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Gilmartin H, Jones C, Nunnery M, Leonard C, Connelly B, Wills A, Kelley L, Rabin B, Burke RE. An implementation strategy postmortem method developed in the VA rural Transitions Nurse Program to inform spread and scale-up. PLoS One 2024; 19:e0298552. [PMID: 38457367 PMCID: PMC10923440 DOI: 10.1371/journal.pone.0298552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 01/25/2024] [Indexed: 03/10/2024] Open
Abstract
BACKGROUND High-quality implementation evaluations report on intervention fidelity and adaptations made, but a practical process for evaluating implementation strategies is needed. A retrospective method for evaluating implementation strategies is also required as prospective methods can be resource intensive. This study aimed to establish an implementation strategy postmortem method to identify the implementation strategies used, when, and their perceived importance. We used the rural Transitions Nurse Program (TNP) as a case study, a national care coordination intervention implemented at 11 hospitals over three years. METHODS The postmortem used a retrospective, mixed method, phased approach. Implementation team and front-line staff characterized the implementation strategies used, their timing, frequency, ease of use, and their importance to implementation success. The Expert Recommendations for Implementing Change (ERIC) compilation, the Quality Enhancement Research Initiative phases, and Proctor and colleagues' guidance were used to operationalize the strategies. Survey data were analyzed descriptively, and qualitative data were analyzed using matrix content analysis. RESULTS The postmortem method identified 45 of 73 ERIC strategies introduced, including 41 during pre-implementation, 37 during implementation, and 27 during sustainment. External facilitation, centralized technical assistance, and clinical supervision were ranked as the most important and frequently used strategies. Implementation strategies were more intensively applied in the beginning of the study and tapered over time. CONCLUSIONS The postmortem method identified that more strategies were used in TNP than planned and identified the most important strategies from the perspective of the implementation team and front-line staff. The findings can inform other implementation studies as well as dissemination of the TNP intervention.
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Affiliation(s)
- Heather Gilmartin
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Healthcare System, Aurora, Colorado, United States of America
- Department of Health Systems, Management and Policy, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, United States of America
| | - Christine Jones
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Healthcare System, Aurora, Colorado, United States of America
- Division of Geriatric Medicine and Division of Hospital Medicine, Department of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, United States of America
| | - Mary Nunnery
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Healthcare System, Aurora, Colorado, United States of America
| | - Chelsea Leonard
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Healthcare System, Aurora, Colorado, United States of America
| | - Brigid Connelly
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Healthcare System, Aurora, Colorado, United States of America
| | - Ashlea Wills
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Healthcare System, Aurora, Colorado, United States of America
| | - Lynette Kelley
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Healthcare System, Aurora, Colorado, United States of America
| | - Borsika Rabin
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Healthcare System, Aurora, Colorado, United States of America
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, San Diego, California, United States of America
- Altman Clinical and Translational Research Institute, Dissemination and Implementation Science Center, University of California San Diego, San Diego, California, United States of America
| | - Robert E. Burke
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center, Philadelphia, Pennsylvania, United States of America
- Hospital Medicine Section – Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States of America
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
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Kelley L, Broadfoot K, McCreight M, Wills A, Leonard C, Connelly B, Gilmartin H, Burke RE. Implementation and Evaluation of a Training Curriculum for Experienced Nurses in Care Coordination: The VA Rural Transitions Nurse Training Program. J Nurs Care Qual 2023; 38:286-292. [PMID: 36857291 PMCID: PMC10205654 DOI: 10.1097/ncq.0000000000000698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND High-quality transitional care at discharge is essential for improved patient outcomes. Registered nurses (RNs) play integral roles in transitions; however, few receive structured training. PURPOSE We sought to create, implement, and evaluate an evidence-informed nursing transitional care coordination curriculum, the Transitions Nurse Training Program (TNTP). METHODS We conceptualized the curriculum using adult learning theory and evaluated with the New World Kirkpatrick Model. Self-reported engagement, satisfaction, acquired knowledge, and confidence were assessed using surveys. Clinical and communication skills were evaluated by standardized patient assessment and behavior sustainment via observation 6 to 9 months posttraining. RESULTS RNs reported high degrees of engagement, satisfaction, knowledge, and confidence and achieved a mean score of 92% on clinical and communication skills. Posttraining observation revealed skill sustainment (mean score 98%). CONCLUSIONS Results suggest TNTP is effective for creating engagement, satisfaction, acquired and sustained knowledge, and confidence for RNs trained in transitional care.
