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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.

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 (

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Poorly executed transitions of care (coordination and continuity of health care when moving from one health care setting to another) at hospital discharge often leads to poor outcomes.1-5 For example, the incidence of adverse events after hospital discharge was studied in two prospective cohorts with adverse event rates between 19% and 23%, respectively, of which half were judged preventable or ameliorable.6,7

Well-executed transitions of care, characterized by early follow-up after hospital discharge and a multimodal approach to the transition including patient education, medication reconciliation, and multidisciplinary coordination, are associated with reduced postdischarge events and costs.8-17 Early completion and receipt of a discharge summary is also crucial to reducing hospital readmissions.18,19 These high-quality transitions are easier to navigate within a single system of care, where information transfer, achieving early postdischarge appointments, and care coordination may be more straightforward to achieve. This is the case within the Veterans Health Administration (VHA), which operates as a largely closed system. However, the VHA is increasingly contracting with community providers to address shortfalls in access to care for Veterans,20,21 resulting in many Veterans being hospitalized in non-VHA hospitals nationally.22 Systems for ensuring safe transitions of care for Veterans who are hospitalized outside the VHA have not been established. Veterans have many unique comorbidities and psychosocial facets that create roadblocks to safe transitions of care not seen in the general population,23-25 and few electronic health records have a system that connects across different levels of care or between different organizations.26

In this pilot interfacility quality improvement intervention, our goal was to improve transitions of care for Veterans hospitalized at a nearby community hospital back to the VHA using a robust quality improvement process. There was not a specific quantitative goal improvement. We sought to do this by targeting processes shown to reduce preventable adverse events during the transitions of care process.

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Design and Ethics Approvals

The local VHA research and development committee and the institutional review board concurred that the intervention consisted of quality improvement rather than human subjects research, Protocol Number: 15–1,107.

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Sample and Setting

Eligible patients included all Veterans hospitalized at the Rose Medical Center (RMC) on a Medical/Surgical floor who were discharged home during our time period of interest and received primary care at the main VHA hospital. We excluded Veterans with patient-aligned care teams (PACTs) outside the main Denver clinics or Veterans who did not wish to follow up with the VHA for our initial plan-do-study-act (PDSA) cycles. We also excluded Veterans whose disposition was other than home (skilled nursing facility, long-term acute care, transfer to other hospital, etc.) and those who died at the RMC.

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Mapping the Preintervention Environment

We began by using “value stream mapping” (a Lean Six Sigma tool)27 to explore the existing process (see Figure, Supplemental Digital Content 1, and found that it had multiple failure points (Table 1). We engaged key stakeholders at two sites, our main VHA medical Center and RMC, the community hospital located across the street, given the close geography, collaboration, and communication.

Table 1

Table 1

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Intervention Development

Our intervention was informed by best practices for ideal transition of care: high-risk cohort, discharge planning, medication reconciliation, and timely communication.28-32 We then performed a quick review and interview of hospitalists and primary care physicians across the four hospitals that housed the Internal Medicine Residency Program to identify transitions of care processes being used at different sites. We found that no sites had an explicit process for connecting Veterans back to the VHA, but did find a multidisciplinary structured discharge information sheet checklist (MISC) used between a nonintegrated hospital and clinic of close proximity that had met with success and elected to modify this as our intervention.

We identified key stakeholders who were providers at the VHA and RMC, including nurse case managers at the community hospital, nurses and physicians on the PACT (the VHA's patient-centered medical home), and in the call center at the VHA. We engaged them in defining the problem and formulating/implementing an intervention. We met through multidisciplinary workgroup meeting and interviews several times before starting and once every PDSA33 cycle to ensure feasibility and acceptability.

Studies show that structured templates to communicate information improve the transitions of care process.28-31,34 Given this, our intervention included a process for (1) identifying Veterans hospitalized at the community site; (2) a checklist (MISC) nurse case managers could use at the community site with accurate fax numbers at the VHA; (3) a reliable process for the community nurse case managers to obtain follow-up appointments with the appropriate VHA PACT clinician through nurses in the VHA call center; and (4) a process for PACT nurses to respond to the faxed MISC in collaboration with the primary care provider. In the first step, Veterans were identified at the RMC by the nurse case managers who asked admitted patients about their payor and usual source of primary care.

