Optimizing care coordination to address social determinants of health needs for dual-use veterans
Abstract Background Veterans increasingly utilize both the Veteran’s Health Administration (VA) and non-VA hospitals (dual-users). Dual-users are at increased risk of fragmented care and adverse outcomes and often do not receive necessary follow-up care addressing social determinants of health (SDOH...
| Main Authors: | , , , , , , |
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| Format: | Article |
| Language: | English |
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BMC
2022-01-01
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| Series: | BMC Health Services Research |
| Subjects: | |
| Online Access: | https://doi.org/10.1186/s12913-021-07408-x |
| _version_ | 1819006758544211968 |
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| author | Heidi Sjoberg Wenhui Liu Carly Rohs Roman A Ayele Marina McCreight Ashlea Mayberry Catherine Battaglia |
| author_facet | Heidi Sjoberg Wenhui Liu Carly Rohs Roman A Ayele Marina McCreight Ashlea Mayberry Catherine Battaglia |
| author_sort | Heidi Sjoberg |
| collection | DOAJ |
| description | Abstract Background Veterans increasingly utilize both the Veteran’s Health Administration (VA) and non-VA hospitals (dual-users). Dual-users are at increased risk of fragmented care and adverse outcomes and often do not receive necessary follow-up care addressing social determinants of health (SDOH). We developed a Veteran-informed social worker-led Advanced Care Coordination (ACC) program to decrease fragmented care and provide longitudinal care coordination addressing SDOH for dual-users accessing non-VA emergency departments (EDs) in two communities. Methods ACC had four core components: 1. Notification from non-VA ED providers of Veterans’ ED visit; 2. ACC social worker completed a comprehensive assessment with the Veteran to identify SDOH needs; 3. Clinical intervention addressing SDOH up to 90 days post-ED discharge; and 4. Warm hand-off to Veteran’s VA primary care team. Data was documented in our program database. We performed propensity matching between a control group and ACC participants between 4/10/2018 – 4/1/2020 (N- = 161). A joint survival model using Markov Chain Monte Carlo technique was employed for 30-day outcomes. We performed Difference-In-Difference analyses on number of ED visits, admissions, and primary care physician (PCP) visits 120-day pre/post discharge. Results When compared to a matched control group ACC had significantly lower risk of 30-day ED visits (Hazard Ratio (HR) = 0.61, 95% Confidence Interval (CI) = (0.42, 0.92)) and a higher probability of PCP visits at 13–30 days post-ED visit (HR = 1.5, 95% CI = (1.01, 2.22)). Veterans enrolled in ACC were connected to VA PCP visits (50%), VA benefits (19%), home health care (10%), mental health and substance use treatment (7%), transportation (7%), financial assistance (5%), and homeless resources (2%). Conclusion We developed and implemented a program addressing dual-users’ SDOH needs post non-VA ED discharge. Social workers connected dual-users to needed follow-up care and resources which reduced fragmentation and adverse outcomes. |
| first_indexed | 2024-12-21T00:13:46Z |
| format | Article |
| id | doaj.art-8bfa5d9e286c47f1a45927c3ea7c769a |
| institution | Directory Open Access Journal |
| issn | 1472-6963 |
| language | English |
| last_indexed | 2024-12-21T00:13:46Z |
| publishDate | 2022-01-01 |
| publisher | BMC |
| record_format | Article |
| series | BMC Health Services Research |
| spelling | doaj.art-8bfa5d9e286c47f1a45927c3ea7c769a2022-12-21T19:22:18ZengBMCBMC Health Services Research1472-69632022-01-0122111210.1186/s12913-021-07408-xOptimizing care coordination to address social determinants of health needs for dual-use veteransHeidi Sjoberg0Wenhui Liu1Carly Rohs2Roman A Ayele3Marina McCreight4Ashlea Mayberry5Catherine Battaglia6Department of Veterans Affairs, Eastern Colorado Health Care SystemDepartment of Veterans Affairs, Eastern Colorado Health Care SystemDepartment of Veterans Affairs, Eastern Colorado Health Care SystemDepartment of Veterans Affairs, Eastern Colorado Health Care SystemDepartment of Veterans Affairs, Eastern Colorado Health Care SystemDepartment of Veterans Affairs, Eastern Colorado Health Care SystemDepartment of Veterans Affairs, Eastern Colorado Health Care SystemAbstract Background Veterans increasingly utilize both the Veteran’s Health Administration (VA) and non-VA hospitals (dual-users). Dual-users are at increased risk of fragmented care and adverse outcomes and often do not receive necessary follow-up care addressing social determinants of health (SDOH). We developed a Veteran-informed social worker-led Advanced Care Coordination (ACC) program to decrease fragmented care and provide longitudinal care coordination addressing SDOH for dual-users accessing non-VA emergency departments (EDs) in two communities. Methods ACC had four core components: 1. Notification from non-VA ED providers of Veterans’ ED visit; 2. ACC social worker completed a comprehensive assessment with the Veteran to identify SDOH needs; 3. Clinical intervention addressing SDOH up to 90 days post-ED discharge; and 4. Warm hand-off to Veteran’s VA primary care team. Data was documented in our program database. We performed propensity matching between a control group and ACC participants between 4/10/2018 – 4/1/2020 (N- = 161). A joint survival model using Markov Chain Monte Carlo technique was employed for 30-day outcomes. We performed Difference-In-Difference analyses on number of ED visits, admissions, and primary care physician (PCP) visits 120-day pre/post discharge. Results When compared to a matched control group ACC had significantly lower risk of 30-day ED visits (Hazard Ratio (HR) = 0.61, 95% Confidence Interval (CI) = (0.42, 0.92)) and a higher probability of PCP visits at 13–30 days post-ED visit (HR = 1.5, 95% CI = (1.01, 2.22)). Veterans enrolled in ACC were connected to VA PCP visits (50%), VA benefits (19%), home health care (10%), mental health and substance use treatment (7%), transportation (7%), financial assistance (5%), and homeless resources (2%). Conclusion We developed and implemented a program addressing dual-users’ SDOH needs post non-VA ED discharge. Social workers connected dual-users to needed follow-up care and resources which reduced fragmentation and adverse outcomes.https://doi.org/10.1186/s12913-021-07408-xsocial determinants of healthveteranssocial workemergency departmentsveterans health administration |
| spellingShingle | Heidi Sjoberg Wenhui Liu Carly Rohs Roman A Ayele Marina McCreight Ashlea Mayberry Catherine Battaglia Optimizing care coordination to address social determinants of health needs for dual-use veterans BMC Health Services Research social determinants of health veterans social work emergency departments veterans health administration |
| title | Optimizing care coordination to address social determinants of health needs for dual-use veterans |
| title_full | Optimizing care coordination to address social determinants of health needs for dual-use veterans |
| title_fullStr | Optimizing care coordination to address social determinants of health needs for dual-use veterans |
| title_full_unstemmed | Optimizing care coordination to address social determinants of health needs for dual-use veterans |
| title_short | Optimizing care coordination to address social determinants of health needs for dual-use veterans |
| title_sort | optimizing care coordination to address social determinants of health needs for dual use veterans |
| topic | social determinants of health veterans social work emergency departments veterans health administration |
| url | https://doi.org/10.1186/s12913-021-07408-x |
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