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Affiliation(s)
- Lynette Kelley
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora CO, United States of America
- Geriatric Research Education and Clinical Center, VA Eastern Colorado Health Care System, Aurora CO, United States of America
| | - Kirsten Broadfoot
- University of Colorado School of Medicine, Center for Advancing Professional Excellence, University of Colorado Anschutz Medical Campus, Aurora CO, United States of America
| | - Marina McCreight
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora CO, United States of America
| | - Ashlea Wills
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora CO, United States of America
| | - Chelsea Leonard
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora CO, United States of America
- Division of Health Care Policy and Research, University of Colorado School of Medicine, Aurora CO, United States of America
| | - Brigid Connelly
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora CO, United States of America
| | - Heather Gilmartin
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora CO, United States of America
- Health Systems, Management and Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora CO, United States of America
| | - Robert E. Burke
- Center for Health Equity Research and Promotion (CHERP), Corporal Crescenz VA Medical Center, Philadelphia, PA, United States of America
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine Philadelphia PA, United States of America
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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Williams PH, Gilmartin HM, Leonard C, McCarthy MS, Kelley L, Grunwald GK, Jones CD, Whittington MD. The Influence of the Rural Transitions Nurse Program for Veterans on Healthcare Utilization Costs. J Gen Intern Med 2022; 37:3529-3534. [PMID: 36042072 PMCID: PMC9585107 DOI: 10.1007/s11606-022-07401-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 01/05/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND The Veterans Affairs (VA) Healthcare System Rural Transitions Nurse Program (TNP) addresses barriers veterans face when transitioning from urban tertiary VA hospitals to home. Previous clinical evaluations of TNP have shown that enrolled veterans were more likely to follow up with their primary care provider within 14 days of discharge and experience a significant reduction in mortality within 30 days compared to propensity-score matched controls. OBJECTIVE Examine changes from pre- to post-hospitalization in total, inpatient, and outpatient 30-day healthcare utilization costs for TNP enrollees compared to controls. DESIGN Quantitative analyses modeling the changes in cost via multivariable linear mixed-effects models to determine the association between TNP enrollment and changes in these costs. PARTICIPANTS Veterans meeting TNP eligibility criteria who were discharged home following an inpatient hospitalization at one of the 11 implementation sites from April 2017 to September 2019. INTERVENTION The four-step TNP transitional care intervention. MAIN MEASURES Changes in 30-day total, inpatient, and outpatient healthcare utilization costs were calculated for TNP enrollees and controls. KEY RESULTS Among 3001 TNP enrollees and 6002 controls, no statistically significant difference in the change in total costs (p = 0.65, 95% CI: (- $675, $350)) was identified. However, on average, the increase in inpatient costs from pre- to post-hospitalization was approximately $549 less for TNP enrollees (p = 0.02, 95% CI: (- $856, - $246)). The average increase in outpatient costs from pre- to post-hospitalization was approximately $421 more for TNP enrollees compared to controls (p = 0.003, 95% CI: ($109, $671)). CONCLUSIONS Although we found no difference in change in total costs between veterans enrolled in TNP and controls, TNP was associated with a smaller increase in direct inpatient medical costs and a larger increase in direct outpatient medical costs. This suggests a shifting of costs from the inpatient to outpatient setting.
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Affiliation(s)
- Piper H. Williams
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, CO USA
| | - Heather M. Gilmartin
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, CO USA
- Health Systems, Management and Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO USA
| | - Chelsea Leonard
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, CO USA
| | - Michaela S. McCarthy
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, CO USA
| | - Lynette Kelley
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, CO USA
| | - Gary K. Grunwald
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, CO USA
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO USA
| | - Christine D. Jones
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, CO USA
- Division of Hospital Medicine, Department of Medicine, University of Colorado, Aurora, CO USA
| | - Melanie D. Whittington
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, CO USA
- University of Kansas Medical Center, Kansas City, KS USA
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Gilmartin HM, Warsavage T, Hines A, Leonard C, Kelley L, Wills A, Gaskin D, Ujano-De Motta L, Connelly B, Plomondon ME, Yang F, Kaboli P, Burke RE, Jones CD. Effectiveness of the rural transitions nurse program for Veterans: A multicenter implementation study. J Hosp Med 2022; 17:149-157. [PMID: 35504490 DOI: 10.1002/jhm.12802] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 01/27/2022] [Accepted: 02/01/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Veterans are often transferred from rural areas to urban VA Medical Centers for care. The transition from hospital to home is vulnerable to postdischarge adverse events. OBJECTIVE To evaluate the effectiveness of the rural Transitions Nurse Program (TNP). DESIGN, SETTING, AND PARTICIPANTS National hybrid-effectiveness-implementation study, within site propensity-matched cohort in 11 urban VA hospitals. 3001 Veterans were enrolled in TNP from April 2017 to September 2019, and 6002 matched controls. INTERVENTION AND OUTCOMES The intervention was led by a transitions nurse who assessed discharge readiness, provided postdischarge communication with primary care providers (PCPs), and called the Veteran within 72 h of discharge home to assess needs, and encourage follow-up appointment attendance. Controls received usual care. The primary outcomes were PCP visits within 14 days of discharge and all-cause 30-day readmissions. Secondary outcomes were 30-day emergency department (ED) visits and 30-day mortality. Patients were matched by length of stay, prior hospitalizations and PCP visits, urban/rural status, and 32 Elixhauser comorbidities. RESULTS The 3001 Veterans enrolled in TNP were more likely to see their PCP within 14 days of discharge than 6002 matched controls (odds ratio = 2.24, 95% confidence interval [CI] = 2.05-2.45). TNP enrollment was not associated with reduced 30-day ED visits or readmissions but was associated with reduced 30-day mortality (hazard ratio = 0.33, 95% CI = 0.21-0.53). PCP and ED visits did not have a significant mediating effect on outcomes. The observational design, potential selection bias, and unmeasurable confounders limit causal inference. CONCLUSIONS TNP was associated with increased postdischarge follow-up and a mortality reduction. Further investigation to understand the reduction in mortality is needed.
