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

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.

Methods and Effectiveness of Communication Between Hospital Allied Health and Primary Care Practitioners: a Systematic Narrative Review

“…None of the included studies speci cally investigated the methods of communication or evaluated the effectiveness of communication between hospital allied health professionals and primary care practitioners. Twelve of the 24 studies, however, described programs or processes that indirectly addressed components of communication between hospital allied health professionals and primary care practitioners [5,8,[36][37][38][39][40][41][42][43][44][45]. Narrative synthesis of each study included exploration of these 12 interventions within the context of their relationship to some guiding theoretical models of care, namely the chronic care model [46], the collaborative care model [47] and the integrated care model [48].…”

“…Chronic care management has evolved to incorporate a collaborative care model, which includes the active engagement of hospital and primary care providers in the shared care of patients beyond usual discharge summaries [47]. All 12 of the interventions identi ed in the literature [5,8,[36][37][38][39][40][41][42][43][44][45] included features consistent with a collaborative model of care in their initiatives to improve hospital discharge planning and continuity of care, even though they did not all reference a theoretical basis. A collaborative care model may have formed the theoretical framework for the 'Accountable Care in Transitions Program' [5] described by Hawes et al (2017), however was not speci cally named.…”

“…The 'Advanced Care Coordination Program' proposed by Miller et al [8] seemed similarly to be based on an integrated model of care, to address the gaps in care during patient care transitions, although a theoretical framework was not discussed. Their social worker-led program focused on social determinants of health in a comprehensive and longitudinal care coordination intervention.…”

“…Their social worker-led program focused on social determinants of health in a comprehensive and longitudinal care coordination intervention. The core components of care coordination were initial noti cation of patient hospital admission, a comprehensive needs assessment, clinical intervention as indicated and a phone call to the primary care providers [8]. The comprehensive needs assessment addressed access to health care, economic status, housing status, psychological status, and social support.…”

“…The comprehensive needs assessment addressed access to health care, economic status, housing status, psychological status, and social support. The program included the development of a shared data base, as well as the provision of continuing education and outreach to bridge healthcare and social care communication after hospital discharge [8].…”