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RCD 06-019 – HSR&D Study

 
RCD 06-019
Improving Care for Older Veterans Discharged from Emergency Treatment
Susan N. Hastings MD MHSc
Durham VA Medical Center, Durham, NC
Durham, NC
Funding Period: April 2008 - March 2013

BACKGROUND/RATIONALE:
Poor coordination and continuity of care as patients transition between health care settings are significant problems for older adults. Much of the research in this area has focused on post-hospitalization transitions, however patients moving between other types of care settings are also at risk. Older veterans who are evaluated in the ED and discharged home to follow up with their primary care provider may be particularly vulnerable to adverse outcomes related to poor care transitions but the extent and nature of this problem has not been adequately investigated.

OBJECTIVE(S):
The overall goal of this research is to examine the problems associated with transitions in care after VA ED use. Specific aims are to: (1) evaluate the incidence and predictors of adverse health outcomes among older Veterans discharged from the ED; (2) to characterize problems associated with the ED discharge process for older Veterans; (3) to explore the relationship between the ED discharge process and adverse health outcomes; and (4) to develop a multi-component intervention to improve processes and outcomes of care for older Veterans discharged from the ED.

METHODS:
Study objectives will be met by conducting 3 distinct but related projects. Project 1 will be a retrospective, cohort study using national VHA administrative data files and facility surveys. Data from VHA Medical SAS Datasets, Vital Status file, and Pharmacy Benefits Management Service will be linked with data from the VHA Clinical Practice Organization Surveys in order to examine facility- and patient-level predictors of repeat ED visits and hospital admissions following ED discharge. Multivariable analyses will be performed using two level hierarchical models considering patients (individual level) to be clustered within facilities (organization level). Project 2 will consist of surveys and semi-structured interviews conducted with Veterans aged 65 and over discharged home from the Durham VAMC ED. We will evaluate patient factors (e.g. demographic and clinical data), ED discharge process measures (e.g. information given at the time of discharge and follow-up plan), and outcomes (unscheduled health service utilization and death). Qualitative data generated from transripts of semi-will be coded and analyzed using content analysis. The results from Projects 1 and 2 will inform the development of an intervention to improve processes of care and outcomes for older Veterans discharged from the ED.

FINDINGS/RESULTS:
Not yet available.

IMPACT:
More than 1.7 million Veterans receive care in VA EDs annually; 80% of these visits result in the Veteran being discharged home from the ED to follow-up with his/her primary care provider. By extending our knowledge of the problems Veterans face after being discharged from the ED, this research can lead to the development of innovative models of care for this vulnerable population.



External Links for this Project

Dimensions for VA

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PUBLICATIONS:

