Why Modernizing Care Transitions Is Gaining Momentum Within the VHA

Ensuring our nation’s veterans receive the right care from the right facility without delay is critical to the Veterans Health Administration (VHA) mission. Veterans Affairs (VA) medical centers continue to broaden access beyond their medical center walls to community and home care settings to improve access and reduce time to care.

Prompt transition to an appropriate care setting such as long/short-term rehabilitation, skilled nursing, palliative, and hospice care is associated with better outcomes and satisfaction, while also improving access within the VA medical center. Lengthy transitions to next level care have a trickledown effect. When veterans are not transferred or discharged efficiently, these delays cause backups in emergency departments (EDs) and intensive care units (ICUs) or even diversions requiring veterans to be transported to community hospitals.

Today’s transition processes continue to be very manual, requiring staff hours for faxing and phone calls, contributing to inefficiency and decreased bed availability. However, Veterans Administration medical centers are increasingly adopting technology platforms to automate and simplify the transition process. In line with consumer solutions like hotel and travel booking services, VA staff responsible for transitions in care can view a continuously updated list of available VA and community providers and facilities appropriate to each veteran’s care needs and in the geography most convenient to them. They can generate multiple referrals simultaneously and monitor responses in minutes instead of hours or days. In addition, they can communicate directly with the recipients of those referrals via electronic messaging.

This efficient and simple transition process supports the critical mission of ensuring that veterans receive optimal care in the right settings, thereby reducing discharge times and maximizing internal facility capacity. All of this can be done while reducing the administrative burden on staff.

Transitions Critical to Outcomes and Care Access

VA medical centers are not alone in their focus on improving care transitions. The broader health care industry recognizes the patient care and economic benefits of efficient system-wide care coordination. Unnecessarily long hospitalizations and delayed discharges are associated with poorer outcomes such as increased fall risks, hospital-acquired conditions, and other never events. Timely transition to an appropriate external level of care, on the other hand, leads to shorter average length of stay (ALOS) within the hospital setting.

For some value-based care payment models that commercial hospitals and accountable care organizations (ACOs) participate in, a shorter ALOS translates to greater reimbursement for their services. Likewise, under fee-for-service payment models, efficient patient throughput is critical for commercial hospital and ACO bottom lines. For the VHA, this means reduced expenses, improved access to care for veterans, increased veteran satisfaction, and improved quality of care. While prudent resource utilization is important for VA medical centers, shorter ALOS also improves the experience for the patient and their family. In an inpatient setting, veterans and their families do not want to extend the hospital stay longer than necessary, especially if it is not close to home. Likewise, a shorter ALOS can improve the experience and outcome for veterans in the ED or ICU or who are scheduled for an elective procedure that requires admission to the hospital. Accelerating the care transition facility referral process can help ensure veterans receive the care they need without delay.

Cutting Paper-Based Processes

Although the VHA was one of the first US health care organizations to embrace electronic health records, community care facility selection and transition processes in many of its medical centers still rely on veteran and hospital staff knowledge of local facilities, which can be quite limiting when dealing with complex cases. Referrals, meanwhile, are typically paper-based, involving faxing a request to individual or multiple recipients to determine availability and acceptance, and then waiting by the fax machine or telephone for a response.

This non-standardized protocol should be updated for several reasons. First, awareness of area care facility availability and capabilities may be limited, even more so if the veteran has multiple comorbidities and needs a more specialized care setting. In such situations, case managers are left calling colleagues at other medical centers outside of their local area for recommendations on facilities farther away. Meanwhile, veterans and caregivers have alternatively characterized the care transition facility selection process as “rushed,” leaving it all up to the veteran. Conversely, they said they felt a “lack of choice or autonomy, leading to dissatisfaction with the outcome,” according to a study of elderly veterans.

Another justification for updating the care transition and referral process is to maximize capacity within VA medical centers themselves. A study of hospitalized neurology patients in a non-VA medical center who were medically ready for discharge with plans for postacute care found that nearly 40% of these patients’ inpatient days were after they were determined medically ready for discharge, with a median 2.5 excess days spent in the hospital. In a recent study of veterans who received total joint arthroplasty, researchers found that discharge within a day did not affect readmissions or additional procedures. Both studies indicate that not efficiently discharging patients to postacute care facilities can unnecessarily extend hospital stays and reduce bed capacity.

A comprehensive, continuously updated electronic solution containing information on care facilities related to level of care, capabilities, and geography facilitates more fully informed discussions between clinicians, the veteran, and caregivers, thereby creating confidence in the decision for all. Further, the reduction in ALOS and unnecessary staff administrative time improves outcomes and overarching patient and staff satisfaction.

Expanding Access Across the Continuum

Instead of faxing, waiting, and hoping for timely response, VA medical centers can adopt a more active strategy towards care transition and referrals. Using an electronic platform to seamlessly identify appropriate facilities and coordinate transfers also aligns with the VHA’s access to care strategy. The strategy is similar to the way commercial health systems have created integrated and centralized access centers to orchestrate care for their patients across the entire continuum of care, including transfers into and out of their hospitals and other venues.

Whether moving a veteran from a community hospital ED to a VA specialty facility or transferring them to hospice for end-of-life care and everything in between, a community-wide perspective provided by modern technology will improve access to care and continuity of care for veterans to help them receive the optimal outcomes and experience they deserve.

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