Multiple studies have documented that poor communication across care transitions leads to medical errors, adverse clinical outcomes, inefficient care, and less favorable patient experiences. However, relatively little attention has been given to the transition between emergency department (ED) and follow-up care for patients discharged directly from the ED. Patients discharged from EDs may have one or more urgent follow-up care needs, such as repeat laboratory assessments, specialty care consultations, and specialized diagnostic testing. Available literature suggests that failures to receive follow-up care after being sent home from ED visits are a crucial patient safety issue. Inadequate communication and coordination of follow-up care recommendations may be leading to such failures. Veterans make approximately 2 million visits to VA EDs each year, and are discharged from the ED nearly 80% of the time. Patients presenting to VA EDs generally have complex medical histories, and therefore are at particularly high risk for experiencing adverse outcomes. Among a cohort of 942 Veterans 65 years of age or older discharged from the Durham VA ED in 2003, 34% had a return ED visit, were hospitalized and/or died within 90 days. Despite this vulnerability, knowledge is scant and outdated about whether Veterans receive the post-ED care they need to prevent these adverse outcomes, and no assessments have been done regarding Veterans’ experiences obtaining this care. Tools for assessing Veterans’ experiences with this care transition are needed. Further, VA operations and QUERI-funded projects have been initiated targeting this transition in VA, and tools are needed to enable rigorous assessment of their effectiveness. This project will develop and test a patient survey to measure the quality of communication and care coordination for this transition. Since ambulatory care can prevent initial chronic disease exacerbations needing ED visits, it is a reasonable extrapolation that ambulatory care follow-up after ED visits could prevent re-exacerbations and ED re-visits. Therefore, this work will focus on Veterans with ED visits for chronic ambulatory care sensitive conditions (ACSCs): 1) asthma, 2) congestive heart failure, 3) chronic obstructive pulmonary disease, 4) diabetes mellitus, and 5) hypertension, since we postulate that these patients are most likely to have follow-up care needs. Given that there is also scant literature on the ED follow-up care needs of patients with ACSCs, the work will begin with characterizing the specific follow-up care needs of these patients using record review. Then, semi-structured interviews will be conducted to investigate patient-centered perspectives on critical components of post-ED care, asking Veterans about their communication and care coordination experiences. Interviews will be analyzed to assess which aspects of communication and coordination are most important for Veterans’ post-ED experiences as well as other factors (e.g., facilitators and barriers to receiving care) relevant to Veterans’ experiences of post-ED care. Finally, these findings will be used to develop and assess content validity of a survey instrument to assess the extent to which Veterans are receiving needed post-ED care, and Veterans’ experiences with this care transition. This survey instrument will be used in subsequent research proposals addressing VA priority areas (e.g. improving care timeliness, focusing resources efficiently), including determining the quality of VA ED follow-up care and assessing the effectiveness of improvement interventions.

Ensuring Veterans receive the benefits, care, and services they need in a timely and efficient manner is a top priority for VA. Coordinating Veterans’ care across vulnerable care transitions, such as the transition between Emergency Department (ED) and follow-up care providers for Veterans discharged from the ED, is essential for realizing this priority. However, assessments of VA care across this transition are limited and outdated, and quality improvement and research efforts focused on this transition are hindered by lack of measurement tools. More specifically, there are currently no measurement tools available for assessing patients’ experiences with this care transition. This work will fill this gap, by creating and testing a survey instrument to measure patient’s experiences, and investigating Veterans’ needs and perspectives, following VA ED visits.