Perspectives of Clinicians, Staff, and Veterans in Transitioning Veterans from non-VA Hospitals to Primary Care in a Single VA Healthcare System
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.
© 2020 Society of Hospital Medicine
As the VA moves toward increased utilization of non-VA care, it is crucial to understand and address the challenges of transitional care faced by dual-use veterans to provide high-quality care that improves healthcare outcomes.7,11,12 The VA implemented a shift in policy from the Veterans Access, Choice, and Accountability Act of 2014 (Public Law 113-146; “Choice Act”) to the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act beginning June 6, 2019.13,14 Under the MISSION Act, veterans have more ways to access healthcare within the VA’s network and through approved non-VA medical providers in the community known as “community care providers.”15 This shift expanded the existing VA Choice Act of 2014, where the program allowed those veterans who are unable to schedule an appointment within 30 days of their preferred date or the clinically appropriate date, or on the basis of their place of residence, to elect to receive care from eligible non-VA healthcare entities or providers.14,15 These efforts to better serve veterans by increasing non-VA care might present added care coordination challenges for patients and their providers when they seek care in the VA.
High-quality transitional care prevents poor outcomes such as hospital readmissions.16-18 When communication and coordination across healthcare delivery systems are lacking, patients and their families often find themselves at risk for adverse events.19,20 Past research shows that patients have fewer adverse events when they receive comprehensive postdischarge care, including instructions on medications and self-care, symptom recognition and management, and reminders to attend follow-up appointments.17,21,22 Although researchers have identified the components of effective transitional care,23 barriers persist. The communication and collaboration needed to provide coordinated care across healthcare delivery systems are difficult due to the lack of standardized approaches between systems.24 Consequently, follow-up care may be delayed or missed altogether. To our knowledge, there is no published research identifying transitional care challenges for clinicians, staff, and veterans in transitioning from non-VA hospitals to a VA primary care setting.
The objective of this quality assessment was to understand VA and non-VA hospital clinicians’ and staff as well as veterans’ perspectives of the barriers and facilitators to providing high-quality transitional care.
