Advanced Care Coordination Program: Bridging Gaps in Veteran Healthcare

The landscape of veteran healthcare is complex, often requiring navigation across both Veterans Affairs (VA) and non-VA healthcare systems. Recognizing the critical need for seamless care transitions, particularly for veterans utilizing non-VA emergency departments (EDs), the Advanced Care Coordination (ACC) program emerges as a vital solution. This initiative, grounded in insights from the previous Care Transition for High-Risk Patients (CHTP) program, is designed to enhance care coordination for veterans, ensuring they receive timely and comprehensive support.

Addressing Care Coordination Gaps Through Social Worker-Led Intervention

The ACC program directly tackles identified gaps in care coordination by implementing a social worker-led, longitudinal approach. This model focuses on bridging the divide between VA and non-VA EDs. Initially launched at the ECHCS Rocky Mountain Regional VAMC (RMR VAMC) in Aurora, Colorado, plans are underway to extend this impactful program to the VA Nebraska-Western Iowa Health Care System. Building upon the valuable lessons learned during the CHTP development, the ACC program is poised for successful implementation and widespread benefit.

Targeted Participant Recruitment for Maximum Impact

The ACC program is strategically designed to provide comprehensive care coordination for dual-use veterans. These are veterans who access healthcare services from both VA and non-VA facilities, specifically targeting those who utilize non-VA EDs within the Denver, Colorado metro area. To pinpoint the most impactful partnerships, the program leverages VA Business Office data to identify non-VA EDs with high volumes of veteran admissions. Factors such as proximity to the RMR VAMC and the demonstrated needs of the veteran population further refine the selection process. The program anticipates enrolling between 250 and 300 veterans annually, ensuring focused and effective support.

Referrals into the ACC program are facilitated by staff at the selected non-VA EDs. They are instructed to notify the ACC social worker upon a veteran’s admission, either through a phone call or by faxing the Veteran’s History and Physical. Crucially, the ACC program focuses on veterans discharged home from non-VA EDs. Veterans requiring hospitalization in non-VA facilities are directed to the CHTP to prevent service duplication and ensure appropriate care pathways.

Eligibility for the ACC program is clearly defined to ensure the right veterans receive the most relevant support. Veterans are eligible if they:

Are already receiving healthcare services through the ECHCS VA.
Wish to establish care within the ECHCS VA system.

Exclusion criteria are also in place to avoid service duplication and ensure program resources are used effectively. Veterans are ineligible if they:

Are already enrolled in ongoing case management services within ECHCS.
Are discharged from the non-VA ED to skilled nursing, long-term care, or assisted living facilities, as these facilities provide their own case management.
Cannot be reached by phone after three attempts over two weeks, or lack a working phone.
Do not wish to receive care through the VA system.

Core Components of the ACC Intervention

The ACC program is structured around four core components, working synergistically to provide robust and effective care coordination:

Non-VA ED Notification: The process begins with timely notification from the non-VA ED to the ACC program about a veteran’s visit. This initial step is crucial for prompt intervention.
Comprehensive Needs Assessment: A thorough needs assessment is conducted by the ACC social worker. This assessment addresses critical Social Determinants of Health (SDOH), including access to healthcare, economic stability, housing situation, psychological well-being, and social support networks. This holistic approach ensures all relevant factors impacting the veteran’s health are considered.
Individualized Clinical Interventions: Based on the needs assessment, tailored clinical interventions are implemented. These interventions involve phone calls and, when necessary, home or community visits. The primary goal is to connect veterans with essential resources both within the VA system and in their local communities.
Seamless Transfer of Care: The final core component is the smooth transfer of care back to the veteran’s assigned VA primary care team. This ensures continuity of care and long-term support within the VA healthcare system.

Figure 1: The Advanced Care Coordination Program Core Components

Upon receiving notification of a veteran’s non-VA ED visit, the ACC social worker immediately reviews the veteran’s VA medical record to confirm program eligibility. Collaboration is key, and the ACC social worker actively communicates with non-VA case managers, social workers, and discharge planners to maintain awareness of the veteran’s ED admissions and discharges. To ensure comprehensive care within the VA system, the ACC program also disseminates information about the veteran’s non-VA ED visits to the veteran’s ECHCS PACT (Patient Aligned Care Team), specialty clinics, and other relevant VA providers.

For eligible veterans, the ACC social worker initiates contact the business day following the non-VA ED discharge. This outreach includes enrolling the veteran in the ACC program and conducting a Social Workers Comprehensive Assessment. This validated tool, integral to the VA’s health record system, is employed nationwide by VA social workers to evaluate veterans’ SDOH. During this assessment, the ACC social worker uses clinical judgment to evaluate the veteran’s biopsychosocial and clinical circumstances, determining an acuity level ranging from 1 (minimal needs) to 4 (significant needs). This acuity level then guides the intensity and duration of subsequent interventions.

