» Table of Contents

New Program Helps Rural Veterans through Transitions in VA and Non-VA Care

Veterans increasingly access healthcare services across multiple healthcare systems, and routinely receive care both within and outside VA. Poorly managed transitions of care between healthcare systems can have negative health outcomes for these dual-use Veterans, such as increased re-hospitalization and increased cost. To ensure continuous access to quality care, investigators with VA HSR&D’s Triple Aim QUERI program developed a Community Hospital Transitions Program that facilitates the transitions of Veterans from community hospitalizations back to VA primary care. This program works in conjunction with the VA Rural Transitions Nurse Program (TNP), which provides nurse-led transitional care coordination for rural Veterans discharged from a tertiary VA facility.

To understand the need for care coordination in the VA, QUERI investigators formally assessed the current state of transitions of care. Prior to implementing the Community Hospital Transitions Program and the Rural TNP, investigators conducted 7 site visits and 123 key informant interviews with VA and community providers, nurses, administrative staff, and Veterans across all sites. These interviews and site visits revealed internal and external barriers that hindered care coordination, as well as suggestions to guide the interventions.

Both the Community Hospital Transitions Program and the Rural TNP have two core elements:

• A Transitions Nurse who acts as a liaison between hospital providers and VA primary care providers, and
• System changes to facilitate increased communication between admitted or recently discharged Veterans, VA primary care, and non-VA community hospitals.

During program implementation, QUERI investigators provided in-services at VA primary care (urban and rural sites) and VA and community hospitals, conducted phone meetings with key stakeholders, and provided resources to community hospitals that included program manuals, newsletters, and quick reference guides. Internal and external facilitation, coupled with audit and feedback, were used to encourage appropriate adaptations of the programs to each implementation site. Finally, to ensure that program success and the sustainability of the program were measured – and to track return on investment, QUERI investigators continue to evaluate their process.

To date, these two transitions programs have reached more than 2,000 Veterans at 12 sites nationwide, covering multiple VISNs (Veterans Integrated Service Networks). The programs implement standardized interventions across sites, yet have adaptable components to allow the programs to fit into the unique contexts of VA facilities. The programs use site champions and locally hired Transitions Nurses, who work closely with the implementation teams. In addition, program interventions, implementation methods, and evaluation plans are outlined in implementation guides. The primary goal of both programs is to address gaps in the current transitions of care process for vulnerable Veterans. A secondary aim is to learn the best methods to implement, evaluate, and sustain the interventions to create seamless transitional care for all Veterans.

For more information about the transitions of care programs and/or Triple Aim QUERI, please contact Catherine Battaglia, PhD, RN, at Catherine.Battaglia@va.gov .