Background: More than 1 million Veterans receive care in Emergency Departments (EDs) in VA Medical Centers (VAMCs) annually. Nearly 1 in 5 Veterans treated and released from a VAMC ED receive additional unscheduled care in the ED or hospital within 30 days. The risk of repeat ED visits is particularly high among patients with chronic medical conditions who have received ambulatory medical services in the ED previously. An explicit goal of newly developed Patient Aligned Care Teams (PACTs) is to promote continuity in primary care clinics and thereby reduce ED utilization;however, there has been little research to guide PACTs in how to accomplish this. A key role for nurses within PACTs will be telephone management of high risk populations, and Veterans treated and released from the ED represent one such high-risk group. However, no studies have examined both the Veteran and system-level impact of using nurse care managers to support Veterans after an ED visit. Objectives: The overall goal of this study is to examine the impact of a primary care-based nurse telephone support program for Veterans treated and released from the ED who are at high risk for repeat visits. We will test the following hypotheses: H1: Veterans who participate in a primary care-based nurse telephone support program after an ED visit will have a lower rate of ED use in the subsequent 30 days compared to usual care. H2: Veterans who participate in a primary care-based nurse telephone support program after an ED visit will have higher satisfaction compared to usual care. H3: Veterans who participate in a primary care-based nurse telephone support program will have lower total VA costs in the 180 days following an ED visit compared to usual care. Methods: The proposed study is a two group randomized, controlled trial to evaluate a structured nurse telephone support program for Veterans treated and released from the ED who are at high risk for repeat visits. After informed consent is obtained, Veterans will be randomized to nurse telephone support [DISPO ED] or usual care. DISPO ED will consist of 2 calls from a study nurse (simulating the role of a PACT RN Care Manager) within 7 days of the index ED visit, with an option for a 3rd call within 14 days. The primary outcome is a dichotomous outcome defined as any ED use within 30 days or not. Secondary outcomes are patient satisfaction with VA health care at 30 and 180 days, and total VA costs within 180 days. Significance: This study will provide important information about how to promote access to and continuity with PACT for a large population of high risk Veterans. The goal of DISPO ED is not to evaluate a new layer of care;but rather to test an intervention that will contribute to the evidence base for what PACT nurse care managers can and should be doing to promote optimal health and health care utilization among Veterans. Designed in close collaboration with clinical partners, and endorsed by leaders in PACT and emergency medicine, DISPO ED could, if proven effective, be readily implemented using existing PACT resources and staffing.
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| Miller, Katherine E M; Duan-Porter, Wei; Stechuchak, Karen M et al. (2017) Risk stratification for return emergency department visits among high-risk patients. Am J Manag Care 23:e275-e279 |
| Hastings, Susan Nicole; Betts, Elizabeth; Schmader, Kenneth E et al. (2014) Discharge information and support for veterans Receiving Outpatient Care in the Emergency Department: study design and methods. Contemp Clin Trials 39:342-50 |