Journal Articles

  1. Whitson HE, Hastings SN, Lekan DA, Sloane R, White HK, McConnell ES. A quality improvement program to enhance after-hours telephone communication between nurses and physicians in a long-term care facility. Journal of the American Geriatrics Society. 2008 Jun 1; 56(6):1080-6. [view]
  2. Hastings SN, Schmader KE, Sloane RJ, Weinberger M, Goldberg KC, Oddone EZ. Adverse health outcomes after discharge from the emergency department--incidence and risk factors in a veteran population. Journal of general internal medicine. 2007 Nov 1; 22(11):1527-31. [view]
  3. Hastings SN, Whitson HE, White HK, Sloane R, MacDonald H, Lekan DA, McConnell ES. After-hours calls from long-term care facilities in a geriatric medicine training program. Journal of the American Geriatrics Society. 2007 Dec 1; 55(12):1989-94. [view]
  4. Whitson HE, Hastings SN, Landerman LR, Fillenbaum GG, Cohen HJ, Johnson KS. Black-white disparity in disability: the role of medical conditions. Journal of the American Geriatrics Society. 2011 May 1; 59(5):844-50. [view]
  5. Hastings SN, George LK, Fillenbaum GG, Park RS, Burchett BM, Schmader KE. Does lack of social support lead to more ED visits for older adults? The American journal of emergency medicine. 2008 May 1; 26(4):454-61. [view]
  6. Hastings SN, Whitson HE, Purser JL, Sloane RJ, Johnson KS. Emergency department discharge diagnosis and adverse health outcomes in older adults. Journal of the American Geriatrics Society. 2009 Oct 1; 57(10):1856-61. [view]
  7. Hastings SN, Smith VA, Weinberger M, Schmader KE, Olsen MK, Oddone EZ. Emergency department visits in Veterans Affairs medical facilities. The American journal of managed care. 2011 Jun 1; 17(6 Spec No.):e215-23. [view]
  8. Hastings SN, Horney C, Landerman LR, Sanders LL, Hocker MB, Schmader KE. Exploring patterns of health service use in older emergency department patients. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2010 Oct 1; 17(10):1086-92. [view]
  9. Hastings SN, Purser JL, Johnson KS, Sloane RJ, Whitson HE. Frailty predicts some but not all adverse outcomes in older adults discharged from the emergency department. Journal of the American Geriatrics Society. 2008 Sep 1; 56(9):1651-7. [view]
  10. Hastings SN, Oddone EZ, Fillenbaum G, Sloane RJ, Schmader KE. Frequency and predictors of adverse health outcomes in older Medicare beneficiaries discharged from the emergency department. Medical care. 2008 Aug 1; 46(8):771-7. [view]
  11. Horney C, Schmader K, Sanders LL, Heflin M, Ragsdale L, McConnell E, Hocker M, Hastings SN. Health care utilization before and after an outpatient ED visit in older people. The American journal of emergency medicine. 2012 Jan 1; 30(1):135-42. [view]
  12. Hastings SN, Smith VA, Weinberger M, Oddone EZ, Olsen MK, Schmader KE. Health services use of older veterans treated and released from veterans affairs medical center emergency departments. Journal of the American Geriatrics Society. 2013 Sep 4; 61(9):1515-21. [view]
  13. Pavon JM, Zhao Y, McConnell E, Hastings SN. Identifying risk of readmission in hospitalized elderly adults through inpatient medication exposure. Journal of the American Geriatrics Society. 2014 Jun 1; 62(6):1116-21. [view]
  14. Hastings SN, Barrett A, Weinberger M, Oddone EZ, Ragsdale L, Hocker M, Schmader KE. Older patients' understanding of emergency department discharge information and its relationship with adverse outcomes. Journal of Patient Safety. 2011 Mar 1; 7(1):19-25. [view]
  15. Hastings S, Stechuchak K, Oddone E, Weinberger M, Tucker D, Knaack W, Schmader K. Older veterans and emergency department discharge information. BMJ quality & safety. 2012 Oct 1; 21(10):835-42. [view]
  16. Hendrix CC, Hastings SN, Van Houtven C, Steinhauser K, Chapman J, Ervin T, Sanders L, Weinberger M. Pilot study: individualized training for caregivers of hospitalized older veterans. Nursing Research. 2011 Nov 1; 60(6):436-41. [view]
  17. Hastings SN, Schmader KE, Sloane RJ, Weinberger M, Pieper CF, Goldberg KC, Oddone EZ. Quality of pharmacotherapy and outcomes for older veterans discharged from the emergency department. Journal of the American Geriatrics Society. 2008 May 1; 56(5):875-80. [view]
  18. Hendrix C, Tepfer S, Forest S, Ziegler K, Fox V, Stein J, McConnell ES, Hastings SN, Schmader K, Colon-Emeric C. Transitional Care Partners: a hospital-to-home support for older adults and their caregivers. Journal of the American Association of Nurse Practitioners. 2013 Aug 1; 25(8):407-14. [view]
  19. Hastings SN, Whitson HE, Sloane R, Landerman LR, Horney C, Johnson KS. Using the past to predict the future: latent class analysis of patterns of health service use of older adults in the emergency department. Journal of the American Geriatrics Society. 2014 Apr 1; 62(4):711-5. [view]
Book Chapters

  1. Hastings SN. Special Considerations of Adherence in Older Adults. In: Improving Patient Treatment Adherence: A Clinician's Guide. New York, NY: Springer; 2010. Chapter 14. 321-340 p. [view]
Conference Presentations

