The ED-PACT Tool Initiative: Communicating Veterans' Care Needs After Emergency Department Visits.

BACKGROUND: Communication failures between providers threaten patient safety. PURPOSE: We developed, implemented, and formatively evaluated the ED-PACT Tool, which uses the Veterans Health Administration's (VA) electronic health record to send messages from emergency department (ED) providers to primary care patient-aligned care team (PACT) registered nurses (RNs) for Veterans discharged home from the ED with urgent or specific follow-up needs. METHODS: We used Plan-Do-Study-Act quality improvement methodology. RESULTS: Between November 1, 2015, and November 30, 2017, the tool was used to send 4,899 messages in one local VA healthcare system (ED and associated primary care clinics). Formative evaluation revealed that providers and RNs perceive the tool as providing substantial benefit for coordinating post-ED care. Patient-aligned care team leaders reported that RN training and "buy-in" facilitated tool implementation, while insufficient staffing posed a barrier. Emergency department providers noted the advantage of having a standardized and reliable system for communicating with PACTs. CONCLUSIONS/IMPLICATIONS: The ED-PACT Tool encapsulates several best practices (standardized processes, "closed-loop" communication, embedding into workflow) to facilitate communication between VA ED and follow-up care providers. Our development process illustrates key lessons in quality improvement and innovation implementation including the value of using rapid-cycle improvement methodology, with interprofessional collaboration and representatives from intended spread sites.

Delivering PACT-principled care: are specialty care patients being left behind?

BACKGROUND: With the reorganization of primary care into Patient Aligned Care Teams (PACT) teams, the Veteran Affairs Health System (VA) aims to ensure all patients receive care based on patient-centered medical home (PCMH) principles. However, some patients receive the preponderance of care from specialty rather than primary care clinics because of the special nature of their clinical conditions. We examined seven VA (HIV) clinics as a model to test the extent to which such patients receive PCMH-principled care. OBJECTIVE: To examine the extent to which HIV specialty care in VA conforms to PCMH principles. DESIGN: Qualitative study. PARTICIPANTS: Forty-one HIV providers from seven HIV clinics and 20 patients from four of these clinics. APPROACH: We conducted semi-structured interviews with HIV clinic providers and patients about care practices and adherence to PCMH principles. Using an iterative approach, data was analyzed using both a content analysis and an a priori, PCMH-principled coding strategy. KEY RESULTS: Patients with HIV receive varying levels of PCMH-principled care across a range of VA HIV clinic structures. The more PCMH-principled HIV clinics largely functioned as PCMHs; patients received integrated, coordinated, comprehensive primary care within a dedicated HIV clinic. In contrast, some clinics were unable to meet the criteria of being a patient's medical home, and instead functioned primarily as a place to receive HIV-related services with limited care coordination. Patients from the less PCMH-principled clinics reported less satisfaction with their care. CONCLUSIONS: Even in a large, integrated healthcare system, there is wide variation in patients' receipt of PCMH-principled care in specialty care settings. In order to meet the goal of having all patients receiving PCMH-principled care, there needs to be careful consideration of where primary and specialty care services are delivered and coordinated. The best mechanisms for ensuring that patients with complex medical conditions receive PCMH-principled care may need to be tailored to different specialty care contexts.

Evaluation of human immunodeficiency virus and hepatitis C telemedicine clinics.

BACKGROUND: Geographical barriers to subspecialty care may prevent optimal care of patients living in rural areas. We assess the impact of human immunodeficiency virus (HIV) and hepatitis C telemedicine consultation on patient-oriented outcomes in a rural Veterans Affairs population. METHODS: This was a pre- and post-intervention study comparing telemedicine with in-person subspecialty clinic visits for HIV and hepatitis C. Eligible patients resided in 2 rural catchment areas. The primary binary outcome was clinic completion. We estimated a logistic regression model with patient-level fixed effects. This approach controls for the clustering of visits by patient, uses each patient's in-person clinic experience as an internal control group, and eliminates confounding by person-level factors. We also surveyed patients to assess satisfaction and patient-perceived reductions in health visit-related time. RESULTS: There were 43 patients who accounted for 94 telemedicine visits and 128 in-person visits. Clinic completion rates were higher for telemedicine (76%) than for in-person visits (61%). In regression analyses, telemedicine was strongly predictive of clinic completion (OR 2.2; 95% confidence interval [CI]: 1.0-4.7). The adjusted effect of telemedicine on clinic completion rate was 13% (95% CI: 12-13). Of the 30 patients (70%) who completed the survey, more than 95% rated telemedicine at the highest level of satisfaction and preferred telemedicine to in-person clinic visits. Patients reported a significant reduction in health visit-related time (median 340 minutes, interquartile range 250-440), mostly due to decreased travel time. CONCLUSIONS: HIV and hepatitis C telemedicine clinics are associated with improved access, high patient satisfaction, and reduction in health visit-related time.

Impact of a kiosk educational module on HIV screening rates and patient knowledge.

We assessed the effect of a kiosk educational module on HIV screening rates and patient knowledge about HIV testing. The evaluation was performed in a walk-in clinic offering routine HIV screening. During alternating two-week periods, patients were referred either to view a kiosk-based, educational module prior to receiving usual care, or the kiosk module was turned off and no alterations to care processes were made. The primary outcome was HIV testing rate. The secondary outcome was knowledge about HIV rapid screening, as measured with a questionnaire. There were 71 patients in the kiosk periods and 79 patients in the usual-care periods. The overall HIV testing rate was 41%. The kiosk period was not associated with greater odds of HIV testing (OR 0.7; 95% CI: 0.4-1.4). In 44 patients who completed the knowledge survey, the kiosk group was strongly associated with increased knowledge (predicted increase in knowledge score: 1.3; 95% CI: 036-2.1). The brief kiosk educational module did not improve HIV screening rates, but it increased overall patient knowledge about HIV testing.