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"I always pray that my patient won’t need supplies, like oxygen, because that means dealing with the VA. It’s impossible.”
Similar sentiments are shared by community health care providers (HCPs) when addressing the needs of their dual-care patients; those veterans who receive care from both the VHA and non-VHA providers and health care organizations.1,2 Many Medicare-eligible VHA primary care patients access primary and specialty care outside of VHA.3-6
Related: Treating Dual-Use Patients Across Two Health Care Systems
The consequences of dual care for veteran patients have been well described in the literature. Dual-care patients are at risk for several suboptimal health outcomes (higher A1c values, dying of colon cancer, rehospitalization for recurrent stroke or for any other cause),7-11 which may result from receiving fragmented or duplicative care.3,12
Much less attention has been paid to the interactions and care processes that occur between VHA providers and their community counterparts. Many community HCPs experience confusion and frustration when trying to coordinate patient care with VHA and are, not surprisingly, unfamiliar with VHA goals, policies, and procedures.
A study that explored perceptions of nonfederal physicians regarding barriers to effective dual care for veterans showed that coordinating care with VHA is often considered difficult.13 Most study respondents indicated that they were rarely or never informed about the visits that the patient makes to the VHA. There was the perception that information sharing is more common from non-VHA to VHA than vice versa. Most respondents indicated that they were unable to access the VHA formulary, making prescribing medications for their veteran patients problematic. More than half noted that the patient transfer to a VHA facility was problematic.
Related: Veterans' Health and Opioid Safety—Contexts, Risks, and Outreach Implications
Similar difficulties were experienced at the White River Junction VAMC (WRJVAMC) in Vermont. In hopes of alleviating the problems, a pilot project was conducted. The project provided information sharing and discussion meetings for community organizations often involved in dual care. As the project progressed, the VHA case managers observed that community nurses were more likely to have relevant data needed to transfer patients to a VA hospital. Meeting attendees expressed a desire to have greater communication and collaboration with VA. The WRJVAMC leadership recognized the positive impact of this pilot project on community engagement. An expanded trial was proposed and funded by the VHA Office of Rural Health (ORH).
The current project began in 2009 and is conducted throughout VISN 1, which encompasses all the New England states and includes 8 VAMCs and 47 additional access points, including community-based outpatient clinics (CBOCs) and outreach clinics. It is hoped that the project can create an organizational culture change in which VHA facilities move from a dual care to a comanaged care perspective. Presentations are made to community HCPs and staff who may provide care to veterans also served by VHA. The presentations explain the processes for delivery of VHA care; the history and mission of the VHA; eligibility for VHA health care; obtaining VHA prescriptions, medical supplies, and medical records; and transferring a patient to a VHA hospital. Presentations also include adequate time for conversation and questions.
The project lead is the director of primary care for VISN 1, and teams of local champions were assembled at each of the 8 medical centers. To facilitate recruitment of project staff, interested individuals attended a kick-off meeting held at a central location. Attendees heard a presentation about the consequences of dual care and spent time in a facilitated brainstorming session regarding the difficulties of comanaging care with community hospitals, providers, and health care organizations. The immediate overarching goal to “be good neighbors” to community partners was discussed. Finally, the expectations of project participation were considered, and questions were answered.
Following the in-person meeting, telephone calls were arranged with each site team to answer any remaining questions and secure participation. The majority of teams were composed of 1 primary care physician and 1 nurse/nurse case manager. The VISN 1 team was aided by staff from the ORH Veterans Rural Health Resource Center-Eastern Region (VRHRC-ER) to support project planning, implementation, and evaluation.
Related: Perceived Attitudes and Staff Roles of Disaster Management at CBOCs
The presentations were developed by the core project team members and the local VAMC project champions. The initial presentations targeted community physicians and primary care providers (PCPs). These short 30- to 60-minute presentations were designed to fit within lunch breaks and staff meetings. Along with the short presentations, longer (up to 3-4 hours), in-depth presentations targeted to medical staff (nurse case managers, social workers, financial/billing personnel) were scheduled through fiscal years (FYs) 2014-2015. These in-depth presentations will continue in FY16.
A 4-step protocol, outlined by Tomioka and colleagues, was chosen to guide dissemination activities and allow for evaluation of the degree of fidelity to the project model on replication.14 The steps begin with identifying the components of the program and advance through determining implementation and evaluating the degree of fidelity at the new site. Described here is the application of step 1 of the protocol. The second component is under way, and all remaining steps will be reported in a future article.
Methods
Through a series of focused discussions, the core project team delineated the specific project components. Each team member independently assigned an Adaptation Traffic Light designation to each component. Red light changes were those elements that cannot be altered without negatively impacting fidelity to the project model. Yellow light changes can be undertaken with caution, as they could potentially result in substantial deviations from the original project model. Finally, green light changes can be made without negative impact on the program.14 The team reconvened, discussed rationales for the assignments, reevaluated the values assigned, and reached an agreement about the light designation for each component. In cases where an agreement could not be reached through discussion, the team reexamined the component and made changes to the definition where warranted. For example, a concept that had been defined too broadly was broken down further until an agreement was reached regarding categorization of the resultant parts.
Results and Discussion
The project components, how they were implemented, and the Adaptation Traffic Light designations are presented in Table 1. This exercise brought clarity and focus to how the core project team viewed the implementation activities.
