Original Research

A Qualitative Study of Treating Dual-Use Patients Across Health Care Systems

Fed Pract. 2015 August;32(8):32-37

References

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Another provider utilized the nursing staff to call patients after their appointments to remind them to give their medical records to their non-VHA provider. The data suggest that responsibility for maintaining communication between providers ultimately falls on the patient. From the perspective of a nurse practitioner, “We just keep trying to educate the community…. I’ve been told that if the patient wants that privilege of using the VA for a pharmacy for an outside provider that we’re glad to do that. But it is their responsibility to communicate with their [non-VHA] physician. I think we just need to keep educating the patients.”

Rules and Regulations

VHA policies governing prescriptions, hospitalizations at outside facilities, and release of patient information regulate, and in some cases hinder, information flow between VHA and non-VHA providers. Many patients use VHA to obtain medications for lower out-of-pocket costs. This contributes to the number of dual-use patients in VHA and results in several challenges for VHA providers trying to manage patients’ prescriptions. For example, patients will ask to fill a prescription at a VHA pharmacy from their non-VHA providers; however, VHA pharmacies can only fill prescriptions from VHA providers.

Many VHA providers are willing to rewrite these prescriptions, but they may need to see the patient before adding or changing the prescription and require documentation to address contraindications, adverse reactions and/or therapeutic failure, and associated risks before making the authorization. VHA providers noted that because the VHA formulary does not contain all medications, non-VHA providers are often unfamiliar with the VHA National Formulary specifics and will write prescriptions for nonformulary medications, which require a nonformulary request from a VHA provider.

Clinic staff also mentioned difficulty in obtaining records from non-VHA providers. This can be particularly problematic if the patient lives a distance away from a VHA facility and does not have the necessary authorization to share records on file.

Barriers and Education Recommendations

Clinic staff identified coordination of care for dual-use patients as a barrier to providing care. Specifically, providers identified coordination as complicated by communication difficulties, inefficient medical record exchange, short staffing in VHA clinics, duplication of diagnostic services, and non-VHA providers’ lack of understanding regarding the services that VHA provides. Specific to rural clinics, comanagement was reportedly hindered by limitations in technology (eg, consistent Internet access), access to routine diagnostic services, and lack of relationships with non-VHA providers. Providers most frequently reported that the critical piece missing in comanagement is a relationship—and implied communication—between VHA clinics and non-VHA community clinics. The concept of a relationship between providers is evoked as a critical element to comanaging dual-use patients; however, clinic staff had a difficult time articulating what that relationship would actually look like if put into practice.

In spite of the numerous barriers identified by clinic staff, the recommendation for education to improve comanagement was consistent across study sites and clinic staff roles. Education was proposed for patients and non-VHA providers as the best intervention. In response to a question about ideas and recommendations to improve comanagement, clinic staff drew on varied experiences. To illustrate this theme, a provider gave this example of dual-use patients seeking prescription medication from VHA and its impact on comanagement: “I would [recommend] an outreach program to community resources and [non-VHA] providers. To let them know more about how the VA works and the resources that are available, and how specifically to coordinate care through the VA, would be a significant benefit.… If the [non-VHA] providers knew how to—who to—talk to, what information the VA needs, for example, for medication changes, it would help the patients make it work…without having to overburden the patients with having to physically hand carry their blood test results, or their notes, discharge summaries, procedure notes.”

Along with providing outreach and education on working with the VHA, clinic staff addressed the need to educate patients more effectively, because they are seen as central to the information exchange. There is motivation on the part of patients to learn the system. “Just making sure that the patients realize that they need to tell their local providers to send us the records and make sure that there is an exchange going on consistently,” explained a case manager. “If the patient wants to get those medications that are costly, then they figure out pretty quick what they have to have, what they need to send to us.” The need for education is an ongoing process; who is responsible for this continues to be a point of debate.