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Ensuring Veterans Get Optimal Care after VA Emergency Department Visits

When Veterans do not receive coordinated services across care transitions, they are at risk of not getting the care they need, as well as having suboptimal care experiences.  At the VA Greater Los Angeles Healthcare System, Emergency Department (ED) and Patient Aligned Care Team (PACT) providers and staff were concerned about frequent communication breakdowns between ED providers and PACT team members, especially for Veterans who had urgent or specific follow-up care needs after ED visits. Therefore, a multidisciplinary and inter-professional team embarked on a quality improvement process to investigate and improve coordination across this vulnerable care transition. This process led to the development and implementation of the ED-PACT Tool.

When an emergency department provider uses the ED-PACT Tool to describe urgent or specific follow-up care needs for a Veteran discharged home from the ED, a message is sent within VA’s Computerized Patient Record System (CPRS) to the patient’s PACT Registered Nurse (RN) care manager in the form of a care coordination order. The RN care manager accesses the message detailing the Veteran’s care needs, embedded within the order, and communicates with the primary care provider and other PACT team members to address and coordinate the Veteran’s follow-up care needs.

The ED-PACT tool encapsulates several communication best practices. In addition to leveraging CPRS to send the messages, the sending and receiving of messages is embedded into the workflow of the ED and PACT providers and nurses. Further, providers sending the messages use a standardized process and form, with the form identifying the critical components of information needed by the receiver for effectively assuming management of the patient’s care. The RN care manager’s “completing” the order signals receipt of the message, thereby creating a “closed loop” communication system.

Since November 1, 2015, the ED-PACT tool has been used to send more than 7,000 messages to PACTs across 20 VA clinics, and the domiciliary, in the VA Greater Los Angeles Healthcare System. As determined by sampling 150 orders, Veterans’ care needs coordinated by this tool include: symptom recheck (55%), care coordination (16%), wound care (5%), medication adjustment (5%), laboratory recheck (5%), radiology follow-up (3%), and blood pressure recheck (3%).

In addition, formative evaluation revealed that providers and RNs perceive the tool as providing substantial benefit for coordinating post-ED care. ED providers have noted the advantage of having a standardized and reliable system for communicating with PACT, and that having such a reliable system has averted some inpatient admissions. Leaders reported that RN training and “buy-in” facilitated tool implementation, while insufficient staffing and limits in the capabilities of CPRS have been barriers.

The ED-PACT Tool was initially formulated as a VISN 22 PACT Demonstration Laboratory (VAIL) Innovation, with support from the VA Office of Primary Care.  Further development, and its implementation across PACT clinics, as well as its formative evaluation, was supported by the Care Coordination QUERI Program. An implementation workbook, describing the ED-PACT Tool in detail, and the steps that GLA took to implement it, is available.

To obtain a copy of this workbook, or for more information, contact Kristina Cordasco, MD, MPH, at Kristina.Cordasco@va.gov .