Red Lights
Several staff roles and project components were identified that were considered essential to success. First on this list was the role of the leader-champion. To have full impact, the leader-champion must be in a position of authority. For this project, the role of leader-champion was filled by the VISN 1 Primary Care Service Line director. The leader-champion actively facilitated weekly meetings, acted as a project ambassador to VA leadership, and expressed an even-tempered, supportive, problem-solving perspective with the various medical center project leads.
Because this project is implemented across a wide geographic area, local champions at each VAMC were deemed a red-light component. Having motivated people “on the ground” who are invested in the project’s goals is essential for success. For optimal outcomes, local champion involvement must be a choice and not an additional assigned responsibility. Maintaining a stable project team is ideal. In the instances where VAMC teams lost members, the core project team would actively assist in finding new members and orienting new members to the project.
An experienced project manager was also thought to be a red-light element for successful implementation. The project manager must maintain project focus, momentum, and trajectory while identifying opportunities for improvement and expansion.
This project could not be successfully implemented without dedicated administrative support and therefore could not be replicated without administrative assistance. Administrative support for this project was provided by 2 individuals. One individual maintained the weekly meeting schedule, arranged in-person team meetings, produced and circulated meeting minutes, and maintained a calendar of presentations. The second individual provided logistic support to ensure that project funds, equipment, and materials were accessible to each local medical center team as needed.
Community attendees were also a red-light component. On project initiation, the study team intended physicians and midlevel PCPs to be the target audience. However, many physicians were unable to attend due to time constraints. Instead, nurses and other office staff attended—only 13% of the attendees identified themselves as physicians or midlevel providers. As a result, the large project team decided to shift the initial focus from targeting providers to a the broader complement of HCPs. Work began to develop a more in-depth presentation, which would be of interest to nurses, case managers, social workers, administrators, and other medical office personnel.
Presentation content must be consistent across the sites and was, therefore, a red-light element. It is vitally important that the core message being delivered is unified. A small number of slides in the presentation were edited locally to include information specific to the individual medical center (clinic locations, addresses, telephone numbers, and local processes), but the majority of slides had identical content and formatting. The slide set is available on request.
Yellow Lights
Three project components were thought to have yellow-light flexibility and could, when changed with caution, allow for dissemination with fidelity to the project model. The printed materials distributed at presentations included booklets, trifold brochures, information sheets, and other resources seen as useful by each medical center team. Any printed materials could be distributed as long as they were VHA vetted and approved.
Although the evaluation is an essential component to tracking project impact and should be carried out in some form, it is recognized that not all facilities will need or want to conduct such a structured and time-intensive evaluation. In this case, evaluation included before-and-after presentation feedback forms and a telephone call 3 to 6 months after attendance.
Immediately following the presentation, participants were asked to rerate their VA-specific knowledge and identify the presentation elements they found most important. At the 3-month follow-up call, attendees were asked to give feedback about any situations in which they had comanaged care with VA, explain how any interactions had gone, and discuss whether they used any of the printed handouts. As of February 28, 2015, 101 presentations were made to more than 1,700 individuals. A total of 1,183 feedback forms (598 before and 585 after) were returned. The results showed a dramatic increase in self-rated knowledge of VA-specific topics and procedures (Table 2). Open-ended comments articulated appreciation for the VA teams’ willingness to openly share information, respectfully hear concerns from the community, and proactively work to improve care for veteran patients.
Presentation demeanor is very important but has some flexibility. The presenter does not have to be a seasoned public speaker. However, the presenter should adopt an unassuming, genuine, open stance and be willing to hear comments and criticisms in a gracious way. In those cases where a participant shares a bad experience in dealing with VA, the presenter must assure the speaker that the intention is to improve collaboration.
Green Lights
Event scheduling and identification of potential presentation sites was largely left up to the local VAMC and CBOC teams. Methods included contacting nearby health care facilities, leveraging existing professional and personal relationships, and targeting community facilities that were known to treat veterans. The status of presentations was reviewed at each team meeting. Finding the time to schedule and arrange presentations was difficult for many of the teams. The core project team enlisted the help of the Geospatial Outcomes Division at the Malcom Randall VAMC in Gainesville, Florida, to use geographic information system technology to create a list of facilities in the area of each VAMC. This allowed the teams to further target potential attendees.
Various other tasks were still noteworthy in their significance to the project’s success in VISN 1. The VISN 1 Care Collaboration project required portable projectors for each team. Funds for the projectors were sent to each participating facility to procure the projector locally. Salary support funding was sent to each participating VAMC to allow overtime as needed for presentations. Funding was also sent to each medical center to cover travel expenses related to project activities. Printing of presentation booklets was handled centrally, using the GPOExpress program, which allows printing at any FedEx office location and provides deep discounts for printed products. The ability to print on demand to a remote location with very short turnaround times was crucial in many instances.
Conculsions
This project began as a pilot implemented at a single medical center in 2009 and grew into a VISN-wide initiative. After expansion, all 8 VISN 1 sites, the core project team was able to have substantive discussions about the project’s components, their relative importance in the dissemination process, and suggestions for alternatives to identified barriers.14
In FY15, the VISN 1 core project team has helped expand the project in VISN 19. The new project team, located at the Salt Lake City VAMC in Utah, has long been interested in improving communication and collaboration with the non-VA health care community. However, interest and enthusiasm alone are not sufficient for successful uptake. Many sites likely will not have special funding to implement this program.