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Affiliation(s)
- Heather M Gilmartin
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
- Department of Health Systems, Management and Policy, School of Public Health, University of Colorado, Aurora, Colorado, USA
| | - Theodore Warsavage
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
| | - Anne Hines
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
| | - Chelsea Leonard
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
| | - Lynette Kelley
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
| | - Ashlea Wills
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
| | - David Gaskin
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
| | - Lexus Ujano-De Motta
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
| | - Brigid Connelly
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
| | - Mary E Plomondon
- Clinical Assessment Reporting and Tracking Program, Office of Quality and Patient Safety, Veterans' Health Administration, Washington, District of Columbia, USA
| | - Fan Yang
- Department of Biostatistics and Informatics, School of Public Health, University of Colorado, Aurora, Colorado, USA
| | - Peter Kaboli
- Research Department, Veterans Rural Health Resource Center-Iowa City, VA Office of Rural Health, and Center for Access and Delivery Research and Evaluation (CADRE) at the Iowa City VA Healthcare System, Iowa City, Iowa, USA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Robert E Burke
- Research Department, Center for Health Equity Research and Promotion, Corporal Crescenz Veterans Health Administration Medical Center, Philadelphia, Pennsylvania, USA
- Hospital Medicine Section - Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Christine D Jones
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
- Division of Hospital Medicine, Department of Medicine, Anschutz Medical Campus, University of Colorado, Aurora, Colorado, USA
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Nunnery MA, Gilmartin H, McCarthy M, Motta LUD, Wills A, Kelley L, Jones CD, Leonard C. Sustainment stories: a qualitative analysis of barriers to sustainment of the National Rural Transitions of Care Nurse Program. BMC Health Serv Res 2022; 22:119. [PMID: 35090448 PMCID: PMC8796421 DOI: 10.1186/s12913-021-07420-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 12/13/2021] [Indexed: 12/03/2022] Open
Abstract
Background Understanding how to successfully sustain evidence-based care coordination interventions across diverse settings is critical to ensure that patients continue to receive high quality care even after grant funding ends. The Transitions Nurse Program (TNP) is a national intervention in the Veterans Administration (VA) that coordinates care for high risk veterans transitioning from acute care VA medical centers (VAMCs) to home. As part of TNP, a VA facility receives funding for a full-time nurse to implement TNP, however, this funding ends after implementation. In this qualitative study we describe which elements of TNP sites planned to sustain as funding concluded, as well as perceived barriers to sustainment. Methods TNP was implemented between 2016 and 2020 at eleven VA medical centers. Three years of funding was provided to each site to support hiring of staff, implementation and evaluation of the program. At the conclusion of funding, each site determined if they would sustain components or the entirety of the program. Prior to the end of funding at each site, we conducted midline and exit interviews with Transitions nurses and site champions to assess plans for sustainment and perceived barriers to sustainment. Interviews were analyzed using iterative, team-based inductive deductive content analysis to identify themes related to planned sustainment and perceived barriers to sustainment. Results None of the 11 sites planned to sustain TNP in its original format, though many of the medical centers anticipated offering components of the program, such as follow up calls after discharge to rural areas, documented warm hand off to PACT team, and designating a team member as responsible for patient rural discharge follow up. We identified three themes related to perceived sustainability. These included: 1) Program outcomes that address leadership priorities are necessary for sustainment.; 2) Local perceptions of the need for TNP or redundancy of TNP impacted perceived sustainability; and 3) Lack of leadership buy-in, changing leadership priorities, and leadership turnover are perceived barriers to sustainment. Conclusions Understanding perceived sustainability is critical to continuing high quality care coordination interventions after funding ends. Our findings suggest that sustainment of care coordination interventions requires an in-depth understanding of the facility needs and local leadership priorities, and that building adaptable programs that continually engage key stakeholders is essential. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-07420-1.
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Koufacos NS, May J, Judon KM, Franzosa E, Dixon BE, Schubert CC, Schwartzkopf AL, Guerrero VM, Traylor M, Boockvar KS. Improving Patient Activation among Older Veterans: Results from a Social Worker-Led Care Transitions Intervention. JOURNAL OF GERONTOLOGICAL SOCIAL WORK 2022; 65:63-77. [PMID: 34053407 PMCID: PMC8982469 DOI: 10.1080/01634372.2021.1932003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 05/14/2021] [Accepted: 05/16/2021] [Indexed: 06/12/2023]
Abstract
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. The Care Transitions Intervention (CTI) is an evidence-based model that helps older adults gain confidence and skills to achieve their health goals post-discharge. Our study examined the impact of CTI upon patient activation for veterans discharged from non-VHA hospitals. In total, 158 interventions were conducted for 87 veterans. From baseline to follow-up there was a significant 1.7-point increase in patient activation scores, from 5.4 to 7.1. This association was only found among those who completed the intervention. The most common barriers to completion were difficulty reaching the veteran by phone, patient declining the intervention, and rehospitalization during the 30 days post-discharge. Care transitions guided by social workers may be a promising way to improve patient activation. However, future research and practice should address barriers to completion and examine the impact of increased patient activation on health outcomes.
