Addressing Social Determinants of Health for Dual‐Use Veterans
Authors: Sjoberg H. , Liu W. , Ayele R. , Rohs C. , Mayberry A. , Battaglia C. 
Published: August 2020

An estimated 40% of Veterans are eligible for community care. Veterans who access care both outside of the Veterans Health Administration (VA) and at the VA are at risk for fragmented care and adverse outcomes. These dual‐use Veterans often do not receive necessary follow‐up care or linkage to resources addressing social determinants of health (SDOH) post–non‐VA emergency department (ED) visits. We created a social worker–led advanced care coordination (ACC) program to reduce fragmented care, enhance care coordination, and provide longitudinal case management to address SDOH for dual users who access non‐VA EDs.ACC collaborated with internal and external stakeholders (ie, clinicians and staff) to enhance care and address SDOH for dual users. The ACC social worker had regular contact with stakeholders through phone calls, emails, and in‐services to enhance relationships and program buy‐in. Stakeholders asked each patient if they were a Veteran and informed ACC of the Veteran’s non‐VA ED visit. Postdischarge, the ACC social worker called the Veteran to complete a comprehensive assessment identifying SDOH needs. The ACC social worker provided case management via phone calls and home visits to the Veteran up to 90 days addressing SDOH needs and reconnected the Veterans to their primary care team through electronic closed‐loop communication. We analyzed VA claim data postimplementation to compare intervention participants with nonparticipants. Using propensity score, Veterans were matched 3 to 1 on age, gender, comorbidities, and number of hospitalization and primary care physician (PCP) visits in the past year.Dual‐use Veterans who accessed non‐VA EDs in Denver, Colorado, and Omaha, Nebraska, metro areas. Veterans had to be eligible to receive care through the VA.When compared to a matched control group, Veterans who received the ACC intervention had significantly lower rates in readmission to the ED within 30 days of ED discharge (16.1% vs. 30.5%, P < 0.01). ACC connected Veterans to services addressing SDOH they may not have otherwise accessed due to lack of knowledge and resources. Using our program database to evaluate Veterans enrolled in ACC since April 2018, we found they were connected to: (1) VA PCP appointments (82%), (2) VA benefits including enrollment (33%), (3) home health care (21%), (4) financial assistance (ie, food benefits, rental and utility assistance, disability benefits, 18%), (5) homeless resources including housing vouchers and shelters (9%), (6) mental health treatment (9%) and transportation assistance (9%), and (7) substance use treatment (4%).Dual‐use Veterans often fall through the cracks after receiving non‐VA care. ACC addressed gaps in transitions by connecting Veterans to resources addressing SDOH needs and linking Veterans back to their VA primary care teams.Gaps in care will continue as Veterans increasingly access non‐VA care. ACC bridged these gaps by enhancing relationships and communication between VA and non‐VA providers. ACC addressed Veteran’s SDOH by connecting them to resources post–non‐VA ED discharge. Programs similar to ACC should be implemented across health care systems to assist dual‐use Veterans with SDOH needs and increase linkage to resources.The study was funded by QUERI.