Improving Transitions of Care for Veterans Transferred to Tertiary VA Medical Centers

Burke, Robert E.; Kelley, Lynette; Gunzburger, Elise; Grunwald, Gary K.; Gokhale, Madhura; Plomondon, Mary E.; Ho, P. Michael

doi:10.1177/1062860617715508

Cited by 15 publications

(31 citation statements)

References 20 publications

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“…This could be ment: 40 Fourth, evidence-based interventions such as nurse-led transitional care programs that have proven helpful in reducing adverse outcomes in both VA and non-VA settings will be useful to implement. [41][42][43][44][45] Such programs could be located in the VA, and a care coordinator role could help facilitate transitional care needs for veterans by working with multiple non-VA hospitals. The limitations of this study are that the perspectives shared by these participants may not represent all VA and non-VA hospitals as well as veterans' experiences with transition of care.…”

Section: Discussionmentioning

confidence: 99%

Perspectives of Clinicians, Staff, and Veterans in Transitioning Veterans from non‐VA Hospitals to Primary Care in a Single VA Healthcare System

Ayele

Lawrence

McCreight

et al. 2019

Journal of Hospital Medicine

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BACKGROUND: Veterans with healthcare needs utilize both Veterans Health Administration (VA) and non-VA hospitals. These dual-use veterans are at high risk of adverse outcomes due to the lack of coordination for safe transitions. OBJECTIVES: The aim of this study was to understand the barriers and facilitators to providing high-quality continuum of care for veterans transitioning from non-VA hospitals to the VA primary care setting. DESIGN: Guided by the practical robust implementation and sustainability model (PRISM) and the ideal transitions of care, we conducted a qualitative assessment using semi-structured interviews with clinicians, staff, and patients. SETTING: This study was conducted at a single urban VA medical center and two non-VA hospitals. PARTICIPANTS: A total of 70 participants, including 52 clinicians and staff (23 VA and 29 non-VA) involved in patient transition and 18 veterans recently discharged from non-VA hospitals, were included in this study. APPROACH: Data were analyzed using a conventional content analysis and managed in Atlas.ti (Berlin, Germany). RESULTS: Four major themes emerged where participants consistently discussed that transitions were delayed when they were not able to (1) identify patients as veterans and notify VA primary care of discharge, (2) transfer non-VA hospital medical records to VA primary care, (3) obtain follow-up care appointments with VA primary care, and (4) write VA formulary medications for veterans that they could fill at VA pharmacies. Participants also discussed factors involved in smooth transition and recommendations to improve care coordination. CONCLUSIONS: All participants perceived the current transition-of-care process across healthcare systems to be inefficient. Efforts to improve quality and safety in transitional care should address the challenges clinicians and patients experience when transitioning from non-VA hospitals to VA primary care.

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Section: Discussionmentioning

confidence: 99%

Perspectives of Clinicians, Staff, and Veterans in Transitioning Veterans from non‐VA Hospitals to Primary Care in a Single VA Healthcare System

Ayele

Lawrence

McCreight

et al. 2019

Journal of Hospital Medicine

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“…Nearly 2.7 million Veterans live in rural communities and use the Veterans Health Administration (VA) for healthcare [1]. Access to care for this population is a challenge due to significant geographic distances between VA tertiary hospitals, located in urban settings, and VA clinics and hospitals, commonly located in rural settings [1,2]. The transition for rural Veterans from hub VA hospitals back home to VA primary care clinics is complicated by communication and logistical barriers as well as limited health resources in rural communities [2].…”

Section: Introductionmentioning

confidence: 99%

“…Access to care for this population is a challenge due to significant geographic distances between VA tertiary hospitals, located in urban settings, and VA clinics and hospitals, commonly located in rural settings [1,2]. The transition for rural Veterans from hub VA hospitals back home to VA primary care clinics is complicated by communication and logistical barriers as well as limited health resources in rural communities [2]. Compared to the urban Veteran population, rural Veterans experience a higher disease prevalence and lower physical and mental quality-of-life scores [3].…”