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Affiliation(s)
- Nicholas S Koufacos
- Geriatric Research Education and Clinical Center, James J. Peters VA, Bronx, New York, USA
| | - Justine May
- Center for Health Information and Communication, Health Services Research & Development Service, Richard L. Roudebush VA, Indianapolis, Indiana, USA
| | - Kimberly M Judon
- Geriatric Research Education and Clinical Center, James J. Peters VA, Bronx, New York, USA
| | - Emily Franzosa
- Geriatric Research Education and Clinical Center, James J. Peters VA, Bronx, New York, USA
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Brian E Dixon
- Center for Health Information and Communication, Health Services Research & Development Service, Richard L. Roudebush VA, Indianapolis, Indiana, USA
- Department of Epidemiology, Indiana University, Fairbanks School of Public Health, Indianapolis, Indiana, USA
- Center for Biomedical Informatics, Regenstrief Institute, Center for Biomedical Informatics, Indianapolis, Indiana, USA
| | - Cathy C Schubert
- Center for Health Information and Communication, Health Services Research & Development Service, Richard L. Roudebush VA, Indianapolis, Indiana, USA
- Department of Medicine, Indiana University, School of Medicine, Indianapolis, Indiana, USA
| | - Ashley L Schwartzkopf
- Center for Health Information and Communication, Health Services Research & Development Service, Richard L. Roudebush VA, Indianapolis, Indiana, USA
| | - Vivian M Guerrero
- Geriatric Research Education and Clinical Center, James J. Peters VA, Bronx, New York, USA
| | - Morgan Traylor
- Center for Health Information and Communication, Health Services Research & Development Service, Richard L. Roudebush VA, Indianapolis, Indiana, USA
| | - Kenneth S Boockvar
- Geriatric Research Education and Clinical Center, James J. Peters VA, Bronx, New York, USA
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Connelly B, Leonard C, Gaskin D, Warsavage T, Gilmartin H. Increasing enrolment in a national VA transitions of care programme: a pre-post evaluation of a data dashboard and nudge-based intervention. BMJ Health Care Inform 2021; 28:bmjhci-2021-100416. [PMID: 34764197 PMCID: PMC8587340 DOI: 10.1136/bmjhci-2021-100416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 10/21/2021] [Indexed: 11/13/2022] Open
Abstract
Background The rural transitions nurse programme (TNP) is a care coordination intervention for high-risk veterans. An interactive dashboard was used to provide real-time performance metrics to sites as an audit and feedback tool. One-year post implementation, enrolment goals were not met. Nudge emails were introduced to increase TNP veteran enrolment. This study evaluated whether veteran enrolment increased when feedback occurred through a dashboard plus weekly nudge email versus dashboard alone. Setting/population This observational study included veterans who were hospitalised and discharged from four Veterans Health Administration hospitals participating in TNP. Methods Veteran enrolment counts between the dashboard phase and dashboard plus weekly nudge email phase were compared. Nudge emails included run charts of enrolment data. The difference of means for weekly enrolment between the two phases were calculated. After 3 months of nudge emails, a survey assessing TNP transitions nurse and physician champion perceptions of the nudge emails was distributed. Results The average enrolment for the four TNP sites during the ~20-month dashboard only phase was 4.23 veterans/week. The average during the 3-month dashboard plus nudge email phase was 4.21 veterans/week. The difference in means was −0.03 (p=0.73). Adjusting for time trends had no further effect. Four nurses responded to the survey. Two nurses reported neutral and two reported positive perceptions of the nudge emails. Conclusion Drawing attention to metrics, through nudge emails, maintained, but did not increase TNP veteran discharges compared to dashboard feedback alone.
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Affiliation(s)
- Brigid Connelly
- Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Aurora, CO, USA
| | - Chelsea Leonard
- Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Aurora, CO, USA
| | - David Gaskin
- Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Aurora, CO, USA
| | - Theodore Warsavage
- Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Aurora, CO, USA
| | - Heather Gilmartin
- Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Aurora, CO, USA .,Department of Health Systems, Management and Policy and Department of Biostatistics and Informatics, University of Colorado School of Public Health, Aurora, Colorado, USA
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McCarthy MS, Ujano-De Motta LL, Nunnery MA, Gilmartin H, Kelley L, Wills A, Leonard C, Jones CD, Rabin BA. Understanding adaptations in the Veteran Health Administration's Transitions Nurse Program: refining methodology and pragmatic implications for scale-up. Implement Sci 2021; 16:71. [PMID: 34256763 PMCID: PMC8276503 DOI: 10.1186/s13012-021-01126-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 05/12/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND When complex health services interventions are implemented in real-world settings, adaptations are inevitable. Adaptations are changes made to an intervention, implementation strategy, or context prior to, during, and after implementation to improve uptake and fit. There is a growing interest in systematically documenting and understanding adaptations including what is changed, why, when, by whom, and with what impact. The rural Transitions Nurse Program (TNP) is a program in the Veterans Health Administration (VHA), designed to safely transition a rural veteran from a tertiary hospital back home. TNP has been implemented in multiple cohorts across 11 sites nationwide over 4 years. In this paper, we describe adaptations in five TNP sites from the first cohort of sites and implications for the scale-up of TNP and discuss lessons learned for the systematic documentation and analysis of adaptations. METHODS We used the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) expanded version of the original Stirman framework to guide the rapid qualitative matrix analysis of adaptations. Adaptations were documented using multiple approaches: real-time database, semi-structured midpoint and exit interviews with implementors, and member checking with the implementation team. Interviews were recorded and transcribed. To combine multiple sources of adaptations, we used key domains from our framework and organized adaptations by time when the adaptation occurred (pre-, early, mid-, late implementation; sustainment) and categorized them as proactive or reactive. RESULTS Forty-one unique adaptations were reported during the study period. The most common type of adaptation was changes in target populations (patient enrollment criteria) followed by personnel changes (staff turnover). Most adaptations occurred during the mid-implementation time period and varied in number and type of adaptation. The reasons for this are discussed, and suggestions for future adaptation protocols are included. CONCLUSIONS This study demonstrates the feasibility of systematically documenting adaptations using multiple methods across time points. Implementors were able to track adaptations in real time across the course of an intervention, which provided timely and actionable feedback to the implementation team overseeing the national roll-out of the program. Longitudinal semi-structured interviews can complement the real-time database and elicit reflective adaptations.
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Affiliation(s)
- Michaela S McCarthy
- Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care (COIN), VA Eastern Colorado Health Care System, 1700 N. Wheeling Street, P1-151 Research, Denver, CO, 80045, USA.