Interventions are strategically designed to improve veteran health outcomes and reduce overall healthcare costs, aligning with the VA Office of Community Care (VA OCC) Care Coordination guidelines. These guidelines emphasize seamless, veteran-centered care coordination between VA and non-VA providers, ensuring veterans receive high-quality and timely healthcare services. The ACC program directly supports these guidelines by proactively coordinating care for veterans following non-VA ED discharges, facilitating a smoother transition back into the VA system and community.

The duration of case management varies based on the veteran’s acuity level. Veterans with lower acuity receive support for up to two weeks, while those with higher acuity may be enrolled for up to 90 days post-discharge. This 90-day timeframe is based on evidence highlighting a critical gap in veteran care during this period following a non-VA ED visit. Clinical interventions include weekly or bi-weekly phone calls, and when necessary, home or community visits, particularly for veterans experiencing homelessness. These interventions focus on addressing identified SDOH needs and connecting veterans with vital resources, including transportation, housing assistance, food banks, financial aid, home healthcare, mental health services, substance use treatment, and both VA and non-VA community resources. Employing teach-back methodology and Motivational Interviewing techniques, the ACC social worker ensures veterans understand and can effectively manage their discharge plans and ongoing disease care. Upon completion of the clinical interventions, a warm hand-off is conducted, transferring the veteran’s care back to their ECHCS PACT. For veterans requiring continued case management beyond 90 days, the ACC social worker facilitates a connection with a PACT social worker for ongoing support within the primary care setting. All data collected throughout these interventions are meticulously stored in the ACC program database for program monitoring and evaluation.

Education and Outreach: Fostering Collaboration and Veteran Empowerment

Education and outreach are integral to the ACC program’s success, targeting both healthcare providers and veterans. Frequent outreach and continuing education initiatives are provided to ECHCS and non-VA providers. This ongoing communication serves to gather program feedback and ensure effective collaboration between the ACC social worker, non-VA ED partners, ECHCS PACTs, and the veterans themselves.

Prior to program launch, in-service meetings are conducted with each partner non-VA ED and relevant VA departments. These initial meetings are crucial for outlining the program’s benefits and clarifying responsibilities, fostering awareness and collaboration from the outset. Following program implementation, regular in-service sessions are provided to non-VA ED staff and ECHCS providers. These sessions facilitate information sharing within the ECHCS system, educate providers on program adaptations, and actively solicit feedback for continuous program improvement. A transitions of care resource guide, modeled after the CHTP resource guide, is disseminated to non-VA partners. This guide serves as a valuable tool, providing information on internal ECHCS resources and program components, streamlining the care coordination process. A concise one-page fact sheet is also distributed to both non-VA and ECHCS partners, summarizing the program and highlighting essential ECHCS resources for coordinating veteran care.

Veteran outreach complements provider education efforts. A Veteran Care Card is created and mailed to veterans participating in the ACC program. This card serves as a readily accessible resource, containing essential care coordination contact information, including direct phone and fax numbers for the ACC program, resources for the VA Billing department, and the name of their ECHCS Primary Care Provider. Accompanying the Care Card is a letter further detailing care coordination resources and providing the contact information for the veteran’s PACT social worker. Upon program completion, veterans receive a graduation letter. This letter summarizes key resources, outlines goals achieved during their ACC program involvement, highlights ongoing goals, and provides pertinent provider contact information, ensuring veterans have a comprehensive resource for future care coordination needs when accessing non-VA EDs.

Partnership and Evaluation: Ensuring Program Sustainability and Impact

Operational Partners and Evaluation Team

The ACC program thrives on strong partnerships. Key collaborators include the VA OCC, ECHCS stakeholders, and the Veterans Integrated Service Network (VISN) 19. Funding is provided by the Office of Veterans Access to Care (OVAC) and the Office of Rural Health (ORH), demonstrating a commitment to veteran-centric care. The program is integrated within the Triple-Aim Quality Enhancement Research Initiative (QUERI) Program, leveraging QUERI’s focus on quality improvement interventions, learning healthcare systems, and enhancing clinical practice through research. The ACC program is designed to strengthen ECHCS and non-VA partnerships by effectively facilitating care coordination for veterans utilizing non-VA EDs.

A multidisciplinary evaluation team is in place, comprised of experts spanning qualitative and quantitative research, statistics, data management, implementation science, clinical intervention, public health, nursing, medicine, health economics, social work, and national training. This diverse expertise ensures a comprehensive and rigorous evaluation of the program’s implementation and impact, paving the way for future expansion and refinement.

Robust Evaluation of Intervention and Implementation

The ACC program’s evaluation is approached with a multi-level strategy, visually represented in Figure 2. Prior data from the CHTP program provided crucial insights into care coordination gaps, directly informing the ACC program’s development during the pre-implementation phase. In addition to CHTP data, ongoing engagement with community partners and the VA system provides further understanding of care transition challenges. The pre-implementation assessment is guided by the LEAN approach and the Practical, Robust Implementation and Sustainability Model (PRISM) framework. This data-driven approach ensures the ACC program is tailored to local needs and effectively implemented. LEAN process mapping and a modified Stirman framework are utilized to track program adaptations throughout implementation. Mid-line assessments further evaluate program adjustments. Data collection focuses on assessing both veteran and provider satisfaction, alongside program effectiveness, measured by utilization, stakeholder engagement, and health outcomes. Economic efficiency is also evaluated by comparing implementation costs against observed health and economic outcomes. Ultimately, a toolkit of training materials will be developed and disseminated to the VA OCC to facilitate the widespread adoption of this comprehensive care coordination intervention.

