Perspectives of Clinicians, Staff, and Veterans in Transitioning Veterans from non-VA Hospitals to Primary Care in a Single VA Healthcare System

Suggestions for Improving the Transitional Care Process

VA and non-VA clinicians suggested hiring a VA liaison, preferably with a clinical background to facilitate care coordination across healthcare systems. They recommended that this person work closely with VA primary care, strengthen the relationship with non-VA hospitals, and help veterans learn more about the transition-of-care processes. Topics discussed for veteran education included how to (1) access their primary care team; (2) alert VA of non-VA hospitalization and the billing process; (3) recognize symptoms and manage care; and (4) obtain follow-up care appointments. Furthermore, they suggested that the liaison would help facilitate the transfer of medical records between VA and non-VA hospitals. Other suggestions included allowing veterans to fill prescriptions at non-VA pharmacies and dedicating a phone line for non-VA clinicians to speak to VA clinicians and staff.

Veterans agreed that improvements to the current process should include an efficient system for obtaining medications and the ability to schedule timely follow-up appointments. Furthermore, veterans wanted education about the VA transition-of-care process following a non-VA hospitalization, including payment and VA notification processes (Table 2, Theme 5).

Participants described the current transitional care process as inefficient with specific barriers that have negative consequences on patient care and clinician and staff work processes. They described difficulties in obtaining medications prescribed by non-VA clinicians from VA pharmacies, delays in follow-up appointments at the VA, and lack of bilateral communication between systems and medical record transfer. Participants also provided concrete suggestions to improving the current process, including a care coordinator with clinical background. These findings are important in the context of VA increasing veteran access to care in the community.

Despite an increasing emphasis on veteran access to non-VA care as a result of the VA strategic goals and several new programs,^7,12,13 there has not been a close examination of the current transition-of-care process from non-VA hospitals to VA primary care. Several studies have shown that the period following a hospitalization is especially vulnerable and associated with adverse events such as readmission, high cost, and death.^12,31,32 Our findings agree with previous research that identified medical record transfer across systems as one of the most challenging issues contributing to deficits in communication between care teams.³³ In addition, our study brought into focus the significant challenges faced by veterans in obtaining medications post non-VA hospital discharge. Addressing these key barriers in transitional care will improve the quality, safety, and value of healthcare in the current transition process.^38,39

Based on our findings, our participants’ concern in transitional care can be addressed in various ways. First, as veterans are increasingly receiving care in the community, identifying their veteran status early on in the non-VA hospital setting could help in improved, real time communication with the VA. This could be done by updating patient intake forms to ask patients whether they are veterans or not. Second, VA policy-level changes should work to provide veterans access to non-VA pharmacy benefits equivalent to the access patients are receiving for hospital, specialty, and outpatient care. Third, patient and provider satisfaction for dual-use veterans should be examined closely. Although participants expressed frustration with the overall transitions of care from non-VA hospitals to VA primary care setting, influence of this on the Quadruple Aim-improving patient outcomes, experience, and reducing clinician and staff burnout should be examined closely.⁴⁰ Fourth, evidence-based interventions such as nurse-led transitional care programs that have proven helpful in reducing adverse outcomes in both VA and non-VA settings will be useful to implement.^41-45 Such programs could be located in the VA, and a care coordinator role could help facilitate transitional care needs for veterans by working with multiple non-VA hospitals.

The limitations of this study are that the perspectives shared by these participants may not represent all VA and non-VA hospitals as well as veterans’ experiences with transition of care. In addition, the study was conducted in one state and the findings may not be applicable to other healthcare systems. However, our study highlighted the consistent challenges of receiving care across VA and other hospital systems. Two strengths of this study are that it was conducted by multidisciplinary research team members with expertise in qualitative research, clinical care, and implementation science and that we obtained convergent information from VA, non-VA, and veteran participants.

Our current transition-of-care process has several shortcomings. There was a clear agreement on barriers, facilitators, and suggestions for improving the current transitions-of-care process among VA and non-VA hospital participants, as well as from veterans who experienced transitions across different delivery systems. Transitioning veterans to VA primary care following a non-VA hospitalization is a crucial first step for improving care for veterans and reducing adverse outcomes such as avoidable hospital readmissions and death.

These results describe the inefficiencies experienced by patients, clinicians, and staff and their suggestions to alleviate these barriers for optimal continuum of care. To avoid frustration and inefficiencies, the increased emphasis of providing non-VA care for veterans should consider the challenges experienced in transitional care and the opportunities for increased coordination of care.