In the second step, the single-page MISC included the following: primary care information (including primary care physician and clinic), a nursing section (assistive devices needed, vaccinations given, etc.), a physician section (diagnosis, outstanding results, high-risk medications needing approval, etc.), and a case management section (durable medical equipment, physical and occupational therapy, home health, substance abuse, etc.). The information was filled out entirely by the nurse case managers after gathering the information from other inpatient team members, typically at interdisciplinary meetings. The MISC was faxed over as a cover sheet with other discharge documentation (e.g., discharge summary, medication reconciliation, and laboratory and imaging results), which comprised the “transition of care documents.” The MISC also had the correct fax numbers for the three main VHA clinics (see Figures, Supplemental Digital Contents 2 and 3, and Patient-aligned care teams clinic and primary care physician assignment were identified when case managers of the RMC were calling to make follow-up appointments as part of the discharge process that began on the day of admission. If there was no PACT assignment for the Veteran, an urgent care appointment at one of the VHA clinics was made. Transitions of care documents were faxed directly to the clinic of follow-up. The hospitalist group at the RMC developed a “same day” discharge summary protocol that could be faxed with the MISC.

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Initiation of Plan-Do-Study-Act Cycles

We completed three PDSA cycles to enhance the intervention and to make it reliable, feasible, and acceptable to stakeholders, interviewing key stakeholders at the conclusion of each cycle to solicit input and identify areas to address in the next PDSA cycle (Table 2). The first cycle involved the development and implementation of our new care process. P1 was the development of the intervention described above (see Figure, Supplemental Digital Content 2, D1 marked the initiation of the intervention for all Veterans at the RMC, which started on February 1, 2015 and ran for 6 weeks. In S1, we interviewed key stakeholders over a 2-week period to study the implementation, focusing on adherence, usability, and feasibility. In A1, we found acceptance of the process on the RMC side, but breakdowns in communication on the VHA side once the faxes were received. We conducted further multidisciplinary workgroup meetings with each of the VHA clinic leaders and providers to formulate a plan to address this in cycle 2.

Table 2

Table 2

P2 involved developing and documenting a process map with VHA clinic leaders and providers on receiving and processing incoming transitions of care documents via a process map (see Figure, Supplemental Digital Content 4, and are summarized elsewhere (Table 2). D2 involved implementing the new plan and process map at the VHA clinics, again for 6 weeks. We studied the implementation adherence through chart review and feasibility and acceptability through key informant interviews in S2. In A2, we learned that the process was mostly well used, feasible, and had a positive perception except regarding a particular problem in primary care clinic “A.” The process map for all other clinics relied on the fact that the primary care physicians of every Veteran were full-time providers. However, primary care clinic “A” was a “resident only” clinic and residents, the primary care physicians for Veterans in this case, were only in the clinic for 1 week every 5 weeks because of the institution's block scheduling system. We collaborated with the attending physicians who worked in this clinic and clinic staff to develop a process incorporating intermittent providers in cycle 3.

In the third cycle, P3 involved documenting a plan to address the particular needs of primary care clinic “A” by altering the previous process map (see Figure, Supplemental Digital Content 4, In D3, we implemented the new VHA process map and intervention for 6 weeks. In S3, we used chart review and held final multidisciplinary workgroup meetings and interviews to study the process. In A3, we found that the entire process was reliable, feasible, and accepted by key stakeholders. However, we did discover that, in some cases, schedulers at the VHA were not working with case managers at the RMC because of the VHA Scheduling Directive requiring that the Veterans have input on the appointment date and time. We worked with our Health Administration Service leadership to develop a process where RMC case managers called the nurse triage line to schedule an appointment while they were with the Veteran to establish a mutually agreeable time. Each PDSA cycle was done by time and not by the number of patients in each cycle. There were 39 Veterans in total over all three cycles. Our intervention period incorporating these cycles ended on July 1, 2015, and after this, the intervention was considered fully implemented.

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Data Collection and Analysis

We categorized eligible Veterans during three time intervals: 6 months before the intervention, which acted as our control, 6 months during the intervention development and PDSA cycles, and 6 months when the intervention was considered fully implemented. Our primary outcomes were as follows: (1) the rate of appropriate transitions of care documents arriving before the postdischarge PACT appointment and (2) the percentage of Veterans attending a follow-up appointment at their VHA PACT site within 30 days. Secondary outcomes were reduction in emergency department visits or hospitalization within 30 days of discharge from the community hospital. All outcomes were ascertained through local chart review of VHA records, including scanned documents. Review was performed by a single physician abstractor with access to the electronic medical record at the VHA and RMC. Abstracted results were recorded on a virtual drive behind the VHA firewall on Excel (MS Excel 2010, Redmond, WA) and displayed on run charts to present and summarize data and evaluate trends; 30-day adverse event rates were compared using t-tests.

