ArticleBMC health services research2022
Optimizing care coordination to address social determinants of health needs for dual-use veterans.
Article in BMC health services research, 2022. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 10 papers.
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Who cites it
10 citing papers in PubMed, 14 citations in OpenAlex.
- Qualitative analysis of clinical and community perinatal providers' perceived barriers to equitable care for food insecurity.Public health nutrition · 2026Article
- Patient Perspectives of Care Integration During Early Implementation of a Care Coordination Initiative.Medical care research and review : MCRR · 2026Article
- Risk of Hospital Readmissions and Association With Receipt of Post-Hospitalization Care Coordination Services Among High-Risk Veterans.Health services research · 2026Observational
- Patient-centered burdens and economic outcomes among patients who are veterans, people with intellectual and developmental disabilities, and people living in rural areas and their caregivers: a scoping review.Frontiers in public health · 2026Article
- Care coordination for persons with mental health challenges: a scoping review.International journal of mental health systems · 2025Article
- Mental Health Treatment among U.S. Military Veterans: Insights from the National Health Interview Survey.Journal of general internal medicine · 2025Article
- Participation of Veterans Affairs Medical Centers in veteran-centric community-based service navigation networks: A mixed methods study.Health services research · 2024Article
- Evaluation of veteran community care outcomes after coronary artery bypass grafting: a retrospective pilot cohort.Journal of cardiothoracic surgery · 2024Article
- 'It Makes You Sit Back and Think Where You Wanna Go': Veteran experiences in virtual whole health peer-led groups.Health expectations : an international journal of public participation in health care and health policy · 2022Article
- Using a longitudinal multi-method approach to document, assess, and understand adaptations in the Veterans Health Administration Advanced Care Coordination program.Frontiers in health services · 2022Article
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Authors and funding
7 authors at 2 institutions in 1 country.
Funding
No grant is acknowledged in the PubMed record.
Abstract
backgroundVeterans increasingly utilize both the Veteran's Health Administration (VA) and non-VA hospitals (dual-users). Dual-users are at increased risk of fragmented care and adverse outcomes and often do not receive necessary follow-up care addressing social determinants of health (SDOH). We developed a Veteran-informed social worker-led Advanced Care Coordination (ACC) program to decrease fragmented care and provide longitudinal care coordination addressing SDOH for dual-users accessing non-VA emergency departments (EDs) in two communities.
methodsACC had four core components: 1. Notification from non-VA ED providers of Veterans' ED visit; 2. ACC social worker completed a comprehensive assessment with the Veteran to identify SDOH needs; 3. Clinical intervention addressing SDOH up to 90 days post-ED discharge; and 4. Warm hand-off to Veteran's VA primary care team. Data was documented in our program database. We performed propensity matching between a control group and ACC participants between 4/10/2018 - 4/1/2020 (N- = 161). A joint survival model using Markov Chain Monte Carlo technique was employed for 30-day outcomes. We performed Difference-In-Difference analyses on number of ED visits, admissions, and primary care physician (PCP) visits 120-day pre/post discharge.
resultsWhen compared to a matched control group ACC had significantly lower risk of 30-day ED visits (Hazard Ratio (HR) = 0.61, 95% Confidence Interval (CI) = (0.42, 0.92)) and a higher probability of PCP visits at 13-30 days post-ED visit (HR = 1.5, 95% CI = (1.01, 2.22)). Veterans enrolled in ACC were connected to VA PCP visits (50%), VA benefits (19%), home health care (10%), mental health and substance use treatment (7%), transportation (7%), financial assistance (5%), and homeless resources (2%).
conclusionWe developed and implemented a program addressing dual-users' SDOH needs post non-VA ED discharge. Social workers connected dual-users to needed follow-up care and resources which reduced fragmentation and adverse outcomes.
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