to share this document with his or her providers to ensure that all health care team members are aware of each other and agree with their designated roles. We hypothesized that Veterans receiving the intervention would be more likely to share their VA Health Summary with non-VA providers and share outside patient portal health information documents with their VA providers. Veterans in the intervention arm would report greater improvement on perceived continuity of care and their providers would report greater satisfaction.
A total of 63 Veterans were randomized to receive either the intervention or usual care. Of these, 58 (92%) were men and 5 (7.9%) were women. The average age was 68 years. The sample was predominantly white (98%) and one participant was black. For education, 41 (65%) had a high school degree and/or some college and 35% reported a college degree or higher. There were no significant differences between treatment groups on any of these demographic variables.
Three of those randomized dropped the study before receiving the intervention, 5 dropped before completing the study and 2 have yet to complete the full study. As of the time of this report, 53 Veterans have completed the study entirely, with 26 in usual care and 32 receiving the intervention.
Veteran perception of the intervention was positive. Of those completing an after training questionnaire (N=22), 17 (77%) endorsed that their community providers will find it useful to have the information in their VA health summary and 95% endorsed that they will continue to use the VA Health Summary to find their VA health information. Of this group, 81% endorsed that using the VA Health Summary helped them to feel more involved in their health care.
Veterans then asked both their VA and community providers to complete questionnaires at the Veteran's next outpatient medical visit. Veterans in the intervention arm were significantly more likely than those in usual care to share their VA Health Summary with their community provider (75% vs. 0%; p<0.001). Community providers also reported higher rates of receiving a document listing all the Veteran's healthcare providers and their roles when compared with usual care (67% vs. 0%; p<0.001). Of the community providers receiving the VA Health Summary, 78% reported the information improved medication reconciliation and 36% indicated that they did not order laboratories because of the information available on the health summary.
Change in Veteran perceptions of continuity of care between baseline and at the end of the study was assessed using Haggerty's measure of Patient-Perceived Continuity of Care from Multiple Clinicians. Patients receiving the intervention demonstrated a trend towards greater improvement than those in usual care in perceived management continuity (t=-1.80; p=0.07) and significantly greater improvement in information continuity (t=2.10; p=0.04). The two groups did not differ in change in provider role clarity (t=0.46; p=0.65). Veterans receiving the intervention also indicated a trend towards greater improvement in general health as indicated on the 10-item PROMIS measure of general health (t=1.87; p=0.07).
There was a qualitative portion of this study where we interviewed community and VA providers after receiving the VA Health Summary from their patient. One community provider stated "Well, the VA Health Summary when I first saw it I was shocked. Cause I was like, 'Wait a minute! How come I haven't been having this for many years?' So I was really happy to see that". When asked about patients accessing their health information online, one VA provider stated. "And why shouldn't they be the captain of their own ships?"
Limitations: Provider response rate was low and we are still in the process of data cleaning to conduct the final analysis.
This study demonstrates the effectiveness of engaging Veterans in playing an active role by using both VA and community patient portals to promote health information exchange. This, in turn, has a significant impact on the information available at community provider visits and VA provider visits. This study also promoted provider-mediated exchange through VLER. Veteran engagement and training is required whether the HIE is consumer or provider mediated and this program is a first step towards developing such a program to meet the specific needs of dual use Veterans.
External Links for this Project
NIH ReporterGrant Number: I01HX001707-01
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DRA: Other Conditions, Health Systems
DRE: Treatment - Efficacy/Effectiveness Clinical Trial
MeSH Terms: none