Section: Introductionmentioning

confidence: 99%

“…The VA rural Transitions Nurse Program (TNP), a nurse-led intensive care coordination quality improvement project, was designed to address the geographical barriers to care rural Veterans experience after discharge from urban VA hospitals. A pilot run from 2014 to 2016 in Denver demonstrated increased rates of follow-up with rural primary care providers, and a trend towards fewer unplanned readmissions for Veterans enrolled in TNP [2]. Due to this, TNP was selected for national expansion to 11 VA hospitals by the VA Office of Rural Health [2,4].…”

Section: Introductionmentioning

confidence: 99%

“…A pilot run from 2014 to 2016 in Denver demonstrated increased rates of follow-up with rural primary care providers, and a trend towards fewer unplanned readmissions for Veterans enrolled in TNP [2]. Due to this, TNP was selected for national expansion to 11 VA hospitals by the VA Office of Rural Health [2,4]. At each VA hospital, TNP is led by a transitions nurse, who completes the TNP intervention, and a site champion, who serves as a liaison between the transitions nurse and VA site leadership.…”

Section: Introductionmentioning

confidence: 99%

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Mapping the reach of a rural Transitions Nurse Program for veterans with geographic information systems

Connelly

Motta

Leonard

et al. 2020

Implement Sci Commun

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Purpose: Rural Veterans who receive inpatient care at a Veterans Health Administration (VA) tertiary facility can face significant barriers to a safe transition home. The VA rural Transitions Nurse Program (TNP) is a national, intensive care coordination quality improvement program for rural Veterans. To communicate the reach of TNP into rural communities, we developed geographic information system (GIS) maps. This study evaluated TNP transitions nurse and site champion perceptions of GIS as a communication tool for illustrating the reach of TNP into rural communities. Methods: Using residence information for TNP enrollees, we built GIS maps using ArcGIS Enterprise, a mapping and analytics platform. Residential addresses were matched to Rural-Urban Commuting Area geographical categories. Transitions nurse and site champion perceptions of the local and national GIS maps were assessed through surveys and interviews. The data were analyzed using descriptive and content analytic methods to identify themes. Results: Transitions nurses and site champions perceived GIS maps as a valuable, easy to understand, acceptable, and appropriate communication tool to illustrate the reach of TNP into rural communities. Interviews revealed three common themes: a picture is worth a thousand words, the GIS maps are an effective communication tool, and the GIS maps revealed surprising and promising information.Conclusions: GIS is a useful communication tool to support to illustrate the reach of an intervention. The GIS maps engaged transitions nurses and site champions in discussion. The availability of open access software programs and publicly available location data will increase access to GIS for researchers and practitioners.

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Effectiveness of the rural transitions nurse program for Veterans: A multicenter implementation study

Gilmartin

Warsavage

Hines

et al. 2022

Journal of Hospital Medicine

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Background: Veterans are often transferred from rural areas to urban VA Medical Centers for care. The transition from hospital to home is vulnerable to postdischarge adverse events. Objective: To evaluate the effectiveness of the rural Transitions Nurse Program (TNP). Design, Setting, and Participants: National hybrid-effectiveness-implementation study, within site propensity-matched cohort in 11 urban VA hospitals. 3001 Veterans were enrolled in TNP from April 2017 to September 2019, and 6002 matched controls.Intervention and Outcomes: The intervention was led by a transitions nurse who assessed discharge readiness, provided postdischarge communication with primary care providers (PCPs), and called the Veteran within 72 h of discharge home to assess needs, and encourage follow-up appointment attendance. Controls received usual care. The primary outcomes were PCP visits within 14 days of discharge and all-cause 30-day readmissions. Secondary outcomes were 30-day emergency department (ED) visits and 30-day mortality. Patients were matched by length of stay, prior hospitalizations and PCP visits, urban/rural status, and 32 Elixhauser comorbidities.

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Improving Transitions of Care for Veterans Transferred to Tertiary VA Medical Centers

Cited by 15 publications

References 20 publications

Perspectives of Clinicians, Staff, and Veterans in Transitioning Veterans from non‐VA Hospitals to Primary Care in a Single VA Healthcare System

Perspectives of Clinicians, Staff, and Veterans in Transitioning Veterans from non‐VA Hospitals to Primary Care in a Single VA Healthcare System

Mapping the reach of a rural Transitions Nurse Program for veterans with geographic information systems

Effectiveness of the rural transitions nurse program for Veterans: A multicenter implementation study

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