- College of Nursing, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Lexus L Ujano-De Motta
- Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care (COIN), VA Eastern Colorado Health Care System, 1700 N. Wheeling Street, P1-151 Research, Denver, CO, 80045, USA
| | - Mary A Nunnery
- Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care (COIN), VA Eastern Colorado Health Care System, 1700 N. Wheeling Street, P1-151 Research, Denver, CO, 80045, USA
| | - Heather Gilmartin
- Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care (COIN), VA Eastern Colorado Health Care System, 1700 N. Wheeling Street, P1-151 Research, Denver, CO, 80045, USA
- Health Systems, Management, and Policy, Colorado School of Public Health, Anschutz Medical Campus, Aurora, CO, USA
| | - Lynette Kelley
- Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care (COIN), VA Eastern Colorado Health Care System, 1700 N. Wheeling Street, P1-151 Research, Denver, CO, 80045, USA
| | - Ashlea Wills
- Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care (COIN), VA Eastern Colorado Health Care System, 1700 N. Wheeling Street, P1-151 Research, Denver, CO, 80045, USA
| | - Chelsea Leonard
- Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care (COIN), VA Eastern Colorado Health Care System, 1700 N. Wheeling Street, P1-151 Research, Denver, CO, 80045, USA
| | - Christine D Jones
- Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care (COIN), VA Eastern Colorado Health Care System, 1700 N. Wheeling Street, P1-151 Research, Denver, CO, 80045, USA
- Division of Hospital Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Borsika A Rabin
- Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care (COIN), VA Eastern Colorado Health Care System, 1700 N. Wheeling Street, P1-151 Research, Denver, CO, 80045, USA
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, CA, USA
- UC San Diego Dissemination and Implementation Science Center, University of California San Diego, La Jolla, CA, USA
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9
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Leonard C, Gilmartin H, McCreight M, Kelley L, Mayberry A, Burke RE. Training registered nurses to conduct pre-implementation assessment to inform program scale-up: an example from the rural Transitions Nurse Program. Implement Sci Commun 2021; 2:28. [PMID: 33685521 PMCID: PMC7938579 DOI: 10.1186/s43058-021-00127-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 02/09/2021] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES Adapting evidence-based practices to local settings is critical for successful implementation and dissemination. A pre-implementation assessment evaluates local context to inform implementation, but there is little published guidance for clinician-implementers. The rural Transitions Nurse Program (TNP) is a care coordination intervention that facilitates care transitions for rural veterans. In year 1 of TNP, pre-implementation assessments were conducted by a centralized project team through multi-day visits at five sites nationwide. In year 2, we tested if local site TNP nurses could conduct pre-implementation assessments using evidence-based tools and coaching from the TNP team. This required developing a multicomponent pre-implementation strategy bundle to guide data collection and synthesis. We hypothesized that (1) nurses would find the pre-implementation assessment useful for tailoring TNP to local contexts and (2) nurses would identify similar barriers and facilitators to those identified at first year sites. METHODS The bundle included guides for conducting key informant interviews, brainwriting, process mapping, and reflective journaling. We evaluated TNP nurse satisfaction and perceived utility of the structure and process of the training and bundle through pre-post surveys. To assess the outcome of data collection efforts, we interviewed nurses 4 months after completion of the pre-implementation assessment to determine if and how they used pre-implementation findings to tailor implementation of TNP to local contexts. To further assess outcomes, all data that the nurses collected were analyzed thematically. Themes related to barriers and facilitators were compared across years. FINDINGS Five nurses at different VA medical centers used the pre-implementation strategy bundle to collect site-level data and completed pre-post surveys. Findings indicated that the pre-implementation assessment was highly recommended, and the bundle provided adequate training. Nurses felt that pre-implementation work oriented them to the local context and illustrated how to integrate TNP into existing processes. Barriers and facilitators identified by nurses were similar to those collected in year 1 by the TNP research team, including communication challenges, need for buy-in, and logistical concerns. CONCLUSIONS This proof-of-concept study suggests that evidence-based tools can effectively guide clinician-implementers through the process of conducting a pre-implementation assessment. This approach positively informed TNP implementation and oriented nurses to their local context prior to implementation.
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Affiliation(s)
- Chelsea Leonard
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Healthcare System, 1700 N Wheeling Street, Aurora, CO, 80045, USA.
| | - Heather Gilmartin
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Healthcare System, 1700 N Wheeling Street, Aurora, CO, 80045, USA.,Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Marina McCreight
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Healthcare System, 1700 N Wheeling Street, Aurora, CO, 80045, USA
| | - Lynette Kelley
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Healthcare System, 1700 N Wheeling Street, Aurora, CO, 80045, USA
| | - Ashlea Mayberry
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Healthcare System, 1700 N Wheeling Street, Aurora, CO, 80045, USA
| | - Robert E Burke
- Center for Health Equity Research and Promotion (CHERP), Corporal Crescenz VA Medical Center, Philadelphia, PA, USA.,Hospital Medicine Section, Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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10
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Practices to support relational coordination in care transitions: Observations from the VA rural Transitions Nurse Program. Health Care Manage Rev 2020; 47:109-114. [PMID: 33181554 DOI: 10.1097/hmr.0000000000000300] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Ensuring safe transitions of care around hospital discharge requires effective relationships and communication between health care teams. Relational coordination (RC) is a process of communicating and relating for the purpose of task integration that predicts desirable outcomes for patients and providers. RC can be measured using a validated survey. PURPOSE The aim of the study was to demonstrate the application of RC practices within the rural Transitions Nurse Program (TNP), a nationwide transitions of care intervention for Veterans, and assess relationships and mechanisms for developing RC in teams. METHODOLOGY/APPROACH TNP implemented practices expected to support RC. These included creation of a transition nurse role, preimplementation site visits, process mapping to understand workflow, creation of standardized communication templates and protocols, and inclusion of teamwork and shared accountability in job descriptions and annual reviews. We used the RC Survey to measure RC for TNP health care teams. Associations between the months each site participated in TNP, number of Veterans enrolled, and adherence to the TNP intervention were assessed as possible mechanisms for developing high RC using Spearman (rs) correlations. RESULTS The RC Survey was completed by 44 providers from 11 Veterans Health Administration medical centers. RC scores were high across sites (mean = 4.19; 1-5 Likert scale) and were positively correlated with months participating in TNP (rs = .66) and number of enrollees (rs = .63), but not with adherence to the TNP intervention (rs = .12). PRACTICE IMPLICATIONS The impact of practices to support RC can be assessed using the RC Survey. Our findings suggest scale-up time is a likely mechanism to the development of high-quality relationships and communication within teams.
