Patient Care

Dissemination of a Care  Collaboration Project

A core project team was able to identify essential implementation  components for a successful dual-care program aimed at improving communication  and collaboration with non-VA health care providers.

Fed Pract. 2015 October;32(10):38-42

Author(s):

Pamela W. Lee, PhD

Richard E. Lee, MA, MPH

Penelope Markle, RN, MSN, MEd

Eric A. Shirley, MD

Phillip Welch, BA

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References

1. Borowsky SJ, Cowper DC. Dual use of VA and non-VA primary care. J Gen Intern Med. 1999;14(5): 274-280.

2. Nayar P, Nguyen AT, Ojha D, Schmid KK, Apenteng B, Woodbridge P. Transitions in dual care for veterans: non-federal physician perspectives. J Community Health. 2013;38(2):225-237.

3. Liu CF, Bryson CL, Burgess JF Jr, Sharp N, Perkins M, Maciejewski ML. Use of outpatient care in VA and Medicare among disability-eligible and age-eligible veteran patients. BMC Health Serv Res. 2012;12:51.

4. Liu CF, Chapko M, Bryson CL, et al. Use of outpatient care in Veterans Health Administration and Medicare among veterans receiving primary care in community-based and hospital outpatient clinics. Health Serv Res. 2010;45(5, pt 1):1268-1286.

5. Lee PW, Markle PS, West AN, Lee RE. Use and quality of care at a VA outreach clinic in northern Maine. J Prim Care Community Health. 2012;3(3):159-163.

6. Petersen LA, Byrne MM, Daw CN, Hasche J, Reis B, Pietz K. Relationship between clinical conditions and use of Veterans Affairs health care among Medicare-enrolled veterans. Health Serv Res. 2010;45(3):762-791.

7. 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. Prim Care Diabetes. 2008;2(2):73-80.

8. Tarlov E, Lee TA, Weichle TW, et al. Reduced overall and event-free survival among colon cancer patients using dual system care. Cancer Epidemiol Biomarkers Prev. 2012;21(12):2231-2241.

9. Wolinsky FD, An H, Liu L, Miller TR, Rosenthal GE. Exploring the association of dual use of the VHA and Medicare with mortality: separating the contributions of inpatient and outpatient services. BMC Health Serv Res. 2007;7:70.

10. Wolinsky FD, Miller TR, An H, Brezinski PR, Vaughn TE, Rosenthal GE. Dual use of Medicare and the Veterans Health Administration: are there adverse health outcomes? BMC Health Serv Res. 2006;6:131.

11. Jia H, Zheng Y, Reker DM, et al. Multiple system utilization and mortality for veterans with stroke. Stroke. 2007;38(2):355-360.

12. Maciejewski ML, Wang V, Burgess JF Jr, Bryson CL, Perkins M, Liu CF. The continuity and quality of primary care. Med Care Res Rev. 2013;70(5):497-513.

13. Miller EA, Intrator O. Veterans use of non-VHA services: implications for policy and planning. Soc Work Public Health. 2012;27(4):379-391.

14. Tomioka M, Braun KL. Implementing evidence-based programs: a four-step protocol for assuring replication with fidelity. Health Promot Pract. 2013;14(6):850-858.

"I always pray that my patient won’t need supplies, like oxygen, because that means dealing with the VA. It’s impossible.”

Similar sentiments are shared by community health care providers (HCPs) when addressing the needs of their dual-care patients; those veterans who receive care from both the VHA and non-VHA providers and health care organizations.^1,2 Many Medicare-eligible VHA primary care patients access primary and specialty care outside of VHA.^3-6

The consequences of dual care for veteran patients have been well described in the literature. Dual-care patients are at risk for several suboptimal health outcomes (higher A_1c values, dying of colon cancer, rehospitalization for recurrent stroke or for any other cause),^7-11 which may result from receiving fragmented or duplicative care.^3,12

Much less attention has been paid to the interactions and care processes that occur between VHA providers and their community counterparts. Many community HCPs experience confusion and frustration when trying to coordinate patient care with VHA and are, not surprisingly, unfamiliar with VHA goals, policies, and procedures.

A study that explored perceptions of nonfederal physicians regarding barriers to effective dual care for veterans showed that coordinating care with VHA is often considered difficult.¹³ Most study respondents indicated that they were rarely or never informed about the visits that the patient makes to the VHA. There was the perception that information sharing is more common from non-VHA to VHA than vice versa. Most respondents indicated that they were unable to access the VHA formulary, making prescribing medications for their veteran patients problematic. More than half noted that the patient transfer to a VHA facility was problematic.

Similar difficulties were experienced at the White River Junction VAMC (WRJVAMC) in Vermont. In hopes of alleviating the problems, a pilot project was conducted. The project provided information sharing and discussion meetings for community organizations often involved in dual care. As the project progressed, the VHA case managers observed that community nurses were more likely to have relevant data needed to transfer patients to a VA hospital. Meeting attendees expressed a desire to have greater communication and collaboration with VA. The WRJVAMC leadership recognized the positive impact of this pilot project on community engagement. An expanded trial was proposed and funded by the VHA Office of Rural Health (ORH).

The current project began in 2009 and is conducted throughout VISN 1, which encompasses all the New England states and includes 8 VAMCs and 47 additional access points, including community-based outpatient clinics (CBOCs) and outreach clinics. It is hoped that the project can create an organizational culture change in which VHA facilities move from a dual care to a comanaged care perspective. Presentations are made to community HCPs and staff who may provide care to veterans also served by VHA. The presentations explain the processes for delivery of VHA care; the history and mission of the VHA; eligibility for VHA health care; obtaining VHA prescriptions, medical supplies, and medical records; and transferring a patient to a VHA hospital. Presentations also include adequate time for conversation  and questions.

The project lead is the director of primary care for VISN 1, and teams of local champions were assembled at each of the 8 medical centers. To facilitate recruitment of project staff, interested individuals attended a kick-off meeting held at a central location. Attendees heard a presentation about the consequences of dual care and spent time in a facilitated brainstorming session regarding the difficulties of comanaging care with community hospitals, providers, and health care organizations. The immediate overarching goal to “be good neighbors” to community partners was discussed. Finally, the expectations of project participation were considered, and questions were  answered.

Following the in-person meeting, telephone calls were arranged with each site team to answer any remaining questions and secure participation. The majority of teams were composed of 1 primary care physician and 1 nurse/nurse case manager. The VISN 1 team was aided by staff from the ORH Veterans Rural Health Resource Center-Eastern Region (VRHRC-ER) to support project planning, implementation, and evaluation.

The presentations were developed by the core project team members and the local VAMC project champions. The initial presentations targeted community physicians and primary care providers (PCPs). These short 30- to 60-minute presentations were designed to fit within lunch breaks and staff meetings. Along with the short presentations, longer (up to 3-4 hours), in-depth presentations targeted to medical staff (nurse case managers, social workers, financial/billing personnel) were scheduled through fiscal years (FYs) 2014-2015. These in-depth presentations will continue in FY16.