Perspectives on supporting Veterans' social needs during hospital to home health transitions: findings from the Transitions Nurse Program.

BACKGROUND: Veterans who need post-acute home health care (HHC) are at risk for adverse outcomes and unmet social needs. Veterans' social needs could be identified and met by community-based HHC clinicians due to their unique perspective from the home environment, acuity of Veterans they serve, and access to Veterans receiving community care. To understand these needs, we explored clinician, Veteran, and care partner perspectives to understand Veterans' social needs during the transition from hospital to home with skilled HHC. METHODS: Qualitative data were collected through individual interviews with Veterans Health Administration (VHA) inpatient & community HHC clinicians, Veterans, and care partners who have significant roles facilitating Veterans' hospital to home with HHC transition. To inform implementation of a care coordination quality improvement intervention, participants were asked about VHA and HHC care coordination and Veterans' social needs during these transitions. Interviews were recorded, transcribed, and analyzed inductively using thematic analysis and results were organized deductively according to relevant transitional care domains (Discharge Planning, Transition to Home, and HHC Delivery). RESULTS: We conducted 35 interviews at 4 VHA Medical Centers located in Western, Midwestern, and Southern U.S. regions during March 2021 through July 2022. We organized results by the three care transition domains and related themes by VHA, HHC, or Veteran/care partner perspective. Our themes included (1) how social needs affected access to HHC, (2) the need for social needs screening during hospitalization, (3) delays in HHC for Veterans discharged from community hospitals, and (4) a need for closed-loop communication between VHA and HHC to report social needs. CONCLUSIONS: HHC is an underexplored space for Veterans social needs detection. While this research is preliminary, we recommend two steps forward from this work: (1) develop closed-loop communication and education pathways with HHC and (2) develop a partnership to integrate a social risk screener into HHC pathways.

"I was Unsure at First": A Qualitative Evaluation of Patient Perceptions of VA Clinical Video Telehealth Visits in the V-IMPACT Program.

Virtual Integrated Multi-Site Patient Aligned Care Team (V-IMPACT) was a Veterans Health Administration (VHA) initiative created to increase access to primary care for Veterans through Clinical Video Telehealth (CVT) appointments. Between January and August 2019, we conducted 48 semi-structured qualitative interviews with Veterans who had a V-IMPACT appointment. Many participants shared feelings of skepticism before their first appointments but for some, their opinions changed. Veterans talked about how their opinion of video care changed for the better when it made care more convenient or timelier or met their health care needs. For some Veterans, their opinion about video care stayed the same or worsened because they had a poor relationship or rapport with their provider, did not feel like they received needed care, or did not feel like video care was useful. These findings offer an opportunity for telecare providers to better understand and support patients and to deliver effective care in the context of rapidly growing telehealth modalities.

Common Ground: Primary Care and Specialty Clinicians' Perceptions of E-Consults in the Veterans Health Administration.

OBJECTIVE: The US Department of Veterans Affairs (VA) introduced electronic consultation (e-consult) to increase access to specialty care. The objective of this study was to understand perceptions of e-consults that may be relevant to increasing adoption in the VA. METHODS: Deductive and inductive content analysis of semistructured qualitative telephone interviews with VA primary care practitioners (PCPs), specialists, and specialty division chiefs was performed. Participants were identified based on rates of e-consult in 2016 at the individual and facility level within primary care, hematology, cardiology, gastroenterology, and endocrinology. Interview guide development was informed by the Practical, Robust, Implementation, and Sustainability (PRISM) framework. RESULTS: We interviewed 35 PCPs and 25 specialists working in 36 facilities. Four themes emerged across both PCPs and specialists: (1) e-consults are best suited for certain types of clinical questions; (2) high-quality e-consults include complete background information from the requesting clinician and clear diagnostic or treatment recommendations from the responding clinician; (3) PCPs and specialists perceive e-consults as a novel opportunity to provide efficient, transparent care; and (4) lack of awareness of e-consults hinders adoption despite obvious benefits. CONCLUSIONS: We identified themes that are informative for further adoption of high-quality e-consults in the VA. Educating PCPs and specialty practitioners about the benefits of e-consults, and providing support, such as lists of specialties available for e-consults at the facility are 2 such practices.

Using a longitudinal multi-method approach to document, assess, and understand adaptations in the Veterans Health Administration Advanced Care Coordination program.

