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Optimizing care coordination to address social determinants of health needs for dual-use veterans

H. Sjoberg, W. Liu, C. Rohs, R.A. Ayele, M. McCreight, A. Mayberry, C. Battaglia
BMC Health Serv Res

Background: Veterans increasingly utilize both the Veteran’s Health Administration (VA) and non-VA hospitals (dual-users). Dual-users are at increased risk of fragmented care and adverse outcomes and often do not receive necessary follow-up care addressing social determinants of health (SDOH). We developed a Veteran-informed social worker-led Advanced Care Coordination (ACC) program to decrease fragmented care and provide longitudinal care coordination addressing SDOH for dual-users accessing non-VA emergency departments (EDs) in two communities. Methods: ACC had four core components: 1. Notification from non-VA ED providers of Veterans’ ED visit; 2. ACC social worker completed a comprehensive assessment with the Veteran to identify SDOH needs; 3. Clinical intervention addressing SDOH up to 90 days post-ED discharge; and 4. Warm hand-off to Veteran’s VA primary care team. Data was documented in our program database. We performed propensity matching between a control group and ACC participants between 4/10/2018 – 4/1/2020 (N- = 161). A joint survival model using Markov Chain Monte Carlo technique was employed for 30-day outcomes. We performed Difference-In-Difference analyses on number of ED visits, admissions, and primary care physician (PCP) visits 120-day pre/post discharge. Results: When compared to a matched control group ACC had significantly lower risk of 30-day ED visits (Hazard Ratio (HR) = 0.61, 95% Confidence Interval (CI) = (0.42, 0.92)) and a higher probability of PCP visits at 13–30 days post-ED visit (HR = 1.5, 95% CI = (1.01, 2.22)). Veterans enrolled in ACC were connected to VA PCP visits (50%), VA benefits (19%), home health care (10%), mental health and substance use treatment (7%), transportation (7%), financial assistance (5%), and homeless resources (2%). Conclusion: We developed and implemented a program addressing dual-users’ SDOH needs post non-VA ED discharge. Social workers connected dual-users to needed follow-up care and resources which reduced fragmentation and adverse outcomes.

Sjoberg H, Liu W, Rohs C, et al. Optimizing care coordination to address social determinants of health needs for dual-use veterans. BMC Health Serv Res. 2022; 22(1):59. Published 2022 Jan 12. doi:10.1186/s12913-021-07408-x PMID: 35022053

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Publication year
Resource type
Peer Reviewed Research
Outcomes
Utilization
Population
Veterans
Social Determinant of Health
Economic Security
Education/Literacy
Employment
Housing Stability
Social Support/Social Isolation
Study design
Pre-post with Comparison Group