The advanced care coordination program: a protocol for improving transitions of care for dual-use veterans from community emergency departments back to the Veterans Health Administration (VA) primary care

Heidi Sjoberg,Marina S Mccreight,Ashlea Mayberry,Lindsay B Miller,Roman A Ayele,Catherine Battaglia

doi:10.1186/s12913-019-4582-3

Abstract

BackgroundVeterans who access both the Veterans Health Administration (VA) and non-VA health care systems require effective care coordination to avoid adverse health care outcomes. These dual-use Veterans have diverse and complex needs. Gaps in transitions of care between VA and non-VA systems are common. The Advanced Care Coordination (ACC) quality improvement program aims to address these gaps by implementing a comprehensive longitudinal care coordination intervention with a focus on Veterans’ social determinants of health (SDOH) to facilitate Veterans’ transitions of care back to the Eastern Colorado Health Care System (ECHCS) for follow-up care.MethodsThe ACC program is an ongoing quality improvement study that will enroll dual-use Veterans after discharge from non-VA emergency department (EDs), and will provide Veterans with social worker-led longitudinal care coordination addressing SDOH and providing linkage to resources. The ACC social worker will complete biopsychosocial assessments to identify Veteran needs, conduct regular in-person and phone visits, and connect Veterans back to their VA care teams.We will identify non-VA EDs in the Denver, Colorado metro area that will provide the most effective partnership based on location and Veteran need. Veterans will be enrolled into the ACC program when they visit one of our selected non-VA EDs without being hospitalized. We will develop a program database to allow for continuous evaluation. Continuing education and outreach including the development of a resource guide, Veteran Care Cards, and program newsletters will generate program buy-in and bridge communication. We will evaluate our program using the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework, supported by the Practical, Robust Implementation and Sustainability Model, Theoretical Domains Framework, and process mapping.DiscussionThe ACC program will improve care coordination for dual-use Veterans by implementing social-work led longitudinal care coordination addressing Veterans’ SDOH. This intervention will provide an essential service for effective care coordination.

Highlights

Veterans who access both the Veterans Health Administration (VA) and non-VA health care systems require effective care coordination to avoid adverse health care outcomes
By expanding the work done with the Community Hospital Transitions Program (CHTP), the Advanced Care Coordination (ACC) program will bridge additional identified gaps in care coordination for dual-use Veterans and provide smooth transitions of care back to their VA primary care
The program will rely upon receiving notifications from non-VA emergency department (ED) staff when Veterans access their non-VA ED

Summary

Introduction

Veterans who access both the Veterans Health Administration (VA) and non-VA health care systems require effective care coordination to avoid adverse health care outcomes. These dual-use Veterans have diverse and complex needs. Allowing Veterans to receive community care improves their access to health care [3, 5]; coordination between VA and non-VA hospitals is often a complex, multi-level, fragmented process [6, 7]. Effective care coordination for this dual-use population is essential to avoid adverse health care outcomes [8,9,10]. Dual-use Veterans are at a higher risk of adverse outcomes [9, 10] including an increased probability of readmission to the hospital within 30 days [9, 15], ED visits and hospitalizations [9, 16], conflicting treatments and duplicated tests [17,18,19], medication errors [20,21,22,23], and decreased satisfaction with their care [24]

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