Background: Understanding adaptations supports iterative refinement of the implementation process and informs scale out of programs. Systematic documentation of adaptations across the life course of programs is not routinely done, and efficient capture of adaptations in real world studies is not well understood. Methods: We used a multi-method longitudinal approach to systematically document adaptations during pre-implementation, implementation, and sustainment for the Veteran Health Administration (VA) Advanced Care Coordination program. This approach included documenting adaptations through a real-time tracking instrument, process maps, Implementation and Evaluation (I&E) team meeting minutes, and adaptation interviews. Data collection was guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) enhanced framework for reporting adaptations and modifications to evidence-based interventions (FRAME) model. Adaptations were evaluated across 9 categories, and analytic team consensus and member-checking were used to validate the results. Results: A total of 144 individual adaptations were identified across two implementation sites and the four data sources; analytic team consensus and member-checking processes resulted in 50 unique adaptations. Most adaptations took place during the early implementation and mid-implementation phases and were: 1) planned; 2) made to address changes in program delivery; 3) made to extend a component; 4) related to the core component of the intervention concerning notification of the community emergency department visit; 5) initiated by the entire or most of the I&E team; 6) made on the basis of: pragmatic/practical considerations; 7) made with an intent to improve implementation domain (to make the intervention delivered more consistently; to better fit the local practice, patient flow or Electronic Health Record (EHR) and/or for practical reasons); 8) a result of internal influences; 9) perceived to impact the RE-AIM implementation dimension (consistent delivery of quality care or costs). I&E team meeting minutes and process maps captured the highest numbers of unique adaptations (n = 19 and n = 13, respectively). Conclusion: Our longitudinal, multi-method approach provided a feasible way to collect adaptations data through engagement of multiple I&E team members, allowing and a broader understanding of adaptations that took place. Recommendations for future research include pragmatic assessment of the impact of adaptations and meaningful data collection without overburdening the implementing teams and front-line staff.

Differences in transitional care processes among high-performing and low-performing hospital-SNF pairs: a rapid ethnographic approach.

BACKGROUND: Despite the increased focus on improving patient's postacute care outcomes, best practices for reducing readmissions from skilled nursing facilities (SNFs) are unclear. The objective of this study was to observe processes used to prepare patients for postacute care in SNFs, and to explore differences between hospital-SNF pairs with high or low 30-day readmission rates. DESIGN: We used a rapid ethnographic approach with intensive multiday observations and key informant interviews at high-performing and low-performing hospitals, and their most commonly used SNF. We used flow maps and thematic analysis to describe the process of hospitals discharging patients to SNFs and to identify differences in subprocesses used by high-performing and low-performing hospitals. SETTING AND PARTICIPANTS: Hospitals were classified as high or low performers based on their 30-day readmission rates from SNFs. The final sample included 148 hours of observations with 30 clinicians across four hospitals (n=2 high performing, n=2 low performing) and corresponding SNFs (n=5). FINDINGS: We identified variation in five major processes prior to SNF discharge that could affect care transitions: recognising need for postacute care, deciding level of care, selecting an SNF, negotiating patient fit and coordinating care with SNF. During each stage, high-performing sites differed from low-performing sites by focusing on: (1) earlier, ongoing, systematic identification of high-risk patients; (2) discussing the decision to go to an SNF as an iterative team-based process and (3) anticipating barriers with knowledge of transitional and SNF care processes. CONCLUSION: Identifying variations in processes used to prepare patients for SNF provides critical insight into the best practices for transitioning patients to SNFs and areas to target for improving care of high-risk patients.

How Context Influences Hospital Readmissions from Skilled Nursing Facilities: A Rapid Ethnographic Study.

INTRODUCTION: Improving hospital discharge processes and reducing adverse outcomes after hospital discharge to skilled nursing facilities (SNFs) are gaining national recognition. However, little is known about how the social-contextual factors of hospitals and their affiliated SNFs may influence the discharge process and drive variations in patient outcomes. We sought to categorize contextual drivers that vary between high- and low-performing hospitals in older adult transition from hospitals to SNFs. DESIGN: To identify contextual drivers, we used a rapid ethnographic approach with interviews and direct observations of hospital and SNF clinicians involved in discharging patients. We conducted thematic analysis to categorize contextual factors and compare differences in high- and low-performing sites. SETTING AND PARTICIPANTS: We stratified hospitals on 30-day hospital readmission rates from SNFs and used convenience sampling to identify high- and low-performing sites and associated SNFs. The final sample included 4 hospitals (n = 2 high performing, n = 2 low performing) and affiliated SNFs (n = 5) with 148 hours of observations. MEASURES: Central themes related to how contextual factors influence variations in high- and low-performing hospitals. RESULTS: We identified 3 main contextual factors that differed across high- and low-performing hospitals and SNFs: team dynamics, patient characteristics, and organizational context. First, we observed high-quality communication, situational awareness, and shared mental models among team members in high-performing sites. Second, the types of patients cared for at high-performing hospitals had better insurance coverage that made it feasible for clinicians to place patients based on their needs instead of financial abilities. Third, at high-performing hospitals a more engaged staff in the transition process and building rapport with SNFs characterized smooth transitions from hospitals to SNFs. CONCLUSIONS AND IMPLICATIONS: Contextual factors distinguish high- and low-performing hospitals in transitions to SNF and can be used to develop interventions to reduce adverse outcomes in transitions.

Competing Demands: Scheduling Challenges in Being Veteran-centric in the Setting of Health System Initiatives to Improve Access.

