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.

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.

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.