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During the intervention, 104 Veterans were admitted at the RMC: 24 during the preintervention period, 39 during early implementation, and 41 after completion of PDSA cycles.

There was a notable increase in the percentage of transitions of care documents received before the follow-up appointment, from 0% in the preintervention period to 16% during intervention development and 83% once fully implemented (Figure 1). Of note, in the final month, the rate dropped to 40% compared with every previous month after implementation being 80% or higher. Veterans also attended their follow-up appointment more frequently as the intervention progressed, from 25% of Veterans attending a follow-up appointment within 30 days of discharge from the RMC before the intervention to 54% during intervention development and 71% after implementation.

There was no significant change in our secondary outcome of any ED visits or hospital readmissions within 30 days, although a few of these events occurred (25% rate preintervention, 3% during early implementation, and 15% rate after PDSA cycle completion, pre–post p = not significant).

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Our primary limitation is that our intervention is context specific and may not be applicable to other situations. For example, our VHA and community hospital were geographically close, and the community hospital was eager to have solutions for Veterans commonly hospitalized at their site. We only initially attempted the intervention between a single community hospital and three clinics at the main VHA facility, and although our process should be similar on the VHA side, we did not trial the intervention using multiple community hospitals and outlying VHA clinic sites. It is also unclear how this process might translate to a non-VHA context because the VHA is largely an integrated care system. We did not abstract why a certain percentage of the time transitions of care documents were not received and follow-up appointments were not attended. Also, we were not powered to detect the intervention's effect on decreasing hospital readmission rates or mortality.

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Our intervention improved transitions of care processes for Veterans hospitalized at a non-VHA facility by increasing the rate of Veteran attendance at follow-up appointments and by having important information and documentation delivered to primary care physicians before that appointment, thus enabling them to make decisions based on accurate clinical information. It continued to be used in the 6-month period after our PDSA cycles ended, indicating early evidence of feasibility and acceptability. We hypothesize that the improvement in postdischarge clinic attendance was simply due to a change in process: instead of using the preimplementation process (where the Veteran was left to coordinate their own postdischarge care), RMC case managers assessed transportation needs and obtained an appointment at a time convenient for Veterans before discharge, enhancing the likelihood of follow-up.35

Previous work in community-based participatory research, chronic care management, Chronic Care Management and in the Partnership for Research Integrity in Science & Medicine shows that engaging multiple stakeholders and “end users” helps in contributing their diverse expertise to the development of research with an increased likelihood of improving patient health and health care.36-38 Our intervention's success may be attributed to engaging stakeholders early in the process to collaborate on an ideal process, simplifying it to make it less burdensome. The intervention may also have been successful because it could be easily integrated within a system and only required two sheets of paper with directions. To our knowledge, this is the first joint VHA-community hospital project undertaken to create and analyze transitions of care intervention between these two types of facilities.

A major focus of our intervention was to increase communication between care teams. Having a discharge summary at a hospital follow-up is not only helpful in clinical decision making, it has been shown to decrease hospital readmission.18,19 Also, rather than a passive pool of information, our intervention directly involves the two important parties in the transitions of care process (hospital and primary care physician) and actively provides the primary care physician with notification of discharge, as well as the most pertinent information. Actively providing transitional information has been previously shown to be a superior strategy for reducing postdischarge adverse events.14,19,26,28 In addition, our intervention improved the rate of follow-up 30 days after discharge to 71%, which is above the national average rate of follow-up in the Medicare population.39 This is of interest given the pressing need for integrated care brought about by patient-centered medical homes and accountable care organizations.40,41

We had a concerning signal about the intervention's sustainability with a drop in the transitions of care documents receipt in the past month postimplementation; similar to other quality improvement interventions, an intervention of this type likely requires ongoing efforts to make the process reliable and sustainable. It is possible that our intervention time period was not long enough to “enculturate” the new process into the workflow of both institutions.

