Evidence-based practice: In FY2021, the Veterans Health Administration (VHA) national compliance rate with the patient-aligned care team (PACT) compass measure two-day post-discharge contact was 61.82%, well below the national benchmark of 75%. Assessed national performance measures and identified strong practices within top performers enterprise wide. Identified variability in two-day post-discharge processes and documentation throughout the VHA. Conducted literature review and applied the Agency for Healthcare Research and Quality Re-Engineered Discharge (RED) toolkit to create national standardized documentation template.

Purpose: An enterprise-wide lean six sigma improvement project workgroup developed an evidence-based standardized post discharge template for primary care nurses. Goal to reduce unnecessary utilization of acute care resources through utilization of evidence-based two-day post-discharge contact utilizing a national standardized documentation template approved by national nursing leadership council. “Readmission following an acute care hospitalization is a costly and often preventable event” (Horwitz et al., 2011, p.7). Poor coordination between settings is associated with poor health outcomes and increased health care utilization and cost. Post-discharge visits can smooth care transitions. Connecting with veterans within two days of hospital discharge affords the opportunity to answer questions, clarify medication regimens, and review appointments.

Description: The two-day post-discharge PI project has been a 1.5-year collaborative project with multiple stakeholders that include Office of Nursing Service (ONS), Office of Nursing Informatics (ONI), Office of Primary Care (OPC), human factor engineering (NFE), front line PACT RNs and LPNs which was coordinated by OPC.

Development: environmental Scan for existing templates, review of the evidence, human factor engineering-heuristic evaluation

Pilot: 6 sites: 1) Hines (VISN 12), 2) Gulf Coast Veterans Health Care System (Biloxi, MS) (VISN 16), 3) Central Iowa (VISN 23), 4) Pittsburg Integrated site (VISN), 5) Asheville, NC (VISN 6). As of 6/2023 template was utilized over 7000 times. Over 75 health factors, seven updates made to the piloted template

Go-live June 2023: training-primary care leaders, pact team members, clinical application coordinators (CACs), template released June 15,2023; training delivered June 20-30, 2023

Evaluation/outcome: pre-pilot two-day post-discharge contact: 62.93%; post-pilot two-day post-discharge contact: 66.392%; continue to track update data post-national go-live to report and share if selected

HRO alignment: leadership commitment; focused on improving an inpatient-based measure through utilization of resources from outpatient services. Culture of safety; focused on preventing harm by proactively reaching out to veterans who have been recently discharged. Continuous process improvement: applying lean methodology and evidence-based practice to create high reliability through standardized process.

Deference with expertise: conducted human factor analysis and involved the front-line PC PACT RNs and LPNs, clinical application coordinators from local facilities, along with national leadership from ONS/ONI and OPC.

Jamie Falk MS, RN-BSN, CNML

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