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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
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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 James.libbon@ucdenver.edu.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article at (www.jhqonline.com).

© 2019 National Association for Healthcare Quality
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