Regional Data Exchange to Improve Care for Veterans After Non-VA Hospitalization

Background: Among older VA patients who have Medicare coverage, 43% use both VA and non-VA
(Medicare-covered) services. VA and non-VA providers are often uninformed about encounters,
treatments and test results provided in the other system. In particular, the absent or
delayed notification of a non-VA hospital encounter is a missed opportunity for the VA to
provide post-hospital transitional care services that have been shown to be effective in
preventing adverse events and hospital readmission after hospital discharge.

Objectives: The overall objective of this project is to examine the effectiveness, cost, and
implementation acceptance of VA provider notification of non-VA hospitalization or emergency
department (ED) visit using electronic health information exchange (HIE), with or without
provision of evidence-based post-hospital transitional care services. Specific Aim 1 is to
examine the impact of these approaches on preventing hospital admission or readmission as the
primary outcome, and, as secondary outcomes, increasing provider follow-up, improving
patient's condition self-knowledge, and preventing medication errors after discharge.
Specific Aim 2 is to examine the effect of these approaches on VA and non-VA costs. Specific
Aim 3 is to examine the acceptance of these approaches among VA and non-VA stakeholders.

Methods: The study sample consists of Veterans followed in geriatrics or primary care clinics
at the Bronx and Indianapolis VAs who are older than 65. The investigators will monitor
patients for non-VA hospital admission or ED visit using technology provided by regional HIE
organizations (i.e., the Bronx Regional Health Information Organization and the Indiana
Health Information Exchange). Patients will be cluster-randomized 1:1 to
notification-plus-coordination or notification-only groups by PACT team, stratified by
facility. For both groups the PACT provider will receive real-time notification of a non-VA
hospital admission or ED visit if it occurs. For the notification-plus-coordination group, a
care transitions coordinator will deliver coordination activities during a home and/or VA
facility visit and via follow-up phone calls over 1 month. Coordination activities will
consist of: reconciliation of and counseling on the patient's VA and non-VA medications,
education on signs of condition worsening, coordination of VA and non-VA follow-up
appointments, and counseling on communicating with VA and non-VA providers, using structured
protocols. All information-gathering by the transitions coordinator will include the HIE as
an information source. The notification-only group will receive usual care after the
notification. Multivariable regression models will be estimated to compare effects of
notification-plus-coordination versus notification-only on primary and secondary outcomes and
costs (Aims 1 and 2). The investigators will conduct interviews with intervention team
members, patients, VA and non-VA staff, and other stakeholders to ascertain the barriers and
facilitators to implementation of these approaches (Aim 3).

Inclusion Criteria:

- established patient in a Bronx VA or Indianapolis VA geriatrics or primary care clinic

- 65 years or older

- be consented in the local health information exchange

- have utilized any non-VA services in the previous two years, including:

- nursing

- lab

- physician

- pharmacy

- and/or hospital services

Exclusion Criteria:

- Refusal to sign informed consent or consent to access local health information
exchange