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Engaging case managers at community hospitals and primary care clinics at the VHA through an integrated quality improvement intervention led to improved communication about Veteran discharge needs and improved Veteran follow-up for postdischarge care. This program is being expanded with VHA support to other hospitals in the area, and the community hospital's case managers have already expanded the practice into other VHA clinics in our system. This will allow better evaluation of both implementation and patient outcomes.

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Our intervention improved the rates of receipt of transitions of care documents before a follow-up appointment and the attendance at a follow-up appointment by Veterans after hospitalization; these process measures are linked with reductions in 30-day readmission rates. Similar to other quality improvement interventions, our program required significant work to map the current process, engage front-line staff at the VHA and the non-VHA hospital, create a new process, and champion the process. This level of effort must be weighed against the positive outcomes of increased information transfer and postdischarge follow-up for Veterans hospitalized outside the VHA. This intervention, if replicated in other settings, may provide opportunities for both VHA, which is increasingly using community resources to provide care for Veterans, and non-VHA organizations, which have increasing responsibility for the postdischarge outcomes of their patients to deliver on the promise of high-quality to perform seamless transitions in care.

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1. Crossing the Quality Chasm. A New Health System for the 21st Century. Washington, DC: The National Academies Press; 2001.
2. Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians: Implications for patient safety and continuity of care. JAMA. 2007;297(8):831–841.
3. Moore C, Wisnivesky J, Williams S, McGinn T. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med. 2003;18(8):646–651.
4. Rennke S, Nguyen OK, Shoeb MH, Magan Y, Wachter RM, Ranji SR. Hospital-initiated transitional care interventions as a patient safety strategy: A systematic review. Ann Intern Med. 2013;158(5 pt 2):433–440.
5. Cibulskis CC, Giardino AP, Moyer VA. Care transitions from inpatient to outpatient Settings: Ongoing challenges and emerging best practices. Hosp Pract (1995). 2011;39(3):128–139.
6. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138(3):161–167.
7. Forster AJ, Clark HD, Menard A, et al. Adverse events among medical patients after discharge from hospital. CMAJ. 2004;170(3):345–349.
8. Gardner R, Li Q, Baier RR, Butterfield K, Coleman EA, Gravenstein S. Is implementation of the care transitions intervention associated with cost avoidance after hospital discharge? J Gen Intern Med. 2014;29(6):878–884.
9. Field TS, Ogarek J, Garber L, Reed G, Gurwitz JH. Association of early post-discharge follow-up by a primary care physician and 30-day rehospitalization among older adults. J Gen Intern Med. 2015;30(5):565–571.
10. Misky GJ, Wald HL, Coleman EA. Post-hospitalization transitions: Examining the effects of timing of primary care provider follow-up. J Hosp Med. 2010;5(7):392–397.
11. Sharma G, Kuo YF, Freeman JL, Zhang DD, Goodwin JS. Outpatient follow-up visit and 30-day emergency department visit and readmission in patients hospitalized for chronic obstructive pulmonary disease. Arch Intern Med. 2010;170(18):1664–1670.
12. Hernandez AF, Greiner MA, Fonarow GC, et al. Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. JAMA. 2010;303:1716–1722.
13. Peter D, Robinson P, Jordan M, Lawrence S, Casey K, Salas-Lopez D. Reducing readmissions using teach-back: Enhancing patient and family education. J Nurs Adm. 2015;45:35–42.
14. Rochester-Eyeguokan CD, Pincus KJ, Patel RS, Reitz SJ. The current landscape of transitions of care practice models: A scoping review. Pharmacotherapy. 2016;36(1):117–133.
15. Kind AJ, Jensen L, Barczi S, et al. Low-cost transitional care with nurse managers making mostly phone contact with patients cut re-hospitalization at a VA hospital. Health Aff (Millwood). 2012;31:2659–2668.
16. Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Schwartz JS. Transitional care of older adults hospitalized with heart failure: A randomized controlled trial. J Am Geriatr Soc. 2004;52:675–684.
17. Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: Results of a randomized controlled trial. Arch Intern Med. 2006;166:1822–1828.
