Perspectives of Clinicians, Staff, and Veterans in Transitioning Veterans from non-VA Hospitals to Primary Care in a Single VA Healthcare System
BACKGROUND: Veterans with healthcare needs utilize both Veterans Health Administration (VA) and non-VA hospitals. These dual-use veterans are at high risk of adverse outcomes due to the lack of coordination for safe transitions.
OBJECTIVES: The aim of this study was to understand the barriers and facilitators to providing high-quality continuum of care for veterans transitioning from non-VA hospitals to the VA primary care setting.
DESIGN: Guided by the practical robust implementation and sustainability model (PRISM) and the ideal transitions of care, we conducted a qualitative assessment using semi-structured interviews with clinicians, staff, and patients.
SETTING: This study was conducted at a single urban VA medical center and two non-VA hospitals.
PARTICIPANTS: A total of 70 participants, including 52 clinicians and staff (23 VA and 29 non-VA) involved in patient transition and 18 veterans recently discharged from non-VA hospitals, were included in this study.
APPROACH: Data were analyzed using a conventional content analysis and managed in Atlas.ti (Berlin, Germany).
RESULTS: Four major themes emerged where participants consistently discussed that transitions were delayed when they were not able to (1) identify patients as veterans and notify VA primary care of discharge, (2) transfer non-VA hospital medical records to VA primary care, (3) obtain follow-up care appointments with VA primary care, and (4) write VA formulary medications for veterans that they could fill at VA pharmacies. Participants also discussed factors involved in smooth transition and recommendations to improve care coordination.
CONCLUSIONS: All participants perceived the current transition-of-care process across healthcare systems to be inefficient. Efforts to improve quality and safety in transitional care should address the challenges clinicians and patients experience when transitioning from non-VA hospitals to VA primary care.
© 2020 Society of Hospital Medicine
Non-VA clinicians, administrators, and staff also discussed the difficulties in scheduling follow-up care with VA primary care. Although discharge paperwork instructed patients to see their VA clinicians, there was no process in place for non-VA clinicians to confirm whether the follow-up care was received due to lack of bilateral communication. In addition, veterans discussed the inefficiencies in scheduling follow-up appointments with VA clinicians where attempts to follow-up with primary care clinicians took eight weeks or more. Several veterans described walking into the clinic without an appointment asking to be seen postdischarge or utilizing the VA emergency department for follow-up care after discharge from a non-VA hospital. Veterans admitted utilizing the VA emergency department for nonemergent reasons such as filling their prescriptions because they are unable to see a VA PCP in a timely manner (Table 2, Theme 3).
Unable to Write VA Formulary Medications for Veterans to Fill at VA Pharmacies
All participants described the difficulties in obtaining medications at VA pharmacies when prescribed by the non-VA hospital clinicians. VA clinicians often had to reassess, and rewrite prescriptions written by clinicians, causing delays. Moreover, rural VA clinicians described lack of VA pharmacies in their locations, where veterans had to mail order medications, causing further delays in needed medications. Non-VA clinicians echoed these frustrations. They noted that veterans were confused about their VA pharmacy benefits as well as the need for the non-VA clinicians to follow VA formulary guidelines. Veterans expressed that it was especially challenging to physically go to the VA pharmacy to pick up medications after discharge due to lack of transportation, limited VA pharmacy hours, and long wait times. Several veterans discussed paying for their prescriptions out of pocket even though they had VA pharmacy benefits because it was more convenient to use the non-VA pharmacy. In other instances, veterans discussed going to a VA emergency department and waiting for hours to have their non-VA clinician prescription rewritten by a VA clinician (Table 2, Theme 4).
Facilitators of the Current Transition Process
Several participants provided examples of when transitional care communication between systems occurred seamlessly. VA staff and veterans noted that the VA increased the availability of urgent care appointments, which allowed for timelier postacute care follow-up appointments. Non-VA hospital clinicians also noted the availability of additional appointment slots but stated that they did not learn about these additional appointments directly from the VA. Instead, they learned of these through medical residents caring for patients at both VA and non-VA hospitals. One VA CBOC designated two nurses to care for walk-in veterans for their postdischarge follow-up needs. Some VA participants also noted that the VA Call Center Nurses occasionally called veterans upon discharge to schedule a follow-up appointment and facilitated timely care.
Participants from a VA CBOC discussed being part of a Community Transitions Consortium aimed at identifying high-utilizing patients (veteran and nonveteran) and improving communication across systems. The consortium members discussed each facility’s transition-of-care process, described having access to local non-VA hospital medical records and a backline phone number at the non-VA hospitals to coordinate transitional care. This allowed the VA clinicians to learn about non-VA hospital processes and veteran needs.