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11
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Ayele RA, Liu W, Rohs C, McCreight M, Mayberry A, Sjoberg H, Kelley L, Glasgow RE, Rabin BA, Battaglia C. VA Care Coordination Program Increased Primary Care Visits and Improved Transitional Care for Veterans Post Non-VA Hospital Discharge. Am J Med Qual 2020; 36:221-228. [PMID: 32772849 DOI: 10.1177/1062860620946362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Veterans are increasingly eligible for non-VA care through the Veteran Health Administration (VA) Maintaining Internal Systems and Strengthening Integrated Outside Networks Act while maintaining care in the VA. Continuity of care is challenging when delivered across multiple systems resulting in avoidable complications. The Community Hospital Transitions Program (CHTP) intervention was developed to address challenges veterans face post non-VA hospitalization. Propensity score-matched analysis was used to compare outcomes between 334 intervention and matched control patients who were discharged from non-VA hospitals. Veterans in CHTP were more likely than matched controls to receive a follow-up appointment within 14 days (mean: 0.43 vs 0.34, P < .05) and 30 days (mean: 0.62 vs 0.50, P < .05). There were no significant differences in 30-day readmissions or 30-day emergency department visits. CHTP veterans received timely follow-up care post discharge in VA facilities. Providing quality care to dual-use veterans is dependent on coordinated transitional care.
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Affiliation(s)
- Roman A Ayele
- Department of Veterans Affairs, Eastern Colorado Health Care System, Aurora, CO University of Colorado, Anschutz Medical Campus, Aurora, CO University of California San Diego, San Diego, CA
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12
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Connelly B, Ujano-De Motta LL, Leonard C, Mayberry A, Kelley L, Gaskin D, Gilmartin HM. Mapping the reach of a rural Transitions Nurse Program for veterans with geographic information systems. Implement Sci Commun 2020; 1:36. [PMID: 32885193 PMCID: PMC7427864 DOI: 10.1186/s43058-020-00026-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 02/28/2020] [Indexed: 12/16/2022] Open
Abstract
PURPOSE Rural Veterans who receive inpatient care at a Veterans Health Administration (VA) tertiary facility can face significant barriers to a safe transition home. The VA rural Transitions Nurse Program (TNP) is a national, intensive care coordination quality improvement program for rural Veterans. To communicate the reach of TNP into rural communities, we developed geographic information system (GIS) maps. This study evaluated TNP transitions nurse and site champion perceptions of GIS as a communication tool for illustrating the reach of TNP into rural communities. METHODS Using residence information for TNP enrollees, we built GIS maps using ArcGIS Enterprise, a mapping and analytics platform. Residential addresses were matched to Rural-Urban Commuting Area geographical categories. Transitions nurse and site champion perceptions of the local and national GIS maps were assessed through surveys and interviews. The data were analyzed using descriptive and content analytic methods to identify themes. RESULTS Transitions nurses and site champions perceived GIS maps as a valuable, easy to understand, acceptable, and appropriate communication tool to illustrate the reach of TNP into rural communities. Interviews revealed three common themes: a picture is worth a thousand words, the GIS maps are an effective communication tool, and the GIS maps revealed surprising and promising information. CONCLUSIONS GIS is a useful communication tool to support to illustrate the reach of an intervention. The GIS maps engaged transitions nurses and site champions in discussion. The availability of open access software programs and publicly available location data will increase access to GIS for researchers and practitioners.
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Affiliation(s)
- Brigid Connelly
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Healthcare System, 1700 N. Wheeling St, Aurora, CO 80045 USA
| | - Lexus L. Ujano-De Motta
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Healthcare System, 1700 N. Wheeling St, Aurora, CO 80045 USA
| | - Chelsea Leonard
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Healthcare System, 1700 N. Wheeling St, Aurora, CO 80045 USA
| | - Ashlea Mayberry
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Healthcare System, 1700 N. Wheeling St, Aurora, CO 80045 USA
| | - Lynette Kelley
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Healthcare System, 1700 N. Wheeling St, Aurora, CO 80045 USA
| | - David Gaskin
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Healthcare System, 1700 N. Wheeling St, Aurora, CO 80045 USA
| | - Heather M. Gilmartin
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Healthcare System, 1700 N. Wheeling St, Aurora, CO 80045 USA
- Health Management, Systems, and Policy, University of Colorado, School of Public Health, Aurora, CO 80045 USA
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13
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Ayele RA, Lawrence E, McCreight M, Fehling K, Glasgow RE, Rabin BA, Burke RE, Battaglia C. Perspectives of Clinicians, Staff, and Veterans in Transitioning Veterans from non-VA Hospitals to Primary Care in a Single VA Healthcare System. J Hosp Med 2020; 15:133-139. [PMID: 31634102 PMCID: PMC7064299 DOI: 10.12788/jhm.3320] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 08/13/2019] [Accepted: 08/27/2019] [Indexed: 01/24/2023]
Abstract
BACKGROUND Veterans with healthcare needs utilize both Veterans Health Administration (VA) and non-VA hospitals. These dual-use veterans are at high risk of adverse outcomes due to the lack of coordination for safe transitions. OBJECTIVES The aim of this study was to understand the barriers and facilitators to providing high-quality continuum of care for veterans transitioning from non-VA hospitals to the VA primary care setting. DESIGN Guided by the practical robust implementation and sustainability model (PRISM) and the ideal transitions of care, we conducted a qualitative assessment using semi-structured interviews with clinicians, staff, and patients. SETTING This study was conducted at a single urban VA medical center and two non-VA hospitals. PARTICIPANTS A total of 70 participants, including 52 clinicians and staff (23 VA and 29 non-VA) involved in patient transition and 18 veterans recently discharged from non-VA hospitals, were included in this study. APPROACH Data were analyzed using a conventional content analysis and managed in Atlas.ti (Berlin, Germany). RESULTS Four major themes emerged where participants consistently discussed that transitions were delayed when they were not able to (1) identify patients as veterans and notify VA primary care of discharge, (2) transfer non-VA hospital medical records to VA primary care, (3) obtain follow-up care appointments with VA primary care, and (4) write VA formulary medications for veterans that they could fill at VA pharmacies. Participants also discussed factors involved in smooth transition and recommendations to improve care coordination. CONCLUSIONS All participants perceived the current transition-of-care process across healthcare systems to be inefficient. Efforts to improve quality and safety in transitional care should address the challenges clinicians and patients experience when transitioning from non-VA hospitals to VA primary care.
