Improving care transitions for Veterans withsocial needs

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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.