My name is Nicki Hastings,
I'm a geriatrician and a researcher
at the Durham VA Healthcare Center.
A major focus of my research
has been improving care for Veterans
that are discharged from the
Emergency Department.
Many people think of the Emergency Department
as the front door of the hospital,
and indeed it is for many Veterans,
however, the majority who seek care
in the emergency department
are evaluated, treated and then released to go home,
after the treatment plan has been formulated.
It's 75 to 80 percent of all Veterans that present to VA emergency departments
that are actually discharged home.
And so, I've been very interested in this transition
based on my own personal experiences
of working in both settings,
the emergency department and primary care.
And working in both those settings
really showed me the challenges that patients face
as they transition between different settings.
For example, in my primary care clinic,
I could see how difficult it was
for Veterans to understand the sometimes
complicated discharge instructions
that they receive.
Like how to take their new medications.
But being on the emergency department side,
I could also really appreciate how difficult it was
to convey information in that setting.
So the study that we just conducted was a randomized clinical trial
that examined the effectiveness of a
primary care-based nurse intervention
for patients treated and released form the ED.
We focused on patients who had been in the ED or hospital at least once before
in the past six months,
and those who had two or more chronic conditions.
And we structured the intervention
to be delivered in two core phone calls.
So on the first phone call, the nurse really focused on,
"Did you get your medications?
Do you have an appointment to go back and see your doctor?
Do you know what to do if you get worse?
Do you know what symptoms might mean you are getting worse?"
And really focused on getting the care delivered that the patient needed
based on the initial reason
they went into the Emergency Department.
On the second call, the idea was,
the dust has now settled from the initial visit,
let's step back and take a bigger look at your overall health
and see if there are other VA programs or services
that can help get things back on track.
And then the nurse interventionist was available up to 30 days afterward
for any other issues that would come up.
These were often issues dealing with VA benefits
or care coordination kind of problems.
We followed the Veterans for 6 months
and then we looked to see
what kinds of VA services they had in fact used during that time period.
Some of the main things we learned
from conducting this trial were that number 1,
Veterans really welcomed this kind of support
after an Emergency Department visit.
The second thing that we learned is that
we could successfully get patients
back in to primary care in a more expedited fashion.
So the Veterans that were randomized to the intervention program
were more likely to see their primary care provider within 30 days
after the emergency department visit.
What we were not able to do is reduce the likelihood
they would come back to the emergency department.
So we saw equivalent numbers of return
visits in the intervention patients
and in the control patients.
What I'm also really excited about is
that we are going to be incorporating
the Veteran voice into the next phases of our research,
because we really feel like the answers of what we need to do
to support patients better in this
sensitive time after an ED visit,
lie with the Veterans themselves.
We have a Veteran Engagement panel
at our Center of Innovations for Health Services Research in Durham,
where we have a wonderful group of Veterans
who sit with us on a very regular basis,
hear our research findings,
hear our research ideas,
and give us really incredible and valuable feedback
about how we can make the research
more appropriate and responsive
to what Veterans really need.
I've worked with Chad Kessler
who is the director of the
National Emergency Medicine Program
for the VA for a number of years,
specifically on this project
and it's been an immensely valuable experience.
He's really able to represent the landscape of VA emergency medicine
in a really important way,
in terms of making sure that our research is practical,
and could be put to use immediately
and in a meaningful way,
so that's been a really important partnership.
But of course, studying any transition
implies that there are at least two settings involved,
so the emergency department
and emergency medicine partners
have been incredibly important,
but also primary care
because that's the receiving service, if you will,
who are picking up the ball and taking it forward.
I appreciate all the Veterans
that have participated in research studies
of mine over the years,
and most particularly, I appreciate the Veterans
that participated in this trial.
We enrolled 514 Veterans in this trial,
many of them 2 or 3 days after they left the emergency department—
a really challenging time to participate in research—
and yet they were willing to do it,
even with the understanding that
half of them would be randomized
to the control group,
meaning they wouldn't get to participate in the program.
But they told us time and again that they were willing to do it
because we might learn something
that would help other Veterans.
The altruism that we see among Veterans
and their willingness to commit their time to help other Veterans,
it's amazing.