• Roman A Ayele, Emily Lawrence, Marina McCreight, Kelty Fehling, Russell E Glasgow, Borsika A Rabin, Robert E Burke, and Catherine Battaglia.
• Department of Veterans Affairs, Eastern Colorado Health Care System, Denver, Colorado.
• J Hosp Med. 2020 Mar 1; 15 (3): 133139133-139.

BackgroundVeterans with healthcare needs utilize both Veterans Health Administration (VA) and non-VA hospitals. These dual-use veterans are at high risk of adverse outcomes due to the lack of coordination for safe transitions.ObjectivesThe aim of this study was to understand the barriers and facilitators to providing high-quality continuum of care for veterans transitioning from non-VA hospitals to the VA primary care setting.DesignGuided by the practical robust implementation and sustainability model (PRISM) and the ideal transitions of care, we conducted a qualitative assessment using semi-structured interviews with clinicians, staff, and patients.SettingThis study was conducted at a single urban VA medical center and two non-VA hospitals.ParticipantsA total of 70 participants, including 52 clinicians and staff (23 VA and 29 non-VA) involved in patient transition and 18 veterans recently discharged from non-VA hospitals, were included in this study.ApproachData were analyzed using a conventional content analysis and managed in Atlas.ti (Berlin, Germany).ResultsFour major themes emerged where participants consistently discussed that transitions were delayed when they were not able to (1) identify patients as veterans and notify VA primary care of discharge, (2) transfer non-VA hospital medical records to VA primary care, (3) obtain follow-up care appointments with VA primary care, and (4) write VA formulary medications for veterans that they could fill at VA pharmacies. Participants also discussed factors involved in smooth transition and recommendations to improve care coordination.ConclusionsAll participants perceived the current transition-of-care process across healthcare systems to be inefficient. Efforts to improve quality and safety in transitional care should address the challenges clinicians and patients experience when transitioning from non-VA hospitals to VA primary care.© 2020 Society of Hospital Medicine.

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