As a tool to support successful implementation, essential implementation components were identified, based on experience. Local facilities can use the information included in Table 1 to consider and assess their assets, identify enthusiastic staff in their facility, consider creative local partnerships that would support implementation, and reach out to local rural health resources for assistance. Efforts to build collegial relationships with community providers will enhance communication and improve the quality of care received by all veterans.
Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
1. Borowsky SJ, Cowper DC. Dual use of VA and non-VA primary care. J Gen Intern Med. 1999;14(5): 274-280.
2. Nayar P, Nguyen AT, Ojha D, Schmid KK, Apenteng B, Woodbridge P. Transitions in dual care for veterans: non-federal physician perspectives. J Community Health. 2013;38(2):225-237.
3. Liu CF, Bryson CL, Burgess JF Jr, Sharp N, Perkins M, Maciejewski ML. Use of outpatient care in VA and Medicare among disability-eligible and age-eligible veteran patients. BMC Health Serv Res. 2012;12:51.
4. Liu CF, Chapko M, Bryson CL, et al. Use of outpatient care in Veterans Health Administration and Medicare among veterans receiving primary care in community-based and hospital outpatient clinics. Health Serv Res. 2010;45(5, pt 1):1268-1286.
5. Lee PW, Markle PS, West AN, Lee RE. Use and quality of care at a VA outreach clinic in northern Maine. J Prim Care Community Health. 2012;3(3):159-163.
6. Petersen LA, Byrne MM, Daw CN, Hasche J, Reis B, Pietz K. Relationship between clinical conditions and use of Veterans Affairs health care among Medicare-enrolled veterans. Health Serv Res. 2010;45(3):762-791.
7. Helmer D, Sambamoorthi U, Shen Y, et al. Opting out of an integrated healthcare system: dual-system use is associated with poorer glycemic control in veterans with diabetes. Prim Care Diabetes. 2008;2(2):73-80.
8. Tarlov E, Lee TA, Weichle TW, et al. Reduced overall and event-free survival among colon cancer patients using dual system care. Cancer Epidemiol Biomarkers Prev. 2012;21(12):2231-2241.
9. Wolinsky FD, An H, Liu L, Miller TR, Rosenthal GE. Exploring the association of dual use of the VHA and Medicare with mortality: separating the contributions of inpatient and outpatient services. BMC Health Serv Res. 2007;7:70.
10. Wolinsky FD, Miller TR, An H, Brezinski PR, Vaughn TE, Rosenthal GE. Dual use of Medicare and the Veterans Health Administration: are there adverse health outcomes? BMC Health Serv Res. 2006;6:131.
11. Jia H, Zheng Y, Reker DM, et al. Multiple system utilization and mortality for veterans with stroke. Stroke. 2007;38(2):355-360.
12. Maciejewski ML, Wang V, Burgess JF Jr, Bryson CL, Perkins M, Liu CF. The continuity and quality of primary care. Med Care Res Rev. 2013;70(5):497-513.
13. Miller EA, Intrator O. Veterans use of non-VHA services: implications for policy and planning. Soc Work Public Health. 2012;27(4):379-391.
14. Tomioka M, Braun KL. Implementing evidence-based programs: a four-step protocol for assuring replication with fidelity. Health Promot Pract. 2013;14(6):850-858.
"I always pray that my patient won’t need supplies, like oxygen, because that means dealing with the VA. It’s impossible.”
Similar sentiments are shared by community health care providers (HCPs) when addressing the needs of their dual-care patients; those veterans who receive care from both the VHA and non-VHA providers and health care organizations.1,2 Many Medicare-eligible VHA primary care patients access primary and specialty care outside of VHA.3-6
Related: Treating Dual-Use Patients Across Two Health Care Systems
The consequences of dual care for veteran patients have been well described in the literature. Dual-care patients are at risk for several suboptimal health outcomes (higher A1c values, dying of colon cancer, rehospitalization for recurrent stroke or for any other cause),7-11 which may result from receiving fragmented or duplicative care.3,12
Much less attention has been paid to the interactions and care processes that occur between VHA providers and their community counterparts. Many community HCPs experience confusion and frustration when trying to coordinate patient care with VHA and are, not surprisingly, unfamiliar with VHA goals, policies, and procedures.
A study that explored perceptions of nonfederal physicians regarding barriers to effective dual care for veterans showed that coordinating care with VHA is often considered difficult.13 Most study respondents indicated that they were rarely or never informed about the visits that the patient makes to the VHA. There was the perception that information sharing is more common from non-VHA to VHA than vice versa. Most respondents indicated that they were unable to access the VHA formulary, making prescribing medications for their veteran patients problematic. More than half noted that the patient transfer to a VHA facility was problematic.
