Every year, more than half a million medically at-risk Veterans visit VA emergency rooms. Of those who are treated and released—the great majority—1 in 5 will end up back in the ER or hospital within 30 days.
And of those who end up back in emergency care, nearly 3 in 4 will not have seen a VA doctor between trips to the ER.
A research team at the Durham VA Medical Center hopes to turn this situation around. ER care is costly, and it is far from the ideal way to provide health care. The goal, rather, is to get the Veterans into a regular routine of primary care.
In the study, primary care nurses will reach out to the at-risk Veterans, via a series of telephone calls, to connect them with the information and resources they need to avoid repeat ER visits. The trial aims to enroll more than 500 Veterans in all.
Potential impact for all health care systems
Lead researcher Dr. Susan Nicole Hastings says the study could have major implications not only for VA, but for all health care organizations.
"The results will be directly relevant to the care of more than 500,000 high-risk patients seen in VA emergency departments annually," she says, "and they will also be informative to health systems outside VA that aim to reduce ED use."
Hastings is a geriatrician at the Durham VA and Duke University. She's also an investigator with VA's Durham Center for Health Services Research in Primary Care, and an associate professor of medicine at Duke.
According to Hastings, telephone support has proved to be a powerful tool in improving primary care. The new study will be yet one more application.
"Telephone care programs have been shown to improve care processes and outcomes in chronic illnesses such as diabetes and heart failure," she says. "In this study we are combining proven elements of nurse-led telephone support programs for chronic illness care, with a focus on addressing acute needs after an ER visit."
Two or more follow-up calls from nurses
Veterans eligible for the study are those with two or more chronic illnesses who were recently in the ER, and who had a hospitalization or ER visit in the six months prior to that.
The first call from the study nurse, to the Veteran or in some cases to a family member or companion, will focus on reviewing ER discharge instructions and medications. The nurse will also discuss any unmet health care needs that come up during the conversation.
After that, there'll be at least one more call, possibly two, focusing on letting the Veteran know about VA primary care, and offering referrals for home care or home telehealth and any other VA services that may be indicated. One example would be MyHealtheVet, an online program that helps Veterans stay better-informed about their own health care.
During all the calls, nurses will use the "teach-back" method, asking the Veteran on the other end of the line to explain, in his own words, the information he's been given.
"The teach-back method has been widely recognized as an effective way to increase understanding of health information, especially for those with low health literacy," says Hastings. Previous studies by her group have shown that more than 4 in 10 ER users at the Durham VA have low health literacy.
VA is ideal place to try model
The study will track outcomes for six months from each patient's "index" ER visit. It will also look at patients' satisfaction with the model, and overall costs to VA.
Hasting says VA is an ideal place to try out an approach that could impact U.S. health care at large in a big way.
"We have an advanced informatics structure and a strong primary care base," she says. "Those are important factors in testing this type of intervention."