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Improving the Transition of Care Process for Veterans Hospitalized at Non-VHA Facilities.
Journal for Healthcare Quality : Official Publication of the National Association for Healthcare Quality 2018 August 31
Veterans receiving primary care through the Veterans Health Administration (VHA) are at increased risk of adverse outcomes when transitioning from a non-VHA hospitalization to VHA primary care. We intervened to improve these care transitions through identifying Veterans at a partnered community hospital, use of a multidisciplinary patient-structured discharge information sheet for community case managers to effectively communicate with VHA clinics, and implementation of a VHA site process for receiving information. We evaluated the intervention on two endpoints: the percentage-relevant documentation was received at the VHA before follow-up appointment and the rate Veterans attended a follow-up appointment at the VHA. Rates for receiving transitions of care documents were as follows: 0% preintervention (N = 24), 16% in the first 6 months of intervention (N = 39), and 83% after plan-do-study-act cycles in the second 6 months (N = 41). Veteran follow-up attendance also improved 25% preintervention to 54% and 71%, respectively. This process could serve as a model for transitions of care improvement.
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