Research-practice partnerships: Adapting a care coordination intervention for rural Veterans over 3 years at multiple sites.

ABSTRACT

PURPOSE: Rural Veterans are more likely than urban Veterans to qualify for community care (Veterans Health Administration [VHA]-paid care delivered outside of VHA) due to wait times ≥30 days and longer travel times for VHA care. For rural Veterans receiving both VHA and community care, suboptimal care coordination between VHA and community providers can result in poor follow-up and care fragmentation. We developed Telehealth-based Coordination of Non-VHA Care (TECNO Care) to address this problem. METHODS: We iteratively developed and adapted TECNO Care with partners from the VHA Office of Rural Health and site-based Home Telehealth Care in the Community programs. Using templated electronic health record notes, Home Telehealth nurses contacted Veterans monthly to facilitate communication with VHA/community providers, coordinate referrals, reconcile medications, and follow up on acute episodes. We evaluated TECNO Care using a patient-level, pre-post effectiveness assessment and rapid qualitative analysis with individual interviews of Veterans and VHA collaborators. Our primary effectiveness outcome was a validated care coordination quality measure. We calculated mean change scores for each care continuity domain. FINDINGS: Between March 2019 and October 2021, 83 Veterans received TECNO Care. Veterans were predominately White (86.4%) and male (88.6%) with mean age 71.4 years (SD 10.4). Quantitative data demonstrated improvements in perceived care coordination following TECNO Care in 7 categories. Qualitative interviews indicated that Veterans and Home Telehealth nurses perceived TECNO Care as beneficial and addressing an area of high need. CONCLUSIONS: TECNO Care appeared to improve the coordination of VHA and community care and was valued by Veterans.