Related: Veterans' Health and Opioid Safety—Contexts, Risks, and Outreach Implications
Similar difficulties were experienced at the White River Junction VAMC (WRJVAMC) in Vermont. In hopes of alleviating the problems, a pilot project was conducted. The project provided information sharing and discussion meetings for community organizations often involved in dual care. As the project progressed, the VHA case managers observed that community nurses were more likely to have relevant data needed to transfer patients to a VA hospital. Meeting attendees expressed a desire to have greater communication and collaboration with VA. The WRJVAMC leadership recognized the positive impact of this pilot project on community engagement. An expanded trial was proposed and funded by the VHA Office of Rural Health (ORH).
The current project began in 2009 and is conducted throughout VISN 1, which encompasses all the New England states and includes 8 VAMCs and 47 additional access points, including community-based outpatient clinics (CBOCs) and outreach clinics. It is hoped that the project can create an organizational culture change in which VHA facilities move from a dual care to a comanaged care perspective. Presentations are made to community HCPs and staff who may provide care to veterans also served by VHA. The presentations explain the processes for delivery of VHA care; the history and mission of the VHA; eligibility for VHA health care; obtaining VHA prescriptions, medical supplies, and medical records; and transferring a patient to a VHA hospital. Presentations also include adequate time for conversation and questions.
The project lead is the director of primary care for VISN 1, and teams of local champions were assembled at each of the 8 medical centers. To facilitate recruitment of project staff, interested individuals attended a kick-off meeting held at a central location. Attendees heard a presentation about the consequences of dual care and spent time in a facilitated brainstorming session regarding the difficulties of comanaging care with community hospitals, providers, and health care organizations. The immediate overarching goal to “be good neighbors” to community partners was discussed. Finally, the expectations of project participation were considered, and questions were answered.
Following the in-person meeting, telephone calls were arranged with each site team to answer any remaining questions and secure participation. The majority of teams were composed of 1 primary care physician and 1 nurse/nurse case manager. The VISN 1 team was aided by staff from the ORH Veterans Rural Health Resource Center-Eastern Region (VRHRC-ER) to support project planning, implementation, and evaluation.
Related: Perceived Attitudes and Staff Roles of Disaster Management at CBOCs
The presentations were developed by the core project team members and the local VAMC project champions. The initial presentations targeted community physicians and primary care providers (PCPs). These short 30- to 60-minute presentations were designed to fit within lunch breaks and staff meetings. Along with the short presentations, longer (up to 3-4 hours), in-depth presentations targeted to medical staff (nurse case managers, social workers, financial/billing personnel) were scheduled through fiscal years (FYs) 2014-2015. These in-depth presentations will continue in FY16.
A 4-step protocol, outlined by Tomioka and colleagues, was chosen to guide dissemination activities and allow for evaluation of the degree of fidelity to the project model on replication.14 The steps begin with identifying the components of the program and advance through determining implementation and evaluating the degree of fidelity at the new site. Described here is the application of step 1 of the protocol. The second component is under way, and all remaining steps will be reported in a future article.
Methods
Through a series of focused discussions, the core project team delineated the specific project components. Each team member independently assigned an Adaptation Traffic Light designation to each component. Red light changes were those elements that cannot be altered without negatively impacting fidelity to the project model. Yellow light changes can be undertaken with caution, as they could potentially result in substantial deviations from the original project model. Finally, green light changes can be made without negative impact on the program.14 The team reconvened, discussed rationales for the assignments, reevaluated the values assigned, and reached an agreement about the light designation for each component. In cases where an agreement could not be reached through discussion, the team reexamined the component and made changes to the definition where warranted. For example, a concept that had been defined too broadly was broken down further until an agreement was reached regarding categorization of the resultant parts.
Results and Discussion
The project components, how they were implemented, and the Adaptation Traffic Light designations are presented in Table 1. This exercise brought clarity and focus to how the core project team viewed the implementation activities.
Red Lights
Several staff roles and project components were identified that were considered essential to success. First on this list was the role of the leader-champion. To have full impact, the leader-champion must be in a position of authority. For this project, the role of leader-champion was filled by the VISN 1 Primary Care Service Line director. The leader-champion actively facilitated weekly meetings, acted as a project ambassador to VA leadership, and expressed an even-tempered, supportive, problem-solving perspective with the various medical center project leads.
Because this project is implemented across a wide geographic area, local champions at each VAMC were deemed a red-light component. Having motivated people “on the ground” who are invested in the project’s goals is essential for success. For optimal outcomes, local champion involvement must be a choice and not an additional assigned responsibility. Maintaining a stable project team is ideal. In the instances where VAMC teams lost members, the core project team would actively assist in finding new members and orienting new members to the project.
An experienced project manager was also thought to be a red-light element for successful implementation. The project manager must maintain project focus, momentum, and trajectory while identifying opportunities for improvement and expansion.
This project could not be successfully implemented without dedicated administrative support and therefore could not be replicated without administrative assistance. Administrative support for this project was provided by 2 individuals. One individual maintained the weekly meeting schedule, arranged in-person team meetings, produced and circulated meeting minutes, and maintained a calendar of presentations. The second individual provided logistic support to ensure that project funds, equipment, and materials were accessible to each local medical center team as needed.
Community attendees were also a red-light component. On project initiation, the study team intended physicians and midlevel PCPs to be the target audience. However, many physicians were unable to attend due to time constraints. Instead, nurses and other office staff attended—only 13% of the attendees identified themselves as physicians or midlevel providers. As a result, the large project team decided to shift the initial focus from targeting providers to a the broader complement of HCPs. Work began to develop a more in-depth presentation, which would be of interest to nurses, case managers, social workers, administrators, and other medical office personnel.