18. Hoyer EH, Odonkor CA, Bhatia SN, Leung C, Deutschendorf A, Brotman DJ. Association between days to complete inpatient discharge summaries with all-payer hospital readmissions in Maryland. J Hosp Med. 2016;11(6):1553–5606.
19. Van Walraven C, Seth R, Austin PC, Laupacis A. ffect of discharge summary availability during post-discharge visits on hospital readmission. J Gen Intern Med. 2002;17(3):186–192.
22. National Center for Veterans Analysis and Statistics. Utilization. 2014. Accessed June 24, 2016.
23. Lee TA, Shields AE, Vogeli C, et al. Mortality rate in Veterans with multiple chronic conditions. J Gen Intern Med. 2007;22(suppl 3):403–407.
24. Patel N, Golzy M, Nainani N, et al. Prevalence of various comorbidities among veterans with chronic kidney disease and its comparison with other datasets. Ren Fail. 2016;38(2):204–208.
25. Nuti S, Qin L, Rumsfeld J, et al. Association of admission to Veterans affairs hospitals vs non-veterans affairs hospitals with mortality and readmission rates among older men hospitalized with acute myocardial infarction, heart failure, or pneumonia. JAMA. 2016;315(6):582–592.
26. Coleman EA, Berenson RA. Lost in transition: Challenges and opportunities for improving the quality of transitional care. Ann Intern Med. 2004;141(7):533–536.
27. Rother M, Shook J. Learning to See: Value Stream Mapping to Add Value and Eliminate Muda. Cambridge: Lean Enterprise Institute; 2003:115.
28. Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Promoting effective transitions of care at hospital discharge: A review of key issues for hospitalists. J Hosp Med. 2007;2(5):314–323.
29. Snow V, Beck D, Budnitz T, et al. Transitions of care consensus policy statement American college of physicians-society of general internal medicine-society of hospital medicine-American geriatrics society-American college of emergency physicians-society of academic emergency medicine. J Gen Intern Med. 2009;24(8):971–976.
30. Tang Ning. A primary care Physician's ideal transitions of care-where's the Evidence?: Ideal transitions of care. J Hosp Med. 2013;8(8):472–477.
31. Joint Commission Center for Transforming Healthcare releases targeted solutions tool for hand-off communications. Jt Comm Perspect. 2012;32(8):1. Accessed April 2, 2016.
32. Burke RE, Guo R, Prochazka AV, Misky GJ. Identifying keys to success in reducing readmissions using the ideal transitions in care framework. BMC Health Serv Res. 2014;14:423.
34. Halasyamani L, Kripalani S, Coleman E, et al. Transition of care for hospitalized elderly patients—development of a discharge checklist for hospitalists. J Hosp Med. 2006;1(6):354–360.
35. Banerjee R, Suarez A, Kier M, et al. If you book it, will they come? Attendance at postdischarge follow-up visits scheduled by inpatient providers. J. Hosp. Med. 2017;8:618–625.
37. Feldstein AC, Glasgow RE. A practical, robust implementation and sustainability model (PRISM) for integrating research findings into practice. Jt Comm J Qual Patient Saf. 2008;34(4):228–243.
38. Burke JG, Jones J, Yonas M, et al. PCOR, CER, and CBPR: Alphabet soup or complementary fields of health research? Clin Transl Sci. 2013;6(6):493–496.
39. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418–1428.
40. Medicare Payment Advisory Commission. Report to the Congress: Promoting Greater Efficiency in Medicare. Washington, DC: Medicare Payment Advisory Commission; 2007.
41. McCarthy D, Johnson MB, Audet A. Recasting readmissions by placing the hospital role in community context. JAMA. 2013;309:351–352.
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Authors' Biographies

James V. Libbon, MD, affiliated to the University of Colorado Hospital in Aurora, CO, is the primary investigator of this study. He is currently a graduate of Internal Medicine Primary Care Residency at the University of Colorado and is a Fellow in Geriatrics at the same institution.

Leta C. Gill-Scott, MSN, CCM, iRNPA, LNC, is currently a lead Case Manager at Rose Medical Center in Denver, CO. She assisted with supervising the implementation of our intervention with the other case managers.

Carrie Meg Austin, MD, was a lead hospitalist at Rose Medical Center in Denver, CO, who assisted with educating other hospitalists regarding the intervention we put in place. She is currently the Chief Medical Officer of Rose Hospital.

Robert E. Burke, MD, MS, was the senior supervisor of the project. He is currently the Chief of Hospital Medicine and Associate Chief of Medicine at Denver, CO VHA where he practices as an academic hospitalist and health services researcher.


transitions of care; quality improvement; veterans

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