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Health Services Research & Development

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HSR&D In Progress

May 2020

In This Issue: Advancements in VA Primary Care
» Table of Contents

Evaluating Care Coordination for Community Hospitalized Veterans

Feature Article

Takeaway: Knowledge from this study will enhance best practices for hospital care transitions, clarify the factors associated with program effectiveness, and enable comparisons of differential impacts among Veterans living in rural areas versus urban areas.

Hospitalization and Emergency Department (ED) visits in community hospitals represent a vulnerable time for Veterans, since dual VA-community healthcare can be associated with adverse health outcomes. While current VA access initiatives should have net-positive impacts for Veterans, there may be negative unintended consequences. To address these concerns, a team at the Ralph H. Johnson VA Medical Center, led by Dr. Robert Axon, has partnered with the VA Office of Community Care (VAOCC) Acute Hospital Care Coordination Program to develop a multi-component, evidence-based care coordination program to help Veterans receiving acute (ED and hospital) care at non-VA facilities navigate back to the VA system. This ongoing HSR&D study (March 2019 – February 2023) is evaluating the VAOCC Acute Program. Specific objectives include:

  • Evaluate the implementation of the program across multiple domains including adoption of key program components, fidelity of implementation, reach to community partners and eligible Veterans, and maintenance of program activities in three VISNs: 7 (VA Southeast Network), 8 (VA Sunshine Healthcare Network), and 19 (VA Rocky Mountain Network).
  • Determine overall program effectiveness in coordinating care for Veterans through—
    • reducing subsequent acute healthcare use,
    • fidelity to key intervention components, and
    • reducing/neutralizing costs.

When implemented nationally, the VAOCC Acute program will be the first in VA to address cross-system hospital care—and the first national rollout in or outside VA of a post-discharge care coordination intervention.


Patient-reported data will be collected using interactive voice response and telephone interviews. Qualitative interviews and questionnaire methods will be used for VA providers. For utilization outcomes, investigators will create a research database of merged VA and state-level all-payer claims data from three states (Florida, South Carolina, and Colorado).


None at this time.

Anticipated Impact

It is expected that after program implementation, Veterans with acute community care events will experience lower rates of 7- and 30-day emergency department revisits, as well as 7- and 30-day hospital readmissions. Investigators also anticipate fewer total hospital days per episode of acute illness as compared to Veterans from the pre-implementation period.

Principal Investigator: Robert Neal Axon, MD, Director of HSR&D’s Charleston Health Equity and Rural Outreach Innovation Center (HEROIC), Charleston, SC.


None at this time.

View study abstract

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