Key Points Question What are primary care clinicians’ perceptions regarding electronic consultation and their clinical workload? Findings In this qualitative study including 34 primary care clinicians in the US Veterans Health Administration health care system, 3 themes regarding electronic consultation and workload were identified. The clinicians viewed electronic consultations as an added time burden, as shifting responsibilities from specialists to themselves, and even with the increased workload, as improving timeliness and quality of care. Meaning The findings of this study suggest that further research is warranted to assess whether the increased workload is objective or perceived.

Introduction The Veterans Health Administration’s (VHA) history of enhancing Veterans’ healthcare access continued in 2016 with the launch of ChooseVA (née: MyVA Access). This initiative was designed to transform the VHA and rapidly increase Veteran’s access to care across all the VHA facilities. Relevant to this article include mandates to improve patient-centered scheduling. In prioritizing patient-centered scheduling, the VHA and other large healthcare systems have the paradoxical task of providing health care that meets not only the needs of individual patients but also the collective needs of the population served. To our knowledge, meeting these competing needs has not been explored through the perspectives and experiences of providers and staff implementing patient-centered scheduling practices. Materials and Methods This was a qualitative exploratory study and was sanctioned as quality improvement (and thus exempt from Institutional Review Board review). We conducted visits at 25 VHA facilities. Sites were selected based on rurality, region, and facility access performance ratings. Data collection included semi-structured interviews and focus groups. Key informant participants included local leadership, administrators, providers, and support staff across primary care, specialty care, and mental health service lines. We analyzed transcribed audio recordings using inductive content analysis to identify barriers, facilitators, and contextual factors affecting the implementation of patient-centered scheduling. Results We conducted 208 individual interviews and focus groups between July and November 2017. Participants expressed dedication to patient-centered approaches to improve access to care for Veterans, stating efforts and challenges to meeting Veterans’ needs and preferences. Being Veteran-centric meant accommodating Veterans, with a tension between meeting the needs of one Veteran versus all Veterans, managing expectations of same-day access, and potential hits to performance metrics. Strategies focused on engaging Veterans through education and establishing new expectations while recognizing the differing needs among subgroups receiving VHA care. Conclusions Veterans Health Administration staff employed a mission-driven, culturally sensitive approach to meeting the diverse scheduling needs of the Veteran population. While potentially unique to the VHA, it may inform patient-centered scheduling practices for other culturally specific populations in other healthcare systems. Continued efforts to put Veterans at the center of VHA healthcare delivery by engaging them in meaningful ways while honoring their distinct needs are essential. Data are forthcoming on Veterans’ perspectives of access, which we hope will further contribute to unfolding understandings of access within the VHA.

BACKGROUND: Decisions about postacute care are increasingly important as the United States population ages, its use becomes increasingly common, and payment reforms target postacute care. However, little is known about how to improve these decisions. OBJECTIVE: To understand whether cognitive biases play an important role in patient and clinician decision-making regarding postacute care in skilled nursing facilities (SNFs) and identify the most impactful biases. DESIGN: Secondary analysis of 105 semistructured interviews with patients, caregivers, and clinicians. SETTING: Three hospitals and three SNFs in a single metropolitan area. PATIENTS: Adults over age 65 discharged to SNFs after hospitalization as well as patients, caregivers, and multidisciplinary frontline clinicians in both hospital and SNF settings. MEASUREMENTS: We identified potential cognitive biases from prior systematic and narrative reviews and conducted a team-based framework analysis of interview transcripts to identify potential biases. RESULTS: Authority bias/halo effect and framing bias were the most prevalent and seemed the most impactful, while default/status quo bias and anchoring bias were also present in decision-making about SNFs. CONCLUSIONS: Cognitive biases play an important role in decision-making about postacute care in SNFs. The combination of authority bias/halo effect and framing bias may synergistically increase the likelihood of patients accepting SNFs for postacute care. As postacute care undergoes a transformation spurred by payment reforms, it is increasingly important to ensure that patients understand their choices at hospital discharge and can make high-quality decisions consistent with their goals.

BackgroundDespite the increased focus on improving patient’s postacute care outcomes, best practices for reducing readmissions from skilled nursing facilities (SNFs) are unclear. The objective of this study was to observe processes used to prepare patients for postacute care in SNFs, and to explore differences between hospital-SNF pairs with high or low 30-day readmission rates.DesignWe used a rapid ethnographic approach with intensive multiday observations and key informant interviews at high-performing and low-performing hospitals, and their most commonly used SNF. We used flow maps and thematic analysis to describe the process of hospitals discharging patients to SNFs and to identify differences in subprocesses used by high-performing and low-performing hospitals.Setting and participantsHospitals were classified as high or low performers based on their 30-day readmission rates from SNFs. The final sample included 148 hours of observations with 30 clinicians across four hospitals (n=2 high performing, n=2 low performing) and corresponding SNFs (n=5).FindingsWe identified variation in five major processes prior to SNF discharge that could affect care transitions: recognising need for postacute care, deciding level of care, selecting an SNF, negotiating patient fit and coordinating care with SNF. During each stage, high-performing sites differed from low-performing sites by focusing on: (1) earlier, ongoing, systematic identification of high-risk patients; (2) discussing the decision to go to an SNF as an iterative team-based process and (3) anticipating barriers with knowledge of transitional and SNF care processes.ConclusionIdentifying variations in processes used to prepare patients for SNF provides critical insight into the best practices for transitioning patients to SNFs and areas to target for improving care of high-risk patients.