Transition From Hospital to Home Post Cardiac Condition
Condition: Cardiac Condition
MeSH terms: Disease
Study type: Interventional

Summary: 
      The study had three parts:

      Part 1: Patients (or their home caretakers) who live outside of Denver and receive their
      primary care at a location other than the Denver VAMC were interviewed after their discharge.
      The interview covered the patient's perspective about the transition of their medical care
      from the Denver VA to their primary care facility.

      Part 2: Primary care providers from the VA facilities that refer patients to the Denver VA
      were interviewed regarding their opinions of transition process from the Denver VA back to
      the primary care VA facilities.

      Part 3: The data from the above interviews were used to develop an intervention to improve
      the transition process from the Denver VA back to the primary care VA facilities.
    

Detailed description: 
      Aim 1 was to describe barriers and facilitators of the transition process from hospital to
      home through qualitative interviews among patients discharged from Denver VA Medical Center
      (tertiary facility) after being transferred from a primary care VA.

      Aim 2 was to describe barriers and facilitators of the transition process through qualitative
      interviews among providers at primary care VA facilities who take care of patients discharged
      from the Denver VA Medical Center for a cardiac condition.

      Aim 3 was to pilot test the transitions of care intervention that targets patients and
      providers to evaluate the feasibility of the intervention to improve process of care
      measures, including: 1) PCP follow-up within 2-4 weeks of hospital discharge; 2) medications
      reconciled between pre and post-hospital discharge; 3) discharge summary available to PCP at
      time of visit; and 4) patient awareness of symptoms that require medical attention. This
      pilot was informed by the interviews from Aims 1 and 2 and best practices from the
      literature. Finally, as part of Aim 3, the primary care providers who saw the patients who
      completed the pilot were contacted to ask for their input and feedback regarding the pilot
      project.

      Description of Enrolled Population: Study Design and Research Methods This was a mixed
      methods study where both qualitative and quantitative methods were employed. Through a series
      of qualitative interviews (n=26), potential barriers and facilitators of the current
      discharge process were assessed in this hub and spoke model of cardiac care. Informed by
      these interviews, the transitions of care intervention refined elements from prior studies
      that have improved this transition process. Finally, a pilot test of this intervention was
      implemented to assess the effectiveness of the intervention to improve important processes of
      care during this transition period among patients (n=8) discharged from Denver VAMC after
      transfer from a primary care VA facility.
    

Intervention name(s): Intervention
Intervention type(s): Behavioral
Intervention description(s): Informed by the interviews and best practices from the literature, pilot test the transitions of care intervention that targets patients and providers to evaluate the feasibility of the intervention to improve process of care measures, including: 1) PCP follow-up within 2-4 weeks of hospital discharge; 2) medications reconciled between pre and post-hospital discharge; 3) discharge summary available to PCP at time of visit; and 4) patient awareness of symptoms that require medical attention
Allocation: Non-Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Health Services Research