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Improving the Transition of Care Process for Veterans Hospitalized at Non-VHA Facilities

Libbon, James V.; Austin, Carrie Meg; Gill-Scott, Leta C.; Burke, Robert E.

The Journal for Healthcare Quality (JHQ): March/April 2019 - Volume 41 - Issue 2 - p 68–74
doi: 10.1097/JHQ.0000000000000159
Original Article

ABSTRACT Veterans receiving primary care through the Veterans Health Administration (VHA) are at increased risk of adverse outcomes when transitioning from a non-VHA hospitalization to VHA primary care. We intervened to improve these care transitions through identifying Veterans at a partnered community hospital, use of a multidisciplinary patient-structured discharge information sheet for community case managers to effectively communicate with VHA clinics, and implementation of a VHA site process for receiving information. We evaluated the intervention on two endpoints: the percentage-relevant documentation was received at the VHA before follow-up appointment and the rate Veterans attended a follow-up appointment at the VHA. Rates for receiving transitions of care documents were as follows: 0% preintervention (N = 24), 16% in the first 6 months of intervention (N = 39), and 83% after plan-do-study-act cycles in the second 6 months (N = 41). Veteran follow-up attendance also improved 25% preintervention to 54% and 71%, respectively. This process could serve as a model for transitions of care improvement.

For more information on this article, contact James V. Libbon at

The authors declare no conflicts of interest.

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© 2019 National Association for Healthcare Quality
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