  1. Hastings SN. A Longitudinal Senior Faculty and Peer Mentoring Program for Junior Investigators and Educators. Presented at: American Geriatrics Society Annual Meeting; 2013 May 4; Grapevine, TX. [view]
  2. Hastings SN, Smith V, Weinberger M, Schmader K, Olsen MK, Oddone EZ. Emergency Department Discharge Information: What is provided and do patients understand. Poster session presented at: VA HSR&D National Meeting; 2011 Feb 17; National Harbor, MD. [view]
  3. Hastings SN. Emergency Department Discharge Information: What is Provided and Do Patients Understand? Poster session presented at: American Geriatrics Society Annual Meeting; 2011 May 12; National Harbor, MD. [view]
  4. Hastings SN. From the Wellderly to the Sickest Elderly: Classifying Older ED Patients According to Patterns of Health Service Use. Poster session presented at: American Geriatrics Society Annual Meeting; 2012 May 3; Seattle, WA. [view]
  5. Van Houtven CH, Boles J, Weidenbacher HJ, Johnson MR, Gentry PW, Rose CM, Knight C, Hastings SN, Olsen MK, Hendrix CC, Oddone EZ, Weinberger M. Helping invested families improve Veterans’ experiences: Pilot study. Paper presented at: VA HSR&D Career Development Annual Meeting; 2012 Jul 16; National Harbor, MD. [view]
  6. Moss J, Bryan W, Wilkerson L, Jackson GL, Stevens M, Powers J, Vaughan C, Hung W, Hwang U, Hastings SN. Impact of Clinical Pharmacy Specialists on the Design and Implementation of Quality Improvement Initiatives Aimed to Decrease Inappropriate Medications in a Veterans Affairs Emergency Department. Presented at: American Geriatrics Society Annual Meeting; 2014 May 8; Orlando, FL. [view]
  7. Hastings SN. Improving Care for Older Veterans Discharged from the Emergency Department. Poster session presented at: VA HSR&D Career Development Annual Meeting; 2010 Feb 25; San Francisco, CA. [view]
  8. Hastings SN. Improving Emergency Department Transitions for Older Veterans. Paper presented at: VA GEC / GRECC National Leadership Conference; 2009 Apr 15; Baltimore, MD. [view]
  9. Hastings SN. Navigating the Obstacle Course: Strategies for Promoting Safe and Effective Care Transitions. Paper presented at: Duke University Joseph and Kathleen Bryan Alzheimer's Disease Research Center Conference; 2011 Feb 10; Research Triangle Park, NC. [view]
  10. Hastings SN, Oddone EZ, Weinberger M. Older Patients' Understanding of Emergency Department Discharge Information and its Relationship with Adverse Outcomes. Poster session presented at: American Geriatrics Society Annual Meeting; 2009 May 15; Chicago, IL. [view]
  11. Hastings SN, Stechuchak KM, Schmader K, Weinberger M, Oddone EZ. Older Veterans treated and released from VAMC Emergency Departments. Poster session presented at: VA HSR&D Career Development Annual Meeting; 2011 Feb 16; National Harbor, MD. [view]
  12. Hastings SN. Older Veterans Treated and Released from VAMC Emergency Departments. Paper presented at: American Geriatrics Society Annual Meeting; 2011 May 12; National Harbor, MD. [view]
  13. Naik AD, Hastings SN. Partnerships to enhance research related to the care of older adults. Paper presented at: American Geriatrics Society Annual Meeting; 2012 May 5; Seattle, WA. [view]
  14. Hastings SN. STRIDE: Assisted Early Mobility for Hospitalized Older Veterans. Paper presented at: American Geriatrics Society Annual Meeting; 2013 May 4; Grapevine, TX. [view]
  15. Hastings SN, Oddone EZ. Suboptimal pharmacotherapy and adverse outcomes among older veterans discharged from the emergency department. Poster session presented at: VA HSR&D National Meeting; 2008 Feb 14; Baltimore, MD. [view]
  16. Hastings SN. Telephone Medicine: High Quality 'On-call' Communication Workshop. Paper presented at: American Medical Directors Association Annual Symposium; 2009 Mar 15; Charlotte, NC. [view]
  17. Hastings SN. Tips for a Successful Career Development Award Application. Presented at: American Geriatrics Society Annual Meeting; 2013 May 3; Grapevine, TX. [view]
  18. Hastings SN. Transitional Care: Challenges and Strategies for Improvement Workshop. Presented at: American Medical Directors Association Annual Symposium; 2009 Mar 15; Charlotte, NC. [view]
  19. Hastings SN. Variability in Adverse Outcomes According to Emergency Department Discharge Diagnosis. Poster session presented at: American Geriatrics Society Annual Meeting; 2009 May 15; Chicago, IL. [view]


DRA: Aging, Older Veterans' Health and Care, Health Systems
DRE: Prevention
Keywords: Emergency care
MeSH Terms: none

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