Presentation content must be consistent across the sites and was, therefore, a red-light element. It is vitally important that the core message being delivered is unified. A small number of slides in the presentation were edited locally to include information specific to the individual medical center (clinic locations, addresses, telephone numbers, and local processes), but the majority of slides had identical content and formatting. The slide set is available on request.
Yellow Lights
Three project components were thought to have yellow-light flexibility and could, when changed with caution, allow for dissemination with fidelity to the project model. The printed materials distributed at presentations included booklets, trifold brochures, information sheets, and other resources seen as useful by each medical center team. Any printed materials could be distributed as long as they were VHA vetted and approved.
Although the evaluation is an essential component to tracking project impact and should be carried out in some form, it is recognized that not all facilities will need or want to conduct such a structured and time-intensive evaluation. In this case, evaluation included before-and-after presentation feedback forms and a telephone call 3 to 6 months after attendance.
Immediately following the presentation, participants were asked to rerate their VA-specific knowledge and identify the presentation elements they found most important. At the 3-month follow-up call, attendees were asked to give feedback about any situations in which they had comanaged care with VA, explain how any interactions had gone, and discuss whether they used any of the printed handouts. As of February 28, 2015, 101 presentations were made to more than 1,700 individuals. A total of 1,183 feedback forms (598 before and 585 after) were returned. The results showed a dramatic increase in self-rated knowledge of VA-specific topics and procedures (Table 2). Open-ended comments articulated appreciation for the VA teams’ willingness to openly share information, respectfully hear concerns from the community, and proactively work to improve care for veteran patients.
Presentation demeanor is very important but has some flexibility. The presenter does not have to be a seasoned public speaker. However, the presenter should adopt an unassuming, genuine, open stance and be willing to hear comments and criticisms in a gracious way. In those cases where a participant shares a bad experience in dealing with VA, the presenter must assure the speaker that the intention is to improve collaboration.
Green Lights
Event scheduling and identification of potential presentation sites was largely left up to the local VAMC and CBOC teams. Methods included contacting nearby health care facilities, leveraging existing professional and personal relationships, and targeting community facilities that were known to treat veterans. The status of presentations was reviewed at each team meeting. Finding the time to schedule and arrange presentations was difficult for many of the teams. The core project team enlisted the help of the Geospatial Outcomes Division at the Malcom Randall VAMC in Gainesville, Florida, to use geographic information system technology to create a list of facilities in the area of each VAMC. This allowed the teams to further target potential attendees.
Various other tasks were still noteworthy in their significance to the project’s success in VISN 1. The VISN 1 Care Collaboration project required portable projectors for each team. Funds for the projectors were sent to each participating facility to procure the projector locally. Salary support funding was sent to each participating VAMC to allow overtime as needed for presentations. Funding was also sent to each medical center to cover travel expenses related to project activities. Printing of presentation booklets was handled centrally, using the GPOExpress program, which allows printing at any FedEx office location and provides deep discounts for printed products. The ability to print on demand to a remote location with very short turnaround times was crucial in many instances.
Conculsions
This project began as a pilot implemented at a single medical center in 2009 and grew into a VISN-wide initiative. After expansion, all 8 VISN 1 sites, the core project team was able to have substantive discussions about the project’s components, their relative importance in the dissemination process, and suggestions for alternatives to identified barriers.14
In FY15, the VISN 1 core project team has helped expand the project in VISN 19. The new project team, located at the Salt Lake City VAMC in Utah, has long been interested in improving communication and collaboration with the non-VA health care community. However, interest and enthusiasm alone are not sufficient for successful uptake. Many sites likely will not have special funding to implement this program.
As a tool to support successful implementation, essential implementation components were identified, based on experience. Local facilities can use the information included in Table 1 to consider and assess their assets, identify enthusiastic staff in their facility, consider creative local partnerships that would support implementation, and reach out to local rural health resources for assistance. Efforts to build collegial relationships with community providers will enhance communication and improve the quality of care received by all veterans.
Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
"I always pray that my patient won’t need supplies, like oxygen, because that means dealing with the VA. It’s impossible.”
Similar sentiments are shared by community health care providers (HCPs) when addressing the needs of their dual-care patients; those veterans who receive care from both the VHA and non-VHA providers and health care organizations.1,2 Many Medicare-eligible VHA primary care patients access primary and specialty care outside of VHA.3-6
Related: Treating Dual-Use Patients Across Two Health Care Systems
The consequences of dual care for veteran patients have been well described in the literature. Dual-care patients are at risk for several suboptimal health outcomes (higher A1c values, dying of colon cancer, rehospitalization for recurrent stroke or for any other cause),7-11 which may result from receiving fragmented or duplicative care.3,12
Much less attention has been paid to the interactions and care processes that occur between VHA providers and their community counterparts. Many community HCPs experience confusion and frustration when trying to coordinate patient care with VHA and are, not surprisingly, unfamiliar with VHA goals, policies, and procedures.
