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FORUM - Translating research into quality health care for Veterans

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Research Highlight

Prior studies demonstrate that a large proportion of Veterans access multiple systems for care, yet Veterans who use both VA and non-VA services (dual care) are at increased risk of adverse events, especially during transitions of care when changes in medication and plan of care may occur without the knowledge of VA physicians.1 Understanding how information is exchanged during care episodes across multiple systems can help identify gaps and suggest potential solutions. Furthermore, identifying factors associated with lapses in information exchange when Veterans receive dual care will allow for design of interventions to prevent such lapses. With the advent of the VA Choice program and Veterans' increased access to non-VA care, the issue of information exchange has grown in significance.

According to the most recent VHA Directive on National Dual Care Policy regarding Veteran use of non-VA care, VA recognizes that while Veterans have the choice of obtaining care from VA and non-VA sources, "coordination and continuity of care are core features of high-quality primary care," particularly with the recent transformation of primary care to the Patient Aligned Care Team (PACT).2, 3 By splitting care between two or more health systems, access to multiple systems of care "may pose risks to patients." VA providers are responsible for managing the care that Veterans receive, "documenting the list of non-VA providers supplied by the patient in the patient's electronic health record, and coordinating care provided by non-VA providers as made available by the patient and non-VA provider." Veterans need to inform their VA provider of all components of their care outside VA and obtain all necessary documentation from their community provider. For example, when Veterans are discharged from a non-VA hospital, they need to inform their VA provider because potential problems may arise when information sharing is incomplete. Although the increasing availability of electronic information from Health Information Exchanges (HIEs) shows promise in expanded information exchange across sites, HIE use is limited by variations in HIEs across different markets.

Currently, we are conducting an observational study to determine how and to what extent information is exchanged within VA primary care teams by monitoring a cohort of urban and rural Veterans recently discharged from non-VA hospitals or emergency rooms. Participating study sites include the James J. Peters VA Medical Center and the Hudson Valley Health Care System, where Veterans in urban and rural areas, respectively, are recruited. Veterans meet the inclusion criteria if they are discharged to home from a non-VA hospital or emergency room; if Veterans do not receive care from a VA PACT in the previous year, they are excluded.

Our analysis of 132 Veterans in urban (50 percent) and rural (50 percent) settings, and of the information exchanged after a non-VA hospitalization or emergency room visit includes the following preliminary findings.

First, information exchange is more uniform when there is an established process. These include VA-based care transition programs where there is VA staff, notified by the discharging non-VA hospital or by health information exchange, initiating contact with Veterans to assist with coordination of care. Also, when Veterans' use of non-VA care occurs in a fee basis manner, for example, when formal authorizations by VA have been issued to the non-VA hospital to provide care, discharge information after non-VA hospitalization is sent to VA providers regularly.

Second, there is variability in Veteran education (6 percent of study cohort has less than high school education), health literacy (24 percent with inadequate or marginal health literacy), self-reported receipt of post-discharge information from non-VA setting (11 percent reported having received none), and confidence in managing their health after a non-VA visit (33 percent reported somewhat confident or not confident). These factors may limit the ability of some Veterans to act as a conduit for information exchange.

Third, a substantial proportion (50 percent) of Veterans have not accessed electronic tools (My HealtheVet) that may allow them to more easily communicate with their VA providers electronically; furthermore, less than half of them have heard about the VA Choice program, and few have utilized it.

Our preliminary findings suggest that it may be important to institute an agreement between VA and non-VA sites that defines a process for their information exchange. Such a step may be particularly important for Veterans who have limited ability to serve as a conduit for notification of non-VA utilization and information exchange. Our findings also suggest that certain VA tools and programs can be further promoted as potential avenues to enhance non-VA healthcare use and information exchange.

1. Helmer D, Sambamoorthi U, Shen Y, et al. "Opting Out of an Integrated Healthcare System: Dual-system Use is Associated with Poorer Glycemic Control in Veterans with Diabetes," Primary Care Diabetes 2008; 2(2):73-80.

2. VHA National Dual Care Policy. VHA Directive 2009-038. In: Affairs. DoV, ed2009.

3. Yano EM, et al. "Patient Aligned Care Teams (PACT): VA's Journey to Implement Patient-Centered Medical Homes," Journal of General Internal Medicine 2014.

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