Improving care transitions for Veterans withsocial needs
Project Number1IK2HX003537-01A2
Former Number1IK2HX003537-01A1
Contact PI/Project LeaderCORNELL, PORTIA YVONNE
Awardee OrganizationPROVIDENCE VA MEDICAL CENTER
Description
Abstract Text
PROJECT SUMMARY
BACKGROUND: Veterans who have experienced social needs—such as hunger, homelessness, poverty,
violence, or isolation—face greater dangers of mortality or readmission after an acute hospitalization than
those who have not. In the VA, social workers are trained to assess and address social needs through case
management, care coordination, and community support. In recent work, I have shown that social workers in
VA primary-care teams reduce unplanned hospital and emergency care. Information on Veterans’ social risks
is available in the VA health record, but social workers lack a ready way to locate it, pull it up, and display it.
Having a tool to find, organize, and present the relevant information would allow the social workers to
prioritize their efforts toward helping the Veterans whom they most need to reach.
SIGNIFICANCE/IMPACT: This research will provide new insight into how specific social risks can exacerbate
the risk of adverse post-acute health outcomes. A new tool for identifying and addressing Veterans’ social
risks will help social workers focus their efforts and may allow them to reduce unplanned post-discharge
inpatient and emergency department use. The proposed project and training will help me to launch an
independently funded research program investigating how addressing the social needs of Veterans can
improve their medical care.
INNOVATION: I will leverage VA data on social risks in a novel way that will enable social workers to deploy
their efforts more effectively. The human-centered-design approach iterates between design and stakeholder-
input phases in order to hone the effectiveness of a case-finding tool.
SPECIFIC AIMS: Aim 1: Determine the effects of Veterans’ specific social risks on unplanned care after
hospital discharge. Aim 2: Design a case-finding tool for social workers to prioritize Veterans with a recent
hospital stay who have experienced social risks. Aim 3: Pilot-test the case-finding tool to assess its feasibility,
acceptability, and usability. While carrying out the research, I will pursue four training goals: 1) to gain
knowledge of social work and care-transition practices, 2) to obtain training in mixed-methods research, 3) to
develop expertise in human-centered design, and 4) to prepare to design and lead a pragmatic trial to evaluate
the effectiveness of the intervention.
METHODOLOGY: In Aim 1, I will determine the association of unplanned care after a VA hospital stay (i.e.,
inpatient or emergency department use) with the social risks identified in a Veteran’s health record through
screenings, diagnosis codes, social work assessments, and neighborhood characteristics. I will also examine
variation across the VA in follow-up from social workers among Veterans with social risk. In Aim 2, I will
design a case-finding tool to display information on the most critical social risk factors identified in Aim 1. I
will refine the tool’s content using a human-centered design methodology with iterative define–prototype–test
cycles. I will 1) define requirements through observation and semi-structured interviews with stakeholders,
including hospitalists, inpatient social workers, outpatient social workers, PACT providers, and Veteran–
caregiver dyads; and 2) incorporate feedback from social workers in rapid iterative prototype revision. In Aim
3, my approach will be to implement the tool at 3 VA medical center pilot sites for 12 months. I will collect
quantitative data (usage data together with scale-based questionnaires) and qualitative data (semi-structured
interviews) to assess the tool's feasibility, acceptability, and usability.
NEXT STEPS & IMPLEMENTATION: I will use the findings from this research and the case-finding tool that
we have created to plan a study to evaluate the effectiveness of the case-finding tool in improving Veterans’
outcomes.
Public Health Relevance Statement
Previous researchers have established that adverse social conditions are strongly associated with Veterans’
needing unplanned care after a hospitalization. In the current project, I will begin by identifying which specific
risk factors contribute most to the need for unplanned care. I will then design and pilot-test a tool that will
allow VA social workers to direct their outreach to the Veterans who need them most, at a vulnerable point in
their care journey, by making the relevant data in the Veterans’ health records salient and accessible. The
project will lead to a pragmatic evaluation that will establish the effectiveness of social work interventions in
care transitions. I will gain training in qualitative methods, human-centered design, and pragmatic trials.
When combined with my quantitative research background, those new skills will enable me to establish a
career leading rigorous evaluations of programs and policies to address the social and long-term needs of
Veterans.
NIH Spending Category
No NIH Spending Category available.
Project Terms
Accident and Emergency departmentAcuteAddressAssessment toolCaregiversCaringCase ManagementCharacteristicsCodeCommunitiesCommunity HealthcareDataData AnalysesDiagnosisEffectivenessEffectiveness of InterventionsEmergency CareEvaluationFaceFeedbackFundingGoalsHealthHomeHomelessnessHospitalistsHospitalizationHospitalsHungerInpatientsInterventionInterviewKnowledgeLeadLength of StayMedicalMedical centerMethodologyMethodsNeighborhoodsOutcomeOutpatientsPatientsPhasePoliciesPovertyProgram EvaluationProviderQualitative MethodsQuestionnairesResearchResearch MethodologyResearch PersonnelRiskRisk FactorsSiteSocial ConditionsSocial WorkSocial WorkersSocial isolationStructureTestingTextTrainingVariantVeteransViolenceWorkacute carecare coordinationcareercase findingclinical practicedesigneffectiveness evaluationexperiencefollow-uphazardhealth recordhigh riskhospital carehospital readmissionhousing instabilityhuman centered designimprovedinformation displayinsightmortalitynoveloutreachpilot testpragmatic trialprimary care teamprogramsprototyperesponsescreeningskillssocialtoolusability
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