A study that explored perceptions of nonfederal physicians regarding barriers to effective dual care for veterans showed that coordinating care with VHA is often considered difficult.13 Most study respondents indicated that they were rarely or never informed about the visits that the patient makes to the VHA. There was the perception that information sharing is more common from non-VHA to VHA than vice versa. Most respondents indicated that they were unable to access the VHA formulary, making prescribing medications for their veteran patients problematic. More than half noted that the patient transfer to a VHA facility was problematic.
Related: Veterans' Health and Opioid Safety—Contexts, Risks, and Outreach Implications
Similar difficulties were experienced at the White River Junction VAMC (WRJVAMC) in Vermont. In hopes of alleviating the problems, a pilot project was conducted. The project provided information sharing and discussion meetings for community organizations often involved in dual care. As the project progressed, the VHA case managers observed that community nurses were more likely to have relevant data needed to transfer patients to a VA hospital. Meeting attendees expressed a desire to have greater communication and collaboration with VA. The WRJVAMC leadership recognized the positive impact of this pilot project on community engagement. An expanded trial was proposed and funded by the VHA Office of Rural Health (ORH).
The current project began in 2009 and is conducted throughout VISN 1, which encompasses all the New England states and includes 8 VAMCs and 47 additional access points, including community-based outpatient clinics (CBOCs) and outreach clinics. It is hoped that the project can create an organizational culture change in which VHA facilities move from a dual care to a comanaged care perspective. Presentations are made to community HCPs and staff who may provide care to veterans also served by VHA. The presentations explain the processes for delivery of VHA care; the history and mission of the VHA; eligibility for VHA health care; obtaining VHA prescriptions, medical supplies, and medical records; and transferring a patient to a VHA hospital. Presentations also include adequate time for conversation and questions.
The project lead is the director of primary care for VISN 1, and teams of local champions were assembled at each of the 8 medical centers. To facilitate recruitment of project staff, interested individuals attended a kick-off meeting held at a central location. Attendees heard a presentation about the consequences of dual care and spent time in a facilitated brainstorming session regarding the difficulties of comanaging care with community hospitals, providers, and health care organizations. The immediate overarching goal to “be good neighbors” to community partners was discussed. Finally, the expectations of project participation were considered, and questions were answered.
Following the in-person meeting, telephone calls were arranged with each site team to answer any remaining questions and secure participation. The majority of teams were composed of 1 primary care physician and 1 nurse/nurse case manager. The VISN 1 team was aided by staff from the ORH Veterans Rural Health Resource Center-Eastern Region (VRHRC-ER) to support project planning, implementation, and evaluation.
Related: Perceived Attitudes and Staff Roles of Disaster Management at CBOCs
The presentations were developed by the core project team members and the local VAMC project champions. The initial presentations targeted community physicians and primary care providers (PCPs). These short 30- to 60-minute presentations were designed to fit within lunch breaks and staff meetings. Along with the short presentations, longer (up to 3-4 hours), in-depth presentations targeted to medical staff (nurse case managers, social workers, financial/billing personnel) were scheduled through fiscal years (FYs) 2014-2015. These in-depth presentations will continue in FY16.
A 4-step protocol, outlined by Tomioka and colleagues, was chosen to guide dissemination activities and allow for evaluation of the degree of fidelity to the project model on replication.14 The steps begin with identifying the components of the program and advance through determining implementation and evaluating the degree of fidelity at the new site. Described here is the application of step 1 of the protocol. The second component is under way, and all remaining steps will be reported in a future article.
Methods
Through a series of focused discussions, the core project team delineated the specific project components. Each team member independently assigned an Adaptation Traffic Light designation to each component. Red light changes were those elements that cannot be altered without negatively impacting fidelity to the project model. Yellow light changes can be undertaken with caution, as they could potentially result in substantial deviations from the original project model. Finally, green light changes can be made without negative impact on the program.14 The team reconvened, discussed rationales for the assignments, reevaluated the values assigned, and reached an agreement about the light designation for each component. In cases where an agreement could not be reached through discussion, the team reexamined the component and made changes to the definition where warranted. For example, a concept that had been defined too broadly was broken down further until an agreement was reached regarding categorization of the resultant parts.
Results and Discussion
The project components, how they were implemented, and the Adaptation Traffic Light designations are presented in Table 1. This exercise brought clarity and focus to how the core project team viewed the implementation activities.
Red Lights
Several staff roles and project components were identified that were considered essential to success. First on this list was the role of the leader-champion. To have full impact, the leader-champion must be in a position of authority. For this project, the role of leader-champion was filled by the VISN 1 Primary Care Service Line director. The leader-champion actively facilitated weekly meetings, acted as a project ambassador to VA leadership, and expressed an even-tempered, supportive, problem-solving perspective with the various medical center project leads.
Because this project is implemented across a wide geographic area, local champions at each VAMC were deemed a red-light component. Having motivated people “on the ground” who are invested in the project’s goals is essential for success. For optimal outcomes, local champion involvement must be a choice and not an additional assigned responsibility. Maintaining a stable project team is ideal. In the instances where VAMC teams lost members, the core project team would actively assist in finding new members and orienting new members to the project.
An experienced project manager was also thought to be a red-light element for successful implementation. The project manager must maintain project focus, momentum, and trajectory while identifying opportunities for improvement and expansion.