INTRODUCTION: The Veterans Health Administration's (VHA) history of enhancing Veterans' healthcare access continued in 2016 with the launch of ChooseVA (née: MyVA Access). This initiative was designed to transform the VHA and rapidly increase Veteran's access to care across all the VHA facilities. Relevant to this article include mandates to improve patient-centered scheduling. In prioritizing patient-centered scheduling, the VHA and other large healthcare systems have the paradoxical task of providing health care that meets not only the needs of individual patients but also the collective needs of the population served. To our knowledge, meeting these competing needs has not been explored through the perspectives and experiences of providers and staff implementing patient-centered scheduling practices. MATERIALS AND METHODS: This was a qualitative exploratory study and was sanctioned as quality improvement (and thus exempt from Institutional Review Board review). We conducted visits at 25 VHA facilities. Sites were selected based on rurality, region, and facility access performance ratings. Data collection included semi-structured interviews and focus groups. Key informant participants included local leadership, administrators, providers, and support staff across primary care, specialty care, and mental health service lines. We analyzed transcribed audio recordings using inductive content analysis to identify barriers, facilitators, and contextual factors affecting the implementation of patient-centered scheduling. RESULTS: We conducted 208 individual interviews and focus groups between July and November 2017. Participants expressed dedication to patient-centered approaches to improve access to care for Veterans, stating efforts and challenges to meeting Veterans' needs and preferences. Being Veteran-centric meant accommodating Veterans, with a tension between meeting the needs of one Veteran versus all Veterans, managing expectations of same-day access, and potential hits to performance metrics. Strategies focused on engaging Veterans through education and establishing new expectations while recognizing the differing needs among subgroups receiving VHA care. CONCLUSIONS: Veterans Health Administration staff employed a mission-driven, culturally sensitive approach to meeting the diverse scheduling needs of the Veteran population. While potentially unique to the VHA, it may inform patient-centered scheduling practices for other culturally specific populations in other healthcare systems. Continued efforts to put Veterans at the center of VHA healthcare delivery by engaging them in meaningful ways while honoring their distinct needs are essential. Data are forthcoming on Veterans' perspectives of access, which we hope will further contribute to unfolding understandings of access within the VHA.

Perspectives of VA Primary Care Clinicians Toward Electronic Consultation-Related Workload Burden: A Qualitative Analysis.

Importance: Electronic consultation (e-consultation) is increasingly being adopted to expand access to specialty care and reduce health care costs. Little is known about clinicians' perceptions of using e-consultations, which may be associated with program adoption. Objective: To identify perceptions of primary care clinicians in the US Veterans Health Administration (VHA) system about e-consultation and workload. Design, Setting, and Participants: A qualitative study using semistructured interviews was conducted from September 2017 through March 2018 in a national sample of VHA primary care clinics in the US. Participants were primary care clinicians who had at least 300 total patient encounters from July 2016 to June 2017, including at least 1 e-consultation request. A convenience sample of participants was recruited using email invitations. Deductive and inductive content analysis were used to identify themes. Data were analyzed from October 2017 to April 2018. Exposures: Use of e-consultation. Main Outcomes and Measures: Primary care clinician perspectives regarding e-consultation and their workload. Results: A total of 34 primary care clinicians enrolled working across 27 VHA clinical sites were included; 9 (26%) were between ages 40-49 years; 23 (68%) were female. Three themes were identified. First, the process of entering, tracking, and following up on e-consultations added a time burden to primary care clinicians. Second, e-consultation was perceived to shift diagnostic and follow-up responsibilities from specialists to primary care clinicians. Third, e-consultations were thought to improve the timeliness and quality of care provided despite a perceived increase in workload. Conclusions and Relevance: In this study, participants perceived e-consultation as valuable for patient care but also as an increase in their workload. Further work is warranted to quantify the workload increase on clinician burnout, job satisfaction, and turnover.

Cognitive Biases Influence Decision-Making Regarding Postacute Care in a Skilled Nursing Facility.

BACKGROUND: Decisions about postacute care are increasingly important as the United States population ages, its use becomes increasingly common, and payment reforms target postacute care. However, little is known about how to improve these decisions. OBJECTIVE: To understand whether cognitive biases play an important role in patient and clinician decision-making regarding postacute care in skilled nursing facilities (SNFs) and identify the most impactful biases. DESIGN: Secondary analysis of 105 semistructured interviews with patients, caregivers, and clinicians. SETTING: Three hospitals and three SNFs in a single metropolitan area. PATIENTS: Adults over age 65 discharged to SNFs after hospitalization as well as patients, caregivers, and multidisciplinary frontline clinicians in both hospital and SNF settings. MEASUREMENTS: We identified potential cognitive biases from prior systematic and narrative reviews and conducted a team-based framework analysis of interview transcripts to identify potential biases. RESULTS: Authority bias/halo effect and framing bias were the most prevalent and seemed the most impactful, while default/status quo bias and anchoring bias were also present in decision-making about SNFs. CONCLUSIONS: Cognitive biases play an important role in decision-making about postacute care in SNFs. The combination of authority bias/halo effect and framing bias may synergistically increase the likelihood of patients accepting SNFs for postacute care. As postacute care undergoes a transformation spurred by payment reforms, it is increasingly important to ensure that patients understand their choices at hospital discharge and can make high-quality decisions consistent with their goals.