Figure 2: The Advanced Care Coordination Program Evaluation Process

The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework serves as the primary framework for evaluating intervention effectiveness and program sustainability.

Reach: Measured by the number, proportion, and representativeness of veterans receiving ACC program interventions. The ACC program access database tracks referrals and program engagement. Data on veteran characteristics, including reason for non-VA ED visit, comorbidities, acuity level, and Care Assessment Need (CAN) scores are also collected. Data sources include the ACC program database, VA’s Computerized Patient Record System (CPRS), Corporate Data Warehouse (CDW), fee basis data, and stakeholder engagement spreadsheets. Data is reviewed bi-annually, with weekly database checks for ongoing monitoring.
Effectiveness: Evaluated by measuring 90-day readmission rates (hospitalization, VA and non-VA ED) for veterans receiving ACC program interventions. This involves reviewing the program database, CDW, and fee basis data annually. Claims data from partner non-VA hospitals further supports readmission rate measurement. The number, proportion, and representativeness of veterans receiving additional care and services due to ACC program involvement are also assessed. Veteran and provider satisfaction are measured using surveys implemented through Interactive Voice Response (IVR) technology. The quality of care transitions is assessed using the validated Care Transition Measure, and patient satisfaction is evaluated using questionnaires adapted from the Survey of Healthcare Experiences in Patients. The ACC program database serves as a key evaluation tool, tracking referrals, interventions, program completion, and veteran outcomes, including 30-day readmission rates, non-VA ED utilization, and mortality. CDW data is used to compare outcomes between ACC participants and non-participants.
Adoption: Measured by the frequency of non-VA ED notifications to the ACC program regarding veteran visits/discharges. Notification methods (phone, fax, etc.) are tracked in the program database. The number and roles of VA providers collaborating with and referring to the ACC program are also monitored using CPRS notes and the program database. Regular database checks and bi-annual data analysis ensure ongoing tracking of adoption metrics.
Implementation: Assessed by identifying barriers and facilitators, and through an economic evaluation comparing implementation costs to cost offsets and health outcomes. Adaptations to the intervention and fidelity to program delivery are also tracked. The ACC program’s secure access database is the primary tool for tracking core component completion. The ACC social worker enters data in real-time, with bi-annual database checks to monitor progress. Data tracked includes veteran acuity levels, core component completion rates, program enrollment duration, interventions provided, and readmission rates. A health economist tracks implementation costs, and qualitative interviews are conducted at program completion to evaluate implementation processes.
Maintenance: Evaluated by assessing local adaptability and continued program implementation post-funding. This includes evaluating internal and external communication, rapid prototyping, and the feasibility of program expansion. The number of expansion sites and their successful program implementation are key indicators of maintenance.

Relational Coordination and Qualitative Analysis

The Relational Coordination Survey, administered in partnership with RC Analytics, assesses the quality of relational coordination between non-VA and ECHCS providers and ACC program staff. Relational coordination, defined as communication and relating for task integration, is evaluated through the survey, focusing on communication frequency, timeliness, accuracy, problem-solving, shared knowledge, and mutual respect. Targeted interventions are implemented to address identified gaps in relational coordination, fostering teamwork and healthy organizational learning.

Qualitative data, collected through conventional content analysis, provides rich insights into program implementation and evaluation. Mid-line evaluations, conducted eight months post-rollout, involve semi-structured interviews guided by the PRISM framework and the Theoretical Domains Framework (TDF). These interviews gather feedback on implementation context, barriers, facilitators, program components, strategies, delivery, and suggestions for improvement. Convenience, snowball, and purposeful sampling methods are used to ensure diverse perspectives. Interviews are audio-recorded, transcribed, and managed using Atlas.ti software. Team-based consensus building is employed to develop a codebook and analyze emerging themes. Qualitative analysts create process maps to visualize ideal care transition processes, iteratively updating these maps with the ACC social worker to reflect program adaptations and refinements. Adaptations are tracked monthly and analyzed during summative evaluations to inform implementation outcomes. The Lean Six Sigma approach is utilized to train ACC social workers in mapping their intervention processes and tracking changes, further enhancing program adaptability and continuous improvement.

Conclusion: Advancing Veteran Care through Coordinated Support

The Advanced Care Coordination Program represents a significant step forward in enhancing veteran healthcare. By proactively addressing care coordination gaps, particularly during vulnerable transitions from non-VA emergency departments, the ACC program aims to improve health outcomes, reduce healthcare costs, and enhance the overall veteran experience. Through its robust, multi-faceted approach encompassing social worker-led interventions, comprehensive needs assessments, targeted outreach, and rigorous evaluation, the ACC program is poised to become a model for advanced care coordination programs nationwide, ensuring veterans receive the seamless, high-quality care they deserve.