Veterans with a hospital discharge in the VA Puget Sound Other
Conditions
Interventions
This is a prospective, cluster-randomized quality improvement trial to evaluate the difference in time to access outpatient follow-up care in Veterans with a hospital discharge in the VA Puget Sound.
Sponsors
VA Puget Sound Health Care System
Eligibility
Sex/Gender
All
Age
18 Years to 100 Years
Inclusion criteria
Inclusion criteria: Clusters/pods of nursing staff will be eligible of there is: 1. >1 active RN care manager per pod serving assigned patients, 2. Pod is located at a clinic within VA Puget Sound 3. RN within a pod is assigned to patient aligned care team (PACT) with primary care providers delivering outpatient continuity care to patients Patients: 1. Assigned to a PACT within an eligible pod RN 2. Receiving empaneled primary care from an clinic in the VA Puget Sound 3. Have at least 1 outpatient visit in the past 24 months 4. Have been discharged from a hospitalization on or after day 0 of the trial start date and/or self-notify the VA Puget Sound of their hospitalization
Exclusion criteria
Exclusion criteria: 1. RNs will be excluded from eligibility if on a team Patient Aligned Care Team (PACT) of: GERI, SCI, or HBPC 2. PACTs will be excluded that had less than 1 patient visit during study time frame for their PACT primary care provider (PCP)
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| Days between nurse index phone call to recently discharged patient and outpatient post-discharge clinic visit with a clinician in primary care measured using patient records at end of study | — |
Secondary
| Measure | Time frame |
|---|---|
| Secondary outcome measures: 1. 28-day count of VA and community care (IVC) hospital readmissions (patient-level), 2. 28-day count of ER visits, VA and community care (IVC) (patient-level) Other prespecified outcome measures: 3. PC utilization post-RN call (outpatient visits - total, and by modality (in-person, VVC, telephone)) within 45-days. 4. Combined ER / urgent care post-RN call, by 28-days. 5. Total prescription medications (controlling for baseline/pre-intervention) at 28 days. 6. Medications discontinued and by type of reason for discontinuation, between index RN call and 28 days. 7. Medication safety events (adverse drug / allergy events), between index RN call and 12 days 8. Post-hospital discharge summary availability among patients with no discharge summary at time of index RN call, by first Licensed Independent Practitioner (LIP) appointment in primary care. | — |
Countries
United States of America
Contacts
Public ContactBrinn Jones
Outcome results
None listed