This project could not be successfully implemented without dedicated administrative support and therefore could not be replicated without administrative assistance. Administrative support for this project was provided by 2 individuals. One individual maintained the weekly meeting schedule, arranged in-person team meetings, produced and circulated meeting minutes, and maintained a calendar of presentations. The second individual provided logistic support to ensure that project funds, equipment, and materials were accessible to each local medical center team as needed.
Community attendees were also a red-light component. On project initiation, the study team intended physicians and midlevel PCPs to be the target audience. However, many physicians were unable to attend due to time constraints. Instead, nurses and other office staff attended—only 13% of the attendees identified themselves as physicians or midlevel providers. As a result, the large project team decided to shift the initial focus from targeting providers to a the broader complement of HCPs. Work began to develop a more in-depth presentation, which would be of interest to nurses, case managers, social workers, administrators, and other medical office personnel.
Presentation content must be consistent across the sites and was, therefore, a red-light element. It is vitally important that the core message being delivered is unified. A small number of slides in the presentation were edited locally to include information specific to the individual medical center (clinic locations, addresses, telephone numbers, and local processes), but the majority of slides had identical content and formatting. The slide set is available on request.
Yellow Lights
Three project components were thought to have yellow-light flexibility and could, when changed with caution, allow for dissemination with fidelity to the project model. The printed materials distributed at presentations included booklets, trifold brochures, information sheets, and other resources seen as useful by each medical center team. Any printed materials could be distributed as long as they were VHA vetted and approved.
Although the evaluation is an essential component to tracking project impact and should be carried out in some form, it is recognized that not all facilities will need or want to conduct such a structured and time-intensive evaluation. In this case, evaluation included before-and-after presentation feedback forms and a telephone call 3 to 6 months after attendance.
Immediately following the presentation, participants were asked to rerate their VA-specific knowledge and identify the presentation elements they found most important. At the 3-month follow-up call, attendees were asked to give feedback about any situations in which they had comanaged care with VA, explain how any interactions had gone, and discuss whether they used any of the printed handouts. As of February 28, 2015, 101 presentations were made to more than 1,700 individuals. A total of 1,183 feedback forms (598 before and 585 after) were returned. The results showed a dramatic increase in self-rated knowledge of VA-specific topics and procedures (Table 2). Open-ended comments articulated appreciation for the VA teams’ willingness to openly share information, respectfully hear concerns from the community, and proactively work to improve care for veteran patients.
Presentation demeanor is very important but has some flexibility. The presenter does not have to be a seasoned public speaker. However, the presenter should adopt an unassuming, genuine, open stance and be willing to hear comments and criticisms in a gracious way. In those cases where a participant shares a bad experience in dealing with VA, the presenter must assure the speaker that the intention is to improve collaboration.
Green Lights
Event scheduling and identification of potential presentation sites was largely left up to the local VAMC and CBOC teams. Methods included contacting nearby health care facilities, leveraging existing professional and personal relationships, and targeting community facilities that were known to treat veterans. The status of presentations was reviewed at each team meeting. Finding the time to schedule and arrange presentations was difficult for many of the teams. The core project team enlisted the help of the Geospatial Outcomes Division at the Malcom Randall VAMC in Gainesville, Florida, to use geographic information system technology to create a list of facilities in the area of each VAMC. This allowed the teams to further target potential attendees.
Various other tasks were still noteworthy in their significance to the project’s success in VISN 1. The VISN 1 Care Collaboration project required portable projectors for each team. Funds for the projectors were sent to each participating facility to procure the projector locally. Salary support funding was sent to each participating VAMC to allow overtime as needed for presentations. Funding was also sent to each medical center to cover travel expenses related to project activities. Printing of presentation booklets was handled centrally, using the GPOExpress program, which allows printing at any FedEx office location and provides deep discounts for printed products. The ability to print on demand to a remote location with very short turnaround times was crucial in many instances.
Conculsions
This project began as a pilot implemented at a single medical center in 2009 and grew into a VISN-wide initiative. After expansion, all 8 VISN 1 sites, the core project team was able to have substantive discussions about the project’s components, their relative importance in the dissemination process, and suggestions for alternatives to identified barriers.14
In FY15, the VISN 1 core project team has helped expand the project in VISN 19. The new project team, located at the Salt Lake City VAMC in Utah, has long been interested in improving communication and collaboration with the non-VA health care community. However, interest and enthusiasm alone are not sufficient for successful uptake. Many sites likely will not have special funding to implement this program.
As a tool to support successful implementation, essential implementation components were identified, based on experience. Local facilities can use the information included in Table 1 to consider and assess their assets, identify enthusiastic staff in their facility, consider creative local partnerships that would support implementation, and reach out to local rural health resources for assistance. Efforts to build collegial relationships with community providers will enhance communication and improve the quality of care received by all veterans.
Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
1. Borowsky SJ, Cowper DC. Dual use of VA and non-VA primary care. J Gen Intern Med. 1999;14(5): 274-280.
2. Nayar P, Nguyen AT, Ojha D, Schmid KK, Apenteng B, Woodbridge P. Transitions in dual care for veterans: non-federal physician perspectives. J Community Health. 2013;38(2):225-237.
3. Liu CF, Bryson CL, Burgess JF Jr, Sharp N, Perkins M, Maciejewski ML. Use of outpatient care in VA and Medicare among disability-eligible and age-eligible veteran patients. BMC Health Serv Res. 2012;12:51.
