Abstract: Improving Post-Hospitalization follow-up for Veterans who are admitted into Non-VA facilities
Objectives: VA policy mandates Non-VA facilities to notify the VA Transfer Center or Fee Basis department about Veterans’ admissions to initiate possible transfers and reviews for reimbursement. Since there is a lack of communication, primary care teams are not aware of the Veterans’ admissions. Consequently, Veterans who are admitted into Non-VA facilities do not receive appropriate and timely post-hospitalization care with their VA primary care teams. The objective of this quality improvement project is to improve post-hospitalization follow-up for Veterans who are admitted into Non-VA facilities by facilitating communications among Transfer …show more content…
DeBakey Veterans Medical Center Office of Care Coordination-Transfer Center. The project lead will be the only person who will involve with the implementation of the projects. In addition, the standards from the Agency for Healthcare Research Re-Engineer Discharge toolkit will be utilized to facilitate communications among Transfer Center, Fee Basis department, and primary care teams. The interventions are 1) notifying primary care teams with 72 hours of Non-VA care notification regarding Veterans’ admission to ensure adequate post-hospitalization follow-up 2) scanning the Veterans’ Non-VA hospital discharge summaries & medical records into VA’s Computerized Patient Record System within 24 hours of receiving the record from Non-VA facilities. Data regarding the Veterans’ admission diagnoses, Non-VA facilities’ admission dates, dates of discharge, primary insurance, dates of follow-up phone calls from primary care teams, and dates of face-to-face appointments with primary care providers will be collected. The Veterans’ identifiable data will be excluded from the data collection process. Furthermore, data will be kept in an electronic password-protected document in the Care Coordination Service drive at the Michael E. DeBakey Veterans Medical Center Transfer Center. Measures are Percent of patients discharged who had a follow-up visit/ phone call with a primary care within 48 hours, percent of discharges where critical information is transmitted at the time of discharge to the next site of care, percent of discharges with a specific clinical condition readmitted for any cause within 30 days of discharge, percent of discharges with readmission for any cause within 30 days, and Emergency Room Visits within 30 Days of Hospital
Objectives: VA policy mandates Non-VA facilities to notify the VA Transfer Center or Fee Basis department about Veterans’ admissions to initiate possible transfers and reviews for reimbursement. Since there is a lack of communication, primary care teams are not aware of the Veterans’ admissions. Consequently, Veterans who are admitted into Non-VA facilities do not receive appropriate and timely post-hospitalization care with their VA primary care teams. The objective of this quality improvement project is to improve post-hospitalization follow-up for Veterans who are admitted into Non-VA facilities by facilitating communications among Transfer …show more content…
DeBakey Veterans Medical Center Office of Care Coordination-Transfer Center. The project lead will be the only person who will involve with the implementation of the projects. In addition, the standards from the Agency for Healthcare Research Re-Engineer Discharge toolkit will be utilized to facilitate communications among Transfer Center, Fee Basis department, and primary care teams. The interventions are 1) notifying primary care teams with 72 hours of Non-VA care notification regarding Veterans’ admission to ensure adequate post-hospitalization follow-up 2) scanning the Veterans’ Non-VA hospital discharge summaries & medical records into VA’s Computerized Patient Record System within 24 hours of receiving the record from Non-VA facilities. Data regarding the Veterans’ admission diagnoses, Non-VA facilities’ admission dates, dates of discharge, primary insurance, dates of follow-up phone calls from primary care teams, and dates of face-to-face appointments with primary care providers will be collected. The Veterans’ identifiable data will be excluded from the data collection process. Furthermore, data will be kept in an electronic password-protected document in the Care Coordination Service drive at the Michael E. DeBakey Veterans Medical Center Transfer Center. Measures are Percent of patients discharged who had a follow-up visit/ phone call with a primary care within 48 hours, percent of discharges where critical information is transmitted at the time of discharge to the next site of care, percent of discharges with a specific clinical condition readmitted for any cause within 30 days of discharge, percent of discharges with readmission for any cause within 30 days, and Emergency Room Visits within 30 Days of Hospital