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1 Lessons Learned From the Field Audit & Feedback with Rapid Prototyping Helped Redesign a Care Coordination Program During Scale-Up Lindsay B. Miller VA Eastern Colorado Health Care System Disclosures 2 No relevant disclosures

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Lessons Learned From the Field

Audit & Feedback with Rapid Prototyping Helped Redesign a Care Coordination Program During Scale-Up

Lindsay B. Miller VA Eastern Colorado Health Care System

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Disclosures

  • No relevant disclosures
  • Disclaimer: The contents of this presentation do not represent the views of the

Department of Veterans Affairs or the United States Government

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Background

  • Veterans with complex care needs often require services at both the Veterans Health

Administration (VA) and non-VA community hospitals

  • Dual-use Veterans are at high-risk of adverse outcomes due to lack of cross-system

coordination:

  • Be hospitalized and readmitted to the hospital within 30 days1,2
  • Have conflicting or duplicated tests and treatments3,4
  • Be less satisfied with their care5
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The Community Hospital Transitions Program6

  • Facilitates information transfer
  • Obtains follow-up appointments and

medications

  • Contacts Veterans after discharge
  • Solves problems with end-users

Community Hospital Transitions Nurse System Changes to Facilitate Coordination

  • Direct phone line for notification
  • Electronic fax for discharge

summary

  • Care Card given to Veterans
  • Database built for evaluation
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Community Hospital Transitions Nurse Workflow

Transitions Nurse receives notification about Veteran admitted at a Community Hospital Transitions Nurse facilitates medical information transfer: receives discharge records and notifies VA Primary Care Transitions Nurse follows up with Veteran post- discharge Transitions Nurse facilitates follow up with VA Primary Care

Veteran is admitted to a community hospital Veteran receives follow up with VA Primary Care

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Need for Recalibration

  • Overwhelming Demand
  • 56 new Veterans each week on average
  • 37 community hospitals
  • Unintended Consequences

1.

High workload for 1 Transitions Nurse

2.

Engaging 37 community hospitals in education is time consuming

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Implementation Strategies

  • Audit and feedback
  • Weekly data reports and communication with study team
  • Rapid Prototyping
  • Revised initial intervention to reduce variability
  • 4 Core Components
  • LEAN approach
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Community Hospital Transitions Program Core Components

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Current Version of the CHTP

  • 4 Core Components
  • Recalibrated the scope of the CHTP

to fit workload

  • 5 Top Community Hospitals
  • High-volume and greatest need
  • Greater buy-in
  • More timely notification of admission
  • Accepted new patients through

hospital notifications or direct contact from patients

  • Real-time updates on VA system

changes Process Changes Improvements

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Results

  • 472 total Veterans who completed the intervention between 10/1/2017 and 9/30/2018
  • Time between Veterans’ admission and our notification: 1.67 days
  • Time between the discharge date and date discharge summary received: 3.44 days
  • Time of first post-discharge call to Veteran by CHTN: 4.63 days
  • Time from discharge to VA follow-up appointment: 12.63 days
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Lessons Learned

  • Start slow--even if it feels too slow
  • Fewer completed interventions is better than many incomplete interventions
  • Record, analyze, implement, repeat!
  • Expanded to the VA Nebraska Western Iowa Health Care System in June 2018
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Reach How do I reach those who need this intervention? Effectiveness How do I know my intervention is working? Adoption How do I develop

  • rganizational

support to deliver my intervention? Implementation How do I ensure the intervention is delivered properly? Maintenance How do I incorporate the intervention so it is delivered over long-term?

Evaluation Framework7

RE-AIM

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References

  • 1. Axon RN, et al. Dual health care system use is associated with higher rates of hospitalization and hospital

readmission among veterans with heart failure. Am Heart J. 2016;174:157-163.

  • 2. Humensky J, et al. Service utilization of veterans dually eligible for VA and Medicare fee-for-service: 1999-
  • 2004. Medicare Medicaid Res Rev. 2012;2(3).
  • 3. Nguyen KA, et al. Medication Use among Veterans across Health Care Systems. Appl Clin Inform.

2017;8(1):235-249.

  • 4. West AN, et al. Insured Veterans’ Use of VA and Non-VA Health Care in a Rural State. J Rural Health Off J Am

Rural Health Assoc Natl Rural Health Care Assoc. 2016;32(4):387-396.

  • 5. Nayar P, et al. Rural veterans’ perspectives of dual care. J Community Health. 2013;38(1):70-77.
  • 6. Ayele RA, Lawrence E, McCreight M, et al. Study protocol: improving the transition of care from a non-network

hospital back to the patient's medical home. BMC Health Serv Res. 2017;17(123).

  • 7. Glasgow RE, Vogt TM, Boles SM. Evaluating the public health impact of health promotion interventions: the

RE-AIM framework. Am J Public Health. 1999;89(9):1322-1327.

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ACKNOWLEDGEMENTS

PI: Catherine Battaglia Roman Ayele Kelty Fehling David Gaskin Russell Glasgow Madhura Gokhale Tuula Kallioniemi Lynette Kelley Wenhui (Grace) Liu Ashlea Mayberry Marina McCreight Lindsay Miller Borsika Rabin Heidi Sjoberg Mehret (Mercy) Tekle CHTP site champion and Transitions Nurse Funding Partners: QUERI

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Questions?

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THANK YOU!

  • Lindsay Miller, BA
  • Denver-Seattle Center of Innovation for Veteran Centered and Value-Driven Care
  • LindsayMiller8@va.gov

@SeaDenCOIN