Abstract
BackgroundVeterans increasingly utilize both the Veteran’s Health Administration (VA) and non-VA hospitals (dual-users). Dual-users are at increased risk of fragmented care and adverse outcomes and often do not receive necessary follow-up care addressing social determinants of health (SDOH). We developed a Veteran-informed social worker-led Advanced Care Coordination (ACC) program to decrease fragmented care and provide longitudinal care coordination addressing SDOH for dual-users accessing non-VA emergency departments (EDs) in two communities.Methods ACC had four core components: 1. Notification from non-VA ED providers of Veterans’ ED visit; 2. ACC social worker completed a comprehensive assessment with the Veteran to identify SDOH needs; 3. Clinical intervention addressing SDOH up to 90 days post-ED discharge; and 4. Warm hand-off to Veteran’s VA primary care team. Data was documented in our program database. We performed propensity matching between a control group and ACC participants between 4/10/2018 – 4/1/2020 (N- = 161). A joint survival model using Markov Chain Monte Carlo technique was employed for 30-day outcomes. We performed Difference-In-Difference analyses on number of ED visits, admissions, and primary care physician (PCP) visits 120-day pre/post discharge.ResultsWhen compared to a matched control group ACC had significantly lower risk of 30-day ED visits (Hazard Ratio (HR) = 0.61, 95% Confidence Interval (CI) = (0.42, 0.92)) and a higher probability of PCP visits at 13–30 days post-ED visit (HR = 1.5, 95% CI = (1.01, 2.22)). Veterans enrolled in ACC were connected to VA PCP visits (50%), VA benefits (19%), home health care (10%), mental health and substance use treatment (7%), transportation (7%), financial assistance (5%), and homeless resources (2%).ConclusionWe developed and implemented a program addressing dual-users’ SDOH needs post non-VA ED discharge.Social workers connected dual-users to needed follow-up care and resources which reduced fragmentation and adverse outcomes.
Highlights
Veterans increasingly utilize both the Veteran’s Health Administration (VA) and non-VA hospitals
Reasons for ineligibility included: 47% were hospitalized/admitted to an inpatient facility (e.g., Skilled Nursing Facilities), 17% had confirmed VA case management, 3% lived outside geographical regions served by Eastern Colorado Health Care System (ECHCS) and NebraskaWestern Iowa Health Care System (NWIHCS), 0.60% were dangerous to staff and 0.40% were readmitted to the emergency department (ED)
After adjusted for Elixhauser score and prior one year ED visit, Advanced Care Coordination (ACC) had significantly lower risk to have an ED visit within 30-days of discharge compared to the control group (HR = 0.61, 95% Confidence Interval (CI) = (0.42, 0.92)) (Fig. 1: Probability of emergency department visits within 30-days post-discharge)
Summary
Veterans increasingly utilize both the Veteran’s Health Administration (VA) and non-VA hospitals (dualusers). Dual-users are at increased risk of fragmented care and adverse outcomes and often do not receive necessary follow-up care addressing social determinants of health (SDOH). We developed a Veteran-informed social worker-led Advanced Care Coordination (ACC) program to decrease fragmented care and provide longitudinal care coordination addressing SDOH for dual-users accessing non-VA emergency departments (EDs) in two communities. Effective care coordination addressing social determinants of health (SDOH) for dual-use Veterans to avoid adverse outcomes is essential [3,4,5, 8, 9]. Care coordination programs may decrease these adverse outcomes, enhance care and address SDOH for dual-use Veterans by linking them to essential social and medical resources
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