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Affiliation(s)
- Roman A Ayele
- Department of Veterans Affairs, Eastern Colorado Health Care System, Denver, Colorado
- University of Colorado, Anschutz Medical Campus, Aurora, Colorado
- Corresponding Author: Roman A. Ayele; E-mail: ; Telephone: (720) 857-5907
| | - Emily Lawrence
- Department of Veterans Affairs, Eastern Colorado Health Care System, Denver, Colorado
| | - Marina McCreight
- Department of Veterans Affairs, Eastern Colorado Health Care System, Denver, Colorado
| | - Kelty Fehling
- Department of Veterans Affairs, Eastern Colorado Health Care System, Denver, Colorado
| | - Russell E Glasgow
- Department of Veterans Affairs, Eastern Colorado Health Care System, Denver, Colorado
- University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Borsika A Rabin
- Department of Veterans Affairs, Eastern Colorado Health Care System, Denver, Colorado
- University of Colorado, Anschutz Medical Campus, Aurora, Colorado
- University of California San Diego, San Diego, California
| | - Robert E Burke
- Department of Veterans Affairs, Eastern Colorado Health Care System, Denver, Colorado
- University of Colorado, Anschutz Medical Campus, Aurora, Colorado
- VA Center for Health Equity Research and Promotion (CHERP), Corporal Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Catherine Battaglia
- Department of Veterans Affairs, Eastern Colorado Health Care System, Denver, Colorado
- University of Colorado, Anschutz Medical Campus, Aurora, Colorado
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14
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McCreight MS, Gilmartin HM, Leonard CA, Mayberry AL, Kelley LR, Lippmann BK, Coy AS, Radcliff TA, Côté MJ, Burke RE. Practical Use of Process Mapping to Guide Implementation of a Care Coordination Program for Rural Veterans. J Gen Intern Med 2019; 34:67-74. [PMID: 31098974 PMCID: PMC6542877 DOI: 10.1007/s11606-019-04968-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Transitions of care are high risk for vulnerable populations such as rural Veterans, and adequate care coordination can alleviate many risks. Single-center care coordination programs have shown promise in improving transitional care practices. However, best practices for implementing effective transitional care interventions are unknown, and a common pitfall is lack of understanding of the current process at different sites. The rural Transitions Nurse Program (TNP) is a Veterans Health Administration (VA) intervention that addresses the unique transitional care coordination needs of rural Veterans, and it is currently being implemented in five VA facilities. OBJECTIVE We sought to employ and study process mapping as a tool for assessing site context prior to implementation of TNP, a new care coordination program. DESIGN AND PARTICIPANTS Observational qualitative study guided by the Lean Six Sigma approach. Data were collected in January-March 2017 through interviews, direct observations, and group sessions with front-line staff, including VA providers, nurses, and administrative staff from five VA Medical Centers and nine rural Patient-Aligned Care Teams. KEY RESULTS We integrated key informant interviews, observational data, and group sessions to create ten process maps depicting the care coordination process prior to TNP implementation at each expansion site. These maps were used to adapt implementation through informing the unique role of the Transitions Nurse at each site and will be used in evaluating the program, which is essential to understanding the program's impact. CONCLUSIONS Process mapping can be a valuable and practical approach to accurately assess site processes before implementation of care coordination programs in complex systems. The process mapping activities were useful in engaging the local staff and simultaneously guided adaptations to the TNP intervention to meet local needs. Our approach-combining multiple data sources while adapting Lean Six Sigma principles into practical use-may be generalizable to other care coordination programs.
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Affiliation(s)
- Marina S McCreight
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Denver, CO, USA. .,VA Eastern Colorado Health Care System, Denver, CO, USA.
