Improving Care Coordination Between Veterans Health Administration Primary Care Teams and Community Home Health Aide Providers: A Qualitative Study.

Effective coordination between medical and long-term services is essential to high-quality primary care for older adults, but can be challenging. Our study assessed coordination and communication through semi-structured interviews with Veterans Health Administration (VHA) primary care clinicians ( = 9); VHA-contracted home health agencies ( = 6); and home health aides ( = 8) caring for veterans at an urban VHA medical center. Participants reported (1) establishing home health services is complex, requiring collaboration between many individuals and systems; (2) communication between medical teams and agencies is often reactive; (3) formal communication channels between medical teams and agencies are lacking; (4) aides are an important source of patient information; and (5) aides report important information, but rarely receive it.

Home Health Aides' Increased Role in Supporting Older Veterans and Primary Healthcare Teams During COVID-19: a Qualitative Analysis.

Background: Home health aides are important but often overlooked members of care teams, providing functional and emotional support to patients. These services became increasingly important during the COVID-19 pandemic as older adults faced disruptions in in-person medical services and family caregiving. Understanding how aides supported healthcare teams is important for informing emergency planning and better integrating home health services with primary care.

Effect of Health Information Exchange Plus a Care Transitions Intervention on Post-Hospital Outcomes Among VA Primary Care Patients: a Randomized Clinical Trial.

Background: Health information exchange (HIE) notifications when patients experience cross-system acute care encounters offer an opportunity to provide timely transitions interventions to improve care across systems.

Objective: To compare HIE notification followed by a post-hospital care transitions intervention (CTI) with HIE notification alone.

Design: Cluster-randomized controlled trial with group assignment by primary care team.

Impact of event notification services on timely follow-up and rehospitalization among primary care patients at two Veterans Affairs Medical Centers.

Objective: To examine the effectiveness of event notification service (ENS) alerts on health care delivery processes and outcomes for older adults.

Materials And Methods: We deployed ENS alerts in 2 Veterans Affairs (VA) medical centers using regional health information exchange (HIE) networks from March 2016 to December 2019. Alerts targeted VA-based primary care teams when older patients (aged 65+ years) were hospitalized or attended emergency departments (ED) outside the VA system.

Improving Patient Activation among Older Veterans: Results from a Social Worker-Led Care Transitions Intervention.

Older veterans enrolled in the Veterans Health Administration (VHA) often use both VHA and non-VHA providers for their care. This dual use, especially around an inpatient visit, can lead to fragmented care during the time of transition post-discharge. Interventions that target patient activation may be valuable ways to help veterans manage complex medication regimens and care plans from multiple providers.

Perceptions of event notification following discharge to improve geriatric care: qualitative interviews of care team members from a 2-site cluster randomized trial.

Objective: To assess primary care teams' perceptions of a health information exchange (HIE) event notification intervention for geriatric patients in 2 Veterans Health Administration (VHA) medical centers.

Materials And Methods: We conducted a qualitative evaluation of an event notification alerting primary care teams to non-VHA hospital admissions and emergency department visits. Data were collected through semistructured interviews (n = 23) of primary care team physicians, nurses and medical assistants.

Characteristics of Veterans With Non-VA Encounters Enrolled in a Trial of Standards-Based, Interoperable Event Notification and Care Coordination.

Introduction: Understanding how veterans use Veterans Affairs (VA) for primary care and non-VA for acute care can help policy makers predict future health care resource use. We aimed to describe characteristics of veterans enrolled in a multisite clinical trial of non-VA acute event notifications and care coordination and to identify patient factors associated with non-VA acute care.

Methods: Characteristics of 565 veterans enrolled in a prospective cluster randomized trial at the Bronx and Indianapolis VA Medical Centers were obtained by interview and chart review.

Utilizing a health information exchange to facilitate COVID-19 VA primary care follow-up for Veterans diagnosed in the community.

The use of alerts from the Bronx RHIO, a health information exchange (HIE) to identify James J. Peters VAMC patients diagnosed with COVID-19 in the community was described to facilitate COVID-19 VA primary care follow-up. COVID-19 hospitalization and testing alerts were delivered on a Bronx RHIO facility report.

Hospital Elder Life Program in Long-Term Care (HELP-LTC): A Cluster Randomized Controlled Trial.

Background/objectives: The Hospital Elder Life Program (HELP) has been shown to prevent delirium in hospitalized older adults. The objective of this study was to test the efficacy of HELP adapted to long-term care (HELP-LTC).

Design: Cluster randomized controlled trial.