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2023 HSR&D/QUERI National Conference Abstract

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1080 — Veteran knowledge, perceptions and receipt of care following visits to VA emergency departments for ambulatory care sensitive conditions

Lead/Presenter: Kristina Cordasco,  COIN - Los Angeles
All Authors: Cordasco KM (Center for the Study of Healthcare Innovation, Implementation & Policy), ; Gable AR (Center for the Study of Healthcare Innovation, Implementation & Policy); Tan GJ (Center for the Study of Healthcare Innovation, Implementation & Policy); Yuan AH (Center for the Study of Healthcare Innovation, Implementation & Policy); Yip K (VA Greater Los Angeles Healthcare System); Khafaf M (VA Greater Los Angeles Healthcare System); Hays R (David Geffen School of Medicine at the University of California, Los Angeles); Faiz JP (National Clinician Scholars Program at the University of California, Los Angeles); Chawla N (Center for the Study of Healthcare Innovation, Implementation & Policy); Ganz DA (Center for the Study of Healthcare Innovation, Implementation & Policy)

Objectives:
Follow-up care needs are common among Veterans with Emergency Department (ED) visits for chronic ambulatory care sensitive conditions (ACSCs) — asthma, chronic obstructive pulmonary disease, heart failure, diabetes, and/or hypertension — and receipt of follow-up chronic disease management is crucial for preventing disease progression and ED revisits. We assessed Veterans’ follow-up care knowledge, perceptions, and receipt of care after visits to Veterans Health Administration (VA) EDs for chronic ACSCs.

Methods:
We used explanatory sequential mixed methods, interviewing Veterans having follow-up care needs after ACSC-related visits to one of eight VA EDs in Veterans Integrated Service Network 22. Interviews were recorded, transcribed, and summarized. We integrated interview summaries with medical record review by abstracting interviewees’ documented follow-up care needs (per ED notes) and care received (per post-ED notes). Grouping data into matrices by domains across interviewees, we engaged in a multidisciplinary team-based analytic process.

Results:
We completed 35 interviews (7 in March 2020; 28 from September-November 2020), 12-27 (mean 19) days after ED visits. In 32 cases, ED notes indicated need for primary care follow-up, whereas notes less commonly specified specialty care follow-up (n = 13), tests to be performed (n = 5), and/or results to be obtained (n = 2). The indicated follow-up care was completely received/scheduled in 20, partially received/scheduled in 8, and not received in 7 Veterans. Among the 28 Veterans in whom all or some follow-up care had been received/scheduled, in 25 cases VA staff reached out to the Veteran after the visit, or the appointment was scheduled prior to or during the ED visit. Timeframes for follow-up care were specified in ED notes for 26 Veterans. However, interviewees often did not recall these specified timeframes or reported them to be longer than specified. Veterans who had not yet received/scheduled follow-up care commonly did not recall follow-up instructions, believed that they did not need this care since they were not currently having symptoms, or thought that such care would be difficult to obtain due to appointment unavailability. Several interviewees expressed frustrations regarding communicating with follow-up care providers (e.g., not having phone calls returned); some stated intention to return to the ED if they had additional care needs. Concerns about COVID-19 exposure risks and frustrations about virtual care were named as additional barriers to receiving follow-up care. Some Veterans with multiple ED visits and/or other frequent contact with providers had difficulty describing instructions provided to them at a particular visit, mentioning instead what they were generally told.

Implications:
A common facilitator to Veterans receiving ED follow-up care was VA staff reaching out to Veterans to arrange care. Veterans lacking knowledge about recommended follow-up care, perceptions that follow-up care was unnecessary, and prior difficulties communicating with follow-up care providers were common barriers to receiving care.

Impacts:
VA should prioritize implementing processes to efficiently communicate Veterans’ needs to follow-up care providers, and systems for reaching out to Veterans and/or arranging for care prior to Veterans leaving the ED. VA should also explore approaches for educating Veterans about recommended ED follow-up care, and mechanisms for Veterans to communicate their needs to follow-up care providers.