4. Liu CF, Chapko M, Bryson CL, et al. Use of outpatient care in Veterans Health Administration and Medicare among veterans receiving primary care in community-based and hospital outpatient clinics. Health Serv Res. 2010;45(5, pt 1):1268-1286.
5. Lee PW, Markle PS, West AN, Lee RE. Use and quality of care at a VA outreach clinic in northern Maine. J Prim Care Community Health. 2012;3(3):159-163.
6. Petersen LA, Byrne MM, Daw CN, Hasche J, Reis B, Pietz K. Relationship between clinical conditions and use of Veterans Affairs health care among Medicare-enrolled veterans. Health Serv Res. 2010;45(3):762-791.
7. Helmer D, Sambamoorthi U, Shen Y, et al. Opting out of an integrated healthcare system: dual-system use is associated with poorer glycemic control in veterans with diabetes. Prim Care Diabetes. 2008;2(2):73-80.
8. Tarlov E, Lee TA, Weichle TW, et al. Reduced overall and event-free survival among colon cancer patients using dual system care. Cancer Epidemiol Biomarkers Prev. 2012;21(12):2231-2241.
9. Wolinsky FD, An H, Liu L, Miller TR, Rosenthal GE. Exploring the association of dual use of the VHA and Medicare with mortality: separating the contributions of inpatient and outpatient services. BMC Health Serv Res. 2007;7:70.
10. Wolinsky FD, Miller TR, An H, Brezinski PR, Vaughn TE, Rosenthal GE. Dual use of Medicare and the Veterans Health Administration: are there adverse health outcomes? BMC Health Serv Res. 2006;6:131.
11. Jia H, Zheng Y, Reker DM, et al. Multiple system utilization and mortality for veterans with stroke. Stroke. 2007;38(2):355-360.
12. Maciejewski ML, Wang V, Burgess JF Jr, Bryson CL, Perkins M, Liu CF. The continuity and quality of primary care. Med Care Res Rev. 2013;70(5):497-513.
13. Miller EA, Intrator O. Veterans use of non-VHA services: implications for policy and planning. Soc Work Public Health. 2012;27(4):379-391.
14. Tomioka M, Braun KL. Implementing evidence-based programs: a four-step protocol for assuring replication with fidelity. Health Promot Pract. 2013;14(6):850-858.
1. Borowsky SJ, Cowper DC. Dual use of VA and non-VA primary care. J Gen Intern Med. 1999;14(5): 274-280.
2. Nayar P, Nguyen AT, Ojha D, Schmid KK, Apenteng B, Woodbridge P. Transitions in dual care for veterans: non-federal physician perspectives. J Community Health. 2013;38(2):225-237.
3. Liu CF, Bryson CL, Burgess JF Jr, Sharp N, Perkins M, Maciejewski ML. Use of outpatient care in VA and Medicare among disability-eligible and age-eligible veteran patients. BMC Health Serv Res. 2012;12:51.
4. Liu CF, Chapko M, Bryson CL, et al. Use of outpatient care in Veterans Health Administration and Medicare among veterans receiving primary care in community-based and hospital outpatient clinics. Health Serv Res. 2010;45(5, pt 1):1268-1286.
5. Lee PW, Markle PS, West AN, Lee RE. Use and quality of care at a VA outreach clinic in northern Maine. J Prim Care Community Health. 2012;3(3):159-163.
6. Petersen LA, Byrne MM, Daw CN, Hasche J, Reis B, Pietz K. Relationship between clinical conditions and use of Veterans Affairs health care among Medicare-enrolled veterans. Health Serv Res. 2010;45(3):762-791.
7. Helmer D, Sambamoorthi U, Shen Y, et al. Opting out of an integrated healthcare system: dual-system use is associated with poorer glycemic control in veterans with diabetes. Prim Care Diabetes. 2008;2(2):73-80.
8. Tarlov E, Lee TA, Weichle TW, et al. Reduced overall and event-free survival among colon cancer patients using dual system care. Cancer Epidemiol Biomarkers Prev. 2012;21(12):2231-2241.
9. Wolinsky FD, An H, Liu L, Miller TR, Rosenthal GE. Exploring the association of dual use of the VHA and Medicare with mortality: separating the contributions of inpatient and outpatient services. BMC Health Serv Res. 2007;7:70.
10. Wolinsky FD, Miller TR, An H, Brezinski PR, Vaughn TE, Rosenthal GE. Dual use of Medicare and the Veterans Health Administration: are there adverse health outcomes? BMC Health Serv Res. 2006;6:131.
11. Jia H, Zheng Y, Reker DM, et al. Multiple system utilization and mortality for veterans with stroke. Stroke. 2007;38(2):355-360.
12. Maciejewski ML, Wang V, Burgess JF Jr, Bryson CL, Perkins M, Liu CF. The continuity and quality of primary care. Med Care Res Rev. 2013;70(5):497-513.
13. Miller EA, Intrator O. Veterans use of non-VHA services: implications for policy and planning. Soc Work Public Health. 2012;27(4):379-391.
14. Tomioka M, Braun KL. Implementing evidence-based programs: a four-step protocol for assuring replication with fidelity. Health Promot Pract. 2013;14(6):850-858.