| | - Heather M Gilmartin
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Denver, CO, USA.,VA Eastern Colorado Health Care System, Denver, CO, USA.,Colorado School of Public Health, University of Colorado, Aurora, CO, USA
| | - Chelsea A Leonard
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Denver, CO, USA.,VA Eastern Colorado Health Care System, Denver, CO, USA
| | - Ashlea L Mayberry
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Denver, CO, USA.,VA Eastern Colorado Health Care System, Denver, CO, USA
| | - Lynette R Kelley
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Denver, CO, USA.,VA Eastern Colorado Health Care System, Denver, CO, USA
| | - Brandi K Lippmann
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Denver, CO, USA.,VA Eastern Colorado Health Care System, Denver, CO, USA
| | - Andrew S Coy
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Denver, CO, USA.,VA Eastern Colorado Health Care System, Denver, CO, USA
| | - Tiffany A Radcliff
- Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station, TX, 77843, USA
| | - Murray J Côté
- Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station, TX, 77843, USA
| | - Robert E Burke
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center, Philadelphia, PA, USA.,Hospital Medicine Section, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
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15
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Abstract
OBJECTIVE Understanding how to successfully implement care coordination programs across diverse settings is critical for disseminating best practices. We describe how we operationalized the Practical Robust Implementation and Sustainability Model (PRISM) to guide the assessment of local context prior to implementation of the rural Transitions Nurse Program (TNP) at five facilities across the Veterans Health Administration (VHA). METHODS We operationalized PRISM to create qualitative data collection techniques (interview guides, semi-structured observations, and a group brainwriting premortem) to assess local context, the current state of care coordination, and perceptions of TNP prior to implementation at five facilities. We analyzed data using deductive-inductive framework analysis to identify themes related to PRISM. We adapted implementation strategies at each site using these findings. RESULTS We identified actionable themes within PRISM domains to address during implementation. The most commonly occurring PRISM domains were "organizational characteristics" and "implementation and sustainability infrastructure." Themes included a disconnect between primary care and hospital inpatient teams, concerns about work duplication, and concerns that one nurse could not meet the demand for the program. These themes informed TNP implementation. CONCLUSIONS The use of PRISM for pre-implementation site assessments yielded important findings that guided adaptations to our implementation approach. Further, barriers and facilitators to TNP implementation may be common to other care coordination interventions. Generating a common language of barriers and facilitators in care coordination initiatives will enhance generalizability and establish best practices. IMPACT STATEMENTS TNP is a national intensive care coordination program targeting rural Veterans. We operationalized PRISM to guide implementation efforts. We effectively elucidated facilitators, barriers, and unique contextual factors at diverse VHA facilities. The use of PRISM enhances the generalizability of findings across care settings and may optimize implementation of care coordination interventions in the VHA.
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16
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Leonard C, Lawrence E, McCreight M, Lippmann B, Kelley L, Mayberry A, Ladebue A, Gilmartin H, Côté MJ, Jones J, Rabin BA, Ho PM, Burke R. Implementation and dissemination of a transition of care program for rural veterans: a controlled before and after study. Implement Sci 2017; 12:123. [PMID: 29058640 PMCID: PMC5651587 DOI: 10.1186/s13012-017-0653-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 10/03/2017] [Indexed: 12/18/2022] Open
Abstract
Background Adapting promising health care interventions to local settings is a critical component in the dissemination and implementation process. The Veterans Health Administration (VHA) rural transitions nurse program (TNP) is a nurse-led, Veteran-centered intervention designed to improve transitional care for rural Veterans funded by VA national offices for dissemination to other VA sites serving a predominantly rural Veteran population. Here, we describe our novel approach to the implementation and evaluation = the TNP. Methods This is a controlled before and after study that assesses both implementation and intervention outcomes. During pre-implementation, we assessed site context using a mixed method approach with data from diverse sources including facility-level quantitative data, key informant and Veteran interviews, observations of the discharge process, and a group brainstorming activity. We used the Practical Robust Implementation and Sustainability Model (PRISM) to inform our inquiries, to integrate data from all sources, and to identify factors that may affect implementation. In the implementation phase, we will use internal and external facilitation, paired with audit and feedback, to encourage appropriate contextual adaptations. We will use a modified Stirman framework to document adaptations. During the evaluation phase, we will measure intervention and implementation outcomes at each site using the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, and Maintenance). We will conduct a difference-in-differences analysis with propensity-matched Veterans and VA facilities as a control. Our primary intervention outcome is 30-day readmission and Emergency Department visit rates. We will use our findings to develop an implementation toolkit that will inform the larger scale-up of the TNP across the VA. Discussion The use of PRISM to inform pre-implementation evaluation and synthesize data from multiple sources, coupled with internal and external facilitation, is a novel approach to engaging sites in adapting interventions while promoting fidelity to the intervention. Our application of PRISM to pre-implementation and midline evaluation, as well as documentation of adaptations, provides an opportunity to identify and address contextual factors that may impede or enhance implementation and sustainability of health interventions and inform dissemination.
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Affiliation(s)
- Chelsea Leonard
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Healthcare System, 1055 Clermont Street, Denver, 80220, CO, USA.
| | - Emily Lawrence
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Healthcare System, 1055 Clermont Street, Denver, 80220, CO, USA
| | - Marina McCreight
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Healthcare System, 1055 Clermont Street, Denver, 80220, CO, USA
| | - Brandi Lippmann
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Healthcare System, 1055 Clermont Street, Denver, 80220, CO, USA
| | - Lynette Kelley
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Healthcare System, 1055 Clermont Street, Denver, 80220, CO, USA
| | - Ashlea Mayberry
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Healthcare System, 1055 Clermont Street, Denver, 80220, CO, USA
| | - Amy Ladebue
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Healthcare System, 1055 Clermont Street, Denver, 80220, CO, USA
| | - Heather Gilmartin
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Healthcare System, 1055 Clermont Street, Denver, 80220, CO, USA
| | - Murray J Côté
- Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station, 77843, TX, USA
| | - Jacqueline Jones
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Healthcare System, 1055 Clermont Street, Denver, 80220, CO, USA.,College of Nursing, University of Colorado Anschutz Medical Campus, 13001 E 17th Pl, Aurora, 80045, CO, USA
| | - Borsika A Rabin
- Department of Family Medicine and Public Health, University of California San Diego, La Jolla, 92093, CA, USA
| | - P Michael Ho
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Healthcare System, 1055 Clermont Street, Denver, 80220, CO, USA.,Division of Cardiology, Department of Medicine, School of Medicine, University of Colorado Denver, 13001 E 17th Pl, Aurora, 80045, CO, USA
| | - Robert Burke
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Healthcare System, 1055 Clermont Street, Denver, 80220, CO, USA.,Hospital Medicine Section, Denver VA Medical Center, 1055 Clermont St, Denver, 80220, CO, USA
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